Discussion
The increased popularity and use of e-cigarettes among adolescents and youth aged 10-21 years has been a focus of public health authorities and regulators, such as the FDA. The scoping review revealed a diverse range of interventions applied at the public and private levels to reduce the incidence of adolescent vaping, including education, curriculum, and skills programs in schools and communities, peer leader support strategies, education and media campaigns, parental interventions, and social media and video games information, education, and communication strategies. Thirty-nine percent of the reviewed studies employed school-based educational curriculum and skills programs, 23% used peer-led support strategies, and 15% used education media campaigns, among the most common behavior change interventions. Two studies used educational video games, while one tested the effectiveness of a parental intervention.
Interventions targeting increasing literacy among adolescents aim to dispel the impact of advertising campaigns by e-cigarette manufacturers depicting the practice as “cool” and harmless. Health messaging raises awareness of the addictive nature of nicotine in vapes and the risk of respiratory problems from the other constituents, such as flavors. The Food and Drug Administration enforces a labeling requirement on e-cigarette packaging and advertising to warn users that the product contains nicotine, an addictive substance associated with several risks, such as increased risk for various cancers and cardiovascular diseases. Strong et al. (2021) found that while labeling has been associated with decreased positive perceptions of cigarette smoking, it does not affect cigarette cessation or consumption level. Consequently, the seven studies recommend educational programs for tobacco use prevention delivered in-person or online. These interventions may be offered to adolescents who have not initiated vaping or tobacco use to decrease intention and willingness to try.
Andrews et al. (2023), Bteddini et al. (2023), Hair et al. (2023), and Hair et al. (2023) tested online educational programs delivered through individual or group learning sessions lasting. The interventions were most effective in changing the normative image of smokers and vapers, friends’ approval of smoking and vaping, and risk perceptions for addiction from vaping and smoking (Andrews et al., 2023). These findings contrast with Strong et al. (2021) conclusions that messaging on cigarette packs, including graphic images and bold lettering, does not entrench negative perceptions about smoking and reduces intentions to initiate smoking. Hollis et al. (2022), McCauley et al. (2023), and Printz (2020) tested school-based in-person behavioral interventions consisting of mystery introduction, knowledge development, and critical reflection to middle and high school students in Canada and the US. The authors hypothesized that behavior change would be successful in students who experience an intrinsic motivation for the change. These findings align with the theory of planned behavior; educating students on the health dangers of nicotine and flavors contained in vapes was effective in improving students’ refusal skills and countering advertising of vaping as cool.
Peer-led support strategies were the second most common behavior change intervention in the reviewed studies. Wyman et al. (2021) concluded that student-nominated peer leaders with integrated friendship networks, ongoing mentoring, and evidence-based campaigns effectively reduced recent vaping and intention to vape. Kelder et al. (2020) piloted a mixed methods intervention involving peer leaders, physical education teachers, and social messaging in 12 middle schools in Texas. The researchers found improvements in knowledge and reduced prevalence of the first use of vapes in the intervention schools. The impact of peers on adolescent behavior has been reported for several positive and negative behaviors. Cheng et al. (2023) found statistically significant evidence that peer e-cigarette use predicts own e-cigarette use for both boys and girls, but particularly in girls. Groom et al. (2021) found that friends were the most common sources of vapers’ first e-cigarettes. Consequently, peer-led vaping control interventions are a viable behavior change option in middle and high schools.
Two studies investigated the impact of media campaigns delivered through vaping prevention advertisements and video ads communicating content of vape fluids, health risks, and connections to tobacco (England et al., 2021; Noar et al., 2022). Public health messaging through traditional media is still a common dissemination strategy for health information, education, and communication. However, Merchant et al. (20210 expressed concerns that media campaigns are not as effective in modern times due to lots of “digital noise” from social media channels. England et al. (2021) found the social media and digital intervention effective in increasing knowledge on vaping and perceptions of risk in post-test results and control group comparisons, suggesting targeted communication through web and social media sites is a viable dissemination channel for adolescent anti-vaping communication. At the same time, Noar et al. (2022) concluded FDA Real Cost vaping advertisements were effective in reducing susceptibility to vaping and cigarette smoking compared to controls. The study ensured engagement with the intervention through monitored online visits, confirming that rampant distractions cause the decreased effectiveness of media campaigns.
Virtual reality and video games have been found to be helpful in education and health promotion, prompting their testing as viable channels to deliver health education on vaping. Immersive VR provides situational learning experiences, thus capable of increasing participation and engagement, especially for adolescents with short attention spans. Weser et al. (2021) tested the preliminary efficacy and acceptability of Invite Only VR to teach adolescents about the health risks of vaping and provide them an opportunity to practice refusal skills. Participants expressed satisfaction with the intervention and showed improvements in their knowledge of the health harms of vaping. The findings accord with findings on the effectiveness of VR games in reducing risky sexual behaviors in adolescents from a minority group (Hadley et al., 2019). Pentz et al. (2019) reported similar findings following brief exposure to videogames in changing knowledge and attitudes towards tobacco use, including e-cigarettes.
Social and Behavior Change Theories
Most selected studies did not identify an underpinning social or behavioral change theory. Five studies identified the theory of planned behavior; four used the social cognitive theory, and one studied the social diffusion theory. The theory of planned behavior (TPB) is a leading behavior change theory in public health (Tapera et al., 2020). TPB posits that behavior is determined by intentions, which are influenced by attitudes, subjective norms, and perceived behavioral control (Tapera et al., 2020). Advertising and the formation of a “cool” culture around vaping have long been recognized as drivers for adolescents experimenting with vaping. The TPB assists behaviorists and educationists in identifying key drivers of intentions and behaviors supporting adolescent vaping. Consequently, five of the studies sought to improve knowledge on nicotine as a significant component of vapes, with similar addiction and other health effects similar to tobacco products. At the same time, the studies employing peer leaders and parents as change agents used the TPB to influence attitudes and enhance perceived control of adolescent vaping.
The social cognitive theory (SCT) recognizes models’ impact on adolescent behavior. The key components of SCT include self-efficacy, engendering adolescent confidence in resisting risky behaviors, and peer pressure towards experimenting and smoking e-cigarettes (Liu et al., 2022). Two peer-led educational interventions employed the SCT to provide role models who did not vape and had no intention to experiment with vaping. At the same time, the SCT recommends changes to social norms, such as the belief that e-cigarettes are safe and modern, through educational campaigns to enhance knowledge of the dangers of nicotine and flavors in vapes. Other studies sought to improve the self-efficacy of the students to refuse offers for vapes from peers or marketers. Additional interventions included warning labels and parental engagement to reinforce and incentivize behavior change, as well as policy changes to remove deceptive advertising of e-cigarettes as safe.
The social diffusion theory (SDT) propounds that behaviors occur through the spread of innovations (Valente et al., 2015). E-cigarettes gained rapid acceptance as safer alternatives to cigarette smoking, assisted by deceptive marketing and the incorporation of flavors that improved the smoking experience. Marketers downplayed the addictive potential of nicotine in their products, while some vapors contain more nicotine in cigarettes (Marques et al., 2021). Studies employing the SDT seek to reverse the rapid diffusion of vapes by establishing social networks and norms against vaping, harnessing peer influence and opinion leaders campaigning against vaping, disseminating messaging through mass and social media, and engaging communities to reduce adolescent vaping.
Design of Interventions
Adolescence is a period of rapid growth and development spanning physical, psychosocial, and cognitive growth. This period is fraught with many influences as the adolescent develops an identity, thus prone to influences that may cause far-reaching and long-lasting effects. Consequently, behavior change interventions targeted at adolescents should address their unique characteristics, especially taking note of their desire for status and respect. Adolescents may resist school-based interventions due to rebelling against the familiar; therefore, alternative approaches aligned with their motivations for behavior change may be more effective (Yeager et al., 2018). The reviewed studies used diverse methodologies and multifaceted approaches to test the effectiveness of interventions to reduce adolescent vaping. Most of the studies were quasi-experimental pre-and-post intervention studies with or without control; four were randomized controlled trials, and one each was mixed methods and cross-sectional studies. In-person or online educational interventions to improve knowledge of the contents of vapors and associated health dangers were the preferred mode of delivering the intervention used in five studies. Two studies used virtual reality video games and educational media campaigns. The effectiveness of peer leaders was tested in three studies; one of the studies incorporated other methods, including in-class physical education teaching and social messaging. Only one study explores the effectiveness of parental interventions.
Evidence on Efficacy and Effectiveness of Behavior Change Interventions
The evidence on the efficacy and effectiveness of behavior change interventions to reduce adolescent vaping is evolving but promising. As Kelder et al. (2020) demonstrated, mixed approaches incorporating traditional in-person and in-class education provided by trained teachers, peer leader information and role modeling, and social messaging effectively increase knowledge, reduce the incidence of experimentation with e-cigarettes and smoking, and facilitate refusal. Other approaches that may be combined with educational interventions include VR and video games, media campaigns, and risk communication. Adolescent-facing interventions should also be supported by policy changes on e-cigarette advertising, clear labeling and conspicuous warning, community engagements to change perceptions on the safety of e-cigarettes, and reducing access to the products; for example, by raising the age of legal sales. Overall, school-based interventions in teacher-led or video education, peer support, skills building, and reflections show the best promise from reviewed studies and other publications.
Conclusion
Adolescent vaping poses a significant threat to adolescent health, stemming from addiction risk to nicotine, respiratory problems from inhalations with multiple constituents, and as a gateway to tobacco smoking and other drugs. School-based vaping interventions for middle and high school students are a promising intervention to reduce adolescent vaping. Combined approaches incorporating traditional teacher-led instruction, multimedia lessons, skills building for refusal and resisting peer pressure, peer-led education, reflection, and VR video games are essential to developing adolescent motivation to refuse or quit vaping.
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