The US Surgeon General declared youth e-cigarette use an epidemic in 2018.1 In 2020, 19.6% (3.02 million) of US high school students reported current e-cigarette use.2 Among North Carolina high school students, e-cigarette use rose 89.4%, from 1.7% in 2011 to 20.9% in 2019.3 E-cigarettes are available in youth-appealing flavors, including menthol, mint, candy, and fruit.4,5 In 2020, 84.7% of high school students who currently used e-cigarettes reported using flavored products.2
The e-cigarette landscape has changed rapidly, since the first products were introduced; newer generations of products, including “pod mod” systems (e.g., JUUL) contain nicotine salts, delivering higher concentrations of nicotine with less throat irritation.1 Nicotine is highly addictive, can harm adolescent brain development, and can prime the brain for addiction to other drugs.5 In addition to nicotine, e-cigarette aerosol can include other harmful ingredients.5 E-cigarettes can also include tetrahydrocannabinol (THC), the primary psychoactive ingredient in cannabis.4 Approximately one-third of US youth e-cigarette users in 2016 reported ever using cannabis in e-cigarettes.6
North Carolina schools are required to have a policy prohibiting tobacco product use, including e-cigarettes, on school grounds or at school-sponsored events.7 However, media reports indicate students use e-cigarettes during school.8,9 A 2018 survey reported 18% of students aged 12–17 had seen JUUL used in school.10,11 In 2018, the US Surgeon General identified teachers as allies who can reduce youth e-cigarette use.5 It is important to assess school staff knowledge of types, student use, and harms of e-cigarettes and to develop evidence-based interventions that staff can implement, because other than parents, teachers are the adults who most frequently interact with school-aged children. A recent national survey of teachers and administrators found that fewer than half could identify a JUUL, and that policies were difficult enforce because e-cigarettes can be discreet in appearance, aerosol, and scent.12 However, data are limited regarding school staff’s awareness of student e-cigarette use in schools, school policies, actions taken, resources needed, and types of e-cigarettes students use. To guide North Carolina’s prevention efforts and identify resources needed in schools to address e-cigarette use, we assessed these topics among school staff from a sample of 12 North Carolina high schools. Additionally, we analyzed e-cigarette products confiscated by staff from students in these schools during 2018–2019.
In May 2019, a random sample of 25 of all 451 public and charter high schools in North Carolina was invited to participate in the assessment, which consisted of an online quantitative survey, in-person semistructured qualitative interviews, and a product assessment. The 25 selected schools were identified using a random number procedure. The principal of each selected school was sent an email inviting staff to participate. Schools were classified into rural and urban areas using 2010 Rural-Urban Commuting Area (RUCA) codes from the US Department of Agriculture.13 No incentives were offered to the schools for participation.
Online Quantitative Survey
The principal of each school emailed the survey to all full- and part-time school staff at participating high schools, including administrators, teachers, coaches, security, and janitorial staff. It consisted of 44 closed-ended questions that were pre-tested in a California-based survey. After survey completion, respondents were asked to volunteer for an in-person interview.
We conducted three interviews per school. If at least one principal or assistant principal volunteered, one was selected; remaining interviewees for each school were randomly selected. The interviews were conducted one-on-one and lasted ~30 minutes. Interviewees provided verbal consent to allow recording of the interview. Interviewees were asked open-ended questions on the same topics assessed during the online survey to obtain more in-depth information regarding staff knowledge of student e-cigarette use behaviors and actions taken, as well as resources needed to address youth e-cigarette use in schools. For example, questions to assess resources at schools included, “What steps has your school taken to reduce students’ use of e-cigarettes?” and, “What kind of training or resources on e-cigarette or vaping devices are needed to better inform school staff about this issue?” Probes were also provided for each question so the interviewer could ask follow-up questions. Interview questions were pre-tested in high school staff who participated in a California-based study. No incentives were provided to interviewees. Interviewers were trained in qualitative interview techniques by CDC staff.
Principals and assistant principals at each school were asked to provide all e-cigarette products, including devices, pods or cartridges, e-liquid bottles, and chargers, confiscated from students or found on school grounds during the 2018–2019 academic year. When schools wanted to keep products, pictures were taken. Confiscated e-cigarette products were categorized as e-cigarettes, pods or cartridges, e-liquid bottles, or other items (e.g., chargers). E-cigarettes were then categorized by brand and e-liquid bottles were categorized as flavored or not.
Descriptive and Qualitative Analysis
Results of descriptive analysis of quantitative surveys were reported as proportions for categorical variables or medians and interquartile ranges for continuous variables. Analyses of questions about actions taken by schools to prevent or reduce student e-cigarette use were restricted to the highest-level administrator (i.e., principal, or assistant principal) who responded to remove within-school clustering. Data were stratified by urban and rural location; results were similar and are presented in aggregate.
All interviews were professionally transcribed. A codebook was created containing themes using interview guide topics. Four investigators (LR, GB, CH, LD) revised the codebook and established uniformity among coders. Using standard protocols, coders independently coded the same transcripts and identified any additional codes. To reach consensus, all coders reviewed and discussed coding decisions from one transcript. Inter-rater reliability was tested through the Dedoose Training Center, which reports a pooled Cohen’s kappa statistic to summarize inter-rater reliability across multiple items.14 Twenty-two excerpts were randomly pulled from a previously coded transcript and all coders re-coded each excerpt. The pooled kappa across coders range was 0.64–0.90, indicating good to excellent agreement. Transcripts were then divided among coders and independently coded. Prominent themes and illustrative quotes across participants were identified.
The Centers for Disease Control and Prevention reviewed this assessment for human subjects protection and it was determined to be a non-research activity. All participants provided written consent and were provided information on youth tobacco use prevention, education, and cessation after the interview.
Of 25 schools invited, 12 schools (48%) in 11 counties geographically dispersed across North Carolina consented to survey participation. Ten were public schools and two were public charter schools. Of these, staff from 10 participated in in-person interviews and nine schools provided confiscated e-cigarette products or allowed pictures to be taken. Based on RUCA codes, one school was in a rural area, one in small-town core, two in micropolitan area core, five in metropolitan area high commuting, and three in metropolitan area core. School size ranged from < 200 students to > 1700 students (median: 805 students).
Online Quantitative Survey
Overall, 959 school staff were sent the quantitative survey and 599 responded (62%). Of these, 25 were excluded because they only answered demographic questions; 60 were excluded because they were staff for middle schools attached to high schools. The final analytic sample was 514 school staff from 12 schools. Median number of surveys returned by school was 48 (interquartile range [IQR]: 30–59).
Among 514 respondents, 67% were female; 34% were aged 40–49 years and 28% were aged ≥ 50 years (Table 1). Respondents worked at their current school for a median of six years (IQR: 2–12 years); most were teachers (76%). Forty (8%) reported ever personally using e-cigarettes, with 20% of those reporting past month use.
Most respondents (91%) indicated that e-cigarette use among students is somewhat (45%) or very (46%) problematic (Table 2). The majority of respondents (90%) also reported student e-cigarette use is a somewhat (43%) or high (47%) priority concern for their school administration. Overall, most respondents (86%) reported that they are somewhat (51%) or very (35%) confident in their ability to recognize e-cigarettes. Most respondents (79%) reported that e-cigarette use among students is very harmful, with none reporting that it is not at all harmful. Additionally, 86% of respondents reported that students’ e-cigarette use somewhat (65%) or largely (21%) contributes to disturbances in learning.
Among 167 (33%) respondents who reported seeing students use e-cigarettes on school grounds during the 2018– 2019 school year, 79% saw students use in bathrooms, 68% in parking lots or personal vehicles, and 48% in classrooms (Table 2). Among non-principal and non-assistant principal respondents (n = 155) who reported seeing students use e-cigarettes on school grounds, 83% reported some students to school administrators; 35% confiscated the e-cigarette and did not return it. Among principals and assistant principals (n = 16), 88% reported assigning out-of-school suspensions, confiscating the e-cigarette, and notifying parents/guardians. In contrast, smaller numbers of principals and assistant principals referred students to counseling (n = 3), a drug program (n = 1), or a tobacco use prevention program (n = 2).
Approximately 90% of respondents were aware that school policy prohibits e-cigarette use by students in school buildings, vehicles, and on school grounds (Table 3). A similar proportion correctly reported that they knew the policy prohibits use by school staff and visitors. A lower proportion correctly reported that the school policy prohibits e-cigarette use at off-campus school-sponsored events by both students (78%) and staff and visitors (71%). Ninety percent reported that they were somewhat (51%) or very confident (39%) their school effectively enforces policy.
Based on responses from the highest-level administrator at each school (i.e., principal or assistant principal), 5 out of 11 reported increased bathroom or hallway patrol was implemented during the past 12 months. Five respondents reported that their school held informational meetings for teachers, four reported educational sessions for students and parents, and three sent an email or letter to parents. Some reported their school had installed cameras (n = 3), educational posters (n = 3), or tobacco-free school signs (n = 1), or adopted e-cigarette prevention curricula or programs (n = 1).
Although 57% of all respondents reported that prevention measures taken by their school were somewhat (52%) or very (5%) sufficient to reduce student e-cigarette use, nearly half (43%) reported they were insufficient (Table 3). Similarly, 34% of respondents were not confident their school had resources to prevent student e-cigarette use, and 57% were not confident their school had resources to help students quit e-cigarettes. The top resources respondents reported needing were education for parents (55%), resources to help students quit (45%), and updated curricula (38%).
In total, 74% of respondents reported being in favor of a state law to raise the minimum legal age to purchase tobacco products from 18 to 21, and 72% favored a law to ban flavored tobacco products.
Thirty-five interviews were conducted; 48% of interviewees were female, 71% were teachers, and 23% were principals or assistant principals. Interviewees worked at their current school for a median of six years (IQR: 2–12 years). Three common themes emerged: pervasiveness of e-cigarette use; varying consequences for student e-cigarette use; and absence of scientific information and educational resources concerning harms of e-cigarettes.
Interviewees reported that student e-cigarette use was common and perceived this was likely attributable to ease of access, product novelty, flavors, and marketing campaigns designed to appeal to youth. Concerns included easy access to e-cigarettes from family, friends, and online sellers, and access to distribution networks within schools from other students. Additionally, interviewees reported that they perceived students of all social groups used e-cigarettes, and some perceived that health and safety misconceptions among students might contribute to widespread use in schools. One interviewee stated, “I mean, every kid does it. It’s not one type of kid that does it. Every kid does it.” Interviewees were concerned about the perceived increase in drug use at their schools and reported they believed students were using e-cigarette devices for cannabis in addition to nicotine: “Kids got pods with THC in it and…they are high as a kite.”
Principals and assistant principals were more knowledgeable about tobacco policies than most teachers and other respondents. Additionally, teachers and other respondents were often unaware of disciplinary processes that occurred after reporting students who used or possessed e-cigarettes. Teachers were adamant they should not be the ones searching students thought to be in possession of e-cigarettes, whereas principals, assistant principals, and school security openly discussed searching students for e-cigarettes. Interviewees described varying enforcement, both between and within schools, ranging from one day in-school suspension to a mandatory five-day out-of-school suspension: “There’s a protocol for the school, but I think some teachers handle it differently.” Several interviewees noted the ineffectiveness of enforcement and advocated harsher punishments, whereas others reported need for increased student counseling and cessation resources: “It [current disciplinary action] does not change their behaviors; we know that. So, we’re trying to figure out what else we can do.”
Most interviewees reported that their schools’ efforts to reduce youth e-cigarette use were insufficient. They believed the constantly changing design (i.e., ability to conceal devices), limited effectiveness of disciplinary actions, and lack of parent support make it difficult to reduce e-cigarette use in schools. Most wanted more information for staff, students, and parents on immediate and long-term health impacts, including information from experts or youth who have suffered health consequences from e-cigarette use. One interviewee stated, “The kind of thing that in my opinion would make a huge impact on kids, is to hear other kids and what they’ve gone through, what it has cost them.”
In total, 336 e-cigarette products were collected from nine schools (Figure 1). This comprised 176 e-cigarettes, 96 pods or cartridges, 27 e-liquid bottles, and 36 other items (e.g., chargers). Approximately half (48%) of e-cigarettes collected were JUUL brand, 16% were SMOK, and 9% were Suorin. Among 27 e-liquid bottles, only two brands appeared more than once. Based on name, 65% of e-liquid bottles were labeled as sweet or fruit flavored.
Findings from the online survey, in-person interviews, and product assessment suggest that e-cigarette use on school grounds is common in 12 North Carolina schools despite presence of a statewide tobacco-free-schools policy.7 Overall, school staff felt underresourced to prevent youth e-cigarette use.
The discreet design of pod mods, product novelty, flavors, marketing campaigns that appeal to youth, and ease of access likely contribute to e-cigarette use among students.1,16–18 The products confiscated consisted of primarily pod mods and flavored e-liquid bottles. Pod mods typically contain nicotine salts, which can be inhaled at higher quantities with less throat irritation than freebase nicotine used in older e-cigarettes.1 Pod mods are also easily concealable, making them appealing to youth, difficult for teachers to identify, and easier to use in school.19–22
Surveyed and interviewed respondents stated that increased patrol in hallways and bathrooms and informational meetings for teachers, parents or guardians, and students were the most common measures taken to address student e-cigarette use. Additionally, in-school or out-of-school suspensions were the most frequently reported disciplinary actions; referrals to counseling or tobacco or drug use prevention programs were less common. However, respondents reported that the prevention and disciplinary measures were insufficient deterrents for students to reduce e-cigarette use. Similar to other research, educators in this study reported that the discreet appearance of e-cigarettes makes it difficult to enforce the policy.12 However, respondents were also confident that their school effectively enforces the policy. This may indicate that the perception of policy success and effective enforcement is influenced by knowledge of emerging e-cigarette products and shifts in use patterns. Moreover, our study reported that school staff perceive that parental knowledge about dangers of e-cigarette use is insufficient. Finally, some respondents believed that suspension failed to address nicotine dependence or addiction. E-cigarettes can deliver high concentrations of nicotine, which is highly addictive.5 Thus, students with nicotine dependency may benefit from cessation interventions to assist them in quitting e-cigarette use. Furthermore, interviews revealed that knowledge of schoolwide tobacco policy and disciplinary action differed among respondents. Although some respondents expressed need for harsher punishments, others voiced need for counseling or cessation treatment for students who used e-cigarettes.
Approximately one-third of respondents were not confident their school had sufficient resources to prevent e-cigarette use among students. Education for parents was the perceived need most reported by respondents. During interviews, respondents reported that information specifically on immediate and long-term health effects of e-cigarettes is crucial for parents. In a survey of US parents of middle and high-school students, 74% reported receiving no communication from their school regarding e-cigarettes.23 The Surgeon General concluded that coordinated, multicomponent interventions that combine school-based policies and programs along with other population-based strategies (e.g., price increases, mass media campaigns, and smoke-free policies) are effective in reducing initiation, prevalence, and intensity of smoking among youth; these approaches have also been recommended to address youth e-cigarette use.5 School staff also reported that highlighting real stories from youth within schools might help reduce and prevent e-cigarette use. In North Carolina, one local teenager who overcame addiction to e-cigarettes has shared his story at multiple North Carolina schools.24–26 Because parents have also been identified as key allies by the Surgeon General in addressing youth e-cigarette use,5 a promising strategy for schools might be to prioritize distribution of information to parents on harms of e-cigarette use.
In addition to the need for school resources to prevent use, approximately half of staff reported needing additional resources to help students quit e-cigarettes. There is limited evidence for effective clinical treatments for youth tobacco cessation, though there are promising interventions, including behavioral interventions.27,28 Increasing school staff awareness of cessation resources for youth, including state quitlines and evidence-based school curricula, is also important.29,30 Additionally, the high proportion of school staff who supported raising the minimum age to purchase tobacco products from 18 to 21 and favored a law to ban flavored tobacco products indicates substantial support for legal measures that may prevent youth tobacco use.
This study is the first in North Carolina, and among the first nationally, to assess school staff’s awareness of students’ e-cigarette use, responses, and resources needed by schools to address use. Nonetheless, the study is subject to limitations. First, only 12 public high schools participated, and these schools might not be representative of all North Carolina high schools. However, participating schools were geographically diverse and in urban and rural locations. Second, quantitative surveys were not collected from all staff at participating schools and the number of surveys received differed by school; however, the response rate was 62%, both urban and rural schools submitted a similar number of surveys with a median of 48 surveys, and different staff positions were represented. Third, e-cigarette products collected by schools might not be representative of all devices used by students. However, literature suggests pod mods and flavored products are popular among youth, consistent with products confiscated.2,20 Finally, data were not collected from students or parents.
This study underscores the significant burden of e-cigarette use on schools, school staff, and youth. Efforts are warranted to incorporate evidence-based curricula; educate staff, parents, and youth regarding health risks; and help youth quit e-cigarettes. Such efforts may occur as part of a comprehensive approach alongside population-based interventions implemented by local and state health departments. This includes ensuring that smoke-free and tobacco-free policies include e-cigarettes and are enforced; increasing price of all tobacco products; restricting young persons’ access to e-cigarettes in retail settings; licensing retailers; developing youth-targeted anti-tobacco public education campaigns that include e-cigarettes; and enforcing policies that raise the minimum age of purchase to 21.1,4,16,31,32
Disclosure of interests
No interests were disclosed.