As a nurse in a public school system, I float between a large urban high school and a smaller rural high school. In both locations, I struggle to make an impact on the students' vaping behaviors. What is the best way to approach this issue with adolescents?-N.K., N.Y.

Matthew A. Privett, MS, FNP, replies: How best to help adolescents avoid nicotine addiction is a timely and important question. An estimated 90% of adult smokers started smoking before age 18, and vaping nicotine via e-cigarettes is increasingly popular with adolescents.1 As recently as 2018, e-cigarette use by high schoolers was reported to be about 21%, which is a 9% increase from the prior year.2 Among middle schoolers, 5% report using e-cigarettes. These numbers continue to climb.2,3

You are right to be concerned about this behavior: Vaping is risky. Besides accidental nicotine poisoning and secondhand exposure comparable to secondhand smoke, chemical burns and explosive injuries are possibilities.2 In addition, exposure to nicotine liquid through skin contact or oral ingestion can lead to seizures, anoxic brain injuries, lactic acidosis, and death.2 Nicotine also plays a role as a gateway drug to even more risky substance abuse.4 School nurses are well positioned to intervene at the point of maximal impact-at or before the time adolescents start using nicotine products.

Timely nursing interventions can promote better outcomes for youth. Adolescents value privacy and are more likely to seek healthcare and share personal health information when assured of confidentiality. Nurses must honor privacy concerns in accordance with federal, state, and school guidelines governing adolescent conditional confidentiality.5 This means that clinicians are required by law to disclose certain situations, such as abuse or suicidal ideation. Nurses should inform adolescents about this, emphasizing that any such disclosure is motivated by concern for the individual's safety and is not intended to punish.5

Communication is critical

To communicate effectively with adolescents, follow the 6 As: Anticipate, Ask, Advise, Assess, Assist, and Arrange.6

* First, help adolescents anticipate circumstances that introduce vaping, such as peer pressure at parties or in high school bathrooms and schoolyards, or just hanging out with friends. Offer preparatory guidance with phrases and strategies to help them navigate through those moments. For example, when experiencing peer pressure to smoke/vape, an adolescent could simply say, "No thanks, I tried it once but it's not for me." Kids can also turn the tables by pointing out a downside of vaping: "No thanks, I have better things to do with my money." Teach them to have the confidence to walk away.7

* Next, ask direct questions about vaping or other substance use, including when and where they vape. The answers may reveal exposure to illicit drugs or other risky behavior, offering the opportunity to provide additional guidance.

* Advise adolescents who are vaping to quit and inform them about risks associated with nicotine use.

* Tactfully assess readiness to quit, using motivational interviewing techniques.8 Guide the conversation with open-ended questions, affirmation, reflective listening, and summaries.9

* Then offer strategies to assist with cessation efforts (see For more information... for helpful resources). In addition, consider other appropriate services as indicated, such as nicotine replacement therapy (NRT).6 All forms of NRT help increase nicotine cessation success rates for those attempting to quit by a rate of up to 60%.10 Although the US Preventive Services Task Force Recommendation Statement reports insufficient research evidence to endorse NRT use with adolescents, the American Academy of Pediatrics recommends that tobacco dependence pharmacotherapy is a reasonable consideration for moderately to severely tobacco-dependent adolescents.11 These conclusions reinforce the need for expert clinical judgment. A prescription is required for adolescents, so consider a referral to a healthcare provider to determine whether NRT is appropriate for them.6

* Finally, arrange for follow-up to monitor progress and provide ongoing support.6 Adolescents often need reminders and the cessation/prevention message is worth repeating. When possible, use modes of communication preferred by students. Besides in-person conversations, phone calls, emails, and texting are options that facilitate contact in any setting, in or out of school.

Cognitive considerations

When working with adolescents, take their developmental level into account. As they continue to mature cognitively, adolescents have a propensity for risky behavior and are more vulnerable to nicotine addiction compared with adults, making intervention and prevention at this developmental stage critical.6,12

Adolescents may need help developing healthy coping skills to deal with stress. Investigate potential areas of concern such as family conflicts or financial, academic, employment, and peer pressure, and help them develop coping strategies to reduce stress. Student educational level, beliefs about addiction, reasons for using nicotine, awareness of the associated risks, and motivators to quit will all affect cessation success, so discuss these topics with students.13 In addition, prepare adolescents with strategies to deal with nicotine withdrawal symptoms, weight control issues, anxiety, and depression as indicated.6

Finally, use motivating strategies

Everyone wants to live a long and prosperous life. In one study, concern about long-term adverse health effects was the most important motivating factor to quit for most adolescents.6 Reminding them of the expense is another motivator. Highlight the benefits of better health, longer life, and more pocket money.

Going along with the crowd is typical adolescent behavior. One-third of adolescents are highly motivated to quit when peers and parents look negatively upon using nicotine.6 Consider starting a peer support group in your school and encourage teachers to have classroom discussions about nicotine use. Better yet, offer to colead a classroom discussion yourself.

For more information...

* American Indian Cancer Foundation: Commercial tobacco cessation & lung cancer preventionhttp://www.americanindiancancer.org/aicaf-project/lung-cancer-awareness

* CDC: Smoking and tobacco usehttp://www.cdc.gov/tobacco/quit_smoking/index.htm?s_cid=osh-stu-home-nav-002

* National Alliance on Mental Illness: Motivational interviewing as a smoking cessation strategyhttps://namimn.org/wp-content/uploads/sites/188/2018/06/FactSheet_Smoking_Motiva

* University of Colorado Anschutz Medical Campus School of Medicine: Dimensions: tobacco free toolkit for healthcare providershttp://www.bhwellness.org/toolkits/Tobacco-Free-Toolkit.pdf

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