Increase provider knowledge and screening comfort

THE RISKS ASSOCIATED with smoking electronic cigarettes (vaping), particularly for adolescents, make it a critical issue for primary healthcare providers. Marketing portrays vaping as a safer alternative to smoking, but Kesimer explains that electronic cigarettes contain an amount of nicotine that reaches the brain in levels similar to traditional cigarette use. Research by Barrington-Trimis and colleagues found an association between recent vaping and increased traditional cigarette smoking. Given this risk, nurses and other providers should ask about vaping during every healthcare visit. (See Stats and risks.)

Adolescents’ responses to general tobacco-related questions may not trigger a positive screening result because they may not understand the connection to vaping or realize its risks. According to Mansour and colleagues, clinicians’ lack of awareness about vaping and lack of documentation in electronic health records (EHRs) hinder the identification of at-risk youth.

In an effort to address these issues, we implemented a project aimed at enhancing provider knowledge of vaping and its risks and increasing screening rates.

Literature review

We began with a review of literature published since 2020 using various databases. Search terms included youth, young adult, and adolescent vaping; vaping screening, vaping screening tools, primary care; Screening, Brief Intervention, and Referral to Treatment (SBIRT); and electronic cigarette use. We identified several key themes: the importance of vaping screening in primary care, barriers to effective screening, and recommendations for validated screening tools.

Importance of screening

Primary care settings have a responsibility to screen for health risks, including vaping, to provide appropriate interventions. The American Academy of Pediatrics (AAP) recommends that all healthcare providers screen for tobacco use and offer prevention and cessation education. The AAP provides resources to support clinicians working with young patients, including the Act-Counsel-Treat (ACT) Model for Youth Cessation, which offers streamlined tips for addressing youth tobacco use.

Barriers to effective screening

Many barriers impacting healthcare providers and adolescents hinder effective vaping screening. Several researchers (Hunt and colleagues, Monsour and colleagues, Oliver and colleagues, and Ruppel and colleagues) note variables that affect healthcare providers, including time constraints, lack of knowledge about vaping, and limited resources for referrals and treatment. Gaps in knowledge and the ability to intervene emphasize the need for additional training and education. In a study by Oliver and colleagues, healthcare providers expressed a need for more education on vaping prevention and cessation assistance. Ranney and colleagues describe the need for educational tools and EHR documentation training.

From the adolescent’s perspective, concerns may include confidentiality, getting into trouble, available support, and discomfort with their healthcare providers. According to Jamal and colleagues and Jenssen and colleagues, some adolescents fear legal ramifications since nicotine products are illegal until age 21. Hunt and colleagues and Ranney and colleagues note that adolescents may be more willing to discuss vaping if healthcare providers approach the topic nonjudgmentally and provide confidentiality. Although state laws don’t explicitly address confidentiality concerning smoking or vaping for minors, the AAP and Jenssen and colleagues report that healthcare providers try to adhere to confidentiality standards with a minor’s best interest in mind.

Validated screening tools

Although adding the term “electronic cigarettes” as a selection in the EHR may increase screening, this approach hasn’t been validated as a reliable tool for identifying vaping. According to Cano Rodriguez and colleagues, questions specific to vaping and EHR prompts have proven effective at identifying electronic cigarette use. Validated screening tools can improve outcomes by detecting vaping early, enabling timely intervention.

One such tool, Car-Relax-Alone-Forget-Friends-Trouble version 2.1 + Nicotine (also known as the CRAFFT 2.1+N), includes detailed questions about vaping tailored to common terminology used by adolescents. AAP recommends confidential, self-administered screening methods to yield more honest results and improve efficiency while providing patient privacy.

Project purpose and questions

This project implemented a validated screening tool in a primary care setting to identify patients ages 12 to 21 who vape. Healthcare providers participated in an educational session on the risks of vaping and the use of the screening tool. The project aimed to answer two questions:

Among primary healthcare providers assessing patients ages 12 to 21, does using the CRAFFT 2.1+N screening tool change vaping detection rates compared to standard clinic practice or no screening?

Among primary healthcare providers, does providing an educational session on using a validated screening tool change knowledge and comfort levels for patient screening and vaping cessation counseling compared to no educational session?

Project methods

Before project implementation, substance use screenings included an annual form with questions about traditional nicotine or cigarette use but no questions specific to vaping. The Boston Children’s Hospital Center for Adolescent Behavioral Health Research, which manages the CRAFFT program, granted permission to use the CRAFFT 2.1 +N self-administered screening tool.

Healthcare providers within the clinic, including nurses, nurse practitioners, and a physician associate, attended an educational session on the screening tool, the significance of screening, and early intervention among adolescent patients. The education session consisted of a presentation provided by the AAP. Providers also received a Centers for Disease Control and Prevention handout on vaping among youth and the importance of screening and intervention within primary care.

Before and after the education session, providers completed an electronic survey to measure self-rated current knowledge, comfort level, vaping perception, and preparedness to address vaping. A separate panel of 10 nurse educators confirmed the face and content validity of the educational survey.

Patients completed the CRAFFT 2.1+N screening form while waiting for appointments. Nursing staff documented screening results in the EHR, and the nurse practitioner or physician associate reviewed the findings with the patient. During training, healthcare providers were encouraged to engage in counseling based on the patient’s vaping activities.

For 3 months before and after project implementation, we collected data on the percentages of patients who screened positive for vaping, negative for vaping, or weren’t screened. We also evaluated healthcare provider survey data pre- and post-implementation. We aimed to determine the effectiveness in identifying youth who vape, screening rates, and if healthcare providers felt prepared to identify and address vaping.

We performed statistical data analysis with SPSS version 29.0.0.0 using two‑sided Mann–Whitney U tests for the Likert scale survey scores, and compared distributions of categorical response options with Fisher’s exact tests. We evaluated vaping screening data between pre‑ and post‑implementation periods using 2×2 Pearson’s chi‑square tests. For verification, we also conducted Fisher’s exact tests.

Project population and setting

The project took place at a primary care clinic in the Midwest that employs six nurses, three nurse practitioners, and one physician associate. Before project implementation, 218 patients, ages 12 to 21, visited the clinic and 305 visited post-implementation.
We obtained a letter of support from the clinic and Institutional Review Board (IRB) approval from a Midwest university. We shredded paper screening tools after documenting information in the EHR. Providers administered the screening tool in a confidential setting while following Health Insurance Portability and Accountability Act guidelines. EHR data contained no patient identifiers. Healthcare providers obtained informed consent.

Results

To strengthen anonymity, we aggregated and analyzed Likert scale responses as independent groups. Two‑sided Mann–Whitney U tests were used for the ordinal items, and Fisher’s exact tests for comparing distributions of categorical response options. The small provider sample (n=8) limited statistical power, and no changes reached significance at α = .05 (Mann–Whitney U P‑values ranged from 0.19 to 0.73; Fisher’s exact P‑values ranged from 0.12 to 1.00). Therefore, we presented results descriptively and recommend caution when interpreting any observed numerical improvements.

Screening

For patients ages 12 to 21, healthcare providers increased documentation of vaping screening from 45% (99/218) before implementation to 75% (229/305) after implementation of the CRAFFT 2.1+N screening tool. This increase was statistically significant (χ²(1)=49.02, P<.001; Fisher’s exact P<.001). Among screened patients, the proportion reporting positive for current daily, some‑day, or former vaping decreased from 17% (17/99) pre‑implementation to 6% (14/229) post‑implementation, while the proportion reporting never use increased from 83% to 94%. A 2×2 chi‑square test comparing positive vs negative vaping status across periods showed a significant shift in distribution (χ²(1)=9.88, P=.002), and results remained significant using Fisher’s exact test (P=.003). (See Education survey results)

Discussion

We found an association between implementation of the CRAFFT 2.1+N screening tool and a significant increase in healthcare provider documentation of screening for vaping in patients ages 12 to 21 years. Among those screened, significantly fewer patients reported being current or former e-cigarette users, and significantly more reported as never users. Before implementing the screening tool, healthcare providers may have screened patients when they suspected an increased risk of vaping. By reducing opportunity for selection bias and making screening universal, we found shifts in screening positive or negative. Adolescents also may under-report vaping if they fear disclosure to parents or guardians, despite assured confidentiality, which also may contribute to increased negative screenings.

Provider survey responses suggest descriptive improvements in self-rated knowledge, comfort, and preparedness to address vaping; however, none of the Likert scale changes were statistically significant. The providers indicated an increased need for education on vaping risks and interventions, but these findings also weren’t statistically significant.

The finding of 6.1% of patients who screened positive for vaping in this project is consistent with the 5.9% use reported by Jamal and colleagues. This project also supports the use of the CRAFFT 2.1+N screening tool, reinforcing previous findings that standardized, validated tools facilitate consistent screening practices and help clinicians identify adolescents with increased health risks.

This project addressed time-constraint barriers identified in earlier studies by incorporating a patient self-administered screening tool and sharing the workflow between the nurses who documented the screening and the nurse practitioner or physician associate who reviewed the findings with the patient. The findings support the use of a validated, self-administered tool to capture e-cigarette use data as a primary strategy for improving screening processes in adolescent primary care.

Nursing implications

Patients in the primary care setting require screening with a validated tool for cigarette use and vaping. Nurses and other providers should document screening information in the EHR and routinely review screening results to provide evidence-based care.

Although this project didn’t demonstrate significant improvements in healthcare provider comfort and knowledge related to screening youth for vaping, an ongoing need for education remains. Ensuring that all healthcare providers have access to clear guidance on vaping risks and practical screening methods may support more consistent implementation and improve identification of adolescents with increased health risks. (See Resources.)

Future work on this topic should evaluate different educational formats, such as e‑learning modules or in‑person skill‑building workshops, using larger sample groups. Longitudinal cohort studies would be beneficial to evaluate provider retention of vaping-related knowledge and clinical behaviors over time.

Jennifer Thornberry is an assistant professor in the graduate nursing program at Wichita State University in Wichita, Kansas. Jennifer Burman is a family nurse practitioner at Sanford Health in Minot, North Dakota. Donna Robison is an associate teaching professor at Wichita State University.

American Nurse Journal. 2026; 21(5). Doi: 10.51256/ANJ052634

References

American Academy of Pediatrics. Addressing pediatric tobacco and nicotine use: Considerations for clinicians. May 19, 2025. aap.org/en/patient-care/tobacco-control-and-prevention/youth-tobacco-cessation/tobacco-use-considerations-for-clinicians/

American Academy of Pediatrics. E‑Cigarettes and vaping toolkit. June 23, 2025. aap.org/en/patient-care/tobacco-control-and-prevention/youth-tobacco-cessation-toolkits/e-cigarettes-and-vaping-toolkit/

Barrington-Trimis JL, Yang Z, Schiff S, et al. E-cigarette product characteristics and subsequent frequency of cigarette smoking. Pediatrics. 2020;145(5):e20191652. doi:10.1542/peds.2019-1652

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Oliver AP, Bell LA, Agley J, Bixler K, Hulvershorn LA, Adams ZW. Examining the efficacy of Project ECHO to improve clinicians’ knowledge and preparedness to treat adolescent vaping. Clin Pediatr. 2022;61(12):869-78. doi:10.1177/00099228221107816

Ranney L, Kowitt S, Mottus K, et al. A mixed methods approach to improving provider counseling of patients who vape. HCA Healthc J Med. 2022;3(5):283-97. doi:10.36518/2689-0216.1443

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Key words: vaping, adolescent vaping, electronic cigarettes, screening for smoking in youth