Toward the Development of a Physician Training Curriculum to Improve Discussions about Electronic Cigarettes with Adolescent Athlete Patients

Emily Peterson

Major Professor: Xiaoquan Zhao, PhD, Department of Communication

Committee Members: Gary Kreps, Carla Fisher, Tesfa Alexander

Research Hall, #162
April 06, 2016, 12:30 PM to 10:30 AM


Electronic cigarettes – also known as e-cigarettes or electronic nicotine delivery systems (ENDS) – are battery-operated devices that dispense nicotine through vapors inhaled by the user. E-cigarette use, or “vaping,” has been rapidly increasing the in United States since its introduction to the market in 2008, especially among adolescents (Stimson, Thom, & Costall, 2014). While only 1-3% of high schoolers reported vaping in 2011, 13.4% reported vaping in 2014 – more than any other tobacco product (Arrazola et al., 2015). The potential harm of e-cigarettes for adolescents is two-fold. First, public health scholars are concerned that e-cigarette use may renormalize cigarette use among youth (Fairchild, Bayer, & Colgrove, 2013). Second, while marketed as a “healthy tobacco alternative,” e-cigarettes often contain nicotine and other hazardous substance which may be detrimental to health (Dwyer et al., 2009; Jensen, Luo, Pankow, Strongin, & Peyton, 2015). Primary healthcare providers (PHP) have played an important role in decreasing the prevalence of other risky behaviors among adolescents, and also have the potential to decreasing vaping prevalence among this demographic (Merzel et al., 2004). Providers may have an especially strong influence on adolescent athletes, who both see their PHP more frequently than non-athletes and are also at higher risk of using alternative tobacco products (Woolf, Rimal, & Sripad, 2014). However, PHPs cite a lack of knowledge about e-cigarettes and insufficient efficacy for successfully initiating and managing discussions about e-cigarettes with patients (Pepper et al., 2014).  


This dissertation consisted of three studies, unified in their goal to support the development of an on-line PHP training curriculum to provide the knowledge and tools to help providers effectively discuss e-cigarettes with their adolescent athlete patients. In Study 1, adolescent athletes (N = 448) completed a survey to determine the strongest determinants of e-cigarette use, grounded in Fishbein and Ajzen’s (2010) reasoned action approach. The survey also questioned athletes on their experiences and preferences for provider-patient communication about tobacco products. In Study 2, PHPs (N = 25) completed one-on-one interviews to explore their knowledge, and beliefs about e-cigarettes, as well as their perceived barriers to e-cigarette clinical discussion. Finally, in Study 3, adolescent athletes (N = 25) participated in focus groups to pilot test potential messages and to further explore their perspectives and experiences with clinical interactions.


Results from Study 1 revealed that athletes’ positive health outcome beliefs, perceived approval from friends, and their estimation of peers who vape were all significantly associated with participants’ vaping behavior and intention. Additional motivations included trying new flavors and performing “vape tricks.” Almost all athletes reported that they had not discussed e-cigarettes with their PHPs, but reported wanting to talk to their PHPs most about discussing e-cigarettes’ relationship to their athletic performance and to tobacco cigarettes. Differences in age and risk groups were also found.  In Study 2, provider cited lack of knowledge and time, feeling uncomfortable, and vague screening tools as barriers to e-cigarette discussion. Providers also discussed successful techniques to facilitate psychosocial counseling with teens. Study 3 revealed that messages about e-cigarettes were most successful when they aroused cognitive dissonance about the potential health effects of vaping, and/or evoked fear. Participants also reported they would be more likely to adhere to their PHP’s advice about vaping if they had an established clinical relationship, and felt their provider cared for them and was knowledgeable about e-cigarettes.


Content recommendations for an on-line training curriculum targeted to PHPs was developed based on the findings of these three studies. Modules for the proposed curriculum emphasize providing necessary background information on e-cigarettes, improving psychosocial counseling with adolescents, and adequately screening for e-cigarette use.