Introduction

Vaping (e-cigarette use) has increased among youth in Great Britain over the past decade [1]. Between 2013 and 2025, the prevalence of current vaping among youth aged 11–17 rose from 1% to 7% [1]. Vaping is substantially less harmful to health than smoking and can help people to quit smoking [2–6]. Most e-cigarettes contain nicotine, which has addictive potential, particularly when delivered rapidly through inhalation [3,4]. Biomarker studies among youth indicate that those who vape have nicotine exposure at levels similar to their peers who smoke tobacco [7]. Vaping also exposes young people to potentially harmful toxicants at lower levels than smoking but higher than non-use [8], and the long-term health effects of these exposures remain uncertain. For youth, both nicotine dependence and toxicant exposure are important risks, as early initiation can sustain nicotine use and extend toxicant exposure across the lifespan [9]. It is also illegal for retailers to sell vaping products to under-18s in Great Britain [10]. Youth who do not smoke should therefore be discouraged from vaping.

Evidence suggests that youth vaping prevention campaigns, including those delivered in school settings, can increase perceptions that vaping can harm health and deter youth from trying vaping [3,11–13]. Most campaigns focus on the absolute risks of vaping (i.e., that vaping risks addiction and harm to health) and some contain statements that vaping causes lung injuries, heart and respiratory diseases, and cancers [3,11–15]. Few campaigns that have been evaluated provide nuanced information about both absolute and relative harms (i.e., that vaping is less harmful than smoking but carries some risks) [3,11,13]. While campaigns focussing on the absolute risks of vaping may reduce vaping, they can also increase misperceptions that vaping is equally or more harmful than smoking [3,13,16]. This could, in turn, increase the likelihood of smoking (a more harmful behaviour) or decrease the likelihood of using a vape in a smoking cessation attempt [3,13,16,17]. Vaping prevention campaigns must therefore be carefully designed to ensure that they do not inadvertently increase misperceptions and encourage smoking. Most evidence on youth vaping prevention campaigns to date is from the US and Canada, with little research from Great Britain [11–13]. In 2022, 25% of youth in England reported being exposed to vaping campaigns or messages in schools [18].

INTENT is an evidence-based smoking prevention programme targeted at secondary school pupils in Great Britain, developed over a period of 20 years and recently expanded to include information about vaping. INTENT is based on implementation intentions, which are specific “if-then” plans on how, where, and when to perform a behaviour (e.g., “If I am offered an e-cigarette at the bus stop, then I will say ‘no thank you, it gives me a dry mouth’”) [19]. The effects of forming implementation intentions are often contingent on the presence of strong motivation or goal intention to perform the behaviour [20,21]. Interventions involving implementation intentions therefore often include information about the risks and/or benefits of engaging in a behaviour [22,23]. Specifically, INTENT provides information about the risks of smoking and vaping.

INTENT reduced youth smoking initiation from 36% to 29% in a pragmatic Randomised Controlled Trial (RCT) [22] and was subsequently deployed in 2021 across secondary schools in England and Scotland to tackle smoking initiation. INTENT was also found to significantly weaken the association between vaping and subsequent smoking among school pupils [24]. In 2022, following concerns about youth vaping among local authorities and teachers and the lack of evidence-based educational vaping materials in Great Britain, INTENT was expanded to include vaping-specific implementation intentions and health risk information. INTENT’s vaping prevention materials have not yet been evaluated.

Understanding teachers’ experiences and perceptions of vaping and of delivering vaping prevention materials, such as those used within INTENT, is important for several reasons. First, schools represent a key context for promoting health behaviours, with implications across the lifespan [25,26]. Second, improving teachers’ knowledge about health behaviours can have wide-ranging impact [26], particularly because teachers educate numerous young people each year (e.g., on average, there are 18 school pupils per teacher in England) [27]. Evidence also suggests that school-based, teacher-led interventions for changing health behaviours are feasible and cost-effective [22]. Third, teachers in Great Britain have reported concerns over what to tell children about vaping due to mixed messaging and absence of official guidance, and they often have misperceptions themselves about the harms of vaping relative to smoking [28] that could inadvertently encourage smoking over vaping [18]. Fourth, intervention success may be partly dependent on delivery, so it is important to ensure delivery experiences are positive. Studies among teachers in the US suggest that there is considerable variation in school approaches to youth vaping and that many teachers feel underprepared to address pupils’ tobacco and nicotine use [15,29].

This project therefore aimed to assess teachers’ experiences with delivering the INTENT youth vaping prevention materials to school pupils in England and Scotland. To our knowledge this is the first study to assess teachers’ perceptions of vaping and vaping prevention materials outside of the US [14,15,29].

Methods

Development and delivery of INTENT youth vaping prevention materials

The INTENT youth vaping prevention materials were developed in collaboration with INTENT’s customers (e.g., local authorities) and university researchers (University of Leeds, King’s College London) between October 2022 and August 2023. The Office of Health Improvement and Disparities (OHID), a government office that is dedicated to improving the nation’s health and has commissioned vaping evidence reviews [3], also provided feedback on the materials. Teachers were asked to deliver the vaping materials after the smoking prevention programme, which focussed on the harms of smoking and implementation intentions to avoid smoking initiation.

The INTENT vaping prevention materials comprised four session plans (Fig 1). Briefly, session plans covered what pupils know about vaping, the impacts of vaping, and to compare vaping to smoking (Session Plan 1), social influences on health behaviours including vaping, including a quiz on harm perceptions and smoking cessation (Session Plan 2), the environmental impacts of vaping (Session Plan 3), and addiction (in general, and specific to nicotine; Session Plan 4). Pupils were also asked at the end of each session to create a personal plan to refuse an offer to vape. The session plans are described in detail in the Supplementary Materials. Further details of the intervention are available upon reasonable request from Evidence to Impact [30].

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Fig 1. Overview of the INTENT vaping prevention materials session plans.

https://doi.org/10.1371/journal.pone.0335474.g001

The INTENT youth vaping prevention materials are designed to be delivered between Year 7 in England (Secondary 1 (S1) in Scotland; typically aged 11–12 years) to Year 10 (S4 in Scotland; typically aged 14–15 years). The recommendation is that between 40 and 50 minutes are allocated for each session and that they are incorporated into the curriculum during Personal, Social, Health, and Economic Education (PSHE) lessons in England or Curriculum for Excellence (CfE) lessons in Scotland.

Design

This was a cross-sectional study in which teachers were asked to complete a 10-minute online survey administered through Qualtrics. Data were collected between 15 February and 31 July 2024. Inclusion criteria were that teachers had to have delivered at least Session Plans 1 and 2 of INTENT, including the quiz in Session Plan 2, because these sessions contained the most information about the health harms of vaping. The Kings College London ethical review committee approved the study (REF: MRA-23/24–39974).

Measures

Measures and response options are shown in Tables 1–3. The full survey is available online osf.io/4rtav [31].

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Table 1. Teacher characteristics (N = 45).

https://doi.org/10.1371/journal.pone.0335474.t001

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Table 2. Teachers’ experiences with INTENT (N = 45).

https://doi.org/10.1371/journal.pone.0335474.t002

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Table 3. Teachers’ perceptions of the impact of INTENT on their pupils (N = 45).

https://doi.org/10.1371/journal.pone.0335474.t003

Teacher characteristics. Teachers’ gender, age group, local council, role within the school, teacher’s vaping and smoking, frequency of finding school pupils possessing or vapes or cigarettes, whether they thought vaping and smoking are problems in their school.

Teachers’ experiences with INTENT. Teachers’ rating of the content of the INTENT youth vaping prevention materials, whether session plans were adhered to, ease of preparation and delivery, overall experience of delivery, reasons for delivering the materials, prior delivery of the materials, whether INTENT had changed teachers’ knowledge about vaping harms and vaping for quitting smoking, and, if so, whether teachers (after delivering the materials) perceived vaping to be less harmful, equally harmful, or more harmful than smoking, and whether they perceived that vaping could help people to quit smoking.

Teachers’ perceptions of the impact of INTENT on their pupils. Feedback received by teachers from pupils about INTENT, whether they thought their pupils were engaged with INTENT, thought that INTENT had changed their pupils’ opinions about vaping, thought that INTENT was appropriate for pupils to make informed choices about vaping, and whether teachers observed a change in pupils’ vaping behaviour, smoking behaviour, knowledge that vaping is less harmful than smoking, knowledge that vaping can help people to quit smoking, and knowledge that youth who have not smoked should not vape.

Analyses

All analyses are descriptive. Findings are summarised and described in the following order: 1) teacher characteristics, 2) teachers’ experiences with INTENT, 3) teachers’ perceptions of the impact of INTENT on their pupils. An anonymised version of the dataset is available online osf.io/kprxc [31].

Results

Discussion

The aim of this study was to assess teachers’ experiences with delivering youth vaping prevention materials to school pupils. A total of 45 teachers in England and Scotland who delivered INTENT’s vaping prevention materials took part in the study. The teachers provided information about their own perceptions and experiences with vaping and the materials delivered as well as their perceptions of their pupils’ responses. To our knowledge this was the first study to assess teachers’ experiences with vaping and delivering vaping prevention materials in schools outside of the US.

Overall, teachers reported frequently finding their pupils possessing or using vapes and perceived vaping to be a problem in schools; both to a greater extent than cigarettes/smoking. Teachers had overall very or somewhat positive experiences with INTENT’s vaping prevention materials, suggesting it may be feasible to implement in schools, and they thought that their pupils had at least somewhat positive experiences as well. They mostly felt that the materials had changed both their own knowledge and their pupils’ knowledge about vaping harms and vaping for smoking cessation, and that they mostly encouraged their pupils to make informed choices about vaping.

While the aim of INTENT’s vaping prevention materials was to reduce use and improve knowledge among school pupils, it is of added benefit that teachers perceived the materials to improve their own knowledge. These results are broadly consistent with prior research in the US finding that vaping educational materials are effective in changing teachers’ perceptions of vaping [14]. Prior interventions evaluated in the US focused on communicating to teachers the absolute harms from vaping (which are not substantiated by evidence, e.g., vaping causes heart disease, cancers) [14] whereas importantly, INTENT provided nuanced, evidence-based information about vaping and smoking risks.

Although most teachers that were surveyed reported a change in perceptions after delivering INTENT, misperceptions that vaping is equally or more harmful than smoking remained high. Importantly, our study did not collect data prior to delivering INTENT, so a pre-/post-evaluation was not possible; harm perceptions may have been higher prior to delivering INTENT, particularly since vaping misperceptions are pervasive among teachers [28] and the general population [32] in Great Britain. Pre-/post- studies (ideally RCTs, which are the gold-standard for evaluating interventions) would be required to assess changes in both teachers’ and pupils’ knowledge about vaping and smoking, as well as changes in behaviour following INTENT’s vaping prevention materials, as has been done for INTENT’s smoking prevention materials [22]. Additionally, interventions are needed across a wider range of formats and settings (e.g., mass media campaigns [3], information on labels/packaging [3], information in pharmacies and clinical settings [33]) to improve knowledge among the general population.

Findings clearly demonstrate teachers’ interest in youth vaping prevention, consistent with qualitative work in the US [29] and anecdotal reports in the UK. Most teachers delivered INTENT’s vaping prevention materials because they felt it was important to teach pupils about vaping. This may be because the majority of teachers in this study perceived vaping to be problematic in schools. Indeed, over half also reported delivering INTENT because they were concerned about vaping in schools or were required to teach about vaping as part of school policy. Teachers are critical in the provision of health education in schools and therefore shaping lifelong health behaviours [25,26]. It is already illegal to sell cigarettes and vaping products to youth in the UK and there are few other evidence-based tools available to help prevent youth vaping; teachers are therefore essential in this mission because they educate numerous young people each year and are influential in informing young people’s views. Teachers’ extensive reach, combined with the standardised nature of their role, positions them well to deliver evidence-based interventions consistently and at scale [25–27]. The teachers that were surveyed reported high rates of finding pupils possessing or using vapes and perceiving that vaping is a problem, both to a greater extent than cigarettes. This is consistent with population estimates that more children have vaped than smoked since 2022 [1] and with qualitative work in the US finding that educators perceive vapes to be easily accessible/obtainable within schools [29]. However, given that smoking prevalence remains at 5.4% among 11–17-year-olds in Great Britain [1], and cigarettes are much more harmful than vapes [2–6], it is important that vaping prevention materials are delivered alongside smoking prevention materials, as INTENT does. School policies and prevention materials for vaping and smoking should also be consistent with evidence on the risk profiles of these products (e.g., tighter smoking policies than vaping policies) to avoid giving mixed signals to school pupils; this is particularly important when teachers perceive vaping as more problematic than smoking.

This study has important strengths. It was the first study of its kind to assess teachers’ experiences of delivering vaping prevention materials in the UK. The teachers in our survey had first-hand experience of delivering vaping prevention materials in schools and so findings offer unique insights for school-based vaping interventions and the feasibility of INTENT. However, there are several limitations. First, the sample of 45 teachers was small, limited to a few areas in England and Scotland that delivered INTENT and where consent was obtained from commissioning organisations to contact schools, and not nationally representative. Findings may also not generalise to other countries, particularly because the materials delivered were UK-specific (e.g., information about legal limits of nicotine in vapes). Second, the data were from one cross-sectional survey administered to teachers after delivering vaping prevention materials, and so rely on retrospective information about the impact of the materials and teachers’ perceptions of how they were received by school pupils. The INTENT smoking prevention materials were effective in reducing youth smoking initiation from 36% to 29% in a pragmatic RCT conducted among school pupils; similar methods are needed to formally evaluate INTENT’s vaping prevention materials. Qualitative research could also be beneficial to understand teachers’ and pupils’ responses to the materials in greater depth. Third, findings may be subject to social desirability biases since this study was conducted by King’s College London in collaboration with Evidence to Impact (who design and own the licence to deliver INTENT); indeed, some teachers reported delivering INTENT specifically because they wanted to take part in this study. Fourth, while teachers were asked to confirm that they had delivered at least Session Plans 1 and 2 (sessions with the most information about the health harms of vaping) to be eligible, and over half delivered all four session plans, this was not formally monitored and many teachers did not fully complete the course.

To conclude, this study found that there were pervasive misperceptions that vaping is equally or more harmful than smoking among a sample of teachers in England and Scotland, and that these teachers reported being more concerned about vaping than smoking in schools. INTENT shows potential to challenge vaping misperceptions and facilitate school pupils to make informed choices about vaping and smoking behaviours. While further studies are required to assess the impact of INTENT on school pupils’ vaping and smoking perceptions and behaviours, this study is an important starting point among a key population.

Supporting information