College health providers' knowledge and confidence in addressing students' vaping: Evidence from a pilot study in New York State

E-cigarette use is highest among young adults, including college students, driven by high awareness and social factors. Despite declining cigarette smoking, young adults are initiating other nicotine products and increasingly using cannabis via vaping. Patient–provider communication can shape perceptions and use, yet prior work shows provider misperceptions about nicotine and conditional support for e-cigarettes as cessation aids. The 2019 EVALI outbreak and expanding cannabis access have produced mixed messages about vaping risks. Campus health centers are key information sources for students, but little is known about college health providers' knowledge, confidence, and practices regarding nicotine and cannabis vaping. This study aimed to: (1) survey college health providers’ knowledge, attitudes, and confidence about discussing nicotine/cannabis vaping; (2) assess training needs, preferred training formats, and prioritization of vaping within cessation/prevention; and (3) qualitatively explore providers’ perceptions and information shared with students.

Awareness of e-cigarettes rose dramatically over the past decade, with high current use among youth and young adults. Among college students, e-cigarette use correlates with other substance use, social acceptance, and positive affective associations. Evidence indicates providers discuss e-cigarettes with patients but may hold misperceptions about nicotine risk and are selective in recommending e-cigarettes for cessation. Cannabis vaping is common among young adults, co-use of nicotine and cannabis is prevalent, and co-use relates to lower quitting odds and higher respiratory risk. The 2019 EVALI outbreak was largely linked to informally purchased or modified cannabis vaping products, complicating public and provider messages about vaping safety. Professional societies call for provider training on vaping, but data are lacking on college health providers’ practices and needs.

Design: Mixed-methods descriptive study using a sequential-explanatory approach: a cross-sectional online survey followed by semi-structured qualitative interviews to explain survey results. Ethics: Approved by SUNY Buffalo State College IRB (STUDY00001679). Survey: Participants were 50 college health employees (non-student staff; broad definition to include varied roles and campus sizes) from 26 State University of New York (SUNY) campuses (18 metro, 8 non-metro; USDA Rural-Urban Continuum Codes). Recruitment via mailed postcards to campus health centers followed by email to directors; electronic Qualtrics survey (English) administered July–November 2019. Due to recruitment method, response rate not calculable. Measures: Demographics, campus type, personal nicotine/tobacco use; knowledge and confidence discussing nicotine/cannabis vaping (5-point Likert, with 'neither' and 'don't know' options); professional practices (screening frequency for e-cigarette and other vaped products, perceived importance/time); past training/educational activities, confidence relaying training messages, interest in harms/benefits information, priority and time for learning about vaping. Analysis: Descriptive statistics using Stata. Interviews: Convenience sample of 11 providers (of 24 who expressed interest) who completed the survey; conducted by phone March–July 2020 (during COVID-19 peaks in NYS); average 16 minutes (range 7–27). Nonparticipants did not respond, declined, or lacked supervisor approval. Interview guide focused on interpreting survey findings and eliciting experiences, perceptions, and messaging (open-ended; see Supplemental Table 1). Analysis: Audio-recorded, transcribed, de-identified; thematic content analysis using a deductive framework aligned with survey domains (knowledge/confidence; professional practices/beliefs; training needs). Two coders independently analyzed, reconciled codes into a codebook; discrepancies (~5%) resolved by discussion; data reviewed until no new themes emerged.

• 90% (n=45) reported understanding what e-cigarettes are; 76% (n=38) indicated e-cigarette use is a problem on their campus. • Confidence exceeded self-rated knowledge: 86% (n=43) felt confident discussing e-cigarettes; 76% (n=38) felt knowledgeable. • Evidence of misinformation: some providers described e-cigarettes as 'unregulated' despite 2016 FDA deeming rule. • Product uncertainty: 64% (n=32) reported not knowing whether students vape nicotine or cannabis most often; interviews emphasized the need to differentiate substance (nicotine vs cannabis), source, delivery system, and quantify nicotine levels (e.g., pods vs liquids), which both providers and students often could not specify. • Clinical practice beliefs: 85% (n=40) and 83% (n=39) believed knowing tobacco product status and e-cigarette status, respectively, improves care; uncertainty persisted about the role of nicotine replacement therapy for students who vape. • Perceived impartiality and learning interests: 68% (n=32) felt able to provide unbiased information. Significantly more providers wanted to learn about harms (n=43) vs benefits (n=33) of e-cigarettes (p<0.01). • Risk perceptions and messaging: 68% (n=32) agreed e-cigarettes are just as harmful as cigarettes and should not be recommended as a safer alternative; only 6% (n=3) believed e-cigarettes are much less harmful than cigarettes (and still not to be recommended). For messaging, 85% (n=40) prioritized that e-cigarettes are not a safe alternative; 15% (n=7) endorsed 'not safe, but much safer than cigarettes.' • Training and policy awareness: 44% (n=22) had participated in vaping-related training/education; 17% (n=8) had not heard of NYS Tobacco 21 at the time. Providers suggested policy changes as triggers for new trainings. • Capacity and preferred formats: 82% reported having time to learn more; 74% considered vaping education a priority. Preferred training formats included webinars and ready-to-use materials (patient handouts, posters, social media assets) for broad student outreach.

Despite high self-reported knowledge and confidence, many college health providers lacked specific, accurate information about vaping—particularly regarding what students vape (nicotine vs cannabis), sources, delivery methods, and nicotine content. This disconnect suggests overconfidence and highlights the need to identify providers’ information sources and to deliver evidence-based training. Given prevalent co-use of nicotine and cannabis among young adults, interventions should help providers distinguish and address both substances, including risks associated with illicit or modified cannabis vaping implicated in EVALI. Providers’ largely unidimensional risk perceptions (e-cigarettes as equally harmful as cigarettes) and preference for 'not safe' messaging may limit nuanced harm reduction discussions for legal-age students who smoke and may use vaping in cessation attempts. Training should cover relative risks, regulatory context (FDA oversight), appropriate cessation strategies (including NRT and behavioral supports), and practical assessment (product, source, delivery, frequency). Incorporating graphics-based risk communication and social media outreach may improve student understanding and dissemination. Ongoing surveillance is needed as products (e.g., delta-8 THC) and markets evolve.

This pilot study provides initial evidence on college health providers’ knowledge, confidence, perceptions, and practices regarding vaping among college students. Findings reveal gaps between perceived and actual knowledge, uncertainty about substances vaped, and limited formal training. There is a clear opportunity to develop targeted, evidence-based trainings and student-facing materials that address nicotine and cannabis vaping, relative risks, product sources, and cessation strategies. Future research should explore providers’ information sources, evaluate training interventions and communication strategies (including social media), and incorporate student perspectives to optimize prevention and intervention efforts on college campuses.

Generalizability is limited due to a small, convenience sample from SUNY campuses with no calculable response rate. The survey occurred during the 2019 EVALI outbreak, and interviews during the COVID-19 pandemic, which may have influenced responses, participation, and providers’ perspectives. Small sample sizes precluded advanced statistical analyses. Timing and workload constraints during the pandemic likely affected qualitative participation.