{
  "abstract": "Electronic cigarettes are the most commonly used tobacco product among U.S. adolescents. Schools most often respond to student e-cigarette use with exclusionary discipline such as suspension, which removes students from school and does not address potential underlying nicotine dependence. Web-based alternatives to suspension offer a way to keep students in school while providing cessation-focused support, but evidence on their effects is limited. This study examined changes in e-cigarette-related attitudes and motivation among adolescents who completed ReFresh, a self-paced, web-based alternative-to-suspension program completed in approximately 3 hours. Using a single-group pre-post design, we analyzed data from 173 middle and high school students (grades 6 to 12; mean age 15.0) referred after being caught using e-cigarettes on school grounds across 24 delivery sites (e.g., schools, afterschool programs, and health centers). The program comprises five interactive online lessons grounded in the 5 As clinical framework (Ask, Advise, Assess, Assist, Arrange), motivational interviewing, and cognitive and behavioral skills training. Changes were analyzed with non-parametric tests. After completing ReFresh, participants reported greater motivation to quit ({chi}2 (6) = 22.79,OR = 3.80, 95% CI [2.2,8.8], p < .001) and rated quitting as more important (V = 3037.50,95% CI [1.00, 2.00], p < .001, r = 0.2). They also viewed e-cigarette use as more harmful and more risky (V = 8137.00, 95% CI [0.50, 0.63, p < .001, r = 0.62; V = 7734.50, 95% CI [0.50,0.80), p < .001, r = 0.65)), with the largest shifts in perceived harm relative to cigarettes and perceived risk of mental health problems. Most students reported comfort and confidence seeking help for e-cigarette use or mental health concerns, ranging from 71.10% of students agreeing they felt \"More confident asking a trusted adult for help at school\" to 80.50% of students agreeing they felt \"More confident encouraging a peer to seek help\". This study suggests that a brief, web-based alternative to suspension may shift the attitudes and motivation that precede quitting while keeping students in school, offering schools a non-exclusionary way to respond to e-cigarette use. Controlled studies measuring actual e-cigarette behavior are needed to confirm whether these programs reduce use.",
  "abstract_shown": true,
  "affiliations": [
    "Playbl"
  ],
  "article_type": "PUBLISHAHEADOFPRINT",
  "arxiv": null,
  "author_total": 2,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "L. D. Litsky"
    },
    {
      "name": "B. C. Moore"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/74rwgnd5fqmrn.bib",
  "cited_by": 0,
  "doi": "10.64898/2026.10.05.26364747",
  "fulltext_url": "https://www.medrxiv.org/content/10.64898/2026.10.05.26364747v1.full",
  "id": "74rwgnd5fqmrn",
  "issns": [],
  "landing_url": "https://www.medrxiv.org/content/10.64898/2026.10.05.26364747v1",
  "language": null,
  "licence": "CC-BY",
  "licence_label": "CC BY",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "medrxiv",
      "public and global health"
    ],
    [
      "openalex",
      "2737|Smoking Behavior and Cessation"
    ]
  ],
  "openalex": "W7221055322",
  "pdf_url": "https://www.medrxiv.org/content/10.64898/2026.10.05.26364747v1.full.pdf",
  "pmcid": null,
  "pmid": null,
  "published": "2026-10-05",
  "publisher": null,
  "ris": "https://research.draconitic.com/paper/74rwgnd5fqmrn.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T12:20:23Z",
      "native_id": "10.64898/2026.10.05.26364747",
      "source": "medrxiv",
      "url": "https://www.medrxiv.org/content/10.64898/2026.10.05.26364747v1"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "medrxiv:public and global health",
      "subfield": "epidemiology-public-health"
    }
  ],
  "title": "Evaluating ReFresh, a Web-Based Alternative to Suspension for Adolescent E-cigarette Use",
  "title_text": "Evaluating ReFresh, a Web-Based Alternative to Suspension for Adolescent E-cigarette Use",
  "type": "preprint",
  "updated_at": "2026-10-30T12:20:23Z",
  "url": "https://research.draconitic.com/paper/74rwgnd5fqmrn",
  "venue": "medRxiv",
  "versions": []
}