Evaluating ReFresh, a Web-Based Alternative to Suspension for Adolescent E-cigarette Use
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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.
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BibTeX
@misc{litsky2026evaluating,
title = {{Evaluating ReFresh, a Web-Based Alternative to Suspension for Adolescent E-cigarette Use}},
author = {L. D. Litsky and B. C. Moore},
howpublished = {medRxiv},
year = {2026},
month = oct,
doi = {10.64898/2026.10.05.26364747},
url = {https://www.medrxiv.org/content/10.64898/2026.10.05.26364747v1},
note = {CC BY},
}
RIS
TY - UNPB
TI - Evaluating ReFresh, a Web-Based Alternative to Suspension for Adolescent E-cigarette Use
AU - L. D. Litsky
AU - B. C. Moore
PY - 2026
DA - 2026/10/05
PB - medRxiv
DO - 10.64898/2026.10.05.26364747
UR - https://www.medrxiv.org/content/10.64898/2026.10.05.26364747v1
AB - 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.
ER -