Exploring Multi-level Determinants of Implementation of Nicotine Replacement Therapy Guidelines for Youth Vaping: A Mixed-Methods Case Study

Exploring Multi-level Determinants of Implementation of Nicotine Replacement Therapy Guidelines for Youth Vaping: A Mixed-Methods Case Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring Multi-level Determinants of Implementation of Nicotine Replacement Therapy Guidelines for Youth Vaping: A Mixed-Methods Case Study Joshua D. Cockroft, Carly Ritger, Becky Bloedow, Brooke Dorsey, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8743595/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: Rates of youth vaping have become a major concern over the past decade with worries about impacts of vaping on neurodevelopment, mental health, transition to cigarettes, and unknown long-term physical sequelae. In 2023, the American Academy of Pediatrics (AAP)’s updated tobacco care guidelines encouraged primary care providers to consider using nicotine replacement therapy (NRT) products to help support youth vaping and tobacco cessation. This study sought to explore the determinants to using NRT products for youth vaping cessation per AAP recommendations amongst primary care providers in an urban, safety-net health system where use of NRT for youth was limited. Methods: This study used a mixed-methods case study design guided by the Practical, Robust Implementation and Sustainability Model (PRISM). Nine primary care providers caring for patients aged 12-17 completed key informant interviews and a modified version of the PRISM Contextual Survey Instrument (PRISM-CSI) between May and July 2025. Qualitative analysis was done using a rapid matrix approach and quantitative analysis was descriptive in nature. Themes/subthemes and mean PRISM-CSI item scores were integrated to generate final mixed meta-inferences. Results: 5 themes with 13 subthemes emerged from qualitative analysis. In quantitative analysis, all PRISM-CSI item mean scores were rated as either neutral (2.50-3.49 on 1-5 rated ordinal scale) or positive (≥3.50). A total of 14 meta-inferences were generated from integration of qualitative and quantitative results, showing that AAP guidelines on NRT were considered acceptable and met an important need, but contextual determinants important to implementation included addressing time/work demands, provider training, confidentiality, insurance coverage/affordability, managing follow up, youth perceptions of harms and treatment preferences, perceived limited concurrent public health/policy intervention, and bolstering existing practice change infrastructure. Conclusions: AAP guidelines on NRT were considered reasonable by providers interviewed and surveyed in this study while acknowledging specific contextual determinants for successful implementation. Providers also felt it was important to strengthen ongoing public health and policy efforts to address youth vaping in addition to clinical intervention. This study provides insight into the translation of efforts such as the AAP guidelines in a specific healthcare system to address a pressing health issue for youth. youth vaping cessation nicotine replacement therapy clinical practice guidelines Figures Figure 1 Figure 2 Figure 3 Figure 4 Contributions to the Literature This study provides transferable insights into important determinants to consider as researchers and public health practitioners seek to implement interventions and policy changes to address the high prevalence of youth vaping This case study provides an example of using rapid, rigorous mixed-methods design to provide ongoing, iterative results for concurrent program/quality improvement efforts This study also provides a case example of exploring contextual determinants important to translating and implementing clinical practice guidelines Background As of 2024, e-cigarettes (vapes) remain the most common tobacco product used by middle and high school age students with 5.9% of youth reporting current use (estimated 1.6 million youth) and 14% of youth reporting having ever used (estimated 3.87 million youth).[ 1 ] Though there appears to have been some drop in the prevalence of vaping from peak rates in the late 2010s, youth vaping remains a persistent issue.[ 2 ] There remain concerns about the impact of vaping on youth neurodevelopment, impact on mental health, conversion to combustible cigarette use, and unknown long-term physical sequelae of vaping use.[ 3 – 6 ] Efforts, interventions, and guidelines to address youth vaping continue to evolve and emerge. 7 Clinical practice guidelines (CPGs) are recommendations, commonly provided by professional societies or coalitions, meant to synthesize evidence and provide guidance to practitioners on specific questions related to clinical care. Though the approach to development of CPGs has been variable and at times lacked transparency, newer standardized methods to guide creation of CPGs have emerged in recent years.[ 8 , 9 ] In this light, CPGs present a potentially important tool in closing the research-to-practice gap, given their focus on reviewing evidence to clinically salient questions, engagement with practitioner and patient interest holders, and emphasis on clear and concise recommendations.[ 8 ] However, there remain questions about the best strategies for disseminating and implementing recommendations from CPGs.[ 10 , 11 ] In 2023, the American Academy of Pediatrics (AAP) used a systematic process and dedicated working group [ 12 – 14 ] to update their CPG on youth tobacco and nicotine use in part to address the rise of youth vaping. As part of these updated guidelines, they provided a recommendation for clinicians to consider the use of pharmacotherapy, particularly nicotine replacement therapy (NRT), for youth tobacco and vaping cessation. Quality of evidence was considered low with strength of recommendation considered “optional.” While there were no robustly powered clinical trials for pharmacotherapy demonstrating efficacy or effectiveness in youth at the time of publication, the AAP argued clinicians should consider NRT as an option in youth nicotine cessation efforts because of evidence of benefit of NRT in adults, evidence of safety for youth, and observational evidence of potential harm of vaping for youth.[ 15 ] In addition to these guidelines, the AAP also published resources to help guide clinicians in the prescription of NRT for youth tobacco and vaping cessation.[ 16 ] Though the strength of recommendation of this specific guideline was considered optional with a low quality of evidence, information regarding using NRT to help treat youth vaping and tobacco use has now appeared in documents provided by some local health departments.[ 17 ] In a city-sponsored grant supporting program improvement of youth vaping cessation services one of our home institutions received, the language stipulated the recipient aim to increase health care providers’ use of NRT in their health system.[ 18 ] After the grant recipient program improvement team recognized very few primary care providers considered or used NRT for youth vaping cessation, they recognized a need to explore the determinants important to implementing of the 2023 AAP NRT guideline. In collaboration between the program improvement team and an implementation research team, this study sought to explore multi-level determinants of implementing AAP guidelines to consider NRT for vaping and tobacco cessation for patients aged 12–17 years old in primary care settings using an implementation science framework-guided, mixed-methods design. Methods Implementation research study supporting program improvement In addition to generation of research findings that might be transferable to other settings, this study also sought to generate rapid, iterative findings to support the efforts of the aforementioned program improvement (PI) grant team. The PI team received funding and began work on the grant in December 2024 for 19 months of support (through June 2026). Investigators from an academic health center (JC, CR, RG, BD) affiliated with the grant recipient institution jointly refined the research question and objectives in collaboration with the grant team leader (BB) from December 2024 through April 2025. After this group identified key findings from the rapid, qualitative matrix in July 2025, the study’s principal investigator (JC) and grant team leader (BB) presented these initial findings to the full PI team. To meet the needs of the PI team’s constricted timeline, implementation strategies to address identified determinants were generated informally at weekly grant team huddle meetings between July and August 2025 and did not employ a more time-demanding method such as Implementation Mapping.[ 19 , 20 ] Final meta-inferences were reviewed with the PI team lead (BB) in October 2025 and the full PI team in January 2026. Implementation science framework and study design To guide evaluation of the multilevel determinants of implementation of NRT for youth, we used the Practical, Robust Implementation and Sustainability Model (PRISM) (Fig. 1 ). PRISM is an implementation, evaluation, and sustainability framework that includes Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) outcomes.[ 21 – 23 ] The determinant domains in PRISM include multi-level perspectives on an intervention, multi-level characteristics of intervention recipients (e.g. providers and patients), implementation and sustainability infrastructure (i.e. capacity for implementing and sustaining new practice innovations), and external environment (e.g. policy or current events).[ 21 – 23 ] As detailed below, the use of PRISM determinants in this study was primarily to organize qualitative and quantitative data collection and initial analysis. The timeframe of this study was conducted in the pre-implementation phase of efforts to increase implementation of the 2023 AAP NRT guideline. Though the findings from this study were used to inform implementation strategies by the PI team, directly addressing or measuring program evaluation outcomes (such as RE-AIM) was beyond the timeframe and scope of this study. We used a convergent, mixed methods design integrating rapid qualitative matrix analysis with quantitative descriptive analysis (Fig. 2 ).[ 24 – 26 ] Qualitative methods were used to provide a nuanced exploration of determinants of implementing NRT use per AAP guidelines in primary care that allowed for emergent findings. Quantitative methods provided a structured, quantifiable measurement and valence assessment (positive, neutral, or negative) using an existing survey instrument of providers’ perceptions of PRISM determinant constructs.[ 27 ] We used the Good Reporting of a Mixed Methods Study (GRAMMS) checklist to organize the reporting of our methods and findings ( Supplemental Appendix 1 ).[ 28 ] Setting and Participants This study was conducted at an urban, safety net health system in a Mountain West state in the United States. We used purposive sampling to recruit primary care providers of various licensure (e.g. advanced practice provider vs medical doctorate) in the specialties of pediatrics and family medicine with a range of experience prescribing NRT for youth. Participants were eligible if they cared for youth aged 12–17 years old and were employed at the study site at the time of participation. We excluded individuals who were members of the program improvement team to avoid potential introduction of bias. Participants were recruited from providers who had completed a prior survey administered by the PI team about youth vaping cessation and marking willingness to be contacted for interviews. Email invitations were sent from the study principal investigator (JC). We used an identical sample for both interviews and surveys. Target sample size was determined by a goal of reaching thematic saturation for qualitative analysis. Providers were given a $ 50 gift card as compensation for study participation. Qualitative Methods: Data Collection We developed two slightly different versions of a PRISM-guided, semi-structured interview guide—differentiating providers’ prior NRT prescription for youth—to help understand the determinants to prescription of NRT for youth in our participants’ settings. AAP guidelines and resources on NRT were sent to all interviewees prior to their scheduled interview and presented again by interviewers at the time of the interview. Interviews elicited information about 1) participants’ perspectives on prescribing NRT for youth and the AAP’s recommendations, 2) patient characteristics and possible perspectives that may impact NRT use, 3) example factors supporting practice changes in their clinics, and 4) characteristics of their health system and external environment that may impact NRT use amongst providers. Audio recorded, individual interviews lasted 45 to 60 minutes and took place over Zoom videoconferencing software between May and July 2025 and were conducted by the study principal investigator (JC) and a qualitative/mixed-methods analyst (CR). Interviews were professionally transcribed by a HIPAA-compliant transcription company. Prior to every interview, each interviewer obtained verbal consent for study procedures and offered a copy of a consent document. Interview recruitment continued until thematic saturation was reached; that is, no novel information was discussed related to use of NRT for youth vaping or tobacco cessation. Qualitative Analysis To analyze interview data, we used a rapid matrix approach.[ 25 , 26 ] The analysis team consisted of the study principal investigator (JC) and analyst (CR). After professional transcription of interview audio, the analysis team populated a rapid matrix with data from each transcript. The rapid matrix was guided by PRISM, with inductive domains added based on the interview guide and after reviewing initial transcripts. To support rigor, we double populated and reconciled 20% of transcripts to iteratively refine the matrix domains.[ 29 , 30 ] After all transcripts were added to the matrix, the analysis team summarized participant findings for each domain (down each column). The analysis team met regularly to agree upon summaries for each domain, discussing and writing memos to identify themes across all domain summaries. Quantitative Methods Instruments/Data Sources Demographic information was collected from all interview participants through an electronic RedCap survey hosted at the authors’ home institution after completion of each interview.[ 31 ] Demographic information collected included sex, racial/ethnic identity, medical specialty, professional clinical licensure, if the participant had prescribed NRT for patients aged 12–17 years old previously, primary care site, years employed with the health system, and years since completion of highest clinical degree. The primary quantitative instrument used in this study was the PRISM Contextual Survey Instrument (PRISM-CSI).[ 27 ] Originally developed and validated for assessing the implementation of an eScreening intervention in Veterans Health Administration settings, the original version of the scale demonstrated a range of internal consistency across subscales and concurrent validity with Weiner’s feasibility, acceptability, and appropriateness measures.[ 32 ] The original version of the instrument is a 5-point ordinal scale consisting of 29 items. Given some item content did not directly match the nature of NRT as an intervention or pre-implementation phase in the study setting, the authors chose pragmatically to either omit items or modify the language of certain items. For details on the nature and rationale for this approach and the resultant, modified 25-item version of the PRISM-CMI survey used in this study, see Supplemental Appendix 3 . Participants were given the PRISM-CSI survey questions using the same electronic RedCap survey used to collect demographic characteristics. Statistical Analysis We completed descriptive statistical analyses on demographic and PRISM-CSI responses with export of data from RedCap and use of Stata 19.5.[ 33 ] Proportions were calculated for all demographic categories. Each individual PRISM-CSI item was converted to a numerical, ordinal score (rated 1–5) and then calculated for mean, standard deviation, and 95% confidence interval. Reverse coded items were converted to the appropriate corresponding score. Mean subscale scores were also calculated similar to the original procedure followed by Pittman and colleagues.[ 27 ] Due to limited sample size and intended pragmatic use of the survey instrument, additional psychometric statistics and more extensive analyses of the modified version of the PRISM-CSI used were not performed. Mixed-methods integration Following completion of qualitative and quantitative analysis, the principal investigator and analyst linked themes/subthemes and constructs relating to PRISM-CSI survey items in a merging joint display.[ 24 ] The authors ultimately chose to link themes/subthemes to individual PRISM-CSI items as opposed to subscales for two reasons. First, we felt that the level of detail in individual items allowed for a richer comparison with themes/subthemes that became diminished in use of mean subscale scores. Second, given the nature of modifications to the PRISM-CSI for use in this study, limited sample size, and degree of variable internal consistency across subscales in the validation of the original version of the scale,[ 27 ] the authors found it challenging to make reliable or useful inferences at the level of the subscale. After completing a merging display, the themes/subtheme content was then compared with the mean scores of individual items rated in pre-determined ranges as “Positive“ ( ≥ 4.00), Moderately Positive” (3.50–3.99), “Neutral” (2.50–3.49), “Moderately Negative” (2.00-2.49), or “Negative” (< 2.00) to generate meta-inferences which were then entered into a final joint display. Themes/subthemes and mean item scores were assessed for convergence, divergence, or complementarity of findings. Convergence was considered if the directionality of item means matched conclusions from themes/subthemes. Divergence was considered if the directionality of item means did not appear to directly match conclusions from themes/subthemes. Complementarity was considered if either qualitative or quantitative strand provided additional insights not mostly captured by the other method strand. The principal investigator and analyst conducted the initial merging process and meta-inference generation jointly until unanimous consensus was reached. Meta-inferences were then reviewed with all authors for clarity and accuracy. Results Demographics Twelve providers were initially invited with a total of 9 providers responding to the invitation to participate. All 9 fully completed an interview and survey. A demographic breakdown is found in Table 1 . Three providers had previously prescribed NRT for youth. The sample included 5 pediatric providers, 3 family medicine providers, and 1 internal medicine-pediatrics provider. 6 providers had a medical doctorate (MD) or doctorate of osteopathic medicine (DO) and 3 were advanced practice providers (APPs). Table 1 Demographics of Participants Demographics n/% of Participants Female 8 (88.9%) Male 1 (11.1%) White 8 (88.9%) Hispanic/Latinx 1 (11.1%) Pediatrics 5 (55.6%) Family Medicine 3 (33.3%) Internal Medicine/Pediatrics 1 (11.1%) MD/DO 6 (66.7%) APP (e.g. Nurse Practitioner, Physician Assistant) 3 (33.3%) Has prescribed NRT for youth 3 (33.3%) Has NOT prescribed NRT for youth 6 (66.7%) Clinic 1 3 (33.3%) Clinic 2 1 (11.1%) Clinic 3 2 (22.2%) Clinic 4 2 (22.2%) Clinic 5 1 (11.1%) Employed 5 years at institution 6 (66.7%) 12 months to 5 years since highest clinical degree 2 (22.2%) > 5 to 20 years since highest clinical degree 2 (22.2%) > 20 years since highest clinical degree 5 (55.6%) Qualitative Findings : Five themes were identified as part of qualitative analysis: 1) Use of NRT per AAP guidelines as a reasonable option given limited other options , 2) provider-level challenges to increasing adoption , 3) systems- and clinic-level considerations to facilitate NRT use , 4) remaining patient and external barriers to uptake , and 5) culture and infrastructure for practice change that may help or hinder implementation. Table 2 provides a list of themes, subthemes, and exemplar quotes. Supplemental Appendix 2 provides additional supporting quotes for themes and subthemes not able to be provided in the narrative here. Table 2 Themes, subthemes, and exemplar quotes Qualitative Findings (n = 9) Theme Subtheme Exemplar Quotes 1) Use of NRT per AAP guidelines as a reasonable option, given limited other options “I think [the AAP recommendation on NRT] sounds great…[when describing a typical visit now without using NRT as an option] we review whether there's any vaping use, and during the questionnaires, when they mark yes, it's really a challenge for me to say anything. I just say it's bad for you. I review the health complications; but whether changes occur [from that such as] stopping vaping? Not very often.” (P003) 2) Provider-level challenges to adoption a) Potential time/work demands of NRT given limited time and other demands “With our adolescent visits, we’re only given...[a] 20 minute block...They’re filling out their PHQ-4 and suicide tests and all the sexual health, and then the drugs, alcohol…I have X amount of time with this patient and if they vape and they have a high PHQ-4, probably I’m gonna focus more on the PHQ-4.’ That can make it hard.” (P008) b) Variable provider comfort levels in managing NRT “Based on the [AAP guidance sheet], coming up with an initial dosage…I would feel comfortable with that. Ongoing management, tapering and all of that stuff—I would definitely need more CME before I could feel comfortable managing that.” (P007) 3) Systems- and clinic-level considerations to facilitate NRT use a) Confidentiality “Another thing that I think is important in our population is confidentiality. Trying to figure out how to—if a patient really wants to stop vaping, but they don't want their family to know they're vaping…That's always something that comes up in pediatrics.” (P005) b) Insurance coverage/ affordability “Another thing that always comes up…especially our lower income families, is what will be covered by Medicaid…I may want somebody to be on a NRT and it's not covered so they're just not gonna do it” (P003) c) Managing NRT follow up “My concern is follow-up. I'm never sure if they actually got [the prescription]…I don't end up seeing them back because we often just see them for their physical…I would say of the kids I prescribed [NRT] to, I really don't know if they actually took it or not.” (P001) 4) Remaining patient and external barriers to uptake a) Patient perceptions of harms of vaping “I think when it was more of a short-term possibility of ending up in the hospital [due to lung injury]], that maybe made [our patients] pay a little bit of attention. The long-term, ‘you could get cancer or stuff,’ they don't listen to that.” (P001) b) Potential patient preference for “non-medication” options “To be honest, most of them, if they even agree that they wanna cut down, most of 'em say, "Oh, I can do this on my own. I don't need medicine." I would say 90 percent of them.” (P001) c) Perceived inadequate public policy/health efforts to address youth vaping "I think we haven't done a great job with vaping. Sometimes, our approach to it seems like the…'Just Say No' campaign of the 1980s, like schools closing their bathrooms at lunch so kids can’t just go in there and vape.” (P007) 5) Culture and infrastructure for practice change that may help or hinder implementation a) Standardized communication channels “I think the communication within the clinic, it's really clear…we also have staff meetings every month and that's when we review any changes… I think that really allows so everybody’s on…the same step, on the clinic changes.” (P003) b) Infrastructure for evaluation and monitoring “If you're not monitoring stuff…attrition is probably the most common thing, is people stop thinking about it, and then they don't do it. Sometimes there's really specific things that might be happening that you might have to dig into.” (P001) c) Multi-level engagement and support for practice change “I feel like our clinic overall has a really good team mentality and people would overall be interested in supporting a practice change…then, yeah, I guess just leadership—more of the logistical changes that would need to be supported by leadership” (P002) d) Clinical champion culture “On our clinic level, not infrequently, we have a whole bunch of people, a whole bunch of providers, who are champions of this or that or the other thing like…tobacco cessation and Reach Out & Read.” (P006) e) “Information overload” “I think it's mass-information overload for one thing. Just a constant stream of information, data changing the surveys...Just like, ‘Don't give me one more thing to do, 'cause I'm already maxed out juggling a million balls.’” (P006) [INSERT Table 2 : Themes, subthemes, and exemplar quotes HERE] Table 2 : Themes, subthemes, and exemplar quotes 1) Use of NRT per AAP guidelines as a reasonable option given limited other options All providers interviewed reported the AAP guidelines recommending consideration of NRT for youth vaping cessation were reasonable , especially given the perceived lack of existing, effective options in their practice . In general, participants regarded the recommendation that providers consider NRT as an option despite the lack of existing robust trials in youth at the time of guideline development and data collection, but evidence of safety in youth and effectiveness in adults, was justifiable. All providers were okay prescribing NRT for both vaping and other tobacco product use. 2) Provider-level challenges to increasing adoption Despite their confidence in the AAP guidelines, participants raised concern that use of NRT might be a “challenging ask” of primary care providers. Individuals who had prescribed NRT before noted the additional time and demand prescribing NRT added to visits including assessing patient readiness to change, awareness of vaping status by family members, counseling on vaping health effects and NRT, and coordinating prescription details such as getting the medication to patients confidentially if needed. This was further made challenging by universal 20-minute appointments for adolescents. When asked about prior practice change interventions that had failed, multiple providers noted interventions that required additional time or mental burden to providers might have a lower chance of success. Providers shared varying levels of comfort using NRT. While some providers had already prescribed NRT, many providers felt comfortable initiating NRT if provided with additional resources but less comfortable independently managing follow up. Only one provider shared they would not feel comfortable initiating or managing on their own but would feel comfortable referring to a clinic champion or specialist. 3) Systems and clinic-level considerations to facilitate NRT use Providers brought up systems- and clinic-level considerations that would be necessary to address in order to increase use of NRT. Across these considerations, providers were able to offer examples of existing resources or system changes to potentially bolster NRT use. Nearly all providers commented on the importance of considering confidentiality in prescribing NRT, given many of their patients had not disclosed vaping status to their parents or families. Providers shared considerations of trying to bolster existing practices and systems they had to provide confidential care including confidential visit registration, one-on-one discussions with adolescents, use of an on-site pharmacy, and use of strategies to help provide patient confidentiality in the health communication portal. Multiple providers shared the importance of ensuring insurance coverage and affordability for NRT products. Most patients served by providers in this study had Medicaid and/or came from lower socioeconomic status backgrounds. Providers shared that as part of provider education on NRT, it would be essential to know what specific products were covered by state Medicaid. Multiple providers raised concern about ensuring the follow up of patients who were started on NRT. This included both providers who had prescribed NRT and those who had not. Multiple providers brought up the fact many adolescent patients would only come annually for their physical or, for some patients, even less frequently. One provider who had previously prescribed NRT mentioned though they had prescribed NRT, they rarely had a chance to see the patient back for follow up to see if it had been helpful or effective. 4) Remaining patient and external barriers to uptake Providers reported additional barriers related to patient and external factors they felt were not directly within their control. Multiple providers brought up the issue of many patients not seeing vaping as a problem and with multiple patients being pre-contemplative about quitting vaping let alone using NRT. This included providers who had prescribed NRT previously and those who had not. In individual discussions with patients about vaping, providers also shared many patients appeared to have limited buy-in to descriptions of the health hazards of vaping. Multiple providers brought up considerations that even among patients who may want to quit, many patients might prefer “non-medication” solutions . Some providers shared this non-medication preference among patients existed for health issues outside of vaping too (e.g., mental health). Many participants shared that provider prescribing of NRT in isolation may have limited impact in a landscape of perceived inadequate public policy/health efforts to address youth vaping to date . This included concerns wishing for stronger interventions on targeted marketing of vaping products towards younger consumers, stronger bans on flavoring in vapes, ease of access to vaping products by youth, addressing vaping use in schools, and limited societal awareness of treatment options for youth vaping. 5) Culture and infrastructure for practice change that may help or hinder uptake of NRT All providers brought up a strong culture and infrastructure at their institution for practice change that they could envision helping increase uptake of NRT use for youth vaping. However, participants cautioned that ongoing efforts around practice improvement could be a potential “double-edged sword,” given the quantity of other new efforts. Multiple providers cited existing standardized communication channels to facilitate dissemination of information about practice improvement efforts. This included routine huddles and staff meetings at clinic sites where introduction to or updates about pilot or quality improvement projects would often be given. Likewise, they cited ongoing email communications about these efforts from leadership or implementers. Some providers cited the benefit of infrastructure that had been used in prior program improvement efforts to help with evaluation and monitoring . This included functionality of the electronic medical record being used to track data and metrics. Some providers cited the value and importance of being able to track these metrics to be able to see measures of improvement and to see their own performance on certain metrics as an incentive. Most providers cited a strong culture of support for practice change and program improvement at multiple levels , including system leadership, clinic leadership, providers, and staff. Many providers stressed the importance of program improvement projects that had purposefully engaged individuals at these different levels to help with successful implementation. Multiple providers described the presence of a clinical champion culture they felt was conducive to practice change and program improvement. This was typically described at the provider level, with individuals who would spearhead practice improvement efforts important to them and often become a go-to resource for their colleagues. Examples included champions of gender-affirming care, tobacco cessation, interventions to address vaccine hesitancy, and childhood literacy interventions. Multiple providers brought up that with a culture of ongoing program improvement efforts there also came the feeling of “ information overload ” at times. This was mentioned in the context of both dissemination of information about ongoing projects as well as expectations that might be added to their delivery of care. Quantitative Findings Table 3 Item and Subscale Scores (scored 1–5, 5 = highest score), RC=Reverse Coding PRISM-CSI Findings (n = 9) Organizational Perspectives Item Mean SD 95% CI Fits with clinic priorities 4.11 0.60 3.65,4.57 Workflow compatible 4.00 0.71 3.46,4.54 No advantages compared to SOC (RC) 3.67 1.12 2.81,4.53 Site readiness 3.44 1.13 2.58,4.31 MEAN SUBSCALE SCORE 3.81 0.92 3.49,4.12 Patient Perspectives Item Mean SD 95% CI Negatively impact care (RC) 4.44 0.73 3.89,5.00 Aligns with patient needs/preferences 3.89 0.60 3.43,4.35 Equitable impact 3.44 1.01 2.67,4.22 Too difficult for patients (RC) 3.33 0.50 2.95,3.72 Easy for patients to access 3.11 0.60 2.65,3.57 MEAN SUBSCALE SCORE 3.64 0.83 3.40,3.89 Implementation and Sustainability Infrastructure Item Mean SD 95% CI Organizational support for NRT 4.00 0.50 3.62,4.38 Potential champion at site 3.78 0.83 3.14,4.42 Minimal training needed 3.78 0.83 3.14,4.42 Lack resources at site (RC) 3.44 1.24 2.49,4.39 MEAN SUBSCALE SCORE 3.75 0.87 3.45,4.05 Organizational Characteristics Item Mean SD 95% CI Senior leadership supports innovation 4.44 0.53 4.04,4.85 Effective supervisor management PI 4.44 0.53 4.04,4.85 Supervisor support new interventions 4.44 0.53 4.04,4.85 Staff member cooperation with care 4.33 0.50 3.95,4.72 Staff member resistance to change (RC) 4.22 0.67 3.71,4.74 Personally empowered initiate improvements 4.22 0.67 3.71,4.74 MEAN SUBSCALE SCORE 4.35 0.56 4.20,4.50 Patient characteristics Item Mean SD 95% CI Patients trust clinicians 4.11 0.33 3.86,4.37 Introducing new interventions hard with patients (RC) 3.44 1.01 2.67,4.22 Patient complexity as a barrier (RC) 3.33 0.87 2.67,4.00 MEAN SUBSCALE SCORE 3.63 0.84 3.23,3.96 External Environment Item Mean SD 95% CI NRT still feasible with future practice changes 4.00 0.50 3.62,4.38 Current events as barrier (RC) 3.44 0.88 2.77,4.12 Regional/national mandates as barrier (RC) 3.33 0.50 2.95,3.72 MEAN SUBSCALE SCORE 3.59 0.69 3.32,3.87 A summary of means, standard deviations, and 95% confidence intervals for all items and subscales asked in the PRISM CSI survey are found in Table 3 . Overall, 16 items’ mean values were positively scored (≥ 3.50 on a 1–5 rated ordinal scale), 9 items’ mean values were in a neutral range (2.50–3.49), and no items’ mean values were negatively rated (< 2.50). Items ranked in order of mean scores are shown in Fig. 3 . The highest rated items had a mean score of 4.44 (SD 0.53, 95% CI: 4.04, 4.85) and included perceptions that NRT would not negatively impact care, senior leadership supported innovation, supervisor management of program improvement efforts was effective, and clinic supervisors supported innovation. The lowest rated item asking if NRT would be easy for patients to access had a mean score of 3.11 (SD 0.60, 95% CI: 2.65, 3.57). The mean subscale scores for each PRISM subscale in the PRISM-CSI are also found in Table 3 . All mean subscale scores were positively rated (≥ 3.50). The highest rated subscale was Organizational Characteristics with a mean score of 4.35 (SD 0.56, 95% CI: 4.20, 4.50) and the lowest rated subscale was External Environment with a mean score of 3.59 (SD 0.69, 95% CI: 3.32, 3.87). Mixed Methods Findings: A joint display demonstrating meta-inferences from the integration of qualitative themes/subthemes and PRISM-CSI item mean scores can be found in Table 4 . Table 4 Joint Display of Integrated Qualitative and Quantitative Findings, RC=Reverse coding Theme Subtheme PRISM CSI Item Meta-Inference 1) Use of NRT per AAP as a reasonable option, given limited other options Positive Factors (≥ 4.00) : • Negatively impact care (RC): 4.44 • Fits with clinic priorities: 4.11 • Organizational support for NRT: 4.00 Moderate Positive Factors (3.50–3.99) : • Alignment patients’ wants/needs: 3.89 • No advantages compared to standard of care (RC): 3.67 NRT guidelines were accepted by providers and likely to receive multi-level support. Given the limited options for addressing youth vaping, NRT was considered a good option (Convergent, Complementary) 2) Provider-level challenges to adoption a) Potential time/work demands of NRT given limited time and other demands Positive factors (≥ 4.00) • Workflow compatible: 4.00 Neutral factors (2.50–3.49) • Introducing new interventions hard with patients (RC): 3.44 • Minimal resources at site (RC): 3.44 • Site readiness: 3.44 • Patient complexity as a barrier (RC): 3.33 Though using NRT may add time or burden to clinic visits, providers felt it was feasible to integrate prescription of NRT into workflow (Divergent, Complementary) b) Variable provider comfort levels in managing NRT Moderate positive factors (3.50–3.99) • Minimal training required: 3.78 When given AAP resources, most providers feel they need little extra training to prescribe NRT, though confidence in specific aspects of NRT management differed (Complementary) 3) Systems- and clinic-level considerations to facilitate NRT use a) Confidentiality Positive factors (≥ 4.00) • Patients trust clinicians: 4.11 Moderate positive factors (3.50–3.99) • Aligns with patients’ preferences and needs: 3.89 Neutral factors (2.50–3.49) • Easy for patients to access: 3.11 Confidentiality concerns influence patient access to NRT. Strengthening systems to protect youth privacy are crucial for adoption ( Convergent, Complementary) b) Insurance coverage/ affordability Moderate positive factors (3.50–3.99) • Aligns with patients’ preferences and needs: 3.89 Neutral factors (2.50–3.49) • Equitable impact: 3.44 • Current events impact NRT: 3.44 • Easy for patients to access: 3.11 Insurance coverage and cost would affect access to NRT. Understanding coverage and affordable options for NRT are essential (Convergent, Complementary) c) Managing NRT follow up Moderate positive factors (3.50–3.99) • Aligns with patients’ preferences and needs: 3.89 Neutral factors (2.50–3.49) • Equitable impact: 3.44 • Lack resources at site (RC): 3.44 • Site readiness: 3.44 • Too difficult for patients (RC): 3.33 • Easy for patients to access: 3.11 Managing follow up for NRT prescriptions is key to implementation and may require site-specific strategies based on resources and readiness (Convergent, Complementary) 4) Remaining patient and external barriers to uptake a) Patient perceptions of harms of vaping Moderate positive factors (3.50–3.99) • Aligns with patients’ preferences and needs: 3.89 Neutral factors (2.50–3.49) • Equitable impact: 3.44 • Current events as barrier (RC): 3.44 • Patient complexity as a barrier (RC): 3.33 Low perceived harm of vaping may hinder youth uptake of NRT. Providers’ views on what patients ‘need’ may differ from what patients ‘want’ (Divergent, Complementary) b) Potential patient preference for “non-medication” options Moderate positive factors (3.50–3.99) • Aligns with patients’ preferences and needs: 3.89 • No advantages compared to SOC (RC): 3.67 Neutral factors (2.50–3.49) • Equitable impact: 3.44 Patients may prefer non-medication options for vaping cessation, but current alternatives may be limited (Divergent, Complementary) c) Perceived inadequate public policy/health efforts to address youth vaping Neutral factors (2.50–3.49) • Current events as barrier (RC): 3.44 • Regional/national mandates as a barrier (RC): 3.33 Use of NRT in isolation without strengthening other ongoing public policy/health efforts to address youth vaping may be challenging (Convergent, Complementary) 5) Culture and infrastructure for practice change that may help or hinder implementation a) Standardized communication channels Positive factors (≥ 4.00) • Senior leadership supports innovation: 4.44 • Effective supervisor management PI: 4.44 Moderately positive factors (3.50–3.99) • Minimal training required: 3.78 Existing communication channels for practice change could help facilitate NRT implementation (Convergent, Complementary) b) Infrastructure for evaluation and monitoring Neutral factors (2.50–3.49) : • Lack resources at site (RC): 3.44 Existing evaluation and monitoring systems could support NRT use, but ensuring adequate resources across sites is important (Divergent, Complementary) c) Multi-level engagement and support for practice change Positive factors (≥ 4.00) • Senior leadership supports innovation: 4.44 • Effective supervisor management PI: 4.44 • Supervisor supports new innovations: 4.44 • Staff member cooperation with care: 4.33 • Staff member resistance to change (RC): 4.22 • Organizational support for NRT: 4.00 Moderate positive factors (3.50–3.99) • Potential champion at site: 3.78 Buy-in to practice change efforts at multiple levels within the organization may help facilitate implementation of NRT (Convergent) d) Clinical champion culture Positive factors (≥ 4.00) • Personally empowered to initiate improvements: 4.22 Moderately positive (3.50–3.99) • Potential champion at site: 3.78 An existing culture of identifying clinical champions to support practice change exists within the organization and could facilitate NRT (Convergent) e) “Information overload” Positive factors (≥ 4.00) • Personally empowered to initiate improvements: 4.22 • Fits with clinic priorities: 4.11 • NRT still feasible with future practice changes: 4.00 • Workflow compatible: 4.00 Moderately positive factors (3.50–3.99) • Minimal training required: 3.78 Neutral factors (2.50–3.49) : • Patient complexity as a barrier (RC): 3.33 While ongoing practice changes can feel overwhelming for some providers, implementing NRT may be feasible and prioritized (Divergent, Complementary) [INSERT Table 4 : Joint Display of Integrated Qualitative and Quantitative Findings, RC=Reverse coding HERE] Table 4 : Joint Display of Integrated Qualitative and Quantitative Findings, RC=Reverse coding Convergence Most quantitative and qualitative findings were found to be convergent, with quantitative item mean scores demonstrating positive or neutral directionality consistent with linked qualitative subthemes. Eight subthemes and all 5 themes were assessed to have some degree of convergence with corresponding survey item mean scores. This included Use of NRT as a reasonable option (qualitative) and positive mean score of not negatively impacting care or having no advantages compared to standard of care (quantitative) Confidentiality concerns (qualitative) and positive mean score for patients trusting clinicians and neutral mean score for NRT being easy for patients to access (quantitative) Insurance coverage/affordability (qualitative) and neutral mean scores for ease of access and equitable impact (quantitative) Systems to help with follow up on NRT (qualitative) and neutral mean scores for sufficient resources at site and site readiness (quantitative) Perceived inadequate public health/policy efforts (qualitative) and neutral mean scores for current events and regional/national mandates (quantitative) Standardized communication channels (qualitative) and effective supervisor management of program improvement (quantitative) Multi-level support for practice change (qualitative) and organizational/senior leadership/staff member/supervisor support for innovation (quantitative) Clinical champion culture (qualitative) and personal empowerment to initiate improvements and potential champion at site (quantitative) Divergence 5 subthemes were assessed to have a mild degree of divergence with mean survey scores. In general, main areas of divergence considered mean item scores providing more “positive” responses than were extrapolated in qualitative findings. Key areas of divergence and resulting meta-inferences are described below. Time/work demands of NRT (qualitative) and workflow compatibility (quantitative) The qualitative assessment that NRT would add time/work demands to provider workflow appeared to be at odds with a positively rated mean score on a survey item asking about workflow compatibility. This meta-inference was integrated to acknowledge the reported increased time/work demands of NRT but recognizing, despite this, providers appeared to feel prescribing NRT could be feasible within their existing workflow. Patient perceptions of vaping and preference for non-medication treatment (qualitative) and alignment with patient needs/preferences (quantitative) The patient-level factor noted that patients’ perceptions of the limited harm of vaping and preference for non-medication cessation treatment options appeared to contradict a positively rated mean score on a survey item asking if use of NRT aligned with patients’ needs and preferences. On assessment during integration, the authors noted the double-barreled nature of the original survey item in asking about patients’ needs vs their preferences . Additionally, the item does not delineate if the patients’ needs are aligned with what providers think the patient may need versus what patients may think they need. The meta-inference was integrated to acknowledge that patients’ perceptions of harm of vaping and potential preference for non-medication treatments may be a barrier but there may be a discrepancy between what providers feel what patients “need” versus what they “want.” Infrastructure for evaluation/monitoring (qualitative) and lacking resources at site (quantitative) We noted during integration that the qualitative finding that the health system had strong evaluation and monitoring infrastructure appeared to be at odds with a more neutrally rated item about providers feeling like they lacked resources at their site to use NRT. The meta-inference was integrated to acknowledge that while there is reported infrastructure for evaluation and monitoring, assessment of resources at a clinic/site level generally may be important to the implementing NRT for youth vaping cessation. “Information overload” (qualitative) and NRT still feasible with other practice changes (quantitative) During integration, we noted that the qualitative finding that care should be taken to not “overload” providers given the possibility of introducing NRT at the same time as many other program improvement projects appeared to be at odds with the positively valued survey item that NRT would still be feasible with other practice changes. The meta-inference was integrated to acknowledge that though the culture of many program improvement programs could be overwhelming, providers specifically felt using NRT would be feasible within this context. Complementarity All subthemes and themes were felt to have some degree of complementary information that was provided by either the qualitative or quantitative strand. In general, quantitative results provided an assessment of valence (positive or neutral) of a given construct that might be linked in qualitative findings. Qualitative results most often expanded upon quantitative survey items that might be more broadly worded and provided specific examples of the quantitative construct being assessed (e.g. affordability addressed during interviews informing a neutral mean score response on the survey item asking about ease of patient access). Complementary findings were added where applicable to meta-inferences. Informing Program Improvement Effort Implementation Strategies: In addition to generating transferable findings on the implementation of AAP guidelines for NRT, this study sought to provide real-time, actionable findings to the PI team working on youth vaping cessation. After sharing findings with the PI team, strategies developed to support increased NRT use included focus on provider-informed preferred topics for provider education, working to identify existing systems in place to provide confidential care, engaging youth directly on preferred options for vaping cessation that could be paired with NRT, finding dedicated clinical champions for youth vaping cessation and NRT, and integrating additional clinical resources and tools into provider workflows to facilitate NRT use and referrals for youth vaping cessation (Fig. 4 ). Discussion This study was a comprehensive, mixed-methods case study of a single health system using qualitative key informant interviews and a quantitative, modified PRISM-CSI survey to explore the determinants of implementing guidelines on the use of NRT for youth vaping in primary care. While the AAP guidelines to consider NRT for youth vaping cessation were considered acceptable and aligned with a pressing health concern, participants identified multiple important determinants to the implementation of NRT in practice. Providers noted specific concerns such as confidentiality considerations of patients who vape, ensuring affordability and insurance coverage of NRT products, and establishing systems of adequate follow up and management of NRT. There were certain determinants felt to be less in direct control of providers, including potential patient perceptions of the harms of vaping and medication-based treatment as well as the perceived need to continue strengthening public health and policy efforts to address the ubiquity and access of vaping products for youth. Despite this, and though it appears using NRT to address youth vaping would pose added time to visits with need for some additional training and support, providers felt it could be integrated into their workflow. Likewise, specific to the health system they worked in, providers felt the existing infrastructure and culture around practice change could facilitate the implementation of guidelines around NRT and that it could be implemented around ongoing program improvement efforts at their institution. Perspectives on the use of NRT fit into the larger landscape of determining what clinical and public health interventions might be feasible and effective to address youth vaping. Interventions have often focused on digital interventions such as This is Quitting [ 34 ] and new smartphone apps [ 35 ] as well as school-based interventions such as CATCH my Breath [ 36 ] but the evidence for other interventions continues to evolve. Even after completion of data collection for this study, a new randomized controlled trial demonstrated the promising effectiveness of varenicline, another pharmacotherapy agent for nicotine cessation, combined with counseling for youth and young adults.[ 37 ] The evidence of this RCT was not available during the creation of the 2023 AAP guidelines and reflects the pace at which evidence-based interventions may emerge and guidelines may change. Given this, the findings from this study highlight the importance of considering NRT as a potential option at this moment in time for the right patient in the right context and, if used, should be considered in the context of rapidly evolving evidence and new treatment options. As providers also highlighted in this study, it is important for vaping prevention and cessation advocates to continue bolstering both clinical and public health/policy interventions. [ 38 , 39 ] Though not the specific focus of this study, our findings also provide insights into the value of clinical practice guidelines and their role in influencing clinical care. In this instance, providers shared their trust of and buy-in to the AAP guidelines presented to them and felt the justification for the recommendation presented was reasonable. This is consistent with prior findings of where practitioners prefer to receive information about evidence-based practice and trust in professional associations.[ 40 ] The provision of additional resources accompanying the recommendation were also seen as helpful in supporting provider self-efficacy and comfort with the guideline. It likewise demonstrates the importance of assessing the fit of guidelines to the specific context of implementation. In this study, for example, providers shared the importance of considerations such as confidentiality concerns, potential patient preferences for non-medication options, or patients’ perceived need for NRT that may limit uptake of guideline recommendations. While methods for CPG development often emphasize considering context, interest holder perspectives, and barriers to implementation, 8 this study provides valuable insight into the implementation of a specific guideline in a real-world setting. Limitations Important limitations should be noted. Though the authors intend for the findings have transferability to inform further research in other similar settings, care should be taken to not extrapolate the generalizability of these findings from a mixed-methods case study of 9 clinicians in a single health system. Given the health system we conducted this study was in the pre-implementation phase of planned implementation of improving youth vaping services, provider perspectives on system support for NRT may have been higher than what would be expected in a system where this was not ongoing. Additionally, though we purposively sampled individuals who had prescribed NRT for youth previously, this has the potential to introduce a greater degree of confidence or support for NRT in responses. Due to the use of the same participants for sequential interviews and surveys and an inability to fully anonymize survey responses, the potential for social desirability bias should also be noted. Finally, although we explored a range of PRISM factors from the perspective of primary care providers who would deliver NRT, this study did not directly assess the perspectives of other important interest holders including youth, organizational decision makers, or clinic staff members. Conclusions This study demonstrates the potential promise of having NRT as an option for youth vaping cessation in primary care while acknowledging potentially important determinants of prescribing and accessing NRT in practice. Further research should involve engagement with other key interest holders that would be necessary for the implementation of NRT and other youth vaping cessation guidelines. This is especially true of engaging youth who use vaping products to gauge interest in different treatment options. Likewise, research situating NRT specifically within the context of novel, emerging treatments, public health efforts, and policy interventions would be beneficial for the field. Abbreviations NRT Nicotine Replacement Therapy AAP American Academy of Pediatrics PRISM Practical, Robust Implementation and Sustainability Model RE-AIM Reach, Effectiveness, Adoption, Implementation, Maintenance PRISM-CSI PRISM Contextual Survey Instrument RC Reverse coding GRAMMS Good Reporting of A Mixed Methods Study Declarations Ethics approval and consent to participate: This study was deemed to be exempt human subjects research by the authors’ university institutional review board (#25-0313). Consent for publication: Not applicable. Availability of data and materials: The datasets used and analyzed for this study are available from the corresponding author on reasonable request. Materials used for this study, including PRISM-guided interview guides and modified PRISM-CSI instrument, are also available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests Funding: This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (T3HP242016) totaling $2,243,839.00 with 0% percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov. The Denver Health grant team (program improvement team) was funded through a subcontract as the Mental Health Provider for the Combatting Youth Vaping grant, administered by the Denver Department of Public Health and Environment who received funding from the Colorado Attorney General’s office through disbursement of JUUL settlement funds. This project totaled $197,000 amount over 19 months. Author contributions: JC contributed to the conceptualization, design, data acquisition, analysis, interpretation, and drafting and revision of the manuscript. CR contributed to the design, data acquisition, analysis, interpretation, drafting and revision of the manuscript. BB contributed to the conceptualization, data acquisition, interpretation, and revision of the manuscript. BD contributed to the design, analysis, interpretation, and revision of the manuscript. RG contributed to the conceptualization, design, interpretation, and revision of the manuscript. Acknowledgements: The authors would like to thank the Denver Health Youth Vaping Cessation team including Erin Harris, Sedona Allen, Valerie Castanon, Tyrone Braxton, Kristie Ladegard, David Vargas Ayala, Laura Elliott, Kelly Shaffer, and Angel Wood. They would also like to thank the ACCORDS Primary Care Research fellowship mentorship, co-fellows, and team including Amy Huebschmann (who also helped review this paper), Mandy Allison, Elizabeth Bayliss, Romana Hasnain-Wynia, Allison Kempe, Emily Dunston, Bailey Martin, Michael Mattiucci, David Higgins, and Kyle Haws. The authors would also like to thank Gina Kruse for reviewing this paper and insights/expertise in tobacco cessation. References Jamal A, Park-Lee E, Birdsey J, Agaku IT, Hu SS, Cullen KA, et al. Tobacco product use among middle and high school students — National Youth Tobacco Survey, United States, 2024. MMWR Morb Mortal Wkly Rep. 2024;73(41):917–24. doi: 10.15585/mmwr.mm7341a2 Furlow B. Youth vaping rates drop in US, but experts remain concerned. Lancet Respir Med. 2024;12(12):944. doi: 10.1016/S2213-2600(24)00340-0 Barrington-Trimis JL, Urman R, Berhane K, Unger JB, McConnell R, Pentz MA, et al. E-cigarettes and future cigarette use. Pediatrics. 2016;138(1):e20160379. doi: 10.1542/peds.2016-0379 . Castro EM, Lotfipour S, Leslie FM. Nicotine on the developing brain. Pharmacol Res. 2023;190:106716. doi: 10.1016/j.phrs.2023.106716 . Lechner WV, Janssen T, Kahler CW, Audrain-McGovern J, Leventhal AM. Bi-directional associations of electronic and combustible cigarette use onset patterns with depressive symptoms in adolescents. Prev Med. 2017;96:73–78. doi: 10.1016/j.ypmed.2016.12.034 . Shehata SA, Toraih EA, Ismail EA, Hagras AM, Elmorsy E, Fawzy MS. Vaping, environmental toxicants exposure, and lung cancer risk. Cancers (Basel). 2023;15(18):4525. doi: 10.3390/cancers15184525 . Becker TD, Rice TR. Youth vaping: a review and update on global epidemiology, physical and behavioral health risks, and clinical considerations. Eur J Pediatr. 2022;181(2):453–62. doi: 10.1007/s00431-021-04220-x Prasad M. Introduction to the GRADE tool for rating certainty in evidence and recommendations. Clin Epidemiol Glob Health. 2024;25:101484. doi: 10.1016/j.cegh.2023.101484 Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839-42. doi: 10.1503/cmaj.090449 Fahim C, Prashad AJ, Silveira K, Chandraraj A, Thombs BD, Tonelli M, et al. Dissemination and implementation of clinical practice guidelines: a longitudinal, mixed-methods evaluation of the Canadian Task Force on Preventive Health Care's knowledge translation efforts. CMAJ Open. 2023;11(4):E684-95. doi: 10.9778/cmajo.20220121 Nagraj SK, Hafver TL, Hohlfeld A, Effa E, Mabetha D, Kunje G, et al. Dissemination strategies of clinical practice guidelines-mixed methods evidence synthesis protocol. Clin Public Health Guidel. 2025;2(2):e70012. doi: 10.1002/gin2.70012 American Academy of Pediatrics Steering Committee on Quality Improvement and Management. Classifying recommendations for clinical practice guidelines. Pediatrics. 2004;114(3):874–877. doi: 10.1542/peds.2004-1260 Shiffman RN, Marcuse EK, Moyer VA, Finnell SM, Ganiats TG, Neber SJ, et al. American Academy of Pediatrics Steering Committee on Quality Improvement and Management. Toward transparent clinical policies. Pediatrics. 2008;121(3):643–646. doi: 10.1542/peds.2007-3398 Jenssen BP, Walley SC, Boykan R, Little MA, McGrath-Morrow SA, Quigley J, et al; American Academy of Pediatrics, Section on Nicotine and Tobacco Prevention and Treatment, Committee on Substance Use Prevention. Technical report: Protecting children and adolescents from tobacco and nicotine. Pediatrics. 2023;151(5):e2023061806. doi: 10.1542/peds.2023-061806 . Jenssen BP, Walley SC, Boykan R, Little MA, McGrath-Morrow SA, Quigley J, et al. Protecting children and adolescents from tobacco and nicotine. Pediatrics. 2023;151(5):e2023061805. doi: 10.1542/peds.2023-061805 American Academy of Pediatrics. Nicotine replacement therapy and adolescent patients: information for pediatricians [Internet]. Itasca (IL): American Academy of Pediatrics; [cited 2026 Jan 23]. Available from: https://downloads.aap.org/AAP/PDF/NRT_and_Adolescents_Pediatrician_Guidance_factsheet.pdf QuitWorks-NH. Nicotine treatment for youth patients. New Hampshire Department of Health and Human Services; 2025 [Cited 30 December 2025]. Available from: https://quitworksnh.org/education-training/treating-special-populations/nicotine-treatment-for-youth-patients/ City and County of Denver Department of Public Health & Environment. Mental health provider for Denver youth vaping cessation & mental health initiative [Internet]. Denver (CO): BidNet Direct; 2024 Aug 9 [cited 2026 Jan 20]. Available from: https://www.bidnetdirect.com/colorado/city-and-county-of-denver-environmental-health/solicitations/Mental-Health-Provider-for-Denver-Youth-Vaping-Cessation-Mental-Health-Initiat/0000359761 Tyler A, Glasgow RE. Implementing improvements: opportunities to integrate quality improvement and implementation science. Hosp Pediatr. 2021;11(5):536–545. doi: 10.1542/hpeds.2020-002246 . Fernandez ME, Ten Hoor GA, van Lieshout S, Rodriguez SA, Beidas RS, Parcel GS, et al. Implementation mapping: using intervention mapping to develop implementation strategies. Front Public Health. 2019;7:158. doi: 10.3389/fpubh.2019.00158 . Feldstein AC, Glasgow RE. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008;34(4):228–43. doi: 10.1016/s1553-7250(08)34030-6 Glasgow RE, Trinkley KE, Ford BS, Rabin BA. The application and evolution of the Practical Robust Implementation and Sustainability Model (PRISM): history and innovations. Glob Implement Res Appl. 2024. doi: 10.1007/s43477-024-00134-6 Trinkley KE, Glasgow RE, D’Mello S, Fort MP, Ford B, Rabin BA. The iPRISM webtool: an interactive tool to pragmatically guide the iterative use of the Practical, Robust Implementation and Sustainability Model in public health and clinical settings. Implement Sci Commun. 2023;4:116. doi: 10.1186/s43058-023-00494-4 Fetters MD. The mixed methods research workbook: activities for designing, implementing, and publishing projects. Thousand Oaks (CA): SAGE Publications; 2019. Taylor B, Henshall C, Kenyon S, Litchfield I, Greenfield S. Can rapid approaches to qualitative analysis deliver timely, valid findings to clinical leaders? A mixed methods study comparing rapid and thematic analysis. BMJ Open. 2018;8(10):e019993. doi: 10.1136/bmjopen-2017-019993 Averill JB. Matrix analysis as a complementary analytic strategy in qualitative inquiry. Qual Health Res. 2002;12(6):855–66. doi: 10.1177/104973230201200611 Pittman JOE, Lindamer L, Almklov E, Glasgow RE, Huebschmann AG, Trinkley KE, et al. Development of a pragmatic measure for the Practical, Robust Implementation and Sustainability Model. Psychol Serv. 2025;22(4):634–40. doi: 10.1037/ser0000947 O'Cathain A, Murphy E, Nicholl J. The quality of mixed methods studies in health services research. J Health Serv Res Policy. 2008;13(2):92–8. doi: 10.1258/jhsrp.2007.007074 Gale RC, Wu J, Erhardt T, Asch SM, Findley PA, Gifford AL, et al. Comparison of rapid vs in-depth qualitative analytic methods from a process evaluation of academic detailing in the Veterans Health Administration. Implement Sci. 2019;14(1):11. doi: 10.1186/s13012-019-0853-y . Hamilton AB, Finley EP. Qualitative methods in implementation research: an introduction. Psychiatry Res. 2019;280:112516. doi: 10.1016/j.psychres.2019.112516 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81. doi: 10.1016/j.jbi.2008.08.010 Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):108. doi: 10.1186/s13012-017-0635-3 StataCorp. Stata statistical software: Release 19. College Station (TX): StataCorp LLC; 2025. Graham AL, Amato MS, Cha S, Jacobs MA, Bottcher MM, Papandonatos GD. Effectiveness of a vaping cessation text message program among young adult e-cigarette users: a randomized clinical trial. JAMA Intern Med. 2021;181(7):923–30. doi: 10.1001/jamainternmed.2021.1793 Palmer AM, Tomko RL, Squeglia LM, Gray KM, McClure EA, Carpenter MJ. A pilot feasibility study of a behavioral intervention for nicotine vaping cessation among young adults delivered via telehealth. Drug Alcohol Depend. 2022;232:109311. doi: 10.1016/j.drugalcdep.2022.109311 Kelder SH, Mantey DS, Van Dusen D, Case K, Haas A, Springer AE. A middle school program to prevent e-cigarette use: a pilot study of "CATCH My Breath". Public Health Rep. 2020;135(2):220–9. doi: 10.1177/0033354919900887 Evins AE, Cather C, Reeder HT, Evohr B, Potter K, Pachas GN, et al. Varenicline for youth nicotine vaping cessation: a randomized clinical trial. JAMA. 2025;333(21):1876–86. National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. E-cigarette use among youth and young adults: a report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US); 2016. Chapter, The call to action. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538685/ Jenssen BP, Walley SC, Boykan R, Little Caldwell A, Camenga D, SECTION ON NICOTINE AND TOBACCO PREVENTION AND TREATMENT, et al. Protecting children and adolescents from tobacco and nicotine. Pediatrics. 2023;151(5):e2023061804. doi: 10.1542/peds.2023-061804 . Shato T, Kepper MM, McLoughlin GM, Tabak RG, Glasgow RE, Brownson RC. Designing for dissemination among public health and clinical practitioners in the USA. J Clin Transl Sci. 2023;8(1):e8. doi: 10.1017/cts.2023.695 Additional Declarations No competing interests reported. Supplementary Files SupplementalAppendix1GRAMMSChecklist.docx SupplementalAppendix2AdditionalQualitativeQuotes.docx SupplementalAppendix3OverviewofModificationstoPRISMCSI.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 07 Apr, 2026 Reviews received at journal 24 Mar, 2026 Reviews received at journal 06 Mar, 2026 Reviewers agreed at journal 26 Feb, 2026 Reviewers agreed at journal 09 Feb, 2026 Reviewers invited by journal 09 Feb, 2026 Editor assigned by journal 08 Feb, 2026 Submission checks completed at journal 04 Feb, 2026 First submitted to journal 30 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8743595","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588533441,"identity":"e4870eb1-2e1b-4199-af14-2a4acfc3b94c","order_by":0,"name":"Joshua D. Cockroft","email":"data:image/png;base64,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","orcid":"","institution":"University of Colorado Anschutz Medical Campus","correspondingAuthor":true,"prefix":"","firstName":"Joshua","middleName":"D.","lastName":"Cockroft","suffix":""},{"id":588533442,"identity":"d64b36cd-7f8c-45b8-9f81-30d2e8415ac1","order_by":1,"name":"Carly Ritger","email":"","orcid":"","institution":"University of Colorado Anschutz Medical Campus","correspondingAuthor":false,"prefix":"","firstName":"Carly","middleName":"","lastName":"Ritger","suffix":""},{"id":588533443,"identity":"a0657c11-d02e-44ad-afe3-10f91aff9fe2","order_by":2,"name":"Becky Bloedow","email":"","orcid":"","institution":"Denver Health and Hospital Authority","correspondingAuthor":false,"prefix":"","firstName":"Becky","middleName":"","lastName":"Bloedow","suffix":""},{"id":588533446,"identity":"f12cd64a-f8b7-4da2-a8ce-ce620cee339b","order_by":3,"name":"Brooke Dorsey","email":"","orcid":"","institution":"University of Colorado Anschutz Medical Campus","correspondingAuthor":false,"prefix":"","firstName":"Brooke","middleName":"","lastName":"Dorsey","suffix":""},{"id":588533448,"identity":"ac160f2c-888d-45e3-8b90-b9e7b2853332","order_by":4,"name":"Russell E. Glasgow","email":"","orcid":"","institution":"University of Colorado Anschutz Medical Campus","correspondingAuthor":false,"prefix":"","firstName":"Russell","middleName":"E.","lastName":"Glasgow","suffix":""}],"badges":[],"createdAt":"2026-01-30 17:09:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8743595/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8743595/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102463116,"identity":"95597586-4f51-4382-bea2-81cdbd8039e0","added_by":"auto","created_at":"2026-02-12 01:14:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":257575,"visible":true,"origin":"","legend":"\u003cp\u003ePractical, Robust, Implementation and Sustainability Model (PRISM) Determinants Framework to Guide Contextual Assessment\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8743595/v1/95cb4dcbab74611252ba200b.png"},{"id":102463118,"identity":"f3fa6466-cf39-4922-8116-8f798e25454f","added_by":"auto","created_at":"2026-02-12 01:14:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":383935,"visible":true,"origin":"","legend":"\u003cp\u003eConvergent Mixed-Methods Study Design\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8743595/v1/2971e686a8c3420462c4b6f7.png"},{"id":102463122,"identity":"a0b4a811-dbcb-42f2-a517-92e5aa5640a5","added_by":"auto","created_at":"2026-02-12 01:14:24","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":615691,"visible":true,"origin":"","legend":"\u003cp\u003eSurvey items ranked per mean score, RC=Reverse Coding\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8743595/v1/b8c76870aaedf25dcd627be7.png"},{"id":102463117,"identity":"5752f4dc-7a4d-4738-bf41-b28f9ebb7286","added_by":"auto","created_at":"2026-02-12 01:14:24","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":251132,"visible":true,"origin":"","legend":"\u003cp\u003eDeterminants and impact on implementation strategies\u003c/p\u003e","description":"","filename":"floatimage41.png","url":"https://assets-eu.researchsquare.com/files/rs-8743595/v1/59a722a81aea6e62655cddd8.png"},{"id":103503810,"identity":"78fc7def-3f15-42d8-9167-b18756d51dd2","added_by":"auto","created_at":"2026-02-26 13:02:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4509720,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8743595/v1/acf40a73-b1b2-4fa0-852c-591160074384.pdf"},{"id":102463121,"identity":"3e532d38-bbba-42e9-9b50-46541981433e","added_by":"auto","created_at":"2026-02-12 01:14:24","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17492,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalAppendix1GRAMMSChecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-8743595/v1/946f2c07d794d90aec734fc0.docx"},{"id":102746439,"identity":"1f578db1-3bc9-4a35-880b-c3983e6fb2dd","added_by":"auto","created_at":"2026-02-16 08:57:43","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23459,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalAppendix2AdditionalQualitativeQuotes.docx","url":"https://assets-eu.researchsquare.com/files/rs-8743595/v1/ffd69be387b20e26a762c4a1.docx"},{"id":102463119,"identity":"d02d9abc-bc97-4099-989f-be8b0b8f51af","added_by":"auto","created_at":"2026-02-12 01:14:24","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20031,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalAppendix3OverviewofModificationstoPRISMCSI.docx","url":"https://assets-eu.researchsquare.com/files/rs-8743595/v1/a17e6b5665f2074b21d1be91.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring Multi-level Determinants of Implementation of Nicotine Replacement Therapy Guidelines for Youth Vaping: A Mixed-Methods Case Study","fulltext":[{"header":"Contributions to the Literature ","content":"\u003cul\u003e\n \u003cli\u003eThis study provides transferable insights into important determinants to consider as researchers and public health practitioners seek to implement interventions and policy changes to address the high prevalence of youth vaping\u003c/li\u003e\n \u003cli\u003eThis case study provides an example of using rapid, rigorous mixed-methods design to provide ongoing, iterative results for concurrent program/quality improvement efforts\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThis study also provides a case example of exploring contextual determinants important to translating and implementing clinical practice guidelines\u003c/li\u003e\n\u003c/ul\u003e\n"},{"header":"Background","content":"\u003cp\u003eAs of 2024, e-cigarettes (vapes) remain the most common tobacco product used by middle and high school age students with 5.9% of youth reporting current use (estimated 1.6\u0026nbsp;million youth) and 14% of youth reporting having ever used (estimated 3.87\u0026nbsp;million youth).[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Though there appears to have been some drop in the prevalence of vaping from peak rates in the late 2010s, youth vaping remains a persistent issue.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] There remain concerns about the impact of vaping on youth neurodevelopment, impact on mental health, conversion to combustible cigarette use, and unknown long-term physical sequelae of vaping use.[\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Efforts, interventions, and guidelines to address youth vaping continue to evolve and emerge.\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eClinical practice guidelines (CPGs) are recommendations, commonly provided by professional societies or coalitions, meant to synthesize evidence and provide guidance to practitioners on specific questions related to clinical care. Though the approach to development of CPGs has been variable and at times lacked transparency, newer standardized methods to guide creation of CPGs have emerged in recent years.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] In this light, CPGs present a potentially important tool in closing the research-to-practice gap, given their focus on reviewing evidence to clinically salient questions, engagement with practitioner and patient interest holders, and emphasis on clear and concise recommendations.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] However, there remain questions about the best strategies for disseminating and implementing recommendations from CPGs.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn 2023, the American Academy of Pediatrics (AAP) used a systematic process and dedicated working group [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] to update their CPG on youth tobacco and nicotine use in part to address the rise of youth vaping. As part of these updated guidelines, they provided a recommendation for clinicians to consider the use of pharmacotherapy, particularly nicotine replacement therapy (NRT), for youth tobacco and vaping cessation. Quality of evidence was considered low with strength of recommendation considered \u0026ldquo;optional.\u0026rdquo; While there were no robustly powered clinical trials for pharmacotherapy demonstrating efficacy or effectiveness in youth at the time of publication, the AAP argued clinicians should consider NRT as an option in youth nicotine cessation efforts because of evidence of benefit of NRT in adults, evidence of safety for youth, and observational evidence of potential harm of vaping for youth.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] In addition to these guidelines, the AAP also published resources to help guide clinicians in the prescription of NRT for youth tobacco and vaping cessation.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThough the strength of recommendation of this specific guideline was considered optional with a low quality of evidence, information regarding using NRT to help treat youth vaping and tobacco use has now appeared in documents provided by some local health departments.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] In a city-sponsored grant supporting program improvement of youth vaping cessation services one of our home institutions received, the language stipulated the recipient aim to increase health care providers\u0026rsquo; use of NRT in their health system.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] After the grant recipient program improvement team recognized very few primary care providers considered or used NRT for youth vaping cessation, they recognized a need to explore the determinants important to implementing of the 2023 AAP NRT guideline.\u003c/p\u003e \u003cp\u003eIn collaboration between the program improvement team and an implementation research team, this study sought to explore multi-level determinants of implementing AAP guidelines to consider NRT for vaping and tobacco cessation for patients aged 12\u0026ndash;17 years old in primary care settings using an implementation science framework-guided, mixed-methods design.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cstrong\u003eImplementation research study supporting program improvement\u003c/strong\u003e \u003cp\u003eIn addition to generation of research findings that might be transferable to other settings, this study also sought to generate rapid, iterative findings to support the efforts of the aforementioned program improvement (PI) grant team. The PI team received funding and began work on the grant in December 2024 for 19 months of support (through June 2026). Investigators from an academic health center (JC, CR, RG, BD) affiliated with the grant recipient institution jointly refined the research question and objectives in collaboration with the grant team leader (BB) from December 2024 through April 2025. After this group identified key findings from the rapid, qualitative matrix in July 2025, the study\u0026rsquo;s principal investigator (JC) and grant team leader (BB) presented these initial findings to the full PI team. To meet the needs of the PI team\u0026rsquo;s constricted timeline, implementation strategies to address identified determinants were generated informally at weekly grant team huddle meetings between July and August 2025 and did not employ a more time-demanding method such as Implementation Mapping.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Final meta-inferences were reviewed with the PI team lead (BB) in October 2025 and the full PI team in January 2026.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eImplementation science framework and study design\u003c/strong\u003e \u003cp\u003eTo guide evaluation of the multilevel determinants of implementation of NRT for youth, we used the Practical, Robust Implementation and Sustainability Model (PRISM) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). PRISM is an implementation, evaluation, and sustainability framework that includes Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) outcomes.[\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] The determinant domains in PRISM include multi-level perspectives on an intervention, multi-level characteristics of intervention recipients (e.g. providers and patients), implementation and sustainability infrastructure (i.e. capacity for implementing and sustaining new practice innovations), and external environment (e.g. policy or current events).[\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] As detailed below, the use of PRISM determinants in this study was primarily to organize qualitative and quantitative data collection and initial analysis. The timeframe of this study was conducted in the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003epre-implementation phase\u003c/span\u003e of efforts to increase implementation of the 2023 AAP NRT guideline. Though the findings from this study were used to inform implementation strategies by the PI team, directly addressing or measuring program evaluation outcomes (such as RE-AIM) was beyond the timeframe and scope of this study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWe used a convergent, mixed methods design integrating rapid qualitative matrix analysis with quantitative descriptive analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).[\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Qualitative methods were used to provide a nuanced exploration of determinants of implementing NRT use per AAP guidelines in primary care that allowed for emergent findings. Quantitative methods provided a structured, quantifiable measurement and valence assessment (positive, neutral, or negative) using an existing survey instrument of providers\u0026rsquo; perceptions of PRISM determinant constructs.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] We used the Good Reporting of a Mixed Methods Study (GRAMMS) checklist to organize the reporting of our methods and findings (\u003cb\u003eSupplemental Appendix 1\u003c/b\u003e).[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSetting and Participants\u003c/strong\u003e \u003cp\u003eThis study was conducted at an urban, safety net health system in a Mountain West state in the United States. We used purposive sampling to recruit primary care providers of various licensure (e.g. advanced practice provider vs medical doctorate) in the specialties of pediatrics and family medicine with a range of experience prescribing NRT for youth. Participants were eligible if they cared for youth aged 12\u0026ndash;17 years old and were employed at the study site at the time of participation. We excluded individuals who were members of the program improvement team to avoid potential introduction of bias. Participants were recruited from providers who had completed a prior survey administered by the PI team about youth vaping cessation and marking willingness to be contacted for interviews. Email invitations were sent from the study principal investigator (JC). We used an identical sample for both interviews and surveys. Target sample size was determined by a goal of reaching thematic saturation for qualitative analysis. Providers were given a \u003cspan\u003e$\u003c/span\u003e50 gift card as compensation for study participation.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eQualitative Methods:\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eData Collection\u003c/strong\u003e \u003cp\u003eWe developed two slightly different versions of a PRISM-guided, semi-structured interview guide\u0026mdash;differentiating providers\u0026rsquo; prior NRT prescription for youth\u0026mdash;to help understand the determinants to prescription of NRT for youth in our participants\u0026rsquo; settings. AAP guidelines and resources on NRT were sent to all interviewees prior to their scheduled interview and presented again by interviewers at the time of the interview. Interviews elicited information about 1) participants\u0026rsquo; perspectives on prescribing NRT for youth and the AAP\u0026rsquo;s recommendations, 2) patient characteristics and possible perspectives that may impact NRT use, 3) example factors supporting practice changes in their clinics, and 4) characteristics of their health system and external environment that may impact NRT use amongst providers. Audio recorded, individual interviews lasted 45 to 60 minutes and took place over Zoom videoconferencing software between May and July 2025 and were conducted by the study principal investigator (JC) and a qualitative/mixed-methods analyst (CR). Interviews were professionally transcribed by a HIPAA-compliant transcription company. Prior to every interview, each interviewer obtained verbal consent for study procedures and offered a copy of a consent document. Interview recruitment continued until thematic saturation was reached; that is, no novel information was discussed related to use of NRT for youth vaping or tobacco cessation.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eQualitative Analysis\u003c/strong\u003e \u003cp\u003eTo analyze interview data, we used a rapid matrix approach.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] The analysis team consisted of the study principal investigator (JC) and analyst (CR). After professional transcription of interview audio, the analysis team populated a rapid matrix with data from each transcript. The rapid matrix was guided by PRISM, with inductive domains added based on the interview guide and after reviewing initial transcripts. To support rigor, we double populated and reconciled 20% of transcripts to iteratively refine the matrix domains.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] After all transcripts were added to the matrix, the analysis team summarized participant findings for each domain (down each column). The analysis team met regularly to agree upon summaries for each domain, discussing and writing memos to identify themes across all domain summaries.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQuantitative Methods\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eInstruments/Data Sources\u003c/strong\u003e \u003cp\u003eDemographic information was collected from all interview participants through an electronic RedCap survey hosted at the authors\u0026rsquo; home institution after completion of each interview.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] Demographic information collected included sex, racial/ethnic identity, medical specialty, professional clinical licensure, if the participant had prescribed NRT for patients aged 12\u0026ndash;17 years old previously, primary care site, years employed with the health system, and years since completion of highest clinical degree.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe primary quantitative instrument used in this study was the PRISM Contextual Survey Instrument (PRISM-CSI).[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] Originally developed and validated for assessing the implementation of an eScreening intervention in Veterans Health Administration settings, the original version of the scale demonstrated a range of internal consistency across subscales and concurrent validity with Weiner\u0026rsquo;s feasibility, acceptability, and appropriateness measures.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] The original version of the instrument is a 5-point ordinal scale consisting of 29 items. Given some item content did not directly match the nature of NRT as an intervention or pre-implementation phase in the study setting, the authors chose pragmatically to either omit items or modify the language of certain items. For details on the nature and rationale for this approach and the resultant, modified 25-item version of the PRISM-CMI survey used in this study, see \u003cb\u003eSupplemental Appendix 3\u003c/b\u003e. Participants were given the PRISM-CSI survey questions using the same electronic RedCap survey used to collect demographic characteristics.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStatistical Analysis\u003c/strong\u003e \u003cp\u003eWe completed descriptive statistical analyses on demographic and PRISM-CSI responses with export of data from RedCap and use of Stata 19.5.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] Proportions were calculated for all demographic categories. Each individual PRISM-CSI item was converted to a numerical, ordinal score (rated 1\u0026ndash;5) and then calculated for mean, standard deviation, and 95% confidence interval. Reverse coded items were converted to the appropriate corresponding score. Mean subscale scores were also calculated similar to the original procedure followed by Pittman and colleagues.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] Due to limited sample size and intended pragmatic use of the survey instrument, additional psychometric statistics and more extensive analyses of the modified version of the PRISM-CSI used were not performed.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eMixed-methods integration\u003c/h3\u003e\n\u003cp\u003eFollowing completion of qualitative and quantitative analysis, the principal investigator and analyst linked themes/subthemes and constructs relating to PRISM-CSI survey items in a merging joint display.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] The authors ultimately chose to link themes/subthemes to individual PRISM-CSI items as opposed to subscales for two reasons. First, we felt that the level of detail in individual items allowed for a richer comparison with themes/subthemes that became diminished in use of mean subscale scores. Second, given the nature of modifications to the PRISM-CSI for use in this study, limited sample size, and degree of variable internal consistency across subscales in the validation of the original version of the scale,[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] the authors found it challenging to make reliable or useful inferences at the level of the subscale.\u003c/p\u003e \u003cp\u003eAfter completing a merging display, the themes/subtheme content was then compared with the mean scores of individual items rated in pre-determined ranges as \u0026ldquo;Positive\u0026ldquo; (\u003cb\u003e\u0026ge;\u003c/b\u003e\u0026thinsp;4.00), Moderately Positive\u0026rdquo; (3.50\u0026ndash;3.99), \u0026ldquo;Neutral\u0026rdquo; (2.50\u0026ndash;3.49), \u0026ldquo;Moderately Negative\u0026rdquo; (2.00-2.49), or \u0026ldquo;Negative\u0026rdquo; (\u0026lt;\u0026thinsp;2.00) to generate meta-inferences which were then entered into a \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003efinal joint display.\u003c/span\u003e Themes/subthemes and mean item scores were assessed for convergence, divergence, or complementarity of findings. Convergence was considered if the directionality of item means matched conclusions from themes/subthemes. Divergence was considered if the directionality of item means did not appear to directly match conclusions from themes/subthemes. Complementarity was considered if either qualitative or quantitative strand provided additional insights not mostly captured by the other method strand. The principal investigator and analyst conducted the initial merging process and meta-inference generation jointly until unanimous consensus was reached. Meta-inferences were then reviewed with all authors for clarity and accuracy.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cstrong\u003eDemographics\u003c/strong\u003e \u003cp\u003eTwelve providers were initially invited with a total of 9 providers responding to the invitation to participate. All 9 fully completed an interview and survey. A demographic breakdown is found in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Three providers had previously prescribed NRT for youth. The sample included 5 pediatric providers, 3 family medicine providers, and 1 internal medicine-pediatrics provider. 6 providers had a medical doctorate (MD) or doctorate of osteopathic medicine (DO) and 3 were advanced practice providers (APPs).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics of Participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en/% of Participants\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (88.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eWhite\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (88.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHispanic/Latinx\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePediatrics\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (55.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFamily Medicine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eInternal Medicine/Pediatrics\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMD/DO\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAPP (e.g. Nurse Practitioner, Physician Assistant)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHas prescribed NRT for youth\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHas NOT prescribed NRT for youth\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eClinic 1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eClinic 2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eClinic 3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (22.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eClinic 4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (22.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eClinic 5\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEmployed\u0026thinsp;\u0026lt;\u0026thinsp;12 months at institution\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEmployed 1\u0026ndash;5 years at institution\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (22.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEmployed\u0026thinsp;\u0026gt;\u0026thinsp;5 years at institution\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;12 months since highest clinical degree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026gt;\u0026thinsp;12 months to 5 years since highest clinical degree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (22.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026gt;\u0026thinsp;5 to 20 years since highest clinical degree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (22.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026gt;\u0026thinsp;20 years since highest clinical degree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (55.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalicUnderline\" class=\"BoldItalicUnderline\" name=\"Emphasis\"\u003eQualitative Findings\u003c/span\u003e: Five themes were identified as part of qualitative analysis: 1) \u003cem\u003eUse of NRT per AAP guidelines as a reasonable option given limited other options\u003c/em\u003e, 2) \u003cem\u003eprovider-level challenges to increasing adoption\u003c/em\u003e, 3) \u003cem\u003esystems- and clinic-level considerations to facilitate NRT use\u003c/em\u003e, 4) \u003cem\u003eremaining patient and external barriers to uptake\u003c/em\u003e, and 5) \u003cem\u003eculture and infrastructure for practice change that may help or hinder implementation.\u003c/em\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides a list of themes, subthemes, and exemplar quotes. \u003cb\u003eSupplemental Appendix 2\u003c/b\u003e provides additional supporting quotes for themes and subthemes not able to be provided in the narrative here.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes, subthemes, and exemplar quotes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eQualitative Findings (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExemplar Quotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1) Use of NRT per AAP guidelines as a reasonable option, given limited other options\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I think [the AAP recommendation on NRT] sounds great\u0026hellip;[when describing a typical visit now without using NRT as an option] we review whether there's any vaping use, and during the questionnaires, when they mark yes, it's really a challenge for me to say anything. I just say it's bad for you. I review the health complications; but whether changes occur [from that such as] stopping vaping? Not very often.\u0026rdquo; (P003)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e2) Provider-level challenges to adoption\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ea) Potential time/work demands of NRT given limited time and other demands\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;With our adolescent visits, we\u0026rsquo;re only given...[a] 20 minute block...They\u0026rsquo;re filling out their PHQ-4 and suicide tests and all the sexual health, and then the drugs, alcohol\u0026hellip;I have X amount of time with this patient and if they vape and they have a high PHQ-4, probably I\u0026rsquo;m gonna focus more on the PHQ-4.\u0026rsquo; That can make it hard.\u0026rdquo; (P008)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eb) Variable provider comfort levels in managing NRT\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Based on the [AAP guidance sheet], coming up with an initial dosage\u0026hellip;I would feel comfortable with that. Ongoing management, tapering and all of that stuff\u0026mdash;I would definitely need more CME before I could feel comfortable managing that.\u0026rdquo; (P007)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e3) Systems- and clinic-level considerations to facilitate NRT use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ea) Confidentiality\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Another thing that I think is important in our population is confidentiality. Trying to figure out how to\u0026mdash;if a patient really wants to stop vaping, but they don't want their family to know they're vaping\u0026hellip;That's always something that comes up in pediatrics.\u0026rdquo; (P005)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eb) Insurance coverage/ affordability\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Another thing that always comes up\u0026hellip;especially our lower income families, is what will be covered by Medicaid\u0026hellip;I may want somebody to be on a NRT and it's not covered so they're just not gonna do it\u0026rdquo; (P003)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ec) Managing NRT follow up\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;My concern is follow-up. I'm never sure if they actually got [the prescription]\u0026hellip;I don't end up seeing them back because we often just see them for their physical\u0026hellip;I would say of the kids I prescribed [NRT] to, I really don't know if they actually took it or not.\u0026rdquo; (P001)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e4) Remaining patient and external barriers to uptake\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ea) Patient perceptions of harms of vaping\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I think when it was more of a short-term possibility of ending up in the hospital [due to lung injury]], that maybe made [our patients] pay a little bit of attention. The long-term, \u0026lsquo;you could get cancer or stuff,\u0026rsquo; they don't listen to that.\u0026rdquo; (P001)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eb) Potential patient preference for \u0026ldquo;non-medication\u0026rdquo; options\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;To be honest, most of them, if they even agree that they wanna cut down, most of 'em say, \"Oh, I can do this on my own. I don't need medicine.\" I would say 90 percent of them.\u0026rdquo; (P001)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ec) Perceived inadequate public policy/health efforts to address youth vaping\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\"I think we haven't done a great job with vaping. Sometimes, our approach to it seems like the\u0026hellip;'Just Say No' campaign of the 1980s, like schools closing their bathrooms at lunch so kids can\u0026rsquo;t just go in there and vape.\u0026rdquo; (P007)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003e5) Culture and infrastructure for practice change that may help or hinder implementation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ea) Standardized communication channels\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I think the communication within the clinic, it's really clear\u0026hellip;we also have staff meetings every month and that's when we review any changes\u0026hellip; I think that really allows so everybody\u0026rsquo;s on\u0026hellip;the same step, on the clinic changes.\u0026rdquo; (P003)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eb) Infrastructure for evaluation and monitoring\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;If you're not monitoring stuff\u0026hellip;attrition is probably the most common thing, is people stop thinking about it, and then they don't do it. Sometimes there's really specific things that might be happening that you might have to dig into.\u0026rdquo; (P001)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ec) Multi-level engagement and support for practice change\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I feel like our clinic overall has a really good team mentality and people would overall be interested in supporting a practice change\u0026hellip;then, yeah, I guess just leadership\u0026mdash;more of the logistical changes that would need to be supported by leadership\u0026rdquo; (P002)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ed) Clinical champion culture\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;On our clinic level, not infrequently, we have a whole bunch of people, a whole bunch of providers, who are champions of this or that or the other thing like\u0026hellip;tobacco cessation and Reach Out \u0026amp; Read.\u0026rdquo; (P006)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ee) \u0026ldquo;Information overload\u0026rdquo;\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I think it's mass-information overload for one thing. Just a constant stream of information, data changing the surveys...Just like, \u0026lsquo;Don't give me one more thing to do, 'cause I'm already maxed out juggling a million balls.\u0026rsquo;\u0026rdquo; (P006)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[INSERT Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e: Themes, subthemes, and exemplar quotes HERE]\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e: Themes, subthemes, and exemplar quotes\u003c/p\u003e \u003cp\u003e \u003cstrong\u003e1) Use of NRT per AAP guidelines as a reasonable option given limited other options\u003c/strong\u003e \u003cp\u003eAll providers interviewed reported the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAAP guidelines recommending consideration of NRT for youth vaping cessation were reasonable\u003c/span\u003e, especially given the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eperceived lack of existing, effective options in their practice\u003c/span\u003e. In general, participants regarded the recommendation that providers consider NRT as an option despite the lack of existing robust trials in youth at the time of guideline development and data collection, but evidence of safety in youth and effectiveness in adults, was justifiable. All providers were okay prescribing NRT for both vaping and other tobacco product use.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e2) Provider-level challenges to increasing adoption\u003c/strong\u003e \u003cp\u003eDespite their confidence in the AAP guidelines, participants raised concern that use of NRT might be a \u0026ldquo;challenging ask\u0026rdquo; of primary care providers.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eIndividuals who had prescribed NRT before noted the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eadditional time and demand prescribing NRT added to visits\u003c/span\u003e including assessing patient readiness to change, awareness of vaping status by family members, counseling on vaping health effects and NRT, and coordinating prescription details such as getting the medication to patients confidentially if needed. This was further made challenging by universal 20-minute appointments for adolescents. When asked about prior practice change interventions that had failed, multiple providers noted interventions that required additional time or mental burden to providers might have a lower chance of success.\u003c/p\u003e \u003cp\u003eProviders shared \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003evarying levels of comfort\u003c/span\u003e using NRT. While some providers had already prescribed NRT, many providers felt comfortable initiating NRT if provided with additional resources but less comfortable independently managing follow up. Only one provider shared they would not feel comfortable initiating or managing on their own but would feel comfortable referring to a clinic champion or specialist.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003e3) \u003cem\u003eSystems and clinic-level considerations to facilitate NRT use\u003c/em\u003e\u003c/strong\u003e \u003cp\u003eProviders brought up systems- and clinic-level considerations that would be necessary to address in order to increase use of NRT. Across these considerations, providers were able to offer examples of existing resources or system changes to potentially bolster NRT use.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eNearly all providers commented on the importance of considering \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003econfidentiality\u003c/span\u003e in prescribing NRT, given many of their patients had not disclosed vaping status to their parents or families. Providers shared considerations of trying to bolster existing practices and systems they had to provide confidential care including confidential visit registration, one-on-one discussions with adolescents, use of an on-site pharmacy, and use of strategies to help provide patient confidentiality in the health communication portal.\u003c/p\u003e \u003cp\u003eMultiple providers shared the importance of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eensuring insurance coverage and affordability\u003c/span\u003e for NRT products. Most patients served by providers in this study had Medicaid and/or came from lower socioeconomic status backgrounds. Providers shared that as part of provider education on NRT, it would be essential to know what specific products were covered by state Medicaid.\u003c/p\u003e \u003cp\u003eMultiple providers raised concern about \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eensuring the follow up of patients\u003c/span\u003e who were started on NRT. This included both providers who had prescribed NRT and those who had not. Multiple providers brought up the fact many adolescent patients would only come annually for their physical or, for some patients, even less frequently. One provider who had previously prescribed NRT mentioned though they had prescribed NRT, they rarely had a chance to see the patient back for follow up to see if it had been helpful or effective.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003e4) \u003cem\u003eRemaining patient and external barriers to uptake\u003c/em\u003e\u003c/strong\u003e \u003cp\u003eProviders reported additional barriers related to patient and external factors they felt were not directly within their control.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eMultiple providers brought up the issue of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003emany patients not seeing vaping as a problem\u003c/span\u003e and with multiple patients being pre-contemplative about quitting vaping let alone using NRT. This included providers who had prescribed NRT previously and those who had not. In individual discussions with patients about vaping, providers also shared many patients appeared to have limited buy-in to descriptions of the health hazards of vaping.\u003c/p\u003e \u003cp\u003eMultiple providers brought up considerations that even among patients who may want to quit, many \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003epatients might prefer \u0026ldquo;non-medication\u0026rdquo; solutions\u003c/span\u003e. Some providers shared this non-medication preference among patients existed for health issues outside of vaping too (e.g., mental health).\u003c/p\u003e \u003cp\u003eMany participants shared that provider prescribing of NRT in isolation may have limited impact in a landscape of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eperceived inadequate public policy/health efforts to address youth vaping to date\u003c/span\u003e. This included concerns wishing for stronger interventions on targeted marketing of vaping products towards younger consumers, stronger bans on flavoring in vapes, ease of access to vaping products by youth, addressing vaping use in schools, and limited societal awareness of treatment options for youth vaping.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003e5) \u003cem\u003eCulture and infrastructure for practice change that may help or hinder uptake of NRT\u003c/em\u003e\u003c/strong\u003e \u003cp\u003eAll providers brought up a strong culture and infrastructure at their institution for practice change that they could envision helping increase uptake of NRT use for youth vaping. However, participants cautioned that ongoing efforts around practice improvement could be a potential \u0026ldquo;double-edged sword,\u0026rdquo; given the quantity of other new efforts.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eMultiple providers cited existing \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003estandardized communication channels\u003c/span\u003e to facilitate dissemination of information about practice improvement efforts. This included routine huddles and staff meetings at clinic sites where introduction to or updates about pilot or quality improvement projects would often be given. Likewise, they cited ongoing email communications about these efforts from leadership or implementers.\u003c/p\u003e \u003cp\u003eSome providers cited the benefit of infrastructure that had been used in prior program improvement efforts to help with \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eevaluation and monitoring\u003c/span\u003e. This included functionality of the electronic medical record being used to track data and metrics. Some providers cited the value and importance of being able to track these metrics to be able to see measures of improvement and to see their own performance on certain metrics as an incentive.\u003c/p\u003e \u003cp\u003eMost providers cited a \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003estrong culture of support for practice change and program improvement at multiple levels\u003c/span\u003e, including system leadership, clinic leadership, providers, and staff. Many providers stressed the importance of program improvement projects that had purposefully engaged individuals at these different levels to help with successful implementation.\u003c/p\u003e \u003cp\u003eMultiple providers described the presence of a \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eclinical champion culture\u003c/span\u003e they felt was conducive to practice change and program improvement. This was typically described at the provider level, with individuals who would spearhead practice improvement efforts important to them and often become a go-to resource for their colleagues. Examples included champions of gender-affirming care, tobacco cessation, interventions to address vaccine hesitancy, and childhood literacy interventions.\u003c/p\u003e \u003cp\u003eMultiple providers brought up that with a culture of ongoing program improvement efforts there also came the feeling of \u0026ldquo;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003einformation overload\u003c/span\u003e\u0026rdquo; at times. This was mentioned in the context of both dissemination of information about ongoing projects as well as expectations that might be added to their delivery of care.\u003c/p\u003e\n\u003ch3\u003eQuantitative Findings\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eItem and Subscale Scores (scored 1\u0026ndash;5, 5\u0026thinsp;=\u0026thinsp;highest score), RC=Reverse Coding\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003ePRISM-CSI Findings (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eOrganizational Perspectives\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFits with clinic priorities\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.65,4.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eWorkflow compatible\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.46,4.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNo advantages compared to SOC (RC)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.81,4.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSite readiness\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.58,4.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMEAN SUBSCALE SCORE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3.81\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.49,4.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatient Perspectives\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eItem\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNegatively impact care (RC)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.89,5.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAligns with patient needs/preferences\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.43,4.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEquitable impact\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.67,4.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eToo difficult for patients (RC)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.95,3.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEasy for patients to access\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.65,3.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMEAN SUBSCALE SCORE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3.64\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.40,3.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImplementation and Sustainability Infrastructure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eItem\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOrganizational support for NRT\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.62,4.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePotential champion at site\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.14,4.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMinimal training needed\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.14,4.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLack resources at site (RC)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.49,4.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMEAN SUBSCALE SCORE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3.75\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.45,4.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOrganizational Characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eItem\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSenior leadership supports innovation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.04,4.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEffective supervisor management PI\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.04,4.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSupervisor support new interventions\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.04,4.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStaff member cooperation with care\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.95,4.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStaff member resistance to change (RC)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.71,4.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePersonally empowered initiate improvements\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.71,4.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMEAN SUBSCALE SCORE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4.35\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.20,4.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatient characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eItem\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePatients trust clinicians\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.86,4.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIntroducing new interventions hard with patients (RC)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.67,4.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePatient complexity as a barrier (RC)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.67,4.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMEAN SUBSCALE SCORE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3.63\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.23,3.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExternal Environment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eItem\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNRT still feasible with future practice changes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.62,4.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCurrent events as barrier (RC)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.77,4.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRegional/national mandates as barrier (RC)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.95,3.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMEAN SUBSCALE SCORE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3.59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.32,3.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA summary of means, standard deviations, and 95% confidence intervals for all items and subscales asked in the PRISM CSI survey are found in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Overall, 16 items\u0026rsquo; mean values were positively scored (\u0026ge;\u0026thinsp;3.50 on a 1\u0026ndash;5 rated ordinal scale), 9 items\u0026rsquo; mean values were in a neutral range (2.50\u0026ndash;3.49), and no items\u0026rsquo; mean values were negatively rated (\u0026lt;\u0026thinsp;2.50). Items ranked in order of mean scores are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The highest rated items had a mean score of 4.44 (SD 0.53, 95% CI: 4.04, 4.85) and included perceptions that NRT would not negatively impact care, senior leadership supported innovation, supervisor management of program improvement efforts was effective, and clinic supervisors supported innovation. The lowest rated item asking if NRT would be easy for patients to access had a mean score of 3.11 (SD 0.60, 95% CI: 2.65, 3.57).\u003c/p\u003e \u003cp\u003eThe mean subscale scores for each PRISM subscale in the PRISM-CSI are also found in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. All mean subscale scores were positively rated (\u0026ge;\u0026thinsp;3.50). The highest rated subscale was Organizational Characteristics with a mean score of 4.35 (SD 0.56, 95% CI: 4.20, 4.50) and the lowest rated subscale was External Environment with a mean score of 3.59 (SD 0.69, 95% CI: 3.32, 3.87).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMixed Methods Findings:\u003c/h2\u003e \u003cp\u003eA joint display demonstrating meta-inferences from the integration of qualitative themes/subthemes and PRISM-CSI item mean scores can be found in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eJoint Display of Integrated Qualitative and Quantitative Findings, RC=Reverse coding\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePRISM CSI Item\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMeta-Inference\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1) Use of NRT per AAP as a reasonable option, given limited other options\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePositive Factors (\u0026ge;\u0026thinsp;4.00)\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e\u0026bull; Negatively impact care (RC): 4.44\u003c/p\u003e \u003cp\u003e\u0026bull; Fits with clinic priorities: 4.11\u003c/p\u003e \u003cp\u003e\u0026bull; Organizational support for NRT: 4.00\u003c/p\u003e \u003cp\u003e\u003cb\u003eModerate Positive Factors (3.50\u0026ndash;3.99)\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e\u0026bull; Alignment patients\u0026rsquo; wants/needs: 3.89\u003c/p\u003e \u003cp\u003e\u0026bull; No advantages compared to standard of care (RC): 3.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eNRT guidelines were accepted by providers and likely to receive multi-level support. Given the limited options for addressing youth vaping, NRT was considered a good option\u003c/b\u003e (Convergent, Complementary)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e2) Provider-level challenges to adoption\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ea) Potential time/work demands of NRT given limited time and other demands\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePositive factors (\u0026ge;\u0026thinsp;4.00)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Workflow compatible: 4.00\u003c/p\u003e \u003cp\u003e\u003cb\u003eNeutral factors (2.50\u0026ndash;3.49)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Introducing new interventions hard with patients (RC): 3.44\u003c/p\u003e \u003cp\u003e\u0026bull; Minimal resources at site (RC): 3.44\u003c/p\u003e \u003cp\u003e\u0026bull; Site readiness: 3.44\u003c/p\u003e \u003cp\u003e\u0026bull; Patient complexity as a barrier (RC): 3.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eThough using NRT may add time or burden to clinic visits, providers felt it was feasible to integrate prescription of NRT into workflow\u003c/b\u003e (Divergent, Complementary)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eb) Variable provider comfort levels in managing NRT\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eModerate positive factors (3.50\u0026ndash;3.99)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Minimal training required: 3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eWhen given AAP resources, most providers feel they need little extra training to prescribe NRT, though confidence in specific aspects of NRT management differed\u003c/b\u003e (Complementary)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e3) Systems- and clinic-level considerations to facilitate NRT use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ea) Confidentiality\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePositive factors (\u0026ge;\u0026thinsp;4.00)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Patients trust clinicians: 4.11\u003c/p\u003e \u003cp\u003e\u003cb\u003eModerate positive factors (3.50\u0026ndash;3.99)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Aligns with patients\u0026rsquo; preferences and needs: 3.89\u003c/p\u003e \u003cp\u003e\u003cb\u003eNeutral factors (2.50\u0026ndash;3.49)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Easy for patients to access: 3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eConfidentiality concerns influence patient access to NRT. Strengthening systems to protect youth privacy are crucial for adoption (\u003c/b\u003eConvergent, Complementary)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eb) Insurance coverage/ affordability\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eModerate positive factors (3.50\u0026ndash;3.99)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Aligns with patients\u0026rsquo; preferences and needs: 3.89\u003c/p\u003e \u003cp\u003e\u003cb\u003eNeutral factors (2.50\u0026ndash;3.49)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Equitable impact: 3.44\u003c/p\u003e \u003cp\u003e\u0026bull; Current events impact NRT: 3.44\u003c/p\u003e \u003cp\u003e\u0026bull; Easy for patients to access: 3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eInsurance coverage and cost would affect access to NRT. Understanding coverage and affordable options for NRT are essential\u003c/b\u003e (Convergent, Complementary)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ec) Managing NRT follow up\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eModerate positive factors (3.50\u0026ndash;3.99)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Aligns with patients\u0026rsquo; preferences and needs: 3.89\u003c/p\u003e \u003cp\u003e\u003cb\u003eNeutral factors (2.50\u0026ndash;3.49)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Equitable impact: 3.44\u003c/p\u003e \u003cp\u003e\u0026bull; Lack resources at site (RC): 3.44\u003c/p\u003e \u003cp\u003e\u0026bull; Site readiness: 3.44\u003c/p\u003e \u003cp\u003e\u0026bull; Too difficult for patients (RC): 3.33\u003c/p\u003e \u003cp\u003e\u0026bull; Easy for patients to access: 3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eManaging follow up for NRT prescriptions is key to implementation and may require site-specific strategies based on resources and readiness\u003c/b\u003e (Convergent, Complementary)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e4) Remaining patient and external barriers to uptake\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ea) Patient perceptions of harms of vaping\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eModerate positive factors (3.50\u0026ndash;3.99)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Aligns with patients\u0026rsquo; preferences and needs: 3.89\u003c/p\u003e \u003cp\u003e\u003cb\u003eNeutral factors (2.50\u0026ndash;3.49)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Equitable impact: 3.44\u003c/p\u003e \u003cp\u003e\u0026bull; Current events as barrier (RC): 3.44\u003c/p\u003e \u003cp\u003e\u0026bull; Patient complexity as a barrier (RC): 3.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eLow perceived harm of vaping may hinder youth uptake of NRT. Providers\u0026rsquo; views on what patients \u0026lsquo;need\u0026rsquo; may differ from what patients \u0026lsquo;want\u0026rsquo;\u003c/b\u003e (Divergent, Complementary)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eb) Potential patient preference for \u0026ldquo;non-medication\u0026rdquo; options\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eModerate positive factors (3.50\u0026ndash;3.99)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Aligns with patients\u0026rsquo; preferences and needs: 3.89\u003c/p\u003e \u003cp\u003e\u0026bull; No advantages compared to SOC (RC): 3.67\u003c/p\u003e \u003cp\u003e\u003cb\u003eNeutral factors (2.50\u0026ndash;3.49)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Equitable impact: 3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ePatients may prefer non-medication options for vaping cessation, but current alternatives may be limited\u003c/b\u003e (Divergent, Complementary)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ec) Perceived inadequate public policy/health efforts to address youth vaping\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNeutral factors (2.50\u0026ndash;3.49)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Current events as barrier (RC): 3.44\u003c/p\u003e \u003cp\u003e\u0026bull; Regional/national mandates as a barrier (RC): 3.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eUse of NRT in isolation without strengthening other ongoing public policy/health efforts to address youth vaping may be challenging\u003c/b\u003e (Convergent, Complementary)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003e5) Culture and infrastructure for practice change that may help or hinder implementation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ea) Standardized communication channels\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePositive factors (\u0026ge;\u0026thinsp;4.00)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Senior leadership supports innovation: 4.44\u003c/p\u003e \u003cp\u003e\u0026bull; Effective supervisor management PI: 4.44\u003c/p\u003e \u003cp\u003e\u003cb\u003eModerately positive factors (3.50\u0026ndash;3.99)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Minimal training required: 3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eExisting communication channels for practice change could help facilitate NRT implementation\u003c/b\u003e (Convergent, Complementary)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eb) Infrastructure for evaluation and monitoring\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNeutral factors (2.50\u0026ndash;3.49)\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e\u0026bull; Lack resources at site (RC): 3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eExisting evaluation and monitoring systems could support NRT use, but ensuring adequate resources across sites is important\u003c/b\u003e (Divergent, Complementary)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ec) Multi-level engagement and support for practice change\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePositive factors (\u0026ge;\u0026thinsp;4.00)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Senior leadership supports innovation: 4.44\u003c/p\u003e \u003cp\u003e\u0026bull; Effective supervisor management PI: 4.44\u003c/p\u003e \u003cp\u003e\u0026bull; Supervisor supports new innovations: 4.44\u003c/p\u003e \u003cp\u003e\u0026bull; Staff member cooperation with care: 4.33\u003c/p\u003e \u003cp\u003e\u0026bull; Staff member resistance to change (RC): 4.22\u003c/p\u003e \u003cp\u003e\u0026bull; Organizational support for NRT: 4.00\u003c/p\u003e \u003cp\u003e\u003cb\u003eModerate positive factors (3.50\u0026ndash;3.99)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Potential champion at site: 3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eBuy-in to practice change efforts at multiple levels within the organization may help facilitate implementation of NRT\u003c/b\u003e (Convergent)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ed) Clinical champion culture\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePositive factors (\u0026ge;\u0026thinsp;4.00)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Personally empowered to initiate improvements: 4.22\u003c/p\u003e \u003cp\u003e\u003cb\u003eModerately positive (3.50\u0026ndash;3.99)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Potential champion at site: 3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eAn existing culture of identifying clinical champions to support practice change exists within the organization and could facilitate NRT\u003c/b\u003e (Convergent)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ee) \u0026ldquo;Information overload\u0026rdquo;\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePositive factors (\u0026ge;\u0026thinsp;4.00)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Personally empowered to initiate improvements: 4.22\u003c/p\u003e \u003cp\u003e\u0026bull; Fits with clinic priorities: 4.11\u003c/p\u003e \u003cp\u003e\u0026bull; NRT still feasible with future practice changes: 4.00\u003c/p\u003e \u003cp\u003e\u0026bull; Workflow compatible: 4.00\u003c/p\u003e \u003cp\u003e\u003cb\u003eModerately positive factors (3.50\u0026ndash;3.99)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; Minimal training required: 3.78\u003c/p\u003e \u003cp\u003e\u003cb\u003eNeutral factors (2.50\u0026ndash;3.49)\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e\u0026bull; Patient complexity as a barrier (RC): 3.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eWhile ongoing practice changes can feel overwhelming for some providers, implementing NRT may be feasible and prioritized\u003c/b\u003e (Divergent, Complementary)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[INSERT Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e: Joint Display of Integrated Qualitative and Quantitative Findings, RC=Reverse coding HERE]\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e: Joint Display of Integrated Qualitative and Quantitative Findings, RC=Reverse coding\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConvergence\u003c/strong\u003e \u003cp\u003eMost quantitative and qualitative findings were found to be convergent, with quantitative item mean scores demonstrating positive or neutral directionality consistent with linked qualitative subthemes. Eight subthemes and all 5 themes were assessed to have some degree of convergence with corresponding survey item mean scores. This included\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eUse of NRT as a reasonable option (qualitative) and positive mean score of not negatively impacting care or having no advantages compared to standard of care (quantitative)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eConfidentiality concerns (qualitative) and positive mean score for patients trusting clinicians and neutral mean score for NRT being easy for patients to access (quantitative)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eInsurance coverage/affordability (qualitative) and neutral mean scores for ease of access and equitable impact (quantitative)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSystems to help with follow up on NRT (qualitative) and neutral mean scores for sufficient resources at site and site readiness (quantitative)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePerceived inadequate public health/policy efforts (qualitative) and neutral mean scores for current events and regional/national mandates (quantitative)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStandardized communication channels (qualitative) and effective supervisor management of program improvement (quantitative)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMulti-level support for practice change (qualitative) and organizational/senior leadership/staff member/supervisor support for innovation (quantitative)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eClinical champion culture (qualitative) and personal empowerment to initiate improvements and potential champion at site (quantitative)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDivergence\u003c/strong\u003e \u003cp\u003e5 subthemes were assessed to have a mild degree of divergence with mean survey scores. In general, main areas of divergence considered mean item scores providing more \u0026ldquo;positive\u0026rdquo; responses than were extrapolated in qualitative findings. Key areas of divergence and resulting meta-inferences are described below.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTime/work demands of NRT (qualitative) and workflow compatibility (quantitative)\u003c/strong\u003e \u003cp\u003eThe qualitative assessment that NRT would add time/work demands to provider workflow appeared to be at odds with a positively rated mean score on a survey item asking about workflow compatibility. \u003cem\u003eThis meta-inference was integrated to acknowledge the reported increased time/work demands of NRT but recognizing, despite this, providers appeared to feel prescribing NRT could be feasible within their existing workflow.\u003c/em\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePatient perceptions of vaping and preference for non-medication treatment (qualitative) and alignment with patient needs/preferences (quantitative)\u003c/strong\u003e \u003cp\u003eThe patient-level factor noted that patients\u0026rsquo; perceptions of the limited harm of vaping and preference for non-medication cessation treatment options appeared to contradict a positively rated mean score on a survey item asking if use of NRT aligned with patients\u0026rsquo; needs and preferences. On assessment during integration, the authors noted the double-barreled nature of the original survey item in asking about patients\u0026rsquo; \u003cem\u003eneeds\u003c/em\u003e vs their \u003cem\u003epreferences\u003c/em\u003e. Additionally, the item does not delineate if the patients\u0026rsquo; needs are aligned with what providers think the patient may need versus what patients may think they need. The \u003cem\u003emeta-inference was integrated to acknowledge that patients\u0026rsquo; perceptions of harm of vaping and potential preference for non-medication treatments may be a barrier but there may be a discrepancy between what providers feel what patients \u0026ldquo;need\u0026rdquo; versus what they \u0026ldquo;want.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInfrastructure for evaluation/monitoring (qualitative) and lacking resources at site (quantitative)\u003c/strong\u003e \u003cp\u003eWe noted during integration that the qualitative finding that the health system had strong evaluation and monitoring infrastructure appeared to be at odds with a more neutrally rated item about providers feeling like they lacked resources at their site to use NRT. \u003cem\u003eThe meta-inference was integrated to acknowledge that while there is reported infrastructure for evaluation and monitoring, assessment of resources at a clinic/site level generally may be important to the implementing NRT for youth vaping cessation.\u003c/em\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e\u0026ldquo;Information overload\u0026rdquo; (qualitative) and NRT still feasible with other practice changes (quantitative)\u003c/strong\u003e \u003cp\u003eDuring integration, we noted that the qualitative finding that care should be taken to not \u0026ldquo;overload\u0026rdquo; providers given the possibility of introducing NRT at the same time as many other program improvement projects appeared to be at odds with the positively valued survey item that NRT would still be feasible with other practice changes. \u003cem\u003eThe meta-inference was integrated to acknowledge that though the culture of many program improvement programs could be overwhelming, providers specifically felt using NRT would be feasible within this context.\u003c/em\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eComplementarity\u003c/strong\u003e \u003cp\u003eAll subthemes and themes were felt to have some degree of complementary information that was provided by either the qualitative or quantitative strand. In general, quantitative results provided an assessment of valence (positive or neutral) of a given construct that might be linked in qualitative findings. Qualitative results most often expanded upon quantitative survey items that might be more broadly worded and provided specific examples of the quantitative construct being assessed (e.g. affordability addressed during interviews informing a neutral mean score response on the survey item asking about ease of patient access). Complementary findings were added where applicable to meta-inferences.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInforming Program Improvement Effort Implementation Strategies:\u003c/h3\u003e\n\u003cp\u003eIn addition to generating transferable findings on the implementation of AAP guidelines for NRT, this study sought to provide real-time, actionable findings to the PI team working on youth vaping cessation. After sharing findings with the PI team, strategies developed to support increased NRT use included focus on provider-informed preferred topics for provider education, working to identify existing systems in place to provide confidential care, engaging youth directly on preferred options for vaping cessation that could be paired with NRT, finding dedicated clinical champions for youth vaping cessation and NRT, and integrating additional clinical resources and tools into provider workflows to facilitate NRT use and referrals for youth vaping cessation (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study was a comprehensive, mixed-methods case study of a single health system using qualitative key informant interviews and a quantitative, modified PRISM-CSI survey to explore the determinants of implementing guidelines on the use of NRT for youth vaping in primary care. While the AAP guidelines to consider NRT for youth vaping cessation were considered acceptable and aligned with a pressing health concern, participants identified multiple important determinants to the implementation of NRT in practice. Providers noted specific concerns such as confidentiality considerations of patients who vape, ensuring affordability and insurance coverage of NRT products, and establishing systems of adequate follow up and management of NRT. There were certain determinants felt to be less in direct control of providers, including potential patient perceptions of the harms of vaping and medication-based treatment as well as the perceived need to continue strengthening public health and policy efforts to address the ubiquity and access of vaping products for youth.\u003c/p\u003e \u003cp\u003eDespite this, and though it appears using NRT to address youth vaping would pose added time to visits with need for some additional training and support, providers felt it could be integrated into their workflow. Likewise, specific to the health system they worked in, providers felt the existing infrastructure and culture around practice change could facilitate the implementation of guidelines around NRT and that it could be implemented around ongoing program improvement efforts at their institution.\u003c/p\u003e \u003cp\u003ePerspectives on the use of NRT fit into the larger landscape of determining what clinical and public health interventions might be feasible and effective to address youth vaping. Interventions have often focused on digital interventions such as This is Quitting [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] and new smartphone apps [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] as well as school-based interventions such as CATCH my Breath [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] but the evidence for other interventions continues to evolve. Even after completion of data collection for this study, a new randomized controlled trial demonstrated the promising effectiveness of varenicline, another pharmacotherapy agent for nicotine cessation, combined with counseling for youth and young adults.[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] The evidence of this RCT was not available during the creation of the 2023 AAP guidelines and reflects the pace at which evidence-based interventions may emerge and guidelines may change. Given this, the findings from this study highlight the importance of considering NRT as a potential option at this moment in time for the right patient in the right context and, if used, should be considered in the context of rapidly evolving evidence and new treatment options. As providers also highlighted in this study, it is important for vaping prevention and cessation advocates to continue bolstering both clinical \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eand\u003c/span\u003e public health/policy interventions. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThough not the specific focus of this study, our findings also provide insights into the value of clinical practice guidelines and their role in influencing clinical care. In this instance, providers shared their trust of and buy-in to the AAP guidelines presented to them and felt the justification for the recommendation presented was reasonable. This is consistent with prior findings of where practitioners prefer to receive information about evidence-based practice and trust in professional associations.[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] The provision of additional resources accompanying the recommendation were also seen as helpful in supporting provider self-efficacy and comfort with the guideline. It likewise demonstrates the importance of assessing the fit of guidelines to the specific context of implementation. In this study, for example, providers shared the importance of considerations such as confidentiality concerns, potential patient preferences for non-medication options, or patients’ perceived need for NRT that may limit uptake of guideline recommendations. While methods for CPG development often emphasize considering context, interest holder perspectives, and barriers to implementation,\u003csup\u003e8\u003c/sup\u003e this study provides valuable insight into the implementation of a specific guideline in a real-world setting.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLimitations\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eImportant limitations should be noted. Though the authors intend for the findings have transferability to inform further research in other similar settings, care should be taken to not extrapolate the generalizability of these findings from a mixed-methods case study of 9 clinicians in a single health system. Given the health system we conducted this study was in the pre-implementation phase of planned implementation of improving youth vaping services, provider perspectives on system support for NRT may have been higher than what would be expected in a system where this was not ongoing. Additionally, though we purposively sampled individuals who had prescribed NRT for youth previously, this has the potential to introduce a greater degree of confidence or support for NRT in responses. Due to the use of the same participants for sequential interviews and surveys and an inability to fully anonymize survey responses, the potential for social desirability bias should also be noted. Finally, although we explored a range of PRISM factors from the perspective of primary care providers who would deliver NRT, this study did not directly assess the perspectives of other important interest holders including youth, organizational decision makers, or clinic staff members.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates the potential promise of having NRT as an option for youth vaping cessation in primary care while acknowledging potentially important determinants of prescribing and accessing NRT in practice. Further research should involve engagement with other key interest holders that would be necessary for the implementation of NRT and other youth vaping cessation guidelines. This is especially true of engaging youth who use vaping products to gauge interest in different treatment options. Likewise, research situating NRT specifically within the context of novel, emerging treatments, public health efforts, and policy interventions would be beneficial for the field.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNRT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNicotine Replacement Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Academy of Pediatrics\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePRISM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePractical, Robust Implementation and Sustainability Model\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRE-AIM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eReach, Effectiveness, Adoption, Implementation, Maintenance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePRISM-CSI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePRISM Contextual Survey Instrument\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eReverse coding\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGRAMMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGood Reporting of A Mixed Methods Study\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was deemed to be exempt human subjects research by the authors\u0026rsquo; university institutional review board (#25-0313).\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials: \u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed for this study are available from the corresponding author on reasonable request. Materials used for this study, including PRISM-guided interview guides and modified PRISM-CSI instrument, are also available from the corresponding author on reasonable request. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (T3HP242016) totaling $2,243,839.00 with 0% percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.\u003c/p\u003e\n\n\u003cp\u003eThe Denver Health grant team (program improvement team) was funded through a subcontract as the Mental Health Provider for the Combatting Youth Vaping grant, administered by the Denver Department of Public Health and Environment who received funding from the Colorado Attorney General\u0026rsquo;s office through disbursement of JUUL settlement funds. This project totaled $197,000 amount over 19 months.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor contributions:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJC contributed to the conceptualization, design, data acquisition, analysis, interpretation, and drafting and revision of the manuscript. CR contributed to the design, data acquisition, analysis, interpretation, drafting and revision of the manuscript. BB contributed to the conceptualization, data acquisition, interpretation, and revision of the manuscript. BD contributed to the design, analysis, interpretation, and revision of the manuscript. RG contributed to the conceptualization, design, interpretation, and revision of the manuscript. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the Denver Health Youth Vaping Cessation team including Erin Harris, Sedona Allen, Valerie Castanon, Tyrone Braxton, Kristie Ladegard, David Vargas Ayala, Laura Elliott, Kelly Shaffer, and Angel Wood. They would also like to thank the ACCORDS Primary Care Research fellowship mentorship, co-fellows, and team including Amy Huebschmann (who also helped review this paper), Mandy Allison, Elizabeth Bayliss, Romana Hasnain-Wynia, Allison Kempe, Emily Dunston, Bailey Martin, Michael Mattiucci, David Higgins, and Kyle Haws. The authors would also like to thank Gina Kruse for reviewing this paper and insights/expertise in tobacco cessation. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJamal A, Park-Lee E, Birdsey J, Agaku IT, Hu SS, Cullen KA, et al. Tobacco product use among middle and high school students \u0026mdash; National Youth Tobacco Survey, United States, 2024. MMWR Morb Mortal Wkly Rep. 2024;73(41):917\u0026ndash;24. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.15585/mmwr.mm7341a2\u003c/span\u003e\u003cspan address=\"10.15585/mmwr.mm7341a2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFurlow B. Youth vaping rates drop in US, but experts remain concerned. Lancet Respir Med. 2024;12(12):944. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2213-2600(24)00340-0\u003c/span\u003e\u003cspan address=\"10.1016/S2213-2600(24)00340-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarrington-Trimis JL, Urman R, Berhane K, Unger JB, McConnell R, Pentz MA, et al. E-cigarettes and future cigarette use. Pediatrics. 2016;138(1):e20160379. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.2016-0379\u003c/span\u003e\u003cspan address=\"10.1542/peds.2016-0379\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCastro EM, Lotfipour S, Leslie FM. Nicotine on the developing brain. Pharmacol Res. 2023;190:106716. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.phrs.2023.106716\u003c/span\u003e\u003cspan address=\"10.1016/j.phrs.2023.106716\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLechner WV, Janssen T, Kahler CW, Audrain-McGovern J, Leventhal AM. Bi-directional associations of electronic and combustible cigarette use onset patterns with depressive symptoms in adolescents. Prev Med. 2017;96:73\u0026ndash;78. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ypmed.2016.12.034\u003c/span\u003e\u003cspan address=\"10.1016/j.ypmed.2016.12.034\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShehata SA, Toraih EA, Ismail EA, Hagras AM, Elmorsy E, Fawzy MS. Vaping, environmental toxicants exposure, and lung cancer risk. Cancers (Basel). 2023;15(18):4525. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/cancers15184525\u003c/span\u003e\u003cspan address=\"10.3390/cancers15184525\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBecker TD, Rice TR. Youth vaping: a review and update on global epidemiology, physical and behavioral health risks, and clinical considerations. Eur J Pediatr. 2022;181(2):453\u0026ndash;62. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00431-021-04220-x\u003c/span\u003e\u003cspan address=\"10.1007/s00431-021-04220-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrasad M. Introduction to the GRADE tool for rating certainty in evidence and recommendations. Clin Epidemiol Glob Health. 2024;25:101484. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.cegh.2023.101484\u003c/span\u003e\u003cspan address=\"10.1016/j.cegh.2023.101484\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839-42. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1503/cmaj.090449\u003c/span\u003e\u003cspan address=\"10.1503/cmaj.090449\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFahim C, Prashad AJ, Silveira K, Chandraraj A, Thombs BD, Tonelli M, et al. Dissemination and implementation of clinical practice guidelines: a longitudinal, mixed-methods evaluation of the Canadian Task Force on Preventive Health Care's knowledge translation efforts. CMAJ Open. 2023;11(4):E684-95. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.9778/cmajo.20220121\u003c/span\u003e\u003cspan address=\"10.9778/cmajo.20220121\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNagraj SK, Hafver TL, Hohlfeld A, Effa E, Mabetha D, Kunje G, et al. Dissemination strategies of clinical practice guidelines-mixed methods evidence synthesis protocol. Clin Public Health Guidel. 2025;2(2):e70012. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/gin2.70012\u003c/span\u003e\u003cspan address=\"10.1002/gin2.70012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Academy of Pediatrics Steering Committee on Quality Improvement and Management. Classifying recommendations for clinical practice guidelines. Pediatrics. 2004;114(3):874\u0026ndash;877. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.2004-1260\u003c/span\u003e\u003cspan address=\"10.1542/peds.2004-1260\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShiffman RN, Marcuse EK, Moyer VA, Finnell SM, Ganiats TG, Neber SJ, et al. American Academy of Pediatrics Steering Committee on Quality Improvement and Management. Toward transparent clinical policies. Pediatrics. 2008;121(3):643\u0026ndash;646. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.2007-3398\u003c/span\u003e\u003cspan address=\"10.1542/peds.2007-3398\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJenssen BP, Walley SC, Boykan R, Little MA, McGrath-Morrow SA, Quigley J, et al; American Academy of Pediatrics, Section on Nicotine and Tobacco Prevention and Treatment, Committee on Substance Use Prevention. Technical report: Protecting children and adolescents from tobacco and nicotine. Pediatrics. 2023;151(5):e2023061806. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.2023-061806\u003c/span\u003e\u003cspan address=\"10.1542/peds.2023-061806\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJenssen BP, Walley SC, Boykan R, Little MA, McGrath-Morrow SA, Quigley J, et al. Protecting children and adolescents from tobacco and nicotine. Pediatrics. 2023;151(5):e2023061805. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.2023-061805\u003c/span\u003e\u003cspan address=\"10.1542/peds.2023-061805\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Academy of Pediatrics. Nicotine replacement therapy and adolescent patients: information for pediatricians [Internet]. Itasca (IL): American Academy of Pediatrics; [cited 2026 Jan 23]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://downloads.aap.org/AAP/PDF/NRT_and_Adolescents_Pediatrician_Guidance_factsheet.pdf\u003c/span\u003e\u003cspan address=\"https://downloads.aap.org/AAP/PDF/NRT_and_Adolescents_Pediatrician_Guidance_factsheet.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuitWorks-NH. Nicotine treatment for youth patients. New Hampshire Department of Health and Human Services; 2025 [Cited 30 December 2025]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://quitworksnh.org/education-training/treating-special-populations/nicotine-treatment-for-youth-patients/\u003c/span\u003e\u003cspan address=\"https://quitworksnh.org/education-training/treating-special-populations/nicotine-treatment-for-youth-patients/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCity and County of Denver Department of Public Health \u0026amp; Environment. Mental health provider for Denver youth vaping cessation \u0026amp; mental health initiative [Internet]. Denver (CO): BidNet Direct; 2024 Aug 9 [cited 2026 Jan 20]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bidnetdirect.com/colorado/city-and-county-of-denver-environmental-health/solicitations/Mental-Health-Provider-for-Denver-Youth-Vaping-Cessation-Mental-Health-Initiat/0000359761\u003c/span\u003e\u003cspan address=\"https://www.bidnetdirect.com/colorado/city-and-county-of-denver-environmental-health/solicitations/Mental-Health-Provider-for-Denver-Youth-Vaping-Cessation-Mental-Health-Initiat/0000359761\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTyler A, Glasgow RE. Implementing improvements: opportunities to integrate quality improvement and implementation science. Hosp Pediatr. 2021;11(5):536\u0026ndash;545. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/hpeds.2020-002246\u003c/span\u003e\u003cspan address=\"10.1542/hpeds.2020-002246\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernandez ME, Ten Hoor GA, van Lieshout S, Rodriguez SA, Beidas RS, Parcel GS, et al. Implementation mapping: using intervention mapping to develop implementation strategies. Front Public Health. 2019;7:158. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpubh.2019.00158\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2019.00158\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeldstein AC, Glasgow RE. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008;34(4):228\u0026ndash;43. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s1553-7250(08)34030-6\u003c/span\u003e\u003cspan address=\"10.1016/s1553-7250(08)34030-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlasgow RE, Trinkley KE, Ford BS, Rabin BA. The application and evolution of the Practical Robust Implementation and Sustainability Model (PRISM): history and innovations. Glob Implement Res Appl. 2024. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s43477-024-00134-6\u003c/span\u003e\u003cspan address=\"10.1007/s43477-024-00134-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrinkley KE, Glasgow RE, D\u0026rsquo;Mello S, Fort MP, Ford B, Rabin BA. The iPRISM webtool: an interactive tool to pragmatically guide the iterative use of the Practical, Robust Implementation and Sustainability Model in public health and clinical settings. Implement Sci Commun. 2023;4:116. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s43058-023-00494-4\u003c/span\u003e\u003cspan address=\"10.1186/s43058-023-00494-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFetters MD. The mixed methods research workbook: activities for designing, implementing, and publishing projects. Thousand Oaks (CA): SAGE Publications; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor B, Henshall C, Kenyon S, Litchfield I, Greenfield S. Can rapid approaches to qualitative analysis deliver timely, valid findings to clinical leaders? A mixed methods study comparing rapid and thematic analysis. BMJ Open. 2018;8(10):e019993. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2017-019993\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2017-019993\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAverill JB. Matrix analysis as a complementary analytic strategy in qualitative inquiry. Qual Health Res. 2002;12(6):855\u0026ndash;66. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/104973230201200611\u003c/span\u003e\u003cspan address=\"10.1177/104973230201200611\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePittman JOE, Lindamer L, Almklov E, Glasgow RE, Huebschmann AG, Trinkley KE, et al. Development of a pragmatic measure for the Practical, Robust Implementation and Sustainability Model. Psychol Serv. 2025;22(4):634\u0026ndash;40. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/ser0000947\u003c/span\u003e\u003cspan address=\"10.1037/ser0000947\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Cathain A, Murphy E, Nicholl J. The quality of mixed methods studies in health services research. J Health Serv Res Policy. 2008;13(2):92\u0026ndash;8. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1258/jhsrp.2007.007074\u003c/span\u003e\u003cspan address=\"10.1258/jhsrp.2007.007074\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGale RC, Wu J, Erhardt T, Asch SM, Findley PA, Gifford AL, et al. Comparison of rapid vs in-depth qualitative analytic methods from a process evaluation of academic detailing in the Veterans Health Administration. Implement Sci. 2019;14(1):11. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13012-019-0853-y\u003c/span\u003e\u003cspan address=\"10.1186/s13012-019-0853-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamilton AB, Finley EP. Qualitative methods in implementation research: an introduction. Psychiatry Res. 2019;280:112516. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.psychres.2019.112516\u003c/span\u003e\u003cspan address=\"10.1016/j.psychres.2019.112516\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377\u0026ndash;81. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jbi.2008.08.010\u003c/span\u003e\u003cspan address=\"10.1016/j.jbi.2008.08.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):108. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13012-017-0635-3\u003c/span\u003e\u003cspan address=\"10.1186/s13012-017-0635-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStataCorp. Stata statistical software: Release 19. College Station (TX): StataCorp LLC; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGraham AL, Amato MS, Cha S, Jacobs MA, Bottcher MM, Papandonatos GD. Effectiveness of a vaping cessation text message program among young adult e-cigarette users: a randomized clinical trial. JAMA Intern Med. 2021;181(7):923\u0026ndash;30. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamainternmed.2021.1793\u003c/span\u003e\u003cspan address=\"10.1001/jamainternmed.2021.1793\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalmer AM, Tomko RL, Squeglia LM, Gray KM, McClure EA, Carpenter MJ. A pilot feasibility study of a behavioral intervention for nicotine vaping cessation among young adults delivered via telehealth. Drug Alcohol Depend. 2022;232:109311. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.drugalcdep.2022.109311\u003c/span\u003e\u003cspan address=\"10.1016/j.drugalcdep.2022.109311\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelder SH, Mantey DS, Van Dusen D, Case K, Haas A, Springer AE. A middle school program to prevent e-cigarette use: a pilot study of \"CATCH My Breath\". Public Health Rep. 2020;135(2):220\u0026ndash;9. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0033354919900887\u003c/span\u003e\u003cspan address=\"10.1177/0033354919900887\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvins AE, Cather C, Reeder HT, Evohr B, Potter K, Pachas GN, et al. Varenicline for youth nicotine vaping cessation: a randomized clinical trial. JAMA. 2025;333(21):1876\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. E-cigarette use among youth and young adults: a report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US); 2016. Chapter, The call to action. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK538685/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK538685/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJenssen BP, Walley SC, Boykan R, Little Caldwell A, Camenga D, SECTION ON NICOTINE AND TOBACCO PREVENTION AND TREATMENT, et al. Protecting children and adolescents from tobacco and nicotine. Pediatrics. 2023;151(5):e2023061804. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.2023-061804\u003c/span\u003e\u003cspan address=\"10.1542/peds.2023-061804\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShato T, Kepper MM, McLoughlin GM, Tabak RG, Glasgow RE, Brownson RC. Designing for dissemination among public health and clinical practitioners in the USA. J Clin Transl Sci. 2023;8(1):e8. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/cts.2023.695\u003c/span\u003e\u003cspan address=\"10.1017/cts.2023.695\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"youth vaping cessation, nicotine replacement therapy, clinical practice guidelines","lastPublishedDoi":"10.21203/rs.3.rs-8743595/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8743595/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Rates of youth vaping have become a major concern over the past decade with worries about impacts of vaping on neurodevelopment, mental health, transition to cigarettes, and unknown long-term physical sequelae. In 2023, the American Academy of Pediatrics (AAP)’s updated tobacco care guidelines encouraged primary care providers to consider using nicotine replacement therapy (NRT) products to help support youth vaping and tobacco cessation. This study sought to explore the determinants to using NRT products for youth vaping cessation per AAP recommendations amongst primary care providers in an urban, safety-net health system where use of NRT for youth was limited.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods: This study used a mixed-methods case study design guided by the Practical, Robust Implementation and Sustainability Model (PRISM). Nine primary care providers caring for patients aged 12-17 completed key informant interviews and a modified version of the PRISM Contextual Survey Instrument (PRISM-CSI) between May and July 2025. Qualitative analysis was done using a rapid matrix approach and quantitative analysis was descriptive in nature. Themes/subthemes and mean PRISM-CSI item scores were integrated to generate final mixed meta-inferences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults: 5 themes with 13 subthemes emerged from qualitative analysis. In quantitative analysis, all PRISM-CSI item mean scores were rated as either neutral (2.50-3.49 on 1-5 rated ordinal scale) or positive (≥3.50). A total of 14 meta-inferences were generated from integration of qualitative and quantitative results, showing that AAP guidelines on NRT were considered acceptable and met an important need, but contextual determinants important to implementation included addressing time/work demands, provider training, confidentiality, insurance coverage/affordability, managing follow up, youth perceptions of harms and treatment preferences, perceived limited concurrent public health/policy intervention, and bolstering existing practice change infrastructure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusions: AAP guidelines on NRT were considered reasonable by providers interviewed and surveyed in this study while acknowledging specific contextual determinants for successful implementation. Providers also felt it was important to strengthen ongoing public health and policy efforts to address youth vaping in addition to clinical intervention. This study provides insight into the translation of efforts such as the AAP guidelines in a specific healthcare system to address a pressing health issue for youth.\u003c/p\u003e","manuscriptTitle":"Exploring Multi-level Determinants of Implementation of Nicotine Replacement Therapy Guidelines for Youth Vaping: A Mixed-Methods Case Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-12 01:14:19","doi":"10.21203/rs.3.rs-8743595/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-07T11:19:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-24T20:35:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-06T22:01:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12724601711082619015184680704442750812","date":"2026-02-26T18:54:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"37747769350998783448003981693076462402","date":"2026-02-09T19:55:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-09T16:55:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-09T01:26:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-04T05:25:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Implementation Science Communications","date":"2026-01-30T16:51:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f10765c9-694d-4796-9a58-23bde8658007","owner":[],"postedDate":"February 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-23T21:38:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-12 01:14:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8743595","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8743595","identity":"rs-8743595","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}