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Abstract

Use of nontobacco nicotine products is increasing among the youth. School nurses aim to prevent such unhealthy habits. However, there is limited evidence relating to the knowledge of these nurses, and their capacity to work with tobacco-free nicotine products. Therefore, we aimed to illuminate the prerequisites and experiences necessary for school nurses to work with secondary school students for preventing the use of nontobacco nicotine products. This qualitative study was based on 18 semi-structured interviews conducted with Swedish school nurses, using conventional content analysis. One main category emerged: Experiences and prerequisites for working preventively in the context of nontobacco nicotine products and four subcategories. Certain nurses in the sample indicated that they had the experience, prerequisites (including time, fewer students per nurse, and an engaged and understanding organization), and competence to enable them to be suitable advocates for working preventively in schools under conducive conditions.

Keywords

nicotine school nontobacco nurse e-cigarette vape white snuff

Introduction

The use of e-cigarettes/vapes and white snuff (nicotine pouches) is increasing among the youth all over the world (Australian Institute of Health and Welfare, 2025; Selling, 2024; Tattan-Birch et al., 2024). Statistics from the United States revealed an increase in 2022/2023 (Department of Health and Human Services, 2024). However, after public education campaigns in the United States were performed, the latest statistics show that this number had decreased (Department of Health and Human Services, 2024; MacMonegle et al., 2025). In the United States, the Food and Drug Administration (FDA) states that selling products containing nicotine from any source to anyone aged < 21 years is forbidden (Federal Register, 2024). However, white snuff is not regulated under the European Unions (EU's) tobacco laws; therefore, rules regarding nicotine limits, advertising, and their sale are determined by individual member countries. Many countries in the EU have restrictions and age limits; or ban specific products such as nicotine e-pouches and white snuff (Galvin, 2025).

Studies have shown that individuals who use e-cigarettes have an increased risk of using other substances, such as cannabis and alcohol, compared to those who have never smoked (Becker & Rice, 2022; Lau et al., 2023). Much of the existing literature indicates that young people perceive e-cigarettes as not dangerous; healthier than “normal cigarettes;” and more socially acceptable (Al-Hamdani et al., 2021; Liu & Wang, 2025; Robertson et al., 2022). Furthermore, white snuff is used among the youth because it is easily shared; and is a discrete way of using nicotine products (Harlow et al., 2022).

Similar to the United States (Department of Health and Human Services, 2024), Sweden is facing problems with the use of nontobacco nicotine products among secondary school students. In August 2022, Sweden instituted a new law requiring consumers to be at least 18 years of age to buy nontobacco nicotine products, such as white snuff and e-cigarettes (Public Health Agency of Sweden, 2024). The same law states that companies cannot market these products on television or radio, yet they are aggressively marketed on social media which, according to Gentzke et al. (2022), is a nearly ubiquitous feature of adolescents and young adults’ social environment. In Sweden, as well as in the US, social media marketing has led to the recruitment of younger students in the use of these products (Public Health Agency of Sweden, 2024; World Health Organization, 2024). Therefore, modern preventive health strategies are needed on social media such as TikTok, Instagram, Snapchat, and YouTube (Vogel et al., 2024).

In Sweden all children and students have the right to a health-promoting, tobacco-free environment in schools (Swedish National Agency for Education, 2024). School nurses play a crucial role in promoting and improving the health habits of children and adolescents (Hilli & Pedersen, 2021; Pawils et al., 2023). Swedish researchers report that health dialogues between students and school nurses can help promote student health (Kostenius & Lundqvist, 2021; Rising Holmstrom et al., 2013). From these dialogues, a school nurse may identify patterns in individuals, classes, or an entire school; and guide effective education on alternative tobacco-free nicotine products. A study by Russel et al. (2025) indicates that school nurses see the effects of e-cigarettes first-hand, and because they are required to be aware of students’ chronic conditions and engage in health promotion and risk education, they may play a crucial role in supporting students.

This study focuses on the experiences of Swedish school nurses and the conditions necessary for their preventive work on nontobacco nicotine product-use. During students’ attendance in school, school nurses and other employees may work individually or in groups on prevention and health promotion activities and discuss alternative tobacco products (Blume & Lines, 2020). However, school nurses face overwhelming workloads and limited time to collaborate with other school professionals (Schroeder et al., 2023; Sutton & White, 2023).

According to Sweden's Education Act (European Commission, 2024A), every school must have a school health service (SHS) including a school nurse. SHSs work primarily on preventive and health promotion and support students on their educational journey (European Commission, 2024A). Russel et al. (2025) show the importance of school employees, including school nurses working together to help students with their health to increase school attendance (Muniz et al., 2022). Unfortunately, studies show that school nurses often face challenges due to insufficient time and support from other professionals to engage in work related to health promotion (Kostenius & Lundqvist, 2021). Since the use of nontobacco nicotine products is increasing among adolescents and young adults all over the world (Australian Institute of Health and Welfare, 2025; Selling, 2024; Tattan-Birch et al., 2024), special attention needs to be paid to preventing students, who may be drawn to use new substances, from initiating the use of these products. School nurses play a critical role in those prevention efforts.

Method

Design

This study used an exploratory qualitative design (Polit & Beck, 2021); and individual interviews were conducted in Sweden between September 2024 and January 2025. Research was conducted in accordance with the ethical principles of the Declaration of Helsinki (Parums, 2024); and was approved by the Regional Ethics Review Board in Gothenburg, Sweden (EPN 2024-04931-01-634253 U). The consolidated criteria for reporting qualitative research (COREQ) were followed (Tong et al., 2007).

Participants and Settings

Purposive sampling was used in this study. The first author (ÅAA) contacted two student healthcare managers in two municipalities who then facilitated the process by providing the contact information of other school managers. The latter shared information with school nurses who contacted the first author if they wanted to participate in the study. Participating school nurses were asked to help with snowball sampling (Naderifar et al., 2017). Their participation played a crucial role in ensuring the smooth conduct of the study, in spreading information regarding the research, and in contacting more respondents. The study was conducted with nurses working for a minimum of 2 years in secondary schools, with students aged 13–16 years. The school nurses were all women aged 37–71 years, with associated work-related experience ranging 2–27 years. They worked from 10 to 100% full-time and were each responsible for 91–600 students. A total of 18 nurses, from both private and municipal schools, participated in the study.

Data Collection

Data were collected through individual interviews, using a semi-structured interview guide. Examples of questions were:

What does preventive and health promotive work mean for you?

Can you tell me what you know about nontobacco nicotine products?

Can you tell me what conditions you need to be able to teach health promotion and prevention around the use of nontobacco nicotine products?

Why do you think students today use nontobacco nicotine products?

All participants were informed of the purpose of the study; that participation was voluntary; and that their anonymity was guaranteed. Before the interview started, informed consent was obtained, and the participants were told that they could withdraw at any time.

A pilot interview was conducted to assess the interview questions, and no changes were made to the interview guide; therefore, the interviews from the pilot phase were included in the data analyses. The interviews, lasting between 20 and 45 min, were conducted by the first author via Microsoft Teams, and were recorded. The first author transcribed the interviews verbatim, and the second author verified the interview transcriptions for accuracy.

Data Analysis

All 18 transcripts were analyzed using qualitative content analysis inspired by Hsieh and Shannon (2005). This method is appropriate when existing theory on a phenomenon is limited. The material was coded, reviewed, and systematically cross-checked until no inconsistencies remained. One main category and four subcategories were inductively developed to provide an overarching description of the content. To ensure credibility, the authors engaged in repeated readings and collaborative discussions throughout the coding process. A main category title was identified to capture the general meaning of the written material, with sub themes that were reviewed and agreed upon by both authors. To enhance confirmability, an audit trail was maintained, including documentation of coding decisions and selected quotations. Along with the codes, subcategories, and the main category, quotations were translated from Swedish to English, with careful attention to preserving the original meaning and context. These steps contributed to the overall trustworthiness of the analysis.

Results

Four themes were identified in the data: school nurses’ experiences of barriers to collaborative work in the context of nontobacco nicotine products, challenges with student perspectives on nontobacco nicotine products, administrative duties as a barrier to preventive work, and consistency and change: experiences with shifting priorities.

Theme 1: School Nurses’ Experiences with Barriers to Collaborative Work in the Context of Nontobacco Nicotine Products

The school nurses agreed that the principal's primary responsibility was to ensure a healthy environment and establish prerequisites for all employees to work with ANDTS (Alcohol, Narcotics, Doping, Tobacco, and gambling addiction), including nontobacco nicotine products in class and individually with students. Nurses noted that it is important that employees work together as a team to have a positive effect on students and agreed that all employees, including cleaning employees, assistant teachers, teachers, management, and caregivers, should be involved in the students’ learning environment. However, the school nurses conveyed that although employees are expected to have a conversation with a student seen vaping, and to inform his or her parents, employees did not. Even if school nurses tried to inform employees of the importance of talking to students and parents about the health issues associated with using tobacco or nicotine products, there was limited engagement by employees because the directive did not come from the principal. The school nurses’ experience was that if the principal informed them that the school had to discuss a subject, all school employees tried to do so. However, if the school nurse made the same request, the reason always given was “they did not have time.”

As one participant noted, “In the municipality they decided on an action plan, regarding ANDTS, on how we are supposed to work preventively in school and in the classrooms…. but the principal responsible, still hasn’t talked about it yet in school and the teachers listen to the principal and not to me.” (Informant 14).

The school nurses understood that there was no evaluation to check whether the school did what they were supposed to do, according to the municipality or board. Many school nurses felt that there were many decision-making and theoretical plans regarding work around the ANDTS, but nothing happened in practice.

Another barrier to working collaboratively with the school team included a pervasive lack of engagement from school staff in addressing student vaping even if school administration encouraged it. Efforts by the nurses to emphasize the health risks associated with nicotine and tobacco-use were largely disregarded by other school employees and teachers. One participant noted, ““I have seen teachers in the first grade in comprehensive school just put a white snuff can on the desk in front of the students that look up to them and think that everything the teacher does has to be ok.” (Informant 4)

This persistent inattention led to a sense of resignation among the nurses, who eventually ceased their advocacy efforts. Many described their role as reactive rather than preventive, likening their daily responsibilities to “putting out small fires” without the time or support necessary to implement long-term preventive strategies.

Some school nurses noted that addressing mental issues in school took so much time from everything else, there was no time left to talk about nontobacco nicotine products. School nurses collaborate closely with school counsellors, but counsellors had many individual students with mental illnesses to take care of, leaving little time for prevention work around nicotine products., as illustrated by one respondent who stated“All the focus is on the student's mental health, so we don’t talk about tobacco-free nicotine products or anything else, really.” (Informant 8).

Certain school nurses liked collaborating with teachers or other employees in the classroom. The belief was that teachers almost always wanted to cooperate but did not have sufficient time to prepare and plan with school nurses. Teachers often asked for information and support from the school nurse but did not necessarily have the nurse in the classroom due to time constraints, as evidenced by one participated who stated, “We have knowledge and ambition, so it is more the school organization that doesn’t work.” (Informant 18).

Hence, while some felt they were part of a team, many felt more like hired consultants.

Addressing nontobacco nicotine usage also entails working collaboratively with students, which requires trust between nurse and student and which requires time to build. As one nurse noted, “I work full time, however, building trust is impossible when you have like me almost 700 students. Therefore, no school nurse should have more than 400 students (Informant 3). All the school nurses agreed on the importance of building relationships and that some students require more time to build relationships. Some students may walk around the school nurse's office or person for a while before finding the strength to come forward and talk. The importance of being visible as a school nurse during breaks, having lunch with students, and talking in groups in classrooms was noted.“You must be patient as a school nurse with students. You must be visible and show that you are available as an adult and a nurse. It can take a while for a specific student to trust you and to be able to tell you things so that you can help them. But when you get that trust with one student there are always other students that will follow and will find strength to come and talk to you” (Informant 8)

Theme 2: Challenges of School Nurses with Students’ Perspectives on Nontobacco Nicotine Products

Many of the school nurses interviewed agreed that the students probably knew more about nontobacco nicotine substances than they did. To learn about the products, school nurses asked students what they knew about them and where they obtained the information. They engaged with students when they had health dialogues, and they looked up facts on the internet together with them. Nurses discussed how students saw commercials about the products, followed influencers, and were “updated” through those channels. Students told the nurses that parents thought it was a better option for their children to use vapor or white snuff than tobacco products. Some school nurses stated that student told them that their parents or siblings bought the products for them. The lack of a shared perspective between nurse, student and parent on using these products was a challenge that was consistently raised by the nurses interviewed.

Nurses also reported that students used vape and white snuff as a means of self-medication in school which created a moral tension for them. One nurse stated,“I knew he used nicotine products to keep calm in school and that it worked for him. I knew he was on the waiting list to see a doctor for medication for ADHD. Here it becomes ethical for me and a trust problem. Nicotine products work for him in school and help him but is bad for his health and his future” (Informant 10).

Theme 3: Administrative Duties as a Barrier to Preventive Work

Workload was a key factor that nurses raised when describing their experiences in conducting preventive work around nontobacco nicotine products. Working hours and number of school building covered varied across participants. One school nurse worked full- time and was responsible for 370 students whereas another school nurse worked full-time and was responsible for 600 students. Some school nurses worked in districts with greater socioeconomic needs and, as a result, there were many meetings with social services, police, and parents, which did not allow time for preventative work. Regardless of employment status and workload, all nurses indicated that they put considerable time and effort into administrative work, which in Sweden includes documentation in the student's health record with regard to visits for health consultations, bandaging, administering medication, a phone call with parents, delivery of health education in the classroom, orientation regarding vaccinations and administration of vaccines. The participants noted that administrative work also included health dialogues, group talks, talks in classrooms, meetings in the corridor, and meetings with newly arrived students or students who have changed schools. After all kinds of meetings, school nurses sometimes must contact parents, healthcare employees, and other professionals in school and SHS. The school nurse may have to call, write, and “chase” different contacts, such as other school nurses or administrations, to find information and journals about a student. As some schools no longer exist, it may take time for school nurses to find information about a new student. Thus, the amount of preventive work that a nurse could engage in was highly dependent on their workload and burden of administrative duties: I only work four days a week and, in that time, I must do my health dialogues, doctor appointments with students, vaccinations. My time goes to so much else, so I don t have time to work preventively.” (Informant 2). More experienced school nurses, if interested, prioritized work differently and made time to work preventively. As one noted, “I have been a school nurse for 25 years so I can prioritize being in the classroom, being in the corridor and take more time to work preventively. I feel comfortable with my decisions and choices. As a new school nurse, you don’t have that privilege as I have with all my experience” (Informant 1)

Theme 4: Consistency and Change: Experiences with Shifting Priorities

The school nurses in this study described the amount of conversations that had with students about nontobacco nicotine products as a function of their own experiences and changing priorities over time. School nurses have different work experiences and backgrounds with varying levels of interest in addressing nontobacco nicotine products among youth. As one participant stated, “I have always been interested in working preventively regarding tobacco and nowadays also with nontobacco nicotine products. I read all reports in these areas as well as I am following them on social media. (Informant 1).

In addition to different personal priorities, participants discussed how changes in school leadership and their priorities have influenced what they focus on in schools. While the Education Act in Sweden stipulates that schools must have access to nursing care, it does not indicate how much time is spend on direct care vs preventative care and thus, it was up to the principal or the school board to decide. One school nurse stated that in 5 years she had 17 different principals; a new principal could mean a new set of priorities for school nurses’ work. This resulted in inconsistency in how much preventative work in general, and more specifically how much dialogue around nontobacco nicotine products occurred and created a level of distress among participants as one participant stated, “If we do not take time to work preventively with the students, who will….” (Informant 16).

In summary, the four themes that emerged from the data indicate a recognition of the growing presence of nontobacco nicotine products in schools and their experiences revealed several barriers to collaborative work, which require systemic changes, including stronger leadership support, more explicit role definitions, improved training; and, importantly, reduced caseloads. Further, school nurses consistently reported that students often possessed more knowledge about nontobacco nicotine products than adults, albeit superficial or misguided. Significant challenge arises from students’ belief that nontobacco nicotine products are benign and the varied parental attitudes that school nurses encounter, often marked by permissiveness or normalization of nicotine use. These attitudes are a significant factor in students’ perceptions and underscore the multifaceted challenges school nurses face in addressing nontobacco nicotine use among students. Administrative responsibilities and structural constraints also hinder the school nurse's capacity to engage in proactive preventative care. In particular, school nurses working in socioeconomically disadvantaged districts faced additional demands, which while essential, often replace time that could otherwise be devoted to preventive health education and student engagement. Findings indicate that current administrative duties and structural constraints limit school nurses’ capacity to engage meaningfully with students. Last, school nurses were committed to their preventive mission, even in the face of changing policies, leadership turnovers, and evolving professional interests. Health dialogues remain a stable and trusted tool, but systemic challenges, such as administrative shifts, threaten the sustainability of preventive work.

Discussion

The experiences of school nurses as described by the participants in this study revealed dedication, complexity, and systemic barriers to addressing nontobacco nicotine use among students. It also requires more than individual effort, it demands institutional alignment so that all aspects of the educational and healthcare systems are working towards the same goal. By investing in leadership support, reducing caseloads, enhancing training, and prioritizing preventive care, schools can empower nurses to fulfill their vital role in safeguarding adolescent health.

All the school nurses in this study agreed that building relationships and working preventively takes time, experience, and knowledge yet efforts by the nurses to emphasize the health risks associated with nicotine and tobacco use were largely disregarded by other school staff. School nurses in this study reported that school principals were responsible for students’ well-being and a tobacco-free environment at school and that knowledge about nontobacco nicotine products was not just the principal's responsibility, but that of all employees at the school. Collective responsibility is a key factor in creating safe and healthy environments for students. Thomas et al. (2025) demonstrated the importance of training school employees, students, and parents to increase their knowledge and to raise awareness in response to students’ use of e-cigarettes, suggesting that collaborative partnerships across all staff within a school are critical to addressing nontobacco nicotine product use.

In describing challenges in addressing student perspectives, school nurses discussed why students used e-cigarettes/white snuff. Students told nurses that their usage was based on curiosity; taste; social acceptability; the need to self-medicate, social media influence and parental explicit or implicit approval. These descriptions validate findings from other studies (Adekeye et al., 2025; Becker & Rice, 2022; Chacon et al., 2024; Jamal et al., 2024;) and highlight the need for more education in society and effective strategies to prevent people from using nontobacco nicotine products.

School nurses felt that there were too administrative duties to complete which prevented them from working preventatively. Their time was spent on pedagogical work, fulfilling obligations, and dealing with acute illnesses within schools. All school nurses felt that preventive work came too late and agreed that the school needed to work more preventively as a team around addressing nontobacco products. The results of this study are aligned with those of current research which states that if school nurses do not have the time to work effectively with students, they will not be able to utilize their expertise and skills in addressing negative health behaviors and ultimately promote students’ health and academic outcomes (Sutton & White, 2023). Finding also suggest that school nurses perceive that they have the right expertise to address nontobacco nicotine usage and that they work well with classroom teachers, but again, feel that they are either time constrained by other duties or not utilized to their full capacity by teachers. There is considerable evidence that shows that school nurses play a key role in improving health and health habits (2023; Hilli & Pedersen, 2021; Sutton & White, 2023) and that interventions by school nurses are linked to improved educational outcomes (Morse et al., 2023; Yoder, 2020). Yet, with the lack of management, time, and knowledge about school nurses’ expertise and abilities from the administration and other employees in schools, it was difficult for school nurses to work preventively and for their voices to be recognized.

Limitations and Recommendations for Future Research

The study findings were based on 18 school nurses. With over 3000 school nurses working in Sweden, this study constitutes a small percentage of their voices. However, the school nurses worked in different parts of Sweden as well as in private and municipal areas. This study focused on school nurses’ experiences with nontobacco nicotine products and prerequisites for working preventively. Future research is needed on how to reach out to all employees in schools, students, and their parents about their perspectives in addressing this growing health problem among youth. Other future research to consider includes a holistic intervention that includes educational initiatives for students, parents, and employees to prevent or terminate the use of these products. These interventions such as these may also offer school nurses the opportunity to assume leadership roles within their professional scope. Pilot interventions such as these may be a useful contribution to school nursing practice in Sweden.

Conclusions

As the use of nontobacco nicotine products among young people continues to increase, understanding school nurses’ experiences is important to begin considering what is needed in schools to address nicotine usage. Working as healthcare leaders in the school environment, school nurses can significantly contribute to helping youth stop using nontobacco nicotine products and enhance public health outcomes in their communities.

Footnotes

Acknowledgment

The authors would like to thank all the participating school nurses. We would like to thank all the study participants for their valuable contribution. We would like to thank Editage () for English language editing.

ORCID iDs

Anja Allansson Åkesson

Ami Hommel

Author Contribution(s)

Anja Allansson Åkesson: Conceptualization; Data curation; Formal analysis; Methodology; Writing – original draft.

Ami Hommel: Conceptualization; Data curation; Formal analysis; Methodology; Supervision; Writing – review & editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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Preventive and Informative Efforts Targeting Secondary School Students Regarding Nontobacco Nicotine Products: Insights from Swedish School Nurses

Abstract

Keywords

Introduction

Method

Design

Participants and Settings

Data Collection

Data Analysis

Results

Theme 1: School Nurses’ Experiences with Barriers to Collaborative Work in the Context of Nontobacco Nicotine Products

Theme 2: Challenges of School Nurses with Students’ Perspectives on Nontobacco Nicotine Products

Theme 3: Administrative Duties as a Barrier to Preventive Work

Theme 4: Consistency and Change: Experiences with Shifting Priorities

Discussion

Limitations and Recommendations for Future Research

Conclusions

Footnotes

Acknowledgment

ORCID iDs

Author Contribution(s)

Funding

Declaration of Conflicting Interests

References