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

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.