Young people get a great deal of information about the world from mass media such as television and radio and, increasingly, online media, not just through the traditional desktop computer but also through a variety of publicly accessible and portable electronic devices.
The Smarter than Smoking campaign is a Western Australian smoking prevention project funded by Healthway since 1996. This comprehensive program has a mass media component, with several media bursts annually targeting 10–15-year-olds. Western Australia is the only state in Australia to have consistently targeted young people through youth-specific media campaigns.
See Chapter 14, Section 14.4 for a detailed discussion of the impact of general and targeted campaigns on young people in Australia.
In marketing parlance, 'new' or emerging technologies include media such as the Internet and web-based programs, interactive web-based mediums such as Facebook, mobile phone communications and electronic games. Terms such as 'e-health,' 'e-marketing' and 'm-marketing'1 (the sending of marketing messages to mobile phones) have now entered our lexicon and teenagers are at the forefront–'digital natives'2 of an increasingly 'wired' world.3 Meaningful supervision of young people's now ubiquitous use of new media becomes ever more unrealistic. The pace of technological change has been incredibly rapid, and many of the technologies commonly used by young people, such as instant messaging, social networking websites, chat rooms, twitter and new forms of portable digital music players, barely existed a decade ago.4
Interactive or emerging technologies present a potential and unique opportunity for new and innovative ways to influence and engage young people in health promotion,5 including in smoking cessation.6 For example, it has been estimated that for every hour that young people use media, they are exposed to 1.25 hours of media content due to media multitasking. 7 Although there is limited literature concerning the use of interactive technologies in youth smoking prevention to date, the potential benefits identified in Table 5.24.1 still apply.
While different forms of new media and technologies are emerging at a rapid pace, two that have received some attention in the tobacco-control literature published to date are mobile phones and the Internet.
Rationales for interactive technologies in health promotion targeting young people
Rationales for interactive technologies in health promotion targeting young people
Creative message and delivery possibilities not available through traditional health education materials.8
Provide alternative or more innovative ways to communicate 'tired' health messages.9
Young people are readily captivated by the Internet and other interactive technologies and so the potential to engage them is enhanced.3,10
Can provide interactive or 'hands on' learning approach.9
Provide flexibility and privacy in terms of where and how information is accessed.9
The capacity to provide responses and feedback through interactive technology enhances learning through reinforcement.12
Action research is possible through interactive technologies, and programs can be modified and updated as required.10
Messages and strategies can be more individually tailored to different target segments13 rather than 'one size fits all'.
For young people, mobile phones are much more than a technological gadget: they are aspirational and symbolise freedom, growing up and having fun, and have spawned a new mode of interaction among friends. A review of the social impact of mobile phones in Australia denotes them as 'must haves' for teenagers wanting to keep up and achieve social acceptance.14 Over 90% of 17-year-old Australians4 and more than three quarters of Australian teenagers 12–14 years15 used a mobile phone in 2007.
Mobile phones are of potential interest to youth smoking prevention for two quite different reasons: first, as a potential channel of communication for smoking prevention strategies, and second, as a type of smoking 'substitute'.
Factors in the potential utility of mobile phone short message service (SMS) to deliver health behaviour change interventions include that the service has wide population reach, can be individually tailored, and allows instant delivery with asynchronous receipt.16 In addition, mobile phone programs have some advantages over current treatment services for smoking cessation, which may appeal to certain groups such as young people, including that they can be delivered anywhere, at appropriate times, confidentially and straight to the participant with minimal direct contact.17 Text messaging interventions have been used with teenagers on a number of specific health issues, such as diabetes management,18 as well as more broadly, as in the UK program that enabled teenagers to text a community nurse with questions or health concerns regarding issues such as sexual health or puberty.19
In a recent content analysis of 47 smartphone applications (commonly referred to as 'apps') available for smoking cessation in June 2009, the researchers concluded that the apps had low levels of adherence to established, evidence-based clinical practice guidelines for smoking cessation. Those that were more frequently downloaded had the lowest adherence scores. Few apps referred the user to a recommended treatment; for example, few, if any, recommended or linked the user to proven treatments such as pharmacotherapy, counselling and/or a quit line.20
Mobile phone-based interventions specifically targeting adolescents or children are sparse in the published tobacco-control literature. A 2009 Cochrane review of interventions for smoking cessation in any age group was based on four randomised or quasi-randomised trials reported in five papers (including two trials involving only text messages and two involving web/email and mobile phone components).17 The review found the mobile phone programs to be effective in the short term (six weeks), while a combined internet–mobile phone program was effective for up to 12 months. There was no effect of mobile phone-based smoking cessation interventions on long-term outcome. The authors conclude that further evidence based on more rigorous research is required to determine if programs delivered over mobile phones can help people to stop smoking.17
One of the reviewed studies was a randomised control trial in New Zealand exploring the use of mobile phones as a delivery medium for smoking cessation programs for young adults (36% of the sample aged 16–19 years). Cessation rates among those receiving the text message intervention were around double those of the control group at six-week follow-up, and reported quit rates at six months remained high,21 although the Cochrane reviewers found there were a range of issues with this trial such as problems with misclassification of long-term outcomes. 17 In Western Australia, Smarter than Smoking piloted messaging 10 000 young people, inviting them to participate in a quiz-based competition. At 34 cents per delivery, evaluation of the pilot study concluded that it was both a cost-effective and an acceptable means of communicating with young people.22
A 2009 review by Australian researchers identified 14 studies published between 1990 and 2008 examining the use of mobile telephones in delivering health behaviour change interventions via text messages.16 Four of the studies used SMS for preventive health behaviours (including two targeting smoking cessation, one among adults and one among US college students), while the remainder examined clinical care such as diabetes self-management. Positive behaviour change outcomes were observed in 13 of the 14 reviewed studies, including both smoking cessation studies; however, the improvements in quitting in only one of these studies (among adult smokers) was significant statistically, and this effect was observed during the first half of the trial and not maintained to the end of the study (26 weeks).16 While the reviewers acknowledged the limited number of high-quality SMS intervention studies undertaken to date, they also identified several important features of SMS-delivered interventions: the method of intervention initiation (e.g. by researcher or participant), whether the participant or the researcher initiated SMS dialogue, tailoring of SMS content and the level of interactivity with participants.16
There has been some interesting debate in the literature around the relationship between mobile phones and smoking among young people. In a letter to the British Medical Journal in 2000, it was hypothesised that observed declines in teen smoking in the UK might be attributable in part to the rising uptake of the mobile phone. The authors contended that mobile phones are an effective competitor in the teen market for products that offer 'grown-up' style, individuality, rebellion, bonding with peers, sociability and adult aspiration.23 Researchers in Japan concurred that smoking prevalence had declined as mobile phone ownership and usage increased.24 However, later studies failed to find evidence to support the hypothesised protective effect of mobile phone ownership on smoking uptake.25,26 In fact, Steggles concluded that:
'We found a positive association between the extent of smoking experience and the likelihood of owning a mobile ... Rather than competing, mobile phone ownership appears to be a complementary behaviour to smoking, possibly reinforcing a young person's image of himself or herself as an aspiring adult.'26
Young people are typically among early adopters of new media and represent a key target for much of the material on the Internet.7 As noted in a review by Ribisl,27 the Internet can, and is, being used both to encourage (overtly or covertly) and discourage youth smoking. At the 'enticing' end of the spectrum, the Internet provides opportunities for young people to access and purchase tobacco products without scrutiny of age,27 and has spawned pro-smoking genre in the 'home-movie' type offerings on websites such as YouTube.i Indeed young people are increasingly engaged in creating their own user generated content and placing this on the web, and this poses some unique challenges for monitoring or regulation of content to which youth may be exposed.28
There are also websites abounding with content or chat rooms that glamorise smoking lifestyle and culture.27,29 While not based in Australia, the cyber world is global, and there are US-based websites, for example, that feature pictures of celebrity smokers, provide information about smoking in movies, and provide smoking advice to teen smokers.27 The tobacco industry has also harnessed the Internet to communicate with young customers30,31 (see also Section 5.15.4 and Chapter 11, Section 6.5).
At the other end of the spectrum, the Internet is used by those in tobacco control to try to engage young people. This includes websites exposing tobacco industry tactics, such as the 'tobacco industry exposed' section on the Australian OxyGen websiteii. The web is also being used in youth tobacco prevention to encourage grassroots advocacy27 and as a delivery vehicle for youth cessation programs.32
A recent Cochrane review examined the effectiveness of internet-based interventions for smoking cessation.6 Of 20 studies reviewed, four were among young people (university students and adolescents). One trial with college students found no effect on sustained abstinence, although increased short-term abstinence was observed. Among three relatively small trials involving adolescents, two trials found no effect on cessation compared to control. A third trial detected a marginally significant benefit of a web-based adjunct to a group program; however, the independent effect of the web component was uncertain as participants also received counselling phone calls.6 The studies suggested that tailored websites are more popular among young people.6 Other elements of youth smoking prevention websites include embedding information and messages on tobacco in games, quizzes, simulations, fact sheets and self-assessments, and in personalised feedback and peer discussion groups.6
The Internet is also being increasingly used as a medium for conducting research, including health promotion research. A recent study comparing three types of web-based recruitment of people aged 18–25 years for a survey on tobacco and other substance use concluded that using several approaches (such as internet advertisements and email invitations) is most likely to generate a broad participant sample.33
The Internet also seems to present new opportunities to tailor information and strategies to particular population groups. For example, some evidence from the US illustrates the potential utility of adapting web-based, youth-focused tobacco-control programs to be culturally appropriate and engaging for young people at high risk of smoking, such as young American Indian/Alaskan natives.34
Key factors in the success of interventions such as web-based smoking prevention programs include having wide reach and efficacy, appealing to both teachers and students, and being readily implemented and adapted to individual needs.35 Canadian research evaluated a classroom-based, web-assisted smoking prevention and cessation intervention among 1402 male and female adolescents (aged 13–15 years) through a randomised controlled trial.35 Participants were assigned to a tailored web-based tobacco intervention or an interactive control condition task. The intervention comprised an interactive website combining quizzes and self-assessments with tailored feedback aimed at fostering resistance to pressures to smoke and promoting self-efficacy, as part of a program also including a paper-based journal, small group motivational interviewing, and tailored emails (based on participants' readiness, confidence and reported intention to change) sent to participants for six months following implementation. The intervention was associated with significant reductions in the likelihood of high intentions to smoke among smokers and of heavy smoking uptake by non-smokers during the study period, as well as an increase in the likelihood of high resistance to continued cigarette use among smokers up to six months later.35
In Australia, www.OxyGen.org.au is a tobacco education website that aims to inform young people about smoking. It is a tri-state initiative of Quit Victoria, Quit South Australia (Smarter than Smoking Project in South Australia) and the Smarter than Smoking Project in Western Australia. The OxyGen website provides information on industry tactics, facts and figures about smoking and tobacco products, interactive educational activities, and updates on tobacco issues and events around Australia. In 2011, the average unique visits to OxyGen was 8,300 per month.
One of the challenges for health related websites is that they are 'competing' with other fascinating high-tech websites that appeal to youth, including sites providing pure entertainment and fun as opposed to an underlying health agenda. OxyGen also has to avoid becoming dated and disengaging for young people, but without the marketing budgets of corporate websites. Since its conception in 1999, the website has been redeveloped twice to incorporate latest web technologies, web formats and fresh graphic design concepts with another upgrade planned shortly to cater for the rapidly growing web technologies. The most recent version of the website was launched in April 2009.
One of the challenges for health-related websites is that they are 'competing' in a crowded market with other fascinating high-tech websites that appeal to youth, including sites providing pure entertainment and fun as opposed to an underlying health agenda. OxyGen also has to avoid becoming dated and disengaging for young people, but without the marketing budgets of corporate websites. To this end, OxyGen has upgraded its website a number of times in an effort to remain current and engaging for its target audience.
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