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Smoking is a major cause of worldwide morbidity and mortality; each year killing about eight million people worldwide1, and 20,000 people in the Netherlands alone2. The most common smoking-related diseases are cancer, cardiovascular diseases, asthma and chronic obstructive pulmonary disease (COPD)1,2. Despite a decrease in the number of Dutch smokers under 16 years, a small increase has been observed in the number of young smokers between the ages of 16 and 253,4. International smoking prevalence rates for this age group show similar patterns5. Regardless of many very important efforts to prevent youth from smoking uptake6,7, it is also critical to invest in smoking cessation interventions for youth.
Unfortunately, smoking youth have been largely overlooked in smoking cessation research and policy building8,9, because the major burden of smoking-related diseases falls on the adult population10. For a long time, intervention researchers assumed that youth just did not need smoking cessation programs11, or that evidence-based adult smoking cessation interventions, such as nicotine replacement therapy or pharmacotherapy, would be equally effective for youth10,12. Crucially, most recent research demonstrates that adult-based interventions are not effective for youth, and that different mechanisms are thought to underly the initiation and continuation of smoking among youth specifically10,13. The research that has been done for youth suffers from poor methodological design, shows mixed results, or simply shows no intervention effects9,10,14,15. In the Netherlands specifically, only one of 11 smoking cessation interventions available in a national database for interventions is tailored to young smokers16. Hence, there is a clear need for novel approaches to successfully engage young smokers in cessation interventions8,18.
There are two main overarching barriers to the effectiveness of smoking cessation interventions among youth. First, the limited evidence available seems to suggest that complex interventions that address a variety of mechanisms related to smoking among youth are most promising10. However, it remains unclear which exact mechanism(s) drive observed effects10. Identifying and targeting underlying mechanisms of change related to the onset and maintenance of smoking among youth is therefore crucial. Closely related, our lack of understanding of successful change in smoking is likely because of all the previous investments in one-size-fits-all approaches. However, young smokers are a highly heterogeneous group: they often do not smoke daily, or see themselves as ‘occasional’ or ‘social’ smokers8.
The second main barrier to successful smoking cessation among youth is a mismatch between youths’ needs and the characteristics of smoking cessation interventions, leading to problems with discoverability, high reactance, and very low retention rates9,17. Young people are just as motivated to quit as adults19, yet they are less likely to use the available smoking cessation interventions and, instead, try quitting on their own18,20. The fact that youth rarely use available interventions is, on the one hand, because youth are unaware of the smoking cessation services out there, or are unable to find them13. On the other hand, their wish to quit smoking on their own is fueled by youths’ need for self-reliance and self-sufficiency21,22: youth often feel that existing smoking cessation programs do not honor their autonomy and react against that13,17.
In an effort to address the two main barriers to successful smoking cessation we took a combined theory-driven and engagement-driven approach. We developed a game-based intervention, as we believe that games are inherently engaging, are an excellent training ground to practice skills, and offer a strong sense of agency23. We designed around a set of transdiagnostic mechanisms of change related to the onset, persistence, and cessation of smoking in youth. Furthermore, and equally important, we used a design thinking approach to amplify engagement processes. This entailed that we not only design for young people but with them as well, and did so from the start of the design process24. Furthermore, our design process was necessarily cross-disciplinary with scientists collaborating from the outset with designers, artists, and programmers. We engaged in this cross-disciplinary collaboration throughout the whole intervention design process, using rapid prototyping and iterative testing to develop this new intervention approach.
Based on the scientific literature, we developed an intervention consisting of several components, namely: 1) strengthening impulse control25; 2) increasing youth's connection with the future26; 3) and creating a support network of peers27,28. In addition to this theory-based approach, we also talked to the target group to better understand why young people start smoking, whether they want to quit smoking and what they need from us to hopefully be able to do that as successfully as possible. Based on these conversations, we learned that: 1) young people asked for an individual approach, taking into account their own needs; 2) young people indicated that they mainly need an intervention that is there when they need it most, namely when their craving is highest; 3) young people indicated that smoking is often a social activity and thus the social context should be part of the intervention.
Based on our theory-based and engagement-based considerations, we developed the game HitnRun in two main design iterations. The final version of HitnRun is a mobile game which trains youths' impulse control by instructing them to respond to neutral pictures and ignore smoking pictures. This training decreases the attractiveness of smoking-related objects, such as a cigarette, and therefore it might be easier to quit smoking. In addition, youth play in teams, in which they collaborate with peers who also want to quit smoking. Within their team, they are given the opportunity to encourage and support each other to resist smoking, and compete against other teams. Youth carry HitnRun with them on their phone, so they can always use it as a distraction tool at moments of high craving.