Designing and Testing a Game Intervention to Help Youth Quit Smoking

Project Lead Category Project status
Hanneke Scholten Substance Abuse Completed

Smoking is one of the leading public health problems in the world. In the Netherlands today, still 1 in 4 youth between the ages of 16 and 25 smoke. Even more worrisome is that there are almost no evidence-based interventions available to help them quit smoking. That’s why we, in collaboration with scientists, game designers and smoking youth, developed and tested a game to help youth quit smoking. HitnRun is a mobile game in which you can train your impulse control, and in which you collaborate in teams, support each other’s quit attempts, and compete against other teams.

Project team

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16-07-2020

Overview project: https://www.youtube.com/watch?v=QvuZxLjVpSI&t=4s

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.


25%

of youth between the ages of 16 and 25 smoke daily

0%

There are no evidence-based interventions in the Netherlands that can help youth quit smoking.

100%

of people having seen me play board games do not recognize me anymore - overly fanatic

Results

In a large study involving 144 youth, we tested whether HitnRun was able to help youth quit smoking, compared to a control group who read a psychoeducational brochure. In contrast to our expectations, we found that participants in both the HitnRun and brochure group showed equal improvements in smoking behavior at post-test and three-month follow-up. Thus, according to scientific guidelines, HitnRun is not evidence-based yet.

However, within the HitnRun group, we found that participants who played HitnRun for a longer amount of time, also showed the most promising effects on smoking behavior. Exploratory analyzes showed that young people who really enjoyed playing HitnRun and who were able to create a social, supportive and positive social context played HitnRun for the longest amount of time, which was in turn related to greatest decreases in weekly smoking levels.

Publications

Project team

Hanneke Scholten title=
Hanneke Scholten

Researcher, interdisciplinary work and collaboration, wants to understand the how's and why's, loves her high heels and coffee in the morning, walks and talks too fast.

Function

Postdoctoral researcher

Contact

E-mail Hanneke

Maartje Luijten title=
Maartje Luijten

Function

Assistant Professor

Contact

E-mail Maartje

Isabela Granic title=
Isabela Granic

Professor and Chair of the Developmental Psychopathology department in the Behavioural Science Institute; writer; voracious podcast consumer; mother of two upstanding little gamers

Function

Director of GEMH Lab

Contact

E-mail Isabela

Ken Koontz title=
Ken Koontz

In house game designer, artist, producer and lover of games. I bring diversity, design experience and the NOISE!!!!

Function

Creative Director

Contact

E-mail Ken

Anouk Poppelaars title=
Anouk Poppelaars

PhD candidate interested in using social regulation of emotion and multidisciplinary game design to promote mental health in youth. Disheveled multi-tasker and provider of snacks.

Function

PhD-Candidate

Contact

E-mail Anouk

Sources

All sources
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  2. Rijksinstituut voor Volksgezondheid en Milieu (RIVM) (2016). Sterfte door roken. Retrieved from https://www.volksgezondheidenzorg.info/onderwerp/roken/cijfers-context/oorzaken-en-gevolgen#!node-sterfte-en-verloren-levensjaren-door-roken.

  3. Centraal Bureau voor de Statistiek (CBS) (2016). Gezondheidsenquête. Retrieved from http://statline.cbs.nl/Statweb/publication/?DM=SLNL&PA=83021NED&D1=0,3-4,17-22&D2=3-13,16&D3=0&D4=l&VW=T

  4. Centraal Bureau voor de Statistiek (CBS) (2017). Jongvolwassenen roken, drinken en blowen meer dan 25-plussers. Retrieved from https://www.cbs.nl/nl-nl/nieuws/2017/04/jongvolwassenen-roken-drinken-en-blowen-meer-dan-25-plussers

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  12. Milton, M. H., Maule, C. O., Backinger, C. L., & Gregory, D. M. (2003). Recommendations and guidance for practice in youth tobacco cessation. American Journal of Health Behavior, 27, S159-S169.

  13. Bader, P., Travis, H. E., & Skinner, H. A. (2007). Knowledge synthesis of smoking cessation among employed and unemployed young adults. American Journal of Public Health, 97, 1434-1443. doi: 10.2105/AJPH.2006.100909

  14. Stockings, E., Hall, W. D., Lynskey, M., Morley, K. I., Reavley, N., Strang, J., ... & Degenhardt, L. (2016). Prevention, early intervention, harm reduction, and treatment of substance use in young people. The Lancet Psychiatry, 3, 280-296. doi: 10.1016/ S2215-0366(16)00002-X

  15. Towns, S., DiFranza, J. R., Jayasuriya, G., Marshall, T., & Shah, S. (2017). Smoking cessation in adolescents: Targeted approaches that work. Paediatric Respiratory Reviews, 22, 11-22. doi: 10.1016/j.prrv.2015.06.001

  16. Nationaal Expertisecentrum Tabaksontmoediging (2013). Interventies stoppen met roken voor jongeren. Utrecht, NL: Trimbos Instituut.

  17. Wolburg, J. M. (2006). College students’ responses to antismoking messages: Denial, defiance, and other boomerang effects. Journal of Consumer Affairs, 40, 294-323. doi: 10.1111/j.1745-6606.2006.00059.x

  18. Thrul, J., & Ramo, D. E. (2017). Cessation strategies young adult smokers use after participating in a facebook intervention. Substance Use & Misuse, 52, 259-264. doi: 10.1080/10826084.2016.1223690 

  19. Ramo, D. E., Thrul, J., Delucchi, K. L., Hall, S., Ling, P. M., Belohlavek, A., & Prochaska, J.J. (2018). A randomized controlled evaluation of the tobacco status project, a Facebook intervention for young adults. Addiction, 113, 1683-1695. doi: 10.1111/add.14245

  20. Curry, S. J., Sporer, A. K., Pugach, O., Campbell, R. T., & Emery, S. (2007). Use of tobacco cessation treatments among young adult smokers: 2005 National Health Interview Survey. American Journal of Public Health, 97, 1464-1469. doi: 10.2105/AJPH.2006.103788

  21. Lenkens, M., Rodenburg, G., Schenk, L., Nagelhout, G. E., Van Lenthe, F. J., Engbersen, G.,... & Van De Mheen, D. (2019). “I need to do this on my own” resilience and self-reliance in urban at-risk youths. Deviant Behavior, 1-16. doi: 10.1080/01639625.2019.1614140

  22. Schenk, L., Sentse, M., Lenkens, M., Engbersen, G., van de Mheen, D., Nagelhout, G. E., & Severiens, S. (2018). At-risk youths' self-sufficiency: The role of social capital and help-seeking orientation. Children and Youth Services Review, 91, 263-270. doi: 10.1016/j.childyouth.2018.06.015

  23. Granic, I., Lobel, A., & Engels, R. C. (2014). The benefits of playing video games. American Psychologist, 69, 66-78. doi: 10.1037/a0034857

  24. Wong, N. T., Zimmerman, M. A., & Parker, E. A. (2010). A typology of youth participation and empowerment for child and adolescent health promotion. American Journal of Community Psychology, 46, 100-114. doi: 10.1007/s10464-010-9330-0

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