Youth smoking is a global public health concern that has been regarded as a “pediatric epidemic” [20]. Building an awareness of tobacco control and smoking cessation among youths is very important in reducing smoking initiation, which in turn can lower the prevalence of cigarette use. This paper reports a study to promote a smoke-free lifestyle and smoking cessation in the community by mobilizing teenagers from secondary schools, youth centres, and uniform groups to serve as smoke-free ambassadors. In addition, we evaluated the effectiveness of the training programme by assessing changes in knowledge, attitudes, and practices of tobacco control and cessation among the ambassadors.
The present study demonstrated that the training programme was effective in enhancing the knowledge of smoking hazards among youths. This is evidenced by the fact that 75.0% of participants were able to correctly answer all items at 6-month follow-up compared with only 58.0% at baseline. Moreover, there were statistically significant improvements in participants’ attitudes towards tobacco control policies, such as expanding non-smoking areas, increasing tobacco tax, and a total ban of the sale of tobacco products. In addition, the results supported the effectiveness of the training programme in changing Smoke-free Teens’ practice of smoking cessation promotion. There were statistically significant increase in the mean number of smokers who received smoking cessation advice and who were referred to smoking cessation services by participants at 6-month follow-up compared with baseline. However, caution must be taken when interpreting these findings. The results might be highly confounded by the number of smokers that the participants had encountered before and during the study. Furthermore, the results could be misleading if the participants only encountered a few smokers at baseline, but more smokers during the period of evaluation. Nevertheless, the results demonstrated that the trained Smoke-free Teens could successfully promote cessation among smokers using the AWARD model. One advantage of the AWARD model is that it can be easily learned and used by teenagers with minimal training. In addition, it takes only a minute or slightly longer to communicate advice based on the AWARD model. This makes it very useful in promoting smoking cessation in community settings and permits a sizeable number of smokers to be reached at low cost.
Following the intensive training, the Smoke-free Teens formed into groups and applied the various skills they had learned to design and implement creative projects to disseminate smoke-free messages in their schools or the community. During the study period, 552 smoke-free activities were held, which reached 144,528 people. These smoke-free activities were effective in raising public awareness about smoking hazards and obtaining support for public health policies. In addition, the activities allowed the promotion of smoke-free messages to a segment of smokers who are difficult to be reached by existing smoking cessation services. When compared with other methods in health promotion, such as educational talks and self-help materials, these activities are a practical and effective way to rapidly disseminate health messages to a large number of people.
We received much positive feedback from the trained Smoke-free Teens. One group of Smoke-free Teens commented that they found the experience of organizing such a large-scale event valuable. They felt that the experience helped them realize the importance of group unity and planning, and that the activities had fully utilized the potential of every teammate. They hoped that everyone might develop a smoke-free healthy lifestyle. Most importantly, by joining this programme, participants were not only equipped with knowledge about tobacco control and smoking hazards, but were also more likely to refrain from trying smoking in the future. One trained Smoke-free Teen of the 2016–2017 champion team stated that “I spent half a year planning and organizing the smoke-free activities and promoting a smoke-free lifestyle. I never regretted joining the programme, as what I learned and experienced was invaluable and could not be acquired at school. It is a very precious memory. Besides, my father reduced his tobacco consumption with my support and encouragement.”
There are several benefits in mobilizing secondary school students to serve as ambassadors of smoking cessation in the community. First, they may encounter smokers in their social circles. Young smokers, particularly those who are reluctant to access smoking cessation services, may be more willing (and may find it easier) to receive brief advice on smoking cessation from the ambassadors owing to the established rapport between them. Second, there are more than 300,000 secondary school students in Hong Kong [21]. Trained Smoke-free Teens could play an important role in helping to widely disseminate smoke-free messages in the community. In particular, they can motivate their smoking peers to quit by being healthy role models.
Despite only small changes in participants’ knowledge and attitudes regarding smoking and tobacco control after the programme, it is meaningful and relevant to public health practice. In particular, within a 6-month period of evaluation, 856 ambassadors were able to deliver brief cessation advice to 1968 smokers in their social circles. The ambassadors also referred 2824 smokers to smoking cessation services. It was expected that the ambassadors would continue such practice after the evaluation. The running cost of this programme is low in comparison to the healthcare cost resulted from treating tobacco-related diseases of a smoker. Therefore, this innovative, inexpensive and sustainable approach can make an important contribution to establishing a smoke-free culture in schools and the community in Hong Kong, consequently saving more lives.
Limitations
There were some limitations of this study. Frist, this study was limited because only 51 out of 450 schools joined the Smoke-free Teens Programme over the past 3 years. The low response rate might be due the Hong Kong education system is exam-oriented and the schools in Hong Kong are highly academic-oriented. Majority schools in Hong Kong are mainly focused on academic results, but neglect the importance of having extra-curricular activities and building students’ personal characters. Consequently, students are busy with attending different tutorial classes after school but no more extra time for joining activities. Given the significant health impact of the Smoke-free Teens Programme on our new generation, more resources and efforts should be allocated to this area to create a rapport with schools and parents with regard to tobacco control advocacy. The second limitation was that we did not follow up smokers who had received brief smoking cessation advice from Smoke-free Teens, and hence could not evaluate the long-term impact of the training programme in the community, particularly in terms of smoking cessation outcomes. Studies with longer follow-ups are therefore warranted to examine the sustainability of the training effects. Furthermore, a comprehensive evaluation is needed to determine whether the training effects are translated into smoking cessation at an individual level. Additional measures, including (1) how many family members and friends are invited to make a quit attempt, (2) whether local quitlines receive more referrals, and (3) whether friends of ambassadors are more willing to receive cessation advices from the ambassadors in comparison to other sources could be assessed in future evaluation. The third limitation was that participation in this study was on a voluntary basis. It was expected that participants and their families were more negative towards cigarette smoking, consequently might bias the results. Despite the family background might influence the participants’ attitudes towards smoking and their smoking status [22], we did not observe any significant difference in these two variables with different family backgrounds in subgroup analyses. Future studies with more stringent design are necessary to confirm our findings.
Implications for practice
The findings from this project have important implications for future practice. The project enhanced the community’s capacity to promote smoking cessation because there was a significant improvement in the knowledge, attitudes, and smoking cessation practices of the trained Smoke-free Teens. Moreover, trained Smoke-free Teens can continue to help promote smoking cessation after training. Participants were encouraged to join the Smoke-free Teens Alumni Programme and they continue to promote a smoke-free message by attending sharing sessions, managing game booths and exhibitions in the community, and participating in other tobacco control activities organized by COSH. The World Health Organization [23] emphasizes the importance of member states implementing multisectoral control measures against the tobacco industry. By joining the Smoke-free Teens Programme, the activities of trained Smoke-free Teens could become one of the main ways of implementing the government’s tobacco control policies in Hong Kong.
