A descriptive study of a Smoke-free Teens Programme to promote smoke-free culture in schools and the community in Hong Kong

With an annual death toll of almost 7 million worldwide, cigarette smoking is the biggest preventable cause of premature death and disease [1]. Two-thirds of all premature deaths of smokers can be directly attributed to smoking, and smoking is especially hazardous for those who start smoking at a young age [2–6]. There is evidence that smoking cessation before the age of 40 can reduce the death rate by more than 90% [2]. Even though early cessation is critical to reducing the hazard that smoking poses to an individual’s health, young people who, driven by curiosity and peer pressure, begin to experiment with smoking are likely to continue the habit into adulthood [7]. Most adult smokers started smoking when they were young [8]. It is therefore essential that healthcare professionals should increase awareness among the young of the health risks and addictive nature of smoking, strength their ability to resist negative peer influence and curiosity, and help those who smoked to quit.

Over the past 30 years, enormous efforts have been made by the Hong Kong government to raise tobacco tax and introduce legislation, law enforcement, and smoke-free campaigns, which have led to remarkable success in tobacco control [9, 10]. The prevalence of daily cigarette smoking in Hong Kong decreased from 23.3% in 1982 to 10.5% in 2015 [11, 12]. Nevertheless, 641,300 people aged 15 years or above still smoke daily [12] and this remains an important public health concern in Hong Kong.

The Hong Kong Council on Smoking and Health (COSH) was established under its own ordinance in 1987. This is a statutory body vested with various functions, as set out in the Hong Kong Council on Smoking and Health Ordinance (http://smokefree.hk/UserFiles/resources/about_us/CAP_389_Eng.pdf), to protect and improve the health of the community by (1) informing and educating the public about smoking and health matters; (2) conducting and coordinating research into the cause, prevention, and cure of tobacco dependence; and (3) advising government, community health organizations, or any public body on matters related to smoking and health. Under this charter, COSH has been an active player and commentator on all issues related to tobacco control. To educate youngsters about smoking hazards and the latest trends in tobacco control, and to encourage them to play a pioneering role in spreading smoke-free messages, COSH launched the Smoke-free Teens Programme in 2012 (formerly named Smoke-free Youth Ambassador Leadership Training Programme). The objectives of the programme are to (1) equip a group of young leaders with up-to-date information about smoking hazards and global trends in tobacco control and to encourage them to play a pioneering role in tobacco control; (2) penatrate the smoke-free message into schools and the community via the Smoke-free Teens; (3) encourage the Smoke-free Teens to act as role models and develop a smoke-free healthy lifestyle; and (4) equip the young leaders with basic smoking cessation counseling skills. In fact, training teenagers to serve as behavior change agents has been widely suggested in the literature [13], and has been proven effective to combat alcohol use and substance abuse [14, 15]. Yet, this strategy has not been applied to establish a smoke-free culture. To address the gap in existing literature, this paper describes an evaluation of this programme’s effectiveness in promoting the smoke-free culture among youths. However, the evaluation was carried in relation to the first three objectives, but not the fourth. This is because, some participants might not encounter any smoker during the study period; it would be difficult for us to assess their smoking cessation counseling skills.

The study evaluated the Smoke-free Teens Programme from July 2014 to March 2017. The study design and the procedure to obtain informed consent were approved by the Institutional Review Board of the University of Hong Kong and Hospital Authority Hong Kong West Cluster (reference UW14–412). Written consent was obtained from the participants’ parents after fully informing them of the study’s purpose and details. They were told that the participation of their child was totally voluntary and without any prejudice.

Design and participants

All students or teenagers aged 14 to 18 years from secondary schools, youth centres and uniform groups were eligible to join the Smoke-free Teens Programme. The uniform groups referred to any organization with their members wearing uniforms to signify the mission of serving different members in the community [16]. Promotion and recruitment was conducted early in each year and the programme was implemented from July to March of the next year. To recruit eligible participants, invitation letters were sent to around 450 secondary schools every year. For those schools that showed interested to join could contact us via the reply mail. Due to the limited capacity and resources., each school could only nominate around 10 students to join the programme every year. A total of 51 schools agreed to join this programme over the past 3 years. This gave an overall response rate of 11.3%. Figure 1 summarizes the recruitment process. The programme contained three major components. The first component was a 2-day-1-night training camp that aimed to train participants as Smoke-free Teens to promote a smoke-free culture. For the second component, participants were asked to organize creative activities to promote smoke-free messages in their schools and community. The third component included an award presentation ceremony to recognize the efforts of outstanding Smoke-free Teens in establishing a smoke-free culture. To publicize the Smoke-free Teens Programme, COSH produced publicity materials such as posters for display in secondary schools, youth centres, and uniform group meetings. Advertisements were placed in newspapers and magazines, on the radio, television and social media platforms. Programme webpage was set up to promote the programme and allow extended learning for the participants. COSH also organized a series of camp briefing sessions, communication skills training workshops, health talks and seminars. To evaluate the effectiveness of the training programme, a one-group pretest–posttest, within-subjects design was used.

A total of 856 teenagers were recruited during the study period. However, 26.5% (227/856) and 34.5% (295/856) lost to follow-up at 3 and 6 months, respectively. Figure 2 is a CONSORT diagram tracking how the participants flowed in this evaluation study.

Over the course of the 3-year study, Smoke-free Teens organized 552 smoke-free programmes, with each group conducting 3.2 programmes on average. These programmes reached 144,528 people in schools and the community. The highly diverse programmes included among the many activities exhibitions, mosaic art and microfilm production, game booths, debate and poster design competitions, as well as the promotion of a smoke-free culture on busy streets. An outstanding example was the team that won the 2014 championship. It organized a wide range of activities including a slogan competition, game booths, an anti-cancer health talk, and video production. To enforce the smoke-free message to primary school students and the public, they also invited people to make a smoke-free pledge, distributed bookmarks and cards with smoking cessation hotline numbers to smokers, as well as hung a banner with a smoke-free slogan at a minibus terminal. Over 2000 citizens were reached by their activities.

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.

Notwithstanding some limitations, the overall results of this study suggest the effectiveness of the training programme in changing knowledge about smoking hazards, attitudes towards smoking, and tobacco control and smoking cessation practices. It is encouraging that the trained Smoke-free Teens not only promoted smoke-free messages among their schoolmates, friends, and families, but also began to gather community support for a smoke-free Hong Kong. The Smoke-free Teens Programme has been instrumental in fostering a new batch of Smoke-free Teens to advocate a smoke-free culture and protect the health of the public.