Interventions on tobacco industry denormalisation and alternative smoking products on Hong Kong primary school students

Abstract

The global rise in alternative smoking product (ASP) use, including electronic cigarettes (ECs) and heated tobacco products (HTPs), among young people calls for swift and effective public health responses. Tobacco industry denormalisation (TID) that reveals the deceptive and manipulative marketing strategies of the industry is an effective tobacco control strategy but seldom used on children. I conducted a quasi-randomised controlled trial (RCT) and 2 cluster RCTs to evaluate the immediate and short-term effects of TID and ASP prevention interventions on Hong Kong primary school students.

From January to March 2019, a very brief TID intervention (10 minutes to complete a worksheet) was conducted on Primary 4-6 (P4-6) students from 4 schools (intervention vs control: 536 vs 523 students). Each worksheet had 4 pages: pre-test, 2 A4-page exercise matching pictures with misplaced statements that described them, and post-test. Immediately after intervention, significantly more intervention group students were aware of the industry’s specific strategies (TID belief) on 3 items.

From October 2020 to January 2021, a very brief ASP prevention intervention comprising the main session (ASP worksheet vs sugar-sweetened beverage (SSB) control worksheet) and booster session (6 WhatsApp e-messages sent within one month) was conducted on P4-6 students from 5 schools. Assessments were conducted immediately after main session (T1, paper-and-pencil) and immediately after booster session (T2, online). The number of analysed ASP and SSB students were 559 and 551 at T1, 169 and 209 at T2 (unmatched). Compared with SSB control group, 3 ASP-related knowledge and 1 TID belief items were significantly improved in ASP group at T1, acceptability of ECs was decreased in ASP group at T2 (marginally significant).

From September 2021 to February 2022, a new TID intervention comprising the main session (group A: TID video, B: TID worksheet vs C: SSB control worksheet) and worksheet booster session was conducted on P4-6 students from 11 schools. Paper-and-pencil assessments were conducted immediately (T1), 1 month (T3) and 3 months (T4) after main session. T1 students (A vs B vs C: 916 vs 880 vs 933), unmatched T3 students (927 vs 880 vs 940) and unmatched T4 students (872 vs 842 vs 896) were analysed. Group A showed significantly greater improvements in 6 TID belief items, 2 ASP-related knowledge items and views on the tobacco industry at various time points than group C. Results of B-C comparisons were similar to A-C comparisons in general. Group A showed significantly greater improvements than group B in 4 TID belief and 1 ASP-related knowledge items at T1, and 1 ASP-related knowledge item at T4.

In conclusion, I have first shown that both the TID video and TID worksheet significantly improved P4-6 students’ TID beliefs, ASP-related knowledge and worsened their views on the tobacco industry. The TID video was more effective than the TID worksheet on TID beliefs and ASP-related knowledge immediately after main session but not at the 2 follow-ups. Students preferred video to picture and text. The present very brief self-administered interventions on TID and ASPs are highly scalable in primary schools.