Secondary School Students’ Perceptions of a Mobile Application Design for Smoking Prevention

Abstract

Introduction:
Our research was based on the BUS model, which provides guidelines for developing mobile applications for health. This model is supported by theories of behavior change, user-centered design, and social marketing. This study aimed to determine secondary school students' perceptions of a mobile application design for smoking prevention.

Methods:
In 2018, qualitative research was conducted in three secondary schools located in the central part of the state of Veracruz, Mexico. Focus groups were established to explore beliefs about smoking and mobile phone use. The sketch technique was used to identify the characteristics for the mobile application.

Results:
The students' perception of smoking allowed us to determine behaviors that can be changed: 1) associating cigarettes with a distraction from problems can be prevented; 2) peer and family pressure as a trigger to starting smoking can be avoided; and 3) tobacco use can be disassociated from being popular. Regarding the design of the mobile application prototype, an entertaining game with levels to help teenagers stay active was proposed.

Conclusions:
Games for health can help modify user behavior and even positively influence their values. The final product was the prototype for the 'No le entres' (don't jump in) application. An important finding was that adolescents living in both urban and rural settings use mobile phones similarly.

Full text

Research Paper Tobacco Prevention & Cessation
1
Published by European Publishing on behalf of the European Network for Smoking and Tobacco Prevention (ENSP).
© 2021 Uribe-Madrigal R. D. et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License.
(https://creativecommons.org/licenses/by/4.0/)
INTRODUCTION
In Mexico, 1.1 million active adolescent smokers have
been reported to exist. Such a figure represents 7.8%
of the population, where, according to the National
Survey on Alcohol, Drugs and Tobacco Consumption1,
the age of onset and daily consumption are 13.7 and
14.3 years, respectively. Therefore, further efforts are
essential to prevent and reduce smoking in this age
group, since by 2030 more than 8 million smoking-
related deaths per year are expected to occur2.
Engaging in healthy behaviors and easy access
to quality information are the fundamentals of
health promotion3. Engaging in healthy behavior
is an individual decision; therefore, the individual
behaviors of a given population group represent
a behavior collective that has an impact on public
health. Tobacco use is an unhealthy behavior,
so individualized information, considering the
characteristics of everyone such as age, sex, and type
of consumption, among others, plays a key role when
people choose whether to smoke or not. In this sense,
Information and Communications Technologies
(ICTs) have enhanced and even created new ways
to perceive healthcare3. Within ICTs, mobile phones
deliver a means of communication easily adaptable
to these needs, since they are communication devices
Tob. Prev. Cessation 2021;7(March):24 https://doi.org/10.18332/tpc/132965
Secondary school students’ perceptions of a mobile
application design for smoking prevention
Rosa Dabinia Uribe-Madrigal1, María del Carmen Gogeascoechea-Trejo2, María de Lourdes Mota-Morales3, Christian
Soledad Ortiz-Chacha3, Betzaida Salas-García2, Enrique Romero-Pedraza4 , María Cristina Ortiz-León3
ABSTRACT
INTRODUCTION Our research was based on the BUS model, which provides
guidelines for developing mobile applications for health. This model is
supported by theories of behavior change, user-centered design, and social
marketing. This study aimed to determine secondary school students’
perceptions of a mobile application design for smoking prevention.
METHODS In 2018, qualitative research was conducted in three secondary
schools located in the central part of the state of Veracruz, Mexico. Focus
groups were established to explore beliefs about smoking and mobile phone
use. The sketch technique was used to identify the characteristics for the
mobile application.
RESULTS The students’ perception of smoking allowed us to determine behaviors
that can be changed: 1) associating cigarettes with a distraction from problems
can be prevented; 2) peer and family pressure as a trigger to starting smoking
can be avoided; and 3) tobacco use can be disassociated from being popular.
Regarding the design of the mobile application prototype, an entertaining
game with levels to help teenagers stay active was proposed.
CONCLUSIONS Games for health can help modify user behavior and even
positively influence their values. The final product was the prototype for
the ‘No le entres’ (don’t jump in) application. An important finding was
that adolescents living in both urban and rural settings use mobile phones
similarly.
AFFILIATION
1 Public Health Institute, Master’s in
Public Health, University of Veracruz,
Veracruz, Mexico
2 Health Sciences Institute, University of
Veracruz, Veracruz, Mexico
3 Public Health Institute, University of
Veracruz, Veracruz, Mexico
4 Psychological Research Institute,
University of Veracruz, Veracruz, Mexico
CORRESPONDENCE TO
María Cristina Ortiz-León. Public
Health Institute, Master’s in Public
Health, University of Veracruz, Av. Dr.
Luis Castelazo Ayala s/n, Col. Industrial
Animas, 91190 Xalapa-Enríquez, Veracruz,
Mexico. E-mail: cortiz@uv.mx ORCID ID:
https://orcid.org/0000-0003-4953-5076
KEYWORDS
prevention, tobacco control, education–
youth prevention, mobile application
prototype
Received: 3 August 2020
Revised: 10 December 2020
Accepted: 31 January 2021

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with a high rate of penetration for a large part of the
population, particularly adolescents4.
Additionally, smartphones combine several
features; they allow for communication, and many
applications deliver immediate access to different
content or entertainment5. The entry of these
devices into people’s daily lives can be exploited for
their benefit. For example, developing applications
gives rise to opportunities to promote health and
make education more dynamic, interactive, and
individual, and this can occur on a large scale, since
the targeted population can be so easily reached. In
addition, they are more profitable than other types of
interventions6.
Article 12 of the Framework Convention
for Tobacco Control establishes that available
communication tools must be used to carry out
interventions to prevent tobacco consumption. If we
consider that adolescents are mobile phone users and
make up a population where most users have access
to mobile applications, then mobile phones could
be used as a tool for smoking prevention in this age
group7.
Digital objects, including mobile applications
(apps), should be designed considering the specific
needs of both the context and the community8. The
BUS model considers these aspects. Its name is
derived from three different concepts: B comes from
Behavior Change Theories, U from User-Centered
Design (UCD), and S from Social Marketing. BUS
considers six stages: 1) situation analysis, 2) concept
generation and prototype design, 3) prototype
development, 4) pilot test, 5) launch campaign, and
6) assessment. In this model, it is critical that users
are involved while the application is being designed
in all stages, from the conceptual design to the final
assessment. Behavior Change Theories and UCD are
both used in all the stages, while Social Marketing
only in five9.
Regarding the Behavior Change Theories to
develop interventions for adolescents, the following
theories stand out: Health Belief Model10, the Theory
of Reasoned Action11, and the Social Learning
Theory12. Thus, we considered them when designing
our app. The Health Belief Model predominated,
which refers to the use of rewards for adherence
to indications provided by health professionals to
improve quality of life and prevent complications
to their health state. The Theory of Reasoned
Action points out that the influence of peers affects
adolescent behavior. The Social Learning Theory
stresses the importance of external influences
on behavior since people learn by observing and
learning about the experiences of others.
There is a history of UCD to study adolescents’
perceptions of the features that smart applications
should have with respect to health in the United
States and Europe. We found that no studies like
these have been conducted in the Latino or Spanish-
speaking adolescent population. In most, the
qualitative approach and focus groups to determine
the characteristics necessary to design feasible and
usable mobile applications for health predominate.
Smoking cessation13, providing sexual education14,
diabetes control15, asthma16,17, and increasing
physical activity18 are some of the health problems
to be solved. We found no studies on developing
UCD-based applications for smoking prevention in
adolescents.
When designing mobile apps, it is necessary to
identify the target population and document the
design process to determine the ideal features by
considering their perspective as potential users
to encourage their use. For the abovementioned
reasons, this project aimed to determine secondary
school students’ perception of the characteristics of a
mobile application for preventing tobacco use.
METHODS
Study design
We conducted a user-centered design qualitative
approach19. We implemented the first two phases of
the BUS model: 1) situation analysis, and 2) concept
generation and prototype design.
Context
We recruited students from three secondary schools
located in the central part of the state of Veracruz,
Mexico. Schools were identified as School 1, School
2, and School 3.
Sampling strategy
We selected the three schools and students by
convenience. We included schools located in
communities with different levels of marginalization
and population centers. We included female and male

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public secondary school students in first, second, and
third grade, aged 12–15 years. Students were both
smokers and non-smokers, and all students were
mobile application users.
Data collection methods
Two focus groups were held between October and
November 2018 and another in February 2019. They
consisted of three students per school grade, female
and male, and both a moderator and a rapporteur took
part. Before holding the focus groups, participants
wrote their school grades and groups, sex, full
name, and phone type (Android or iPhone) on the
attendance list.
We used the same guide at the beginning of each
focus group to standardize data collection, so we
structured it as follows: a presentation to generate
empathy among the participants and establish
the rules for participation was shown. After this,
the students received a brief introduction about
health mobile applications, their purpose, and some
examples. The next sections of the guide explored
beliefs about tobacco use and mobile phone use in
everyday life. To obtain the attributes, design, and
contents of an app designed to prevent tobacco
consumption, we used the sketch technique, where
students were told to express themselves through
drawings on white sheets with colored pencils. In the
final part of the guide, we thanked participants for
taking part in the sessions.
We reminded them that the information given in
the group was exclusively for academic purposes and
that it would be handled confidentially. We created
an attendance list that included school grade, group,
sex, age, and phone type. Since the participants
were minors, informed consent forms were signed
by the participants’ parents. Students gave us their
informed approval. This project was approved by
the Technical Council of Instituto de Salud Pública
(Public Health Institute), part of the University of
Veracruz, which is empowered to issue both ethical
and methodological opinions on research and is also
the body empowered by the regulations with force in
the university.
The sessions were recorded, with the consent of
the participants, using a MacBook Air computer and a
smartphone. RDUM and MCOL held the focus groups,
as they have experience working with these groups.
Processing and analyzing information
We considered the following category analysis for data
collected by the focus groups: 1) beliefs about tobacco
use, with subcategories – health, family, friends, and
status; 2) mobile phone use in everyday life, with
the following usability subcategories – internet
access, mobile applications, social networks, costs,
rewards, and usage time; and 3) attributes of mobile
applications, with the following subcategories – avatar,
rewards, health behavior, color, type of application,
and use of other elements.
BSG, MCGT and MLMM, which previously have
done analysis, considered category analysis and
manually transcribed and codified data collected by
the focus groups. We then performed both a content
analysis using segmentation and an iconic memory
analysis to process visual information.
CSOC and MCOL, which have experience with
qualitative research, verified transcribed data after
codification was finished and if a segment matched
the category analysis identified by at least two of the
codifiers, then it was kept. Once identifying category
analysis was analyzed and verified, results from the
analysis were presented to the research team. ERP,
RDUM and MCOL then selected eligible behaviors
to be improved by developing a smart application, so
they were able to generate the concepts that gave rise
to our application.
After we generated the concepts, we then
designed a low-fidelity prototype of our application
to prevent smoking.
RESULTS
Situation analysis
Relevant characteristics of participants
School 3 is located in a rural town with a high level of
marginalization, and internet access is limited. School
3 and School 2 were those with a greater number of
participants (Table 1). In all the three groups, male
participation predominated. In the focus groups of
Schools 1 and 2 (Focus Groups 1 and 2, respectively),
all participants had a mobile phone while the research
was being conducted. In the focus group of School 3
(Focus Group 3), some participants had no mobile
phones for unspecified family reasons. In all the
three focus groups, Android-based mobile phones
predominated, while in Focus Group 2 some students
had IOS-based mobile phones.

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Beliefs about tobacco use during the adolescent stage
Secondary school participants knew about the health
damage caused by tobacco use. They recognized that
such a habit leads to death. A participant pointed out
that:
‘Smoking damages and contaminates your body,
causing death.’ (School 3, Male student)
They also identified substances contained in
cigarettes that can affect their health. In turn, they
stated that smoking not only damages the smoker,
but also those around him or her.
‘Mom taught me that smoking causes a lot of
physical pain, like cirrhosis, and affects your liver. It
is also bad for people living around you … as tobacco
smoke is in your clothes, you can make them sick and
your lungs can get sick.’ (School 2, Male student)
They have also heard or seen other people smoking,
from which they had received positive messages about
this habit, and they conceived this activity as pleasant,
stress-relieving, and fun (because smoke comes out of
your mouth). Some stated that flavored and colored
cigarettes are an incentive to start smoking.
‘When I smoke, I think of several flavored and
colored cigarettes - those are not so strong.’ (School 1,
Male participant)
According to participants, their decision to start
smoking is influenced by family. They emphasized
that family problems affect them and cause them to
smoke. They felt that, if a family member smokes, it
is an invitation to experience and start smoking.
‘[Family] influences start smoking for several
reasons. Problems at home is one of them and you try to
find something to kill time or a family member smokes
and he or she somehow convinces you, influences
you or makes you try to smoke.’ (School 2, Male
participant)
However, some participants assigned their parents
the role of counselors because they often give advice.
Nevertheless, participants themselves stay away from
counselling sessions and make decisions without
taking them into account.
‘Parents often give advice because they want to help
you, but you don't listen, you don't give a f… damn.’
(School 3, Male participant)
They believe that friendship plays a key role
in decision-making, particularly when starting to
smoke. In the three schools, young smokers are
visible and put pressure on others to start smoking.
To do so, they use challenging phrases such as:
‘You are a man, men smoke, are you a pussy or
what?’ (School 1, Male participant)
The belief that smoking brings popularity,
importance and power stood out in the focus groups:
‘Smoking makes you popular, the others see you as
an older and a mature guy and you become important
for them, they want to be like you, they start admiring
you for an unknown reason.’ (School 2, Female
participant)
‘You smoke because you want to imitate artists,
singers, if they smoke and just do fine, why can't you?’
(School 1, Male participant)
Mobile phones in everyday life
Mobile phones are used to play games, competition
games as well as violent or war games. Participants
from both urban and rural environments play the same
games. They also use mobile phones to communicate
Table 1. Characteristics of both schools and
participants taking part in the focus groups
Characteristics School 1 School 2 School 3
Name of the town Tlaltetela Xalapa Cantaranas
Type of town Urban Urban Rural
Level of marginalization High Very low High
Total number of students 267 1500 11 3
Participants per school 610 10
Sex
Female 1 6 1
Male 5 4 9
School grade
First 0 4 4
Second 2 6 2
Third 4 0 4
Type of mobile OS
Android 6 7 5
IOS 0 3 0
Does not have one 0 0 5

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with their friends through social networks or instant
messaging services.
‘I use my mobile phone for chatting or checking
Facebook and catching up with gossips about other
classmates. I like playing either Free Fire or Fortnite
because we can kill people.’ (School 2, Female
participant)
‘I use more Facebook, Messenger and games like
Free Fire or that one … Fortnite, they are so cool.
Besides, they have a lot of levels and their graphics are
so f… cool.’ (School 3, Male participant)
In addition, mobile phones are useful for them to
keep themselves informed about sports as well as
watch and download videos.
‘I use my mobile phone for Messaging my friends
and parents and watching and listening to musical
videos. For watching porn. For playing Free Fire. It's so
cool!’ (School 3, Male participant)
In a single group, it was mentioned that mobile
phones were used to do homework.
‘I use it [the mobile phone] for doing homework or
researching topics.’ (School 1, Male participant)
We observed that social networks are part of the
daily life of young people. Social networks have
become essential for them, regardless of whether
they come from communities with low or high levels
of marginalization.
‘I check Facebook and YouTube. I also play Fortnite
or Free Fire, as you can meet people and chat with
others.’ (School 2, Male participant)
Participants only download free apps that provide
them with prizes or rewards to keep their interest.
‘I like that games and apps are free, as I can
download them. I prefer playing on PC, it is easier and
free … using the keyboard is pretty cool, as my mobile
phone freezes and you can't play very well.’ (School 2,
Male participant)
We observed that they are constantly close to their
phones so that they can spend more time on them.
Participants living in rural environments spend fewer
hours on their mobile phones because of the quality
of the signal – not because of a lack of desire or
interest.
‘At school you are not allowed to check your phone
in classes, but I am virtually checking my apps all day.
Sometimes I only want to watch what time it is, when
I realize I already have notifications about my apps
and I stay hours looking at them … all day I have an
urge to be checking notifications.’ (School 2, Female
participant)
‘Well, I spent about 4 hours checking my apps,
because my Internet is unstable.’ (School 3, Male
participant)
Attribute coding for app design
According to participants’ perception, designing an
application to prevent tobacco use must be governed
by an avatar (Figure 1a). Games must be developed,
for example, to kill cigarettes, answer questions, and
earn points to improve the appearance of the avatar
(Figure 1b).
Regarding the prevention of tobacco use, they
Figure 1. Sketches drawn by focus group participants

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stated that it is important to be informed and aware
of the risks of smoking by using audiovisual tools,
which would reinforce their knowledge and provide
motivational messages. They also pointed out that,
at the end of each level of the game, they should be
told how important it is not to start smoking. They
said that it should be emphasized that not smoking is
beneficial for their health and for maintaining a high
quality of life and that they save money when they do
not buy cigarettes (Figure 1c).
Use of vibrant and bright colors prevailed in the
designs of the three groups. There was a preference
to developing war-based games with weapons.
However, there were variants where the user was
a caregiver that prevented the person they are
looking after from starting to smoke. They also said
that a game to strengthen their thinking skills with
questions to assess their knowledge and learning
should be developed. Moreover, they also proposed
a decision-making game where, if the player decides
not to smoke, then the player can move on to the next
level (Figure 1d).
Participants said that watching educational
videos on YouTube was important for them to stay
informed about tobacco risks (Figure 2a). A chat
was also proposed whereby participants can meet
other participants who have smoked and, through
interaction, learn from their experience. They
also stated that health professionals should be
included so that participants can learn more about
the consequences of tobacco use from an expert’s
perspective. Another interesting suggestion was
to link the app with associations that fight tobacco
use and addictions, and the money collected when
playing the app should be given to these associations
(Figure 2b). All groups proposed to link the app with
other social networks such as Facebook, Instagram,
and WhatsApp (Figure 2c), in addition to relying on
games like Free Fire (Figure 2d).
Concept generation and app design to smoking
prevention
With the information collected, we proceeded to target
behaviors that could be feasibly modified by an app:
1. Regarding cigarettes as a distraction for
participants’ problems.
2. Being pressured from friends and family.
3. Regarding tobacco use as popular.
Table 2 shows the behaviors to be modified, the
way to intervene, and the elements that can be easily
incorporated into our app.
Prototype design
Our app prototype was called ‘No le entres’ (don’t
jump in), as a warning against starting smoking.
Figure 3 shows the navigation map. It starts with
application access through three social networking
sites: Facebook, Twitter, and Gmail. After that, the
privacy notice pops up and provides information about
data protection. The next few lines briefly describe
Figure 2. Sketches drawn by focus group participants

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our app and provide instructions on how to play each
of the three levels.
In the next screen, the player will choose the
gender of the avatar. The player will interact with
this avatar throughout the entire game and be able to
customize her or him according to personal taste by
selecting clothes, shoes, and style.
The first level is trivia, answering questions about
tobacco use, physical and social damage, as well as
the benefits of not smoking. If the player answers
questions correctly, then the player can move on to
the next level, but if the player does not, then the
app will provide pieces of information such as short
videos, infographics, pictures and memes, which will
dispel doubts about the correct answer. The level
will aim to inform participants, based on scientific
evidence, about tobacco use to prevent classmates
and family members from inducing them to smoke
by giving them false information.
The second level is a rally that will be designed
Registration
screen Privacy notice Introduction Avatar
selection
Avatar
characteristics
Level 1: Trivia
Wrong answer
right
information
pops up
Correct answer
players moves
on to level 2
Level 2: Rally
A map
showing the
items to be
found pops up
Decision making
What are you
goanna do with
the item you
found?
Wrong choice,
it is possible to
find other item
Correct choice:
players moves
on to level 3
Level 3:
Obstacle Game
Avoid
obstacles
Awards earned
Figure 3. Navigation map of ¡No le entres! (Don´t jump in) app
Table 2. List of behaviors to be changed, how to intervene and elements to be incorporated into our app
Behaviors to be changed How to intervene Element to be incorporated into our app
• Prevent associating the
cigar as a distraction for
problems.
• Leisure and entertaining
activities.
• A three-level game as a positive distraction to avoid tobacco use.
• Prevent pressure from
peers and family to start
smoking.
• Strengthening the
autonomy of teenagers
with positive messages
and information on
the damage caused by
tobacco use during the
adolescent stage, so that
they can recognize harmful
behaviors.
• Short videos with positive non-smoking messages, infographics, illustrations
and memes will contain ‘Did you know that’ … information, supported by data
and statistics. According to the Theory of Reasoned Action that emphasizes
the inuence of peers on behavior, YouTubers and inuencers, who are popular
among teenagers, will be invited to participate in the short videos.
• Do not associate
tobacco use with being
popular.
• Stimulating talents, skills
and interests to benet
their health. Prevent
relating tobacco use with
acceptance to social groups
in their environment.
• Answering questions. According to the Model of Health Beliefs, if answers
are correct, teenagers will receive rewards, either a gift coupon or accessories
for the avatar, in addition to moving on to the next level.
• A decision-making level, where teenagers will put into practice what they
have learned and choose between two situations (one that puts them at risk
and another that keeps them healthy). Thus, teenagers will reinforce their self-
esteem and condence in themselves and avoid associating tobacco use with
the need to being accepted by the social groups around them and achieve a
popularity status.

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using augmented reality. The player will travel
around the city he or she is living in when accessing
our app to find two graphical elements: smokers and
cigarette butts, which will be collected by clicking
on. Then, on the screen the adolescent will see a
question about what to do with that element. The
player will have to choose wisely to move on to the
next level.
The more elements caught by the player, the
more points the player gets. This level aims to
develop abilities for searching and recreation so
that adolescents can perceive themselves as skillful
and useful people who are able to make the best
decisions on their health.
The third level is an obstacle game where the
player using his or her avatar has to dodge cigarettes,
while collecting water balloons to throw at smokers.
It is a time-trial level whose objective is to reinforce
in adolescents that smoking is harmful and they must
avoid cigarette smoke.
Once players beat the three levels correctly
and satisfactorily, they receive rewards consisting
of discounts at movie theaters, clothing stores,
bookstores, music stores, and entertainment as well
as accessories for their avatars.
DISCUSSION
Our research was based on the BUS methodology,
whereby three focus groups were held. We used User-
Centered Design and Behavior Change Theories,
resulting in the prototype for the ‘No le entres’ (don’t
jump in) mobile application, which aims to prevent
smoking among adolescents. It is innovative in that
we found no evidence of mobile applications being
developed to prevent smoking among the Latino
adolescent population.
In the participants’ discourse, the Health Belief
Model predominated, since they recognized the
effects of smoking as a very serious issue. However,
smoking is still a source of satisfaction for them.
Thus, it is necessary for people not only to determine
the risks of smoking, but also the benefits of not
using tobacco10. We also used this model to design
our app, since it considers that the player will receive
prizes once all three levels of the game are beaten.
The Theory of Reasoned Action was another
theory that was made visible in the participants’
discourse, since participants frequently mentioned
that friends usually induce them to smoke. However,
if we replace a ‘negative peer’ with a peer with
positive behavior, it will be easier to prevent young
people from starting to smoke11. Considering this
theory, we will include YouTubers and influencers to
send positive messages.
Since participants mentioned that chatting with
people, who have already gone through tobacco use
disorder to determine the negative consequences,
had positive effects12, we considered the Social
Learning Theory to enhance the talent and ability
of the user by asking him or her to make a correct
decision.
When we explored mobile phone usage, the
penetration of this device and the internet were
both confirmed in different contexts. Although the
three schools are located in towns with different
levels of marginalization, the activities carried out
by adolescents using this device did not differ.
Therefore, at least for this population group, there
are no technological gaps, since, regardless of
whether they live in urban or rural areas, mobile
phone usage is the same. This is consistent with
Ferras et al.20 who claim that mobile phone usage
seems to be resolving the lack of communication and
isolation among adolescents living in rural contexts,
which is also in line with what UNESCO stated in
2013, as regards the fact that an increasing number
of people, including those from impoverished areas,
own and use mobile devices21.
The results showed that adolescents spend
around eight hours a day using their mobile phones.
On weekends, usage increases, and this may be a
problem. However, several authors recognize that,
due to the time intended for this device, mobile
phones can be used as a tool for adolescents to
engage in healthy behaviors, especially prevention of
drug use22-24.
Adolescents think that avatars they designed
should be used to design our app and that the app
should include chats to communicate with other
young people. This is similar to the results obtained
by Whittaker et al.13, since according to these authors
an application is attractive for adolescents if there
is music for relaxation, interaction with others, and
exposure to ‘real’ and ‘honest’ role models with
credible stories and animations.
Young people stated that informational videos

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should include information on how tobacco damages
health. This is consistent with a study carried out in
2017 by Park et al.25 who evaluated the effectiveness
of videos made to prevent tobacco use.
Finally, adolescents feel more empathy and
pleasure for game-type applications that provide
them with features that encourage them to
continue playing, such as abilities to improve avatar
characteristics and to buy items on the internet.
The same results were reported by Pope et al.18 who
demonstrated that a game-type application needs to
have rewards, competences, and accessibility to be
attractive to young people.
The prototype design was based on a game with
levels that help adolescents to stay active and
enhance their skills. This game for health has been
proven to help change user behavior26,27, and it can
even influence one’s values positively28.
The BUS methodology allowed adolescents, as the
target population, to be involved in the application
design since the beginning of the process, because,
as has been demonstrated, for an application to be
successful, the end user must be considered in the
design. The sketch technique allowed adolescents
to exercise their creativity and increase their
confidence when expressing their ideas about the
app, achieving completely user-centered results.
Few apps are aimed at preventing tobacco use8,
including the Smokerface app. However, our ‘No
le entres’ app is different, because in the initial
conception Smokerface used the Mirroring29
approach, so end users were not involved. Most
applications available on the market are aimed at
treating it30.
Within the MPOWER plan to reverse the smoking
epidemic, MPOWER stresses that adolescents who
receive effective messages through television are
less likely to become smokers. Such a plan was
elaborated in 2008, a time when mobile phone use
was not as popular as it is today. Thus, it is believed
that using mobile phones to deliver these messages
could be as effective as television31. Therefore, it is
advisable for public health authorities to include in
their traditional programs for adolescents to promote
health, prevent diseases, and encourage the use of
ICTs, since, as this study has shown, mobile phones
are popular, and adolescents spend a substantial
amount of time on them.
Limitations
Regarding limitations in this study, we mention
that most participants were male, which possibly
influenced the development of a war-type game.
Another limitation was that we only applied the first
two stages of the BUS model due to the resources
available for the study. Therefore, it is important to
continue to develop this app to evaluate its use and
effect among adolescents; data on use frequency and
the effectiveness of the theories of behavior change
need to be obtained.
CONCLUSIONS
Guidelines for digital content design are provided
to prevent tobacco consumption in the adolescent
population. An important finding was that adolescents
living in both urban and rural settings use mobile
phones similarly. Thus, developing applications for
this population group has a great potential to grow
still further for m-Health strategies. Games for health
can help modify user behavior and even positively
influence their values. The final product was the
prototype for the ‘No le entres’ (don’t jump in)
application.
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ACKNOWLEDGMENTS
We thank Miguel Alejandro Cámara Arciga for helping us design the
prototype. We also thank the education authorities of the three schools
and students who took part in the focus groups.
CONFLICTS OF INTEREST
The authors have completed and submitted the ICMJE Form for Disclosure
of Potential Conicts of Interest and none was reported.
FUNDING
This research received internal funding, in coordination with the Master’s in
Public Health of the University of Veracruz.
PROVENANCE AND PEER REVIEW
Not commissioned; externally peer reviewed.