Phase 1 procedures.

During Phase 1, the qualitative sessions were conducted using the online video conferencing software Zoom. Qualitative procedures involved one lead researcher (GEK, gender: male, credentials: M.P.H., Ph.D.), one graduate research assistant (DM, gender: male, credentials: M.A.), and one research coordinator (ER, gender: female, credentials: B.S.). As the moderator, ER was trained in qualitative research methods and engaged in 5 rehearsal sessions using this study’s qualitative instrument. For quality assurance, a qualitative research scientist was present during the sessions and did not identify any interviewer-related biases. The moderator instructed participants to be in a room by themselves during a session and began each session with an icebreaker to help establish a relationship between participants. The icebreaker was followed by a debriefing about the session and the qualitative instrument. For quantitative data collection, participants received an online survey that was distributed via Redcap [30]. Sessions took approximately 90 minutes.

Phase 2 procedures.

Our study team and the YDC participated in one one-hour co-design online ideation session per month for seven months, during which attendees (1) brainstormed new versions of the messages from the initial library to end up with a final library and (2) participated in the design and ideation of an interactive tobacco prevention program. The current paper only describes the results of message design. First, the moderator read each text message out loud and asked all youth committee members to brainstorm in silence, ways to reframe the message based on their preferences. With several versions written by all committee members, the moderator read every new version of the message out loud and allowed participants to discuss the new version. This was done while considering the results of the qualitative sessions at Phase 1. Participants then made additional updates to their messages and discussed the new versions until a consensus was reached for their preferred version, making a final decision on each message. During the workshop, as attendees discussed the results of the Phase 1 qualitative sessions, they were allowed to make a decision to remove a particular topic from the library or add new topics that they find important.

Assuming a level of knowledge.

The extent of adolescents’ knowledge of tobacco was revealed when participants were asked what they knew about different tobacco products. Participants were aware that cigarettes, smokeless tobacco, and cigars are dangerous in a general sense but had little knowledge of other products. Participants knew that cigarettes cause cancer, lung disease, and heart disease. They were also aware that cigarettes are highly addictive, and that quitting can be difficult. Participants did not report any knowledge of the psychological and social dangers of tobacco.

• “They often tell us that it causes like cancer and like lung cancer, and that I think it causes heart disease and some other–like blood pressure problems, and things like that” (Participant 3, Focus group 1)
• “I know cancer and heart problems and–it’s addicting. So it’s hard to quit” (Participant 1, Focus group 1)
• “It can also have–like, it affects your lungs. So it’ll make it harder to breathe and make it more difficult. It also can make you immunocompromised later in periods of time.” (Participant 1, Focus group 4)

During the focus group discussions, it became evident that adolescents possessed some awareness of the harmful components present in tobacco products, particularly cigarettes and cigars. Participants said that others their age try to avoid these products. They expressed their concerns regarding these substances, emphasizing that they should never find their way into the human body. Notably, they specifically mentioned alarming elements like metals and chemicals commonly employed as rat poison. Some adolescents were also aware of tobacco use consequences. Without evidence of knowledge, they expressed familiarity with e-cigarettes, because of the products’ popularity among their peers.

• “Like we kind of look at it like, ‘Eww, you smoke cigarettes.’ You know what I mean?… Like I see mostly older people smoking blacks and cigars and stuff. But I don’t think our age group really–because that’s really frowned upon. Like it’s kind of a double standard, but it’s really frowned upon.” (Participant 2; In-depth interview)
• “Because they’re [vapes] the most talked about and–probably the most talked about in this generation.” (Participant 3; Focus group 2)
• “I know that there’s rat poison products in cigarettes.” (Participant 5; Focus group 2)
• “Yeah [I know something about this product], you could inhale toxic metals from it.” (Participant 4, Focus group 5)

Unexpected tobacco information.

When presented with the first version of the text messages, participants were “shocked” to learn that tobacco products contained many dangerous ingredients. Participants had strong reactions when they were told about the dangerous content of tobacco and thought messages on this topic were effective.

• “I was most shocked about the carbon monoxide. Because… you can literally die because it’s so toxic to us. So the fact that they would put it in a product and that it is legal to sell that really shocking to me” (Participant 1; Focus group 1)
• “Because when I hear like about the poisons, the toxic chemicals the effects and stuff, and it’s just like I would not want to do that” (Participant 5; Focus group 2)

While they were well-informed about cigarettes, cigars, e-cigarettes, and smokeless tobacco, they knew little about Hookah. Hookah was the most common response when participants were asked which product they knew the least about. Participants were especially surprised to learn how much smoke users inhaled when using Hookah.

• “I think it’s kind of crazy, especially with the–the pipe one. Like 100 cigarettes… if you think about it, that’s a lot of packs.” (Participant 5; Focus group 2)
• “[I know the least about the hookah] because I never like–even though I’ve seen it, I’ve never really understood hookah.” (Participant 1; Focus group 3)

A need for new information.

Adolescents expressed that they have been exposed to anti-tobacco messages for much of their life and said that they were tired of repeatedly being told the same thing. Some messages covered things participants already knew, and these messages were disliked because they were “Obvious” (Participant 1; Focus group 1) or “Common sense” (Participant 2; In-depth interview) and were not needed. One participant thought messages containing information they knew were “Boring” and hearing them repeated was “Annoying and Obnoxious” (Participant 4; Focus group 4).

• “So just it gets old… we don’t want to hear it anymore” (Participant 3; Focus group 4)
• “And then there’s no safe tobacco product, I mean, we hear that all the time, again, with the like–sort of like statements that are just like–we all know” (Participant 1; Focus group 4)

Social exposure.

Adolescents mentioned the prevalent nature of tobacco use within social contexts, particularly for vaping. Many adolescents shared their experiences of being exposed to tobacco, both through their peers and even within their own homes during family events or gatherings. This exposure highlighted the pervasive presence of tobacco in their social circles.

• “People who come to parties, they’ll be using them… Family members.” (Participant 3; Focus group 1)
• “Since they see that their friends are doing it, they like kind of become more open to it.” (Participant 2; In-depth interview)
• “It could be any party, yeah. It’s likely there’s going to be some type of smoking.” (Participant 1; Focus group 2)
• “That’s the hookah. I know there’s like hookah lounges in Gainesville. Like I know before Covid, like my friend, she had a birthday party at a hookah lounge downtown one time.” (Participant 2; Focus group 3).

Participants also discussed the popularity of E-cigarettes at sporting events and parties and how they can be hard to escape. Vaping is also common in schools where adolescents tend to sneak off and find places to hide and vape.

• “Like I’ve seen people go into the school bathrooms and vape.” (Participant 4; Focus group 2)
• “Like clubs and like–like parties–most definitely friend’s parties, or it could be with family and friends too. It could be any party, yeah. It’s likely there’s going to be some type of smoking.” (Participant 1; Focus group 2)
• “Like definitely at like parties and like football games and, you know, the bathroom, like at school, like the gym… But it’s just like yeah, like anywhere, anywhere they can like find a ducked off spot. Yeah, they’re going to hit that Juul.” (Participant 2; In-depth interview)

Social belonging and social image.

Adolescents acknowledged that some of their peers use tobacco to feel a sense of belonging and inclusion within their social groups and improve their social image. They explained that they wanted to look “cool” and “fit in”.

• “Probably because they just want to do it, just because. And to show their friends like they’re cool and stuff.” (Participant 3; Focus group 5)
• “Mostly why teens get addicted to nicotine or drugs is that they don’t want to be lame in front of their friends.” (Participant 5; Focus group 5)

Diffused trendy products.

Adolescents’ desire for social belonging and the aspiration to enhance their social image can be attributed to their exposure to a pervasive image associated with tobacco use, especially vaping. Adolescents revealed that tobacco, particularly vaping, had gained popularity and diffused as a prevalent trend or innovation within their social circles. Adolescents reported observing new and emerging tobacco products’ widespread acceptance and adoption within their peer groups.

• “It’s like seen as cool, it’s like pictured as cool in like movies and stuff, and like when you’re a young age you see it all the time in movies.” (Participant 1; Focus group 4)
• “They’re [vapes] the most talked about and–probably the most talked about in this generation.” (Participant 3; Focus group 2)
• “Everyone had Juuls, like the freshmen, sophomore, like everyone had like the Juuls.” (Participant 2; In-depth interview)

Peer pressure.

Participants were also quick to mention the prevalence of peer pressure and how it can often lead people to start using tobacco products. They expressed that friends’ tobacco use can play a key role in influencing their decisions, showcasing the powerful impact of social influence within their circles.

• “But then like peer pressure most definitely, like what causes people to do it.” (Participant 1; Focus group 2)
• “I would say the biggest one [reason why people my age might start using tobacco] is peer pressure.” (Participant 4; Focus group 6).

During the evaluation of the initial version of text messages, it was noted that some adolescents found the messages addressing peer pressure as the most impactful. This preference stemmed from their personal experiences with peer pressure. Participants found these messages to resonate with their struggles and encounters with peer pressure. The discussions surrounding the influence of friends and the challenges of resisting tobacco use within their social circles affected them based on their personal experiences. Additionally, participants highlighted the importance of having the “right friends”, a social circle that supports them and helps them stay tobacco-free.

• “For me, it’s probably the ones that [are] about having the right friends [that] can help. That’s very important to me because I’ve seen a lot of peer pressure. I’ve experienced it myself. And I’ve come to the realization that having the right friends is very important because if you have the wrong friends, they can lead you down somewhere that you really don’t want to go.” (Participant 3; Focus group 6)

Teen-tailored marketing.

When asked why people their age use tobacco, participants highlighted that several tobacco products are targeted toward youth, particularly those that are electronic and include flavors. Participants mentioned this concern when presented with text messages regarding tobacco marketing. They were particularly surprised that marketing of tobacco products tends to be tailored to a wide variety of customer types, including youth.

• “… vapes and stuff is like more catered towards the younger age. Because it’s electronic and there were flavors at one point. And so that was sort of like catering to our age.” (Participant 1; In-depth interview)
• “I thought they usually targeted certain groups. But it sounds–if they’re marketed to everybody, that was pretty shocking to me.” (Participant 1; Focus group 1)
• “… it’s like seen as cool, it’s like pictured as cool in like movies and stuff, and like when you’re a young age you see it all the time in movies.” (Participant 1; In-depth interview)

Product appeal.

The effect of tobacco marketing is accumulated by the product appeal, particularly with vaping products. Flavors are a key appealing characteristic of vaping products, and participants find this appeal to be a strong motivator of youth vaping.

• “… another thing is it comes in like fruity flavors, which is very appealing to people.” (Participant 4; Focus group 2)
• “Some have flavors which make a lot of teens get attracted to it.” (Participant 5; Focus group 5)

Misinformation.

Participants reported that tobacco advertisements can be misleading, particularly when it comes to the marketing of vaping products. They explained that tobacco companies would not be looking after their customers if they misled them. When presented with the first version of the text message, participants expressed surprise to learn that tobacco companies that sell cigarettes can also sell vaping products, advertising them as a healthier choice, but they are not surprised to learn that not surprised that they would mislabel their products when they involve harmful content.

• “Misinformation. Some people think that vaping isn’t all that harmful because it isn’t cigarettes.” (Participant 1; Focus group 6)
• “… how with the companies that are creating like the cigarettes and then selling you e-cigs, like saying that they’re like less addictive.” (Participant 3; Focus group 4)
• “I feel like they’re kind of not really looking out for the people that use their products, because they’re giving false information or they’re saying whatever they have to say to make people think that their product isn’t as dangerous as it really is.” (Participant 1; Focus group 1)
• “[I am] not surprised that these companies are willing to put these dangerous products out on the market. I’m not surprised that the labels would be like false. (Participant 1; Focus group 1)

Preference for empathetic messages.

When discussing the anti-tobacco message used in the game, adolescents disliked messages that they saw as heavy-handed. They advised taking a softer tone to not offend people who use tobacco. Participants were worried that there could be a backlash if messages sounded judgmental.

• “Because if it becomes too strong an opinion, I think it would make those that may have already been involved with tobacco products see it in–it would be tough for them to absorb the facts, because they’d become more defensive about it.” (Participant 2; Focus group 4)
• “I think a lot of them [messages] would be received as judgmental. Because I know people get addicted to things for other underlying reasons. And I think if someone heard someone saying this about them, it would only make their situation worse.” (Participant 4; Focus group 6)
• “[Some messages are] portraying it in a very negative sense, which I feel like… you’ve got to be a little bit more lighthearted with things.” (Participant 1; Focus group 4)

Participants were also concerned about the tone of messages discussing some of the health outcomes of tobacco use. Adolescents felt that messages focusing on mental health were too negative and may offend or put off people who have mental illnesses.

• “I feel like this is one of them, because people who have like anger management issues and depression and anxiety and stuff like that, sort of have like an insecurity about that. And they, you know, can’t really control that as well as other people.” (Participant 1; Focus Group 4)

Some participants suggested that testimonial messages can help convey one’s experience with tobacco with fewer judgments.

• “… maybe show like actual people that use tobacco and like how it affected–let them talk about how it affected their life. Because it’s more like convincing if someone’s actually there telling you what they went through.” (Participant 1; Focus group 1)

Low self-efficacy versus confidence.

By keeping in mind tobacco users’ lost self-efficacy, some participants highlighted the importance of designing messages that are sensitive to the challenges associated with quitting. They emphasized the need for mindful design, considering the difficulty that tobacco users may face during the quitting process. Conversely, when presented with motivational messages, participants expressed the belief that improving self-efficacy by empowering individuals to maintain a tobacco-free lifestyle can be helpful.

• “… because like some people may get offended or feel uncomfortable about [me talking to them about tobacco] because often people want to quit, but they can’t. [You could] make someone feel like uncomfortable if you approach them about it. (Participant 1; Focus group 1)
• “I think that’s really important to realize that just because you started don’t mean that you have to continue, and that you have the power to be able to fight back.” (Participant 3; Focus group 6)
• “My [favorite messages were] the ones where talks about the cheer, the power to basically overcome these habits. A lot of people think that once they start that they can’t stop, that they need to live off of smoking. But if they really think about it, and they really think that we can get out of this situation, we have the power to get out of the troubles. And to figure out what causes us to get in these troubles and staying away from these problems to try to keep ourselves out.” (Participant 4; Focus group 6)

Messages on appearance and aesthetics.

Participants noted that messages regarding physical attractiveness were effective. Messages that highlighted how tobacco use would change the way they looked were impactful, in their opinion, particularly when the message allowed them to picture their change in appearance due to tobacco use.

• “It’s a lot more about like the–what it physically does to you, and I know a lot of people care about their appearance. So this may be really important to them, about what they look like.” (Participant 1; Focus group 1)
• “… the descriptiveness of it [losing teeth], where I can almost imagine like what you’re talking about. Like… it kind of makes me like think about what it would look like, and it kind of grosses you out.” (Participant 2; In-depth interview)

One message that mentioned acne was singled out for its effectiveness and relevance to adolescents who are already dealing with acne.

• “I feel like everyone would feel the first one, about the acne. Because we’re already going through enough acne on our own. I don’t want anything else to be contributing to that.” (Participant 2; In-depth interview)

Messages that convey statistics.

Adolescents reported that they find factual messages, especially those that convey statistical data, effective. Many felt facts, especially numbers, can help adolescents realize the severity of the harm. Some reported that the messages can be more interactive by showing data for different scenarios (e.g., taking healthy and unhealthy actions).

• “I think the one with the numbers, because people like to see numbers to know like, like, I think tend to attract people more. Like I know I kind of scanned and saw the 200 and it popped out at me.” (Participant 1; Focus group 1)
• “It’s because once people would see numbers, like they’ll know like okay, this will really do some harm to my body due to the percentage that like it has with it. (Participant 3; Focus group 1)
• “I feel like it should’ve been more interactive, like here is what will happen but here’s how you can have healthy coping mechanisms instead of turning to this. And understand why it’s not good and why it’s better to do something else.” (Participant 4; Focus group 2
• “Maybe show how addicting it is. Like possibly show like how many times you use it. Like how many times smoking a cigarette will cause you to become addicted. (Participant 1; Focus group 1)

Updated library of text messages (Phase 2).

For Phase 2, of those who participated in the YDC (n = 11), 9 (81.82%) were female (mean age = 16.06 years, SD = 1.65). For Phase 2, nine YDC members (81.82%) identified as non-Hispanic White, and 3 members (27.27%) were susceptible to using tobacco in the future. During the design sessions, participants brainstormed between 1 and 7 iterations of the initial version of the messages. Following discussions and consensus, the design sessions resulted in a library of 306 messages under 7 sections, categorized based on the processes of change from the TTM. Table 2 presents examples of messages before and after design.

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Table 2. Examples of messages before and after design.

https://doi.org/10.1371/journal.pone.0296503.t002

Our library of messages presented topics that are common for tobacco education under each process of change from the TTM. In addition, the library included topics that are unique to new and emerging products (vaping products and hookah), and it considered sub-themes that we identified during the qualitative sessions conducted in Phase 1. Each group of messages covered an average of 4.28 sub-themes. We also retrieved 238 key terms that researchers and public health professionals can use to identify certain messages of interest (Table 3).

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Table 3. Library of messages by topics and covered keywords and subthemes.

https://doi.org/10.1371/journal.pone.0296503.t003