Use of Internet Viral Marketing to Promote Smoke-Free Lifestyles among Chinese Adolescents

Ip, Patrick, Tai-Hing Lam, Sophia Siu-Chee Chan, Frederick Ka-Wing Ho, Lewis A. Lo, Ivy Wing-Sze Chiu, Wilfred Hing-Sang Wong, and Chun-Bong Chow

Plos One 9, no. 6 (2014): e99082


Most smokers in Hong Kong begin smoking at an early age, with approximately two out of three starting to smoke weekly between the ages of 10 and 19. Smoking has also been on the rise among young adults in the city. Early health education intervention is important, as youth smoking is linked to an increased risk of many diseases in adulthood, including cardiovascular diseases and cancers. Internet viral marketing holds promise for such interventions because messages are spread quickly and widely and are easily shared among peers. However, evidence of the effectiveness of viral marketing in health education for behavior change is sparse. This study examined the effectiveness of an online quiz game in changing young people’s attitudes toward smoking.


An online multiple-choice quiz game was developed based on focus group sessions with Hong Kong residents ages 10 to 24. The group discussed factors that motivate young people to share smoking information with their peers and to visit smoking cessation websites. Participants also talked about useful features and functions of a website to include and the use of games in websites promoting smoking cessation. The goal of the game was to get the highest score to win an electronic device priced at USD $650. To earn points, participants had to correctly answer 20 questions about smoking. The questions were developed to maximize attitude change among participants using the Elaboration Likelihood Model of persuasion. The model aims to produce stronger and longer-lasting behavior change after the intervention. The game was available for 22 days, from October to November 2012. Participants were encouraged to refer the game to other youth to boost their scores in the competition.


Design: The evaluation was a pilot study, with the participants’ data collected before and after the quiz (quasi-experimental design). Upon registering, participants completed a short questionnaire about their background and attitudes toward smoking; they also entered referral codes if they were referred to the game by a peer. Participants could also complete an optional post-game questionnaire to receive a small cash incentive. The first round of participants (those not referred by others) were called Level 1 users; Level 2 users were referred by Level 1 users, and so on.

The Tobacco Attitude Survey was used to assess changes in smoking attitudes before and after the quiz; the authors used the six items in the survey related to general attitude toward smoking and grouped participants into three categories: positive (favorable attitude toward smoking), neutral, and negative. Perceived likelihood of smoking in the future was measured using two binary variables that captured whether participants would smoke with a close friend’s offer and whether they would smoke in the next 12 months. The referral rates were analyzed and tracked. The analysis focused on the referral pathways that began with Level 1 users and any patterns in their age groups that influenced the number of referrals they made to their peers.

Sample: Researchers reached out to three randomly selected seventh to ninth grade classes in local secondary schools, a university dorm, and a nongovernmental organization center to recruit Level 1 users ages 10-24 years. They recruited 121 Level 1 users, of whom only two self-identified as ex-smokers and none as current smokers. By the end of the 22-day competition, the number of participants increased to 928 after referrals, 22% of whom were ex-smokers and 13% current smokers. More than half (55%) were male, and the majority were between ages 10 and 14 (37%). Only 203 (22%) participants completed the pre- and post-game questionnaires.


After the competition, negative attitudes toward smoking increased from 57% to 73% and positive attitudes decreased from 26% to 12%. Participants’ likelihood of having a negative attitude toward smoking increased with every quiz question they attempted. Similarly, the more quiz questions they answered, the less likely they were to conceive themselves smoking because of a close friend’s offer or smoking in the next 12 months. Younger users ages 10-19 were more likely to reach out to more people to refer the program, while older users ages 20-24 had more successful referral attempts and researchers noted they were more susceptible to anti-smoking messaging.

Limitations: Limitations of this study include a short study duration and a low response rate (22%). The low response rate could bias the results if those who completed the post-game survey were more enthusiastic and, therefore, had a more positive attitude about the game than non-respondents. The authors also expressed concern over potential self-referrals, as the same person could register for the game more than once. Lastly, the ratio of females to males in the sample did not reflect the ratio in the target population. 


In this study, viral marketing reached a large number of people in a short period and successfully promoted tobacco-related health information among urban youth in China. The results demonstrate that viral marketing campaigns are promising platforms for promoting attitudinal change among young smokers through health education.