Co-design of the ‘OurFutures Vaping’ programme: a school-based eHealth intervention to prevent e-cigarette use

Abstract

Effective preventive interventions are urgently needed to address e-cigarette use (‘vaping’) and related harms among young people. There is a strong evidence base supporting the delivery of substance use preventive interventions in the school setting, and eHealth interventions can overcome common implementation barriers. However, there is a dearth of effective school-based e-cigarette preventive interventions available. This study summarizes the co-design and user testing of the ‘OurFutures Vaping’ programme, a universal school-based eHealth preventive intervention targeting e-cigarette use. The intervention is based on the effective ‘OurFutures’ prevention model, which adopts a harm minimization and comprehensive social influence approach to prevention and delivers content via interactive cartoons and supporting resources. Beginning in March 2022, the development process involved four iterative stages: (i) scoping of the literature; (ii) consultations with young people (n = 34; 14–16 years) to understand attitudes and perceptions about e-cigarettes/tobacco cigarettes and develop cartoon character profiles and storylines; (iii) content and web development; and (iv) user testing and refinement with students (n = 37; 13–14 years) and teachers (n = 13). Key areas for improvement included lesson length, believability and relevance of some storylines, incorporating resources on e-cigarette addiction and cessation, and tweaking illustrations. Refinements were made and the final intervention comprised four 40 min online cartoon lessons with accompanying teacher-facilitated activities, factsheets, and resources. The ‘OurFutures Vaping’ programme is the first school-based e-cigarette preventive intervention in Australia to be developed via iterative co-design, grounded in evidence, and to undergo rigorous evaluation (cluster randomized controlled trial, 2023–26), holding the potential to make significant health and economic impact.

Contribution to Health Promotion.

• Adolescent e-cigarette use (‘vaping’) is a global public health concern, highlighting the urgent need for effective and scalable prevention approaches.

• This paper describes a four-stage iterative co-design process used to develop the ‘OurFutures Vaping’ programme, a school-based eHealth intervention aimed at preventing the uptake of vaping among adolescents.

• The ‘OurFutures Vaping’ programme is Australia’s first digital school-based e-cigarette preventive intervention to be developed via iterative co-design, grounded in evidence, and to undergo rigorous evaluation.

• The findings of this paper offer key insights into co-designing digital health behaviour change interventions for adolescents.

INTRODUCTION

Adolescent e-cigarette use (‘vaping’) has rapidly increased in recent years, with 16.8% of young people globally having used an e-cigarette (Salari et al. 2024). In Australia, one in four adolescents has tried e-cigarettes and the average age of onset is 14 years (Gardner et al. 2023a, Scully et al. 2023). Use of e-cigarettes is associated with a growing number of harms including exposure to harmful chemicals (Cheng 2014), nicotine dependence (Yuan et al. 2015), poisonings, inhalation toxicity (including seizures), lung damage (Banks et al. 2023), poorer mental health (Truong and Cotton 2023, Gardner et al. 2024a), and increased risk of cigarette smoking (Soneji et al. 2017). In response to this, the Australian government has implemented a suite of strong regulatory controls on the importation, manufacture, advertisement, supply, and commercial possession of e-cigarettes. For example, since July 2024, e-cigarettes are only legally available from pharmacies as a therapeutic aid to quit smoking (Parliament of Australia 2024). While such supply-reduction strategies are an important component of drug prevention (Stockings et al. 2016), to date they have not been wholly effective in reducing illicit e-cigarette supply nor demand (Wodak 2015, Gartner 2023, Mendelsohn et al. 2023, Stockings et al. 2023). As such, it is critical to also implement effective demand-reduction strategies whereby young people are empowered with knowledge and skills to make informed health decisions (Stockings et al. 2023).

There is a strong evidence base for school-based substance use preventive interventions (Boyd et al. 2023), with some interventions demonstrating long-term health and economic benefits. For example, Newton et al. (2022b) found a school-based alcohol and cannabis preventive intervention resulted in reduced odds of binge drinking and alcohol-related harms 7 years later. Additionally, Kuklinski et al. (2021) found the ‘Communities That Care’ intervention led to greater abstinence from alcohol, tobacco, and other drugs and was cost beneficial (returning $12.88 per dollar invested) at 12 years post-baseline. The most effective school-based substance use preventive interventions are grounded in a social influence and social competence approach, which focuses on developing problem-solving, decision-making, and resistance and assertiveness skills that help young people overcome pressure to use tobacco, alcohol, or other drugs (Cuijpers 2002, Thomas et al. 2015). Delivery in the school setting is advantageous, as large numbers of young people can be reached prior to harmful patterns of substance use developing in a setting primed for learning. Schools additionally provide the infrastructure to deliver these programmes, given drug education is a mandatory part of the health education curriculum in many countries (Australian Curriculum Assessment and Reporting Authority 2022). Despite this, many programmes used in schools lack evidence of effectiveness, and implementation is generally poor (Stapinski et al. 2017, Newton and Lee 2019), largely due to barriers such as insufficient resources, time, a lack of teacher training/support and modifications that undermine the fidelity and established programme efficacy (Dusenbury et al. 2005, Miller-Day et al. 2013).

Electronic health interventions (‘eHealth’) can overcome many common implementation barriers. For example, online availability means they are readily and widely accessible. Further, the use of pre-programmed content can save teachers time, aid the delivery of education on sensitive topics—such as substance use—where confidence may be lacking, and preserve programme fidelity and efficacy (Champion et al. 2013, Stapinski et al. 2017, Liu et al. 2025). Importantly, eHealth interventions can also be more efficiently and economically updated than other education resources, such as textbooks, which is particularly beneficial for e-cigarette education given the rapidly changing landscape and legislation. Additionally, eHealth interventions can increase student engagement compared with traditional didactic learning (Haleem et al. 2022). However, to promote engagement, eHealth programmes must be age appropriate, inclusive, and culturally relevant (Thabrew et al. 2018). Co-design, defined in this context as the collective creativity and active collaboration between researchers and end users throughout the eHealth intervention development process, is imperative to achieve this (Thabrew et al. 2018, Vargas et al. 2022). This active and meaningful participation of young people in the research and development of eHealth interventions is advocated by the World Health Organization (2020), ensuring young people are leaders in decisions regarding their own health and well-being (Raeside et al. 2023).

The ‘OurFutures’ prevention model is a universal school-based model that adopts a harm minimization and comprehensive social influence approach to prevention, utilizes eHealth methodology, and centres on co-designed educational cartoon stories (Newton et al. 2022a). Students engage with a series of online cartoon slides which incorporate characters around their age who deliver peer-led education about their experiences with alcohol and other drugs in an engaging story format. The pre-programmed cartoons are the core intervention component, imparting knowledge, normative education, and resistance skills training, with accompanying factsheets and optional teacher-facilitated class activities to reinforce key content and skill development. The model has been evaluated in eight randomized control trials (RCTs) across 240 Australian secondary schools (>21 000 students aged ∼12–16 years), demonstrating ‘OurFutures’ is more effective than usual school-based health education in reducing the use of alcohol, cannabis, and MDMA, decreasing harms from substance use, reducing intentions to use substances, improving mental health, and increasing knowledge for up to 3 years following intervention delivery (Newton et al. 2010, Vogl et al. 2014, Slade et al. 2021, Smout et al. 2024). Longer term impacts have also been observed, including reductions in harmful alcohol use up to age 20 (7 years post-intervention; Newton et al. 2022b).

Capitalizing on the effective ‘OurFutures’ prevention model, we developed the ‘OurFutures Vaping’ programme to address the urgent need for evidence-based, engaging and scalable e-cigarette preventive interventions. The intervention consists of four 40 min lessons, ideally delivered over a 4-week unit to Year 7 and/or Year 8 students (∼12–14 years of age) during health education class. Each lesson involves: (i) an online cartoon component with embedded quizzes and reflective activities, that forms one part of the four-part story; (ii) optional teacher-facilitated activities that can be completed individually, in groups, or as a class (e.g. quizzes, class discussions, and role plays); and (iii) student and teacher versions of factsheets and additional resources to summarize the key content and provide more detailed information and support. This study provides an overview of the co-design and user testing of the ‘OurFutures Vaping’ programme.

MATERIALS AND METHODS

The ‘OurFutures Vaping’ programme was co-designed through the collective creativity and active collaboration of a team of experts in tobacco control, e-cigarettes, substance use prevention, mental health, and eHealth interventions, with end users (students and teachers). The co-design process centred on four iterative stages (Fig. 1).

Figure 1.

Co-design process of the ‘OurFutures Vaping’ programme.

Stage 1: scoping of the literature

We conducted a systematic review and meta-analysis to understand the existence and efficacy of school-based preventive interventions for e-cigarette use, along with the key characteristics associated with efficacious interventions. The full review findings are described in detail elsewhere (Gardner et al. 2024b). In brief, of 11 eligible studies, only 5 were cluster RCTs (Brown et al. 2019, Lisboa et al. 2019, Bonell et al. 2020, Beeres et al. 2022, Haug et al. 2022) and the remainder were quasi-experimental (Rozema et al. 2018, Okamoto et al. 2019, Kelder et al. 2020, Weser et al. 2021, Williams et al. 2022, Asdigian et al. 2023), mostly conducted in the USA. Most interventions targeted e-cigarette and tobacco cigarette use simultaneously (n = 8; Rozema et al. 2018, Brown et al. 2019, Lisboa et al. 2019, Okamoto et al. 2019, Kelder et al. 2020, Beeres et al. 2022, Haug et al. 2022, Asdigian et al. 2023), with only one solely targeting e-cigarette use (Weser et al. 2021). Studies varied in terms of the intervention delivery format (e.g. peer and/or teacher-led classroom education, school-wide policy, eHealth, face-to-face, or hybrid), duration/frequency (ranging from a single 45 min presentation to a 3-year tobacco-free contract between adolescents and an adult) and the behavioural theory underpinning the intervention.

Our meta-analyses provided no evidence that existing school-based interventions were associated with the prevention of e-cigarette use at the longest follow-up assessment (ranging between 6 and 36 months post-intervention; Gardner et al. 2024b). Meta-analyses did, however, reveal significant effects on the reduction of past 30 day tobacco use at the longest follow-up assessment, which encompassed e-cigarettes in some studies, along with moderate improvements in knowledge and small but significant improvements in intentions and attitudes towards e-cigarettes and tobacco at post-intervention. Narrative synthesis supported these mixed results, showing some school-based interventions prevented or reduced e-cigarette and/or tobacco use; however, two inadvertently increased use. The small number of trials and large variation between studies and intervention types made it challenging to identify intervention characteristics that should be included in future programmes. However, efficacious interventions commonly involved classroom education that included resistance and social skills training, kept teachers within a central role, and was delivered over multiple sessions. Peer-led and eHealth intervention components also appeared beneficial among the interventions that improved theorized precursors of behaviour change (e.g. knowledge, attitudes, and intentions). While the stated theories varied, efficacious interventions typically aligned with the principles of a social competence and influence approach. In contrast, the two interventions that produced iatrogenic effects on the prevention of e-cigarette use and tobacco smoking onset utilized broad whole-of-school initiatives (i.e. approaches that aim to address the school’s culture, policies, and/or practices) without any accompanying classroom education and skill-building components, nor a theoretical underpinning. Overall, findings suggested that e-cigarette prevention programmes may have a transient beneficial effect; however, we lacked certainty in this finding given the substantial underlying variability in study designs, interventions, and follow-up assessment points. This highlights the need for more high-quality research to develop effective prevention programmes.

Despite the mixed evidence produced by our systematic review and meta-analysis, strong evidence exists for school-based programmes in preventing tobacco, alcohol, and other drug use (Wiehe et al. 2005, Tully 2007, Thomas et al. 2015, Song and Park 2021). As such, further scoping of the literature was conducted to identify the key behavioural theories/models and evidence-based principles associated with the effective prevention of substance use, and tobacco cigarette smoking in particular, that may be applied to e-cigarette use. This was a key step given the ‘OurFutures Vaping’ programme aimed to take an integrated approach in addressing both e-cigarette and tobacco cigarette use. Specifically, systematic reviews and meta-analyses examining the effectiveness of school-based tobacco, alcohol, and other drug prevention programmes were identified (Cuijpers 2002, Thomas et al. 2013, 2015). Aligning with the findings of our systematic review, the most effective interventions for the prevention of tobacco cigarette smoking were grounded in a social influence and social competence approach. This suggested that the ‘OurFutures’ prevention model, which adopts a harm minimization and comprehensive social influence approach to drug prevention, was appropriate to apply to the prevention of e-cigarette and tobacco cigarette use.

Finally, a literature search was conducted to identify studies that might help us to better understand adolescent motives for e-cigarette use and common scenarios in which young people use e-cigarettes (Barker et al. 2019, Donaldson et al. 2021, Sharma et al. 2021, Pettigrew et al. 2022, Watts et al. 2022, Sun et al. 2023). These findings formed the basis of character and storyline ideas that were presented to young people in Stage 2.

Stage 2: consultations with young people

Consistent with the successful ‘OurFutures’ prevention model, young people were consulted via focus groups and surveys at school to understand current attitudes and perceptions about e-cigarette and tobacco cigarette use and develop character profiles and storylines for the ‘OurFutures Vaping’ programme. This methodology was practical in that it provided an opportunity to efficiently reach multiple young people in the setting in which the intervention would be implemented. Additionally, the literature highlights the need to ensure young people feel comfortable to provide input when conducting co-design workshops, and the inclusion of naturally occurring groups (e.g. classmates or friends) can assist conversation (Thabrew et al. 2018). However, it is also acknowledged that discussing sensitive topics may be uncomfortable for some young people. For this reason, students participating in our focus groups were instructed not to identify themselves or anyone else when discussing ideas and instead to talk about ‘a person I know’ (Supplementary Appendix G). Moreover, the additional confidential surveys were completed individually and anonymously, ensuring students had an opportunity to provide ideas and feedback that they may not otherwise be comfortable sharing in a group setting.

Although the ‘OurFutures Vaping’ programme is designed for Year 7 and 8 students (aged ∼12–14 years), older students from Year 9 and Year 10 (aged ∼14–16 years) were targeted in this initial phase of development. This was due to their increased likelihood of exposure to e-cigarettes (Scully et al. 2023), without which it would have been challenging to generate realistic, believable, and detailed character profiles of e-cigarette users and scenarios related to e-cigarette use. This would impact students’ acceptance of, and engagement with, the cartoon stories, thereby undermining the efficacy of the intervention.

Participants and procedure

Forty-nine independent (i.e. private or non-government) secondary schools in Sydney, Australia, that had previously expressed interest in being involved in the research teams’ research were invited to participate via email. The study was also promoted to the research teams’ networks via newsletters and social media. Two schools (one all boys and one all girls) agreed to take part. Information and consent forms were sent to the parents/guardians of Year 9 and Year 10 students (n = 34 students). Both opt-out parental consent and active student consent were required for participation (100% consent rate), in line with approval by the University of Sydney Human Research Ethics Committee (2018/882).

In June and July 2022, two research staff (A.-L.R. and L.E.) attended a health education lesson at each school (∼45 min in length). Students firstly completed an anonymous survey to obtain demographic details and confidentially assess perceptions and beliefs related to e-cigarette and tobacco cigarette use. The research staff then facilitated a focus group discussion, following a semi-structured format. Discussions focused on further exploring students’ attitudes, perceptions, and beliefs, along with developing character profiles and scenarios that could be used in a story about e-cigarettes (see Supplementary Appendix G). Sessions were audio recorded and later transcribed. Students were entered into a random draw to receive a $100 gift voucher (two per school).

Measures

Demographics: Information on age, sex (male, female, prefer not to answer), and gender (male, female, non-binary, I use a different term, prefer not to answer) were collected.

Peer tobacco and e-cigarette use: Students responded to two items about the proportion of their friends and acquaintances who have used tobacco cigarettes and e-cigarettes. Responses were on a 5-point scale from ‘none’ to ‘all or almost all’.

Risk perceptions and beliefs: Students responded to three items about risks associated with (i) vaping once or twice, (ii) vaping occasionally, and (iii) vaping regularly. Responses were rated on a four-point scale from ‘no risk’ to ‘great risk’. Students also responded to six statements about their perceptions and beliefs related to e-cigarettes on a scale ranging from 1 (strongly agree) to 5 (strongly disagree), e.g. ‘E-cigarettes are less harmful than tobacco cigarettes’ and ‘I know what ingredients are in e-cigarettes’. Finally, three open-ended questions assessed reasons young people (i) use and (ii) avoid using e-cigarettes, and (iii) situations e-cigarettes are commonly used in.

Analysis

Descriptive statistics were generated from the survey data using IBM SPSS Statistics 26. The open-ended survey data and focus group transcripts were independently reviewed by two researchers (A.-L.R. and L.A.G.) to create key themes and ideas to inform character and storyline development. Our theme and idea generation followed a codebook thematic analysis approach (Braun and Clarke 2022, 2024). This method suited our aim to both systematize coding across a research team and remain responsive to the experiential and socially constructed meanings expressed by participants regarding e-cigarette and tobacco cigarette use among young people. Specifically, A.-L.R. and L.A.G. coded different sections of the data and discussed them to develop an initial codebook, which they applied systematically across all responses. Coding was iterative, and codes were adjusted as needed to reflect the developing insights of the data. A.-L.R. then continued to construct themes with explanatory value that were subsequently reviewed, further defined, named, and refined collaboratively by the research team to ensure alignment with participants’ responses and our goal to develop relevant character profiles and scenarios for the programme.

Findings

A total of 34 students (M_age = 14.85, SD = 0.88; 47% female) participated in the survey and focus group.

Perceptions and beliefs related to e-cigarettes and tobacco cigarettes: Most students (97%) estimated that none or less than half of their friends/acquaintances had used ‘tobacco cigarettes’. When asked about the proportion of their friends or acquaintances who had used ‘e-cigarettes’, 38% estimated less than half, 30% estimated none, 15% estimated about half, 12% estimated more than half, and 3% estimated all or almost all. Most students felt there was a slight risk associated with vaping once or twice (53%), a moderate risk with vaping occasionally (68%), and a great risk with vaping regularly (79%). Supplementary Appendix A presents the responses to the six items assessing perceptions and beliefs related to e-cigarettes. Most students believed people could become dependent on e-cigarettes (82%) that e-cigarettes were easy to access (74%) and that e-cigarettes typically contain nicotine (71%). However, only a minority felt they knew the ingredients in e-cigarettes (26%), and there was less certainty about whether e-cigarettes are less harmful than tobacco cigarettes and marketed towards adolescents. Drawing on students’ responses to the open-ended survey questions and focus group discussions, commonly cited reasons for e-cigarette use included peer pressure, curiosity, and stress relief. Common reasons for avoiding e-cigarettes included the perceived harms, fear of addiction, and concerns about the impact on sporting performance. Finally, example situations in which young people use e-cigarettes included at parties, in the park, and in the school toilets. A full overview of the themes generated from the qualitative data is available in Supplementary Appendix B.

Developing characters who vape: Students identified two distinct character profiles for someone who vapes. The first was extroverted, confident, social, impulsive and rebellious. This person was described as sporty and popular. The second was antisocial, withdrawn, unintelligent, and sensitive. This person was described as experiencing physical and mental health challenges and being unpopular. Other themes for vapers included troubled home lives and engaging with other substance use. Students also described physical attributes and clothing, such as ripped jeans and non-vibrant colours.

Developing characters who choose not to vape: Students described these characters as kind, calm, and responsible. They also described them as healthy, energetic, and good at sport along with unlikely to engage in other substance use and having a supportive home environment.

Developing key scenarios and storylines about vaping: In line with the data obtained via the anonymous survey, students again suggested vaping scenarios would most likely include parties, school toilets, and parks. They emphasized that social groups include a mix of vapers and non-vapers, with the latter potentially trying to help their friends stop vaping. Students also proposed peer pressure scenarios, vaping to self-medicate, conflicts within friendship groups, and punishment for being caught vaping. Students consistently emphasized the need to incorporate online elements such as social media and online communication, particularly as a way for young people to source vapes.

Stage 3: content and web development

Based on the findings from the consultations in Stage 2, two members of the research team (L.A.G. and A.-L.R.) generated character profiles including names, background stories, key personality traits, strengths/weaknesses, and appearances. Key messages and storylines were then generated based on the Stage 2 findings pertaining to students’ perceptions, beliefs, knowledge gaps, and proposed scenarios, along with learnings and key messages from the previous successful ‘OurFutures’ substance use prevention programmes (Newton et al. 2010, 2022a, Vogl et al. 2014, Champion et al. 2023), with the scientific literature and legislation underpinning all information consulted to ensure it was consistent with current evidence. As per the ‘OurFutures’ prevention model, the key messages and concepts aligned with the theoretical tenets of the effective comprehensive social influence and harm minimization approach to prevention [Botvin 2000, Thomas et al. 2013; i.e. aimed to (i) deliver evidence-based information about the relevant substance and its associated harms; (ii) provide normative education to correct inflated perceptions of peer substance use; and (iii) deliver assertiveness and refusal skills training]. For example, an older character who is completing a health science degree was used to impart knowledge about the effect of nicotine on the adolescent brain (Yuan et al. 2015). Additionally, to correct misperceptions of peer e-cigarette use and develop assertiveness and refusal skills, a party scene involving peer pressure to vape was proposed in which one character recalled learning that most young people have not tried vaping (a ‘fact check’ provided the specific national statistic; Scully et al. 2023) and modelled an assertive response to decline (Botvin 2000). Emerging literature in the e-cigarette space was also used to inform storylines (e.g. the positive portrayal of e-cigarettes on TikTok; Sun et al. 2023), and the topics covered in the ‘CATCH My Breath’ programme (Kelder et al. 2020), which was the only similar classroom-based skills and education programme existing that had demonstrated a significant preventative effect on e-cigarette use, were also reviewed. Importantly, consideration was also given to the plotline to ensure the story was both educational and engaging across all four lessons, with the key messages and opportunities for skills training being mapped and spread out alongside the key points of drama, climax, and resolution. The broader research team then reviewed the character profiles and storylines to ensure the messaging aligned with the best available scientific evidence and identified any other evidence-based messages that could be incorporated. Further informal feedback was sought from young people in the research teams’ personal networks to ensure that it was age appropriate and relevant to a diverse group of young people. A colleague of the research team was also engaged as a lived experience representative to ensure appropriateness of a gender-diverse character.

Following this, two members of the research team (L.A.G. and A.-L.R.) developed a full script for the four lessons and engaged an illustrator to create the cartoon drawings. The process for character and script development was iterative, whereby one lesson was reviewed by the research team and young people, refinements were made in line with feedback, and these insights guided the development of the next lesson. For example, refinements included making characters look younger, adding jewellery for self-expression, updating clothing, and increasing inclusivity and diversity in representations of gender and body shape and size. The original and refined character line-up is shown in Fig. 2. As per the ‘OurFutures’ prevention model, optional teacher-facilitated activities, factsheets, and additional resources were also created to reinforce the educational content from the cartoons and provide an opportunity for practising skills.

Figure 2.

Original and refined character line-up.

Stage 4: user testing and refinement

User testing was conducted with Year 8 students (n = 37) and teachers (n = 13) to gain feedback on the acceptability and feasibility of the content and guide refinements prior to programme implementation.

Student testing: participants and procedure

Independent secondary schools in Sydney, Australia, were invited to participate in a focus group, with two schools (one all girls and one all boys) agreeing to take part. As per the same ethical approval in Stage 2 (2018/882), opt-out parental consent and active student consent were obtained (37 students approached with a 100% consent rate). In November 2022, two members of the research team (A.-L.R. and L.E.) conducted a 45 min focus group with Year 8 students (n = 37) at each school during a regular health education lesson. The focus group consisted of students viewing the Lesson 1 cartoon as a group, followed by a semi-structured class discussion about the likeability and relatability of the storylines, characters, language, and any other general feedback (Supplementary Appendix G). The sessions were audio recorded and later transcribed. Following the discussion, students also completed an anonymous hardcopy questionnaire (10 min) to provide demographic information and written feedback on the lesson. Students were entered into a random draw to receive a $100 gift voucher for participating (two per school). Subsequently, participating students were asked to provide feedback on the cartoons for Lessons 2, 3, and 4 outside of class via online surveys and were reimbursed $20 for each survey completion.

Teacher testing: participants and procedure

Health education teachers (n = 13) at the participating independent secondary schools from Stages 2 and 4 were invited to participate in the user-testing process. Additionally, teachers were recruited from the research teams’ personal and professional networks and social media. After providing active written consent, teachers were sent a digital copy of Lessons 1 and 2 and/or Lessons 3 and 4 of the ‘OurFutures Vaping’ programme (including cartoons, class activities, factsheets, resources, and links to curriculum outcomes). Teachers were invited to provide feedback via an online questionnaire or interview. Teachers received a $100 gift voucher for each pair of lessons they reviewed.

Analysis

Descriptive statistics, including the percentage agreement for each survey item, were generated from the student and teacher questionnaire data using IBM SPSS Statistics 24. Two researchers (A.-L.R. and L.A.G.) independently reviewed responses to the open-ended questions and transcript to inform refinements to the ‘OurFutures Vaping’ programme, prioritizing frequently raised feedback. If feasible, individual comments and specific recommendations were also considered and incorporated.

RESULTS

User testing results

A total of 37 students [mean age 13.51 years, SD 0.51; 54.1% (20/37) female] provided feedback on the lessons. Due to optional, out-of-class reviews for Lessons 2–4, response rates varied from 54% for Lesson 3 to 100% for Lesson 1. Overall ratings of the lessons were positive (rated as ‘good’ or ‘very good’ by 81%–100% of students across the four lessons), with students providing favourable feedback on the believability and relevance of the storylines and characters and reporting the information was easy to understand. A summary of the quantitative and qualitative student feedback is provided in Supplementary Appendices C and D.

Thirteen teachers participated in user testing, with seven from coeducational schools and five from single-sex schools that were a mixture of government, independent and Catholic schools. Additionally, one teacher was not currently affiliated with a school. On average, teachers had 16.9 years (SD = 10.57) of teaching experience. Overall, teachers rated the ‘OurFutures Vaping’ programme positively, highlighting the age appropriateness and good alignment of content with the health education syllabus, while indicating some concern that the content could be adequately covered within the length of a lesson. A summary of the quantitative and qualitative teacher feedback is provided in Supplementary Appendices E and F.

Key changes made to the programme after user testing

The student and teacher user-testing feedback led to several refinements which are summarized in Table 1. Briefly, the cartoon scripts and factsheets were revised to reduce length where possible, storylines were modified to include more realistic age-appropriate scenarios, additional support resources were created and embedded within the cartoon and as standalone resources, and cartoon illustrations were tweaked.

Table 1.

Examples of refinements made to the ‘OurFutures Vaping’ programme due to student and teacher user testing.

Key issues identified in user testing	Refinements
Lesson length
Too much text on screen	Reduced text and split large paragraphs into separate speech bubbles
Storyline
Overly optimistic ending including successfully quitting vaping	Emphasized the struggle to quit throughout and reinforced the message in the host wrap-up
Need to depict the curiosity about vapes that non-vapers might experience	Added thought bubble to depict curiosity about vaping from a character who has never vaped
More social media references needed	Incorporated greater social media references (e.g. TikTok)
Young people would not know/be speaking about that many facts about vaping	Shifting some of the fact-based information from young people to the older host or ‘fact-checks’
Content
Need for more resources on addiction and quitting	Updated an existing pamphlet shown in the cartoon to include a more extensive list of support resources
Quiz confusing for some, and too easy for others	Edited quiz questions for clarity and updated statistics and laws
Visual considerations
Text too small in fact-checks	Increased text size
Graphic design elements—character appeared to be always wearing lipstick which was unrealistic	Lip colour changed to a natural shade
Graphic design elements—disliked blushing on characters	Removed blushing from characters in specified slides
Graphic design elements—greater emotion on character faces needed	Added more emotion to the facial expressions

The final ‘OurFutures Vaping’ programme

The final ‘OurFutures Vaping’ programme consists of four 40 min online lessons, ideally delivered 1-week apart during health education classes. Underpinned by a harm minimization and comprehensive social influence approach to prevention, the programme provides evidence-based information about e-cigarettes and tobacco smoking, normative education to correct misperceptions on use, and resistance skills training. The programme has been designed to meet the criteria outlined in the Years 7 and 8 Australian Health and Physical Education Curriculum for Queensland, the Stage 4 New South Wales Personal Development, Health and Physical Education syllabus, and the Years 7 and 8 Western Australia Health and Physical Education Curriculum. Table 2 provides an overview of the key content addressed in each lesson, with each lesson including:

Table 2.

Overview of ‘OurFutures Vaping’ programme content.

Lesson	Content
1	The harmful chemicals in vapes Prevalence and patterns of vaping/cigarette smoking Short- and long-term consequences of vaping Reasons young people choose to, or not to, vape Passive vaping
2	The positive portrayal of vaping on social media Vaping and smoking as ineffective ways to cope Nicotine and the developing brain Where to seek help for vaping, smoking, and mental health Nicotine as a poison Assertive communication and refusal skills
3	Vaping/smoking and the law Short- and long-term consequences of smoking cigarettes Marketing tactics and the influence of social media The links between vaping and smoking Help-seeking for vaping, smoking and mental health
4	Assertive communication and refusal skills Signs of nicotine dependence Where to seek help and strategies to break the cycle of nicotine dependence The benefits of avoiding or stopping vaping

1. An online cartoon: Students read through a cartoon that follows a group of teenagers as they navigate new experiences, friendships, and learn about vaping and tobacco cigarette smoking (Fig. 3). The cartoon characters impart key evidence-based information about e-cigarette and tobacco cigarette smoking via peer-led messaging, challenge and modify perceptions of norms, and introduce and practise resistance skills. Quizzes and reflective activities are embedded in the cartoons to ensure student engagement, comprehension, and critical thinking.

2. Optional teacher-facilitated activities: Teachers can choose from 4 to 6 activities per lesson that are designed to reinforce learning from the cartoon, encourage critical thinking and discussion, and promote interpersonal skills. The activities vary in length (5–20 min) and format (e.g. paired interviews, group work, class discussion, and worksheet), ensuring teachers have flexibility to meet their students’ needs.

3. Factsheets and additional resources: Students and teachers are provided with tailored PDF factsheets for each lesson which provide a summary of the key lesson content, along with additional resources (e.g. more information about the chemicals in vapes and contact details for support services).

4. Teacher resources: Teachers can also access an implementation guide (covering teacher and student registration, resetting student passwords, and implementing the programme) and a curriculum mapping overview.

Figure 3.

Example cartoons from the ‘OurFutures Vaping’ programme.

Programme implementation

The ‘OurFutures Vaping’ programme is designed for all Year 7 and 8 students, regardless of their level of risk for e-cigarette and tobacco use. Students complete the lessons during their regular health education classes, ideally one lesson per week over a 4-week period. Both students and teachers can access programme materials via their respective dashboards. Teachers can view and download an implementation guide from the teacher portal, although no formal training is required.

DISCUSSION

This study describes the co-design and development process of the ‘OurFutures Vaping’ programme. This comprehensive and iterative approach involved collective creativity and active collaboration between students, teachers, and relevant experts to create a four-lesson digital school-based e-cigarette preventive intervention that is aligned with the best available scientific evidence and the Australian and state-based health education curriculums. Such evidence-based interventions are urgently needed to respond to surge in e-cigarette use among adolescents in recent years (Gardner et al. 2023a, Scully et al. 2023, Salari et al. 2024), the growing evidence of associated harms to both physical and mental health (Yuan et al. 2015, Banks et al. 2023, Truong and Cotton 2023, Gardner et al. 2024a), and the frequent pleas from teachers for support to address vaping in their schools.

Strengths and limitations

The well-established evidence base behind the ‘OurFutures’ prevention model, along with the utilization of key theories and concepts that have been successful for the prevention of tobacco and other substance use, are key strengths of the ‘OurFutures Vaping’ programme. Additionally, the use of digital components may enhance student engagement compared with other types of learning (e.g. via didactic teaching), and the pre-programmed content can overcome common implementation barriers reported for school-based substance use prevention education (e.g. teacher time constraints, a lack of teacher confidence and training to deliver drug education, and programme modifications that compromise fidelity and efficacy; Dusenbury et al. 2005, Miller-Day et al. 2013, Stapinski et al. 2017). Further, eHealth methodology enables the content to be easily updated alongside the evolving landscape of e-cigarette use and supports scalability. Indeed, the ‘OurFutures’ platform is already established to allow for immediate research translation. However, despite these advantages, it is important to acknowledge the potential limitations of eHealth interventions. This includes a dependence on access to devices and digital literacy, with some evidence suggesting eHealth interventions may be less effective for those experiencing disadvantage, thereby exacerbating health disparities (König et al. 2023, Chidambaram et al. 2024, Raeside 2025). Individual device access was reported as a potential implementation barrier by some teachers in the present research (Supplementary Appendix F); however, it is important to note that the ‘OurFutures’ prevention model allows for flexibility in delivery, with some teachers opting for students to complete the cartoons individually, while others choose to complete them together as a class (i.e. on one device or using an offline version). While the iterative co-design process allowed for ongoing user feedback and refinement which may further promote engagement among young people, only three schools were involved across the four focus groups, and fewer students provided user-testing feedback for Lessons 2–4 compared with Lesson 1. This may have introduced a degree of self-selection bias. Additionally, we acknowledge that the perspectives of the researchers conducting this analysis, who have expertise in adolescent health/public health research contexts, may have influenced the analysis and findings. Another key limitation was that students involved in the focus groups were only from independent schools in Sydney due to ethical and time constraints. However, evidence suggests young people’s use of e-cigarettes is similar across regional and metropolitan areas as well as socioeconomic groups (Gardner et al. 2023a), and teachers from a mix of independent, government, and Catholic schools were involved in user testing.

Future directions

To evaluate the efficacy of the ‘OurFutures Vaping’ programme in preventing the uptake of e-cigarettes and improving secondary outcomes (e.g. the frequency and quantity of e-cigarette and tobacco cigarette use, knowledge about e-cigarettes/tobacco cigarettes, motives and attitudes relating to e-cigarettes, and mental health), we are conducting a cluster RCT in 40 schools (>5000 students) across New South Wales, Western Australia, and Queensland. The cost-effectiveness of the intervention compared with health education as usual will also be evaluated. This is the first—and currently only—rigorous evaluation of a school-based e-cigarette preventive intervention in Australia (Gardner et al. 2023b).

CONCLUSION

Given the rapidly increasing use and emerging evidence of harms of e-cigarettes among adolescents, the ‘OurFutures Vaping’ programme holds the potential to make significant health and economic impact by preventing, delaying, and reducing e-cigarette use. If found to be effective, the intervention will be made immediately available to Australian schools via the ‘OurFutures’ platform, and could be adapted internationally as an efficient global intervention.

Author contributions

L.A.G., M.T., and N.C.N. conceptualized the study. L.A.G., M.T., K.E.C., and N.C.N. acquired funding to support the study. L.A.G., A.-L.R., E.S., L.E., M.T., K.E.C., and N.C.N. contributed to Stage 1 (Scoping of the Literature). A.-L.R. and L.E. co-facilitated focus group discussions for Stages 2 (Consultations with Young People) and 4 (User Testing and Refinement). L.A.G., A.-L.R., L.E., and A.H. were involved in the planning of focus groups and surveys for Stages 2 and 4, and associated administrative duties. L.A.G. and A.-L.R. conducted the formal analysis of focus group and survey data findings collected in Stages 2 and 4. L.A.G. and A.-L.R. developed the materials for Stage 3 (Content and Web Development), which all authors reviewed and edited. All authors contributed to the final ‘OurFutures Vaping’ programme. L.A.G., A.-L.R., L.E., and K.B. drafted the main body of this manuscript. All authors participated in revising this manuscript and approved the final version.

Supplementary data

Supplementary data is available at Health Promotion International online.

Conflict of interest

M.T. and N.C.N. are cofounders of the Our Futures Institute, a not-for-profit company. M.T., N.C.N., L.A.G., A.-L.R., E.S., and K.E.C. were the developers of the ‘OurFutures Vaping’ programme, which has been commercialized by the University of Sydney and is being distributed through the not-for-profit organization, Our Futures Institute.

The OurFutures Vaping program (Program IP) is co-owned by The University of Sydney and Climate Schools Pty Ltd. Climate Schools Pty Ltd is a private company of which M.T and N.C.N are directors and shareholders. The Program IP is licensed by the University of Sydney to OurFutures Institute Limited, a not for-profit entity that distributes the Program IP. The University of Sydney and Climate Schools Pty Ltd are equal members of OurFutures Institute. M.T., N.C.N. and other developers may, in the future, receive royalties from commercialisation of Program IP under the University's commercialisation framework (IP Policy), contingent on the Institute meeting ambitious licencing targets designed to prioritise public benefits.

Netfront Pty Ltd, directed by N.C.N.'s spouse, was engaged by the University of Sydney through its procurement process that excluded N.C.N. None of M.T.'s family members who are University of Sydney staff will receive commercialisation income.

M.T. & E.S. attended the Australian Commonwealth “Illicit tobacco and novel nicotine products” roundtable (unpaid). L.G., N.C.N., E.S., A.-L.R. and M.T. are members of the NSW Health “E-Cigarette and Young people” meeting (unpaid). Funders had no role in the study design, data collection, decision to publish, or manuscript preparation.

Funding

This study was funded by the Paul Ramsay Foundation and via seed funding from the Centre of Research Excellence in the Prevention and Early Intervention in Mental Illness and Substance Use (APP11349009). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data availability

The data used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

All procedures were performed in compliance with relevant laws and institutional guidelines and have been approved by the appropriate institutional committee (University of Sydney Human Research Ethics Committee; approval no. 2018/882; 23 May 2022). The privacy rights of human subjects have been observed, and informed consent was obtained for as described in the manuscript.