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COVID-19 vaccines are highly effective in preventing severe disease and death but are underused. Interventions to address COVID-19 vaccine hesitancy are paramount to reducing the burden of COVID-19. We aimed to evaluate the preliminary efficacy, usability, and acceptability of a chatbot for promoting COVID-19 vaccination and examine the factors associated with COVID-19 vaccine hesitancy. In November 2021, we conducted a pre-post pilot study to evaluate “Vac Chat, Fact Check,” a web-based chatbot for promoting COVID-19 vaccination. We conducted a web-based survey (N=290) on COVID-19 vaccination at a university in Hong Kong. A subset of 46 participants who were either unvaccinated (n=22) or were vaccinated but hesitant to receive boosters (n=24) were selected and given access to the chatbot for a 7-day trial period. The chatbot provided information about COVID-19 vaccination (eg, efficacy and common side effects), debunked common myths about the vaccine, and included a decision aid for selecting vaccine platforms (inactivated and mRNA vaccines). The main efficacy outcome was changes in the COVID-19 Vaccine Hesitancy Scale (VHS) score (range 9-45) from preintervention (web-based survey) to postintervention (immediately posttrial). Other efficacy outcomes included changes in intention to vaccinate or receive boosters and willingness to encourage others to vaccinate on a scale from 1 (not at all) to 5 (very). Usability was assessed by the System Usability Scale (range 0-100). Linear regression was used to examine the factors associated with COVID-19 VHS scores in all survey respondents. The mean (SD) age of all survey respondents was 21.4 (6.3) years, and 61% (177/290) of respondents were female. Higher eHealth literacy (B=–0.26; P<.001) and perceived danger of COVID-19 (B=–0.17; P=.009) were associated with lower COVID-19 vaccine hesitancy, adjusting for age, sex, chronic disease status, previous flu vaccination, and perceived susceptibility to COVID-19. The main efficacy outcome of COVID-19 VHS score significantly decreased from 28.6 (preintervention) to 24.5 (postintervention), with a mean difference of –4.2 (P<.001) and an effect size (Cohen d) of 0.94. The intention to vaccinate increased from 3.0 to 3.9 (P<.001) in unvaccinated participants, whereas the intention to receive boosters increased from 1.9 to 2.8 (P<.001) in booster-hesitant participants. Willingness to encourage others to vaccinate increased from 2.7 to 3.0 (P=.04). At postintervention, the median (IQR) System Usability Scale score was 72.5 (65-77.5), whereas the median (IQR) recommendation score was 7 (6-8) on a scale from 0 to 10. In a post hoc 4-month follow-up, 82% (18/22) of initially unvaccinated participants reported having received the COVID-19 vaccine, whereas 29% (7/24) of booster-hesitant participants received boosters. This pilot study provided initial evidence to support the efficacy, usability, and acceptability of a chatbot for promoting COVID-19 vaccination in young adults who were unvaccinated or booster-hesitant.

IntroductionHealth information about COVID-19 has been circulating in social networking sites, including unproven claims that smoking and alcohol drinking could protect against COVID-19. We examined if exposure to such claims was associated with changes in tobacco and alcohol consumption.MethodsWe conducted a population-based, landline and mobile phone survey of 1501 randomly sampled adults aged 18 years or older (47.5% male) in Hong Kong in April 2020. Respondents reported if they had ever seen claims that ‘smoking/alcohol drinking can protect against COVID-19’ from popular social networking platforms. Current tobacco and alcohol users reported if they had increased or reduced their consumption since the outbreak. Prevalence data were weighted by sex, age and education of the general adult population.Results19.0% (95% CI 16.8% to 21.4%) of all respondents reported having seen claims that ‘smoking/alcohol drinking can protect against COVID-19’ from social networking sites. Multinomial logistic regression showed that exposure to the claims was significantly associated with increased tobacco use (OR 2.37, 95% CI 1.08 to 5.20) in current tobacco users (N=280) and increased alcohol use (OR 4.16, 95% CI 2.00 to 8.67) in current drinkers (N=722), adjusting for sex, age, education level, alcohol/tobacco use status, home isolation, anxiety and depressive symptoms, and survey method.ConclusionOur results first showed that exposure to health misinformation that smoking/alcohol drinking can protect against COVID-19 was associated with self-reported increases in tobacco and alcohol consumption in Chinese during the pandemic.

Alcohol use attenuates successful smoking cessation. We examined the feasibility, acceptability, and preliminary efficacy of a brief alcohol intervention in smokers. In this two-arm, assessor-blinded randomized controlled trial, we randomized 100 daily smokers (82.0% male, mean age = 43.7 years) with past-year alcohol use in smoking cessation clinics. Both intervention ( n  = 51) and control ( n  = 49) groups received conventional smoking cessation treatment, the intervention group additionally received a brief alcohol intervention. Primary outcome was biochemically validated tobacco abstinence at 2 months. Secondary outcomes included Alcohol Use Disorders Identification Test (AUDIT) scores, self-reported past 7-day alcohol consumption in alcohol units, feasibility, and acceptability scores at 2 months. By intention-to-treat, the intervention group showed higher validated abstinence (11.8% vs. 10.2%, Risk Ratio = 1.15, 95%CI = 0.38–3.53), lower AUDIT score (5.3 vs. 6.5), and lower alcohol consumption (5.6 vs. 7.1) than the control group, but the differences were not significant. Overall, the feasibility was high (4.2/5.0), and the acceptability was modest (5.0/7.0). In all participants, reduction in smoking relapse risk due to alcohol use from baseline to 2-month follow-up was associated with higher biochemically validated abstinence (Adjusted odds ratio: 1.55, 95% CI = 1.05–2.28). Our brief alcohol intervention is feasible, acceptable, and potentially efficacious to promote tobacco abstinence and alcohol reduction.

Older adults' utilization of digital health care remains low despite a high demand for regular health services. Easily accessible eHealth interventions designed for older adults are needed. This study aimed to examine the feasibility and effectiveness of an intergenerational, home-based eHealth literacy intervention package on older adults in Hong Kong. In this study, 101 older adults (n=64, 63.4% female) with a median age of 80 (IQR 77-85) years received an intergenerational, home-based eHealth literacy intervention package, delivered by trained university student interventionists. The intervention (median 60, IQR 40.8-70 minutes) included personalized guidance on using mobile health apps, QR code scanners and instant messaging, and access to online health information, along with recommendations for physical and mental well-being. Following the intervention, a daily health-coaching message was sent to older adults via WhatsApp for 14 days. eHealth literacy, health, and lifestyle were assessed at baseline and at a 2-week follow-up using paired t tests. Retention rate for the 2-week follow-up was 70.3% (71/101). Compared to baseline, eHealth literacy scores increased by 2.39 points (P=.11; Cohen d=0.20), and daily smartphone use rose by 0.45 hours (P=.07; Cohen d=0.05). Participants self-reported increased physical activity (50/71, 70%), more frequent viewing of health videos (43/70, 61%), and improved handwashing practices (39/71, 55%). The intervention achieved a high satisfaction rating of 4.32 out of 5. The intergenerational, home-based eHealth literacy intervention package was feasible and acceptable, showing promise for increasing older adults' engagement with digital health care resources and promoting healthy behaviors. Future studies should explore longer-term effects and ways to further improve the intervention.

The relationships between alcohol marketing exposure, alcohol use, and purchase have been widely studied. However, prospective studies examining the causal relationships in real-world settings using mobile health tools are limited. We used ecological momentary assessment (EMA) to examine both the within-person- and between-person-level effects of alcohol marketing exposure on any alcohol use, amount of alcohol use, any alcohol purchase, and frequency of alcohol purchase among university students. From January to June 2020, we conducted a prospective cohort study via EMA among university students in Hong Kong who reported current drinking. Over 14 consecutive days, each participant completed 5 fixed-interval, signal-contingent EMAs daily via a smartphone app. Each EMA asked about the number and types of alcohol marketing exposures, the amount and types of alcohol used, and whether any alcohol was purchased, all within the past 3 hours. We used 2-part models, including multilevel logistic regressions and multilevel gamma regressions, to examine if the number of alcohol marketing exposure was associated with subsequent alcohol use and alcohol purchase. A total of 49 students participated, with 33% (16/49) being male. The mean age was 22.6 (SD 2.6) years. They completed 2360 EMAs (completion rate: 2360/3430, 68.8%). Participants reported exposure to alcohol marketing in 5.9% (140/2360), alcohol use in 6.1% (145/2360), and alcohol purchase in 2.4% (56/2360) of all the EMAs. At the between-person level, exposure to more alcohol marketing predicted a higher likelihood of alcohol use (adjusted odd ratio [AOR]=3.51, 95% CI 1.29-9.54) and a higher likelihood of alcohol purchase (AOR=4.59, 95% CI 1.46-14.49) the following day. Exposure to more alcohol marketing did not increase the amount of alcohol use or frequency of alcohol purchases the following day in participants who used or purchased alcohol. At the within-person level, exposure to more alcohol marketing was not associated with a higher likelihood of alcohol use, amount of alcohol use, higher likelihood of alcohol purchase, or frequency of alcohol purchases the following day (all P >.05). Each additional exposure to alcohol marketing within 1 week predicted an increase of 0.85 alcoholic drinks consumed in the following week (adjusted B=0.85, 95% CI 0.09-1.61). On days of reporting alcohol use, the 3 measures for alcohol marketing receptivity were not associated with more alcohol use or purchase (all P >.05). By using EMA, we provided the first evidence for the effect of alcohol marketing exposure on initiating alcohol use and purchase in current-drinking university students. Our findings provide evidence of the regulation of alcohol marketing for the reduction of alcohol use and purchase among young adults.

Background Mobile health (mHealth) is promising in developing personalised smoking cessation interventions. By using an adaptive trial design, we aim to evaluate the effectiveness of personalised mHealth intervention in increasing smoking cessation. Methods This study is a two-arm, parallel, accessor-blinded Sequential Multiple-Assignment Randomised Trial (SMART) that randomises 1200 daily cigarette smokers from 70 community sites at two timepoints. In the first phase, participants receive brief cessation advice plus referral assistance to smoking cessation services and are randomly allocated to receive personalised instant messaging (PIM) or regular instant messaging (RIM). In the second phase, PIM participants who are non-responders (i.e. still smoking at 1 month) are randomised to receive either optional combined interventions (multi-media messages, nicotine replacement therapy sampling, financial incentive for active referral, phone counselling, and family/peer support group chat) or continued-PIM. Non-responders in the RIM group are randomised to receive PIM or continued-RIM. Participants who self-report quitting smoking for 7 days or longer at 1 month (responders) in both groups continue to receive the intervention assigned in phase 1. The primary outcomes are biochemical abstinence validated by exhaled carbon monoxide (< 4 ppm) and salivary cotinine (< 10 ng/ml) at 3 and 6 months from treatment initiation. Intention-to-treat analysis will be adopted. Discussion This is the first study using a SMART design to evaluate the effect of adaptive mHealth intervention on abstinence in community-recruited daily smokers. If found effective, the proposed intervention will inform the development of adaptive smoking cessation treatment and benefits smokers non-responding to low-intensity mHealth support. Trial registration ClinicalTrials.gov NCT03992742 . Registered on 20 June 2019.

Changes in tobacco use since the COVID-19 outbreak differed by countries and little is known about changes in the use of specific tobacco products. We analyzed data from four cross-sectional telephone/online surveys from April to June 2020 to investigate such changes since the 1st and 2nd wave outbreaks (February to April 2020) in Hong Kong. The respondents were 1595 adults (83.2% male) who used tobacco before the COVID-19 outbreak from our previous intervention study and surveys. We investigated the changes in tobacco use, intention to quit and quit attempts during the outbreak. About two-thirds (65.3%) of respondents reported no change in overall tobacco use, while 23.1% used less (including cessation) and 11.6% used more, resulting in a net decrease of 11.5 percentage points. A greater net decrease was observed for cigarettes (14.3% points) than heated tobacco products (HTPs, 3.3% points) and electronic cigarettes (e-cigarettes, 2.5% points). Decreased use was mainly due to the more extended stay at home (63.2%), health considerations (52.6%) and mask-wearing (47.4%), while increased use was for passing time (75.0%) and releasing stress (46.4%). Eight percent of cigarette, HTP and e-cigarette users reported a higher intention to quit since the pandemic outbreak. Nineteen percent of tobacco users (176/948) attempted to quit during the pandemic. Only 2.9% (46/1569) were abstinent at the time of the survey. Overall tobacco use decreased after the first two waves of the COVID-19 outbreak in Hong Kong. A greater proportion of cigarette users decreased use than HTP and e-cigarette users. Given the different methods used in the four surveys, future studies should aim for a large and representative sample.

Objective Most smokers who achieve short-term abstinence relapse even when aided by evidence-based cessation treatment. Mobile health presents a promising but largely untested avenue for providing adjunct behavioral support for relapse prevention. This paper presents the rationale and design of a randomized controlled trial aimed at evaluating the effectiveness of personalized mobile chat messaging support for relapse prevention among people who recently quit smoking. Methods This is a two-arm, assessor-blinded, randomized controlled trial conducted in two clinic-based smoking cessation services in Hong Kong. An estimated 586 daily tobacco users who have abstained for 3 to 30 days will be randomized (1:1) to intervention group or control group. Both groups receive standard-of-care smoking cessation treatment from the services. The intervention group additionally receives 3-month relapse prevention support via mobile chat messaging, including cessation advice delivered by a live counselor and access to a supportive chatbot via WhatsApp. The control group receives text messaging on generic cessation advice for 3 months as attention control. The primary outcome is tobacco abstinence verified by an exhaled carbon monoxide of <5 parts per million or a negative salivary cotinine test at 6 months after randomization. Secondary outcomes include self-reported 6-month prolonged tobacco abstinence, 7-day point-prevalent abstinence, and relapse rate. The primary analyses will be by intention-to-treat, assuming participants with missing data are non-abstinent. This trial is registered with ClinicalTrials.gov (NCT05370352) and follows CONSORT-EHEALTH. Conclusion This trial will provide new evidence on the effectiveness of mobile chat messaging as a scalable and accessible intervention for relapse prevention.

Although vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the most desired solution to end the coronavirus disease (COVID-19) pandemic, there are growing concerns that vaccine hesitancy would undermine its potential. We examined the intention to receive vaccination against SARS-CoV-2 and the associated factors in a representative sample of Chinese adults in Hong Kong. We did a dual-frame (landline and mobile) cross-sectional survey of a random sample of 1501 Hong Kong residents aged 18 years or older (53.6% females) in April 2020. We collected data on the intention to receive SARS-CoV-2 vaccine when it becomes available (yes/ no/ undecided), knowledge and perceptions of COVID-19, smoking, alcohol drinking, and sociodemographic factors. Prevalence estimates were weighted by the sex, age, and education of the general population of Hong Kong. Overall, 45.3% (95% CI: 42.3–48.4%) of the participants had intentions to vaccinate against SARS-CoV-2 when it becomes available, 29.2% (26.5–32.1%) were undecided, and 25.5% (22.9–28.2%) had no intention. The most common reason for vaccine hesitancy (undecided or no intention) was safety concerns (56.5%). Multivariable partial proportional odds model showed higher vaccine hesitancy in males, younger adults, those with no chronic disease, current smokers, and non-alcohol drinkers. After adjusting for sociodemographic and other factors, inadequate knowledge of SARS-CoV-2 transmission (adjusted ORs ranged from 1.27 to 2.63; P < 0.05) and lower perceived danger of COVID-19 (adjusted ORs ranged from 1.62 to 2.47; P < 0.001) were significantly associated with vaccine hesitancy. In a representative sample of Chinese adults in Hong Kong, only 45.3% of the participants intended to vaccinate against SARS-CoV-2 when available. Vaccine hesitancy was associated with inadequate knowledge about SARS-CoV-2 transmission and lower perceived danger of COVID-19, which needed to be addressed to improve vaccination uptake.

Background: Secondhand smoke (SHS) contributes to significant morbidity and mortality worldwide including Hong Kong, a densely-populated city with the lowest daily smoking prevalence (10.5%) in the developed world. Most Hong Kong citizens reside in multiunit housing where SHS can transmit from one unit to another because of the shared ventilation system and crowded living environment. We explored the prevalence of SHS infiltration and its sociodemographic correlates in the Hong Kong general population. Methods: A cross-sectional sample of 5151 randomly selected Hong Kong residents aged 15+ were interviewed by telephone (response rate = 85.8%) for the Hong Kong Tobacco Control Policy-related Survey in 2016. Participants reported the number of days experiencing SHS infiltration from neighbour at home in the past 7 days, and their sociodemographic characteristics and smoking status. Data were weighted by the Hong Kong official data on age, gender and smoking status distributions. Chi-square tests and multivariable logistic regression examined the associations of home SHS infiltration with sociodemographic and smoking status. Results: Overall, the prevalence (95% CI) of ever and daily SHS infiltration at home in the past 7 days were 22.2% (20.3 to 24.2%) and 5.8% (4.8 to 7.1%) respectively. SHS infiltration was individually associated with female (P = 0.002), younger age (P < 0.001) and never smoking status (P < 0.001) but not with indices of socioeconomic status including highest education level (P = 0.07), family income (P = 0.43), employment (0.89) or immigrant (P = 0.09) statuses. Multivariable regression analyses showed that current smokers were less likely to report home SHS infiltration (OR = 0.43, 95% CI 0.32-0.58). Conclusions: In Hong Kong, the prevalence of home SHS infiltration was very high given the low prevalence of smoking and did not vary with socioeconomic status. Implementation of smoke-free policy in multiunit housing is imperative to safeguard its residents from passive smoking.