Interaction between science advice and policymaking in time of COVID-19: a French perspective.

BACKGROUND: In the coronavirus disease 2019 (COVID-19) context, many governments relied on scientific consultative bodies to advise their policy, but their contribution remains poorly documented. This article aims to fill this gap by reviewing the role played by the French High Council for Public Health (HCSP) in the French government's response to COVID-19. METHODS: We studied the time distribution of the COVID-19 guidelines produced by the HCSP until November 2020, computed their delay of production and analyzed the thematic areas they cover. To assess their use by the authorities, we looked for references to these guidelines in the regulatory texts, protocols and press communicates issued by national and local authorities until January 2021. RESULTS: The HCSP was strongly demanded with 102 guidelines produced following 97 official requests and two self-referrals. Most of them (N = 43) concerned protective measures to constrain the infection, while health inequalities and mental health were poorly addressed. Timing was very constraint as half of the guidelines were requested within 4 days. In total, 73% of the guidelines were used by policymakers to implement new obligations or within communication toward the public at national and local levels. CONCLUSIONS: This article informs on the HCSP's contribution during the crisis and stresses the difficulties it encountered to provide quality recommendations in very short times. It prompts governments to enlarge the competencies of their advisory boards and to consider the multidimensional aspects of health in policy design.

Empowerment Through Participation in a Cancer Prevention Exhibit: Evidence from the Hygée Lab Intervention.

While many countries have launched cancer prevention initiatives to improve the public's understanding of risk and protective factors, few are systematically evaluated. Hygée Lab, a living lab in a socioeconomically deprived area of France, is designed to interactively communicate evidence-based information about cancer prevention and treatment with the goal to improve visitors' understanding of cancer risk and prevention factors, reduce fatalism in regard to cancer, and increase feelings of empowerment. Pre- and post-visit data were collected during the first 18 months of the exhibit's opening from two segments of the population: adolescents from local schools (N = 134) and the general public (N = 112). Adolescents from the same schools who did not participate in the visit comprised the control group (N = 94). A further 232 general public visitors completed post-surveys only. Pre-post-visit comparisons reveal significant changes in both adolescent and general public visitors: cancer understanding improves, fatalism in regard to cancer is reduced, and feelings of empowerment increase. This systematic evaluation of Hygée Lab offers promise for how interactive exhibits may be used for cancer prevention amongst low health literacy populations.

Cancer-associated thrombosis in patients with implanted ports: a prospective multicenter French cohort study (ONCOCIP).

The need to accurately identify cancer outpatients at high risk of thrombotic complications is still unmet. In a prospective, multicenter cohort study (ONCOlogie et Chambres ImPlantables [ONCOCIP]), consecutive adult patients with a solid tumor and implanted port underwent 12-month follow-up. Our primary objective was to identify risk factors for (1) catheter-related thrombosis, defined as ipsilateral symptomatic upper-limb deep-vein thrombosis with or without pulmonary embolism, and (2) venous thromboembolism other than catheter-related, defined as any symptomatic superficial- or deep-vein thrombosis (other than catheter-related) or pulmonary embolism, and incidental pulmonary embolism. All events were objectively confirmed and centrally adjudicated. Rate assessments integrated competing risk of death. Overall, 3032 patients were included (median age: 63 years; women: 58%). The most frequent cancer locations were breast (33.7%), lung (18.5%), and colorectal (15.6%), cancer being metastatic in 43.2% of patients. Most patients (97.1%) received chemotherapy. By 12 months, 48 (1.6%) patients had been lost to follow-up and 656 (24.6%) had died; 3.8% (n = 111) of patients had experienced catheter-related thrombosis, and 9.6% (n = 276) venous thromboembolism other than catheter-related. By multivariate analysis, use of cephalic vein for catheter insertion predicted catheter-related thrombosis, whereas ongoing antiplatelet therapy was protective; risk factors for venous thromboembolism other than catheter-related were advanced age, previous venous thromboembolism, cancer site, and low hemoglobin level or increased leukocyte count before chemotherapy. In conclusion, this large prospective cohort study showed a high rate of venous thromboembolism in patients with a solid tumor and implanted port. Risk factors for catheter-related thrombosis differed from those for venous thromboembolism not catheter-related. This trial was registered at www.clinicaltrials.gov as #NCT02025894.

Drug Management in End-of-Life Hospitalized Palliative Care Cancer Patients: The RHESO Cohort Study.

OBJECTIVE: Little data about the management of drugs in terminally ill palliative care cancer patients is available. The present study aimed at describing the evolution of anticancer and non-anticancer treatments (NACTs) in cancer patients in palliative care units. The second objective was to identify factors leading to the medical decision to withdraw or not NACTs. METHODS: Data from 1,091 cancer patients hospitalized in palliative care units were prospectively collected in 2010-2011, through a multicenter, observational French cohort. RESULTS: The median overall survival after admittance in palliative care units was 15 days. Specific anticancer treatments were systematically stopped in the first 24 h in palliative care units, but for 4.5% of patients. Regarding NACTs, patients were heavily treated with strong opioids (74%), corticosteroids (51%), and antidepressants (21.8%) until death. Antiulcer agents (63.4%), antibiotics (25.7%), thrombosis prevention (21.8%), antidiabetics (7.6%), and transfusions (4%) were often also continuously prescribed. In multivariate analysis, ECOG PS 4 was an independent predictor of continuous prescription of morphine and an independent predictor of discontinuation of corticosteroids, proton-pump inhibitors, antidiabetics, and preventive anticoagulant therapy. Infection symptoms independently predicted continuous prescription of paracetamol. Paralysis and cancer palpable mass independently predicted corticosteroid withdrawal. Brain metastases independently predicted antiulcer withdrawal. Hemorrhage independently predicted preventive anticoagulant withdrawal. Availability to a venous access independently predicted paracetamol and antiulcer continuous prescriptions. Co-prescriptions independently predicted continuous prescriptions (antibiotics with antiulcer, antifungals with antibiotics) or withdrawal (preventive anticoagulant with antiplatelets and antifungals). CONCLUSIONS: NACT prescription remained commonplace in terminally ill palliative cancer patients, although their benefit is questionable.

Health policy analysis of the non-implementation of HPV vaccination coverage in the pay for performance scheme in France.

Background: The French National Cancer Control Plan (NCCP) launched in 2014 set the objective to improve human papillomavirus (HPV) vaccination coverage (VC). The NCCP included a measure to integrate a VC indicator in the pay for performance (P4P) scheme for general practitioners (GPs), which was not implemented. The objective of the study was to analyse the reasons for non-implementation of this measure, using the health policy analysis framework. Methods: The policy from proposal to non-implementation of the HPV VC indicator into the P4P scheme was analysed through the actors involved, the content of the measure, the contextual factors and the processes of policy-making. Results: The actors were the Ministry of Health (MOH) and National Cancer Institute as policy-makers, the public health insurance as an indirect target, and GPs as direct targets. The content of the policy was not evidence-informed and was not included into the NCCP preparation report. The context included vaccine hesitancy and ethical concerns from GPs in opposition with MOH. The process involved a diversity of stakeholders with a complex governance and no strict monitoring of the measure. Conclusions: Complex vaccination policy governance associated with a non-evidence-informed policy content and an unfavourable context may have been the reasons for the policy failure.

The impact of social inequalities on children's knowledge and representation of health and cancer.

Reducing inequalities in the field of cancer involves studying the knowledge and mental representations of cancer among children. A qualitative study was conducted on 191 children aged 9 to 12 using the "write and draw" technique to get spontaneous mental representations of "healthy things", "unhealthy things" and "cancer". We grouped the voluntary schools according to two deprivation levels. In response to the request to "write or draw anything you think keeps you healthy", the main responses categories were physical activity, healthy food and basic needs. Smoking, drinking alcohol, sedentary lifestyles/lack of sport were identified as "unhealthy". The first theme associated with "cancer" is the "cancer site" implying children have a segmented perception of cancer. Deprived children have radically different views about the key items representing cancer: they are more likely to believe the illness is systematically deadly. They are less likely to believe it is a treatable illness. They are less likely to associate cancer with risky behaviors, particularly alcohol consumption. CONCLUSION: Social inequalities affect representations of cancer and health literacy from early childhood. Prevention programs taking into account these representations need to be introduced at school. What is Known: • Social inequalities for cancer mortality are observed in all European countries and are particularly pronounced in France. • Reducing these inequalities in prevention programs implies studying the knowledge and mental representations of cancer among children. What is New: • This study identified representations of cancer in young children according to social level. • At age 9, children living in deprived areas are less able to produce content in discussions about cancer and have narrower mental representations and a more fatalistic view.

Inequalities and Barriers to the Use of Supportive Care Among Young Breast Cancer Survivors: a Qualitative Understanding.

The development of supportive care for cancer patients has been shown to have a positive impact on both mortality rates and many aspects of life after cancer, particularly in young women. Meanwhile, there are still numerous inequalities in terms of cancer mortalities and quality of life among cancer survivors in France. The processes leading to unequal access to supportive care services, and the impact this has on the post-treatment period, have been poorly documented, however. The goal of this study was to understand the barriers to using supportive care services among young women breast cancer survivors under the age of 50 and to find out how this can contribute to inequalities. Thirty-six young breast cancer survivors, one third of which deemed socially deprived, were interviewed using a qualitative, inductive approach at two comprehensive care centres in France. Our findings primarily show that there are still a number of barriers to accessing supportive care for a large number of patients. The way information about supportive services is delivered is a major cause of inequalities in the use of these services. The guidance provided does not take into account either the patients' needs or their capacity to integrate the information and anticipate problems. Certain specific post-treatment issues have yet to be addressed. Some systemic barriers could be lifted by changing the way information on supportive care services is currently organised and thereby prevent the survivorship plans now being implemented in cancer care settings from reinforcing health inequalities.

Pandémie : quel lien entre la première ligne et la santé publique ?

Réunir les professionnels de la première ligne et les responsables des politiques publiques pour définir les missions et les rôles de chacun.

Prognostic factors for overall survival in elderly patients with advanced ovarian cancer treated with chemotherapy: Results of a pooled analysis of three GINECO phase II trials.

BACKGROUND: The GINECO led three multicentric prospective phase II studies, Elderly Woman Ovarian Trials 1 (EWOT1), EWOT2, and EWOT3, to evaluate the impact of geriatric covariates on the outcome of elderly patients treated with six courses of first-line chemotherapy for FIGO stage IIIIV ovarian cancer. This pooled analysis was designed to evaluate the validity of the geriatric vulnerability parameters identified in EWOT3 (Falandry et al., 2013). PATIENTS AND METHODS: From 1997 to 2011, 266 patients were recruited: 83 in EWOT1, 72 in EWOT2, and 111 in EWOT3, which evaluated respectively a 4-weekly carboplatin-cyclophosphamide regimen, a 3-weekly standard carboplatin-paclitaxel doublet and a carboplatin monotherapy. All patients were analyzed in this pooled analysis for treatment completion, toxicity, and overall survival. RESULTS: The global treatment completion rate was 73% and ranged from 68% in EWOT2 to 74% in EWOT3. Toxicities were generally manageable: neutropenia was more frequent in EWOT2 and thrombopenia in EWOT1 and EWOT3. In multivariate analysis, covariates associated with decreased survival were: being "depressed" according to the investigators' assessment, hypoalbuminemia <35g/L, and FIGO stage IV. In addition, a Hospital Anxiety and Depression Scale (HADS) score>14 and Instrumental Activities of Daily Living (IADL) score<25 confirmed a deleterious impact in the EWOT2+EWOT3 population subanalysis. CONCLUSIONS: Despite moderate heterogeneity among the studies, this pooled analysis confirmed the deleterious effects on overall survival of emotional disorders ("depressed", as assessed by investigators or the HADS score), and decreased functionality (IADL score), in addition to FIGO stage.

[Organized or individual breast cancer screening: what motivates women?]. / Dépistage organisé ou individuel du cancer du sein ? Attitudes et représentations des femmes.

OBJECTIVE: The breast cancer screening programme, proposed to all women between 50 and 69 years, consisting of two-view mammography screening every two years, has been generalized in France since 2004. The programme coexists with opportunistic mammography screening, provided outside official frameworks. This qualitative study was designed to identify the pros and cons of these two screening modes. METHODS: Three hundred and forty-five women were randomly selected from women who had participated in a previous quantitative study and who were invited to attend for breast cancer screening in 13 French departments between 2010 and 2011. These women were asked to participate in a face-to-face semistructured interview conducted by a sociologist. RESULTS: 48 women (17 from deprived areas) were interviewed. All chose to be screened for breast cancer either because they feared cancer, or because they wanted to control their own health. Twenty-seven women chose the organized screening programme, which they considered to be trustworthy, as negative mammograms are double checked by a second radiologist. Twenty-one women preferred individual screening, which they considered to be more reliable, less anonymous and providing them with more liberty to take control of their own health. CONCLUSION: Gynaecologists play an important role in women's decision to undergo individual breast cancer screening. They also have an important role to play in the promotion of organized breast cancer screening programme with this public.

European transnational ecological deprivation index and participation in population-based breast cancer screening programmes in France.

BACKGROUND: We investigated factors explaining low breast cancer screening programme (BCSP) attendance taking into account a European transnational ecological Deprivation Index. PATIENTS AND METHODS: Data of 13,565 women aged 51-74years old invited to attend an organised mammography screening session between 2010 and 2011 in thirteen French departments were randomly selected. Information on the women's participation in BCSP, their individual characteristics and the characteristics of their area of residence were recorded and analysed in a multilevel model. RESULTS: Between 2010 and 2012, 7121 (52.5%) women of the studied population had their mammography examination after they received the invitation. Women living in the most deprived neighbourhood were less likely than those living in the most affluent neighbourhood to participate in BCSP (OR 95%CI=0.84[0.78-0.92]) as were those living in rural areas compared with those living in urban areas (OR 95%CI=0.87[0.80-0.95]). Being self-employed (p<0.0001) or living more than 15min away from an accredited screening centre (p=0.02) was also a barrier to participation in BCSP. CONCLUSION: Despite the classless delivery of BCSP, inequalities in uptake remain. To take advantage of prevention and to avoid exacerbating disparities in cancer mortality, BCSP should be adapted to women's personal and contextual characteristics.

[Joining forces for prevention: a public health challenge?] / S'unir pour prévenir, un enjeu de santé publique ?

In recent years, and particularly since the 2017 national health strategy, prevention has become one of the priorities in the French healthcare system. It's important to understand why this theme has emerged to the point of changing the title of the Ministry of Health, which is now called the Ministry of Health and Prevention. It is also essential to see how the entire healthcare system, and above all the care system, can mobilize to develop prevention in our country, and thus enable our fellow citizens to live as long as possible in good health.

[Development and validation of a tool for the systematic identification of social vulnerabilities in cancer patients: the DEFCO tool]. / Développement et validation d'un outil de dépistage systématique des fragilités sociales des patients atteints de cancer : l'outil DEFCO.

INTRODUCTION: Literature suggests that patients from deprived backgrounds are less likely to adhere to their treatments, continue to expose themselves to risk factors and, as a result, have poorer health outcomes. It is therefore crucial to identify these vulnerable populations early on, in order to provide them with tailored and reinforced care. The primary aim of this research is to construct and validate a systematic screening tool for identifying patients at highest risk of social vulnerability due to deprivation, through the use of psychometric techniques. This tool is intended to be easily used by healthcare professionals, to provide tailored and targeted care throughout the patient's journey. METHOD: This study involves the development and assessment of a screening tool, along with a self-questionnaire and a decision support tool incorporating an artificial neural network. It is a prospective, monocentric, 2-stage psychometric validation study. RESULTS: This study has demonstrated the successful development of the self-questionnaire using psychometric methodology. The tool was found a good performance in screening social vulnerabilities. DISCUSSION: This validated self-questionnaire is an easy-to-use tool, allowing systematic screening for social vulnerabilities for cancer patients. This early identification allows to reinforce patient's pathway in order to avoid disruption. The integration of the tool in an artificial neuron network system allows to automate and disseminate this method of deprived patients' detection, while limiting the workload for the staff.

Evaluating the Knowledge of and Behavior Toward COVID-19 and the Possibility of Isolating at a City Level: Survey Study.

BACKGROUND: Mass testing campaigns were proposed in France during the first wave of the COVID-19 pandemic to detect and isolate asymptomatic individuals infected by SARS-CoV-2. During mass testing in Saint-Étienne (February 2021), we performed a survey of the general population. OBJECTIVE: We evaluated, on the scale of a city's population, the literacy level about SARS-CoV-2 transmission, barrier gesture respect, and isolation acceptability or possibility in case of SARS-CoV-2 infection. METHODS: We used the validated CovQuest-CC questionnaire. Data were analyzed and correlated with volunteer characteristics and their SARS-CoV-2 screening results using multivariate analysis. RESULTS: In total, 4707 participants completed the CovQuest-CC questionnaire. Multivariate analysis revealed that female sex was a determinant of a higher score of knowledge about SARS-CoV-2 transmission (adjusted ß coefficient=0.14, 95% CI 0.04-0.23; corrected P=.02). Older ages of 50-59 years (adjusted ß coefficient=0.25, 95% CI 0.19-0.31; corrected P<.001) and ≥60 years (adjusted ß coefficient=0.25, 95% CI 0.15-0.34; corrected P<.001) were determinants of a higher score on barrier gesture respect compared to ages 20-49 years considered as reference. Female sex was also a determinant of a higher score on barrier gesture respect (adjusted ß coefficient=0.10, 95% CI 0.02-4.63; corrected P<.001). The knowledge score was correlated with the score on barrier gesture respect measures (adjusted ß coefficient=0.03, 95% CI 0.001-0.004; corrected P=.001). Older ages of 50-59 years (adjusted ß coefficient=0.21, 95% CI 0.13-0.29; corrected P<.001) and ≥60 years (adjusted ß coefficient=0.25, 95% CI 0.1-0.38; corrected P<.001) were determinants of a higher score on isolation acceptability or possibility compared to the age of 20-49 years considered as reference. Finally, the knowledge score regarding SARS-CoV-2 transmission was significantly associated with a lower risk of RT-PCR (reverse transcriptase-polymerase chain reaction) positivity (adjusted odds ratio 0.80, 95% CI 0.69-0.94; corrected P<.03), implying that a 1-point increase in the knowledge score lowers the risk of positivity by 20% on average. CONCLUSIONS: This study identified factors associated with health literacy regarding SARS-CoV-2 infection in asymptomatic individuals in a large French city's population. We can confirm that in the context of the COVID-19 pandemic, the determinants of better health literacy are not the same as those in other contexts. It seems critical to obtain a more detailed understanding of the determinants of individual citizens' behavior, as part of a strategy to combat the large-scale spread of the virus. The harsh experience of this pandemic should teach us how to nurture research to structure customized interventions to encourage the adoption of ad hoc behaviors to engage citizens in adapting behaviors more favorable to their health.

Prevention of sexually transmitted infections among girls and young women in relation to their HPV vaccination status.

BACKGROUND: Having been vaccinated against the human papilloma virus (HPV) may affect other behaviours related to sexual health. This study assessed knowledge and behaviour relevant to the prevention of sexually transmitted infections (STIs) among girls/women aged 14-23 years in relation to their HPV vaccination status. METHODS: From November 2008 to February 2009, 328 girls/women from the Rhône-Alpes region were recruited by general practitioners and completed a self-administered questionnaire. RESULTS: In all, 316 of the 328 respondents provided information on their HPV vaccination status: 135 (42.7%) had been vaccinated (51.2% of girls aged 14-16 years, 44% of women aged 17-20 years and 18.9% of 21-23-year-olds). Knowledge about HPV and the Pap smear was poor overall but greater in those who had been vaccinated: vaccinated 14-16-year-olds were significantly more likely to know the aim of the Pap smear than those not vaccinated (72.7% vs. 41.3%, P < 0.001), and vaccinated 21-23-year-olds were more likely to know about the need to continue Pap smear screening, despite vaccination (60.0% vs. 25.6%, P = 0.06). Irrespective of vaccination status, >80% cited condoms as a means of STI prevention and >85% of those who were sexually active used them. No difference was observed between vaccinated and non-vaccinated groups regarding requests for HIV serology, history of abortions or emergency hormonal contraception. CONCLUSION: Knowledge about cervical cancer prevention was better among those who had been vaccinated against HPV than among those who had not. Knowledge and behaviour relevant to STI prevention seemed appropriate whatever the respondents' vaccination status.

Measuring Health Literacy Among French Pupils With the Health Literacy Survey Child Questionnaire-15 (HLS-Child-Q15).

BACKGROUND: Health literacy is a critical health determinant. To implement initiatives aiming at improving health literacy among children, adapted measurement tools are needed. OBJECTIVE: This study aimed to translate, adapt, and test the Health Literacy Survey Child Questionnaire-15 (HLS-Child-Q15) to assess health literacy among French-speaking 8- to 11-year-old pupils. METHODS: The HLS-Child-Q15 was translated and adapted to the French context to become the HLS-Child-Q15-FR. A cross-sectional survey was carried out using a written, self-reported questionnaire to assess the psychometric properties of the HLS-Child-Q15-FR. KEY RESULTS: Translation and adaptation of the HLS-Child-Q15 German-French translated versions were cross-referenced. Back-translation led to minor refinements. Qualitative pre-test among children led to simplifications in wording and structure. Validation of the HLS-Child-Q15-FR. Four trained interviewers collected data among 3,107 pupils in 74 elementary schools of the Auvergne-Rhône-Alpes region. HLS-Child-Q15-FR showed good reliability (alpha = 0.83). Exploratory factor analysis showed a two-factor model related to health care and primary prevention. Construct validity analyses suggested removing 3 items. External validity analyses indicated a significant and moderate relationship with perceived self-efficacy. CONCLUSION: This study aimed to address the issue of measuring health literacy among French-speaking 8- to 11-year-old pupils. The HLS-Child-Q15-FR showed a high internal consistency. Statistics suggested a two-dimensional thematic scale. These findings should be further investigated. [HLRP: Health Literacy Research and Practice. 2023;7(3):e144-e153.].

The Acti-Pair program helps men with prostate cancer increase physical activity with peer support: a mixed method pilot study.

Background: Although the health benefits of physical activity (PA) are recognized, prostate cancer patients do not follow PA recommendations. Barriers to PA, whether physical, environmental or organizational, are known. Furthermore, even when these barriers are overcome, this achievement is not systematically accompanied by lifestyle change. Many strategies have shown to be effective in increasing patient adherence to PA. This study aims to assess the feasibility and the viability of the Acti-Pair program which combines three strategies: peer support, a personalized and realistic PA project, and support from health and adapted physical activity professionals in a local context. Methods and analysis: We conducted a pilot study utilizing a mixed qualitative and quantitative methodology, employing feasibility and viability assessments. Quantitative assessments included recruitment, retention adherence rates, process and potential effectiveness (PA and motivation) indicators; while qualitative methods were used to evaluate the program's practicality, suitability and usefulness. Indicators of potential effectiveness were assessed before and after the intervention using a Wilcoxon test for matched data. Qualitative data were collected through semistructured interviews conducted by two researchers with various program stakeholders. The study lasted for 3 years. Results: Twenty-four patients were recruited over a 25-month period. Forty-two percent of patients completed the program 3 months after the beginning. We recruited 14 peers and trained nine peers over a 10-month period. The program was coordinated extensively by adapted PA professionals, while health professionals were involved in recruiting patients and peers. Self-reporting of moderate to vigorous PA was increased after the Acti-Pair program initiation [42.86 (30.76) at baseline to 53.29 (50.73)]. Intrinsic motivation significantly increased after participation in the Acti-Pair program [1.76 (1.32) before the intervention vs. 2.91 (1.13) after the intervention]. The key player to support the Acti-Pair program in the field has been the PA support system. The main challenge has been the difficulty of health professionals in promoting PA. Discussion: This pilot study has shown that the Acti-Pair program is feasible and viable. It will allow us to extend the peer support intervention to other contexts and assess the effectiveness of this intervention and its generalization.

A Smoking Prevention Intervention Among Young People in an Online Community Game: Results from a Pilot Randomized Controlled Trial.

Background: Innovative methods for smoking prevention interventions need to be investigated to increase attractiveness, access hard-to-reach populations, and increase effectiveness. We studied the feasibility and immediate effects of an intervention to reinforce norms and behaviors of young people related to antismoking, integrated into a popular online community game. Methods: A pilot randomized controlled trial was conducted through the HABBO online community. The intervention group was exposed to repeated discussion sessions with small groups of peer players and two facilitators once a week for 1 month (four sessions), inside the game. The control group had access to antismoking information websites. Process indicators (attractiveness, participation) and immediate outcomes (norms and intentions with regard to smoking) were assessed by questionnaire. Results: One hundred sixteen players were invited to participate in the intervention; 10 did not meet eligibility criteria, 30 were allocated to the intervention group, and 76 to the control group. Median age was 23. Twenty-four percent were not in education, employment, or training. A median of eight players attended each session and the median number of exchange chats by session was 399; 70% of chat time was occupied by the players. Twenty players attended all four sessions. Immediate norms, representations, and intentions were evaluated in 39 players and showed small differences between groups. Conclusion: Delivering and evaluating a smoking prevention intervention in an online game is feasible. In the targeted online community game, the intervention was attractive and allowed the delivery of innovative interventions to audiences with diverse social profiles. Long-term effects, sustainability, and evaluation methodology are discussed.