Design and Implementation of an Information Strategy About the Risks Associated with E-Cigarette Use in Oral Health Students

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript presents a timely and relevant topic. The topic is important, as it addresses both a growing public health concern and an innovative educational approach. The manuscript is well structured and generally clear, but certain aspects could be strengthened. The aims and hypotheses could be mentioned more explicitly at the end of the introduction to help the reader understand the planned outcomes. The approach is sound; nevertheless, more information on the three-phase strategy's implementation, validation of data collection equipment, and participant selection reasoning would improve transparency and replicability. The findings are interesting and well supported by data. The Discussion may benefit from more in-depth consideration of the implications for behavioural change and long-term information retention. A brief mention of the limitations, such as the short exposure duration and small follow-up group, would also improve the manuscript.

Author Response

We sincerely thank the reviewer for the thoughtful and constructive feedback. We carefully revised the manuscript to address all suggestions and improve clarity, methodological transparency, and interpretative depth. Below we provide a detailed, point-by-point response. Changes to the document are highlighted in a different color (blue).

General Comment

“This manuscript presents a timely and relevant topic. The topic is important, as it addresses both a growing public health concern and an innovative educational approach. The manuscript is well structured and generally clear, but certain aspects could be strengthened.”

Response:
We greatly appreciate the reviewer’s positive assessment of the manuscript’s relevance, structure, and clarity. The revisions below were made to strengthen the study’s methodological transparency, interpretative discussion, and integration of aims and hypotheses, as suggested.

1. Comment on Aims and Hypotheses

“The aims and hypotheses could be mentioned more explicitly at the end of the introduction to help the reader understand the planned outcomes.”

Author’s Response:
We thank the reviewer for this valuable suggestion. The final paragraph of the Introduction has been rewritten to clearly state the study’s aim and hypothesis.

 2. Comment on Methodological Transparency

“The approach is sound; nevertheless, more information on the three-phase strategy's implementation, validation of data collection equipment, and participant selection reasoning would improve transparency and replicability.”

Response:
We appreciate this constructive observation. To improve methodological transparency and facilitate replicability, we expanded the Materials and Methods section. 

3. Comment on Discussion

“The findings are interesting and well supported by data. The Discussion may benefit from more in-depth consideration of the implications for behavioral change and long-term information retention.”

Response:
We appreciate this insightful suggestion. The Discussion section was expanded to explore the implications of gamified learning for behavioral change, motivation, and sustained information retention among dental students. The revised text emphasizes how interactive educational strategies can foster self-directed learning, strengthen preventive health attitudes, and support long-term health literacy development.

4. Comment on Limitations

“A brief mention of the limitations, such as the short exposure duration and small follow-up group, would also improve the manuscript.”

Author’s Response:
We have expanded the Limitations paragraph in the Discussion to acknowledge these aspects, along with additional considerations related to evidence-based content variability and study design.

 

 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript is well-structured and well-written, but you should add some modifications to improve the paper's impact and clarity:
In introduction, you should expand the rationale and theoretical framework for the educational intervention. Please link your work to existing theories on health literacy, behavioral change, and gamification in health education. Moreover, clarify the specific research gap addressed in comparison with previous literature.

The study is quasi-experimental, but you don't make clear the type of comparison, control group, and pre–post measures. Please, specify the design framework, sampling strategy and the inclusion criteria.

Please, add a more detailed description on the “three-phase strategy", on the educational content, implementation steps, and assessment procedures for each phase.

Please, explain how ethical approval and informed consent were obtained, and which institution granted approval.

Please, clarify if statistical tests were conducted or if results are only descriptive.

In limitations section add explicity the study limitations e.g. small sample in Phase 3, self-report bias, short intervention time, and lack of longitudinal follow-up.

Please, rephrase the conclusion to focus on implications for oral health education policy and recommendations for future longitudinal or multicenter studies.

Author Response

We thank the reviewer for their thorough and constructive comments. Below we address each point in detail and describe the corresponding changes made to the manuscript.

1. Introduction: rationale, theoretical framework, and research gap

Reviewer comment:
“In introduction, you should expand the rationale and theoretical framework for the educational intervention. Please link your work to existing theories on health literacy, behavioral change, and gamification in health education. Moreover, clarify the specific research gap addressed in comparison with previous literature.”

Response:
We appreciate this valuable suggestion. In the Introduction, we have expanded the rationale and theoretical framework supporting our educational intervention. Specifically, we now:

• Link the gamified strategy to key concepts in health literacy

• Incorporate references to behavioral change theories commonly used in health education.

• Connect the gamified components to current frameworks on gamification in health education.

• Clarify the research gap, underscoring that very few studies have explored gamified interventions focused on oral health topic in undergraduate dental education.

2. Study design, comparison framework, and inclusion criteria

Reviewer comment:
“The study is quasi-experimental, but you don't make clear the type of comparison, control group, and pre–post measures. Please, specify the design framework, sampling strategy and the inclusion criteria.”

Response:

We thank the reviewer for this observation. In the revised Methods section, we now specify that the study followed a quasi-experimental, post-measurement–only design, a commonly used framework in educational and health sciences research when randomization and baseline assessments are not feasible. Consistent with methodological definitions, this design includes: (1) no control group, (2) no pre-intervention measurement, and (3) a single post-intervention assessment of the study variables. This approach is appropriate for educational interventions implemented in intact groups and subject to institutional or ethical constraints.

We have also acknowledged the methodological implications of this design, including its lower internal validity and greater susceptibility to selection and confounding bias, which limit causal inference. These considerations are now explicitly reflected in the Limitations section.

In addition, we expanded the description of participant selection. A non-probabilistic convenience sample was used, consisting of students enrolled in the current academic year. Inclusion criteria required active enrollment in the current academic period and voluntary participation.

3. Description of the three-phase strategy and procedures

Reviewer comment:
“Please, add a more detailed description on the ‘three-phase strategy’, on the educational content, implementation steps, and assessment procedures for each phase.”

Response:
We agree that a more detailed description improves clarity. In the Methods section, we have expanded the description of the three-phase strategy.

4. Ethical approval and informed consent

Reviewer comment:
“Please, explain how ethical approval and informed consent were obtained, and which institution granted approval.”

Response:
We appreciate this observation. In the Methods section, under a new Institutional Review Board Statement subsection, we now specify that:

• The study was reviewed and approved by the Research Ethics Committee of both institutions, including the corresponding approval code.

• All participants received information about the study objectives and procedures and provided informed consentprior to participation.

• Participation was voluntary, and anonymity/confidentiality of responses was ensured.

5. Clarification of statistical tests vs. descriptive analysis

Reviewer comment:
“Please, clarify if statistical tests were conducted or if results are only descriptive.”

Response:
Thank you for this important clarification request. In the Data Analysis subsection of the Methods, we now explicitly state that given the groups size and the ordinal nature of some variables, we used non-parametric tests, specifically the Kruskal–Wallis test, together with post-hoc pairwise comparisons with appropriate corrections for multiple testing.

6. Limitations: explicit mention of key study limitations

Reviewer comment:
“In limitations section add explicity the study limitations e.g. small sample in Phase 3, self-report bias, short intervention time, and lack of longitudinal follow-up.”

Response:
We thank the reviewer for this precise guidance. We have revised the Limitations section to explicitly include the points mentioned.

7. Conclusion: focus on policy implications and future studies

Reviewer comment:
“Please, rephrase the conclusion to focus on implications for oral health education policy and recommendations for future longitudinal or multicenter studies.”

Response:
We fully agree with this recommendation. The Conclusion section has been rewritten.

We have attached the updated version of the document, and the changes are highlighted in blue.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript addresses an interesting topic and could be excellent after revisions.

Comments for author File: Comments.pdf

Author Response

We thank the reviewer for their thoughtful and constructive feedback. Below, we address each point and indicate the revisions made accordingly.

1. Lack of Pre-Test Knowledge Assessment

Reviewer comment:
“Without pre-intervention data, it is not possible to reliably conclude that the tool improved knowledge. The results can only reflect perceived usefulness and acceptability, not actual knowledge gains.”

Response:
We appreciate this important clarification. In the revised manuscript, we have explicitly stated that, due to the post-measurement–only design, the study cannot infer knowledge improvement. Instead, the results focus on perceived usefulness, and acceptability of the digital strategy. This clarification has been incorporated in the Introduction, Methods, and Discussion, and the wording has been adjusted to avoid implying causal effects on knowledge acquisition.

2. Questionable Validity of Knowledge Assessment During the Game

Reviewer comment:
“Students answered questions within the game and received immediate feedback, which mostly measures short-term recall rather than true knowledge acquisition. Given that the game lasted about five minutes, meaningful learning is hard to establish.”

Response:
Thank you for pointing this out. We have revised the text to acknowledge that the assessment embedded in the game primarily captures short-term recall and immediate feedback response, rather than sustained knowledge or deep understanding. We also highlight in the Limitations section that the short duration of the intervention (≈5 minutes) restricts claims regarding learning outcomes. The revised Discussion now interprets these results as indicators of engagement and interaction, not knowledge improvement.

3. Time Lag in the Survey Assessment

Reviewer comment:
“Two months after the game, students were surveyed about their attitudes. Without pre-test data or temporal control, it is unclear whether perceptions are attributable to the intervention.”

Response:
We agree with this concern. The manuscript has been updated to clarify that the two-month delay introduces potential temporal confounding and limits the ability to attribute responses solely to the intervention. This limitation is now explicitly acknowledged in the Limitations section, and we emphasize that the survey results reflect perceptions and acceptability rather than enduring effects of the intervention.

4. Limitations of Statistical Analysis

Reviewer comment:
“Only descriptive statistics were used. Inferential tests would be necessary to support claims of effectiveness.”

Response:
We appreciate this methodological observation.  In the revised Methods and Results section, we now specify that, although the study primarily relied on descriptive statistics, non-parametric inferential analyses (Kruskal–Wallis and post-hoc pairwise comparisons) were conducted to explore differences in participants’ responses during the interactive phase. These tests were selected due to the non-normal distribution and ordinal structure of several variables.

5. Terminology and Interpretation of Results

Reviewer comment:
“Claims of effectiveness are not appropriate. The outcomes should be described in terms of engagement and acceptability.”

Response:
We have revised the manuscript to avoid using terms such as effectiveness. All sections now describe the outcomes in terms of interactivity, engagement, usability, and acceptability. This change ensures alignment between the design, the data collected, and the interpretation provided.

Table 4 Formatting

Reviewer comment:
“The font is too small and difficult to read.”

Response:
Table 4 has been reformatted with a larger font size and reduced row spacing to improve readability according to the reviewer’s recommendation.

Clarification of the Three Phases

Reviewer comment:
“The methodology section could better describe the three phases and distinguish gameplay from the acceptability assessment.”

Response:
We thank the reviewer for this suggestion. The Methods section has been reorganized to clearly differentiate each phase.

We have attached the updated version of the document, and the changes are highlighted in blue.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

Electronic nicotine delivery systems (ENDS) are widely perceived as safer alternatives to conventional smoking, posing a significant public health concern due to limited knowledge regarding their general and oral health risks.

AUTHORS propose a quasi-experimental study aimed to evaluate the effectiveness and acceptability of an innovative information strategy concerning the potential harms of e-cigarettes among university students in oral health programs in Mexico and Colombia.

THEIR methodology involved implementing a three-phase strategy, utilizing an interactive, self-managed educational game (bowling game) developed on the Genially digital platform and anchored in scientific evidence.

THEIR RESULTS show the following:

-Of the 230 invited students, 213 consented to participate in the initial phase.

High engagement was demonstrated in the second phase, with 94.8% (n=203) of students using the game for an average of 5 minutes and 16 seconds, and 25.62% answering all embedded knowledge questions correctly on the first attempt.

Results from the acceptability phase (n=36) were highly positive, with 72.2% of IUVA students and 19.4% of BUAP students agreeing the strategy was both entertaining and useful for knowledge improvement.

AUTHORS conclude that: (A) the findings suggest that gamified and interactive digital learning strategies are highly accepted and strengthen academic commitment and knowledge acquisition regarding the public health risks of e-cigarettes. (B) Further longitudinal studies are necessary to evaluate the sustained impact of these digital educational tools.

 

The study is very attractive, interesting, and enthusiastically written.

I have a few comments for the authors:

1) In the introduction, I would include a section on the dissemination and use of this e tool, with data and percentages.

2) Table 1 appears in the methods, but apparently isn't referenced in the text. This table should be better placed in context and referenced in the body of the manuscript.

3) The methods include a long series of lists of paragraphs, often with a long list of tasks with bullet points. Consider whether this section could be improved editorially, perhaps by introducing an outline and initial summary and transforming some sections into a narrative format.

4) The results could be improved editorially. Figure 1 isn't very clear, and Table 4 is difficult to read. I don't think the tables are referenced in the body of the text. Some passages use list format too much (see lines 242-262). An introduction that makes it easier to read is missing.

Author Response

We sincerely thank the reviewer for their positive evaluation of our work and for the constructive suggestions provided. Below, we address each comment in detail and describe the revisions implemented in the manuscript.

1. Inclusion of information on the dissemination and use of e-tools in the Introduction

Reviewer comment:
“In the introduction, I would include a section on the dissemination and use of this e tool, with data and percentages.”

Response:
Thank you for this helpful suggestion. In the revised Introduction, we have added a description of the dissemination, adoption, and increasing use of digital and gamified educational tools in health sciences. This contextualizes the relevance of our intervention within broader trends in technology-enhanced learning and strengthens the rationale for developing and implementing an e-tool for oral health education.

2. Table 1 placement and referencing

Reviewer comment:
“Table 1 appears in the methods, but apparently isn't referenced in the text. This table should be better placed in context and referenced in the body of the manuscript.”

Response:
We appreciate the reviewer’s observation. Table 1 is now explicitly referenced in the Methods section where the demographic characteristics of the participants are first described.

3. Editorial adjustments to the Methods section

Reviewer comment:
“The methods include a long series of lists of paragraphs, often with a long list of tasks with bullet points. Consider whether this section could be improved editorially, perhaps by introducing an outline and initial summary and transforming some sections into a narrative format.”

Response:
Thank you for this stylistic recommendation. The Methods section has been reorganized to improve narrative flow and readability.

4. Editorial improvements in the Results section, including Figures and Tables

Reviewer comment:
“The results could be improved editorially. Figure 1 isn't very clear, and Table 4 is difficult to read. I don't think the tables are referenced in the body of the text. Some passages use list format too much (see lines 242-262). An introduction that makes it easier to read is missing.”

Response:
We agree with the reviewer’s assessment and have implemented several revisions: Table 4 has been reformatted with a larger font size, adjusted spacing, and improved alignment to enhance readability, all tables and figures are now explicitly referenced at the appropriate points in the Results section.

We have attached the updated version of the document, and the changes are highlighted in blue.

Author Response File: Author Response.pdf

Reviewer 5 Report

Comments and Suggestions for Authors

Dear Authors,

Gamification is a popular and well-liked method among young people, used by teachers of various subjects for teaching purposes. Elements such as clearly defined goals combined with transparent rules and a clear path work best in practice.

 The concept and its implementation confirmed once again that for teaching and popular science purposes, appropriately selected tools should be used, tailored to the audience/users.

The reviewer has no other comments addressed to the Authors.

Author Response

We sincerely thank the reviewer for their thoughtful and encouraging comments. We appreciate the recognition of the relevance of gamification as a well-received strategy among younger learners and its value in supporting educational and popular science initiatives. We agree that clearly defined goals, transparent rules, and well-structured pathways are essential components for effective gamified learning, and we have emphasized these aspects in the manuscript.

We also acknowledge the reviewer’s insight regarding the importance of selecting tools that are appropriately tailored to the target audience. This principle guided the design of our intervention, and we have clarified this alignment in the revised version of the text.

We are grateful for the reviewer’s positive assessment and have addressed all prior recommendations accordingly. Thank you for your constructive feedback and supportive evaluation. We have attached the updated document containing the recommendations received from all reviewers. Changes are in blue.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript is now much clearer and more structured. The authors have fully addressed previous comments, improving the introduction, the description of the study design, and the implications section. The broadening of the theoretical framework is evident in the first part of the text, which integrates references to health literacy, behavior change theories, and gamification, as seen in the initial sections of the introduction.

The Methods section is now consistent: the post-only design, the lack of a control group, and methodological limitations are clearly explained, including the inclusion criteria and the ethics procedure (pages 4–7 of the PDF). The description of the three phases of the intervention is adequately detailed. The results tables and the participation flow, such as the response distributions in the tables on pages 9–10, are readable and relevant.

The discussion is balanced and contextualizes the findings in relation to recent literature. The conclusions now include educational implications and directions for future studies.

Only two minor points remain:

• I would suggest a slight linguistic revision to streamline some very long sentences;
• clarify that the improvement in knowledge cannot be attributed to the intervention in the absence of pre-intervention measures, as the authors already indicate in the Limitations section.

Author Response

We thank the reviewer for the valuable comments. Below we detail the corresponding revisions made to improve the clarity and rigor of the manuscript.

Reviewer comment 1:
“I would suggest a slight linguistic revision to streamline some very long sentences”

Response:
We appreciate this helpful suggestion. We have carefully revised the manuscript to streamline overly long sentences and improve overall readability. In particular, we edited several passages in all sections to make the phrasing more concise and clearer. 

Reviewer comment 2:
“…clarify that the improvement in knowledge cannot be attributed to the intervention in the absence of pre-intervention measures, as the authors already indicate in the Limitations section.”

Response:
Thank you for pointing out this important issue. We agree that, in the absence of pre-intervention measures, we cannot attribute any improvement in knowledge directly to the intervention. To address this, we have revised the wording of our hypothesis and related statements to emphasize association rather than causation.