A major health dilemma occurring in many countries today is smoking behavior. In 2017, the World Health Organization (WHO) revealed that tobacco consumption is increasing worldwide; as many as 1.3 billion people out of 6.7 billion of the world's population are smokers (Sholihah & Novita, 2021). Indonesian people have the highest cigarette consumption behavior in the ASEAN region, which is 65.19 million people (Tan & Dorotheo, 2018). The data presented by GYTS / Global Youth Tobacco Survey Indonesia in 2019 showed that out of 5,125 school students aged 13-15 years, 19.2% of students were recorded as active smokers. Smokers are dominated by male students with a percentage of 35.6% (National Health Research and Development Agency, 2019).

Currently, the trend of smoking behavior extends to the adolescent and child age groups (Sholihah & Novita, 2021). The results of the National Basic Health Survey (Riskdas) in 2018 found that the prevalence of adolescent smokers increased to 9.1% from 7.2% over the past five years (Almaidah et al., 2020). East Java is one of the regions with a relatively high number of adolescent smokers, ranked 8th in Indonesia (BPS Indonesia, 2020). Based on data from the Central Statistics Agency, Rachmawati et al. (2023) stated that the average teenage and child smoker in Malang City consumes more than 60 cigarettes in one week. The Malang City Health Office in 2022 screened smoking behavior in children aged 10-18. In Malang City, out of 111,016 children, 2,859 (2.6%) of them are active smokers. Among the 16 Puskesmas working areas in Malang City, the Arjuno Puskesmas working area has the highest number of active smokers aged 10 to 18 years in Malang City, namely 403 (8.9%) children with smoking status (Malang City Health Office, 2023).

The background of children in choosing to smoke is based on the inner self who wants to try cigarettes for reasons of curiosity. Then, there are also factors from the social environment around children who smoke, such as parents, siblings, and peers. Children's curiosity about cigarettes will be huge when they see that few social environments smoke (Oqui et al., 2022). Smoking behavior in the age group of adolescents and children is also based on the lack of dissemination of information that clearly states the dangers and long-term effects of chemicals in cigarettes (Munir, 2019). Chemicals such as tar, nicotine, arsenic, carbon monoxide, and nitrosamine in cigarettes are the main causes of a person developing non-communicable diseases (Yuningrum et al., 2021). In addition, nicotine in cigarettes can affect brain function and psychological health, causing addiction and toxic effects on cognitive function (Atmasari et al., 2020). As a result, if no efforts are made to prevent smoking behavior in adolescents, the effects of dependence will continue to be felt until adulthood (Muslim et al., 2023).

Given the many risks and side effects of smoking, it is necessary to carry out health promotion efforts to build a culture of non-smoking behavior in school-age children (Mujito et al., 2022). In implementing health promotion efforts, consideration must be given to selecting media and methods tailored to the target group (Rahmawati & Fitriyah, 2020). Simple language using fun elements is undoubtedly needed to help school-age children understand and understand the health information presented (Mujito et al., 2022). The selection of targets in this study, referring to the recommendation of the Arjuno Health Center, chose Oro-Oro Dowo Malang State Elementary School because of its location in the middle of the city, which allows children to be more exposed to an environment where smoking is more common, both through advertisements, media, and associations in the surrounding environment.

Based on the results of the needs analysis conducted by the researcher, the Snakes and Ladders educational game is a suitable media used as a promotive effort for the dangers of smoking behavior because it can attract interest in participating in health promotion activities and increase student knowledge with a new atmosphere about the dangers of smoking behavior for school students. The specifications of the Snakes and Ladders game media regarding the dangers of smoking are expected to display interesting text and images about smoking behavior, the selection of background colors that present the characteristics of the target, namely children and pastel color combinations, medium media size, and the material contained in the snakes and ladders game media, namely the definition of smoking, the content in cigarettes, and the impact of smoking.

Various studies have shown that game-based approaches effectively improve health behaviors and knowledge. A Zhou et al. (2020) meta-analysis showed that narrative game-based interventions significantly increased the adoption of healthy behaviors, particularly among children and adolescents. Similarly, systematic studies by Cuevas-Lara et al. (2021) and Shiau et al. (2021) confirmed that game-based interventions positively impact improving health understanding and management across different age groups, including children and the elderly. This effectiveness can be explained through the learning-through-play theory approach, which emphasizes the importance of emotional engagement, hands-on experience, and interactivity in the learning process (Piki et al., 2016; Nijhof et al., 2018). In addition, play is also known to support cognitive reinforcement, creativity, and learning motivation, which are essential in behavior change-based learning (Kinder et al., 2019). Therefore, developing educational media such as Snakes and Ladders games is visually appealing and supported by strong theoretical foundations and scientific evidence in health promotion.

Research and development conducted by Mujito et al. (2022) also used Snakes and Ladders game promotional media to improve children's smoking prevention behavior. The study used game media that used practical instructions and game support facilities, namely playing board sheets, dice, and pawns. Meanwhile, the Snakes and Ladders game media used in this study consists of practical instructions with supporting facilities in the form of a playing board using game card instruments, dice, and pawns. The novelty of this research lies in the technical details of the game, which stimulates the target to discuss further to find answers to the questions in the game. The advantages of Snakes and Ladders game educational media are that it is more practical and learning takes place in a relaxed atmosphere, allowing faster absorption of health messages (Mujito et al., 2022).

Research conducted by Hafif Hamdalah in Thaha et al. (2022) stated that the Snakes and Ladders educational game media is superior in increasing target knowledge compared to picture story media. The Snakes and Ladders game material will be more imprinted on the target's memory because all students' senses are actively used as a result of packaging the material with engaging visualizations that children easily accept. Children can understand information when reading 10%, hearing 20%, seeing 30%, and half based on what is heard and seen, 70% of what is said, and 90% of what is done (Thaha et al., 2022).

Although play-based health interventions have demonstrated effectiveness in improving children's health knowledge and behaviors, there are significant gaps in the literature regarding integrating deep learning theory and long-term evaluation of such interventions. Most existing studies focus on short-term outcomes and lack consideration of motivational aspects and children's emotional engagement in the learning process through play. According to Baranowski et al. (2016), many game-based interventions do not fully utilize game design principles that can increase intrinsic motivation and user engagement. In addition, Peng et al. (2019) emphasized the need for a more holistic approach to designing game-based interventions, including integrating learning theory and evaluating the long-term impact on children's health behaviors. Therefore, further research is needed that combines strong learning theory with engaging game design to create more effective and sustainable health interventions for children.

Based on the description above, efforts to promote the dangers of smoking behavior in school-age children need to be made. Researchers want to develop educational game media in the form of snakes and ladders to deliver health information about the dangers of smoking to Oro-Oro Dowo Malang State Elementary School students.

The results showed that the majority of respondents were males aged 13 years and in grade six, which is an age group vulnerable to smoking behavior. Sulastri and Rindu (2019) stated that the highest prevalence of smokers occurs at the age of 13-15 years, with the first experiment generally starting at the age of 12-13 years. Individual factors, such as easy access to cigarettes without understanding the risks (Hamdan et al., 2015), as well as environmental factors, such as the influence of parents, siblings, or peers who smoke, influence children's behavior. In this study, two respondents aged 9-13 years reported already having a smoking habit. Therefore, it is important to instill an understanding of the dangers of smoking from an early age through education at school (Rahman et al., 2021).

The Snakes and Ladders game media proved feasible to be used as a health promotion media to increase children's knowledge about the dangers of smoking. Educational institutions are expected to play an active role through the School Health Effort (UKS) program. In contrast, health agencies such as the Community Health Center (Puskesmas) and education offices are expected to collaborate to promote their efforts. Health promoters are advised to develop media similar to other games, and future researchers can explore more interesting methods and add variables and control groups. The Ministry of Health can also consider integrating this game into the School Health Effort (UKS) program.

The researcher would like to thank the Malang City Education Office, all Public Elementary Schools in Malang City involved in this research, and the State Universitas Negeri Malang for supporting the research team so that this research can be completed properly.

The data used in this study were obtained from the results of trials and usage tests of game media on students of Oro-Oro Dowo State Elementary School, Malang City. Data is limited and not publicly available to maintain the privacy of learners. However, data can be provided by the correspondence author upon reasonable request and with the consent of the school and related institutions.

This research did not receive external funding.

The authors declare that there is no conflict of interest in conducting research or in preparing and publishing this article.