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The association of media exposure and media literacy with adolescent alcohol and tobacco use Fong-ching Chang, Nae-fang Miao, Ching-mei Lee, Ping-hung Chen, Chiung-hui Chiu and Shu-ching Lee J Health Psychol published online 1 May 2014 DOI: 10.1177/1359105314530451 The online version of this article can be found at: http://hpq.sagepub.com/content/early/2014/04/30/1359105314530451
Published by: http://www.sagepublications.com
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530451 research-article2014
HPQ0010.1177/1359105314530451Journal of Health PsychologyMiao et al.
Article
The association of media exposure and media literacy with adolescent alcohol and tobacco use
Journal of Health Psychology 1–13 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105314530451 hpq.sagepub.com
Fong-ching Chang1, Nae-fang Miao2, Ching-mei Lee1, Ping-hung Chen1, Chiung-hui Chiu1 and Shu-ching Lee3
Abstract This study examined the relationship of media exposure and media literacy to alcohol and tobacco use among adolescents in Taiwan. A total of 2992 10th-grade students recruited from 26 high schools in Taipei, Taiwan, completed a questionnaire in 2010. The multivariable analysis results indicated that the students with higher alcohol and tobacco media exposure were more likely to use alcohol and tobacco and have intentions to drink and smoke, while students with higher media literacy were less likely to use alcohol and have intentions to drink and smoke.
Keywords alcohol, media exposure, media literacy, Taiwan, tobacco
Introduction Alcohol and tobacco use are the leading causes of preventable death in many countries. The use of alcohol and tobacco accounted for 3.8 and 8.7 percent of all global deaths and 4.6 and 3.7 percent of global disability-adjusted life years, respectively (Rehm et al., 2009; World Health Organization (WHO), 2011). A majority of smokers begin using tobacco before reaching adulthood (Shafey et al., 2009). According to the 2007 Taiwan National Youth Risk Behavior Survey (Bureau of Health Promotion, 2011a), 22.1 and 14.8 percent of high-school students reported having used alcohol and tobacco, respectively, in the previous month. Those who begin to use alcohol and tobacco early are more likely to become dependent (Ellickson et al., 2003; Henry et al., 2011; Riggs et al., 2007).
Youth alcohol drinking can result in a number of health and social problems, including academic problems (Ellickson et al., 2003), illicit drug use (Adam et al., 2011; Ellickson et al., 2003), motor vehicle accidents (Sommers et al., 2011), violent crimes (Ellickson et al., 2003; Patra et al., 2011), risky sexual behaviors (Connor et al., 2010; 1National
Taiwan Normal University, Taiwan Medical University, Taiwan 3Chung-Ho High School, Taiwan 2Taipei
Corresponding author: Fong-ching Chang, Department of Health Promotion and Health Education, National Taiwan Normal University, 162, Ho-Ping East Road, Section 1, Taipei 10610, Taiwan. Email: [email protected]
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Stueve and O’Donnell, 2005), and serious injuries (O’Brien et al., 2013). Youth cigarette use also relates to poor academic performance (Cox et al., 2007), illicit drug use (Kamal et al., 2011), delinquent behavior (Yu et al., 2012), and suicide attempts (Kim and Kim, 2010). Evidence suggests that exposure to alcohol and tobacco advertisements, portrayals, and promotion activities contribute to adolescent alcohol drinking and smoking. For example, cross-sectional and longitudinal studies (Anderson et al., 2009; Hurtz et al., 2007; Morgenstern et al., 2011; Nunez-Smith et al., 2010; Smith and Foxcroft, 2009) indicate that exposure to alcohol advertising, portrayals, and promotion activities is associated with adolescent alcohol-drinking initiation, increased drinking among drinkers, and subsequent alcohol consumption in young people. In addition, despite increasing restrictions in many countries on tobacco advertisements on TV, in newspapers, in magazines, and on billboards, studies (Lovato et al., 2011; Nunez-Smith et al., 2010; Paynter and Edwards, 2009) show that tobacco advertising and promotion at retailers has increased adolescent smoking initiation. Exposure to film/movie smoking portrayals is also associated with adolescent smoking initiation (Choi et al., 2012; Thrasher et al., 2009). A study indicated that media exposure was associated with smoking intentions via perceived prevalence of peer smoking (Yang et al., 2013), while another study showed that the motives that cause drinking by peers influence individual alcohol use through individual motives (Kuntsche and Stewart, 2009). According to Social Cognitive Theory, media promotes changes by informing, enabling, motivating, and guiding participants (Bandura, 2001). In addition, a Message Interpretation Model demonstrated that media alcohol portrayals influence youth drinking through a progressive decision-making process (Austin et al., 2006). To buffer the influence of media messages on adolescent alcohol drinking and smoking, media literacy is proposed as a key strategy toward preventing adolescent substance use. Media literacy is generally defined as the ability
to understand, analyze, evaluate, and create media messages in a wide variety of forms (Aufderheide, 1992; Primack et al., 2009). Media literacy education was suggested as a tool to empower youth to critically analyze media messages and to deter the potentially negative influence of media on behavior (Hobbs, 2011; National Association for Media Literacy Education, 2011; Rodesiler, 2010). Studies (Primack et al., 2006a; Primack and Hobbs, 2009) show that adolescent smoking media literacy is associated with both reduced adolescent smoking and reduced susceptibility to future smoking. Media literacy programs (Austin and Johnson, 1997; Kupersmidt et al., 2010) have been effective for children substance use prevention. Taiwan implemented the Tobacco Hazards Prevention Amendment Act in 2009 to strengthen a range of tobacco control measures, which included expanding the number of smoke-free areas; adding graphic health warnings to cigarette packages; totally banning tobacco advertisements, promotion, and sponsorship; and raising tobacco tax, as recommended by the WHO Framework Convention on Tobacco Control (FCTC) (WHO, 2003). However, children and adolescents in Taiwan are exposed to alcohol advertisements on TV (after 9 p.m.), in magazines, in newspapers, on web sites, in outdoor campaigns, and so on (Centre for Social and Health Outcomes Research and Evaluation, 2006). In addition, large numbers of children and adolescents are exposed to smoking depictions on TV and in movies (Bureau of Health Promotion, 2011b). Some studies (Anderson et al., 2009; Hurtz et al., 2007; Morgenstern et al., 2011; NunezSmith et al., 2010; Smith and Foxcroft, 2009) in developed countries have documented the relationship between media exposure and adolescent substance use, while relatively few studies have examined the relationship among media exposure, media literacy, and adolescent alcohol and tobacco use. This study was an examination of the relationship of media exposure and media literacy to alcohol and tobacco use and intentions to drink alcohol and smoke
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Chang et al. among adolescents in Taiwan. This study was also undertaken to explore whether gender differences existed in alcohol and tobacco use media exposure, media literacy, alcohol and tobacco use, and intentions to drink alcohol and smoke. We hypothesized that higher media exposure would be associated with an increased likelihood of current smoking and drinking and intentions to smoke and drink, while higher media literacy would be associated with an decreased likelihood of current smoking and drinking and intentions to smoke and drink.
this study. The response rate was 80 percent. Of all participating schools, 54 percent were public schools, while 88 percent were located in urban areas. Data for this study were collected as a part of the “Needs Assessment of Adolescent Digital and Media Literacy and Health Impact Study” survey. A questionnaire was developed to assess media exposure, digital media literacy, and risk behaviors. The language of the survey questionnaire was Mandarin.
Measures Methods Participants and procedure In 2010, a total of 72,327 10th-grade highschool students attended 122 high schools (including vocational high schools) in Taipei City and New Taipei City, Taiwan. Based on the sampling frame, which was a list of schools and their 10th-grade student enrollments, a probability-proportionate-to-size sampling method was used to systematically draw a random sample of schools. There was an average of 46 classes per school, and an average of 40 students per class. Three to four classes were randomly selected from each sample school. Approval from the Institutional Review Board at the Taipei Medical University was obtained. Following class selection, teachers helped to give students consent forms to take home to parents requesting their permission to allow the children to participate in the survey. Students also filled out an assent form to indicate their willingness to participate in this study. After the consent forms were collected, researchers visited the schools to conduct the self-administered survey and address students’ questions. Students were assured the information would remain confidential. All questionnaires were completed over a couple of months. In 2010, a total of 2992 10th-grade students from 102 classes in 26 sample schools completed the questionnaire. About one-seventh of schools disagreed to participate in this study. In addition, one-fifth of parents and students declined to participate in
The self-administered questionnaire was developed based on previous studies. A group of 10 experts was invited to assess the content validity of the questionnaire. A pretest survey was conducted at two schools, which were not a part of the sample schools, in order to interpret the students’ responses to the survey and to evaluate the reliability of the scales in the questionnaire. In total, 90 10th-grade students completed the pretest survey. Parental consent for child participation was obtained. Alcohol and tobacco use. The dependent variables in this study included current alcohol and tobacco use and intentions to drink and smoke. The measurement was developed based on previous studies (Pierce et al., 1996; Primack et al., 2006b). Alcohol use was measured based on the respondents’ answer to how often they drank alcohol. Tobacco use was measured based on the respondents’ answer to how often they smoked. Response options for each item included the following: “never,” “ever (ever before a year),” “seldom (a few times within a year),” “sometimes (a few times within a month),” and “usual (a few times within a week).” If participants answered “sometimes (a few times within a month)” or more frequently, they were coded as current drinker/smoker. Students’ intentions to drink was measured based on the respondents’ answer to whether they thought they would drink alcohol in the next year. Students’ intentions to smoke were measured based on the respondents’ answer to the
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question of whether they thought they would smoke cigarettes in the next year. Response options for each item were evaluated on a 5-point Likert-type scale including the following: “definitely not” (0%) (scoring 1), “probably not” (25%) (scoring 2), “half likely”(50%) (scoring 3), “probably yes” (75%) (scoring 4), and “definitely yes” (100%) (scoring 5). A higher score indicated higher intentions to drink alcohol and smoke. Alcohol and tobacco media exposure. Alcohol and media exposure measurement was developed based on previous studies (Anderson et al., 2009; Choi et al., 2012; Smith and Foxcroft, 2009; Snyder et al., 2006). Alcohol media exposure was measured using five items. Participants were asked the following: During the past year, how often did you see (1) alcohol advertisements on TV; (2) alcohol advertisements in newspapers or magazines; (3) alcohol advertisements in campaigns, on broadcasts, or on outdoor billboards; (4) actors drinking alcohol or alcohol brands on television or in movies or films; and (5) discussions of alcohol drinking on the Internet. In addition, tobacco media exposure was measured using two items. Participants were asked the following: During the past year, how often did you see (1) actors smoking on TV or in movies or films and (2) discussions of smoking on the Internet. Response options for each item included the following: “never” (scoring 1), “a few times yearly” (scoring 2), “a few times monthly” (scoring 3), “a few times weekly” (scoring 4), and “almost daily” (scoring 5). Cronbach’s α of alcohol media exposure for the present sample was 0.81. Alcohol and tobacco media literacy. The determination of alcohol drinking and smoking media literacy was developed based on the Primack Smoking Media Literacy Scale (Primack and Hobbs, 2009) and key questions analyzing media messages suggested by the U.S. National Association for Media Literacy Education (2011). The revised Alcohol and Tobacco Media Literacy Scale included 18 items, which
contained three theoretical domains: (1) authors/audience, (2) messages/meanings, and (3) representations/reality. The authors/audience domain included two concepts: (1) authors create media messages for profit or influence (3 items) and (2) authors target a specific audience (2 items). Examples included “Buy-oneget-one-free deals on alcohol are designed to get people addicted,” “Tobacco and alcohol companies are very powerful, even outside of the cigarette and alcohol business,” and “Certain cigarette brands are designed to appeal to younger people.” The messages/meanings domain included four concepts: (1) messages contain values and specific points of view (2 items), (2) different people interpret messages differently (2 items), (3) messages affect attitude and behaviors (1 item), and (4) multiple production techniques are used (1 item). Examples included “Different people can see the same alcohol ads in a magazine and feel completely different about it,” “People are influenced by TV and movies,” “Cigarette and alcohol ads show green, natural, healthy scenes to make people forget about the health risks,” and “When people make movies and TV shows, every camera shot is very carefully planned.” The representations/reality domain included three concepts: (1) messages filter reality (4 items), (2) messages omit information (2 items), and (3) critical thinking (1 item). Examples included “Alcohol ads link drinking to things that humans want like love, good looks, and power,” “Advertisements usually leave out a lot of important information,” and “When you see an alcohol ad, it is very important to think about what was left out of the ad (i.e. health hazards).” Each item was evaluated on a 4-point Likert-type scale from “strongly agree” (scoring 4) to “strongly disagree” (scoring 1). A higher score indicated higher alcohol drinking and smoking media literacy. Cronbach’s α of the authors/audience, messages/meanings, and representations/reality subscales for the present sample were 0.70, 0.65, and 0.51, respectively. Cronbach’s α of the complete Alcohol Drinking and Smoking Media Literacy Scale was 0.81.
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Chang et al. Media use. Media use included TV, magazine, newspaper, and Internet use hours per week. Each of the media weekly use hours was calculated from two questions. Participants were asked the following questions: (1) During the past week, how much time did you spent on TV/magazine/ newspaper/Internet in a weekday (Monday to Friday)? The response options included the following: “0 minutes,” “1–29 minutes,” “30–59 minutes,” “1 hour-less than 2 hours,” and “2 hours-less than 3 hours,” “3 hours and more, please fill in the number of hours.” (2) During the past week, how much time did you spent on TV/ magazine/newspaper/Internet in a weekend day (Saturday and Sunday)? The response options included the following: “0 hour,” “2 hours,” “3 hours,” “4 hours,” and “5 hours and more, please fill in the number of hours.”
Statistical analysis SAS software (version 9.3) (SAS Institute, 2011) was used to perform the statistical analysis. Percentages and means were calculated for all variables. A t-test was conducted to test gender differences in alcohol and tobacco media exposure and media literacy, while a chi-squared test was conducted to test gender differences in alcohol and tobacco use and intentions to drink and smoke. To account for the clustering of students in 26 schools, Generalized Estimating Equation Method (GENMOD programs with REPEATED statement) was performed to examine adolescent gender, alcohol and tobacco media exposure, media literacy related to adolescents’ current alcohol and tobacco use, and intentions to drink and smoke.
Results Demographic characteristics Of the 2992 student participants, 52 percent were male and 48 percent were female. Students were 15–17 years of age (mean = 15.5 years, standard deviation (SD) = 0.6 years). Twothirds of the students reported parents with a high-school education level or lower. One-third
of students came from families with low or lower middle household incomes (Table 1).
Alcohol and tobacco use and intentions to drink and smoke by gender Of the 2992 student participants, 9.2 percent had drunk alcohol in the past month, while 6.9 percent had smoked in the past month (Table 1). By gender, males had a higher prevalence of alcohol drinking (11.3%) and smoking (10.9%) compared with females (alcohol use: 6.9%; tobacco use: 2.6%). Of the non-drinkers, adolescents tended to report that they would probably not drink alcohol in the next year. Of the non-smokers, adolescents tended to report that they definitely would not smoke. By gender, boys had higher intentions to smoke than girls.
Media use and alcohol/tobacco media exposure by gender Table 2 lists adolescent media use and alcohol and tobacco media exposure by gender. Adolescents spent more time using the Internet (17.5 hours a week) and watching TV (12.3 hours a week), while adolescents spent less time reading newspapers (2.0 hours a week) and magazines (1.9 hours a week). By gender, boys spent more time using the Internet (19.2 hours a week) than girls (15.7 hours a week), while girls spent more time watching TV (12.9 hours a week) than boys (11.7 hours a week). Adolescents averaged a few times of weekly exposure to TV alcohol commercials, while adolescents averaged a few times of monthly exposure to alcohol advertisements in magazines, outdoor billboards, and alcohol-drinking portrayals in film/TV. Adolescents’ exposure to online alcohol messages averaged a few times yearly. By gender, males had higher exposure to online discussions of alcohol compared with females. Adolescents averaged a few times of weekly exposure to film/TV smoking portrayals, while
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Table 1. Demographic characteristics and alcohol/tobacco use by gender. N
Father’s education level High school/lower College and higher Mother education level High school/lower College and higher Household poverty No Yes Current alcohol use No Yes Current tobacco use No Yes
Total
Male
Female %
χ2 test
n
%
1788 1071
62.5 37.5
914 580
61.2 38.8
874 491
64.0 36.0
1999 928
68.3 31.7
1027 499
67.3 32.7
972 429
69.4 30.6
1908 1046
64.6 35.4
981 551
64.0 36.0
927 495
65.2 34.8
2705 274
90.8 9.2
1371 175
88.7 11.3
1334 99
93.1 6.9
2772 206
93.1 6.9
1377 169
89.1 10.9
1395 37
97.4 2.6
n
%
n
2.48 1.46 0.43 17.33***
80.45***
***p < 0.001.
Table 2. Media use, media exposure, and intentions to drink/smoke by gender. Total Media use (hours per week) TV Magazine Newspaper Internet Alcohol media exposure TV alcohol advertisements Magazine alcohol advertisements Outdoor alcohol advertisements TV, film portrayals of drinking Online discussion of alcohol Tobacco media exposure TV, film portrayals of smoking Online discussion of tobacco Intention To drink To smoke
Male
Female
t-test
Mean
SD
Mean
SD
Mean
SD
12.30 1.88 2.00 17.51
9.89 2.96 2.59 13.99
11.71 1.76 2.03 19.20
10.36 2.91 2.53 15.08
12.94 2.00 1.96 15.72
9.34 3.01 2.65 12.50
−3.35*** −2.11* 0.83 6.75***
3.60 2.88 2.89 3.32 2.30
0.99 1.07 1.02 1.04 1.04
3.61 2.89 2.92 3.35 2.40
1.00 1.11 1.05 1.05 1.11
3.58 2.87 2.85 3.28 2.18
0.98 1.02 0.98 1.02 0.95
0.84 0.47 1.86 1.92 5.79***
3.56 2.49
1.00 1.09
3.63 2.57
1.01 1.14
3.48 2.40
0.98 1.03
4.10*** 4.42***
1.76 1.18
1.08 0.56
1.74 1.21
1.10 0.60
1.78 1.14
1.05 0.51
−0.86 3.01**
SD: standard deviation. Total N = 2988, male n = 1554, female n = 1434. Intentions to drink: non-current drinker total N = 2703, male n = 1370, female n = 1333. Intentions to smoke: non-current smoker total N = 2769, male n = 1374, female n = 1395. Media exposure score range 1–5: 1 = none; 2 = a few times yearly; 3 = a few times monthly; 4 = a few times weekly; 5 = almost daily. Intentions to drink/smoke score range 1–5: 1 = definitely not (0%); 2 = probably not (25%); 3 = half likely (50%); 4 = probably yes (75%); 5 = definitely yes (100%). *p < 0.05; **p < 0.01; ***p < 0.001.
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Chang et al. Table 3. Alcohol and tobacco media literacy by gender. Subscale (number of items)
Total
Male
Female
Mean
SD
Mean
SD
Mean
SD
Alcohol and tobacco media: authors/audience Authors create media messages for profit/ influence (3) Authors target specific audiences (2) Alcohol and tobacco media: messages/meanings Messages contain values and specific points of view (2) Different people interpret messages differently (2) Messages affect attitude and behaviors (1) Multiple production techniques are used (1) Alcohol and tobacco media: representations/ reality Messages filter reality (4) Messages omit information (2) Critical thinking (1) Total
2.64 2.72
0.52 0.56
2.62 2.70
0.55 0.59
2.66 2.73
0.49 0.53
−1.90 −1.57
2.51 2.83 2.46
0.67 0.43 0.66
2.49 2.81 2.48
0.69 0.46 0.67
2.54 2.86 2.43
0.64 0.40 0.66
−1.67 −3.32*** 1.83
2.99
0.60
2.93
0.64
3.06
0.56
−5.88***
2.96 3.13 2.85
0.66 0.64 0.37
2.91 3.12 2.83
0.69 0.66 0.39
3.02 3.15 2.87
0.63 0.61 0.34
−4.31*** −1.27 −3.42***
2.66 3.20 2.88 2.79
0.39 0.57 0.70 0.36
2.65 3.16 2.88 2.76
0.41 0.59 0.71 0.38
2.68 3.25 2.89 2.81
0.37 0.53 0.69 0.33
−2.26* −4.29*** −0.38 −3.54***
t-test
SD: standard deviation. Media literacy score range 1–4. Higher score indicated higher media literacy. Total N = 2988, male n = 1554, female n = 1434. *p < 0.05; ***p < 0.001.
adolescents’ exposure to online tobacco messages averaged a few times yearly. By gender, males had higher exposure to TV/film smoking portrayals and online discussions of tobacco compared with females.
Alcohol and tobacco media literacy by gender Of the three domains of media literacy, students had the highest score on the representations/ reality domain, followed by the message/meaning domain, and the authors/audience domain (Table 3). For example, adolescents tended to agree that “Alcohol ads omit information” and “Multiple production techniques are used,” while adolescents tended to disagree that “Messages contain values and specific points of view.” By gender, males had lower levels of alcohol drinking and smoking media literacy compared with females.
Media exposure, media literacy, and alcohol and tobacco use Multivariable analysis results indicated that after controlling for gender, students with a higher alcohol media exposure were more likely to use alcohol, while students with a higher level of alcohol drinking and smoking media literacy were less likely to use alcohol. Similarly, students with a higher tobacco media exposure were more likely to smoke (Table 4). For non-drinkers, students with a higher alcohol media exposure were more likely to report having intentions to drink, while students with higher alcohol drinking and smoking media literacy were less likely to have intentions to drink. Similarly, for non-smokers, students with higher tobacco media exposure were more likely to report having intentions to smoke, while students with higher media literacy were less likely to have intentions to smoke (Table 5).
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Table 4. Media exposure, media literacy, and current alcohol and tobacco use. Alcohol use
Tobacco use
β
SE
p
β
SE
p
Intercept Gender (male = 1/female = 0) Media exposure Media literacy
−3.24 0.45 0.11 −0.39
0.47 0.17 0.02 0.16
The association of media exposure and media literacy with adolescent alcohol and tobacco use Fong-ching Chang, Nae-fang Miao, Ching-mei Lee, Ping-hung Chen, Chiung-hui Chiu and Shu-ching Lee J Health Psychol published online 1 May 2014 DOI: 10.1177/1359105314530451 The online version of this article can be found at: http://hpq.sagepub.com/content/early/2014/04/30/1359105314530451
Published by: http://www.sagepublications.com
Additional services and information for Journal of Health Psychology can be found at: Email Alerts: http://hpq.sagepub.com/cgi/alerts Subscriptions: http://hpq.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - May 1, 2014 What is This?
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530451 research-article2014
HPQ0010.1177/1359105314530451Journal of Health PsychologyMiao et al.
Article
The association of media exposure and media literacy with adolescent alcohol and tobacco use
Journal of Health Psychology 1–13 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105314530451 hpq.sagepub.com
Fong-ching Chang1, Nae-fang Miao2, Ching-mei Lee1, Ping-hung Chen1, Chiung-hui Chiu1 and Shu-ching Lee3
Abstract This study examined the relationship of media exposure and media literacy to alcohol and tobacco use among adolescents in Taiwan. A total of 2992 10th-grade students recruited from 26 high schools in Taipei, Taiwan, completed a questionnaire in 2010. The multivariable analysis results indicated that the students with higher alcohol and tobacco media exposure were more likely to use alcohol and tobacco and have intentions to drink and smoke, while students with higher media literacy were less likely to use alcohol and have intentions to drink and smoke.
Keywords alcohol, media exposure, media literacy, Taiwan, tobacco
Introduction Alcohol and tobacco use are the leading causes of preventable death in many countries. The use of alcohol and tobacco accounted for 3.8 and 8.7 percent of all global deaths and 4.6 and 3.7 percent of global disability-adjusted life years, respectively (Rehm et al., 2009; World Health Organization (WHO), 2011). A majority of smokers begin using tobacco before reaching adulthood (Shafey et al., 2009). According to the 2007 Taiwan National Youth Risk Behavior Survey (Bureau of Health Promotion, 2011a), 22.1 and 14.8 percent of high-school students reported having used alcohol and tobacco, respectively, in the previous month. Those who begin to use alcohol and tobacco early are more likely to become dependent (Ellickson et al., 2003; Henry et al., 2011; Riggs et al., 2007).
Youth alcohol drinking can result in a number of health and social problems, including academic problems (Ellickson et al., 2003), illicit drug use (Adam et al., 2011; Ellickson et al., 2003), motor vehicle accidents (Sommers et al., 2011), violent crimes (Ellickson et al., 2003; Patra et al., 2011), risky sexual behaviors (Connor et al., 2010; 1National
Taiwan Normal University, Taiwan Medical University, Taiwan 3Chung-Ho High School, Taiwan 2Taipei
Corresponding author: Fong-ching Chang, Department of Health Promotion and Health Education, National Taiwan Normal University, 162, Ho-Ping East Road, Section 1, Taipei 10610, Taiwan. Email: [email protected]
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Stueve and O’Donnell, 2005), and serious injuries (O’Brien et al., 2013). Youth cigarette use also relates to poor academic performance (Cox et al., 2007), illicit drug use (Kamal et al., 2011), delinquent behavior (Yu et al., 2012), and suicide attempts (Kim and Kim, 2010). Evidence suggests that exposure to alcohol and tobacco advertisements, portrayals, and promotion activities contribute to adolescent alcohol drinking and smoking. For example, cross-sectional and longitudinal studies (Anderson et al., 2009; Hurtz et al., 2007; Morgenstern et al., 2011; Nunez-Smith et al., 2010; Smith and Foxcroft, 2009) indicate that exposure to alcohol advertising, portrayals, and promotion activities is associated with adolescent alcohol-drinking initiation, increased drinking among drinkers, and subsequent alcohol consumption in young people. In addition, despite increasing restrictions in many countries on tobacco advertisements on TV, in newspapers, in magazines, and on billboards, studies (Lovato et al., 2011; Nunez-Smith et al., 2010; Paynter and Edwards, 2009) show that tobacco advertising and promotion at retailers has increased adolescent smoking initiation. Exposure to film/movie smoking portrayals is also associated with adolescent smoking initiation (Choi et al., 2012; Thrasher et al., 2009). A study indicated that media exposure was associated with smoking intentions via perceived prevalence of peer smoking (Yang et al., 2013), while another study showed that the motives that cause drinking by peers influence individual alcohol use through individual motives (Kuntsche and Stewart, 2009). According to Social Cognitive Theory, media promotes changes by informing, enabling, motivating, and guiding participants (Bandura, 2001). In addition, a Message Interpretation Model demonstrated that media alcohol portrayals influence youth drinking through a progressive decision-making process (Austin et al., 2006). To buffer the influence of media messages on adolescent alcohol drinking and smoking, media literacy is proposed as a key strategy toward preventing adolescent substance use. Media literacy is generally defined as the ability
to understand, analyze, evaluate, and create media messages in a wide variety of forms (Aufderheide, 1992; Primack et al., 2009). Media literacy education was suggested as a tool to empower youth to critically analyze media messages and to deter the potentially negative influence of media on behavior (Hobbs, 2011; National Association for Media Literacy Education, 2011; Rodesiler, 2010). Studies (Primack et al., 2006a; Primack and Hobbs, 2009) show that adolescent smoking media literacy is associated with both reduced adolescent smoking and reduced susceptibility to future smoking. Media literacy programs (Austin and Johnson, 1997; Kupersmidt et al., 2010) have been effective for children substance use prevention. Taiwan implemented the Tobacco Hazards Prevention Amendment Act in 2009 to strengthen a range of tobacco control measures, which included expanding the number of smoke-free areas; adding graphic health warnings to cigarette packages; totally banning tobacco advertisements, promotion, and sponsorship; and raising tobacco tax, as recommended by the WHO Framework Convention on Tobacco Control (FCTC) (WHO, 2003). However, children and adolescents in Taiwan are exposed to alcohol advertisements on TV (after 9 p.m.), in magazines, in newspapers, on web sites, in outdoor campaigns, and so on (Centre for Social and Health Outcomes Research and Evaluation, 2006). In addition, large numbers of children and adolescents are exposed to smoking depictions on TV and in movies (Bureau of Health Promotion, 2011b). Some studies (Anderson et al., 2009; Hurtz et al., 2007; Morgenstern et al., 2011; NunezSmith et al., 2010; Smith and Foxcroft, 2009) in developed countries have documented the relationship between media exposure and adolescent substance use, while relatively few studies have examined the relationship among media exposure, media literacy, and adolescent alcohol and tobacco use. This study was an examination of the relationship of media exposure and media literacy to alcohol and tobacco use and intentions to drink alcohol and smoke
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Chang et al. among adolescents in Taiwan. This study was also undertaken to explore whether gender differences existed in alcohol and tobacco use media exposure, media literacy, alcohol and tobacco use, and intentions to drink alcohol and smoke. We hypothesized that higher media exposure would be associated with an increased likelihood of current smoking and drinking and intentions to smoke and drink, while higher media literacy would be associated with an decreased likelihood of current smoking and drinking and intentions to smoke and drink.
this study. The response rate was 80 percent. Of all participating schools, 54 percent were public schools, while 88 percent were located in urban areas. Data for this study were collected as a part of the “Needs Assessment of Adolescent Digital and Media Literacy and Health Impact Study” survey. A questionnaire was developed to assess media exposure, digital media literacy, and risk behaviors. The language of the survey questionnaire was Mandarin.
Measures Methods Participants and procedure In 2010, a total of 72,327 10th-grade highschool students attended 122 high schools (including vocational high schools) in Taipei City and New Taipei City, Taiwan. Based on the sampling frame, which was a list of schools and their 10th-grade student enrollments, a probability-proportionate-to-size sampling method was used to systematically draw a random sample of schools. There was an average of 46 classes per school, and an average of 40 students per class. Three to four classes were randomly selected from each sample school. Approval from the Institutional Review Board at the Taipei Medical University was obtained. Following class selection, teachers helped to give students consent forms to take home to parents requesting their permission to allow the children to participate in the survey. Students also filled out an assent form to indicate their willingness to participate in this study. After the consent forms were collected, researchers visited the schools to conduct the self-administered survey and address students’ questions. Students were assured the information would remain confidential. All questionnaires were completed over a couple of months. In 2010, a total of 2992 10th-grade students from 102 classes in 26 sample schools completed the questionnaire. About one-seventh of schools disagreed to participate in this study. In addition, one-fifth of parents and students declined to participate in
The self-administered questionnaire was developed based on previous studies. A group of 10 experts was invited to assess the content validity of the questionnaire. A pretest survey was conducted at two schools, which were not a part of the sample schools, in order to interpret the students’ responses to the survey and to evaluate the reliability of the scales in the questionnaire. In total, 90 10th-grade students completed the pretest survey. Parental consent for child participation was obtained. Alcohol and tobacco use. The dependent variables in this study included current alcohol and tobacco use and intentions to drink and smoke. The measurement was developed based on previous studies (Pierce et al., 1996; Primack et al., 2006b). Alcohol use was measured based on the respondents’ answer to how often they drank alcohol. Tobacco use was measured based on the respondents’ answer to how often they smoked. Response options for each item included the following: “never,” “ever (ever before a year),” “seldom (a few times within a year),” “sometimes (a few times within a month),” and “usual (a few times within a week).” If participants answered “sometimes (a few times within a month)” or more frequently, they were coded as current drinker/smoker. Students’ intentions to drink was measured based on the respondents’ answer to whether they thought they would drink alcohol in the next year. Students’ intentions to smoke were measured based on the respondents’ answer to the
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Journal of Health Psychology
question of whether they thought they would smoke cigarettes in the next year. Response options for each item were evaluated on a 5-point Likert-type scale including the following: “definitely not” (0%) (scoring 1), “probably not” (25%) (scoring 2), “half likely”(50%) (scoring 3), “probably yes” (75%) (scoring 4), and “definitely yes” (100%) (scoring 5). A higher score indicated higher intentions to drink alcohol and smoke. Alcohol and tobacco media exposure. Alcohol and media exposure measurement was developed based on previous studies (Anderson et al., 2009; Choi et al., 2012; Smith and Foxcroft, 2009; Snyder et al., 2006). Alcohol media exposure was measured using five items. Participants were asked the following: During the past year, how often did you see (1) alcohol advertisements on TV; (2) alcohol advertisements in newspapers or magazines; (3) alcohol advertisements in campaigns, on broadcasts, or on outdoor billboards; (4) actors drinking alcohol or alcohol brands on television or in movies or films; and (5) discussions of alcohol drinking on the Internet. In addition, tobacco media exposure was measured using two items. Participants were asked the following: During the past year, how often did you see (1) actors smoking on TV or in movies or films and (2) discussions of smoking on the Internet. Response options for each item included the following: “never” (scoring 1), “a few times yearly” (scoring 2), “a few times monthly” (scoring 3), “a few times weekly” (scoring 4), and “almost daily” (scoring 5). Cronbach’s α of alcohol media exposure for the present sample was 0.81. Alcohol and tobacco media literacy. The determination of alcohol drinking and smoking media literacy was developed based on the Primack Smoking Media Literacy Scale (Primack and Hobbs, 2009) and key questions analyzing media messages suggested by the U.S. National Association for Media Literacy Education (2011). The revised Alcohol and Tobacco Media Literacy Scale included 18 items, which
contained three theoretical domains: (1) authors/audience, (2) messages/meanings, and (3) representations/reality. The authors/audience domain included two concepts: (1) authors create media messages for profit or influence (3 items) and (2) authors target a specific audience (2 items). Examples included “Buy-oneget-one-free deals on alcohol are designed to get people addicted,” “Tobacco and alcohol companies are very powerful, even outside of the cigarette and alcohol business,” and “Certain cigarette brands are designed to appeal to younger people.” The messages/meanings domain included four concepts: (1) messages contain values and specific points of view (2 items), (2) different people interpret messages differently (2 items), (3) messages affect attitude and behaviors (1 item), and (4) multiple production techniques are used (1 item). Examples included “Different people can see the same alcohol ads in a magazine and feel completely different about it,” “People are influenced by TV and movies,” “Cigarette and alcohol ads show green, natural, healthy scenes to make people forget about the health risks,” and “When people make movies and TV shows, every camera shot is very carefully planned.” The representations/reality domain included three concepts: (1) messages filter reality (4 items), (2) messages omit information (2 items), and (3) critical thinking (1 item). Examples included “Alcohol ads link drinking to things that humans want like love, good looks, and power,” “Advertisements usually leave out a lot of important information,” and “When you see an alcohol ad, it is very important to think about what was left out of the ad (i.e. health hazards).” Each item was evaluated on a 4-point Likert-type scale from “strongly agree” (scoring 4) to “strongly disagree” (scoring 1). A higher score indicated higher alcohol drinking and smoking media literacy. Cronbach’s α of the authors/audience, messages/meanings, and representations/reality subscales for the present sample were 0.70, 0.65, and 0.51, respectively. Cronbach’s α of the complete Alcohol Drinking and Smoking Media Literacy Scale was 0.81.
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Chang et al. Media use. Media use included TV, magazine, newspaper, and Internet use hours per week. Each of the media weekly use hours was calculated from two questions. Participants were asked the following questions: (1) During the past week, how much time did you spent on TV/magazine/ newspaper/Internet in a weekday (Monday to Friday)? The response options included the following: “0 minutes,” “1–29 minutes,” “30–59 minutes,” “1 hour-less than 2 hours,” and “2 hours-less than 3 hours,” “3 hours and more, please fill in the number of hours.” (2) During the past week, how much time did you spent on TV/ magazine/newspaper/Internet in a weekend day (Saturday and Sunday)? The response options included the following: “0 hour,” “2 hours,” “3 hours,” “4 hours,” and “5 hours and more, please fill in the number of hours.”
Statistical analysis SAS software (version 9.3) (SAS Institute, 2011) was used to perform the statistical analysis. Percentages and means were calculated for all variables. A t-test was conducted to test gender differences in alcohol and tobacco media exposure and media literacy, while a chi-squared test was conducted to test gender differences in alcohol and tobacco use and intentions to drink and smoke. To account for the clustering of students in 26 schools, Generalized Estimating Equation Method (GENMOD programs with REPEATED statement) was performed to examine adolescent gender, alcohol and tobacco media exposure, media literacy related to adolescents’ current alcohol and tobacco use, and intentions to drink and smoke.
Results Demographic characteristics Of the 2992 student participants, 52 percent were male and 48 percent were female. Students were 15–17 years of age (mean = 15.5 years, standard deviation (SD) = 0.6 years). Twothirds of the students reported parents with a high-school education level or lower. One-third
of students came from families with low or lower middle household incomes (Table 1).
Alcohol and tobacco use and intentions to drink and smoke by gender Of the 2992 student participants, 9.2 percent had drunk alcohol in the past month, while 6.9 percent had smoked in the past month (Table 1). By gender, males had a higher prevalence of alcohol drinking (11.3%) and smoking (10.9%) compared with females (alcohol use: 6.9%; tobacco use: 2.6%). Of the non-drinkers, adolescents tended to report that they would probably not drink alcohol in the next year. Of the non-smokers, adolescents tended to report that they definitely would not smoke. By gender, boys had higher intentions to smoke than girls.
Media use and alcohol/tobacco media exposure by gender Table 2 lists adolescent media use and alcohol and tobacco media exposure by gender. Adolescents spent more time using the Internet (17.5 hours a week) and watching TV (12.3 hours a week), while adolescents spent less time reading newspapers (2.0 hours a week) and magazines (1.9 hours a week). By gender, boys spent more time using the Internet (19.2 hours a week) than girls (15.7 hours a week), while girls spent more time watching TV (12.9 hours a week) than boys (11.7 hours a week). Adolescents averaged a few times of weekly exposure to TV alcohol commercials, while adolescents averaged a few times of monthly exposure to alcohol advertisements in magazines, outdoor billboards, and alcohol-drinking portrayals in film/TV. Adolescents’ exposure to online alcohol messages averaged a few times yearly. By gender, males had higher exposure to online discussions of alcohol compared with females. Adolescents averaged a few times of weekly exposure to film/TV smoking portrayals, while
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Table 1. Demographic characteristics and alcohol/tobacco use by gender. N
Father’s education level High school/lower College and higher Mother education level High school/lower College and higher Household poverty No Yes Current alcohol use No Yes Current tobacco use No Yes
Total
Male
Female %
χ2 test
n
%
1788 1071
62.5 37.5
914 580
61.2 38.8
874 491
64.0 36.0
1999 928
68.3 31.7
1027 499
67.3 32.7
972 429
69.4 30.6
1908 1046
64.6 35.4
981 551
64.0 36.0
927 495
65.2 34.8
2705 274
90.8 9.2
1371 175
88.7 11.3
1334 99
93.1 6.9
2772 206
93.1 6.9
1377 169
89.1 10.9
1395 37
97.4 2.6
n
%
n
2.48 1.46 0.43 17.33***
80.45***
***p < 0.001.
Table 2. Media use, media exposure, and intentions to drink/smoke by gender. Total Media use (hours per week) TV Magazine Newspaper Internet Alcohol media exposure TV alcohol advertisements Magazine alcohol advertisements Outdoor alcohol advertisements TV, film portrayals of drinking Online discussion of alcohol Tobacco media exposure TV, film portrayals of smoking Online discussion of tobacco Intention To drink To smoke
Male
Female
t-test
Mean
SD
Mean
SD
Mean
SD
12.30 1.88 2.00 17.51
9.89 2.96 2.59 13.99
11.71 1.76 2.03 19.20
10.36 2.91 2.53 15.08
12.94 2.00 1.96 15.72
9.34 3.01 2.65 12.50
−3.35*** −2.11* 0.83 6.75***
3.60 2.88 2.89 3.32 2.30
0.99 1.07 1.02 1.04 1.04
3.61 2.89 2.92 3.35 2.40
1.00 1.11 1.05 1.05 1.11
3.58 2.87 2.85 3.28 2.18
0.98 1.02 0.98 1.02 0.95
0.84 0.47 1.86 1.92 5.79***
3.56 2.49
1.00 1.09
3.63 2.57
1.01 1.14
3.48 2.40
0.98 1.03
4.10*** 4.42***
1.76 1.18
1.08 0.56
1.74 1.21
1.10 0.60
1.78 1.14
1.05 0.51
−0.86 3.01**
SD: standard deviation. Total N = 2988, male n = 1554, female n = 1434. Intentions to drink: non-current drinker total N = 2703, male n = 1370, female n = 1333. Intentions to smoke: non-current smoker total N = 2769, male n = 1374, female n = 1395. Media exposure score range 1–5: 1 = none; 2 = a few times yearly; 3 = a few times monthly; 4 = a few times weekly; 5 = almost daily. Intentions to drink/smoke score range 1–5: 1 = definitely not (0%); 2 = probably not (25%); 3 = half likely (50%); 4 = probably yes (75%); 5 = definitely yes (100%). *p < 0.05; **p < 0.01; ***p < 0.001.
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Chang et al. Table 3. Alcohol and tobacco media literacy by gender. Subscale (number of items)
Total
Male
Female
Mean
SD
Mean
SD
Mean
SD
Alcohol and tobacco media: authors/audience Authors create media messages for profit/ influence (3) Authors target specific audiences (2) Alcohol and tobacco media: messages/meanings Messages contain values and specific points of view (2) Different people interpret messages differently (2) Messages affect attitude and behaviors (1) Multiple production techniques are used (1) Alcohol and tobacco media: representations/ reality Messages filter reality (4) Messages omit information (2) Critical thinking (1) Total
2.64 2.72
0.52 0.56
2.62 2.70
0.55 0.59
2.66 2.73
0.49 0.53
−1.90 −1.57
2.51 2.83 2.46
0.67 0.43 0.66
2.49 2.81 2.48
0.69 0.46 0.67
2.54 2.86 2.43
0.64 0.40 0.66
−1.67 −3.32*** 1.83
2.99
0.60
2.93
0.64
3.06
0.56
−5.88***
2.96 3.13 2.85
0.66 0.64 0.37
2.91 3.12 2.83
0.69 0.66 0.39
3.02 3.15 2.87
0.63 0.61 0.34
−4.31*** −1.27 −3.42***
2.66 3.20 2.88 2.79
0.39 0.57 0.70 0.36
2.65 3.16 2.88 2.76
0.41 0.59 0.71 0.38
2.68 3.25 2.89 2.81
0.37 0.53 0.69 0.33
−2.26* −4.29*** −0.38 −3.54***
t-test
SD: standard deviation. Media literacy score range 1–4. Higher score indicated higher media literacy. Total N = 2988, male n = 1554, female n = 1434. *p < 0.05; ***p < 0.001.
adolescents’ exposure to online tobacco messages averaged a few times yearly. By gender, males had higher exposure to TV/film smoking portrayals and online discussions of tobacco compared with females.
Alcohol and tobacco media literacy by gender Of the three domains of media literacy, students had the highest score on the representations/ reality domain, followed by the message/meaning domain, and the authors/audience domain (Table 3). For example, adolescents tended to agree that “Alcohol ads omit information” and “Multiple production techniques are used,” while adolescents tended to disagree that “Messages contain values and specific points of view.” By gender, males had lower levels of alcohol drinking and smoking media literacy compared with females.
Media exposure, media literacy, and alcohol and tobacco use Multivariable analysis results indicated that after controlling for gender, students with a higher alcohol media exposure were more likely to use alcohol, while students with a higher level of alcohol drinking and smoking media literacy were less likely to use alcohol. Similarly, students with a higher tobacco media exposure were more likely to smoke (Table 4). For non-drinkers, students with a higher alcohol media exposure were more likely to report having intentions to drink, while students with higher alcohol drinking and smoking media literacy were less likely to have intentions to drink. Similarly, for non-smokers, students with higher tobacco media exposure were more likely to report having intentions to smoke, while students with higher media literacy were less likely to have intentions to smoke (Table 5).
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Table 4. Media exposure, media literacy, and current alcohol and tobacco use. Alcohol use
Tobacco use
β
SE
p
β
SE
p
Intercept Gender (male = 1/female = 0) Media exposure Media literacy
−3.24 0.45 0.11 −0.39
0.47 0.17 0.02 0.16
