The association of media exposure and media literacy with adolescent alcohol and tobacco use

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; 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; Nunez-Smith 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 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.

Methods

Participants and procedure

In 2010, a total of 72,327 10th-grade high-school 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 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

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 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-one-get-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.

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). Two-thirds 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).

Table 1.

Demographic characteristics and alcohol/tobacco use by gender.

N	Total		Male		Female		χ² test
	n	%	n	%	n	%	χ² test
Father’s education level							2.48
High school/lower	1788	62.5	914	61.2	874	64.0
College and higher	1071	37.5	580	38.8	491	36.0
Mother education level							1.46
High school/lower	1999	68.3	1027	67.3	972	69.4
College and higher	928	31.7	499	32.7	429	30.6
Household poverty							0.43
No	1908	64.6	981	64.0	927	65.2
Yes	1046	35.4	551	36.0	495	34.8
Current alcohol use							17.33***
No	2705	90.8	1371	88.7	1334	93.1
Yes	274	9.2	175	11.3	99	6.9
Current tobacco use							80.45***
No	2772	93.1	1377	89.1	1395	97.4
Yes	206	6.9	169	10.9	37	2.6

***

p < 0.001.

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).

Table 2.

Media use, media exposure, and intentions to drink/smoke by gender.

	Total		Male		Female		t-test
	Mean	SD	Mean	SD	Mean	SD	t-test
Media use (hours per week)
TV	12.30	9.89	11.71	10.36	12.94	9.34	−3.35***
Magazine	1.88	2.96	1.76	2.91	2.00	3.01	−2.11*
Newspaper	2.00	2.59	2.03	2.53	1.96	2.65	0.83
Internet	17.51	13.99	19.20	15.08	15.72	12.50	6.75***
Alcohol media exposure
TV alcohol advertisements	3.60	0.99	3.61	1.00	3.58	0.98	0.84
Magazine alcohol advertisements	2.88	1.07	2.89	1.11	2.87	1.02	0.47
Outdoor alcohol advertisements	2.89	1.02	2.92	1.05	2.85	0.98	1.86
TV, film portrayals of drinking	3.32	1.04	3.35	1.05	3.28	1.02	1.92
Online discussion of alcohol	2.30	1.04	2.40	1.11	2.18	0.95	5.79***
Tobacco media exposure
TV, film portrayals of smoking	3.56	1.00	3.63	1.01	3.48	0.98	4.10***
Online discussion of tobacco	2.49	1.09	2.57	1.14	2.40	1.03	4.42***
Intention
To drink	1.76	1.08	1.74	1.10	1.78	1.05	−0.86
To smoke	1.18	0.56	1.21	0.60	1.14	0.51	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.

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 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.

Table 3.

Alcohol and tobacco media literacy by gender.

Subscale (number of items)	Total		Male		Female		t-test
	Mean	SD	Mean	SD	Mean	SD	t-test
Alcohol and tobacco media: authors/audience	2.64	0.52	2.62	0.55	2.66	0.49	−1.90
Authors create media messages for profit/influence (3)	2.72	0.56	2.70	0.59	2.73	0.53	−1.57
Authors target specific audiences (2)	2.51	0.67	2.49	0.69	2.54	0.64	−1.67
Alcohol and tobacco media: messages/meanings	2.83	0.43	2.81	0.46	2.86	0.40	−3.32***
Messages contain values and specific points of view (2)	2.46	0.66	2.48	0.67	2.43	0.66	1.83
Different people interpret messages differently (2)	2.99	0.60	2.93	0.64	3.06	0.56	−5.88***
Messages affect attitude and behaviors (1)	2.96	0.66	2.91	0.69	3.02	0.63	−4.31***
Multiple production techniques are used (1)	3.13	0.64	3.12	0.66	3.15	0.61	−1.27
Alcohol and tobacco media: representations/reality	2.85	0.37	2.83	0.39	2.87	0.34	−3.42***
Messages filter reality (4)	2.66	0.39	2.65	0.41	2.68	0.37	−2.26*
Messages omit information (2)	3.20	0.57	3.16	0.59	3.25	0.53	−4.29***
Critical thinking (1)	2.88	0.70	2.88	0.71	2.89	0.69	−0.38
Total	2.79	0.36	2.76	0.38	2.81	0.33	−3.54***

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.

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).

Table 4.

Media exposure, media literacy, and current alcohol and tobacco use.

	Alcohol use			Tobacco use
	β	SE	p	β	SE	p
Intercept	−3.24	0.47	<0.001	−3.62	0.70	<0.001
Gender (male = 1/female = 0)	0.45	0.17	0.009	1.33	0.21	<0.001
Media exposure	0.11	0.02	<0.001	0.14	0.04	0.002
Media literacy	−0.39	0.16	0.013	−0.29	0.18	0.113

SE: standard error.

Using GENMOD programs with REPEATED statement, distribution: binominal, link: logit.

Cluster n = 26 schools.

Observation n = 2870 (alcohol use model), 2875 (tobacco use model).

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).

Table 5.

Media exposure, media literacy, and intentions to drink and smoke.

	Intentions to drink			Intentions to smoke
	β	SE	p	β	SE	p
Intercept	1.63	0.23	<0.001	1.23	0.13	<0.001
Gender (male = 1/female = 0)	−0.03	0.04	0.420	0.06	0.03	0.046
Media exposure	0.04	0.01	<0.001	0.04	0.01	<0.001
Media literacy	−0.15	0.06	0.031	−0.11	0.04	0.009

SE: standard error.

Using GENMOD programs with REPEATED statement, distribution: normal, link: identity.

Cluster n = 26 schools.

Observation n = 2603 (intentions to drink model), 2676 (intentions to smoke model).

Discussion

The study results were consistent with those of previous studies (Anderson et al., 2009; Collins et al., 2007; Morgenstern et al., 2011; Pasch et al., 2007; Smith and Foxcroft, 2009) indicating that exposure to alcohol advertising, marketing, and portrayals was associated with alcohol drinking and intentions to drink. In addition, in this study, adolescents averaged a few times weekly exposures to alcohol advertisements on TV and a few times monthly exposures to alcohol advertisements in magazines, on outdoor billboards, and through film/TV alcohol portrayals. Although alcohol advertisements are banned on TV before 9 p.m. in Taiwan, adolescents remain exposed to many alcohol commercial advertisements and alcohol-drinking messages through TV, magazines, outdoor billboards, and Internet venues. To protect children and adolescents from alcohol media influence, the Taiwan Government should restrict alcohol advertisements on TV, in magazines, on outdoor billboards, and in a variety of marketing practices. Some countries have considered more restricted alcohol advertisement bans to prevent underage and harmful drinking (Chung et al., 2010).

In addition, this study also showed that exposure to TV/film smoking portrayals is associated with current adolescent smoking and intentions to smoke. Previous studies (Charlesworth and Glantz, 2005; Hunt et al., 2011; Thrasher et al., 2009; Titus-Ernstoff et al., 2008; Waylen et al., 2011; Wills et al., 2008) also found that exposure to smoking depictions in films and movies had a dose–response relationship and was more likely to initiate smoking. The Taiwan Government has totally banned tobacco advertisements and promotion since 2009 (Bureau of Health Promotion, 2011b). However, results from this study show that adolescents remain exposed to smoking depictions in TV/film a few times weekly. Studies suggest that eliminating smoking depictions in movies may prevent smoking in a substantial number of adolescents (Heatherton and Sargent, 2009). Experts have advocated that rating movies containing smoking as “R” should reduce adolescent exposure to smoking and subsequent smoking (Charlesworth and Glantz, 2005). The Thailand Government, in line with the policies of the WHO and many other governments worldwide, has banned smoking depictions on TV, while some TV series and cartoons in Taiwan continue to show smoking depictions. The Taiwan Government should consider banning smoking depictions on TV to help prevent child and adolescent smoking.

Moreover, this study found that males had a higher exposure to TV/film portrayals of smoking and online discussions of alcohol and tobacco compared with females and a higher prevalence of alcohol and tobacco use than females. We found that the Internet was the most heavily used media among adolescents (18 hours per week). Studies (Frangos and Sotiropoulos, 2011; Ko et al., 2008) indicated that problem Internet use was associated with adolescent smoking, drinking, and drug use. Future studies are needed to examine the relationship between Internet use and adolescent substance use. The Taiwan Government, like any other government interested in protecting adolescent health, should monitor and regulate alcohol and tobacco messages to reduce adolescent alcohol and tobacco online exposure. In addition, a study found that campaign advertisements lowered the willingness to engage in alcohol-related risky behaviors (Comello and Slater, 2011). Government should continuously implement campaigns to prevent alcohol and tobacco use by youth.

Prior studies (Primack et al., 2006a; Primack and Hobbs, 2009) indicated that higher media literacy was independently associated with lower current alcohol and tobacco use and a lower frequency of intentions to drink and smoke. Our results showed that even after controlling for adolescent gender and media exposure, higher alcohol drinking and smoking media literacy were significantly negatively associated with current alcohol and tobacco use and intentions to drink and smoke. These results support the recommendations of experts (Bergsma and Carney, 2008; Office of National Drug Control Policy, 2001) on the implementation of media literacy education programs to reduce substance use by adolescents. Media literacy interventions can strengthen child and adolescent logical responses to media messages to interrupt the progression from negative to positive substance use expectancies and to enhance critical thinking skills to diminish the relationship between media exposure and subsequent substance use (Kupersmidt et al., 2010).

Furthermore, this and other studies (Levin-Zamir et al., 2011) found that males had lower media literacy compared with females. In addition, males had a higher prevalence of intentions to smoke. These results suggest that the development and implementation of gender-specific media literacy programs should help students to decode media messages and industry techniques aimed at specific target audiences. In addition, since the content and techniques of alcohol and tobacco media messages are different at different time periods and in different countries, the development of culture-sensitivity and timely media literacy programs is needed to help strengthen media literacy capability for children and adolescents in different cohorts and in different countries.

Limitations

This research has some limitations. First, a social desirability bias may influence the truthfulness of adolescents’ reports of substance use. However, anonymity was emphasized, and trained investigators collected the questionnaires immediately. Second, approximately one-fifth of parents and students refused to participate in this study; hence, potential biases from selection and refusal to participate must be considered. Third, since the policies of banning alcohol and tobacco advertisements differ across countries, the measurements of alcohol drinking/smoking media literacy in this study differed from those in other studies. Caution should be exercised when comparing media literacy across studies and countries. Fourth, this study examined the relationship between overall alcohol and tobacco media literacy and alcohol/tobacco use. Future study could develop alcohol-specific and tobacco-specific media literacy and could examine the relationships with alcohol and tobacco use, respectively. Fifth, self-reporting of media exposure can be biased. Sixth, this study controlled only for gender, while other studies (Heatherton and Sargent, 2009; Sargent et al., 2006) also controlled for factors such as sensation seeking, rebelliousness, and parenting styles. Finally, this study is cross-sectional; thus, it precludes causal inferences. Future longitudinal research is needed to assess the long-term impact of media exposure and media literacy on adolescent substance initiation and progression. In addition, whether media literacy has more of an influence when a person has higher media exposure could be examined. Despite these limitations, this study adds to the limited amount of literature that found alcohol and tobacco media exposure and media literacy were associated with adolescent alcohol use and intentions to use alcohol and tobacco.

Conclusion

In conclusion, the results showed that 10th-grade students on average reported that they viewed TV alcohol commercials and smoking portrayals in TV and films a few times per week. Male students had a higher prevalence of alcohol (11.3%) and tobacco use (10.9%) compared with female students (alcohol use: 6.9%; tobacco use: 2.6%). Multivariable analysis results indicated that 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 levels of alcohol and tobacco media literacy were less likely to use alcohol and have intentions to drink and smoke. In conclusion, media exposure was a risk factor for adolescent alcohol and tobacco use, while media literacy was a protective factor in preventing adolescent alcohol and tobacco use.

Footnotes

Acknowledgements

We acknowledge the editor and two anonymous reviewers for their helpful comments and suggestions. Many thanks go to the participant schools and students.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a research grant from the Taiwan National Science Council (NSC 99-2511-S-003-029-MY2).

References

Adam

Faouzi

Gaume

. (2011) Age of first alcohol intoxication: Association with risky drinking and other substance use at the age of 20. Swiss Medical Weekly 141: w13226.

Anderson

de Bruijn

Angus

. (2009) Impact of alcohol advertising and media exposure on adolescent alcohol use: A systematic review of longitudinal studies. Alcohol and Alcoholism 44(3): 229–243.

Aufderheide

(1992) Aspen media literacy conference report: Part II: Proceedings and next steps. Available at: http://www.medialit.org/reading-room/aspen-media-literacy-conference-report-part-ii

Austin

Johnson

(1997) Effects of general and alcohol-specific media literacy training on children’s decision making about alcohol. Journal of Health Communication 2(1): 17–42.

Austin

Chen

Grube

(2006) How does alcohol advertising influence underage drinking? The role of desirability, identification and skepticism. Journal of Adolescent Health 38(4): 376–384.

Bandura

(2001) Social cognitive theory of mass communication. Media Psychology 3(3): 265–299.

Bergsma

Carney

(2008) Effectiveness of health-promoting media literacy education: A systematic review. Health Education Research 23(3): 522–542.

Bureau of Health Promotion (2011a) 2007 Youth Risk Behavior Survey. Taipei, Taiwan: Bureau of Health Promotion.

Bureau of Health Promotion (2011b) Taiwan Tobacco Control Annual Report 2011. Taipei, Taiwan: Bureau of Health Promotion.

10.

Centre for Social and Health Outcomes Research and Evaluation (2006) Alcohol marketing in the Western Pacific Region. Palmerston North, New Zealand: Massey University.

11.

Charlesworth

Glantz

(2005) Smoking in the movies increases adolescent smoking: A review. Pediatrics 116(6): 1516–1528.

12.

Choi

Forster

Erickson

. (2012) The reciprocal relationships between changes in adolescent perceived prevalence of smoking in movies and progression of smoking status. Tobacco Control 21(5): 492–496.

13.

Chung

Garfield

Elliott

. (2010) Association between adolescent viewership and alcohol advertising on cable television. American Journal of Public Health 100(3): 555–562.

14.

Collins

Ellickson

McCaffrey

. (2007) Early adolescent exposure to alcohol advertising and its relationship to underage drinking. Journal of Adolescent Health 40(6): 527–534.

15.

Comello

Slater

(2011) Effects of adverts from a drug and alcohol prevention campaign on willingness to engage in alcohol-related risky behaviors. Journal of Health Psychology 16(8): 1268–1276.

16.

Connor

Gray

Kypri

(2010) Drinking history, current drinking and problematic sexual experiences among university students. Australian and New Zealand Journal of Public Health 34(5): 487–494.

17.

Cox

Zhang

Johnson

. (2007) Academic performance and substance use: Findings from a state survey of public high school students. Journal of School Health 77(3): 109–115.

18.

Ellickson

Tucker

Klein

(2003) Ten-year prospective study of public health problems associated with early drinking. Pediatrics 111(5): 949–955.

19.

Frangos

Sotiropoulos

(2011) Problematic Internet use among Greek university students: An ordinal logistic regression with risk factors of negative psychological beliefs, pornographic sites, and online games. Cyberpsychology, Behavior and Social Networking 14(1–2): 51–58.

20.

Heatherton

Sargent

(2009) Does watching smoking in movies promote teenage smoking? Current Directions in Psychological Science 18(2): 63–67.

21.

Henry

McDonald

Oetting

. (2011) Age of onset of first alcohol intoxication and subsequent alcohol use among urban American Indian adolescents. Psychology of Addictive Behaviors 25(1): 48–56.

22.

Hobbs

(2011) Empowering learners with digital and media literacy. Knowledge Quest 39(5): 12–17.

23.

Hunt

Henderson

Wight

. (2011) Exposure to smoking in films and own smoking among Scottish adolescents: A cross-sectional study. Thorax 66(10): 866–874.

24.

Hurtz

Henriksen

Wang

. (2007) The relationship between exposure to alcohol advertising in stores, owning alcohol promotional items, and adolescent alcohol use. Alcohol and Alcoholism 42(2): 143–149.

25.

Kamal

Islam

Raihan

(2011) Differentials of tobacco consumption and its effect on illicit drug use in rural men in Bangladesh. Asia-Pacific Journal of Public Health 23(3): 349–362.

26.

Kim

(2010) Early initiation of alcohol drinking, cigarette smoking, and sexual intercourse linked to suicidal ideation and attempts: Findings from the 2006 Korean Youth Risk Behavior Survey. Yonsei Medical Journal 51(1): 18–26.

27.

Yen

. (2008) The association between Internet addiction and problematic alcohol use in adolescents: The problem behavior model. CyberPsychology & Behavior 11(5): 571–576.

28.

Kuntsche

Stewart

(2009) Why my classmates drink: Drinking motives of classroom peers as predictors of individual drinking motives and alcohol use in adolescence: A mediational model. Journal of Health Psychology 14(4): 536–546.

29.

Kupersmidt

Scull

Austin

(2010) Media literacy education for elementary school substance use prevention: Study of media detective. Pediatrics 126(3): 525–531.

30.

Levin-Zamir

Lemish

Gofin

(2011) Media Health Literacy (MHL): Development and measurement of the concept among adolescents. Health Education Research 26(2): 323–335.

31.

Lovato

Watts

Stead

(2011) Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours. Cochrane Database of Systematic Reviews 10: CD003439.

32.

Morgenstern

Isensee

Sargent

. (2011) Exposure to alcohol advertising and teen drinking. Preventive Medicine 52(2): 146–151.

33.

National Association for Media Literacy Education (2011) Core principles of media literacy education in the United States. Available at: http://namle.net/wp-content/uploads/2009/09/NAMLE-CPMLE-w-questions2.pdf

34.

Nunez-Smith

Wolf

Huang

. (2010) Media exposure and tobacco, illicit drugs, and alcohol use among children and adolescents: A systematic review. Substance Abuse 31(3): 174–192.

35.

O’Brien

McNamara

McCoy

. (2013) Alcohol-related injury among Greek-letter college students: Defining a target population for secondary prevention. Journal of Health Psychology 18(4): 461–469.

36.

Office of National Drug Control Policy (2001) Helping youth navigate the media age: A new approach to drug prevention. Available at: http://www.medialiteracy.net/pdfs/media_age.pdf

37.

Pasch

Komro

Perry

. (2007) Outdoor alcohol advertising near schools: What does it advertise and how is it related to intentions and use of alcohol among young adolescents? Journal of Studies on Alcohol and Drugs 68(4): 587–596.

38.

Patra

Rehm

Popova

(2011) Avoidable alcohol-attributable criminality and its costs due to selected interventions in Canada. International Journal of Drug Policy 22(2): 109–119.

39.

Paynter

Edwards

(2009) The impact of tobacco promotion at the point of sale: A systematic review. Nicotine & Tobacco Research 11(1): 25–35.

40.

Pierce

Choi

Gilpin

. (1996) Validation of susceptibility as a predictor of which adolescents take up smoking in the United States. Health Psychology 15(5): 355–361.

41.

Primack

Hobbs

(2009) Association of various components of media literacy and adolescent smoking. American Journal Health Behavior 33(2): 192–201.

42.

Primack

Gold

Land

. (2006a) Association of cigarette smoking and media literacy about smoking among adolescents. Journal of Adolescent Health 39(4): 465–472.

43.

Primack

Gold

Switzer

. (2006b) Development and validation of a smoking media literacy scale for adolescents. Archives of Pediatrics & Adolescent Medicine 160(4): 369–374.

44.

Primack

Sidani

Carroll

. (2009) Associations between smoking and media literacy in college students. Journal of Health Communication 14(6): 541–555.

45.

Rehm

Mathers

Popova

. (2009) Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. The Lancet 373(9682): 2223–2233.

46.

Riggs

Chou

. (2007) Adolescent to emerging adulthood smoking trajectories: When do smoking trajectories diverge, and do they predict early adulthood nicotine dependence? Nicotine & Tobacco Research 9(11): 1147–1154.

47.

Rodesiler

(2010) Empowering students through critical media literacy: This means war. The Clearing House: A Journal of Educational Strategies, Issues and Ideas 83(5): 164–167.

48.

Sargent

Wills

Stoolmiller

. (2006) Alcohol use in motion pictures and its relation with early-onset teen drinking. Journal of Studies on Alcohol 67(1): 54–65.

49.

SAS Institute (2011) SAS Software (version 9.3). Cary, NC: SAS Institute.

50.

Shafey

Eriksen

Ross

. (2009) The Tobacco Atlas (3rd edn). Atlanta, GA: American Cancer Society.

51.

Smith

Foxcroft

(2009) The effect of alcohol advertising, marketing and portrayal on drinking behaviour in young people: Systematic review of prospective cohort studies. BMC Public Health 9: 51.

52.

Snyder

Milici

Slater

. (2006) Effects of alcohol advertising exposure on drinking among youth. Archives of Pediatrics & Adolescent Medicine 160(1): 18–24.

53.

Sommers

Fargo

Lyons

. (2011) Societal costs of risky driving: An economic analysis of high-risk patients visiting an urban emergency department. Traffic Injury Prevention 12(2): 149–158.

54.

Stueve

O’Donnell

(2005) Early alcohol initiation and subsequent sexual and alcohol risk behaviors among urban youths. American Journal of Public Health 95(5): 887–893.

55.

Thrasher

Sargent

Huang

. (2009) Does film smoking promote youth smoking in middle-income countries? A longitudinal study among Mexican adolescents. Cancer Epidemiology, Biomarkers & Prevention 18(12): 3444–3450.

56.

Titus-Ernstoff

Dalton

Adachi-Mejia

. (2008) Longitudinal study of viewing smoking in movies and initiation of smoking by children. Pediatrics 121(1): 15–21.

57.

Waylen

Leary

Ness

. (2011) Cross-sectional association between smoking depictions in films and adolescent tobacco use nested in a British cohort study. Thorax 66(10): 856–861.

58.

Wills

Sargent

Stoolmiller

. (2008) Movie smoking exposure and smoking onset: A longitudinal study of mediation processes in a representative sample of U.S. adolescents. Psychology of Addictive Behaviors 22(2): 269–277.

59.

World Health Organization (WHO) (2003) WHO Framework Convention on Tobacco Control. Geneva: WHO.

60.

World Health Organization (WHO) (2011) WHO Report on Global Tobacco Epidemic, 2011. Geneva: WHO.

61.

Yang

Salmon

Pang

. (2013) Media exposure and smoking intention in adolescents: A moderated mediation analysis from a cultivation perspective. Journal of Health Psychology. Epub ahead of print 20 September. DOI: 10.1177/1359105313501533.

62.

Nebbitt

Lombe

. (2012) Understanding tobacco use among urban African American adolescents living in public housing communities: A test of problem behavior theory. Addictive Behaviors 37(8): 978–981.