Introduction
Youth smoking continues to be a significant concern worldwide. Exposure to smoking in the movies has been linked with smoking initiation among adolescents in several regional longitudinal adolescent samples: three in the US (Dalton et al.
2003; Distefan et al.
2004; Titus-Ernstoff et al.
2008) and one in Germany (Hanewinkel and Sargent
2008); and with current smoking (within the past 30 days) in a Mexican study (Thrasher et al.
2009). The robust association between exposure to movie smoking and behavior has been interpreted as evidence of a causal effect in one recent review, conducted by the National Cancer Institute (
2008). This causal statement has been followed by research demonstrating a decline in movie smoking that coincides with recent declines in adolescent smoking in the United States (Sargent and Heatherton
2009). Thus, research that examines how, why, and for whom these important media effects occur could have implications on youth smoking.
This manuscript focuses on factors that moderate the association between movie smoking and adolescent smoking onset. Exploring moderation factors, particularly those factors that replicate from study-to-study, can enhance our understanding of how media exerts its influence and for whom media influence is important. One moderation factor that has been examined is race/ethnicity. The majority of movie stars and movie smokers are white and upper class (Dalton et al.
2002; Dozier et al.
2005; Hazan and Lipton
1994; Tanski et al.
2009; Worth et al.
2007); exploring moderation by race/ethnicity assesses the extent to which the predominantly White role models in movies may influence youth of other race/ethnicity. The association between movie exposure and smoking has been found to differ by Black versus White race in one longitudinal study such that Black youth were relatively non-responsive to movie exposure as compared to Whites (Jackson et al.
2007). (See also Gibbons et al.
2010 for a similar pattern of results for the effects of media exposure to alcohol use.) A longitudinal study examining the association between movie smoking exposure and smoking for Mexican-American adolescents found a weaker association for Mexican-American youth than that previously found for Whites (Wilkinson et al.
2009), while a different longitudinal study of Mexican adolescents found an association only for 30-day smoking, but not for smoking onset (Thrasher et al.
2009). In aggregate, these studies suggest weaker entertainment media effects among minority adolescents. These racial and ethnic differences raise the question of whether Black and, to a lesser extent, Hispanic adolescents process the predominantly White actor smoking they see in movies differently from White adolescents. By separating movie smoking exposure into White and Black actor smoking, this study begins to explore these issues.
Other studies have reported additional moderation effects for the movie smoking-adolescent smoking relation. For example, there is a stronger movie influence on initiation among children whose parents do not smoke (Dalton et al.
2003; Hanewinkel and Sargent
2008), and a stronger response to movie smoking in progression to established smoking among adolescents lower in sensation seeking (as compared to those high is sensation seeking) (Sargent et al.
2007). Another study has examined moderation of the movie smoking--behavior relation by team sports participation, finding that team sports participants (but not non-participants) responded to movie smoking (Adachi-Mejia et al.
2009). The commonality for each of these moderation effects (parent smoking, sensation seeking, or extracurricular sports involvement) is that the movie smoking/behavior relation is stronger within the groups considered at
lower risk for smoking (low sensation seeking, nonsmoking parents, etc). In previous articles, we have suggested that these interaction patterns argue against an unmeasured risk factor that correlates with movie smoking and adolescent smoking in such a way as to confound the movie smoking effect (Sargent et al.
2007). What has not been addressed, however, is whether these moderation patterns point to a general conclusion or theory about the circumstances under which media exposures exert influence on behavior.
The intent of this report is to evaluate racial differences in the association between media exposures and smoking initiation in a multi-ethnic longitudinal observational study of U.S. adolescents, with specific attention to previously reported moderation effects for race/ethnicity, parent smoking, sensation seeking, and extracurricular activities. We focus on exposure to movie smoking and weekday television viewing as media influences. Additionally, we conduct an analysis for White and Black adolescents to determine whether they respond differently to exposure to White and Black movie character smoking.
Methods
A detailed description of the recruitment methods for study participants has been published previously (Sargent et al.
2005). Briefly, between June and October 2003, a random-digit dialed telephone survey recruited 6,522 US adolescents aged 10–14 years. Compared with the 2000 U.S. Census, the sample was nationally representative by age, sex, household income and region, but had higher percentages of Hispanics and slightly lower percentages of Blacks. Race was determined at the time of enrollment based on parent report. Parents could respond yes/no to multiple race and ethnicity questions. For these analyses, “White” comprises those who responded yes only to White race, and “Black” comprises those who responded yes only to Black race. All respondents reporting Hispanic ethnicity were categorized as Hispanic. All others (e.g., Asian, Native American) and those who identified themselves as multiple races were categorized as “other” race because their numbers were too small to break them out separately. Parental consent and adolescent assent were obtained prior to each phone interview, and all sensitive responses were captured using the telephone keypad to increase confidentiality. The survey cooperation rate was 0.66, and our most conservative estimate of the response rate—one that estimates the number of eligible households among nonresponders, the Council of American Survey Research Organizations (CASRO) response rate—was 32% (6,522 interviewed adolescents / an estimated 20,436 eligible households). All aspects of the survey were approved by the institutional review boards at Dartmouth Medical School and the survey research firm Westat (Rockville, MD). Given the study aim to examine the effect of movie smoking exposure on smoking uptake by White, Black and Hispanic adolescents, these analyses exclude 559 “multi-racial” or “other” adolescents. Analyses were conducted in 2009.
Discussion
The moderation analyses conducted on this are consistent with previous analyses, showing that the smoking behavior of Black (Jackson et al.
2007), and to a lesser extent, Hispanic (Wilkinson et al.
2009) adolescents is resistant to the influence of movie smoking as compared to Whites. These analyses also replicated expected moderation effects regarding parent smoking but not sensation seeking. However, when transition to established smoking was examined within this sample in a previous manuscript, a moderation effect
was found for sensation seeking, with larger effects for low sensation seeking adolescents (Sargent et al.
2007).
This study extends previous studies in its examination of media effects by race and ethnicity by elucidating different media response patterns for White, Black and Hispanic adolescents in the context of whether parents smoke. White adolescents were responsive to movie smoking regardless of parental smoking status, albeit with significantly weaker responses when parents smoked. In contrast, Black adolescents had the highest exposure to movies and television but were relatively unresponsive to movie smoking, regardless of parent smoking status. Hispanic adolescents were somewhere in between, a modest reponse to movies that did not reach statistical significance and a somewhat stronger response to increased amounts of television, only when their parents did not smoke.
While Black youth appear resistant to movies’ influence when measured in aggregate, the disaggregation of movie exposure by White and Black actors demonstrates an association between exposure to same-race actor smoking and adolescent smoking. The findings raise the possibility that racial and ethnic minorities are more responsive to seeing actors smoke when the actors are matched to their own race/ethnicity. It should also be noted that White adolescents responded to both White and Black character smoking, so the results should not be taken to suggest that there are no effects across racial and ethnic categories. An effect of Black actor smoking on White adolescents seems plausible, as Black culture often sets national trends, with Black role models impacting mainstream White culture. This is readily seen in the music industry: Hip-Hop music spawned a culture that went beyond music to influence dance and clothing, and continues to be popular with some groups of White male adolescents. The finding for Hispanics and television should prompt closer scrutiny of exposure to smoking on Spanish language television, where Hispanic adolescents could be exposed to character smoking of their own ethnicity with higher frequency than would be possible in movies.
The moderation of media effects on parent smoking (Dalton et al.
2003; Hanewinkel and Sargent
2008), sensation seeking (Sargent et al.
2007; Stoolmiller et al.
2010), and extracurricular participation (Adachi-Mejia et al.
2009) supports previous suggestions that media effects are most apparent for adolescents generally considered at lower risk. This seems logical when one considers a population of youth as a “spectrum” of risk: One would not expect exposure to entertainment media to substantively alter risk for smoking of a high sensation-seeking adolescent whose parents and friends smoke—it is already quite high. At the other end of the risk spectrum, large doses of movie smoking are unlikely to prompt a highly motivated honors scholar-athlete whose parents and friends do not smoke to contemplate smoking. Instead, media exposure is more likely to affect those in the middle of the risk spectrum: adolescents who are relatively ambivalent about smoking; i.e., those who are not intending to smoke, but may be willing to under some circumstances (Gerrard et al.
2005). This is analogous to media effects on voters’ decisions. Political campaigns direct their media messages to the “swing voter” (Mayer
2008)—the roughly 30% of the electorate that could vote either way because they see value in both candidates—because swing voters are more likely to change their vote in response to a media campaign than those at the extreme ends of the political spectrum. This concept may have implications for how we target adolescents for anti-smoking media campaigns. If studies confirm media effects are more pronounced for ambivalent (swing) adolescent non-smokers, these youth may be an appropriate target for anti-smoking advertising messages, rather than, for example, high sensation seeking youth who are already at high risk of smoking (Palmgreen et al.
2001; Sargent et al.
2010; Stephenson et al.
2002).
Development of a low-risk profile for smoking due to high resistance to smoking and hence, as we posit, a low susceptibility to media influence, is likely to be a multidimensional phenomenon and warrants further investigation. The influences and processes that produce ambivalent and pro-smoking teens may be determined by distinctly different phenomena than the development of low-risk teens. We suggest that although a single, powerful risk factor (parent smoking or high sensation seeking) may be sufficient to attenuate the effect of media, the absence of that factor does not necessarily make all adolescents invulnerable. Instead, we suggest that certain factors may moderate risk for some groups of non-smokers and not for others; e.g., having low sensation seeking may serve as a buffer against movie exposure for adolescents who are generally resistant to smoking but not for the “swing” adolescents, those who are ambivalent about smoking or willing (but not intending) to smoke. Consistent with previous research on willingness to use substances (Gibbons et al.
2003), exposure to smoking in the media may have relatively little short-term impact on adolescents who are unwilling to consider smoking or those who intend to try smoking, but significant impact on adolescents who indicate a willingness to try smoking under some circumstances. Further research is needed to confirm if this group of willing non-smokers behaves like the swing voter--susceptible to media messages--and can be targeted based on their willingness to smoke.
This study is strengthened by the use of a nationally representative sample, enhancing the external validity of the results, and the large sample size, which improves power to detect interactions by race/ethnicity. As with any study, there are several limitations that affect interpretation of the results. As with other longitudinal studies, this sample had higher rates of attrition among minorities and subjects at higher risk for adverse risk behaviors. Higher attrition in these groups could thus bias comparisons. However, within this sample the Black and Hispanic youth actually had slightly higher rates of smoking initiation over time, suggesting there was no bias against retention of minority adolescents that were at risk for trying smoking or the multiple imputation procedure eliminated potential attrition bias. The measure for television viewing was crude compared to the assessment of exposure to movies, so caution is warranted in interpreting the effect of television viewing on Hispanic youth. Self-reports of adolescent smoking are subject to recall and social desirability bias; however, several previous studies have found that adolescents accurately report smoking status when assured confidentiality (Murray et al.
1987; Murray and Perry
1987; Wills and Cleary
1997). Finally, although there were controls for many factors related to youth smoking, there may be an unmeasured confounding factor that accounts for some of the reported media effects.
In conclusion, using a multi-ethnic sample, this study replicates moderation effects for movie smoking on smoking initiation, provides an explanation for attenuated response among Black and Hispanic adolescents, and suggests a reason for negative moderation effects on several important smoking risk factors. Future studies should explore the hypothesis that media effects are more influential among adolescents in the middle of the risk spectrum, defining these youth through attitudinal mediators such as willingness to smoke, or through use of a multi-dimensional risk score for smoking propensity.