IJE Advance Access published online on June 22, 2007
International Journal of Epidemiology, doi:10.1093/ije/dym128
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Exposure to alcohol use in motion pictures and teen drinking in Germany
1Institute for Therapy and Health Research, Düsternbrooker Weg 2, 24105 Kiel, Germany.
2Dartmouth Medical School, Cancer Control Research Program, Norris Cotton Cancer Center, Lebanon, NH 03756, USA.
*Corresponding author. Institute for Therapy and Health Research, IFT-Nord, Düsternbrooker Weg 2, 24105 Kiel, Germany. E-mail: hanewinkel{at}ift-nord.de
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Abstract |
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Background To assess whether movie alcohol exposure is associated with alcohol use during early adolescence.
Methods We conducted a survey of adolescents (N = 5581) from 27 schools in Germany. Each was asked if he/she had seen a list of 50 movie titles, randomly selected from a sample of 398 US box office hits released there. Screen alcohol use was timed for each movie, summed for movies each adolescent had seen, and adjusted to reflect exposure to all 398 movies. We assessed the association between this exposure and any alcohol use without parental knowledge (WPK) and binge drinking (> = 5 drinks).
Results Alcohol use was depicted in 88% of the 398 movies. Median exposure to movie alcohol use was 3.44 h (interquartile range = 1.51–6.23 h). Overall 36.6% of subjects used alcohol WPK and 18.1% reported binge drinking. Movie alcohol exposure was directly associated with alcohol use WPK and binge drinking, after controlling for multiple covariates including sociodemographics, personality characteristics and social influences. Compared with quartile one, the adjusted odds of alcohol use WPK were 1.47 [95% confidence interval (CI) 1.19–1.82], 2.12 (1.75–2.57) and 2.95 (2.35–3.70) for quartiles 2, 3 and 4, respectively; similarly, adjusted odds of binge drinking were 1.42 (0.93–2.28), 1.84 (1.27–2.67) and 2.59 (1.70–3.95).
Conclusion This study demonstrates an association between exposure to alcohol use in US movies and alcohol use without parental knowledge in Germany, and is the first study to link movie exposure with binge drinking. Given international distribution of US movies, depicted behaviours may influence adolescents outside the country of origin.
Accepted 21 May 2007
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Introduction |
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Alcohol use is a major contributor to morbidity and mortality worldwide,1 causing 1.8 million deaths each year. Initiation of alcohol use during early adolescence is an important predictor of alcohol-related motor vehicle crashes,2 involvement in physical fights,3 unintentional injuries4 and alcohol dependence/abuse at later ages.5 Early use of alcohol and binge drinking are common among European adolescents,6 where alcohol consumption is responsible for some 55 000 deaths among young people aged 15–29 years.7,8
In assessing predictors of early alcohol use, researchers have emphasized the impact of alcohol advertising,9–17 direct social influences including drinking by peers and parents,18,19 and vicarious social influences such as those seen in mass media.20–22 Examining the positive association between alcohol advertising and adolescent alcohol use, one study has found very young children to be attitudinally responsive to alcohol advertising many years before they begin to drink.23 A similar effect may occur when favourable images of alcohol use delivered to young audiences through entertainment programming. These forms of media are readily accessed by young people in Europe, but there has been little research to date on their impact on youth. Research with Belgian youth indicates that television viewing habits and music video exposure are linked with teen alcohol consumption.20,21 Another study found a relationship between exposure to American television programming and intentions to drink among adolescents in Norway, notably a country without televised alcohol advertising.22
With regard to movies, alcohol use is often depicted,24 even in movies intended for young children.25 Recently, Roberts et al.26 examined alcohol use in the top 200 video rental movies in the US for 1996–97, showing that alcohol appeared in 93%, and that the majority (65%) of adult characters used alcohol. However, it was also noted that adverse consequences of alcohol use were shown in 43% of movies, raising the possibility that viewers receive enough information about adverse consequences to blunt any positive social influence effect. One recent study assessed the relationship between exposure to alcohol use in US movies and onset of drinking alcohol in US adolescents.27 The study demonstrated a strong and statistically significant relationship between viewing alcohol use in movies and drinking, even after controlling for a number of potential covariates. Further, a curvilinear dose–response curve was noted, with the impact of movie alcohol exposure being larger among lower-exposed adolescents. The relationship held for both cross-sectional and longitudinal analyses. Similar studies have not been replicated, to our knowledge, outside the US.
Given the popularity of US films in Germany, with many US movies in wide release in theatres as well as available on DVD and video, this study focuses on depictions of alcohol use in US movies as a risk factor for early alcohol use among German youth. We report the results of a study that assessed exposure among German adolescents to alcohol depictions in US movies that were released and became popular in Germany. We determined the association between exposure to movie alcohol use and alcohol use without parental knowledge (WPK) as well as binge drinking.
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Methods |
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Selection of the study sample
Letters inviting participation were sent to 42 randomly selected secondary schools in Schleswig-Holstein, a Bundesland (State) of Germany (Figure 1). Twenty seven (64%) schools agreed to participate. Schleswig-Holstein has four types of schools in the system, with the type of school strongly associated with socioeconomic status (SES) of the student.28 The ‘Hauptschule’ recruits pupils from low SES, the ‘Realschule’ recruits students with mid SES, the ‘Gymnasium’ pupils with mid to high SES background, and the ‘Gesamtschule’ is a mixed form. The recruited schools, stratified by type of school, reflected the distribution of schools within Schleswig-Holstein as a whole. In October/November 2005, trained research staff administered the confidential survey during class time to the 5–9th grade students in these schools. Parental written permission and student assent were obtained prior to participation in the survey. The study was approved by the Ministry of Cultural Affairs of the Bundesland Schleswig-Holstein. In total, 85% of students attending the schools were surveyed; 836 (12.7%) were disqualified because parents did not give written permission for student participation, and 145 (2.5%) students were absent the day of the survey. Finally, 45 surveys (0.8%) were excluded for inconsistent or missing responses to the alcohol questions.
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Exposure measurement
To estimate exposure to movie alcohol use, we used methods that have been previously validated for measuring exposure to movie smoking.29 Movies chosen for this study included all internationally distributed movies from the top 25 German box-office hits every year from 1994 to 2001 (n = 172) and from the top 100 German box office hits per year from 2002 to 2004 (n = 226). Internationally distributed movies dominate the German market; this sample represents 80% of the German box office hits in these years. Of the parent sample of 398 movies, 388 (97%) were produced and/or distributed internationally by American companies (Hollywood studios), comprising the majority of box office hits in the German film market.
Each movie was content coded for alcohol use by two trained movie content coding technicians with 12 years combined experience with the Dartmouth Media Research Laboratory, allowing for a high level of consistency, reliability and quality control. ‘Alcohol use’ was defined as real or implied use of an alcoholic beverage by any character in the film, including purchasing alcohol, or occasions where alcoholic is clearly in the possession of a character (e.g. characters sitting at dinner with filled wine glasses), but actual alcohol use was not shown. Empty alcoholic beverage containers (bottles, glasses, etc.) and alcohol containers that were displayed but were not implied as being consumed by a character (e.g. in stores, drinking establishments) were not counted as alcohol use. All alcohol use and implied use was timed in seconds from the moment the alcohol appeared on screen. A randomly selected subset of 10% of movies was double-coded to allow for assessment of inter-rater reliability. Concordance between coders was based on agreement of on-screen alcohol use at 1 s intervals, with mean kappa 0.86 (SD = 0.17) indicating good coding reliability.
Adolescents’ exposure to these movies was assessed by asking whether the respondent had ever seen 50 film titles; this sub-sample was randomly selected from the parent sample of 398 movies. The random selection was stratified by Motion Picture Association of America rating to reflect the distribution of the parent pool: 32% R, 44% PG-13, 16% PG and 7% G. Thus, each adolescent questionnaire contained a unique sub-sample of movie titles. Based on the movies the adolescent had seen, and the amount of drinking in each one, we determined hours of movie alcohol exposure from the sub-sample. We divided minutes of alcohol use seen by the respondent by the total minutes of movie alcohol use the adolescent would have been exposed to had he/she seen all 50 movies (the denominator for each subject was different because each responded to a unique set of movies). That proportion was then multiplied by 18.02 (the total hours of alcohol exposure in the 398 movies) to produce an estimate of exposure to alcohol use in the parent sample. Exposure to movie alcohol use was then classified into quartiles using median and interquartile range as cutoffs.
Outcome measurement
Parent-sanctioned alcohol use is common in German households; we were interested in the initiation of alcohol use outside the family context and alcohol abuse. Initiation of adolescent alcohol use was therefore determined through the question: ‘Have you ever drunk alcohol that your parents didn't know about?’ (yes, no); and binge drinking (a single-item measure of alcohol abuse) through the question, ‘Have you ever had five or more drinks of alcohol in a row, that is within a couple of hours?’ (yes, no) ‘By alcohol we mean beer, wine, alcopops, bowle and other alcohol beverages like vodka or rum.’ The adolescent assent statement assured confidentiality; the questionnaires were distributed by research staff; teachers sat in front of the class, unable to see pupils’ responses; and questionnaires were collected by research staff and sealed in an envelope in full view of the class.
Data on a number of covariates that could confound the relation between exposure to alcohol use in movies and teen drinking were also collected, including: type of school (a proxy for SES); grade in school; gender; school performance (‘How would you describe your grades last year?’ excellent, good, average, below average); rebelliousness and sensation-seeking (12-item index, range 0–36, Cronbach's 
= 0.77);30 parenting style (8-item index, range 0–24, = 0.64)31 and lifetime smoking prevalence (‘How many cigarettes have you smoked in your life?’). Peer alcohol use was measured with the item ‘How many of your friends drink alcohol?’ (none, some, most), and parent alcohol use with the question ‘Which of the following statements best describes how often your parents drink alcohol?’ (never, once a year, once a month, once a week, every day). Given that depictions of alcohol use are also seen in television programming and advertising, we controlled for TV, DVD and video use on weekdays and on the weekend, assessed by ‘How many hours a day do you watch TV, DVD or Video in your leisure time?’ (none, about half an hour, about 1 h, about 2 h, about 3 h, about 4 h, >4 h a day).
Statistical analysis
Chi-square procedures were used to assess the association between movie alcohol exposure and alcohol use WPK, binge drinking and each of the confounding variables. Lowess (locally weighted scatter plot) smoothed methods were used to graphically represent the relationship between exposure to movie alcohol use and adolescent alcohol use. Multivariate logistic regression models were specified to examine the independent association between movie alcohol exposure and alcohol use including crude and adjusted models. In each model, the first (lowest) quartile of exposure to alcohol use in movies was the reference category. The adjusted model controlled for all covariates listed above, including type of school (a proxy for socioeconomic status), grade, gender, school performance, rebelliousness and sensation-seeking, parenting style, smoking prevalence, peer alcohol use and TV, DVD and video use. The analysis was performed in Stata. As data were gathered at the school-level, school was used to generate clustered robust standard errors using the ‘cluster’ command in Stata's logistic regression platform.
To address concerns that we may have over-specified the model by including intermediate variables, we also added variables in blocks, first adding two blocks of exogenous covariates (first sociodemographics, then a block with parent drinking, parenting style and school performance). Our past research suggests that adolescent smoking, friend use of alcohol and sensation seeking/rebelliousness may each be influenced by movie exposure. Several studies now link seeing smoking in movies with adolescent smoking.32–34 To the extent that seeing movie smoking may prompt an adolescent to try smoking, and trying smoking facilitates the adoption of drinking, this may be an intermediate variable. We have also shown that change in friend smoking is an intermediate variable between exposure to movie smoking and adolescent smoking.35 To the extent that friends watch movies together and these movies prompt drinking initiation in members of the peer group, friend drinking could be an intermediate variable as well. In unpublished research, we have shown that exposure to R-rated movies affects growth in sensation seeking over time and therefore feel that this covariate may also be an intermediate variable. Finally, we controlled for television viewing, which mixes viewing of television programming and movies delivered over television channels or DVD. These variables were added in one block as potential intermediate variables.
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Results |
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Characteristics of the study sample
The final sample consisted of 5581 pupils, of which 51.3% were male. The mean age was 12.8 (SD = 1.2) years. School was a proxy measure for socioeconomic status; by that metric, the sample reflected the local German population, with 2329 (41.7%) students attending the ‘Gymnasium’, 1127 (20.2%) the ‘Realschule’, 1705 (30.6%) the ‘Hauptschule’ and 420 (7.5%) the ‘Gesamtschule’.
Alcohol use in popular contemporary movies and adolescent exposure assessment
Overall, 87.6% of movies in this sample depicted some alcohol use. Median screen time per movie for movie alcohol use was 1.86 min [interquartile range (IQR) = 0.48, 3.73 min]. Adolescents had seen a mean of 14 (SD = 9) of the 50 movies on their individual list, and this translated into an estimated median exposure to alcohol use in the entire sample of 398 movies of 3.44 h (IQR = 1.51, 6.23h). Figure 2 shows the distribution curve for estimated exposure to alcohol use from the 398 popular contemporary movies among German adolescents. The curve is skewed left, with relatively few students (7.3%) having more than 10 h of movie alcohol exposure and with about 10.3% of the sample receiving only up to half an hour of exposure.
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Table 1 shows mean exposure to movie alcohol use grouped by covariate characteristics. For this sample of adolescents, exposure to movie alcohol use was significantly higher among males, pupils in higher grade, pupils living in lower SES communities (other school types than ‘Gymnasium’), students with poorer school performance, pupils with parents or friends who drank alcohol, pupils with higher sensation seeking and rebelliousness scores, those who had tried smoking or had higher TV, DVD and video use on weekdays and weekends, and pupils who rated their mothers as less responsive and demanding.
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Association between alcohol use in movies and adolescent drinking outcomes
The prevalence of alcohol use WPK and binge drinking was 36.6% and 18.1%, respectively. Figure 3 illustrates the curvilinear association between exposure to movie alcohol use and alcohol use WPK, as well as a more linear association with the prevalence of binge drinking. For the measure of alcohol use WPK, the strongest dose–response was seen through exposure quartiles 1–3 of exposure (from 0–6 h of exposure), with the dose–response becoming relatively flat past the 95th percentile (10.9 h of movie alcohol exposure). In contrast, the relation between exposure to movie alcohol and prevalence of binge drinking was linear through most of the exposure distribution, with a slight flattening of slope past the 95th percentile.
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Table 2 summarizes the prevalence of alcohol use WPK and binge drinking by movie alcohol exposure and covariates. When examined by quartile of exposure, differences in the prevalence of alcohol use by quartile were substantial. For example, the prevalence of binge drinking among adolescents in the highest quartile of movie alcohol use exposure was over 36%, as compared with only 3.6% for adolescents in the lowest quartile. Other covariates significantly associated with alcohol use included gender, grade, school type, school performance, parenting style, parent and friend drinking behaviour, rebelliousness, sensation seeking, TV, DVD and video use on weekdays and weekends and having tried smoking.
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Table 3 provides crude and adjusted odds ratios for the associations between exposure to movie alcohol use and both outcome variables. After adjustment for covariates, the exposure retained a strong and statistically significant association with both alcohol outcomes. Compared with adolescents with the lowest movie alcohol exposure (quartile 1), the adjusted odds ratio for students in the highest quartile was 2.95 [95% confidence interval (CI) 2.35, 3.70] for alcohol use WPK and 2.59 (1.70, 3.95) for binge drinking. Other variables associated with alcohol use WPK included grade in school, parent and friend drinking, school performance, sensation seeking and rebelliousness and having tried smoking. Other variables associated with binge drinking included sex, grade in school, friend drinking, sensation seeking and rebelliousness and having tried smoking.
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Table 4 shows how the odds ratios for the associations between exposure to movie alcohol use and adolescent alcohol use change as covariates are added in blocks. Focusing on the comparison of quartile 4 with the reference quartile, the crude odds ratio is reduced by about half (from 11.7 to 6.6 for alcohol use WPK and from 15.5 to 7.4 for binge drinking) when sociodemographics, and exogenous covariates are added. Introducing possible intermediate covariates reduces the effect size again by about half, and adding controls for television and videogame use has little additional impact.
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Discussion |
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This study is the first to examine exposure to movie alcohol use in an adolescent sample outside the United States. The results demonstrate that German youth are exposed to hours of alcohol use depicted in internationally marketed, primarily Hollywood movies and that this exposure is strongly associated with early onset of alcohol use. This study also shows, for the first time, that exposure to movie alcohol use is associated with binge drinking, a problematic drinking behaviour. As is seen with drinking WPK, the association between exposure to alcohol use in movies and binge drinking persists after controlling for a number of potential confounders. Given recent studies implicating early-onset substance use as a modifier of adolescent brain development,36 risk factors for early-onset substance use deserve specific attention.
Compared with samples of American adolescents,27 who viewed an average of 8.3 h of movie alcohol use from 601 movies, European adolescents in this sample were exposed to alcohol in movies on a similar scale (average exposure = 3.4 h from 398 movies). This is not surprising, when one considers the dominance of American fiction in the European media market; for example, a recent study showed that American films comprised between 60 and 80% of all films shown on commercial television channels in European countries.37 This testifies to the effectiveness of international movie marketing campaigns, which time movie releases in other countries to coincide with the release in America and with the roll-out of advertising campaigns for the movie and products placed within it.38 Since 2005, as a result of these world-wide releases, a large share of box office movie revenue from Hollywood movies has come from outside the United States.39 This international movie market greatly extends the reach of US-produced movies in populations outside the United States.
Countries vary considerably in the prevalence of adolescent drinking pattern,40 and this is demonstrated here, with the European adolescents in this study having higher rates of alcohol use WPK than their American counterparts: 36.6% among European 5th to 9th graders compared with 23.1% among Americans in similar grades.27 The prevalence difference could have many cross-cultural explanations. For example, whereas drinking during meals at home is relatively rare in US adolescents, it is common in German families. In addition, the legal drinking age in the United States is 21; German adolescents may purchase alcohol at the age of 16 years. Despite these cultural differences, German adolescents have similar risk factors for drinking outside the home during early adolescence. Exposure to daily family and friend use of alcohol, higher sensation seeking/rebelliousness propensity, and adoption of other risk behaviors (cigarette smoking) all increase risk of early onset use. The demonstration that exposure to movie alcohol use also relates to risk in both cultures, combined with the observation that the form of the dose–response curve is similar in both USA and German samples, suggests to us that this exposure deserves further examination.
There are several limitations to this study. First, due to the cross-sectional design, the temporal sequence of events cannot be determined; prospective studies are needed to show whether seeing alcohol use in movies precedes alcohol initiation. However, the fact that most movies contain alcohol use suggests that children watch movie depictions of alcohol use beginning in early childhood, long before they enter the age where they try drinking. Looking to a different risk behaviour that is associated with movie viewing, one study that has examined the relation between exposure to smoking in movies and adolescent smoking found little difference between cross-sectional and longitudinal multivariate estimates of the association.41 Next, our measure of alcohol asks about ‘alcohol your parents didn't know about’, in order to differentiate from family sanctioned alcohol use such as with meals or religious ceremonies, both common in Germany. As such, this measure does not entirely capture prevalent alcohol use, but intends to capture covert alcohol use outside of family supervision. The role of family alcohol use beyond that of siblings and parents is not fully explored, nor is family problem drinking. Another criticism of observational research is concern about unmeasured confounding, for example that the measure of movie alcohol use exposure is actually capturing another unmeasured causal factor such as parental limit setting. We have tried to address that concern controlling for many confounders, some of which are highly correlated with both the behaviour and the exposure. While is certainly possible that an unmeasured confounder exists, it would have to be strongly linked with exposure to movie drinking, strongly linked with adolescent drinking, and not correlated with the other control variables. Further, in our efforts to fully control for confounding, we introduced variables that could be intermediate variables. Table 4 shows that these intermediate variables had a large impact, especially on the Quartile 4 estimates of risk. To the extent that the may have over-specified the model, this suggests that the odds ratios could be as much as twice as high as the ones we report. While there may be other unmeasured intermediate variables, which may moderate the relationship between movie alcohol exposure and alcohol use, such as attention to or comprehension of alcohol content, our methodology did not allow us to assess these factors. The consistency of the association between movie alcohol exposure and alcohol use across cultures with different norms regarding teen alcohol use and different prevalence of teen alcohol use argues in favour of movie alcohol exposure as an independent social influence risk factor rather than another unmeasured confounder accounting for these findings.
Finally, movies are but one of many entertainment media that include depictions of alcohol use. Although we controlled for time spent watching television, we did not capture exposure to televised alcohol advertising or alcohol use in television programs with the same rigour that we applied to measuring exposure to movie alcohol use. Therefore other entertainment depictions may contribute to the alcohol use identified in this study. One recent survey assessed exposure to US-produced television entertainment by asking whether the adolescents had watched specific shows,22 finding that never-drinkers with high exposure to these shows had more favourable attitudes toward alcohol use, but only for adolescents whose friends did not use alcohol. Clearly, more research is needed to determine the relative contributions of television alcohol advertising, (which has been extensively studied),13–15,42 and depictions of alcohol in television entertainment programming and motion pictures, which have been understudied. From a communications perspective, entertainment depictions of alcohol use may be even more powerful than advertising because the message is not perceived as advertising, and is therefore less likely to stimulate counter-arguing.43 It is also important to recognize that recent prominent product placements in movies will make it even more difficult to distinguish between the effects of entertainment vs advertisement, as entertainment programming is blending with advertising.
In summary, this study shows a strong and independent relationship between exposure to alcohol use from internationally distributed American movies and early onset alcohol use in a European sample of adolescents. Although this is a cross-sectional finding only, and needs to be confirmed in longitudinal samples, this raises concern about the role movies may be playing in early-onset adolescent alcohol use worldwide.
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The study was funded by the Ministry of Health of the Federal Republic of Germany. The content analysis of American movies and the effort of Dr Tanski was funded by CA-77026 and the contribution by Dr Sargent by AA 015591 of the National Institutes of Health. We would like to thank Dan Nassau and Balvinder Rakhra for coding the movies, Elana Bergamini for supervising the content analysis, Catharina Banneck, Gabriele Banneck, Lars Grabbe, Patrick Kruse, Asja Maass, Christa Panzlaff, Bilge Sayim, Björn Sülter and Gudrun Wiborg for assistance in conducting the surveys and data preparation.
Conflict of interest: None declared.
KEY MESSAGES
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