portrayal of alcohol consumption in movies and drinking initiation in low-risk adolescents

DOI: 10.1542/peds.2013-3880; originally published online May 5, 2014; 2014;133;973Pediatrics

Engels, Ron H.J. Scholte, Federica Mathis, Ewa Florek and Matthis MorgensternReiner Hanewinkel, James D. Sargent, Kate Hunt, Helen Sweeting, Rutger C.M.E.

Low-Risk AdolescentsPortrayal of Alcohol Consumption in Movies and Drinking Initiation in

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Portrayal of Alcohol Consumption in Movies andDrinking Initiation in Low-Risk Adolescents

WHAT’S KNOWN ON THIS SUBJECT: Several experimental andobservational studies reveal an association between exposure toalcohol consumption in movies and youth drinking, but little isknown about the effect of such exposure on drinking onset amonglow-risk adolescents.

WHAT THIS STUDY ADDS: In a longitudinal study, exposure toalcohol consumption in movies was associated with drinkinginitiation in a sample of adolescents from 6 European countrieswho had never drunk alcohol and were attitudinallynonsusceptible to future use at the time of exposure.

abstractOBJECTIVES: To investigate the hypothesis that exposure to alcoholconsumption in movies affects the likelihood that low-risk adolescentswill start to drink alcohol.

METHODS: Longitudinal study of 2346 adolescent never drinkers whoalso reported at baseline intent to not to do so in the next 12 months(mean age 12.9 years, SD = 1.08). Recruitment was carried out in 2009and 2010 in 112 state-funded schools in Germany, Iceland, Italy,Netherlands, Poland, and Scotland. Exposure to movie alcoholconsumption was estimated from 250 top-grossing movies in eachcountry in the years 2004 to 2009. Multilevel mixed-effects Poissonregressions assessed the relationship between baseline exposureto movie alcohol consumption and initiation of trying alcohol, andbinge drinking ($ 5 consecutive drinks) at follow-up.

RESULTS: Overall, 40% of the sample initiated alcohol use and 6% ini-tiated binge drinking by follow-up. Estimated mean exposure to moviealcohol consumption was 3653 (SD = 2448) occurrences. After age,gender, family affluence, school performance, TV screen time, person-ality characteristics, and drinking behavior of peers, parents, andsiblings were controlled for, exposure to each additional 1000 moviealcohol occurrences was significantly associated with increased relativerisk for trying alcohol, incidence rate ratio = 1.05 (95% confidenceinterval, 1.02–1.08; P = .003), and for binge drinking, incidence rateratio = 1.13 (95% confidence interval, 1.06–1.20; P , .001).

CONCLUSIONS: Seeing alcohol depictions in movies is an independentpredictor of drinking initiation, particularly for more risky patterns ofdrinking. This result was shown in a heterogeneous sample of Euro-pean youths who had a low affinity for drinking alcohol at the time ofexposure. Pediatrics 2014;133:973–982

AUTHORS: Reiner Hanewinkel, PhD,a,b James D. Sargent,MD,c Kate Hunt, PhD,d Helen Sweeting, PhD,d Rutger C.M.E.Engels, PhD,e Ron H.J. Scholte, PhD,e Federica Mathis, BSc,f

Ewa Florek, MD,g and Matthis Morgenstern, PhDa,b

aInstitute for Therapy and Health Research (IFT-Nord), Kiel,Germany; bInstitute for Medical Psychology and MedicalSociology, University Medical Center Schleswig-Holstein, Kiel,Germany; cGeisel School of Medicine at Dartmouth, Lebanon, NewHampshire; dMRC/CSI Social & Public Health Sciences Unit,University of Glasgow, Scotland; eBehavioural Science Institute,Radboud University, Nijmegen, Netherlands; fPiedmont Centre forDrug Addiction Epidemiology, ASL TO3, Grugliasco, Italy; andgLaboratory of Environmental Research, Department ofToxicology, University of Medical Sciences, Poznan, Poland

KEY WORDSalcohol imagery, movies, binge drinking, young people, Europe

ABBREVIATIONSCI—confidence intervalIRR—incidence rate ratio

Dr Hanewinkel designed the study, contributed to dataacquisition in Germany, carried out the statistical analysis, anddrafted the article; Dr Sargent designed the study, contributedto data acquisition (alcohol occurrences in movies), and revisedthe manuscript critically for important intellectual content; DrHunt contributed to data acquisition in Scotland and revised themanuscript critically for important intellectual content; DrSweeting contributed to data acquisition in Scotland and revisedthe manuscript critically for important intellectual content; DrEngels contributed to data acquisition in the Netherlands andrevised the manuscript critically for important intellectualcontent; Dr Scholte contributed to data acquisition in TheNetherlands and revised the manuscript critically for importantintellectual content; Ms Mathis contributed to data acquisition inItaly and revised the manuscript critically for importantintellectual content; Dr Florek contributed to data acquisition inPoland and revised the manuscript critically for importantintellectual content; Dr Morgenstern designed the study,contributed to data acquisition in Germany, carried out thestatistical analysis, and revised the manuscript critically forimportant intellectual content; and all authors agreed to beaccountable for all aspects of the work in ensuring thatquestions related to the accuracy or integrity of any part of thework were appropriately investigated and resolved andapproved the final manuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-3880

doi:10.1542/peds.2013-3880

Accepted for publication Feb 20, 2014

Address correspondence to Reiner Hanewinkel, PhD, Institute forTherapy and Health Research (IFT-Nord), Harmsstrasse 2, 24114Kiel, Germany. E-mail: [email protected]

(Continued on last page)

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The causes of alcohol use andmisuse inyoung people are multifactorial andinclude cultural norms, parental andpeer influences, personality traits, al-cohol use expectancies, and hereditaryfactors.1 In the last decade some at-tention has been given to the questionof whether alcohol exposure in themedia might also account for variancein young people’s alcohol consumption.The theoretical background for thesestudies is social learning theory, whichsuggests that behavior is learned fromthe environment as people observe andthen imitate the actions of influentialothers.2 Such models include parents,friends, teachers, and charactersdepicted in the media or advertising.For example, given access to cigarettesand alcohol in a Barbie play scenario,preschool children will enact smokingand alcohol scripts in their play, scriptsthey have learned from watching theirparents.3

Alcohol portrayals are widespread inthe mass media. A recent contentanalysis of popularly viewed televisionin the United Kingdom found that al-cohol imagery occurred in .40% ofbroadcasts.4 In movies, alcohol use andbrand appearances are even moreprevalent: Some 86% ofmovies popularin the United Kingdom5 and 83% ofHollywood blockbusters6 depicted al-cohol use. More importantly, resultsfrom experimental7–9 and cross-sectionalobservational studies10–12 have shown aconsistent link between exposure toalcohol use in movies and drinkingbehavior in young people. This asso-ciation has also been shown in 3cohorts recruited in New England,13

across the United States,14–17 and innorthern Germany.18

One gap in the literature to date is thatlittle is known about the effect of ex-posure to drinking in movies ondrinking among low-risk adolescents,those who have never drunk alcoholand are attitudinally nonsusceptible to

future use. Conceptually, this is a veryimportant group, because they canshed more light on the temporal se-quence of the exposure–behavior link(it is hard to imagine how they could bedrawn to movies with alcohol becauseof favorable attitudes toward drinkingat baseline). Empirically, they are ex-tremely difficult to study, becauseusually only a small proportion of anearly- to mid-adolescent samplebelongs to this group, and analyses failbecause of a lack of statistical power.One could solve these sample sizeproblems by studying younger agegroups (eg, 6- to 10-year-olds). How-ever, the central behavioral outcomesunder question are alcohol use andmisuse initiation, and this cannot berealistically studied in young childrenor requires a long follow-up period.

From2009 to 2011we conducted a largeEuropean study on the effects ofmovieson smoking and drinking behavior ofyoung people.12,19,20 In this study, 16 551adolescents from 6 countries (fromGermany, Iceland, Italy, Poland, Neth-erlands, and Scotland) were inter-viewed at baseline, and.80% of thesewere followed up 12 months later. Thesample size of this study providesa unique opportunity to perform sub-sample analyses such as the one out-lined earlier. In addition, it is one of thefew longitudinal studies on alcohol usein movies and only the second everconducted outside the United States.The 6 European countries involved inthe study show variation in both alco-hol policies and prevalence of alcoholuse in young people.21,22 This variationprovides valuable insight into the ro-bustness and consistency of mediaeffects across different cultural con-texts.

In this article we present results on thelongitudinal association between alco-hol use in movies and drinking out-comes in adolescents who have neverusedalcohol in their lives, notevenasip,

and indicated at baseline that theywould “definitely not” drink alcohol inthe next year and “definitely not” drinkalcohol offered by friends. As primaryoutcomes we studied the initiation ofever drinking and binge drinking.

METHODS

Design, Procedure, and StudySample

A school-based longitudinal study wasconducted in 6 European countries byresearch centers in Germany (Kiel),Iceland (Reykjavik), Italy (Turin andNovara), Poland (Poznan), Netherlands(Nijmegen), and Scotland (Glasgow).Study samples were all recruitedfrom state-funded schools, with datacollected through self-completionquestionnaires overseen by trainedresearch staff. Participants were givenassurances about confidentiality andanonymity, and each completed ques-tionnairewasplaced inanenvelopeandsealed in front of participants to re-assure them that teachers, peers, orfamilymemberswould not see them. Topermit linking of the baseline andfollow-up surveys, identical question-naire front sheets allowed participantstogenerate individual 7-character codes(based on prespecified digits or let-ters from memorable names anddates, including date of birth andmother’s first name). This procedurehas been tested in previous studies.23

Ethical approval for the research wasgained from the relevant body in eachcountry. Additional approvals (eg, fromeducational authorities and individualhead teachers) were sought as re-quired. Additional details are givenelsewhere.12

Pupils were recruited from 865 classesin 114 schools. Baseline surveys (n =16 551) were conducted between Novem-ber 2009 and June 2010 (mean age 13.4years, SD = 1.18), and follow-up surveyswere conducted between January andMay 2011 (mean between-wave interval =

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12 months, range 10–14 months). Ofthese 16 551 pupils it was possible tomatch follow-up data for 13 642 pupils(82%) from 843 classes in 112 schools.Following a concept of Pierce et al,24 wemeasured susceptibility toward futurealcohol use by asking pupils at base-line, “Do you think you will drink alco-hol one year from now?” and “If one ofyour best friends were to offer you al-cohol, would you drink it?” Responseoptions were “Definitely yes,” “Proba-bly yes,” “Probably not,” and “Definitelynot.” Some 2706 pupils had neverdrunk alcohol in their lives, not evena sip, at baseline and indicated thatthey would “definitely not” drink alcoholin the next year and would “defi-nitely not” drink alcohol offered byfriends. This is the sample for thepresent analysis of drinking onset.Country-specific overall matching ratesand other sample details are given inthe Appendix.

Measures

Exposure to Alcohol Use in Movies

Exposure to alcohol consumption inmovieswasassessedbyusingamethoddeveloped by researchers at Dart-mouth Medical School. This methodrelies on the recall of having seenmovies presented to respondents asa list of movie titles.25 First, the re-search centers in each country com-piled a master list of the 250 mostcommercially successful box office hitsin their country, using publicly avail-able data on movie revenues. Eachcountry-specific master list containedthe top 50 box office hits for the years2005 to 2008 and the 25 most suc-cessful movies for the years 2004 and2009. Then, through a process of ran-dom selection from the master list,each pupil was presented witha unique list of 50 movies from theircountry-specific list. To minimizebetween-subject variation in the com-position of the individual lists, the

random selection of movies was strat-ified by year of release and country-specific age rating. Pupils indicatedhow often (never, once, twice, .2times) they had seen each movie ontheir unique list. For the present anal-ysis, answers were dichotomized into“ever seen” and “never seen.”

In a parallel procedure, all includedmovieswere content codedwith regardto alcohol use occurrences. Because ofa highoverlap of box office hits betweencountries, the complete sample of 1500movies (6 countries, 250 movies each)contained 655 differentmovies. Fifty-sixpercent (n = 368) had already beencontent coded at the Dartmouth MediaResearch Laboratory. The remaining44% (n = 287) were content coded inthe 6 European study centers. In thiscoding process, trained codersreviewed each movie and counted thenumber of occurrences of on-screenalcohol use. An alcohol occurrencewas counted whenever a major or mi-nor character handled or used alcoholin a scene or when alcohol use wasshown in the background (eg, extrasdrinking alcohol in a bar scene).Occurrences were counted each timealcohol use appeared on the screen.Interrater reliability was studied via 2types of correlations: (1) between thecoding results of the European codersand the European trainer on a selectednumber of training movies and (2) be-tween the European trainer and theDartmouth coders, based on a blindedEuropean recoding of a random sam-ple of 40 Dartmouth-coded movies.European coder–trainer correlationsranged from r = 0.93 (Iceland) to r =0.99 (Italy); the European recounts ofalcohol occurrences in the randommovie selection correlated (r = 0.87)with the Dartmouth counts.

We calculated exposure to alcohol usein movies for all pupils by summing thenumber of alcohol occurrences in eachmovie they had seen. To adjust the

measure for variation in the country-specific movie lists, individual ex-posure to movie alcohol use wasexpressed as a proportion of the totalnumber of possible alcohol occur-rences each pupil could have seen onthebasisof themovies included inhisorher unique list of 50 movies. The finalexposure estimate was the proportionof alcohol occurrences the adolescenthad seen in his or her unique listmultiplied by the number of alcoholoccurrences in the 250 movies of thatcountry.

Drinking Behavior

Both surveys included identical ques-tions about alcohol use. We askedparticipants, “Have you ever drunk anyalcohol, even just a sip?” (yes/no).Those responding “yes” at follow-upwere categorized as having initiatedany kind of alcohol use over the follow-up period. The transition from non-drinker to having any experience ofbinge drinking was assessed throughthe question, “How often have you had 5or more drinks of alcohol on one oc-casion?” Response categories were 0 =never, 1 = once, 2 = 2 to 5 times, or 3 =.5 times. Pupils who reported neverwere classified as “never binge drink-ers” and all others as “ever bingedrinkers.”

Covariates

A number of covariates were included(Table 1) that could confound or modifythe relationship between exposure toalcohol use in movies and drinkinginitiation, including sociodemographic(gender, age, family affluence), per-sonal (school performance, TV screentime, sensation seeking and rebel-liousness), and social environmental(drinking of peers, parents, and sib-lings) characteristics.

Statistical Analysis

All data analyses were conducted in2013 with Stata version 13.0 (Stata

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Corp, College Station, TX). Baselinedifferences between successfullyfollowed-up and lost students wereanalyzed by using x2 and t tests. Ad-justed associations between expo-sure to alcohol use in movies anddrinking initiation were analyzedwith multilevel mixed-effects Poissonregressions (uncentered data in allanalyses). Poisson regression allowsthe presentation of incidence rateratios (IRRs) and 95% confidenceintervals (CIs) for the relationshipbetween movie alcohol use occur-rences and initiation of any drinkingand of binge drinking. IRRs were cal-culated in respect of exposure toevery 1000 alcohol occurrences. Be-cause the data were clustered atthe country, school, and classroomlevel, random intercepts for all 3levels were included in the adjustedmodels. In these models, movie alco-hol use and all covariates were en-tered as fixed effects. Multiplepairwise comparisons after logisticregression were Bonferroni adjusted.

Missing data were handled by listwisedeletion.

A sensitivity analysiswasundertaken toassess for differential country-specificassociations between movie alcoholexposure and the 2 alcohol initiationoutcomes. Instead of using the countryof data assessment as a random effectin the regressionmodel, we included anexposure 3 country interaction termto test for differential country-specificassociations.

RESULTS

Descriptive Statistics at Baselineand Attrition Analysis

Table 2 lists descriptive statistics for allnonsusceptible never drinkers at base-line, for those lost to follow-up, and forthe final analyzed sample, allowingcomparisons of differences due to at-trition. Never drinkers lost to follow-uphad higher exposure to alcohol use inmovies, weremore often recruited fromschools in Poland and less often fromschools in Italy, were significantly older,

rated their school performance morepoorly, had higher scores on the sen-sation seeking and rebelliousnessscale, had more friends and siblingswho drink alcohol, and more often hadfathers who never drink alcohol.

Drinking Initiation During theObservation Period

Overall, 40% of the nonsusceptiblebaseline never drinkers tried alcoholduringthe12-monthsobservationperiod,and about 6% initiated binge drinking(Table 3). Initiation rates varied betweenthe 6 countries, with the lowest rates inIceland and the highest in Germany andPoland. After Bonferroni adjustment,pairwise country comparisons for alco-hol use initiation were significant forIceland in comparison with all othercountries. For binge drinking initiationthere were additional differences be-tween Germany versus Italy and Italyversus Poland. No significant differencewas found for the rates of binge drinkingin Dutch compared with the Icelandicsample.

TABLE 1 Covariates and Their Assessment

Variable Survey Question Response Categories

SociodemographicsAge How old are you? YearsGender Are you a girl or a boy? Boy, GirlFamily affluence scale Does your family own a car, van, or truck? No, Yes: 1, 2, or more

Do you have your own bedroom for yourself? No, YesDuring the past 12 mo, how many times did you

travel away on holiday with your family?Not at all, Once, Twice, More than twice

How many computers does your family own? None, 1, 2, More than 2Personal characteristicsSchool performance How would you describe your grades last year? Excellent, Good, Average, Below averageTV screen time On a school day, how many hours a day do you

usually spend watching TV?None, Less than 1 h, 1–2 h, 3–4 h, More than 4 h

Number of movies seen Below is a list of movie titles. Please mark if, andhow often, you have seen each movie.

Never, Once, Twice, More than twice

Sensation seeking or rebelliousness(Cronbach’s a = 0.70)

How often do you do dangerous things for fun? Not at all, Once in a while, Sometimes,Often, Very oftenHow often do you do exciting things, even if they

are dangerous?I believe in following rules. (recoded) Not at all, A bit, Quite well, Very wellI get angry when anybody tells me what to do.

Social environmentPeer drinking How many of your friends drink alcohol? None, A few, Some, Most, AllMother drinking How often does your mother or female guardian

drink alcohol?Never, Seldom, Often but not every day, Every dayDon’t have (coded “no”)

Father drinking How often does your father or male guardiandrink alcohol?

Never, Seldom, Often but not every day, Every dayDon’t have (coded “no”)

Sibling drinking Do any of your brothers or sisters drink alcohol? Yes, No, Don’t have (coded “no”)



Exposure to Alcohol Use in Movies

Overall, 86% of the total 655 moviesincluded at least 1 alcohol scene, witha range of 0 to 617 and a mean of 68(SD = 87) occurrences per movie. Onaverage, participants in the analyzedsample had seen 18 (SD = 9) of themovies on their movie list, whichtranslated to an estimated mean in-dividual exposure to movie alcohol useof 3653 (median = 3233, SD = 2448)occurrences, with a range of 0 to 14 498

occurrences, based on the extrapola-tion to the respective 250 movies.

Association Between Exposure toAlcohol Use in Movies andAdolescent Drinking Initiation

Figure 1 shows the adjusted associa-tion between the exposure to moviealcohol consumption and alcohol useinitiation of nonsusceptible neverdrinkers at baseline. After age, gender,family affluence, school performance,

TV screen time, personality character-istics, and drinking behaviors of peers,parents, and siblings were controlledfor, exposure to movie alcohol use wassignificantly related to drinking initia-tion. The adjusted IRR for any alcoholuse in the observation period was 1.05(95% CI, 1.02–1.08; P = .003) for eachadditional 1000 occurrences of alcoholmovie exposure. Figure 1 illustratesthat going from lowest to highest ex-posure raised the incidence of alcohol

TABLE 2 Descriptive Statistics at Baseline, and Attrition Analysis, %

Baseline Nonsusceptible Never-Drinkers (n = 2706)

Lost to Follow-Up(n = 380)

Analyzed Sample(n = 2326)

Lost to Follow-Up VersusAnalyzed Sample P

CountryGermany 21.7 21.8 21.6 (n = 503) ,.01Iceland 35.4 36.8 35.2 (n = 819)Italy 12.9 8.7 13.6 (n = 315)Netherlands 4.2 3.4 4.3 (n = 101)Poland 15.1 20.3 14.3 (n = 332)

Scotland 10.7 8.9 11.0 (n = 256)SociodemographicsAge at baseline (y), M (SD) 12.91 (1.10) 13.18 (1.15) 12.86 (1.08) ,.001GenderFemale 53.9 50.0 54.6 .101Male 46.1 50.0 45.5

Family affluenceLow 9.2 11.3 8.9 .198Medium 36.6 37.9 36.3High 54.2 50.8 54.8

Personal CharacteristicsSchool performanceBelow average 4.0 3.7 6.4 ,.01Average 25.5 24.8 29.6Good 44.7 45.1 42.3Excellent 25.8 26.4 21.7

TV screen time per day (h), M (SD) 1.92 (0.84) 1.91 (0.89) 1.92 (0.83) .746Sensation seeking and rebelliousness, M (SD) 0.81 (0.62) 0.92 (0.70) 0.79 (0.60) ,.001Exposure to alcohol use in movies, M (SD) 3707 (2472) 4037 (2590) 3653 (2448) .005

Social EnvironmentPeer drinkingNone 71.3 63.3 72.7 ,.01A few 17.9 22.4 17.1Some 8.5 11.9 7.9Most or all 2.3 2.4 2.3

Mother figure drinkingNever 37.0 39.3 36.6 .682Seldom 55.7 52.8 56.2Often but not every day 6.6 7.2 6.5Every day 0.7 0.8 0.7

Father figure drinkingNever 26.4 31.9 25.6 ,.05Seldom 57.4 51.3 58.4Often but not every day 13.8 14.9 13.6Every day 2.4 1.9 2.5

Any sibling drinkingNo 81.2 76.3 82.0 ,.01Yes 18.8 23.7 18.0

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onset by about 30 percentage points.For binge drinking the adjusted IRRwas 1.13 (95% CI, 1.06–1.20; P , .001).Figure 1 illustrates that going fromlowest to highest exposure raised theincidence of binge drinking by about 20percentage points. For alcohol use ini-tiation, the only other significant lon-gitudinal associations were found fordrinking of siblings (IRR = 1.25; 95% CI,1.09–1.52; P = .003) and drinking fre-quency of the mother (IRR = 1.14; 95%CI, 1.01–1.29; P = .035). Binge drinkinginitiation was significantly related toschool performance (IRR = 0.67; 95% CI,0.55–0.84; P , .001), family affluence(IRR = 0.77; 95% CI, 0.60–0.99; P = .045),and sensation seeking (IRR = 1.48; 95%CI, 1.15–1.91; P = .003).

Sensitivity Analysis

None of the exposure 3 country in-teraction terms reached significance,indicating either that the reportedassociations did not differ betweencountries or that statistical power wasnot high enough to show such differ-ences.

DISCUSSION

This study demonstrates that moviealcohol exposure is associated withinitiation of alcohol use and bingedrinking among low-risk Europeanadolescents, independent from otherrisk factors that model the social en-vironment and personal character-istics. The range of exposure wassubstantial, such that high alcohol usein movies independently accounted forincreases in the incidence of alcoholinitiation by 30 percentage points andbinge drinking by 20 percentage points.

There are at least 3 contributions ofthe current study. The first is the lon-gitudinal design, which enables theinvestigation of the incidence of be-havioral transitions, placing the expo-sure before these transitions. To dateonly 3 other cohorts have been followedup to explore the effects of exposure tomovie depictions of alcohol, 2 from theUnited States and 1 from Germany. Thesecond contribution is the large anddiverse sample that was recruited in 6European countries. These countriesdiffer in respect of both macro-levelcontextual environmental factors (eg,alcohol control policies) and preva-lence of alcohol use. An association thatholds across this source of significant(unmeasured) variance is likely to berobust and extends beyond themultipleindividual risk factors controlled for inthis study. Third, for the first time wereported the effect of movie alcoholexposure on a subgroup of adolescents

who have a very low affinity for alcohol(never users without intention to usealcohol). This limits the argument thatseeing specific movies with alcohol issimplyabyproductofotherunmeasuredpersonal characteristics that are in-dicative of alcohol use.

There are limitations to the study,whichmust be taken into account. Loss tofollow-up affects the generalizability ofresults, especially if there is selectiveattrition, which was the case in thecurrent study: Adolescents at higherrisk of drinking were more likely to belost to follow-up. The fact that loststudents had a higher exposure to al-coholdepictions inmoviesmight lead toan underestimation of the true asso-ciation. Although we captured a largenumber of covariates and studied avery restricted sample, it is still pos-sible that the results may be biasedby unmeasured confounding on theindividual level. Additional tests are

TABLE 3 Age- and Gender-Adjusted Incidence Rates (%) for Ever Alcohol Use (Even Just a Sip) and Binge Drinking During the 12-mo Study Period (n =2326)

Total Germany (de) Iceland (is) Italy (it) Netherlands (nl) Poland (pl) Scotland (uk)

Alcohol use initiation 40.3 46.7is 29.6de,it,nl,pl,uk 34.2is 41.4is 54.1is 49.9is

Binge drinking initiation 6.2 12.8is,it 1.0de,it,pl,uk 4.7de,is,pl 3.0 11.4is,it 6.2is

Superscripts indicate significant between-country comparisons after Bonferroni correction.

FIGURE 1Adjusted association between exposure to alcohol use occurrences inmovies and adolescents’drinkinginitiation. Note: Covariate adjustment for age, gender, family affluence, school performance, TV screentime, sensation seeking and rebelliousness, and alcohol consumption in the social environment(friends, siblings, and parents).



needed to tap into unmeasured con-founding on the side of the predictor. Inaddition, because alcohol use is oftenpresented together with other adultmovie contents such as violence, pro-fanity, tobacco, and sex, the reportedassociations may not be specific,a feature one would expect if a riskfactor is causal.

Implications for Prevention

This study provides evidence of a ro-bust longitudinal association betweenseeing drinking scenes in movies anddrinking initiation in a sample of low-risk early adolescents recruited in 6European countries. Generally, pre-vention measures can be classifiedinto structural and behavioral mea-sures. One structural preventive mea-sure applying this concept would beto incorporate movie alcohol use intothe movie rating systems, which wouldlower the “dose” of exposure. Sucha proposal is currently debated for

on-screen smoking26 but should also beapplied for alcohol use in movies.When it comes to more behavior-oriented preventive measures, healthcare practitioners, teachers, andother professionals could stress theimportance of prudent media man-agement for parents of young chil-dren. Parents might help preventmovies and other media from influ-encing their children’s susceptibilityto alcohol use via two different meth-ods27: First, they could reduce expo-sure to movies that show alcohol use.This could be done by reducing theoverall movie and media use of chil-dren, which has also other healthbenefits.28 It has been shown thatchildren who report less parentalrestrictions on watching moviesdesigned for older adolescents havea higher risk of engaging in bingedrinking.29 Second, parents could talkto their children regularly about whatthey are seeing or hearing in media

related to alcohol use, or they couldview movies together with their chil-dren. They can discuss false or mis-leading information from alcohol imageryon screen (in movies but also throughalcohol advertisements). This strategycan be subsumed under the heading“media literacy education,” but this re-search field is just emerging.30

ACKNOWLEDGMENTSWe gratefully acknowledge the work ofStefan Hrafn Jonsson, Solveig Karlsdottir,Fabrizio Faggiano, and Evelien Poelenof the Smoking in Movies Europe studygroup. We thank Abita Bhaskar, DariaBuscemi, Lars Grabbe, Roberto Gullino,Leonie Hendriksen, Maksymilian Kulza,Martin Law, Dan Nassau, BalvinderRakhra, Monika Senczuk-Przybylowska,and Tiziano Soldani for coding themovies. And we are also very thankfulto all pupils and staff in participatingschools and the survey field forces ineach country.

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(Continued from first page)

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2014 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: The study was supported by the European Commission and the Ministry of Health of the Federal Republic of Germany. The coding of the US movies wassupported by the National Institutes of Health (AA015591/AA/NIAAA NIH HHS/United States). The Scottish fieldwork was supported by additional funds from the UKMedical Research Council (MC_US_A540_0041). Funded by the National Institutes of Health (NIH).

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.



APPENDIX

StudySampleDetails

Germ

any

Iceland

Italy

Poland

TheNetherlands

Scotland

Setting

Publicschools,4

schooltypes:Gymnasium

Gemeinschaftsschule,

Regionalschule,

Hauptschule

Publicschools

Publicschools,

second

classof

secondaryschool

andfirstclass

ofhigh

school

Publicschools,1

schooltype

(Gym

nasium

)

Publicschools,4

different

school

types:VM

BO,HAVO,

Atheneum

,Gymnasium

Mainstream(state-

funded)schools

Locations

Schleswig-Holstein,

Germ

any

Schoolsfrom

each

region

(north,south,

east,w

est)ofIcelandin

additiontothecapital

area

(Reykjavík)

Piedmontregion,

Italy

Wielkopolska

region

Gelderland,Limburg,

Brabant

Centralbeltof

Scotland

DistrictofKiel,Flensburg,

Schleswig-Flensburg,

andRendsburg-

Eckernförde

Schoolswith

head

office

inTurinand

Novara

provinces

Timeofbaseline

assessment

November–December

2009

January–February

2010

March–June

2010

April–June

2010

December2009–June

2010

January–March

2010

Timeoffollow-up

assessment

February–March

2011

January–February

2011

March–May

2011

January–April2011

February–May

2011

January–February

2011

Eligibilitycriteria

forschools

Location

Numberof

participating

pupils.100

LocationinTurinand

Novara

provinces

Locationin

Wielkopolska

region

Nospecialpedagogic

educationcenter

Locationineither

Midlothianor

East

Dumbartonshire

Numberofclasses.8

Nospecialpedagogic

educationcenter

Nocurrent

participation

inotherstudies

oftheBSI,Radboud

University

Nospecialeducation

Nospecialpedagogic

educationcenter

Noprivateeducation

Nootherstudiesof

IFT-Nord

No.ofschools

potentially

eligible

104

Notknow

n578

253

Notknow

n14

No.ofschoolsinvited

6023

31253

437

Invitationcriteria

forschools

Random

Convenience

sampling

Convenience

sampling

Alleligibleschools

Random

Selected

basedon

proportionoffree

schoolmeals

No.ofschoolsthat

agreed

(baseline)

2120

2635

57

No.ofschoolsthat

agreed

(follow-up)

2120

2633

57

Eligibilitycriteria

forpupils

Active(“opt-in”)

parentalconsent

Passive(“opt-out”)

parentalconsent

Activeor

passive

parentalconsent

Active(“opt-in”)

parentalconsent

Passiveparental

consent

Passive(“opt-out”)

parentalconsent

Presence

ontheday

ofassessmentor,

ifabsent,w

illing

tocompletea

questionnaire

and

return

bypost

Pupil’spresence

onthedayof

assessment

Willingnesstoparticipate

or,ifabsent,willing

tocompletea

questionnaire

and

return

bypost

Presence

onthe

dayofassessment

Presence

onthe

dayofassessment

Presence

ontheday

ofassessmentor,

ifabsent,w

illing

tocompletea

questionnaire

and

return

bypost

Willingto

participate

Willingto

participate

Willingto

participate

Willingto

participate

Willingtoparticipate

No.ofp

upils

exam

ined

foreligibility

3544

2798

2953

5078

1706

3189

No.confirm

edeligible

2754

2664

2668

4105

1423

2937

ARTICLE



APPENDIX

Continued

Germ

any

Iceland

Italy

Poland

TheNetherlands

Scotland

Reasonsfor

nonparticipation

Noparentalconsent

(n=515),absence

(n=264),refusal

(n=11)

Noparentalconsent

(n=19),absence

(n=102),refusal

(n=13)

Noparentalconsent

(n=100),absence

(n=175),refusal

(n=10)

Noparentalconsent

(n=396),absence

(n=527),refusal

(n=50)

Noparentalconsent

(n=18),absence

(n=265),refusal

(n=0)

Noparentalconsent

(n=11),absence

(n=226),refusal

(n=15)

No.participating

atbaseline

2754

2664

2668

4105

1423

2937

No.analyzedat

baseline

2754

2664

2668

4105

1423

2937

Response

rateat

baseline(%

)78

9590

8183

92

Meanageatbaseline(y)

12.7

13.1

13.6

14.2

13.8

13.0

No.participated

atfollow-up

2645

2594

2404

3698

1676

3012

No.m

atched

2336

2168

2272

3148

1215

2503

Reasonsfor

nonm

atch

Absenceat

baseline

Absenceatbaseline

Absenceat

baseline

Absenceatbaseline

Absenceatbaseline

Absenceatbaseline

Absenceat

follow-up

Absenceatfollow-up

Absenceat

follow-up

Absenceatfollow-up

Absenceatfollow-up

Absenceatfollow-up

Incorrectcode

Incorrectcode

Incorrectcode

Incorrectcode

Incorrectcode

Incorrectcode

No.ofb

aselinepupils

losttofollow-up

388

496

396

957

208

434

Matchingrate(%

)84.8

81.4

85.2

76.7

84.4

80.0

BSI,BehavioralScienceInstitute.



DOI: 10.1542/peds.2013-3880; originally published online May 5, 2014; 2014;133;973Pediatrics

Engels, Ron H.J. Scholte, Federica Mathis, Ewa Florek and Matthis MorgensternReiner Hanewinkel, James D. Sargent, Kate Hunt, Helen Sweeting, Rutger C.M.E.

Low-Risk AdolescentsPortrayal of Alcohol Consumption in Movies and Drinking Initiation in

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