Reiner Hanewinkel

Co-Occurrence of Addictive Behaviours: Personality Factors Related to Substance Use, Gambling and Computer Gaming

Aim: To investigate co-occurrence and shared personality characteristics of problematic computer gaming, problematic gambling and substance use. Methods: Cross-sectional survey data were collected from 2,553 German students aged 12–25 years. Self-report measures of substance use (alcohol, tobacco and cannabis), problematic gambling (South Oaks Gambling Screen – Revised for Adolescents, SOGS-RA), problematic computer gaming (Video Game Dependency Scale, KFN-CSAS-II), and of twelve different personality characteristics were obtained. Results: Analyses revealed positive correlations between tobacco, alcohol and cannabis use and a smaller positive correlation between problematic gambling and problematic computer gaming. Problematic computer gaming co-occurred only with cannabis use, whereas problematic gambling was associated with all three types of substance use. Multivariate multilevel analyses showed differential patterns of personality characteristics. High impulsivity was the only personality characteristic associated with all five addictive behaviours. Depression and extraversion were specific to substance users. Four personality characteristics were specifically associated with problematic computer gaming: irritability/aggression, social anxiety, ADHD, and low self-esteem. Conclusions: Problematic gamblers seem to be more similar to substance users than problematic computer gamers. From a personality perspective, results correspond to the inclusion of gambling in the same DSM-V category as substance use and question a one-to-one proceeding for computer gaming.

Using sensation seeking to target adolescents for substance use interventions.

AIMS This study examines the predictive validity of sensation seeking as a predictor of adolescent substance use, in order to optimize targeting for substance use prevention programs. DESIGN Longitudinal study. SETTING Random-digit dial telephone survey. Participants A total of 6522 US adolescents aged 10-14 years at baseline, resurveyed at 8-month intervals for three subsequent waves. MEASUREMENTS Two outcomes were assessed-onset of binge drinking (more than five drinks in a short time) and established smoking (>100 cigarettes life-time). Sensation seeking level was assessed at baseline. Logistic regression was used to predict onset of substance use at any follow-up wave as a function of sensation seeking. The receiver operating characteristics curve was used to illustrate how well sensation seeking predicted substance use as a function of different cut-off points for defining high sensation seeking, and area under the receiver operating characteristics curve (AROC) was the metric of predictive validity. FINDINGS Of 5834 participants with one or more follow-up assessments, 5634 reported no binge drinking and 5802 were not established smokers at baseline, of whom 717 (12.7% of 5634) reported binge drinking and 144 (2.5% of 5802) reported established smoking at one or more follow-up interviews. Sensation seeking predicted binge drinking moderately well [AROC = 0.71 (95% confidence interval 0.69, 0.73)] and was a significantly better predictor of established smoking onset [AROC = 0.80 (0.76, 0.83)]. For binge drinking, predictive validity was significantly lower in blacks; for established smoking it was significantly higher for Hispanics. Implications for two targeting interventions are discussed. CONCLUSIONS Sensation seeking works moderately well at identifying adolescents at risk for onset of binge drinking and established smoking. This study offers a guide for determining the appropriate targeting cut-off value, based on intervention efficacy, costs and risks.

Longitudinal study of exposure to entertainment media and alcohol use among German adolescents

BACKGROUND. Entertainment media exposure may predict teenager alcohol use, but few longitudinal studies have been reported. METHODS. A longitudinal study was conducted of 2708 German adolescents aged 10 to 16 years who had never drunk alcohol. Each adolescent was surveyed at school about daily television use, whether they had a television in their bedroom, and their exposure to movie alcohol depictions. Adolescents were resurveyed 12 to 13 months later (retention rate: 85%) to determine onset of drinking alcohol without parental knowledge and binge drinking (≥5 consecutive drinks). RESULTS. Overall, 885 (33%) students initiated alcohol use without parental knowledge (17% in quartile 1 movie alcohol exposure), and 387 (14%) initiated binge drinking during follow-up. After controlling for baseline covariates, exposure to movie alcohol use significantly increased percent initiating alcohol use (to 24% in exposure quartile 2, 33% in quartile 3 and 34% in quartile 4) and percent initiating binge drinking (to 8.6% in exposure quartile 2, 12% in quartile 3 and 13% in quartile 4). Having a television in the bedroom also predicted both outcomes, but daily television use did not. CONCLUSIONS. Movie exposure and having a television in the bedroom are both independent predictors of onset of problematic alcohol use among German teenagers. Media restrictions could play a role in prevention.

Exposure to Smoking in Internationally Distributed American Movies and Youth Smoking in Germany: A Cross-cultural Cohort Study

OBJECTIVE. Studies of US adolescents have linked exposure to movie smoking with smoking behavior. It is unclear whether European adolescents are also responsive to movie tobacco imagery. METHODS. A longitudinal study was conducted to assess exposure to movie smoking in 2711 German never-smokers (aged 10 to 16 years). Movie smoking exposure was estimated by asking adolescents if they had seen movies from a list of 50 movie titles, randomly selected for each adolescent from 398 internationally distributed movies released between 1994 and 2004 that became box-office hits in Germany. These films were reviewed for smoking content. Adolescents were resurveyed 12 to 13 months later to determine smoking status, and results were compared with a similarly designed survey of 2603 white US adolescents. We hypothesized replication of the main effect of the exposure on trying smoking, and an interaction, with a significantly larger response among adolescents whose parents did not smoke. RESULTS. The 398 internationally distributed movies represented 80% of the German box-office hits within this time frame, with the majority (388) produced and/or distributed internationally by US companies. Smoking was present in 74% of the movies. Overall, 503 (19%) of the students tried smoking during the follow-up period. The incidence of trying smoking was associated with increased exposure to movie smoking. The form of the dose-response was similar to the US sample, with the strongest response to movies seen in the lower 2 quartiles of exposure. After controlling for baseline covariates, exposure to movie smoking remained a significant predictor of trying smoking in German adolescents, and the effect was significantly stronger in adolescents whose parents did not smoke. CONCLUSIONS. Smoking in internationally distributed US movies predicts trying smoking among German adolescents, closely replicating findings from a longitudinal study of white US adolescents. Smoking in these movies could have important worldwide public health implications.

Alcohol Consumption in Movies and Adolescent Binge Drinking in 6 European Countries

OBJECTIVE: The goal of this study was to investigate whether the association between exposure to images of alcohol use in movies and binge drinking among adolescents is independent of cultural context. METHODS: A cross-sectional survey study in 6 European countries (Germany, Iceland, Italy, Netherlands, Poland, and Scotland) was conducted. A total of 16 551 pupils from 114 public schools with a mean (± SD) age of 13.4 (± 1.18) years participated. By using previously validated methods, exposure to alcohol use in movies was estimated from the 250 top-grossing movies of each country (years 2004−2009). Lifetime binge drinking was the main outcome measure. RESULTS: Overall, 27% of the sample had consumed >5 drinks on at least 1 occasion in their life. After controlling for age, gender, family affluence, school performance, television screen time, sensation seeking and rebelliousness, and frequency of drinking of peers, parents, and siblings, the adjusted β-coefficient for lifetime binge drinking in the entire sample was 0.12 (95% confidence interval: 0.10−0.14; P < .001). The crude relationship between movie alcohol use exposure and lifetime binge drinking was significant in all countries; after covariate adjustment, the relationship was still significant in 5 of 6 countries. A sensitivity analysis revealed that the association is content specific, as there was no significant association between lifetime binge drinking and exposure to smoking in movies. CONCLUSIONS: The link between alcohol use in movies and adolescent binge drinking was robust and seems relatively unaffected by cultural contexts.

Cigarette Advertising and Teen Smoking Initiation

OBJECTIVE: To test the specificity of the association between cigarette advertising and adolescent smoking initiation. METHODS: A longitudinal survey of 2102 adolescents, aged 10 to 17 years at baseline, who never smoked was conducted by using masked images of 6 cigarette advertisements and 8 other commercial products with all brand information digitally removed. The exposure variable was a combination of contact frequency and cued recall of brands for cigarette and other advertisements. Multilevel mixed-effects Poisson regressions were used to assess smoking initiation 9 months after the baseline assessment as a function of cigarette-advertisement exposure, other advertisement exposure, and baseline covariates. RESULTS: Thirteen percent (n = 277) of students initiated smoking during the observation period. Although the incidence of trying smoking was associated with increased exposure to cigarette advertisements (10% in the low, 12% in the medium, and 19% in the high cigarette-advertisement exposure tertile initiated smoking), exposure to other advertisements did not predict smoking initiation. Compared with low exposure to cigarette advertisements, high exposure remained a significant predictor of adolescent smoking initiation after controlling for baseline covariates (adjusted relative risk: 1.46 [95% confidence interval: 1.08–1.97]; P < .05). CONCLUSIONS: Our results support the notion of a content-related effect of cigarette advertisements and underlines the specificity of the relationship between tobacco marketing and teen smoking; exposure to cigarette advertisements, but not other advertisements, is associated with smoking initiation.

Sedentary behavior and indicators of mental health in school-aged children and adolescents: A systematic review.

OBJECTIVE The presented systematic review aims at giving a comprehensive overview of studies assessing the relationship between sedentary behavior and indicators of mental health in school-aged children and adolescents. METHODS Six online databases (MEDLINE, EMBASE, PsycINFO, PsycARTICLES, CINAHL and SPORTDiscus) as well as personal libraries and reference lists of existing literature were searched for eligible studies. RESULTS Ninety-one studies met all inclusion criteria. There was strong evidence that high levels of screen time were associated with more hyperactivity/inattention problems and internalizing problems as well as with less psychological well-being and perceived quality of life. Concerning depressive symptoms, self-esteem, eating disorder symptoms, and anxiety symptoms, no clear conclusion could be drawn. But, taking quality assessment into account, self-esteem was negatively associated with sedentary behavior, i.e. high levels of time engaging in screen-based sedentary behavior were linked to lower scores in self-esteem. CONCLUSIONS Overall, the association between sedentary behavior and mental health indicators was rather indeterminate. Future studies of high quality and with an objective measure of sedentary behavior will be necessary to further examine this association as well as to investigate longitudinal relationships and the direction of causality. Furthermore, more studies are needed to identify moderating and mediating variables.

Comparing the effects of entertainment media and tobacco marketing on youth smoking in Germany

AIMS To examine differential effects of smoking in films and tobacco advertising on adolescent smoking. We hypothesize that movie smoking will have greater effects on smoking initiation, whereas tobacco advertising receptivity will primarily affect experimentation. DESIGN Longitudinal observational study of adolescents. SETTING School-based surveys conducted in Schleswig-Holstein, Germany. PARTICIPANTS A total of 4384 adolescents age 11-15 years at baseline and re-surveyed 1 year later; ever smoking prevalence was 38% at time 1. MEASUREMENTS The main outcome variable combined two items assessing life-time and current smoking (alpha = 0.87). Baseline never smokers were analyzed separately from those who had tried smoking (ever smokers). Exposure to smoking in 398 internationally distributed US movies was modeled as a continuous variable, with 0 corresponding to the 5th percentile and 1 to the 95th percentile of exposure. Tobacco marketing receptivity consisted of naming a brand for a favorite tobacco advertisement. Ordinal logistic regressions controlled for socio-demographics, other social influences, personality characteristics of the adolescent and parenting style. FINDINGS Whereas 34% of ever smokers were receptive to tobacco marketing at time 1, only 6% of never smokers were. Among time 1 never smokers, exposure to movie smoking was a significantly stronger predictor of higher time 2 smoking level [adjusted proportional odds ratio = 2.76, 95% confidence interval (1.84, 4.15)] than was tobacco marketing receptivity (1.53 [1.07, 2.20]). Among time 1 ever smokers, both tobacco marketing receptivity and exposure to movie smoking predicted higher levels of time 2 smoking [2.17 (1.78, 2.63) and 1.62 (1.18, 2.23), respectively], and the two estimates were not significantly different. CONCLUSIONS In this longitudinal study, exposure to movie smoking was a stronger predictor of smoking initiation than tobacco marketing receptivity, which was more common among ever smokers. The results suggest that entertainment media smoking should be emphasized in programs aimed at preventing onset, and both exposures should be emphasized in programs aimed at experimental smokers.

Longitudinal study of parental movie restriction on teen smoking and drinking in Germany

AIMS To determine if adolescents who report that their parents restrict viewing movies based on rating have a lower risk of trying smoking and drinking alcohol in the future. DESIGN Prospective observational study. A cohort of 2110 German adolescents younger than 15 years who had never smoked or drunk alcohol at baseline were surveyed 12-13 months later to determine smoking and binge drinking initiation. Risk of substance use was assessed as a function of parental restriction on viewing FSK-16 movies (movies that only those aged 16 years and over would be allowed to see in theaters). FINDINGS The percentage of students who tried smoking was 16.3%, 10.9% initiated binge drinking and 5.0% used both substances during the follow-up period. There was a significant effect of parental movie restriction on each substance use outcome measure after controlling for covariates. Compared with adolescents whose parents never allowed them to view FSK-16 movies, the adjusted relative risk [(RR) (95% confidence interval (CI)] for use of both substances were 1.64 (1.05-2.58) for adolescents allowed to view them once in a while, 2.30 (1.53-3.45) for sometimes and 2.92 (1.83-4.67) for all the time. FSK-16 restrictions were associated with lower viewership of all classes of movies, but especially FSK-16/18 movies; in addition, FSK-16 restrictions were associated with substantially lower exposure to movie depiction of tobacco and alcohol use, suggesting a mediational mechanism for the association. CONCLUSIONS Among young adolescents, parental restriction from viewing movies rated for older adolescents/adults decreases the risk of substance use in the future.

Exposure to alcohol advertising and teen drinking

OBJECTIVE Assessing the association between alcohol ad exposure and alcohol use in German adolescents, controlling for general ad exposure. METHOD Cross-sectional survey of 3415 sixth to eighth graders (mean 12.5 years) from 29 schools in three German states (June 2008). Exposure to 9 alcohol and 8 non-alcohol advertisements was measured with masked ad images; students indicated contact frequency and brand recall. Main outcomes were ever drinking, current drinking, binge drinking, alcohol use intentions and outcome expectancies. RESULTS There was a bivariate association between both exposures (alcohol and non-alcohol ads) and all alcohol use measures. After adjustment for confounding, only alcohol ad exposure retained a significant association with outcomes. Multi-level logistic regressions revealed that compared with quartile one alcohol ad exposure, the adjusted odds ratios for quartile four were 2.4 (95% confidence interval 1.7-3.4) for trying drinking, 2.7 (1.8-3.9) for current drinking and 2.3 (1.6-3.5) for ever binge drinking. There was also an independent association between alcohol ad exposure and alcohol-related attitudes among never drinkers. CONCLUSION This study demonstrates a positive association between exposure to alcohol advertising and multiple youth drinking outcomes, showing that the association is content-specific, not just a function of general ad exposure.