8
R ESEARCH A RTICLE Smoking Media Literacy in Vietnamese Adolescents RANDY M. PAGE, PhD a NGUYEN T. HUONG, MSc, MPH, PhD b HOANG K. CHI, MPH c TRUONG Q. TIEN, MD, MPH d ABSTRACT BACKGROUND: Smoking media literacy (SML) has been found to be independently associated with reduced current smoking and reduced susceptibility to future smoking in a sample of American adolescents, but not in other populations of adolescents. Thus, the purpose of this study was to assess SML in Vietnamese adolescents and to determine the association with smoking behavior and susceptibility to future smoking. METHODS: A cross-sectional survey of 2000 high school students completed the SML scale, which is based on an integrated theoretical framework of media literacy, and items assessing cigarette use. Ordinal logistic regression was used to determine the association of SML with smoking and susceptibility to future smoking. Ordinal logistic regression was also to determine whether smoking in the past 30 days was associated with the 8 domains/core concepts of media literacy which comprise the SML. RESULTS: Smoking media literacy was lower among the Vietnamese adolescents than what has been previously reported in American adolescents. Ordinal logistic regression analysis results showed that in the total sample SML was associated with reduced smoking, but there was no association with susceptibility to future smoking. Further analysis showed that results differed according to school and grade level. There did not appear to be association of smoking with the specific domains/concepts that comprise the SML. CONCLUSIONS: The association of SML with reduced smoking suggests the need for further research involving SML, including the testing of media literacy training interventions, in Vietnamese adolescents and also other populations of adolescents. Keywords: cigarette smoking; media literacy; tobacco use; Vietnam; tobacco marketing. Citation: Page RM, Huong NT, Chi HK, Tien TQ. Smoking media literacy in Vietnamese adolescents. J Sch Health. 2011; 81: 34-41. Received on August 10, 2009 Accepted on January 20, 2010 M edia exposure to smoking contributes strongly to adolescent smoking, whether the exposure occurs in persuasive (eg, advertising and promotion) or in narrative contexts such as movies. 1 The World Health Organization Framework Convention on Tobacco Control conceptualizes tobacco use as an epidemic spread by a number of complex factors, including ‘‘global marketing, trans-national tobacco advertising, promotion and sponsorship.’’ 2 Media is a primary means of tobacco promotion and advertising. One common tactic of the tobacco industry is to promote cigarettes through the portrayal of smoking in movies. 3 A recent review of the literature by a Professor, (randy [email protected]), Department of Health Science, Brigham Young University, 221 Richards Building, Provo, UT 84602. b Vice Head of the Faculty, ([email protected]), Department of Health Education, Faculty of Social Sciences, Behaviour, and Health Education, Hanoi School of Public Health, 138B Giang Vo, Hanoi, Vietnam. c Facilitator of Ethics in Public Health, ([email protected]), Department of Health Education, Faculty of Social Sciences, Behaviour, and Health Education, Hanoi School of Public Health, 138B Giang Vo, Hanoi, Vietnam. d Deputy Head of the Department, ([email protected]), Department of Health Education, Faculty of Social Sciences, Behaviour, and Health Education, Hanoi School of Public Health, 138B Giang Vo, Hanoi, Vietnam. Address correspondence to: Randy M. Page, Professor, (randy [email protected]), Department of Health Science, Brigham Young University, 221 Richards Building, Provo, UT 84602. Charlesworth and Glantz 4 revealed several studies showing increases in the amount of smoking in movies and reported strong empirical evidence indicating that smoking in movies increases smoking initiation among US adolescents. Research by Worth et al 5 shows 80-90% of all box-office hits that are viewed in many countries are produced and/or distributed by US media companies and 80% of these contain portrayals of smoking behavior. A recent study by Hanewinkel and Sargent 6 appears to have important global public health implications and specific possible impacts for adolescent smoking in specific countries. This study found that among German adolescents, 34 Journal of School Health January 2011, Vol. 81, No. 1 © 2011, American School Health Association

Smoking Media Literacy in Vietnamese Adolescents

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RE S E A R C H AR T I C L E

Smoking Media Literacy in VietnameseAdolescentsRANDY M. PAGE, PhDa NGUYEN T. HUONG, MSc, MPH, PhDb HOANG K. CHI, MPHc TRUONG Q. TIEN, MD, MPHd

ABSTRACTBACKGROUND: Smoking media literacy (SML) has been found to be independently associated with reduced current smokingand reduced susceptibility to future smoking in a sample of American adolescents, but not in other populations of adolescents.Thus, the purpose of this study was to assess SML in Vietnamese adolescents and to determine the association with smokingbehavior and susceptibility to future smoking.

METHODS: A cross-sectional survey of 2000 high school students completed the SML scale, which is based on an integratedtheoretical framework of media literacy, and items assessing cigarette use. Ordinal logistic regression was used to determine theassociation of SML with smoking and susceptibility to future smoking. Ordinal logistic regression was also to determine whethersmoking in the past 30 days was associated with the 8 domains/core concepts of media literacy which comprise the SML.

RESULTS: Smoking media literacy was lower among the Vietnamese adolescents than what has been previously reported inAmerican adolescents. Ordinal logistic regression analysis results showed that in the total sample SML was associated withreduced smoking, but there was no association with susceptibility to future smoking. Further analysis showed that resultsdiffered according to school and grade level. There did not appear to be association of smoking with the specificdomains/concepts that comprise the SML.

CONCLUSIONS: The association of SML with reduced smoking suggests the need for further research involving SML,including the testing of media literacy training interventions, in Vietnamese adolescents and also other populations ofadolescents.

Keywords: cigarette smoking; media literacy; tobacco use; Vietnam; tobacco marketing.

Citation: Page RM, Huong NT, Chi HK, Tien TQ. Smoking media literacy in Vietnamese adolescents. J Sch Health. 2011; 81:34-41.

Received on August 10, 2009Accepted on January 20, 2010

Media exposure to smoking contributes stronglyto adolescent smoking, whether the exposure

occurs in persuasive (eg, advertising and promotion)or in narrative contexts such as movies.1 TheWorld Health Organization Framework Conventionon Tobacco Control conceptualizes tobacco use as anepidemic spread by a number of complex factors,including ‘‘global marketing, trans-national tobaccoadvertising, promotion and sponsorship.’’2 Media is aprimary means of tobacco promotion and advertising.One common tactic of the tobacco industry is topromote cigarettes through the portrayal of smokingin movies.3 A recent review of the literature by

aProfessor, (randy [email protected]), Department of Health Science, BrighamYoung University, 221 Richards Building, Provo, UT 84602.bVice Head of the Faculty, ([email protected]), Department of Health Education, Faculty of Social Sciences, Behaviour, and Health Education, Hanoi School of Public Health, 138BGiang Vo, Hanoi, Vietnam.cFacilitator of Ethics in Public Health, ([email protected]), Department of Health Education, Faculty of Social Sciences, Behaviour, and Health Education, Hanoi School of PublicHealth, 138B Giang Vo, Hanoi, Vietnam.dDeputy Head of the Department, ([email protected]), Department of Health Education, Faculty of Social Sciences, Behaviour, and Health Education, Hanoi School of Public Health,138B Giang Vo, Hanoi, Vietnam.

Address correspondence to: Randy M. Page, Professor, (randy [email protected]), Department of Health Science, BrighamYoung University, 221 Richards Building, Provo, UT 84602.

Charlesworth and Glantz4 revealed several studiesshowing increases in the amount of smoking in moviesand reported strong empirical evidence indicatingthat smoking in movies increases smoking initiationamong US adolescents. Research by Worth et al5

shows 80-90% of all box-office hits that are viewedin many countries are produced and/or distributedby US media companies and 80% of these containportrayals of smoking behavior. A recent study byHanewinkel and Sargent6 appears to have importantglobal public health implications and specific possibleimpacts for adolescent smoking in specific countries.This study found that among German adolescents,

34 • Journal of School Health • January 2011, Vol. 81, No. 1 • © 2011, American School Health Association

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movie smoking exposure predicts smoking and thatmost of the exposure to smoking in movies comesfrom the viewing of internationally marketed moviesthat are produced and distributed by US mediacompanies. In addition to the portrayal of smokingbehavior, Hollywood movies also provide cigarettebrand appearances so that these brands are seen bymillions worldwide.7,8

Given the difficulty and infeasibility of reducingadolescents’ media exposure to smoking, media lit-eracy has been advocated as a supplementary andattractive public health strategy ‘‘to buffer the effectsof media messages on adolescent smoking.’’9 The focusof smoking media literacy (SML) is to teach young peo-ple to understand, analyze, and evaluate advertisingand other media messages about smoking. The acqui-sition of these skills facilitates active processing andcritical thinking of media messages rather than beingpassive message targets.9 Thus, the potential of medialiteracy is to prevent and reduce harmful health behav-iors, including smoking, that are promoted throughmedia.10,11 Research in this area has been limited bythe lack of a reliable, validated scale measuring theconstruct of SML in youth. As a result, Primack et al12

developed a theoretically based SML scale, which inte-grates two theoretical models of media literacy13,14 intoa comprehensive media literacy framework comprisedof the core domains/concepts exhibited in Table 1. Thefirst of these is Bazalgette’s media education modelthat emphasizes the following in the teaching of medialiteracy: the purposes of media producers, the char-acteristics of target audiences, that there are multiplecomplex production techniques and symbols used toconvey messages and meanings, and there is a com-plex relationship between media representation andsocial reality.13 Similarly, Thoman14 proposes thatmedia literacy emphasizes that media messages arecarefully constructed by media producers, different

Table 1. Media Literacy Domains and Core Concepts in theTheoretical Framework Used by Primack et al1 forDevelopment of the Smoking Media Literacy Scale

Media Literacy DomainsRelated Media Literacy

Core Concepts

Authors and audience (AA) AA1: Authors create media messages forprofit and/or influence

AA2: Authors target-specific audience

Messages and meanings (MM) MM1: Messages contain values and specificpoints of view

MM2: Different people interpret messagesdifferently

MM3: Messages affect attitudes andbehaviors

MM4: Multiple production techniques

Representation and reality (RR) RR1: Messages filter realityRR2: Messages omit information

individuals interpret different messages differently,messages contain inherent values and perspectives,and media messages are produced for profit orpower.

Primack et al12 found that adolescents’ overallSML score was independently associated with bothreduced adolescent smoking and reduced susceptibil-ity to future smoking in a sample of American highschool students. Controlling for a variety of potentialconfounders known to be associated with smoking,SML was independently associated with an odds ratiofor smoking of 0.84 and an odds ratio for smoking sus-ceptibility of 0.68. The association between smokingand SML scores was similar in magnitude to the asso-ciation between smoking and other factors thoughtto be important predictors of smoking including age,parental smoking, and grades. These authors commentthat the findings regarding SML are important froman educational standpoint because unlike factors suchas parental smoking and age, there is the potential toteach young people media literacy and thereby posi-tively influence smoking behavior and susceptibility.9

A follow-up study by Primack et al1 investigatedvarious components of the media literacy scale todetermine which might be associated with adolescentsmoking. These components, described as medialiteracy domains and core concepts, are identified andsummarized in Table 1. The authors-audiences (AA)domain examines the extent to which the tobaccoindustry is viewed as powerful and manipulative andfocuses its advertising and marketing efforts on specifictarget audiences, whereas the messages-meanings(MM) domain assesses the extent to which tobaccoadvertisements using appealing imagery, messages,and other means evoke emotional responses intarget audiences. Finally, the representation-reality(RR) domain examines the degree to which tobaccoadvertisements negate the true effects of tobacco useon health.

Despite the fact that the SML scale was foundto be independently associated with reduced currentsmoking in this one study of American high schoolstudents,9,12 there has not been any additional vali-dation of the SML or the SML construct in any otheradolescent populations. It is important to point out thatthe previously mentioned research with this scale wasconducted in an adolescent population drawn from asingle large US high school that was largely homoge-neous in terms of its racial and ethnic background,12

and more recently in a single American university.15

Thus, there is a need for additional validation andapplication of this scale in other diverse adolescentpopulations, and the scale authors stress that their find-ings should be confirmed in more diverse populations.9

With this in mind, this study investigates SML in asample of 2000 Vietnamese high school students. Thepurpose of this study was to assess SML with the SML

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scale and to determine its association with currentsmoking and susceptibility to future smoking in thesestudents. Based on the previous research with Ameri-can high school students, we hypothesized that medialiteracy scores would be associated with a decreasedlikelihood of current smoking, and that among non-smokers, those with higher media literacy would havea lower susceptibility to future smoking.

METHODS

SubjectsThe sample consisted of students in grades 10-12

in two high schools. The first school is in ThanhMien District (Hai Duong Province) and consists ofall the 1009 students in these grades and who were inattendance on the day the survey was administered.Hai Duong Province is a rural, agricultural provincein the northern river delta located 58 km from Hanoi.The province has 1.8 million people and the ThanhMien District has 131,000. This district is composed ofrural communities and rice production provides themain source of income for families. The area servingthe school is generally noted as poor, with the povertyrate estimated to be between 15% and 25%. Thereare high rates of malnutrition among children under5 years of age and women of reproductive age sufferfrom chronic energy deficit.16,17

The other school is in Hanoi which has apopulation estimated to exceed 6 million. This schoolis located in the Ba Dinh District, an urban, denselypopulated district characterized by middle to uppersocioeconomic status families and housing areas. Thestudy includes 991 students who were in 30 randomlyselected classes, representing half of the classes in theschool. These 991 students represent approximately47% of the total school population of 2110 students.This sampling procedure was used by the Vietnameseresearchers in order to obtain an equivalent numberof subjects from the Hanoi school as the Hai Duongschool. Thus, the sample consists of 2000 students,with 604 10th graders, 667 11th graders, and 728 12thgraders (1 did not report their grade level). The sampleincludes 858 males and 1005 females, and 137 who didnot report their gender. The mean age was 16.8 years(SD = 1.2), with a range of 15-19.

InstrumentsThe SML scale was obtained from the scale devel-

opers and its development is described in detail inthe literature.12 The construct of media literacy thatthe scale purports to measure is based on an inte-grated theoretical framework of media literacy thatemphasizes the following elements: (1) AA domain(recognition of the tobacco industry as powerful andmanipulative of particular target markets); (2) MM

domain (how marketers promote tobacco by usingappealing production techniques to evoke emotionalresponses); and (3) RR domain (understanding thedifference between what is represented in media andthe true effects of tobacco use on health). The scaleconsists of 18 Likert-type items (strongly disagree, dis-agree, agree, strongly agree) representing the threedomains described above related to both persuasivemedia (eg, advertisements) and narrative media (eg,films). Items were both general and smoking-specificitems. Examples of general media literacy items are‘‘People are influenced by TV and movies, whetherthey realize it or not’’ and ‘‘Advertisements usuallyleave out a lot of important information.’’ Examplesof smoking-specific items are ‘‘Certain cigarette brandsare designed to appeal to younger people’’ and ‘‘Mostmovies and TV shows that show people smoking makeit look more attractive than it really is.’’

The scale has been shown to have excellent inter-nal consistency reliability (Cronbach alpha = 0.87),strong content validity (items based on a frameworkintegrating models of media literacy and items repre-senting core concepts of the framework), and supportfor concurrent criterion validity. This support for valid-ity comes from the fact that higher scores on medialiteracy were found to be associated with lower smok-ing, less susceptibility to smoking, less positive attitudesabout smoking, and greater likelihood of antismokingnorms.12 Smoking media literacy scores are convertedto a 10-point scale by dividing the raw score for the54-point scale by 5.4.

Respondents were asked how many days theysmoked in the past 30 days. A current smoker wasdefined as having smoked on at least 1 day. Sus-ceptibility to future smoking was assessed with themeasurement technique developed by Pierce et al,18

which assesses ‘‘nonsusceptibility’’ as answering ‘‘def-initely no’’ to the following three items: (1) Do youthink that you will smoke a cigarette soon? (2) Doyou think you will smoke a cigarette in the next year?(3) If one of your best friends were to offer you acigarette, would you smoke it? A smoking suscep-tibility scale was also used in our analyses, whichranged from 0 (answering no to all three of thesequestions to 3 (answering definitely or probably yes toall three). Respondents were asked whether their par-ents smoked. Demographic information collected wasgender, grade level, and age. The survey also asked‘‘In general what grade do you get in school?’’ andstudents responded on a scale of 1-5 (with 5 being thehighest).

The survey instrument was translated from Englishinto Vietnamese and back translated into English toensure equivalence of the English and Vietnamese sur-vey versions. Before survey administration, the instru-ment was pilot tested in a classroom to ensure thatstudents clearly understood each item. The internal

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consistency reliability of the scale was 0.75 (Cronbachalpha) in our sample of 2000 Vietnamese students.

ProcedurePermission to conduct the study was sought and

obtained from school officials. Survey instrumentswere administered in classes to students in grades10-12 by Hanoi School of Public Health staff. Studentswere informed that their participation in the surveywas voluntary and that they could refuse to partici-pate if they desire. There were no reports of studentsdeclining participation. Students were also informednot to put their name on the survey questionnaire andto place their completed survey forms in an envelope,which was subsequently sealed by the staff adminis-tering the survey. This ensured that completed surveyswere not seen by teachers or other school personnel.In addition, teachers were not present in the classduring the questionnaire administration.

Data AnalysisCurrent smoking, susceptibility to future smoking,

and days smoked in the past 30 days were calculatedand chi-square tests were used to test for differencesbetween boys and girls on these variables. Ordinallogistic regression examined the relationship of SMLwith days smoked in the past 30 days and also sepa-rately for susceptibility to smoking in the future. Thelevels of days smoked in the past 30 days were 0 days,1-9 days, and 10 or more days. The levels of suscepti-bility to smoking were 0 (no susceptibility), 1, 2, and3 (high susceptibility). The models that examined theassociation of SML with these ordinal dependent vari-ables (days smoked in past 30 days and susceptibility tofuture smoking) also included gender, grade level, age,self-reported performance in school, parental smoking,and school (Thanh Mien vs Hanoi) as predictor vari-ables. Ordinal logistic regression was also conductedseparately for these ordinal dependent and predictorvariables according to school (Than Mien and Hanoi)and according to grade level (grade 10, grade 11, andgrade 12). Because there were only 8 female sub-jects who had smoked 1-9 days and only 5 femalesubjects who had smoked 10 or more days, ordinallogistic models run separately for males and femaleswere not meaningful. Ordinal logistic regression wasalso conducted in an effort to identify relationshipbetween days of smoking in the past 30 days and the8 domains/core concepts of media literacy (these areidentified in Table 1) with a model that also includedgender, grade level, age, self-reported performance inschool, parental smoking, and school (Thanh Mien vsHanoi) as predictor variables. These ordinal regressionanalyses were conducted and reported for the totalsample and in subsets of the sample in which SML was

previously found to be associated with days smoked inthe past 30 days (grade 10 and the Hanoi school).

RESULTS

Current smoking was higher among boys (9.2%)than girls (1.3%). Also, among nonsmokers, suscep-tibility to smoking in the future was higher in boys(47.6%) than girls (10.8%). Smoking behavior andsusceptibility to smoking in the future are presentedin Table 2.

The mean score on the SML scale was 5.69(SD = 1.19). Smoking media literacy scores differedsignificantly between boys (M = 5.59, SD = 1.27) andgirls (M = 5.77, SD = 1.30), when controlling forgrade level, age, and self-reported performance inschool, F(4, 1544) = 8.33, p = .0039. Smoking medialiteracy scores did not differ significantly between cur-rent smokers (M = 5.87, SD = 1.22) and nonsmokers(M = 5.68, SD = 1.44), when controlling for gen-der, grade level, age, and self-reported performancein school, F(5, 1543) = 1.68, p = .1949. Also, amongnonsmokers, there was no significant difference inSML between those susceptible to smoking in thefuture (M = 5.69, SD = 1.32) and those not suscepti-ble (M = 5.68, SD = 1.18), when controlling also forgender, grade level, age, and self-reported performancein school, F(5, 1544) = 0.00, p = .9491.

Ordinal logistic regression showed that SML wasa significant predictor of days smoked in the past30 days, but not of susceptibility to future smoking,when entered into models along with gender, gradelevel, age, self-reported performance in school, school

Table 2. Smoking Behavior and Susceptibility to FutureSmoking

Boys% (n)

Girls% (n)

Significanceχ2 (df), p

Current smoking∗ 9.2 (79)† 1.3 (13) 62.0 (1), p < .0001Susceptibility to future

smoking∗,†47.6 (408) 10.8 (108) 3.13 (1), p < .0001

Daily smoking∗ 3.0 (26) 0.3 (3) 22.5 (1), p < .0001Smoked a cigarette at 12 years

of age or younger∗12.8 (110) 2.0 (20) 83.6 (1), p < .0001

Ever tried smoking∗ 28.6 (245) 6.6 (66) 161.6 (1), p < .0001Days smoked in the past

30 days∗62.8 (2), p < .0001

0 days 90.5 (774) 98.6 (991)1-9 days 4.6 (39) 0.9 (8)10 or more days 4.9 (42) 0.5 (5)

Level of susceptibility to futuresmoking∗,†

265.5, p < .0001

0 57.2 (444) 90.3 (896)1 5.8 (102) 4.4 (44)2 13.1 (107) 2.3 (23)3 15.9 (123) 2.9 (2)

∗Boys and girls differed significantly (p < .05) on chi-square test.†Among current nonsmokers.

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Table 3. Ordinal Logistic Regression for Days Smoked in thePast 30 Days and Susceptibility to Future Smoking andSmoking Media Literacy and Other Predictors

Predictor

OR (95% CI) fordays smoked in

past 30 days∗

OR (95% CI) forsusceptibilityto smoking†

Gender (male vs female) 8.58 (4.32, 17.04) 7.44 (5.56, 9.96)Age 2.13 (1.19, 3.80) 1.16 (0.79, 1.71)Grade level (11 vs 10) 1.85 (0.80, 4.27) 1.17 (0.71, 1.94)Grade level (12 vs 10) 4.76 (0.86, 26.39) 1.19 (0.37, 3.78)School (Thanh Mien vs Hanoi) 1.30 (0.77, 2.18) 1.02 (0.78, 1.33)Parental smoking (Yes vs No) 2.33 (1.36, 4.01) 1.26 (0.97, 1.63)School performance (reported) 1.63 (1.23, 2.16) 1.09 (0.93, 1.29)SML as a continuous variable (1

point on a 10-point scale)0.79 (0.64, 0.97) 0.93 (0.83, 1.03)

OR, odds ratio; CI, confidence interval.∗0 days, 1-9 days, 10 or more days.†Among current nonsmokers, on ordinal scale 0 (not susceptible), 1, 2, or 3 (highestsusceptibility).

(Thanh Mien vs Hanoi), and parental smoking as otherpredictors (Table 3). The other significant predictors fordays smoked in the past 30 days were gender (male vsfemale), age, grade level, self-reported performance inschool, and parental smoking. Of the variables in theordinal logistic model predicting susceptibility to smok-ing, only gender was a significant predictor. Smokingmedia literacy was associated with days smoked inthe Hanoi school, but not the Thanh Mien school(Table 4). Table 4 also identifies that SML was associ-ated with days smoked in grade 10, but not in grades11 and 12. Gender was the only variable that wasconsistently associated with days smoked across bothschools and all three grade levels. Parental smokingwas highly associated with smoking among Hanoi stu-dents, but not among Thanh Mien students. Ordinallogistic regression analyses, which included the specificdomains/core concepts of media literacy for the totalsample, Hanoi students, and grade 10 students, withone exception, failed to identify associations with daysof smoking. Among grade 10 students, the domainof authors targeting specific audiences was associatedwith fewer days of smoking (Table 5).

DISCUSSION

This study stems from the previous work byPrimack et al12 on the construct of SML in adolescents;through theoretical modeling, scale development, itemrefinement, and scale validation, these researchersidentified SML to be independently associated withsmoking status and susceptibility to future smokingin an American sample of adolescents.1 This studyinvolving Vietnamese adolescents moves forward theresearch involving this construct of SML to a non-Western population of youth.

We found SML to be lower in the Vietnamesestudents (M = 5.7, SD = 1.2) than was found inPrimack et al’s9 study of SML conducted in a suburbanPittsburgh, PA (United States) high school (M = 6.8,SD = 1.3). This may imply that Vietnamese studentsare less likely than their US counterparts to engagein critical thinking and active mental processing aboutmedia’s role in the promotion of cigarette smoking. Itmay also signal that perhaps that these Vietnameseyouth are less likely to have been exposed to orencouraged to apply critical thinking strategies inschools and/or other settings.

Similar to the previous SML research in the UnitedStates,9 we found reduced smoking (days smokedin the past 30 days) in the Vietnamese studentsto be independently associated with the SML scaletotal score and the magnitude of the association(OR = 0.79) was similar to what was observed in theUS sample (OR = 0.80). A closer examination of thesmoking-SML association revealed strong and inde-pendent associations among students in the Hanoischool (OR = 0.65) and in grade 10 across the twoschools (OR = 0.46), but no association in the ThanhMien school and across the grade 11 and grade 12students. It is interesting that smoking and SML wasassociated in a school representing students of urbanand middle-high socioeconomic status, but not in theThanh Mien school, which is located in a poor, rural,agrarian area of North Vietnam. It should be pointedout that the two schools did not differ in terms of mean

Table 4. Ordinal Logistic Regression Predicting Number of Days Smoked in Past 30 Days According to School and Grade Level

PredictorHanoi SchoolOR (95% CI)

Thanh Mien SchoolOR (95% CI)

Grade 10 OR(95% CI)

Grade 11 OR(95% CI)

Grade 12 OR(95% CI)

Gender (male vs female) 3.61 (1.55, 8.41) 57.69 (7.84, 424.62) 9.40 (1.84, 48.06) 9.09 (2.61, 31.67) 7.84 (2.93, 20.92)Age 2.58 (0.37, 17.84) 2.15 (1.12, 4.16) 1.04 (0.32, 3.33) 5.92 (1.02, 34.3) 6.04 (2.06, 17.69)Grade level (11 vs 10) 2.15 (0.25, 18.56) 3.24 (0.77, 6.50) NA NA NAGrade level (12 vs 10) 11.86 (0.33, >999.99)∗ 3.24 (0.51, 20.46) NA NA NASchool (Thanh Mien vs Hanoi) NA NA 1.18 (0.62, 2.22) 2.12 (0.82, 5.46) 1.15 (0.51, 2.59)Parental smoking (Yes vs No) 25.93 (3.47, 193.72) 1.10 (0.53, 2.06) 3.09 (0.95, 0.95, 10.02) 2.58 (0.94, 7.05) 1.74 (0.78, 3.90)School performance (reported) 1.84 (1.26, 2.68) 1.28 (0.84, 1.94) 2.15 (1.32, 3.50) 1.18 (0.62, 2.22) 1.61 (1.03, 2.53)SML as a continuous variable

(1 point on a 10-point scale)0.65 (0.49, 0.87) 0.96 (0.73, 1.27) 0.46 (0.30, 0.70) 0.98 (0.68, 1.41) 0.90 (0.66, 1.23)

OR, odds ratio; CI, confidence interval; NA, not applicable.∗Low cell size resulted in inestimable OR.

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Table 5. Ordinal Logistic Regression Number of Days Smoked in Past 30 Days With Smoking Media Literacy Scale Domains/CoreConcepts and Other Predictors for Total Sample, for Hanoi School, and for Grade 10

Domain/Related Core Concept or OtherPredictor Variables Total Sample OR (95% CI) Hanoi School OR (95% CI) Grade 10 OR (95% CI)

Gender (male vs female) 7.75 (3.83, 15.66) 3.29 (1.40, 7.72) 8.22 (1.58, 42.71)Age 2.63 (1.38, 4.98) 3.20 (0.39, 25.87) 1.39 (0.39, 4.89)Grade level (11 vs 10) 3.10 (1.24, 7.75) 3.37 (0.32, 35.59) NAGrade level (12 vs 10) 10.89 (1.63, 72.94) 28.82 (0.05, >.999.99)∗ NASchool (Thanh Mien vs Hanoi) 1.16 (0.66, 2.04) NA 1.07 (0.31, 3.61)Parental smoking (Yes vs No) 3.18 (1.72, 5.84) 14.75 (3.40, 63.93) 3.81 (1.01, 14.43)School performance (reported) 1.91 (1.41, 2.58) 1.97 (1.34, 2.91) 2.29 (1.38, 3.81)AA1: Authors create media messages for profit and/or influence 0.86 (0.67, 1.09) 0.84 (0.59, 1.18) 0.88 (0.52)AA2: Authors target-specific audience 0.82 (0.65, 1.05) 0.77 (0.54, 1.09) 0.54 (0.32, 0.91)MM1: Messages contain values and specific points of view 0.85 (0.69, 1.06) 0.99 (0.73, 1.34) 1.02 (0.67, 1.58)MM2: Different people interpret messages differently 1.15 (0.91, 1.44) 1.23 (0.89, 1.71) 1.20 (0.75, 1.93)MM3: Messages affect attitudes and behaviors 0.99 (0.83, 1.18) 0.91 (0.70, 1.17) 0.76 (0.52, 1.18)MM4: Multiple production techniques 1.06 (0.91, 1.24) 1.03 (0.84, 1.27) 1.15 (0.85, 1.56)RR1: Messages filter reality 0.89 (0.75, 1.06) 0.84 (0.64, 1.08) 0.81 (0.55, 1.19)RR2: Messages omit information 0.97 (0.82, 1.15) 1.05 (0.84, 1.31) 0.94 (0.64, 1.36)

OR, odds ratio; CI, confidence interval; NA, not applicable.∗Low cell size resulted in inestimable OR.

scores on the SML scale, but there was a higher rateof current smokers in Thanh Mien (6.4%) than Hanoi(3.9%). The finding of association among grade 10students, but not grade 11 and grade 12, is also inter-esting and suggests that media literacy might exert agreater ‘‘protective’’ influence on smoking behaviorbefore grade 11 in this population.

Unlike the US study, SML was not associated withsusceptibility to smoking among the Vietnamese non-smoking students. This finding is difficult to interpretin light of the fact that little is presently known aboutwhy some adolescents are ‘‘susceptible’’ while othersare not and a general scarcity of research concerningthis construct.19 Susceptibility is conceptualized as anearly stage in the process of moving from a nonsmokerto a smoker, but little is also known about the varianceof susceptibility to smoking across different popula-tions of youth and it is well recognized that youthsmoking initiation is a complex phenomenon deter-mined by a multitude of factors.20 It has been suggestedthat effective media literacy may require actual lifeexperience or personally acquired information beforeone can effectively analyze media messages. Becausethose susceptible to smoking may lack actual life expe-rience or generally be naive about cigarette smokingmight be one explanation for the lack of associationfound in this study. However, this does explain thediscrepancy between the previous finding in Ameri-can students showing association of susceptibility withSML and the lack of association in the Vietnamesestudents. Certainly more research is needed to helpexplore this issue.

The SML research in the United States found thatreduced smoking was highly associated with the RRdomain and core concepts, and not with the author-audience and MM domains/concepts.1 In contrast, we

did not find association of smoking with any of thedomains/concepts in the total sample, but did find ingrade 10 that reduced smoking was associated withthe authors’ target-specific audiences core concept.Thus, these findings concerning the media literacydomains/core concepts differ from the only previousresearch conducted to date available for comparison,which has attempted to examine these constructs.

Our findings showing a low level of media literacyin comparison with adolescents in the United Statesand a different pattern of association with smokingbehavior and susceptibility to smoking are difficult tointerpret because of the myriad of differences betweenthese two adolescent populations (eg, differencesin media exposure to smoking, school/educationalsystems, teaching styles, cultural norms, and smok-ing norms). There are likely important differences inthe amount and types of media exposure about smok-ing between the two populations, and the relationshipbetween this exposure and the development of medialiteracy needs to be explored in future research. How-ever, it is important to point out that based on datafrom the Global Youth Tobacco Survey (GYTS) con-ducted in Vietnam in 2007, Vietnamese youth reportfrequent exposure to media promoting and depict-ing smoking.21 When watching TV, videos, or movies,37% said that they see actors smoking a lot and another52% said they see this depiction of smoking some-times. In the GYTS, Vietnamese youth also frequentlyreported that they: see cigarette brand names whenwatching sports events or other programs on TV, seeadvertisements for cigarettes on billboards, see adver-tisements or promotions for cigarettes in newspapersor magazines, and possess items (eg, T-shirts, pen, andbackpacks) with a cigarette logo.

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Another important area of difference between theprevious research on SML conducted in the UnitedStates and this study in Vietnam is in the area ofsmoking norms, as there is a relatively low preva-lence of smoking among Vietnamese students. Incontrast to the American study in which 19% of thesubjects were current smokers,12 we found currentsmoking among 9.2% of male students and 1.3% offemale students. Incidentally, this smoking prevalenceis nearly identical to what has been found in previousresearch in Vietnam in the GYTS, which found 9.1%of Vietnamese male and 1.5% of female students tohave smoked in the past 30 days.22 Unfortunately,smoking rates escalate among Vietnamese males bythe time of adulthood while they have remained lowamong adult females. The National Health Survey23

in 2002 found that 56% of adult men and 1.8%of adult women smoke regularly and the VietnamLiving Standard Survey (1997)24 found that 50% ofVietnamese men and 3.5% of Vietnamese womensmoked.

Although the focus of this study has been on theassociation of SML and smoking, it is important topoint out that gender, grade level, parental smoking,and age were found to be strong predictors of adoles-cent smoking. These are important findings becausethere is essentially no previous research reportedin the international literature investigating determi-nants of smoking among Vietnamese youth. Researchinvestigating the determinants of youth smoking canhelp to inform smoking prevention efforts. The lowrates of smoking among adolescent females shouldnot lull school health professionals into a false senseof security, as multinational tobacco companies areincreasingly targeting young Southeast Asian femalesto smoke. Therefore, vigilant efforts need to be under-taken to prevent young Vietnamese women fromtaking up the smoking habit, so that smoking ratesdo not climb upward. Unfortunately, predictors suchas gender, grade level, parental smoking, and age arenot amenable to intervention. For this reason, researchinvolving a factor potentially amenable to change, suchas media literacy that is practical to teach to youngpeople, in school and other community settings, is animportant line of research.

LimitationsThere are important limitations in this study that

deserve mention. Although the survey instrument wastranslated from English to Vietnamese and then backto English to ensure that items were equivalent andpilot tested for understanding with Vietnamese stu-dents, it is possible that there were differences ininterpretation by the Vietnamese students. The factthat the internal consistency reliability of the scalewas lower in the Vietnamese sample (0.75) than in

the US sample (0.87) could be a function of culturalor other differences in interpretation and response toitems. Also, the media environment in which the SMLscale was developed (eastern United States) may besubstantially different than in Vietnam, where thereis likely to be differences in persuasive and narrativemedia exposure regarding tobacco products. Anotherlimitation concerns the cross-sectional study designof this exploratory and descriptive study. This design,while making it possible to determine associationsbetween SML and smoking outcomes, cannot deter-mine causation. Future research will be enhancedthrough surveying students at more than 1 point intime and through the introduction and testing of SMLinterventions in order to conclusively answer whetheryouth with different levels of SML will have differentrates of initiating the use of cigarettes.9 This studyis also limited by the fact that the survey was onlyadministered in 2 schools and these schools may not berepresentative of other Vietnamese secondary schools.Future research focusing on SML in Vietnam wouldprofit by including students from a greater and widerrange of schools to increase the generalizability of studyfindings.

IMPLICATIONS FOR SCHOOL HEALTH

On the basis of the findings from this study, it ispremature to firmly advocate for adding media liter-acy training to smoking prevention efforts in Vietnamin school- and community-based settings. However,because SML was found to be associated with reducedsmoking, we believe that further studies utilizingmore sophisticated research designs and the introduc-tion and testing of media literacy training interven-tions should be conducted in Vietnam. Furthermore,additional studies of SML need to be initiated andconducted in various additional populations of adoles-cents. Media literacy appears to be an attractive addi-tion to established health promotion efforts designedto impact youth smoking and is gaining support as apreventative strategy, yet unfortunately, to date therehas been limited research about the SML construct.11

As a result, we advocate for school health professionalsin the United States, Vietnam, and other areas of theworld to include SML as a potential enhancing factorin efforts to advance smoking prevention.

Media literacy takes into account how media influ-ence youth and how youth can actively negotiate themeaning of messages by questioning and challeng-ing assumptions and assertions portrayed in media.10

Media literacy has the potential to be effective amongvarious populations of youth because it moves awayfrom attempts to scare or persuade young peopleinto healthy attitudes and behaviors, to concentrateinstead on helping youth develop skills for better deci-sion making. Pinkleton et al11 explained that helping

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young people build their own resistance to persuasivemessages via media literacy training may provide animportant bridge to better decision making regardinghealth-related behaviors.

Previous research supports the theoretical foun-dations of SML.15 For example, smoking preventionefforts are likely to be enhanced when educationalmessages taken into account that tobacco mediamessages are created by tobacco companies to gainprofit and/or for influence and there is an emphasison the tobacco industry as powerful and manipu-lative. The theme of tobacco industry power andmanipulation has been used in the United Statesin statewide media and countermarketing campaignssuch as those employed in Florida, Massachusetts,and California25 and these tobacco prevention mes-sages appear to be effective in fostering negativeattitudes about the industry and lower levels of smok-ing among adolescents.26 It has been suggested thateducational and communication messages that focuson how the tobacco industry manipulates people maybe effective in ‘‘breaking down’’ the forces that ofteninfluence youth to smoke such as rebelliousness andindependence.26 Recent research involving an inter-vention of media literacy in Washington demonstratedthat improving media literacy improved smoking out-comes in both youth naive to smoking and experiencedsmokers.26

Human Subjects Approval StatementThis research was approved by the Brigham Young

University institutional review board.

REFERENCES

1. Primack BA, Hobbs R. Association of various components ofmedia literacy and adolescent smoking. Am J Health Behav.2009;33(2):192-201.

2. Shibuya K, Ciecierski C, Guindon E, Bettcher DW, Evans DB,Murray CJ. WHO Framework Convention on Tobacco Control:development of an evidence based global public health treaty.BMJ. 2003;327:154-157.

3. Mekemson C, Glantz SA. How the tobacco industry built itsrelationship with Hollywood. Tob Control. 2002;11(suppl 1):i81-i91.

4. Charlesworth A, Glantz SA. Smoking in the movies increasesadolescent smoking: a review. Pediatrics. 2005;116:1516-1528.

5. Worth K, Tanski S, Sargent JD. Trends in Top Box Office MovieTobacco Use 1996-2004. Washington, DC: American LegacyFoundation; 2006.

6. Hanewinkel R, Sargent JD. Exposure to smoking in interna-tionally distributed American movies and youth. Pediatrics.2008;121:e108-e117. DOI: 10.1542/peds.2007-1201.

7. Adachi-Mejia AM, Dalton MA, Gibson JJ, et al. Tobacco brandappearances in movies before and after the master settlementagreement. JAMA. 2005;293:2341-2342.

8. Sargent JD, Tickle JJ, Beach ML, Dalton MA, Ahrens MB,Heatherton TF. Brand appearances in contemporary cinemafilms and contribution to global marketing of cigarettes. Lancet.2001;357:29-32.

9. Primack BA, Gold MA, Land SR, Fine MJ. Association ofcigarette smoking and media literacy about smoking andliteracy. J Adolesc Health. 2006;39:465-472.

10. Gonzales R, Glik D, Davoudi M, Ang A. Media literacy andpublic health: Integrating theory, research, and practice fortobacco control. Am Behav Sci. 2004;48(2):189-201.

11. Pinkelton BE, Austin EW, Cohen M, Miller A, Fitzgerald E. Astatewide evaluation of media literacy training to preventtobacco use among adolescents. Health Commun. 2007;21(3):23-34.

12. Primack BA, Gold MA, Switzer GE, Hobbs R, Land SR, Fine MJ.Development and validation of a smoking media literacy scalefor adolescents. Arch Pediatr Adolesc Med. 2006;160:369-374.

13. Bazalgette C. Key aspects of media education. In: Alvarado M,Boud-Barett O, eds. Media Education: An Introduction. London:British Film Institute; 2002:198-219.

14. Thoman E. Skills and Strategies for Media Education. Santa Monica,CA: Center for Media Literacy; 2003.

15. Primack BA, Sidani J, Carroll MV, Fine MJ. Associationsbetween smoking and media literacy in college students.J Health Commun. 2009;14:541-555.

16. Khan NC, Thanh HTK, Berger J, et al. Community mobiliza-tion and social marketing to promote weekly iron-folic acidsupplementation: a new approach. Nutr Rev. 2005;63(12);S87-S94.

17. Cuong DV, Cuong VD. The improvement of micronutrientstatus of women of reproductive age in Thanh Mien District,Hai Duong Province. Vietnam J Sci Edu. 2001;11:45-46.

18. Pierce JP, Choi WS, Gilpin EA, Farkas AJ, Berry CC. Tobaccoindustry promotion of cigarettes and adolescent smoking.JAMA. 1996;279:511-515.

19. Chen W, Bottorff JL, Johnson JL, Saewyc EM, Zumbo BD. Sus-ceptibility to smoking among White and Chinese nonsmokingadolescents in Canada. Public Health Nurs. 2007;25(1):18-27.

20. Unger JB, Rohrbach LA, Cruz TB, Baezconde-Garbanti L,Howard KA, Palmer PH. Ethnic variation in peer influenceson adolescent smoking. Nicotine Tob Res. 2001;3(2):167-176.

21. Regional Office of the Western Pacific. Codebook for the 2007GYTS in Vietnam All Schools Regions 2-10. Manila, Philippines:World Health Organization; 2007.

22. Regional Office of the Western Pacific. The 2003 GYTS inVietnam: A Preliminary Report. Manila, Philippines: World HealthOrganization; 2003.

23. Ministry of Health. Vietnam National Health Survey: A PreliminaryReport. Hanoi, Vietnam: Ministry of Health; 2003.

24. Bales S, Kinh VK. An Empirical Analysis of Smoking using theVietnam Living Standard Survey; 2000. Report submitted to theWorld Bank.

25. Farrelly MC, Niederdeppe J, Yarsevidh, J. Youth tobacco pre-vention mass media campaigns: past, present, and futuredirections. Tob Control. 2003;12(suppl I):i35-i47.

26. Thrasher JF, Niederdeppe JD, Jackson C, Farrelly MC. Usinganti-tobacco industry messages to prevent smoking amonghigh-risk adolescents. Health Educ Res. 2006;21(3):325-337.

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