The Journal of School Nursing2024, Vol. 40(4) 391–400© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221112105journals.sagepub.com/home/jsn
Abstract
Studies on how smoking media literacy (SML) is associated with susceptibility to smoking among adolescents in South Korea and Vietnam are scarce. Thus, we examined the association of SML with susceptibility to smoking among adolescents in these countries to initiate a collaborative global health program. In total, 460 adolescents (Vietnam: 277, South Korea: 183) aged 15–18 completed an online cross-sectional survey. SML was measured using the 15-item SML scale. Susceptibility to smoking was measured by three questions on future smoking and if offered a cigarette by a friend. A multiple logistic regression model explored the association of SML with susceptibility to smoking. The study revealed that higher SML was significantly associated with lower susceptibility to smoking among Vietnamese, but not South Korean adolescents. Further studies to identify pathways between other factors associated with SML and susceptibility to smoking are needed to develop culture-specific intervention strategies for smoking prevention.
Keywordssmoking, media literacy, smoking media literacy, smoking susceptibility, association
Smoking is a well-known risk factor for non-communicable diseases, with attention being focused on reducing its global prevalence (World Health Organization, 2019a). Smoking prevention in adolescents is important because of the high likelihood that it will lead to adult smoking; moreover, longterm smokers are greatly dependent on nicotine, a craving that requires tremendous effort to overcome (Park et al., 2017). Particularly, adolescents should pay attention to smoking prevention with regard to social media because social media is their main means of communication through which they will be more likely to be exposed to content that encourages smoking, such as online cigarette advertising and cigarette sales (Vogel et al., 2020).
Adolescent smoking is a major public health issue in Vietnam and South Korea (hereafter Korea). Vietnam is now a middle-income country with a high prevalence— 24.9% (males 46.1%, females 3.1%)—of tobacco use, including cigarette use (World Health Organization, 2019b). A recent nationwide survey of 13–15-year-olds in Vietnam revealed that 11.2% (boys 15.3%, girls 7.5%) of the respondents reported that a friend had recommended smoking or that they wanted to smoke within the next year (Hoang et al., 2019). The current smoking prevalence among youth in Korea was 6.0% in males and 2.7% in females in 2020, a marked decrease from 17.2% in males and 6.5% in females in 2011 (Korea Centers for Disease Control and Prevention, 2020). However, the smoking cessation attempt rate of current smokers did not change significantly from 69.5% in 2011 to 69.4% in 2020 (Korea Centers for Disease Control and Prevention, 2020). Therefore, there is a need to identify the factors affecting smoking among Vietnamese and Korean adolescents. As Vietnamese women account for the largest proportion of married immigrants in Korea, a study comparing the factors influencing smoking in these countries has implications as evidence for initiating a collaborative global health program. In addition, understanding the impact of sociocultural context on smoking behavior in these two countries would help school nurses design culturally congruent interventions for preventing smoking in immigrant adolescents living in host countries such as the USA, as studies have shown that Korean Americans (20%) and Vietnamese (16.3%) adults had the highest smoking rates among Asian American population from 2010 to 2013 (Martell et al., 2016).
Smoking media literacy (SML) refers to understanding, analyzing, appraising, and interpreting media messages about smoking, thereby making one less accepting of messages that promote smoking (Office of National Drug Control Policy., 2001). A high SML contributes to lower susceptibility to smoking, reflecting future smoking intention through decreased receptiveness to messages encouraging smoking (Sudo & Kuroda, 2017). More than half of the initial smoking experience in adolescence is related to exposure to smoking scenes in media (Dalton et al., 2003). The average internet usage rate in 2018 was 70.3% in Vietnam and 96% in Korea (International Telecommunication Union, 2020). Even in Vietnam, the risk of being exposed to smoking messages through new media such as social media is increasing as smartphones become the main means of communication for teenagers. Because this population is heavily dependent on the internet to access information at earlier stages of their lives, SML is considered a popular and effective approach for smoking prevention among adolescents (Primack et al., 2006; Shensa et al., 2016).
In addition, smoking attitudes and smoking-related normative beliefs have been shown to affect future smoking (Rhodes & Ewoldsen, 2009). According to the theory of planned behavior, the intention that causes planned action is affected by attitudes, subjective norms, and perceived behavioral control (Ajzen, 1991). Adolescents’ attitudes and norms about smoking (Elmore et al., 2017) are affected positively or negatively by adopting, internalizing, and perceiving personal relevance to the intended messages of media products, as proposed in the Message Interpretation Process Model (Austin, 2007). A meta-analysis of 15 studies supports the role of adolescents’ media literacy in changing their attitudes and intentions toward risky health behaviors including smoking (Vahedi et al., 2018). Considering the extent of media exposure adolescents experience currently, media, specifying the role of smoking attitudes and normative beliefs about smoking on the relationship between SML and future smoking may contribute to understanding the mechanisms of smoking initiation in adolescents.
Thus, a study that not only considers the smoking attitudes and normative beliefs about smoking but also understands SML and its impacts on susceptibility to smoking in adolescents from Vietnam and Korea is needed. Susceptibility to smoking is a valid factor that more strongly predicts future smoking behavior than does having smokers among family members or close friends (Cole et al., 2019; Pierce et al., 1996; Strong et al., 2015). Understanding the factors that influence adolescent susceptibility to smoking could help researchers develop more culturally appropriate interventions to reduce smoking behaviors that are specific to adolescents. In addition, because the most marriage migrants in Korea are Vietnamese women, this study might have implications for researchers and public health practitioners to integrate cultural contexts across both countries to help develop policies for immigrants.
This preliminary comparative study was conducted by international scholars from Vietnam, the United States, and Korea to initiate a collaborative global health program and relevant policies to prevent future smoking behavior among adolescents in Korea and Vietnam. It aims to explore the differences in the level of SML and the association with susceptibility to smoking, which is widely used as a measure of smoking intention among adolescents. The specific aim was to compare the level of SML and susceptibility to smoking of Vietnamese and Korean adolescents, and to compare the association between SML and susceptibility to smoking in these two countries in terms of sociocultural context including smoking attitudes and smoking-related normative beliefs.
This comparative study aimed to understand the influence of SML on smoking behavior among Vietnamese and Korean adolescents. The Vietnamese adolescent participants were tenth-grade students from two conveniently selected high schools located in Quảng Trị Vietnam. Out of 300 adolescents who agreed to voluntarily participate in the study, 294 students (98%) completed the online survey. The data of Korean adolescent samples analyzed in this study were derived from an earlier online survey of 215 Korean adolescents from five different high schools living in Seoul, Korea, conducted between August 4 and 21, 2020 (Kim et al., 2021). Informed consent for secondary use of the data was obtained from the Korean participants (IRB No.Y-2020-0066). Current smokers (Korea: 7, Vietnam: 2) and adolescents who reported having experienced smoking (Korea: 25, Vietnam: 15) were excluded to measure study participants’ susceptibility to smoking. Finally, 183 Korean and 277 Vietnamese adolescents were included in this analysis.
In this study, tools measuring SML, susceptibility to smoking, smoking attitudes, and normative beliefs were used. For the Vietnamese version of the instruments, the SML tools and survey items related to susceptibility to smoking (Kim et al., 2021; Pierce et al., 1996), smoking attitudes (Kim & Choi, 2017), and normative beliefs (Ra & Cho, 2018) were translated from Korean to Vietnamese, following the process of the Guidelines for Tool Translation and Application to ensure accuracy and cultural appropriateness in the Vietnamese cultural context (World Health Organization, 2015). First, a public health professor who was fluent in both Korean and Vietnamese performed forward translation from Korean to Vietnamese. Second, another professor who was also fluent in Korean and Vietnamese, and had never seen the original Korean tools, performed backward translation from Vietnamese to Korean. Third, the final consensus translation of the SML and susceptibility to smoking tools into Vietnamese was reviewed by a forward translator, a backward translator, a public health professor, and the co-authors who compared the original tools and the reverse translation to confirm and supplement the parts with different meanings. Finally, pre-testing was conducted. Eight tenth-grade students voluntarily responded via online survey and text message from June 28 to July 3, 2021. No changes were made to the final versions after evaluating whether students adequately understood the meaning of the translated tools and they were deemed appropriate for Vietnamese culture. For the Korean version of the instruments, the SML tools (Primack et al., 2006) and survey items on susceptibility to smoking (Cole et al., 2019; Pierce et al., 1996) were translated from English to Korean in the same way, following the process of the Guidelines for Tool Translation and Application (Kim et al., 2021). Pre-testing was also conducted, via an online survey of six students, and no further amendments were made.
After excluding current smokers, susceptibility to smoking was assessed, and smoking was defined as the use of any tobacco product (cigarettes, heat-not-burn tobacco products, liquid e-cigarettes, etc.). Susceptibility to smoking was measured using three survey items including “Do you think you will try a cigarette soon?”, “If one of your best friends were to offer you a cigarette, would you smoke it?”, and “Do you think you will be smoking cigarettes 1 year from now?” (Cole et al., 2019; Pierce et al., 1996). Each item was rated on a 4-point Likert scale (1 = will definitely smoke, 2 = will probably smoke, 3 = will probably not smoke, 4 = will definitely not smoke). Those who did not respond “will definitely not smoke” to even one item were considered to be susceptible to smoking.
SML was measured using the Korean version of the SML scale for adolescents developed by Kim et al. (2021). This tool in Korean was validated by modifying the original SML tool, which was developed by Primack et al. (2006). It consists of 15 items: 3 items on “Authors/Audiences” (e.g., “tobacco companies only care about making money.”), 9 items on “Messages/Meanings” (e.g., “social media [YouTube, Instagram, etc.] cigarette promotion link smoking to natural things that humans want like love, good looks, and power.”) and 3 items on “Representation/Reality” (e.g., “social media [YouTube, Instagram, etc.] cigarette promotion show green, natural, healthy scenes to make people forget about the health risks.”). Each item was rated on a 4-point Likert scale (0 = strongly disagree, 3 = strongly agree), then divided by 4.5 to convert it to a 10-point scale. High scores indicate higher SML level. The Cronbach’s α, representing reliability, was .87 in the original tool (Primack et al., 2006) and .71 among the Korean adolescents and .72 among Vietnamese students in this preliminary study.
Smoking attitudes was measured using the Korean version of the instrument modified by Kim and Choi (2017) from the smoking attitudes tool originally developed by de Vries et al. (2003). It consists of 12 items on the benefits and disadvantages of smoking (e.g., “Smoking is bad for my health”, “If I smoke, it will make me relax”). Each item was rated on a 5-point Likert scale (1 = definitely yes, 5 = definitely not). The Cronbach’s α of this tool was .83 in the original tool (de Vries et al., 2003) and 0.63 among the Korean adolescents, and .70 among Vietnamese students in this study.
Normative beliefs attitudes were measured using the Korean version of the tool modified by Ra and Cho (2018) from the normative beliefs involving smoking tool originally developed by Primack et al. (2007). The tool measuring normative beliefs involving smoking consists of three subscales, including 3 items on perceived prevalence of smoking (e.g., “What percentage of middle school students smoke cigarettes?”), 3 items on disapproval of smoking by parents/peers (e.g., “According to my parents, it is very important for me to not smoke cigarettes.”), and 4 items on perceived popularity of smoking among successful/elite people (e.g., “Most successful businesspeople smoke cigarettes.”). The first subscale of perceived prevalence of smoking was measured on a 10-point interval scale from 0 to 100 and the other subscales of perceived disapproval of parents/peers and perceived popularity of successful/elite people were rated on a 4-point Likert scale. The Cronbach’s α was .82 for the perceived prevalence of smoking, .67 for the perceived disapproval of parents/peers, and .67 for the perceived popularity of successful/elite people in the original instrument (Primack et al., 2007). In this study, the Cronbach’s α was .92, .79, and .66, respectively among Korean adolescents, and .85, .87, and .53, respectively among Vietnamese students.
Sociodemographic variables including age, sex, father’s education, mother’s education, smoking experience, parents’ smoking experience, friends’ smoking experience, and daily smartphone and computer usage as well as key variables were self-reported.
The Vietnam data was collected from July 24 to August 4, 2021. Teachers of the two high schools, who were trained by the research team, explained the aim, method, and process of the study to the students and their parents. A total of 300 students and parents voluntarily submitted a consent form. The online survey link was then sent to the mobile phone number recorded in the consent form. The Korean data were likewise collected via the online survey from five high schools in the capital city of Korea. More detailed information on Korean data collection was described elsewhere (Kim et al., 2021). This study was approved by the Institutional Review Board at Yonsei University (IRB No. 4-2021-0334).
We used the means (±standard deviation) to describe continuous variables with normal distribution and frequency (%) to describe categorical variables. The differences in variables according to susceptibility to smoking were analyzed using the two-sample t-test for continuous variables and the chi-square test or Fisher’s exact test for categorical variables. The overall association of SML with susceptibility to smoking among Vietnamese and Korean adolescents was analyzed using multiple logistic regression models sequentially adjusted for covariates. In Model 1, we adjusted for sociodemographic factors such as age, father’s education, parents’ smoking experience, friends’ smoking experience, and daily usage of smartphone and computer. In Model 2, we also adjusted for smoking attitude. In Model 3, we additionally adjusted for normative beliefs involving smoking such as perceived disapproval of smoking by parents/peers, perceived popularity of smoking among successful/elite people, and perceived prevalence of smoking. The putative interaction of SML and smoking attitudes was included and tested in Model 1. Effect sizes were reported using p-values and odds ratios (ORs) with 95% confidence intervals (CIs). All statistical tests were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).
Table 1 displays the sociodemographic characteristics of Vietnamese and Korean adolescents according to smoking susceptibility. Among the Vietnamese adolescents, the proportion of boys susceptible to smoking tended to be higher than that of girls (boys: 54.1%, girls: 46.0%). The mean age was 16.6 (±9.8) and 15.6 (±2.5) in the non-susceptibility and susceptibility to smoking groups, respectively (p = .190). Father’s and mother’s educational qualification tended to be high school or below. In terms of adolescents’ susceptibility to smoking, parents’ smoking experience made no difference (p = .305). The proportion of friend’s smoking (yes) in the susceptibility to smoking group was likely to be about two times higher than in the nonsusceptibility to smoking group (p = .438).
Among Korean adolescents, the proportion of boys susceptible to smoking tended to be lower than that of girls (boys: 21.9%, girls: 78.1%). The mean age was 16.7 (±0.8) and 16.9 (±0.8) in the non-susceptibility and susceptibility to smoking groups, respectively (p = .164). Father’s or mother’s educational qualification was university or above in more than half of the Korean youth. In terms of adolescents’ susceptibility to smoking, parents’ smoking experience made no difference (p = .921). The proportion of friends’ smoking (yes) in the susceptibility to smoking group was likely to be higher than in the non-susceptibility to smoking group (p = .055).
Table 2 shows the differences in SML, smoking attitudes, and normative beliefs involving smoking between Vietnamese and Korean adolescents according to susceptibility to smoking. The mean of the total SML score for Vietnamese adolescents (6.58 ± 1.41) was lower than that for Korean adolescents (7.48 ± 1.18, p = .024). Among Vietnamese adolescents, the mean of the total SML score in the susceptibility to smoking group (6.09 ± 1.67) tended to be lower than that in the nonsusceptibility to smoking group (6.65 ± 1.35, p = .053). Similarly, the mean of the total SML score in the susceptibility to smoking group (7.27 ± 1.15) was likely to be lower than that in the non-susceptibility to smoking group among the Korean adolescents (7.52 ± 1.194, p = .271). No significant differences were found in the mean of the subdomain of SML according to susceptibility to smoking among both Vietnamese and Korean adolescents.
The mean of the smoking attitudes of Vietnamese adolescents (53.29 ± 6.33) was lower than that of Korean adolescents (54.59 ± 5.31, p = .017), and the mean of the smoking attitudes in the susceptibility to smoking group was lower than in the non-susceptibility to smoking group among both Vietnamese and Korean adolescents (all p = <.005). The mean of disapproval of smoking by parents/peers in the susceptibility to smoking group was likely to be higher than that in the susceptibility to smoking group among both Vietnamese and Korean adolescents (p = .012, .138, respectively). The mean of perceived popularity of smoking among successful/elite people and perceived prevalence of smoking was lower among Vietnamese adolescents than among Korean adolescents (p = <.001, .038, respectively).
The results of multiple logistic regression analyses for SML and smoking susceptibility among Vietnamese and Korean adolescents are illustrated in Table 3. Among Vietnamese adolescents, 37 participants (13.4%) were susceptible to smoking. Model 1 reveals that higher SML is associated with lower susceptibility to smoking after adjusting for age, sex, father’s education, smoking experience, parents’ smoking experience, friends’ smoking experience, and daily smartphone and computer usage (OR: 0.74, 95% CI: 0.56–0.98). However, this association was slightly attenuated after a sequential adjustment for smoking attitudes in Model 2 (OR: 0.78, 95% CI: 0.59–1.04) and normative beliefs involving smoking in Model 3 (OR: 0.76, 95% CI: 0.57–1.02). On the other hand, while 32 Korean adolescents (17.5%) were susceptible to smoking, SML was not associated with susceptibility to smoking in all models among Korean adolescents. Higher smoking attitudes were associated with lower susceptibility to smoking in Models 2 and 3 for adolescents from both countries. The significant interaction between SML and smoking attitudes was found after adding the SML* smoking attitudes term in Model 1 for adolescents from both countries (all p = <.001).
In keeping with globalization, international research collaborations seeking strategies to prevent smoking should be encouraged. Vietnam is among the largest multicultural population groups residing in Korea with active socioeconomic cultural exchanges. Therefore, this study highlights the mutual benefit in understanding the factors affecting smoking among adolescents in both population groups. In particular, it presents the basis for the development of future interventions by elaborating the factors related to smoking in adolescence—during which preventive health behavior should be encouraged—and confirms the influence of the digital environment on SML.
The proportion of adolescents with susceptibility to smoking was similar among both Vietnamese (13.4%) and Korean (17.5%) participants. Surprisingly, these levels were relatively lower than the 51.1–68.0% susceptibility to smoking rate among Western adolescent populations (Kaleta et al., 2019; Trinidad et al., 2017), but it was still higher compared to other Asian adolescent populations. While comparing these results with the results of this study, it should be considered that these studies used two questions to measure susceptibility to smoking, as opposed to the three questions used in this study. In a cross-sectional study conducted among adolescents aged 13–18 in China using nationally representative samples of school students, only 9.27% of 12,278 participants were found to be susceptible to smoking (Yang et al., 2021). Another cross-sectional study conducted in Malaysia among 389 non-smoking adolescents aged 16–19 found that the prevalence of susceptibility to smoking was 12.4% (Lim et al., 2019). A two-year follow-up prospective study in Taiwan found that 6.79% of 12,954 adolescents with a mean age of 16.5 was susceptible to smoking (Chien et al., 2019). The relatively higher susceptibility to smoking among adolescents in Korea and Vietnam compared to adolescents in other Asian countries reveals an urgent need to take immediate action to develop culturally appropriate and acceptable interventions to prevent future smoking among adolescents in these two countries.
Adolescents are frequently exposed to smoking-related information through media such as social network services early on in life, which could affect their smoking intentions and experiences (Coreas et al., 2021; Sudo & Kuroda, 2017). In this context, SML plays a crucial role in preventing future smoking because students with higher SML are less likely to have the intention to smoke (Chang et al., 2016). In this study, SML among Vietnamese adolescents was found to be associated with susceptibility to smoking, which reflects smoking intention. SML among Vietnamese adolescents was also found to be lower than among Korean adolescents. Despite the strong association between SML and smoking behavior, we realized that not much research has been conducted to compare the SML levels of adolescents from other Asian countries.
We found no association between SML and susceptibility to smoking among Korean adolescents. This is probably because Korea had a higher proportion (72.1%) of female students, who were more likely to provide skewed responses than male students due to social desirability and approval biases (Bernardi & Guptill, 2008; Tang et al., 2022). These random misclassification errors may have skewed the results of this study toward a null association. Another possible reason may be that there is residual confounding such as stress and depression affecting the association between SML and susceptibility to smoking in Korean adolescents. The high prevalence of depression among adolescents is a serious social issue in Korea, and there are numerous studies supporting the association between adolescents’ poor mental health and smoking (Pakalska-Korcala et al., 2021; Stubbs et al., 2018). Further studies are needed to confirm the association between SML and susceptibility to smoking in Korean adolescents including variables that indicate mental health status.
The SML scale was developed and validated by Primack et al. (2006) and has been recognized as a feasible and teachable smoking intervention method. Since exposure to media advertising is associated with unhealthy behaviors, such as the use of tobacco products, pediatric health care providers should be aware of how adolescents are exposed to this advertising and develop media literacy skills in them to help prevent negative outcomes (Radesky et al., 2020). Newer media provide numerous opportunities for marketers to adapt their messages to reach millions of adolescents (Reid Chassiakos et al., 2016), and these media are expected to continue to develop. The major strength of this study is that it is the first to identify the SML of Vietnamese and Korean adolescents. The results from this study correspond with those of previous studies that show SML to be an effective and popular approach that should be integrated into farreaching interventions to promote SML among adolescents.
This study serves as a reference to highlighting the significance of SML for Vietnamese and Korean adolescents and in developing smoking prevention and culture-specific interventions in school health professionals, school nurses, and school health policy experts. The risk of exposure to smoking messages through new media is globally increasing as smartphones become the main means of communication among adolescents. Therefore, reducing the influence of newer media on adolescent smoking is an urgent need, as smoking marketing or messaging is not regulated in newer media. Because adolescents’ media dependence has increased, essential to their daily lives, school nursing that applies interventions that can minimize the negative impact on smoking behavior and maximize the positive impact in a context where the media is the representative means of adolescents’ information acquisition should be established urgently.
There are some limitations to this study. First, since it was a cross-sectional study, the causality between SML and susceptibility to smoking could not be confirmed. Second, it is possible that students may have underreported their susceptibility to smoking due to social desirability bias. This random misclassification might have skewed our results toward a null association. Lastly, as the sample used in this study only included high school students in a specific area, selected using convenience sampling, caution is needed while generalizing the interpretation of the results to all Vietnamese and Korean adolescents, or other populations.
High SML levels were found to be significantly associated with a lower susceptibility to smoking only among Vietnamese adolescents. This finding highlights the need for policies to promote SML to prevent smoking among Vietnamese adolescents. It also reveals that smoking among adolescents may be prevented by broadening our perspectives with culturally appropriate policies that consider national differences in a digital era. Further studies are needed to not only identify pathways between other possible factors affecting smoking intention, SML, and susceptibility to smoking but also develop culture-specific intervention strategies for smoking prevention among adolescents in Vietnam and Korea.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a 2022 International Joint Research Grant from Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing (grant number 6-2020-0059).
Hyeonkyeong Lee https://orcid.org/0000-0001-9558-7737
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Sun Young Shim, MPH, is a PhD student at the College of Nursing, Yonsei University, Korea.
Hyeonkyeong Lee, PhD, is a professor at the College of Nursing, Yonsei University, Korea.
Sookyung Kim, PhD, is an assistant professor at the School of Nursing, Soonchunhyang University, Korea.
Nguyen Thi Thanh Huong, PhD, is an assistant professor at the College of Health Sciences, VinUniversity, Vietnam.
Young-Me Lee, PhD, is a professor at the College of Science and Health, DePaul University, USA.
Phương Lê Thị, MS, is an assistant professor at Quang Tri Medical College, Vietnam.
Bui Thi Thanh Loan, MPH, is an assistant professor at Quang Tri Medical College, Vietnam.
1 College of Nursing, Yonsei University, Seoul, Republic of Korea
2 Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, Seoul, Republic of Korea
3 School of Nursing, Soonchunhyang University, Cheonan, Republic of Korea
4 College of Health Sciences, VinUniversity, Hanoi, Vietnam
5 College of Science and Health, DePaul University, Chicago, IL, USA
6 Department of Nursing, Quang Tri Medical College, Quang Tri, Vietnam
Corresponding Author:Hyeonkyeong Lee, Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea.Email: hlee39@yuhs.ac