The Effect of the Internet on Teen and Young Adult Tobacco Use

A Literature Review

Susan R. Forsyth, MS, RN; Christine Kennedy, PhD, RN, FAAN; Ruth E. Malone, PhD, RN, FAAN


J Pediatr Health Care. 2013;27(5):367-376. 

In This Article

Smoking Imagery on the World Wide Web

Researching smoking imagery on the Web is a relatively new phenomenon, coinciding with the rise of the majority of Americans having online access in their homes and/or workplaces. Currently 77.3% of the population is online (Internet World Stats, 2010), with the percentage even higher among young people (Rideout et al., 2010). The majority of studies that have been published are descriptive in nature, attempting to quantify and describe the types of tobacco content available.

The first studies about smoking imagery on the Internet examined the content of pro-tobacco Web sites (Hong and Cody, 2002, Ribisl et al., 2003). Like other, more traditional pro-smoking imagery, many of these Web sites portrayed smokers as young, thin, and attractive, leading exciting lives. The sites also were found to be accessible to children, and they often mentioned brands or featured brand images and displayed pictures depicting smoking, usually with female smokers. Several displayed partial or full nudity, linking sex with cigarette use. However, these studies were published before the rapid rise of the interactive Web 2.0, which greatly changed the online experience for many users. In addition, neither of the studies addressed whether the Web sites they surveyed received any traffic nor did they provide any information about demographics about the visitors to the Web sites.

Hrywna, Delnevo, and Lewis (2007) tried to partially address this question of exposure in a cross-sectional repeated survey of adult recall of Internet tobacco advertising. In 2001, 6.9% of adults indicated that they could recall seeing tobacco advertising online. By 2005, that number had risen to 17.8%, with the highest concentration of adult recall in men ages 18 to 24 years, Asians, and those with college educations (Hrywna et al., 2007). However, most adults recalled the advertising in the form of banner or pop-up ads, which, because technology for blocking such ads has penetrated to most users, are not as frequently used as in the past. In addition, this survey did not attempt to measure other types of online smoking imagery that may have been embedded in other, less obvious places.

More recently, researchers have begun examining online content for this type of embedded smoking imagery. Likely because of its popularity and accessibility, several studies have focused on the Web site YouTube. YouTube is an interactive video-sharing site where users can upload their own videos and receive feedback and comments. Other users can forward the videos to their friends, and the more people view each video, the higher the video is placed in YouTube's search engine. Popular videos may receive several million or more views. In February 2011, in the United States, YouTube received 1.2 billion visits, representing 122 million people. Twenty-six percent of YouTube's users were younger than 18 years (Quantcast, 2011), thus making it a rich environment in which to assess the accessibility and type of Internet smoking imagery available to adolescents.

Possibly the first research article that examined tobacco imagery on YouTube was an exploration of content. The word "smoking" was placed into YouTube's search engine, and the first 50 videos obtained were sorted by relevance, the default search mode of YouTube. The search was repeated, sorting by view count. Of those 100 videos, 40 contained smoking imagery. The videos were coded and subsequently classified by genre. The researchers found more pro-smoking videos than videos that portrayed smoking negatively. However, the anti-smoking videos had received more actual views, partly because one video had "gone viral" and had become very popular through Internet sharing (Freeman & Chapman, 2007).

In 2010, two more descriptive studies were published that investigated smoking imagery on YouTube. Both of these studies found that positive smoking imagery far outweighed anti-smoking imagery, both in view count and numbers of videos, suggesting the rapidly changing nature of the medium and the variability of results depending on search strategies (Elkin, Thomson, & Wilson, 2010; Forsyth & Malone, 2010). Forsyth and Malone (2010) did a repeated cross-sectional survey of YouTube videos, entering the terms "cigarettes" and "smoking cigarettes" into the search engine and sorting by both relevance and view count. The same search was repeated 2 months later. In both searches, pro-tobacco videos constituted 81% of the sample. When the number of views was taken into account, pro-tobacco views made up 87% of the sample in time one and 91% in time two. The most popular videos were music videos, followed by magicians using cigarettes as props with which to do tricks, both of which are likely to appeal to young people. In addition, in the 2 months from time one to time two, the gross number of videos that the search terms retrieved increased more than 11%.

Elkin, Thomson and Watson (2010) used a slightly different YouTube search strategy. The researchers used the five leading non-Chinese tobacco brands as search terms and sorted by view count. The authors coded 71% of the sample as pro-smoking, 4% as anti-tobacco, and 25% as "other." Seventy-one percent of the sample contained images of cigarette brands. The genre with the largest number of videos was "archives" (old commercials), followed by clips featuring celebrities and sports figures, with the latter likely to be popular with adolescents.

A fourth recent YouTube study took yet another tack. Kim, Paek, and Lynn (2010) searched YouTube with the term "smoking fetish." Three months later the search was repeated. This investigation retrieved a subset of smoking videos that ties images of smoking behavior together with sex, creating powerful pro-smoking imagery (Kim, Paek, & Lynn, 2010). These researchers found that although nearly 97% of the videos explicitly portrayed smoking behaviors, 85% were not flagged as being inappropriate for persons younger than 18 years (although this flag could potentially make the videos even more desirable to adolescents). Using the criteria that the Motion Picture Association uses to rate movies, the researchers rated 40% of the videos as PG, 32% as PG-13, and 27% as R. The study also reported that nearly 90% of the models used were female and more than 50% appeared to be young adults between the ages of 18 to 24 years.

Although these smoking fetish videos may be numerous on YouTube, they appear to appeal to a limited audience, and it is unclear who that audience is and whether it includes a large number of adolescents at risk for smoking initiation. Forsyth and Malone (2010) found that although smoking fetish videos constituted approximately 20% of their sample, they were only a little over 2% of the total view counts. Elkin et al. (2010) classified only about 4% of their sample as relating to "sex/romance."

Interactive sites such as YouTube have searchable databases with vast amounts of new content being added every day. For example, in 2011, 35 hours of content was uploaded on YouTube every minute (YouTube, 2011) thus making it an extremely fluid and flexible environment. Each of these studies of YouTube might have been made stronger if repeated measures were conducted over longer periods to assess the stability or fluidity of the phenomenon. In addition, using search terms such as "smoking fetish," "smoking cigarettes," or brand names of cigarettes are highly likely to bring up content that contains smoking imagery, as confirmed by all four of these studies. However, conducting a search using terms specifically related to smoking does not necessarily shed light on how much tobacco content the average browsing teenager who is not looking explicitly for smoking imagery is exposed to during a typical online session. Freeman and Chapman (2007) addressed this issue briefly by looking at a snapshot of the 50 most-viewed videos regardless of subject. They found that two of 50 videos, or 4% of those videos, contained smoking imagery. Whether this amount is increasing or decreasing and whether this exposure level has an impact on teen smoking rates may be a subject for further investigation. Moreover, unless a user posts a comment on the video, it appears that few if any methods currently exist to ascertain what demographic is actually watching each video.

One recent study attempted to investigate this question of how much smoking content teenagers might be exposed to on the Internet (Jenssen, Klein, Salazar, Daluga, & DiClemente, 2009). Using random digit dialing, the researchers identified 591 teens willing to have their online activity tracked for a 30-day period. Of those, 346 actually participated in the project. The final sample was skewed toward White teens who came from higher-income families. The researchers found that together the subjects viewed more than 1.2 million Web pages during the month-long observation period. Using specific tobacco-related search terms, the researchers queried this data set for tobacco content. They found that 0.72% of the Web pages in their query contained tobacco content. By the end of the 30 days, 68% of the teens had viewed at least some tobacco content, and social networking sites accounted for 53% of the pages on which tobacco content was found. Interestingly, and conflicting with the findings of the YouTube studies, only 22% of the tobacco pages viewed contained pro-tobacco imagery, whereas 18% were anti-tobacco, with about 60% being either being complex, unclear, or neutral. After tracking the subjects for a year, the authors did not find a correlation between smoking initiation and number of smoking Web sites viewed, leaving open the question of the amount of impact that online smoking imagery has on the incidence and prevalence of teen smoking. Although this study is important and appears to be the only one of its type, similar studies, perhaps with larger sample sizes and more representative demographics, would certainly benefit this emerging field.

Although all of these studies indicate that tobacco content is available on the Web, only a small amount of research thus far has examined to what extent the tobacco industry is involved with creating tobacco's online presence. Although all tobacco companies had formal Web sites, they are not likely destinations for the average browsing teen, who spends the majority of his or her screen time on social networking sites (Rideout et al., 2010). However, given the vastness and relatively anonymous nature of the Internet, it is likely that plenty of opportunity exists for the tobacco industry to insert pro-tobacco imagery in other, less formal venues. Recently Freeman and Chapman (2010) published a study that explored this phenomenon. They first searched Facebook, a popular social networking Web site, with the terms "Lucky Strikes" or "Dunhill cigarettes," two British American Tobacco (BAT) brands, and found 434 groups and pages. A second search was performed to identify members of Facebook who also identified themselves as employees of BAT. These searches were cross-referenced to ascertain which BAT employees also belonged to the promotion groups/pages, and the researchers found that 3% of the promotion groups/pages also had BAT employees as fans/members (Freeman & Chapman, 2010).

In 2009, Freeman and Chapman published another study of the tobacco industry's use of online technology for brand promotion. Although this study did not examine social networking sites, it did investigate RJ Reynolds' use of the Internet's new interactive features as part of a brand promotion. In this case study, the authors explored RJ Reynolds' attempt to redesign the packaging for Camel Signature Blend Cigarettes using Internet-driven consumer input. Users were allowed to design the new packaging, including content for the brand. RJ Reynolds stated that the purpose of this redesign using Internet-driven consumer input was to "reignite the brand" and "attract smokers—young females especially" (Freeman & Chapman, 2009). The results of this case study suggest that investigation of the tobacco industry's use of Web 2.0 as a method for brand promotion is an important next step in tobacco control.

RJ Reynolds also used the Internet to test-market Camel Snus, a smokeless tobacco product, by creating an online discussion board (while maintaining editing rights) of Snus and potential Snus users' experiences with the new product (Wackowski, Lewis, & Delnevo, 2011). A total of 322 unique users posted on the site and made a total of 522 comments. The Swedish Match Company also has used the Internet to market Snus, posting a total of seven videos on YouTube to promote the product. Total views for each video ranged from 1500 to 200, indicating relatively little Internet traffic (Seidenberg, Rees, & Connolly, 2010).