Alcohol in the Media and Young People: What Do We Need for Liberal Policy-making?

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1 PUBLIC HEALTH ETHICS VOLUME 7 NUMBER Alcohol in the Media and Young People: What Do We Need for Liberal Policy-making? Boudewijn de Bruin, Faculties of Economics and Business and Philosophy, University of Groningen Corresponding author: Boudewijn de Bruin, Faculty of Economics and Business, University of Groningen, Nettelbosje 4, 9747 AE Groningen, The Netherlands and Faculty of Philosophy, Oude Boteringestraat 52, 9712 GL Groningen, The Netherlands. Tel: (31) ; b.p.de.bruin@rug.nl There is evidence to the effect that exposing children to alcohol consumption in the media increases the chances that they will consume alcohol as minors or as adults, and since alcohol consumption is associated with numerous public health issues, calls for stricter regulation can be heard from many quarters. This article argues that with the available research we cannot conclude that exposure to portrayals of alcohol consumption plays a genuine causal role in bringing about the things with which it is associated, that the strength of the correlation is too weak to justify regulation and that the sorts of things with which it is associated only rarely count as genuine harms from a liberal point of view. This article also argues that even if genuine harms were caused, no justification for regulation would directly follow because alcohol in the media could still be protected by freedom of speech and expression. Yet, the article argues that regulation is defensible if it can be shown that the harmful consequences arise in ways that bypass autonomy, or if it can be shown that the harmful consequences are unacceptable from the point of view of so-called proleptic autonomy. Introduction With its association with aggressive behaviour and crime, risky sexual behaviour, traffic accidents, increased likelihood of developing addiction, liver cirrhosis, a weakened immune system, cancer, decreased IQ, tuberculosis, brain damage, various mental problems and mental disorders, alcohol consumption is implicated in numerous public health issues. Throughout the world a staggering two million people are estimated to die every year from alcohol-related causes (World Health Organization, 2011). A growing empirical literature examines whether such negative effects of alcohol consumption are exacerbated by exposing people to portrayals of alcohol consumption in advertisements, films, video games, social networking sites and elsewhere. The received view among researchers is to answer the question affirmatively, and this has led a number of influential research groups and individual policy makers to advocate stricter regulation of alcohol exposure in the media. Because exposing children to portrayals of alcohol consumption in the media (AM) is thought to encourage them to start drinking at younger ages, to drink more and to drink more frequently, children are a particular cause for concern (Munthe, 2011). It is true that some regulations are already in place. Alcohol advertisers in the UK follow the self-regulatory Code of Non-Broadcast Advertising, Sales Promotion and Direct Marketing. Dutch alcohol advertisers subscribe to a voluntary ban on advertising in media with more than 25 per cent of underage viewers, and broadly similar bans exist in Belgium, Italy and other European countries (Van Dalen and Kuunders, 2006). However, a frequently heard complaint is that such bans are ineffective and insufficient (Zwarun and Farrar, 2005; Measham, 2006). Ofcom (2013), an alcohol research group, recently recommended an overhaul of alcohol advertising regulations. Another think tank, Alcohol Concern (2011), found that because young people increasingly embrace social networking sites, official alcohol marketing should not be permitted on social networking sites (see also Griffiths and Casswell, 2010). A recent editorial in the British Medical Journal even went so far as to support a complete ban on alcohol advertising and sponsorship (Hastings and Sheron, 2013: 1228, emphasis mine). Similar suggestions are coming from many different directions across the world. The question I address in this article is whether the current state of empirical evidence justifies a complete ban on alcohol advertisements, or other ways of regulating the exposure of children to portrayals of AM. If something (X) has harmful consequences (Y), liberal policy makers find their prima facie justification for regulating X in the harm principle. In the context in which doi: /phe/phu004 Advance Access publication on 12 March 2014! The Author Published by Oxford University Press. Available online at

2 36 DE BRUIN regulating X would potentially clash with freedom of speech and expression, however, more has to be done than merely showing that X causes harm Y. Freedom of speech and expression is a rather peculiar freedom in liberal thought. It allows people to speak or otherwise to express themselves in ways that harm others, that is, it allows people to set aside the harm principle where speech and expression are concerned. To show when setting aside the harm principle is acceptable from a liberal point of view, additional special protection arguments are needed that offer special protection to freedom of speech and expression. The relevance of this is that if we want to develop an argument in favour of regulating AM, we have to show two things. First, we have to show that exposing children to AM leads to harm because otherwise the harm principle would not sanction regulation in the first place. Second, we have to show that no special protection argument offers special protection to AM, that is, no special protection argument can be used to reject AM regulation. The answers to both questions depend on empirical research on AM, alcohol consumption and its associated harms. I begin with a brief review of the empirical literature. In the following two sections, I examine the question of whether the statement that exposing children to AM leads to harm is sufficiently well established to defend the first claim, that exposure to AM leads to harm. I argue that we ought to be very careful here for two reasons, namely, because of the strength of the correlation between exposure to AM and harm (does it cause harm?) and because most of the research is not concerned with consequences of exposure to AM that would count as genuine harm from a liberal point of view (does it cause harm?). Subsequently, I turn to the issue of freedom of speech and expression and examine whether special protection arguments can be successfully overcome in the case of AM. The conclusion is that the existing state of research offers no support for liberal regulation of AM. Along the way, however, I offer insights into empirical research that ought to be performed to get a better grasp of the justifiability of liberal regulation of children s exposure to AM, since it cannot be ruled out that future research will offer support for such regulation. By exploring the similarities and dissimilarities with the regulation of media violence (because of its alleged connection with aggressive behaviour), however, I show that once it can be demonstrated that a particular form of empirical support exists, a rather powerful argument in favour of AM regulation can be developed based on the right to autonomy possessed by people exposed to AM. This article assumes a liberal point of view of policymaking, using liberalism as a default position for policy-making (Dawson, 2009: 122). The assumptions of liberal policy-makers are often fairly minimal compared with those made by others, as a result of which liberal arguments against certain forms of regulation may not go through on other accounts. Not everything said in this article will be relevant to all alternatives to liberalism. Yet many observations will just as much inform communitarian (Fry et al., 2005), social justice (Beauchamp, 1976) and other views of public health and harm reduction. This is particularly true inasmuch as this article points to ways in which children may be found to be vulnerable vis-à-vis exposure to alcohol in the media, for regulation receiving liberal support is often supported by other approaches too. Empirical Research There follows a rapid general survey of the literature, based mainly on such reviews and meta-analyses as Fischer et al. (2011), Grube (2004), Hastings et al. (2005) and Smith and Foxcroft (2009), all papers that figure prominently in the background of important policy papers. To begin with, media scholars attempt to examine the incidence of portrayals of AM. Content analysis research overwhelmingly supports the view that a majority of traditional and new media contain portrayals of and references to alcohol use, including those with underage viewer restrictions. Relevant studies give striking numbers of 77 per cent references to alcohol on television (Christensen et al., 2000), 93 per cent references in films (Roberts et al., 1999) and some 56 per cent references on social networking websites (Moreno et al., 2010). Rather lower figures of around 20 per cent are found for music (lyrics and videos) (DuRant et al., 1997). Turning to the consequences of exposure to AM, the first body of evidence comes from econometric studies of the effect of alcohol advertising on alcohol consumption (consumers of all ages). The consensus here seems to be that advertising has only a very moderate effect on total alcohol consumption. Duffy (2001) and Nelson (1999), for instance, maintain that a 100 per cent increase in advertising expenditures would lead to an increase in total alcohol consumption of only 1 per cent. A second body is based on experimental work. Under controlled conditions, subjects are exposed to alcohol advertisements or short excerpts from films depicting alcohol use, after which variables such as their readiness

3 ALCOHOL IN THE MEDIA AND YOUNG PEOPLE 37 to consume alcohol are measured. Such studies report hardly any effect. Survey studies do find a correlation, though. Tucker (1985) used questionnaires to estimate televisionwatching habits and alcohol consumption among high school boys and concluded that intensive viewers consume more alcohol, and Neuendorf (1985) found that intensive viewers tend to agree with statements associating drinking with happiness and fun. Longitudinal studies support this view, showing that exposing children and young people to AM is linked to such things as a more positive view of drinking, a greater intent among children to drink when they reach adult age and an increase in actual alcohol consumption, inter alia. To be sure, some publications report inverse effects (Robinson et al., 1998), and other problems also remain to be addressed. Nevertheless, the authors of the review and survey articles cited all agree that exposure to portrayals of alcohol consumption or to alcohol advertising has an effect, albeit rather small, on the beliefs children maintain about alcohol consumption and on alcohol consumption itself. Harm Principle: Does Exposure to AM Cause Harm? When policy-makers find that some X has to be regulated because X causes something harmful Y, the evidence they have about the causal premiss of their argument is almost always statistical in nature. A statement to the effect that exposing children to AM leads to certain forms of harm is ideally based on statistical inferences drawn from observations of instances of exposure to AM, and instances of the specific harm. When researchers draw such inferences, they observe, for instance, the number of hours that research subjects have been exposed to AM (the independent variable X) and the intensity or frequency of subsequent harm (the dependent variable Y); they then try to establish a statistical correlation between X and Y. What this means can be illustrated by means of a scatter diagram. Observations are represented as dots on a two-dimensional graph where the values on the X-axis and Y-axis indicate, for instance, the hours of exposure to AM and the intensity of subsequent harm, respectively. Each dot represents one observation. A scatter diagram is obtained by plotting all data, resulting in a graph with many dots. These many dots will generally be distributed in some way over the graph rather than lying on one line. The statistical tool of regression analysis is used to draw an artificial line intended to summarize the observations in a way that fits them best. Often, however, the line will look rather artificial, failing to acknowledge the fact that significant differences exist between situations when dots can be found everywhere on the graph and situations when they already lie almost perfectly on one line. The concept of correlation and other measures of size effect for which the statements in this section also hold encapsulates the degree to which the diagram obtained lies between these two extremes. The stronger the correlation, the closer we are to a situation where the dots already lie on one line. In rather impressionistic terminology, the correlation expresses how artificial the regression line is. The stronger the correlation, the more confident researchers are of having found something of a real link. An influential classification due to Cohen (1969) takes a correlation of r = 0.10 to be small, finds r = 0.30 to reflect a medium correlation and views r = 0.50 as large. Thus, the stronger the correlation, the more confidently policy-makers can be that when they develop appropriate regulation, it will have the desired effect. It is true that large correlations are rare, and policy-makers are often satisfied with small ones. Passive smoking on the work floor and lung cancer, for instance, have a correlation of r = 0.10, and this also applies to asbestos exposure and laryngeal cancer. Such a small correlation does not stand in the way of some regulation; a correlation lower than r = 0.10 is too low for policy-making, however. A quick glance at the empirical literature on AM may suggest that this hurdle is easily overcome; many studies since the 1980s have found correlations larger than this threshold of r = 0.10 (Atkin, 1995). In line with Cohen s classification, researchers themselves have sometimes called the effects meagre (Strickland, 1983), but this is not to say that correlations higher than the threshold are exceptional. It should be noted, however, that these studies concern alcohol consumption in general, not just alcohol misuse. From the point of view of regulation, we are solely interested in connecting the exposure of children to AM and the harmful effects thereof, and once we restrict ourselves to harmful consequences, correlation drops below the threshold in many cases, but not always. Using a questionnaire involving a measure of the respondent s degree of hazardous drinking, Atkin et al. (1983), for instance, found a correlation of r = 0.29 between exposure to alcohol advertisements, and hazardous drinking and driving habits and attitudes. While a decent correlation is a necessary condition for regulation, it is not sufficient. What we also need is

4 38 DE BRUIN evidence of a causal link between exposure to AM and harm. First of all, a correlation between X and Y may indeed be a reflection of the fact that X causes Y, but it may equally well reflect the fact that Y causes X. Such reverse causation will not be plausible in every situation, but when we turn our attention to new media we should not be too quick to dismiss the possibility that consumers of alcohol turn to the websites and Facebook profiles of their favourite beer brands more frequently, rather than the other way round. With respect to new media, that is, alcohol consumption may just as well lead to exposure to AM, at least sometimes. The so-called third causes constitute another challenge. There is an almost perfect correlation in children between height and age; height does not cause age and age does not cause height, however. Rather, there is a third thing causing a child both to grow taller and to grow older: adequate nourishment, say. This example shows what factors may play a role in determining the strength of the correlation: third causes. Just as regulating X to avoid harm Y in a case where Y causes X is senseless, it is equally senseless to regulate X if X and Y are caused by some third cause Z. Moreover, when correlational research is used to back policy-making, unintended consequences may arise. Evidence to the effect that X causes harmful effects Y provides no insights into what would happen if X were to be banned. Banning X may have the result that even though Y disappears it is replaced by something S, which is even worse than Y. Criminalizing the possession and use of alcohol in the USA, for instance, is claimed to have led to an increase in the number of minors with criminal records, making it significantly more difficult to find a job or take out a mortgage, and similar observations have been made about prevention programmes in Europe. These effects are generally considered to be unintended and undesired (Sulkunen et al., 2004; Wolfson and Hourigan, 1997). This is relevant to AM regulation. Probing the links between exposure to AM and alcohol-related harm, Saffer (1991) claimed that countries adopting more stringent rules on alcohol advertising have lower rates of alcohol consumption and alcohol-related traffic incidents. It would be wrong, however, to quote this study in defence of regulation. Young (1993) made a case that both stringent regulation and lower alcohol intake stem from a common, third, cause, namely, a conservative attitude vis-à-vis alcohol in which rules will be stringent and consumption will be low. Similarly, the association between television viewing and drinking among schoolboys, which Tucker (1985) uncovered, does not rule out a third cause. Television viewing and drinking may both be part of a particular culture among high school boys. This is not to say that the problem of causation is insurmountable for policy-makers witness the examples of passive smoking and asbestos. The received view among researchers, however, is that for AM we are not yet there. In addition, the task is considerably more daunting than for passive smoking or asbestos because the causal mechanisms are much more difficult to trace. Even though it took several decades to lay bare the precise connection between active and passive smoking and lung cancer, the mechanism involves physiological processes only. The causal mechanisms connecting exposure to AM and harmful effects of alcohol consumption, if they exist, will be decidedly more complex, involving, as they do, not only cognitive and neurological mechanisms of processing the information gained from exposure but also the processes leading to alcohol consumption itself, as well as the connections with the ultimate harmful effects. Harm Principle: Does Exposure to AM Cause Harm? If X causes something harmful Y, the harm principle gives policy-makers a prima facie reason to regulate X. An insufficiently strong correlation between X and Y and the impossibility of excluding third causes, reverse causation, and unintended consequences may stand in the way of regulating X. But that is not all. Another issue is how researchers measure the variables. Advocates of regulation should realize that the research they cite often demonstrates an association not so much between the variables X and Y that are relevant to policy-making but rather between something like X and something like Y. If, for instance, the latter (the something like Y ) is not a genuine form of harm, the harm principle remains inoperative. I use research on media violence and aggression briefly to introduce the topic, also because I return to this example at later stages in my argument. A significant number of policy-makers wish to regulate exposure to violence in the media (variable X) because it is supposed to cause aggressive behaviour in viewers (variable Y). (I assume causation here for expository purposes, but nothing hinges on this assumption.) To back their support for regulation, policy-makers refer to longitudinal survey research, to experimental research and to a lesser extent to econometric research, all of which measure variables X and Y differently. The independent

5 ALCOHOL IN THE MEDIA AND YOUNG PEOPLE 39 variable of exposure to violence in the media is measured by such things as hours per day spent watching television, stated preference for violent video games or a random assignment of watching violent or non-violent films in experimental settings. The dependent variable, aggressive behaviour, is measured by such things as what children s teachers report about their level of aggressiveness, self-reports about aggression, observed play with aggressive toys and also by the number of convictions for crime. Now suppose that in defence of regulating media violence one were to cite an academic paper demonstrating a correlation between hours per day watching television and playing with aggressive toys. What regulation would follow? Since hours per day watching television includes any kind of television programme, policymakers using this publication would not be able to distinguish between violent and non-violent television programmes. The independent variable is not subtle enough. Worse still, playing with aggressive toys is not immoral or illegal by any liberal standards. The dependent variable does not measure genuine harm. Hence liberal policy-makers would have to refrain from regulation on the basis of this piece of research. This shows that policy-makers should do their utmost to avoid supporting regulation proposals on research which measures or operationalizes variables in ways that are irrelevant to policy-making. This is not to discredit the value of the academic research reported in these articles, which may have great value in other domains such as education or child care, but it is irrelevant when it comes to regulation of media violence. Let me now turn to AM regulation. Researchers measure the independent variable of exposure to AM in many different ways. Econometric studies consider the alcohol industry s advertisement expenditures as a way to measure exposure to AM, or they take the introduction of new alcohol advertisement regulation in a certain country as a natural experiment, decreasing or increasing exposure to AM. Experimental research randomly exposes underage participants to printed alcohol advertisements, television beer commercials, anti-drinking public service advertisements or manipulated film footage containing AM. Research into new media randomly exposes young people to websites or randomly examines such things as Facebook profiles in more qualitative research contexts. Moreover, the most promising longitudinal studies use questionnaires to follow children when they grow to adult age, asking participants to provide information about hours spent watching television per day, hours spent watching music videos, self-reports about watching particular television programmes (adjusted for alcohol advertisements or other portrayals of alcohol consumption in these programmes), reported familiarity with particular alcohol advertisements, reported appreciation of alcohol advertisements, recall of beer commercials and identification with characters in alcohol advertisements. The dependent variable is supposed to capture genuine harm, measuring it by such things as quarterly consumer expenditures on alcoholic beverages, total alcohol consumption in a country, liver cirrhosis mortality and total vehicle fatalities. Survey studies consider self-reports of current consumption patterns or experimentation with alcohol, intentions to drink in future, perceived desirability of toys or clothes with alcoholrelated logos, knowledge of beer brands, intention to drink when old enough, positive beliefs about drinking, self-reported drinking problems, frequency and quantity of alcohol consumption (now or, in longitudinal studies, at later age), drinking-related aggression, perception of social approval for drinking, incidence of counter-arguments to views expressed in the commercials or films, the expectation of positive effects from alcohol consumption and beliefs about how common alcohol consumption is. This list is again not meant to discredit the research itself. It is rather meant to show how far away much of the research is from actually establishing a link between exposure of children to AM and actual harmful consequences. Research linking television viewing (or familiarity with and appreciation of alcohol advertisements) to the presence of intentions to drink when old enough, knowledge about beer brands, positive beliefs about drinking or a perception of social approval of drinking such research offers no reason for liberal policy-making. It is neither immoral nor illegal for adults to drink, nor is it immoral or illegal to form the intention, at the age of 10 or 15 years, to drink at adult age, and it is also not particularly harmful to believe that moderate drinking can be part of a pleasant social event or to have knowledge about beer brands. In sum, then, for research to be relevant to liberal policy-making, the variables have to be measured or operationalized in such a way that the dependent variable measures genuine harm, and the independent variable is subtle enough to permit sensible regulation. Freedom of Speech: Should AM Obtain Special Protection? Now let us assume that the variables have been operationalized in a relevant way, that reverse causation, third

6 40 DE BRUIN causes, unintended effects and similar fallacies can be excluded and that the correlation is higher than the threshold. Would that justify AM regulation? It is true that under such conditions the harm principle would provide prima facie reasons for regulating AM. But even if X causes something genuinely harmful Y, liberal policy-makers will resist regulation if X receives special protection for other reasons. In this example, a potentially countervailing argument would be to the effect that a ban on exposing children to AM infringes on a very central liberty: freedom of speech and expression. If this argument is true, the freedom to expose children to AM would receive special protection. Whether this argument is actually true depends on empirical evidence, which the present section examines. For a start, freedom of speech and expression occupies a rather peculiar position in liberal thought: despite its centrality it is not protected by the harm principle. A newspaper revealing that the prime minister has secretly negotiated a deal with the opposition harms the prime minister, and consequently, the publication goes against the harm principle. Yet the newspaper s freedom to publish the news receives special protection on such grounds as that citizens have an interest in obtaining information about political decision-making in a democracy. The argument from democracy is not the only special protection argument for freedom of speech. Other arguments refer to such things as truth finding, diversity, tolerance and pressure release. To see whether AM regulation would lead to an acceptable restriction of freedom of speech, we have to examine, then, whether any special protection argument offers special protection to AM. It is hard to see why AM would be protected by considerations of democracy, truth finding and the like. Perhaps, with the exception of a documentary about whisky distilleries (potentially protected by the argument from truth finding), exposing children to AM would scarcely foster any of these things. These special protection arguments are not considered to be particularly powerful in any case. In debates about the regulation of such things as pornography, hate speech, Nazi symbolism or Internet filters, liberal policy-makers typically employ one special protection argument only, the argument from autonomy, which argues that since restrictions on pornography and the like would infringe the right to autonomy of the sender and/or the receiver of speech (also called speaker and hearer), regulation cannot be justified, even though this will admittedly lead to genuinely harmful consequences (Brison, 1998). To defend liberal regulation of AM, the challenge, then, is to disarm the argument from autonomy. One might think that an easy way to meet the challenge is to observe that the argument from autonomy cannot offer special protection to exposure to AM in a situation where children are involved. Children, the objection goes, lack the capacity for autonomous decision-making almost by definition. That would be too rash, however. It does not, for instance, apply to the special protection argument cast in terms of sender autonomy. While many senders of AM on social networking sites will be minors, most senders of AM (advertisements, films and music videos) are adults. It is true that the sender version of the autonomy argument offers little protection of commercial speech on the grounds that the sender autonomy argument applies to individuals, not corporations: alcohol advertisements are not offered special protection. But portrayals of alcohol consumption in films, video games or on social networking sites do receive protection from the sender autonomy argument (Vladek et al., 2004). As a result, arguing against the sender autonomy argument is not a very promising strategy for advocates of AM regulation. What about the receiver version of the argument from autonomy? One may believe that since children lack autonomy, they also lack the right to autonomy and that consequently no form of regulation would disrespect that right and go against the receiver autonomy argument. The receiver autonomy argument would, if that view were correct, offer protection to any form of potentially harmful speech and expression directed at children. This line of reasoning fails to convince, though. First of all, we might just as easily reason the other way round and maintain that since children lack autonomy, invoking the receiver autonomy argument in defence of freedom of speech and expression is out of place if it concerns children; under that reading, it would offer protection to no form of potentially harmful speech and expression directed at children. More importantly, however, some of the supposed effects of exposing children to AM only manifest at adult age, when the assumption of autonomy is justified without further ado. Thirdly, we do attribute autonomy to children to various degrees in particular realms of decision-making. We do respect children s autonomy, for instance, when it comes to choosing their friends or their fields of study, even if not to the full extent (we make maths compulsory at school). Finally, parents and educators afford children what could be called proleptic autonomy. They give children opportunities to practise decision-making. They anticipate their autonomy, treating children as if they are autonomous with the explicit

7 ALCOHOL IN THE MEDIA AND YOUNG PEOPLE 41 aim of helping them acquire autonomous decisionmaking capacities. In sum, disarming the receiver version of the argument from autonomy is not a trivial task when it comes to children s exposure to AM. But why would showing that the argument from receiver autonomy offers no special protection to AM help justify AM regulation when at the same time, as we saw above, AM does receive special protection from the sender version of the argument from autonomy (except commercial AM)? To answer this question, a brief excursion into empirical research on media violence and aggressive behaviour is again helpful, suggesting, as it does, that AM regulation may actually be seen as actively contributing to receiver autonomy. Examining the empirical evidence brings us to the topic of mediation. This topic arises when some X is associated with something harmful Y, not directly, but mediated by a factor M. Let me illustrate. In such public health issues as smoking or asbestos, the connection between cause X and harmful effect Y is immediate or unmediated. Exposure to smoke leads to an increase in the likelihood of contracting lung cancer, and so in similar unmediated ways does exposure to asbestos lead to harm. But if, as Smith and Geller (2009), for instance, claim, exposing children to AM (variable X) leads to the harm of traffic fatalities (variable Y), there is a mediating factor M: the decision to consume alcohol prior to driving. The relevance of this observation is that the existence of a mediating factor can be seen as creating a potential locus of autonomy: receiver autonomy, to be precise. Between exposure to AM and the alleged harms there is a place where the receivers of AM can exercise autonomy and form a decision about what to do with the information gained from being exposed to AM. It may seem that just as connecting autonomy and children, alcohol consumption and autonomy do not go well together; yet I am not here talking about autonomy of people who have already become intoxicated after their decision to consume alcohol. Autonomy resides rather in the interval after the exposure to AM, but before consumption. It is not alcohol then that may undermine autonomy here, but the exposure to AM itself. It is instructive to examine the similarities with media violence and aggression once again. If individuals exposed to media violence tend to be involved more frequently in aggressive acts harming themselves and other people, an obvious mediating factor is their decision to engage in these aggressive acts in a situation of potential aggressive interaction. At first sight, this mediating factor seems to create an opportunity for autonomous decision-making; the time span between their exposure to media violence and their aggressive acts offers them such opportunity. More generally, viewers of media violence have an opportunity autonomously to decide what to do with the information gained from being exposed to media violence. The fundamental assumption of the argument from receiver autonomy is that viewers also have a right to autonomy, and from the combination of opportunity and right it follows that removing the opportunity (which is what a ban on media violence would do) cannot be justified from a liberal point of view. Or can it? Hurley (2004) has developed a very interesting counterargument to this line of reasoning, claiming that the causal processes by means of which people become more aggressive after watching violent films are such that they bypass the autonomy of the viewers. Viewers of violent films do not have the opportunity autonomously to decide what to do with the information gained; they do not have the opportunity to make an autonomous choice about starting or avoiding a fight. Rather, when triggered they will unconsciously copy the violence they have seen in the film. Hurley uses concepts from cognitive science and neuroscience (chameleon effect, ideomotor theory and mirror neurons, in particular) to bolster her claim (Gallese and Goldman, 1998; Chartrand and Bargh, 1999; Prinz, 2004). The details need not detain us; it is important to point out, however, that if Hurley is successful, she has not only shown that the argument from receiver autonomy fails to give special protection to media violence. More strongly, she has shown, then, that the argument from receiver autonomy necessitates active retraction of special protection to media violence on the grounds that exposure to media violence undermines autonomy by taking away opportunities for exercising the right to autonomy. In other words, the receiver autonomy argument in that case offers protection to vulnerable persons lacking the capacity to make informed judgements (Dawson and Verweij, 2008: 195). The central question now is whether exposure to AM undermines autonomy in the way exposure to media violence does. In other words, the question is whether exposure to AM leads to increased alcohol consumption with harmful effects in such a way that it bypasses the receiver s autonomy. In contrast to research on media violence, research on AM has only infrequently explicitly examined the relation with the mediating factor. Some research links exposure to AM to beliefs about the acceptability of drinking or the intention to drink, but it is unclear, first, whether these beliefs and intentions have formed in ways that bypass autonomy, and second,

8 42 DE BRUIN whether they lead to increased alcohol consumption with harmful effects in ways that bypass autonomy. Other research connects exposure to AM to alcohol consumption directly, or to resultant harm in the form of traffic accidents, for instance, but again without allowing us to ascertain whether autonomy is bypassed. More research is needed. A particular research challenge has to do with the fact that we are here concerned with exposing children to AM. Exposing children to AM may result in two sorts of harms: self-directed and other-directed harms. Moreover, harm may be the result of actions performed at two crucially different points in time: while still a child or at adult age. Self-directed harm includes brain damage, addiction, cancer, tuberculosis, weakened immune systems, mental disorders or the injuries to oneself resulting from traffic and other alcohol-related accidents. While self-harm in adults hardly ever inspires liberal policy-making if autonomy is preserved (to avoid charges of paternalism), protecting children from autonomously harming themselves is defensible. Otherdirected harm primarily includes injuries and fatalities that result from drunk driving, alcohol-related aggression and the increased costs of health care to cover alcohol-related injuries and diseases. When we consider the self- and other-directed harms resulting from the exposure of children to AM, some of them result from actions carried out at young age, such as binge drinking or drunk driving (in the USA and other countries where age restrictions are stricter on alcohol than on driving). Others, however, will only be carried out later, at adult age. For empirical research of AM to be useful in addressing the question of whether the receiver autonomy argument offers special protection to children s exposure to AM, two scenarios have to be examined. One scenario is when a child is exposed to AM but the alcohol consumption with harmful effects takes place at adult age. Here the only research question is whether the causal link between exposure to AM and the ultimate harm bypasses the autonomy of the adult person. True, the exposure occurred when the person was a child, but the information gained from the exposure is used only at a later decision moment (when the agent decides on whether to consume alcohol), at which time the adult person may be supposed to have acquired autonomous decision-making skills. Only if autonomy is bypassed at that very moment (at adult age) will there be a reason to limit exposure at young age. Quite apart from the daunting methodological difficulties that researchers have to overcome to address this issue, it may seem rather unlikely that we shall ever find evidence of autonomy bypassing, given the long time span that separates the exposure from the moment at which autonomy would have to be bypassed. How could exposure to AM at age 15 have an autonomy-bypassing effect at age 21? Provided the earlier conditions on strength, causation and the like have been met, however, once we have an affirmative answer, policy-makers are justified in developing AM regulation. A different scenario involves a child exposed to AM who, while still a child and because of the exposure, starts to consume alcohol in ways that lead to self- or other-directed harm. It is clear that if exposing children to AM leads to underage alcohol consumption in ways that bypass autonomy, the receiver autonomy argument does not give special protection to exposing children to AM. There is, to my knowledge, little concrete research that would support this view, though, and despite the considerably shorter time span than in the first scenario, I believe it is rather unlikely here, too, that we shall find evidence for a sufficiently strong causal link between exposure of children to AM and autonomy-bypassing alcohol consumption with harmful effects in a sufficiently large number of people to justify liberal regulation of AM. That such evidence is unlikely to be forthcoming is supported by a comparison with Hurley s argument about media violence. Hurley has to provide evidence for the existence of autonomy-bypassing acts of aggression performed by viewers of violent media. The evidence from cognitive science and neuroscience to which she refers involves people who unconsciously literally copy the behaviour they see. An example is a setting where the experimenter starts to scratch her nose and the research subject also starts to scratch her nose, even though the research subject remains unaware of the fact that she is copying the experimenter s behaviour (Chartrand and Bargh, 1999). This experiment involves a rather obvious instance of autonomy bypassing. As I have shown elsewhere, however, focussing on unconscious copying in the context of media violence considerably weakens Hurley s argument (De Bruin, 2008). In order for regulation of media violence to be justified, there has to be evidence of (i) exposure to media violence and (ii) subsequent unconsciously, non-autonomously copied aggressive behaviour that (iii) harms other people. This, though, applies to only a small minority of the viewers of media violence. Most viewers of media violence do not harm other people, thereby falsifying condition (iii). Some viewers do become aggressive but their aggressive acts do not involve copying, or, while they copy the aggressive behaviour, they plan their copying consciously and autonomously, thereby

9 ALCOHOL IN THE MEDIA AND YOUNG PEOPLE 43 falsifying condition (ii). In other words, only a very small minority satisfies all three conditions and copies aggressive behaviour unconsciously and non-autonomously. Apart from the fact that the correlation will in all likelihood be lower than the threshold of r = 0.10 discussed above, such a small minority does not warrant liberal regulation. The prospects for AM regulation are even dimmer, however. An alcohol commercial, say, would have to make viewers copy the actors behaviour exactly. This may happen. Some commercials are realistic enough to involve behaviour that may literally be copied. Many commercials are set in rather unusual environments, though, considering the fancy ways in which bartenders pour drinks into glasses, and these are less easily literally copied. The mere bodily movements of bringing a glass to one s mouth, on the other hand, are so common that it is hard to see whether the person really copies the actual actor consuming beer in the commercial. And a rare study of actual copying of alcohol consumption, Koordeman et al. (2012), found no relevant effects among young men watching a film with alcohol advertisement breaks. This is often true of non-commercial portrayals of alcohol consumption too. This shows that what is true of media violence is also true of alcohol in the media. For most viewers, exposure to portrayals of alcohol consumption has no effect. It does for some viewers, but the effect is that they consciously decide to drink. For a small minority, finally, it may have an autonomy-bypassing effect. The present state of empirical research does not, however, suggest that the correlation between exposure to AM and autonomy-bypassing harmful alcohol consumption is going to be strong enough to warrant liberal regulation. If I am wrong and sufficiently large autonomy-bypassing effects can be found, then the receiver version of the argument from autonomy gives no protection to exposing children to AM. This would open the way to AM regulation. But even if I am right and no sufficiently large effects can be found, AM regulation could still be defensible from a liberal perspective. To see why, the concept of proleptic autonomy is useful. Children are not generally considered to be fully autonomous, but we do assume that autonomy increases during childhood, partly due to bodily and cognitive developments and partly because parents and educators offer children opportunities to practise decision-making. The sorts of choices that are acceptable for the purpose of practice will generally depend on the risks of the potentially harmful consequences involved. Leaving 5-year-olds alone in the kitchen to prepare a hot lunch is a misplaced form of proleptic autonomy because of the risk that they seriously injure or even kill themselves or others. Leaving 10-year-olds alone in the kitchen with the same task is still risky, but the risks are, let us assume, acceptable. Suppose now that no autonomy-bypassing effects can be found. For the receiver autonomy argument to protect exposure of children to AM, it still ought to be shown that the risks involved in exposing children to AM are acceptable as a kind of proleptic autonomy. There is as yet little research that might help us to estimate the risks, as few papers have explicitly examined the correlation between children s exposure to AM and harmful consequences. An unusual example serves to illustrate the idea here. As we saw, Smith and Geller (2009) studied the relation between exposing children to AM and other-directed harmful consequences by examining the influence the existence of a ban on alcohol advertising targeted at minors has on the incidence of alcohol-related youth traffic fatalities. They found that US states that have such bans in place report over 30 per cent fewer deaths among year-old drivers in single-car accidents than states where such regulation is absent. This may still be relatively small, given the fact that the chance of dying in a single-car accident is not very great in the first place. We should also bear in mind that these harms result only in countries where minors are allowed to drive cars, and that liberal policy-makers may propose stricter driving age restrictions rather than AM regulation. However, these findings do give some initial plausibility to the view that exposing children to AM may be associated with risks that cannot be justified in terms of proleptic autonomy, and they clearly suggest avenues for further research. Nor is this the only sort of harm to consider. While traffic accidents may be a prominent form of other-directed harm resulting from underage alcohol consumption, an increasingly prominent form of selfdirected harm is brain damage. A recent wave of empirical research provides evidence that alcohol consumption harms developing brains in children and even in young adults. Alcohol consumption is associated with a decrease in the size of the hippocampus, the likely effects of which are a decrease in memory and learning skills, and it is also linked to damage to the prefrontal cortex, which may be of particular liberal concern, as it is thought to play a central role in autonomous decision-making. It is not unlikely that these harms are substantial and serious enough not to count as an acceptable risk from the perspective of proleptic autonomy, and I believe that the most promising argument for liberals and others justifying regulation of exposing children to

10 44 DE BRUIN AM would be phrased in terms of unacceptable risks of brain damage. To see whether the risks are really unacceptable, however, more research is needed. This research should focus not so much on the correlation between alcohol consumption and brain damage; we know that such a correlation exists. What policy-makers should be interested in, by contrast, is research on the correlation between exposing children to AM and brain damage itself. Just as Smith and Geller s (2009) article directly examined the relation between exposure to AM and other-directed harmful effects, what we need is research examining the self-directed harmful effects that result from exposing children to AM. It may seem unlikely that we shall find evidence that exposing children to media portrayals of alcohol consumption causes brain damage in a sufficiently large number of children to warrant regulation of AM. But that it is unlikely does not mean it is impossible. Conclusions There is evidence that backs the claim that exposing children to AM increases the chances that they will consume alcohol as minors or as adults, and since alcohol consumption is associated with a plethora of public health issues, calls for the stricter regulation of AM can be heard from many quarters. What underlies these calls is often the following logic: when something causes something bad, then ban it. I have argued that from the available research we cannot conclude that exposure to AM plays a genuine causal role in bringing about the things with which it is associated. Second, even if causal connections can be established, the strength of the correlation is still too weak to justify regulation. And third, the sorts of things with which it is associated in the existing research only infrequently count as genuine harms from a liberal point of view. Even if exposing children to AM were to lead to genuine harms, no justification for AM regulation would directly follow because we would still have to address the question of whether the freedom to expose children to AM obtains special protection from one of the existing arguments for freedom of speech and expression. Ultimately, the claim I have defended is that AM regulation is defensible if it can be shown that exposing children to AM leads to harmful consequences in ways that bypass autonomy, or if it can be shown that it leads to harmful consequences that are unacceptable from the point of view of proleptic autonomy. Whether one or both of these two conditions apply, though, is still an open empirical question. Acknowledgements The author is grateful to David Archard, Anthony Mark Cutter and the participants of an Alcopop TV Culture workshop on Media, Alcohol and Violence in Young People: Research and Policy Perspectives held in Gothenburg in October He owes special thanks to Christian Munthe and two anonymous referees for their thoughtful and constructive comments on earlier versions of this article. Thanks are also due to his research assistant Sjoerd Norden for preparing the bibliography. References Alcohol Concern. (2011). New Media, New Problem? Alcohol, Young People and the Internet. London: Alcohol Concern. Atkin, C. (1995). Survey and Experimental Research on Effects of Alcohol Advertising. In Martin, S. (ed.), Television and Music Video Exposure and Risk of Adolescent Alcohol Use. Bethesda: U.S. Department of Health and Human Services. Atkin, C., Neuendorf, K. and McDermott, S. (1983). The Role of Alcohol Advertising in Excessive and Hazardous Drinking. Journal of Drug Education, 13, Beauchamp, D. (1976). Exploring New Ethics for Public Health: Developing a Fair Alcohol Policy. Journal of Health Politics, Policy and Law, 1, Brison, S. (1998). The Autonomy Defense of Free Speech. Ethics, 108, Chartrand, T. L. and Bargh, J. A. (1999). The Chameleon-Effect: The Perception-Behavior Link and Social Interaction. Journal of Personal and Social Psychology, 76, Christensen, P., Hendriksen, L. and Roberts, D. (2000). Substance Use in Popular Prime-Time Television. Washington: Office of National Drug Control Policy. Cohen, J. (1969). Statistical Power Analysis for the Behavioral Sciences. San Diego: Academic. Dawson, A. (2009). Editorial: Political Philosophy and Public Health Ethics. Public Health Ethics, 2, Dawson, A. and Verweij, M. (2008). The Steward of the Millian State. Public Health Ethics, 1, De Bruin, B. (2008). Media Violence and Freedom of Speech: How to Use Empirical Data. Ethical Theory and Moral Practice, 11,