1. Introduction
Underage drinking is an emerging public health problem. Globally, alcohol use was the seventh leading risk factor for both deaths and disability-adjusted life years (DALYs) in 2016. Among the population aged 15–49 years, 12.2% of male deaths and 3.8% of female deaths are attributed to the consumption of alcohol [
1]. Both early initiation and heavy consumption of alcohol throughout adolescence are associated with increased risks of alcohol-related harm [
2]. Abuse of alcohol by adolescents is associated with poor health outcomes across the lifespan [
3]. A review study associated adolescents’ binge drinking with poorer cognitive functioning in areas such as learning, memory, executive functioning, and impulsivity [
4]. A longitudinal study has also associated even low levels of alcohol consumption with the risk for later abuse of cannabis [
5].
The availability and sales of non-alcoholic beer have increased in several countries [
6,
7]. There is debate as to whether the consumption of non-alcoholic beer serves as a substitute for alcohol or as a gateway to its consumption. Some studies show that increasing the availability of non-alcoholic beers seems to substitute for the purchase of alcoholic products [
8,
9]. Other studies indicate that alcohol-free liquor products are being marketed to increase consumption among children, adolescents, and pregnant women rather than being marketed to lower the consumption of traditional alcoholic products. These studies also stress the intent to increase the acceptable number of occasions that alcohol-free liquor products might be considered for consumption (i.e., weekday lunchtimes and sports/fitness activities) [
10,
11]. In Japan, about 30% of advertisements for alcohol-flavored non-alcoholic beverages were aired during times that typically restrict alcohol advertising [
12]. Since most non-alcoholic beer products are made to appear very similar to alcoholic beer packaging, experts worry about the risks involved when children and adolescents consume drinks that look, smell, and taste like alcohol. Some scholars have raised concerns that the marketing of zero-alcohol beverages might serve as a gateway to the consumption of alcohol among minors and have suggested conducting more research to aid in establishing meaningful policy regulations [
13].
As children and adolescents spend more time online and using social media [
14], they are increasingly exposed to the digital marketing of non-alcoholic products that mimic alcohol. Studies have indicated that exposure to such products on social media is related to increased intention to consume alcohol [
15,
16]. Review studies have shown that adolescents and young adults who view digital alcohol marketing by clicking on alcohol ads, visiting alcohol-branded websites, and liking or sharing ads on social media were more likely to consume alcohol [
17] and to later develop alcohol-related problems [
18]. A study of four countries also showed that greater exposure to online alcohol marketing was related to drinking initiation and binge drinking [
19]. In other studies, content analysis of Instagram posts has shown that the majority of influencers who post about alcohol show positive and appealing characteristics, such as positive emotional experiences, achievement, individuality, and camaraderie [
20,
21]. Compared with brand posts, influencer posts lead to more brand “likes” [
22]. Future research is needed to examine the impact of influencer marketing on alcohol consumption among minors [
20].
Parents have an important role to play in reducing adolescents’ risk for initiating the consumption of alcohol. Studies have positively associated social media alcohol content exposure with the consumption of alcohol and shown that parental mediation reduces this relationship [
23,
24]. A review study positively associated the risk of adolescent consumption of alcohol with parental provision of alcohol, favorable parental attitudes towards alcohol consumption, and parental drinking. The same study negatively associated consumption of alcohol with parental monitoring, high-quality parent-child relationships, parental support, and parental involvement [
25]. A study found that youth whose parents critiqued media messages reported more critical thinking skills, less interaction with alcohol brands on social media, and less interest in alcohol [
26]. Parenting factors and peer influences in early adolescence should be considered valuable exercises to reduce the risk of later alcohol-related harm [
2].
In Taiwan, children and adolescents are spending more time using social media for entertainment and communication. A national survey in Taiwan showed that about 57% of children and adolescents use Instagram and spend 1.5 h per day on the platform [
27]. The advertising of non-alcoholic beer and alcohol products in the form of social media influencer marketing has increased in Taiwan. However, there are no clear regulations that require influencers disclose sponsored content, and many young influencers endorse non-alcoholic beer and associated products on social media. Although Taiwanese law bans the sale or delivery of alcohol to children and adolescents, the Taiwan Youth Health Survey has shown that half of middle school students and about three-fourths of high school students have consumed alcohol [
28]. School teachers complained that students bring non-alcoholic beer products to schools to share with classmates. A study conducted in Taiwan has associated adolescent exposure to alcohol advertising in the media with both the initiation and the persistence of alcohol consumption [
29]. Experts are concerned that children and adolescents are more susceptible to influencer marketing and non-alcoholic beer products that look identical to their alcoholic counterparts.
Due to COVID-19, children and adolescents have increased their time online and tend to be more vulnerable to mental distress [
30,
31]; alcohol companies are known to market their products and brands on social media platforms related to COVID-19 [
32]. The World Health Organization (WHO) has stated that the alcohol industry has used increasingly sophisticated advertising and promotion techniques, such as linking alcohol brands to sports, sponsorships and social media, to gain new customers (i.e., youth) [
33]. Despite studies showing the effect that social media and influencer marketing has on the intake of unhealthy foods and beverages among minors [
34,
35,
36,
37], relatively few studies have been conducted in Asian societies to examine the relationships between exposure to the influencer marketing of non-alcoholic beer and the impact of non-alcoholic beer use on the intentions of adolescents to consume alcohol. Thus, the present study examines the relationship of exposure to the influencer marketing and consumption of non-alcoholic beer with adolescents’ intention to purchase and consume alcohol during the COVID-19 pandemic.
4. Discussion
The results of this study show that more than one-fourth of adolescents had consumed alcohol in the past year. Adolescents’ exposure to influencer marketing of alcohol was associated with the purchase and drinking of alcohol. These results were consistent with a previous study that positively associated exposure to social influencers’ alcohol-related posts (alcohol posts) with the drinking of alcohol by adolescents [
20]. Prior studies have also associated adolescents’ exposure to alcohol-related social media and digital alcohol marketing with alcohol consumption [
15,
16,
17,
19]. In response to these findings, researchers have suggested regulating digital marketing [
36,
37], and the WHO has taken the position that alcohol marketing presents cross-border challenges in the form of influencer marketing [
33]. In 2018 Lithuania enacted a law on alcohol control to provide a comprehensive ban on alcohol advertising, which included all digital media, but court rulings have been contradictory regarding the potential utilization of zero-alcohol beverages by alcohol companies to promote the sale of alcoholic beverages [
39]. Future research is needed to examine whether the marketing of non-alcoholic beer increases alcohol consumption by minors.
In addition, in the present study we found that about one-fifth of adolescents had consumed non-alcoholic beer in the past year, which was associated with the consumption of alcohol when influencer marketing of alcohol was considered. Both the consumption of non-alcoholic beer and exposure to the influencer marketing of alcohol have also been positively associated with adolescents’ intentions to consume alcohol. Prior studies have established these behavioral patterns in both children and adolescents [
40,
41]. These findings support the notion that alcohol-free liquor products seem to be marketed to children and adolescents [
10,
11]. Since most non-alcoholic beer products look identical to their alcoholic counterparts, children could have difficulty differentiating between the two. Experts are concerned about the risk for children and adolescents in consuming a drink that looks, smells, and tastes like alcohol. It is logical to assume that developing an early habit of consuming non-alcoholic drinks that have the other characteristics of alcoholic drinks is likely to transition to regularly drinking alcohol later. The Czech Republic launched a campaign called “Don’t Hop Children” to warn parents of the risks associated with giving children non- or low-alcoholic beers.
The results of the present study show that adolescent exposure to influencer marketing of non-alcoholic beer and alcoholic drinks is common and is positively associated with non-alcoholic beer/alcohol consumption and purchase. Another study has shown that influencers have a significant impact on social comparison, materialism, and the fear of being excluded, which affects the intention to purchase of endorsed products [
42]. Children and adolescents may not be aware that the sponsored influencer posts are actually advertising, which makes them more vulnerable to persuasive attempts [
43,
44]. At least one study has shown that only a few alcohol posts disclose advertisement information, and that posts with sponsorship disclosures yield fewer likes and comments than posts without such disclosures [
20]. Several studies have suggested mandating disclosures of influencer marketing to increase children’s and adolescents’ advertising literacy and reduce advertising effects [
44,
45,
46,
47]. Some countries, such as the United States [
48] and the United Kingdom [
49], have published guidelines requiring that social media influencers disclose material connections they have with brands they endorse.
Moreover, the results of the present study negatively associated parental restrictive mediation with adolescents’ alcohol consumption and purchase. Prior studies have positively associated social media exposure with alcohol consumption among adolescents, while showing that parental mediation moderates the association between social media exposure and consumption of alcohol [
23,
24]. At least one study has shown that the combination of written and spoken sponsorship disclosure information and an active parental mediation style increases adolescents’ cognitive advertising literacy [
50]. Pediatricians could guide parents and children to develop digital literacy skills to prevent or mitigate negative outcomes [
51]. Many studies suggest implementing media literacy enhancement programs and parental mediation to strengthen critical thinking skills and prevent online risks [
26,
52].
Furthermore, results of the present study show that boys purchase alcohol at higher rates than girls, while girls have higher rates of intention to drink non-alcoholic beer and alcoholic drinks. A separate study involved analysis of posts concerning alcohol on social media and found that drinking was presented as a feminine practice, which could appeal to a wider range of women [
53]. Another study showed that lower-strength alcoholic products tend to target non-traditional consumers, such as adolescents and pregnant women, in an effort to extend the range of consumers [
10]. Future studies could further analyze influencer marketing regarding non-alcoholic beer and alcohol content and assess the advertising effects on boys and girls, respectively. At least one study has shown that strengthening social media literacy has a protective role for adolescents, and for girls in particular, and that it reduces the damaging effects of exposure to idealized images on social media [
54]. Schools could develop and implement gender-specific programs and involve parents in social media literacy educational interventions to prevent the consumption of alcohol and reduce negative impacts from social media marketing.
The present study had some limitations. First, this was a cross-sectional study and could not demonstrate causality for topics such as influencer marketing exposure, non-alcoholic beer drinking, and alcohol consumption among adolescents. Future studies could conduct longitudinal studies to examine the causal relationship between the consumption of non-alcoholic beer and the drinking of alcohol. Second, self-reporting of influencer marketing exposure and non-alcoholic beer/alcohol drinking are prone to potential recall bias. Third, 12th grade students had a higher rate of refusing to participate in the survey compared with 10th and 11th grade students due to college entrance exam preparation. Selection bias must be considered. Fourth, the survey was conducted over six months, and the nature of change during adolescence may have created bias in the interpretation of the results. Finally, social desirability bias could have influenced the truthfulness of adolescents’ reports of alcohol consumption, meaning that the rates of adolescents’ drinking could be underestimated. However, confidentiality was emphasized in this study. Despite these limitations, the strength of the present study was its large sample size which was used to examine the relationships between influencer marketing exposure, parental mediation, and the consumption of non-alcoholic beer, and to establish how these relationships affect adolescents’ intention to purchase and consume alcohol.