Smartphones—The good, the bad and the ugly consequences of use

During the last five decades, nothing has reformed our way of life as much as the Internet. Those of us over the age of 40 can remember using wired telephones, how to hand write letters, find our way, play in nature, use cash and many more practical skills from the time before the emergence of Internet-connected mobile devices such as smartphones and tablets. Admittedly, these devices do make life easier and safer in many ways. One example is the recent creation of the 112-emergency application (app), which localises your geographical position and calls assistance in case you get lost or injured. As a parent, a smartphone can help you stay in close contact with your children—even if they do not always agree on the benefits—more than ever previously possible. Many innovators also have great hopes that smartphones will help improve lifestyle habits through apps that encourage physical activity and other health-related behaviours. However, so far, there is only modest evidence that apps can achieve and sustain these behavioural changes, and for children there is less research to support this prospect.1 Which other consequences might this rapid new technological development have on children's health and development? Interestingly, the scientific literature provides accumulating evidence regarding negative health effects of electronic devices, including TV. Exaggerated use of social media and TV has been convincingly linked to obesity in several western countries.2, 3 A Canadian study including 5000 11- to 20-year-old students showed that greater use of social media was associated with shorter sleep duration in a dose-response fashion.4 The growing amount of alarming scientific reports has led the European Academy of Paediatrics and the European Childhood Obesity Group to write a consensus statement targeting parents and other stakeholders.5 Their main messages concern the negative influence of social media and TV on children's sleep and the consumption of unhealthy foods—both are also strong risk factors for obesity. When it comes to smartphones, their warning against overuse concerns the negative effects of advertising to children, but also the lack of face-to-face contact with peers, which may increase social problems and lead to mental ill-health.5 They recommend parents not to allow children under 4 years of age to use TV, computers or social media unsupervised. For children over 4 years, they recommend a maximum of 1.5 hours use per day. More unrealistically, they also recommend that children should not receive their first smartphone before 12 years of age. While there is very little evidence that specific apps in smartphones or tablets may have a positive effect on children's physical activity, a relevant question is if they have a negative effect. International comparative studies have shown that after five years of age there is an average cross-sectional decrease of 4% per life year in total physical activity, due mainly to increased sedentary time.6 In high-income countries, only about 30% of young people meet physical activity guidelines.7 Does this trend have something to do with the emergence of Internet-connected mobile devices? In this issue of Acta Paediatrica, Raustorp et al publish a study indicating a negative association between high use of smartphones and tablets and physical activity.8 The study included 550 students aged 8 to 14, who self-reported their time spent with smartphones and tablets during 4 consecutive weekdays in 2017 while wearing accelerometers to measure steps per day. The authors found a moderately inverse correlation between mean steps per day and mean daily minutes of smartphone and tablet usage. When stratifying for sex and age, the correlation was significant for teen-aged girls only. However, self-reported time of use of smartphones and tablets is not a very reliable method, especially not in younger children as also acknowledged by the authors. Therefore, it cannot be excluded that the lack of an association in the younger age groups could be due to inaccurate reporting of user time. When comparing high and low users of these devices, only teen-age girls demonstrated a significantly lower number of steps in high users. It is therefore tempting to conclude that the use of smartphones and tablets leads to a decrease in physical activity, at least in teen-aged girls. However, causality cannot be established in this cross-sectional study and reverse causation could also be at hand. Similar results have, however, been reported from the USA by Kenney et al investigating the cross-sectional associations between screen time and consumption of sugary drinks, sleep, physical activity and obesity (all self-reported) in a sample of 25 000 US high school students.3 Here, authors reported a high use (≥5 hours per day excluding schoolwork) of electronic devices other than TV in 20% of the students. High use was associated with inadequate physical activity, high daily sugar-sweetened beverage consumption, inadequate sleep and obesity. Again, authors could not exclude the possibility of reverse causation. There is an even uglier aspect of using mobile devices like smartphones, namely addiction. Noë et al used the smartphone addiction scale over 8 weeks on 64 participants aged between 19 and 46 of both sexes.9 Participants had a smartphone monitoring app called Thymer installed on their phones allowing the researchers to monitor user's detailed physical interactions with the interface. The researchers found that total time on the smartphone alone was not a strong indicator of smartphone addiction, while high levels of interaction with lifestyle and social apps were, especially for girls. Use of the app Snapchat in particular, correlated positively with the smartphone addiction scale. This app has a combination of design features promoting high-frequency usage such as, for example gamification. It is well known that developers purposely design apps which stimulate prolonged usage through, for example ‘infinite scrolling’, which lacks stopping cues, or apps which make you want to come back enticed by notifications or daily rewards.9 Apps are thus purposely constructed to occupy one's mind for as long as possible; often for commercial reasons, they simply steal our time! This phenomenon is called the ‘attention economy’ treating a potential consumer's attention as a resource. So, the question is what type of activities do they steal time from? In survey from 2018 by Norton, a security software company it was reported that smartphones reduce children's sleep and outdoor activities,10 where physical activity is generally higher. Here, 6000 parents from 8 European countries with children aged 5-16 years answered an online survey regarding their own and their children's use of smartphones and tablets. The shocking results showed that children today spend more time on these screens than playing outside. The older the child, the more time is ‘stolen’. For Sweden, the average time spent daily on these devices was 2 hours and 47 minutes (second highest after the UK), while playing outdoors (across weekends and weekdays) was only 1 hour and 56 minutes. For the age group 14-16 years, the time spent on connected mobile devices was 3 hours and 14 minutes, quite similar numbers to those reported by Raustorp for the oldest age group.8 One must remember that a fair share of this time has probably been ‘stolen’ from the TV and other indoor activities. Nevertheless, today, smartphone use makes up for most of the screen time among children, and many already own a device from 5 years of age. While many parents in this survey saw a positive impact of mobile screen time on children's problem solving and learning skills, just as many were also concerned about the risk of children getting too little sleep, being bullied online and being exposed to inappropriate material. Many parents also expressed guilt about the time they themselves spent online and worried that they set a bad example for their children. Of all the countries included in the study, the proportion of parents reporting restrictions in the home and school was lowest in Sweden. Another interesting finding was that parents from all European countries reported that their child is more hooked on their smartphone than on sugar! Finally, the report noted that parents were asking for expert support and advice when it comes to setting up controls, restrictions of use and on how to protect their children online. The time has come to disseminate the European Academy of Paediatrics advice more actively to parents and teachers, not the least advising adults to be good role models. Also, more research is needed to evaluate the linkages between the use of these devices, sleep, physical activity and psychosocial well-being, as well as family interventions to promote healthy screen use behaviours. Importantly, app developers should also take their share of responsibility by abstaining from luring children and adults into overconsumption of goods and entertainment and outright smartphone addiction. The author has no conflicts of interest to declare. Liselotte Schäfer Elinder

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