Dependency on Smartphone Use and Its Association with Anxiety in Korea

Abstract

Objective

South Korea has the highest rate of smartphone ownership worldwide, which is a potential concern given that smartphone dependency may have deleterious effects on health. We investigated the relationship between smartphone dependency and anxiety.

Methods

Participants included 1,236 smartphone-using students (725 men and 511 women) from six universities in Suwon, South Korea. Participants completed measures of smartphone use, smartphone dependency, anxiety, and general characteristics (i.e., demographic, health-related, and socioeconomic characteristics). To measure smartphone dependency and anxiety, we used questionnaires of Yang's test developed from Young's Internet Addiction Test and Zung's Self-Rating Anxiety Scale. We used multiple logistic regression to determine the association between smartphone dependency and anxiety after adjusting for relevant factors.

Results

On a scale from 25 to 100, with higher scores on the smartphone dependency test indicating greater dependency, women were significantly more dependent on smartphones than were men (mean smartphone dependency score: 50.7 vs. 56.0 for men and women, respectively, p<0.001). However, the amount of time spent using smartphones and the purpose of smartphone use affected smartphone dependency in both men and women. Particularly, when daily use time increased, smartphone dependency showed an increasing trend. Compared with times of use <2 hours vs. ≥6 hours, men scored 46.2 and 56.0 on the smartphone dependency test, while women scored 48.0 and 60.4, respectively (p<0.001). Finally, for both men and women, increases in smartphone dependency were associated with increased anxiety scores. With each one-point increase in smartphone dependency score, the risk of abnormal anxiety in men and women increased by 10.1% and 9.2%, respectively (p<0.001).

Conclusion

Among this group of university students in South Korea, smartphone dependency appeared to be associated with increased anxiety. Standards for smartphone use might help prevent deleterious health effects.

Smartphones (mobile telephones that run on portable operating systems) are more advanced than regular mobile telephones because they have advanced capabilities, such as wireless Internet access.¹ Smartphone sales have increased rapidly worldwide, with an estimated 300 million smartphones being purchased annually after 2010.^2,3 South Korea has the highest rate of smartphone ownership worldwide, with 58% of adults and 84% of college students reportedly using smartphones in 2012. Moreover, the number of smartphone users continues to increase.^4,5

Because smartphones afford greater access to media, their use may lead to unexpected health problems, such as Internet addiction.^6,7 Although addiction is considered to be a pathologic condition characterized by persistent use and excessive dependency,⁸ studies on the health effects of smartphone use (e.g., psychological effects, smartphone dependency risk) are scarce. Hwang et al. found a positive correlation between smartphone overuse and upper extremity pain, while several case reports and studies noted increased addictive and depressive symptoms as a function of smartphone use.^9–12 Im et al. reported positive correlations of smartphone addiction level with scores measuring psychotic depression and obsessive-compulsive disorder.¹¹ However, most studies were limited in their sampling techniques (e.g., small sample sizes, convenience samples)^7,11,13 or did not control for confounding factors. Assessing compulsive and dependent symptoms as confounding factors would help address the effects of potential comorbidities on smartphone addiction.^10,14

Given that smartphones are portable, provide convenient Internet access, and have functions that allow for multitasking, they could promote dependence to a greater degree than regular mobile telephones or Internet accessed from a computer.^1,15 Increased smartphone dependency is a putative risk factor for industrial injuries or automobile accidents (via disrupted concentration), muscular pain, and anxiety.^7,9,15 Increased use of smartphones also relates to mental health problems, such as increasing depression and anxiety.^5,10,11 Anxiety disorders, which are among the most prevalent mental disorders, may be particularly exacerbated by smartphone use because they are related to substance addiction and dependency.^16,17 Notably, the relationship between smartphone overuse and negative psychological adaptation is moderated by demographic characteristics, smartphone use preferences, and inappropriate use.^18–20 However, research studies identifying the health effects from smartphone overuse considering those factors are rare.

Apparent differences by sex exist in the perceptions of social contact, motivation for technology use, and compulsive use of media and substances.^19,21 For example, men are at greater risk for addiction to alcohol, smoking, and computer games, whereas^19,22,23 women are more likely to immerse themselves in online social networking.^1,21 Hwang et al. reported that men's smartphone use was driven by the desire to show off new technologies and entertainment media, while women's smartphone use was motivated by the desire to communicate.¹⁴ Thus, sex may affect smartphone dependency.^20,24

We examined health-related, demographic, and socioeconomic factors as potential influences on smartphone dependency. Additionally, we investigated the relationship between smartphone dependency and anxiety by sex.

METHODS

Participants

Participants were students in large, open-lecture classrooms of six universities located in Suwon, South Korea, recruited via cluster sampling. First, we selected all universities (four institutions with four-year curriculums and two institutions with two-year curriculums) in Suwon and investigated summer lecture schedules. Then, we selected classes in each university in which the registration was not limited by major or grade.

Of the 1,296 open-lecture students, a total of 1,261 (97.3%) consented to participate. The survey was conducted in July and August 2013 via a closed-ended questionnaire. Five trained investigators visited classes in six universities and performed face-to-face interviews for anxiety and smartphone dependency. Participants self-reported demographic characteristics and behavioral characteristics on smartphone use in questionnaires. Data collected from researchers and participants were electronically entered and checked for accuracy by research staff members.

Data collection instruments and variables

The survey assessed smartphone use patterns (including total use time), situations in which smartphones are frequently used, average daily use (in hours), and purpose of use. Situations were described as activities they frequently perform while using smartphones, such as commuting or traveling, transportation or walking, working or attending a lecture, and before sleeping. We included the activity of spending a break time using mobile telephones for participants who use their smartphones during break time or do nothing else when using their smartphones. We defined smartphone dependency as persistent smartphone use despite problems related to that use. We measured smartphone dependency using Yang's questionnaire on mobile telephone dependency, which was based on Young's Internet Addiction Test.^25,26 We modified the items in Yang's questionnaire to assess smartphone dependency.

The questionnaire has established validity^15,25–28 and comprises 25 items in four subscales (obsession, withdrawal, reliance, and disturbances in daily life). Obsession indicates persistent use of smartphones (e.g., “How often do you use a smartphone longer than you intended?”). Withdrawal indicates experiencing nervous symptoms or repetitive illusions of ringing when not using a smartphone. Reliance, characterized as excessive psychological attachment, indicates attaching great importance to smartphones. We measured reliance in terms of the frequency of experiencing a deep sense of loss when unable to use smartphones (e.g., “How often do you fear that life without your smartphone would be boring, empty, and joyless?”). Disturbances in daily life indicates a significant distress and impairment of social, occupational, and role functioning due to excessive use of smartphones. We measured disturbances in daily life with questions such as, “How often do you lose sleep due to late-night use of a smartphone?” (Table 1).

Table 1.

Questionnaire assessing problematic use of mobile telephones by Yanga for a study of smartphone use among students at six universities in Suwon, South Korea, July–August 2013^a

^aScoring on each item was 1 to 4 based on participants' answers, with 1 = rarely, 2 = occasionally, 3 = often, and 4 = always. Total scores ranged from 25 to 100, with higher scores indicating greater smartphone dependency. Adapted with permission from: Yang SY. Studies for mobile phone addiction in high school students. Sejong-si (South Korea): Korea National Youth Policy Institute; 2002.

Total scores ranged from 25 to 100, with higher scores indicating greater smartphone dependency. Cronbach's a for the total score in the present study was 0.90 (range: 0.87–0.89 for the subscales in previous studies),^26,28 which is considered reliable.

We assessed anxiety, defined as uncontrollably excessive and persistent worrying that causes exacerbated distress, with an adapted version of Zung's Self-Rating Anxiety Scale. This scale comprises 20 items in four subscales. Total scores range from 20 to 80, with a normal level of anxiety defined as ≤44. Cronbach's a for the scale was 0.96.²⁹

We assessed demographic, socioeconomic, and health-related characteristics, including sex, age, economic status, academic achievement, self-rated health, smoking patterns, amount of alcohol consumed, presence of physical or mental illness, and family history of mental illness. For smoking patterns, participants reported whether or not they had smoked during the past six months; for alcohol consumption, participants rated the number of times they had consumed alcohol in the past month (i.e., >60 grams of pure alcohol each time for men, >40 grams of pure alcohol each time for women). Those who consumed alcohol more than once per week were classified as high risk. We also collected data on physical and mental illness diagnoses (including anxiety) during the past three years. Physical illnesses (e.g., arrhythmia and thyroid disease) included those assessed by Flint³⁰ and mental illnesses (e.g., depression, schizophrenia, and bipolar disorder) includes those assessed by Alloy et al.³¹

Statistical analysis

We stratified all data by sex and excluded missing values from the analysis. We used the Mann-Whitney U-test and Pearson's χ² test to compare smartphone dependency scores by participants' characteristics and smartphone use patterns. We used analysis of covariance to compare smartphone dependency scores by sex while controlling for general characteristics and smartphone use patterns. Finally, we computed the association between smartphone dependency and incidence of anxiety using odds ratios (ORs) via multiple logistic regression. We used SPSS^® version 19.0 for all analyses.³²

RESULTS

Of the 1,261 participants, 15 (1.2%) did not use smartphones and 10 (0.8%) did not answer all of the questions; as such, their data were excluded. Thus, the final sample comprised 1,236 participants (725 men and 511 women).

Participants' mean age differed significantly (p<0.001) between men (23.6 years) and women (21.5 years). Additionally, compared with women, men reported significantly higher rates of smoking (38.8% vs. 27.8%) and high-risk alcohol consumption (28.4% vs. 6.7%) (p<0.001). Compared with men, women reported significantly worse subjective health (p<0.001) and higher prevalence rates of physical illness (31.6% vs. 22.8%, p=0.001) and family history of mental illness (6.5% vs. 3.4%, p=0.019). The rate of abnormal anxiety, which was >44 according to Zung's scale, was reported by 20.1% of women and 8.9% of men (p<0.001) (Table 2).

Table 2.

Demographic characteristics and anxiety scores, by sex, of students who use smartphones at six universities, Suwon, South Korea, July–August 2013

^aPercentages may not total to 100 because of rounding.

^bMann Whitney U-test and Pearson's ÷² test

^cSelf-reports were recorded for economic status, academic achievement, health status, and physical illness. The levels of high, middle, and low income were determined by participants' subjective opinion of their relative state compared with their surroundings.

^dAverage alcohol consumption in the past month (>60 grams of pure alcohol each time for men and >40 grams of pure alcohol each time for women)

^eParticipants who reported that they had smoked during the past six months

^fMental illnesses were based on self-report of diagnosed illness from a doctor within the past two years.

^gTotal scores range from 20 to 80, with a normal level of anxiety defined as ≤44. Adapted from: Zung WW. A rating instrument for anxiety disorders. Psychosomatics 1971;12:371-9.

SD = standard deviation

Smartphone use patterns differed by sex. More women than men reported owning a smartphone for more than two years (61.6% vs. 46.3%, p<0.001) and using a smartphone in bed before sleeping (33.7% vs. 24.3%, p<0.001). We found a significant difference by sex in usage situations: 40.7% of women and 24.8% of men reported using smartphones frequently during break time, 31.5% of men and 37.2% of women reported using smartphones frequently while commuting or traveling between places, and 3.5% of men and 4.3% of women reported using smartphones frequently during work or class (p<0.001) (Table 3).

Table 3.

Smartphone use patterns and mean smartphone dependency scores, by sex, of students at six universities, Suwon, South Korea, July–August 2013

^aSex differences were compared using Mann-Whitney's U-test in dependency score and Pearson's chi-squared test in smartphone use patterns.

^bRespondents were asked to choose only one answer that most applied to themselves from the list in each question.

^cMedia-based entertainment functions includes digital multimedia broadcasting, MP3, video player, camera, and games.

^dTotal scores ranged from 25 to 100, with higher scores indicating greater smartphone dependency. Adapted from: Yang SY. Studies for mobile phone addiction in high school students. Sejong-si (Korea): Korea National Youth Policy Institute; 2002.

SD = standard deviation

We also found significant differences by sex in average daily smartphone use (p<0.001). Twice the percentage of women as men (22.9% vs. 10.8%) used smartphones for ≥6 hours per day, a greater percentage of women than men used their smartphones for 4–<6 hours per day (31.1% vs. 18.6%), and a greater percentage of men than women used their smartphones for <2 hours per day (29.2% vs. 12.5%) (Table 3).

The purpose of smartphone use differed by sex (p<0.001). The most common purpose of smartphone use was social networking services for both men and women, but women reported using social networking services more frequently than did men (51.7% vs. 39.2%). After social networking services, the next most frequent use of smartphones by men and women was to search the Internet (20.5% of women and 23.7% of men) and for entertainment (18.2% of women and 23.9% of men). Overall, women were significantly more dependent on smartphones than were men (mean dependency score: 56.0 vs. 50.8, p<0.001) (Table 3).

Men and women also differed significantly when we examined smartphone dependency score by average daily use time and purpose of smartphone use, with higher scores on a scale from 25 to 100 indicating greater smartphone dependency. For <2 hours, ≥2–<4 hours, ≥4–<6 hours, and ≥6 hours of daily use time, men scored 46.2, 51.4, 53.4, and 56.0, respectively, while women scored 48.0, 54.8, 57.3, and 60.4, respectively (p<0.001). Thus, smartphone dependency showed an increasing trend as daily use time increased (Table 4). Those who most frequently used their smartphones for entertainment, searching the Internet, and social networking services had significantly greater smartphone dependency than did those who most frequently used their smartphones for calling/miscellaneous functions (p<0.001).

Table 4.

Smartphone dependency scores,^a by sex, according to use patterns of students at six universitiea, Suwon, South Korea, July–August 2013

^aTotal scores ranged from 25 to 100, with higher scores indicating greater smartphone dependency. Adapted from: Yang SY. Studies for mobile phone addiction in high school students. Sejong-si (Korea): Korea National Youth Policy Institute; 2002.

^bAll variables of behavioral patterns of smartphone use and other variables that contributed to significant differences in dependency (e.g., academic achievement in men and academic achievement and alcohol consumption in women) were adjusted.

^cAn analysis of covariance was used to compare the mean of smartphone dependency scores between groups of use patterns.

^eMedia-based entertainment function including digital media broadcasting, MP3, video player, camera, and games

CI = confidence interval

With each one-point increase in smartphone dependency score, the odds of having abnormal anxiety in men and women increased by 10.6% and 9.2%, respectively (p<0.001) (Table 5). After adjusting for known risk factors for anxiety disorders (e.g., age, health, presence of physical and mental illness, and economic status), the odds of having abnormal anxiety in men and women increased by 7% and 9%, respectively (p<0.001), for every one-point increase in smartphone dependency score.

Table 5.

Association between smartphone dependency score and anxiety score,^a by sex, in students at six universities, Suwon, South Korea, July–August 2013

^aTotal scores ranged from 20 to 80, with a normal level of anxiety defined as ≤44. Adapted from: Zung WW. A rating instrument for anxiety disorders. Psychosomatics 1971;12:371-9.

^bUsing multiple logistic regression adjusting for known risk factors (i.e., age, health status, physical and mental illness, and economic status)

OR = odds ratio

CI = confidence interval

DISCUSSION

Women had higher smartphone dependency scores than men, suggesting that women might be more vulnerable to smartphone addiction. This finding supports previous research. For example, Kim et al. noted that the risk of mobile telephone addiction may be higher in female adolescents than in male adolescents because females regard interpersonal interaction more highly.³³ Recently, mobile telephones have come to be perceived as a medium for interpersonal interaction and quick communication, which may explain why women tend to use their smartphones for longer periods of time.^21,33 Considering that smartphones have strengthened interpersonal interaction by online access (e.g., social networking), according to a study by Kim et al., the risk of smartphone addiction in women may be higher than the increase in mobile telephone addiction.¹

Average daily use time and purpose of smartphone use also accounted for significant differences in smartphone dependency and differences by sex. More than half of all sampled women, compared with one-third of men, used smartphones for >4 hours per day. Furthermore, more than twice the percentage of women as men used their smartphones for ≥6 hours per day. Notably, Young explained that the more individuals experience a sense of immersion in the Internet, the more they will become further immersed.²⁷ Thus, continuous, excessive Internet use can lead to -dependence. It is possible that the same principle applies to smartphone use. Namely, women who are dependent on smartphones may use their smartphones for longer periods of time, which may, in turn, increase their dependence on smartphones. However, further study is needed to provide evidence for this explanation.

Regarding purpose of use, smartphone dependency was higher among participants who used smartphones for social networking services, Internet searches, and media-based entertainment than among participants who used smartphones for mobile telephone-related functions. For example, both male and female social networking services users had high smartphone dependency scores; however, 51.7% of women, compared with 39.2% of men, were social networking services users. Social networking services use might have led to women having higher dependency scores than men. Specifically, more women appeared to believe that interpersonal relationships can be fostered via the Internet, which is consistent with women's preferences for social networking services.³⁴ Additionally, women tend to believe that media are useful in the development and maintenance of relationships, which coincides with their greater media use.³⁵ For example, in a longitudinal study of Japanese texting behavior, women communicated with more people using text messages than did men.¹ Furthermore, compared with men, women used smartphones to communicate with others more often, which may contribute to greater smartphone dependency among women. Although not shown in the tables, the interaction between women's preferences for social networking services and total smartphone use was not significant. However, smartphone dependency scores differed significantly by average daily use and purpose of use; thus, the main purpose of smartphone use and average daily use may independently affect smartphone dependency.

Smartphone dependency scores were also high among students who mainly used smartphones' entertainment functions compared with students using smartphones as conventional mobile telephones. This result coincides with previous results showing that mobile telephone addiction was highly associated with entertainment-based use.³⁶ Additionally, Park and Shin noted that smartphone dependency increased when users' need for fun was satisfied via playing games or watching videos with the device.⁸ The fact that smartphone dependency increased by playing games can be partially explained as an effect of video game addiction. According to a study of Hong Kong adolescents, video game addiction was significantly higher among those who preferred multiplayer online games than among those who preferred other games. Wang et al. assumed that multiplayer online games increased enjoyment and interaction with other players, which might result in prolonged gaming sessions.³⁷ Because the smartphone is optimized for portable online access, people who use it to play games could end up using it more persistently. Thus, our results may show a positive correlation between Internet and video game addiction, although it should be directly confirmed in future studies.

Men and women also differed by situations in which they used smartphones. Although men used smartphones frequently when resting, women used them frequently when commuting or traveling or just before sleeping. Smartphone dependency did not differ significantly by usage situation among men, but dependency scores were significantly higher among women who used smartphones during work or just before sleeping. However, the increase in dependency scores was non-significant after controlling for smartphone use and confounding variables. Importantly, smartphone dependency was significantly related to anxiety, the most prevalent mental disease, in both men and women; this finding suggests that dependency is not a habit but, rather, a potential public health issue for smartphone use.

When the smartphone dependency score increased by one point, the odds of having anxiety rose by 7% in men and 9% in women after adjusting for anxiety disorder risk factors. This finding supports work by Yun et al.,¹⁰ who reported that 62.6% of smartphone-addicted users complained of anxiety.¹³ University students in Turkey demonstrated increased anxiety among heavy users of smartphones, which the researchers proposed was mediated by sleep disturbances.³⁸ Furthermore, Hwang et al. researched the relationship between psychological characteristics and mobile telephone addiction among female university students and found that social extraversion and anxiety positively influenced addiction.¹⁴

Limitations

This study was subject to several limitations. First, because the study was cross-sectional, causal relationships between smartphone dependency and anxiety could not be inferred. Second, the sample was limited to Suwon and a specific age group. As such, the results are not necessarily representative of Korea because socioeconomic status and environmental conditions affecting smartphone use (e.g., population growth rate and social infrastructure for accessing the Internet) differ among regions.

CONCLUSION

Our study identified significant differences in smartphone use and dependency for several different use factors, such as average daily use time and purpose of use. Our study also found an association between smartphone dependency and abnormal anxiety. These findings add to the current knowledge base concerning dependency on smartphone use and abnormal anxiety that might be related to smartphone use and dependency.

The average amount of time spent using a smartphone is rising yearly in Korea (from 124 minutes per day in 2011 to 134 minutes per day in 2012), and use is concentrated heavily among young people. More than 77.1% of all smartphone users are aged 20–39 years, with a smartphone distribution rate in this age range of approximately 98%.³⁴ These young people are at a time in life when they must begin managing their behaviors to preserve health in later years. Together with other published studies and studies to come, our results may help form a stepping-stone toward recommendations for the use of smartphones to prevent dependency and its associated health effects.