Is Cannabis a Medical issue, a Policy issue, or a Criminal Issue? A Framing Analysis of Cannabis for...

Running Head: FRAMING OF CANNABIS FOR THERAPEUTIC PURPOSES

Is Cannabis a Medical issue, a Policy issue, or a Criminal Issue?

A Framing Analysis of Cannabis for Therapeutic Purposes (CTP) in Israeli Newspaper

Coverage

Nehama Lewis, Ph.D. Department of Communication

University of Haifa, Rabin Building, room 8035

Mt. Carmel, 3190501 Haifa, Israel TEL: +972-545-396913 [email protected]

Doron Broitman

University of Haifa / University of Tel-Aviv Tel Aviv 6997801, Israel TEL: +972- 54-584-9488

[email protected]

&

Sharon R. Sznitman Ph.D. School of Public Health

University of Haifa Eshkol Tower, room 705

Mt. Carmel, 3190501 Haifa, Israel TEL: +972- 4 828 8604

Email: [email protected]

FRAMING OF CANNABIS FOR THERAPEUTIC PURPOSES

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Abstract

Cannabis for Therapeutic Purposes (CTP) has become a topic of increasing public

interest and debate worldwide, particularly in Israel, where demand for, and provision of

licenses for CTP has increased substantially since 2007. News media framing of CTP

may influence public perceptions and public opinion regarding CTP policy. We

conducted a content analysis of all news items related to CTP (N=208) published in three

Israeli national news sources from January 2007 through June 2013 to examine how this

issue is framed in Israeli news coverage. This study examines three principal frames for

CTP: a medical frame, a policy frame, and a law enforcement frame. Each frame was

associated with a distinct pattern of textual elements, including sources cited, portrayal of

patients, and whether cannabis was described as a drug or as a medicine. The most

common frame for CTP in news coverage during this period was the policy frame.

Key words: framing, content analysis, news coverage, cannabis for therapeutic purposes,

public opinion.


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Introduction

Cannabis for therapeutic purposes (CTP) is an unconventional and highly contested

treatment. On the one hand, the 1961 UN Convention on Narcotic Drugs classifies

cannabis as a Schedule I drug, a classification which indicates that it has no accepted

medical use, and high potential for abuse (Ballotta, Bergeron, & Hughes, 2008;

Bostwick, 2012; UN Single Contention on Narcotic Drugs, 1961). On the other hand,

there is a growing basis of clinical research to suggest that cannabis may offer a range of

medical benefits (e.g. Bonn-Miller, Boden, Bucossi, & Babson, 2014; Earlywine, 2002;

Hazekamp & Grotenherman, 2010; Institute of Medicine, 1999). The issue of CTP has

become the subject of heated debate and is a major policy issue in many parts of the

world.

To date, 23 states in the U.S. and Washington, D.C., and other countries (Belle-Isle,

Walsh, Callaway et al., 2014) have enacted laws to legalize CTP (National Conference of

State Legislatures, 2013). In Israel, cannabis is defined as a Schedule 1 drug of abuse,

and CTP is not formally defined as a therapy, nor has it been declared safe and

efficacious for medical use (MOH 2013). However, authorities at the Ministry of Health

have noted that cannabis may alleviate the symptoms of a number of medical conditions

and reduce patients’ suffering.

As early as 1995, a subcommittee formed by the Israeli Parliament Drug

Committee recommended that the government continue to categorize cannabis as illegal,

but also that it allow and regulate access to CTP for patients who are severely ill (Brinn,

2009). As a result, Israel has been running a state-supported program providing CTP

since the late 1990’s. Initially serving fewer than 100 people, the CTP program started to


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grow substantially in 2007 and onwards. In 2013 there were approximately 13,000

licensed CTP patients in Israel (Ministry of Health, 2013). Specialist physician

recommendations for CTP are referred to medical professionals in the Medical Cannabis

Unit of the Ministry of Health who are authorized to issue CTP licenses (Waissengrin,

Urban, Leshem, Garty, & Wolf, 2014). In addition, 11 authorized oncologists have the

authority to directly issue licenses for cancer patients.

Media framing

At present, when CTP policies are changing rapidly within and across countries, it

is important to examine media coverage of CTP. Indeed, media coverage is one of the

major factors that influence public policy through shaping the public’s opinions on an

issue (McCombs & Reynolds, 2002). Seen from the perspective of framing theory, an

issue such as CTP, can be understood from a range of perspectives and be perceived as

having implications for multiple values or considerations (Chong & Druckman, 2007).

Framing can make a difference in the way that people think about issues – the way in

which an issue is described provides advantages to one possible perspective and

disadvantages to another (Wolfsfeld, 2011). By emphasizing particular aspects of an

issue in news coverage, the media aids audience understanding of an issue, and attaches

meaning to news content (Entman, 1993; Gitlin, 1980; Goffman, 1974; Reese, Gandy, &

Grant, 2001). The impact of this process is to promote a perspective which is consistent

with that construction, rather than a contrasting perspective.

The process of framing is dynamic, and involves mutually influential

relationships between media coverage, policy, and public opinion. Framing involves a

continuous interaction between journalists, elite groups (Gans, 1979), and social


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movements (Gitlin, 1980). Elite groups are defined here as a “distinct group within a

society which enjoys privileged status and exercises decisive control over the

organization of society." Elite groups are those who can exercise a degree of control over

the productive assets and institutions, which enables them to influence both the allocation

of resources and the allocation of authority (Amsden, Di Caprio & Robinson, 2009).

Journalists construct frames, in part, in response to external political factors such as elite

discourses and changes in policy and public opinion. Media frames, in turn, influence

policy and public opinion. Thus, it is expected that there is a (non-causal) relation

between frames and policy. This perspective is consistent with, Wolfsfeld's Politics-

Media-Politics (PMP) principle, which proposes that the media responds to changes in

the political environment, and, in turn, influences further political changes in the political

environment (Wolfsfeld, 2011). Thus, media framing of CTP is likely to be influenced

by, as well as impact, political changes and shifts in public opinion related to CTP.

A number of studies have shown that framing influences policy support for drug

policies (Elliot & Chapman, 2000: Forsyth, 2012; Lawrence, Bammer & Chapman, 1997;

McArthur, 1999). Despite the increasing debate surrounding the topic, we found only

one study that has analyzed the framing of CTP specifically in news media. Kaiser

(2011) examined the framing of CTP in U.S. print media, focusing on the question of

whether the issue was portrayed as a policy issue or a medical issue (Kaiser, 2011). The

author found that the majority of news items framed the issue as policy related. The

Kaiser study is important as it suggests that the public may be particularly likely to view

CTP as a policy rather than a medical issue in the U.S. Kaiser suggested that the

dominance of the policy frame for CTP may sway the debate over CTP and its


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legalization to one in which policy concerns take precedence over its (potential) risks or

benefits as a medical treatment, thus possibly delaying its ‘path to legitimization’ (Kaiser,

2011, p. 45).

The current study builds and expands upon this previous work, firstly by examining

CTP media framing in another geographical and CTP policy context (Israeli).

Furthermore, the current paper extends the framing analysis to examine the extent to

which CTP is framed as a law enforcement issue, a policy issue or a medical issue.

Certainly, the blurring of boundaries between illegal and medical uses of cannabis is

likely to be an issue of interest to law enforcement professionals - an elite group who may

influence media coverage on CTP. The inclusion of a law enforcement frame is also

motivated by research on the media construction of issues related to crime and its

influence on policy. For example, the classic study by Hall and colleagues (Hall,

Critcher, Jefferson, et al., 1978) found that UK media coverage that presented ‘mugging’

as a moral panic racially associated with African-Americans and black immigrants to

Britain boosted the legitimacy of harsh law enforcement measures. Despite the potential

importance of the law enforcement frame, to date, research examining news coverage

about CTP has not examined this frame.

Three competing frames for CTP

The current study focuses on three competing frames for CTP that represent three

powerful groups in Israeli society with a stake in CTP and who approach CTP from

different perspectives and with varying, and often conflicting, interests. These groups

include (i) the medical (and research) community, (ii) regulators and politicians, and (iii)

law enforcement. Each of these groups is directly involved in the issue of CTP in Israel,


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and would benefit from media coverage which reflects and promotes their perspective.

Each of these groups can also be categorized as an elite group in the context of CTP (see

above – Amsden et al., 2009).

For Israel’s medical establishment’s, interest in CTP focuses on its potential utility

as a treatment for patients and evidence basis for CTP or lack thereof. This group

comprises doctors, nurses, researchers, other medical practitioners, and medical staff. In

light of the growing empirical research suggesting potential medical benefits of cannabis

for some patients (see above), a substantial proportion of doctors have shown support for

the continued expansion of the CTP program and its use among some patients

(Nussbaum, Boyer, & Konrad, 2011), including world renowned experts in this field,

such as Prof. Raphael Mechoulam and Prof. Ruth Galily (Wilson, 2013). However, this

positive attitude toward CTP is not uniform across the medical establishment. A number

of studies from the U.S. indicate that physician beliefs and attitudes regarding CTP vary

widely across physician populations, perhaps as a result of the clinical population served

and differences in training (Williams, Rost & Dietrich et al., 2000; Harrold, Field, &

Gurwitz, 1999; Uritsky, McPherson, & Pradel, 2011; Kondrad, & Reid, 2013). While no

study, to the best of our knowledge, has explored attitudes towards CTP among Israeli

physicians, some Israeli physicians argue that more evidence is needed to demonstrate its

efficacy as a treatment (e.g. Bar-Sela, Avisar, Batash, & Schaffer, 2014). Others have

raised concerns about pressure from patients or their relatives on medical practitioners to

provide CTP (Israel Medical Association, 2013). Some medical professionals have also

cited fears of a “slippery slope of the evolving list of medical conditions” for which CTP

is indicated (Thompson & Koenen, 2011).


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Law enforcement officials include police officers and lawyers, among others,

whose most pressing concern is to prevent the diversion of CTP from patients to other

individuals. In Israel, cannabis is considered an illegal drug, and the CTP program is

seen as a threat to the enforcement of sanctions for the use and distribution of cannabis

(Knesset Labor, Welfare and Health Committee, 2013). In addition, if CTP finds its way,

through sale or otherwise, to the streets, this may lead to increased criminal activity,

generating an additional burden on law enforcement officials (Harkov, 2012).

Consequently, the perspective of those in law enforcement is likely to reflect and

highlight these concerns.

The perspective of policy makers, which include among others, officials at the

Ministry of Health and members of various parliamentary committees, reflects the need

to maintain control of the CTP industry. Policy makers must also take into account the

interests of the medical establishment, as well as the welfare of patients, and the concerns

of law enforcement officials. In addition, policy makers are cognizant of the sizeable

economic potential of this industry (Short, 2014), which could be of great economic

benefit to the Ministry of Health as well as other (aligned) interest groups. The economic

potential of CTP may also be a concern for pharmaceutical companies, who are likely to

see their profits eroded to some degree by a natural treatment that they cannot patent.

Patients and growers are also involved and interested parties with regard to Israel’s

CTP program. Tens of thousands of patients in Israel have received licenses for treatment

with CTP and many more are waiting to be granted licenses. However, unlike the three

elite groups described above, patients represent a diverse group of individuals without

agreed-upon spokespersons or organizations to promote their interests in the media.


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There is also a select group of growers of CTP in Israel who are supportive of the

continued growth of this industry. This group, however, has relatively limited financial

resources and access to the media. In contrast, policy makers, the medical establishment

and law enforcement represent large institutional bodies with greater resources and

greater access to the media. As this study focuses on the framing of CTP by elite groups,

we include patients and growers as part of the discourse, for example, by comparing the

ways in which patients are portrayed within each frame, but not as a group promoting a

coherent principal frame.

Study objectives

The objective of the current study is identify and measure the occurrence of three

dominant issue-specific frames (De Vreese, 2001) – a medical frame, a policy frame, and

a law enforcement frame, each of which promotes a particular perspective on CTP. In

contrast to generic news frames, which are broadly applicable to a variety of different

news topics, issue-specific news frames focus on specific topics, such as CTP (De Vrees,

2001; 2005).

Frames can be best understood as groups of various independent textual elements

working together to create an overall frame. In addition to making up a frame, each

independent textual element can also signal different meanings to the reader (Entman,

1993). This approach draws from the sociological foundation of framing that has been

used by researchers including Entman (1993), Gamson & Modigliani (1989), Gitlin

(1980), and Goffman (1974). This body of research investigates the way in which news

is presented to audiences by journalists (Kaiser, 2011). This approach to framing

research includes “words, imagines, phrases, and presentation styles” that are used by


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journalists to create news stories (Druckman, 2001, p. 227). Choice of words, imagines,

phrases, and presentation styles impact the interpretation and definitions of issues, such

as CTP, and may even shape moral judgments and shape policy. To better understand

how the news media frames the issue of CTP we investigate the association between

textual elements within news coverage and the overall framing of CTP (i.e.

Medical/Policy/Law enforcement).

Competing frames for CTP

To achieve these objectives we separately coded and examined a news item’s

overall frame as well as the association between an overall measure of framing and a

range of distinct textual elements which are expected to be associated with the overall

frame. We examined the associations between each of the overall frames for CTP and

the sources who were cited directly (i.e. in direct quotes), the most prominent source in

each item (sources cited first and/or most frequently throughout), characterization of

cannabis (i.e. as a drug, a medicine, or an economic business), and the way in which

patients were portrayed in each news item (e.g. as needy or in distress, or untrustworthy).

By examining the association between overall frames and distinct textual elements we

aim not only to identify subtle patterns in terms of how CTP is reported on in the press

and how the overall frame is achieved. We also aim to attenuate the (potential) influence

of the researcher’s subjective perceptions (Kohring & Matthes, 2002).

Sources cited directly. We hypothesized that particular textual elements within

news items would be associated with the overall (holistic) framing of CTP (i.e. as a

medical, policy, or a law enforcement issue). First, we expected that in news items

framing the topic of CTP as a medical issue, medical and health professionals would be


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the sources that are most frequently cited directly (i.e. in the source’s own words),

compared with other sources (H1a). In news items in which CTP is framed as a policy

issue, we expected that politicians and regulators would be the sources most frequently

cited directly (H1b). In contrast, in news items framing CTP as a law enforcement issue,

we expected that law enforcement sources would be those cited directly most frequently,

compared with other sources (H1c).

Source prominence. We expected to see similar patterns with regard to the most

prominent source cited (not necessarily the same source that was quoted directly) in each

news item and the overall frame. The measure of source prominence takes into account

the source cited in the headline or in larger type and/or most frequently throughout the

news item. In news items framing CTP as a medical issue the most prominent sources

were expected to be medical and health professionals (H2a). In news items framing CTP

as a policy issue, we expected that regulators or politicians would be the most prominent

sources, compared with others (H2b). Finally, in news items in which CTP was framed as

a law enforcement issue we expected that law enforcement professionals would be the

most prominent sources cited, compared with others (H2c).

Framing of cannabis. Third, we expected that news items in which CTP is framed

as a medical issue will refer to cannabis as a medicine more frequently than as a drug (or

other reference) (H3a). In contrast, in news items framing CTP as a law enforcement

issue, we expected that cannabis would be referred to as a drug more than as a medicine

(or other) (H3b). As policy-makers maintain a balanced perspective, which treats

cannabis as both a treatment for certain patients, but also an illicit substance, we expect


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that there will be approximately equal distribution of references to cannabis as a drug

than as a medicine for items with a policy frame (H3c)

Portrayal of patients. We also examine associations between the portrayal of

patients and framing of CTP. News items framing CTP as a medical issue were expected

to portray patients most frequently as victims of disease (i.e. needy, distressed). (H4a).

News items framing CTP as a policy issue were expected to refer to patients in

objective/neutral terms (H4b), while news items framing CTP as a law enforcement issue

were expected to refer to patients in negative terms (e.g. untrustworthy, liars) (H4c).

In the second part of the analysis we examined changes in the relative proportion

and stability of frames during the study period (January 2007 through June 2013). With

regard to relative proportions, we expected that the policy frame would be more prevalent

in news coverage, overall, than the medical and the law enforcement frame (H5a), based

on prior research (Kaiser, 2011). In addition we asked the research question (RQ1) –

how stable is each of these frames over time?

METHOD

Sample

To quantify and analyze news coverage of CTP, we sampled all news stories that

focused on CTP that were published in the three highest circulation national newspapers

in Israel (Yediot, Maariv and Haaretz) from January 2007 through June 2013. We began

our study period in 2007 to capture the period in which CTP licenses first began to

increase. Our sampling frame included both print and online articles accessible through

the newspapers’ websites (ynet.co.il, nrg.co.il, and haaretz.co.il). For news items which

were published in a newspaper’s print and online site, we included the print item only in


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order to avoid duplication in our sample. Based on the most recent available data, print

circulation ranged from 300,000-600,000 (Yediot), 160,000-270,000 (Maariv) and

65,000-75,000 (Haaretz). According to Alexa Traffic Rank (Hypestat, 2014), Yediot’s

website (ynet.co.il) receives about 310,841 unique visitors and 1,059,967 page views per

day, Maariv’s website (nrg.co.il) receives about 101,365 unique visitors and 304,095

page views per day, and Haaretz’s website (haaretz.co.il) has approximately 53,082

unique visitors and 159,245 page views per day (Alexa, 2014).

News Coverage Selection

We used the online archives of each of the three newspapers to collect news media

stories, as well as the periodicals library in Bet Ariella, an archive of Israeli press

coverage located in Tel-Aviv. To generate a sample frame of news stories, we used the

following search terms: “cannabis” or “medical cannabis” and “marijuana” or “medical

marijuana” (N=1,233). We searched entire articles, including titles. From this sampling

frame, we selected the articles which related specifically to CTP, and excluded those that

referred only to marijuana or cannabis generally but not to medical usages specifically.

News stories that were classified as letters to the editor, duplicate items, or book reviews

were also excluded. The search led to a total sample of 229 news stories and editorials

related to CTP. Twenty-one of these articles did not relate to the framing of cannabis as a

medical issue, a policy issue, or a legal issue (i.e. focused on diverse issues such as CTP

as a religious practice, or as a commercial industry) and were excluded from the current

analysis, leading to a final analytic sample of 208 articles.

Measures


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Overall frame. To measure the overall frame of CTP in each news article, coders

assessed whether CTP was discussed within the context of medicine, regulation, or as a

law enforcement issue. The measure of overall frame took into account the primary focus

of the news item, the context in which CTP was discussed and other references to CTP

throughout the article. For example, articles which put the issue of CTP in the context of

medical treatment or research findings were coded as having a medical frame. News

items which emphasized the diversion of CTP to the black market and other aspects of

criminal activities were coded as having a law enforcement frame. Articles which

focused on the regulatory or political context of CTP were coded as having a policy

frame. These articles focused on governmental regulations, policy decisions by the

Ministry of Health, or administrative issues related to licensing of CTP. The coding was

based on the understanding that framing of CTP may include elements from each of these

constructs, but that the overall framing of a news item will tend to be dominated by one

of these perspectives.

Correlates with overall frame. In addition to describing the distribution of each of

the overall frames, this study tests hypotheses relating to other elements within the body

of the news item and their associations with the overall frame (see H1- H4 above). These

hypotheses serve to validate our measure of overall frame of CTP by testing proposed

associations between the overall measure and other textual elements. They also enable an

investigation of how the overall frames were conceptualized. For this purpose we

measured four textual elements. Firstly, coders evaluated the References to sources

within each news item, through two variables. The first variable assessed which sources

were directly cited (i.e. quoted verbatim), while the second measured the most prominent


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source (overall) within the news item. It should be noted that these measures are

positively and significantly correlated (r=.58, p<.001). However, as we were interested

in the independent effects of both frequency of direct citations and overall prominence

we include hypotheses to test the association between each measure and the holistic

frame. For both of these variables, categories included (1) Medical and health

professionals; (2) Regulators and politicians; (3) Law enforcement officials and (4)

patients or growers.

Next, coders judged references to cannabis, a measure which included the

following categories: (1) cannabis as a drug (e.g. used terms such as “grass” or “joint”);

(2) cannabis as a medicine (e.g. used terms such as “medical cannabis”, “medicine” or

“treatment”), or (3) other (e.g. cannabis is described as a religious practice, or an

economic product). Finally, coders assessed the portrayal of patients. This variable

included the following categories: (1) neutral description of patients; (2) negative

portrayal - patients as untrustworthy; (3) patients as victims of disease; or (4) no mention

of patients.

Time trends. To examine trends over time a variable was created that indicated the

6 month time period in which articles were published. As only 11 articles were published

between January 2007 and June 2008, the four six-month intervals that comprise this time

period were collapsed. To explore potential curvilinear relationships squared and cubed

versions of the time trend variable were created.

Coding and reliability

A coding instrument was developed that sought to identify an exhaustive list of

textual elements which were expected to be related to the overall frame of CTP. Two


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graduate student coders were extensively trained by two researchers during a two month

period to become familiar with the codebook measures and to practice coding news

stories. In order to establish proper training and inter-coder reliability before coding the

entire sample, the coders met on several occasions during the coding process, checking

reliability for measures on a subset of articles. Adjustments were made to the coding

protocol during this process to reduce discrepancies. Coders then used the revised

codebook to independently code a random sample of 24 news stories (12% of the

sample), as recommended by Wimmer and Dominick (2006), and consistent with

methods used in similar studies (e.g. McKeever, 2012). Intercoder reliability was

calculated for each item in the coding protocol using Krippendorff’s Alpha (Hayes &

Krippendorf, 2007). Reliability for each item was measured using K statistics which all

met conventional standards for adequate reliability (≥.80) (Hayes & Krippendorf, 2007)

and ranged from 0.83 to 1.00. The final coefficients were as follows: overall frame

(α=1.00), reference to cannabis (α=1.00), sources cited directly (α=.89), prominent

source (α=.87), and portrayal of patients (α=.83). These reliability scores are also

consistent with other published content analyses (e.g. Matthes, 2009; McKeever, 2012).

Data Analysis

The unit of analysis for this content analysis was individual newspaper articles. The

analysis employs a deductive approach to framing analysis, which involves defining

specific frames prior to analysis in order to examine the incidence of that frame in news

coverage (Semetko & Valenkenberg, 2000). This approach enables a systematic and

methodologically rigorous strategy for examining the way in which textual elements

within media coverage work together to shape the framing of CTP. In order to identify


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and validate the overall framing of cannabis as a medical issue, a policy issue, or a law

enforcement issue (see hypotheses H1-H4) we relied on chi square tests of independence.

To examine the relative distribution of frames (H5) we used two-sample tests of

proportion (Acock 2014) and to examine the distributions of frames over time we

graphed the trends in framing. Furthermore, to examine potential linear and curvilinear

time trends statistically, step-wise logistic regression was used where each of the three

frames were separately entered as the dependent variable and a variable indicating the

linear time trend was entered as the independent variable at the first step. In the second

step, the quadratic time trend independent variable was added and in the third step the

cubed time trend variable was added. The time trend variables were standardized in order

to avoid multicollinearity (Marquardt 1980).

RESULTS

The sample consisted of 208 articles, of which 190 were news articles, 14 were

editorials and nine were ‘other’ category articles. Table 1 shows the percentage of news

items for each frame according to the four parameters studied. The sources cited differed

by overall frame, χ2 (8) = 59.07, p<.001, confirming H1. Medical and health

professionals were cited directly (i.e. in their own words) more frequently in articles

framing cannabis as a medical issue (52.3%) compared with articles using other frames,

supporting H1a. Regulators and politicians were cited directly most often in articles

employing a policy frame (41.1%), compared with other frames, confirming H1b.

Similarly, as hypothesized (H1c), representatives of the criminal justice system were

most frequency (directly) cited in articles with a law enforcement frame (46.7%),

compared with other frames.


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------INSERT TABLE 1 HERE-----

We observed similar patterns for the most prominent source within news items

(H2), χ2 (8) = 72.14, p<.001. Across frames, medical and health professionals were the

most prominent sources cited in articles with a medical frame (22%); however the

differences in proportions across the three frames did not reach statistical significance.

Regulators and politicians were significantly more likely to be prominent sources in

policy framed articles (54.2%), compared with others, supporting H2b. Law enforcement

officials were also more likely to be prominent sources in articles employing a law

enforcement frame (23.7%) than in articles with other frames, providing partial support

for H2c. Although not directly related to the hypotheses tested here, results show that

patients and growers were featured less prominently, compared with other sources, in

news items with a policy frame (23.3%) compared with the other frames.

Results provide partial support for Hypothesis 3, χ2 (4) =67.31, p<.001). In news

items in which CTP was framed as a medical issue, cannabis was referred to as a

medicine in the vast majority of news items (93.9%), confirming H3a. Furthermore,

cannabis was described as a drug more frequently in articles with a law enforcement

frame (81.6%), compared with a medical or policy frame, confirming H3b. Cannabis was

described as a medicine in two-thirds (66.7%) of news items with a policy frame

(66.7%), a distribution that is less extreme than was observed in the other frames.

Finally, we found that the way that patients were portrayed differed by overall

frame (H4), χ2 (6) = 58.15, p<.001. Patients were more frequently described as needy or

in distress in news items with a medical frame (62%) compared with other frames,

supporting H4a. Patients were referred to in neutral terms in almost half of news items


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with a policy frame (47.1%), although the difference in proportions across frames did not

reach significance (p>.05). Results show a significant association between the portrayal

of patients as untrustworthy and the law enforcement frame. Half of all news items

(50%) in this category described patients in a negative manner, which is significantly

more than in other frames, thus supporting H4c.

The hypothesis that, overall, there would be a greater number of articles that framed

CTP as a policy issue (H5), was confirmed; 58% (n=120) framed the issue as a policy

issue, 24% (n=50) used a medial frame and 18% (n=38) used a law enforcement frame.

Proportional tests showed that the policy frame was significantly more common that the

medical and law enforcement frame (p<0.001), whereas there was no significant

difference in the prominence of the medical and the law enforcement frame (p=0.50).

Figure 1 shows the trends in framing over time and shows that the policy frame was

more prevalent across the entire study period. Furthermore, it shows that while the policy

frame was relatively stable over time, the prevalence of the other frames fluctuated

substantially over the study period. In order to explore these time trends more carefully

we ran logistic regression models for each of the three frames where linear, quadratic and

cubed versions of the time trend variable were entered step-wise as predictors. Results

confirm the visual representation of the data in that none of the time trend variables were

significantly related to the policy frame (p>0.05), whereas the cubed time trend variable

was significant for the law enforcement (p<0.003) and the medical frame (p<0.001).

-----INSERT FIGURE 1 HERE------

Discussion


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This study describes a first attempt to examine the framing of CTP in Israeli news

coverage. The study is based on established approaches in framing research (e.g. Martins,

Weaver, & Yeshua-Katz, et al., 2013) and examines the overall frame as well as a range

of textual features. Research on the framing of CTP is important as the way in which an

issue is framed may shape public opinion (Price, Tewskbury & Powers, 1997) including

opinion about policy relating to CTP, which, in turn is likely to impact CTP policy.

Results of the current study show that the three competing frames for CTP are

shaped by, and comprised of, a number of contextual elements within the news items.

These elements include the sources cited directly, the most prominent source, references

to cannabis (i.e. a drug, a medicine, or an economic business), and the portrayal of

patients. These elements work together to promote a particular view of CTP, which is

likely to influence perceptions of this issue and of patients. For example, by citing

sources from the medical, regulatory, or law enforcement establishments, journalists may

affect how audiences receive, process, comprehend, and form opinions about various

issues (e.g. Gamson, 1992; Kinder, 2007), including CTP. Similarly, by portraying

patients as suffering and in need of treatment, the media encourages sympathy for patient

demand for CTP. In contrast, the portrayal of patients as untrustworthy (i.e. the most

frequent reference to patients in the law enforcement frame), promotes the notion that the

provision of CTP should be carefully restricted, and requires the oversight of law

enforcement to prevent potential abuse.

This study illustrates the way in which framing CTP as a medical issue, a policy

issue, or a law enforcement issue promotes (likely unintentionally on the part of

journalists) the interests and perspectives of particular stakeholders involved in this issue.


20

As the most dominant frame in Israeli news coverage, the policy frame promotes a

relatively neutral view of CTP and of patients. This is somewhat in contrast to the

second most prevalent frame (the medical frame) for which CTP is a treatment option for

patients above all and in which patients are frequently described as victims of disease

who are suffering and in need of treatment. Lastly, the criminal frame, which was the

least prominent frame in news coverage, promotes a more negative view of CTP as a

drug and patients as untrustworthy or criminal. These findings may be interpreted as a

positive sign for stakeholders who are interested in the continued expansion of the Israeli

CTP program. The relative scarcity of media items in which CTP was framed in the

context of crime or law enforcement may also suggest that there is a distinction made,

among media professionals, between cannabis for recreational purposes and CTP.

The finding that the policy frame was the most prominent is consistent with

research by Kaiser (2011) that found that the policy frame was the dominant issue frame

in U.S. newspaper coverage of CTP. One explanation for this finding may relate to the

differences in access to journalists across different sources. Policy makers have a vested

interest in receiving media coverage that is consistent with their policy goals and an elite

status that would enable relatively great access to journalists. In contrast, medical

professionals and law enforcement agents are not dependent, in the same way, on public

support and opinion. Thus, there may be a structural advantage for policy makers as far

as promoting a policy frame for medical cannabis, compared with politicians and

regulators or law enforcement agents.

When examining the stability of frames over time, the difference between the stable

policy frame and the volatile medical and law enforcement frame is striking (see Figure


21

1). One explanation for this finding may be that journalists covering CTP may be

influenced, in their choice of frame, by breaking events such as a medical research

breakthrough regarding CTP, or a crime story relating to CTP (for example, the arrest of

CTP users who were driving under the influence). The effect of these events is likely to

influence the choice of frame for CTP in immediate news coverage, but also be short-

lived. This is consistent with the sudden changes in the proportions of news items using

these frames. In contrast, the policy frame focuses on long-term issues and regulatory

debates, which may be less controversial and attention grabbing in the short-term, but

may also be less likely to be influenced by onetime events.

Limitations

A frequently raised concern regarding the analysis of news media is that the advent

of online social media and the shift from broadcasting to narrowcasting have altered what

we know about media effects, particularly the effects of the “mass” media such as

framing through news coverage (Chaffee & Metzger, 2001; Bennett & Iyengar, 2008).

Fragmentation of media and increasingly selective exposure of audience to niche content

provides audiences with the opportunity to choose news coverage that is more likely to

frame issues in a way that resonates with, and reinforces, their existing opinion, thus

mitigating framing effects.

However, as Wolfsfeld (2011) notes, many of the issues that are discussed in new

media are first raised in the mass media, including in newspaper coverage. Newspapers

(and their online versions) remain a useful proxy for news reporting, as they are likely to

set the agenda for other news formats (Clegg Smith, Wakefield, & Siebel, et al., 2002;

Wakefield, Flay, & Nichter, et al., 2003). Among some audiences, and for some topics,


22

selective exposure to particular frames may attenuate the effects of framing, however, the

basic concept remains important within the study of media effects (Wolfsfeld, 2011, p.

110). For example, the news media is an important source of health information

(Kenterelidou, 2012), especially for topics that are not easily comprehended by the

majority of individuals, such as CTP. Furthermore, newspapers (online and/or in print)

are read by 95% of Israeli adults, which in an international perspective is extremely high

(European Neighbourhood Journalism Network, 2014). As such, newspapers are clearly

an important channel for shaping the public opinion in relation to CTP.

This study has a number of strengths, including the use of rigorous methods of

analysis to examine an important, but unexplored research area. However, despite these

strengths this study has a number of limitations that should be noted. One limitation is the

relatively small sample size. It should be noted that Israeli (Hebrew language)

newspaper coverage tends to focus rather heavily on issues relating to the security and

political arena, including the Palestinian-Israeli conflict. This overarching focus on

political issues is at the expense of the quantity of coverage of other topics, including

health, which receives relatively little coverage, compared with media coverage of health

in other countries. Consequently, the total number of articles focusing on this health topic

(i.e. CTP) is fairly small (N=229). However, news items focusing specifically on CTP

comprised approximately 20% of all coverage about cannabis (N=1,332), which suggests

that the topic of CTP is an important policy issue. In addition, CTP and related policy

impacts tens of thousands of patients, such that the volume of coverage alone should not

be seen as an indicator of the significance of this topic in Israel.


23

This study focuses on Israeli news media coverage from three popular news

sources. Although there appear to be some similarities as far as the prevalence of the

policy frame in coverage of CTP, we do not know whether the findings reported here are

generalizable to news media coverage from other news sources, and in other countries.

Furthermore, the sample included only Hebrew language news articles and it is unclear

whether the current results are generalizable to Arabic and other language news articles

published in Israel.

In addition, although this study sheds light on trends in framing of CTP in Israeli

media coverage, it does not investigate the readers’ interpretation of the competing

frames, and the effect of these frames on public opinion and policy discussion related to

CTP. Nevertheless, mass communication theory suggests that the news coverage is likely

to influence public opinion related to medical cannabis (Lancaster, Hughes, & Spicer, et

al., 2011). As the competing frames represent competing economic and political interests

in, and perspectives on CTP, it is important for researchers to track which frames are

dominant, and which of these perspectives are reflected in news media coverage.

Conclusions

As Kaiser (2011) notes, certain medical issues are, by their nature, also political

issues. The issue of CTP is a particularly interesting and important case study for

framing analysis as it can be approached from a range of different, and competing,

perspectives. It is also a complex issue about which many readers may be unfamiliar, and

thus will rely more heavily on media coverage for information and interpretation. As a

result, the media can be expected to play an important role in shaping public perceptions

of, and attitudes toward CTP. Indeed, media framing of CTP in news coverage may


24

influence the debate on this topic by placing greater emphasis on considerations and

perspectives which are consistent with the perspective of one elite group (e.g. politicians

or regulators), while relegating others (e.g. the medical establishment or law

enforcement).to the background.

The finding that the CTP policy frame was more common than the medical frame

suggests that the Israeli public may be most likely to view CTP as a policy rather than a

medical issue. As already noted elsewhere (Kaiser, 2011) this may influence the debate

over CTP to one in which policy concerns take precedence over its (potential) risks or

benefits as a medical treatment, thus possibly delaying the legitimacy of cannabis as a

medicine. At the same time, the finding that the law enforcement frame was relatively

uncommon suggests that the debate about CTP in Israel is not overly focused on negative

social or moral concerns with regard to the continued expansion of the current CTP

program.


25

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32

Table 1. Percentages of news items with each frame by row Medical Frame

(n=50) Policy Frame

(n=120) Law enforcement

frame (n=38) n

n (%)

n (%)

n (%)

N=208

Source directly cited Medical/ health professionals

23 a (52.3%)

16 b (16.8%)

5 b (16.7%)

44

Regulators / Politicians 2 a (4.5%)

39 b (41.1%)

0 a (0.0%)

41

Law enforcement 1 a (2.3%)

6 a (6.3%)

8 b (26.7%)

15

Patients or growers 17 a (38.6%)

27 a (28.4%)

14 a (46.7%)

58

Other 1 a (2.3%)

7 a (7.4%)

3 a (10.0%)

11

Most prominent source Medical/ health professionals

11a (22.0%)

12 a (10.0%)

6 a (15.8%)

29

Regulators / Politicians 7 a (14.0%)

65 b (54.2%)

0 c (0.0%)

72

Law enforcement 0 a (0.0%)

6 a (5.0%)

9 b (23.7%)

15

Patients or growers 29 a (58.0%)

28 b (23.3%)

22 a (57.9%)

79

Other 3 a (6.0%)

9 a (7.5%)

1 a (2.6%)

12

Frame of cannabis Cannabis is a drug 3 a

(6.1%) 31 b

(25.8%) 31 c

(81.6%) 65

Cannabis is medicine 46 a (93.9%)

80 b (66.7%)

7 c (18.4%)

133

Cannabis as other (e.g. business)

0 a (0.0%)

9 a (7.5%)

0 a (0.0%)

9

Portrayal of patients In distress/needy 31 a

(62.0%) 38 b

(31.9%) 9 b

(23.7%) 78

Untrustworthy 3 a (6.0%)

12 a (10.1%)

19 b (50.0%)

34

Neutral 14 ab (28.0%)

56 b (47.1%)

4 a (10.5%)

74

No mention of patients 2 a (4.0%)

13 a (10.9%)

6 b (15.8%)

21

* Each subscript letter denotes a subset of overall frame categories whose column proportions do not differ significantly from each other at the .05 level


Figure 1.

Mean proportions of overall frame for CTP in news coverage (1/2007 – 6/2013).

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