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Smoking in the Movies: Its Impact on Youth and Youth Smoking

Bonnie L. Halpern-Felsher

Department of Pediatrics

University of California, San Francisco


Jodi L. Cornell

Department of Pediatrics

University of California, San Francisco1

INTRODUCTION

Smoking in the movies doubled in the 1990s, bringing exposure rates closer to those observed in the 1950s (Glantz et al. 2004). While recent data suggest that depictions of smoking in the movies have declined from 2000–2004 (Worth et al. 2006), youth exposure to smoking in the movies remains high. In addition to its inclusion in R-rated movies, smoking can be observed readily in many youth-rated movies, including movies rated G, PG, and PG-13 (Charlesworth and Glantz 2005). Studies employing content analysis have documented that smoking is portrayed in approximately 87 percent of movies produced from 1988 to 1997 (Dalton et al. 2002b), in 77 percent of movies in 2004 (Worth et al. 2006) and in more than 66 percent of children’s animated movies released between 1937 and 1997 (Goldstein et al. 1999). Health professionals and tobacco control advocates are concerned that youth exposure to smoking in the movies will have an impact on adolescents’ attitudes toward smoking as well as smoking behavior itself (Charlesworth and Glantz 2005; Sargent 2005; Worth et al. 2006). These concerns are consistent with social cognitive theory indicating that adolescents are especially vulnerable to social modeling influences on behavior, including risky behavior such as tobacco and other drug use (Akers and Lee 1996; Bandura 1986).

It has been shown that the tobacco industry has done extensive research to determine how and when to best influence older adolescents’ and young adults’ initiation and continuation of tobacco use (Ling and Glantz 2002). Clearly, there is a strong relationship between exposure to pro-tobacco campaigns and tobacco advertising and adolescent uptake of smoking and age of initiation of smoking ( Biener and Siegel 2000; Biener and Siegel 2001; Pierce et al. 1998; Pierce et al. 1999; Pierce et al. 2002). Pierce and colleagues (1998) found that adolescents in California who were able to describe a favorite tobacco advertisement were twice as likely to start smoking, and adolescents who used a tobacco-promotional product were three times as likely to begin. Sargent and colleagues (2000) also found that smoking uptake is more likely among adolescents who posses tobacco-promotional items, such as a T-shirt (Sargent et al. 2000; see also Pierce et al. 1999). Longitudinal research indicates that approximately 34 percent of all new tobacco ex-

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This research was supported in part by grants awarded to Dr. Halpern-Felsher from the Tobacco-Related Disease Research Program, Office of the President, University of California (#9K-0072 and #14RT-0010)



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Ending the Tobacco Problem: A Blueprint for the Nation H Smoking in the Movies: Its Impact on Youth and Youth Smoking Bonnie L. Halpern-Felsher Department of Pediatrics University of California, San Francisco Jodi L. Cornell Department of Pediatrics University of California, San Francisco1 INTRODUCTION Smoking in the movies doubled in the 1990s, bringing exposure rates closer to those observed in the 1950s (Glantz et al. 2004). While recent data suggest that depictions of smoking in the movies have declined from 2000–2004 (Worth et al. 2006), youth exposure to smoking in the movies remains high. In addition to its inclusion in R-rated movies, smoking can be observed readily in many youth-rated movies, including movies rated G, PG, and PG-13 (Charlesworth and Glantz 2005). Studies employing content analysis have documented that smoking is portrayed in approximately 87 percent of movies produced from 1988 to 1997 (Dalton et al. 2002b), in 77 percent of movies in 2004 (Worth et al. 2006) and in more than 66 percent of children’s animated movies released between 1937 and 1997 (Goldstein et al. 1999). Health professionals and tobacco control advocates are concerned that youth exposure to smoking in the movies will have an impact on adolescents’ attitudes toward smoking as well as smoking behavior itself (Charlesworth and Glantz 2005; Sargent 2005; Worth et al. 2006). These concerns are consistent with social cognitive theory indicating that adolescents are especially vulnerable to social modeling influences on behavior, including risky behavior such as tobacco and other drug use (Akers and Lee 1996; Bandura 1986). It has been shown that the tobacco industry has done extensive research to determine how and when to best influence older adolescents’ and young adults’ initiation and continuation of tobacco use (Ling and Glantz 2002). Clearly, there is a strong relationship between exposure to pro-tobacco campaigns and tobacco advertising and adolescent uptake of smoking and age of initiation of smoking ( Biener and Siegel 2000; Biener and Siegel 2001; Pierce et al. 1998; Pierce et al. 1999; Pierce et al. 2002). Pierce and colleagues (1998) found that adolescents in California who were able to describe a favorite tobacco advertisement were twice as likely to start smoking, and adolescents who used a tobacco-promotional product were three times as likely to begin. Sargent and colleagues (2000) also found that smoking uptake is more likely among adolescents who posses tobacco-promotional items, such as a T-shirt (Sargent et al. 2000; see also Pierce et al. 1999). Longitudinal research indicates that approximately 34 percent of all new tobacco ex- 1 This research was supported in part by grants awarded to Dr. Halpern-Felsher from the Tobacco-Related Disease Research Program, Office of the President, University of California (#9K-0072 and #14RT-0010)

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Ending the Tobacco Problem: A Blueprint for the Nation perimentation occurs as a result of tobacco advertising and promotions (Pierce et al. 1999). Emery and colleagues (1999) estimated that each year, tobacco-marketing efforts generate approximately 193,000 additional adult smokers who began smoking as adolescents because of such marketing (Emery et al. 1999). The influence of these pro-tobacco campaigns has been shown to be stronger than the presence of antismoking messages (Straub et al. 2003). The body of research linking pro-tobacco campaigns to the initiation of youth smoking is alarming, especially given studies indicating that approximately one-third of adolescents who initiate smoking progress into addicted smoking (Anthony et al. 1994; Choi et al. 1997). It is thus important to explore whether and to what extent exposure to smoking in movies has a similar influence on adolescent tobacco use and whether such influence varies by age, gender, and parental influences. In this appendix, we provide a comprehensive review of empirical research investigating the relationship between exposure to smoking depictions in movies, adolescent smoking-related attitudes, and adolescent smoking behavior. We begin with some theoretical bases underlying the links between exposure to tobacco use in the movies and youth behavior. THEORIES OF MOVIES AS SOCIAL MODELING INFLUENCES ON ADOLESCENT TOBACCO USE The theoretical basis for the important role of social constructs in shaping smoking behaviors stems largely from Social Cognitive Theory (e.g., Akers and Lee 1996; Bandura 1986), Social Norms Theory, and Social Marketing Theory, which are also the basis for much of the health research investigating the relationship between exposure to smoking in movies and adolescent smoking behavior. These theories posit that social modeling (observing others perform a behavior and reaping the rewards of that behavior [Bandura 1986]) and social norms (believing that a given behavior is normative and frequent [Wakefield et al. 2003]) are powerful influences on teaching adolescents about behavior in social contexts and are strongly related to adolescents’ behavior. Applied to smoking, depictions of smoking in the movies often serve to influence or change youth’s attitudes about smoking, in part by glamorizing smoking and the smoker him or herself. Often the smoker is portrayed positively—attractive, slim, wealthy, and sexy. Smokers are often shown reaping smoking-related benefits (e.g., coping, relaxation), yet rarely are they seen experiencing any harm or negative stigma from smoking. Depictions of smoking in the movies are also expected to increase the perception that smoking is normative. Current opinion about adolescent smoking largely considers social factors to be the main set of variables influencing experimental smoking (Lynch and Bonnie 1994; Sargent 2005), including peers and family, which are also key influences on the development of social norms. Adolescents are particularly cued into the social context around them, including media influences on depictions of various behaviors and related positive and negative outcomes. Parallel with physical and cognitive maturation, important social changes take place in adolescence that shift the focus of affiliation gradually from parents to peers and from group relations to intimate relations with individuals outside the family. These expanding social relationships from adolescence through young adulthood broaden adolescents’ sense of extrafamilial reality and reinforce their increasing sense of individuality and need for autonomy. Adolescents’ newly acquired ability to think abstractly and to take a third person’s perspective is an important prerequisite for successful socialization and is tied to new responsibilities and freedom, including trying new and risky behavior such as drinking alcohol, having sex, and smoking cigarettes (e.g., Steinberg and Cauffman 1996). This sets the stage for a variety of social factors to influence adolescents’ attitudes and beliefs for numerous behaviors, including movies and television depictions of behav-

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Ending the Tobacco Problem: A Blueprint for the Nation ior, and since adolescents have increased power over their own choices about what media and movies they expose themselves to, the extent to which these media influence their socialization is worthy of attention (Arnett 1995). RESEARCH ON SMOKING IN THE MOVIES AND YOUTH PERCEPTIONS AND BEHAVIOR Research investigating the impact of youth exposure to smoking in movies has yielded three important findings: (1) exposure to smoking depictions in movies influences perceptions of smoking, (2) exposure to smoking in movies increases the risk for smoking initiation, and (3) the increased risk for smoking initiation from exposure to smoking in movies can be reduced by antismoking advertisements and parental restriction of movies. A review of the scientific evidence for these three findings is summarized next (see also Tables H-1, H-2, and H-3). The current review includes only published scientific research articles specifically investigating the relationship between smoking in the movies and adolescent attitudes and tobacco use (see also Charlesworth and Glantz 2005; Worth et al. 2006). Exposure to Smoking Depictions in Movies Influences Adolescent Perceptions of Smoking A small set of literature has addressed the extent to which youth are exposed to smoking in the movies and whether such exposure has an effect on youth perceptions of smoking images (Table H-1). Sargent and colleagues (2003) provided evidence for a dose effect between access to movies and increased exposure to smoking in movies (Sargent et al. 2003). Access to cable movie channels and videotapes and number of movie outings per month were strongly associated with adolescents’ increased exposure to smoking in the movies (F = 63.4, adjusted R2 = .34). Exposure to smoking increased by 10 percent (150 occurrences) for each additional movie channel and video watched per week. Movie theater outings more than once a month were associated with a 20 percent (300 occurrences) increase in movie smoking exposure. A qualitative study conducted by Watson and colleagues (2003) sheds light on the content of media attended to by adolescents. This study examined perceptions of smoking images in television, movies, newspapers, and magazines to gauge the extent to which adolescents notice smoking in the media and how they interpret social acceptability of smoking through visual cues. Their findings showed that 78 percent of their sample noticed and commented on the smoking images unprompted by the facilitator and 64 percent of responses were positive for social acceptability, especially the social benefits of smoking. Negative physical health responses were 46 percent, and positive ratings were 33 percent, but there was rarely sufficient information to rate the media item on physical health effects. Alarmingly, 65 percent of mood ratings were positive, especially issues of stress relief and emotional control, 39 percent of ratings were positive and 44 percent were negative for appearance effects. Most positive ratings were from depictions of physically attractive persons. Finally, 52 percent of the sample rated smoking as a good thing to do, whereas 48 percent rated it as a bad thing (Watson et al. 2003). Clearly adolescents are aware of the conflicting messages conveyed through the media; alarmingly, these results indicate that the social desirability effects are also functioning. Unfortunately, these results were not linked to behavior or intentions to smoke. McCool and colleagues (2004) have conducted a number of studies examining adolescent perceptions and smoking depictions in film. McCool and colleagues (2004) also found support

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Ending the Tobacco Problem: A Blueprint for the Nation that image concerns influence adolescent perceptions of smoking in films and that these perceptions differed by gender (McCool et al. 2004). Further, “sexy” and “stylish” were stereotypes significantly associated with smoking susceptibility (p < .01) for both female and male smokers in films. However, a serious limitation of this study was that the measure of stereotypes was linguistically trait-based with matching from a generalized question rather than based on specific actors or viewed images. Thus, although these results point to general adolescent perceptions of male and female smokers on film, they do not capture information about the specific actors that are viewed most favorably by adolescents themselves and thus might have a more profound impact on adolescents’ attitudes and perceptions of smoking. In their 2001 and 2003 studies utilizing focus groups, McCool and colleagues (2001; 2003) examined how smoking depictions are related to adolescent smoking perceptions. McCool and colleagues (2001) showed that young adolescents from New Zealand perceived smoking depictions in movies as very prevalent and recognizable and they regarded these depictions as a reflection of reality. The adolescents had nonchalant attitudes toward inclusion of smoking depictions in movies, and these attitudes were linked to the perception that smoking prevalence is high among peers and adults (McCool et al. 2001). The authors suggest that smoking imagery in film may reinforce perceptions of smoking as a way to reduce stress and to develop self-image, and to serve as a marker of adult independence. In their study with older adolescents, McCool and colleagues (2003) showed that adolescents were receptive to smoking depictions when used in a credible way to portray an emotional state, subculture affiliation, and life-style. Experience as a smoker appeared to inflate credibility of depictions of smoking, particularly in gritty realism or drama. Stereotypical images were readily recalled and appeared to support misconceptions of smoking, and recall of images was associated with stress, anxiety, drug use, and seduction (McCool et al. 2003). The results suggest that pervasive and credible smoking scenes may offer support and reassurance to smokers or teens who are ambivalent about smoking. Taken together, these studies demonstrate that youth are exposed to a vast amount of smoking in the movies and that such depictions are associated with more favorable attitudes toward smoking and smoking characters. These positive views are particularly prevalent among youth who themselves smoke. Exposure to Smoking Depictions in Movies Increases Risk for Smoking Initiation As the above section demonstrates, there is little doubt that youth are being exposed to smoking in the media—including through movies, television, magazines, and newspapers—and that such exposure influences smoking-related perceptions. The question then becomes whether such exposure creates a heightened risk for youth’s own smoking. A number of studies employing different methodology have addressed this concern (see Table H-2). These studies, reviewed next, suggest a relationship between exposure to smoking in the movies and smoking initiation. However, studies have not yet been conducted to determine whether such a relationship between viewing smoking in the movies and tobacco use continues after initial tobacco use. Favorite Movie Stars’ Use of Tobacco in Movies Several studies have examined whether and to what extent viewing movies in which popular or favorite movie stars smoke on-screen has an effect on youth smoking. After controlling for other variables associated with adolescent smoking (e.g., parent and friend smoking, receptivity to tobacco ads; see Table H-2). Distefan and colleagues (1999) showed that adolescent never-

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Ending the Tobacco Problem: A Blueprint for the Nation smokers who shared favorite stars with adolescent ever-smokers were more likely to be susceptible to smoking than adolescent never smokers who did not share stars with adolescent ever-smokers (OR = 1.35, 95 percent confidence interval 1.12–1.62; p < .01) (Distefan et al. 1999). Similarly, Tickle and colleagues (2001) provided some support that smoking by movie stars is associated with greater risk of smoking initiation among adolescents. For youth with smoking experience, after controlling for possible confounds, the odds of having a higher smoking status (ranging from nonsusceptible never-smoker to smoker, see Table H-2) increased with their favorite stars’ on-screen smoking. For adolescents whose star smoked in one film, the odds of being higher in smoking status were 0.78 (0.53–1.15, 95 percent confidence interval [CI]). For adolescents whose stars smoked in two films, odds increased to 1.53 (1.01–2.32, 95 percent CI), and whose stars smoked in three or more films, the odds of being higher in smoking status increased to 3.1 (1.34–7.12, 95 percent CI). The same pattern was found for never-smokers, that is susceptibility to smoking increased as their favorite stars’ smoking increased. Specifically, for adolescents whose star smoked in one film, the odds of being higher in smoking status were 2.16 (0.86–5.45, 95 percent CI). For those whose stars smoked in two films, 4.78 (95 percent CI, 1.60–14.23), and for those whose stars smoked in three or more films, the risk increased to 16.18 (95 percent CI, 2.33–112.61). However, no effects were found for adolescents in other stages of smoking initiation or for current smokers. Thus, the direction of influence between exposure to smoking in movies and adolescent smoking status was not determined (Tickle et al. 2001). Unfortunately, since both the Distefan and colleagues (1999) and the Tickle and colleagues (2001) studies used a cross-sectional design, it is impossible to determine whether adolescents who were more susceptible to smoking paid more attention to smoking in films or whether they were truly influenced by smoking images (Distefan et al. 1999; Tickle et al. 2001). Using a longitudinal design, Distefan and colleagues (2004) shed further light on the relationship between exposure to favorite movie stars’ smoking on-screen and tobacco use among adolescents. They showed that adolescents with a favorite star who smoked on-screen were more likely to have smoked at follow-up 3 years later (odds ratio [OR] = 1.36; 95 percent CI 1.02–1.82). For adolescent females, the corresponding values were strong (OR = 1.86; 95 percent CI 1.26–2.73) when all other variables were controlled (including receptivity to tobacco advertising). For adolescent males, smoking initiation at follow-up was associated only with receptivity to tobacco advertising and promotions but not with having a favorite star smoke on-screen (Distefan et al. 2004). Finally, using a controlled experimental design in which adolescents were exposed to a film clip depicting either smoking or nonsmoking by popular male and female actresses, adolescents were asked to rate character attractiveness and similarity to themselves (Hines and Saris 2000). Adolescents who viewed the smoking clips reported a greater likelihood of smoking (mean = 2.5, standard deviation [SD] = 1.6) than participants who viewed the nonsmoking clips (mean = 2.2, SD = 1.5; F(1,135) = 7.44, p = .007). This effect accounted for 5.2 percent of the variance. Adolescents’ current smoking status also had a significant relationship with adolescents’ report of their likelihood to smoke in the future (F(2,135) = 446.75, p < .001), with regular smokers (mean = 4.7, SD = 0.5) more likely to smoke than occasional smokers (mean = 3.3, SD = 1), who in turn were more likely to smoke than nonsmokers (mean = 1.3, SD = 0.4). This effect accounted for 86.7 percent of the variance. Thus, these results indicate that smoking status has a much stronger effect on likelihood of smoking than viewing smoking depictions in film clips. Although these studies were modest in size and scope, they do provide evidence that adolescents are more susceptible to initiating tobacco use if they have observed their favorite movie

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Ending the Tobacco Problem: A Blueprint for the Nation star smoke on-screen. However, given the limited experimental and longitudinal data available to date, caution must be exercised in interpreting these findings. Exposure to Smoking Depictions in Movies and Television A number of studies have questioned whether exposure to smoking in the movies more generally, not just by one’s favorite actor or actress, has an influence on youth smoking. The majority of the research on movie smoking exposure and adolescent smoking initiation has been conducted by Sargent and colleagues (2001) and has employed both cross-sectional and longitudinal designs. Using quartiles of smoking exposure in movies in a cross-sectional study, Sargent and colleagues (2001) showed that increased exposure to smoking in movies was associated with greater risk of trying smoking (Sargent et al. 2001). Further, this relationship was demonstrated among a nationally representative sample including adolescents from broad geographic regions of the United States and among different racial and ethnic groups (Sargent et al. 2005). Sargent and colleagues (2005) estimated that exposure to smoking in movies is an independent, primary risk factor for smoking initiation among 38 percent of the adolescents who tried smoking in the study sample (0.10 ever tried smoking prevalence in overall study sample of 6,522) (Sargent et al. 2005). It was also shown that higher exposure to smoking in movies and increased smoking susceptibility (OR = 1.60; 95 percent CI, 1.24–2.07), more normative views of adult smoking (OR = 1.37; 95 percent CI 1.09–1.71), and more positive expectations from smoking (OR = 1.38; 95 percent CI 1.13–1.70) were related to adolescent smoking initiation (Sargent et al. 2002). These results also showed that exposure to 50 occurrences of smoking in movies (about five R-rated movies) has a moderate effect on smoking attitudes similar to other social influences, such as having family members or friends who smoke (Sargent et al. 2002). No association was found between more exposure to smoking in movies and peer norms of smoking when controlling for sociodemographics, social influences, and personality factors. Using a longitudinal design, Dalton and colleagues (2003) provided support for a clear dose effect between movie exposure and initiation, with greater exposure to smoking in the movies associated with a greater likelihood of tobacco initiation, particularly in participants with nonsmoking parents. The dose effect size ranged from 2.0 to 2.7, even when controlling for a number of covariates including demographics; school achievement; parent, sibling, and friend smoking; receptivity to tobacco promotions; parental education; parenting styles; and perception of parental disapproval of smoking. However, only a small proportion of the sample (10 percent) initiated smoking, and a positive relationship was found between exposure and personal characteristics of adolescents such as sensation seeking, rebelliousness, or a negative association with school performance and parenting styles, suggesting that these results may reflect only a particular subset of adolescents (Dalton et al. 2003). An alternate view of these data is that a small subset of adolescents who already have many variables that contribute to a higher likelihood of smoking initiation, such as personality traits and parenting factors, could pay more attention to depictions of smoking than adolescents in general. Dalton and colleagues (2003) acknowledged that some aspects of R-rated movies other than smoking could conceivably contribute to smoking initiation and that further research is needed to determine other possible aspects. Two studies examined whether there is a similar relationship between television and smoking behavior. Gutschoven and Van den Bulck (2004) examined the relationship between television viewing and the amount of cigarettes smoked by adolescent smokers per unit time of television. Smoking volume was correlated with self-assessed health, even when controlling for level of education and age (r = −0.11, p = .03), with heavier smokers feeling less healthy. Television

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Ending the Tobacco Problem: A Blueprint for the Nation viewing was a significant predictor of smoking volume, with smokers who watch 5 or more hours a day reporting smoking between 60 and 147 more cigarettes per week than those who watch an hour or less a day. Television viewing explained an additional 3 percent of the variance (F(8,399) = 30.975, model R2 = .383, p < .0001) when gender, educational level, parental and peer smoking, and frequency of going out were accounted for in the model. Using longitudinal data from the National Longitudinal Survey of Youth, Gidwani and colleagues (2002) examined whether youth with greater exposure to television exhibited higher rates of smoking initiation. They found a dose–response relation between amount of TV viewing and smoking initiation when taking control variables into account; specifically, adolescents who watched more than 5 hours of TV per day were 5.99 times more likely to initiate smoking than adolescents who watched 0–2 hours a day (p = .02; 95 percent CI 1.39–25.71) (Gidwani et al. 2002). Similarly, adolescents who watched more than 4 to 5 hours per day were 5.24 times more likely to initiate smoking than adolescents who watched 0–2 hours per day (p = .03; 95 percent CI 1.19–23.10) (Gutschoven and Van den Bulck 2004). These cross-sectional and longitudinal studies provide clear support that youth report greater susceptibility and intentions to smoke and are more likely to actually try smoking following exposure to smoking in the movies and on television. Further, even after controlling for other factors known to be associated with adolescent tobacco intention and use, studies show a clear dose effect, whereby greater exposure to smoking in the movies is associated with a greater chance of smoking. Studies have not yet been conducted to determine whether such a relationship between viewing smoking in the movies and tobacco use continues after initial tobacco use (Sargent 2005). The Effects of Smoking in Movies Can Be Reduced by Antismoking Advertisements and Parental Restriction of R-Rated Movies As shown in Table H-3, a small number of studies have investigated whether antismoking advertisements can ameliorate the influence that exposure to smoking in the movies has on youth tobacco use. Pechmann and Shih (1999) conducted the first experimental study addressing this question, with results yielding significant interactions between viewing or not viewing an anti-smoking advertisement on the level of positive arousal (F[1227] = 6.91, p < .01), perceptions of a smoker’s stature (F[1228] = 4.82, p < .05), smoker’s perception of their own stature (F[1228] = 4.88, p < .05), and participants’ intent to smoke (F[1203] = 4.88, p < .05). Further, when viewing an antismoking advertisement, more negative thoughts were generated about the lead characters when the character was a smoker as compared to not being a smoker (2.37 vs. 1.31, t = 2.70, p < .01). This effect was not found if an antismoking ad was not viewed (F[1188] = 6.98, p < .01). A limitation of this study is that the outcome measure was not related to actual smoking behavior of adolescents. Nevertheless, the study provides evidence that antismoking advertisements may help to combat the positive associations that smoking in movies may foster (Pechmann and Shih 1999). Edwards and colleagues (2004) attempted to replicate and expand on Pechmann and Shih’s results by using the “real-world” environment of actual movie theaters to evaluate the effect of antismoking advertisement on women’s perceptions of smoking in movies and their intentions to smoke. Nonsmokers who saw the ad were more likely to perceive smoking as “not ok” (48.2 percent) compared to nonsmokers who did not view the ad (25.2 percent, X2=83.11, df = 3, p = .0001). This difference was maintained when age and movie exposure differences were adjusted (Wald X2 = 75.784, df = 1, p = .0001). However, no effect was found for smokers, even when

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Ending the Tobacco Problem: A Blueprint for the Nation age and movie were accounted for, and no overall effect was found for the antismoking ad on intentions to smoke. When smokers and nonsmokers were analyzed separately, smokers were more likely to have lower intentions to smoke (31.9 percent versus 47.8 percent; X2 = 9.03, df = 2, p = .01), and when age and movie were accounted for the group of smokers who saw the ad continued to have lower intentions to smoke (Wald X2 = 4.59, df = 1, p = .03). No effect was found for nonsmokers (X2 = .97, df = 2, p = .62), even when age and movie were accounted for (Wald X2 = 1.25, df = 1, p = .263). These results may indicate that antismoking advertisements may have only a small effect upon intention to smoke and that other factors may play a role in adolescents’ intentions to smoke (Edwards et al. 2004). Dixon and colleagues (2001) also found similar results in their quasi-experimental study investigating the effects of viewing a movie with anti-tobacco content. Theater patrons were surveyed before and after viewing the film The Insider, with results indicating that their perceptions of the business conduct of the tobacco industry were more negative than perceptions held by theater patrons who saw a control movie without anti-tobacco content. Further, viewing the anti-tobacco industry content also appeared to promote a short-term reduction in intentions to smoke (Dixon et al. 2001). In a study examining the effect of parental restriction of R-rated movies on adolescent smoking initiation, Sargent and colleagues (2004) found that decreased parental restriction was associated with higher risk of smoking initiation. They also found a reverse effect, where increased parental restriction was associated with decreased risk, compared to adolescents reporting no change (Sargent et al. 2004). This pattern was even more pronounced for adolescents from nonsmoking families compared to adolescents from families that smoke. Similarly, Dalton and colleagues (2002a) found higher levels of trying smoking and drinking alcohol among adolescents with no parental restriction of R-rated movies compared to adolescents whose parents did not allow them to view any R-rated movies (Dalton et al. 2002a). Although limited in scope and methodology, the results from this set of studies provide evidence that viewing antismoking advertising and parental restrictions limiting youth exposure to R-rated movies can ameliorate the effect that smoking in the movies has on youth. SUMMARY AND RECOMMENDATIONS Portrayals of smoking in the movies, especially images that put smoking in a positive or sexy vein, are likely to alter perceived norms about smoking, resulting in smoking being viewed as more normative, positive and socially acceptable. Indeed, the convergence of study results provides persuasive evidence of a relationship between exposure to smoking in the movies and adolescent perceptions of tobacco, as well as actual tobacco use, and that the effects are at least comparable to those of pro-tobacco advertisements. It is clear that youth’s exposure to smoking in movies, including but not limited to tobacco use among the more popular youth film stars, has an effect on youth initiation. Research provides evidence for a relationship between smoking exposure in movies and adolescent smoking behavior, but it also indicates avenues by which this risk of smoking initiation from exposure to smoking in movies can be reduced. Given the serious public health concern, action to closely monitor and limit adolescent exposure to smoking in the movies is warranted. A number of recommendations can guide engaging the movie industry in a discussion and educating the many decision makers in the industry about the issue of smoking in the movies and adolescent tobacco use. We recommend two strategies that the movie industry should consider to reduce smoking in the movies and combat the effect tobacco exposure has on youth.

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Ending the Tobacco Problem: A Blueprint for the Nation Recommendation 1: First and foremost, we encourage the entertainment industries to create a set of self-regulatory strategies that closely limit and monitor youth exposure to smoking in the movies, television programming, and videos that combat the effect tobacco exposure has on youth’s smoking attitudes and behavior. These strategies should both guide and educate the movie industry about the evidence linking smoking in the movies and adolescent tobacco use (e.g., Dalton et al. 2003; Sargent et al. 2005), as well as spark a cogent discussion within the industry and between the industry and policy makers. We recommend a number of strategies and a range of options that the entertainment industries, and in particular the Motion Picture Association of America (MPAA), should adopt to reduce smoking in the movies. The industries’ self-regulation should include but not be limited to the following possible options: Recommendation 1a: The film rating board of the MPAA should consider the use of tobacco in the movies as a criterion in assigning mature film ratings (e.g., an R-rating indicating Restricted: no one under age 17 admitted without parent or guardian) to films that depict tobacco use. A Ratings Board, which is appointed by the president of the MPAA, decides on ratings assigned to each movie. Currently, such ratings are based on the extent to which there is violence, language, nudity, sensuality, and drug abuse in the film. Tobacco use is not a criterion by which ratings are assigned. Assigning films with tobacco use a mature rating (R-rating) increases the likelihood that parents will restrict youth access to such films, a strategy that has been shown to reduce smoking initiation (Dalton et al. 2002a; Sargent et al. 2003; Sargent et al. 2004). Recommendation 1b: The MPAA should encourage the use of antismoking advertisements before the film. As reviewed above, the effects of youth viewing smoking in the movies is reduced among youth who first viewed an antismoking advertisement (e.g., Edwards et al. 2004; Pechmann and Shih 1999). Investigations of the effectiveness of antismoking advertisements with adolescents indicate strategies that are effective in reducing the influence of viewing smoking depictions in the media in general and can be applied to smoking depictions in the movies as well. Goldman and Glantz (1998) showed that messages that are aggressive, delegitimize the tobacco industry, deglamorize smoking, and portray the negative effects of secondhand smoke were the most effective messages for changing perceptions about the normality of smoking and reducing cigarette consumption (Goldman and Glantz 1998). A recent study of a specific antismoking advertising campaign (the Truth campaign) echoes the same results and found this counter-industry media campaign to be effective in increasing negative beliefs and attitudes about the tobacco industry and associated with lower receptivity to pro-tobacco advertising and less progression of smoking intention and behavior (Hershey et al. 2005). Recommendation 1c: The MPAA should regulate smoking on all movie and television sets so as to minimize exposure to smoke among actors and crewmembers. Emphasis should also be given to banning smoking on all sets in which children, including child actors, are present.

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Ending the Tobacco Problem: A Blueprint for the Nation Findings from the Environmental Protection Agency (EPA) and other studies showing the adverse health effects of secondhand smoke led the EPA to classify secondhand smoke as a human carcinogen (DHHS 2002a). The findings also led several states and municipalities to create laws restricting smoking in workplaces and other public places. Further, the Healthy People 2010 objectives included a goal to reduce the percentage of nonsmokers exposed to secondhand smoke by 45 percent (DHHS 2000; DHHS 2002b). Reducing one’s exposure to secondhand smoke should be applied to all individuals, but especially to infants, children, and youth for whom secondhand smoke has been shown to cause sudden infant death syndrome, low birth weight, chronic middle ear infections, and respiratory illnesses including asthma, bronchitis, and pneumonia (DHHS 1999). Many of these adverse health effects linked to secondhand smoke are expected to continue into adulthood, including increasing one’s chance of developing lung cancer (Janerich et al. 1990). Given that movie sets are workplaces, they should fall under similar regulations that restrict exposure to secondhand smoke among employees in other work settings. Further, the evidence summarized in this report strongly suggest that the MPAA, film directors, and other film producers should create extensive strategies to ensure that youth have limited exposure to tobacco smoke while on the movie and television sets. Such strategies adopted by the MPAA should include restricting the use of tobacco on the set unless absolutely necessary, reducing the number of times a scene that includes smoking is filmed, and creating as many outdoor scenes as possible. Recommendation 2: Congress should appropriate the necessary funds to enable the U.S. Department of Health and Human Services to conduct a periodic review of a representative sample of movies, television programs, and videos that are offered at times or in venues in which there is likely to be a significant youth audience (e.g., 15 percent) in order to ascertain the nature and frequency of images portraying tobacco use. The results of these reviews should be reported to Congress and to the public. Despite our overall recommendation that strategies to reduce youth exposure to the portrayal of tobacco use in movies, television, and videos should be implemented on a voluntary basis by the relevant entertainment industry and related trade associations, some independent oversight of these standards and strategies is warranted. Such oversight of industry accountability should be facilitated through public monitoring and awareness of industry practices. Accordingly, we recommend that the U.S. Department of Health and Human Services be authorized and funded to monitor these media practices and report to Congress and the public. Recommendation 3: Finally, we encourage additional research on the effects of smoking in the movies on adolescent tobacco use. The research on how and the extent to which exposure to smoking in the movies influences adolescent tobacco use is still nascent and thus should be replicated and expanded. Current studies are a key step in the right direction, but there are questions that still must be addressed. For example, Dalton and colleagues’ (2003) longitudinal study provided the most persuasive evidence that smoking depictions in movies influence adolescent smoking initiation (Dalton et al. 2003). However, the sample was predominately comprised of white, rural, nonsmoking youth and therefore should be replicated with a more diverse sample. Further, it is not clear how to measure cumulative effects of repeated exposure to smoking depictions from not only movies but also the combination of various media outlets. Sargent and colleagues’ (2005) study provided the most comprehensive study

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Ending the Tobacco Problem: A Blueprint for the Nation of a large, diverse group of adolescents and includes an impressive list of control variables, but the study’s cross-sectional design still leaves unanswered questions (Sargent et al. 2005). Measures of adolescent smoking in current research are also limited, with most studies focusing on smoking initiation (Dalton et al. 2003; Distefan et al. 2004; Sargent et al. 2004; Sargent et al. 2001; Sargent et al. 2002) or other factors such as intentions to smoke, susceptibility to smoking (Edwards et al. 2004; Hines and Saris 2000; McCool et al. 2004) or perceptions of smoking (Pechmann and Shih 1999; Watson et al. 2003). No information is available to date that indicates effects of smoking depictions in movies on long-term or addicted smoking. Another related issue is the lack of information about possible effects of exposure to smoking in movies depending upon different smoking status and experience of the adolescent. For example, results from Hines and Saris (2000) indicate that smoking status has a much stronger effect on likelihood of smoking than viewing smoking depictions in film clips. Additional prospective research is needed with nonsmokers to establish predictive relationships. Another limitation of current research is determining whether adolescents with an interest in tobacco or with greater intentions to try cigarettes are more likely to attend to or notice smoking in movies. Adolescents who are more susceptible to smoking may pay more attention to smoking in films or admire stars who smoke more than less susceptible adolescents; the direction of this relationship is yet to be clearly answered. Although the Dalton and colleagues (2003) study provided evidence that movie exposure is predictive of initiation, the limitations of the study prevent definitive conclusions about causal relationships. Finally, finer-tuned measures of smoking exposure in movies are needed (Dalton et al. 2003). The specific factors of smoking depictions in movies that influence behavior must be identified, including possible genre-specific smoking depictions, smoking by actors with different character traits, and smoking in contexts with different situational and affective variables, and the way the gender and ethnicity of both actors and viewers influence interpretation of depictions, must be determined. We thus recommend that further research be conducted in a number of areas. One question that remains to be answered by research is how the movies influence actual smoking behavior and whether viewing smoking depictions in the movies and other media has a lasting effect on continued smoking, since the crucial health issue of concern is adolescent smoking that results in health problems. Further, research on identifying the cumulative effect of advertising and other media depictions of smoking and movies is needed in order to gauge appropriate public health measures to address smoking in the movies. Finally, effects of exposure to smoking in the movies and other media must be considered within the entire context of variables that influences adolescent smoking, including parents, peers, and individual-level variables.

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Ending the Tobacco Problem: A Blueprint for the Nation Table H-2. Exposure To Smoking Depictions In Movies Increases Risk For Smoking Initiation (Gidwani et al. 2002) Authors and Research Question Methods Sample Measures Findings Limitations Gidwani et al., 2002 Determine whether youth with greater exposure to television exhibit higher rates of smoking initiation Longitudinal Annual interviews from the National Longitudinal Survey of Youth (NLSY) compared between 1990-1992 Adolescents from 10 to 15 years old mean age 11.5 years from the NLSY nationally representative sample of youth which was over sampled for African American, Hispanic American, and poor non-Hispanic white populations N=592 Only participants who had completed reports of television viewing and no smoking before 1990 Television viewing time: average television viewing in hours per day categorized into 0-2, >2-3, >3-4, >4-5, and >5 hours per day Initiation of smoking: self-reported smoking in the last 3 months Control variables: ethnicity, household poverty, marital status, number of children in household, maternal education, intelligence, employment, gender, baseline aptitude scores Smoking increased from 4.8% in 1990 to 12.3% in 1992 Average hours of television viewing was 4.8 hours in 1990, of the participants who initiated smoking in 1992, 42% viewed >5 hours of television per day Dose-response relation was found between amount of TV viewing and smoking initiation when taking control variables into account: adolescents who watch >5 hours of TV per day were 5.99 times more likely to initiate smoking (P=.02; 95%CI:1.39-25.71) than adolescents who watched 0-2 hours a day. Similarly, adolescents who watched >4-5 hours per day were 5.24 times more likely to initiate smoking than adolescents who watched 0-2 hours per day (P=.03; 95% CI: 1.19-23.10) Content of TV viewing, peer smoking, and exposure to other media were not measured

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Ending the Tobacco Problem: A Blueprint for the Nation Table H-2. Exposure To Smoking Depictions In Movies Increases Risk For Smoking Initiation (McCool et al. 2005) Authors and Research Question Methods Sample Measures Findings Limitations McCool et al., 2005 To assess the media interpretation model of adolescents’ exposure to smoking in film, perceptions of smoking imagery in film, and smoking intentions Cross-sectional School based surveys during required class or after-school assembly Two samples of adolescents median age 12 and median age16 years from schools in Auckland, New Zealand N=3041 Ever smoker 12 yrs cohort: 28.8% and 16 yrs cohort: 66.4% Film experiences: film exposure, perception of smoking depiction frequency, nonchalant attitudes toward smoking in movies, positive stereotypes of smokers in movies Smoking beliefs and intentions: perceptions of smoking prevalence, attitudes towards smokers, intentions to smoke Film exposure predicted higher levels of perceived smoking frequency and nonchalant attitudes about smoking imagery 24% of the variance of smoking intentions was accounted for by the media interpretation model Perceptions of smoking were prevalent, non-judgmental attitudes toward smoking and positive smoker stereotypes independently accounted for variance within smoking intentions Direction of influence of noticing smoking depictions and perceptions of smoking frequency is unclear Smoking experience was not taken into account

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Ending the Tobacco Problem: A Blueprint for the Nation Table H-2. Exposure To Smoking Depictions In Movies Increases Risk For Smoking Initiation (Goldberg 2003) Authors and Research Question Methods Sample Measures Findings Limitations Goldberg, 2003 Examine the relationship between level of exposure to American movies and videos, exposure to American cigarette advertising and access to promotional products for cigarettes,and smoking behavior including exploratory puffing, cigarettes smoked in the last week, and intentions to smoke in the future Cross-sectional School based surveys during free class time Adolescents aged between 14 and 16 years from schools in Hong Kong N=3041 Ever smoker 12 yrs cohort: 28.8% and 16 yrs cohort: 66.4% Film exposure: Number of American movies and videos seen over the past 2 months Smoking behavior and intentions: ever puffed a cigarette, smoked in the last 7 days, expectations of smoking cigarettes one year from now Brand of cigarette smoked and brand of cigarette advertising recalled Number of cigarette promotional products owned Adolescents had seen an average of 1.4 American movies and 1.2 American videos Significant differences in smoking experience and intentions found between adolescents who saw 0-1 movies vs. 4 or more movies (34% vs. 47% and 21% vs. 30%, p<.01, Chi square values not reported) Significant differences in smoking experience, current smoking, and intentions to smoke found between adolescents who reported seeing 0-5 cigarette advertising products vs. 9 or more products (28% vs. 50%; 13% vs. 27%; 16% vs. 34%, p,.001) Significant differences in smoking experience, current smoking, and intentions to smoke found between adolescents who reported owing no vs. 2 or more cigarette promotional products (34% v.71%, 16% vs. 44%, 22% vs.58%; p<.001) Depictions of smoking in movies not measured Direction of influence not discernable No other variables controlled for or measured

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Ending the Tobacco Problem: A Blueprint for the Nation Table H-3. The Effects of Smoking in Movies Can Be Reduced by Anti-Smoking Advertisements and Parental Restriction of R-Rated Movies (Pechmann and Shih, 1999) Authors and Research Question Methods Sample Measures Findings Limitations Pechmann and Shih, 1999 Experimental design to test rival theses about the effects of smoking in movies on adolescents and whether these effects can be nullified with antismoking advertising Pechmann and Shih, Controlled Experiments School based surveys and film showings during class Study 1: Clips of 2 films with smoking either present or professionally edited out Study 2: Entire feature length film with smoking present or edited out Ratings of arousal and smoking perceptions elicited after each scene in both studies 9th graders aged 14-15 years from southern California Non smokers, half female Study 1: N= 607; 75% Caucasian Study 2: N= 232; 50% Caucasian, screened out if already seen stimulus movie Study 1: Smoking in Movies: 14 scenes from 2 feature films (16 minutes of total footage) that included high and low positive arousal scenes with a female and a male star who either originally smoke in the scene or the smoking is professionally edited out of the scene Positive arousal: Each scene rated sad vs. happy and boring vs. exciting Perceptions of Smokers: “How does a teenager who smokes cigarettes look to you?” (1-9 , 9= most favorable), rating teenage smokers on 4 factors: stature (intelligent, smart, rich, successful), vitality (healthy, well, fit, athletic, clean, good-smelling), popularity (well-liked, fun to be with, desirable to date, sexy, cute, good-looking), and poise (confident, comfortable around others, own person, free to make own decisions, contented, relaxed), and “If you were to smoke a cigarette, how do you think it would make you feel?”, rating on same 4 factors Study 2: Smoking in Movies: original version of feature film Reality Bites, 12 (30%) out of 40 scenes depicted smoking, a total of99 minutes of footage, and version of same film with smoking, cigarettes, ash trays, Study 1: The smoking vs. nonsmoking scenes elicited more positive arousal (x=3.42 vs. 3.19; F(1596)=10.06, p<.01); more positive perceptions of how smokers are perceived by others in stature (3.58 vs. 3.13, F(1601)=7.49, p<.01) and vitality (3.16 vs. 2.76, F(1601)=4.86, p<.01); and more positive perceptions about how a smoker perceives their own stature (3.63 vs. 3.27, F(1601)=5.85, p<.01) Study 2: In control ad condition, the smoking vs. nonsmoking scenes elicited more positive arousal (x=4.35 vs. 4.03, t=2.19, p<.05); more positive perceptions of how smokers are perceived by others in stature (3.91 vs. 3.13, t=2.33, p<.05); more positive perceptions of smoker self-perception of stature (3.80 vs. 2.96, t= 2.32, p<.05); and more intentions to smoke (1.91 vs. 1.59, t=1.88, p<.05). In the antismoking ad condition, the smoking scenes did not differ from the other scenes (p<.05) Significant interactions were found between the ad conditions and smoking depictions with the level of positive arousal (F(1227)=6.91,p<.01); other’s perceptions of a smoker’s stature (F(1228)=4.82,p<.05); smoker’s perception of their own stature (F(1228)=4.88, p<.05); and participants’ intent to smoke (F(1203)=4.88, p<.05) In the antismoking ad, more negative thoughts were generated when the lead characters were smokers vs. nonsmokers (2.37 vs.1.31, t=2.70, Outcome measure was not actual smoking behavior Reactions were measured after each scene which could have influenced results Smoking depictions limited to one movie, further research is needed with more smoking depictions in movies

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Ending the Tobacco Problem: A Blueprint for the Nation Table H-3. The Effects of Smoking in Movies Can Be Reduced by Anti-Smoking Advertisements and Parental Restriction of R-Rated Movies (Pechmann and Shih, 1999) Authors and Research Question Methods Sample Measures Findings Limitations 1999     and secondhand smoke professionally edited out Positive arousal and Perceptions of Smokers: Same as above Anti-Smoking Advertisement: 30-second television spot of negative caricatures of a smoker vs. control advertisement on AIDS with same length and format of caricatures Intentions to Smoke: “Do you think that you will smoke at any time during the next year? and Would you smoke if your best friend dared you?” (1=definitely not, 4=definitely yes) Ad-induced increases in negative smoker-related thoughts (positive, negative, or neutral) Extensive manipulation and suspicion checks also included p<.01), this was not found in the control ad condition. Significant interaction between the ad conditions and smoking depictions with the number of negative thoughts about the lead characters (F(1188)=6.98, p<.01)  

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Ending the Tobacco Problem: A Blueprint for the Nation Table H-3. The Effects of Smoking in Movies Can Be Reduced by Anti-Smoking Advertisements and Parental Restriction of R-Rated Movies (Edwards et al. 2004) Authors and Research Question Methods Sample Measures Findings Limitations Edwards, et al., 2004 Evaluate the effect of anti-smoking advertisement on women’s perceptions of smoking in movies and their intentions to smoke Quasi-experimental Surveys administered after viewing movies in movie theater to patrons who looked between 12 and 17 years old Five movies with various amounts of smoking viewed in ‘real-world’ movie theaters Control condition: no ad was shown before the movie (week 1) Experimental condition: Anti-smoking advertisement shown before the movie (week 2) Female movie theater patrons aged 12-17 years in Sydney, Australia N=2038 Mean age=13.9 years (SD=1.58) Age not evenly distributed for 16 and 17 year olds 9.2% reported smoking cigarettes in the previous 4 weeks Movie exposure to smoking: 5 movies on “Screenit”, an internet film review site were identified for varying levels of smoking depiction Perceptions of smoking in movies: whether smoking was present in the movie seen and which characters smoked, answer to question: “was it perok the characters were smoking?” 5-point Likert scale responses Smoking history and intentions: “have you smoked cigarettes in the last 4 weeks?” and “do you think you will be smoking cigarettes this time next year?” 7-point Likert scale Anti-smoking advertisement: A national anti-tobacco campaigns’s ad was modified with an anti-smoking voice-over by a popular female teen star was shown before the movie Nonsmokers who saw the ad were more likely to see smoking as “not ok” (48.2%) vs. nonsmokers who did not see the ad (25.2%, X2=83.11, df=3, p=.0001); this difference was maintained when age and movie exposure differences were adjusted for (Wald X2=75.784, df=1, p=.0001). No effect was found for smokers (X2=2.52, df=2, p=.28), even when age and movie were accounted for (Wald X2=1.37, df=1, p=.242). No overall effect was found for the intervention on intentions to smoke (X2=3.26, df=2, p=.196). When smokers and nonsmokers were analyzed sepamovie rately, smokers were more likely to not intend to smoke (31.9% vs. 47.8%; X2=9.03, df=2, p=.01), and campaign’s when age and movie were accounted for the intervention group of smokers continued to have lower intentions to smoke (Wald X2=4.59, df=1, p=.03). No effect was found for nonsmokers (X2=.97, df=2, p=.62), even when age and movie were accounted for (Wald X2=1.25, df=1, p=.263). No baseline information about perceptions of smoking or intentions to smoke. Sampling strategy open to researcher bias and may not be representative.

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Ending the Tobacco Problem: A Blueprint for the Nation Table H-3. The Effects of Smoking in Movies Can Be Reduced by Anti-Smoking Advertisements and Parental Restriction of R-Rated Movies (Dixon 2001) Authors and Research Question Methods Sample Measures Findings Limitations Dixon, 2001 Assess public perceptions of the tobacco industry and tobacco use intentions after watching the movie The Insider Quasi-experimental Surveys administered before and 2 weeks after viewing movies in a movie theater for a free movie pass Control movie: Erin Brockovich Commercial theater patrons between ages 15-60+ years (majority between 20-39 years) in Melbourne,Australia N=322, Insider viewers =182 Brokovich viewers=141 Only participants who had not seen either movie were included in the sample Both sets of viewers had comparable smoking status (majority nonsmoker) and education. Film conditions: both rated “M15+” which means viewers 15 year or under not admitted unless with a parent or adult guardian The Insider was a tale of a whistle-blower of the tobacco industry cover up of the harmful health effects of their products. Erin Brokovich which had an analogous plot but without the tobacco industry content. Perceptions of different professions: List of professions were presented and rating on “ethics and honest” and “power” elicited. Statements of agreement presented about business conduct of tobacco industry and other industries. Intentions to smoke: “Do you think you will be smoking cigarettes this time next year?” Perception of smoking prevalence: in real life and in movies compared to real life Patrons who viewed The Insider held more negative views of the tobacco industry business conduct than those who saw the control movie, even when preexisting attitudes were controlled for (pre-film means = 1.68 vs. 1.78, post-film means = 1.63 vs. 1.90, F(1, 242)= 3.09, p=.0004) Viewing The Insider was also associated with short term reductions in intentions to smoke (pre-film mean = 1.97 (SD: 1.57) vs. post-film mean = 1.76 (SD: 1.44) F(4,188)=114.97, p<.001). No baseline information about perceptions of smoking or intentions to smoke. Self-selection bias of viewing The Insider and nonequivalent control movie make the intentions finding difficult to interpret.

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Ending the Tobacco Problem: A Blueprint for the Nation Table H-3. The Effects of Smoking in Movies Can Be Reduced by Anti-Smoking Advertisements and Parental Restriction of R-Rated Movies (Sargent et al. 2004) Authors and Research Question Methods Sample Measures Findings Limitations Sargent, et al., 2004 Examine the effect of parental R-rated movie restriction on adolescent smoking initiation Longitudinal School-based surveys at baseline and follow up phone interviews 13-26 months later List of specific R-rated movies with smoking occurrences measured for each Adolescents aged 10-14 years at 14 schools in New England, USA N=2596 Only participants who reported no lifetime smoking experience on baseline were eligible for follow up interviews Non-participants comparable to participants in age, sex, grade, and parental R-rated movie restriction but were more slightly more susceptible to smoking at baseline; were more likely to have parents, and friends who smoke; have parents who did not complete high school and were more likely to have lower school performance Exposure to smoking in R-rated movies: Ratio of total number of smoking occurrences viewed by total possible number of smoking occurrences in a subset of 50 movies selected from 601 movies from 1988-99, adolescents classified into 3 categories of R-rated movie exposure: no exposure (n=594), low (n=1109, exposure to 1-499 occurrences of R-rated movie smoking), and high (n=893, exposure to 500-3376 occurrences) Parental Restriction of R-rated movies: ”How often do your parents let you watch movies or videos that are rated R?” responses ranged from “never” to “all the time” and then coded into 3 categories: greater strictness (score moved to more restrictive category during follow up), greater leniency (score moved to a less restrictive category) , or no change Confound variables: sex, age, school, self-reported school performance, sensation seeking, rebelliousness, self esteem; Parent, sibling, friend smoking, receptivity to tobacco advertising; parent education, authoritative parenting, and adolescent perceptions of parental disapproval of smoking Smoking Initiation: Any lifetime cigarette smoking reported on follow up survey Exposure to R-rated movie smoking decreased significantly (p<.001) with increasing parental restriction, adolescents who were “never” allowed to view R-rated movies had low exposure to R-rated movie smoking (4.9%), compared to 20% for adolescents allowed to watch them “once in while”, and 54% for adolescent allowed to “sometimes/all the time” After controlling for confound variables, risk of smoking initiation increased with decreased parental restriction from viewing R-rated movies RR 1.8(95% CI 1.1-3.1) for “once in a while” vs. RR 2.8 (95%CI 1.6-4.7) for “sometimes” or “all the time” This pattern was even more pronounced for adolescents from non-smoking families (RR 4.3 (95% CI, 1.4-13) when “once in while” vs. “sometimes, all the time” RR 10 (95%CI 3.6-31) compared to adolescents from families that smoke (RR 12 (4.1-37) for “once in a while” vs. “sometimes, all the time” RR 13 (4.4-38) Decreased parental restriction was associated with higher risk of smoking initiation and increased restriction with decreased risk, compared with adolescents reporting no change. Only measures smoking initiation, no indication of continued or addicted smoking

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Ending the Tobacco Problem: A Blueprint for the Nation Table H-3. The Effects of Smoking in Movies Can Be Reduced by Anti-Smoking Advertisements and Parental Restriction of R-Rated Movies (Dalton et al. 2002) Authors and Research Question Methods Sample Measures Findings Limitations Dalton et al., 2002 Examine the effect of parental R-rated movie restriction on adolescent smoking and alcohol use Cross-sectional School-based surveys List of specific R-rated movies elicited whether student had seen or not Primarily White (93%) adolescents average age 12 years at 30 schools in New England, USA N=4544 Exposure to smoking in R-rated movies: List of a subset of 50 movies selected from 603 movies from 1988-99 rated on whether participant saw movie or not Parental Restriction of R-rated movies: ”How often do your parents let you watch movies or videos that are rated R?” responses ranged from “never” to “all the time” Confound variables: sex, school, grade, school performance, sensation seeking, rebelliousness, self esteem; parent education, parental disapproval of smoking, maternal supervision and responsiveness Whether participant ever tried smoking or alcohol: “How many cigarettes have you smoked in your life?” any answer of “just a few puffs” or more coded as tried smoking. “Have you ever had beer, wine, or other drink with alcohol that your parents didn’t know about?” yes or no. Trying smoking prevalence was 35% for no restriction of R-rated movies, 12% for partial restrictions, and 2% with complete restrictions. Trying alcohol prevalence was 46% for no restrictions, 16% for partial restriction, and 4% with complete restriction. When R-rated movies were completed restricted, adolescents were less likely to smoke (Relative Risk 0.29, 95% CI, 0.19-0.45) and drink alcohol (Relative Risk 0.30, CI, 0.21- 0.42) compared with no restrictions of R-rated movies, even after controlling for confound variables. Not a clear measure of smoking depiction exposure Only measures trying behavior, not continued use Not clear that other variables associated with smoking and drinking behavior, e.g. peer behaviors, account for findings

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