EFFECTS OF SMOKING SCENES IN MOVIES?’
Psychological Reports, 2007, 100, 3-18. © Psychological Reports 2007
CAN CIGARETTE WARNINGS COUNTERBALANCE
EFFECTS OF SMOKING SCENES IN MOVIES?’
ISABELLE GOLMIER JEAN-CHARLES CHEBAT
National Bank of Canada HEC-Montreal School of Management
Ecole des Hautes Etudes Commerciales de Montreal
CLAIRE GELINAS-CHEBAT
Department of Linguistics
- click here for more information on this paper
Universitc> du Que’hec a Montrc’al
Summary. Scenes in movies where smoking occurs have been empirically shown to influence teenagers to smoke cigarettes. The capacity of a Canadian warning label on cigarette packages to decrease the effects of smoking scenes in popular movies has been investigated. A 2 x 3 factorial design was used to test the effects of the same movie scene with or without electronic manipulation of all elements related to smoking, and cigarette pack warnings, i.e., no warning, text-only warning, and text +picture warning. Smoking-related stereotypes and intent to smoke of teenagers were measured. It was found that, in the absence of warning, and in the presence of smoking scenes, teenagers showed positive smoking-related stereotypes. However, these effects were not observed if the teenagers were first exposed to a picture and text warning. Also, smoking-related stereotypes mediated the relationship of the combined presentation of a text and picture warning and a smoking scene on teenagers’ intent to smoke. Effectiveness of Canadian warning labels to prevent or to decrease cigarette smoking among teenagers is discussed, and areas of research are proposed.
The problem of teenager consumption of tobacco is serious. Approximately 22% of Canadian teenagers between 15 and 19 years currently smoke cigarettes (Health Canada, 2003). Sociodemographic analyses indicated that they are more likely to be found in the lower income and lower education segment of the Canadian population (Health Canada, 1995, 1999), as is also the case in other countries (Goldberg, Kindra, Lefebvre, Liefeld, Madill-Marshall, Martoharadjono, & Vredenburg, 1995; Blum, Beuhring, Shew, Bearinger, Sieving, & Resnick, 2000). In Canada, warning labels on cigarette packages have been conceived as one of the key strategies to prevent teenagers from smoking.
In 2000, the Canadian government adopted one of the world’s toughest laws for cigarette warnings (Health Canada, 2004). Each warning label coy-
‘Address correspondence to Jean-Charles Chebat, Chair of Commercial Space and Customer Service Management Holder, HEC-Montreal School of Management, 3000 Cote-Sainte-Catherine Local 4.348, Montreal, Quebec, Canada 11.3T 2A7 or e-mail ( Jean-Ch.arles.Chebat@hec. ca), The first and third authors gratefully acknowledge a research grant they received from the Quebec Council of Social Research (CQRSC).
DOT 10.2466/P80.100.1.3-18
| Influence of Motion Picture Rating on AdolescentResponse to Movie Smoking |
| WHAT’S KNOWN ON THIS SUBJECT: The US Surgeon General hasdetermined that the relationship between movie smoking exposure (MSE) and youth smoking is causal; however, it is not known whether movie rating influences how adolescents respond. |
| WHAT THIS STUDY ADDS: The response to PG-13–rated MSE wasindistinguishable from R-rated MSE. An R rating for smoking could reduce smoking onset in the United States by 18% (by eliminating PG-13 MSE), an effect similar to making all parents maximally authoritative in their parenting. |
| AUTHORS: James D. Sargent, MD,a Susanne Tanski, MD,MPH,a and Mike Stoolmiller, PhDb |
| Cotton Cancer Center, Geisel School of Medicine atDartmouth, Lebanon, New Hampshire; and bCollege of Education, University of Oregon, Eugene, Oregon |
| KEY WORDSadolescent smoking, motion picture rating, movie smoking |
| ABBREVIATIONSCI—confidence interval MPAA—Motion Picture Association of America MSE—movie smoking exposure |
| www.pediatrics.org/cgi/doi/10.1542/peds.2011-1787 |
| doi:10.1542/peds.2011-1787 |
| aNorris |
- click here for more information on this paper
| abstract |
| OBJECTIVE: To examine the association between movie smoking expo-sure (MSE) and adolescent smoking according to rating category. |
| METHODS: A total of 6522 US adolescents were enrolled in a longitudinalsurvey conducted at 8-month intervals; 5503 subjects were followed up at 8 months, 5019 subjects at 16 months, and 4575 subjects at 24 months. MSE was estimated from 532 recent box-office hits, blocked into 3 Motion Picture Association of America rating categories: G/PG, PG-13, and R. A survival model evaluated time to smoking onset. |
| RESULTS: Median MSE in PG-13–rated movies was ∼3 times higher thanmedian MSE from R-rated movies, but their relation with smoking was essentially the same, with adjusted hazard ratios of 1.49 (95% confidence interval [CI]: 1.23–1.81) and 1.33 (95% CI: 1.23–1.81) for each additional 500 occurrences of MSE respectively. MSE from G/PG-rated movies was small and had no significant relationship with adolescent smoking. At- tributable risk estimates showed that adolescent smoking would be re- duced by 18% (95% CI: 14–21) if smoking in PG-13–rated movies was reduced to the fifth percentile. In comparison, making all parents max- imally authoritative in their parenting would reduce adolescent smoking by 16% (95% CI: 12–19). |
| CONCLUSIONS: The equivalent effect of PG-13-rated and R-rated MSEsuggests it is the movie smoking that prompts adolescents to smoke, not other characteristics of R-rated movies or adolescents drawn to them. An R rating for movie smoking could substantially reduce adolescent smoking by eliminating smoking from PG-13 movies. Pediatrics 2012;130:228–236 |
| Accepted for publication Apr 16, 2012 |
Address correspondence to James D. Sargent, MD, Dartmouth-Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH
|
| PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). |
| Copyright © 2012 by the American Academy of Pediatrics |
| FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose. |
| FUNDING: Supported by the National Cancer Institute (grantCA077026) and the American Legacy Foundation. Funded by the National Institutes of Health (NIH). |
| COMPANION PAPER: A companion to this article can be found onpage 221, and online at www.pediatrics.org/cgi/doi/10.1542/ peds.2011-1792. |
| 228 |
| SARGENT et al |
| Downloaded from pediatrics.aappublications.org by guest on December 8, 2014 |
| ARTICLE |
| Almost 50 years since the 1964 SurgeonGeneral’s Report on Smoking and Health, smoking remains the number 1 cause of preventable death in the United States, responsible for .400 000 deaths per year, prompting a need to know more about what fuels this epidemic. In March 2012, a new Surgeon General’s Report was released, entitled “Preventing To- bacco Use Among Youth and Young Adults,” and in which the Surgeon Gen- eral stated: “The evidence is sufficient to conclude that there is a causal rela- tionship between depictions of smoking in movies and the initiation of smoking among young people.”1 Thus, much is known about the relation between ex- posure to movie smoking and youth smoking, but studies are only beginning to examine whether the context in which movie smoking is presented modifies its association with adolescent smoking. In a recently published experiment,2 ex- posure to movie clips portraying smok- ing as relaxing was associated with a significantly stronger desire to smoke compared with exposure to clips without a motive for the smoking. Al- though experimental studies allow the researcher to control exposure and serve to tease out underlying cognitive mechanisms, it is difficult to study actual smoking behavior in an experimental setting, and therefore it is hard to judge what the behavioral implications of the findings would be. |
| Another way to assess context is toconsider movie rating. Movie ratings are a marker for the presence of con- textual elements considered to be “adult” by the ratings board. To the extent that sex, violence, profanity, and illicit drug use are considered in the Motion Picture Association of America (MPAA) ratings system,3 smoking in movies with an adult rating (eg, R [re- stricted to individuals aged $17 years unless accompanied by a parent or guardian]) would depict characters who model these behaviors, along with |
| PEDIATRICS Volume 130, Number 2, August 2012 |
| FIGURE 1 |
| Examples of different contextual treatments of movie smoking, clockwise from top left: Cruella de Vil, anuncomplicated villain in 101 Dalmatians (rated G; Walt Disney Productions, 1961); Gwyneth Paltrow smoking in the context of a sexually provocative scene in Great Expectations (rated R; 20th Century Fox Film Corporation, 1998); Ethan Hawke blowing smoke into a backlit wine glass to show what the planet Titan looks like in Gattica (rated PG-13; Columbia Pictures Corporation, 1997); and Brad Pitt smoking after a brutal fight scene from Fight Club (rated R; Fox 2000 Pictures, 1999). |
| smoking. Indeed, a content analysisfound that MPAA ratings can reliably distinguish levels of sex, violence, and profanity but not tobacco use.4 Figure 1 depicts several examples of movie smoking by rating and a range of con- texts that might be seen with movie smoking according to rating category: simple villainy (G [appropriate for gen- eral audiences]), visually stimulating (PG- 13 [parents are strongly cautioned, con- tent may not be suitable for children aged ,13 years]), and violence and sex (R). |
- click here for more information on this paper
| Examining how movie ratings affect themovie smoking–behavior association could have important implications on ratings for movie smoking,5 especially given that 60% of the movie smoking exposure (MSE) comes from youth- rated (almost entirely PG-13) movies.6 In the United States, an R rating for smoking would serve to effectively eli- minate smoking from movies marketed to youths, based on the current business model for movie production, in which the rating is negotiated between pro- duction company and the director be- fore movie production.7 The implication is that a production company intending to include the youth market would have to eliminate smoking in the production |
| process, as is currently done with sexand violence to obtain the PG-13 rating. However, the hypothetical benefits of limiting MSE in youth-rated movies depends partly on how strongly the smoking in them is linked with ado- lescent smoking. Importantly, limiting smoking to R-rated movies would have little impact if the dose-response be- tween smoking in youth-rated movies and adolescent smoking was small. |
| In addition, if only R-rated movie smokingwas linked with behavior, it would se- riously undermine the idea that it is movie smoking specifically, as opposed to the sex, violence, profanity, and illicit drug use that prompts smoking onset. Indeed, a recent essay speculated that the movie smoking–youth smoking re- lationship might not be causal because MSE is “inextricably entangled with a host of other variables in movies… such as alcohol or recreational drug portrayal, violence, coarse language, and sexual content,”8 raising concerns about specificity. The essay went fur- ther, suggesting that it may not be the movies at all that prompt adolescents to smoke. Instead, adult movies may attract risk-taking adolescents who come to see the proscribed behaviors |
| 229 |
| Downloaded from pediatrics.aappublications.org by guest on December 8, 2014 |
| (ie, adolescents who end up smokingfor other reasons). In this scenario, R-rated MSE would be hypothesized to be overwhelmingly strong in its ability to predict youth smoking, because R-rated MSE picks up the effect of seeing “adult” behaviors relegated to these movies and identifies unmeasured risk factors among the adolescents that see them. |
| The current study examined smokingonset in a cohort of US adolescents followed up for 4 waves over a 2-year period. Exposure to smoking in movies at study onset was divided into 3 cat- egories (G/PG, PG-13, and R) to assess the prospective relationship between each type of exposure and onset of smoking. Based on the idea that it is primarily the movie smoking that prompts adolescents to smoke (with the adult context being secondary), we hy- pothesized that R-rated movie smoking would have only a slightly stronger as- sociation with adolescent smoking than PG-13–rated movie smoking and that PG-13–rated movie smoking would still be an important predictor of smoking, given that it accounts for a large share of the exposure. |
| in the unweighted sample were compa-rable to those of the 2000 US Census.9 |
| Missing data/attrition increased from 7adolescents at baseline to 2451 at 24 months. Attrition analyses indicated that adolescents lost to follow-up were more likely to be nonwhite; were from families with lower parental education/ income and lived in rented versus parent-owned residences; had poorer school performance; and scored higher on sensation-seeking scales. To mini- mize attrition bias, estimation was carried out after multiple imputation using the missing at random assump- tion (missing data are missing at ran- dom conditional on covariates included in the model).10 The MICE procedure in R was used to stochastically impute missing data.11 To improve the quality of the imputations, baseline auxiliary variables that were predictive of missing data (but not necessarily the outcomes) were also included in the imputation. All variables were treated as numeric, and the predictive mean matching procedure was used to cre- ate 15 imputed values for each missing score. Convergence was assessed by checking plots of the mean and vari- ance of the imputations for each vari- able across the 15 streams for signs of problems, such as trends or lack of proper mixing. No problems were ap- parent. For descriptive statistics, we averaged across the 15 imputations to obtain a single best estimate for each missing data point. |
| Assessment of MSE Dose |
| Adolescents’ exposure to movie smok-ing was estimated by using previously validated methods.12 The top 100 movies with highest US gross revenues each year were selected for each of the 5 years preceding the baseline survey (1998–2002, N = 500) and 32 high earners during the first 4 months of
cause adolescents often watch these |
| movies on video/DVD. The survey ran-domly selected 50 movie titles from the larger pool of 532 movies for each ad- olescent interview. Movie selection was stratified according to the MPAA rating so that the distribution of movies in each list reflected the distribution of the full sample of movies (19% G/PG, 41% PG-13, and 40% R). Respondents were asked (no/yes) whether they had ever seen each movie title on their unique list. |
| Trained coders counted the number ofsmoking occurrences in each of the 532 movies by using previously validated methods.13 A smoking occurrence was counted whenever a major or minor character handled or used tobacco in a scene or when tobacco use was de- picted in the background (eg, brands present or “extras” smoking in a bar scene), irrespective of the scene’s du- ration or how many times the tobacco product appeared. We summed the number of smoking occurrences each adolescent had seen from his or her unique list of 50 movies, stratifying counts by rating blocks (G/GP, PG-13 and R categories), and scaling these counts to reflect exposure to that of the full sample of 532 movies, given the adolescent’s reported viewing habits by rating.12 To limit extreme values and reduce the effect of outliers, MSE measures were Winsorized14 at the second and 98th percentiles (values more extreme were recoded back to the second or 98th percentile value). To assess equivalent doses of exposure, the response to each increment of 500 movie smoking occurrences was modeled, which would approximate the median overall dose of MSE. |
| Outcome Assessment |
| Smoking initiation was assessed byasking: “Have you ever tried smoking a cigarette, even just a puff?” Those who answered “yes” were classified as having tried smoking. This measure |
| METHODS |
| Participants and Procedure |
| Participants were 6522 adolescents,ages 10 to 14 years, recruited in 2003 by using random digit dial methods de- scribed previously.9 After verbal paren- tal consent and adolescent assent were obtained, participants were surveyed via telephone about media exposures, tobacco and alcohol use, sociodemo- graphic characteristics, and other risk factors. Subjects were resurveyed every 8 months 3 more times, with the last follow-up at 24 months. The study pro- cedures were approved by the Dart- mouth College Committee for Protection of Human Subjects. The completion rate for the survey was 66%; distri- butions of age, gender, ethnicity, household income, and census region |
| 230 |
| SARGENT et al |
| Downloaded from pediatrics.aappublications.org by guest on December 8, 2014 |
| ARTICLE |
| was used rather than current (30-day)smoking because current smoking is infrequent in the early stages of ciga- rette use.15 Smoking initiation is an important outcome because approxi- mately one-third of initiators go on to become addicted smokers.16,17 For the US sample, confidentiality in responses was assured in the adolescent assent statement, and subjects indicated their answers to sensitive questions by pressing numbers on the telephone. |
| seeking.34 To prevent problems due tooutliers, covariates were Winsorized at the second and 98th percentiles.14 |
| Statistical Analysis |
| Onset of smoking was ascertained atthe 8-, 16-, and 24-month surveys. An incident case was defined as an ado- lescent who became a smoker from the pool of those who were not smokers at the previous survey. As a first step, generalized additive logistic models werefittoshow the crude dose-response relation between the MSE according to MPAA rating and probability of smoking initiation. In addition to strong linear trends, both PG-13– and R-rated MSE had significant negative quadratic trends (significantly stronger response at lower dose ranges); however, only the negative quadratic effect for R-rated MSE remained significant after adjust- ing for all covariates in the full model. For ease of interpretation and because conclusions did not change, only the linear effects for all MSE measures were used (quadratic estimates avail- able on request from the first author). For the models, MSE was entered as a continuous variable and scaled so that each 1-point increment represented an increase in dose of 500 movie smoking occurrences. To determine the associa- tion between exposure to movie smok- ing according to MPAA rating and time to smoking initiation, discrete time hazard survival models35–37 were fit to each of the 15 imputed complete data sets fol- lowing standard procedures for pooling the estimates and obtaining SEs.11 The hazard model assessed time to onset based on data from all 3 intervals over the 24-month period. For all models, results for main effects were judged significant for P values ,.05. |
| Attributable fraction calculations wereconducted after model fitting by ob- taining the model-predicted number of events with the observed data and the model-predicted number of events when |
| Covariates |
| In addition to the movies viewed, otherinformation was collected from the adolescents, including age, gender, race, parent education, household income, school performance, involvement in ex- tracurricular activities, weekly spending money, television watching (hours per day), personality characteristics (rebel- liousness, sensation-seeking propensity), parent/sibling/peer smoking, cigarette availability at home, and adolescent- reported parenting practices.18 Author- itative parenting style describes parents that are both responsive and effective in monitoring their children19; this con- struct has a strong and consistent track record in predicting lower levels of substance use.18,20–32 The current study used a 10-item version of the Authoritative Parenting Index,18 in which we combined results for questions about responsiveness (“he/she makes me feel better when I’m upset/listens to what I have to say”) and monitoring (“he/she asks me what I do with my friends/knows where I am on the weekend” [a = .79 survey 1, .81 survey 2]) and referenced questions to the per- son the adolescent viewed as the main caregiver. The assessment of other covariates and their reliabilities has been described previously.9,33 The sensation-seeking scale used here has been validated in longitudinal research and has a reliabilities comparable to other accepted scales for sensation |
| levels of MSE in our sample were alteredto a low level (ie, the fifth percentile) to indicate what might happen if smoking was largely removed from movies the adolescents had watched. The attrib- utable fractions were compared with similar assessments for sensation seeking (setting all adolescents at the lowest level), or authoritative parenting (setting all parents at the most author- itative level). For each of the 15 impu- tations, estimates and SEswere obtained for the attributable fractions using 100 bootstrap replications. The bootstrap estimates and SEs were then pooled across the 15 multiple imputation mo- dels using standard procedures. |
| RESULTS |
| Description of the Sample |
| Table 1 describes the predictor varia-bles for the study sample at baseline. Age was equally represented and ranged from 10 to 14 years at baseline; male and female genders were also equally represented. Race/ethnicity was broadly reflective of the US population, with 11% black and 19% Hispanic ethnicity. Some 18% of families were classified as low-income, with 7% having incomes of #$20 000 and 11% having income between $20 000 and $29 000 per year. At baseline, 83%, 88%, and 69% of ado- lescents reported having no friends, siblings, or parents, respectively, who smoked, and 14% thought there was at least some chance that they could ob- tain cigarettes from home without their parent’s knowledge. With respect to media use, 28% watched $3 hours of television per day. Only 15% reported no weekly spending money, and 10% reported having .$20 per week to spend. |
| Dose of MSE by MPAA Rating and ItsRelation With Smoking Onset |
| Table 1 also displays the median andinterquartile range for MSE according to MPAA rating category. High-dose |
| 231 |
| PEDIATRICS Volume 130, Number 2, August 2012 |
| Downloaded from pediatrics.aappublications.org by guest on December 8, 2014 |
| (95th percentile) MSE was similar forPG-13– and R-rated movies (894 and 1002 occurrences, respectively) and ∼5 times that of the 95th percentile for G/PG-rated MSE. However, the typical (median) dose to adolescents for PG- 13–rated MSE was much higher than for R-rated MSE (275 and 93 occurrences, respectively), reflecting higher viewer- ship of PG-13–rated movies overall. The correlation between the 3 MSE variables was .53 for PG-13–rated versus R-rated movies, .18 for PG-13–rated versus G/ PG-rated movies, and .15 for R-rated versus G/PG-rated movies. |
| Figure 2 shows the dose-response re-lation of MSE according to rating cat- egory with the 8-month probability of trying smoking using all three 8-month observation periods; the unadjusted probability of trying smoking was not significantly different across the 3 periods. The null hypothesis is repre- sented by the horizontal line set at the average probability of trying smoking (6.4%). Figure 2 illustrates the mark- edly larger exposure to PG-13–rated and R-rated movie smoking compared with G/PG-rated movies, for which dose did not extend past 200 occurrences, even for the most highly exposed ado- lescents. The relation for G/PG-rated MSE and adolescent smoking (dotted green line) was not significantly differ- ent from zero. The unadjusted hazard ratio associated with a 500-smoking occurrence dose of G/PG-rated MSE was 1.47 (95% CI: 0.65–3.36). Restrict- ing G/PG-rated MSE to the observed range (0–165 occurrences) made the unadjusted hazard ratio even lower: 1.14 for the 95th percentile compared with fifth percentile of actual G/PG- rated MSE. In contrast, PG-13–rated (dashed red line) and R-rated (solid blue line) MSE had much larger ex- posure ranges and crude relations with youth smoking that were similar to each other and strongly diver- gent from the null hypothesis. The |
| 232 |
| SARGENT et al |
| TABLE 1 Description of the Never Smoker Sample at Baseline (N = 5830) |
| N |
| Age, y10 11 12 13 14 Race/ethnicity White Black Hispanic Other Gender Male Female Family income (31000), $ ,20 20–29 30–49 50–74 75–99 $100 Parent education #9th grade 9th–11th grade 12th grade High school diploma Vocational/technical school Some college Associate degree Bachelor degree Postgraduate Either parent smokes No Yes Cigarettes available at home Definitely no Probably no Probably yes Definitely yes Sibling(s) smoke No Yes Peers smoke None Some Most Television viewing None ,1 h/d 1–2 h/d 3–4 h/d .4 h/d School performance Below average Average Above average Excellent Weekly spending money, $ None 1–5 6–0 11–15 |
| 11601244 1238 1213 975 |
| 3619619 1095 497 |
| 29702860 |
| 401625 693 1183 1180 1748 |
| 353414 229 1274 199 1004 501 1116 740 |
| 39991831 |
| 5005487 251 87 |
| 5115715 |
| 4854879 97 |
| 3181151 2760 1139 462 |
| 1261340 2479 1885 |
| 8541907 1362 359 |
| Proportion |
| .2.21 .21 .21 .17 |
| .62.11 .19 .09 .51 .49 |
| .07.11 .12 .2 .2 .3 |
| .06.07 .04 .22 .03 .17 .09 .19 .13 |
| .69.31 |
| .86.08 .04 .01 |
| .88.12 |
| .83.15 .02 |
| .05.2 .47 .2 .08 |
| .02.23 .43 .32 |
| .15.33 .23 .06 |
| Downloaded from pediatrics.aappublications.org by guest on December 8, 2014 |
| ARTICLE |
| TABLE 1 Continued |
| N |
| 16–2021–50 .50 |
| 796458 94 |
| Median |
| Continuous variablesResponsive parenting Demanding parenting Sensation seeking Rebelliousness Extracurricular activities Movie Smoking Exposure G/PG-rated PG-13–rated R-rated |
| Proportion |
| .14.08 .02 |
| Interquartile Range (25th–75th) |
| 2.42.3 0.8 0.2 1.8 |
| 61275 93 |
| 22 0.5 1.5 |
| 1597 0 |
| 2.82.8 1.3 0.4 2.2 |
| 123514 393 |
| indistinguishable from that of R-ratedMSE, a finding that directly refutes spec- ulation8 that it is other adult-oriented content or some yet-to-be-identified individual risk factor that attracts youths to R movies which causes the response. Combined with recently published experimental data that show a movie smoking effect on susceptibil- ity to smoke using a randomized de- sign,38 the results strongly support the idea that it is the movie smoking in PG-13- and R-rated movies that stim- ulates youths to smoke. |
| Because exposure to PG-13–rated mov-ies is large,39 the smoking in these movies accounts for about two-thirds of the population effect. Thus, an un- ambiguous R rating for smoking could reduce adolescent smoking onset by almost one-fifth, as newly produced smoke-free PG-13–rated movies come into the market and old ones lose the adolescent audience. The attributable fraction estimate for PG-13– and R- rated MSE is smaller than previous estimates in predominantly white adolescents40–42 (the pooled estimate for those studies from an earlier meta- analysis5 was 0.44 [95% CI: 0.34–0.58] compared with 0.26 [95% CI: 0.23–0.29] for this study), in part because the response to movie smoking among minority adolescents was less strong than among whites.43,44 Regardless of what the final attributable risk is, however, the public health impact of PG-13 smoking is important: it ranks on the order of the impact of parenting effectiveness. |
| Not only was exposure to G/PG MSE-rated small, the relation for G/PG- rated MSE was not significantly different from zero. Low responsiveness to smoking in G/PG movies is consistent with the results of an experimental study that failed to find an effect of cartoon and G/PG movie smoking on attitudes in elementary school-aged children.45 Another similarly designed |
| 233 |
| unadjusted hazard ratios for each500 occurrences of PG-13–rated and R-rated MSE were 3.44 (95% CI: 2.74– 4.32) and 3.14 (95% CI: 2.58–3.83), respectively. |
| Table 2 shows the adjusted hazard ra-tios for MSE according to MPAA rating. There was no significant relation be- tween exposure to G/PG-rated MSE and adolescent smoking. The adjusted haz- ard ratios for a 500-occurrence dose of PG-13– and R-rated MSE were 1.49 (95% CI: 1.23–1.81) and 1.33 (95% CI: 1.13– 1.57), respectively. Wald tests showed that the MSE–youth smoking relation for PG-13– and R-rated movies was not significantly different from each other but both were significantly higher than the G/PG-rated MSE–youth smok- ing relation. |
| This study was designed to detect a maineffect of MSE on adolescent smoking and powered to detect an overall odds ratio of 1.4 for the relation between smoking in movies and smoking onset with a powerof 0.97.Power for these analyses was considerably reduced when MSE was subdivided by MPAA rating into 3 correlated variables, especially consid- ering the small range of G/PG-rated MSE. However, additional power calculations indicated that, even with this small range, the power of the study to detect an effect similar to PG-13 MSE (an |
| PEDIATRICS Volume 130, Number 2, August 2012 |
| adjusted hazard ratio of 1.5 for a 500-occurrence dose) was 0.71. |
| Attributable Fraction Estimation |
| The attributable fraction estimate forsetting all PG-13– and R-rated MSE to the fifth percentile was 0.26 (95% CI: 0.23–0.29), indicating that largely re- moving the risk factor would reduce smoking onset over the period by 26%. Setting PG-13-rated MSE alone to the fifth percentile (which approximates the probable impact of an R rating for smoking) was associated with an at- tributable fraction of 0.18 (95% CI: 0.14–0.21). For comparison, the attrib- utable fractions for setting authorita- tive parenting to the highest level or sensation seeking to the lowest level were 0.16 (95% CI: 0.19–0.12) and 0.30 (95% CI: 0.35–0.25), respectively. Thus, eliminating smoking from youth-rated movies would reduce smoking by as much as making all parents maximally authoritative in their parenting. |
| DISCUSSION |
| This study provided a test of whether itis primarily the smoking in movies, not the other adult behaviors that go along with it, that affects adolescents’ be- havior. The dose-response between PG- 13–rated MSE and youth smoking is |
| Downloaded from pediatrics.aappublications.org by guest on December 8, 2014 |
| FIGURE 2 |
| The unadjusted relation between exposure to G/PG-, PG-13–, and R-rated MSE and the 8-month hazardprobability of smoking onset for US adolescents. The unadjusted probability (hazard) of trying smoking was not significantly different across each of the three 8-month follow up periods and was equal to 0.064, shown in the plot as a thin horizontal line. All 3 exposures (G/PG [dotted green line], PG-13 [dashed red line], and R [solid blue line]) were entered as linear effects. The small lines on either side of each curve represent the 95% CIs for the estimate. The model was estimated on the log odds scale by using logistic regression as is standard for discrete time survival analysis. Because the log odds scale is difficult to interpret, however, the fitted relations were converted to the probability scale. The change of scaling of the y-axis from log odds to probability creates the apparent curvilinearity. |
| TABLE 2 Association Between MSE According to MPAA Rating and Time to Trying (Hazard of) |
| Smoking |
| Adjusted Hazard Odds Ratio |
| Low |
| MSEa according to movie ratingG/PG-rated PG-13–rated R-rated |
| 0.491.49 1.33 |
| Test |
| Wald testsG/PG versus R and PG-13 G/PG versus PG-13 G/PG versus R PG-13 versus R |
| a |
| 95% CI |
| High |
| 1.091.81 1.57 |
| P |
| the findings of this study and a relatedpublication50 are consistent with this causal interpretation. Our conclusion that it is the smoking in PG-13– and R- rated movies that prompts adolescents to smoke is strengthened theoretically on the parsimonious notion of a social modeling effect and supported by social cognitive theory.51 Our study was not powered to detect a small effect, such as that seen in the unadjusted relation between G/PG-rated MSE and adoles- cent smoking in this study (but it is adequate to rule out an effect similar to that of PG-13–rated movies). It also does not empirically test what might be found if smoking in G/PG movies was in- creased to the point that it was pro- vided similar to exposure in other types of movies. Thus, the study cannot be used as a justification for adding more smoking to G/PG-rated movies. Finally, this study cannot tell us exactly what contextual situations are most problematic, as the study by Shadel et al2 was able to do. |
| With the elimination of image-based to-bacco marking, the epidemic of smoking is maintained, in part, by movie images of smoking. This study suggests that it is the depiction of smoking in movies, not other contextual variables, that matters for the onset of youth smoking. It sug- gests greater emphasis on reducing exposure to smoking in PG-13–rated movies through an unambiguous R rat- ing for smoking52 and less emphasis on images of smoking commonly found in G- and PG-rated movies, which contrib- ute little to exposure. Finally, even if the MPAA agrees to modernize its volun- tary film rating system to eliminate smoking from youth-rated films, youth will still receive some exposure to smoking from R-rated movies, so it is also important to motivate and assist parents in restricting access to these movies, which would further reduce adolescent exposure to onscreen smoking.53–59 |
| 0.221.23 1.13 |
| df |
| 6.5322.55 22.37 0.74 |
| 21 1 1 |
| .038.011 .018 .458 |
| MSE entered as a continuous variable and scaled so that each 1-point increment represents 500 movie smokingoccurrences. |
| experimental study found an effect forsmoking in a PG-13–rated movie.46 These 2 experimental studies, combined with our population-level results, suggest that the explanation is that smoking images delivered by G/PG cartoons and other family-oriented films fail to effectively communicate favorable ex- pectancies or utilities for smoking. Thus, the emphasis afforded to cartoon smok- ing in previous studies47,48 may be mis- placed from a public health standpoint. |
| 234 |
| SARGENT et al |
| This finding also suggests that onlyeliminating smoking from G/PG-rated films would not reduce the effects of smoking in movies on youth smoking; there is little MSE in G/PG-rated films6,49 and what imagery is there is not partic- ularly salient. Thus, the only effective ratings option for the MPAA in limiting the impact of MSE is an R rating for smoking. |
| The causal inference for movie smokingand youth smoking mentioned earlier1 cannot be made from 1 study alone, but |
| Downloaded from pediatrics.aappublications.org by guest on December 8, 2014 |
| ARTICLE |
| REFERENCES |
Services. Preventing Tobacco Use Among
C, Primack BA. Smoking motives in movies
ratings, 2011. Available at: www.mpaa.org/
alcohol, and other risk behaviors in film:
to movies with tobacco imagery is essen-
to movie smoking among US adolescents
Law and Business of the Entertainment
against the adult-rating of movies with
et al. Exposure to movie smoking: its re-
view of the state of the art. Psychol Meth-
mice: Multivariate imputation by chained
Heatherton TF. Population-based assess-
Ahrens MB, Heatherton TF. The incidence |
winsorization on power and type 1 error of
Merritt RK. Validation of susceptibility as
Berry CC. Which adolescent experimenters
tobacco/nicotine dependence in male ever-
Authoritative Parenting Index: predicting
and social competence. Youth Soc. 1978;9
lopment of adolescent alcohol misuse: a six-
style on adolescent competence and sub-
monitoring and adolescent alcohol risk in
monitoring on initiation of drug use
Pomery EA, Brody GH. The impact of par-
ing behaviors and the onset of smoking
Family processes for children in early ele- |
thoritative parenting, child competencies,
its relation to children’s competence and
children’s adjustment in families of young
nen L, Kaprio J, Dick DM. Parenting mech-
enting style and adolescent smoking.
parenting and sensation seeking as pre-
ing in internationally distributed American
winkel R. Using sensation seeking to target
sion for Longitudinal Event Data. Thousand
Data Analysis: Modeling Change and Event
mixture analysis. J Educ Behav Stat. 2005;
Primack BA, Scharf D. Motives for smoking
Exposure to smoking depictions in movies:
et al. Early exposure to movie smoking |
| PEDIATRICS Volume 130, Number 2, August 2012 |
| 235 |
| Downloaded from pediatrics.aappublications.org by guest on December 8, 2014 |
| 41. |
| 42. |
| 43. |
| 44. |
| 45. |
| 46. |
| teens and young adults. Pediatrics. 2009;123(4). Available at: www.pediatrics.org/ cgi/content/full/123/4/e551 Dalton MA, Sargent JD, Beach ML, et al. Ef- fect of viewing smoking in movies on ado- lescent smoking initiation: a cohort study. Lancet. 2003;362(9380):281–285 Titus-Ernstoff L, Dalton MA, Adachi-Mejia AM, Longacre MR, Beach ML. Longitudinal study of viewing smoking in movies and initiation of smoking by children. Pediat- rics. 2008;121(1):15–21 Jackson C, Brown JD, L’Engle KL. R-rated movies, bedroom televisions, and initia- tion of smoking by white and black ado- lescents. Arch Pediatr Adolesc Med. 2007; 161(3):260–268 Tanski SE et al. Moderation of the associ- ation between media exposure and youth smoking onset: Race/ethnicity, and parent smoking. Prev Sci. 2012;13(1):55–63 Lochbuehler K et al. Influence of smoking cues in movies on explicit smoking cogni- tions and implicit associations towards smoking among children. Pediatrics. 2012; 130(2):XXXX Pechmann C, Shih CF. Smoking scenes in movies and antismoking advertisements |
| 47. |
| 48. |
| 49. |
| 50. |
| 51. |
| 52. |
| 53. |
| before movies: effects on youth. J Mark.1999;63(3):1–13 Goldstein AO, Sobel RA, Newman GR. Tobacco and alcohol use in G-rated children’s ani- mated films. JAMA. 1999;281(12):1131–1136 Thompson KM, Yokota F. Depiction of alco- hol, tobacco, and other substances in G- rated animated feature films. Pediatrics. 2001;107(6):1369–1374 Polansky GS Jr. First-Run Smoking Pre- sentations in U.S. Movies 1999–2006. San Francisco CA: Center for Tobacco Control Research and Education; 2007 Dal Cin S, Stoolmiller M, Sargent JD. When Movies Matter: Exposure to Smoking in Movies and Changes in Smoking Behavior. J Health Commun. 2011;17(1):76–84 Bandura A. Social Foundations of Thought and Action. A Social Cognitive Theory. Eng- lewood Cliffs, NJ: Prentice Hall; 1986 Glantz SA. Smoking in movies: a major problem and a real solution. Lancet. 2003; 362(9380):258–259 Dalton MA, Adachi-Mejia AM, Longacre MR, et al. Parental rules and monitoring of children’s movie viewing associated with children’s risk for smoking and drinking. Pediatrics. 2006;118(5):1932–1942 |
Relation between parental restrictions
DiFranza JR. R-rated film viewing and ado-
fect of parental R-rated movie restriction on
Worth KA, Gibbons FX. R-rated movie view-
early-onset alcohol use. J Stud Alcohol
Scholte RH, Engels RC, Tanski SE. Association |
Trackbacks & Pingbacks
… [Trackback]
[…] Read More on on that Topic: uselitetutors.com/2018/10/22/effects-of-smoking-scenes-in-movies/ […]
Leave a Reply
Want to join the discussion?Feel free to contribute!