Madeline A. Dalton

Effect of viewing smoking in movies on adolescent smoking initiation: A cohort study.

BACKGROUND Exposure to smoking in movies has been linked with adolescent smoking initiation in cross-sectional studies. We undertook a prospective study to ascertain whether exposure to smoking in movies predicts smoking initiation. METHOD We assessed exposure to smoking shown in movies in 3547 adolescents, aged 10-14 years, who reported in a baseline survey that they had never tried smoking. Exposure to smoking in movies was estimated for individual respondents on the basis of the number of smoking occurrences viewed in unique samples of 50 movies, which were randomly selected from a larger sample pool of popular contemporary movies. We successfully re-contacted 2603 (73%) students 13-26 months later for a follow-up interview to determine whether they had initiated smoking. FINDINGS Overall, 10% (n=259) of students initiated smoking during the follow-up period. In the highest quartile of exposure to movie smoking, 17% (107) of students had initiated smoking, compared with only 3% (22) in the lowest quartile. After controlling for baseline characteristics, adolescents in the highest quartile of exposure to movie smoking were 2.71 (95% CI 1.73-4.25) times more likely to initiate smoking compared with those in the lowest quartile. The effect of exposure to movie smoking was stronger in adolescents with non-smoking parents than in those whose parent smoked. In this cohort, 52.2% (30.0-67.3) of smoking initiation can be attributed to exposure to smoking in movies. INTERPRETATION Our results provide strong evidence that viewing smoking in movies promotes smoking initiation among adolescents.

Exposure to Movie Smoking: Its Relation to Smoking Initiation Among US Adolescents

Objective. Regional studies have linked exposure to movie smoking with adolescent smoking. We examined this association in a representative US sample. Design/Methods. We conducted a random-digit-dial survey of 6522 US adolescents aged 10 to 14 years. Using previously validated methods, we estimated exposure to movie smoking, in 532 recent box-office hits, and examined its relation with adolescents having ever tried smoking a cigarette. Results. The distributions of demographics and census region in the unweighted sample were almost identical to 2000 US Census estimates, confirming representativeness. Overall, 10% of the population had tried smoking. Quartile (Q) of movie smoking exposure was significantly associated with the prevalence of smoking initiation: 0.02 of adolescents in Q1 had tried smoking; 0.06 in Q2; 0.11 in Q3; and 0.22 in Q4. This association did not differ significantly by race/ethnicity or census region. After controlling for sociodemographics, friend/sibling/parent smoking, school performance, personality characteristics, and parenting style, the adjusted odds ratio for having tried smoking were 1.7 (95% confidence interval [CI]: 1.1, 2.7) for Q2, 1.8 (95% CI: 1.2, 2.9) for Q3, and 2.6 (95% CI: 1.7, 4.1) for Q4 compared with adolescents in Q1. The covariate-adjusted attributable fraction was 0.38 (95% CI: 0.20, 0.56), suggesting that exposure to movie smoking is the primary independent risk factor for smoking initiation in US adolescents in this age group. Conclusions. Smoking in movies is a risk factor for smoking initiation among US adolescents. Limiting exposure of young adolescents to movie smoking could have important public health implications.

Viewing tobacco use in movies: does it shape attitudes that mediate adolescent smoking?

BACKGROUND Social cognitive theory posits that children develop intentions and positive expectations (utilities) about smoking prior to initiation. These attitudes and values result, in part, from observing others modeling the behavior. This study examines, for the first time, the association between viewing tobacco use in movies and attitudes toward smoking among children who have never smoked a cigarette. DESIGN/SETTING Cross-sectional school-based survey was used among randomly selected Vermont and New Hampshire middle schools. The sample consisted of 3766 middle school students (grades 5-8). The sample was primarily white and equally distributed by gender. The primary exposure was number of movie tobacco-use occurrences viewed. We first counted occurrences of tobacco use in each of 601 recent popular motion pictures. Each student was asked to select movies they had seen from a random subset of 50 movies. Based on movies the adolescent had seen, movie tobacco-use occurrences were summed to determine exposure . The outcome was susceptibility to smoking, positive expectations, and perceptions of smoking as normative behavior for adolescents or adults. RESULTS The movies in this sample contained a median of five occurrences of tobacco use (interquartile range=1, 12). The typical adolescent never-smoker had viewed 15 of the 50 movies on his/her list. From movies adolescents reported seeing, exposure to movie tobacco-use occurrences varied widely: median=80, and interquartile range 44 to 136. The prevalence of susceptibility to smoking increased with higher categories of exposure: 16% among students who viewed 0 to 50 movie tobacco occurrences; 21% (51 to 100); 28% (101 to 150); and 36% (>150). The association remained statistically significant after controlling for gender, grade in school, school performance, school, friend, sibling and parent smoking, sensation-seeking, rebelliousness, and self-esteem. Compared with adolescents exposed to < or =50 occurrences of tobacco use, the adjusted odds ratio of susceptibility to smoking for each higher category was 1.2 (95% confidence interval 0.9, 1.5), 1.4 (1.1, 1.9), and 1.6 (1.3, 2.1), respectively. Similarly, higher exposure to tobacco use in movies significantly increased the number of positive expectations endorsed by the adolescent and the perception that most adults smoke, but not the perception that most peers smoke. CONCLUSIONS This study provides empirical evidence that viewing movie depictions of tobacco use is associated with higher receptivity to smoking prior to trying the behavior.

Brand appearances in contemporary cinema films and contribution to global marketing of cigarettes.

BACKGROUND The appearance of a cigarette brand in a cinema film gives the brand a certain distinction through its association with the characters and general tone of the film. Through the worldwide distribution of films, brands are promoted globally. We assessed the tobacco-brand appearances in a 10-year sample of contemporary films. METHODS We viewed the contents of the top 25 US box-office films for each year of release, from 1988 to 1997 (250 films in total). We compared the prevalence of brand appearances for films produced before a voluntary ban on paid product placement by the tobacco industry (1988-90) with films produced after the ban (1991-97). Tobacco-brand appearance was defined as the screen appearance of a brand name, logo, or identifiable trademark on products or product packaging, billboards, store-front advertising, or tobacco promotional items. We defined actor endorsement of a brand as the display of a brand while being handled or used by an actor. FINDINGS More than 85% of the films contained tobacco use. Tobacco brands appeared in 70 (28%) films. Brand appearances were as common in films suitable for adolescent audiences as they were in films for adult audiences (32 vs 35%), and were also present in 20% of those rated for children. Prevalence of brand appearance did not change overall in relation to the ban. However, there was a striking increase in the type of brand appearance depicted, with actor endorsement increasing from 1% of films before the ban to 11% after. Four US cigarette brands accounted for 80% of brand appearances. Revenues outside the USA accounted for 49% of total revenues for these films, indicating a large international audience. INTERPRETATION Tobacco-brand appearances are common in films and are becoming increasingly endorsed by actors. The most highly advertised US cigarette brands account for most brand appearances, which suggests an advertising motive to this practice.

Longitudinal Study of Viewing Smoking in Movies and Initiation of Smoking by Children

BACKGROUND. Previous studies showed an association between viewing of smoking in movies and initiation of smoking among adolescents. However, all studies except one were cross-sectional, and none updated movie smoking exposure prospectively or assessed its influence on children. METHODS. We enrolled elementary school students, 9 to 12 years of age, in a longitudinal study to assess the influence of movie smoking exposure on smoking initiation among children. Movie smoking content was coded for the most popular movie releases; exposure was assessed by asking children which movies they had seen, on the basis of unique lists of 50 movies sampled randomly from top box office hits and video rentals. Data collection occurred in 3 waves (the baseline survey and 2 follow-up surveys), ∼1 year apart. Movie lists were updated for each data collection wave, to reflect recent releases. Movie smoking exposure was analyzed in relation to smoking initiation by the end of the study period. RESULTS. Approximately 80% of the childrens smoking exposure occurred through movies rated G, PG, or PG-13. Childrens movie smoking exposure predicted smoking initiation significantly, after adjustment for multiple covariates including child and parent characteristics. The relative risks were 1.09, 1.09, and 1.07 for a 1-decile increase of movie smoking exposure measured at the baseline, second, and third data collection waves, respectively. The adjusted attributable risk of smoking initiation attributable to movie smoking exposure was 0.35. CONCLUSION. Our study, which is the first to enroll children in elementary school and to update movie smoking exposure longitudinally, indicates that early exposure has as much influence on smoking risk as does exposure nearer the outcome. Overall, movie smoking may be responsible for at least one third of smoking initiation for children in this age group.

Children with a TV in their bedroom at higher risk for being overweight

Objective:We examined having a TV in the bedroom as a risk factor for child overweight.Design:Cross-sectional study.Setting:School- and telephone-based surveys in New Hampshire and Vermont between 2002 and 2004.Participants:Two thousand three hundred and forty-three children enrolled in public schools, aged 9–12 years, and one of their parents.Main exposures:The child having a TV in the bedroom.Main outcome measures:Age- and gender-standardized child body mass index (zBMI). Overweight was defined as equal to or above the 95th percentile for zBMI.Results:Overall, 22.3% (N=523) of the children were overweight, and almost half of all children (48.2%, N=1130) had a TV in their bedroom. Children with a TV in their bedroom had a higher zBMI and were significantly more likely to be overweight compared to those without a TV in their bedroom (27.3 versus 17.7%, respectively; P<0.05). After controlling for sociodemographics, physical activity, frequency of TV or movie watching and internet use, children with a TV in their bedroom who watched at least one session of TV or movies per day were more likely to be overweight compared to those without a TV in their bedroom (odds ratio=1.32, 95% confidence interval: 1.03, 1.70).Conclusions:Having a TV in the bedroom is a risk factor for child overweight, independent of reported physical activity, participation in team sports, TV or movie watching time and internet use at home. Further study is needed to fully understand the mechanism by which having a TV in the bedroom increases childrens risk for overweight.

Content Analysis of Tobacco, Alcohol, and Other Drugs in Popular Music

OBJECTIVE To perform a comprehensive content analysis of substance use in contemporary popular music. DESIGN We analyzed the 279 most popular songs of 2005 according to Billboard magazine. Two coders working independently used a standardized data collection instrument to code portrayals of substance use. OUTCOME MEASURES Presence and explicit use of substances and motivations for, associations with, and consequences of substance use. RESULTS Of the 279 songs, 93 (33.3%) portrayed substance use, with an average of 35.2 substance references per song-hour. Portrayal of substance use varied significantly (P < .001) by genre, with 1 or more references in 3 of 35 pop songs (9%), 9 of 66 rock songs (14%), 11 of 55 R & B/hip-hop songs (20%), 22 of 61 country songs (36%), and 48 of 62 rap songs (77%). While only 2.9% of the 279 songs portrayed tobacco use, 23.7% depicted alcohol use, 13.6% depicted marijuana use, and 11.5% depicted other or unspecified substance use. In the 93 songs with substance use, it was most often motivated by peer/social pressure (45 [48%]) or sex (28 [30%]); use was commonly associated with partying (50 [54%]), sex (43 [46%]), violence (27 [29%]), and/or humor (22 [24%]). Only 4 songs (4%) contained explicit antiuse messages, and none portrayed substance refusal. Most songs with substance use (63 [68%]) portrayed more positive than negative consequences; these positive consequences were most commonly social, sexual, financial, or emotional. CONCLUSIONS The average adolescent is exposed to approximately 84 references to explicit substance use daily in popular songs, and this exposure varies widely by musical genre. The substance use depicted in popular music is frequently motivated by peer acceptance and sex, and it has highly positive associations and consequences.

Parental Rules and Monitoring of Children’s Movie Viewing Associated With Children’s Risk for Smoking and Drinking

OBJECTIVES. Evidence suggests that media portrayals of tobacco and alcohol use are important predictors of adolescent smoking and drinking. We examined the role of parents in monitoring and limiting children’s movie exposure and whether or not this was associated with a lower risk of adolescent smoking and drinking. DESIGN. We surveyed 2606 child-parent dyads between 2002 and 2003. We asked children (9–12 years of age) how often their parents engaged in specific behaviors to monitor their movie viewing and if their parents allowed them to watch R-rated movies. We also surveyed children about parental monitoring of nonmedia-related behaviors. The primary outcomes were risk of smoking and drinking alcohol, defined by attitudinal susceptibility or early experimentation with either substance. RESULTS. Less than half (45.0%) the children were prohibited from watching R-rated movies. Of those who were allowed to watch R-rated movies, one third (34.7%) always viewed them with a parent and two thirds (65.3%) sometimes watched them without a parent. Less than 10% of the children reported that their parents consistently engaged in all 4 movie-monitoring behaviors. Even after controlling for parental monitoring of nonmedia-related behaviors and other covariates, children were at lower risk of smoking and drinking if their parents prohibited them from watching R-rated movies. Parental coviewing of R-rated movies was associated with a lower risk of child smoking but not drinking if parents consistently monitored what their children watched. CONCLUSIONS. Parental rules and monitoring of children’s movie viewing may have a protective influence on children’s risk for smoking and drinking, over and above parental monitoring of nonmedia related behaviors. This highlights a potential role for parents in preventing early initiation of tobacco and alcohol use among adolescents.

Exposure to cigarette promotions and smoking uptake in adolescents: evidence of a dose-response relation

OBJECTIVE To assess whether a dose-response relation exists between the number of cigarette promotional items (CPIs) owned by an adolescent, and smoking behaviour. DESIGN AND SETTING Voluntary, self administered survey of 1265 sixth through to 12th grade students (ages 10–19 years), representing 79–95% of all students attending five rural New Hampshire and Vermont public (state funded) schools in October 1996. The association between the number of CPIs owned by students and smoking behaviour was examined using multivariate regression methods. OUTCOME MEASURES Adjusted odds of being a smoker (⩾ 100 cigarettes lifetime) and, among never and experimental smokers, adjusted cumulative odds of having higher levels on a smoking uptake index given the number of CPIs owned. RESULTS One third of students owned a CPI (n = 406). Among owners, 211 owned one, 82 owned two, 57 owned three, 24 owned four, 23 owned five, and 7 students owned six CPIs. The number of CPIs owned by students was not associated with grade in school but was significantly higher in males, those with poorer school performance, those who perceived high prevalence of peer smoking, and those with higher exposure to peer and family smoking. The more items a student owned, the greater the chances of being a smoker. For example, smoking prevalence was 11.2% for those not owning a CPI, 41.5% for those owning two, 58.5% for those owning four, and 71.4% for those owning six CPIs. The dose-response relation remained after controlling for confounding; compared with those who did not own a CPI, the likelihood of being a smoker was significantly higher for those who owned one CPI, with an adjusted odds ratio (OR) of 2.7 (95% confidence interval (CI) 1.7 to 4.1); OR was 3.4 (95% CI 1.9 to 5.9) for those owning two CPIs, and 8.4 (95% CI 5.0 to 14.2) for those owning three or more CPIs. After excluding smokers, there was a crude dose-response association between CPI ownership and higher rates of experimentation with cigarettes among sixth to ninth graders (ages 11–15 years) only (n = 543). After controlling for confounding influences, the dose-response relation remained, with the likelihood of being higher on the smoking uptake index rising with the number of CPIs owned: one CPI, adjusted cumulative OR 1.7 (95% CI 1.1 to 2.60); two CPIs, OR 2.5 (95% CI 1.2 to 5.1); and three or more CPIs, OR 4.8 (95% CI 1.9 to 12.2). CONCLUSIONS This study offers evidence of a dose-response relation between the number of CPIs owned by adolescents and higher likelihood of experimental and established smoking. The dose-response relation persists after controlling for confounding influences. These data provide further support of a causal relation between tobacco promotional campaigns and smoking behaviour among adolescents.

Early exposure to movie smoking predicts established smoking by older teens and young adults.

OBJECTIVE. Movie smoking exposure is a strong predictor of smoking initiation by adolescents; however, we do not know whether it is a long-term predictor of established smoking. We conducted a prospective study to determine whether movie smoking exposure during early adolescence predicts established smoking in older teens and young adults. DESIGN. We assessed movie smoking exposure and smoking status through a written school-based survey in 1999, when participants were 10 to 14 years of age. We enrolled 73% (n = 2603) of those who had never tried smoking in a follow-up study. In 2006–2007, we conducted telephone interviews with 69% (n = 1791) of the cohort to ascertain current smoking status. The primary outcome was established smoking, defined as having smoked >100 cigarettes. Mean age at follow-up was 18.7 years. RESULTS. Thirteen percent (n = 235) progressed from never smoking to established smoking during the follow-up period. Eighty-nine percent (n = 209) of established smokers smoked during the 30 days before the survey. Even after controlling for a wide range of baseline characteristics, the relative risk for established smoking increased by one third with each successive quartile of movie smoking exposure. Those in the highest quartile for baseline movie smoking exposure were twice as likely to be established smokers at follow-up compared with those in the lowest quartile. CONCLUSIONS. Movie smoking exposure significantly predicted progression to established smoking in long-term follow-up. We estimate that 34.9% of established smoking in this cohort can be attributed to movie smoking exposure.