Smoking in movies and increased smoking among young adults.

This study assessed whether smoking in the movies was associated with smoking in young adults.



A national web-enabled cross-sectional survey of 1528 young adults, aged 18-25, was performed between September and November 2005. Logistic regression and path analysis using probit regression were used to assess relationships between exposure to smoking in the movies and smoking behavior. Analysis was completed in December 2006.



Exposure to smoking in the movies predicted current smoking. The adjusted odds of current smoking increased by a factor of 1.21 for each quartile increase in exposure to smoking (p<0.01) in the movies, reaching 1.77 for the top exposure quartile. The unadjusted odds of established smoking (100+ cigarettes with current smoking) increased by 1.23 per quartile (p<0.001) of exposure, reaching 1.86 for the top quartile. This effect on established smoking was mediated by two factors related to smoking in the movies: positive expectations about smoking and exposure to friends and relatives who smoked, with positive expectations accounting for about two thirds of the effect.



The association between smoking in the movies and young adult smoking behavior exhibited a dose-response relationship; the more a young adult was exposed to smoking in the movies, the more likely he or she would have smoked in the past 30 days or have become an established smoker.

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title: Smoking in movies in 2000 exceeded rates in the 1960s
abstract: Smoking in movies has been linked to increased smoking among teens.1-5 We have previously published data from 1960 through 1997 that shows that smoking fell from the 1960s through the 1980s, then increased during the 1990s.6 7 We have used similar methods (analysis of a random …

title: Back to the future: Smoking in movies in 2002 compared with 1950 levels.
abstract: We reviewed smoking shown in a random sample of major motion pictures from 1950 through 2002. Smoking incidents declined from 10.7 incidents per hour in 1950 to a minimum of 4.9 in 1980-1982 but increased to 10.9 in 2002. Despite declining tobacco use and increasing public understanding of the dangers of smoking in the real world, smoking in movies has returned to levels observed in 1950, when smoking was nearly twice as prevalent in reality as it was in 2002.

title: Smoking in the Movies Increases Adolescent Smoking: A Review
abstract: Despite voluntary restrictions prohibiting direct and indirect cigarette marketing to youth and paid product placement, tobacco use remains prevalent in movies. This article presents a systematic review of the evidence on the nature and effect of smoking in the movies on adolescents (and others).  We performed a comprehensive literature review.  We identified 40 studies. Smoking in the movies decreased from 1950 to ∼1990 and then increased rapidly. In 2002, smoking in movies was as common as it was in 1950. Movies rarely depict the negative health outcomes associated with smoking and contribute to increased perceptions of smoking prevalence and the benefits of smoking. Movie smoking is presented as adult behavior. Exposure to movie smoking makes viewers' attitudes and beliefs about smoking and smokers more favorable and has a dose-response relationship with adolescent smoking behavior. Parental restrictions on R-rated movies significantly reduces youth exposure to movie smoking and subsequent smoking uptake. Beginning in 2002, the total amount of smoking in movies was greater in youth-rated (G/PG/PG-13) films than adult-rated (R) films, significantly increasing adolescent exposure to movie smoking. Viewing antismoking advertisements before viewing movie smoking seems to blunt the stimulating effects of movie smoking on adolescent smoking.  Strong empirical evidence indicates that smoking in movies increases adolescent smoking initiation. Amending the movie-rating system to rate movies containing smoking as “R” should reduce adolescent exposure to smoking and subsequent smoking.

title: Smoking Scenes in Movies and Antismoking Advertisements before Movies: Effects on Youth
abstract: In two experiments, the authors test rival theses regarding the effects of smoking in feature films on youths and the ability of antismoking advertising to nullify those effects. Eight hundred ninth graders watched either original movie footage with smoking or control footage with the smoking edited out. Emotional reactions were recorded during viewing, and smoking-related thoughts, beliefs, and intent were assessed afterward. The findings support the Forbidden Fruit thesis, in that smoking (versus nonsmoking) scenes positively aroused the young viewers, enhanced their perceptions of smokers’ social stature, and increased their intent to smoke. However, youths’ opinions were malleable, and showing them an antismoking advertisement before the film effectively repositioned the smoking from forbidden to tainted, thereby nullifying the aforementioned effects. No support was obtained for the Excitation Transfer theory, which predicts that the positive arousal evoked by movie scenes would transfer to smokers who were depicted in those scenes. The authors discuss policy implications for film content and antismoking advertising.

title: Exposure to Movie Smoking: Its Relation to Smoking Initiation Among US Adolescents
abstract: Regional studies have linked exposure to movie smoking with adolescent smoking. We examined this association in a representative US sample.  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.  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.  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.

title: Smoking in movies: impact on adolescent smoking.
abstract: This article examines the evidence that supports an association between seeing smoking depictions in movies and adolescent smoking. The portrayal of tobacco use is common in movies and often is modeled by stars, who, from a social influences standpoint, should be powerful behavior change agents. The results of studies that assess audience responses to tobacco portrayal in movies are remarkably consistent in showing a moderate to strong association between seeing movie smoking and more positive attitudes toward smoking and adolescent smoking initiation. The two published longitudinal studies show an independent link between exposure to movie smoking at baseline and initiation in the future, with estimates of the effect size being remarkably consistent with their cross-sectional counterparts. Pediatricians should support public health campaigns to pressure the movie industry to voluntarily reduce smoking in movies and encourage parents to adhere to the Motion Picture Ratings System to reduce adolescent exposure to this powerful social influence to smoke.

title: Effect of viewing smoking in movies on adolescent smoking initiation: a cohort study
abstract: 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.



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.



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.



Our results provide strong evidence that viewing smoking in movies promotes smoking initiation among adolescents.

title: How many adolescents start smoking each day in the United States?
abstract: To provide daily estimates of first experimentation and attainment of established smoking in adolescents 11-17 years of age.



The 1989 and 1993 Teenage Attitudes and Practices Surveys (TAPS) (16,954 observations) was used to estimate rates in 1991 for: (a) first experimentation (even a few puffs), and (b) established smoking (reaching a lifetime level of at least 100 cigarettes). The 1992 and 1993 Current Population Surveys (CPS) (82,279 adults) allowed calculation of year-specific initiation rates (1980-1989) from the age respondents reported as having started smoking "fairly regularly." Rates were applied to Census data for the appropriate years to yield numbers accruing each day. Estimates were calculated for adolescents (11- to 17-year-olds) and youth (11- to 20-year-olds).



For TAPS, in 1991, 4824 adolescents first tried cigarettes and 1975 became established smokers each day. Considering all youth, these estimates increase to 5497/day for first experimentation and to 2933/day for established smokers. For CPS, from 1980 to 1989, around 2300 adolescents initiated fairly regular smoking each day. For all youth, the estimate has increased to about 3400/day.



Because approximately 4800 adolescents and 5500 youth appear to be experimenting with cigarettes for the first time each day, and close to 3000 youth become established smokers daily, increased prevention efforts are clearly justified.

title: A historical analysis of tobacco marketing and the uptake of smoking by youth in the United States: 1890-1977.
abstract: This article presents evidence for sex-specific temporal associations between major cigarette marketing campaigns and increases in youth smoking initiation using national survey data for 1910-1977 (N = 165,876). Considerable smoking initiation occurred in males under 18 and born before 1890 when marketing focused only on males. Initiation in male youth increased greatly during 1910-1919; in 1912, R.J. Reynolds launched its unprecedented campaign for Camel brand. Initiation in female youth began in the mid-1920s, coincident with the Chesterfield and Lucky Strike women's marketing campaigns. In the late 1960s, smoking uptake among young females again increased rapidly, coincident with large-scale marketing of women's brands. Male initiation did not increase with these campaigns. Thus, in each instance, major marketing impact occurred in youth smoking initiation only in the sex group targeted.

title: Validation of susceptibility as a predictor of which adolescents take up smoking in the United States.
abstract: Smoking onset has 4 levels, with a "susceptibility" level preceding early experimentation. This study assessed the predictive validity of smoking susceptibility in a longitudinal study of a nationally representative sample of 4,500 adolescents who at baseline reported never having puffed on a cigarette. At follow-up 4 years later, 40% of the sample had experimented with smoking, and 8% had established a smoking habit. Baseline susceptibility to smoking, defined as the absence of a firm decision not to smoke, was a stronger independent predictor of experimentation than the presence of smokers among either family or the best friend network. However, susceptibility to smoking was not as important as exposure to smokers in distinguishing adolescents who progressed to established smoking from those who remained experimenters at follow-up.

title: The role of curiosity in smoking initiation.
abstract: Although advertising theories have long viewed curiosity as an intermediate goal to encouraging consumption of a product among previous nonusers, this variable is rarely discussed in psychological theories and its role in smoking uptake has not been addressed adequately.



Using a longitudinal design, in 1999, we reinterviewed 12- to 15-year-old adolescent never smokers (N=2119; 970 committed never smokers, 1199 susceptible never smokers) 3 years after they responded to a population survey on tobacco use in California.



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title: Effect of seeing tobacco use in films on trying smoking among adolescents: cross sectional study
abstract: To test the hypothesis that greater exposure to smoking in films is associated with trying smoking among adolescents.  Cross sectional survey of 4919 schoolchildren aged 9–15 years, and assessment of occurrence of smoking in 601 films.  Randomly selected middle schools in Vermont and New Hampshire, USA.  Number of schoolchildren who had ever tried smoking a cigarette.  The films contained a median of 5 (interquartile range 1-12) occurrences of smoking. The typical adolescent had seen 17 of 50 films listed. Exposure to smoking in films varied widely: median 91 (49–152) occurrences. The prevalence of ever trying smoking increased with higher categories of exposure: 4.9% among students who saw 0–50 occurrences of smoking, 13.7% for 51–100 occurrences, 22.1% for 101-150, and 31.3% for >150. The association remained significant after adjustment for age; sex; school performance; school; parents' education; smoking by friend, sibling, or parent; and receptivity to tobacco promotions. The adjusted odds ratios of ever trying smoking for students in the higher categories of exposure, compared with students exposed to 0–50 occurrences of smoking in films, were 1.7 (95% confidence interval 1.2 to 2.4), 2.4 (1.7 to 3.4), and 2.7 (2.0 to 3.8). These odds ratios were not substantially affected by adjustment for parenting style or for personality traits of the adolescent.  In this sample of adolescents there was a strong, direct, and independent association between seeing tobacco use in films and trying cigarettes, a finding that supports the hypothesis that smoking in films has a role in the initiation of smoking in adolescents. What is already known on this topic Smoking is often depicted in films, and watching films is a favourite activity of adolescents Adolescents whose favourite actors smoke in films are more likely to have tried smoking What this study adds Adolescents' exposure to smoking in films varies widely Adolescents with higher exposure are significantly more likely to have tried smoking, even when other factors linked with adolescent smoking have been taken into account This study supports the hypothesis that depictions of smoking in films influence adolescents to smoke

title: Do the majority of Asian-American and African-American smokers start as adults?
abstract: Identifying ethnic differences in the age of smoking onset from nationally representative data can lead to improved targeted prevention programs and policies to combat smoking in ethnic communities.



Analyzing data from the Tobacco Use Supplements of the U.S. Census Bureau's Current Population Surveys throughout the 1990s, differences in the age of regular smoking onset among Asians/Pacific Islanders (A/PI), African Americans (AA), Hispanics/Latinos (H/L) and non-Hispanic whites (WH) are reported. Data on people aged 26 to 50 years at the time of the survey interview (n =130,356; mean age=38.4 years; 47.9% male; 1.9% A/PI, 7.8% AA, 5.2% H/L, and 85.1% WH) were examined.



Results indicate significant ethnic disparities in when people start smoking, among A/PIs in particular, and AAs and H/Ls to a lesser degree, who initiate regular smoking at later ages than do WHs. The majority of A/PIs and AAs initiated smoking as young adults, with almost half (47.8%) of A/PIs who were ever regular smokers starting between ages 18 and 21, compared with 39.8% of AAs, 37.5% of H/Ls, and 36.7% of WHs.



These findings indicate significant ethnic disparities in relation to when people start smoking, with the majority of A/PIs and AAs initiating as young adults. The findings suggest that prevention strategies should begin at a young age and continue throughout young adulthood, especially among ethnic minority populations. Further consideration of the different influences on later initiation in ethnic minorities may lead to suggestions to improve current smoking-prevention programs aimed at adolescents and young adults.

title: What fraction of young adults are at risk for future smoking, and who are they?
abstract: Recent evidence indicates that higher smoking rates among young adults in the United States may be related in part to increased initiation during young adulthood. The tobacco industry, restricted from overtly targeting adolescents, appears to be focusing on young adults. Thus it is important to estimate the percentage and identify the characteristics of the young adult population (aged 18-29 years) at risk for future smoking. This group would include all current established smokers (smoked at least 100 cigarettes in their lifetime), current experimenters, former established smokers, and former experimenters at risk for smoking again, as well as never-smokers who do not rule out future smoking. Using data from the population-based 2002 California Tobacco Survey (N = 9,364 young adults aged 18-29 years), we designated groups of young adults at risk and identified factors associated with risk. Altogether, 86.7+/-1.5% of current and former established smokers were at risk for future smoking, and 59.6+/-4.3% of former established smokers were at risk. Over half (52.2+/-2.0%) of all experimenters but only 9.0+/-1.2% of never-smokers were at risk. Overall, 43.0+/-1.2% of the young adult population was at risk. Although different demographic and other factors were associated with risk among former established smokers, experimenters, and never-smokers, three factors were consistently associated in each group: Younger age, not having a smoke-free home, and going to bars and clubs. We conclude that the group of young adults at risk for future smoking is sizable and presents a fertile target for tobacco industry efforts to promote smoking. Counter-efforts might include promotion of smoke-free environments.

title: Tobacco Control Successes in California: A Focus on Young People, Results from the California Tobacco Surveys, 1990-2002
abstract: Executive Summary The California Tobacco Surveys (CTS), along with other data sources, have helped document the progress and success of over a decade of tobacco control efforts in California. Some of the most important findings are highlighted below, with reference to Selected Key Findings (KF) appearing on the following pages that provide more detail. Since young people are the focus of this report, findings pertaining to adolescents and young adults are presented first.

title: The incidence and context of tobacco use in popular movies from 1988 to 1997.
abstract: The aim of this study was to describe tobacco use in a large representative sample of movies.



We analyzed the content of the top 25 box office hits per year from 1988 to 1997. Outcomes included the number of occurrences of tobacco use, the time tobacco use appeared on screen, the context in which tobacco use was portrayed, and characteristics of smokers compared with nonsmokers.



Eighty-seven percent of the movies portrayed tobacco use, with a median of 5 occurrences per film. Tobacco use was not related to year of release or box office success of the movie. R-rated movies had the greatest number of occurrences (median = 8.5; P < 0.05) and were most likely to feature major characters using tobacco (81%, P < 0.001). Among major characters, males were more likely to use tobacco than females (28% vs 17%, P < 0.001), but there was no difference in the prevalence of tobacco use by age, race, or socioeconomic status. Tobacco users were typically adults (96.3%) who were more likely to engage in a variety of other risk behaviors. Most tobacco use involved cigarettes or cigars (89.5%). Motivations for on-screen smoking included agitation (20.1%), sadness (5.1%), happiness (15.3%), and relaxation (17.1%). Characters were often shown smoking while confiding in others (30.7%) or in social/celebratory situations (18.0%). Negative reactions to tobacco use were rarely shown (5.9%) and negative consequences resulting from tobacco use were depicted for only 3.4% of the major characters who used tobacco.



Despite increasing anti-smoking sentiments in our society, negative reactions to smoking are rare and there is no evidence that tobacco use in movies has declined over the past decade. Movies continue to model smoking as a socially acceptable behavior and portray it as both a way to relieve tension and something to do while socializing. By depicting positive images of tobacco use, movies have the potential to influence adolescent smoking behavior as much as any other environmental exposure, such as family or friend smoking.

title: A retrieval model for both recognition and recall.
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title: Relation between parental restrictions on movies and adolescent use of tobacco and alcohol.
abstract: Viewing smoking and drinking in movies may prompt adolescents to initiate these behaviors. Movies with R ratings contain more smoking than do movies in all other rating categories.



To evaluate the extent to which parents restrict the exposure of adolescents to R-rated movies and to determine whether such restrictions are associated with decreased tobacco and alcohol use in adolescents.



Cross-sectional, self-administered survey.



Students in grades 5 through 8 enrolled in New Hampshire and Vermont schools.  Fifteen schools in Vermont and New Hampshire were randomly selected from all middle schools with > or = 150 students.



Students who had tried smoking cigarettes or tried drinking alcohol without parental knowledge.



Of 4544 students surveyed, 18% had tried cigarettes and 23% had tried alcohol. Although 90% were younger than 14 years of age, only 16% were completely restricted from viewing R-rated movies. The prevalence of having tried smoking was 35% for those with no restrictions on viewing R-rated movies, 12% for those with partial restrictions, and 2% for those with complete restrictions. The prevalence of having tried alcohol was 46% for those with no restrictions on viewing R-rated movies, 16% for those with partial restrictions, and 4% for those with complete restrictions. Even after controlling for other factors, including grade, parental disapproval of smoking, maternal supervision, maternal responsiveness, peer and family smoking, and child personality characteristics, children who were completely restricted from viewing R-rated movies were significantly less likely to smoke (relative risk, 0.29; 95% CI, 0.19 to 0.45) or drink (relative risk, 0.30; CI, 0.21 to 0.42) compared with those who had no restrictions on viewing R-rated movies.



Limiting the exposure of adolescents to R-rated movies may prevent early use of alcohol and tobacco.

title: Population Receptivity to Tobacco Advertising/ Promotions and Exposure to Anti-Tobacco Media: Effect of Master Settlement Agreement in California: 1992-2002
abstract: Tobacco marketing contributes to adolescent smoking initiation, and the Master Settlement Agreement (MSA), therefore, included relevant restrictions. We analyzed data from large population surveys of Californians, conducted in 1992 (11,905 adults, ages 18 years and older), 1993 (5,531 adolescents, ages 12 to 17 years), and 1996 (6,252 adolescents, 18,616 adults) before the MSA, and in 1999 (6,090 adolescents, 14,729 adults) and 2002 (5,857 adolescents, 20,525 adults) following its implementation. Camel lost favorite-advertisement popularity after 1996, and between 1999 and 2002, there were large increases in the percentages declining to name a favorite advertisement. Ownership of tobacco promotional items declined from its peak in 1996. Furthermore, in 2002, close to 90% of adolescents and young adults reported seeing anti-tobacco messages on television in the past month, significantly higher than 1996. These trends indicate less receptivity to tobacco advertising and promotions following the MSA but leave room for additional restrictions to further reduce receptivity.

title: Sharing the blame: smoking experimentation and future smoking-attributable mortality due to Joe Camel and Marlboro advertising and promotions
abstract: Despite public denials, internal tobacco company documents indicate that adolescents have long been the target of cigarette advertising and promotional activities. Recent longitudinal evidence suggests that 34% of new experimentation occurs because of advertising and promotions.  To apportion responsibility for smoking experimentation and future smoking-attributable mortality among major cigarette brands attractive to young people (Camel and Marlboro).  Data were from confirmed never-smoking adolescents (12–17 years old) responding to the 1993 (n = 2659) and 1996 (n = 2779) population-based California Tobacco Surveys.  Adolescents named the brand of their favourite cigarette advertisements and tobacco promotional items. Using these “market shares” and the relative importance of advertising and promotions in encouraging smoking, we estimated how many new experimenters from 1988 to 1998 in the United States can be attributed to Camel and Marlboro. From other data on the natural history of smoking, we projected how many future deaths in the United States can be attributed to each brand.  Although Camel advertisements were favoured more than Marlboro and other brands in 1993 and 1996, the “market share” for promotional items shifted markedly during this period from Camel and other brands towards Marlboro. We estimated that between 1988 and 1998, there will be 7.9 million new experimenters because of tobacco advertising and promotions. This will result in 4.7 million new established smokers: 2.1, 1.2, and 1.4 million due to Camel, Marlboro, and other brands’ advertising and promotions, respectively. Of these, 1.2 million will eventually die from smoking-attributable diseases: 520 000 from Camel, 300 000 from Marlboro, and the remainder from other brands.  Our analysis provides a reasonable first estimate at sharing the blame for the long-term health consequences of smoking among the major brands that encourage adolescents to start smoking.

title: Alternative Ways of Assessing Model Fit
abstract: This article is concerned with measures of fit of a model. Two types of error involved in fitting a model are considered. The first is error of approximation which involves the fit of the model, with optimally chosen but unknown parameter values, to the population covariance matrix. The second is overall error which involves the fit of the model, with parameter values estimated from the sample, to the population covariance matrix. Measures of the two types of error are proposed and point and interval estimates of the measures are suggested. These measures take the number of parameters in the model into account in order to avoid penalizing parsimonious models. Practical difficulties associated with the usual tests of exact fit or a model are discussed and a test of “close fit” of a model is suggested.

title: Do favorite movie stars influence adolescent smoking initiation?
abstract: We sought to determine whether adolescents whose favorite movie stars smoke on-screen are at increased risk of tobacco use.



During interviews, adolescent never smokers taking part in the California Tobacco Survey nominated their favorite stars. We reviewed popular films released during 1994 through 1996 to determine whether stars smoked on-screen in at least 2 films.



One third of never smokers nominated a star who smoked on-screen, which independently predicted later smoking risk (odds ratio [OR] = 1.36; 95% confidence interval [CI] = 1.02, 1.82). The effect was strong among girls (OR = 1.86; 95% CI = 1.26, 2.73). Among boys, there was no independent effect after control for receptivity to tobacco industry promotions.



Public health efforts to reduce adolescent smoking must confront smoking in films as a tobacco marketing strategy.

title: Effect of viewing smoking in movies on adolescent smoking initiation: a cohort study
abstract: 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.



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.



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.



Our results provide strong evidence that viewing smoking in movies promotes smoking initiation among adolescents.

title: Smoking in film and impact on adolescent smoking: with special reference to European adolescents.
abstract: This review examines the evidence supporting an association between seeing smoking depictions in movies and adolescent smoking. The portrayal of tobacco use is common in movies and often modeled by movie stars who, from a social influences standpoint, should be powerful behavior change agents. The results of studies assessing audience responses to tobacco portrayal in movies are remarkably consistent in showing a moderate to strong association between seeing movie smoking and more positive attitudes toward smoking and adolescent smoking initiation. The population-based data include cross sectional samples from different regions of the United States, all supporting a movie smoking-teen smoking link. The 2 published longitudinal studies show an independent link between exposure to movie smoking at baseline and initiation in the future, with estimates of the effect size being remarkably consistent with their cross-sectional counterparts. Experimental research adds support by showing that scene depictions of smoking enhance positive views of smokers and increase intent to smoke in the future. Taken as a whole, this rich research base provides very strong support for the notion that movie smoking plays a role in smoking initiation among adolescents that warrants action at the individual and societal level. A major gap in our understanding is the impact of Hollywood movies on adolescents outside the United States. There is a real need for studies to be conducted in European and other populations to better understand the global reach of smoking in American film, since over half of box office revenues come from outside the United States.

title: Exposure to smoking in popular contemporary movies and youth smoking in Germany.
abstract: Studies have linked exposure to movie smoking and smoking initiation among adolescents in the United States, but there has been only one published study of adolescents outside the U.S.



A cross-sectional survey of 5586 schoolchildren aged 10-17 with a mean of 12.8 (SD=1.2) years from randomly selected secondary schools in Schleswig-Holstein, Germany, was taken in October/November 2005. In August 2006, using previously validated methods, exposure to movie smoking was estimated from 398 internationally distributed films (98% produced and distributed by U.S. studios) released in Germany and examined its relationship with ever and current (30-day) smoking.



Overall, 40.7% of the sample had tried smoking, and 12.3% were current smokers. The sample quartile (Q) of movie smoking exposure was significantly associated with the prevalence of smoking initiation: 0.17 of adolescents in Q1 had tried smoking; 0.35 in Q2; 0.47 in Q3; and 0.64 in Q4. Movie smoking exposure was significantly associated with the prevalence of current smoking: 0.03 for adolescents in Q1; 0.08 in Q2; 0.14 in Q3; and 0.25 in Q4. After controlling for sociodemographics, parent/friend/sibling smoking, school performance, personality characteristics, TV consumption, receptivity to tobacco marketing, and parenting style, the adjusted odds ratios for having tried smoking were 1.7 (95% confidence interval [CI]=1.4-2.1) for Q2, 1.8 (95% CI=1.5-2.3) for Q3, and 2.2 (95% CI=1.8-2.8) for Q4 compared with adolescents in Q1. The adjusted odds ratios for current smoking were 1.4 (95% CI=0.9-2.2) for Q2, 1.7 (95% CI=1.1-2.6) for Q3, and 2.0 (95% CI=1.3-3.1) for Q4 compared with adolescents in Q1.



Smoking in internationally distributed movies is associated with ever and current smoking among German adolescents. This suggests the need for prospective studies of this association in countries other than the U.S. and research into the potential impact of countrywide policies that would limit exposure of young adolescents to movie smoking.

title: US college students' exposure to tobacco promotions: prevalence and association with tobacco use.
abstract: We assessed young adults' exposure to the tobacco industry marketing strategy of sponsoring social events at bars, nightclubs, and college campuses.



We analyzed data from the 2001 Harvard College Alcohol Study, a random sample of 10904 students enrolled in 119 nationally representative 4-year colleges and universities.



During the 2000-2001 school year, 8.5% of respondents attended a bar, nightclub, or campus social event where free cigarettes were distributed. Events were reported by students attending 118 of the 119 schools (99.2%). Attendance was associated with a higher student smoking prevalence after we adjusted for demographic factors, alcohol use, and recent bar/nightclub attendance. This association remained for students who did not smoke regularly before 19 years of age but not for students who smoked regularly by 19 years of age.



Attendance at a tobacco industry-sponsored event at a bar, nightclub, or campus party was associated with a higher smoking prevalence among college students. Promotional events may encourage the initiation or the progression of tobacco use among college students who are not smoking regularly when they enter college.

title: Some Immediate Effects of Televised Violence on Children's Behavior.
abstract: The hypothesis that exposure to televised violence would increase the willingness of children to hurt another child was investigated. Boys and girls of two age groups (5-6 and 8-9 years) first viewed excerpts from actual television programs depicting either aggresive or nonaggressive scenes, and were then provided with an opportunity to aggress against a peer. All subjects were subsequently placed in a free play situation and the frequency of their aggressive responses observed. Results indicated that children exposed to the aggressive program engaged in longer attacks against an ostensible child victim than subjects exposed to the nonaggressive program. The aggressive program also elicited a higher level of aggressive play than the nonaggressive one, particularly among the younger boys.

title: Smoking in Movies, Implicit Associations of Smoking With the Self, and Intentions to Smoke
abstract: We examined whether identifying with a film character who smokes increases implicit associations of the self with smoking. Undergraduate men were randomly assigned to view film clips in which the male protagonist either smoked or did not smoke. We measured subsequent levels of self-smoking associations using a reaction time task, as well as self-reported beliefs about smoking and smokers. Greater identification with the smoking protagonist predicted stronger implicit associations between the self and smoking (for both smokers and nonsmokers) and increased intention to smoke (among the smokers). Stronger implicit self-smoking associations uniquely predicted increases in smokers' intentions to smoke, over and above the effects of explicit beliefs about smoking. The results provide evidence that exposure to smoking in movies is causally related to changes in smoking-related thoughts, that identification with protagonists is an important feature of narrative influence, and that implicit measures may be useful in predicting deliberative behavior.

title: Perceived risks and benefits of smoking: differences among adolescents with different smoking experiences and intentions.
abstract: Explanations of adolescent smoking often make reference to adolescents' beliefs that they are invulnerable to harm. However, empirical examination of whether adolescents do acknowledge risks. Further, few studies have considered perceived benefits in adolescents' behavioral decisions. This study examined perceived smoking-related physical and social risks and benefits between adolescents who have vs. have not smoked and do vs. do not intend to smoke.



Three hundred and ninety-five students (mean age = 14.0) completed a survey concerning their smoking experiences, intentions, and perceived risks and benefits of smoking.



Adolescent smokers and those who intend to smoke estimated their chance of experiencing a smoking-related negative outcome as less likely than did nonsmokers and non-intenders. Smokers and intenders also reported the chance of addiction as less likely than did others. In contrast, adolescent smokers and intenders perceived the chance of experiencing a smoking-related benefit as more likely than did nonsmokers and non-intenders.



The data suggest that rather than solely focusing on health risks as a way to deter adolescent smoking, the role of perceived social risks and benefits in adolescents' smoking may be an additional critical focus for intervention. In addition, efforts should be made to increase adolescents' awareness of the addictive nature of cigarettes.

title: Beyond invulnerability: the importance of benefits in adolescents' decision to drink alcohol.
abstract: Some investigators propose that adolescents engage in risky behaviors mainly because they perceive themselves to be invulnerable to risk. However, studies have typically not included perceived benefits. In the current study, 5th, 7th, and 9th graders were surveyed about their perceptions of and experience with alcohol and tobacco. Results indicated that perceptions of the benefits were significantly related to drinking and smoking 6 months later, over and above perceptions of the risks, age of the respondent, and experience level. Further, the importance of benefits was replicated across 3 separate analyses. Experience with alcohol alone, especially positive experience, was also related to perception and behavior. These findings are discussed in terms of how to improve messages and influence adolescents' decisions regarding risk-taking behaviors.

title: A model of smoking among inner-city adolescents: the role of personal competence and perceived social benefits of smoking.
abstract: Based on current trends, smoking will remain a major public health problem in the 21st century. Effective smoking prevention approaches offer the best hope for decreasing the rise in adolescent smoking rates. Competence enhancement approaches to smoking prevention are among the most successful. Yet, there is not a full understanding of how effective prevention approaches work. This study tests whether a deficiency in competence (poor decision-making skills and low personal efficacy) is linked to acquiring beliefs in the perceived benefits of smoking and whether these perceived benefits are then related to subsequent smoking.



A sample of 1459 students attending 22 middle and junior high schools in New York City participated. Students completed surveys at baseline, 1-year follow-up and 2-year follow-up during a regular class period. They self-reported smoking, decision-making skills, personal efficacy and beliefs in the perceived benefits of smoking.



The tested structural equation model had a good fit and was parsimonious and consistent with the theory underlying the competence approach to smoking prevention.



This research highlights the importance of addressing decision-making skills, personal efficacy, and beliefs in the social benefits of smoking within adolescent smoking prevention programs.