Discouraging Smoking in Feature Films to Avoid Influencing Youth to Smoke

Through past policy statements, the American Public Health Association (APHA) has recognized the importance of addressing the alcohol and tobacco industry product placement in feature films (“movies”) and has called for the film industry to “voluntarily eliminate in feature films the portrayal of alcohol and tobacco products as glamorous and desirable when not an integral part of the story.”¹ This policy statement complements the earlier referenced APHA policy by providing current data and research to inform actions that APHA can use to help avoid the influence that smoking in the movies can have on youth who are watching these movies.² Past voluntary measures to eliminate tobacco products in movies have been inconspicuous and ineffective because of “rating creep,” in which an increasing number of movies are rated as acceptable for people younger than 17 years of age.^3,4 A review of the scientific literature and the Dartmouth Medical School, the National Cancer Institute USA, and the American Legacy Foundation report titled, First Look Report, Trends in top box office movie tobacco use, 1996–2004, revealed that, “smoking in youth-rated movies has a greater reach among adolescents because these movies are seen by three times as many youth as R-rated movies.”³, p 4 A May 2007 report used a nationally representative US survey and a content analysis of 534 contemporary box office hits to identify smoking in feature films to quantify the exposure of adolescents 10 to 14 years old. “Overall, these movies delivered 13.9 billion gross smoking impressions, an average of 665 to each adolescent aged 10–14.”⁵, p 1167 This finding may underestimate exposure because a movie could have been seen more than once by a child or adolescent.

A growing literature links adolescents’ exposure to viewing smoking in movies to the initiation of their own smoking behavior.^6–19 As demonstrated in a cohort study by Dalton et al.,¹³ adolescents in the highest quartile of exposure to movie smoking were 2.71 times more likely to initiate smoking compared with those in the lowest quartile. The authors estimated that 52.2% of adolescent smoking initiated in this cohort can be attributed to their prior exposure to smoking in movies. Reducing exposure to smoking in movies is likely to reduce the incidence of adolescent smoking, because adolescents’ exposure to movie smoking predicts their future smoking behavior, and the impact of adolescents’ viewing smoking in movies has a clear dose–response relationship to initiating smoking.²⁰ “… [M]ovies play an important social-influence role in contemporary Western cultures [because] they not only depict modern societal norms but also help to define them.”¹⁰, p 149

The Centers for Disease Control and Prevention (CDC) has named tobacco use as the leading cause of preventable death in the United States. An Morbidity and Mortality Weekly Report documenting the stalled national decline in youth smoking observed from 2003 to 2005 identifies a number of factors that might have contributed to this lack of decline. “[A]fter decades of decline, smoking in movies, which has been linked to youth smoking, increased rapidly beginning in the early 1990s, and by 2002 was at levels observed in 1950.”²¹, p 726 In its 2007 report, Ending the Tobacco Problem: a Blueprint of the Nation, the Institute of Medicine (IOM) stated that “Exposure to smoking in movies increases the risk for smoking initiation… Furthermore, even after controlling for other factors known to be associated with adolescent smoking intention and tobacco use, studies show a clear dose effect, whereby greater exposure to smoking in the movies is associated with greater chance of smoking.”²², p 25

There is an increasing consensus about limiting youth exposure to smoking in movies. In a recent study, Sargent et al. concluded that in their national US adolescent sample,”. . . exposure to smoking in movies predicted risk of becoming an established smoker, an outcome linked with adult dependent smoking and its associated morbidity and mortality.”²³, p 84 Moreover, a study conducted by Mississippi State University and the American Medical Association Alliance demonstrated that a majority of US adults agree that smoking in movies influences youth to start smoking, and 70% support an R-rating for movies with on-screen tobacco imagery unless the film clearly demonstrates the dangers of smoking.²⁴ Recommendation 37 of the IOM Report states, ”. . . The film rating board of the [Motion Picture Association of America] MPAA should consider the use of tobacco in the movies as a factor in assigning mature film ratings (e.g., an R-rating indicating Restricted: no one under age 17 admitted without parent or guardian) to films that depict tobacco use.”²², p 25 A majority of state attorney generals have been very supportive of this issue; they have added their voices to the call for an R rating.²⁵

On February 23, 2007, Dean Barry R. Bloom, PhD, led the Harvard School of Public Health in organizing a scientific presentation for the MPAA on the impact of youth smoking and the behavioral influence of movies that depict tobacco use. Dr. Bloom outlined not only the scientific relationship between smoking in the movies and youth initiation of smoking but also his opinion regarding why a ban would not be a step toward censorship.²⁶ On May 10, 2007, the MPAA announced that smoking would be “considered” in assigning movie ratings. Although health organizations have criticized weaknesses in the MPAA view of smoking in the movies, it is clear that even the MPAA has recognized the strong demands for smoking to be integrated into the ratings system.²⁷ In the business section of the July 16, 2007, edition of the Washington Post, the first paragraph states, “Walt Disney Co., responding to congressional calls for

Hollywood to discourage tobacco use, will eliminate cigarette smoking from some films.”²⁸

Concerns regarding threats to freedom of speech have been raised related to the proposal to extend R ratings to movies with smoking. However, the MPAA rating system does not control the content of films; rather, film labels inform parents of movie content so parents can determine whether specific movies are appropriate for their children to view. Furthermore, the movie rating system is voluntary, and most studios submit their films for rating because of consumer demand.

Currently, the four objectives of the Smoke Free Movies project²⁹ are endorsed by many organizations including the World Health Organization, the American Medical Association, the American Heart Association, the American Academy of Pediatrics, the American Lung Association, the Campaign for Tobacco Free Kids, Americans for Non Smokers’ Rights, the American Legacy Foundation and the American Public Health Association. The four objectives of the project are as follows:

1. Rate new smoking movies R: Any film that shows or implies tobacco should be rated R. The only exceptions should be when the presentation of tobacco clearly and unambiguously reflects the dangers and consequences of tobacco use or is to represent smoking of a real historical figure.
2. Certify no pay-offs: The producers should post a certificate in the credits at the end of the movie declaring that nobody on the production received anything of value (cash money, free cigarettes or other gifts, free publicity, interest-free loans, or anything else) from anyone in exchange for using or displaying tobacco.
3. Require strong antismoking ads: Studios and theaters should require a genuinely strong antismoking ad (not one produced by a tobacco company) to run before any film with any tobacco presence, regardless of its MPAA rating.
4. Stop identifying tobacco brands: There should be no tobacco brand identification nor the presence of tobacco brand imagery (such as billboards) in the background of any movie scene.

Therefore the American Public Health Association:

1. Urges the MPAA and the major media corporations that it represents to restore a more favorable public image for the motion pictures industry by endorsing and initiating efforts to implement the four objectives of the Smoke Free Movies Project.
2. Further urges the MPAA and major media corporations that it represents to encourage movie producers to eliminate scenes depicting smoking in movies of interest to adolescents and their previews.
3. Encourages state attorney generals to endorse and advocate for the implementation of objectives set forth in the Smoke Free Movies project. 
4. Requests Congress pursue opportunities to regulate the showcasing and use of products, such as tobacco, that have demonstrated serious public health consequences to end sending erroneous messages reinforcing smoking as a positive behavior.

References

1. American Public Health Association policy statement 89-20. Alcohol and tobacco industry product placement in feature films. Washington, DC: American Public Health Association; 1989. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=1199. Accessed November 17, 2008.
2. Morris, SE, ed. The role of the media in promoting and reducing tobacco use. NCI Tobacco Control Monograph Series 19. Bethesda, Md: National Cancer Institute; 2008.
3. Worth K, Tanski S, Sargent J. Report 16: trends in top box office movie tobacco use, 1996–2004, a first look. Washington, DC: American Legacy Foundation; 2006. 
4. Thompson K, Yokota F. Violence, sex, and profanity in films: correlation of movie ratings with content. MedGenMed. 2004;6(3):3. Available at: www.medscape.com/viewarticle/480900. Accessed November 17, 2008.
5. Sargent JD, Tanski SE, Gibson G. Exposure to movie smoking among US adolescents aged 10–14 years: a population estimate. Pediatrics. 2007;119(5):e1167–e11176.
6. Charlesworth A, Glantz SA. Smoking in movies increases adolescent smoking: a review. Pediatrics. 2005;116:1516–1528.
7. Pechmann C, Shih CF. Smoking scenes in movies and antismoking advertisements before movies: effects on youth. J Mark. 1999:63:1–13.
8. Primack BA, Gold MA, Land SR, Fine MJ. Association of cigarette smoking and media literacy about smoking among adolescents. J Adolesc Health. 2006;39:465–472.
9. Proxyinformation. As You Sow Foundation. Smoking in movies. Available at: www.proxyinformation.com/smokingissue.html. Accessed December 30, 2005.
10. Sargent J, Beach M, Dalton M, et al. Effect of parental R-rated movie restriction on adolescent smoking initiation: a prospective study. Pediatrics. 2004;114:149–156.
11. Sargent JD, Beach ML, Adachi-Mejia AM, et al. Exposure to movie smoking: its relation to smoking initiation among US adolescents. Pediatrics. 2005;116:1183–1191.
12. Sargent JD. Smoking in film and impact on adolescent smoking: with special reference to European adolescents. Minerva Pediatr. 2006;58:27–45.
13. Dalton M, Sargent J, Beach M, et al. Effect of viewing smoking in movies on adolescent smoking initiation: a cohort study. Lancet [online]. 2003;362(9380):281–285. Abstract available at: www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)13970-0/abstract Accessed November 17, 2008.
14. Polansky J, Glantz S. First-Run Smoking Presentations in US Movies 1999–2003. San Francisco, Calif: Center for Tobacco Control Research and Education. Tobacco Control Policy Making: United States; 2004. Available at: http://repositories.cdlib.org/ctcre/tcpmus/Movies2004. Accessed November 17, 2008.
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16. Hines D, Saris RN, Throckmorton-Belzer L. Cigarette smoking in popular films: does it increase viewers’ likelihood to smoke? J Appl Soc Psychol. 2000;30:2246–2269.
17. Distefan JM, Pierce JP, Gilpin EA. Do favorite movie stars influence adolescent smoking initiation? Am J Public Health. 2004;94:1239–1244.
18. 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. Pediatrics. 2008;121;15–21.
19. Hanewinkel R, Sargent JD. Exposure to smoking in internationally distributed movies and youth smoking a Germany: a cross-cultural cohort study. Pediatrics. 2008;121;e108–e117.
20. Glantz S. Smoking in movies: a major problem and a real solution. Lancet. 2003; 362:258–259.
21. Cigarette use among high school students—United States, 1991–2005. MMWR. 2006:55:724–726. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5526a2.htm. Accessed November 17, 2008.
22. Bonnie RJ, Stratton K, Wallace RB, eds., and Committee on Reducing Tobacco Use: Strategies, Barriers, and Consequences. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: Institute of Medicine, 2007.
23. Sargent J, Stoolmiller, M, Worth KA, et al. Exposure to smoking depictions in movies: its association with established adolescent smoking. Arch Pediatr Adolesc Med. 2007;161:849–856
24. McMillen RC, Tanski S, Winickoff J, Valentine N. Attitudes About Smoking in Movies. 2006. www.ssrc.msstate.edu/socialclimate/Site/Home_files/Attitudes_Smoking_Movies.pdf
25. Puzzanghera J. Movie ratings target cigarette smoking. Los Angeles Times/San Jose Mercury News. May 11, 2007. Available at: www.mercurynews.com/portlet/article/html/fragments/print_article.jsp?articleId=58. Accessed 5/21/2007.
26. Bloom BR. Dean’s message: Hollywood smoke-out. Harvard Public Health Review. Spring/Summer 2007 Available at: www.hsph.harvard.edu/review/spring07/dean1.html. Accessed February 11, 2008.
27. DiOrio C. Smoke in MPAA’s eyes: ratings criteria affected. Hollywood Reporter.com. May 11, 2007. Available at: www.hollywoodreporter.com/hr/content_display/news/e3ic39ac604ab41fd2187aaf2487abdd48b. Accessed November 17, 2008.
28. Fixer, A. Walt Disney to snuff smoking in some films. Washington Post. July 26, 2007: D-2.
29. Smoke Free Movies. The solution. Available at: www.smokefreemovies.ucsf.edu/solution/index.html. Accessed November 17, 2008. 

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