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

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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
  1. 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

  1. E-mail: james.d.sargent@dartmouth.edu
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
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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).

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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
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(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

  1. Older movies were included be-

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
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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
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(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

0

.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

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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

0

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

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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
  1. click here for more information on this paper
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 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

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ARTICLE
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