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Re: Late to the Party

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Re: Smoking imagery in movies requires action now

Simon Chapman’s recent commentary on smoking in movies misses several important points with regard to the influence of media portrayal of tobacco on children’s health (1). Chapman fails to recognize the ease with which other socially questionable behavior is rated R in US films. Using the Motion Picture Association of America voluntary ratings system (2), use of the 'F' word as an exclamation twice, or once in a sexual context, yields an "R".

Other potentially adverse role modeled behavior does not have tobacco's highly addictive drug, nicotine, as a factor in children's exposure. The behavioral expectancy establishes a modeled response which then is reinforced by pharmacology, with well established and substantial health results. This is why the American Academy of Pediatrics and many other medical and public health organizations have endorsed the R rating. The other Smoke-Free Movie goals: certification of no payoffs, true nonsmoking counter-messages in trailers, and elimination of brand identification, are important compliments to the R rating in helping protect youth. Together, these strategies will moderate the smoking that youth may still be exposed if smoking were out of the G, PG, and PG-13 rated movies that are designed specifically for children. Far from triggering the "backlash" that Chapman fears, national surveys have shown that 70 percent of US adults agree that movies that show smoking should be rated R (3).

The evidence base for what strategies are most effective for changing the effect of smoking in the movies is less strong. However, proposing experiments to discover the best way to change the imagery promoting social acceptability of smoking would not be appropriate or ethical. Ridiculing strategies to make it easier for parents to avoid or counter pro-smoking imagery, as Chapman does, is also not terribly helpful. Definitive action should be taken now, consistent with each nation's intent to protect their youth.

Jonathan D. Klein, MD, MPH, Director American Academy of Pediatrics Julius B. Richmond Center of Excellence www.aap.org/richmondcenter (585)275-7760 fax 585-242-9733 jklein@aap.org

1) Chapman, S. What should be done about smoking in movies? Tobacco Control 2008;17:363-367; doi:10.1136/tc.2008.027557. http://tobaccocontrol.bmj.com/cgi/content/full/17/6/363. <http://tobaccocontrolbmj.com/cgi/content/full/17/6/363.> Accessed 11/25/08.

2) Motion Picture Association of America. Rating system. 2005. http://www.mpaa.org/FilmRatings.asp. Accessed 11/25/08.

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Re: Business as Usual

Simon Chapman's editorial supports business as usual for Hollywood. By considering only the commercial element of paid product placement, he ignores that making films in Hollywood is a business. Free artistic speech is a fundamental right that everyone in Western societies supports, but Hollywood uses it as a mantra to avoid changing how they do business. Movies are a combination of art and business, just like many other products that include artistic design elements, such as cars, furniture and appliances. Movie production includes negotiations about what is suitable for the audience and what sells tickets. Big movie producers shoot several endings and focus group tests determine which one to use and decide on the rating they want before they shoot a frame. That’s why an R rating for smoking would simply cause them to leave smoking out of films aimed at kids. Just as they trim violence and sex to get the rating they want, they would also trim the smoking.

Chapman unfairly criticizes the Smoke Free Movies R-rating proposal under the “Banning all Smoking in Movies” section of his editorial. In the R rating proposal, smoking triggers and R rating not a ban. Movie ratings systems are designed to warn parents of unsuitable content. We are used to thinking of violent content as unsuitable, and few one question that trigger. The research that links movie smoking with kid smoking is new, but it is also very compelling, with movies being responsible for one-third to one-half of youth smoking onset. Movie ratings systems are designed to warn parents of unsuitable content. From a health perspective, trying smoking is one of the biggest mistakes an adolescent can make. Surely this warrants an R-rating as much as using the “F” word twice, one of the current MPAA triggers.

Chapman argues against an R rating because it would not prevent all children from seeing all smoking onscreen. No one has ever suggested that the R rating would eliminate exposure to onscreen smoking for all adolescents, just reduce it. The average R-rated movie is seen by only 14% of young adolescents, compared to about 30% for a typical PG-13 movie (see Sargent, J. D., S. E. Tanski, et al. (2007). Exposure to Movie Smoking Among US Adolescents Aged 10 to 14 Years: A Population Estimate. Pediatrics 119(5): e1167-1176). Movie producers know that fewer adolescents see R rated movies; that's why they fight an R rating for smoking.

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Re: Missing the Point

The responses so far to Dr. Chapman's article have missed the fundamental point of his argument: that a policy requiring an R-rating for any movie which depicts smoking is a narrow-minded one that treats smoking differently than other dangerous health behaviors depicted in films and which fails to address the overall public health problem of the media portrayal of unhealthy behaviors.

In order to defend the policy from Dr. Chapman's criticism, one would have to justify why smoking should be treated differently than the myriad of other unhealthy behaviors shown in films that influence adolescent behavior: violence, unprotected sex, alcohol abuse, sexual abuse, and physical abuse. While Smoke Free Movies and other public health groups are calling for a single depiction of smoking - under virtually any circumstances - to automatically trigger an "R" rating, they fail to argue that depictions of violence, alcohol abuse, and sexual or physical abuse should similarly trigger an automatic "R" rating.

In fact, this narrow-minded approach results in the rather perverse result of having these organizations publicly "endorse" (with a thumbs-up rating) a number of movies which don't depict smoking, but which show alcohol abuse, violence, and spousal abuse.

Dr. Klein makes an attempt to differentiate smoking by arguing that unlike these other behaviors, it is addictive. This argument not only fails (alcohol is also an addictive drug) but seems irresponsible, since it sanctions the depiction of violence and abuse on the grounds that these are not addictive behaviors.

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Re: blunt instraments for a nuanced issue

I do support R ratings (actually M15, as this is roughly the Australian equivalent to an American R) for films that decidedly glamourise or blatantly promote smoking. I do however believe that smoking can be shown in films in ways that do not promote the product - without having to be a hit-you-over-the-head health message.

While I agree the current system of ratings for films has to be considered in any realistic smoking in movies tobacco control strategy, why doesn't the system that supports the absurdity of counting F-word instances merit questioning? I appreciate that supporters and researchers of smokefree movies have done the hard yards and found a solution to eliminate tobacco promotion that best fits with the American moving making and rating system. That doesn't mean that those of us who are relatively newish to the debate cannot argue that the blunt instrument of an automatic R rating that equates seeing any onscreen smoking as enticing children to smoke is a poor tool.

Yes, movie making is a business, and as the current economic climate attests, businesses must be regulated in order to protect the public interests. But is this black and white form of regulation truly the ONLY way forward?

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Re: Response so far

Jim Sargent says I support business as usual for Hollywood. What I emphatically and unapologetically do support is business as usual for consistency. R-rating of any scene of smoking invites unavoidable questions about parallel controls on a wide range of activity that an equally wide range of interest groups would wish to see implemented in the name of health, religion or morality. Jonathan Klein implies that because nicotine is addictive, this confers exceptionalist status on the importance of keeping smoking scenes away from children. Smoking is extraordinarily dangerous, but is it any worse than violence, crime, or racism to name but three which are often seen in movies to which children are admitted?

The reductio ad absurdum of arguments to prevent children seeing any smoking in movies would be to stop children seeing any smoking anywhere. By what magic process could the sight of smoking in film be influential while being benign in reality? Doubtless the time is not far away when someone wielding research will call for public smoking to classified alongside indecent exposure as a felony. I would not wish to be associated with such nonsense and believe many others share my concerns that momentum to selectively prune unacceptable health related behaviours from film holds open the door for a conga line of other supplicants using the same reasoning. This should be resisted by all who value freedom of expression.

I do not doubt that a majority of Americans agree with the proposition that any smoking scene should cause a movie to be R-rated. But I’d be confident that many of the same people who support that proposition would also support proposals to do the same with scenes showing liquor or many other health concerns, blasphemy and various moral panics. And let’s remember also that many Americans also believe in miracles (89%), hell (69%), ghosts (51%), astrology (31%) and reincarnation (27%) [1] and 40%- 50% accept a creationist account of the origins of life [2]. The popularity of beliefs is not always a reliable guide to their wisdom. Not long ago, the “wardrobe malfunction” that exposed Janet Jackson’s breast on national TV for a nano-second caused national outrage. Such reactions perplex many outside the US who have long been used to far more relaxed regulation of film and television.

R-rating advocates are fond of arguing that scenes of smoking should be treated identically to use of the word “fuck”, which many in the USA apparently believe holds special powers to corrupt and deprave children. Perhaps some of these advocates need to get out more and broaden their horizons. Non R-rated movies in many other nations (eg: Europe, Australia, Canada) frequently contain swearing, moderate violence and sex scenes where panels appointed to judge the rating for the entire film have decided that these scenes do not overwhelm the overall suitability of the film to be screened to those legally defined as children. These panels are typically not constrained by prescribed formulae as would appear to be the case with swearing in the USA, but asked to make a holistic judgement with reference to unspecified community standards. Part of the problem in this debate may lie in US advocates believing that the rest of the world shares (or ought to share) its standards, which have historical roots in Puritanism.

Finally, if my critics are correct that smoking scenes in movies have increased in the last 15 years, that these scenes “predict one-third to half of smoking uptake”, and that there is a dose-response relationship between exposure and smoking uptake, how do they reconcile this with the major declines in youth smoking that have happened in the USA[3], Canada [4] and Australia (to name three) over the same period? The answer can only be that whatever effect smoking in movies has is small in relation to other influences which are acting to reduce uptake. Such a conclusion needs to be taken into consideration when we discuss moves to direct artistic expression in the name of health.