NOT PEER REVIEWED Glantz & Polansky respectfully suggest that I should (1) "Base my criticisms on actual data and analysis, rather than raising hypothetical problems and presenting them as if they had been demonstrated to be real" and (2) "Criticise the proposal based on the actual behavior of the motion picture industry, not on whether or not youth see some R-rated films."

Suggestion 1 seems to be proposing that no one should ask questions about others' research but instead, keep silent until they complete their own studies. I will reflect on that advice next time I receive reviewers' comments on my research. However, in 17 years of editing, I don't believe I ever saw an author respond to a reviewer's criticisms by saying these would be ignored until the reviewer submitted their own research.

In fact, Matthew Farrelly who co-authored our PLoS Med paper[1] has done such research[2] - cited in our paper -- which demonstrated that smoking is inextricably intertwined with a range of other youth-enticing variables in movies [2]. As we wrote, smoking characters never just smoke, and movies showing smoking have a lot more in them that might appeal to youth at risk of smoking than just smoking. This is a core issue that has been ignored in all studies to date, other than Farrelly et al's.

Glantz and Polansky's main finding is that "movies with smoking make 87% of what comparably rated smoke-free films make". Consider why this might be the case. It is implausible that this could be explained by market forces whereby word would quickly spread around a nation "do not go to see movie X .. it contains smoking!" Rather, it is far more likely that movies where smoking occurs are from less popular genres: another illustration of how preoccupation with judging a movie by whether or not it contains smoking can obscure consideration of the totality of a movie's appeal, both in box-office potential and to youth at risk of smoking.

As to their second suggestion, it is indisputable that large proportions of young people often see adult-rated material. There are many studies showing this in the violence and sexual content areas, as well as in the tobacco field. My point is simply this: if the R-rating solution is designed to prevent youth seeing smoking, it may prevent them seeing it in cinemas, but it will not prevent them seeing the newly rated R movies elsewhere with consummate ease, increasingly so as download and i-View markets rapidly expand. This being the case, it surely cannot be long until proponents of R-rating realize that they will need to call for total movie censorship of smoking. If they are comfortable with that, is it time to be open about it?

References

1. Chapman S, Farrelly M. Four arguments against the adult-rating of movies with smoking scenes. PLoS Med 2011; e1001078. doi:10.1371/journal.pmed.1001078 Published Aug 23 2011

2. Farrelly M, Kamyab K, Nonnemaker J, E. C (2011) Movie smoking and youth initiation: parsing smoking imagery and other adult content. Social Science Research Network. Social Science Research Network. Available: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1799561.

Conflict of Interest:

None declared

Chapman speculates that basing our analysis on box office gross receipts while omitting what he describes as available video revenue data is problematic. However, Chapman does not actually present an analysis based on reliable data that demonstrates that including post-theatrical film receipts would reverse the conclusion drawn in our paper.

We used industry-reported "domestic" (Canada and United States) gross theatrical sales totals -- not including domestic or foreign ancillary revenues, such as DVD sales -- because these same data were used to determine what motion pictures were included in the sample of top-grossing films (ranking among the top ten films in gross sales in any week of their first-run, domestic theatrical release). In addition, evidence suggests that domestic theatrical gross is positively correlated with both DVD sales and foreign box office (1,2), so it is very unlikely that adding estimated domestic video revenue to reported domestic theatrical box office gross would reverse our results, as Chapman speculates.

Chapman also appears to have misunderstood the paper (3) he cited as evidence that youth have widespread access to R-rated movies. The paper in question shows that the median viewership rate for an R-rated movie is only about 17% for adolescents aged 10-14. Thus, even though R-rated films are smokier on average than youth-rated (G/PG/PG-13) films, youth-rated films deliver the majority of exposure to onscreen smoking.

Chapman is "perplexed" about why the R rating would reduce youth exposure to smoking in movies. Here is why the CDC, WHO and a wide range of public health organizations have endorsed the R rating for on-screen smoking:

1. Motion pictures are products mostly made by multinational corporations to sell to a pre-determined market.

2. Obtaining the desired rating for a film is an integral part of its marketing plan, made before production begins.

3. To obtain the rating desired for marketing purposes, film content is calibrated in light of the factors that the MPAA uses in assigning ratings: violence, sex, illegal drugs, and language. 4. If smoking triggered an R rating, studios would integrate this fact into production plans and see that smoking was left out of films designed for general and youth markets.

5. As a result, smoking would not appear in future G, PG, and, most important, PG-13 movies.

6. Youth receive almost 60% of their exposure to onscreen smoking from youth rated films.

7. If studios adapt to the R rating for smoking as expected, there will be a proportionate reduction in the dose of smoking delivered to youth in films.

8. Because of the dose-response relationship between exposure to smoking in movies and adolescent (and young adult) smoking, there will be less adolescent smoking.

Note that this logic has nothing to do with whether or not youth see R-rated films.

Chapman has repeatedly denigrated the R rating for smoking as a way to reduce the substantial impact that smoking in movies has on youth smoking behavior. We respectfully suggest that in the future he:

1. Base his criticisms on actual data and analysis, rather than raising hypothetical problems and presenting them as if they had been demonstrated to be real.

2. Criticise the proposal based on the actual behavior of the motion picture industry, not on whether or not youth see some R-rated films.

Stanton A. Glantz Jonathan R. Polansky

REFERENCES

(1) Elberse A and Oberholzer-Gee F (2007) Superstars and underdogs: An examination of the long-tail phenomenon in video sales. Harvard Business School Working Paper Series, No. 07-015. Accessed at http://www.aeaweb.org/annual_mtg_papers/2007/0107_1015_1002.pdf on 18 October 2011.

(2) World Health Organization. Smoke-free movies: From evidence to action (second edition). Box 2: Tobacco images in films from the United States have worldwide impact. Geneva, 2011. Accessed at http://whqlibdoc.who.int/publications/2011/9789241502399_eng.pdf on 19 October 2011.

(3) Sargent JD, Tanski SE, Gibson J. Exposure to movie smoking among US adolescents aged 10 to 14 years: a population estimate. Pediatrics. 2007 May;119(5):e1167-76.

Conflict of Interest:

None declared

Glantz and Polansky's paper is titled "Movies with smoking make less money" but it should have continued "... at the box office" because it failed to consider the major sources of revenue to film studios other than from box office receipts (DVD and blu-ray sales, rentals and video-on- demand or iVOD). They write that data from DVD sales and rentals are not available. However, Nash Information Services (which they reference) provide estimates from February 12, 2006 for DVD sales and for box office receipts from 1992. http://www.the-numbers.com/dvd/charts/annual/2010.php Nash explain "Precise information on DVD sales is not generally available. Our DVD sales figures are estimates based on studio figures, publicly available data, and private research on retail sales carried out by Nash Information Services. The figures include estimated sales at Wal-Mart and other retailers that do not publicly release sales information."

As can be seen, box office sales remain the dominant source of revenue to movie studios in the short term, but over time DVD purchases, rentals and iVODs combined can erode and sometimes overhaul that lead. It would be wise to re-calculate Glantz and Polansky's data (at least from 2006 from when DVD sales data is available) to see whether their conclusions hold. But this would still underestimate total revenue. While Nash provides rankings of DVD rentals, they do not provide their dollar value. In 2010, the US iVOD market was worth $385m http://www.internetretailer.com/2011/02/15/apple-has-65-streaming-demand- videos-market, a still small but rapidly growing fraction of the total income for movie studios as testified by the on-going demise of suburban video rental outlets.

I also remain perplexed as to how the proposed R-rating for smoking scenes would actually reduce exposures to these scenes in youth. As I have argued previously, studies in this field include R-rating movies in their exposure assessments. For example, in Sargent et al's 2007 paper, 40% of the films on the list provided to children to determine exposure were R- rated(1). Sargent et al have also shown that between 68-81% of US adolescents are allowed to watch R-rated movies(2-3). Many more watch without parental approval via downloads and file-sharing. Furthermore, 88.2% of youth-rated movies in the US now have no tobacco scenes (http://www.cdc.gov/mmwr/p...).

Putting these together, estimates of the effect of movie smoking exposure already include the impact of the R-rated solution being proposed to reduce that exposure. If youth who allegedly start smoking because of exposure to smoking in movies are already watching lots of R-rated movies, how would an R-rating significantly reduce such exposure? They would not see them in cinemas, but with consummate ease at home. Moving nearly all movies with smoking to R-rating would put the onus on parents to regulate their children's viewing. Few would disagree with that. But why would parents regulate their children more because of concern about smoking than they do now with because of concerns about exposure to strong violence and explicit sex in R-rated movies?

References

1. Sargent JD, Tanski SE, Gibson J. Exposure to movie smoking among US adolescents aged 10 to 14 years: a population estimate. Pediatrics. 2007 May;119(5):e1167-76.

2. Sargent JD, Beach ML, Dalton MA, Ernstoff LT, Gibson JJ, Tickle JJ, et al. Effect of parental R-rated movie restriction on adolescent smoking initiation: a prospective study. Pediatrics. 2004 Jul;114(1):149- 56. 3. de Leeuw RN, Sargent JD, Stoolmiller M, Scholte RH, Engels RC, Tanski SE. Association of smoking onset with R-rated movie restrictions and adolescent sensation seeking. Pediatrics. 2011 Jan;127(1):e96-e105.

Conflict of Interest:

None declared