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Abstract
Background India implemented tobacco-free film and TV rules (Rules) to protect adolescents and young adults from tobacco exposure.
Objective To assess tobacco imagery in online series popular among adolescents and young adults.
Methods Ten popular online series on streaming platforms were identified after discussions with participants (aged 15–24 years) in New Delhi, and content-coded for tobacco imagery following the Breathe California protocol. Incidents of tobacco use and brand appearances in each series episode were counted, and compliance with Indian Rules was recorded.
Results 188 episodes across 10 series on Netflix and Amazon Prime Video were coded. Seven series were rated age 16+, two were 18+ and one was 13+. The median number of tobacco incidents per episode in foreign productions was as follows: Amazon’s ‘The Marvellous Mrs Maisel’ (87.5, IQR 62.0–116.0) and Netflix’s ‘The Crown’ (29.0, 18.0–36.0) were higher than Indian productions: Netflix’s ‘Sacred Games’ (9.0, 0.5–14.5) and Amazon’s ‘Mirzapur’ (7.0, 4.0–11.0) (p=0.84). Tobacco incidents per hour ranged from 0 (Bodyguard, Riverdale, 13 Reasons Why) to 106.1 (The Marvellous Mrs Maisel). Seven of 10 series had tobacco imagery and none were compliant with the Rules.
Conclusion Contrary to Section 5 of India’s Cigarettes and Other Tobacco Products Act, its Rules are not being complied with by the streaming platforms. US-produced streaming media contains more tobacco incidents than Indian-produced media. There is an urgent need for better enforcement of existing Rules on streaming platforms in India, and modernisation of the WHO Framework Convention on Tobacco Control, Article 13 guidelines to account for new streaming platforms to protect youth from tobacco imagery globally.
- advertising and Promotion
- low/middle income country
- media
- prevention
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Background
Tobacco use is responsible for over 8.1 million preventable deaths across the globe annually.1 The burden of tobacco-attributable health problems is substantial in India, where almost 266 million people, aged 15 years or above use tobacco.2 India is one of the earliest signatories to the WHO Framework Convention on Tobacco Control (FCTC) and has strengthened tobacco control efforts in the country, including introducing laws prohibiting tobacco advertising, promotions and sponsorships (TAPS).3 Studies from several countries have shown that exposure to tobacco use in films increases the probability of adolescents initiating tobacco use.4–6 A study conducted in New Delhi (India) showed that adolescents aged 12–16 years with high exposure to tobacco occurrences in Bollywood films were 2.3 times more likely to have ever used tobacco compared with adolescents with low exposure.7 To protect adolescents and young adults from such exposure to tobacco imagery, a provision exists in Indian law. Section 5 of India’s Cigarettes and Other Tobacco Products Act (COTPA) 2003 is consistent with Article 13 of WHO FCTC and specifies that “No person engaged in, or purported to be engaged in the production, supply or distribution of cigarettes or any other tobacco products shall advertise and no person having control over a medium shall cause to be advertised cigarettes or any other tobacco products through that medium and no person shall take part in any advertisement which directly or indirectly suggests or promotes the use or consumption of cigarettes or any other tobacco products.”3 This provision essentially implies that any form of advertising and promotion of cigarettes or any other tobacco products in any form of media is banned in India and its violations are punishable by law. Subsequently, the government of India adopted specific rules to curb tobacco imagery in all films and television (TV) programmes from November 2011,8 which were further strengthened in 2012.9
Since 2012, the tobacco-free film and TV rules9 required all films containing tobacco imagery to provide a strong editorial justification for the display of tobacco to the Central Board of Film Certification. If tobacco imagery is shown, films are required to display prominently, an anti-tobacco static health warning at the bottom of the screen during the period of tobacco display, display anti-tobacco health spots for 30 s and provide an audio-visual disclaimer on the ill effects of tobacco use, with a minimum 20 s duration each at the beginning and the middle (intermission) of the film. These rules also apply to TV programmes broadcast in India. A previous study conducted in India found that despite the inconsistent implementation of rules for films and TV programmes, these rules are effective in generating awareness about tobacco’s harms and also increase the intention to quit.10
More recently, there has been an increasing trend in subscription to on-demand streaming platforms. Globally, young adults aged 18–24 years spend an average of 39 min a day using a Subscription Video-on-Demand service through on-demand streaming platforms, including Netflix, Hulu, Amazon Prime Video.11 By 2019 these platforms had also become popular among Indian viewers, especially adolescents and young adults.12 A market research study determined that 36%, 17%, 2% and 3% of Indians aged 20–25 years spend 5–10 hours, 10–15 hours, 15–20 hours and >20 hours watching online shows each week, respectively.13 The remaining 42% spend 0–5 hours per week watching shows online. Reflecting on the increasing popularity of online videos and TV series, India had about 160 million digital video viewers in 2016, a number which continues to increase.14
As adolescents and young adults now extensively watch on-demand streaming content and there are few reports of content analysis of on-demand streaming platforms, there is a need to quantify the extent of tobacco imagery in the content available on these platforms. This study assesses tobacco imagery in on-demand streaming series popular among urban Indian adolescents and young adults. This study also assesses compliance of the content shown on these online series with tobacco-free film and TV Rules in India.
Methods
Study design and data sources
The study is a cross-sectional descriptive assessment (content-coding) of tobacco imagery in online series available in Indian on-demand streaming platforms popular among Indian adolescents and young adults. Four focus group discussions (FGDs) were conducted using a semistructured interview schedule with 33 adolescents and young adults to select the most frequently watched online films and series, for the content analysis of tobacco imagery. Invitations to participate in this study were sent to 10 private, co-educational, senior secondary schools governed by the Directorate of Education, Government of National Capital Territory of Delhi and students of colleges under the University of Delhi and private educational institutions which had participated earlier in our organisation’s activities and projects related to nutrition and physical activity. Two schools and students from one college in New Delhi were purposively selected to recruit participants based on their interest in participating in the study. Consent was received from participants (who were 18 or >18 years) in colleges, the school authorities (who provided consent on behalf of parents) and in addition, student agreements were obtained from minors (<18 years) before conducting FGDs.
The 33 participants in FGDs comprised 14 boys (nine school students aged 15–17 years and five college students aged 18–24 years), and 19 girls (nine school students aged 15–17 years and 10 college students aged 18–24 years). Discussions with the participants included their preferences for watching films and series available online and their choice of platforms. A free-listing technique was used during discussions to list the names of preferred films and online series along with the respective platforms. Free-listing is a technique in which a respondent is asked a question about a domain of interest and invited to respond with a ‘list’ of answers that represent elements in that domain.15 The participants’ listed choices (of films/series and on-demand streaming platforms on which they watched these films/series) were tabulated and analysed for frequency. Subsequently, the most frequently listed films and series were shortlisted.
Of the 33 adolescents and young adults, 22 stated that they watch online series on Netflix, eight on Amazon Prime Video, two on YouTube (US platforms) and one on Hotstar Premium (an Indian platform). Participants listed 39 series they watched on these platforms. Out of these, the 10 most frequently listed series from 2016 to 2018 (all seasons and episodes available at the time of data collection) were selected for content-coding of tobacco imagery (table 1). None of the participants listed any theatrical films that were available on the streaming platforms in the discussions. Of the 10 selected series, eight were available on Netflix and two on Amazon Prime Video. None of these most frequently watched series were available on YouTube or Hotstar Premium. Only two of the 10 selected series were Indian productions (one on Netflix and one on Amazon Prime Video), while eight (seven on Netflix and one on Amazon Prime Video) were foreign productions.
Number of tobacco incidents in the 10 most popular online series shown on Netflix and Amazon Prime Video in India
Data collection
To estimate tobacco imagery in the 10 selected series, content-coding was done using the validated Breathe California methodology.16 17 The methodology involves counting the number of tobacco incidents in all the episodes and seasons of the selected series. Two coders were provided with a full-day training on use of the method, followed by hands-on practice of content-coding. The training included an introduction to the method, using the validated coding protocol and introduction to the tobacco-free film and TV rules in India.18 The 10 series were then randomly distributed among the coders, and coding was completed over 2 months during 2018–19. Separate data collection forms were filled by each coder for each episode of their allocated series.
The data collection form contained information about the number of tobacco incidents.17 19 A tobacco incident was defined as the use or implied use of a tobacco product by an actor/actress. Every time an actor/actress was shown using or handling a tobacco product, it was counted as one incident. The coders noted the depiction of tobacco brands, whether directly on the tobacco product/pack shown in the incident or in some other way, such as a kiosk, or billboard post.
To assess compliance (if any) of the selected series with existing tobacco-free film and TV rules in India, the coders recorded the following on the data collection forms: the episode age rating (13+, 16+ or 18+); presence of anti-tobacco static warning message at the bottom of the screen during the period of display of tobacco products; anti-tobacco health spots displayed for 30 s; display of tobacco products/packs/brands (including blurring or masking of these); close-up of tobacco brands or products; whether tobacco use was shown by an actual historical character who actually used tobacco (because recommended policies to adult rate content have an exception for historical figures who actually used tobacco)20–22 ; and presence of the specified audio-visual disclaimers for 20 s about the ill effects of tobacco use.
The length of each episode was also noted by coders, details of which are provided in online supplementary file 1.
Supplemental material
Inter-rater agreement analysis
Wilcoxon signed-rank test was performed on 30 randomly selected episodes to determine if there was consensus about the number of tobacco incidents estimated by coders in this study. The Wilcoxon signed-rank test is relevant for assessing inter-rater agreement as the variable of interest (tobacco incidents) is a numerical variable rather than a categorical variable for which a kappa coefficient is suitable.23 We found that there was no significant difference in the total number of tobacco incidents between the two coders (p=0.16), indicating sufficient inter-rater agreement.
Data analysis
The primary outcome variable was the number of tobacco incidents and the secondary outcomes were brand depiction and compliance with the tobacco-free film and TV rules in India. The total number of tobacco incidents for each series were derived by summation of the tobacco incidents in the corresponding seasons and episodes. In addition, we present aggregated statistics using the median and IQR for the number of tobacco incidents per episode, per season and per series as comparators, because the number of seasons and episodes in the selected series differed widely. The number of tobacco incidents per 60 min in each series were also evaluated, which can be used by future studies to compare the number of tobacco incidents in these series with tobacco incidents in other media/platforms. Brand placement and compliance with the tobacco-free film and TV rules were assessed to analyse any patterns of tobacco imagery in these series. Data were analysed using the STATA v.13.1 (StataCorp, LP, Texas, USA) statistical software.
The study was approved by the institutional review board of the Centre for Chronic Disease Control, New Delhi (reference: IRB00006330).
Results
The selected 10 series contained a minimum of one and a maximum of three seasons. The seasons consisted of a minimum of six to a maximum of 43 episodes. In total, 188 episodes across 10 selected series available on Netflix and Amazon Prime Video were coded for the content analysis of tobacco imagery. Seven of the 10 selected series were rated 16+ (suitable for viewers aged >16 years). Two series were rated 18+ and one was rated 13+ (table 1). The length of each episode ranged from 42 to 70 min.
Incidents of tobacco use
Of the 188 episodes, 108 (57.4%) contained at least one incident of tobacco use. As illustrated in table 1, the total number of tobacco incidents in the 10 selected series ranged from zero (in Bodyguard, Riverdale and 13 Reasons Why) to 1652 (in The Marvellous Mrs Maisel). The total number of tobacco incidents in other series that contained tobacco were 833 in ‘Narcos’, 599 in ‘The Crown’, 233 in ‘Stranger Things’, 171 in ‘Chilling Adventures of Sabrina’, 78 in ‘Mirzapur’ and 67 in ‘Sacred Games’.
One of the most popular series among adolescents and young adults who participated in this study, Amazon’s ‘The Marvellous Mrs Maisel’ with 18 episodes over two seasons, had the highest median number of tobacco incidents (87.5 (IQR 62.0–116.0)) per episode for the entire series. The Netflix series ‘The Crown’ (20 episodes over two seasons) had the second-highest median number of tobacco incidents (29.0 (IQR 18.0–36.0)) per episode.
The median number of tobacco incidents per episode for another Netflix series, ‘Narcos’ was 26.5 (IQR 16.0–37.0). In contrast to the above-mentioned foreign-produced series that showed high tobacco incidents, the median number of tobacco incidents per episode in the Indian-produced series such as Netflix’ ‘Sacred Games’ (9.0, IQR 0.5–14.5) and Amazon’s ‘Mirzapur’ (7.0, IQR 4.0–11.0), were low. However, there was no significant difference (p=0.84 by Mann-Whitney rank sum test) in the median number of tobacco incidents across foreign-produced series episodes (5.0, IQR 0–29.0) and Indian-produced series episodes (8, IQR 1–11). Other foreign production series, Netflix’ ‘Stranger Things’ and Netflix’ ‘Chilling Adventures of Sabrina’ also had 10.0 (IQR 5.0–21.0) and 11.0 (IQR 6.0–26.0) median number of tobacco incidents per episode for the entire series, respectively. Figure 1 shows the number of tobacco incidents per hour (60 min) of screen time for each of the series coded. The foreign-produced ‘The Marvellous Mrs Maisel’ had the highest tobacco incidents per hour (106.1), followed by other foreign-produced series, ‘Narcos’ (33.5) and ‘The Crown’ (30.8). The Indian productions, ‘Mirzapur’ and ‘Sacred Games’ contained fewer (11.0 and 10.3 respectively) tobacco incidents per hour.
Tobacco incidents per hour of the screen time in online series.
Brand appearances in the series
Four out of 10 series depicted tobacco brands. All of these series which showed tobacco brands were foreign productions. The two series (Sacred Games and Mirzapur) produced in India contained no tobacco brand appearances. The tobacco brands depicted in the series included Mayburn, Camel, Marlboro, Salem and Newport. The tobacco brands were depicted 35 times in Netflix’ ‘Narcos’, followed by Netflix’ ‘Stranger Things’ (21 times), Amazon’s ‘The Marvellous Mrs Maisel’ (four times) and Netflix’ ‘13 Reasons Why’ (once) (table 2).
Tobacco brands shown in the 10 most popular online series shown on Netflix and Amazon prime video
Compliance with Tobacco-Free Film and TV Rules
None of the series that contained tobacco incidents (both foreign productions and Indian productions having any tobacco incidents) complied with the tobacco-free film and TV rules in India (table 3). None of the episodes in any season of these seven series, including the ones which featured historical characters (The Crown and Narcos), had anti-tobacco static warning messages, anti-tobacco health spots or displayed an audio-visual disclaimer about the ill effects of tobacco use. In addition, close-up of tobacco products were shown in six episodes of Netflix’ ‘The Crown’ and two episodes each in Amazon’s ‘The Marvellous Mrs Maisel’ and Netflix’ ‘Narcos’.
Compliance of 10 online series with tobacco-free film and TV rules in India
Discussion
Our findings suggest that the extent of tobacco imagery and brand placement in series available from on-demand streaming platforms including Netflix and Amazon Prime Video are high in India. It was observed that 70% of the series popular with young adults on these platforms portray tobacco use, of which the highest number was recorded in Amazon’s ‘The Marvellous Mrs Maisel’ followed by Netflix’ ‘Narcos’ and ‘The Crown’. Similar results were seen in a study conducted by the Truth Initiative in 2018 in the USA, which found that 79% of the on-demand streaming series popular among young people in the USA aged 15–24 years depict smoking.24 A recently published US study also highlighted that the total number of tobacco occurrences (n=1185) were higher in programmes shown on Netflix than in broadcast or cable TV programmes (n=482) popular among US adolescents and youth aged 15–24 years.25 A study conducted in the United Kingdom to assess tobacco imagery in the five highest-rated series on Netflix and Amazon Prime found similar results.26
It is well established that exposure to pro-tobacco imagery in media increases the likelihood of tobacco uptake in adolescents and young adults27–29 and that this relationship is causal,30–32 with a strong dose–response relationship.4 Consistent with results from other countries, a longitudinal study conducted in 32 schools in Delhi and Chennai indicated that adolescents (10–16 years old) with an increased exposure to tobacco advertisements were 1.5 times (95% CI 1.12 to 1.94) more likely to progress towards tobacco use in comparison with those who were not exposed,33 indicating that exposure to tobacco imagery can result in tobacco uptake among Indian adolescents. There is no reason to expect that the effects of exposure to tobacco imagery in streaming shows should be any different than the effects of tobacco imagery in films. On-demand streaming content providers and governments should heed the lessons learnt from the film industry and apply the same rules to including tobacco imagery in the content available through on-demand streaming platforms.
This study found that none of the series with tobacco incidents were compliant with the tobacco-free film and TV rules in India. In 2018, a non-governmental organisation in New Delhi filed a Public Interest Litigation in the Delhi High Court under Article 226 of the Constitution of India, seeking guidelines to regulate the content broadcast on the online platforms in India.34 This litigation highlighted that the content broadcast on the online platforms is self-generated and there is no certifying or governing body to regulate the content.34 After dismissal of this litigation from the Delhi High Court, the Supreme Court of India issued legal notices to the Ministries of Information and Broadcasting, Law and Justice, and Communications and Information Technology requiring them to present their response on the lack of regulation of content shown on online platforms.35 While the matter is still being heard at the Supreme Court of India, it could be argued that the Information Technology Act 2000, the Cinematograph Act 1952 and the Cable Television Network (Regulation) Act, 1995 should govern online platform content.36 However, because such platforms are a blend of many fields (from different countries and having customised content delivery network points), there is no single law or agency in India which regulates the content shown on online platforms, such as Netflix or Amazon Prime Video.36
At this time, the content available on streaming platforms is governed solely by the company’s guidelines, which are not available to the public. Nonetheless, similar to the voluntary code of conduct observed by the Advertising Standards Council of India for self-regulation in advertising for the promotion of products, online streaming companies have recently made a move to adopt voluntary rules for certain types of content.37 Leading online curated content providers, signed a self-regulatory code of best practices under the aegis of the Internet and Mobile Association of India.37 This self-regulatory voluntary code aims to stop the online platforms from showing content that is banned by Indian courts, or promotes terrorism, violence or shows children and women in sexual acts.37 However, earlier evidence suggests that voluntary arrangements are not successful in regulating exposure to tobacco use.38 39 Consequently, our findings suggest that there is an urgent need to devise strong regulatory and enforcement measures related to the depiction of tobacco imagery on on-demand streaming platforms in the interest of public health. Such measures will also protect adolescents and young adults from exposure to pro-tobacco messaging consistent, with implementing Section 5 of COTPA and guidelines for FCTC Article 13,22 which seek to prevent the use of entertainment media to promote tobacco products.
This is the first study in India to estimate the extent of tobacco imagery in series popular among adolescents and young adults and available through on-demand streaming platforms. Moreover, our study directly addresses and reiterates the decision on TAPS in entertainment media at the eighth session of Conference of Parties (Geneva, 2018) of the WHO FCTC.40 The decision called for continued action by parties, including monitoring of depiction of tobacco in entertainment media, implementing a comprehensive TAPS ban and considering the need for modernisation of FCTC Article 13 guidelines on depiction of tobacco in entertainment media to deal with its newer forms, such as internet and mobile communications.
The study has some limitations. The discussions were conducted with only 33 adolescents and young adults in the urban setting of Delhi, who listed the most watched series. Also, these participants were selected from purposively recruited schools and colleges. It is possible that adolescents and young adults from other schools and colleges in Delhi have different viewing preferences on streaming platforms. However, no publicly available, nationally representative data are available on viewer choices for these age groups on streaming platforms in India. Moreover, the sample was only 10 series popular with adolescents and young adults in an Indian city. As the popularity of on-demand streaming platforms is higher in urban areas than in rural settings,13 the study focused on urban Indian school and college-going students. Consequently, the generalisability of the results is limited.
This study highlights that the extent of tobacco imagery in series popular among Indian adolescents and young adults, and available through on-demand streaming platforms, is high, particularly in series produced by the US companies, Amazon Prime Video and Netflix. Contrary to the provision of Section 5 of COTPA, which mandates a complete ban on tobacco advertising and promotion in any form of media, these online streaming platforms do not comply with the tobacco-free film and TV rules. We recommend better enforcement of the existing tobacco control laws (COTPA Section 5) in India and further emphasize that these rules do apply to streaming platforms as well. The implementing guidelines for WHO FCTC Article 13 should be updated to deal specifically with tobacco use in streaming and other new media. The study also highlights a need for discussion with the companies providing online content about better compliance with domestic laws, to protect adolescents and young adults from exposure to tobacco imagery on such platforms.
What this paper adds
Section 5 of India’s Cigarettes and Other Tobacco Products Act (COTPA) imposes a complete ban on tobacco advertising and promotion in any form of media.
Streaming is a new form of media popular among adolescents and young adults in India.
We found that out of the 188 episodes across 10 on-demand streaming series studied, the US produced series – Amazon’s ‘The Marvellous Mrs Maisel’ and Netflix’ ‘Narcos’ and ‘The Crown’ had higher tobacco imagery compared with Indian produced series – Amazon’s ‘Mirzapur’ and Netflix’ ‘Sacred Games’.
Section 5 of COTPA is blatantly being violated in this new media indicating the need for better enforcement of existing rules in India and updating WHO Framework Convention on Tobacco Control Article 13 guidelines.
Acknowledgments
We would like to acknowledge the coders from HRIDAY involved in the study. We would also like to thank the participants from schools and colleges in New Delhi who participated in the study.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
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Footnotes
Twitter @DrMonikaArora, @gaurang_nazar, @chugh_aastha, @still_surbhi, @ProfGlantz
Contributors MA, GPN, TR, JRP and SG conceptualised the study. GPN, AC, TR and SS contributed to data collection and analyses. MA, GPN, SG, KS, PS, FTT, VGM, and JRP contributed to interpretation of results. AC and GPN drafted the manuscript and all other authors revised the manuscript critically for intellectual contents. All the authors approved the final manuscript.
Funding WHO Country Office for India provided technical oversight and support for this study which was conducted by HRIDAY in collaboration with University of California San Francisco and Onbeyond LLC (USA).
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request.