Elsevier

The Lancet

Volume 362, Issue 9380, 26 July 2003, Pages 281-285
The Lancet

Articles
Effect of viewing smoking in movies on adolescent smoking initiation: a cohort study

https://doi.org/10.1016/S0140-6736(03)13970-0Get rights and content

Summary

Background

Exposure to smoking in movies has been linked with adolescent smoking initiation in cross-sectional studies. We undertook a prospective study to ascertain whether exposure to smoking in movies predicts smoking initiation.

Method

We assessed exposure to smoking shown in movies in 3547 adolescents, aged 10–14 years, who reported in a baseline survey that they had never tried smoking. Exposure to smoking in movies was estimated for individual respondents on the basis of the number of smoking occurrences viewed in unique samples of 50 movies, which were randomly selected from a larger sample pool of popular contemporary movies. We successfully re-contacted 2603 (73%) students 13–26 months later for a follow-up interview to determine whether they had initiated smoking.

Findings

Overall, 10% (n=259) of students initiated smoking during the follow-up period. In the highest quartile of exposure to movie smoking, 17% (107) of students had initiated smoking, compared with only 3% (22) in the lowest quartile. After controlling for baseline characteristics, adolescents in the highest quartile of exposure to movie smoking were 2·71 (95% CI 1·73–4·25) times more likely to initiate smoking compared with those in the lowest quartile. The effect of exposure to movie smoking was stronger in adolescents with non-smoking parents than in those whose parent smoked. In this cohort, 52·2% (30·0–67·3) of smoking initiation can be attributed to exposure to smoking in movies.

Interpretation

Our results provide strong evidence that viewing smoking in movies promotes smoking initiation among adolescents.

Published online June 10, 2003 http://image.thelancet.com/extras/03art1353web.pdf

Introduction

Many studies have linked tobacco marketing with an increased risk of smoking uptake in adolescents.1, 2, 3, 4, 5, 6, 7 For example, owning tobacco promotional items and being able to recall cigarette advertisements can double the odds that an adolescent will become an established smoker.3 Movie images, like commercial advertising, associate smoking with celebrities and depict it as an attractive behaviour.8 In popular contemporary movies, smoking is frequently associated with characteristics many adolescents find appealing-such as toughness, sexiness, and rebelliousness.9 Endorsement of cigarette brands in movies by actors has also increased substantially over the past decade.10

Several studies have described how smoking is portrayed in movies,9, 11, 12, 13, 14, 15, 16 but only a few have specifically assessed whether viewing smoking in movies affects adolescent smoking behaviour. In an experimental study, Pechmann and Shih17 showed that adolescents were more likely to report positive attitudes toward smoking after seeing smoking portrayed in movies. Results of two crosssectional studies18, 19 indicated that adolescents were more likely to have tried smoking if their favourite movie stars smoked on screen. In our previous study of adolescents in New England, USA, exposure to smoking in movies was associated with smoking experimentation, even after controlling for the effects of other social influences, parenting, and personality characteristics of the child.20

Collectively, these results suggest that movie smoking influences adolescent smoking behaviour. However, the cross-sectional design of these studies precludes establishment of a temporal relation. To determine whether exposure to movie smoking predicts smoking initiation in adolescents, we did a longitudinal study of adolescents in New England, USA, who had never previously tried smoking.

Section snippets

Participants

In 1999, we distributed a self-administered written survey to adolescents (aged 10–14 years) enrolled in grades 5 through 8 at 14 schools in Vermont and New Hampshire, USA. The purpose of this baseline survey was to assess exposure to smoking in movies and investigate its association with lifetime smoking experience. Details of the methods for the survey have been published previously.20

Through the baseline survey, we identified 3547 adolescents who had never tried smoking cigarettes and were

Procedures

We assessed lifetime smoking experience at baseline and follow-up by asking “How many cigarettes have you smoked in your life?”, to which respondents could answer “none”, “just a few puffs”, “one to 19 cigarettes”, “20 to 100 cigarettes”, or “more than 100 cigarettes”. Only students who answered “none” at baseline were eligible for follow-up. Students who reported any cigarette smoking (just a few puffs, one to 100 cigarettes, more than 100 cigarettes) on the follow-up survey were classified as

Statistical analysis

Preliminary analyses consisted of descriptive frequencies, χ2 tests to compare differences in proportions, and t tests to compare mean differences by group. We used generalised linear models28 to assess smoking initiation as a function of both movie exposure and baseline covariates. We used a log link, rather than a logistic regression, so that relative risks could be estimated directly. An overdispersion variable was used to account for possible clustering by schools. Exposure to movie smoking

Role of the funding source

The sponsor of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Results

Our final sample of 2603 adolescents was mainly white (94%, n=2392), as was the underlying population (96%); equally distributed by sex; with a mean age at baseline of 12 years (SD 1.1). Participants who were followed up were much the same as non-participants in age, sex, grade, and exposure to movie smoking, but nonparticipants were more likely than participants to have parents who smoke (41% [383] vs 30% [773], respectively) and slightly more likely to be susceptible to smoking30 at baseline (

Discussion

Our results suggest that viewing smoking in movies strongly predicts whether or not adolescents initiate smoking, and the effect increases significantly with greater exposure. Adolescents who viewed the most smoking in movies were almost three times more likely to initiate smoking than those with the least amount of exposure. The magnitude of this association is consistent with the results of our cross-sectional study of adolescents in New England, USA.20 It is also consistent with the results

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