Effect of seeing tobacco use in films on trying smoking among adolescents: cross sectional study
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7326.1394 (Published 15 December 2001) Cite this as: BMJ 2001;323:1394All rapid responses
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There are so many unaccounted variables in the Sargent
et al study that it is unwise to base sweeping legislative
proposals on its findings. Many studies have found
adolescent and adult smoking are part of constellations
of high-risk and thrill-seeking behaviors, and this
constellation may well include heavy popular media
consumption--especially the sorts of movies where
characters themselves engage in risky behaviors such as
smoking. Just as violent individuals tend to prefer more
violent media, so smokers may prefer movies where
their habit is depicted frequently and positively, while
those disinclined to smoke may reject movies where a
habit they reject is depicted. Evidence for my
counter-hypothesis is found in the Sargent study’s
finding that the odds ratio for smoking in the
highest-movie-exposed set of youths drops dramatically
from 8.8 (based on 4.9% smoking incidence in the
least-exposed set to 31.3% in the most exposed) to 2.7
when the selected sociopersonal variables in the study
are controlled. This suggests the sociopersonal variables
powerfully mediate the tendency of adolescents to
attend movies where heavy smoking is depicted.
The second objection is that the measure (ever tried
smoking) is overly broad. Most adolescents try smoking;
only a minority of those who try take up the habit.
Absent is any showing that those adolescents for whom
movie depictions of smoking (as opposed to other
variables) form a significant motivation to try a cigarette
are likely to continue the habit, or whether these
comprise the one-time experimenters.
The chief objection, however, is the proposal by Action
on Smoking and Health and Dr. Stanton Glantz, among
others, for legislated restrictions on youths attending
movies in which smoking is depicted. First, the present
study finding is correlational only. The fact that the
variables the authors did control for sharply reduced
their initial correlation is a warning signal that control
for additional variables might reduce it to insignificance.
For example, it is crucial to know whether the
correlation is in reverse (i.e., do teenage smokers simply
prefer movies depicting heavy smoking more than do
teenage nonsmokers?) or mediated by more important
variables (i.e., do poorer youth both smoke more and
attend the types of movies where smoking is prevalent?).
The study authors acknowledge that their preliminary
study should not been seen as proof that movies cause
teen smoking, especially since directional causation
cannot be determined.
Second, I would invite those proposing legislation to
consider what rating movies depicting smoking as
Restricted (under 17 requires guardian) means in effect.
Such restrictions have been found ineffective in
curtailing adolescent media patronage in any case; the
only effective measure would be to rate such movies as
NC-17 (no youths allowed at all) or to ban such movies
altogether. Even assuming a way could be found to
prohibit youths from seeing smokers in movies they
want to see, consider the thousands of movies, including
virtually all classic war, newspaper, crime, and comedy
films to which restrictions would apply. Are Dr. Glantz
and ASH suggesting that a 14- or 16 year-old must have
a guardian to see “Casablanca,” “Pink Panther,” or “The
Graduate”? A quick glance at the American Film
Institute’s 10 “Best American Movies of All Time”
indicates at least eight would be restricted for youth
under the proposed policy. Setting age limits for films
depicting smoking is simply too great a curtailment of
young people’s basic right to participate in their culture
even given the policy’s laudable goal of reducing
smoking. It is all the more cavalier in light of the
dubious evidence for it and the more moderate and
focused measures (such as requiring filmmakers to
disclose promotional payments and taxing them at 100%
of value). It should be emphasized that more than
two-thirds of youths exposed to even the heaviest
depictions of smoking do not try cigarettes even once,
yet they would be punished by one-size-fits-all
restrictions.
American anti-smoking policies of the last decade have
been woefully ineffective precisely because
anti-smoking lobbies too quickly veer into popular
panaceas affirming media-message determinism and
involving ever-accumulating age restrictions.
Unfortunately, ineffectual popular salvos typically grab
legislative attention, reducing support for politically
difficult, effective measures. The fact is that the large
majority of teenagers who smoke come from families
and communities where adults smoke, and the most
effective policies to curtail smoking involve raising
tobacco taxes and restricting adult smoking. Dr. Glantz
has been a rare pioneer and leader in rational
anti-smoking strategies, and his concern over the corrupt
relationship between movie makers and the tobacco
promotion industry is not misplaced. But I ask that he,
ASH, and other anti-smoking lobbies to reconsider their
proposal to punish adolescents en masse by restricting
them from movie attendance and instead to propose
policies that directly and exclusively penalize the film
and tobacco industries at fault.
Mike Males, Ph.D.
Sociology Department
University of California, Santa Cruz
Santa Cruz, CA 95061-7842
Email: mmales@earthlink.net
http://home.earthlink.net/~mmales/
Competing interests: No competing interests
I may only be a 2nd year medical student, but I've seen enough
evidence-based medicine examples over the previous year to be able to spot
when I think somebody is jumping to the wrong conclusion when interpreting
data.
In the article that asserts that adolescents who saw more incidents
of smoking in films were more likely to start the habit, the author backed
this up by saying that there was a higher incidence of smoking uptake in
adolescents who had seen more incidences of smoking in the time period.
However, I would like to suggest that this merely reflects the fact that
adolesecent smokers socialize a lot in public, due to smoking bans in home
(by parents), so this increased social interaction leads them to become
the sort of people who are more likely to go to the cinema more often, and
thus be exposed to a greater number of incidences of smoking.
In conclusion, I am suggesting that it is not the films that
encourage people to take up smoking, rather smoking that encourages
people to go out to the cinema more and socialize.
Competing interests: No competing interests
Smokier films or simply more films?
Sargent et al demonstrate that in a large series of adolescents,
those who have ever tried smoking have a higher level of exposure to
watching smoking in films than those who have not. The smoking outcome
studied is not restricted to instances of starting smoking for the first
time. An unusual feature of this context is that most likely practically
everyone in the series has some exposure to films containing smoking, so
what is shown here should be regarded as dose-response, not a comparison
of the exposed and unexposed.
Both the authors and responders (Richard Hutchinson and Mike Males)
discuss confounding as a major issue in interpreting an observational
study such as this. Among many confounders considered by the authors, age
plays a crucial role: as an individual ages, both the total number of
films ever watched can only increase, and also the only possible smoking
transition is from "never" to "ever". In recognition of this, figure 3
shows how the relationship is demonstrable within age bands also.
However, in this instance, there is a related issue, which is not
confounding as such, hence more covert. The exposure measure has been
developed as a proxy for total exposure to viewing smoking on films and is
probably valid for this purpose. But it is a composite measure.
Adolescents in the study varied widely in how many of the 50 designated
films they had seen (figure 2), as well as in the kinds of films they
chose. The authors state that the latter factor is unlikely to explain
the findings. Hence, might it not be the case that the study is largely
picking up some sort of association of smoking with total amount of
viewing? Both factors may be inversely related to physical activity,
which does not appear to have been considered. Surely it would be helpful
to split up the exposure measure and to examine how smoking and non-
smoking adolescents differed both in the "smokiness" of the average film
they watched and also how many of the films they had seen, the latter as a
proxy for overall film-watching activity (if that is not an oxymoron).
My purpose in pointing this out is not in any way to seek to disparage the
hypothesis that the portrayal of smoking in films may be harmful, merely
to reiterate the principle that our prior belief that a hypothesis is
correct does not obviate the need to consider carefully alternative
explanations of what is observed. Indeed, many other practices
deleterious to health and wellbeing feature strongly in films, and given
the choice, adolescents tend to select such films. The issue of
appropriate film content extends far beyond the depiction of smoking.
Competing interests: No competing interests