Exposure to on-screen smoking in movies causes youths to smoke. There is a ‘dose-response’: the more smoking youths see, the more likely they are to smoke, with heavily exposed youths about three times as likely to begin smoking as lightly exposed youths, after controlling for other factors linked with smoking (peer smoking, parental smoking, academic performance, exposure to cigarette advertising and other factors).
These results from the USA have been confirmed both qualitatively and quantitatively in New Zealand, Mexico and Germany. (One study using secondary data analysis from Scotland found no effect, but the authors noted that there may be problems in exposure assessment which biases the results towards the null.) Concern over the effects of on-screen smoking on adolescent smoking initiation has led many organisations, including the British Medical Association, Institute of Medicine of the US National Academy of Sciences and the World Health Organization to call for reductions in youth exposure to on-screen smoking. Addressing the fact that on-screen smoking promotes youth smoking is part of implementing the WHO Framework Convention on Tobacco Control.
One way to reduce exposure would be to integrate tobacco imagery into national film age-classification systems to give films depicting tobacco an adult content rating. The British Board of Film Classification (BBFC), the non-governmental, film industry-funded agency that recommends ratings for films in the UK, states that a rating of ‘18’, which precludes people under from seeing a film in a cinema, should be awarded to films ‘where material or treatment appears to the Board to risk harm to individuals or, through their behaviour, to society’, a standard met by the available scientific evidence on the effect of on-screen smoking on youth behaviour. As of February 2010 the BBFC had refused to apply its rules to on-screen smoking.
The BBFC is, however, only advisory to local councils. The BBFC notes, ‘[s]tatutory powers on film remain with the local councils, which may over-rule any of the Board’s decisions, passing films we reject, banning films we have passed, and even waiving cuts, instituting new ones, or altering categories for films exhibited under their own licensing jurisdiction’. Because of the BBFC’s failure to act, in 2008 Liverpool announced it was considering applying an ‘18’ rating to films with tobacco use and on 12 June 2009 initiated the formal consultation process to integrate this policy into its local licensing procedure.
Amount of smoking in films in the UK market
There were 738 motion pictures in the top 10 weekly box office lists for 1 January 2001–31 December 2006 that earned at least ₤250 000 in the UK19 (excluding ET, The Extraterrestrial, a 1982 film, and Alien, a 1979 film, re-released during the study period). We obtained the number of tobacco occurrences in 572 films (546 top grossing films in the UK that also ran in the USA, and top grossing films in the UK market not released to US theatres) from the Cancer Control Research Program at Dartmouth-Hitchcock Medical Center using the same established methods as have been used for the epidemiological studies of the effects of on-screen smoking on adolescent and young adult smoking behaviour.
Briefly, trained coders reviewed each film, recorded ‘tobacco episodes’, defined as the appearance of tobacco use or handling of tobacco products by a major or minor character in one scene (with two people smoking in the same scene counting as two episodes) and ‘tobacco incidents’, defined as the appearance of tobacco in a scene without use by a character (with all such ‘incidents’ in a single scene coded as one incident). ‘Tobacco occurrences’ are the sum of tobacco episodes plus tobacco incidents in a film.
The vast majority of smoking events in films shown in the UK was delivered by youth-rated films (89%). Although US film studios were responsible for almost all of the movies with smoking events viewed in the UK (96%), more smoking occurs in films rated for youths in the UK (6.22 average occurrences) than occurs in youth-rated films in the USA (4.50 average occurrences). This difference is mainly because the large number of films rated ‘R’ in the USA (under 17 not admitted without parent or guardian) are re-classified as ‘15’ in the UK. Of 190 films rated ‘R’ by the MPAA in the USA, BBFC assigned 21% an ‘18’, 77% a ‘15’ rating and 2% a ‘12A’ rating. More smoking appears in US ‘R’-rated films than appears in films rated for youths; assigning such films a youth classification in the UK means British youths have greater potential exposure to smoking in movies. In both the UK and USA, youth-rated films comprise the majority of films with smoking and deliver the majority of tobacco impressions to theatre audiences: unsurprising, since US films dominate the UK market. In the UK, however, because of BBFC rating practice, the share of tobacco occurrences seen in youth-rated films (87%) is nearly twice that in the USA (45%). Other countries (eg, Germany) with ratings systems that are less conservative (in terms of language and sexuality) than the USA will also be likely to deliver more on-screen tobacco impressions to youths.
Four studies in the USA have estimated the attributable risk fraction of adolescent and young adult smokers, three based on northern New England longitudinal studies and one based on a national cross-sectional study, all of which used multivariate models, so they control for confounding. The original New England cohort (middle school students at baseline) found that 0.52 (95% CI 0.30 to 0.67) of those who ‘tried smoking’ was attributable to smoking in the movies. A later follow-up in the same cohort23 found an attributable risk fraction of 0.35 (95% CI 0.14 to 0.56) for established smoking at young adulthood because of movie smoking exposure. A different northern New England longitudinal cohort that started with younger children (4th–6th graders at baseline) found that 0.46 (95% CI 0.11 to 0.70) of youths who tried smoking was attributable to movie exposure. Finally a national cross-sectional study (adolescents 10–14 years old) found that the adjusted attributable fraction for having tried smoking was 0.38 (95% CI 0.20 to 0.56). It is likely that the attributable risk fractions in the UK would be higher than in the USA for two reasons. First, in the USA conventional cigarette advertising is also contributing to youth smoking initiation, but such advertising has been all but banned in the UK, which increases the relative importance of films as a promotional medium. (Even in the USA and Germany, where promotion of tobacco products continues, the effect of films on youth smoking behaviour exceeds that of traditional advertising and promotion.) Second, because of the differences in rating practices documented in this paper, the level of adolescents’ exposure to on-screen smoking is substantially higher in the UK than the USA.
In addition to lowering the probability that a youth will see a film, an ‘18’ rating for smoking would create an economic incentive for motion picture producers to simply leave smoking out of films developed to be marketed to youths. By comparing total box office sales of a random sample of youth-rated films with that of the ‘18’-rated films, we determined that youth-rated films grossed 1.75 times as much as ‘18’-rated films. The decision to classify a film as appropriate for youths clearly has economic benefits for the film industry.
In the USA, one thing that paediatricians can do is advise parents to keep children and teenagers from seeing R-rated movies, thereby substantially reducing the exposure to children. In the USA, children of parents who restrict their access to R-rated films are less likely to smoke, in a way consistent with the observed dose-response relation. This intervention is not available to paediatricians in the UK because the BBFC rates 75% of US R-rated for children (‘15’ or ‘12’).
Exposure to smoking in films accessible to youths is a substantial contributor to youth smoking initiation. UK youths are potentially exposed to even more on-screen smoking than are youths in the USA, where the strong dose-response effect is firmly established. Implementing the BBFC film rating system’s current standard that films in which ‘material or treatment appears … to risk harm to individuals or, through their behaviour, to society’ and assigning future films with tobacco imagery an ‘18’ rating would reduce UK youth exposure to on-screen smoking even more than a comparable change in the USA, with a correspondingly greater reduction in films’ effect on youth smoking initiation.
By Stacey J Anderson, Christopher Millett, Jonathan R Polansky, Stanton A Glantz