Published online November 1, 2006
PEDIATRICS Vol. 118 No. 5 November 2006, pp. 1932-1942 (doi:10.1542/peds.2005-3082)
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ARTICLE

Parental Rules and Monitoring of Children’s Movie Viewing Associated With Children’s Risk for Smoking and Drinking

Madeline A. Dalton, PhDa,b,c, Anna M. Adachi-Mejia, PhDa,b,c, Meghan R. Longacre, PhDa,b,c, Linda T. Titus-Ernstoff, PhDb,c,d, Jennifer J. Gibson, MSb,c,d, Susan K. Martin, BSa,b, James D. Sargent, MDa,b,c,d and Michael L. Beach, MD, PhDb,c,d,e

a Pediatrics
d Community and Family Medicine, Dartmouth Medical School, Lebanon, New Hampshire
e Department of Anesthesia
b Community Health Research Program, Hood Center for Children and Families
c Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVES. Evidence suggests that media portrayals of tobacco and alcohol use are important predictors of adolescent smoking and drinking. We examined the role of parents in monitoring and limiting children’s movie exposure and whether or not this was associated with a lower risk of adolescent smoking and drinking.

DESIGN. We surveyed 2606 child-parent dyads between 2002 and 2003. We asked children (9–12 years of age) how often their parents engaged in specific behaviors to monitor their movie viewing and if their parents allowed them to watch R-rated movies. We also surveyed children about parental monitoring of nonmedia-related behaviors. The primary outcomes were risk of smoking and drinking alcohol, defined by attitudinal susceptibility or early experimentation with either substance.

RESULTS. Less than half (45.0%) the children were prohibited from watching R-rated movies. Of those who were allowed to watch R-rated movies, one third (34.7%) always viewed them with a parent and two thirds (65.3%) sometimes watched them without a parent. Less than 10% of the children reported that their parents consistently engaged in all 4 movie-monitoring behaviors. Even after controlling for parental monitoring of nonmedia-related behaviors and other covariates, children were at lower risk of smoking and drinking if their parents prohibited them from watching R-rated movies. Parental coviewing of R-rated movies was associated with a lower risk of child smoking but not drinking if parents consistently monitored what their children watched.

CONCLUSIONS. Parental rules and monitoring of children’s movie viewing may have a protective influence on children’s risk for smoking and drinking, over and above parental monitoring of nonmedia related behaviors. This highlights a potential role for parents in preventing early initiation of tobacco and alcohol use among adolescents.

Key Words: smoking • alcohol • movie exposure • parental monitoring • parenting • children’s risk behaviors

Abbreviations: RR—relative risk • CI—confidence interval

Media is undeniably an integral part of children’s lives, accounting for a tremendous proportion of their recreational activity. A national survey of US youth found that the average adolescent spends 6.5 hours each day using media.1 Television and movie viewing account for the majority of this exposure, together averaging ~4 hours a day. Numerous content analyses have documented a high frequency of alcohol and smoking portrayals in both television programming and movies,2–11 indicating that today’s youth are likely exposed to frequent portrayals of alcohol and tobacco use in entertainment media.

Over the past 20 years, researchers have investigated whether a relationship exists between exposure to various media content and children’s health risk behaviors.12–16 In the area of substance use, several early experimental studies demonstrated that children who viewed drinking portrayals on television had more positive beliefs about alcohol than children who did not.15,17 Additional studies have found associations between higher levels of television viewing and alcohol use among adolescents, but these studies did not use content-specific measures.16,18,19

Research on the effects of media portrayals of smoking have focused on movies rather than television, in part because movies are now a much more important component of home entertainment (reviewed by Charlesworth and Glantz20). In both regional and national studies, we found that viewing smoking in movies is positively associated with adolescent smoking initiation21–23 and attitudinal predictors of smoking among adolescent never smokers.24 Other studies have demonstrated that adolescents are more likely to try smoking if their favorite movie stars smoke.25,26 In addition to smoking, we found recently that adolescent initiation of alcohol use is linked to their exposure to alcohol use in movies.27 Collectively, these studies identify movies as an important risk factor for adolescent smoking and possibly drinking.

Additional research suggests that parents who do not want their children to smoke should limit their children’s exposure to R-rated movies.28 R-rated movies are of particular concern, because they portray numerous occurrences of smoking and drinking,29,30 often in the context of other adult behaviors. In both cross-sectional and longitudinal analyses, we found that adolescents 10 to 14 years of age were much less likely to smoke cigarettes or drink alcohol if their parents did not allow them to watch R-rated movies.31,32 This association was independent of other parental characteristics, including maternal supervision in areas other than media use, maternal responsiveness, and parental disapproval of smoking.

Numerous studies have shown that general parental monitoring of children’s behavior is associated with a lower prevalence of adolescent substance use, including tobacco and alcohol use.33–53 However, none of these studies have examined movie rules or movie monitoring as a component of parental monitoring. In this study, we examined parental rules about R-rated movie viewing and whether parents consistently engaged in specific behaviors to monitor their children’s movie viewing. We then assessed whether these parental rules and movie monitoring behaviors were associated with children’s risk for smoking cigarettes or drinking alcohol.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Data for this study were collected through child and parent surveys designed to investigate the association among parenting factors, movie viewing, and smoking uptake in children. The study was approved by the Committee for the Protection of Human Subjects at Dartmouth College.

Study Design
We identified child participants for this study through surveys administered in New Hampshire and Vermont public schools between October 2002 and December 2003. We randomly selected schools from a list of all New Hampshire and Vermont schools containing grades 4 through 6 (N = 559), stratified by state and number of students enrolled. Twenty-six schools participated in the study, which represents 30% of those contacted. Each school received a stipend of between $500 and $750.

The child survey included 2 components: a short self-administered written questionnaire completed at school and a telephone survey administered an average of 8.7 (SD: 5.0) weeks later. Students who completed the questionnaire at school were asked to provide their names and telephone numbers on a separate sheet of paper. We then contacted all of the households for which children had provided a working telephone number and obtained parental consent for the telephone surveys. If ≥2 siblings completed the school survey, we randomly selected 1 child from each household to ensure unique parent/child dyads. Parent surveys were conducted by telephone. Whenever possible, we surveyed the child’s mother. Trained interviewers administered the child and parent telephone surveys using an individualized computer-assisted telephone interview system. To protect participant confidentiality, children indicated their answers by pressing numbers on their telephone.

Survey Measures
Children’s age, gender, race, and school performance were assessed through the child school survey. All of the other measures described below were assessed through the telephone surveys. We asked children about their parents’ rules and monitoring, because studies have shown that children’s reports of parent behavior are better predictors of youth outcomes than parental reports.34,44,54–56

Outcomes
The primary outcomes for this study were children’s risk of smoking cigarettes or risk of drinking alcohol, defined as either being susceptible57 to or having experience with either substance. As shown in Table 1, children were considered at risk for each respective behavior if they reported that they had tried smoking or drinking alcohol or if they could not definitely rule out smoking or drinking alcohol in the near future. Because of the young age of the participants, we did not have any established smokers or drinkers in the sample.


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  		TABLE 1 Questions and Responses Used to Identify Children at Risk of Smoking Cigarettes or Drinking Alcohol

 
Parental Rules About R-Rated Movies
We measured parental restriction of R-rated movies by asking children, "How often do your parents let you watch movies or videos that are rated R?" to which they could respond, "never," "sometimes," "most of the time," or "all the time." We have used this measure of R-rated movie restrictions in previous studies and have demonstrated internal validity via a highly positive correlation with actual R-rated movie exposure.31,32 Among children who reported that they were allowed to watch R-rated movies at least sometimes, we asked, "When you watch an R-rated movie, how often do you watch it with one or both of your parents?" (never, sometimes, most of the time, or all the time). Responses to these 2 questions were combined into a single variable describing parental rules about R-rated movies as follows: 0 indicates they were allowed to watch R-rated movies without a parent (permits); 1 indicates they were allowed to watch R-rated movies, but always with a parent (coviews); and 2 indicates they were never allowed to watch R-rated movies (prohibits).

Parental Monitoring of Children’s Movie Viewing
To assess parental monitoring of children’s movie viewing, we asked children about the following 4 specific parental movie monitoring behaviors: (1) "How often do your parents want to know what a movie is rated before you can see it?" (2) "How often do you have to check with your parents before watching a movie?" (3) "How often do your parents go into the video store with you when you rent a movie?" and (4) "When you go to a friend’s house, how often do your parents check to see what movie you might be watching?" To identify parents who consistently monitored their children’s movie viewing, we collapsed the responses for each question (never, sometimes, most of the time, or all the time) into dichotomous variables (0 = not all the time; 1 = all the time). We chose to dichotomize the variables based on whether or not parents always engaged in the behavior, not only because this split minimizes the chances of misclassification but also because it provides a clearer interpretation and message for parents. We did run the analyses using the variables as continuous measures and also with a dichotomous split between "sometimes" and "most of the time," and the findings were consistent.

Covariates
To assess parental monitoring of nonmedia-related behaviors, we used 7 items from an authoritative parenting58–60 scale that was developed and validated previously in an adolescent sample.43 We asked children to tell us how well each of the following 7 statements described their mother (or primary caregiver if they did not live with their mother): "She tells me what time to come home," "She makes sure I tell her where I’m going," "She knows where I am after school," "She has rules about how I spend my time after school," "She asks me what I do at my friends’ houses," "She knows what I do on weekends," and "She checks to see if I do my homework." Children responded using a 4-point Likert scale (0 = not like her; 3 = exactly like her). Responses for all 7 of the items were summed ({alpha} = .70) and then categorized by quartiles for the analysis. Other covariates assessed through the child telephone survey included friend smoking and friend drinking. Parent education, household income, parental smoking, and parental drinking were assessed through the parent survey.

Statistical Analysis
Categorical data were analyzed initially using {chi}2 tests. Generalized linear models were used to assess the risk for smoking and drinking as a function of parental R-rated movie rules, parental monitoring of children’s movie viewing, and covariates.61 We used a log link, rather than logistic regression, to estimate relative risks directly. We tested for interactions between parental movie monitoring behaviors and parental rules about R-rated movies by comparing the residual deviance between models with and without interaction terms. An overdispersion parameter was used to account for possible clustering by school. Five imputed data sets were analyzed, and the results were combined62 to create statistical inferences that reflect uncertainty because of missing values and to avoid bias that may result from excluding adolescents with missing data for any of the included covariates. We first used separate models to assess each parental movie monitoring behavior as a discrete dichotomous predictor of smoking and drinking risk. Our models indicated that each movie monitoring behavior had approximately equal predictive power, and the sum fit as well as each behavior separately. Therefore, to evaluate the influence of engaging in multiple behaviors to monitor children’s movie viewing, we then summed the dichotomous variables to indicate the total number of parental movie monitoring behaviors. Data were analyzed using SAS 9.1.63 Graphs were created using S-plus 6.1.64 A P < .05 (2-sided) was considered statistically significant, without adjustment for multiple comparisons.

Subjects
Our final sample consisted of 2606 child-parent dyads (Fig 1). Approximately 63% of the participants lived in rural or semirural communities with population densities <500 persons per square mile.65 Slightly more than one third (36.3% [N = 909]) of participant households had annual incomes less than $40000, which is comparable to the income distribution for New Hampshire, Vermont, and the United States overall (30.0%, 36.7%, and 39.5%, respectively, have incomes less than $35000).66 Ninety-three percent (N = 2427) of parent respondents were mothers, 4.7% (N = 122) were fathers, and 2.0% (N = 57) were other primary care givers. One third (33.3% [N = 835]) of the parents reported high school as their highest level of education; 38.8% (N = 983) received some college education, and 28.0% had earned a bachelor’s degree or higher. Thus, in terms of education, the parent sample was similar to adults in New Hampshire and Vermont, of whom 32% have earned a bachelor’s degree. Three fourths of the children (74.8% [N = 1951]) reported their race as white and 7.8% (N = 206) as Latino. Reflecting the underlying population in Northern New England, only a total of 4% of the children reported that they were black, Asian, or Native American. Thirteen percent (N = 348) of the children reported that they were mixed race, but we suspect this high percentage was because they did not understand the question and were referring to mixed ancestry (eg, Italian and Irish). Ninety percent (N = 2351) of parents reported their race as white, which is more similar to New Hampshire and Vermont demographics where >95% of the population is white. Half of the children (N = 1305) were boys, and their ages ranged from 9 to 12 years. Eighty-eight percent (N = 2241) of the parent respondents said that they have a spouse or partner, but we did not assess whether the partner was living in the same household as the child. Eighty-six percent (N = 2187) of the parents said that their child lives with them all the time, whereas 14% (N = 359) said their child sometimes stays with another parent or relative.


Figure 1
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  		FIGURE 1 Cohort recruitment.

 

   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Sample Characteristics
Children’s exposure to friend smoking and drinking was relatively low, with 9% of the children reporting that they had friends who smoked (N = 233) or friends who drank alcohol (N = 238). In contrast, 34.8% (N = 883) had ≥1 parent who smoked, and >85% of children had ≥1 parent who drank alcohol; 52.3% (N = 1422) of the parents drank occasionally, and 30.1% (N = 761) drank weekly or more (Table 2).


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  		TABLE 2 Covariates by Parental Movie Restrictions and Monitoring

 
Overall, 12.5% (N = 325) of the children were at risk for smoking, and 20.3% (N = 528) were at risk for drinking alcohol. As expected, children’s risks for both smoking and drinking were positively associated with children’s age, friend smoking, and friend drinking and inversely associated with school performance and parental monitoring of nonmedia-related behaviors. Boys were more likely to be at risk for drinking alcohol than girls (P = .002), but there was no significant difference by gender in risk for smoking (P = .79). Children were more likely to be at risk for smoking if their parents smoked (P < .0001) and at risk for drinking if their parents drank alcohol (P = .014). Children’s risk for smoking was inversely associated with parental education (P = .008) and household income (P < .0001), whereas their risk for drinking did not differ significantly by these parental characteristics (P = .87 and 0.24, respectively; Table 2).

Parental Rules About R-Rated Movies
Overall, less than half (45.4%) of the children reported that their parents prohibited them from watching R-rated movies. Nineteen percent of children watched R-rated movies, but always with a parent (ie, coviews). Slightly more than one third (35.9%) were permitted to watch R-rated movies without a parent (Table 2). As expected, parental rules about R-rated movies were stricter for younger children, such that 59.2% of 9-year-olds were prohibited from watching R-rated movies compared with only 30.6% of 12-year-olds (P < .0001; Table 2). Parents were less likely to prohibit R-rated movies for boys, children with average or below average school performance, and children with friends who smoke or drink alcohol. Parents with higher levels of education, household income, and monitoring of nonmedia-related behaviors were more likely to prohibit their children from watching R-rated movies (Table 2).

Parental Monitoring of Children’s Movie Viewing
The frequency with which parents engaged in specific behaviors to monitor their children’s movie viewing varied considerably from 63.5% of children who reported that their parents always went into the video store with them to rent a movie to only 16.8% of children who said their parents always checked to see what movie they might be watching at a friend’s house (Table 2). Half of the children (51.5%) reported that their parents always wanted to know what a movie is rated before allowing them to watch it, and approximately one third (35.7%) said that they always had to check with their parents before watching a movie. The 4 parental movie monitoring behaviors were not significantly associated with parental education or household income, but they were inversely associated with children’s age (P ≤ 0.01) and positively associated with quartile scores of parental monitoring of nonmedia-related behaviors (P < .001; Table 2).

Association Between Parental Rules and Monitoring and Children’s Risk for Smoking and Drinking Alcohol
Even after adjusting for all of the covariates, including parental monitoring of nonmedia-related behaviors, children were at lower risk for smoking if their parents prohibited them from watching R-rated movies (relative risk [RR]: 0.54; 95% confidence interval [CI]: 0.41–0.70) or always coviewed R-rated movies with them (RR: 0.72; 95% CI: 0.54–0.96) compared with children who were permitted to watch R-rated movies without a parent (Table 3). Compared with children of parents who did not always engage in each of the following movie monitoring behaviors, children were at lower risk for smoking if their parents always accompanied them into the video store to rent a movie (RR: 0.75; 95% CI: 0.61–0.92), always wanted to know a movie rating before allowing them to watch it (RR: 0.79; 95% CI: 0.64–0.99); and/or always checked to find out what movie they might watch at a friend’s house (RR: 0.61; 95% CI: 0.42–0.90). In our fully adjusted model, children were less likely to be at risk for drinking alcohol if their parents prohibited them from watching R-rated movies (RR: 0.59; 95% CI: 0.48–0.72) and/or if their parent always checked to find out what movie they might watch at a friend’s house (RR: 0.60; 95% CI: 0.44–0.81; Table 3).


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  		TABLE 3 RRs and 95% CIs for Being at Risk for Smoking and Drinking

 
Less than 10% (N = 212) of the children reported that their parents consistently engaged in all 4 of the movie monitoring behaviors, but 25% (N = 651) reported that their parents consistently engaged in ≥3 movie monitoring behaviors. Figure 2 illustrates the relationship among parental monitoring of children’s movie viewing, parental rules about R-rated movies, and children’s risk for smoking and drinking, after controlling for all of the covariates. Parental rules about R-rated movies were not significantly associated with a decreased risk of smoking or drinking if parents did not consistently engage in any movie-monitoring behaviors. However, when parental rules about R-rated movies occurred in conjunction with parental movie monitoring, children whose parents prohibited them from watching R-rated movies had a significantly lower risk of smoking and drinking compared with those who were permitted to watch R-rated movies (P < .001). Parental coviewing of R-rated movies, compared with those who permit, was associated with a lower risk of smoking if parents consistently engaged in ≥2 movie-monitoring behaviors (P < .05). In fact, parental coviewing of R-rated movies seems to be equivalent to prohibiting when the number of movie monitoring behaviors is ≥2 (P > .05 at each level), as illustrated by the convergence of the 2 lines as the number of movie-monitoring behaviors increase. In contrast, parental coviewing of R-rated movies was not significantly different from permitting R-rated movies with respect to risk of drinking alcohol, regardless of the number of movie-monitoring behaviors. At each level of movie monitoring, prohibiting R-rated movies was associated with a lower risk of drinking compared with coviewing.


Figure 2
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  		FIGURE 2 A, Risk of smoking by parental monitoring of children’s movie viewing and rules about R-rated movies. B, Risk of drinking by parental monitoring of children’s movie viewing and rules about R-rated movies. P value comparisons: first row, coviews versus permits; second row, prohibits versus permits; and third row, prohibits versus coviews. a RRs are adjusted for child’s age, gender, race, school performance, friend smoking, friend drinking, parental education, household income, parental monitoring of nonmedia-related behaviors, parent smoking, and parent drinking.

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The results of this study indicate that parents are fairly permissive about their rules and monitoring of children’s movie viewing. Although all of the children in this study were <13 years of age, more than half (55%) reported that their parents allowed them to watch R-rated movies at least some of the time. Among those who watched R-rated movies, two thirds of the children were permitted to watch them at least sometimes without a parent. Only half the children (51.5%) reported that their parents always wanted to know the rating of a movie before allowing them to watch it, and <20% of parents always checked to see what movies their children watch at friends’ houses.

Compared with children who were permitted to watch R-rated movies without a parent, children whose parents prohibited them from watching R-rated movies were ≥40% less likely to be at risk for smoking or drinking, even after controlling for child characteristics, friend and parent smoking/drinking, and parental monitoring of nonmedia-related behaviors. This finding is supported by previous studies demonstrating that exposure to R-rated movies is strongly associated with early stages of smoking initiation.31,32 Parental coviewing of R-rated movies was associated with a lower risk for child smoking but not drinking. Several possible explanations could explain this distinction. For example, content analyses suggest that smoking and drinking are portrayed differently in movies,67 and alcohol use is more prevalent than smoking in movies rated for youth audiences.30 It is also possible that the higher prevalence of parental alcohol use compared with parental smoking may mitigate some of the movie influence. Finally, because other studies have found that parent-child interactions around media vary depending on the content,68–70 we cannot rule out the possibility that parental coviewing behavior may differ when watching smoking-related content versus alcohol-related content.

In addition to prohibiting children from viewing R-rated movies, our findings indicate that parents should also monitor their children’s movie viewing by always accompanying their children to the video store, finding out what a movie is rated before allowing their children to watch it, and checking what movies their children watch at friends’ houses. When examined separately, each of these individual movie-monitoring behaviors was more strongly associated with a lower risk for child smoking than drinking. We found a significant interaction between parental movie monitoring and parental rules about R-rated movies in that prohibiting R-rated movie viewing was significantly associated with a lower risk of smoking and drinking only if it was combined with parental movie monitoring. Similarly, increasing the number of parental movie-monitoring behaviors did not seem to decrease children’s risk of smoking or drinking if parents permitted them to watch R-rated movies. The data suggest that if parents choose to coview R-rated movies with their children, they can lower their children’s risk of smoking to the same level as that of children who are prohibited from watching R-rated movies by consistently engaging in the movie-monitoring behaviors. This illustrates that it is important for parents to both set limits and to use a variety of strategies to monitor and enforce the limits on their children’s movie viewing.

The results of this study suggest that parental rules and monitoring of children’s movie viewing may have a protective influence on children’s risk for smoking and drinking, over and above parental monitoring of nonmedia-related behaviors. Many studies have demonstrated that parental monitoring of children’s behavior in areas other than media use is associated with a lower prevalence of risk behaviors among adolescents.33–53 This information has been used to guide parents on how to protect their children from substance use. For example, parents are advised to know where their children are after school, to get to know their children’s friends, and to set rules for how children spend their time.71,72 Although these messages still represent sound advice for parents, it is important to keep pace with the changing lives of children and adolescents. Given the significant amount of time youth spend viewing movies and the wide range of content contained in these movies, parents should be equally concerned about limiting and monitoring their children’s movie exposure as they are about monitoring their activities and whereabouts.

Our measures of parental rules and media monitoring do not allow us to assess the extent to which parent-child discussion occurred during movie coviewing or monitoring. Existing literature suggests that the nature of parent-child discussion about media is an important influence on children’s cognitions and behaviors vis-à-vis the endorsement or counterreinforcement of media messages.68,70,73,74 We believe that this is an important direction to pursue in future studies. Our measure of parental monitoring of nonmedia behaviors, taken from an authoritative parenting scale, included items that could be considered knowledge (eg, "She knows where I am after school"), rules (eg, "She has rules about how I spend my time after school,"), and monitoring (eg, "She asks me what I do at my friends’ houses"). Recent reinterpretations of the parental monitoring literature suggest that monitoring of whereabouts, parental rules, children’s perceptions of parental knowledge of their activities, and parent-child communication are independent components of monitoring with potentially differential influences on child outcomes.47,49,50,75,76 Future research may consider using measures that allow for separate estimates of these monitoring components on child outcomes for both general monitoring and media-specific monitoring. In addition, it is important to note that actual parental monitoring may differ from child report of their parents’ behavior. Ideally, more objective measures of parental monitoring are needed.

Our ability to infer a temporal or causal relationship between parental movie monitoring and children’s risk for smoking or drinking is limited by the cross-sectional design of the study. However, our results are supported by numerous studies, which demonstrate that parenting style and monitoring predict future risk behaviors among children. Our findings are based on a regional sample of predominantly white children and parents from New Hampshire and Vermont, which may limit the generalizability of our conclusions. We chose to study preteens, because we believe that parents are more likely to have an influence on both their children’s movie viewing and the early stages of smoking and drinking initiation before children reach their teenage years. Because of the young age of the children and low prevalence of smoking or drinking behavior, we used risk for smoking and drinking as our primary outcomes. We know that children who are attitudinally susceptible to smoking or drinking and those who have tried cigarettes or alcohol are more likely to become smokers and drinkers. However, additional longitudinal studies are needed to assess how well parental rules and monitoring of children’s movie viewing predict established smoking and drinking behaviors.

Recent studies demonstrating that children are influenced by what they see in movies raises the question, "What should parents do?" Our findings highlight a potential role for parents in preventing early initiation of tobacco and alcohol use among adolescents. This study identifies specific strategies that parents may use to effectively monitor and limit their children’s exposure to R-rated movies. Ultimately, randomized trials will be needed to fully evaluate the extent to which these strategies can lower children’s risk for smoking and drinking.


   ACKNOWLEDGMENTS
 
This study was funded by National Cancer Institute grant CA-94273.

We thank Holly L. Pierce, BA, for her assistance in helping prepare the article.


   FOOTNOTES
 
Accepted Jun 14, 2006.

Address correspondence to Madeline A. Dalton, PhD, Hood Center for Children and Families, Community Health Research Program, HB 7465, Dartmouth Medical School, One Medical Center Dr, Lebanon, NH 03756. E-mail: madeline.dalton{at}dartmouth.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


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 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
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