TABLE 1.

Epidemiological Studies of Effects of Smoking in Movies on Adolescent Smoking

Author (Year)Design Sample MethodOutcome MeasureIndependent VariableControl Variables*Results
Distefan et al44 (1999)Cross-sectional (6252 California adolescents aged 12–17; 51.5% male; 54.8% white); telephone surveySusceptibility to smokingFavorite-star smoking statusSociodemographics; social influences; child characteristics; parenting characteristics; smoking attitudes; teen smoking statusStars favored by male and female smokers and never smokers differed (P < .01), with adolescent smokers favoring stars who were more likely to smoke on screen; in adolescent never smokers who named a favorite star, those whose favorite star was preferred by ever smokers were more likely than others to be susceptible to smoking (OR: 1.35; 95% CI: 1.12–1.62; P < .01), an effect only slightly weaker than exposure to family/friends smoking (OR: 1.45; 95% CI: 1.13–1.85)
Tickle et al46 (2000)Cross-sectional (632 New England students aged 10–19; 90% white); self-report surveySusceptibility to smoking; adolescent smoking behaviorFavorite-star smoking statusSociodemographics; social influences; child characteristicsFor adolescents whose favorite stars smoked in only 1 film, the odds of being higher on the smoking index was 0.78 (95% CI: 0.53–1.15); for adolescents who chose stars who were smokers in 2 films, the adjusted odds of being higher on the smoking index was 1.5 (95% CI: 1.01–2.32); for those who chose stars smoking in ≥3 films, adjusted odds of being higher on the smoking index was 3.1 (95% CI: 1.34–7.12); adolescent never smokers who chose stars who were smokers in films were much more likely to be susceptible to smoking (adjusted OR: 4.8; 95% CI: 1.60–14.23, for stars who smoked in 2 films, and OR: 16.2; 95% CI: 2.33–112.61, for stars who smoked in ≥3 films)
Sargent et al26 (2002)Cross-sectional (3702 never-smoking adolescents in New England in grades 5–8; primarily white); self-report surveysSusceptibility to smokingExposure to smoking in filmsSociodemographics; social influences; child characteristics; parenting characteristicsStrong linear relationship between susceptibility and higher levels of exposure to movie tobacco use; 14% of never smokers in the lowest category of exposure were susceptible to smoking, compared to 36% of those who had viewed ≥150 occurrences (P < .001); strong association between endorsement of positive expectations and exposure to higher levels of tobacco use in movies; only 14% of those in the lowest category of exposure to tobacco use in movies endorsed >2 positive expectations compared with 31% of those in the highest category of exposure (P < .0001); category of exposure (P < .0001); compared with adolescents exposed to <50 occurrences of tobacco use, the adjusted OR of susceptibility to smoking for each higher category was 1.2 (51–100 occurrences) (95% CI: 0.9–1.5), 1.4 (101–150 occurrences) (95% CI: 1.1–1.9), and 1.6 (>150 occurrences) (95% CI: 1.3–2.1)
Dalton et al48 (2002)Cross-sectional (4544 New England adolescents in grades 5–8; primarily white); self-administered surveysSmoking (and drinking alcohol) initiationParental restriction on R-rated moviesSociodemographics; social influences; child characteristics; parenting characteristicsNinety percent of students in the sample were younger than 14, but only 16% reported that they were never allowed to watch R-rated movies; one third (31%) indicated that parents never restricted them from watching R-rated movies; across all grade levels, students who reported complete or partial restrictions for R-rated movies viewed significantly fewer PG-13- and R-rated movies than students whose viewing was not restricted (mean for complete restriction: 0.9; mean for partial restriction: 4.0; mean for no restriction: 7.8); 18% of the student sample had tried smoking and 23% had tried drinking; both smoking and drinking were significantly associated with the level of restriction for R-rated movies; compared with children with no restrictions, the adjusted relative risk for having tried smoking were 0.74 (95% CI: 0.65–0.85) for those partially restricted and 0.29 (95% CI: 0.19–0.45) for those with complete restrictions
Sargent et al49 (2003)Cross-sectional (4910 New England adolescents aged 9–15; primarily white); self-administered surveysExposure to movie smokingParental limits on children's movie accessSociodemographics; social influences; child characteristics parenting characteristics; media habitsSmoking exposure increased by ∼10% (150 depictions) for each additional movie channel and for every 2 videos watched each week; going to the movie theater more than once per month was associated with an average increase of ∼30% more movie smoking depictions; parental restriction of R-rated movies had the strongest and most significant effect on exposure to movie smoking; compared to children who reported full restrictions, those with no restrictions had seen an average of ∼50% more smoking occurrences (650 occurrences), and those with partial restrictions had seen an additional 260 occurrences
Dixon40 (2003)Cross-sectional (2610 Victoria, Australia, adolescents in grades 7–12; primarily white; no former smokers); self-administered surveySmoking statusAmount of on-screen smoking by favorite actors and actressesSociodemographics; social influencesNo significant effect of favorite-star smoking status on beliefs or intention to smoke among never and experimental smokers; on-screen smoking by favorite male actors was positively associated with smoking behavior, especially among female adolescents; no significant effect of on-screen smoking by female favorite actors
Dalton et al50 (2003)Cohort (2603 New England adolescents in grades 5–8; primarily white; never smoking at baseline); self-administered survey; follow-up 13–26 months laterSmoking initiationExposure to movie smokingSociodemographics; child characteristics; social influences; parenting characteristicsTen percent of the students (259) initiated smoking during the follow-up period; most (80%) of the initiated reported smoking “just a few puffs” of a cigarette (n = 208); only 2% (n = 6) of those had smoked >100 cigarettes during the follow-up period; relative to the lowest quartile of movie smoking exposure, the relative risk for smoking initiation was 2.71 (95% CI: 1.73–4.25) for adolescents in the top quartile of exposure, with a positive dose-response relationship; significant interactions were found between exposure and parental smoking behavior (P = .003); in adolescents with nonsmoking parents, the risk of initiating smoking increased substantially with greater exposure to movie smoking, with the risk of smoking among adolescents in the highest level of movie smoking exposure being similar regardless of parents' smoking behavior; after controlling for all other covariates, 52.2% (95% CI: 30.0–67.3%) of smoking initiation in this cohort can be attributed to exposure to smoking in the movies
Distefan et al45 (2004)Cohort (2084 California adolescents aged 12–15; nonsmokers at baseline); telephone survey; follow-up survey 3 years laterSmoking initiationFavorite-star smoking statusSociodemographics; social influences; child characteristics; parenting characteristics; smoking attitudes; teen smoking statusOne third of never smokers nominated a star who smoked on screen, which independently predicted later smoking risk (OR: 1.36; 95% CI: 1.02–1.82); adolescents whose favorite stars smoked on screen (34.6%) were more likely to be girls (39.2% vs 29.9%) aged 14–15 at baseline (40.7%); significant interactions were also found between adolescent gender and favorite-star onscreen smoking (P = .01); when multivariate analysis was restricted to girls, having a favorite star who smoked on screen increased the risk of smoking almost twofold (OR: 1.86; 95% CI: 1.26–2.73); compared with adolescent girls whose favorite stars did not smoke, those whose favorite stars smoked in movies that were released from 1994 to 1996 (prebaseline) had increased odds of smoking by >80%
Sargent et al51 (2004)Cohort (2596 New England adolescents aged 10–14; nonsmokers at baseline; primarily white); self-administered survey at baseline; telephone survey 13–26 months laterSmoking initiationParental restrictions on viewing R-rated moviesSociodemographics; social influences; child characteristics; parenting characteristicsOnly 19% of adolescents at baseline reported that their parents never allow them to view R-rated movies, 29% were allowed to see them once in a while, and 52% could see R-rated movies sometimes or all the time; 10% of the sample reported trying smoking during the follow-up period; exposure to R-rated movies decreased significantly with increasing parental R-rated–movie restriction; only 4.9% of adolescents who were never allowed to see R-rated movies had high exposure to movie smoking, compared with 20% who were allowed to watch once in a while, and 54% who were allowed to watch sometimes or all the time; smoking-initiation rates increased as parental restriction of R-rated movies decreased (2.9% for adolescents reporting that their parents never allowed R-rated movies, 7.0% for those who were allowed to view them once in a while, and 14.3% for those who were allowed to view them sometimes or all the time); compared with adolescents who were never allowed to view R-rated movies, the adjusted relative risk for trying smoking was 1.8 (95% CI: 1.1–3.1) for those who were allowed to watch R-rated films once in a while and 2.8 (1.6–4.7) for those who were allowed to watch some or all the time; effects were especially strong among adolescents from nonsmoking families for whom the adjusted relative risk for smoking was 4.3 (95% CI: 1.4–13) for those who were allowed to view R-rated films once in a while and 10.0 (3.6 to 31) for those who were allowed to view R-rated films sometimes or all the time
Sargent et al52 (2005)Cross-sectional (6522 US adolescents aged 10–14); random-digit-dial telephone surveySmoking initiationExposure to movie smokingSociodemographics; child characteristics; social influences; parenting characteristicsOverall, 10% of the sample had tried smoking (corresponding to 2.2 million US adolescents); relative to the lowest quartile of exposure, the OR for smoking initiation was 2.6 (95% CI: 1.7–4.1) for adolescents in the top quartile of exposure, with a positive dose-response relationship
  • Sociodemographic factors include gender, school, age, and parental education. Social-influence factors include exposure to smoking by family members and friends and receptivity to tobacco promotions. Child characteristics include rebelliousness, sensation seeking, self-esteem, and school performance. Parenting characteristics include parenting style and parental disapproval of smoking. Smoking attitudes includes attitudes toward smokers, perceived benefits of smoking, and perceived safety of experimenting with cigarettes. Media habits include movie access (movie channels, videotape use, movie theater outings) and the number of hours spent watching television and playing video games.

  • * Control variables.