ASSIGNMENT PART 1

DOI: 10.1542/peds.2010-1635 ; originally published online September 27, 2010; 2010;126;791Pediatrics

The Council on Communications and Media Children, Adolescents, Substance Abuse, and the Media

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located on the World Wide Web at: The online version of this article, along with updated information and services, is

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point publication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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Policy Statement—Children, Adolescents, Substance Abuse, and the Media

abstract The causes of adolescent substance use are multifactorial, but the media can play a key role. Tobacco and alcohol represent the 2 most significant drug threats to adolescents. More than $25 billion per year is spent on advertising for tobacco, alcohol, and prescription drugs, and such advertising has been shown to be effective. Digital media are increasingly being used to advertise drugs. In addition, exposure to PG-13– and R-rated movies at an early age may be a major factor in the onset of adolescent tobacco and alcohol use. The American Academy of Pediatrics recommends a ban on all tobacco advertising in all media, limitations on alcohol advertising, avoiding exposure of young children to substance-related (tobacco, alcohol, prescription drugs, illegal drugs) content on television and in PG-13– and R-rated movies, incor- porating the topic of advertising and media into all substance abuse– prevention programs, and implementingmedia education programs in the classroom. Pediatrics 2010;126:791–799

INTRODUCTION Although parents, schools, and the federal government are trying to get children and teenagers to “just say no” to drugs, more than $25 billion worth of cigarette, alcohol, and prescription drug advertising is effectively working to get them to “just say yes” to smoking, drinking, and other drugs.1,2 In addition, television programs andmovies contain appreciable amounts of substance use. Unlike traditional advertising, media depictions of legal drugs are generally positive and invite no criticism, because they are not viewed as advertising.3 The result is that young people receive mixed messages about substance use, and the media contribute significantly to the risk that young people will engage in substance use.

ADOLESCENT DRUG USE

Although illegal drugs take their toll on American society, 2 legal drugs—alcohol and tobacco—pose perhaps the greatest danger to children and teenagers. Both represent significant gateway drugs and are among the earliest drugs used by children or teenagers. A pread- olescent or adolescent who smokes tobacco or drinks alcohol is 65 times more likely to use marijuana, for example, than someone who abstains.4 The younger the age at which experimentation occurs, the greater the risk of serious health problems.5 Every year, more than 400 000 Americans die from illnesses directly related to cigarette use—more than from AIDS, car crashes, murder, and suicide com- bined.6 More than 100 000 deaths annually can be attributed to exces-

THE COUNCIL ON COMMUNICATIONS AND MEDIA

KEY WORDS adolescence, substance use, alcohol, tobacco, cigarettes, illicit drugs, TV, movies, Internet

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

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PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2010 by the American Academy of Pediatrics

FROM THE AMERICAN ACADEMY OF PEDIATRICS

Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

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sive alcohol consumption,7 including the death of 5000 people younger than 21 years.8 Drug use also represents one of many risky behaviors that occur during adolescence: teenagerswho re- port that at least half of their friends are sexually active are 31 times more likely to drink, 5 times more likely to smoke, and 22 times more likely to try marijuana than are teenagers who do not report such a high prevalence of sexual activity among friends.9

EFFECTS OF ADVERTISING

The power of advertising to influence children and adolescents (and adults, for that matter) is incontrovertible.1,10

Advertising works; otherwise, compa- nieswould not spend billions of dollars on it.1 Many ads use celebrity endors- ers, humor, rock music, or attractive young models, all of which have been shown to be effective with children and adolescents.11 Advertising makes smoking and drinking seem like nor- mative activities and may function as a “superpeer” in subtly pressuring teen- agers to experiment.12 Research has revealed that advertising may be re- sponsible for up to 30% of adolescent tobacco and alcohol use.13,14

Cigarettes

More money is spent advertising to- bacco than any drug—an estimated $15 billion per year,15 almost half of what the National Institutes of Health spends each year to study all aspects of health (www.nih.gov/about/budget. htm). The tobacco industry (often re- ferred to as “Big Tobacco”) has en- gaged in a systematic campaign to attract underage smokers for decades and then lied to Congress about it.16–19

Given the demographics of smoking (1200 deaths per day, half of which are of middle-aged adults; 50% of smokers begin by 13 years of age, and 90% of smokers begin by 19 years of age), the industry must recruit young people as smokers.20 Recent statistics show that

they continue to succeed. According to the 2009 Monitoring the Future study, nearly half of all teenagers have tried smoking, as have 20% of all 8th- graders.21 Cigarette advertising seems to increase teenagers’ risk of smoking by glamorizing smoking and smok- ers.3,20 Smokers are depicted as young, independent, rebellious, healthy, and adventurous. By contrast, the adverse consequences of smoking are never shown. As a result, the US Surgeon General concluded in 1994 that ciga- rette advertising increases young peo- ple’s risk of smoking.20

The most heavily advertised brands of cigarettes are also the most popular.22

Tobacco advertising may even trump strong parenting practices.23 Teen magazines have attracted an increas- ing number of cigarette ads since 1965.24–26 Numerous studies have re- vealed that children or teenagers who pay closer attention to cigarette ads, who are able to recall such ads more easily, or who own promotional items are more likely to become smokers themselves.27–31 Joe Camel single- handedly increased the market share for Camel cigarettes from 0.5% of ado- lescent smokers to 32%.32 A recent meta-analysis of 51 separate studies revealed that exposure to tobacco marketing and advertising more than doubles the risk of a teenager begin- ning to smoke.33

Alcohol

Approximately $6 billion is spent annu- ally on alcohol advertising and promo- tion.34 Similar to tobacco ads, beer commercials are virtually custom- made to appeal to children and adoles- cents, using images of fun-loving, sexy, successful young people having the time of their lives.3,35,36 Unlike tobacco advertising, alcohol advertising faces few restrictions. For example, whereas the tobacco industry gave up television advertising in the 1960s, beer, wine,

and liquor ads are frequently featured on prime-time television, and young people view 1000 to 2000 alcohol ads annually.12,37 Much of the advertising is concentrated during teen-oriented shows and sports programming. All of the top-15 teen-oriented shows con- tain alcohol ads.38 Currently, teenag- ers are 400 times more likely to see an alcohol ad than to see a public service announcement (PSA) that discourages underage drinking.39 Teen-oriented magazines contain 48%more advertis- ing for beer, 20% more advertising for hard liquor, and 92%more advertising for sweet alcoholic drinks than do magazines aimed at adults of legal drinking age.40,41

According to the research, the effects of all of this advertising are increas- ingly clear.3,42,43 A sample of 9- to 10- year-olds could identify the Budweiser frogs nearly as frequently as they could Bugs Bunny.44 In a study of more than 3500 South Dakota students, 75% of 4th-graders and nearly 90% of 9th- graders recognized the Budweiser fer- ret ad.45 Many studies have revealed that exposure to alcohol advertising results in more positive beliefs about drinking and is predictive of drinking during early adolescence and young adulthood.46–52 The results of several longitudinal studies have shown a sim- ilar trend,53,54 although they have sometimes been mixed.48

Prescription Drugs

Nearly $4 billion is spent annually on prescription drug advertising.55 Drug companies now spend more than twice as much money on marketing as they do on research and development, and studies have revealed that the marketing efforts pay off56: results of a recent survey of physicians showed that 92% of patients had requested an advertised drug.57 Children and teen- agers get the message that there is a pill to cure all ills and a drug for every

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occasion, including sexual inter- course. In the first 10 months of 2004, drugs companies spent nearly half a billion dollars advertising Viagra, Lev- itra, and Cialis.58 Yet, the advertising of condoms, birth control pills, and emer- gency contraception is haphazard and rare and remains controversial.1,59

DRUGS IN ENTERTAINMENT MEDIA

Cigarettes

Scenes with smoking remain common in movies and, to a lesser extent, on prime-time television. Hollywood seems to use smoking as a shorthand for troubled or antiestablishment charac- ters, but the smoking status of the ac- tors themselves is also influential in whether their characters will smoke on-screen.60 On prime-time television, 19% of shows portray tobacco use, and approximately one-fourth of them de- pict negative statements about smok- ing.61 In addition, smoking is also found in nearly one-fourth of all music vid- eos,62 one-fourth of ads for R-rated movies, and 7.5% of ads for PG-13 and PG movies.63

Box-office movies and their subse- quent video and pay-per-view distribu- tion have become a major route of ex- posure to tobacco use. Although the most recent analyses show that smok- ing has decreased in popular mov- ies,64,65 the occurrence remains high. A content analysis of the top 100 box- office hits between 1996 and 2004 re- vealed that tobacco use was depicted in three-quarters of G-, PG-, and PG-13– rated movies and in 90% of R-rated movies.66 Half of all G-rated animated films between 1937 and 1997 con- tained tobacco use.67 Although the most recent content analysis of top- grossing movies between 1991 and 2009 showed that tobacco use peaked in 2003 and has since declined, in 2009, more than half of PG-13 movies still contained tobacco use.65 But overall, the percentage of all top-grossing

movieswithout smoking exceeded 50% for the first time in 2009.65

Unique longitudinal research has re- vealed that one of the most important factors in the onset of adolescent sub- stance use is exposure to others who use drugs.68 Nowhere is that exposure greater than on contemporary movie screens, and teenagers constitute 26% of the movie-going audience (but only 16% of the US population).69 Results of a number of correlational and longitu- dinal studies have confirmed that ex- posure to television and movie smok- ing is now one of the key factors that prompt teenagers to smoke.29,70–77 Ac- cording to a new meta-analysis, it may account for nearly half of smoking ini- tiation in young teenagers.80 In fact, ex- posure to movie smoking may even trump parents’ smoking status as be- ing the key factor in adolescents’ initi- ation of smoking.73 A prospective study of more than 3500 teenagers revealed that exposure to R-rated movies dou- bles the risk of smoking, even when controlling for all other known fac- tors.79 Preadolescents whose parents forbid them from seeing R-rated mov- ies are less likely to begin smoking (or drinking).80 A study of 735 12- to 14- year-olds, with a 2-year follow-up, re- vealed that exposure to R-ratedmovies or having a television in the bedroom significantly increased the risk of smoking initiation for white teenag- ers.81 The movie effect seems not to be confined to US teenagers but applies also to teenagers from other countries as well.82,83

Alcohol

Alcohol remains the number one drug portrayed on American television: 1 drinking scene is shown every 22 min- utes, compared with 1 smoking scene every 57 minutes and 1 illicit drug use scene every 112 minutes.84 On Music Television (MTV), teenagers can see al-

cohol use every 14 minutes. An analy- sis revealed that drugs were present in nearly half of 359 music videos— alcohol in 35%, tobacco in 10%, and il- licit drugs in 13%.85 On prime-time tele- vision, 70% of programs depict alcohol use.61 More than one-third of the drink- ing scenes are humorous, and nega- tive consequences are shown in only 23%. One study revealed that alcohol portrayals are as common on shows for 9- to 14-year-olds as on adult- oriented shows.86 In popular music, the average teenager is exposed to nearly 85 drug references a day, the majority of which are for alcohol.87

Popular movies are nearly equally rife with alcohol, with only 2 of the 40 highest-grossing movies not contain- ing alcohol depictions.88 Even G- and PG-rated movies contain frequent ref- erences to alcohol.89,90 And, drinking is frequently depicted as normative be- havior, even for teenagers.91

Again, the impact is increasingly clear from the research. A longitudinal study of more than 1500 California 9th- graders revealed that increased televi- sion and music video viewing was a risk factor for the onset of alcohol use among adolescents.92 Results of a Co- lumbia University study showed that teenagers who watch more than 3 R-rated films per month are 5 times more likely to drink alcohol compared with teenagerswhowatch none.93 Also, in an intriguing study of 2- to 6-year- olds (n� 120) who were asked to role- play in a make-believe store, children were 5 times more likely to “buy” beer or wine if they had been allowed to see PG-13 or R-ratedmovies.94 Finally, good longitudinal evidence is emerging to indicate that watching more movie de- pictions of alcohol is strongly predic- tive of drinking onset and binge drink- ing in US adolescents,86,95,96 and the same results are being found for ado- lescents from other countries.82,97

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Illegal Drugs

Illicit drugs are rarely seen on televi- sion,61 with the exception of pro- grams such as Showtime’s Weeds and Fox’s That 70s Show. Drug scenes are more common in movies (22% of the movies in 1 study con- tained drug scenes), and no harmful consequences are shown more than half of the time.90 Marijuana is the most frequent drug seen in movies and seems to be making a comeback in R-rated movies such as Harold and Kumar Go to White Castle (2004) and The Pineapple Express (2008).98 A Co- lumbia study revealed that viewing R-rated movies was associated with a sixfold increased risk of trying marijuana.93 Hollywood filmmakers do not seem to understand that hu- mor tends to undermine normal ad- olescent defenses against drugs and legitimizes their use.3 Increased con- sumption of popular music is also associated with marijuana use.95,99

NEW MEDIA

The new technologies—the Internet, social networking sites, and even cel- lular phones—offer new and prob- lematic opportunities for adolescent drug exposure.3,100 A variety of Web sites sell tobacco products, and few of them have effective age-verification procedures.3,101 One national survey of more than 1000 youths 14 to 20 years of age revealed that 2% reported hav- ing purchased alcohol online, and 12% reported having a friend who did so.102

Prescription drugs can also be pur- chased online with minimal difficulty. Popular beer brands use “adver- games” online to entice a younger au- dience.103 Teenagers also see consid- erable alcohol and drug content in online videos104 and on social network- ing sites,105 on which 1 study revealed that 40% of profiles referenced sub- stance abuse.106

SUMMARY

The so-called war on drugs has been waged for decades, yet teenagers con- tinue to use and abuse a variety of sub- stances, especially tobacco and alco- hol. The contribution of the media to adolescent substance use is only re- cently becoming fully recognized and appreciated. The Master Settlement Agreement has greatly restricted to- bacco marketing by the tobacco com- panies that signed the agreement. However, tobacco continues to appear frequently in movies, and this fact con- trasts markedly with US reality (ap- proximately half of the US population lives in a community with restrictions on indoor smoking). Moreover, the case is strong for the argument that smoking shown in entertainment me- dia plays a causal role in smoking on- set. Certainly, it is time to eliminate all tobacco advertising and to decrease greatly the depiction of smoking in mainstream media. Because alcohol use is still condoned in many venues and use in moderation may be health- ful for adults, such severe restrictions on alcohol advertising and program- ming may not be indicated. On the other hand, underage alcohol use does pose a clear and immediate threat to the teenagers who use it. Taken to- gether, the evidence supports strong actions aimed at the entertainment industry about media depictions of tobacco use and strong actions aimed at motivating and assisting parents of children and young teen- agers to restrict access to adult me- dia venues with excessive substance use exposure.

Anticipatory Guidance by Pediatricians

1. Pediatricians should encourage parents to limit unsupervised me- dia use and especially encourage removal of televisions from chil- dren’s bedrooms. At every well-

child visit, pediatricians should be asking at least 2 questions regard- ing media use: (a) How much en- tertainment media per day is the child or adolescent watching? and (b) Is there a television set or In- ternet access in the child’s or ad- olescent’s bedroom?107 Research has revealed that having a televi- sion in the bedroom is associated with greater substance use and sexual activity in teenagers.108

2. Pediatricians should encourage parents to limit access by children and young adolescents to televi- sion venues with excessive sub- stance use depictions (eg, MTV, HBO, Showtime, Comedy Central).

3. Pediatricians should encourage parents to limit younger chil- dren’s exposure to PG-13 movies and avoid R-rated movies.29,75–81,109

4. Pediatricians should encourage parents to co-view media with their children and teenagers and discuss the content being viewed.

5. Pediatricians should encourage parents to turn off the television during evening meals.

6. Pediatricians should ensure that their waiting rooms are free of magazines that accept cigarette and alcohol advertising.

Community Advocacy by Pediatricians

7. Pediatricians should encourage their local school systems to in- corporate media education into their curricula. In particular, drug-prevention programs should use basic principles of media liter- acy, designed to imbue skepticism toward media advertising. Cur- rently, Drug Abuse Resistance Ed- ucation (DARE) does not accom- plish this goal, nor is there any evidence that DARE is effec- tive.12,110 More psychologically so- phisticated drug-prevention cur-

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ricula are available and should be used.110–113

Legislative Advocacy by Pediatricians

8. Pediatricians should encourage Congress to ban tobacco advertis- ing in all media accessible to chil- dren, which several European countries have already done. Such a ban would seem to be constitu- tional, given that the US Supreme Court has already ruled that com- mercial speech does not enjoy the absolute First Amendment pro- tections that free speech does.114

Recently, Congress gave the Food and Drug Administration the authority to regulate tobacco products; however, the tobacco industry is expected to challenge any advertising bans.115,116

9. Pediatricians should encourage Congress to require the alcohol in- dustry to report its annual expen- ditures to the Federal Trade Com- mission, including expenditures for media venues in which chil- dren and adolescents represent more than 10% of the market share (currently, voluntary adver- tising restrictions allow for ven- ues in which up to 30% of the au- dience is children).

10. Pediatricians should encourage the alcohol industry to restrict ad- vertising and product placement in venues in which more than 10% of the audience is children and adolescents.

11. Pediatricians should encourage the White House Office of National Drug Control Policy to begin con- ductingantismokingandanti–teen- drinking public service campaigns, including strong antismoking and antidrinking ads to be placed be- fore television programming and movies that have youth ratings

and contain alcohol and tobacco depictions.

12. Pediatricians should encourage allocation of more money in media research, given the importance of the media on the development and behavior of children and adoles- cents. Higher taxes on tobacco products and alcohol could be used to fund such research.

13. Pediatricians should encourage Congress to pass new strict laws regulating digital advertising that targets children and adolescents.100,117

Involvement of the Alcoholic Beverage, Tobacco, Drug, and Entertainment Industries in Encouraging Responsible Behavior

14. Pediatricians should encourage the advertising industry, drug companies, public health groups, and medical groups to have a full and open debate on the necessity of advertising prescription drugs. In addition, ads for erectile dys- function drugs should be confined to after 10 PM in all time zones and should not be overly suggestive.1

15. Pediatricians should encourage the entertainment industry to have greater sensitivity about the effects of television andmovies on children and adolescents and accept that the industry does, indeed, have a public health responsibility.118 Cigarette smoking in movies should be avoided at all costs and should never be glamorized.119,120 Disney has already promised to eliminate smoking in itsmovies.121Makingfilm sets smoke-free zones would go far to diminish theportrayal of smoking in movies and would protect actors and actresses from secondhand smoke. Antismoking ads should pre- cede the showing of any film that has tobacco use depicted.119 Alcohol use should not be portrayed as nor-

mative behavior for teenagers, and the traditional depiction of the “funny drunk” should be retired. Television networks that have a large adolescent viewership should air public service ads about the dan- gers of smoking and drinking. Fi- nally, theMotion Picture Association of America (MPAA) ratings need to be amended so that tobaccousewill routinely garner an R rating in all new movies unless the risks and consequences of smoking are un- ambiguously shownor thedepiction is necessary to represent a real historical figure who actually used tobacco.119 So far, the MPAA has only agreed to consider smoking as a factor in assigning a rating.122,123

16. Pediatricians should encourage state and federal agencies, the en- tertainment industry, and the ad- vertising industry to develop and maintain vigorous anti–drug- advertising campaigns that focus on the 2 drugs most dangerous to adolescents—tobacco and alcohol—in addition to illegal drugs. Antidrug ads have been shown to be highly effective at times (eg, the Truth campaign),124–129 but the effectiveness of the National Youth Anti-Drug Media Campaign has been questioned.130 Recently, and laudably, 6majorHollywoodstu- dios have agreed to place antismok- ing ads on new movie DVDs that ap- peal to children.131,132

17. Pediatricians should work with and support the American Acad- emy of Pediatrics Julius Richmond Center of Excellence (www.aap. org/richmondcenter), the mission of which is “to improve child health by eliminating children’s exposure to tobacco and second- hand smoke,” including through media exposure.119

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LEAD AUTHOR Victor C. Strasburger, MD

COUNCIL ON COMMUNICATIONS AND MEDIA EXECUTIVE COMMITTEE, 2009–2010 Gilbert L. Fuld, MD, Chairperson Deborah Ann Mulligan, MD, Chair-elect Tanya Remer Altmann, MD Ari Brown, MD Dimitri A. Christakis, MD Kathleen Clarke-Pearson, MD Benard P. Dreyer, MD

Holly Lee Falik, MD Kathleen G. Nelson, MD Gwenn S. O’Keeffe, MD Victor C. Strasburger, MD

PAST EXECUTIVE COMMITTEE MEMBERS Regina M. Milteer, MD Donald L. Shifrin, MD

LIAISONS Michael Brody, MD – American Academy of Child and Adolescent Psychiatry

Brian Wilcox, PhD – American Psychological Association

CONTRIBUTOR James D. Sargent, MD

STAFF Gina Ley Steiner Veronica Laude Noland [email protected]

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