Essay

Does Watching Smoking in Movies Promote Teenage Smoking? Todd F. Heatherton1,2 and James D. Sargent2,3

1 Department of Psychological and Brain Sciences, Dartmouth College,

2 Norris Cotton Cancer Center, and

3 Department of

Pediatrics, Dartmouth Medical School

ABSTRACT—Compared to adolescents with low exposure to

smoking in movies, those with high exposure are about

three times as likely to try smoking or become smokers. We

have observed this effect in nationally representative

samples using cross-sectional and longitudinal designs.

This effect remains statistically significant after control-

ling for numerous other traditional risk factors, such

as personality, parenting style, and sociodemographics.

Indeed, the movie-smoking exposure effect on adolescent

smoking initiation is greatest among those traditionally

considered at lower risk for smoking, such as those low in

sensation seekingand those whose parents do not smoke. In

this article, we consider possible moderators and media-

tors of this important media effect as well as health-policy

implications. The take-home message is that eliminating

smoking in movies may prevent a substantial number of

adolescents from smoking.

KEYWORDS—smoking; adolescence; media influence;

sensation seeking; movies

Nearly everyone knows that smoking is a leading cause of death

in the world. Yet each day in the United States nearly 2,000

adolescents try their first cigarette, and many of them will go on

to smoke regularly, which might ultimately contribute to an early

demise. So, why do adolescents try smoking? It is clear that

social influences, such as having friends or parents who smoke,

play important roles in smoking initiation. Many children who

try smoking, however, appear to have few such risk factors. An

open question, then, is the extent to which other environmental

factors encourage adolescent smoking. Over the past 10 years,

our research group and others have documented the pernicious

effects of movie portrayals of smoking on smoking uptake among

children as young as 10 years old. In this article, we describe

research using multiple methods and nationally representative

samples showing that smoking in movies is an important

promoter of adolescent smoking initiation.

Given the central role of movies in American culture, the

potential for them to shape attitudes and influence behavior has

long been of concern to psychologists (Anderson & Bushman,

2002). Most of the research to date has focused on media vio-

lence. But media also have a profound impact on the adolescent

self-concept: They shape views of what is ‘‘cool,’’ what is

attractive, and what is grown-up—all things that adolescents are

trying to be. Indeed, casual observance at any local mall dem-

onstrates that visual media affect how teenagers talk, how they

dress, and how they behave. It seems plausible, then, that media

exposure might affect other behaviors. Our central tenet is that

the more children observe smoking in movies—especially when

smoking is portrayed by highly popular actors who serve as teen

role models—the more likely they are to take up smoking.

EXPOSURE TO SMOKING IN MOVIES

Is it reasonable to suggest that movies contain a lot of smoking?

About 70% of movies made in the United States today contain

cigarette smoking. A variety of content analyses have estab-

lished that the percentage of adults who smoke in movies is

approximately 20 to 25% of characters, that smoking is rarely

associated with negative health outcomes, and that smokers

in movies are more affluent than the typical U.S. smoker. Yet

on-screen smoking is only 1 to 2 minutes, on average, per film.

At issue is the extent to which vulnerable children are exposed

to this smoking. It could be argued that, since the majority

of smoking occurs in movies aimed at older adolescents (i.e.,

PG-13 and R films), children under age 14 might have low

Address correspondence to Todd F. Heatherton, Department of Psy- chological and Brain Sciences, 6207 Moore Hall, Dartmouth College, Hanover, NH 03755; e-mail: [email protected].

CURRENT DIRECTIONS IN PSYCHOLOGICAL SCIENCE

Volume 18—Number 2 63Copyright r 2009 Association for Psychological Science

exposure to movie smoking. However, the available evidence

indicates that children in this age group are frequent viewers of

movies that were never intended for young audiences—satellite

television, cable movie channels, home videos, and DVDs

greatly increasing children’s access to the world depicted in

motion pictures.

Only recently has the extent to which young children view

movies been documented. One study showed widespread view-

ing of R movies by children aged 10 to 14, with some particularly

violent movies (such as Scream) reportedly having been seen by

nearly half of fifth graders in one large sample (Sargent,

Heatherton, et al.,2002). Similarly,a recent nationally represen-

tative study (using random-digit dialing) of 6,522 adolescents

found that an estimated one million American 10-year-olds

reported having seen Scary Movie, in which a cheerleader is

decapitated and her head is disposed of in a lost-and-found bin

in the school locker room (Worth, Chambers, Nassau, Rakhra, &

Sargent, 2008). Thus, children are seeing many movies (and a lot

of violence)—but how much smoking do they see in these

movies? Our studies have allowed us to answer this question by

linking adolescents’ responses to the movies they’ve watched to

a content analysis that assessed smoking in some 1,000 movies

(using carefully validated measures). The survey technique

allows us to estimate the percentage of children who have viewed

each of these movies in a nationally representative sample.

Applying techniques from the marketing and advertising fields,

we estimated that some 500 movies delivered nearly 14 billion

smoking impressions to U.S. children ages 10 to 14 (Sargent,

Tanski, & Gibson, 2007). In short, young children are exposed

to a great deal of smoking from the movies they see.

Of course, the context in which smoking is portrayed is likely

to affect the extent to which it encourages a child to smoke.

Consider one such important factor: star smoking. In the study

just described, some 30 actors delivered more than 50 million

smoking impressions each. For instance, Mel Gibson’s 21 epi-

sodes of smoking delivered more than 90 million smoking

impressions because of the popularity of his films. In earlier

studies, smoking status of the adolescents’ favorite stars was

related to the adolescent’s attitude toward smoking (for never

smokers) or their smoking status (Distefan, Pierce, & Gilpin,

2004; Tickle, Sargent, Dalton, Beach, & Heatherton, 2001).

MOVIE VIEWING AND ADOLESCENT SMOKING

Several studies have now examined the relation between the

smoking adolescents see in movies (based on content-based

estimates of exposure to movie smoking) and adolescent smok-

ing. An initial study in 2001 found that there was a strong

relation between exposure to movie smoking and smoking

initiation among a large sample of northern New England

adolescents (grades 5–8) and that this statistical association

remained after controlling for numerous traditional risk factors

for smoking (Sargent et al., 2001). Among the adolescents who

had never tried a cigarette, exposure to movie smoking was as-

sociated with more positive attitudes about tobacco use and the

perception that most adults smoke. A follow-up study of these

never-smoking adolescents found that exposure to movie

smoking at baseline predicted smoking initiation 1 to 2 years

later (Dalton et al., 2003). The follow-up study showed that the

exposure preceded the behavior—an important requirement for

making a causal argument. Indeed, nearly 20% of those in the

highest-exposure quartile tried smoking compared to only 3% in

the lowest-exposure quartile; and this relationship remained

after controlling for smoking by family and friends, risk-taking

propensity in adolescence, and maternal warmth and limit

setting (as well as other sociodemographic variables). Interest-

ingly, the effect was stronger among children of nonsmokers than

it was among children of smokers, suggesting that the movie-

exposure effect was potentiated by the absence of more tradi-

tional risk factors.

To generalize across racial or ethnic groups from different

geographical regions, a random-digit-dial telephone longitudi-

nal survey was conducted on 6,522 U.S. adolescents aged 10 to

14 years old (Sargent et al., 2005). This sample was represen-

tative of the entire population of American adolescents. Once

again, adolescents with higher exposure to movie smoking were

much more likely to try smoking, even after statistically con-

trolling for sociodemographics, peer smoking, personality, par-

enting styles, and other social factors (see Fig. 1). The results of

this study, under review, largely mirror the results obtained from

the Northern New England sample. In this U.S. representative

sample, it has been confirmed that exposure to smoking in

movies is associated with established smoking (having smoked

more than 100 cigarettes) among adolescents over a 2-year

period (Sargent, Stoolmiller, et al., 2007). Another group of

researchers studied a sample of North Carolina adolescents and

found a longitudinal relationship between seeing PG-13 and

0

5

10

15

20

25

30

4321 Movie Smoking Exposure Quartile

P ro

po rt

io n

W ho

T rie

d S

m ok

in g

10 11 12 13 14

Age (years)

Fig. 1. Proportion of adolescents aged 10 to 14 who tried smoking as a function of exposure to movie smoking (amount of exposure broken down by quartile). The sample consisted of 4,538 U.S. adolescents who were never smokers at baseline and who were surveyed 16 months later on their tobacco use (unpublished data).

64 Volume 18—Number 2

Smoking in the Movies

R-rated movies and smoking initiation (Jackson, Brown, &

L’Engle, 2007). Another study found that German adolescents

have similar exposure to movie-smoking levels as U.S. teens

(about 80% of the movies they see are produced and distributed

by U.S. movie studios). German adolescents have higher

smoking rates, in part because there are fewer restrictions on

tobacco marketing and public smoking in that country. Despite

the cultural differences in approach to tobacco control, German

adolescents were shown to have much the same response to

movie smoking as their American counterparts (Hanewinkel &

Sargent, 2008). Thus, there is consistent and reliable evidence

demonstrating a strong relationship between exposure to

smoking in movies and adolescent smoking in longitudinal

studies and across cultures.

Moderation Effects

To determine if certain groups of adolescents were more or less

influenced by exposure to movie smoking in the studies men-

tioned, the researchers looked for moderation effects. In the New

England longitudinal study, adolescents with low exposure to

parent smoking were significantly more responsive to the movie

effect (Dalton et al., 2003). This same pattern was observed in a

longitudinal study of German adolescents, providing a cross-

cultural validation of the moderation effect (Hanewinkel &

Sargent, 2008). The effect suggests that adolescents exposed to

real-world images of smokers are less responsive to the glam-

orized images delivered by movies. Similarly, adolescents low in

sensation seeking were about 12 times more responsive to movie

images of smoking, another negative moderation that undercuts

the argument that kids who watch a lot of smoking are at high risk

for smoking because of other unmeasured risk factors (Sargent,

Stoolmiller, et al., 2007; see Fig. 2). Instead, it appears that the

low-risk adolescents are most responsive to movie smoking.

Other researchers have found apparent moderation by race,

with African American adolescents having little or no response

to movie smoking despite the fact that their exposure is 20 to

30% higher than that of Caucasians (Jackson et al., 2007). The

fact that African American adolescents are not responsive may

explain, in part, why they have such low rates of smoking during

adolescence compared with Caucasian adolescents.

Mediation Variables

Current research is beginning to explore mediating variables that

maygiveinsightintothemechanismsthroughwhichmoviesaffect

behavior. Postulated mediators include attitudes and cognitions,

as well as other factors such as smoking by peers. A longitudinal

structural model that included as endogenous variables identifi-

cation as a smoker, normative beliefs about smoking, and positive

expectancies about smoking was developed (Tickle, Hull, Sar-

gent, Dalton, & Heatherton, 2006); paths from movie-smoking

exposureto adolescentsmoking werefound through identification

as a smoker and through positive expectancies, and we have

replicated this finding in our more recent longitudinal work

(Wills, Sargent, Stoolmiller, & Gibbons, 2007; Wills, Sargent,

Stoolmiller, Gibbons, & Gerrard, 2008). It seems theoretically

plausible that continued exposure to smoking by movie stars

would increase positive expectancies over time, and this fits with

the finding of a strong association between seeing movie smoking

and more favorable attitudes toward smoking among those who

have never smoked (Sargent, Dalton, et al., 2002).

Another interesting mediational pathway involves smoking by

peers. Adolescents watch movies with their friends, and there-

fore they are exposed to movies in groups, not only on their own.

Seeing actors smoke could affect group norms about smoking.

One adolescent in the peer group with a slightly lower threshold

for trying smoking might be pushed into trying smoking and

become the proximal influence for other members of the peer

group. In this scenario, one might see a mediational pathway

through increases in adolescents’ perceptions of the number of

their peers that smoke, and this is exactly what was found (Wills

et al., 2007, 2008). However, at this point it is not clear whether

this mediational path is due to more peers smoking within stable

peer groups or to changes in peer affiliations prompted by

exposure to movie smoking.

EXPERIMENTAL STUDIES

Several studies have examined the effect of movies or movie

clips with smoking on attitudes and cognitions in adolescents

12

10

8

6

4

2

0

A dj

us te

d H

az ar

d R

at io

, E

st ab

lis he

d S

m ok

in g

0.0 0.2 0.4 0.6 0.8 1.0 Sensation-Seeking Level

Adjusted hazard ratio Lower bounds, 95% CI

Fig. 2. Effect of sensation seeking on the effect of exposure to movie smoking. The black line reflects the established smoking hazard ratio (risk of becoming an established smoker during the study) as sensation seeking varies. Sensation seeking is scaled so that 0 equals the 5th percentile and 1 equals the 95th percentile for the distribution. The hazard ratio is adjusted for other media variables (movie-viewing venues, movies viewed in the past week, movies viewed with parents), social and other environmental influ- ences (friend smoking, sibling smoking, parent smoking, poor school per- formance, parental style, extracurricular activities), and characteristics of the adolescent (age, sex, parent education, race, tried smoking at baseline, and rebelliousness). Adapted from ‘‘Exposure to Smoking Depictions in Movies: Its Association With Established Adolescent Smoking,’’ by J.D. Sargent, M. Stoolmiller, K.A. Worth, S. Dal Cin, T.A. Wills, F.X. Gibbons, et al., 2007, Archives of Pediatric Adolescent Medicine, 161, p. 854. Copyright 2007, American Medical Association. Adapted with permission.

Volume 18—Number 2 65

Todd F. Heatherton and James D. Sargent

and young adults. The results indicate that even brief exposures

to movie smoking can influence beliefs and cognitions about

smoking among actors, smoking in other people, and also per-

sonal prosmoking intentions. Pechman and Shih (1999) showed

adolescents scenes from the movie Reality Bites; the control

group saw the same film, but with smoking scenes edited out.

Adolescents who saw smoking scenes attributed higher social

status to adolescent smokers generally and also reported in-

creased personal intentions to smoke. Interestingly, the effect of

showing the entire movie on personal intentions was blunted by

showing an antismoking advertisement prior to viewing the

movie. These findings need to be replicated, but they provide the

basis for urging movie makers to include antismoking ads on

DVDs for movies that contain smoking.

Dal Cin and colleagues (Dal Cin, Gibson, Zanna, Shumate,

& Fong, 2007) recently published a theoretically important

manuscript based on transportation theory, the idea that viewers

are affected by stories because of their identification with the

storyline and characters. They looked at implicit associations

between self and smoking as a function of identification with

a smoking protagonist and found that greater identification

predicted stronger associations between the self and smoking

(for both smokers and nonsmokers) and increased intentions

to smoke (among the smokers). In addition, stronger implicit

associations between the self and smoking uniquely predicted

increases in smokers’ intentions to smoke. Taken together, the

experimental research published to date adds support to

epidemiologic studies.

PUBLIC HEALTH IMPLICATIONS

The findings summarized above have important public health

implications. First, if movies really are a causal element in youth

smoking, then movie smoking should be monitored just as we

would monitor any environmental exposure that adversely

affects health. We partner with the American Legacy Foundation

to publish annual reports on smoking in the top 100 box-office

hits released each year (see Legacy First Look Reports 16 and

18 at http://www.americanlegacy.org/publications.aspx). These

reports provide a validated metric to determine whether or not

progress is being made in reducing depictions of smoking by the

entertainment industry. Our most recent publications show a

significant decline in depictions of character smoking, espe-

cially for R-rated movies (see Recommended Reading).

Another issue is the identification and promotion of policy

measures that could reduce adolescent exposure. Various public

health advocacy groups (e.g., Smoke Free Movies, http://

smokefreemovies.ucsf.edu/) have encouraged the movie indus-

try to take voluntary actions that would reduce exposure, such as

giving an R rating to movies with smoking, declaring that no

funds have been provided by the tobacco industry, requiring

antismoking advertisements to run before any film with any

tobacco presence, and no longer showing tobacco brands in any

movie scenes. Several individual movie studios have imple-

mented internal guidelines designed to limit smoking depictions

in movies aimed at youth, although most have not.

Another group promoting policies to reduce smoking in movies

is theNational Association of Attorneys General (NAAG). NAAG

is charged with enforcing the Master Settlement Agreement be-

tween the State Attorneys General and the tobacco industry that

contains a ban on paying for brand placement in movies by any of

the major tobacco companies. Since this policy was adopted,

tobacco brand placement in movies dropped to almost nil. More

recently, and based in part on our research, NAAG has asked the

major movie studios to put an antismoking ad in any DVD with

smoking. This suggestion has been taken up by the Weinstein

Brothers, a production company that now puts Legacy Founda-

tion Truth s ads in all DVDs with smoking. It has been gratifying

to us to see the research findings so quickly translated into policy

initiatives to protect children from movie smoking.

Recommended Reading Sargent, J.D. (2005). Smoking in movies: Impact on adolescent smok-

ing. Adolescent Medicine, 16, 345–370. A readable detailed overview of the research described in this report.

Tickle, J.J., Hull, J.G., Sargent, J.D., Dalton, M.A., & Heatherton, T.F.

(2006). (See References). Describes a social psychological theory

of how movies might promote smoking uptake; the model is

supported by structural equation modeling.

Worth, K., Tanski, S., & Sargent, J.D. (2006). Trends in top box office movie tobacco use 1996–2004 (No. 16). Washington, DC: American Legacy Foundation. Report describing trends in how smoking

is portrayed in the movies.

Acknowledgments—Preparation of this manuscript and the

research described herein was supported in part by grants from

the National Cancer Institute (CA 61021, CA 77026), the

National Institute of Drug Abuse (DA12623), and the American

Legacy Foundation. The authors wish to acknowledge their

collaborators on this research, including Michael Beach, Sonya

Dal Cin, Madeline Dalton, Meg Gerrard, Fredrick Gibbons,

Reiner Hanewinkel, Jay Hull, Mike Stoolmiller, Susanne

Tanski, Jennifer Tickle, Linda Titus-Ernstoff, Tom Wills, and

Keilah Worth.

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Dalton, M.A., Sargent, J.D., Beach, M.L., Titus-Ernstoff, L., Gibson, J.J.,

Ahrens, M.B., et al. (2003). Effect of viewing smoking in movies

on adolescent smoking initiation: A cohort study. Lancet, 362, 281–285.

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Todd F. Heatherton and James D. Sargent