Pediatrics Article

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 theMedia

abstract The causes of adolescent substance use are multifactorial, but the media can play a key role. Tobacco and alcohol represent the 2most significantdrug threats toadolescents.More than$25billionper year is spent on advertising for tobacco, alcohol, and prescription drugs, andsuchadvertisinghasbeenshowntobeeffective.Digitalmediaare increasingly being used to advertise drugs. In addition, exposure to PG-13–andR-ratedmoviesatanearlyagemaybeamajor factor in the onsetofadolescent tobaccoandalcoholuse.TheAmericanAcademyof Pediatrics recommends a ban on all tobacco advertising in allmedia, limitationsonalcoholadvertising,avoidingexposureofyoungchildren to substance-related (tobacco, alcohol, prescription drugs, illegal drugs) content on television and in PG-13– andR-ratedmovies, incor- porating the topic of advertising andmedia into all substanceabuse– preventionprograms,andimplementingmediaeducationprogramsin 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 billionworthofcigarette, alcohol, andprescriptiondrugadvertising is effectively working to get them to “just say yes” to smoking, drinking, andotherdrugs.1,2 Inaddition, televisionprogramsandmoviescontain appreciable amounts of substanceuse. 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 receivemixedmessages about substance use, and the media contribute significantly to the risk that young people will engage in substanceuse.

ADOLESCENTDRUGUSE

Although illegal drugs take their toll on American society, 2 legal drugs—alcohol and tobacco—pose perhaps the greatest danger to childrenand teenagers.Bothrepresentsignificantgatewaydrugsand are among the earliest drugs usedby children or teenagers. A pread- olescent or adolescent who smokes tobacco or drinks alcohol is 65 timesmore likely to usemarijuana, 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.6More than 100 000deaths annually canbeattributed to exces-

THECOUNCIL ONCOMMUNICATIONSANDMEDIA

KEYWORDS adolescence, substanceuse, alcohol, tobacco, cigarettes, illicit drugs, TV,movies, Internet

This document is copyrighted and is property of the American Academyof Pediatrics and its Board of Directors. All authors have filed conflict of interest statementswith the American Academyof Pediatrics. Any conflicts have been resolved through aprocess approvedby theBoard of Directors. The American Academyof Pediatrics hasneither solicited nor accepted any commercial involvement in the development of the content of this publication.

www.pediatrics.org/cgi/doi/10.1542/peds.2010-1635

doi:10.1542/peds.2010-1635

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

Copyright©2010by the American Academyof Pediatrics

FROM THE AMERICAN ACADEMYOF 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 thedeathof 5000people younger than 21 years.8 Drug use also represents oneofmanyriskybehaviorsthatoccur duringadolescence: teenagerswhore- port that at least half of their friends are sexually active are 31 timesmore likely to drink, 5 times more likely to smoke, and 22 timesmore likely to try marijuana than are teenagerswho do not report such a high prevalence of sexual activity among friends.9

EFFECTSOF ADVERTISING

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

Advertising works; otherwise, compa- nieswouldnotspendbillionsofdollars on it.1 Many ads use celebrity endors- ers, humor, rock music, or attractive youngmodels, all of which have been shown to be effective with children and adolescents.11 Advertising makes smoking and drinking seem like nor- mativeactivitiesandmay functionasa “superpeer” insubtlypressuring teen- agers to experiment.12 Research has revealed that advertising may be re- sponsible for up to 30% of adolescent tobacco andalcohol 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 attractunderagesmokersfordecades and then lied to Congress about it.16–19

Given the demographics of smoking (1200deathsperday,halfofwhichare ofmiddle-agedadults; 50%ofsmokers begin by 13 years of age, and 90% of smokersbeginby19yearsofage), the industrymust recruit youngpeople as smokers.20 Recent statistics show that

theycontinue tosucceed. According to the 2009Monitoring the Future study, nearly half of all teenagers have tried smoking, as have 20% of all 8th- graders.21Cigaretteadvertisingseems to increase teenagers’ riskof smoking by glamorizing smoking and smok- ers.3,20Smokersaredepictedasyoung, 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- retteadvertising increasesyoungpeo- ple’s risk of smoking.20

Themost heavily advertised brands of cigarettesarealso themostpopular.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 childrenor teenagerswho pay closer attention to cigarette ads, who are able to recall such adsmore easily, or who own promotional items are more likely to become smokers themselves.27–31 Joe Camel single- handedly increased themarket share forCamel cigarettes from0.5%ofado- lescent smokers to 32%.32 A recent meta-analysis of 51 separate studies revealed that exposure to tobacco marketing and advertisingmore than doubles the risk of a teenager begin- ning to smoke.33

Alcohol

Approximately$6billion isspentannu- ally onalcohol advertisingandpromo- tion.34 Similar to tobacco ads, beer commercials are virtually custom- madetoappeal tochildrenandadoles- cents,using imagesof fun-loving, sexy, successful young people having the time of their lives.3,35,36 Unlike tobacco advertising, alcohol advertising faces fewrestrictions.Forexample,whereas thetobaccoindustrygaveuptelevision advertising in the 1960s, beer, wine,

and liquoradsare frequently featured on prime-time television, and young people view 1000 to 2000 alcohol ads annually.12,37Muchof theadvertising is concentrated during teen-oriented showsandsportsprogramming. All of the top-15 teen-oriented shows con- tain alcohol ads.38 Currently, teenag- ersare400 timesmore likely toseean alcohol ad than to seeapublic service announcement (PSA) thatdiscourages underage drinking.39 Teen-oriented magazinescontain48%moreadvertis- ing forbeer, 20%moreadvertising for hard liquor,and92%moreadvertising 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 theBudweiser frogs nearly as frequently as they couldBugsBunny.44 In a studyofmore than3500SouthDakota students, 75% of 4th-graders and nearly 90% of 9th- gradersrecognized theBudweiser 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 longitudinalstudieshaveshownasim- ilar trend,53,54 although they have sometimesbeenmixed.48

PrescriptionDrugs

Nearly $4 billion is spent annually on prescription drug advertising.55 Drug companies now spend more than twiceasmuchmoneyonmarketingas theydoon researchanddevelopment, and studies have revealed that the marketingeffortspayoff56: resultsofa recent survey of physicians showed that 92%of patients had requestedan advertised drug.57 Children and teen- agers get themessage that there is a pill to cureall ills andadrug for every

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occasion, including sexual inter- course. In the first 10months of 2004, drugs companies spent nearly half a billion dollars advertising Viagra, Lev- itra,andCialis.58 Yet, theadvertisingof condoms,birthcontrolpills,andemer- gency contraception is haphazardand rare and remains controversial.1,59

DRUGS IN ENTERTAINMENTMEDIA

Cigarettes

Sceneswith smoking remain common in movies and, to a lesser extent, on prime-time television. Hollywood seems to use smoking as a shorthand for troubledor 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%ofshowsportraytobaccouse,and approximately one-fourth of them de- pict negative statements about smok- ing.61 Inaddition,smokingisalsofound 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 PGmovies.63

Box-office movies and their subse- quent videoandpay-per-viewdistribu- tion have becomeamajor route of ex- posure to tobacco use. Although the most recentanalysesshowthat smok- ing has decreased in popular mov- ies,64,65 theoccurrenceremainshigh.A content analysis of the top 100 box- office hits between 1996 and 2004 re- vealed that tobacco use was depicted in three-quartersofG-,PG-, andPG-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 in2003andhassincedeclined, in2009, more than half of PG-13 movies still contained tobacco use.65 But overall, the percentage of all top-grossing

movieswithoutsmokingexceeded50% for the first time in 2009.65

Unique longitudinal research has re- vealed that one of themost important factors in theonset of adolescent sub- stance use is exposure to others who usedrugs.68 Nowhere is that exposure greater than on contemporary movie screens,andteenagersconstitute26% of themovie-going audience (but only 16%of theUSpopulation).69 Results of anumberof 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 toanewmeta-analysis, itmay account for nearly half of smoking ini- tiation inyoungteenagers.80 In fact, ex- posure to movie smoking may even trump parents’ smoking status as be- ing the key factor in adolescents’ initi- ationofsmoking.73Aprospectivestudy ofmore 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-ratedmov- iesare less likely tobeginsmoking (or drinking).80 A study of 735 12- to 14- year-olds, with a 2-year follow-up, re- vealedthatexposuretoR-ratedmovies or having a television in the bedroom significantly increased the risk of smoking initiation for white teenag- ers.81 Themovieeffect seemsnot tobe confined to US teenagers but applies alsototeenagersfromothercountries aswell.82,83

Alcohol

Alcohol remains the number one drug portrayed on American television: 1 drinking scene is shownevery 22min- utes, comparedwith 1 smoking scene every 57minutes and 1 illicit druguse scene every 112 minutes.84 On Music Television(MTV), teenagerscanseeal-

cohol use every 14minutes. An analy- sis revealed that drugs were present in nearly half of 359 music videos— alcohol in 35%, tobacco in 10%, and il- licitdrugs in13%.85Onprime-timetele- vision,70%ofprogramsdepictalcohol use.61Morethanone-thirdof thedrink- 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

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

Again, the impact is increasingly clear fromtheresearch.Alongitudinalstudy of more than 1500 California 9th- gradersrevealedthat increasedtelevi- sion and music video viewing was a risk factor for theonset 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 withteenagerswhowatchnone.93Also, in an intriguing study of 2- to 6-year- olds(n�120)whowereaskedtorole- play in a make-believe store, children were5 timesmore likely to “buy” beer orwine if theyhadbeenallowedtosee PG-13orR-ratedmovies.94 Finally,good longitudinal evidence is emerging to indicate thatwatchingmoremoviede- pictions of alcohol is strongly predic- tive of drinking onset andbingedrink- ing in US adolescents,86,95,96 and the same results are being found for ado- lescents fromother countries.82,97

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Illegal Drugs

Illicit drugsare rarely seenon 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 shownmore than half of the time.90 Marijuana is the most frequent drug seen in movies and seems to bemaking a comeback inR-ratedmoviessuchasHaroldand Kumar Go toWhite Castle (2004) and ThePineapple 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 withmarijuana use.95,99

NEWMEDIA

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 tobaccoproducts, and fewof 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- ingpurchasedalcoholonline, and12% reportedhavinga friendwhodidso.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 onlinevideos104 andonsocialnetwork- ing sites,105 onwhich 1 study revealed that 40% of profiles referenced sub- stance abuse.106

SUMMARY

The so-called war on drugs has been waged fordecades, yet teenagerscon- tinuetouseandabuseavarietyofsub- 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- baccomarketing by the tobacco com- panies that signed the agreement. However, tobaccocontinues toappear frequently inmovies, and this factcon- 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 toeliminateall tobacco advertising and to decrease greatly the depiction of smoking in mainstream media. Because alcohol use is still condoned in many venues and use inmoderationmay be health- ful foradults, suchsevere restrictions on alcohol advertising and program- ming may not be indicated. On the otherhand,underagealcoholusedoes pose a clear and immediate threat to the teenagers who use it. Taken to- gether, theevidencesupportsstrong 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 adultme- dia venueswith excessive substance use exposure.

Anticipatory Guidanceby Pediatricians

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

child visit, pediatriciansshouldbe askingat least2questionsregard- ing media use: (a) Howmuch en- tertainment media per day is the childoradolescentwatching?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 parentsto limitaccessbychildren and young adolescents to televi- sion venues with excessive sub- stance use depictions (eg, MTV, HBO, Showtime, ComedyCentral).

3. Pediatricians should encourage parents to limit younger chil- dren’s exposure to PG-13 movies andavoid R-ratedmovies.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 eveningmeals.

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

Community Advocacy by Pediatricians

7. Pediatricians should encourage their local school systems to in- corporate media education into their curricula. In particular, drug-preventionprogramsshould usebasicprinciplesofmedia liter- acy,designedto imbueskepticism 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 areavailable andshouldbe used.110–113

Legislative Advocacy by Pediatricians

8. Pediatricians should encourage Congress toban tobaccoadvertis- ing in allmedia accessible to chil- dren, which several European countrieshavealreadydone.Such a ban would seem to be constitu- tional, given that the US Supreme Court has already ruled that com- mercial speechdoesnotenjoy the absolute First Amendment pro- tections that freespeechdoes.114

Recently, Congress gave the Food and Drug Administration theauthority toregulate tobacco products; however, the tobacco industry isexpected tochallenge any advertising bans.115,116

9. Pediatricians should encourage Congresstorequirethealcohol 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 thealcohol industry to restrict ad- vertising and product placement in venues inwhichmore than10% of the audience is children and adolescents.

11. Pediatricians should encourage theWhite 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 allocationofmoremoney inmedia research, given the importance of themediaonthedevelopmentand 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 topassnewstrict laws regulating digital advertising that targets children and adolescents.100,117

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

14. Pediatricians should encourage the advertising industry, drug companies, public health groups, andmedical groups to have a full and open debate on the necessity of advertising prescription drugs. In addition, ads for erectile dys- functiondrugsshouldbeconfined toafter 10 PM inall time zonesand should not be overly suggestive.1

15. Pediatriciansshouldencourage the entertainment industry to have greater sensitivity about theeffects of televisionandmoviesonchildren andadolescentsandacceptthatthe industrydoes, indeed,haveapublic 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 smokinginitsmovies.121Makingfilm sets smoke-free zoneswouldgo far todiminishtheportrayalofsmoking inmoviesandwouldprotect actors and actresses from secondhand smoke.Antismokingadsshouldpre- cede the showing of any film that hastobaccousedepicted.119Alcohol useshouldnotbeportrayedasnor-

mative behavior for teenagers, and the traditional depiction of the “funny drunk” should be retired. Television networks that have a largeadolescent viewership should airpublicserviceadsaboutthedan- gers of smoking and drinking. Fi- nally, theMotionPictureAssociation of America (MPAA) ratings need to beamendedsothattobaccousewill routinely garner an R rating in all new movies unless the risks and consequences of smoking are un- ambiguouslyshownorthedepiction is necessary to represent a real historical figure who actually used tobacco.119 So far, theMPAA has only agreed to consider smoking as a factor in assigning a rating.122,123

16. Pediatricians should encourage stateand federalagencies, theen- 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 showntobehighlyeffectiveattimes (eg, the Truth campaign),124–129 but the effectiveness of the National Youth Anti-Drug Media Campaign has been questioned.130 Recently, andlaudably,6majorHollywoodstu- dioshaveagreedtoplaceantismok- ingadsonnewmovieDVDs thatap- peal tochildren.131,132

17. Pediatricians should work with and support the American Acad- emyofPediatricsJuliusRichmond Center of Excellence (www.aap. org/richmondcenter), themission 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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LEADAUTHOR Victor C. Strasburger,MD

COUNCIL ONCOMMUNICATIONSAND MEDIA EXECUTIVE COMMITTEE, 2009–2010 Gilbert L. Fuld,MD, Chairperson DeborahAnnMulligan,MD, Chair-elect TanyaRemer Altmann,MD Ari Brown,MD Dimitri A. Christakis,MD KathleenClarke-Pearson,MD BenardP. Dreyer,MD

Holly Lee Falik,MD KathleenG. Nelson,MD GwennS. O’Keeffe,MD Victor C. Strasburger,MD

PAST EXECUTIVE COMMITTEE MEMBERS ReginaM.Milteer,MD Donald L. Shifrin,MD

LIAISONS Michael Brody,MD–AmericanAcademyof Child andAdolescent Psychiatry

BrianWilcox, PhD–AmericanPsychological Association

CONTRIBUTOR JamesD. Sargent,MD

STAFF Gina Ley Steiner Veronica LaudeNoland [email protected]

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