Adolescents Why do they Smoke?depts.washington.edu/tobacco/docs/Sargent08.pdf · “Most people my age smoke.” Positive Expectancies or Utilities What do I Gain by Smoking? “Smoking

AdolescentsAdolescentsWhy do they Smoke?Why do they Smoke?

James D. James D. Sarg entSarg ent , M.D., M.D.

Director, Cancer Contro l ResearchDirector, Cancer Contro l ResearchProg ramProg ram

Norris Cotton Cancer CenterNorris Cotton Cancer Center

Professor of Ped iatricsProfessor of Ped iatrics

Dartm outh Medical SchoolDartm outh Medical School

Dartmouth M ediaResearchLaboratory

Current Use Among Middle and High SchoolCurrent Use Among Middle and High SchoolStudents by Tobacco ProductStudents by Tobacco Product

National Youth Tobacco Survey, 2004National Youth Tobacco Survey, 2004

0

5

10

15

20

25

30

Any Use Cigarettes Cigars Smokeless Pipes Bidis Kreteks

PE

RC

EN

T

Middle School

High School

Note: Used tobacco on ³ 1 of the 30 days preceding the surveySource: American Legacy Foundation, National Youth Tobacco Survey

11.7

28.0

8.1

22.3

5.2

12.8

2.9 6.0

2.6 3.1 2.6 1.52.3 2.3

Trends in Youth Cigarette SmokingTrends in Youth Cigarette SmokingPast 30 days (current smoking)Past 30 days (current smoking)

United States, 1975-2007 United States, 1975-2007

0

5

10

15

20

25

30

35

40

45

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

YEAR

PERCENT

Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys

12th Grade

8th Grade

10th Grade 21.6% in 2007

14.0% in 2007

7.1% in 2007

Trends in Cigarette Use among 12Trends in Cigarette Use among 12thth Grade GradeStudents -- United States, 1975-2007Students -- United States, 1975-2007

0

10

20

30

40

50

60

70

80

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

YEAR

PERCENT

Source: Institute for Social Research, University of Michigan, Monitoring the Future Survey

Lifetime Use

30-day Use

Daily Use

½ pack+/day

46.2% in 2007

21.6% in 2007

12.3% in 2007

5.7% in 2007

Daily Smoking among EuropeanDaily Smoking among European 15 year olds 15 year olds

Trends in Prevalence off Current Cigarette SmokingTrends in Prevalence off Current Cigarette SmokingHigh School Seniors by GenderHigh School Seniors by Gender

United States, 1975-2007United States, 1975-2007

0

5

10

15

20

25

30

35

40

45

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005

YEAR

PERCENT


Male

Female

Trends in Prevalence of Past MonthTrends in Prevalence of Past MonthCigarette Smoking Among High SchoolCigarette Smoking Among High School

Seniors by Race Seniors by Race –– United States, 1977-2007 United States, 1977-2007

0

5

10

15

20

25

30

35

40

45

1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007

YEAR

PERCENT

Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys; for racial subgroups, data

for the current year and the previous year are combined

White

Black

Hispanic

Age

(in

year

s)

Newborn2

10

20

30

40

EXPERIMENTATION

ADDICTION

Social Influences Model

Addiction Model

What Motivates Smoking?What Motivates Smoking?

ChildPersonality

GenderAge

GradesSES

SmokingInitiation

Behavior

Social Influences ModelSocial Influences Model

ParentSmoking

Support/ControlMedia Restrictions

PeersSmokingConduct

MediaMovies

Marketing

ChildPersonality

GenderAge

GradesSES

SmokingInitiation

Behavior

SocialInfluences


ParentSmoking


PeersSmokingConduct

MediaMovies

Marketing

ChildPersonality

GenderAge

GradesSES

NormsSmoker Image

Beliefs/Expectations

Cognitions

SmokingInitiation

Behavior

SocialInfluences


ParentSmoking


PeersSmokingConduct

MediaMovies

Marketing

ChildPersonality

GenderAge

GradesSES

NormsSmoker Image


Cognitions

Desire to Fit inIdentificationReward Value

Assumed Mechanism

SmokingInitiation

Behavior

SocialInfluences


Smoking as Normative Behavior“Most people my age smoke.”

Positive Expectancies or UtilitiesWhat do I Gain by Smoking?

“Smoking would be relax me”“Smoking would make more comfortable at a party”

“Smoking would be a good way to lose weight”

Key ConstructsKey Constructs

PrototypesNow I’d like you to think about kids your age who smoke.

“How attractive are they?”“How grown up are they?”

ParentSmoking


PeersSmokingConduct

MediaMovies

Marketing

ChildPersonality

GenderAge

GradesSES

NormsSmoker Image


Cognitions

Desire to Fit inIdentificationReward Value

Assumed Mechanism

SusceptibilityIntentions

Resistance to peer offersWillingnessSmoking

InitiationAttitudes

Behavior

SocialInfluences


WillingnessFredrick Gibbons / Meg Gerrard

Willingness

Intentions

Prototype

Health Belief ModelBehavior

Susceptibility to SmokingJohn Pierce

Inability to Rule out Smoking“Do you think you might try smoking in the next 6 mos?”

“Do you think you might smoke if a friend offered?”

Key ConstructsKey Constructs

Tobacco Marketing as a Risk FactorTobacco Marketing as a Risk Factor

$0

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

$30,000,000

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

Year

Dol

lars

(in

thou

sand

s)

Total NIH Budget

$0

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

$30,000,000

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

Year

Dol

lars

(in

thou

sand

s)

Total NIH BudgetTobacco Marketing

Marketing ExpendituresMarketing Expenditures

•• Tobacco AdvertisingTobacco Advertising–– StorefrontStorefront–– Print adsPrint ads–– Sponsorships (music events and racing)Sponsorships (music events and racing)

•• Tobacco PromotionsTobacco Promotions–– Price discounts (two for one deals)Price discounts (two for one deals)–– Free merchandise (bar promotions)Free merchandise (bar promotions)

$0

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

$30,000,000

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

Year

Dol

lars

(in

thou

sand

s)

Total NIH BudgetTobacco Marketing

Tobacco Branded Merchandise

Tobacco Branded MerchandiseTobacco Branded Merchandise

•• Marlboro Miles CampaignMarlboro Miles Campaign•• Camel Cash CampaignCamel Cash Campaign

Cross-Sectional SurveyCross-Sectional Survey

•• 5 rural schools5 rural schools•• AnonymousAnonymous•• Grades 6-12Grades 6-12•• N = 1265N = 1265•• One-third of students owned one orOne-third of students owned one or

more tobacco promotional itemsmore tobacco promotional items

0

20

40

60

A B C D E

School

Percent

Brought Item

Saw Item

0

10

20

30

40

50

60

6 7 8 9 10 11 12

Grade in School

>100 C

igs L

ifeti

me

(perc

en

t)

Owns TBM

Does not own

TBM

0

20

40

60

80

1 2 3 >=4

Number of TPI's

Pe

rc

en

t

>=100

Longitudinal StudyLongitudinal Study

•• 3 Surveys3 Surveys•• 3 Schools3 Schools•• N = 480N = 480•• < 100 cigarettes< 100 cigarettes•• Smoking indexSmoking index

–– 0 = never smoker, not susceptible0 = never smoker, not susceptible–– 1 = never smoker, susceptible1 = never smoker, susceptible–– 2 = 2 = ≤≤ 11–– 3 = 2-993 = 2-99–– 4 = 4 = ≥≥100100

Key ConstructKey Construct

Receptivity to Tobacco MarketingReceptivity to Tobacco MarketingJohn PierceJohn Pierce

•• Persuasive Communications FrameworkPersuasive Communications Framework–– Exposure to advertising messageExposure to advertising message–– Attending to and understanding the messageAttending to and understanding the message–– Development of a cognitive and affective response toDevelopment of a cognitive and affective response to

the messagethe message

•• Adolescent is receptive if:Adolescent is receptive if:–– Can name the brand for a favorite adCan name the brand for a favorite ad–– The own or are willing to use tobacco brandedThe own or are willing to use tobacco branded

merchandisemerchandise

Science Leads to Action:Science Leads to Action:Master Settlement AgreementMaster Settlement Agreement

(f) Ban on Tobacco Brand Name Merchandise. Beginning July 1, 1999, no ParticipatingManufacturer may, within any Settling State, market, distribute, offer, sell, licenseor cause to be marketed, distributed, offered, sold or licensed (including, withoutlimitation, by catalogue or direct mail), any apparel or other merchandise (otherthan Tobacco Products, items the sole function of which is to advertise TobaccoProducts, or written or electronic publications) which bears a Brand Name.Provided, however, that nothing in this subsection shall (1) require anyParticipating Manufacturer to breach or terminate any licensing agreement

Maggie Gyllenhaal; “Mona Lisa Smile”

Media Influences on AdolescentMedia Influences on AdolescentSmoking BehaviorSmoking Behavior

AIMSAIMS•• Describe smoking in popularDescribe smoking in popular

contemporary moviescontemporary movies•• Assess exposure to movie smokingAssess exposure to movie smoking

among adolescentsamong adolescents•• Determine if movie smoking exposureDetermine if movie smoking exposure

is linked with adolescent smokingis linked with adolescent smoking

Supported since 1997 by National Cancer Institute (CA-77026)Supported since 1997 by National Cancer Institute (CA-77026)

04

1636

64

G PG PG-13 R28 (25%) 71 (44%) 220 (76%) 215 (87%)

Num

ber o

f Mov

ie S

mok

ing

Occ

urre

nces

Smoking Occurrences in 532 Box Office Hits

N - Movies (% w smk)MPAA Rating

0 0

47

020

4060

80

Perc

ent o

f Mov

ies

0 5 10 15 20 25

Minutes of Screen Smoking

Smoking Screentime in 532 Box office hits

Nicholas Cage; “Matchstick Men”

BMJ 2001;323(7326):1394-7

Gene Hackman; “Heartbreakers”

Study DesignStudy Design

•• Cross-sectional school-based surveyCross-sectional school-based survey•• 15 randomly selected VT and NH15 randomly selected VT and NH

middle schoolsmiddle schools•• Included grades 5-8Included grades 5-8•• From urban and rural communitiesFrom urban and rural communities•• Sparse minority representationSparse minority representation

Steve Buscemi; “28 Days”

Primary OutcomePrimary Outcome

•• How many cigarettes have you smoked inHow many cigarettes have you smoked inyour life?your life?

nonenone Never smokedNever smokedjust a few puffsjust a few puffs Tried smokingTried smokingOne to 19 cigarettesOne to 19 cigarettes20 to 100 cigarettes20 to 100 cigarettesMore than 100 cigarettesMore than 100 cigarettes

Sandra Bullock; “28 Days”

Select Popular MoviesSelect Popular Movies•• Box office hits Box office hits N N Top 25,1988-1995 200 Top 25,1988-1995 200 Top 100,1996-1998 300 Top 100,1996-1998 300 Top 50,1999 (assessed 6/30/99) 50 Top 50,1999 (assessed 6/30/99) 50•• With popular teen stars 51 With popular teen stars 51

Beach Method


•• Count the smoking occurrences Count the smoking occurrences in each movie in each movie

Content AnalysisContent Analysis

Beach Method

Generate movie listsGenerate movie lists


•• Questionnaire assesses which of the Questionnaire assesses which of the 50 movies the adolescent has ever seen 50 movies the adolescent has ever seen Median = 17, Median = 17, InterquartileInterquartile range 11-22 range 11-22

Survey StudentsSurvey Students

•• Randomly select 50 movies for each survey Randomly select 50 movies for each survey •• Use stratified sampling to ensure Use stratified sampling to ensure representative distribution by rating representative distribution by rating (45% R, 31% PG 13, 20% PG, 4% G) (45% R, 31% PG 13, 20% PG, 4% G)


Beach Method


Generate movie listsGenerate movie lists


•• Questionnaire assesses which of the Questionnaire assesses which of the 50 movies the adolescent has ever seen 50 movies the adolescent has ever seen Median = 17, Median = 17, InterquartileInterquartile range 11-22 range 11-22

Survey StudentsSurvey Students

•• Randomly select 50 movies for each survey Randomly select 50 movies for each survey •• Use stratified sampling to ensure Use stratified sampling to ensure representative distribution by rating representative distribution by rating (45% R, 31% PG 13, 20% PG, 4% G) (45% R, 31% PG 13, 20% PG, 4% G)


Number movie smoking occurrences seenNumber movie smoking occurrences seen Median = 91, Median = 91, InterquartileInterquartile range 49-152 range 49-152

Movie Smoking Exposure VariableMovie Smoking Exposure Variable

MergeMerge

Beach Method


Exposure to Smoking from 601Exposure to Smoking from 601Popular Contemporary MoviesPopular Contemporary Movies


Number of smokingNumber of smokingoccurrences seenoccurrences seen

–– 0-600 24%0-600 24%



–– 0-600 24%0-600 24%–– 601-1200 28%601-1200 28%



–– 0-600 24%0-600 24%–– 601-1200 28%601-1200 28%–– 1201-2000 24%1201-2000 24%



–– 0-600 24%0-600 24%–– 601-1200 28%601-1200 28%–– 1201-2000 24%1201-2000 24%–– >2000 24%>2000 24%

Dose-responseDose-responseStrength of the AssociationStrength of the Association

0

5

10

15

20

25

30

35

40

Q1 Q2 Q3 Q4

Movie Smoking Exposure Quartile

Tri

ed

S

mo

kin

g (p

erc

en

t)

0

5

10

15

20

25

30

35

40

Q1 Q2 Q3 Q4

Sensation Seeking Quartile

Tri

ed

S

mo

kin

g (p

erc

en

t)

0

5

10

15

20

25

30

35

40

Grade 5 Grade 6 Grade 7 Grade 8

Grade in School

Tri

ed

S

mo

kin

g (p

erc

en

t)

05

10152025303540

0-600 601-1200 1201-2000

>=2000

Exposure to Movie Smoking

Trie

d Sm

okin

g (p

erce

nt)

Grade 5Grade 6Grade 7Grade 8

Stratification: No movie effectStratification: No movie effect

05

10152025303540

0-600 601-1200 1201-2000

>=2000


Trie

d Sm

okin

g (p

erce

nt)

Grade 5

StratificationStratification

05

10152025303540

0-600 601-1200 1201-2000

>=2000


Trie

d Sm

okin

g (p

erce

nt)

Grade 5Grade 6


05

10152025303540

0-600 601-1200 1201-2000

>=2000


Trie

d Sm

okin

g (p

erce

nt)

Grade 5Grade 6Grade 7


05

10152025303540

0-600 601-1200 1201-2000

>=2000


Trie

d Sm

okin

g (p

erce

nt)

Grade 5Grade 6Grade 7Grade 8


Other Covariates

Sociodemographics•• Grade in SchoolGrade in School•• GenderGender•• Parent EducationParent Education

Social InfluencesSocial Influences•• Parent smokingParent smoking•• Sibling smokingSibling smoking•• Friend smokingFriend smoking•• Tobacco promotionalTobacco promotional

itemitem

PersonalityPersonalityCharacteristicsCharacteristics

•• Self EsteemSelf Esteem•• Sensation seekingSensation seeking•• RebelliousnessRebelliousness

ParentingParenting•• MaternalMaternal

responsivenessresponsiveness•• Maternal supervisionMaternal supervision•• Parental disapproval ofParental disapproval of

smokingsmoking

Multivariate AssociationMultivariate Association

Pierce Brosnan; “Die Another Day”

Chicken and the Egg:Chicken and the Egg:

Longitudinal Study ofLongitudinal Study ofNever SmokersNever Smokers

Temporal RelationshipTemporal Relationship

Selma Blair; “Down to You”

Convergence: Replication of Results in Independent SamplesConvergence: Replication of Results in Independent Samplesand Using Different Study Designsand Using Different Study Designs

Movie

smoking

exposure

Quartile 1

Quartile 2

Quartile 3

Quartile 4

Movie

smoking

exposure

Quartile 1

Quartile 2 Reference

Quartile 3

Quartile 4

1.9 (1.3, 2.7)

2.6 (1.8, 3.7)

2.5 (1.7, 3.5)

1.6 (1.3, 2.0)

1.8 (1.5, 2.3)

2.2 (1.8, 2.8)

1.7 (1.1, 2.6)

1.8 (1.2, 2.8)

2.6 (1.7, 4.1)

1.5 (1.1, 2.1)

2.0 (1.3, 2.9)

2.5 (1.9, 3.4)

1.2 (1.1, 1.4)

1.4 (1.1, 2.0)

1.7 (1.2, 2.7)

3.0 (1.5, 5.9)

PG-13 Movie Exp

5.1 (2.7, 9.7)

1.8 (1.3, 2.7)

1.9 (1.3, 2.8)

2.7 (1.9, 4.0)

1.09 (1.03, 1.15)1.4 (1.0, 1.8)

1.8 (1.4, 2.3)

2.0 (1.5, 2.6)

2.0 (1.3, 3.2)

2.2 (1.4, 3.4)

2.7 (1.7, 4.3)

Adj OR (95% CI) Adj OR (95% CI) Adj OR (95% CI) Adj OR (95% CI)

Adj OR (95% CI)

Convergence of Results: Longitudinal Studies

Adj OR (95% CI)

Mexican

(N = 3876) Ages 11-16

Northern New England

(N=4919) Ages 10-14


(N=2603) Ages 10-14

U.S. National

(N=6522) Ages 10-14

US Young Adult

(N = 1828) Ages 18-25

Reference

Reference ReferenceReference

Reference

Reference

U.S. National Sample*

(N = 2976) Ages 10-14

German

(N = 5586) Ages 10-15

Reference

RR reflects each decile of movie

smoking.

German

(N = 2711) Ages 10-15

Reference

* Whites only

Adj RR (95% CI) Adj RR (95% CI) Adj RR (95% CI) Adj RR (95% CI)

North Carolina*

(N = 735) Ages 12-14


(N = 2499) Ages 7-10

Convergence of Results: Cross Sectional Studies

1.0 (0.6, 1.5)

Adj OR (95% CI)

1.5 (0.9, 2.3)

1.4 (0.9, 2.1)

Scottish Young Adult

(N = 1258) Ages 18-20

Reference

0.2

.4.6

0 20 40 60 80 100

Percentile Rank for Movie Smoking Exposure at Baseline

White BlackHispanic

Inci

denc

e, E

ver T

ried

Smok

ing

N = 4162 Never smoker baseline sample, excludes “Other” race

Smoothed Curve of 24M Smoking Incidence VS. Exposure to Movie Smoking at Baseline

By Race/Ethnicity


Movie

smoking

exposure

Quartile 1

Quartile 2

Quartile 3

Quartile 4

Movie

smoking

exposure

Quartile 1


Quartile 3

Quartile 4

1.9 (1.3, 2.7)

2.6 (1.8, 3.7)

2.5 (1.7, 3.5)

1.6 (1.3, 2.0)

1.8 (1.5, 2.3)

2.2 (1.8, 2.8)

1.7 (1.1, 2.6)

1.8 (1.2, 2.8)

2.6 (1.7, 4.1)

1.5 (1.1, 2.1)

2.0 (1.3, 2.9)

2.5 (1.9, 3.4)

1.2 (1.1, 1.4)

1.4 (1.1, 2.0)

1.7 (1.2, 2.7)

3.0 (1.5, 5.9)

PG-13 Movie Exp

5.1 (2.7, 9.7)

1.8 (1.3, 2.7)

1.9 (1.3, 2.8)

2.7 (1.9, 4.0)

1.09 (1.03, 1.15)1.4 (1.0, 1.8)

1.8 (1.4, 2.3)

2.0 (1.5, 2.6)

2.0 (1.3, 3.2)

2.2 (1.4, 3.4)

2.7 (1.7, 4.3)


Adj OR (95% CI)


Adj OR (95% CI)

Mexican

(N = 3876) Ages 11-16


(N=4919) Ages 10-14


(N=2603) Ages 10-14

U.S. National

(N=6522) Ages 10-14

US Young Adult

(N = 1828) Ages 18-25

Reference


Reference

Reference


(N = 2976) Ages 10-14

German

(N = 5586) Ages 10-15

Reference


smoking.

German

(N = 2711) Ages 10-15

Reference

* Whites only


North Carolina*

(N = 735) Ages 12-14


(N = 2499) Ages 7-10


1.0 (0.6, 1.5)

Adj OR (95% CI)

1.5 (0.9, 2.3)

1.4 (0.9, 2.1)


(N = 1258) Ages 18-20

Reference

Findings apply to children as young as 8Who mainly watch movies for kidsFinding applies to young adultsEffects mediated through expectancies and friend smoking

Black adolescents seem resistant to movie effect


Movie

smoking

exposure

Quartile 1

Quartile 2

Quartile 3

Quartile 4

Movie

smoking

exposure

Quartile 1


Quartile 3

Quartile 4

1.9 (1.3, 2.7)

2.6 (1.8, 3.7)

2.5 (1.7, 3.5)

1.6 (1.3, 2.0)

1.8 (1.5, 2.3)

2.2 (1.8, 2.8)

1.7 (1.1, 2.6)

1.8 (1.2, 2.8)

2.6 (1.7, 4.1)

1.5 (1.1, 2.1)

2.0 (1.3, 2.9)

2.5 (1.9, 3.4)

1.2 (1.1, 1.4)

1.4 (1.1, 2.0)

1.7 (1.2, 2.7)

3.0 (1.5, 5.9)

PG-13 Movie Exp

5.1 (2.7, 9.7)

1.8 (1.3, 2.7)

1.9 (1.3, 2.8)

2.7 (1.9, 4.0)

1.09 (1.03, 1.15)1.4 (1.0, 1.8)

1.8 (1.4, 2.3)

2.0 (1.5, 2.6)

2.0 (1.3, 3.2)

2.2 (1.4, 3.4)

2.7 (1.7, 4.3)


Adj OR (95% CI)


Adj OR (95% CI)

Mexican

(N = 3876) Ages 11-16


(N=4919) Ages 10-14


(N=2603) Ages 10-14

U.S. National

(N=6522) Ages 10-14

US Young Adult

(N = 1828) Ages 18-25

Reference


Reference

Reference


(N = 2976) Ages 10-14

German

(N = 5586) Ages 10-15

Reference


smoking.

German

(N = 2711) Ages 10-15

Reference

* Whites only


North Carolina*

(N = 735) Ages 12-14


(N = 2499) Ages 7-10


1.0 (0.6, 1.5)

Adj OR (95% CI)

1.5 (0.9, 2.3)

1.4 (0.9, 2.1)


(N = 1258) Ages 18-20

Reference

No effect for young adults in west of Scotland

•• Established smokingEstablished smoking–– Lifetime smoking of > 100 cigarettesLifetime smoking of > 100 cigarettes

Johnny Depp; “Blow”

Gwen Paltrow

Indirect Pathways from MovieIndirect Pathways from MovieExposure to SmokingExposure to Smoking

Peer SmokingPeer Smoking

John Travolta; “Swordfish”

MOVIE EXPOSURE

MOTHER DEMANDINGNESS

MOTHERRESPONSIVENESS

SELF-ESTEEM

REBELLIOUSNESS

SENSATIONSEEKING

SIBLINGSMOKING

PARENT SMOKING

FRIENDS SMOKING 1

SMOKINGEXPECTANCIES 2

FRIENDSSMOKING 2

EVER SMOKE 2

.13

.23

.26

.17 .30 .27

SMOKING EXPECTANCIES 1

.10.05

.06- .04

- .04

- .04

- .06

.08

.08

.05.11

.11

.10

.08

- .06

.07

.07

.20

.25

.08

.31

GENDER

AGE

SES

U.S. Sample

So How Many Adolescent StartSo How Many Adolescent StartSmoking Because of Movies?Smoking Because of Movies?

•• The concept of attributable riskThe concept of attributable risk•• Northern New EnglandNorthern New England

–– Study 1: 50%Study 1: 50%–– Study 2: 35-45%Study 2: 35-45%

•• US SampleUS Sample–– Cross-sectional: 38%Cross-sectional: 38%–– Longitudinal:Longitudinal:

ConclusionsConclusions•• Lots of smoking in moviesLots of smoking in movies•• Adolescents like to watch themAdolescents like to watch them•• Hypothesis is theoretically Hypothesis is theoretically plausibleplausible•• Exposure to smoking in movies startsExposure to smoking in movies starts

beforebefore the onset of smoking the onset of smoking•• The association between exposure andThe association between exposure and

adolescent smoking:adolescent smoking:–– is is strong strong and and separateseparate from a host of other from a host of other

risk factorsrisk factors–– shows a shows a dose-responsedose-response–– is is consistentconsistent across samples, smoking across samples, smoking

outcomes, and methodsoutcomes, and methodsLeonardo DiCaprio; “The Beach”

Why did Youth Smoking Trends DropWhy did Youth Smoking Trends Dropafter 1997?after 1997?

0

5

10

15

20

25

30

35

40

45

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

YEAR

PERCENT


12th Grade

8th Grade

10th Grade 21.6% in 2007

14.0% in 2007

7.1% in 2007

Total Cigarette Sales and Cigarette Prices, US, 1970-2005

18000

20000

22000

24000

26000

28000

30000

1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003

Fiscal Year

To

tal

Sa

les

(m

illi

on

pa

ck

s)

$1.20

$1.70

$2.20

$2.70

$3.20

$3.70

$4.20

Real C

igare

tte P

rice

Cigarette Sales (million packs) Real Cigarette Price

Source: Tax Burden on Tobacco, 2006, and author’s calculations

Trends in Youth Cigarette SmokingTrends in Youth Cigarette SmokingPast 30 days (current smoking)Past 30 days (current smoking)

United States, 1975-2007 United States, 1975-2007

0

5

10

15

20

25

30

35

40

45

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

YEAR

PERCENT


12th Grade

8th Grade

10th Grade 21.6% in 2007

14.0% in 2007

7.1% in 2007

0

5

10

15

20

25

30

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Movie Characters:

Top 100 Box Office Hits

How Do Tobacco Marketing EffectsHow Do Tobacco Marketing EffectsCompare with Movie Exposure Effects?Compare with Movie Exposure Effects?

Characteristic* N (%)

Tried Smoking

Prevalence N (%)

Tried Smoking

Incidence

Number of videos per week

0 551 (12) 14 318 (13) 6

1-2 2793 (65) 16 1628 (65) 10

3-4 760 (16) 21 391 (16) 13

>=5 409 (7) 27 169 (7) 8

Quartile of movie smoking exposure

Q1 1170 (26) 4 651 (26) 4

Q2 1288 (29) 13 600 (25) 7

Q3 890 (20) 22 634 (25) 13

Q4 1165 (26) 32 621 (25) 16

Has a favorite cigarette ad

No 4060 (90) 12 2410 (96) 10

Yes 453 (10) 68 42 (1.7) 21

Owns or would wear branded merchandise

No 3719 (82) 14 2203 (88) 9

Yes 794 (18) 36 303 (12) 18

Table 1. Distribution of movie and tobacco marketing variables.Cross-sectional (n = 4513) Longitudinal (n =2506)

Table 2. Association between movie and tobacco marketing variables and adolescent tria l of smoking.

Cross - sectional (n = 4513) Longitudinal (n = 2506)

Adjusted Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI)

Entered Individually* Entered

Together† Entered Individually* Entered

Together†

Characte ristic* Min‡¶ Full

Adjustme nt_¶

Full

Adjustment_¶ Min‡¶ Full

Adjustment_¶

Full

Adjustment_¶

Num ber of videos watched per week 1.14 1.08 (1.01, 1.15) 1.00 (0.93, 1.07) 1.06 1.05 (0.93, 1.18) 0.98 (0.85, 1.06)

Quartile o f exposure to movie smoking 1.67 1.37 (1.25, 1.50) 1.32 (1. 21, 1.44) 1.50 1.36 (1.23, 1.50) 1.37 (1.24, 1.51)

Has a favorite cigarette ad 11.82 6.80 (5.64, 8.19) 6.77 (5.47, 8.37) 1.49 1.10 (0.73, 1.65) 0.99 (0.67, 1.46)

Owns or would wear branded merchandise 2.11 1.31 (1.03, 1.67) 0.85 (0.67, 1.08) 1.78 1.31 (0.78, 2.18) 1.23 (0.69, 2.21)

* Movie and tobacco marketing variables entered individually into a minimally then a fully adjusted model; eac h cell represents a separate model.

† Movie variables entered together into a fully adjusted m odel; each estimate in the colum n comes from one model.

‡ Adjusted for age, gender, parent educ ation, school performanc e, and maternal demandingness.

_ Adjusted for age, gender, parent educ ation, school performance, parent smoking, friend smoking, sensation seeking, maternal demandingness.

¶ p < 0.05 in bold font

Addiction ModelsAddiction Models

•• There are a lot of themThere are a lot of them•• This area is owned and operated by about ten well knownThis area is owned and operated by about ten well known

and highly regarded addiction psychologistsand highly regarded addiction psychologists–– Who mainly study adultsWho mainly study adults–– Who believe that people have to smoke daily in order to beWho believe that people have to smoke daily in order to be

addictedaddicted

•• The literature is huge and enormously complexThe literature is huge and enormously complex•• II’’m presenting a relatively simple model that has beenm presenting a relatively simple model that has been

floated by a tobacco control scientistfloated by a tobacco control scientist–– And an MD to bootAnd an MD to boot

Loss of AutonomyLoss of Autonomy

•• Loss of control over the behaviorLoss of control over the behavior

Most Report LOA at Low Use RatesMost Report LOA at Low Use Rates

LOA begins Soon after InitiationLOA begins Soon after Initiation

LOA Predicts Continued SmokingLOA Predicts Continued Smoking

Predicting LOA:Predicting LOA:Recollections on the First InhalationRecollections on the First Inhalation

What do they Remember?What do they Remember?

Predicting LOAPredicting LOA

Questions and CommentsQuestions and Comments

•• The fact that students of color and poor studentsThe fact that students of color and poor studentsdisproportionately dropout of school suggests thatdisproportionately dropout of school suggests thatattrition may be a likely explanation for results thatattrition may be a likely explanation for results thatshowed use of tobacco by African American youth asshowed use of tobacco by African American youth assignificantly lower than white youthsignificantly lower than white youth

•• I would like to know more about the suggestion thatI would like to know more about the suggestion thatthe tobacco control movement shift from focusing onthe tobacco control movement shift from focusing onyouth access to cigarettes to youth exposure inyouth access to cigarettes to youth exposure inmovies by requiring an R rating for smoking inmovies by requiring an R rating for smoking inmovies.movies.

•• I heard a presentation on a couple years ago aboutI heard a presentation on a couple years ago aboutwork in this arena being done by people at thework in this arena being done by people at theHarvard School of Public Health. What are the mostHarvard School of Public Health. What are the mostrecent developments?recent developments?

•• How proactive is the tobacco industry in seeking toHow proactive is the tobacco industry in seeking toplace cigarettes and other products into movies andplace cigarettes and other products into movies andother media accessible to and popular with kids?other media accessible to and popular with kids?

•• Do you think an R rating would lead to a similarDo you think an R rating would lead to a similardrop in smoking rates as banning smokingdrop in smoking rates as banning smokingcompletely would?completely would?

•• Is the demand for R rating on movies aIs the demand for R rating on movies acompromise when in reality we would like tocompromise when in reality we would like toban smoking completely?ban smoking completely?

•• Is it possible that an R rating would suggestIs it possible that an R rating would suggestthat smoking is an adult activity, making itthat smoking is an adult activity, making itmore appealing to youths?more appealing to youths?

ConclusionsConclusions

•• The scientific findings support action onThe scientific findings support action onthis issuethis issue–– The focus should be on reducing exposureThe focus should be on reducing exposure

during childhood and early adolescenceduring childhood and early adolescence–– RATE SMOKING IN FILMSRATE SMOKING IN FILMS–– SHOW ANTISMOKING AD BEFORE FILMSSHOW ANTISMOKING AD BEFORE FILMS

WITH SMOKINGWITH SMOKING–– NO TOBACCO MONEY INVOLVEMENTNO TOBACCO MONEY INVOLVEMENT–– PARENTS SHOULD MONITOR ANDPARENTS SHOULD MONITOR AND

RESTRICT MEDIA ACCESSRESTRICT MEDIA ACCESS

Sandra Bullock; “28 Days”

Parental R-Movie RestrictionsParental R-Movie Restrictions

•• How often do your parents let you watchHow often do your parents let you watchmovies or videos that are rated movies or videos that are rated ““RR””??–– Never Never (complete(complete

restriction)restriction)–– Once in a while Once in a while (partial(partial

restriction)restriction)–– Sometimes/All the time Sometimes/All the time (little or no(little or no

restriction)restriction)

•• My mom saw the title of the Dalton et al.My mom saw the title of the Dalton et al.article and said, article and said, ““Oh, I bet smoking inOh, I bet smoking inmovies has a bad effect on teenmovies has a bad effect on teensmoking.smoking.”” Most people would say the Most people would say thesame thing; this paper providessame thing; this paper providespowerful scientific evidence for anpowerful scientific evidence for anintuitive conceptintuitive concept

•• If If ““loss of autonomy is the common denominatorloss of autonomy is the common denominatoramong drugs of dependenceamong drugs of dependence”” ( (DiFranzaDiFranza et al.), et al.),has the construct been used to measure levels ofhas the construct been used to measure levels ofother types of dependence? In other words, isother types of dependence? In other words, isthere a there a ““hooked on hooked on alcoholalcohol checklist checklist””??

•• Has the use of the HONC and other measures ofHas the use of the HONC and other measures ofnicotine dependence been generalized to assessnicotine dependence been generalized to assessother forms of tobacco (e.g., chewing tobacco) useother forms of tobacco (e.g., chewing tobacco) useamong adolescent and young adult populations?among adolescent and young adult populations?

•• I am interested in whether gender may moderateI am interested in whether gender may moderateassociations between specific expectancies andassociations between specific expectancies andoutcomes, as I would imagine females may beoutcomes, as I would imagine females may bemore likely to smoke to control their weight, andmore likely to smoke to control their weight, andperhaps males more likely to smoke in relation toperhaps males more likely to smoke in relation torisk taking behaviors.risk taking behaviors.

•• with all potentially addictive agents, thewith all potentially addictive agents, theshort-term positively reinforcing effectsshort-term positively reinforcing effectsare stronger than the long-tern negativeare stronger than the long-tern negativeconsequences. Iconsequences. I’’m not quite sure howm not quite sure howto get around this conundrum andto get around this conundrum andwould love to have a discussion aboutwould love to have a discussion aboutit.it.

•• I found the statistics saying that African-I found the statistics saying that African-Americans were the least likely to use drugsAmericans were the least likely to use drugsamong African-Americans, Whites and Hispanicsamong African-Americans, Whites and Hispanicsintriguing.intriguing.

Racial/Ethnic Differences inRacial/Ethnic Differences inSmoking Onset and ProgressionSmoking Onset and Progression

Among U.S. AdolescentsAmong U.S. Adolescents

James James SargentSargent****

KeilahKeilah Worth* Worth*Mike Mike StoolmillerStoolmillerThomas WillsThomas Wills††

Fredrick GibbonsFredrick Gibbons‡‡

*Norris Cotton Cancer Center,Dartmouth Medical School†Albert Einstein College of Medicine‡Iowa State University

Established SmokingEstablished Smoking

Rat

e (p

er th

ousa

nd)

IncidencePrevalence

02468

10121416

T1 T1 to T2 T2 to T3 T3 to T4

WhiteBlackHispanic

Tried SmokingTried Smoking

Perc

ent

IncidencePrevalence

0

2

4

6

8

10

12

14


WhiteBlackHispanic

Susceptibility to SmokingSusceptibility to Smoking

Perc

ent

IncidenceSusc=0, previous wave

PrevalenceEver smk=0

0

5

10

15

20

25


WhiteBlackHispanic

Positive Expectancies ScorePositive Expectancies Score

Perc

ent

Among never smokers

* Significantly higher than White score

0

0.05

0.1

0.15

0.2

0.25

0.3

T1 T2 T3 T4

WhiteBlackHispanic

* * * * *

•• I found the statistics saying that African-I found the statistics saying that African-Americans were the least likely to use drugsAmericans were the least likely to use drugsamong African-Americans, Whites and Hispanicsamong African-Americans, Whites and Hispanicsintriguing.intriguing.

•• I feel like drug use, at least in my high schoolI feel like drug use, at least in my high schooland among the students, is correlated more withand among the students, is correlated more withparents who donparents who don’’t care for or pay attention tot care for or pay attention totheir children.their children.

Authoritative Parenting StyleAuthoritative Parenting Style

•• ResponsiveResponsive–– She listens to what IShe listens to what I

have to sayhave to say–– She makes me feelShe makes me feel

better when Ibetter when I’’m upsetm upset–– She wants to hearShe wants to hear

about my problemsabout my problems

•• DemandingDemanding(rules/monitoring)(rules/monitoring)–– She makes me follow herShe makes me follow her

rulesrules–– She tells me what time IShe tells me what time I

have to be homehave to be home–– She knows where I amShe knows where I am

after schoolafter school

Parenting StyleParenting Style

No YesNo Neglectful Authoritarian

Yes Indulgent Authoritative

Demanding

Res




Demanding

Res




Demanding

Res




Demanding

Res

0

5

10

15

20

25

30

Neg

lect

ful

Indulg

ent

Auth

orita

rian

Auth

orita

tive

Tri

ed S

mo

kin

g (

per

cen

t)Parenting Style and SmokingParenting Style and Smoking

By Parenting Style

05

10152025303540

0-600 601-1200 1201-2000 > 2000

Movie Smoking Exposure

Trie

d Sm

okin

g (p

erce

nt)

Neglectful Indulgent Authoritarian Authoritative

•• I was wondering if you could expandI was wondering if you could expandmore on why exactly smoking in moviesmore on why exactly smoking in movieshas such a huge effect on kids. Why ishas such a huge effect on kids. Why isit the it the ““subliminal effects of smoking insubliminal effects of smoking inmovies is a far more powerful force thanmovies is a far more powerful force thanovert advertising?overt advertising?”” Is it when anyone is Is it when anyone isthe movie smokes or just thethe movie smokes or just theprotagonist?protagonist?

0.1

.2.3

.4

0 50 100 150 200

Positive

NegativeMixed

Trie

d Sm

okin

g In

cide

nce

Exposure to Movie Smoking (number of character episodes)

Character Valence

•• By measuring this with By measuring this with ““hithit”” movies, movies,does this only captures data for the kidsdoes this only captures data for the kidsthat are that are ““inin”” and and ““coolcool”” ? ?

•• These These ““coolcool”” kids are more likely to kids are more likely toengage in activities to go overboard inengage in activities to go overboard insetting trends and become popular insetting trends and become popular inthe eyes of their peers. I donthe eyes of their peers. I don’’t think thatt think thatthe movie selection had a true measurethe movie selection had a true measureto include a wide range of personalitiesto include a wide range of personalitiesand styles of kids.and styles of kids.

Documents

Adolescents Why do they Smoke?depts.washington.edu/tobacco/docs/Sargent08.pdf · “Most people my age smoke.” Positive Expectancies or Utilities What do I Gain by Smoking? “Smoking