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[Commentary] EVIDENCE‐BASED POLICY: AN R‐RATING FOR MOVIES WITH SMOKING

2009; Wiley; Volume: 104; Issue: 5 Linguagem: Inglês

10.1111/j.1360-0443.2009.02582.x

1360-0443

James D. Sargent, Reiner Hanewinkel,

Obesity, Physical Activity, Diet

We read Dr Chapman's commentary [1] with interest, but were surprised to find no reference to the main conclusion of our paper: that in a longitudinal study that controlled for a wide range of confounders, exposure to movie smoking was a stronger predictor of smoking initiation than tobacco marketing receptivity [2]. Instead there were broad statements, unsupported by any quantitative analysis, that communicated skepticism towards the US National Cancer Institute's (NCI) conclusion [3] that movie smoking is a cause of youth smoking onset. With respect to factors that contribute to youth smoking onset, ‘reductionist methods’ have, in fact, gone a long way towards unraveling the ‘soup of (environmental) influence with its multitude of mutually infusing ingredients’. Evidence used by the NCI to conclude that exposure to movie smoking causes adolescent smoking was not based upon simple trend analysis, as suggested, but on a broad collection of evidence—including a historical analysis; content analyses of smoking in movies; exposure assessments among adolescents; and the convergence of results from carefully conducted experiments, qualitative investigations and epidemiological studies of adolescent attitudes and behavior involving thousands of individuals (now from several countries). Additional cross-sectional [4–7] and longitudinal [8–11] studies, some showing that positive tobacco attitudes mediate the effect of movies on behavior [7,8,12], and all published since the NCI monograph was written, bolster the causal conclusion. The suggestion that trends in movie smoking are not congruent with recent downward trends in adolescent smoking during the 1990s is a common misperception. Congruent trends are not necessary to prove causality, but they are reassuring when consistent with the causal hypothesis. Downward time trends in movie smoking overall and movie character smoking in Hollywood films began in the mid-1990s [14–16], approximately when adolescent smoking began trending downwards in many countries. No one has suggested that movie smoking is the only cause of adolescent smoking or its recent downward trend. Indeed, in the last decade we have seen effective anti-tobacco campaigns, tobacco price increases and other tobacco control policies, as well as increased marketing efforts by tobacco companies. But there is little doubt that movie smoking is a factor in this mix, one the US Centers for Disease Control accepts as important [13]. Hollywood movies are not meant only for domestic consumption; they play into the media diets of adolescents all over the world. For example, 80% of the top box office hits in Germany were Hollywood releases, and German adolescents viewed and responded in ways similar to their US counterparts [5,11]. Thus, far from being ‘awkward for the core thesis’, the parallel declines in smoking in internationally distributed Hollywood movies and youth smoking in many countries are consistent with a causal interpretation and published attributable risk figures [10,17]. Regarding policy, we support the four Smoke Free Movies campaign policies (see http://www.smokefreemovies.ucsf.edu/solution/index.html) as a way to reduce the ‘dose’ delivered to youth, because the epidemiological studies show a dose–response. An ‘R’ rating for smoking would reduce youth exposure to onscreen smoking in two ways. First, and most obviously, while youth do see some R-rated films, they are much less likely to see them than youth-rated (G, PG and PG-13) ones [18]. Secondly, it is essential to understand that movies are products intended for specific audiences. The rating for a film is part of the contractual agreement signed at the beginning of the process, before the film enters production, and so an R rating for smoking would cause producers to simply leave smoking out of the films intended for youth. The R rating for smoking supports movie industry rights of free speech and recognizes its need to make sound business decisions. If smoking is deemed artistically necessary, producers are free to include it in exchange for an R rating. If reaching the adolescent audience is deemed the greater value, the smoking is cut. It is as simple as that. Movie producers make these types of decisions routinely each day when they cut scenes of sex and violence because of movie rating board assessments, or whenever a movie is adapted for television or airline viewing. We prefer an unambiguous rule on rating smoking because no one knows how to take a parsimonious approach to cutting smoking in youth films: it is simply not clear which scenes impact adolescents the most. The concerns voiced about movie realism seem unrealistic. Movies that children watch involve love and fantasy, not historical 1950s movie sets. The cigar smoking in Hellboy 2 was hardly necessary for a more realistic portrayal of superheroes fighting elf warlords, forest gods and tooth fairies. The scientific basis for a ratings policy is substantial and growing. This is why there is a broad consensus among public health and medical professionals, and the public as a whole [19], for an application of evidence-based principles to the existing rating system, in light of the new science demonstrating that onscreen smoking causes smoking onset. Modernizing the rating system to rate onscreen smoking R is a simple policy, based on evidence that it will reduce exposure substantially and result in further declines in youth smoking. None. Dr Sargent receives funding from the US National Cancer Institute (CA-77026) and the American Legacy Foundation. Dr Hanewinkel receives funding from the Ministry of Health of the Federal Republic of Germany and the European Commission.