examine the association between movie smoking expo-

OBJECTIVE: To examine the association between movie smoking expo-

sure (MSE) and adolescent smoking according to rating category.

METHODS: A total of 6522 US adolescents were enrolled in a longitudinal

survey conducted at 8-month intervals; 5503 subjects were followed up at

8 months, 5019 subjects at 16 months, and 4575 subjects at 24 months.

MSE was estimated from 532 recent box-office hits, blocked into 3 Motion

Picture Association of America rating categories: G/PG, PG-13, and R. A

survival model evaluated time to smoking onset.

RESULTS: Median MSE in PG-13–rated movies was ∼3 times higher than

median MSE from R-rated movies, but their relation with smoking was

essentially the same, with adjusted hazard ratios of 1.49 (95% confidence

interval [CI]: 1.23–1.81) and 1.33 (95% CI: 1.23–1.81) for each additional

500 occurrences of MSE respectively. MSE from G/PG-rated movies was

small and had no significant relationship with adolescent smoking. At-

tributable risk estimates showed that adolescent smoking would be re-

duced by 18% (95% CI: 14–21) if smoking in PG-13–rated movies was

reduced to the fifth percentile. In comparison, making all parents max-

imally authoritative in their parenting would reduce adolescent smoking

by 16% (95% CI: 12–19).

CONCLUSIONS: The equivalent effect of PG-13-rated and R-rated MSE

suggests it is the movie smoking that prompts adolescents to

smoke, not other characteristics of R-rated movies or adolescents

drawn to them. An R rating for movie smoking could substantially

reduce adolescent smoking by eliminating smoking from PG-13 movies.

Pediatrics 2012;130:228–236

Accepted for publication Apr 16, 2012
Address correspondence to James D. Sargent, MD, Dartmouth-

Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH

  1. E-mail: james.d.sargent@dartmouth.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have

no financial relationships relevant to this article to disclose.

FUNDING: Supported by the National Cancer Institute (grant

CA077026) and the American Legacy Foundation. Funded by the

National Institutes of Health (NIH).

COMPANION PAPER: A companion to this article can be found on

page 221, and online at www.pediatrics.org/cgi/doi/10.1542/

peds.2011-1792.

228
SARGENT et al
Downloaded from pediatrics.aappublications.org by guest on December 8, 2014

ARTICLE
Almost 50 years since the 1964 Surgeon

General’s Report on Smoking and Health,

smoking remains the number 1 cause of

preventable death in the United States,

responsible for .400 000 deaths per

year, prompting a need to know more

about what fuels this epidemic. In March

2012, a new Surgeon General’s Report

was released, entitled “Preventing To-

bacco Use Among Youth and Young

Adults,” and in which the Surgeon Gen-

eral stated: “The evidence is sufficient to

conclude that there is a causal rela-

tionship between depictions of smoking

in movies and the initiation of smoking

among young people.”1 Thus, much is

known about the relation between ex-

posure to movie smoking and youth

smoking, but studies are only beginning

to examine whether the context in which

movie smoking is presented modifies its

association with adolescent smoking.

In a recently published experiment,2 ex-

posure to movie clips portraying smok-

ing as relaxing was associated with

a significantly stronger desire to smoke

compared with exposure to clips

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