Research article
Smoking in Movies and Adolescent Smoking Initiation: Longitudinal Study in Six European Countries

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Background

Longitudinal studies from the U.S. suggest a causal relationship between exposure to images of smoking in movies and adolescent smoking onset.

Purpose

This study investigates whether adolescent smoking onset is predicted by the amount of exposure to smoking in movies across six European countries with various cultural and regulatory approaches to tobacco.

Methods

Longitudinal survey of 9987 adolescent never-smokers recruited in the years 2009–2010 (mean age=13.2 years) in 112 state-funded schools from Germany, Iceland, Italy, The Netherlands, Poland, and the United Kingdom (UK), and followed up in 2011. Exposure to movie smoking was estimated from 250 top-grossing movies in each country. Multilevel mixed-effects Poisson regressions were performed in 2012 to assess the relationship between exposure at baseline and smoking status at follow-up.

Results

During the observation period (M=12 months), 17% of the sample initiated smoking. The estimated mean exposure to on-screen tobacco was 1560 occurrences. Overall, and after controlling for age; gender; family affluence; school performance; TV screen time; personality characteristics; and smoking status of peers, parents, and siblings, exposure to each additional 1000 tobacco occurrences increased the adjusted relative risk for smoking onset by 13% (95% CI=8%, 17%, p<0.001). The crude relationship between movie smoking exposure and smoking initiation was significant in all countries; after covariate adjustment, the relationship remained significant in Germany, Iceland, The Netherlands, Poland, and UK.

Conclusions

Seeing smoking in movies is a predictor of smoking onset in various cultural contexts. The results confirm that limiting young people's exposure to movie smoking might be an effective way to decrease adolescent smoking onset.

Introduction

In 2012, the U.S. Surgeon General determined that:

the evidence is sufficient to conclude that there is a causal relationship between depictions of smoking in the movies and the initiation of smoking among young people.1

However, robust longitudinal evidence on this relationship derives almost entirely from studies of adolescents in the U.S. Apart from two longitudinal studies (one from the North of Germany, the other from Mexico2, 3), studies from elsewhere in the world of the relationship between “movie smoking” and young people's own smoking have been cross-sectional.4, 5, 6, 7, 8, 9, 10, 11 It is therefore unclear whether the U.S. Surgeon General's conclusion about causality is applicable outside the U.S.

Although most European countries have ratified the WHO Framework Convention on Tobacco Control, which recommends modification of the movie rating system so that new movies portraying smoking are classified as appropriate for adults only,12, 13 there has, with the exception of Great Britain, been almost no discussion or action in Europe.14 Studies of young people from a number of very different European countries (Germany, Iceland, Italy, The Netherlands, Poland, and UK) have found that all have access to substantially more movies containing smoking than adolescents in the U.S.15, 16 This lack of action might be due to the limited longitudinal evidence to support policy outside the U.S.

The present study addresses this relative paucity of longitudinal research pertaining to European youth by reporting the results of a large-scale longitudinal survey of young adolescents in six European countries. Exposure to movie smoking was assessed in more than 16,000 adolescents, and the incidence of smoking onset was determined 1 year later to investigate whether exposure to movie smoking predicted smoking onset, overall and separately by country, before and after adjustment for other known risk factors for smoking onset.

Section snippets

Design, Procedure, and Study Sample

A school-based longitudinal study was conducted in six European countries by research centers in Germany (Kiel); Iceland (Reykjavik); Italy (Turin and Novara); Poland (Poznan); The Netherlands (Nijmegen); and UK (Glasgow). To permit linking of the baseline and follow-up survey, each questionnaire was labeled with a seven-digit individual code generated by the student, following a procedure tested in previous studies.17 Ethical approval for the research was gained from the relevant ethical body

Descriptive Statistics at Baseline and Attrition Analysis

Table 1 gives descriptive statistics for all never-smokers at baseline, for those lost to follow-up, and for the final analyzed sample of baseline never-smokers, allowing comparisons of differences due to attrition. Never-smokers lost to follow-up were significantly older; more often male; had lower scores on the family affluence scale; rated their school performance more poorly; had higher scores in sensation-seeking/rebelliousness; had more friends, siblings, and parents who smoked; and were

Discussion

To our knowledge, this is the largest cross-cultural longitudinal study on the association between smoking in movies and smoking onset in youth. The results show that an exposure to 1000 smoking depictions increases the relative risk of initiating smoking by about 13%. The study fills a gap in current understanding, showing that the well-documented longitudinal finding among U.S. adolescents also applies in European countries. The association holds despite (1) controlling for a number of

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