Commentary on Hanewinkel <i>et al</i>. (2010): Anti‐smoking advertisments vaccinate movie viewers against effects of on‐screen smoking

Smoking onscreen in movies causes youth to smoke [1–5], with a dose–response effect: the more smoking youth see, the more likely they are to smoke, with heavily exposed youth about three times as likely to begin smoking as lightly exposed youth. These initial results from the United States [6] have been confirmed both qualitatively and quantitatively in other countries with different regulatory environments surrounding smoking and tobacco marketing (New Zealand [7], Mexico [8,9] and Germany [10,11]). Because of the dose–response relationship, the World Health Organization [12] (WHO) and others [13] have called for reductions in youth exposure to onscreen smoking by modernizing rating systems to give films with smoking a ‘mature content’ rating (e.g. ‘R’ in the United States, ‘18’ in the United Kingdom and ‘FSK-18’ in Germany) to reduce youth exposure and the attendant smoking. (Addressing the fact that onscreen smoking promotes youth smoking is part of implementing the WHO Framework Convention on Tobacco Control [12].) Because of concerns over freedom of expression, none of these organizations have called for an outright ban on portrayal of smoking in movies. Therefore, even if these policies are implemented, they would represent only a partial solution to the health problems created by smoking in movies because, while less likely to see mature content-rated films than youth-rated films, youth still see some of these films and, thus, are subject to their pro-tobacco influence. To try to ‘immunize’ youth against this remaining exposure, the WHO and others have recommended showing an anti-smoking advertisement before any film showing smoking. The paper by Hanewinkel et al. [14] in this issue of Addiction presents important evidence to support this policy by showing that such an advertisement shown in real theaters before real films including smoking in Germany blunts the pro-tobacco influence of these films among both youth (aged 10–17 years) and adults. Patrons seeing the anti-smoking advertisement had higher awareness of smoking in the movies, and lower levels of approval of smoking in the movie and smoking in general. Seeing smoking in the film increased the urge to smoke among smokers, but the advertisement did not. While these effects occurred at all ages, they were bigger in youth than in adults. This work, in Germany where there are few restraints on the tobacco industry, is consistent with earlier experimental studies on youth in the United States [15] and real-world observational studies in theaters in Australia [16,17], suggesting that the benefits of anti-smoking advertisements before smoking films is not heavily dependent upon the cultural context. The fact that the advertisement increased concern over the issue of smoking in movies could also have the secondary effect of building support for tobacco control and the policy of rating smoking films for ‘mature audiences’ to reduce youth exposure [18]. The idea of including anti-smoking advertisements before films with smoking has already been implemented partially in the United States. The Weinstein Company, an influential New York-based independent producer and distributor, announced that it would start adding American Legacy Foundation truth® spots to its smoking DVDs with smoking in January 2007. Disney and Time-Warner followed suit in early 2008 and in July 2008, the six major US studios announced that they had signed agreements to run spots produced by the State of California on youth-rated DVDs. Disney, Time-Warner and Weinstein and Time Warner continued to include spots on both youth-rated and R-rated DVDs, using both Legacy and California spots. In 2009 more than 6.5 million Time-Warner DVDs containing anti-smoking public service announcements (PSAs) were distributed in the United States, bringing the total since this practice began in 2008 to more than 20 million distributed by Time-Warner alone, with a probable viewership of more than 40 million people (Michelle Yates, personal communication). While these steps represent real progress, they are limited. To date, the bulk of the advertisements have been on youth-rated DVDs distributed only in the US–Canadian market and they have not yet been included on newer Blu-ray disks, in theatrical showings, video-on-demand, satellite, cable or network television showings or internet downloads. (Audience research has shown that, unlike commercial advertising, people appreciate seeing these advertisements in theaters [19].) It is important that the anti-smoking advertisements, produced by health authorities with a track record of producing effective advertisements, expand to the other media and world-wide. Hanewinkel et al. [14] demonstrate that such an expansion is warranted and important. In the United States, the media companies have included these advertisements voluntarily in response to pressure from health interests. In many, if not most, of the 169 countries that have ratified the WHO Framework Convention on Tobacco Control (FCTC), government has the authority to require that anti-smoking advertisements in all distribution channels as a condition for importing the films. Consistent with WHO recommendations, they should do so as part of their FCTC implementation [12]. Dr Glantz is American Legacy Foundation Distinguished Professor in Tobacco Control. The American Legacy Foundation played no role in preparing this commentary. Dr Glantz manages the Smoke Free Movies project (http://www.smokefreemovies.ucsf.edu), which advocates for requiring anti-smoking advertisements before films with smoking and other tobacco use.

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