EFFECTS OF SMOKING SCENES IN MOVIES?’

exposure (MSE) and youth smoking is causal; however, it is not

known whether movie rating influences how adolescents respond.

reduce smoking onset in the United States by 18% (by eliminating

PG-13 MSE), an effect similar to making all parents maximally

authoritative in their parenting.

University of Oregon, Eugene, Oregon

MPAA—Motion Picture Association of America

MSE—movie smoking exposure

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.

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).

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

6. E-mail: james.d.sargent@dartmouth.edu

National Institutes of Health (NIH).

peds.2011-1792.

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

without a motive for the smoking. Al-

though experimental studies allow the

researcher to control exposure and

serve to tease out underlying cognitive

mechanisms, it is difficult to study actual

smoking behavior in an experimental

setting, and therefore it is hard to judge

what the behavioral implications of the

findings would be.

are a marker for the presence of con-

textual elements considered to be

“adult” by the ratings board. To the

extent that sex, violence, profanity, and

illicit drug use are considered in the

Motion Picture Association of America

(MPAA) ratings system,3 smoking in

movies with an adult rating (eg, R [re-

stricted to individuals aged $17 years

unless accompanied by a parent or

guardian]) would depict characters

who model these behaviors, along with

smoking in the context of a sexually provocative scene in Great Expectations (rated R; 20th Century Fox

Film Corporation, 1998); Ethan Hawke blowing smoke into a backlit wine glass to show what the planet

Titan looks like in Gattica (rated PG-13; Columbia Pictures Corporation, 1997); and Brad Pitt smoking

after a brutal fight scene from Fight Club (rated R; Fox 2000 Pictures, 1999).

distinguish levels of sex, violence, and

profanity but not tobacco use.4 Figure 1

depicts several examples of movie

smoking by rating and a range of con-

texts that might be seen with movie

smoking according to rating category:

simple villainy (G [appropriate for gen-

eral audiences]), visually stimulating (PG-

13 [parents are strongly cautioned, con-

tent may not be suitable for children aged

,13 years]), and violence and sex (R).

could have important implications on

ratings for movie smoking,5 especially

given that 60% of the movie smoking

exposure (MSE) comes from youth-

rated (almost entirely PG-13) movies.6

In the United States, an R rating for

smoking would serve to effectively eli-

minate smoking from movies marketed

to youths, based on the current business

model for movie production, in which

the rating is negotiated between pro-

duction company and the director be-

fore movie production.7 The implication

is that a production company intending

to include the youth market would have

to eliminate smoking in the production

However, the hypothetical benefits of

limiting MSE in youth-rated movies

depends partly on how strongly the

smoking in them is linked with ado-

lescent smoking. Importantly, limiting

smoking to R-rated movies would have

little impact if the dose-response be-

tween smoking in youth-rated movies

and adolescent smoking was small.

riously undermine the idea that it is

movie smoking specifically, as opposed

to the sex, violence, profanity, and illicit

drug use that prompts smoking onset.

Indeed, a recent essay speculated that

the movie smoking–youth smoking re-

lationship might not be causal because

MSE is “inextricably entangled with a

host of other variables in movies…

such as alcohol or recreational drug

portrayal, violence, coarse language,

and sexual content,”8 raising concerns

about specificity. The essay went fur-

ther, suggesting that it may not be the

movies at all that prompt adolescents

to smoke. Instead, adult movies may

attract risk-taking adolescents who

come to see the proscribed behaviors

R-rated MSE would be hypothesized to

be overwhelmingly strong in its ability

to predict youth smoking, because R-rated

MSE picks up the effect of seeing “adult”

behaviors relegated to these movies

and identifies unmeasured risk factors

among the adolescents that see them.

followed up for 4 waves over a 2-year

period. Exposure to smoking in movies

at study onset was divided into 3 cat-

egories (G/PG, PG-13, and R) to assess

the prospective relationship between

each type of exposure and onset of

smoking. Based on the idea that it is

primarily the movie smoking that

prompts adolescents to smoke (with the

adult context being secondary), we hy-

pothesized that R-rated movie smoking

would have only a slightly stronger as-

sociation with adolescent smoking than

PG-13–rated movie smoking and that

PG-13–rated movie smoking would still

be an important predictor of smoking,

given that it accounts for a large share

of the exposure.

months. Attrition analyses indicated

that adolescents lost to follow-up were

more likely to be nonwhite; were from

families with lower parental education/

income and lived in rented versus

parent-owned residences; had poorer

school performance; and scored higher

on sensation-seeking scales. To mini-

mize attrition bias, estimation was

carried out after multiple imputation

using the missing at random assump-

tion (missing data are missing at ran-

dom conditional on covariates included

in the model).10 The MICE procedure in

R was used to stochastically impute

missing data.11 To improve the quality

of the imputations, baseline auxiliary

variables that were predictive of

missing data (but not necessarily the

outcomes) were also included in the

imputation. All variables were treated

as numeric, and the predictive mean

matching procedure was used to cre-

ate 15 imputed values for each missing

score. Convergence was assessed by

checking plots of the mean and vari-

ance of the imputations for each vari-

able across the 15 streams for signs of

problems, such as trends or lack of

proper mixing. No problems were ap-

parent. For descriptive statistics, we

averaged across the 15 imputations to

obtain a single best estimate for each

missing data point.

validated methods.12 The top 100 movies

with highest US gross revenues each

year were selected for each of the 5

years preceding the baseline survey

(1998–2002, N = 500) and 32 high

earners during the first 4 months of

3. Older movies were included be-

cause adolescents often watch these

larger pool of 532 movies for each ad-

olescent interview. Movie selection was

stratified according to the MPAA rating

so that the distribution of movies in

each list reflected the distribution of

the full sample of movies (19% G/PG,

41% PG-13, and 40% R). Respondents

were asked (no/yes) whether they had

ever seen each movie title on their unique

list.

movies by using previously validated

methods.13 A smoking occurrence was

counted whenever a major or minor

character handled or used tobacco in a

scene or when tobacco use was de-

picted in the background (eg, brands

present or “extras” smoking in a bar

scene), irrespective of the scene’s du-

ration or how many times the tobacco

product appeared. We summed the

number of smoking occurrences each

adolescent had seen from his or her

unique list of 50 movies, stratifying

counts by rating blocks (G/GP, PG-13

and R categories), and scaling these

counts to reflect exposure to that of the

full sample of 532 movies, given the

adolescent’s reported viewing habits

by rating.12 To limit extreme values and

reduce the effect of outliers, MSE

measures were Winsorized14 at the

second and 98th percentiles (values

more extreme were recoded back to

the second or 98th percentile value). To

assess equivalent doses of exposure,

the response to each increment of 500

movie smoking occurrences was

modeled, which would approximate the

median overall dose of MSE.

cigarette, even just a puff?” Those who

answered “yes” were classified as

having tried smoking. This measure

using random digit dial methods de-

scribed previously.9 After verbal paren-

tal consent and adolescent assent were

obtained, participants were surveyed

via telephone about media exposures,

tobacco and alcohol use, sociodemo-

graphic characteristics, and other risk

factors. Subjects were resurveyed every

8 months 3 more times, with the last

follow-up at 24 months. The study pro-

cedures were approved by the Dart-

mouth College Committee for Protection

of Human Subjects. The completion

rate for the survey was 66%; distri-

butions of age, gender, ethnicity,

household income, and census region

infrequent in the early stages of ciga-

rette use.15 Smoking initiation is an

important outcome because approxi-

mately one-third of initiators go on to

become addicted smokers.16,17 For the

US sample, confidentiality in responses

was assured in the adolescent assent

statement, and subjects indicated

their answers to sensitive questions by

pressing numbers on the telephone.

the second and 98th percentiles.14

incident case was defined as an ado-

lescent who became a smoker from the

pool of those who were not smokers at

the previous survey. As a first step,

generalized additive logistic models

werefittoshow the crude dose-response

relation between the MSE according to

MPAA rating and probability of smoking

initiation. In addition to strong linear

trends, both PG-13– and R-rated MSE

had significant negative quadratic trends

(significantly stronger response at

lower dose ranges); however, only the

negative quadratic effect for R-rated

MSE remained significant after adjust-

ing for all covariates in the full model.

For ease of interpretation and because

conclusions did not change, only the

linear effects for all MSE measures

were used (quadratic estimates avail-

able on request from the first author).

For the models, MSE was entered as a

continuous variable and scaled so that

each 1-point increment represented an

increase in dose of 500 movie smoking

occurrences. To determine the associa-

tion between exposure to movie smok-

ing according to MPAA rating and time to

smoking initiation, discrete time hazard

survival models35–37 were fit to each of

the 15 imputed complete data sets fol-

lowing standard procedures for pooling

the estimates and obtaining SEs.11 The

hazard model assessed time to onset

based on data from all 3 intervals over

the 24-month period. For all models,

results for main effects were judged

significant for P values ,.05.

taining the model-predicted number of

events with the observed data and the

model-predicted number of events when

adolescents, including age, gender, race,

parent education, household income,

school performance, involvement in ex-

tracurricular activities, weekly spending

money, television watching (hours per

day), personality characteristics (rebel-

liousness, sensation-seeking propensity),

parent/sibling/peer smoking, cigarette

availability at home, and adolescent-

reported parenting practices.18 Author-

itative parenting style describes parents

that are both responsive and effective

in monitoring their children19; this con-

struct has a strong and consistent

track record in predicting lower levels

of substance use.18,20–32 The current

study used a 10-item version of the

Authoritative Parenting Index,18 in which

we combined results for questions

about responsiveness (“he/she makes

me feel better when I’m upset/listens

to what I have to say”) and monitoring

(“he/she asks me what I do with my

friends/knows where I am on the

weekend” [a = .79 survey 1, .81 survey 2])

and referenced questions to the per-

son the adolescent viewed as the

main caregiver. The assessment of

other covariates and their reliabilities

has been described previously.9,33 The

sensation-seeking scale used here has

been validated in longitudinal research

and has a reliabilities comparable to

other accepted scales for sensation

indicate what might happen if smoking

was largely removed from movies the

adolescents had watched. The attrib-

utable fractions were compared with

similar assessments for sensation

seeking (setting all adolescents at the

lowest level), or authoritative parenting

(setting all parents at the most author-

itative level). For each of the 15 impu-

tations, estimates and SEswere obtained

for the attributable fractions using 100

bootstrap replications. The bootstrap

estimates and SEs were then pooled

across the 15 multiple imputation mo-

dels using standard procedures.

Age was equally represented and ranged

from 10 to 14 years at baseline; male

and female genders were also equally

represented. Race/ethnicity was broadly

reflective of the US population, with

11% black and 19% Hispanic ethnicity.

Some 18% of families were classified

as low-income, with 7% having incomes

of #$20 000 and 11% having income

between $20 000 and $29 000 per year.

At baseline, 83%, 88%, and 69% of ado-

lescents reported having no friends,

siblings, or parents, respectively, who

smoked, and 14% thought there was at

least some chance that they could ob-

tain cigarettes from home without their

parent’s knowledge. With respect to

media use, 28% watched $3 hours of

television per day. Only 15% reported no

weekly spending money, and 10%

reported having .$20 per week to

spend.

to MPAA rating category. High-dose

1002 occurrences, respectively) and

∼5 times that of the 95th percentile for

G/PG-rated MSE. However, the typical

(median) dose to adolescents for PG-

13–rated MSE was much higher than

for R-rated MSE (275 and 93 occurrences,

respectively), reflecting higher viewer-

ship of PG-13–rated movies overall. The

correlation between the 3 MSE variables

was .53 for PG-13–rated versus R-rated

movies, .18 for PG-13–rated versus G/

PG-rated movies, and .15 for R-rated

versus G/PG-rated movies.

egory with the 8-month probability of

trying smoking using all three 8-month

observation periods; the unadjusted

probability of trying smoking was not

significantly different across the 3

periods. The null hypothesis is repre-

sented by the horizontal line set at the

average probability of trying smoking

(6.4%). Figure 2 illustrates the mark-

edly larger exposure to PG-13–rated

and R-rated movie smoking compared

with G/PG-rated movies, for which dose

did not extend past 200 occurrences,

even for the most highly exposed ado-

lescents. The relation for G/PG-rated

MSE and adolescent smoking (dotted

green line) was not significantly differ-

ent from zero. The unadjusted hazard

ratio associated with a 500-smoking

occurrence dose of G/PG-rated MSE

was 1.47 (95% CI: 0.65–3.36). Restrict-

ing G/PG-rated MSE to the observed

range (0–165 occurrences) made the

unadjusted hazard ratio even lower:

1.14 for the 95th percentile compared

with fifth percentile of actual G/PG-

rated MSE. In contrast, PG-13–rated

(dashed red line) and R-rated (solid

blue line) MSE had much larger ex-

posure ranges and crude relations

with youth smoking that were similar

to each other and strongly diver-

gent from the null hypothesis. The

11

12

13

14

Race/ethnicity

White

Black

Hispanic

Other

Gender

Male

Female

Family income (31000), $

,20

20–29

30–49

50–74

75–99

$100

Parent education

#9th grade

9th–11th grade

12th grade

High school diploma

Vocational/technical school

Some college

Associate degree

Bachelor degree

Postgraduate

Either parent smokes

No

Yes

Cigarettes available at home

Definitely no

Probably no

Probably yes

Definitely yes

Sibling(s) smoke

No

Yes

Peers smoke

None

Some

Most

Television viewing

None

,1 h/d

1–2 h/d

3–4 h/d

.4 h/d

School performance

Below average

Average

Above average

Excellent

Weekly spending money, $

None

1–5

6–0

11–15

1238

1213

975

1095

497

693

1183

1180

1748

229

1274

199

1004

501

1116

740

251

87

97

2760

1139

462

2479

1885

1362

359

.21

.21

.17

.19

.09

0

.51

.49

.12

.2

.2

.3

.04

.22

.03

.17

.09

.19

.13

.04

.01

.02

.47

.2

.08

.43

.32

.23

.06

.50

94

Demanding parenting

Sensation seeking

Rebelliousness

Extracurricular activities

Movie Smoking Exposure

G/PG-rated

PG-13–rated

R-rated

.02

0.8

0.2

1.8

93

0.5

0

1.5

0

1.3

0.4

2.2

393

ulation8 that it is other adult-oriented

content or some yet-to-be-identified

individual risk factor that attracts

youths to R movies which causes the

response. Combined with recently

published experimental data that show

a movie smoking effect on susceptibil-

ity to smoke using a randomized de-

sign,38 the results strongly support the

idea that it is the movie smoking in

PG-13- and R-rated movies that stim-

ulates youths to smoke.

movies accounts for about two-thirds

of the population effect. Thus, an un-

ambiguous R rating for smoking could

reduce adolescent smoking onset by

almost one-fifth, as newly produced

smoke-free PG-13–rated movies come

into the market and old ones lose the

adolescent audience. The attributable

fraction estimate for PG-13– and R-

rated MSE is smaller than previous

estimates in predominantly white

adolescents40–42 (the pooled estimate

for those studies from an earlier meta-

analysis5 was 0.44 [95% CI: 0.34–0.58]

compared with 0.26 [95% CI: 0.23–0.29]

for this study), in part because the

response to movie smoking among

minority adolescents was less strong

than among whites.43,44 Regardless of

what the final attributable risk is,

however, the public health impact of

PG-13 smoking is important: it ranks on

the order of the impact of parenting

effectiveness.

rated MSE was not significantly different

from zero. Low responsiveness to

smoking in G/PG movies is consistent

with the results of an experimental

study that failed to find an effect of

cartoon and G/PG movie smoking on

attitudes in elementary school-aged

children.45 Another similarly designed

R-rated MSE were 3.44 (95% CI: 2.74–

4.32) and 3.14 (95% CI: 2.58–3.83),

respectively.

There was no significant relation be-

tween exposure to G/PG-rated MSE and

adolescent smoking. The adjusted haz-

ard ratios for a 500-occurrence dose of

PG-13– and R-rated MSE were 1.49 (95%

CI: 1.23–1.81) and 1.33 (95% CI: 1.13–

1.57), respectively. Wald tests showed

that the MSE–youth smoking relation

for PG-13– and R-rated movies was not

significantly different from each other

but both were significantly higher

than the G/PG-rated MSE–youth smok-

ing relation.

powered to detect an overall odds ratio

of 1.4 for the relation between smoking

in movies and smoking onset with

a powerof 0.97.Power for these analyses

was considerably reduced when MSE

was subdivided by MPAA rating into 3

correlated variables, especially consid-

ering the small range of G/PG-rated MSE.

However, additional power calculations

indicated that, even with this small

range, the power of the study to detect

an effect similar to PG-13 MSE (an

the fifth percentile was 0.26 (95% CI:

0.23–0.29), indicating that largely re-

moving the risk factor would reduce

smoking onset over the period by 26%.

Setting PG-13-rated MSE alone to the

fifth percentile (which approximates

the probable impact of an R rating for

smoking) was associated with an at-

tributable fraction of 0.18 (95% CI:

0.14–0.21). For comparison, the attrib-

utable fractions for setting authorita-

tive parenting to the highest level or

sensation seeking to the lowest level

were 0.16 (95% CI: 0.19–0.12) and 0.30

(95% CI: 0.35–0.25), respectively. Thus,

eliminating smoking from youth-rated

movies would reduce smoking by as

much as making all parents maximally

authoritative in their parenting.

the other adult behaviors that go along

with it, that affects adolescents’ be-

havior. The dose-response between PG-

13–rated MSE and youth smoking is

was not significantly different across each of the three 8-month follow up periods and was equal to

0.064, shown in the plot as a thin horizontal line. All 3 exposures (G/PG [dotted green line], PG-13

[dashed red line], and R [solid blue line]) were entered as linear effects. The small lines on either side

of each curve represent the 95% CIs for the estimate. The model was estimated on the log odds scale by

using logistic regression as is standard for discrete time survival analysis. Because the log odds scale

is difficult to interpret, however, the fitted relations were converted to the probability scale. The change

of scaling of the y-axis from log odds to probability creates the apparent curvilinearity.

PG-13–rated

R-rated

1.33

G/PG versus PG-13

G/PG versus R

PG-13 versus R

1.57

causal interpretation. Our conclusion

that it is the smoking in PG-13– and R-

rated movies that prompts adolescents

to smoke is strengthened theoretically

on the parsimonious notion of a social

modeling effect and supported by social

cognitive theory.51 Our study was not

powered to detect a small effect, such

as that seen in the unadjusted relation

between G/PG-rated MSE and adoles-

cent smoking in this study (but it is

adequate to rule out an effect similar to

that of PG-13–rated movies). It also does

not empirically test what might be found

if smoking in G/PG movies was in-

creased to the point that it was pro-

vided similar to exposure in other

types of movies. Thus, the study cannot

be used as a justification for adding

more smoking to G/PG-rated movies.

Finally, this study cannot tell us exactly

what contextual situations are most

problematic, as the study by Shadel

et al2 was able to do.

is maintained, in part, by movie images

of smoking. This study suggests that it is

the depiction of smoking in movies, not

other contextual variables, that matters

for the onset of youth smoking. It sug-

gests greater emphasis on reducing

exposure to smoking in PG-13–rated

movies through an unambiguous R rat-

ing for smoking52 and less emphasis on

images of smoking commonly found in

G- and PG-rated movies, which contrib-

ute little to exposure. Finally, even if the

MPAA agrees to modernize its volun-

tary film rating system to eliminate

smoking from youth-rated films, youth

will still receive some exposure to

smoking from R-rated movies, so it is

also important to motivate and assist

parents in restricting access to these

movies, which would further reduce

adolescent exposure to onscreen

smoking.53–59

1.13

22.37

0.74

1

1

.018

.458

2 experimental studies, combined with

our population-level results, suggest

that the explanation is that smoking

images delivered by G/PG cartoons

and other family-oriented films fail to

effectively communicate favorable ex-

pectancies or utilities for smoking. Thus,

the emphasis afforded to cartoon smok-

ing in previous studies47,48 may be mis-

placed from a public health standpoint.

films would not reduce the effects of

smoking in movies on youth smoking;

there is little MSE in G/PG-rated films6,49

and what imagery is there is not partic-

ularly salient. Thus, the only effective

ratings option for the MPAA in limiting the

impact of MSE is an R rating for smoking.

cannot be made from 1 study alone, but

1. US Department of Health and Human

Services. Preventing Tobacco Use Among

Youth and Young Adults: A Report of the

Surgeon General. Atlanta, GA: U.S. De-

partment of Health and Human Services,

Centers for Disease Control and Pre-

vention, National Center for Chronic Dis-

ease Prevention and Health Promotion,

Office on Smoking and Health, 2012.

2. Shadel WG, Martino SC, Haviland A, Setodji

C, Primack BA. Smoking motives in movies

are important for understanding adoles-

cent smoking: a preliminary investigation.

Nicotine Tob Res. 2010;12(8):850–854

3. Motion Picture Association of America. Film

ratings, 2011. Available at: www.mpaa.org/

ratings. Accessed February 6, 2012

4. Tickle JJ, Beach ML, Dalton MA. Tobacco,

alcohol, and other risk behaviors in film:

how well do MPAA ratings distinguish con-

tent? J Health Commun. 2009;14(8):756–767

5. Millett C, Glantz SA. Assigning an ‘18’ rating

to movies with tobacco imagery is essen-

tial to reduce youth smoking. Thorax. 2010;

65(5):377–378

6. Sargent JD, Tanski SE, Gibson J. Exposure

to movie smoking among US adolescents

aged 10 to 14 years: a population estimate.

Pediatrics. 2007;119(5). Available at: www.

pediatrics.org/cgi/content/full/119/5/e1167

7. Biederman DE, Pierson EP, Silfen ME, et al.

Law and Business of the Entertainment

Industries. Santa Barbara, CA: Praeger;

2006

8. Chapman S, Farrelly MC. Four arguments

against the adult-rating of movies with

smoking scenes. PLoS Med. 2011;8(8):

e1001078

9. Sargent JD, Beach ML, Adachi-Mejia AM,

et al. Exposure to movie smoking: its re-

lation to smoking initiation among US

adolescents. Pediatrics. 2005;116(5):1183–

1191

1. Schafer JL, Graham JW. Missing data: our

view of the state of the art. Psychol Meth-

ods. 2002;7(2):147–177

1. van Buuren S, Groothuis-Oudshoorn K.

mice: Multivariate imputation by chained

equations in R. J Stat Softw. 2011;45(3):1–67

2. Sargent JD, Worth KA, Beach M, Gerrard M,

Heatherton TF. Population-based assess-

ment of exposure to risk behaviors in

motion pictures. Commun Methods Meas.

2008;2(1–2):134–151

3. Dalton MA, Tickle JJ, Sargent JD, Beach ML,

Ahrens MB, Heatherton TF. The incidence

and context of tobacco use in popular

movies from 1988 to 1997. Prev Med. 2002;

34(5):516–523

4. Shete S, Beasley TM, Etzel CJ, et al. Effect of

winsorization on power and type 1 error of

variance components and related methods

of QTL detection. Behav Genet. 2004;34(2):

153–159

5. Pierce JP, Choi WS, Gilpin EA, Farkas AJ,

Merritt RK. Validation of susceptibility as

a predictor of which adolescents take up

smoking in the United States. Health Psy-

chol. 1996;15(5):355–361

6. Choi WS, Pierce JP, Gilpin EA, Farkas AJ,

Berry CC. Which adolescent experimenters

progress to established smoking in the

United States. Am J Prev Med. 1997;13(5):

385–391

7. Kawakami N, Takatsuka N, Shimizu H, Takai
8. Life-time prevalence and risk factors of

tobacco/nicotine dependence in male ever-

smokers in Japan. Addiction. 1998;93(7):

1023–1032

8. Jackson C, Henriksen L, Foshee VA. The

Authoritative Parenting Index: predicting

health risk behaviors among children and

adolescents. Health Educ Behav. 1998;25(3):

319–337

9. Baumrind D. Parental disciplinary patterns

and social competence. Youth Soc. 1978;9

(3):239

1. Barnes GM, Reifman AS, Farrell MP, Dintcheff
2. The effects of parenting on the deve-

lopment of adolescent alcohol misuse: a six-

wave latent growth model. J Marriage Fam.

2000;62(1):175–186

1. Baumrind D. The influence of parenting

style on adolescent competence and sub-

stance use. J Early Adolesc. 1991;11:56–65

2. Beck KH, Boyle JR, Boekeloo BO. Parental

monitoring and adolescent alcohol risk in

a clinic population. Am J Health Behav.

2003;27(2):108–115

3. Chilcoat HD, Anthony JC. Impact of parent

monitoring on initiation of drug use

through late childhood. J Am Acad Child

Adolesc Psychiatry. 1996;35(1):91–100

4. Cleveland MJ, Gibbons FX, Gerrard M,

Pomery EA, Brody GH. The impact of par-

enting on risk cognitions and risk behavior:

a study of mediation and moderation in

a panel of African American adolescents.

Child Dev. 2005;76(4):900–916

5. Cohen DA, Richardson J, LaBree L. Parent-

ing behaviors and the onset of smoking

and alcohol use: a longitudinal study. Pe-

diatrics. 1994;94(3):368–375

6. Fleming CB, Kim H, Harachi TW, Catalano RF.

Family processes for children in early ele-

mentary school as predictors of smoking

initiation. J Adolesc Health. 2002;30(3):184–

189

7. Jackson C, Bee-Gates DJ, Henriksen L. Au-

thoritative parenting, child competencies,

and initiation of cigarette smoking. Health

Educ Q. 1994;21(1):103–116

8. Jackson C, Henriksen L, Dickinson D, Levine
9. The early use of alcohol and tobacco:

its relation to children’s competence and

parents’ behavior. Am J Public Health. 1997;

87(3):359–364

9. Kandel DB. Parenting styles, drug use, and

children’s adjustment in families of young

adults. J Marriage Fam. 1990;52(1):183

1. Latendresse SJ, Rose RJ, Viken RJ, Pulkki-

nen L, Kaprio J, Dick DM. Parenting mech-

anisms in links between parents’ and

adolescents’ alcohol use behaviors. Alcohol

Clin Exp Res. 2008;32(2):322–330

1. O’Byrne KK, Haddock CK, Poston WS. Par-

enting style and adolescent smoking.

J Adolesc Health. 2002;30(6):418–425

2. Stephenson MT, Helme DW. Authoritative

parenting and sensation seeking as pre-

dictors of adolescent cigarette and mari-

juana use. J Drug Educ. 2006;36(3):247–270

3. Hanewinkel R, Sargent JD. Exposure to smok-

ing in internationally distributed American

movies and youth smoking in Germany:

a cross-cultural cohort study. Pediatrics.

2008;121(1). Available at: www.pediatrics.

org/cgi/content/full/121/1/e108

4. Sargent JD, Tanski S, Stoolmiller M, Hane-

winkel R. Using sensation seeking to target

adolescents for substance use interven-

tions. Addiction. 2010;105(3):506–514

5. Allison PD. Event History Analysis: Regres-

sion for Longitudinal Event Data. Thousand

Oaks, CA: Sage Publications, Inc; 1984

6. Singer JD, Willett JB. Applied Longitudinal

Data Analysis: Modeling Change and Event

Occurrence. New York, NY: Oxford Univer-

sity Press; 2003

7. Muthen B, Masyn K. Discrete-time survival

mixture analysis. J Educ Behav Stat. 2005;

30(1):27–58

8. Shadel WG, Martino SC, Setodji C, Haviland A,

Primack BA, Scharf D. Motives for smoking

in movies affect future smoking risk in

middle school students: An experimental

investigation[published online ahead of print

November 8, 2011]. Drug Alcohol Depend.

doi: 10.1016/j.drugalcdep.2011.10.019

9. Sargent JD, Stoolmiller M, Worth KA, et al.

Exposure to smoking depictions in movies:

its association with established adolescent

smoking. Arch Pediatr Adolesc Med. 2007;

161(9):849–856

1. Dalton MA, Beach ML, Adachi-Mejia AM,

et al. Early exposure to movie smoking

predicts established smoking by older

cgi/content/full/123/4/e551

Dalton MA, Sargent JD, Beach ML, et al. Ef-

fect of viewing smoking in movies on ado-

lescent smoking initiation: a cohort study.

Lancet. 2003;362(9380):281–285

Titus-Ernstoff L, Dalton MA, Adachi-Mejia

AM, Longacre MR, Beach ML. Longitudinal

study of viewing smoking in movies and

initiation of smoking by children. Pediat-

rics. 2008;121(1):15–21

Jackson C, Brown JD, L’Engle KL. R-rated

movies, bedroom televisions, and initia-

tion of smoking by white and black ado-

lescents. Arch Pediatr Adolesc Med. 2007;

161(3):260–268

Tanski SE et al. Moderation of the associ-

ation between media exposure and youth

smoking onset: Race/ethnicity, and parent

smoking. Prev Sci. 2012;13(1):55–63

Lochbuehler K et al. Influence of smoking

cues in movies on explicit smoking cogni-

tions and implicit associations towards

smoking among children. Pediatrics. 2012;

130(2):XXXX

Pechmann C, Shih CF. Smoking scenes in

movies and antismoking advertisements

Goldstein AO, Sobel RA, Newman GR. Tobacco

and alcohol use in G-rated children’s ani-

mated films. JAMA. 1999;281(12):1131–1136

Thompson KM, Yokota F. Depiction of alco-

hol, tobacco, and other substances in G-

rated animated feature films. Pediatrics.

2001;107(6):1369–1374

Polansky GS Jr. First-Run Smoking Pre-

sentations in U.S. Movies 1999–2006. San

Francisco CA: Center for Tobacco Control

Research and Education; 2007

Dal Cin S, Stoolmiller M, Sargent JD. When

Movies Matter: Exposure to Smoking in

Movies and Changes in Smoking Behavior.

J Health Commun. 2011;17(1):76–84

Bandura A. Social Foundations of Thought

and Action. A Social Cognitive Theory. Eng-

lewood Cliffs, NJ: Prentice Hall; 1986

Glantz SA. Smoking in movies: a major

problem and a real solution. Lancet. 2003;

362(9380):258–259

Dalton MA, Adachi-Mejia AM, Longacre MR,

et al. Parental rules and monitoring of

children’s movie viewing associated with

children’s risk for smoking and drinking.

Pediatrics. 2006;118(5):1932–1942

4. Dalton MA, Ahrens MB, Sargent JD, et al.

Relation between parental restrictions

on movies and adolescent use of tobacco

and alcohol. Eff Clin Pract. 2002;5(1):

1–10

5. Laugesen M, Scragg R, Wellman RJ,

DiFranza JR. R-rated film viewing and ado-

lescent smoking. Prev Med. 2007;45(6):454–

459

6. Sargent JD, Beach ML, Dalton MA, et al. Ef-

fect of parental R-rated movie restriction on

adolescent smoking initiation: a prospective

study. Pediatrics. 2004;114(1):149–156

7. Stoolmiller M, Gerrard M, Sargent JD,

Worth KA, Gibbons FX. R-rated movie view-

ing, growth in sensation seeking and al-

cohol initiation: reciprocal and moderation

effects. Prev Sci. 2010;11(1):1–13

8. Tanski SE, Dal Cin S, Stoolmiller M, Sargent
9. Parental R-rated movie restriction and

early-onset alcohol use. J Stud Alcohol

Drugs. 2010;71(3):452–459

9. de Leeuw RN, Sargent JD, Stoolmiller M,

Scholte RH, Engels RC, Tanski SE. Association

of smoking onset with R-rated movie res-

trictions and adolescent sensation seeking.

Pediatrics. 2011;127(1). Available at: www.

pediatrics.org/cgi/content/full/127/1/e96