Exposure to smoking in movies among British
adolescents 2001e2006
Stacey J Anderson,
1
Christopher Millett,
2,3
Jonathan R Polansky,
4
Stanton A Glantz
5,6
ABSTRACT
Objective To estimate youth exposure to smoking in
movies in the UK and compare the likely effect with the
USA.
Methods We collected tobacco occurrences data for
572 top-grossing films in the UK screened from 2001 to
2006 and estimated the number of on-screen tobacco
impressions delivered to British youths in this time
period.
Results 91% of films in our sample that contained
smoking were youth-rated films (British Board of Film
Classification rating ‘15’ and lower), delivering at least
1.10 billion tobacco impressions to British youths during
theatrical release. British youths were exposed to 28%
more smoking impressions in UK youth-rated movies than
American youth-rated movies, because 79% of movies
rated for adults in the USA (‘R’) are classified as suitable
for youths in the UK (‘15’ or ‘12A’).
Conclusion Because there is a dose-response relation
between the amount of on-screen exposure to smoking
and the likelihood that adolescents will begin smoking,
the fact that there is substantially higher exposure to
smoking in youth-rated films in the UK than in the USA
suggests that the fraction of all youth smoking because
of films in the UK is probably larger than in the USA.
Other countries with ratings systems that are less
conservative (in terms of language and sexuality) than
the USA will also be likely to deliver more on-screen
tobacco impressions to youths. Assigning an ‘18’
classification to movies that contain smoking would
substantially reduce youth exposure to on-screen smoking
and, hence, smoking initiation among British youths.
INTRODUCTION
Exposure to on-screen smoking in movies causes
youths to smoke.
1e5
There is a ‘dose-response’: the
more smoking youths see, the more likely they are
to smoke, with heavily exposed youths about three
times as likely to begin smoking as lightly exposed
youths, after controlling for other factors linked
with smoking (peer smoking, parental smoking,
academic performance, exposure to cigarette adver-
tising and other factors).
6
These results from the
USA have been confirmed both qualitatively and
quantitatively in New Zealand,
7
Mexico
8
and
Germany.
9e11
(One study using secondary data
analysis from Scotland found no effect,
12
but the
authors noted that there may be problems in
exposure assessment which biases the results
towards the null.) Concern over the effects of on-
screen smoking on adolescent smoking initiation
has led many organisations, including the British
Medical Association,
3
Institute of Medicine of the
US National Academy of Sciences
2
and the World
Health Organization
13
to call for reductions in
youth exposure to on-screen smoking. Addressing
the fact that on-screen smoking promotes youth
smoking is part of implementing the WHO Frame-
work Convention on Tobacco Control.
13
One way to reduce exposure would be to inte-
grate tobacc o imagery into national film age-
classification systems to give films depicting tobacco
an adult content rating.
13 14
The British Board of Film
Classification (BBFC), the non-governmental, film
industry-funded agency that recommends ratings
for films in the UK, states that a rating of ‘18’,
which precludes people under 18 from seeing a film
in a cinema, should be awarded to films ‘where
material or treatment appears to the Board to risk
harm to individuals or, through their behaviour, to
society’,
15
a standard met by the available scientific
evidence on the effect of on-screen smoking on
youth behaviour. As of February 2010 the BBFC
had refused to apply its rules to on-screen smoking.
The BBFC is, however, only advisor
y to local
councils. The BBFC notes, ‘[s]tatutory powers on
film remain with the local councils, which may
over-rule any of the Board’s decisions, passing films
we reject, banning films we have passed, and even
waiving cuts, instituting new ones, or altering
categories for films exhibited under their own
licensing jurisdiction’.
16
Because of the BBFC’s
failure to act, in 2008 Liverpool announced it was
considering applying an ‘18’ rating to films with
tobacco use
517
and on 12 June 2009 initiated the
formal consultation process to integrate this policy
into its local licensing procedure.
18
To estimate the potential effect of such a policy,
we estimated the level of exposure to smoking in
youth rated (BBFC ratings U, PG, 12A and 15) films.
METHODS
Amount of smoking in films in the UK market
There were 738 motion pictures in the top 10
weekly box office lists for 1 January 2001e31
December 2006 that earned at least ₤250 000 in the
UK
19
(excluding ET, The Extraterrestrial, a 1982 film,
and Alien, a 1979 film, re-released during the study
period). We obtained the number of tobacco occur-
rences in 572 films (546 top grossing films in the UK
that also ran in the USA, and 26 top grossing films in
the UK market not released to US theatres) from the
Cancer Control Research Program at Dartmouth-
Hitchcock Medical Center using the same established
methods
20
as have been used for the epidemiolog-
ical studies of the effects of on-screen smoking on
adolescent
68e12 21 e23
and young adult
24
smoking
behaviour.
Briefly,
20
trained coders reviewed each film,
recorded ‘tobacco episodes’,defined as the appear-
ance of tobacco use or handling of tobacco products
1
Division of Epidemiology and
Public Health, University of
Nottingham, Nottingham, UK
2
Division of General Internal
Medicine, San Francisco General
Hospital, University of California,
San Francisco, California, USA
3
Department of Primary Care
and Social Medicine, Imperial
College, London, UK
4
Onbeyond LLC, Fairfax,
California, USA
5
Division of Cardiology,
University of California, San
Francisco, California, USA
6
Center for Tobacco Control
Research and Education,
University of California, San
Francisco, California, USA
Correspondence to
Professor Stanton A Glantz,
Center for Tobacco Control
Research and Education,
University of California, San
Francisco, Box 1390, Room 366,
530 Parnassus, San Francisco,
CA 94143-1390, USA
Received 24 November 2009
Accepted 7 January 2010
This paper is freely available
online under the BMJ Journals
unlocked scheme, see http://
tobaccocontrol.bmj.com/site/
about/unlocked.xhtml
Tobacco Control 2010;19:197e200. doi:10.1136/tc.2009.034991 197
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by a major or minor character in one scene (with two people
smoking in the same scene counting as two episodes) and
‘tobacco incidents’,defined as the appearance of tobacco in
a scene without use by a character (with all such ‘incidents’ in
a single scene coded as one incident). ‘Tobacco occurrences’ are
the sum of tobacco episodes plus tobacco incidents in a film.
Tobacco impressions delivered by movies in theatrical release
The number of ‘tobacco impressions ’ delivered by a film is
a measure of its impact promoting adolescent tobacco use. One
impression is one person seeing one tobacco occurrence one time.
We obtained the average ticket price for each of the years in
our study (2001e2006) from the UK Film Council
25
and divided
the total box office earnings of each film by the year’s average
ticket price, yielding the estimated number of in-theatre views of
each film. We multiplied the number of views by the tobacco
occurrences to estimate the ‘tobacco impressions’ delivered to UK
cinema-going audiences by each film.
We obtained statistics for movie attendance by rating and by
age for the years 2005e2007 from the UK Film Council.
25
The
fraction of the audience comprising children and adolescents ages
7e17 remained stable over this period, so we used average frac-
tions of ticket sales for each rating (‘U’: 37.7%, ‘PG’: 36.3%, ‘12A’ :
27.0%, ‘15’: 16.7%) to estimate tobacco impressions delivered to
children and adolescents (box 1 provides an example of this
calculation).
We performed similar calculations after dividing the films
based
on the US (Motion Picture Association of America, MPAA)
rating scheme.
17
We compared smoking occurrences and
impressions in US, UK and European produced films.
RESULTS
Tobacco occurrences in films rated for youths
Of the 572 films in this 2001e2006 sample (table 1), 396 (69%)
featured tobacco. Of films depicting tobacco, 359 (91%) received
a UK youth rating (BBFC ‘15’ and below). Of the 3808 tobacco
occurrences presented by this 2001e2006 film sample, 3308
(87%) were in UK youth-rated films. The films in this sample
delivered a total of 5.07 billion tobacco impressions to UK cinema
audiences; 4.49 billion (89%) of these impressions were delivered
in youth-rated films. Over the time period studied, youth-rated
films delivered 1.09 billion tobacco impressions while in theat-
rical release to UK children and adolescents aged 7e17 years.
For comparison, 45% of the tobacco occurrences in the sample
were in films that the US MPAA gave a youth rating (G, PG or
PG-13), whereas 87% were in films that the BBFC gave a youth
rating. Because 79% of movies rated for adults in the USA (‘R’)
are classified as suitable for youths in the UK (‘15’ or ‘12A’),
British youths were exposed to 28% more smoking impressions
in UK youth-rated movies than in American youth-rated films
(1.09 billion tobacco impressions vs 850 million, both based on
UK audience youth composition data). Although UK-produced
films contained more tobacco occurrences on average than
US-produced films, the dominance of US-produced films in the
cinema market means US studios were responsible for the vast
majority of tobacco impressions delivered to UK audiences.
DISCUSSION
The vast majority of smoking events in films shown in the UK
was delivered by youth-rated films (89%). Although US film
studios were responsible for almost all of the movies with
smoking events viewed in the UK (96%), more smoking occurs
in films rated for youths in the UK (6.22 average occurrences)
than occurs in youth-rated films in the USA (4.50 average
occurrences). This difference is mainly because the large number
of films rated ‘R’ in the USA (under 17 not admitted without
parent or guardian) are re-classifi ed as ‘15’ in the UK. Of 190 films
rated ‘R’ by the MPAA in the USA, BBFC assigned 21% an ‘18’,
77% a ‘15’ rating and 2% a ‘12A’ rating. More smoking appears in
US ‘R’-rated films than appears in films rated for youths;
assigning such films a youth classification in the UK means
British youths have greater potential exposure to smoking in
movies. In both the UK and USA, youth-rated films comprise the
majority of films with smoking and deliver the majority of
tobacco impressions to theatre audiences: unsurprising, since US
films dominate the UK market. In the UK, however, because of
BBFC rating practice, the share of tobacco occurrences seen in
youth-rated films (87%) is nearly twice that in the USA (45%).
Other countries (eg, Germany
10
) with ratings systems that are
less conservative (in terms of language and sexuality) than the
USA will also be likely to deliver more on-screen tobacco
impressions to youths.
Four studies in the USA have estimated the attributable risk
fraction of adolescent and young adult smokers, three based on
northern New England longitudinal studies
6 22 23
and one based
on a national cross-sectional study,
21
all of which used multi-
variate models, so they control for confounding. The original
New England cohort
6
(middle school students at baseline) found
that 0.52 (95% CI 0.30 to 0.67) of those who ‘tried smoking’ was
attributable to smoking in the movies. A later follow-up in the
same cohort
23
found an attributable risk fraction of 0.35 (95% CI
0.14 to 0.56) for established smoking at young adulthood because
of movie smoking exposure. A different northern New England
longitudinal cohort
22
that started with younger children
(4the6th graders at baseline) found that 0.46 (95% CI 0.11 to
0.70) of youths who tried smoking was attributable to movie
exposure. Finally a national cross-sectional study
21
(adolescents
10e14 years old) found that the adjusted attributable fraction for
having tried smoking was 0.38 (95% CI 0.20 to 0.56). It is likely
that the attributable risk fractions in the UK would be higher
Box 1 Example of calculation of youth exposure to
smoking in a specific film
<
The Terminal, a 2004 film, grossed £6 052 047 during its run.
The average ticket price in 2004 was £4.49. Dividing 6 052 047
by 4.49 gives us 1 347 895 estimated total in-theatre views of
this film. There were nine tobacco occurrences in this film,
hence 12 131 055 tobacco impressions (1 347 89539) deliv-
ered to UK cinema audiences.
<
This film was classified ‘12A’ by the BBFC. According to the UK
Film Council, 27.0% of audiences viewing films classified ‘12A’
were aged 7e17. Therefore, we multiplied the total tobacco
impressions (12 131 055) by 0.27 to obtain 3 275 385
impressions delivered to youths aged 7e17 by The Terminal
during its theatrical run.
<
We summed total impressions delivered to youths aged 7e17
by all films classified ‘12A’ to obtain a total estimate of youth
exposure by films with that classification.
<
We performed these calculations for each of the film
classification categories to obtain estimates of youth exposure
by films classified ‘U’ or ‘PG’, ‘12A’ and ‘15A’. The UK Film
Council does not collect youth attendance data for films
classified ‘18A’, so we were not able to obtain exposure
estimates for films classified ‘18A’.
198 Tobacco Control 2010;19:197e200. doi:10.1136/tc.2009.034991
Research paper
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than in the USA for two reasons. First, in the USA conventional
cigarette advertising is also contributing to youth smoking
initiation, but such advertising has been all but banned in the
UK, which increases the relative importance of films as
a promotional medium. (Even in the USA
26
and Germany,
27
where promotion of tobacco products continues, the effect of
films on youth smoking behaviour exceeds that of traditional
advertising and promotion.) Second, because of the differences in
rating practices documented in this paper, the level of adoles-
cents’ exposure to on-screen smoking is substantially higher in
the UK than the USA.
In addition to lowering the probability that a youth will see
a film,
28
an ‘18’ rating for smoking would create an economic
incentive for motion picture producers to simply leave smoking
out of films developed to be marketed to youths. By comparing
total box office sales of a random sample of 40 youth-rated films
with that of the 40 ‘18’-rated films, we determined that youth-
rated films grossed 1.75 times as much as ‘18’-rated films. The
decision to classify a film as appropriate for youths clearly has
economic benefits for the film industry.
In the USA, one thing that paediatricians can do is advise
parents to keep children and teenagers from seeing R-rated
movies, thereby substantially reducing the exposure to chil-
dren.
29
In the USA, children of parents who restrict their access
to R-rated films are less likely to smoke, in a way consistent with
the observed dose-response relation. This intervention is not
available to paediatricians in the UK because the BBFC rates 75%
of US R-rated for children (‘15’ or ‘12’).
Limitations
Our analysis is based on 572 (78%) out of the 738 most popular
films in the UK from 2001 to 2006. The films included in our
sample accounted for 92% of total box office takings in that
period, so our estimates of UK youths’ level of exposure to on-
screen smoking are likely to be low. Similarly, because the UK
Film Council does not collect data for the fraction of the cinema
audience aged 7e17 for ‘18’-rated films, we assumed that this
number was zero. To the extent that youths have access to films
rated ‘18’, our results underestimate exposure.
Additionally, our estimate of tobacco impressions delivered to
this age group underestimates total youth exposure, since it does
not include children younger than 7 or youth exposure to
cinematic tobacco imagery through video media and the
internet.
Conclusions
Exposure to smoking in films accessible to youths is a substan-
tial contributor to youth smoking initiation. UK youths are
potentially exposed to even more on-screen smoking than are
youths in the USA, where the strong dose-response effect is
firmly established. Implementing the BBFC film rating system’s
current standard that films in which ‘material or treatment
appears . to risk harm to individuals or, through their behaviour,
to society’ and assigning future films with tobacco imagery an
‘18’ rating would reduce UK youth exposure to on-screen
smoking even more than a comparable change in the USA, with
a correspondingly greater reduction in films’ effect on youth
smoking initiation.
Acknowledgements We would like to thank the Cancer Control Research Program
at Dartmouth-Hitchcock Medical Center for providing tobacco occurrences ratings for
the movies in our sample.
Table 1 Level of exposure to on-screen smoking by BBFC and MPAA classification, 2001e2006
BBFC classification MPAA classification
TotalU/PG 12A 15 18
UK
G/PG PG-13 R
USA
Total youth
rated* z
Total youth
ratedyz
Total films 145 199 188 40 532 119 263 190 382 572
Films with tobacco 58 148 153 37 359 40 192 164 232 396
Occurrences
UK-produced 1 39 37 22 77 16 10 73 26 99
US-produced 315 1149 1701 464 3165 202 1486 1941 1688 3629
Other produced 6 0 60 14 66 0 6 74 6 80
Total 322 1188 1798 500 3308 218 1502 2088 1720 3808
Impressions (millions)
UK-produced 0.4 10 20 20 30 6 9 40 20 50
US-produced 750 1900 1770 570 4420 290 2690 2020 2980 5000
Other produced 0.6 NA 30 3 31 0 0.6 20 1 20
Totaly 750 1920 1820 590 4490 290 2700 2080 2990 5070
Total 7e17 years 270 520 300 NA 1100 110 740 250 850 1100
*U, PG, 12A, 15.
yG, PG, and PG-13.
zSums may not equal totals owing to rounding.
NA, not available; data not collected on number of youths who are admitted to ‘18’ rated films.
What this paper adds
<
Studies from the USA, New Zealand, Mexico and Germany
demonstrate that exposure to smoking in movies causes
youths to smoke and that there is a dose-response effect of
film smoking exposure on youth smoking uptake.
<
This study demonstrates that, because of differences in rating
practices in the UK and USA, youths in the UK experience
much heavier exposure to tobacco impressions by top-
grossing films in cinematic release, suggesting that the
effects of on-screen smoking as a stimulant for smoking
behaviour in the UK are even larger than in the USA. A film
classification policy that keeps on-screen smoking out of films
rated for youths (eg, films classified 15 and below) would
reduce this exposure for people under 18 years of age and
probably lead to a substantial reduction in youth smoking.
Tobacco Control 2010;19:197e200. doi:10.1136/tc.2009.034991 199
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Funding This research was supported by Health@Work Liverpool, Liverpool Primary
Care Trust, Smokefree Northwest, Roy Castle Lung Cancer Foundation and the
American Legacy Foundation. CM undertook this study during a Harkness Fellowship in
Health Care Policy and Practice and was supported of the Commonwealth Fund in New
York. The funding agencies had no role in the conduct of the research or preparation of
the manuscript.
Competiting interests None.
Contributors In addition to all authors’ intellectual contributions to the
conceptualisation of the study, interpretation of the data and final approval of the
submitted manuscript, SJA designed the study, collected and analysed film box office
data and BBFC/MPAA classification data, and co-wrote the manuscript; CM analysed
audience composition data and commented on earlier drafts of the paper; JRP
collected and analysed film studio data, provided general consultation on the structure
of the film industry and commented on earlier drafts of the manuscript; and SAG
co-wrote the manuscript, provided general consultation on the relevant literature and
supervised the project.
Provenance and peer review Not commissioned; externally peer reviewed.
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