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OBJECTIVE: To determine if young adolescents who report that their parents restrict viewing R-rated movies have a lower risk of trying smoking in the future. DESIGN: Prospective observational study. Students from 15 schools in New Hampshire and Vermont, randomly selected from all middle schools with >150 students, were surveyed in 1999. Baseline never-smokers were surveyed again by telephone 13 to 26 months later to determine smoking status. OUTCOME MEASURE: Trying smoking during the follow-up period. RESULTS: The majority of the 2596 students were white, with ages ranging from 10 to 14 years. Nineteen percent reported that their parents never allowed them to view R-rated movies, 29% were allowed once in a while, and 52% were allowed sometimes or all the time. Ten percent of students tried smoking during the follow-up period. Smoking-initiation rates increased as parental restriction of R-rated movies decreased (2.9% for adolescents reporting that their parents never allowed them to view R-rated movies, 7.0% for those allowed to view them once in a while, and 14.3% for those allowed to view them sometimes or all the time). There was a strong and statistically significant effect of parental R-rated movie restriction on adolescent smoking even after controlling for sociodemographics, social influences (friend smoking, receptivity to tobacco promotions), parenting style (maternal support and control, parental disapproval of smoking), and characteristics of the adolescent (school performance, sensation seeking, rebelliousness, self-esteem). Compared with adolescents whose parents never allowed them to view R-rated movies, the adjusted relative risk for trying smoking was 1.8 (95% confidence interval [CI]: 1.1, 3.1) for those allowed to watch them once in a while and 2.8 (95% CI: 1.6, 4.7) for those allowed to watch them sometimes or all the time. The effect was especially strong among adolescents not exposed to family (parent or sibling) smoking, among whom the adjusted relative risk for smoking was 4.3 (95% CI: 1.4, 13) for those allowed to view R-rated movies once in a while and 10.0 (95% CI: 3.6, 31) for those allowed to view them sometimes or all the time. CONCLUSIONS: Parental restriction from watching R-rated movies strongly predicts a lower risk of trying smoking in the future. The effect is largest among adolescents not exposed to family smoking. By exerting control over media choices and by not smoking themselves, parents may be able to prevent or delay smoking in their children. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Studies of US adolescents have linked exposure to movie smoking with smoking behavior. It is unclear whether European adolescents are also responsive to movie tobacco imagery. METHODS: A longitudinal study was conducted to assess exposure to movie smoking in 2711 German never-smokers (aged 10 to 16 years). Movie smoking exposure was estimated by asking adolescents if they had seen movies from a list of 50 movie titles, randomly selected for each adolescent from 398 internationally distributed movies released between 1994 and 2004 that became box-office hits in Germany. These films were reviewed for smoking content. Adolescents were resurveyed 12 to 13 months later to determine smoking status, and results were compared with a similarly designed survey of 2603 white US adolescents. We hypothesized replication of the main effect of the exposure on trying smoking, and an interaction, with a significantly larger response among adolescents whose parents did not smoke. RESULTS: The 398 internationally distributed movies represented 80% of the German box-office hits within this time frame, with the majority (388) produced and/or distributed internationally by US companies. Smoking was present in 74% of the movies. Overall, 503 (19%) of the students tried smoking during the follow-up period. The incidence of trying smoking was associated with increased exposure to movie smoking. The form of the dose-response was similar to the US sample, with the strongest response to movies seen in the lower 2 quartiles of exposure. After controlling for baseline covariates, exposure to movie smoking remained a significant predictor of trying smoking in German adolescents, and the effect was significantly stronger in adolescents whose parents did not smoke. CONCLUSIONS: Smoking in internationally distributed US movies predicts trying smoking among German adolescents, closely replicating findings from a longitudinal study of white US adolescents. Smoking in these movies could have important worldwide public health implications. [ABSTRACT FROM AUTHOR]

BACKGROUND: Several studies have linked seeing smoking in movies with adolescent smoking, but none have determined how much movie smoking adolescents see. OBJECTIVE: Our aim was to determine exposure to movie smoking in a representative sample of young US adolescents. METHODS. We surveyed 6522 nationally representative US adolescents aged 10-14 years. We content analyzed 534 contemporary box-office hits for movie smoking. Each movie was assigned to a random subsample of adolescents (mean: 613) who were asked whether they had seen the movie. Using survey weights, we estimated the total number of US adolescents who had seen each movie and then multiplied by the number of smoking depictions in each movie to obtain gross smoking impressions seen by adolescents. RESULTS: The 534 movies were mainly rated PG-13 (41%) and R (40%), and 74% contained smoking (3830 total smoking occurrences). On average, each movie was seen by 25% of the adolescents surveyed. Viewership was higher with increased age and lower for R-rated movies. Overall, these movies delivered 13.9 billion gross smoking impressions, an average of 665 to each US adolescent aged 10-14 years. Although this sample's R-rated movies contained 60% of smoking occurrences, they delivered only 39% of smoking impressions because of lower adolescent viewership. Thirty popular movies each delivered > or =100 million gross smoking impressions. Thirty actors each delivered >50 million smoking impressions, such that just 1.5% of actors delivered one quarter of all character smoking to the adolescent sample. CONCLUSIONS: Popular movies deliver billions of smoking images and character smoking depictions to young US adolescents. Removing smoking from youth-rated films would substantially reduce exposure from new box-office hits. Furthermore, the popular actors who frequently smoke in movies could have a major impact on adolescent movie smoking exposure by choosing not to portray characters who smoke. [ABSTRACT FROM AUTHOR]

BACKGROUND: The relationship between media exposure and school performance has not been studied extensively in adolescents. OBJECTIVE: The purpose of this work was to test the relative effects of television, movie, and video game screen time and content on adolescent school performance. METHODS: We conducted a population-based cross-sectional survey of middle school students (grades 5-8) in the Northeastern United States. We looked at weekday television and video game screen time, weekend television and video game screen time, cable movie channel availability, parental R-rated movie restriction, and television content restriction. The main outcome was self-report of school performance (excellent, good, average, or below average). We used ordinal logistic-regression analysis to test the independent effects of each variable, adjusting for demographics, child personality, and parenting style. RESULTS: There were 4508 students who participated in the study; gender was equally represented, and 95% were white. In multivariate analyses, after adjusting for other covariates, the odds of poorer school performance increased with increasing weekday television screen time and cable movie channel availability and decreased with parental restriction of television content restriction. As compared with children whose parents never allowed them to watch R-rated movies, children who watched R-rated movies once in a while, sometimes, or all of the time had significantly increased cumulative odds of poorer school performance. Weekend screen time and video game use were not associated with school performance. CONCLUSIONS: We found that both content exposure and screen time had independent detrimental associations with school performance. These findings support parental enforcement of American Academy of Pediatrics guidelines for media time (particularly weekdays) and content limits to enhance school success. [ABSTRACT FROM AUTHOR]

Objective: Subgroups of adolescent single and dual e-cigarette and cigarette users have been identified, but usage patterns have changed in recent years, and there has been an increase in marijuana use. Research is needed with current data to identify subgroups of use including marijuana and determine their behavioral correlates., Methods: We cross classified ever and recent use of e-cigarettes, combustible cigarettes, and marijuana among US high school students in the 2019 Youth Risk Behavior Survey (YRBS), providing 8 different groups. Levels of 14 risk and protective factors were compared across groups in general linear models with demographic covariates using omnibus tests, pairwise comparisons, and planned contrasts. Replicability was tested through identical analyses for 2017 YRBS data., Results: The nonuser group was 43.9% of the sample. The most frequent user groups were triple users (ever-use proportion: 16.9%), dual (e-cigarette and marijuana) users (15.8%), and exclusive e-cigarette users (13.2%). For risk profiles on levels of psychosocial variables, the triple-user group was typically elevated above all other groups. Exclusive e-cigarette users were above nonusers in risk profile but below dual users (both cigarettes and marijuana). Results were similar for ever use and recent use. The patterning of results in 2019 YRBS data were closely replicated in 2017 YRBS data., Conclusions: Co-occurrence of e-cigarette, cigarette, and marijuana use is currently substantial among adolescents and is associated with an elevated psychosocial risk profile. This has implications for both epidemiology and prevention studies. Further research is needed to study prevalence and identify pathways to triple use., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: Fast-food intake is a modifiable obesity risk factor in early childhood, and child-directed fast-food marketing is common. Per self-regulatory guidelines regarding deception, premiums (ie, incentives or toy giveaways) in child-directed advertisements must be secondary to the advertised product., Methods: Content analyses were performed of all child-directed fast-food television (TV) advertisements aired on four national US children's TV networks, February 1, 2019, through January 31, 2020, to assess the emphasis of premiums relative to food. We quantified the percent of the audio transcript (word count) and visual airtime (seconds) that included premiums or food and the on-screen size of premiums relative to food in randomly selected frames from each advertisement., Results: There were 28 unique child-directed advertisements for children's fast-food meals in the study year; 27 advertisements were from one restaurant and accounted for nearly all (99.8%) of the total airtime for the 28 advertisements. Premiums were present in 27 of the 28 unique advertisements. On average, premiums (versus food) accounted for 53.0% (vs 16.0%) of words in the audio transcript and 59.2% (vs 54.3%) of the visual airtime per advertisement. In the random subset of frames that includes both premiums and food imagery, imagery of premiums accounted for 9.7% (95% CI: 6.4%-13.0%) of the on-screen area, whereas imagery of food accounted for 5.7% (95% CI: 4.4%-7.0%), an average ratio of 1.9:1 within each frame when excluding one large outlier., Conclusions: Child-directed fast-food TV advertisements emphasize premiums over food in violation of self-regulatory guidelines, counter to childhood obesity prevention efforts., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background and Objectives: Non-cigarette tobacco marketing is less regulated and may promote cigarette smoking among adolescents. We quantified receptivity to advertising for multiple tobacco products and hypothesized associations with susceptibility to cigarette smoking., Methods: Wave 1 of the nationally representative PATH (Population Assessment of Tobacco and Health) study interviewed 10 751 adolescents who had never used tobacco. A stratified random selection of 5 advertisements for each of cigarettes, e-cigarettes, smokeless products, and cigars were shown from 959 recent tobacco advertisements. Aided recall was classified as low receptivity, and image-liking or favorite ad as higher receptivity. The main dependent variable was susceptibility to cigarette smoking., Results: Among US youth, 41% of 12 to 13 year olds and half of older adolescents were receptive to at least 1 tobacco advertisement. Across each age group, receptivity to advertising was highest for e-cigarettes (28%-33%) followed by cigarettes (22%-25%), smokeless tobacco (15%-21%), and cigars (8%-13%). E-cigarette ads shown on television had the highest recall. Among cigarette-susceptible adolescents, receptivity to e-cigarette advertising (39.7%; 95% confidence interval [CI]: 37.9%-41.6%) was higher than for cigarette advertising (31.7%; 95% CI: 29.9%-33.6%). Receptivity to advertising for each tobacco product was associated with increased susceptibility to cigarette smoking, with no significant difference across products (similar odds for both cigarette and e-cigarette advertising; adjusted odds ratio = 1.22; 95% CI: 1.09-1.37)., Conclusions: A large proportion of US adolescent never tobacco users are receptive to tobacco advertising, with television advertising for e-cigarettes having the highest recall. Receptivity to advertising for each non-cigarette tobacco product was associated with susceptibility to smoke cigarettes., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Objective: To examine whether the industry-run television (TV) Parental Guidelines discriminate on violence, sexual behavior, alcohol use, and smoking in TV shows, to assess their usefulness for parents., Methods: Seventeen TV shows (323 episodes and 9214 episode minutes) across several TV show rating categories (TVY7, TVPG, TV14, and TVMA) were evaluated. We content-coded the episodes, recording seconds of each risk behavior, and we rated the salience of violence in each one. Multilevel models were used to test for associations between TV rating categories and prevalence of risk behaviors across and within episodes or salience of violence., Results: Every show had at least 1 risk behavior. Violence was pervasive, occurring in 70% of episodes overall and for 2.3 seconds per episode minute. Alcohol was also common (58% of shows, 2.3 seconds per minute), followed by sex (53% of episodes, 0.26 seconds per minute), and smoking (31% of shows, 0.54 seconds per minute). TV Parental Guidelines did not discriminate prevalence estimates of TV episode violence. Although TV-Y7 shows had significantly less substance use, other categories were poor at discriminating substance use, which was as common in TV-14 as TV-MA shows. Sex and gory violence were the only behaviors demonstrating a graded increase in prevalence and salience for older-child rating categories., Conclusions: TV Parental Guidelines ratings were ineffective in discriminating shows for 3 out of 4 behaviors studied. Even in shows rated for children as young as 7 years, violence was prevalent, prominent, and salient. TV ratings were most effective for identification of sexual behavior and gory violence., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2016 by the American Academy of Pediatrics.)

Background and Objective: Internet alcohol marketing is not well studied despite its prevalence and potential accessibility and attractiveness to youth. The objective was to examine longitudinal associations between self-reported engagement with Internet alcohol marketing and alcohol use transitions in youth., Methods: A US sample of 2012 youths aged 15 to 20 was surveyed in 2011. An Internet alcohol marketing receptivity score was developed, based on number of positive responses to seeing alcohol advertising on the Internet, visiting alcohol brand Web sites, being an online alcohol brand fan, and cued recall of alcohol brand home page images. We assessed the association between baseline marketing receptivity and both ever drinking and binge drinking (≥6 drinks per occasion) at 1-year follow-up with multiple logistic regression, controlling for baseline drinking status, Internet use, sociodemographics, personality characteristics, and peer or parent drinking., Results: At baseline, ever-drinking and binge-drinking prevalence was 55% and 27%, respectively. Many (59%) reported seeing Internet alcohol advertising, but few reported going to an alcohol Web site (6%) or being an online fan (3%). Higher Internet use, sensation seeking, having family or peers who drank, and past alcohol use were associated with Internet alcohol marketing receptivity, and a score of 1 or 2 was independently associated with greater adjusted odds of initiating binge drinking (odds ratio 1.77; 95% confidence interval, 1.13-2.78 and odds ratio 2.15; 95% confidence interval, 1.06-4.37 respectively) but not with initiation of ever drinking., Conclusions: Although high levels of engagement with Internet alcohol marketing were uncommon, most underage youths reported seeing it, and we found a prospective association between receptivity to this type of alcohol marketing and future problem drinking, making additional research and ongoing surveillance important., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2016 by the American Academy of Pediatrics.)

Background: Nutritionally poor foods are heavily advertised to children on television. Whether those same products are also advertised to parents on television has not been systematically examined., Methods: This study is a content analysis of advertisements for children's packaged foods and beverages aired over US network, cable, and syndicated television for 1 year (2012 to 2013). The target audience of each advertisement was defined as children or parents based on advertisement content, where parent-directed advertisements included emotional appeals related to family bonding and love. Advertisement characteristics and patterns of airtime were compared across target audience, and the proportion of total airtime devoted to advertisements targeting parents was computed., Results: Fifty-one children's food or beverage products were advertised over the study year, 25 (49%) of which were advertised directly to parents. Parent-directed advertisements more often featured nutrition and health messaging and an active lifestyle than child-directed advertisements, whereas child-directed advertisements more frequently highlighted fun and product taste. Over all products, 42.4% of total airtime was devoted to advertisements that targeted parents. The products with the most amount of airtime over the study year were ready-to-eat cereals, sugar-sweetened beverages, and children's yogurt, and the proportion of total advertisement airtime for those products devoted to parents was 24.4%, 72.8%, and 25.8%, respectively., Discussion: Television advertisements for children's packaged foods and beverages frequently targeted parents with emotional appeals and messaging related to nutrition and health. Findings are of concern if exposure to such advertisements among parents may shape their beliefs about the appropriateness of nutritionally questionable children's foods and beverages., (Copyright © 2015 by the American Academy of Pediatrics.)

Objective: To describe electronic cigarette (e-cigarette) use and cigarette use among adolescents and determine whether established risk factors for smoking discriminate user categories., Methods: School-based survey of 1941 high school students (mean age 14.6 years) in Hawaii; data collected in 2013. The survey assessed e-cigarette use and cigarette use, alcohol and marijuana use, and psychosocial risk and protective variables (eg, parental support, academic involvement, smoking expectancies, peer smoking, sensation seeking). Analysis of variance and multinomial regression examined variation in risk and protective variables across the following categories of ever-use: e-cigarette only, cigarette only, dual use (use of both products), and nonuser (never used either product)., Results: Prevalence for the categories was 17% (e-cigarettes only), 12% (dual use), 3% (cigarettes only), and 68% (nonusers). Dual users and cigarette-only users were highest on risk status (elevated on risk factors and lower on protective factors) compared with other groups. E-cigarette only users were higher on risk status than nonusers but lower than dual users. E-cigarette only users and dual users more often perceived e-cigarettes as healthier than cigarettes compared with nonusers., Conclusions: This study reports a US adolescent sample with one of the largest prevalence rates of e-cigarette only use in the existing literature. Dual use also had a substantial prevalence. The fact that e-cigarette only users were intermediate in risk status between nonusers and dual users raises the possibility that e-cigarettes are recruiting medium-risk adolescents, who otherwise would be less susceptible to tobacco product use., (Copyright © 2015 by the American Academy of Pediatrics.)

Objectives: To investigate the hypothesis that exposure to alcohol consumption in movies affects the likelihood that low-risk adolescents will start to drink alcohol., Methods: Longitudinal study of 2346 adolescent never drinkers who also reported at baseline intent to not to do so in the next 12 months (mean age 12.9 years, SD = 1.08). Recruitment was carried out in 2009 and 2010 in 112 state-funded schools in Germany, Iceland, Italy, Netherlands, Poland, and Scotland. Exposure to movie alcohol consumption was estimated from 250 top-grossing movies in each country in the years 2004 to 2009. Multilevel mixed-effects Poisson regressions assessed the relationship between baseline exposure to movie alcohol consumption and initiation of trying alcohol, and binge drinking (≥ 5 consecutive drinks) at follow-up., Results: Overall, 40% of the sample initiated alcohol use and 6% initiated binge drinking by follow-up. Estimated mean exposure to movie alcohol consumption was 3653 (SD = 2448) occurrences. After age, gender, family affluence, school performance, TV screen time, personality characteristics, and drinking behavior of peers, parents, and siblings were controlled for, exposure to each additional 1000 movie alcohol occurrences was significantly associated with increased relative risk for trying alcohol, incidence rate ratio = 1.05 (95% confidence interval, 1.02-1.08; P = .003), and for binge drinking, incidence rate ratio = 1.13 (95% confidence interval, 1.06-1.20; P < .001)., Conclusions: Seeing alcohol depictions in movies is an independent predictor of drinking initiation, particularly for more risky patterns of drinking. This result was shown in a heterogeneous sample of European youths who had a low affinity for drinking alcohol at the time of exposure., (Copyright © 2014 by the American Academy of Pediatrics.)

Objective: To examine the association between movie smoking exposure (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. Attributable risk estimates showed that adolescent smoking would be reduced by 18% (95% CI: 14-21) if smoking in PG-13-rated movies was reduced to the fifth percentile. In comparison, making all parents maximally 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.

Objective: Experimental research has revealed that short exposure to movie smoking affects beliefs about smoking in adolescents. In this study, we tested that association in children., Methods: In 2 experiments, participants were exposed to either a cartoon or family-oriented movie and randomly assigned to 20-minute segments with or without smoking characters. Data collection took place at elementary schools. A total of 101 children (8-10 years; 47.5% boys) were exposed to a cartoon, and in a second experiment, 105 children (8-11 years; 56.2% boys) were exposed to a family-oriented movie. Beliefs about smoking (assessed by questionnaire) and implicit associations toward smoking (single target implicit association task) were assessed after watching the movie., Results: The majority of both samples of children viewed smoking unfavorably. Exposure to movie smoking had no effect on implicit associations toward smoking when experiments were analyzed separately or if the results were combined. For smoking beliefs, effects were again small and only statistically significant for social norms regarding smoking., Conclusions: Short-term exposure to smoking in cartoon and family-oriented movies had little immediate impact on beliefs about smoking in preadolescent children, but a significant cumulative impact on norms cannot be ruled out.

Objective: The goal of this study was to investigate whether the association between exposure to images of alcohol use in movies and binge drinking among adolescents is independent of cultural context., Methods: A cross-sectional survey study in 6 European countries (Germany, Iceland, Italy, Netherlands, Poland, and Scotland) was conducted. A total of 16 551 pupils from 114 public schools with a mean (± SD) age of 13.4 (± 1.18) years participated. By using previously validated methods, exposure to alcohol use in movies was estimated from the 250 top-grossing movies of each country (years 2004-2009). Lifetime binge drinking was the main outcome measure., Results: Overall, 27% of the sample had consumed >5 drinks on at least 1 occasion in their life. After controlling for age, gender, family affluence, school performance, television screen time, sensation seeking and rebelliousness, and frequency of drinking of peers, parents, and siblings, the adjusted β-coefficient for lifetime binge drinking in the entire sample was 0.12 (95% confidence interval: 0.10-0.14; P < .001). The crude relationship between movie alcohol use exposure and lifetime binge drinking was significant in all countries; after covariate adjustment, the relationship was still significant in 5 of 6 countries. A sensitivity analysis revealed that the association is content specific, as there was no significant association between lifetime binge drinking and exposure to smoking in movies., Conclusions: The link between alcohol use in movies and adolescent binge drinking was robust and seems relatively unaffected by cultural contexts.

Objective: To test the specificity of the association between cigarette advertising and adolescent smoking initiation., Methods: A longitudinal survey of 2102 adolescents, aged 10 to 17 years at baseline, who never smoked was conducted by using masked images of 6 cigarette advertisements and 8 other commercial products with all brand information digitally removed. The exposure variable was a combination of contact frequency and cued recall of brands for cigarette and other advertisements. Multilevel mixed-effects Poisson regressions were used to assess smoking initiation 9 months after the baseline assessment as a function of cigarette-advertisement exposure, other advertisement exposure, and baseline covariates., Results: Thirteen percent (n = 277) of students initiated smoking during the observation period. Although the incidence of trying smoking was associated with increased exposure to cigarette advertisements (10% in the low, 12% in the medium, and 19% in the high cigarette-advertisement exposure tertile initiated smoking), exposure to other advertisements did not predict smoking initiation. Compared with low exposure to cigarette advertisements, high exposure remained a significant predictor of adolescent smoking initiation after controlling for baseline covariates (adjusted relative risk: 1.46 [95% confidence interval: 1.08-1.97]; P < .05)., Conclusions: Our results support the notion of a content-related effect of cigarette advertisements and underlines the specificity of the relationship between tobacco marketing and teen smoking; exposure to cigarette advertisements, but not other advertisements, is associated with smoking initiation.

Objectives: In this study, we examined how often US youths reported having complete parental restrictions on watching R-rated movies. In addition, we assessed the relationship between parental R-rated movie restrictions and adolescents' sensation seeking and how this interplay is related to smoking onset., Methods: Data from a 4-wave longitudinal study of 6522 adolescents (10-14 years of age) who were recruited through a random-digit-dial telephone survey were used. At baseline, subjects were nationally representative of the US population. Subjects were monitored for 2 years and queried about their smoking status, their sensation-seeking propensity, and how often they were allowed to watch R-rated movies. A cross-lagged model combined with survival analysis was used to assess the relationships between parental R-rated movie restrictions, sensation-seeking propensity, and risk for smoking onset., Results: Findings demonstrated that 32% of the US adolescents reported being completely restricted from watching R-rated movies by their parents. Model findings revealed that adolescents' sensation seeking was related to greater risk for smoking onset not only directly but also indirectly through their parents becoming more permissive of R-rated movie viewing. Parental R-rated movie restrictions were found to decrease the risk of smoking onset directly and indirectly by changing children's sensation seeking., Conclusions: These findings imply that, beyond direct influences, the relationship between adolescents' sensation seeking and parental R-rated movie restrictions in explaining smoking onset is bidirectional in nature. Finally, these findings highlight the relevance of motivating and supporting parents in limiting access to R-rated movies.

Objective: To assess the association between smoking onset and exposure to movie smoking according to character type., Methods: A longitudinal, random-digit-dial telephone survey of 6522 US adolescents was performed with movie exposure assessed at 4 time points over 24 months. Adolescents were asked whether they had seen a random subsample of recently released movies, for which we identified smoking by major characters and type of portrayal (divided into negative, positive, and mixed/neutral categories). Multivariate hazard regression analysis was used to assess the independent effects of these exposures on the odds of trying smoking., Results: By the 24-month follow-up survey, 15.9% of baseline never-smokers had tried smoking. Within the sample of movies, 3848 major characters were identified, of whom 69% were male. Smokers represented 22.8% of 518 negative characters, 13.7% of 2486 positive characters, and 21.1% of 844 mixed/neutral characters. Analysis of the crude relationship showed that episodes of negative character smoking exposure had the strongest influence on smoking initiation. However, because most characters were portrayed as positive, exposure to this category was greatest. When the full population effect of each exposure was modeled, each type of character smoking independently affected smoking onset. There was an interaction between negative character smoking and sensation-seeking with stronger response for adolescents lower in sensation-seeking., Conclusions: Character smoking predicts adolescent smoking initiation regardless of character type, which demonstrates the importance of limiting exposure to all movie smoking. Negative character portrayals of smoking have stronger impact on low risk-taking adolescents, undercutting the argument that greater exposure is a marker for adolescent risk-taking behavior.

Background: Entertainment media exposure may predict teenager alcohol use, but few longitudinal studies have been reported., Methods: A longitudinal study was conducted of 2708 German adolescents aged 10 to 16 years who had never drunk alcohol. Each adolescent was surveyed at school about daily television use, whether they had a television in their bedroom, and their exposure to movie alcohol depictions. Adolescents were resurveyed 12 to 13 months later (retention rate: 85%) to determine onset of drinking alcohol without parental knowledge and binge drinking (>/=5 consecutive drinks)., Results: Overall, 885 (33%) students initiated alcohol use without parental knowledge (17% in quartile 1 movie alcohol exposure), and 387 (14%) initiated binge drinking during follow-up. After controlling for baseline covariates, exposure to movie alcohol use significantly increased percent initiating alcohol use (to 24% in exposure quartile 2, 33% in quartile 3 and 34% in quartile 4) and percent initiating binge drinking (to 8.6% in exposure quartile 2, 12% in quartile 3 and 13% in quartile 4). Having a television in the bedroom also predicted both outcomes, but daily television use did not., Conclusions: Movie exposure and having a television in the bedroom are both independent predictors of onset of problematic alcohol use among German teenagers. Media restrictions could play a role in prevention.

Objective: Despite concerns about exposure to violent media, there are few data on youth exposure to violent movies. In this study we examined such exposure among young US adolescents., Methods: We used a random-digit-dial survey of 6522 US adolescents aged 10 to 14 years fielded in 2003. Using previously validated methods, we determined the percentage and number of US adolescents who had seen each of 534 recently released movies. We report results for the 40 that were rated R for violence by the Motion Picture Association of America, UK 18 by the British Board of Film Classification and coded for extreme violence by trained content coders., Results: The 40 violent movies were seen by a median of 12.5% of an estimated 22 million US adolescents aged 10 to 14 years. The most popular violent movie, Scary Movie, was seen by >10 million (48.1%) children, 1 million of whom were 10 years of age. Watching extremely violent movies was associated with being male, older, nonwhite, having less-educated parents, and doing poorly in school. Black male adolescents were at particularly high risk for seeing these movies; for example Blade, Training Day, and Scary Movie were seen, respectively, by 37.4%, 27.3%, and 48.1% of the sample overall versus 82.0%, 81.0%, and 80.8% of black male adolescents. Violent movie exposure was also associated with measures of media parenting, with high-exposure adolescents being significantly more likely to have a television in their bedroom and to report that their parents allowed them to watch R-rated movies., Conclusions: This study documents widespread exposure of young US adolescents to movies with extreme graphic violence from movies rated R for violence and raises important questions about the effectiveness of the current movie-rating system.

Objectives: Evidence suggests that media portrayals of tobacco and alcohol use are important predictors of adolescent smoking and drinking. We examined the role of parents in monitoring and limiting children's movie exposure and whether or not this was associated with a lower risk of adolescent smoking and drinking., Design: We surveyed 2606 child-parent dyads between 2002 and 2003. We asked children (9-12 years of age) how often their parents engaged in specific behaviors to monitor their movie viewing and if their parents allowed them to watch R-rated movies. We also surveyed children about parental monitoring of nonmedia-related behaviors. The primary outcomes were risk of smoking and drinking alcohol, defined by attitudinal susceptibility or early experimentation with either substance., Results: Less than half (45.0%) the children were prohibited from watching R-rated movies. Of those who were allowed to watch R-rated movies, one third (34.7%) always viewed them with a parent and two thirds (65.3%) sometimes watched them without a parent. Less than 10% of the children reported that their parents consistently engaged in all 4 movie-monitoring behaviors. Even after controlling for parental monitoring of nonmedia-related behaviors and other covariates, children were at lower risk of smoking and drinking if their parents prohibited them from watching R-rated movies. Parental coviewing of R-rated movies was associated with a lower risk of child smoking but not drinking if parents consistently monitored what their children watched., Conclusions: Parental rules and monitoring of children's movie viewing may have a protective influence on children's risk for smoking and drinking, over and above parental monitoring of nonmedia related behaviors. This highlights a potential role for parents in preventing early initiation of tobacco and alcohol use among adolescents.

Objective: We sought to determine whether there is evidence of a causal link between exposure to tobacco promotion and the initiation of tobacco use by children., Methods: We conducted a structured search in Medline, PsycINFO, and ABI/INFORM Global to identify relevant empirical research. The literature was examined against the Hill epidemiologic criteria for determining causality., Results: (1) Children are exposed to tobacco promotion before the initiation of tobacco use; (2) exposure increases the risk for initiation; (3) there is a dose-response relationship, with greater exposure resulting in higher risk; (4) the increased risk is robust; it is observed with various study methods, in multiple populations, and with various forms of promotion and persists after controlling for other factors; (5) scientifically plausible mechanisms whereby promotion could influence initiation exist; and (6) no explanation other than causality can account for the evidence., Conclusions: Promotions foster positive attitudes, beliefs, and expectations regarding tobacco use. This fosters intentions to use and increases the likelihood of initiation. Greater exposure to promotion leads to higher risk. This is seen in diverse cultures and persists when other risk factors, such as socioeconomic status or parental and peer smoking, are controlled. Causality is the only plausible scientific explanation for the observed data. The evidence satisfies the Hill criteria, indicating that exposure to tobacco promotion causes children to initiate tobacco use.

Objective: Regional studies have linked exposure to movie smoking with adolescent smoking. We examined this association in a representative US sample., Design/methods: We conducted a random-digit-dial survey of 6522 US adolescents aged 10 to 14 years. Using previously validated methods, we estimated exposure to movie smoking, in 532 recent box-office hits, and examined its relation with adolescents having ever tried smoking a cigarette., Results: The distributions of demographics and census region in the unweighted sample were almost identical to 2000 US Census estimates, confirming representativeness. Overall, 10% of the population had tried smoking. Quartile (Q) of movie smoking exposure was significantly associated with the prevalence of smoking initiation: 0.02 of adolescents in Q1 had tried smoking; 0.06 in Q2; 0.11 in Q3; and 0.22 in Q4. This association did not differ significantly by race/ethnicity or census region. After controlling for sociodemographics, friend/sibling/parent smoking, school performance, personality characteristics, and parenting style, the adjusted odds ratio for having tried smoking were 1.7 (95% confidence interval [CI]: 1.1, 2.7) for Q2, 1.8 (95% CI: 1.2, 2.9) for Q3, and 2.6 (95% CI: 1.7, 4.1) for Q4 compared with adolescents in Q1. The covariate-adjusted attributable fraction was 0.38 (95% CI: 0.20, 0.56), suggesting that exposure to movie smoking is the primary independent risk factor for smoking initiation in US adolescents in this age group., Conclusions: Smoking in movies is a risk factor for smoking initiation among US adolescents. Limiting exposure of young adolescents to movie smoking could have important public health implications.

Objective: To evaluate the hypothesis that adolescents are less likely to smoke if their parents voice strong disapproval of smoking., Design and Setting: Three-wave school-based cohort study of rural Vermont adolescents attending 3 K-12 schools. We evaluate cross-sectional and longitudinal associations between perceived parental disapproval of smoking and the adoption of smoking behavior., Outcome Measures: Students' perceptions of their parents' reaction to their own smoking was ascertained by asking the following question for mothers and fathers: "How do you think your mother (father) would react if you were smoking cigarettes and she (he) knew about it?" A response of "S/he would tell me to stop and be very upset" was considered to indicate strong parental disapproval. Outcome measures include a 6-level smoking index for cross-sectional analyses and, for a longitudinal analysis of 372 never smokers at baseline, being an established smoker (smoked > or =100 cigarettes lifetime and within the past 30 days) by survey 3., Results: The study samples for the cross-sectional analyses were 662 (baseline), 758 (year 2), and 730 (year 3). Students were equally distributed across grade (4th-11th grades) and gender. At baseline, most (65.9%) adolescents perceived both parents as disapproving of smoking, with 110 (16.6) perceiving 1 parent as disapproving, and 116 (17.5%) perceiving neither parent as disapproving. Perceived disapproval of smoking was inversely associated with adolescent smoking, grade in school, parental and sibling smoking, friend smoking, and ownership of tobacco promotional items. After controlling for confounding influences, adolescents who perceived strong parental disapproval of their smoking were less than half as likely to have higher smoking index levels compared with those who did not perceive strong parental disapproval. In the longitudinal sample of baseline never smokers, those who perceived strong disapproval in both parents at baseline were less than half as likely to become established smokers (adjusted odds ratio 0.4 [0.1, 1.0]). Those who perceived their parents becoming more lenient over time were significantly more likely to progress to established smokers. In all analyses, the effect of parental disapproval of smoking was stronger and more robust than the effect of parent smoking. In addition, the effect of parent disapproval was as strong for parents who smoked as it was for nonsmoking parents. An interaction analysis suggests that the peer smoking effect is attenuated when both parents strongly disapprove of smoking, suggesting that parent disapproval makes adolescents more resistant to the influence of peer smoking., Conclusions: These findings contrast with the widespread notion that there is little parents can do to prevent their adolescents from becoming smokers. Instead, adolescents who perceive that both parents would respond negatively and be upset by their smoking are less likely to smoke. Interventions that enhance parental self-efficacy in conveying and enforcing no-smoking policies for their children could reduce adolescent smoking.

Background: Recent statements from the American Academy of Pediatrics and Centers for Disease Control and Prevention recommend diagnostic venous blood lead testing within 90 days of a marginally elevated screening test (10-14 microg/dL)., Objective: To evaluate the ability of a marginally elevated capillary (CScr) or venous (VScr) blood lead screening test to predict venous diagnostic (VPb) blood lead (taken within 90 days of the screening test) that would prompt environmental evaluation (>/=20 microg/dL)., Design: Population-based follow-up study comparing CScr and VScr with VPb drawn within 90 days of the screening sample. This study population was drawn from all children aged 0 to 4 years who were screened in Worcester County, Massachusetts, and Providence County, Rhode Island, with CScr and VScr during calendar year 1994., Outcome Measures: To evaluate predictive validity, CScr and VScr were correlated with VPb. CScr, VScr, and VPb results were then separated into the following categories: <10, 10 to 14, 15 to 19, and >/=20 microg/dL. CScr and VScr categories were cross-tabulated against VPb categories, and logistic regression analysis was used to evaluate categorical elevations of CScr and VScr as predictors of VPb >/=20 microg/dL., Results: Of 31 904 children screened with CScr, 5450 (17.1%) were elevated and 1278 were followed up with VPb within 90 days. Of 14 623 children screened with VScr, 2979 (20.4%) were elevated and 614 were followed up with VPb within 90 days. CScr was only weakly correlated with VPb (r = 0.39), whereas VScr was more strongly correlated with VPb (r = 0.73). Compared with CScr <10 microg/dL, CScr in the 10 to 14 microg/dL range did not identify a higher percentage of children with VPb elevation in any category, and falsely misclassified as lead poisoned some 77% of children. Compared with VScr <10 microg/dL, VScr in the 10 to 14 microg/dL range identified higher percentages of children with VPb in the 10 to 19 microg/dL range but not with VPb >/=20 microg/dL, and falsely misclassified as lead poisoned 42% of children. Compared with screening tests <10 microg/dL, the odds of identifying a child with VPb >/=20 were no different from 1 for CScr of 10 to 14 microg/dL (adjusted odds ratio 1.4 [95% confidence interval 0.3, 6.6]), CScr of 15 to 19 microg/dL (3.2 [0.7, 15.7]), or VScr of 10 to 14 microg/dL (0.9 [0.3, 3.0]). CScr and VScr in the 15 to 19 microg/dL range were associated with significantly higher odds of having VPb >/=20 microg/dL when compared with screening tests <10 microg/dL., Conclusions: These data indicate that special diagnostic testing within 90 days for children with CScr and VScr in the 10 to 14 microg/dL range does not result in greater identification of VPb >/=20. Raising the set point for diagnostic testing to 15 microg/dL in this sample would eliminate the unnecessary follow-up of 5162 children, of whom 3360 were falsely misclassified as having undue lead exposure.