Discussion

The findings in this report indicate that although there were previously reported declines in the number of youth-rated movies with tobacco incidents observed during 2005–2010 (4,5), since 2010 there has been no progress in reducing the total number of tobacco incidents in youth-rated movies. Had the trend established from 2005 to 2010 continued, all youth-rated films would have been smoke-free by 2015. Although there were fewer top-grossing movies depicting tobacco use in 2016 compared with 2010, an increase in the number of such incidents occurred, thereby concentrating exposure to tobacco use in fewer films. The average number of tobacco incidents increased 55% in youth-rated movies with any tobacco depiction, from 22 incidents in 2010 to 34 incidents in 2016, and increased 91% in R-rated films with any tobacco depictions, from 35 incidents in 2010 to 67 incidents in 2016. Tobacco use depictions are now uncommon in G and PG films; however, the 43% increase in the total number of tobacco-use incidents in PG-13 movies, from 564 in 2010 to 809 in 2016, is of particular public health concern because of the established causal relationship between youths’ exposure to smoking in movies and smoking initiation (1).

The six major motion picture companies have policies to reduce depictions of tobacco use in youth-rated films,¶ which likely contributed to the reduction in the number of movies with tobacco incidents during 2005–2010. TUTD started systematic data collection of onscreen tobacco use in movies in 1991. Occurrences of tobacco use in movies varied from 1991 to 2010, reaching a peak in 2005 then declining by almost half by 2010 (4,5). Public health organizations, investors, state health departments, and state attorneys general raised concerns regarding tobacco incidents in movies beginning in 2001, which might account, in part, for the decrease in onscreen tobacco incidents after 2005 and before major motion picture companies adopted policies regarding tobacco imagery in youth-rated films (4,5). However, the lack of progress in recent years suggests that enhanced measures to address tobacco incidents in movies are warranted.

One such intervention would be the assignment of an R rating to any movie with smoking or other tobacco-use imagery (unless the portrayal is of actual historical figures who smoked, a documentary, or if the portrayal includes the negative effects of tobacco use) (7–9). Other interventions include certifying that no payments have been received by the studio or producers for depicting tobacco use in the movies and ending the onscreen depiction of actual tobacco brands (7,8). These and additional interventions, if implemented, could help eliminate tobacco incidents in youth-rated movies (7–9). State and local health departments could also work with state agencies that manage movie subsidies to ensure that such subsidies do not go to films that include depictions of tobacco use. During 2010–2016, approximately 24 states awarded approximately $3.5 billion in public subsidies, such as tax credits, to productions of movies with tobacco incidents, including youth-rated movies.**

Currently the MPAA does not assign R ratings to movies based on tobacco use incidents. In 2007, the MPAA developed a smoking “rating descriptor” that is applied to a few movies that contain smoking. These descriptors can appear in fine print in the box with the letter rating for a movie and can appear on advertisements and promotions to describe the type of content in a movie, such as language, violence, nudity, or sexual content. However, 89% of top-grossing, youth-rated movies with smoking did not carry the MPAA “smoking descriptor” in 2015 (9). A longitudinal cohort study of smoking onset among youths viewing movies released during 1998–2003 concluded that classifying movies with smoking with an R rating could reduce the number of teen smokers by approximately 18% (7). The Surgeon General notes that the magnitude of the effect of an R rating for smoking would be similar to increasing the price of cigarettes from $6.00 to $7.50 per pack (10).

The findings in this report are subject to at least three limitations. First, detailed audience composition data are not publicly available; therefore, the number of tobacco use impressions (one person seeing one tobacco incident one time, a measure of total audience exposure) delivered by a particular movie to children and adolescents could not be determined. Second, the sample did not include all movies. However, the samples of top grossing movies were used because they are expected to account for approximately 95% of theater tobacco-use impressions (4–6). Finally, the measure used to assess tobacco exposure from movies should be interpreted cautiously because movies can be viewed through other channels (e.g., recorded media, such as DVDs and Blu-ray; television; and online streaming) that do not contribute to the calculation of in-theater impressions. As viewing platforms expand, it is important to identify whether youths are being exposed to tobacco imagery through other media sources, such as broadcast and cable television, on-demand services, and social media. Further research into youths’ exposure to tobacco imagery in these and other forms of media could also help identify the impact that exposure through these sources has on youths’ tobacco use.

If current trends continue, 5.6 million youths who are alive today are projected to die from tobacco-related diseases (10). Whereas the number of top-grossing movies with tobacco use incidents continued to decline from 2010 to 2016, one in four youth-rated movies featured tobacco imagery, which is harmful to youths and causes youths to start using tobacco. The frequency and increase in tobacco incidents in PG-13 movies is of public health concern because these movies are rated as appropriate for youths. Opportunities exist for movie studios to reduce tobacco incidents that appear in youth-related movies, including rating films with smoking R, which would help prevent or delay the initiation of tobacco use among young persons and prevent premature deaths from tobacco-related diseases.