Harvard Public Health Review Winter 2007
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young women smokingResponding to mounting pressure from anti-smoking activists and researchers, including those at the Harvard School of Public Health (HSPH), the Motion Picture Association of America (MPAA) announced on May 10 that, from this point forward, the “pervasive” or “glamorized” depiction of smoking in films outside the context of “historic or other mitigating contexts” would join sex, violence, and adult language as a factor in determining movie ratings.

The addition of smoking as a determinant of a movie’s rating marks an important step by the film industry towards protecting children and adolescents from addiction to tobacco and the devastating health consequences that derive from it. To combat the glamorization—and even normalization—of tobacco use inundating young people in this country and abroad, HSPH researchers have spent many years learning how to reduce smoking in public places and change individual behaviors.

In February, at the invitation of new MPAA Chairman and Chief Executive Officer Dan Glickman, I brought experts from HSPH and the Johns Hopkins Bloomberg School of Public Health to make a presentation to film industry leaders in Hollywood of scientific evidence establishing smoking’s harmful impact upon young people, in real life and on screen. In the context of increased media attention and public pressure generated by a host of organizations—including states’ attorneys general, the American Medical Association, the U.S. Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), nongovernmental organizations, and religious and parents groups—we believe that our presentation helped to spur this change.

“There is broad awareness of smoking as a unique public health concern due to nicotine’s highly addictive nature, and no parent wants their child to take up the habit,” Glickman said in announcing MPAA’s new policy. The appropriate response of the rating system, he said, is to “give parents more information on this issue.”

SMOKE GETS IN THEIR EYES
Tobacco is the largest single preventable cause of death and disease in the world. About 4.8 million people die of tobacco-related illness each year, according to WHO. In the United States, the CDC currently estimates that number to be 438,000 needless annual deaths.

At HSPH, we have long recognized that tobacco dwarfs other challenges to preserving the health of the world’s citizens, not least because, although toxic, it is a legal, intensely marketed and glamorized product in the United States and globally. Most offensively, this lethal product is sold on street corners, in supermarkets, and even in drugstores, and can be accessed by the most vulnerable of populations: our children and adolescents. Surveys reveal that the average age in the United States for initiating smoking is 13 and, tragically, that smokers who find themselves addicted in their teens are, in the long run, the least able to quit.

The year 1998 signaled change for the future health of our young people, even despite the failure of Congress to enact federal legislation curtailing the tobacco industry. In that year, a Master Settlement Agreement (MSA) was signed between 46 U.S. states’ attorneys general and the five biggest tobacco companies, establishing the largest monetary settlement ever awarded—estimated to be about $245 billion within the first 25 years. While many hoped that the settlement would create resources in perpetuity for anti-smoking education, regrettably the funds thus far have gone mostly into states’ general revenues for every purpose other than the one intended.

What the MSA largely did accomplish, however, was to ban tobacco advertising from media outlets broadly accessible to children and teenagers, including outdoor billboards, youth-oriented magazines, radio, and television. The agreement also prohibited paid product placements in the movies. Tobacco companies, no longer able to pay film studios to put their branded products on the silver screen, would now in theory be less able to reach young potential smokers, the most promising source of future profits. In reality, film studios have continued to depict tobacco use, unwittingly supplying the tobacco industry with free advertising. Meanwhile, celebrity actors—idolized by today’s youth—perpetuate an image of smoking as appealing, cool, even glamorous.

And so, despite smoking’s precipitous decline in the United States, from 52 percent in men and 34 percent in women in 1965 to 21 percent overall today, according to CDC figures, the incidence of smoking in films produced by the six major studios has actually doubled over the past two decades. This has been an ominous trend for the public’s health, given that Hollywood continues to exert an extraordinary degree of influence on trends and norms of behavior. Just as Hollywood may have a positive impact on health, as by depicting racial integration instead of violence, for example, or by helping curb drunk driving by embedding into programming the “designated driver” originally initiated by HSPH—Hollywood can equally exert a powerful negative influence, as when smoking is normalized in films and on television. It is for this irresponsible approach to young audiences that industry leaders increasingly have been censured by health-advocacy and anti-smoking groups.

OVERWHELMING EVIDENCE
Fortunately, the MPAA’s Dan Glickman appears to have a fresh attitude. A former congressman, later secretary of Agriculture, Glickman is a former director of the Institute of Politics at Harvard’s Kennedy School of Government. As MPAA’s new leader, Glickman asked me to make a considered recommendation to the MPAA on smoking in the movies, with no preconditions. I was privileged in February to be able to bring two experts to present our views to senior representatives of the MPAA, the Guild of Directors, the Screen Actors Guild, and the National Organization of Theater Owners. These experts were HSPH’s Jay Winsten, associate dean for Public and Community Affairs, the Frank Stanton Director of the Center for Health Communication, and leader of the highly successful “Designated Driver” campaign; and Professor Jonathan Samet, chair of Epidemiology at the Johns Hopkins Bloomberg School of Public Health, an author of the last five reports on smoking from U.S. surgeons general, and a national and international expert on smoking’s health effects. For the full transcripts of our presentations, visit the HSPH website at www.hsph.harvard.edu/MPAA.

Together we reviewed for film industry representatives the science demonstrating that nicotine is among the most addictive substances known—comparable to heroin and crack cocaine—and that smoking is harmful to the health of children, youths, and adults. Most significant, we pointed out that the mean age for initiating smoking in the United States is just 13 years, and that population studies indicate that if an individual does not start to smoke between ages 12 and 24, he or she runs only about a five to ten percent lifetime risk of ever smoking. Tellingly, about a third of all movie viewers are between the ages of 12 and 24. Thus the industry, and popular film stars who smoke, have the attention of young people at precisely the most crucial time in their lives for resisting tobacco initiation.

We reviewed, as well, the compelling body of evidence underlying our assertion that young people are influenced by television and movie images of smoking, and we explained the social-behavior theory behind changes in social norms. When industry spokespersons stated that directors’ depictions of smoking in the movies merely reflects “reality,” we responded that, in fact, widespread smoking expressly does not mirror reality. We pointed out that only about 21 percent of the U.S. population smokes, and that the highest proportion of smokers is among minority and disadvantaged socioeconomic groups. By contrast, in the movies, more than half of lead actors are depicted smoking, and the majority are white and well-off.

NO SLIPPERY SLOPE
We presented one final and, we believe, pivotal argument to urge the MPAA to take substantive action, by addressing the position held by some filmmakers that curtailing smoking in movies would compromise their artistic freedom or signal the beginning of a “slippery slope” toward censorship. Our argument regarding freedom of expression comes from experience: As a graduate faculty of Harvard University, we are acutely sensitive to potential infringements of academic freedom, the freedom to pursue our own ideas and scholarly inquiry into how to preserve and protect human life. But nearly a decade ago, the HSPH faculty began to recognize that accepting money from tobacco companies to do our scientific studies, no matter how worthy, would be antithetical to the mission of public health. The HSPH faculty debated intensively the implications of forswearing support from tobacco-related industries and their subsidiaries, and out of responsibility to our shared goals voted unanimously to forgo funding from them. Because tobacco, aside from guns, is the only product that, when used as directed, kills, no “slippery slope” issues have emerged since relating to any other products. HSPH was among the very first academic research institution in the nation to make such a formal policy. Many other schools have followed suit.

As deeply committed to academic freedom as our faculty researchers were, they believed that the higher value of taking responsibility for preventing the largest cause of death and disease in the world was sufficient for them to constrain that freedom, to say nothing of support for their research, even their ability to make a living. The film industry needs to take responsibility for the consequences of its actions, and to be creative in doing so.

With the greatest respect for the complexity and expense of making films, and for the creativity of the artists in all aspects of the industry, we made the following recommendation to Dan Glickman and the MPAA:

“Take substantive and effective action to eliminate the depiction of tobacco smoking from films accessible to children and youths, and take leadership and credit for doing so.” For industry leadership to have real impact, we said, we hoped the MPAA’s message would be clear, simple, and publicly accountable. And we asked all the major studios and guilds to use their leadership to make it a policy.

The May 10 announcement by the MPAA and Ratings Board, we believe, represents an historic and important step in the right direction by the leadership of the industry to recognize the dangers of smoking in movies. We hope it will be but one step of many undertaken by the motion picture and television industries toward a still more significant and impactful public health goal: eliminating the depiction of tobacco use from all youth-accessible films.

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Photos: top, ©Corbis; bottom,©Superstock

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