Children, Adolescents, Substance Abuse, and the Media

sive alcohol consumption, 7 includingthe death of 5000 people younger than21 years. 8 Drug use also representsone of many risky behaviors that occurduring adolescence: teenagers who reportthat at least half of their friendsare sexually active are 31 times morelikely to drink, 5 times more likely tosmoke, and 22 times more likely to trymarijuana than are teenagers who donot report such a high prevalence ofsexual activity among friends. 9EFFECTS OF ADVERTISINGThe power of advertising to influencechildren and adolescents (and adults,for that matter) is incontrovertible. 1,10Advertising works; otherwise, companieswould not spend billions of dollarson it. 1 Many ads use celebrity endorsers,humor, rock music, or attractiveyoung models, all of which have beenshown to be effective with childrenand adolescents. 11 Advertising makessmoking and drinking seem like normativeactivities and may function as a“superpeer” in subtly pressuring teenagersto experiment. 12 Research hasrevealed that advertising may be responsiblefor up to 30% of adolescenttobacco and alcohol use. 13,14CigarettesMore money is spent advertising tobaccothan any drug—an estimated$15 billion per year, 15 almost half ofwhat the National Institutes of Healthspends each year to study all aspectsof health (www.nih.gov/about/budget.htm). The tobacco industry (often referredto as “Big Tobacco”) has engagedin a systematic campaign toattract underage smokers for decadesand then lied to Congress about it. 16–19Given the demographics of smoking(1200 deaths per day, half of which areof middle-aged adults; 50% of smokersbegin by 13 years of age, and 90% ofsmokers begin by 19 years of age), theindustry must recruit young people assmokers. 20 Recent statistics show thatthey continue to succeed. According tothe 2009 Monitoring the Future study,nearly half of all teenagers have triedsmoking, as have 20% of all 8thgraders.21 Cigarette advertising seemsto increase teenagers’ risk of smokingby glamorizing smoking and smokers.3,20 Smokers are depicted as young,independent, rebellious, healthy, andadventurous. By contrast, the adverseconsequences of smoking are nevershown. As a result, the US SurgeonGeneral concluded in 1994 that cigaretteadvertising increases young people’srisk of smoking. 20The most heavily advertised brands ofcigarettes are also the most popular. 22Tobacco advertising may even trumpstrong parenting practices. 23 Teenmagazines have attracted an increasingnumber of cigarette ads since1965. 24–26 Numerous studies have revealedthat children or teenagers whopay closer attention to cigarette ads,who are able to recall such ads moreeasily, or who own promotional itemsare more likely to become smokersthemselves. 27–31 Joe Camel singlehandedlyincreased the market sharefor Camel cigarettes from 0.5% of adolescentsmokers to 32%. 32 A recentmeta-analysis of 51 separate studiesrevealed that exposure to tobaccomarketing and advertising more thandoubles the risk of a teenager beginningto smoke. 33AlcoholApproximately $6 billion is spent annuallyon alcohol advertising and promotion.34 Similar to tobacco ads, beercommercials are virtually custommadeto appeal to children and adolescents,using images of fun-loving, sexy,successful young people having thetime of their lives. 3,35,36 Unlike tobaccoadvertising, alcohol advertising facesfew restrictions. For example, whereasthe tobacco industry gave up televisionadvertising in the 1960s, beer, wine,and liquor ads are frequently featuredon prime-time television, and youngpeople view 1000 to 2000 alcohol adsannually. 12,37 Much of the advertising isconcentrated during teen-orientedshows and sports programming. All ofthe top-15 teen-oriented shows containalcohol ads. 38 Currently, teenagersare 400 times more likely to see analcohol ad than to see a public serviceannouncement (PSA) that discouragesunderage drinking. 39 Teen-orientedmagazines contain 48% more advertisingfor beer, 20% more advertising forhard liquor, and 92% more advertisingfor sweet alcoholic drinks than domagazines aimed at adults of legaldrinking age. 40,41According to the research, the effectsof all of this advertising are increasinglyclear. 3,42,43 A sample of 9- to 10-year-olds could identify the Budweiserfrogs nearly as frequently as theycould Bugs Bunny. 44 In a study of morethan 3500 South Dakota students, 75%of 4th-graders and nearly 90% of 9thgradersrecognized the Budweiser ferretad. 45 Many studies have revealedthat exposure to alcohol advertisingresults in more positive beliefs aboutdrinking and is predictive of drinkingduring early adolescence and youngadulthood. 46–52 The results of severallongitudinal studies have shown a similartrend, 53,54 although they havesometimes been mixed. 48Prescription DrugsNearly $4 billion is spent annually onprescription drug advertising. 55 Drugcompanies now spend more thantwice as much money on marketing asthey do on research and development,and studies have revealed that themarketing efforts pay off 56 : results of arecent survey of physicians showedthat 92% of patients had requested anadvertised drug. 57 Children and teenagersget the message that there is apill to cure all ills and a drug for every792 FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded from pediatrics.aappublications.org by guest on December 14, 2011

FROM THE AMERICAN ACADEMY OF PEDIATRICSoccasion, including sexual intercourse.In the first 10 months of 2004,drugs companies spent nearly half abillion dollars advertising Viagra, Levitra,and Cialis. 58 Yet, the advertising ofcondoms, birth control pills, and emergencycontraception is haphazard andrare and remains controversial. 1,59DRUGS IN ENTERTAINMENT MEDIACigarettesScenes with smoking remain commonin movies and, to a lesser extent, onprime-time television. Hollywood seemsto use smoking as a shorthand fortroubled or antiestablishment characters,but the smoking status of the actorsthemselves is also influential inwhether their characters will smokeon-screen. 60 On prime-time television,19% of shows portray tobacco use, andapproximately one-fourth of them depictnegative statements about smoking.61 In addition, smoking is also foundin nearly one-fourth of all music videos,62 one-fourth of ads for R-ratedmovies, and 7.5% of ads for PG-13 andPG movies. 63Box-office movies and their subsequentvideo and pay-per-view distributionhave become a major route of exposureto tobacco use. Although themost recent analyses show that smokinghas decreased in popular movies,64,65 the occurrence remains high. Acontent analysis of the top 100 boxofficehits between 1996 and 2004 revealedthat tobacco use was depictedin three-quarters of G-, PG-, and PG-13–rated movies and in 90% of R-ratedmovies. 66 Half of all G-rated animatedfilms between 1937 and 1997 containedtobacco use. 67 Although themost recent content analysis of topgrossingmovies between 1991 and2009 showed that tobacco use peakedin 2003 and has since declined, in 2009,more than half of PG-13 movies stillcontained tobacco use. 65 But overall,the percentage of all top-grossingmovies without smoking exceeded 50%for the first time in 2009. 65Unique longitudinal research has revealedthat one of the most importantfactors in the onset of adolescent substanceuse is exposure to others whouse drugs. 68 Nowhere is that exposuregreater than on contemporary moviescreens, and teenagers constitute 26%of the movie-going audience (but only16% of the US population). 69 Results ofa number of correlational and longitudinalstudies have confirmed that exposureto television and movie smokingis now one of the key factors thatprompt teenagers to smoke. 29,70–77 Accordingto a new meta-analysis, it mayaccount for nearly half of smoking initiationin young teenagers. 80 In fact, exposureto movie smoking may eventrump parents’ smoking status as beingthe key factor in adolescents’ initiationof smoking. 73 A prospective studyof more than 3500 teenagers revealedthat exposure to R-rated movies doublesthe risk of smoking, even whencontrolling for all other known factors.79 Preadolescents whose parentsforbid them from seeing R-rated moviesare less likely to begin smoking (ordrinking). 80 A study of 735 12- to 14-year-olds, with a 2-year follow-up, revealedthat exposure to R-rated moviesor having a television in the bedroomsignificantly increased the risk ofsmoking initiation for white teenagers.81 The movie effect seems not to beconfined to US teenagers but appliesalso to teenagers from other countriesas well. 82,83AlcoholAlcohol remains the number one drugportrayed on American television: 1drinking scene is shown every 22 minutes,compared with 1 smoking sceneevery 57 minutes and 1 illicit drug usescene every 112 minutes. 84 On MusicTelevision (MTV), teenagers can see alcoholuse every 14 minutes. An analysisrevealed that drugs were presentin nearly half of 359 music videos—alcohol in 35%, tobacco in 10%, and illicitdrugs in 13%. 85 On prime-time television,70% of programs depict alcoholuse. 61 More than one-third of the drinkingscenes are humorous, and negativeconsequences are shown in only23%. One study revealed that alcoholportrayals are as common on showsfor 9- to 14-year-olds as on adultorientedshows. 86 In popular music,the average teenager is exposed tonearly 85 drug references a day, themajority of which are for alcohol. 87Popular movies are nearly equally rifewith alcohol, with only 2 of the 40highest-grossing movies not containingalcohol depictions. 88 Even G- andPG-rated movies contain frequent referencesto alcohol. 89,90 And, drinking isfrequently depicted as normative behavior,even for teenagers. 91Again, the impact is increasingly clearfrom the research. A longitudinal studyof more than 1500 California 9thgradersrevealed that increased televisionand music video viewing was arisk factor for the onset of alcohol useamong adolescents. 92 Results of a ColumbiaUniversity study showed thatteenagers who watch more than 3R-rated films per month are 5 timesmore likely to drink alcohol comparedwith teenagers who watch none. 93 Also,in an intriguing study of 2- to 6-yearolds(n 120) who were asked to roleplayin a make-believe store, childrenwere 5 times more likely to “buy” beeror wine if they had been allowed to seePG-13 or R-rated movies. 94 Finally, goodlongitudinal evidence is emerging toindicate that watching more movie depictionsof alcohol is strongly predictiveof drinking onset and binge drinkingin US adolescents, 86,95,96 and thesame results are being found for adolescentsfrom other countries. 82,97PEDIATRICS Volume 126, Number 4, October 2010 793Downloaded from pediatrics.aappublications.org by guest on December 14, 2011

Illegal DrugsIllicit drugs are rarely seen on television,61 with the exception of programssuch as Showtime’s Weedsand Fox’s That 70s Show. Drugscenes are more common in movies(22% of the movies in 1 study containeddrug scenes), and no harmfulconsequences are shown more thanhalf of the time. 90 Marijuana is themost frequent drug seen in moviesand seems to be making a comebackin R-rated movies such as Harold andKumar Go to White Castle (2004) andThe Pineapple Express (2008). 98 A Columbiastudy revealed that viewingR-rated movies was associated witha sixfold increased risk of tryingmarijuana. 93 Hollywood filmmakersdo not seem to understand that humortends to undermine normal adolescentdefenses against drugs andlegitimizes their use. 3 Increased consumptionof popular music is alsoassociated with marijuana use. 95,99NEW MEDIAThe new technologies—the Internet,social networking sites, and even cellularphones—offer new and problematicopportunities for adolescentdrug exposure. 3,100 A variety of Websites sell tobacco products, and few ofthem have effective age-verificationprocedures. 3,101 One national survey ofmore than 1000 youths 14 to 20 yearsof age revealed that 2% reported havingpurchased alcohol online, and 12%reported having a friend who did so. 102Prescription drugs can also be purchasedonline with minimal difficulty.Popular beer brands use “advergames”online to entice a younger audience.103 Teenagers also see considerablealcohol and drug content inonline videos 104 and on social networkingsites, 105 on which 1 study revealedthat 40% of profiles referenced substanceabuse. 106SUMMARYThe so-called war on drugs has beenwaged for decades, yet teenagers continueto use and abuse a variety of substances,especially tobacco and alcohol.The contribution of the media toadolescent substance use is only recentlybecoming fully recognized andappreciated. The Master SettlementAgreement has greatly restricted tobaccomarketing by the tobacco companiesthat signed the agreement.However, tobacco continues to appearfrequently in movies, and this fact contrastsmarkedly with US reality (approximatelyhalf of the US populationlives in a community with restrictionson indoor smoking). Moreover, thecase is strong for the argument thatsmoking shown in entertainment mediaplays a causal role in smoking onset.Certainly, it is time to eliminate alltobacco advertising and to decreasegreatly the depiction of smoking inmainstream media. Because alcoholuse is still condoned in many venuesand use in moderation may be healthfulfor adults, such severe restrictionson alcohol advertising and programmingmay not be indicated. On theother hand, underage alcohol use doespose a clear and immediate threat tothe teenagers who use it. Taken together,the evidence supports strongactions aimed at the entertainmentindustry about media depictions oftobacco use and strong actionsaimed at motivating and assistingparents of children and young teenagersto restrict access to adult mediavenues with excessive substanceuse exposure.Anticipatory Guidance byPediatricians1. Pediatricians should encourageparents to limit unsupervised mediause and especially encourageremoval of televisions from children’sbedrooms. At every wellchildvisit, pediatricians should beasking at least 2 questions regardingmedia use: (a) How much entertainmentmedia per day is thechild or adolescent watching? and(b) Is there a television set or Internetaccess in the child’s or adolescent’sbedroom? 107 Researchhas revealed that having a televisionin the bedroom is associatedwith greater substance use andsexual activity in teenagers. 1082. Pediatricians should encourageparents to limit access by childrenand young adolescents to televisionvenues with excessive substanceuse depictions (eg, MTV,HBO, Showtime, Comedy Central).3. Pediatricians should encourageparents to limit younger children’sexposure to PG-13 moviesand avoid R-rated movies. 29,75–81,1094. Pediatricians should encourageparents to co-view media withtheir children and teenagers anddiscuss the content being viewed.5. Pediatricians should encourageparents to turn off the televisionduring evening meals.6. Pediatricians should ensure thattheir waiting rooms are free ofmagazines that accept cigaretteand alcohol advertising.Community Advocacy byPediatricians7. Pediatricians should encouragetheir local school systems to incorporatemedia education intotheir curricula. In particular,drug-prevention programs shoulduse basic principles of media literacy,designed to imbue skepticismtoward media advertising. Currently,Drug Abuse Resistance Education(DARE) does not accomplishthis goal, nor is there anyevidence that DARE is effective.12,110 More psychologically sophisticateddrug-prevention cur-794 FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded from pediatrics.aappublications.org by guest on December 14, 2011

FROM THE AMERICAN ACADEMY OF PEDIATRICSricula are available and should beused. 110–113Legislative Advocacy byPediatricians8. Pediatricians should encourageCongress to ban tobacco advertisingin all media accessible to children,which several Europeancountries have already done. Sucha ban would seem to be constitutional,given that the US SupremeCourt has already ruled that commercialspeech does not enjoy theabsolute First Amendment protectionsthat free speech does. 114Recently, Congress gave theFood and Drug Administrationthe authority to regulate tobaccoproducts; however, the tobaccoindustry is expected to challengeany advertising bans. 115,1169. Pediatricians should encourageCongress to require the alcohol industryto report its annual expendituresto the Federal Trade Commission,including expendituresfor media venues in which childrenand adolescents representmore than 10% of the marketshare (currently, voluntary advertisingrestrictions allow for venuesin which up to 30% of the audienceis children).10. Pediatricians should encouragethe alcohol industry to restrict advertisingand product placementin venues in which more than 10%of the audience is children andadolescents.11. Pediatricians should encouragethe White House Office of NationalDrug Control Policy to begin conductingantismokingandanti–teendrinkingpublic service campaigns,including strong antismoking andantidrinking ads to be placed beforetelevision programming andmovies that have youth ratingsand contain alcohol and tobaccodepictions.12. Pediatricians should encourageallocation of more money in mediaresearch, given the importance ofthe media on the development andbehavior of children and adolescents.Higher taxes on tobaccoproducts and alcohol could beused to fund such research.13. Pediatricians should encourageCongress to pass new strict lawsregulating digital advertisingthat targets children andadolescents. 100,117Involvement of the AlcoholicBeverage, Tobacco, Drug, andEntertainment Industries inEncouraging Responsible Behavior14. Pediatricians should encouragethe advertising industry, drugcompanies, public health groups,and medical groups to have a fulland open debate on the necessityof advertising prescription drugs.In addition, ads for erectile dysfunctiondrugs should be confinedto after 10 PM in all time zones andshould not be overly suggestive. 115. Pediatricians should encourage theentertainment industry to havegreater sensitivity about the effectsof television and movies on childrenand adolescents and accept that theindustry does, indeed, have a publichealth responsibility. 118 Cigarettesmoking in movies should beavoided at all costs and shouldnever be glamorized. 119,120 Disneyhas already promised to eliminatesmoking in its movies. 121 Making filmsets smoke-free zones would go farto diminish the portrayal of smokingin movies and would protect actorsand actresses from secondhandsmoke. Antismoking ads should precedethe showing of any film thathas tobacco use depicted. 119 Alcoholuse should not be portrayed as normativebehavior for teenagers, andthe traditional depiction of the“funny drunk” should be retired.Television networks that have alarge adolescent viewership shouldair public service ads about the dangersof smoking and drinking. Finally,the Motion Picture Associationof America (MPAA) ratings need tobe amended so that tobacco use willroutinely garner an R rating in allnew movies unless the risks andconsequences of smoking are unambiguouslyshown or the depictionis necessary to represent a realhistorical figure who actuallyused tobacco. 119 So far, the MPAAhas only agreed to considersmoking as a factor in assigninga rating. 122,12316. Pediatricians should encouragestate and federal agencies, the entertainmentindustry, and the advertisingindustry to develop andmaintain vigorous anti–drugadvertisingcampaigns that focuson the 2 drugs most dangerousto adolescents—tobacco andalcohol—in addition to illegaldrugs. Antidrug ads have beenshown to be highly effective at times(eg, the Truth campaign), 124–129 butthe effectiveness of the NationalYouth Anti-Drug Media Campaignhas been questioned. 130 Recently,and laudably, 6 major Hollywood studioshave agreed to place antismokingads on new movie DVDs that appealto children. 131,13217. Pediatricians should work withand support the American Academyof Pediatrics Julius RichmondCenter of Excellence (www.aap.org/richmondcenter), the missionof which is “to improve childhealth by eliminating children’sexposure to tobacco and secondhandsmoke,” including throughmedia exposure. 119PEDIATRICS Volume 126, Number 4, October 2010 795Downloaded from pediatrics.aappublications.org by guest on December 14, 2011

LEAD AUTHORVictor C. Strasburger, MDCOUNCIL ON COMMUNICATIONS ANDMEDIA EXECUTIVE COMMITTEE,2009–2010Gilbert L. Fuld, MD, ChairpersonDeborah Ann Mulligan, MD, Chair-electTanya Remer Altmann, MDAri Brown, MDDimitri A. Christakis, MDKathleen Clarke-Pearson, MDBenard P. Dreyer, MDREFERENCES1. American Academy of Pediatrics, Committeeon Communications. Children, adolescents,and advertising [published correctionappears in Pediatrics. 2007;119(2):424]. Pediatrics. 2006;118(6):2563–25692. Strasburger VC, Wilson BJ, Jordan, A. Children,Adolescents, and the Media. 2nd ed.Thousand Oaks, CA: Sage; 20093. Borzekowski DLG, Strasburger VC. Tobacco,alcohol, and drug exposure. In: CalvertS, Wilson BJ, eds. Handbook of Childrenand the Media. Boston, MA:Blackwell; 2008:432–4524. National Institute on Drug Abuse. Drug UseAmong Racial/Ethnic Minorities, 1995.Rockville, MD: National Institute of DrugAbuse; 1995. NIH publication 95-38885. Belcher HM, Shinitzky HE. 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FROM THE AMERICAN ACADEMY OF PEDIATRICS32. DiFranza Jr, Richards JW Jr, Paulman PM,et al. RJR Nabisco’s cartoon camel promotesCamel cigarettes to children [publishedcorrection appears in JAMA. 1992;268(15):2034]. JAMA. 1991;266(22):3149–315333. Wellman RJ, Sugarman DB, DiFranza J,Winickoff JP. The extent to which tobaccomarketing and tobacco use in films contributeto children’s use of tobacco. ArchPediatr Adolesc Med. 2006;160(12):1285–129634. Center on Alcohol Marketing and Youth. AlcoholAdvertising and Youth [fact sheet].Washington, DC: Center on Alcohol Marketingand Youth; 200735. Wilcox GB, Gangadharbatla H. What’schanged? Does beer advertising affectconsumption in the United States? Int J Advert.2006;25(1):35–5036. Grube JW, Waiters E. Alcohol in the media:content and effects on drinking beliefs andbehaviors among youth. Adolesc Med Clin.2005;16(2):327–34337. Jernigan DH. Importance of reducingyouth exposure to alcohol advertising.Arch Pediatr Adolesc Med. 2006;160(1):100–10238. 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Children, Adolescents, Substance Abuse, and the MediaThe Council on Communications and MediaPediatrics 2010;126;791; originally published online September 27, 2010;DOI: 10.1542/peds.2010-1635Updated Information &Servicesincluding high resolution figures, can be found at:http://pediatrics.aappublications.org/content/126/4/791.full.htmlReferencesCitationsSubspecialty CollectionsPermissions & LicensingReprintsThis article cites 85 articles, 44 of which can be accessed freeat:http://pediatrics.aappublications.org/content/126/4/791.full.html#ref-list-1This article has been cited by 2 HighWire-hosted articles:http://pediatrics.aappublications.org/content/126/4/791.full.html#related-urlsThis article, along with others on similar topics, appears inthe following collection(s):Adolescent Medicinehttp://pediatrics.aappublications.org/cgi/collection/adolescent_medicineInformation about reproducing this article in parts (figures,tables) or in its entirety can be found online at:http://pediatrics.aappublications.org/site/misc/Permissions.xhtmlInformation about ordering reprints can be found online:http://pediatrics.aappublications.org/site/misc/reprints.xhtmlPEDIATRICS is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned, published,and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, ElkGrove Village, Illinois, 60007. Copyright © 2010 by the American Academy of Pediatrics. Allrights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Downloaded from pediatrics.aappublications.org by guest on December 14, 2011