Children, Adolescents, Substance Abuse, and the Media

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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
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Children, Adolescents, Substance Abuse, and the Media

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