Entertainment Media and Tobacco-related Inequalities: A Global Perspective K. Viswanath, Ph. D. Harvard University Dana-Farber Cancer Institute Dana-Farber/Harvard Cancer Center On Behalf of Tobacco Research Network on Disparities (TReND) 15th World Conference on Tobacco or Health, Singapore
Exposure to Smoking in Movies• Meticulous methods to quantify and categorize > 2000 films• Number of smoking occurrences• Compelling cohort and experimental data supports causal effect• Data by race/ethnicity are limited• 95% have been to the cinema < 6 mo
Movies Smoking Exposure byRace/Ethnicity, Adolescents• Blacks have OR = 5.6 and Latinos OR=1.7 of seeing R movie• Minorities have increased exposure to smoking in movies• Smoking prevalence increased among all groups in top quartile of exposure• No data on Asian or Pacific Islanders
Movies Smoking Exposure byRace/Ethnicity, Adolescents• Global youth culture dominates but differences present• Longitudinal effect of exposure on smoking among Whites and Latinos, but not consistently for African Americans• Effects of exposure to race concordant actors among Af Ams - more smoking among Black actors• Black youth were not responsive to White actors smoking
Effects of Movies SmokingExposure in Mexico• Risk increased for current smoking with OR=2.65, but not significant for ever trying• More positive attitudes towards smoking• Attenuated effect compared to US• Fewer public restrictions on tobacco marketing, parenting rules• More liberal movie rating system• Friends who smoke and DVD in room assoc with movies exposure
A recent migration of tobacco advertisement to movies in Hong Kong
Films in India• India is the largest film producing industry in the world - Produces over 900 films every year.• Approximately 15 million people watch an Indian films every day either in theatre or at home on TV.• These films have a tremendous reach and are exported to almost every continent in the world to fulfill the demands of ex-patriot Indians.
…continued• The primary reach of cinema in India is 61 million individuals.• This reach is compounded by the reach of Cable and Satellite television that reaches roughly 40 million households (200m individuals).• Film stars are ambassadors for Bollywood - They lead very public lives and get a lot of media coverage.
Influence of movies and television on adult tobacco use in India*• Does watching television and movies influence adult tobacco use?• National Family Health Survey (2005-2006) Data was used for analysis.• Nationally representative cross-sectional survey of 123,768 women (15-49 years)and 74,068 men (15-54 years) in India.Viswanath K, Ackerson LK, Sorensen G, Gupta PC. Movies and TV Influence Tobacco Use in India: findings from aNational Survey. PLoS ONE. June 2010. Volume 5. Issue 6.•
Movies and Smoking• Smoking was more common among men (RR: 1.17; 95% CI: 1.12-1.23) who attended cinema at least once a month compared to those who did not.• Smoking was more common among women (RR: 1.55; 95% CI: 1.04-2.31) who attended cinema at least once a month compared to those who did not.
Television and Smoking• Smoking was more common among men who watched television daily compared to those who never watched television (RR: 1.06; 95% CI: 1.02-1.11)• No such association was found for women
Movies and Tobacco Chewing• Men who watched a movie at least once a month (RR: 1.15; 95% CI: 1.11-1.20) were more likely to chew than those who watched movies less than that.• There was no association between watching movies and tobacco chewing among women.
Television and Tobacco Chewing• Men who watched television daily (RR: 1.12; 95% CI: 1.07-1.18) were more likely to chew than those did not watch television.• Women who watched television daily (RR: 1.16; 95% CI: 1.07-1.27) had higher likelihood of tobacco chewing.
Smoke Free Movies CampaignFour Proposals• No brand displays or recognition in movies• R rating if smoking is shown• Certify lack of tobacco industry funding for all involved in the credits• Strong anti-smoking ad to precede movies that show smoking
Advocacy for Smoke Free Movies• Experimental evidence that exposure to movies leads young adults to smoke more• Effects on 6 major studios with decreases from 2005-2009• Marked increase in smoking among independent films• No work targeting minority studios
Cognitive psychologyTransportation into a Narrative World • Experience while reading, watching video or other activity • Integrative melding of attention, affect and imagery and transported some distance from world of origin • Mechanism how exposure to movies smoking may have effect • Little data by race/ethnicity, education, SES, or language
Future Directions• Research to identify mechanisms of how different components affect race and ethnic minorities• Data on young adults - to age 30; similar effects?• International validation and lessons• New devices: Changes
Mobile Devices, New Media• Transformation of use in a decade among youth• TV was 50% in 2000 and now is 32%• Mobile devices (77% of youth have) and computers increased• Radio, DVD decrease• Video games, U Tube, social networks
Entertainment MediaDiversification• Minorities and lower SES adults and youth more likely to watch TV• Exposure to smoking on TV?• Content analysis of 163 brand-related You Tube videos: 71% pro-tobacco• Advertising placed in Video Games, social networks, mobile devices• Measuring exposure, monitoring
Concluding Comments • Exposure to smoking in movies causes smoking among adolescents and probably young adults • Differential effects by race/ethnicity poorly understood • Role of new media tools • Will advocacy and policy change address the issue?
Lessons learnt from India’s actions towards smoke-free movies Barbara Zolty, MPH Tobacco Free Initiative WHO, SEARO 21 March 2012
The world of film cannot beaccused of causing cancer.But they do not have topromote a product that does. - WHO, WNTD 2003: Tobacco Free Film & Fashion
Movies are effective in promoting smoking Exposure to movie smoking depictions causes youth to start smoking. India study (Arora M et al, 2011) : Tobacco use > double for youth with high exposure to tobacco images in Bollywood movies. 2012 US SGR: “The evidence is sufficient to conclude that there is a causal relationship between depictions of smoking in the movies and the initiation of smoking among young people.” Present a strong pro-tobacco message, helping to shape social norms for youth.
WHO FCTC“Tobacco advertising and promotion" means anyform of commercial communication,recommendation or action with the aim, effect orlikely effect of promoting a tobacco product ortobacco use either directly or indirectlyWHO FCTC Guidelines:Depiction of tobacco in entertainment mediaproducts such as films is a form of TAPS.
WHO calls for enforceable policies to restrict smoking in movies Certify no payoffs Stop identifying tobacco brands Require strong anti-tobacco ads Implement rating system to keep smoking out of youth- rated filmsBased on Article 13 recommendations
India’s smoke-free movie rules In 2003, India enacted 89 comprehensive tobacco 90 76 76 control legislation (COTPA), 80 including a comprehensive 70 54 60 Percentage ban on TAPS. 46 50 40 Following this, there was 1990-2002 30 increase in: 20 2004-2005 – Movies depicting tobacco 10 3 use 0 movies instances of Movies – Tobacco use depictions depicting tobacco use depicting by lead actors tobacco use depictions by tobacco – Tobacco branding in lead actors branding movies WHO, 2009
India’s smoke-free movie rules In 2005, COTPA Rules were amended to include a complete ban on depiction of tobacco products or tobacco use in movies/ television. In 2006, following discussion with Ministry of Information and Broadcasting (MoIB) new rules were notified which allowed tobacco depiction with editorial justification, with A rating given. Provisions were challenged in the High Court by a Bollywood producer. Rules were struck down by Delhi High Court in 2009. In 2009, Government of India filed an appeal with the Supreme Court which suspended the order of the High Court. Following additional consultation with MoIB, the MoHFW issued a revised notification to take effect on 14 Nov 2011.
Central Board of Film Certification (CBFC) responsible for enforcement of the rules In September 2011, MOH/WHO organized sensitization workshop for MoIB, CBFC officials from all the regional centers. Following this, MOH held additional meetings with CBFC to discuss next steps for implementation. CBFC invited MOH/WHO to regional SAMVAAD (meeting for producers, directors).
Bollywood supporters ofsmoke-free movies speak out Instances of scenes where smoking is essential are very rare for the story of any film. There are thousands ways of showing a character than showing smoking…"It is only lazy directors and lazy script writers who put in smoking scenes instead of finding other ways." --- Rekha Nigam, Bollywood scriptwriter “I have never encouraged smoking in my films…Youngsters worship actors and follow them blindly. So I always try to project my actors in a manner that his or her character does not glorify things which are not good.” --- A. Murugadoss, Bollywood director
MoHFW notified Rules on restricting tobacco use in films and TV, effective 14 Nov 2011 Films with tobacco must show: 30 second anti-tobacco spots at beginning & middle. – Tobacco control spots provided by MoH to MoIB New films with tobacco depictions shall be issued a “UA” Certificate. Health scroll at bottom of Bezawada is first movie to screen during each scene implement health scrolls during with tobacco. tobacco scenes
Smoke-free movie rules New films with tobacco use must have strong editorial justification Representatives from MoHFW on CBFC panels. Must include disclaimer by the actor about the harms of tobacco. Promotional materials (trailers, posters, etc.) shall not depict tobacco use.
No brand names of tobacco products shown on screen and no close-ups of tobacco packages
The film also runs warnings before and during the film.Agneepath,releasedJanuary 2011.Includesrequiredhealthscrolls.
Some lessons learnt from India’sexperience with smoke-free movies Important to frame issue as a part of TAPS. Need for engagement with Ministry of Information and Broadcasting before, during and after rules are formulated. Build alliances with the film and TV fraternity to get them on board. Media can play an important role in bringing the issue up for public debate and create necessary pressure.
Actions in India will protect youth globally India is the world’s largest producer of films. Indian films viewed in over 100 countries, with a growing fan base in the West. Worldwide, viewership for Bollywood movies is even higher than Hollywood films. India’s success in reducing tobacco depictions in movies will set a global precedent and protect youth in India and in many countries around the world.
Nandita Murukutla, PhDDirector of Research and Evaluation Singapore 2012
About World Lung FoundationWLF partners with WHO’s Global TobaccoFree Initiative.Reach Core StrengthsWLF is headquartered in New York City and has offices • Capacity Building • Operational Researchand 40 staff and consultants in strategic cities worldwide. • Health Communications • Project Management 80 20 41 social marketing countries promoted campaigns around the world policy change
Evidence Strong evidence from high-income countries for the efficacy of tobacco control mass media campaigns when implemented effectively and in the appropriate context. Durkin S, Brennan E, Wakefield M, Tobacco Control, 2012 U.S. Surgeon General’s Report, 2012 Wakefield MA, Loken B, Hornik RC, Lancet 2010 National Cancer Institute (NCI), 2008
Evidence The impact is multi-fold, and ultimately prompts quitting. Gain new insights, knowledge about tobacco usage Motivate quitting Increase interpersonal discussion about tobacco use Influence and create social norms Increase support for policy change Increase compliance with laws MPOWER, FCTCDurkin S, Brennan E, Wakefield M (2012). Mass media campaigns to promote smoking cessationamong adults: an integrative review. Tobacco Control, 21:127e138
Building The Evidence In 2008, when WLF began this work, there was limited evidence from low and middle- income countries (LMICs). • Message-testing • Outcome evaluations
Background & Methodology Partners: Cancer Council, Victoria & Cancer Institute, NSW Two major international studies Anti-smoking ads with smokers Second-hand smoke (SHS) ads with smokers, non-smokers Standardized quantitative-qualitative methodology Ads tested on the following dimensions: Message acceptance Personalized perceived effectiveness Negative emotion (Discomfort) Likelihood to discuss/ Potential behavior change
Anti-Smoking Ads: 10 Country Study 10 countries: China, Russia, Mexico, the Philippines, India, Indonesia, Vietnam, Bangladesh, Turkey, Egypt. Sample: 2399 smokers aged 18 - 34 years Groups split by age, gender, location and order of presentation Five anti-smoking ads tested in all countries: Cigarettes are Artery Sponge Eating You Bubblewrap Zita Alive Wakefield, M., Bayly, M., Durkin, S., Cotter, T., Mullin, S., Warne, C., for the International Anti-Tobacco Advertisement Rating Study Team. Smokers responses to television advertisements about the serious harms of tobacco use: pre-testing results from 10 low- to middle-income countries. Tob Control 2011
ResultsPredicted probabilities of positive ad ratings by country and ad for all outcomes • Consistently high ratings for the three graphic ads that communicate about health harms (AAS). • Ads that employed visual simulation and personal testimonial more variable across countries.
Key Findings • Ads that graphically communicate the serious harms of tobacco use performed consistently highly across all countries. • Ads with complex medical terms or metaphors, or those that feature personal testimonials, are more variable. • Graphic ads can be readily translated and adapted for local use.
General Methodology• Campaign types: • Tobacco cessation • SHS/ Smoke-free law• Evaluation design: Pre-post or post-only surveys• Methodologies: Typically multi-stage, random household surveys; street intercept surveys where necessary• Samples: • Tobacco users and non-users between 16 – 55 years; • Subgroups: tobacco user types; location; gender; SES
General MethodologyKey indicators:• Recall (unprompted, prompted)• Accuracy of messages recalled• Message appraisal• Knowledge, attitudes, risk perceptions• Behavioral intentions, quit attempts, changes in behaviorAnalysis:• Comparisons between proportions/ means: comparing baseline vs. post-campaign; key subgroup analysis• Regression analysis: Campaign awareness was regressed on dichotomised key indicators. • Covariates: age, gender, location, region, SES, media usage, # of product consumed, intentions to quit.
Brazil: Smoke-free São Paulo, 2009Objectives• Educate on SHS exposure harms• Build support for smoke-free environments in Sao PauloEvaluation Pre-post campaign street intercept surveys of smokers and non-smokers (Baseline N = 603; Post-campaign = 618) May June July August September Survey1 Survey2 Drauzio ACT- WLF
ACT-WLF rated as personally more important andconvincing Response to the Drauzio and the ACT-WLF ads Easy to understand 97 97 Believe what ad says 95 92 Caught my attention 91 88 Gave me new information 80 80 ACT-WLF Said something personally 82 * important to me 73 Drauzio More convincing than other 81 * ads against smoking 73 Made me want to change my behavior about being near 63 64 people who are smoking ** p < 0.01, * p < 0.05
Campaign awareness of ACT-WLF ad associated with greater support and compliance with SF law Campaign awareness and attitudes towards SHS exposure and SF law Drauzio campaign ACT-WLF campaign Attitudinal Statements Aware Unaware OR Aware Unaware ORIf someone doesn’t want to breathe cigarettesmoke, he/she should go to some other place (% 57% 42% 2.1 49% 45% 0.94agree)Smokers have a right to smoke in indoor public 19% 25% 0.6 4% 21% 0.17*places (% agree)Clients that are in indoor places have the right tobreath clean air, without cigarette smoke (% 94% 91% 2.3 100% 92% 1agree)How willing are you to inform about violation tothe Law that prohibits to smoke in indoor places 24% 23% 1 49% 29% 2.3**(% totally/very)To prohibit smoking is fair, because the benefits 84% 91% 0.7 94% 74% 5.1**it will bring to people like you (% agree)The law that prohibits smoking in indoor places 57% 60% 0.9 68% 55% 1.5will help smokers to quit (% agree)The Law will allow people like you to claim yourrights to breath clean air, without cigarette 98% 81% 0.8 94% 76% 4**smoke (% agree) ** p < 0.01, * p < 0.05
CHINA: Gift Giving, 2009Objectives• Increase awareness of health harms• Denormalize the practice of giving cigarettes as giftsEvaluationTwo sources of data: Pre-post street-intercept survey data Independent evaluation by ITC project, China
Significant increases in knowledge andchanges in behavioral intentions Percentage agreeing that … Smoking causes poor 74 health 65 Post- Smoking causes heart 60 campaign diseases 29 Pre- campaign Plan to give cigarettes as 24 gifts 45 Beijing: Pre-campaign, N = 200; Post-campaign, N = 700** p < 0.01, * p < 0.05
Convergence from ITC project surveysSuggestion of a dose-response relationship between number of campaignchannels reported and disagreement that cigarettes are good gifts. Huang L, Thrasher JT, Chang Y, Winnie C, Jiang Y, Li Q, Fong GT. Impact of level and type of media channels on knowledge and attitude targeted by "giving cigarettes is giving harm" campaign in china: findings from the ITC China survey
POLAND: Alive and Baby Alive, 2009Objectives• Raise awareness of smoking and SHS exposure harms• Denormalize smoking, SHS exposure• Encourage cessationEvaluationPre-post nationally representativehousehold survey of general population(N = 1005)Collaborators: Health Promotion Foundation, Poland
Significant increases in knowledge aboutharms related to smoking.** p < 0.01, * p < 0.05
Significant increase in calls to quit line during the campaign period. Polish Quitline Service Number of received reactive calls - daily data (November - December 2009) 160 145 - Great polish Smoke-out (19.XI) 140 120 115 98 100 93Number of calls 84 81 80 77 75 73 65 66 67 60 63 59 60 55 45 40 39 40 42 35 36 27 28 26 25 32 27 22 22 23 22 24 24 19 18 22 21 19 20 14 21 20 12 8 7 0 03.11 05.11 09.11 12.11 16.11 18.11 20.11 23.11 25.11 27.11 30.11 02.12 04.12 07.12 09.12 11.12 14.12 16.12 18.12 22.12 24.12 29.12 31.12 1 Period of "Cigarettes eat you alive" campaign realization 8 . 1 1
Significant increase in calls to quit line duringcampaign period compared to previous year. Polish Quitline Service Number of received reactive calls (by month) 2008 vs. 2009 1200 1086 2009 2008 1000 893 800 Number of calls 591 600 543 549 534 536 500 498 477 459 463 450 433 430 432 407 417 401 397 392 400 362 353 347 200 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Significant changes in campaign-relevant knowledge andattitudes; no changes in campaign not-relevant items.
Campaign awareness associated with increasedcommunication and cessation thoughts/behaviors.
Sub-Groups Replication of findings among: Gender Rural/Urban Young and older adults
Limitations Operational evaluation designs Yet, valuable in extending evidence Drops in prevalence? Early days yet, quit attempts recorded
ConclusionsEvidence from LMICs finds that tobacco control campaigns: Internationally generalizable: Case for adaptations. Media weight and media message are important. Create awareness about smoking harms, SHS exposure. Create support for smoke-free policies, increase compliance. Change social norms. Increase interpersonal discussion. Motivate quitting.
Nandita Murukutla, PhD Director, Research and Evaluationnmurukutla@worldlungfoundation.org