Media and tobacco control

1. 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

2. Historical Perspective: Movies

3. Historical Perspective: Movies

4. 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

5. Movies Smoking Exposure by
Race/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

6. Movies Smoking Exposure by
Race/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

8. Effects of Movies Smoking
Exposure 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

9. A recent migration of tobacco advertisement to movies in Hong Kong

10. “She inhales not smoke but solitude”

11. 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.

12. …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.

13. 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 a
National Survey. PLoS ONE. June 2010. Volume 5. Issue 6.
•

14. 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.

15. 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

16. 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.

17. 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.

18. Smoke Free Movies Campaign
Four 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

19. 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

20. Cognitive psychology
Transportation 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

21. 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

22. 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

23. Entertainment Media
Diversification
• 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

24. 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?

25. Lessons learnt from India’s actions
towards smoke-free movies
Barbara Zolty, MPH
Tobacco Free Initiative
WHO, SEARO
21 March 2012

26. The world of film cannot be
accused of causing cancer.
But they do not have to
promote a product that does.
- WHO, WNTD 2003: Tobacco Free Film & Fashion

27. 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.

28. WHO FCTC
“Tobacco advertising and promotion" means any
form of commercial communication,
recommendation or action with the aim, effect or
likely effect of promoting a tobacco product or
tobacco use either directly or indirectly
WHO FCTC Guidelines:
Depiction of tobacco in entertainment media
products such as films is a form of TAPS.

29. 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 films
Based on Article 13 recommendations

30. 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

31. 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.

32. 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).

33. Bollywood supporters of
smoke-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

34. 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

35. 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.

36. No brand names of tobacco products shown on
screen and no close-ups of tobacco packages

37. The film also
runs warnings
before and
during the film.
Agneepath,
released
January 2011.
Includes
required
health
scrolls.

38. ???

39. Some lessons learnt from India’s
experience 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.

40. 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.

41. Nandita Murukutla, PhD
Director of Research and Evaluation
Singapore 2012

42. About World Lung Foundation
WLF partners with WHO’s Global Tobacco
Free Initiative.
Reach Core Strengths
WLF is headquartered in New York City and has offices • Capacity Building • Operational Research
and 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

43. 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

44. 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, FCTC
Durkin S, Brennan E, Wakefield M (2012). Mass media campaigns to promote smoking cessation
among adults: an integrative review. Tobacco Control, 21:127e138

45. 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

46. International Message Testing
Projects

47. 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

48. 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

49. Results
Predicted 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.

50. 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.

51. Outcome Evaluations

52. 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

53. General Methodology
Key indicators:
• Recall (unprompted, prompted)
• Accuracy of messages recalled
• Message appraisal
• Knowledge, attitudes, risk perceptions
• Behavioral intentions, quit attempts, changes in behavior
Analysis:
• 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.

54. Brazil: Smoke-free São Paulo, 2009
Objectives
• Educate on SHS exposure harms
• Build support for smoke-free
environments in Sao Paulo
Evaluation
 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

55. ACT-WLF rated as personally more important and
convincing
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

56. 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 OR
If someone doesn’t want to breathe cigarette
smoke, he/she should go to some other place (% 57% 42% 2.1 49% 45% 0.94
agree)
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 to
breath clean air, without cigarette smoke (% 94% 91% 2.3 100% 92% 1
agree)
How willing are you to inform about violation to
the 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% 1.5
will help smokers to quit (% agree)
The Law will allow people like you to claim your
rights to breath clean air, without cigarette 98% 81% 0.8 94% 76% 4**
smoke (% agree)
** p < 0.01, * p < 0.05

57. CHINA: Gift Giving, 2009
Objectives
• Increase awareness of health harms
• Denormalize the practice of giving
cigarettes as gifts
Evaluation
Two sources of data:
 Pre-post street-intercept survey data
 Independent evaluation by ITC project,
China

58. Significant increases in knowledge and
changes 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

59. Convergence from ITC project surveys
Suggestion of a dose-response relationship between number of campaign
channels 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

60. POLAND: Alive and Baby Alive, 2009
Objectives
• Raise awareness of smoking and
SHS exposure harms
• Denormalize smoking, SHS exposure
• Encourage cessation
Evaluation
Pre-post nationally representative
household survey of general population
(N = 1005)
Collaborators: Health Promotion Foundation, Poland

61. Significant increases in knowledge about
harms related to smoking.
** p < 0.01, * p < 0.05

62. 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 93
Number 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

63. Significant increase in calls to quit line during
campaign 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

64. INDIA: Surgeon, 2009
Objectives
• Raise awareness
• Denormalize smokeless use
• Build risk perceptions and
encourage cessation
Evaluation
Post-campaign nationally representative
household survey of smokeless tobacco
users (N = 2898)

65. Significant changes in campaign-relevant knowledge and
attitudes; no changes in campaign not-relevant items.

66. Campaign awareness associated with increased
communication and cessation thoughts/behaviors.

67. Sub-Groups
 Replication of findings among:
 Gender
 Rural/Urban
 Young and older adults

68. Limitations
 Operational evaluation designs
 Yet, valuable in extending evidence
 Drops in prevalence?
 Early days yet, quit attempts recorded

69. Conclusions
Evidence 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.

70. Nandita Murukutla, PhD
Director, Research and Evaluation
nmurukutla@worldlungfoundation.org