Exposure to smoking in internationally distributed American movies and youth smoking in Germany: A cross-cultural cohort study

OBJECTIVE. Studies of US adolescents have linked exposure to movie smoking with smoking behavior. It is unclear whether European adolescents are also responsive to movie tobacco imagery. METHODS. A longitudinal study was conducted to assess exposure to movie smoking in 2711 German never-smokers (aged 10 to 16 years). Movie smoking exposure was estimated by asking adolescents if they had seen movies from a list of 50 movie titles, randomly selected for each adolescent from 398 internationally distributed movies released between 1994 and 2004 that became box-office hits in Germany. These films were reviewed for smoking content. Adolescents were resurveyed 12 to 13 months later to determine smoking status, and results were compared with a similarly designed survey of 2603 white US adolescents. We hypothesized replication of the main effect of the exposure on trying smoking, and an interaction, with a significantly larger response among adolescents whose parents did not smoke. RESULTS. The 398 internationally distributed movies represented 80% of the German box-office hits within this time frame, with the majority (388) produced and/or distributed internationally by US companies. Smoking was present in 74% of the movies. Overall, 503 (19%) of the students tried smoking during the follow-up period. The incidence of trying smoking was associated with increased exposure to movie smoking. The form of the dose-response was similar to the US sample, with the strongest response to movies seen in the lower 2 quartiles of exposure. After controlling for baseline covariates, exposure to movie smoking remained a significant predictor of trying smoking in German adolescents, and the effect was significantly stronger in adolescents whose parents did not smoke. CONCLUSIONS. Smoking in internationally distributed US movies predicts trying smoking among German adolescents, closely replicating findings from a longitudinal study of white US adolescents. Smoking in these movies could have important worldwide public health implications.