European Journal of Cardiovascular Medicine

Cinema is a powerful medium that has the ability to shape and influence various aspects of society, including behaviours and attitudes. Adolescence is a critical developmental phase characterized by a heightened susceptibility to external influences and a desire for exploration and identity formation. Among the numerous impacts cinema has on its audience, its potential influence on smoking behaviours, particularly among adolescents, has become a subject of increasing concern¹.

Adolescent smoking is a major global problem affecting public health, society, and the economy. Approximately 900,000 individuals in India die from tobacco usage each year, and it is believed that 30% of adult male smokers consume tobacco. Tobacco kills close to 6 million people annually.²

The primary element behind children starting to smoke is the way that smoking is portrayed in films. It is believed that seeing films with depictions of smoking is a major role in motivating teenagers to start smoking.³

This glamorization of smoking, supported by a tobacco industry valued at 30,000 crores, is largely facilitated by Indian movies. Almost 320 out of the 400 films examined in the WHO study had tobacco use of some type. China and India will account for the greatest number of tobacco-related deaths worldwide in the future.⁴ Numerous studies attest to the fact that superstars who smoke in films arouse the feelings and emotions of those who do not smoke, strengthening the likelihood that they will identify smoking as a sign of status and vibrancy.³

In recent years, the images of good guys in movies using tobacco or smoking have increased despite the fact that displaying stars in films and television shows have been banned.⁵

Adolescents who smoke face the risk of developing numerous health issues, including nicotine addiction, impacts on the respiratory and non-respiratory systems, and other substance usage.⁶

RATIONALE:

Lifestyle disease, BCC for de-addiction burden decreases if we treat the root causes like smoking, alcohol, etc. Only a few studies are there in India exploring this aspect. This study aims to assess the impact of cinema on smoking behaviours among students.

RESEARCH QUESTION:

To what extent does exposure to cinematic portrayals of smoking influence smoking behaviour among adolescents?

OBJECTIVES:

To estimate the prevalence of smoking in adolescents

To estimate the smoking exposure rates among adolescents.

To determine the impact of cinema on smoking behaviour among adolescents

Study Design: A Cross-sectional study.

Study Area: Teaching institutes.

Study Duration: 1 month.

Study Population: Adolescent age group students.

Sampling Method: Systematic random sampling method.

Sample Size: 300.

From formula 4pq/l2 with a 25% prevalence of smoking in adolescents in India ²

    P= 25%;

    q = 75%;

l = 5

N= 4 x 25 x 75/5 x 5

N= 300

Study Tools: Pre-tested, semi-structured questionnaire

Inclusion Criteria: Students (10-19 years) present on the day of data collection.

Exclusion Criteria: Students who are not willing to participate.

Data Collection: Data was collected by Google form.

Data analysis: Data was entered in Microsoft Excel version 11 & analysis was done using the SPSS 24.

METHODOLOGY:

The present study is a cross sectional study done in a tertiary care teaching centre for a period of 1 month. This study aims to know to what extent the cinematic exposure to portrayals of smoking influence smoking behaviour among adolescents. Sample size had been calculated as 300 from formula 4pq/l2 with a 25% prevalence of smoking in adolescents in India from previous studies. Systematic random sampling technique was used for selection of the study subjects. 300 subjects satisfying the inclusion criteria and gave consent participated in the study. A pre tested semi structured questionnaire was sent to all the participants through Google forms. The questionnaire consisted of multiple choice and open ended questions. Questions regarding age, gender, socio economic status, smoking habit were present to get information regarding socio demographic factors. questions were designed to get information regarding movies watching time in hours/ day, frequency of seeing the presence of smoking and tobacco products in movies, awareness regarding movie ratings, weather following rating while watching movies,  perception of smoking in movies, tendency to imitate smoking after watching their movie idols smoke,  and are movies the main factors for their smoking initiation.

All the 300 participants responded and this data was collected by Google form. Data was entered in Microsoft Excel version 11 & analysis was done using the SPSS 24.

Inter-group differences have been analysed for significance using chi-square test and p value less than 0.05 was considered significant. The prevalence rates are reported in percent. Ethical clearance to conduct this study was granted by the Institutional Ethical Committee and permission was obtained from individual schools.

TABLE 1: SHOWING GENDER DISTRIBUTION IN THE PARTCIPANTS

A total of 300 adolescents participated in the present study. In distribution of subjects according to gender majority 189 were female (63 %) compared to 37% men.

TABLE 2: SHOWING DISTRIBUTION OF SMOKING IN THE PARTCIPANTS

Table no 2 shows notable difference in smoking behavior among the surveyed adolescents. 30.0% of the adolescents surveyed reported smoking. This suggests that a significant minority of the sample engages in smoking behaviour. 70.0% of the adolescents surveyed reported not smoking. This distribution provides a foundational understanding of smoking prevalence among adolescents in the surveyed population. It underscores the importance of further investigation into factors influencing smoking behavior among youth, such as gender, socioeconomic status, and perceptions related to smoking, which are likely pivotal in shaping prevention and intervention strategies.

TABLE 3: SHOWING PERCEPTION OF SMOKING IN THE PARTCIPANT

Table 3 reveals a split perception among the adolescents surveyed regarding smoking. 171 (57%) adolescents perceive smoking as repulsive and unappealing, 129 (43%) adolescents perceive smoking as cool, fashionable, seductive, or appealing. This reveals a split perception among the adolescents surveyed regarding smoking. A majority (57%) of adolescents find smoking repulsive and unattractive. This suggests a prevalent negative attitude towards smoking in this subgroup. A significant minority (43%) of adolescents perceive smoking as cool, fashionable, seductive, or appealing. This indicates that a notable portion of the sample views smoking positively or neutrally.

TABLE 4: SHOWING DISTRIBUTION OF SOCIO ECONOMIC STATUS IN THE PARTCIPANTS

Table 4 shows the distribution of socio-economic statuses among the surveyed adolescents. Adolescents from a wide spectrum of socio-economic backgrounds participated in the survey. The largest groups are those classified as upper class (30.0%) and upper-middle class (32.0%), together comprising 62.0% of the total sample. Lower class (10.0%), lower-middle class (12.0%), and middle class (16.0%) groups collectively account for only 38.0% of the sample.

TABLE 5: SHOWING FREQUENCY OF WATCHING MOVIES AS HOURS PER DAY IN THE PARTCIPANTS

The above results show a diverse pattern in adolescents' movie-watching habits. A substantial proportion of adolescents watch movies for 1 to 3 hours daily, with each category (1 hour/day, 2 hours/day, and 3 hours/day) constituting around 26.0% to 27.0% of the total sample. There are smaller groups of adolescents who either do not watch movies at all (10.0%) or watch movies for more extended periods (4 hours/day or more, collectively 10.0%). The majority of adolescents fall within the 1 to 3 hours/day range, suggesting that moderate movie-watching is common among the surveyed group

TABLE 6: SHOWING AN ASSOCIATION BETWEEN DURATION OF WATCHING MOVIES AND ADOLESCENTS' PERCEPTION OF SMOKING

The table provides data on how adolescents perceive smoking in movies based on their daily duration of watching movies. 46.5% of adolescents who watch movies for less than 2 hours perceive smoking in movies as repugnant and repulsive, 24.1% find it cool and fashionable, 25% find it seductive and appealing, and 75% find it cool, fashionable, and seductive.48.9% of adolescents who watch movies for 2 – 4 hours perceive smoking in movies as repugnant and repulsive, 75.8% find it cool and fashionable, 70% find it seductive and appealing, and 25% find it cool, fashionable, and seductive. 4.6% of adolescents who watch movies for more than 4 hours perceive smoking in movies as repugnant and repulsive, none find it cool and fashionable, 4.2% find it seductive and appealing, and 0% find it cool, fashionable, and seductive. The totals for each perception category sum up to 129 for repugnant and repulsive, 87 for cool and fashionable, 72 for seductive and appealing, and 12 for cool, fashionable, and seductive, out of the total sample size of 300 adolescents. A statistically significant association between the duration of watching movies and adolescents' perceptions of smoking in movies was found with a p-value of 0.00 indicates

Adolescents who watch movies for less than 2 hours per day and those who watch for 2 – 4 hours per day are more likely to find smoking in movies repugnant and repulsive compared to those who watch for more than 4 hours per day. Adolescents who watch movies for 2 – 4 hours per day are more likely to perceive smoking as cool, fashionable, seductive, or appealing compared to other groups.

TABLE 7: SHOWING THE ASSOCIATION BETWEEN AWARENESS AND FOLLOWING THE    MOVIE RATING WHILE WATCHING MOVIES

180 Adolescents are aware of different movie ratings while 120 adolescents are not aware of different movie ratings. Among adolescents who are aware of movie ratings 75% (135 out of 180) follow different movie ratings while watching but 25% (45 out of 180) do not follow different movie ratings while watching. Among adolescents who are not aware of movie ratings 22.50% (27 out of 120) follow different movie ratings while watching and 77.50% (93 out of 120) do not follow different movie ratings while watching. This shows a statistically significant association between awareness of movie ratings and following these ratings while watching movies with a p-value of 0.00. Adolescents who are aware of movie ratings are significantly more likely to follow these ratings while watching compared to those who are not aware.  A notable proportion (22.50%) of adolescents who are not aware of movie ratings still choose to follow them, suggesting some level of informal understanding or adherence to content guidelines.

TABLE 8: SHOWING THE ASSOCIATION BETWEEN DURATION OF WATCHING MOVIES AND MOVIES AS A MAIN FACTOR FOR SMOKING INTIATION

31.6% (18 out of 108) of adolescents who watch movies for less than 2 hours per day perceive movies as one of the main factors behind their smoking initiation. 57.9% (33 out of 57) of adolescents who watch movies for 2 – 4 hours per day perceive movies as one of the main factors behind their smoking initiation. 10.5% (6 out of 9) of adolescents who watch movies for more than 4 hours per day perceive movies as one of the main factors behind their smoking initiation. With a p-value of 0.00 indicates a statistically significant association between the duration of watching movies and the perception of movies as a factor behind smoking initiation.

Adolescents who watch movies for longer durations (2 – 4 hours/day) are significantly more likely (57.9%) to perceive movies as a main factor behind their smoking initiation compared to those who watch for shorter (< 2 hours/day) or longer (> 4 hours/day) durations. These findings suggest that prolonged exposure to movies (2 – 4 hours/day) may contribute to a stronger perception that movies influence smoking initiation.

In the present study female were 63 % compared to 37% men. Contrasting results were found a similar study done by Arora et.al, boys were 54.1% and girls were 45.9%. In a study done by Thrasher et al, Young men were 48% among the participants. ^7,8 In a similar study done by Soumita Ghose et al, the youngest participant was 18 years old and the oldest was 22 years of age; one-third of the respondents were women. ⁹

Present study shows a notable difference in smoking behavior among the surveyed adolescents. 30.0% of the adolescents surveyed reported smoking. 70.0% of the adolescents surveyed reported not smoking. This suggests that a significant minority of the sample engages in smoking behavior. In studies done by alexander etal, and Morgenstern etal, similar results were found. 12% were current smokers in similar study done by Thrasher et al,. ^8,,10,11

The results of Soneji et al, showed that SES moderates the effect of movie smoking. higher SES is associated with a stronger relationship between exposure to movie smoking and ever smoking, the risk ratio of smoking between those at the 90^th percentile of exposure to movie smoking versus the 10^th percentile was 1.79.¹²

The table provides data on smoking perception based on daily duration of watching movies. A statistically significant association between the duration of watching movies and adolescents' perceptions of smoking in movies was found with a p-value of 0.00 indicates Soumita Ghose et al in their study concluded that There is evidence from the developed world that a significant percentage of youth take up smoking due to their exposure to on-screen portrayal of tobacco use  and  a WHO bulletin on this issue emphasises the need to control the portrayal of such smoking on screen in movies and other programmes.^9,13,14

Adolescents who watch movies for less than 2 hours per day and those who watch for 2 – 4 hours per day are more likely to find smoking in movies repugnant and repulsive compared to those who watch for more than 4 hours per day. Adolescents who watch movies for 2 – 4 hours per day are more likely to perceive smoking as cool, fashionable, seductive, or appealing compared to other groups. Similarly in a study done Dalton et.al, by 10% (259) of participants initiated smoking during the follow-up period. Most (80%, n=208) of those who initiated smoking reported that they had smoked which is significantly associated with watching movies. ¹⁵ Trasher et al in their study indicated significant, positive associations between exposure to film smoking and increased likelihood of being a current smoker. ⁸

31.6% (18 out of 108) of adolescents who watch movies for less than 2 hours per day perceive movies as one of the main factors behind their smoking initiation. 57.9% (33 out of 57) of adolescents who watch movies for 2 – 4 hours per day perceive movies as one of the main factors behind their smoking initiation. 10.5% (6 out of 9) of adolescents who watch movies for more than 4 hours per day perceive movies as one of the main factors behind their smoking initiation. With a p-value of 0.00 indicates a statistically significant association between the duration of watching movies and the perception of movies as a factor behind smoking initiation.

In a longitudinal study done by Distefan JM et al,  results indicate that smoking by stars in movies significantly increases the risk of future smoking among adolescent. Adolescent had more than 80% increased odds of smoking to those whose favorite star did not smoke on-screen. ¹⁶

Adolescents who watch movies for longer durations (2 – 4 hours/day) are significantly more likely (57.9%) to perceive movies as a main factor behind their smoking initiation compared to those who watch for shorter (< 2 hours/day) or longer (> 4 hours/day) durations. These findings suggest that prolonged exposure to movies (2 – 4 hours/day) may contribute to a stronger perception that movies influence smoking initiation.

Data from study done by Thrasher et,al. found never-smokers were analyzed to determine associations between film-smoking exposure and psychological antecedents of smoking uptake with significant, positive associations between exposure and susceptibility to smoking  p 0.05 and favorable attitudes toward smoking with p value 0.0001. ⁸

A prospective study done by Sargent JD et al, showed that Exposure to R-rated movie smoking decreased significantly with increasing parental R-rated movie restriction (P .001), suggesting that the effect of parental R-rated movie restriction on adolescent smoking is mediated through lower exposure to R rated movie smoking. Only 4.9% of those never allowed to view R-rated movies had high exposure to R-rated movie smoking, compared with 20% for those allowed to watch them once in a while and 54% among those allowed to watch them sometimes or all the time.¹⁷

In a study to examine the factors associated with exposure to movie smoking done by Sargent JD et al, exposure to movie smoking increased (all P values <.001) by about 10% for each additional movie channel and for every 2 videos watched per week. Exposure increased by 30% for those going to the movie theater more than once per month compared with those who did not go at all. Parent restriction on viewing R-rated movies resulted in a 50% reduction in exposure to movie smoking.¹⁸

Adachi-Mejia AM et al, in their follow up study established that the odds of smoking habit increased across levels of movie smoking exposure (P = 0.01). Exposure to the highest level of movie smoking compared with the lowest significantly increased the likelihood of established smoking (OR = 1.63; 95% CI, 1.03-2.57).¹⁹

In a national web based cross sectional study Song AV et al, found that the odds of having smoked at least 100 cigarettes and smoking every day or on some days significantly increased by a factor of 1.23 for each quartile of movie exposure (p- 0.001), corresponding to an OR of 1.86 for the highest quartile of movie exposure.²⁰

Prevalence of smoking in adolescents is 30%, and exposure rate of smoking is 0.42. Movie watch time has an impact on perception, imitation, and initiation of smoking behaviour. Understanding these patterns can help in assessing the potential influence of media exposure on attitudes and behaviors related to smoking and other surveyed variables. Adolescents who are aware of movie ratings are significantly more likely to follow these ratings while watching compared to those who are not aware. Effective communication and education about movie ratings can play a crucial role in shaping media literacy and responsible viewing habits among youth.

RECOMMENDATIONS:

Further analysis could explore correlations between movie-watching habits and perceptions or behaviours identified in other parts of the survey. Awareness regarding different ratings of movies should be followed. As the watch time is significantly associated with habit formation, it is recommended to reduce the time of watching movies.

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