Reducing the prevalence of tobacco use requires both efforts to encourage cessation
among existing smokers, and to reduce uptake among young people. One area of success
is the growth in restrictions on tobacco advertising in a number of countries, which
now includes the introduction of standardized (also known as “plain”) tobacco packaging.
However, there remain a number of relatively unregulated channels through which tobacco
brands, and tobacco-related imagery more generally, can be promoted. These include
social media, movies, television, and video games, among others. However, the evidence
regarding the prevalence and impact of tobacco marketing via these channels is uneven;
for example, there is a far larger literature on smoking in movies than in other domains.
In this issue, Forsyth and Malone
1
address this gap by reviewing the literature on smoking imagery in video games.
There is now substantial evidence that smoking in movies is associated with tobacco
use initiation in young people
2
. Much of the evidence comes from cross-sectional studies, where determining a temporal
order is obviously not possible. However, there is also a growing number of prospective
studies, recently summarized by Leonardi-Bee and colleagues
2
, which provide stronger support for the possibility that exposure to smoking in movies
may indeed contribute to subsequent tobacco use initiation. This relationship appears
to depend on the degree of exposure, with the most exposed young people 40% more likely
to become smokers than the least exposed
2
. Given that tobacco imagery is relatively common in movies, and therefore exposure
among young people is high, it is plausible (particularly as other forms of promotion
have been removed) that this exposure is now a substantial driver of tobacco use uptake.
Indeed, the US Surgeon General has concluded that the evidence is sufficiently strong
to conclude that there is a causal relationship between smoking in movies and tobacco
use uptake in young people
3
.
In this context, it is likely that similar imagery in other media, such as video games,
will show similar associations. Nevertheless, it is still necessary to develop an
evidence base around this question in order to inform policy. In this context the
review by Forsyth and Malone is both timely and important. They conclude that research
into the associations between tobacco imagery in video games and tobacco use and attitudes
in young people remains in its infancy. However, they also highlight methodological
difficulties specifically related to video game research. For example, while tobacco
use occurs in various video games, the nature of this imagery may be very different,
from characters who are smokers and who smoker regularly, through to brief static
images. Moreover, video game play is interactive, so that the degree of exposure will
depend very much on engagement with the game, including length of time spent playing
it, and progress through it.
Until recently, most tobacco marketing occurred through channels relatively amenable
to regulation and codes. Movies could be given ratings that reflected their content
(although in the context of tobacco imagery this was often applied unevenly), television
programmes could be shown after a certain time, and so on. However, more recent technologies
have proven increasingly difficult to regulate. Movies and television programmes can
be watched online, allowing age and time restrictions to be more readily circumvented,
while social media channels are difficult, if not impossible, to regulate. Video gaming,
in particular, is rapidly becoming a major form of entertainment for young people,
but as Forsyth and Malone report their age ratings typically do not reflect tobacco
imagery content. Understanding this important but rapidly changing landscape is critical
if we are to continue the success of attempts to reduce exposure to tobacco marketing
among young people. The review by Forsyth and Malone is an important step towards
addressing this.