Tobacco Imagery in the 20 Best-Selling Video Games of 2018.

INTRODUCTION: Video games are played by the majority of American adolescents. A small body of research has shown that video games expose users to tobacco imagery, potentially influencing subsequent smoking behavior. We examine the presence, type, and quantity of tobacco imagery in recent popular video games. METHODS: After identifying 20 best-selling US video games of 2018 and selecting each YouTube video of all cut scenes and bridging game play, we coded each video for the presence of five types of tobacco imagery. We also recorded the length of time tobacco content was visible during the video. RESULTS: Seven of the top 20 video games contained tobacco imagery, which comprised between 7 seconds and 38 minutes of game play. All five types of tobacco imagery were accounted for: visible tobacco paraphernalia, tobacco products used to further game play, background characters using tobacco products, and main characters (playable and nonplayble) using tobacco products. Visible tobacco paraphernalia was the most common type of tobacco imagery and included both real and fictionalized tobacco brands that sometimes drew on real cigarette brand imagery. Three games allowed players to control tobacco-using characters. CONCLUSIONS: Popular video games continue to expose players to tobacco imagery. Because video games are played repeatedly, the potential exists for adolescents to experience even more tobacco imagery than the baseline exposure established here, further increasing the potential for harm. Existing voluntary and regulatory approaches to policing tobacco content are inadequate; thus, policymakers should consider further interventions to minimize tobacco content in video games. IMPLICATIONS: Video games, popular among youth and young adults, are known to contain tobacco imagery. Less is known about the quantity and type of this imagery among recent popular games. We found that 7 of the 20 best-selling video games of 2018 in the United States contained a variety of tobacco imagery and exposed players to as much as 38 minutes of tobacco content. Given the established link between exposure to tobacco marketing in media such as films and subsequent smoking behavior, policies to minimize tobacco imagery in video games that exceed the scant protections offered by the Master Settlement Agreement could help reduce smoking prevalence among youth.

'Cease and desist?' The persistence of Marlboro brand imagery in racing video games.

BACKGROUND: Since 1972, Philip Morris (PM) has sponsored motorsports. Racing video games are a popular genre among youth and often emulate the branding of their real-life counterparts, potentially exposing youth to tobacco imagery. We examined racing video games for the presence of Marlboro imagery and explored the history of efforts to remove or regulate such imagery. METHODS: We searched the Truth Tobacco Industry documents for relevant documents and used information from video game-related websites and game play videos to identify racing video games that contained Marlboro trademarks and imagery. We also collected information on the Entertainment Software Ratings Board's (ESRB) tobacco-specific and overall game ratings. FINDINGS: In 1989, negative publicity surrounding the presence of Marlboro logos in racing games led PM to threaten legal action against two game makers for copyright infringement. PM also launched a media campaign promoting this intervention as evidence of its commitment to youth smoking prevention. Nonetheless, we identified 219 video games from 1979 to 2018 that contained Marlboro trademarks and/or Marlboro-sponsored drivers and livery. Among the games in our sample with an ESRB game rating, all but one received an 'E,' indicating appropriateness for everyone, and all but three lacked tobacco content descriptors. CONCLUSION: Racing video games have been and continue to be a vehicle for exposing adolescents to the Marlboro brand. Because voluntary efforts by PM and the video game industry to prevent youth exposure to tobacco brands in video games have been ineffective, USA and international policy-makers should prohibit tobacco content in video games.

Tobacco Content in Video Games: Categorization of Tobacco Imagery and Gamer Recall.

INTRODUCTION: Tobacco content has been identified in popular video games played by adolescents. To date, there are no established instruments for categorizing tobacco content. We describe development and demonstrate the use of an instrument to categorize types of tobacco content. METHODS: Interviews were conducted with 61 participants: 20 adolescents (mean age 17.7), and 41 adults (mean age 23.9), who discussed favorite games and recalled tobacco content. All games mentioned were examined for tobacco content by watching movies of game play on YouTube, examining individual game Wiki sites, and reviewing content descriptors provided by the Entertainment Software Rating Board (ESRB), Common Sense Media, and the Internet Movie Database (IMDb). A typology of tobacco content was created and correlated with gamer recall of tobacco content. RESULTS: Participants together mentioned 366 games, of which 152 were unique. Tobacco content was verified in 39.5% (60/152) of games. Six categories of content were identified, including "no tobacco content." Of games containing tobacco, 88% (53/60) contained at least two categories of content. Games with more categories were associated with greater gamer recall of tobacco content. CONCLUSION: Tobacco content is present in video games and consciously recalled by players, with higher accuracy of recall associated with games featuring multiple types of tobacco content and more engaging, player-active content. IMPLICATIONS: Playing video games is now a daily part of most adolescents' lives. Tobacco content is present in many popular games. Currently there are no published instruments to assist in categorizing tobacco content in video games. This study describes a systematic approach to categorize tobacco content in video games and demonstrates that games featuring more categories of tobacco content are associated with more accurate gamer recall of the presence of tobacco content when compared with games with fewer categories of content. Understanding the extent of such content will be essential in formulating tobacco control strategies to address tobacco content in games.

Exposure to tobacco in video games and smoking among gamers in Argentina.

BACKGROUND: Our objective was to assess whether exposure to tobacco in video games is associated with smoking among adolescent gamers from Argentina. METHODS: Cross-sectional data were analysed from students in public and private middle schools in Argentina. Tobacco content in video games was estimated using previously validated methods and adolescents' tobacco exposure was assessed by multiplying tobacco content in the top three video games they play by the hours played per day. The primary outcome was current smoking. Multilevel logistic regression models adjusted for clustering within schools, regressing current smoking on tobacco exposure in video games (ie, none, low, high) after controlling for age, sex, parental education, parenting style, parental rules about the use of video games, rebelliousness, sensation seeking and 'technophilia'. RESULTS: Of the 3114 students who participated, 92% of boys (1685/1802) and 56% of girls (737/1312) played video games and were included in the analytical sample. The prevalence of smoking was 13.8% among boys and 22.0% among girls; 74.5% of boys played video games more than 1 hour per day compared with 47.7% of girls. High exposure to tobacco content in video games compared with no exposure was independently associated with current smoking among girls (OR 1.78; 95% CI 1.02 to 3.09) but not among boys (OR 0.98; 95% CI 0.64 to 1.51). CONCLUSIONS: Greater exposure to tobacco content in video games was associated with higher likelihood of smoking among Argentine girls who play video games, suggesting the need for policies that limit these exposures.

Smoking in Video Games: A Systematic Review.

INTRODUCTION: Video games are played by a majority of adolescents, yet little is known about whether and how video games are associated with smoking behavior and attitudes. This systematic review examines research on the relationship between video games and smoking. METHODS: We searched MEDLINE, psycINFO, and Web of Science through August 20, 2014. Twenty-four studies met inclusion criteria. Studies were synthesized qualitatively in four domains: the prevalence and incidence of smoking imagery in video games (n = 6), video game playing and smoking behavior (n = 11), video game addiction and tobacco addiction (n = 5) and genre-specific game playing and smoking behavior (n = 3). RESULTS: Tobacco content was present in a subset of video games. The literature is inconclusive as to whether exposure to video games as a single construct is associated with smoking behavior. Four of five studies found an association between video game addiction and smoking. For genre-specific game playing, studies suggest that the type of game played affected association with smoking behavior. CONCLUSIONS: Research on how playing video games influences adolescents' perceptions of smoking and smoking behaviors is still in its nascence. Further research is needed to understand how adolescents respond to viewing and manipulating tobacco imagery, and whether engaging in game smoking translates into changes in real-world attitudes or behavior. Smoking imagery in video games may contribute to normalizing adolescent smoking. IMPLICATIONS: A large body of research has shown that smoking imagery in a variety of media types contributes to adolescent smoking uptake and the normalization of smoking behavior, and almost 90% of adolescents play video games, yet there has never been a published systematic review of the literature on this important topic. This is the first systematic review to examine the research on tobacco and video games.We found that tobacco imagery is indeed present in video games, the relationship between video game playing and smoking remains unclear, there appears to be a correlation between problem gaming and smoking and the genre of games may play a role in adolescent smoking behavior.

Tobacco imagery in video games: ratings and gamer recall.

OBJECTIVE: To assess whether tobacco content found in video games was appropriately labelled for tobacco-related content by the Entertainment and Software Ratings Board (ESRB). METHODS: Sixty-five gamer participants (self-identified age range 13-50) were interviewed in-person (n=25) or online (n=40) and asked (A) to list favourite games and (B) to name games that they could recall containing tobacco content. The ESRB database was searched for all games mentioned to ascertain whether they had been assigned tobacco-related content descriptors. Games were independently assessed for tobacco content by examining user-created game wiki sites and watching YouTube videos of gameplay. Games with tobacco-related ESRB content descriptors and/or with tobacco imagery verified by researchers were considered to contain tobacco content. Games identified by participants as including tobacco but lacking verifiable tobacco content were treated as not containing tobacco content. RESULTS: Participants recalled playing 140 unique games, of which 118 were listed in the ESRB database. Participants explicitly recalled tobacco content in 31% (37/118) of the games, of which 94% (35/37) included independently verified tobacco content. Only 8% (9/118) of the games had received ESRB tobacco-related content descriptors, but researchers verified that 42% (50/118) contained such content; 42% (49/118) of games were rated 'M' for mature (content deemed appropriate for ages 17+). Of these, 76% (37/49) contained verified tobacco content; however, only 4% (2/49) received ESRB tobacco-related content descriptors. CONCLUSIONS: Gamers are exposed to tobacco imagery in many video games. The ESRB is not a reliable source for determining whether video games contain tobacco imagery.

Critical appraisal training increases understanding and confidence and enhances the use of evidence in diverse categories of learners.

BACKGROUND: Training in evidence-based medicine is most commonly offered to physicians, medical students and health-care decision-makers. SETTING AND PARTICIPANTS: We partnered with community organizations to recruit participants and develop trainings for consumers, non-physician health-care providers and journalists in California. INTERVENTION: We conducted half-day and one-day workshops in critical appraisal of health evidence. Workshops consisted of didactic presentations, small-group practice sessions and class discussions. OUTCOME MEASURES: We measured knowledge and confidence immediately before and after the workshops and at follow-up 6 months later. We also asked participants to describe their use of health evidence before the workshops and at follow-up. RESULTS: At baseline, 41% of the consumers, 45% of the providers and 57% of the journalists correctly answered questions about health evidence. Scores increased by about 20% (P < 0.05) in all groups at the end of the workshops and remained significantly over baseline at follow-up. At baseline, 26% of the participants were confident in their understanding of critical appraisal concepts, significantly increasing to 54% after the workshops and sustained (53%) at follow-up. During discussions, participants' comments often focused on funding and the potential effects of financial conflicts of interest on study findings. Participants did not use evidence more frequently at follow-up but said that they applied workshop skills in evaluating research, communicating with others and making decisions about health care. CONCLUSION: It is possible to successfully conduct critical appraisal workshops to aid health-related decision making for groups who have previously not had access to this kind of training.

"Tired of watching customers walk out the door because of the smoke": a content analysis of media coverage of voluntarily smokefree restaurants and bars.

BACKGROUND: News media are key sources of information regarding tobacco issues, and help set the tobacco control policy agenda. We examined US news coverage of voluntarily smokefree restaurants and bars in locales without mandatory policies to understand how such initiatives are perceived. METHODS: We searched three online media databases (Access World News, Lexis Nexis, and Proquest) for all news items, including opinion pieces, published from 1995 to 2011. We coded retrieved items quantitatively, analyzing the volume, type, provenance, prominence, and content of news coverage. RESULTS: We found 986 news items, most published in local newspapers. News items conveyed unambiguous support for voluntarily smokefree establishments, regardless of venue. Mandatory policies were also frequently mentioned, and portrayed positively or neutrally. Restaurant items were more likely to mention health-related benefits of going smokefree, with bar items more likely to mention business-related benefits. CONCLUSION: Voluntary smokefree rules in bars and restaurants are regarded by news media as reasonable responses to health and business-based concerns about worker and customer exposure to secondhand smoke. As efforts continue to enact comprehensive smokefree policies to protect all in such venues, the media are likely to be supportive partners in the advocacy process, helping to generate public and policymaker support.

"I'll be your cigarette--light me up and get on with it": examining smoking imagery on YouTube.

INTRODUCTION: Smoking imagery on the online video sharing site YouTube is prolific and easily accessed. However, no studies have examined how this content changes across time. We studied the primary message and genre of YouTube videos about smoking across two time periods. METHODS: In May and July 2009, we used "cigarettes" and "smoking cigarettes" to retrieve the top 20 videos on YouTube by relevance and view count. Eliminating duplicates, 124 videos were coded for time period, overall message, genre, and brand mentions. Data were analyzed using descriptive statistics. RESULTS: Videos portraying smoking positively far outnumbered smoking-negative videos in both samples, increasing as a percentage of total views across the time period. Fifty-eight percent of videos in the second sample were new. Among smoking-positive videos, music and magic tricks were most numerous, increasing from 66% to nearly 80% in July, with music accounting for most of the increase. Marlboro was the most frequently mentioned brand. DISCUSSION: Videos portraying smoking positively predominate on YouTube, and this pattern persists across time. Tobacco control advocates could use YouTube more effectively to counterbalance prosmoking messages.

Exploiting the "video game craze": A case study of the tobacco industry's use of video games as a marketing tool.

BACKGROUND: Video games have grown in popularity since the 1970s, and tobacco imagery is present in a substantial subset of games, including those oriented to youth. Much like exposure to tobacco content in films, exposure to tobacco content in video games may influence smoking uptake and use; however, the tobacco industry's role in facilitating or promoting the use of tobacco imagery in video games is unclear. We explored the industry's interest in and use of video games to market their products to youth and young adults. METHODS: We retrieved and analyzed archival tobacco industry documents. We supplemented information from the documents with current and archived versions of several brand and corporate websites and one website containing user-supplied information on video games. RESULTS: Tobacco companies recognized the youth appeal and marketing potential of video games as early as 1980. Initial marketing ideas included incorporating video game themes into product packaging and design. More fully realized plans focused on incorporating video games into product promotions in bars, as a high visibility way to attract younger patrons and increase long-term marketing opportunities by generating names for tobacco company direct-marketing databases. Tobacco companies also incorporated video games into in-home product promotions, primarily as components of brand websites, in order to enhance brand image and generate repeat website traffic. A similar desire to attract and keep visitors led to discussions about the inclusion of video games on corporate youth smoking prevention websites, although only one company, Lorillard, followed through. CONCLUSIONS: Video game players are an attractive target market for tobacco companies. Video games, as used by these companies, facilitate consumer engagement with particular tobacco brands or particular corporate messages. Eliminating the use of video games as a promotional vehicle may require limiting tobacco marketing in both physical and online environments.

"It Feels More Real": An Interpretive Phenomenological Study of the Meaning of Video Games in Adolescent Lives.

The pervasiveness of video gaming among adolescents today suggests a need to understand how gaming affects identity formation. We interviewed 20 adolescents about their experiences of playing, asking them to describe how they used games and how game playing affected their real-world selves. Adolescents presented a complicated developmental picture: gaming placed players into virtual worlds that felt "real"; games were used to practice multiple identities; and gaming, often undertaken within a world of hyperviolence, provided stress relief, feelings of competence, and relaxation. Gaming occurred in complex "virtual" but "real" social arenas where adolescents gathered to interact, emulate, and develop identities.

Conflicts of interest and critiques of the use of systematic reviews in policymaking: an analysis of opinion articles.

BACKGROUND: Strong opinions for or against the use of systematic reviews to inform policymaking have been published in the medical literature. The purpose of this paper was to examine whether funding sources and author financial conflicts of interest were associated with whether an opinion article was supportive or critical of the use of systematic reviews for policymaking. We examined the nature of the arguments within each article, the types of disclosures present, and whether these articles are being cited in the academic literature. METHODS: We searched for articles that expressed opinions about the use of systematic reviews for policymaking. We included articles that presented opinions about the use of systematic reviews for policymaking and categorized each article as supportive or critical of such use. We extracted all arguments regarding the use of systematic reviews from each article and inductively coded each as internal or external validity argument, categorized disclosed funding sources, conflicts of interest, and article types, and systematically searched for undisclosed financial ties. We counted the number of times each article has been cited in the "Web of Science." We report descriptive statistics. RESULTS: Articles that were critical of the use of systematic reviews (n=25) for policymaking had disclosed or undisclosed industry ties 2.3 times more often than articles that were supportive of the use (n=34). We found that editorials, comments, letters, and perspectives lacked published disclosures nearly twice as often (60% v. 33%) as other types of articles. We also found that editorials, comments, letters, and perspectives were less frequently cited in the academic literature than other article types (median number of citations=5 v. 19). CONCLUSIONS: It is important to consider whether an article has industry ties when evaluating the strength of the argument for or against the use of systematic reviews for policymaking. We found that journal conflict of interest disclosures are often inadequate, particularly for editorials, comments, letters, and perspectives and that these articles are being cited as evidence in the academic literature. Our results further suggest the need for more consistent and complete disclosure for all article types.

The effect of the internet on teen and young adult tobacco use: a literature review.

Research has shown that a positive association exists between exposure to smoking imagery, such as that found in movies and print advertising, and the subsequent uptake of cigarette smoking. Children appear to be especially vulnerable to advertising messaging and other positive portrayals of smoking, given that most adult smokers develop the habit before age 18 years. Although many traditional types of media have been studied, the current generation of youth is growing up as digital natives, with young people increasingly using the Internet for entertainment and to obtain information. Currently the Internet is an essentially unregulated marketplace of ideas and images. However, the effect of the Internet on teen smoking initiation has received little attention in studies. In this literature review, we summarize and critique the existing work, identify current knowledge gaps, and offer suggestions to health care providers about how to address this issue.

The cycle of bias in health research: a framework and toolbox for critical appraisal training.

Recognizing bias in health research is crucial for evidence-based decision making. We worked with eight community groups to develop materials for nine modular, individualized critical appraisal workshops we conducted with 102 consumers (four workshops), 43 healthcare providers (three workshops), and 33 journalists (two workshops) in California. We presented workshops using a "cycle of bias" framework, and developed a toolbox of presentations, problem-based small group sessions, and skill-building materials to improve participants' ability to evaluate research for financial and other conflicts of interest, bias, validity, and applicability. Participant feedback indicated that the adaptability of the toolbox and our focus on bias were critical elements in the success of our workshops.