Associations between advertisement-supported media exposure and dietary quality among preschool-age children.

Foods of low nutritional quality are heavily marketed to children, and exposure to food ads shapes children's preferences and intake towards advertised foods. Whether food ad exposure independently relates to an overall lower diet quality among children remains unclear. We examined the association between ad-supported media use, a proxy for food ad exposure, and diet quality using the baseline data (2014-2015) from 535 3-5-year-olds in a community-based cohort study. Parents reported their child's dietary intake over 3 days via a diary, and diet quality was assessed with the Healthy Eating Index (HEI-2015) where higher scores reflect greater adherence to USDA dietary guidelines. Children's media exposure was measured through online parent surveys. Mean HEI score was 54.5 (SD = 9.4). In models adjusted for sociodemographic characteristics and metrics of parent diet quality, children's HEI scores were 0.5 points lower (adjusted beta = -0.5 [95% CI: 0.8, -0.1]; P < 0.01) for each 1-h increment in weekly viewing of ad-supported children's TV networks. Children's use of media that may have food ads (e.g., apps, online games) also related to a lower diet quality yet to a lesser extent (adjusted beta -0.2 [-0.2, -0.1]; P < 0.01). In contrast, children's ad-free media use was not associated with diet quality (P = 0.21). Findings support the premise that exposure to food advertisements via media may result in a lower quality diet among children independently of other risk factors.

Influence of child-targeted fast food TV advertising exposure on fast food intake: A longitudinal study of preschool-age children.

INTRODUCTION: Fast food (FF) advertising is a potential risk factor for FF consumption among children, yet the impact of such advertising on children's FF intake has not been assessed in a longitudinal, naturalistic study. Whether parents' FF consumption mitigates advertising effects is also unknown. METHODS: One-year, longitudinal study among 624 preschool-age children, 3-5 years old, and one parent each recruited from New Hampshire, 2014-2015. Parents completed six online surveys every eight weeks and, at each, reported the number of times their children consumed FF in the past week. Each child's advertisement exposure was determined by counting the brand-specific FF advertisements aired within the programs they viewed on children's TV networks during the study. At baseline, parents reported the frequency of their own FF consumption. Data were analyzed in 2017-2018. RESULTS: Three FF brands targeted TV advertising to children during the study: McDonald's, Wendy's and Subway. Few children were exposed to child-targeted advertising for Wendy's or Subway. Results from adjusted Poisson regression models focused on McDonald's showed a differential effect of advertisement exposure on children's McDonald's intake in the past week (any or mean intake) by parental FF consumption (P < 0.01). Specifically, McDonald's intake was consistently high among children whose parents consumed FF more frequently (≥monthly), regardless of children's advertisement exposure. However, advertisement exposure increased the risk of McDonald's intake among children nearly two-fold when parents consumed FF less frequently (

Child-targeted fast-food television advertising exposure is linked with fast-food intake among pre-school children.

OBJECTIVE: To determine whether exposure to child-targeted fast-food (FF) television (TV) advertising is associated with children's FF intake in a non-experimental setting. DESIGN: Cross-sectional survey conducted April-December 2013. Parents reported their pre-school child's TV viewing time, channels watched and past-week FF consumption. Responses were combined with a list of FF commercials (ads) aired on children's TV channels during the same period to calculate children's exposure to child-targeted TV ads for the following chain FF restaurants: McDonald's, Subway and Wendy's (MSW). SETTING: Paediatric and Women, Infants, and Children (WIC) clinics in New Hampshire, USA. SUBJECTS: Parents (n 548) with a child of pre-school age. RESULTS: Children's mean age was 4·4 years; 43·2 % ate MSW in the past week. Among the 40·8 % exposed to MSW ads, 23·3 % had low, 34·2 % moderate and 42·5 % high exposure. McDonald's accounted for over 70 % of children's MSW ad exposure and consumption. Children's MSW consumption was significantly associated with their ad exposure, but not overall TV viewing time. After adjusting for demographics, socio-economic status and other screen time, moderate MSW ad exposure was associated with a 31 % (95 % CI 1·12, 1·53) increase and high MSW ad exposure with a 26 % (95 % CI 1·13, 1·41) increase in the likelihood of consuming MSW in the past week. Further adjustment for parent FF consumption did not change the findings substantially. CONCLUSIONS: Exposure to child-targeted FF TV advertising is positively associated with FF consumption among children of pre-school age, highlighting the vulnerability of young children to persuasive advertising and supporting recommendations to limit child-directed FF marketing.

Child-targeted TV advertising and preschoolers' consumption of high-sugar breakfast cereals.

Breakfast cereals represent the most highly advertised packaged food on child-targeted television, and most ads are for cereals high in sugar. This study examined whether children's TV exposure to child-targeted, high-sugar breakfast cereal (SBC) ads was associated with their consumption of those SBC brands. Parents of 3- to 5-year-old children were recruited from pediatric and Women, Infants, and Children (WIC) clinics in Southern New Hampshire, USA, and completed a cross-sectional survey between April-December 2013. Parents reported their child's consumption of SBC brands; whether their child had watched any of 11 kids' channels in the past week; their child's TV viewing time; and socio-demographics. Children's exposure to child-targeted SBC TV ads was calculated by combining TV channel and viewing time with advertising data for SBC ads aired on kids' TV channels during the same timeframe. Five hundred forty-eight parents completed surveys; 52.7% had an annual household income of $50,000 or less. Children's mean age was 4.4 years, 51.6% were female, and 72.5% were non-Hispanic white. In the past week, 56.9% (N = 312) of children ate SBCs advertised on kids' channels. Overall, 40.6% of children were exposed to child-targeted SBC TV ads in the past week. In fully adjusted analyses, the number of SBC brands children consumed was positively associated with their exposure to child-targeted SBC ads. Children consumed 14% (RR = 1.14, 95% CI: 1.02, 1.27) more SBC brands for every 10 SBC ads seen in the past 7 days. Exposure to child-targeted SBC TV advertising is positively associated with SBC brand consumption among preschool-aged children. These findings support recommendations to limit the marketing of high-sugar foods to young children.

A toy story: Association between young children's knowledge of fast food toy premiums and their fast food consumption.

Fast food restaurants spend millions of dollars annually on child-targeted marketing, a substantial portion of which is allocated to toy premiums for kids' meals. The objectives of this study were to describe fast food toy premiums, and examine whether young children's knowledge of fast food toy premiums was associated with their fast food consumption. Parents of 3- to 5-year old children were recruited from pediatric and WIC clinics in Southern New Hampshire, and completed a cross-sectional survey between April 2013-March 2014. Parents reported whether their children usually knew what toys were being offered at fast food restaurants, and whether children had eaten at any of four restaurants that offer toy premiums with kids' meals (McDonald's, Burger King, Subway, Wendy's) during the 7 days preceding the survey. Seventy-one percent of eligible parents participated (N = 583); 48.4% did not receive any education beyond high school, and 27.1% of children were non-white. Half (49.7%) the children had eaten at one or more of the four fast food restaurants in the past week; one-third (33.9%) had eaten at McDonald's. The four restaurants released 49 unique toy premiums during the survey period; McDonald's released half of these. Even after controlling for parent fast food consumption and sociodemographics, children were 1.38 (95% CI = 1.04, 1.82) times more likely to have consumed McDonald's if they usually knew what toys were offered by fast food restaurants. We did not detect a relationship between children's toy knowledge and their intake of fast food from the other restaurants. In this community-based sample, young children's knowledge of fast food toys was associated with a greater frequency of eating at McDonald's, providing evidence in support of regulating child-directed marketing of unhealthy foods using toys.

School food reduces household income disparities in adolescents' frequency of fruit and vegetable intake.

OBJECTIVE: The aim of this study is to examine whether school food attenuates household income-related disparities in adolescents' frequency of fruit and vegetable intake (FVI). METHOD: Telephone surveys were conducted between 2007 and 2008 with adolescent-parent dyads from Northern New England; participants were randomly assigned to be surveyed at different times throughout the year. The main analysis comprised 1542 adolescents who typically obtained breakfast/lunch at school at least once/week. FVI was measured using 7-day recall of the number of times adolescents consumed fruits and vegetables. Fully adjusted linear regression was used to compare FVI among adolescents who were surveyed while school was in session (currently exposed to school food) to those who were surveyed when school was not in session (currently unexposed to school food). RESULTS: Mean FVI was 8.0 (SD=5.9) times/week. Among adolescents unexposed to school food, household income and FVI were strongly, positively associated. In contrast, among adolescents exposed to school food, FVI was similar across all income categories. We found a significant cross-over interaction between school food and household income in which consuming food at school was associated with higher FVI among adolescents from low-income households versus lower FVI among adolescents from high-income households. CONCLUSION: School food may mitigate income disparities in adolescent FVI. The findings suggest that the school food environment positively influences FVI among low-income adolescents.

Factors Correlated With Ultra-Processed Food (UPF) Intake in Preschool-Aged Children and Association With Weight.

OBJECTIVE: Understand the correlates of ultra-processed food (UPF) intake and examine the association of UPF on body mass index in children aged 3-5 years. DESIGN: Secondary analysis of a prospective cohort of 3-5-year-olds/parent, followed 1-year between March 2014 and October 2016. Usual UPF intake from 2 3-day food records completed 1 year apart, a standardized nutrient database customized with child-specific foods, and a NOVA food classification system was used. Child/parent characteristics and media use were measured via parent-reported surveys. Child weight/height objectively measured. SETTING: New Hampshire community. PARTICIPANTS: Six hundred and sixty-seven parent-child dyads were screened, and 624 were enrolled with 90% follow-up. MAIN OUTCOME MEASURE(S): Primary outcome: identify correlates of UPF intake. SECONDARY OUTCOME: determine if UPF intake is associated with body mass index change. ANALYSIS: Adjusted ß linear regression, linear regression, P <0.05. RESULTS: Ultra-processed food accounted for 67.6% of total caloric intake. In adjusted models, children's UPF intake was positively associated with increasing child age, greater hours watching television, and more frequent parent soda/fast-food intake. Ultra-processed food intake was negatively associated with higher parent education and reported race/ethnicity other than non-Hispanic White. There was no association between UPF intake and weight. CONCLUSIONS AND IMPLICATIONS: There are several predictors of UPF intake in young children. Family-level interventions could be implemented to encourage the intake of minimally processed foods before and during preschool years.

Smart density: A more accurate method of measuring rural residential density for health-related research.

BACKGROUND: Studies involving the built environment have typically relied on US Census data to measure residential density. However, census geographic units are often unsuited to health-related research, especially in rural areas where development is clustered and discontinuous. OBJECTIVE: We evaluated the accuracy of both standard census methods and alternative GIS-based methods to measure rural density. METHODS: We compared residential density (units/acre) in 335 Vermont school neighborhoods using conventional census geographic units (tract, block group and block) with two GIS buffer measures: a 1-kilometer (km) circle around the school and a 1-km circle intersected with a 100-meter (m) road-network buffer. The accuracy of each method was validated against the actual residential density for each neighborhood based on the Vermont e911 database, which provides an exact geo-location for all residential structures in the state. RESULTS: Standard census measures underestimate residential density in rural areas. In addition, the degree of error is inconsistent so even the relative rank of neighborhood densities varies across census measures. Census measures explain only 61% to 66% of the variation in actual residential density. In contrast, GIS buffer measures explain approximately 90% of the variation. Combining a 1-km circle with a road-network buffer provides the closest approximation of actual residential density. CONCLUSION: Residential density based on census units can mask clusters of development in rural areas and distort associations between residential density and health-related behaviors and outcomes. GIS-defined buffers, including a 1-km circle and a road-network buffer, can be used in conjunction with census data to obtain a more accurate measure of residential density.

Fast food intake and excess weight gain over a 1-year period among preschool-age children.

BACKGROUND: Fast food is cross-sectionally associated with having overweight and obesity in young children. OBJECTIVES: To examine whether fast food intake independently contributes to the development of overweight and obesity among preschool-age children. METHODS: Prospective cohort of 3- to 5-year-old children (n = 541) followed for 1 year. Children's height and weight were objectively measured at baseline and study end. Parents reported their child's fast food intake frequency in the past week from 11 chain fast food restaurants in six online follow-up surveys, completed approximately 8 weeks apart. Poisson regression with robust standard errors modelled the risk of a child increasing in weight status (ie, transitioning from a having a healthy weight to having overweight or from having overweight to having obesity) over the study period in relation to their average weekly fast food intake, adjusted for sociodemographics, child obesogenic behaviours, and parent weight status. RESULTS: At baseline, 18.1% of children had overweight and 9.8% had obesity; 8.1% of children transitioned to a greater weight status over the 1-year period. Mean fast food intake frequency among consumers was 2.1 (SD: 1.4) times per week. The risk of increasing in weight status increased linearly with each additional time fast food was consumed in an average week over the study year (RR: 1.38; 95% CI, 1.13-1.67; P < .01). CONCLUSIONS: Greater fast food intake over 1 year was associated with increasing weight status during that time in this preschool-age cohort.

Tobacco, alcohol, and other risk behaviors in film: how well do MPAA ratings distinguish content?

To evaluate the usefulness of Motion Picture Association of America (MPAA) ratings for parental selection of appropriate films for children, the 100 top grossing movies each year from 1996 through 2004 (N = 900) were content analyzed to measure risk behaviors in each film. More restrictive MPAA ratings (R and PG-13) were associated with increased mean seconds of portrayals of tobacco use, alcohol use, and sexual content; increased frequency of violent content; and increased salience of drug use. MPAA ratings, however, did not clearly distinguish films based on tobacco or alcohol use. Fifty percent of R-rated movies contained 124 seconds or more of tobacco use, comparable with 26% of PG-13 and 17% of PG movies. Fifty percent of R-rated movies contained 162 seconds or more of alcohol use, comparable with 49% of PG-13 and 25% of PG movies. Because of the high degree of overlap in alcohol and tobacco content between rating categories, the MPAA rating system, as currently defined, is not adequate for parents who wish to limit their children's exposure to tobacco or alcohol content in movies.

Media exposure and marijuana and alcohol use among adolescents.

We aimed to determine which media exposures are most strongly associated with marijuana and alcohol use among adolescents. In 2004, we surveyed 1,211 students at a large high school in suburban Pittsburgh regarding substance use, exposure to entertainment media, and covariates. Of the respondents, 52% were female, 8% were non-White, 27% reported smoking marijuana, and 60% reported using alcohol. They reported average exposure to 8.6 hr of media daily. In adjusted models, exposure to music was independently associated with marijuana use, but exposure to movies was independently associated with alcohol use. Implications, limitations, and suggestions for further research are discussed.

Exposure to Child-Directed TV Advertising and Preschoolers' Intake of Advertised Cereals.

INTRODUCTION: Child-directed TV advertising is believed to influence children's diets, yet prospective studies in naturalistic settings are absent. This study examined if child-directed TV advertisement exposure for ten brands of high-sugar breakfast cereals was associated with children's intake of those brands prospectively. METHODS: Observational study of 624 preschool-age children and their parents conducted in New Hampshire, 2014-2015. Over 1 year, parents completed a baseline and six online follow-up surveys, one every 8 weeks. Children's exposure to high-sugar breakfast cereal TV advertisements was based on the network-specific TV programs children watched in the 7 days prior to each follow-up assessment, and parents reported children's intake of each advertised high-sugar breakfast cereal brand during that same 7-day period. Data were analyzed in 2017-2018. RESULTS: In the fully adjusted Poisson regression model accounting for repeated measures and brand-specific effects, children with high-sugar breakfast cereal advertisement exposure in the past 7 days (i.e., recent exposure; RR=1.34, 95% CI=1.04, 1.72), at any assessment in the past (RR=1.23, 95% CI=1.06, 1.42), or recent and past exposure (RR=1.37, 95% CI=1.15, 1.63) combined had an increased risk of brand-specific high-sugar breakfast cereal intake. Absolute risk difference of children's high-sugar breakfast cereal intake because of high-sugar breakfast cereal TV advertisement exposure varied by brand. CONCLUSIONS: This naturalistic study demonstrates that child-directed high-sugar breakfast cereal TV advertising was prospectively associated with brand-specific high-sugar breakfast cereal intake among preschoolers. Findings indicate that child-directed advertising influences begin earlier and last longer than previously demonstrated, highlighting limitations of current industry guidelines regarding the marketing of high-sugar foods to children under age 6 years.

Degrading and non-degrading sex in popular music: a content analysis.

OBJECTIVES: Those exposed to more degrading sexual references in popular music are more likely to initiate intercourse at a younger age. The purpose of this study was to perform a content analysis of contemporary popular music with particular attention paid to the prevalence of degrading and non-degrading sexual references. We also aimed to determine if sexual references of each subtype were associated with other song characteristics and/or content. METHODS: We used Billboard magazine to identify the top popular songs in 2005. Two independent coders each analyzed all of these songs (n = 279) for degrading and non-degrading sexual references. As measured with Cohen's kappa scores, inter-rater agreement on degrading vs. non-degrading sex was substantial. Mentions of substance use, violence, and weapon carrying were also coded. RESULTS: Of the 279 songs identified, 103 (36.9%) contained references to sexual activity. Songs with references to degrading sex were more common than songs with references to non-degrading sex (67 [65.0%] vs. 36 [35.0%], p < 0.001). Songs with degrading sex were most commonly Rap (64.2%), whereas songs with non-degrading sex were most likely Country (44.5%) or Rhythm & Blues/Hip-Hop (27.8%). Compared with songs that had no mention of sexual activity, songs with degrading sex were more likely to contain references to substance use, violence, and weapon carrying. Songs with non-degrading sex were no more likely to mention these other risk behaviors. CONCLUSIONS: References to sexual activity are common in popular music, and degrading sexual references are more prevalent than non-degrading references. References to degrading sex also frequently appear with references to other risky behaviors.

Improving measurement of normative beliefs involving smoking among adolescents.

OBJECTIVES: To identify different components of smoking normative beliefs and determine if each component is independently associated with 2 clinically relevant measures of smoking in adolescents. DESIGN: Cross-sectional survey. SETTING: One large suburban high school. PARTICIPANTS: A total of 1211 high school students aged 14 to 18 years. OUTCOME MEASURES: Current smoking and susceptibility to smoking. RESULTS: Of the 1138 students with data on current smoking, 216 (19.0%) reported current smoking, and 342 (38.3%) of the 893 nonsmoking students with susceptibility data were susceptible to future smoking. Factor analysis identified 3 normative belief constructs, labeled "perceived prevalence of smoking," "perceived popularity of smoking among elite/successful elements of society," and "disapproval of smoking by parents/peers." On average, students believed that 56% of people in the United States smoke cigarettes; 27.7% believed that wealthy people smoke more than poor people. Multiple logistic regression showed that each of the 3 constructs was independently associated with current smoking (adjusted odds ratios, 1.05 [95% confidence interval {CI}, 1.02-1.08], 1.12 [95% CI, 1.02-1.23], and 0.66 [95% CI, 0.59-0.75], respectively), even after controlling for covariates. Students' perceptions of smoking among the successful/elite and disapproval by parents/peers were independently associated with susceptibility to future smoking (adjusted odds ratios, 1.20 [95% CI, 1.11-1.29] and 0.87 [95% CI, 0.79-0.96], respectively). CONCLUSIONS: Adolescents' normative beliefs about smoking are multidimensional and include at least 3 distinct components, each of which was independently related to smoking outcomes. These distinct components should be considered in the design and evaluation of programs related to prevention and cessation of adolescent smoking.

Effect of viewing smoking in movies on adolescent smoking initiation: a cohort study.

BACKGROUND: Exposure to smoking in movies has been linked with adolescent smoking initiation in cross-sectional studies. We undertook a prospective study to ascertain whether exposure to smoking in movies predicts smoking initiation. METHOD: We assessed exposure to smoking shown in movies in 3547 adolescents, aged 10-14 years, who reported in a baseline survey that they had never tried smoking. Exposure to smoking in movies was estimated for individual respondents on the basis of the number of smoking occurrences viewed in unique samples of 50 movies, which were randomly selected from a larger sample pool of popular contemporary movies. We successfully re-contacted 2603 (73%) students 13-26 months later for a follow-up interview to determine whether they had initiated smoking. FINDINGS: Overall, 10% (n=259) of students initiated smoking during the follow-up period. In the highest quartile of exposure to movie smoking, 17% (107) of students had initiated smoking, compared with only 3% (22) in the lowest quartile. After controlling for baseline characteristics, adolescents in the highest quartile of exposure to movie smoking were 2.71 (95% CI 1.73-4.25) times more likely to initiate smoking compared with those in the lowest quartile. The effect of exposure to movie smoking was stronger in adolescents with non-smoking parents than in those whose parent smoked. In this cohort, 52.2% (30.0-67.3) of smoking initiation can be attributed to exposure to smoking in movies. INTERPRETATION: Our results provide strong evidence that viewing smoking in movies promotes smoking initiation among adolescents.

Use of cigarettes and alcohol by preschoolers while role-playing as adults: "Honey, have some smokes".

OBJECTIVE: To examine preschoolers' attitudes, expectations, and perceptions of tobacco and alcohol use. DESIGN: Structured observational study. Children used props and dolls to act out a social evening for adults. As part of the role play, each child selected items from a miniature grocery store stocked with 73 different products, including beer, wine, and cigarettes, for an evening with friends. SETTING: A behavioral laboratory at the Department of Psychological and Brain Sciences, Dartmouth College. PATIENTS: One hundred twenty children, 2 to 6 years old, participated individually in the role-playing. MAIN OUTCOME MEASURE: Whether or not a child purchased cigarettes or alcohol at the store. RESULTS: Children purchased a mean of 17 of the 73 products in the store. Thirty-four children (28.3%) bought cigarettes and 74 (61.7%) bought alcohol. Children were more likely to buy cigarettes if their parents smoked (adjusted odds ratio [OR], 3.90; 95% confidence interval [CI], 1.20-12.63). Children were more likely to buy beer or wine if their parents drank alcohol at least monthly (adjusted OR, 3.04; 95% CI, 1.02-9.10) or if they viewed PG-13- or R-rated movies (adjusted OR, 5.10; 95% CI, 1.14-22.90). Children's play behavior suggests that they are highly attentive to the use and enjoyment of alcohol and tobacco and have well-established expectations about how cigarettes and alcohol fit into social settings. CONCLUSIONS: The data suggest that observation of adult behavior, especially parental behavior, may influence preschool children to view smoking and drinking as appropriate or normative in social situations. These perceptions may relate to behaviors adopted later in life.

Modifying exposure to smoking depicted in movies: a novel approach to preventing adolescent smoking.

BACKGROUND: Most behavioral approaches to adolescent smoking address the behavior directly. We explore an indirect approach: modifying exposure to portrayals of smoking in movies. OBJECTIVES: To describe adolescents' exposure to smoking in movies and to examine factors that could modify such exposure. DESIGN: Occurrences of smoking were counted in each of 601 popular movies. Four thousand nine hundred ten northern New England junior high school students were asked to report which movies they had seen from a randomly generated subsample of 50 films, and responses were used to estimate exposure to the entire sample. Analysis The outcome variable was exposure to movie smoking, defined as the number of smoking occurrences seen. Risk factors for exposure included access to movies (movie channels, videotape use, and movie theater); parenting (R [restricted]-rated movie restrictions, television restrictions, parenting style); and characteristics of the child (age, sex, school performance, sensation-seeking propensity, rebelliousness, and self-esteem). We used multiple regression to assess the association between risk factors and exposure to movie smoking. RESULTS: Subjects had seen an average of 30% of the movie sample (interquartile range, 20%-44%), from which they were exposed to 1160 (interquartile range, 640-1970) occurrences of smoking. In a multivariate model, 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. There was no association between parenting style and exposure to movie smoking. Much of the protective effect of parent R-rated movie restriction on adolescent smoking was mediated through lower exposure to movie smoking. CONCLUSIONS: Adolescents see thousands of smoking depictions in movies, and this influences their attitudes and behavior. Exposure to movie smoking is reduced when parents limit movie access. Teaching parents to monitor and enforce movie access guidelines could reduce adolescent smoking in an indirect, yet powerful, manner.

Viewing tobacco use in movies: does it shape attitudes that mediate adolescent smoking?

BACKGROUND: Social cognitive theory posits that children develop intentions and positive expectations (utilities) about smoking prior to initiation. These attitudes and values result, in part, from observing others modeling the behavior. This study examines, for the first time, the association between viewing tobacco use in movies and attitudes toward smoking among children who have never smoked a cigarette. DESIGN/SETTING: Cross-sectional school-based survey was used among randomly selected Vermont and New Hampshire middle schools. The sample consisted of 3766 middle school students (grades 5-8). The sample was primarily white and equally distributed by gender. The primary exposure was number of movie tobacco-use occurrences viewed. We first counted occurrences of tobacco use in each of 601 recent popular motion pictures. Each student was asked to select movies they had seen from a random subset of 50 movies. Based on movies the adolescent had seen, movie tobacco-use occurrences were summed to determine exposure . The outcome was susceptibility to smoking, positive expectations, and perceptions of smoking as normative behavior for adolescents or adults. RESULTS: The movies in this sample contained a median of five occurrences of tobacco use (interquartile range=1, 12). The typical adolescent never-smoker had viewed 15 of the 50 movies on his/her list. From movies adolescents reported seeing, exposure to movie tobacco-use occurrences varied widely: median=80, and interquartile range 44 to 136. The prevalence of susceptibility to smoking increased with higher categories of exposure: 16% among students who viewed 0 to 50 movie tobacco occurrences; 21% (51 to 100); 28% (101 to 150); and 36% (>150). The association remained statistically significant after controlling for gender, grade in school, school performance, school, friend, sibling and parent smoking, sensation-seeking, rebelliousness, and self-esteem. Compared with adolescents exposed to < or =50 occurrences of tobacco use, the adjusted odds ratio of susceptibility to smoking for each higher category was 1.2 (95% confidence interval 0.9, 1.5), 1.4 (1.1, 1.9), and 1.6 (1.3, 2.1), respectively. Similarly, higher exposure to tobacco use in movies significantly increased the number of positive expectations endorsed by the adolescent and the perception that most adults smoke, but not the perception that most peers smoke. CONCLUSIONS: This study provides empirical evidence that viewing movie depictions of tobacco use is associated with higher receptivity to smoking prior to trying the behavior.

Adolescent exposure to extremely violent movies.

PURPOSE: To determine exposure of young adolescents to extremely violent movies. DESIGN: Cross-sectional school-based survey of middle school students at 15 randomly selected New Hampshire and Vermont middle schools. Each survey contained a unique list of 50 movies, randomly selected from 603 top box office hits from 1988 to 1999, 51 of which were determined by content analysis to contain extremely violent material. Movie titles only were listed, and adolescents were asked to indicate which ones they had seen. Each movie appeared on approximately 470 surveys. We calculated the percentage of students who had seen each movie for a representative subsample of the student population. We also examined characteristics associated with seeing at least one extremely violent movie. Complete survey information was obtained from 5,456 students. The sample was primarily white and equally distributed by gender. RESULTS: On average, extremely violent movies were seen by 28% of the students in the sample (range 4% to 66%). The most popular movie, Scream, was seen by two-thirds of students overall and over 40% of fifth-graders. Other movies with sexualized violent content were seen by many of these adolescents. Examples include The General's Daughter (rated R for "graphic images related to sexual violence including a rape scene and perverse sexuality") and Natural Born Killers (rated R for "extreme violence and graphic carnage, shocking images, language, and sexuality"), seen by 27% and 20%, respectively. Older students, males, those of lower socioeconomic status, and those with poorer school performance were all significantly more likely to have seen at least one extremely violent movie. CONCLUSION: This study documents widespread exposure of young adolescents to movies with brutal, and often sexualized, violence. Given that many of these films were marketed to teens, better oversight of the marketing practices of the film industry may be warranted.

Two-method measurement for adolescent obesity epidemiology: reducing the bias in self-report of height and weight.

BACKGROUND: Despite validation studies demonstrating substantial bias, epidemiologic studies typically use self-reported height and weight as primary measures of body mass index because of feasibility and resource limitations. PURPOSE: To demonstrate a method for calculating accurate and precise estimates that use body mass index when objectively measuring height and weight in a full sample is not feasible. METHODS: As part of a longitudinal study of adolescent health, 1,840 adolescents (ages 12-18) self-reported their height and weight during telephone surveys. Height and weight was measured for 407 of these adolescents. Sex-specific, age-adjusted obesity status was calculated from self-reported and from measured height and weight. Prevalence and predictors of obesity were estimated using self-reported data, measured data, and multiple imputation (of measured data). RESULTS: Among adolescents with self-reported and measured data, the obesity prevalence was lower when using self-report compared with actual measurements (p < .001). The obesity prevalence from multiple imputation (20%) was much closer to estimates based solely on measured data (20%) compared with estimates based solely on self-reported data (12%), indicating improved accuracy. In multivariate models, estimates of predictors of obesity were more accurate and approximately as precise (similar confidence intervals) as estimates based solely on self-reported data. CONCLUSIONS: The two-method measurement design offers researchers a technique to reduce the bias typically inherent in self-reported height and weight without needing to collect measurements on the full sample. This technique enhances the ability to detect real, statistically significant differences, while minimizing the need for additional resources.