• smoking/tobacco use
• tobacco branding
• UK films
• tobacco policy
• clinical epidemiology
• psychology
• tobacco and the lung
• asthma guidelines
• cystic fibrosis
• exhaled airway markers
• lung physiology
• paediatric asthma
• paediatric lung disease

Every day thousands of children try a cigarette for the first time, a seemingly innocuous step that for many leads to a lifelong and ultimately fatal addiction to smoking. Preventing this early experimentation is crucially important to preventing the huge toll of death and disability—particularly from respiratory diseases—that smoking causes. There is now increasing international evidence that exposure to smoking behaviour and other imagery in films is a major cause of smoking experimentation and uptake among children and young people.1–3 Three new studies in this issue of Thorax provide further evidence on this effect, this time in UK populations.

In a study of 15-year-old adolescents in the Avon birth cohort, Waylen et al4 demonstrate a direct relation between exposure to smoking in films and experimentation with smoking which remains significant even after exhaustive adjustment for potential confounders. Among Scottish adolescents exposed to smoking in films, Hunt et al5 report an exposure-related increase in the odds of smoking that was enhanced by allowance for repeated viewings. In a wider European study, Morgenstern et al6 demonstrate exposure-related increases in the odds of smoking among adolescents exposed to smoking in films in six countries, including the UK, demonstrating that this association applies across different cultural contexts and levels of implementation of other tobacco control policy. These new studies thus provide further and urgent evidence in support of calls—as yet unheeded—for a radical overhaul of film classification to protect all children and young people from this pervasive and highly damaging imagery.2 3 7–9

The British Board of Film Classification (BBFC) is an independent organisation which, in return for fees paid by film makers, allocates all UK films intended for general release into one of five age classifications (table 1).10 The BBFC lists drug misuse and dangerous imitable behaviours as examples of harmful behaviour, and both U and PG category guidance specifically proscribes ‘potentially dangerous behaviour which young children are likely to copy’.10 Smoking imagery is excluded from these categories, however, and acknowledged only, and if at all, in consumer advice printed on publicity materials and DVD cases or in extended classification information published on the BBFC website.11 As a result, as we have recently demonstrated, smoking and other forms of smoking imagery are extremely common in films classified as suitable for viewing by children and young people in the UK, and particularly so in films classified as suitable for viewing by children aged 12 and over.12

Our strong impression formed while carrying out that work is that, while some smoking in age-restricted films appears to be justified on artistic or factual grounds, the great majority is not. An example of the latter occurs in Avatar, the most popular film of all time and classified 12A in the UK, in which a lead adult character emerges from a sleeping pod in a science base on a distant planet over a century into the future to say, “Who's got my goddamn cigarette?” She then lights up and smokes throughout a conversation with other characters in a working environment in which smoking would be inconceivable even on 21st century Earth. The director of Avatar, James Cameron, justified the smoking on the grounds that ‘from a character perspective, we were showing that Grace doesn't care about her human body, only her Avatar body’.13 Another and more egregious example is Remember Me, a 2010 ‘romantic drama set in New York City during the summer of 2001 where Tyler, a rebellious young man, meets Ally through a twist of fate’.14 According to extended classification information, the original version of this film would have been classified 15 but, at the request of the makers, was awarded a 12A classification on condition of removal of two scenes—one referring to sodomy and the other considered to contain excessive violence.15 Tyler smokes repeatedly, and in one scene particularly ostentatiously,16 throughout the film.

After the publication of our study on UK film content,12 we wrote to the BBFC suggesting that current practice was failing to protect children from this particularly harmful imagery. The BBFC responded that their guidelines were ‘proportionate; take due account of the available evidence of harm; and reflect the clear wishes of the public’, citing data from a recent public consultation and pointing out that ‘any film which could potentially cause harm through encouraging smoking through tobacco imagery would be awarded an appropriate, restrictive classification’.17 At a subsequent meeting, however, the senior policy advisor who wrote the letter to us was unable to give an example of a film for which this had occurred. He also advised us that any change to current practice would be likely to provoke powerful opposition from the film industry, and was therefore unlikely to occur in the absence of public complaint or a directive from the Department for Culture, Media and Sport (DCMS), the government department that sets the fees that the BBFC charges for its services. We requested a meeting with the DCMS to explore their position and were refused in a letter stating that ‘[DCMS] believe that current safeguards are already fit for purpose’.18

At our meeting at the BBFC we raised the examples of Avatar and Remember Me, and we note that the latest BBFC Annual Report, published in June 2011, refers in detail to the Remember Me classification process.19 The report cites Remember Me as a good example of sexual content that crossed the line between implication and portrayal that results in a 12A rather than PG classification. It also remarks on two important factors relating to the smoking content: first, that Tyler was 21 and hence less identifiable with 12 year olds than previous characters played by the same actor (in the Twilight films); and second, that his smoking is constantly criticised by other characters for its health risks (p 35).19 The inconsistency and inadequacy of BBFC classification stringency in relation to these different forms of content—in which the balance between sexual portrayal and implication is finely judged, on the one hand, to be too much for a PG classification and discreet editing of language and violent content are requested and made to avoid a 15 classification, on the other, while the sustained and highly damaging imagery of a powerfully addictive and hazardous drug use throughout the film is considered acceptable for 12-year-old children to watch—is clearly evident.

BBFC classifications are not legally binding in the UK and can be overruled by Local Authorities with whom ultimate responsibility for cinema licensing lies.20 In practice, however, this rarely happens and a recent high-profile campaign to encourage Liverpool City Council to impose stricter local classifications on films containing smoking failed.21 Protecting children from an exposure that is so potentially damaging is, however, a national governmental responsibility22 and the solution to the problem is simple: for UK and indeed other film classification agencies to apply, a default 18 classification on all films containing smoking in the absence of powerful justification3 and irrespective of whether the smoking is judged by regulators to be promotional or glamorous or offset by comments from other characters. Film makers are acutely aware of classification criteria and, as the Remember Me example demonstrates, are prepared to manage film content carefully to achieve a desired age classification. If smoking content contributed to classification decisions to a similar extent to other harmful imitable behaviours, film makers wanting to reach young audiences would think twice about the necessity for smoking in films. James Cameron would have found an alternative and almost certainly more credible way to communicate his character's disdain for her body. The lead character in Remember Me would have portrayed his roguish but lovable rebelliousness without resorting to cigarettes.

This simple but radical change in the landscape of film classification needs political leadership to make it happen. Earlier in 2011 the UK government published a new Tobacco Control Plan for England23 which recognised the importance of smoking in films as a driver of uptake among young people, but as a response proposed only to work with media regulators and the entertainment industry to ‘consider what more can be done’. Our dealings with the BBFC and DCMS indicate that neither organisation is likely to consider that any change is necessary. To our knowledge, no other country has imposed mandatory adult film classification on films that contain unjustifiable smoking imagery. While at an international level the WHO Framework Convention on Tobacco Control, an international tobacco control treaty, proscribes tobacco advertising, promotion or sponsorship, it does not clearly address the problem of behavioural imagery as opposed to brand imagery in film. Therefore, in the rest of the world as in the UK, smoking in films remains a major and persistent driver of smoking uptake among children and young people which the actions of irresponsible film makers, incompetent regulators and insouciant politicians are abjectly failing to control.