Commentary: A New Generation Gets Hooked on Tobacco

Here are some known facts: When used as intended by its manufacturers, tobacco kills up to half of its regular users. Each year it costs the United States more than 440,000 lives – exceeding AIDS, alcohol, drug abuse, car crashes, murders, suicides and fires combined – and $96.8 billion in productivity losses.

Less widely understood is how young people’s attachment to new media forms, including video games, may play a part in glamorizing smoking as desirable, cool and empowering. My doctoral work is an attempt to document the relationship between playing video games and young people’s risk-taking behavior and health.

The Path to Video Game Placement

Young people start and continue to smoke for a variety of reasons, including immature brains that are highly susceptible to influences such as advertising, peer and adult behavior, proximity to stores selling cigarettes and cigarette product placement in various media.

A multitude of studies have found that one influence – viewing smoking imagery in movies – is strongly linked to increased risk for teen smoking. This led me to wonder whether other forms of smoking imagery, such as those found in video games, might have similar associations.

The tobacco industry appears to believe it does. In 2006, the last year for which information is available, the industry spent nearly $12.5 billion on cigarette advertising, or over $34 million a day. The spending was on everything from web-based activities to “viral” marketing and insertion of products into popular culture.

As the industry began this effort, young people were increasing the amount of time they spend using computers and other electronic devices. A 2008 Future Child article reported that in 1999 the average 8- to 18-year-old adolescent spent 5.7 hours using electronic media, with 26 minutes of that time spent playing video games. By 2009, a Kaiser Family Foundation study (2010) found that average daily media use had risen to 7.7 hours per day, with 60 percent of young people playing video games on any given day – and with the average time spent playing those games rising nearly threefold, to 73 minutes daily.

In addition, some believe that the active nature of video games make the effects of smoking imagery even more pronounced than they are in movies. In a large 2011 study, researchers found that risk glorification, including smoking, in various media formats was causally linked to increased risk-taking inclinations and behaviors in the real world, with the effects stronger for active media such as video games than for passive media such as film.

That’s disturbing when one considers the following “commercial” in the video game Grand Theft Auto: San Andreas, which ends with this voice-over:

Stress kills millions of people each year, and causes divorces, automobile accidents, and even war. When stress is about to get you, get a Redwood.
[sound of horse whinnying]
Redwood Cigarettes. Proud Sponsor of the LS City Marathon.

Smoking and the Video Game Experience

Though limited to date, research suggests that the prevalence of smoking imagery in video games is rising. A 2012 article in The Lancet Oncology found that in games rated as appropriate for everyone over the age of 10, reported tobacco content increased nearly 16-fold, from being in 0.8 percent of games in 2005 to 12.6 percent of games in 2011.

Moreover, the Entertainment Software Rating Board does not consistently code games with smoking imagery as portraying substance use. More than 20 percent of games rated “M” for mature – which research has suggested may make the games more attractive to all age groups – contain tobacco-related imagery. Yet according to a 2006 study, the ESRB had given only 3 percent of such games a content descriptor for substances.

In addition, the video game experience is rapidly evolving. Teens can now play games with complex graphics and story lines on a variety of platforms, from consoles and computers to handheld devices. Often, they play together in large online communities known as massively multiplayer online role-playing games. In these worlds, players can engage in rich, collaborative social interactions by creating a personal avatar.

No previous studies have qualitatively explored how adolescents experience tobacco imagery in video games, how it relates to their virtual role-playing and practice in games, and how it may influence health practices and risk decisions. This led me, in my doctoral work, to design and implement a qualitative pilot study to examine these issues with eight participants from an undergraduate college in the San Francisco Bay Area. These young people had been gaming on average for 14 years and self-reported that they currently gamed about 4.4 hours a day.

What Young Adults Told Us

Initial findings suggested that gaming was an important part of participants’ lives. The games’ immersive environments enabled these young people to practice and try on different identities, with outcomes that spilled over into the ways they perceived themselves in actual life.

This is a significant development. While historically young people’s experiments with identity were limited to changes they could make in their visual, emotional and practical presentation of self within their own physical body, the video games freed these young people to create and inhabit avatars who practice behaviors and identities unconstrained by their actual physical body’s characteristics. Most study participants reported exploring personality traits that they didn’t necessarily exhibit yet in their lives outside of the electronic worlds.

For example, one participant told me:

Definitely online…any sort of emotion…feels more real.… I mean, back in middle school, I couldn’t drive. We couldn’t – we didn’t have money to go anywhere. We couldn’t watch any movies or anything like that. So getting together in real life, even though it was thrilling, it was also kind of boring. Online, it gives you a lot more chances to, you know, have something to do, and then maybe later on when you get back together in real life, we actually have something to talk about.

Notably, smoking was ubiquitous within many of the games they played. Participants noted that virtual smoking was used as a sort of shorthand to convey coolness, rebelliousness, edginess and being grown-up.

One participant – who had played Duke Nukem, a first-person shooter game – noted that Duke, the title character, smokes a cigar throughout the game. The participant stated about Duke: “He is supposed to be the epitome of manliness.… He has a big box of them [cigars].”

Woven throughout the participants’ narratives were stories of how smoking enhanced or heightened the intended personality of the character or avatar. As a group, the participants seemed to agree that smoking should be an artistic choice of the game designer and that viewing smoking imagery is by and large harmless and should not be further regulated. They noted that smoking appears in many types of games, in a variety of social situations, and seems to be fully accepted by the participants.

Greater Understanding Is Necessary

Most of the preliminary findings from this small sample suggest that adolescents understand these social worlds within games as “real” settings to explore identities and practice behaviors. Tobacco-related imagery appears to be accepted as normal, and smoking appears to be associated with positive characteristics, including being cool, tough and strong.

To date, there has been little research establishing a relationship between interacting with smoking imagery in video games and teen smoking. Epidemiological data from 2009 estimate that 8.2 percent of US middle school students and 23.9 percent of high school students were current users of tobacco. While these rates are lower than ones in the past, they have remained essentially unchanged since 2006, despite vigorous educational efforts about smoking’s health-related dangers in schools and public awareness campaigns by the government and public interest groups.

That’s why, as more adolescents spend more time playing these games, it will become increasingly important for researchers to examine how the games’ content influences health and risk-taking behaviors. Greater understanding is essential for developing effective tobacco control strategies that address these new media influences.

Susan Forsyth is a fourth-year doctoral candidate in the Department of Social and Behavioral Sciences at UCSF School of Nursing and is interested in how new media influence health behavior and risk taking in adolescents and young adults. Chair of the Department of Social and Behavioral Sciences Ruth Malone is her doctoral advisor.