Parents who monitor their child's movie choices are usually thinking language, violence, and sex. But a survey of nearly 5,000 middle-school students in New Hampshire and Vermont suggests that parents should also be watching for the role tobacco plays in the film.

Students who had seen more films in which smoking was depicted as cool, sexy, or otherwise positive, were more likely to try cigarettes themselves, wrote the authors of a study reported in the British Medical Journal (Vol. 323: 1394-1397).

The typical adolescent watching 150 films a year will see 800 depictions of smoking, noted the authors. They point out young children could see more smoking in the movies than in the real world. The end result of this extensive exposure to smoking in movies is that movies encourage young people to start smoking.

"Most parents think of violence when they think of movies, but lots of other behaviors we would not want our children to take up are depicted in a glamorous context within movies," said lead author James D. Sargent, MD, associate professor of pediatrics and adolescent medicine at Dartmouth College in New Hampshire.

The link between kids watching smoking in movies and actually trying it is so strong, Sargent said, that he would one day like to see the Motion Picture Association of America (MPAA), which rates movies, consider smoking just as they do strong language.

Sargent said he worries much more about a young child or adolescent seeing smokers than hearing actors swear. "That's not going to make him die before he turns 60," Sargent said.

Movie ratings don't list "smoking," nor do film critics. But Sargent and his co-authors found that R-rated movies were more likely to show smoking.

Not surprisingly, G-rated films had about one smoking episode in each film, while R-rated films had the highest number, about 8.5. Only one in 10 films that were rated PG or PG-13 had no smoking.

How can parents know whether a movie will show smoking in a glamorous light? "Abide by the MPAA ratings," Sargent advises parents. "No PG-13 before the kid is 13, and no R movies before the kid is 17."

Period pieces set in the 1930s to 1950s were more likely to show characters smoking, he said. Action films had a lot of smoking, and therefore boys were more likely to be exposed to more smoking because they watched more of these films, Sargent said.

And, certain stars are more likely to have a cigarette dangling from their mouths.

But it's not just a few actors, according to the article. "Although cigarette smoking is infrequent on prime-time television, it is depicted in almost all films," the authors wrote.

"The thing about smoking in the movies is it's like a cigarette commercial, because movie directors and actors use cigarettes to amplify character traits associated with smoking in cigarette advertising," Sargent said.

"Tough guys smoke in movies," he said. "Are real world smokers any tougher than non smokers? No! So the typical movie with five smoking scenes is like a two-hour TV special with five smoking ads."

"Smoking in movies is so much like advertising that I think it could be regulated," Sargent said. "I have some hope that film stars will voluntarily give up smoking [in films]."

The pervasiveness of smoking in films, and its influence on young people, is a double-whammy, said Ron Todd, director of tobacco control for the American Cancer Society.

"It's unfortunate the smoking is usually done by actors that appeal to young people and is too often shown in a positive light," Todd said. "Good actors and directors don't need cheap props like tobacco to establish a character."

What can be done? In an editorial in the same journal, Stanton Glantz, MD, professor of medicine at University of California in San Francisco and a longtime foe of the tobacco industry, wrote that teenagers in the US are not the only victims. Films made in Hollywood offer a major marketing vehicle for the tobacco industry worldwide.

"It is time for the entertainment industry to accept responsibility for its actions and stop serving the interests of tobacco companies," wrote Glantz.

To accomplish this goal, Glantz recommended several steps that the film industry could take:

• Certify that there was no payment to the producers in exchange for using or displaying tobacco.
• Display a strong anti-tobacco advertisement before any film that contains smoking; also in the DVD, video, and TV releases.
• Stop identifying brands.
• Rate any films with smoking as “R”.