Tobacco Marketing by Stealth

1389 This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/ licenses/by-nc-nd/3.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals. Reducing the prevalence of tobacco use requires both efforts to encourage cessation among existing smokers, and to reduce uptake among young people. One area of success is the growth in restrictions on tobacco advertising in a number of countries, which now includes the introduction of standardized (also known as " plain ") tobacco packaging. However, there remain a number of relatively unregulated channels through which tobacco brands, and tobacco-related imagery more generally, can be promoted. These include social media, movies, television, and video games, among others. However, the evidence regarding the prevalence and impact of tobacco marketing via these channels is uneven; for example, there is a far larger literature on smoking in movies than in other domains. In this issue, Forsyth and Malone 1 address this gap by reviewing the literature on smoking imagery in video games. There is now substantial evidence that smoking in movies is associated with tobacco use initiation in young people 2. Much of the evidence comes from cross-sectional studies, where determining a temporal order is obviously not possible. However, there is also a growing number of prospective studies, recently summarized by Leonardi-Bee and colleagues 2 , which provide stronger support for the possibility that exposure to smoking in movies may indeed contribute to subsequent tobacco use initiation. This relationship appears to depend on the degree of exposure, with the most exposed young people 40% more likely to become smokers than the least exposed 2. Given that tobacco imagery is relatively common in movies , and therefore exposure among young people is high, it is plausible (particularly as other forms of promotion have been removed) that this exposure is now a substantial driver of tobacco use uptake. Indeed, the US Surgeon General has concluded that the evidence is sufficiently strong to conclude that there is a causal relationship between smoking in movies and tobacco use uptake in young people 3. In this context, it is likely that similar imagery in other media, such as video games, will show similar associations. Nevertheless, it is still necessary to develop an evidence …