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A Meta-analysis

Robert J. Wellman, PhD; David B. Sugarman, PhD; Joseph R. DiFranza, MD; Jonathan P. Winickoff, MD, MPH

Arch Pediatr Adolesc Med. 2006;160:1285-1296.

Objective  To quantify the effect of exposure on initiation of tobacco use among adolescents.

Data Sources  A systematic literature search of MEDLINE, PsychINFO, ABI/INFORM, and Business Source Premier through October/November 2005 was conducted. Unpublished studies were solicited from researchers.

Study Selection  Of 401 citations initially identified, 51 (n = 141 949 participants) met the inclusion criteria: reporting on exposure and tobacco use outcomes and participants younger than 18 years. Included studies reported 146 effects; 89 were conceptually independent effects. Data were extracted independently by 3 of us using a standardized tool. Weighted averages were calculated using a linear mixed-effects model. Heterogeneity and publication bias were assessed.

Main Exposures  Exposures (tobacco advertising, promotions, and samples and pro-tobacco depictions in films, television, and videos) were categorized as low or high engagement based on the degree of psychological involvement required.

Main Outcome Measures  Outcomes were categorized as cognitive (attitudes or intentions) or behavioral (initiation, tobacco use status, or progression of use).

Results  Exposure to pro-tobacco marketing and media increases the odds of youth holding positive attitudes toward tobacco use (odds ratio, 1.51; 95% confidence interval, 1.08-2.13) and more than doubles the odds of initiating tobacco use (odds ratio, 2.23; 95% confidence interval, 1.79-2.77). Highly engaging marketing and media are more effective at promoting use (odds ratio, 2.67; 95% confidence interval, 2.19-3.25). These effects are observed across time, in different countries, with different study designs and measures of exposure and outcome.

Conclusions  Pro-tobacco marketing and media stimulate tobacco use among youth. A ban on all tobacco promotions is warranted to protect children.

Author Affiliations: Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester (Drs Wellman and DiFranza); Department of Behavioral Sciences, Fitchburg State College, Fitchburg, Mass (Dr Wellman); Department of Psychology, Rhode Island College, Providence (Dr Sugarman); and Center for Child and Adolescent Health Policy, Massachusetts General Hospital, Boston (Dr Winickoff).

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