Exclusive: Report finds TV tobacco imagery persists, and says young viewers turn to vaping

Bill Keveney

When young viewers see smoking on television, it can increase the likelihood they will try e-cigarettes, according to a first-of-its-kind study, part of a new report on tobacco and smoking imagery on TV.

The study, published in the scholarly journal Preventive Medicine and referenced in the third annual report on TV and smoking by public health group Truth Initiative, says young viewers with the highest exposure to TV tobacco depictions can be three times as likely to start vaping as those who don't.

It did not find a significant connection between viewing and traditional smoking, but it suggests that may be due statistically to low smoking rates among young people, for whom vaping is their primary choice of nicotine.

Truth Initiative's "Straight to Vape," obtained exclusively by USA TODAY, also finds tobacco and smoking depictions in the most popular shows for young people appear to be rising since the group's first While You Were Streaming reports in 2018 and 2019. Nearly three-quarters of shows popular with young people studied feature tobacco/smoking images.

Netflix's "Stranger Things," the '80s period horror drama, recorded 721 tobacco-related incidents in last year's Season 3, by far the most of any show included in the report and about four times the number of images recorded in its first season in 2016.

The streaming service last year adopted a tobacco-free policy for new shows aimed at younger audiences (14 or under), but the new edict doesn't apply to current series and includes exceptions for "creative vision" and historical accuracy.

Police chief Jim Hopper (David Harbour) confronts Jonathan Byers (Charlie Heaton) in Netflix's "Stranger Things." Once again, the period horror series recorded the most instances of smoking among shows popular with young people in a report released by anti-smoking group Truth Initiative.

The report also singles out first-season HBO teen drama "Euphoria" for the most e-cigarette depictions (67) in shows studied in 2018 and 2019.

Concerns about tobacco images and their behavioral effects are magnified amid the coronavirus pandemic as young people have had more time to binge shows, Truth Initiative president and CEO Robin Koval says.  The report also cites new research that finds people who vape are five times more likely to be diagnosed with COVID-19.

"We now know that imagery influences young people to vape, we're in the middle of a pandemic where we know that vaping makes young people more vulnerable and young people are watching more content than ever before," Koval says. "We've got a bit of a perfect storm here."

The latest While You Were Streaming report includes data from a study of 4,604 young viewers, ages 15 to 24, published in Preventive Medicine that finds a link between TV smoking depictions and e-cigarette use. Such behavior may start at an earlier age, too.

Jules (Hunter Schafer, left) and Rue (Zendaya) are best friends and love interests in Season 1 of HBO's 'Euphoria,' which had 67 depictions of e-cigarettes/vaping over eight episodes, according to a new report by Truth Initiative.

E-cigarettes, which generally contain nicotine and are considered especially unsafe for children, teens and young adults by the Centers for Disease Control and Prevention, are the dominant form of nicotine use among young people. (The CDC says e-cigarettes can benefit smokers who use them as a substitute for regular cigarettes.)

The report says usage among high school students rose from 11.7% in 2017 to 27.5% in 2019, compared with traditional cigarette smoking levels that dropped from 23% in 2000 to 5.4% in 2017, according to a study sponsored by the National Institute on Drug Abuse.

The 2020 While You Were Streaming report, which continues the practice of tracking the 15 most popular shows with youths and young adults based on ratings, social media mentions and the preferences of those surveyed, finds traditional smoking, from a character puffing on a cigarette to a power wall of convenience-store brands, remains the dominant depiction, but vaping images are on the rise.

Season 3 of "Stranger Things," which focuses on supernatural events in a small Indiana town in the 1980s, featured more than three times as many tobacco depictions as any show tracked in 2018 and 2019. Showtime's "Shameless" came in a distant second with 226 incidents, and three animated series, Fox's "The Simpsons" and "Family Guy" and Netflix's "Big Mouth," each featured more than 50 examples.

Koval says that "Stranger Things" is going "in the wrong direction" and that the Netflix ban on smoking and e-cigarette images announced last year contains "big loopholes."

In a statement, Netflix said: "We are committed to reducing smoking in our content. This year the lion's share of our new youth-rated shows had no smoking. But given our production schedules it will take time. We're the first entertainment company to feature information about smoking in the ratings for our members.”

Showtime declined to comment.

Overall, a review of 277 episodes from 15 shows released in 2018 found 576 tobacco/smoking incidents. In 152 episodes studied from 2019's top 15, researchers counted 1,156 incidents.

Vaping images are also on the rise, the report says. In addition to the 67 seen on HBO's "Euphoria," which follows high school students dealing with drugs, sex, trauma and social media, shows featuring e-cigarette depictions in 2019 include four on Netflix – “Big Mouth” (11), “On My Block” (6), “Black Mirror” (3) and “You” (1) – and ABC's “Black-ish” (1).

In a statement, HBO parent WarnerMedia said "Euphoria" has a median viewing age of 38 and depicts real-world behavior without trying to glamorize it.

"'Euphoria' is a drama series created for and marketed to adult audiences that depicts the challenges faced by contemporary youth in these turbulent times," the statement says. "E-cigarette usage is a part of the modern high school experience, as the Truth Initiative’s own research indicates. 'Euphoria'’s creators took great care not to glamorize certain behaviors and to show the consequences of the characters’ actions and decisions."

Netflix's "Big Mouth," which follows teens going through puberty finished second to "Stranger Things" in tobacco/smoking depictions on shows popular with young viewers, according to the third annual While You Were Streaming report by anti-smoking group Truth Initiative.

Raymond Niaura, interim chair of the department of epidemiology at the NYU School of Global Public Health, says the report's findings echo earlier studies on movies and smoking.

"I think it's a bad look for any kind of popular media/art to depict smoking," says Niaura, who previously worked for Truth Initiative. He adds that while adolescents shouldn't be vaping, he'd be more concerned if the study found the images led to an increase in traditional smoking.

"Cigarette smoking is terrible. It's less clear that vaping is as harmful as cigarette smoking," he says. "Nobody wants kids to be using any nicotine product. But this is far less worrying to me than if we saw a relationship between exposure and smoking uptake."

Some shows not on the list of youth favorites – ABC's "Grey's Anatomy," Amazon's "Upload" and NBC's "New Amsterdam" and "Chicago Med" – are cited in "Straight to Vape" for episodes highlighting the negative health effects of e-cigarettes.

In a statement, Altria, which owns Philip Morris USA (Marlboro, Virginia Slims), said that  "we do not want our brands depicted in movies, television shows" or other entertainment media. Juul said in a statement that its e-cigarette products are "intended solely for adult smokers as an alternative to combustible cigarettes." Both companies say they deny all requests for placement in entertainment media.

Truth Initiative recommends incorporating smoking depictions and information in show ratings; increasing anti-smoking and anti-vaping advertising; eliminating local tax breaks for shows that feature tobacco imagery; and educating writers, directors and producers about the hazards of smoking depictions.

"The best thing would be to work in concert with the entertainment industry to do something that's right for their young viewers," Koval says. "We have never been in a situation where we are more concerned about our health. I can't think of a better time for them to take the right steps."