Abstract:

The objectives of this research were to evaluate whether there was an association between seeing an actor smoke in telenovelas, Brazilian films, or international films, and trying to quit and quitting among adult Brazilian smokers. Data from 39,425 participants in the Global Adult Tobacco Survey were used. Quit ratio (former smoker/former smoker + ever smoker) and proportions of current, former, and never smokers were calculated. Multivariable weighted regression was used to determine significant associations between quitting smoking and exposure to telenovelas and films. For current smokers, the odds of trying to quit were significantly higher among those who saw an actor smoking in a Brazilian film. Those who believed smoking caused serious illness and had rules in the home prohibiting smoking were significantly more likely to have tried to quit or had quit smoking. Exposure to smoking in the media may be different in adults than adolescents. Influential factors for trying to quit and quitting are rules prohibiting smoking at home, belief that smoking causes serious illness, and hearing about dangers of smoking in media.

Keywords:
Smoking Cessation; Smoking; Television; Adult

Introduction

The morbidity and mortality of tobacco-related diseases have been studied extensively in the developed world. With globalization, tobacco consumption has shifted so that almost 80% of the world’s smokers now live in low- and middle-income countries ¹1. World Health Organization. Tobacco fact sheet 339. Geneva: World Health Organization; 2014.. Although tobacco-related deaths are expected to increase by 50% in developed countries over the next century, an increase of 700% is predicted in low- and middle-income countries ²2. Müller F, Wehbe L. Smoking and smoking cessation in Latin America: a review of the current situation and available treatments. Int J Chron Obstruct Pulmon Dis 2008; 3:285-93.^,33. Mackay J, Eriksen M, Shafey O. The tobacco atlas. Atlanta: American Cancer Society; 2006..

Over 180,000 Brazilians die every year from tobacco-related diseases ⁴4. World Health Organization. WHO Global Report: mortality attributable to tobacco. Geneva: World Health Organization; 2012.. Of all deaths in Brazil, 13% were attributable to smoking, equivalent to 357 deaths per day from tobacco-related disease ⁵5. Pinto M, Pichon-Riviere A. Relatório final: carga das doenças tabaco-relacionadas para o Brasil. São Paulo: Aliança de Controle do Tabagismo; 2012.. The overall prevalence of smoking in Brazil among people 18 years or older in 2013 was 15% (21.9 million people), a significant reduction from the 34% reported in 1989 ⁶6. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde. Percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil, Grandes Regiões e Unidades da Federação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014.^,77. Szklo AS, Almeida LM, Figueiredo VC, Autran M, Malta D, Caixeta R, et al. A snapshot of the striking decrease in cigarette smoking prevalence in Brazil between 1989 and 2008. Prev Med 2012; 54:162-7.. There was a concomitant decline in tobacco usage among individuals aged 25 years or less ⁸8. Sanchez ZM, Prado MC, Sanudo A, Carlini EA, Nappo SA, Martins SS. Trends in alcohol and tobacco use among Brazilian students: 1989 to 2010. Rev Saúde Pública 2015; 49:70.^,99. Szklo AS, Levy D, Souza MC, Szklo M, Figueiredo VC, Perez C, et al. Changes in cigarette consumption patterns among Brazilian smokers between 1989 and 2008. Cad Saúde Pública 2012; 28:2211-5.^,1010. Monteiro CA, Cavalcante TM, Moura EC, Claro RM, Szwarcwald CL. Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989-2003). Bull World Health Organ 2007; 85:527-34.. This reduction could largely be attributed to tobacco control measures including price increases, smoke-free air laws, marketing restrictions, health warnings, anti-smoking media campaigns, and cessation treatment programs ¹¹11. Levy D, de Almeida LM, Szklo A. The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLoS Med 2012; 9:e1001336..

At the time this study was conducted, Brazil had prohibited tobacco use in public places such as schools, government buildings, theaters, and public transportation. However, smoking was permitted in public and private enclosed places if there was a ventilated designated smoking area. A federal law also introduced graphic warnings on one side of cigarette packages and prohibited tobacco advertisements in magazines, newspapers, television, radio, and outdoor billboards, restricting tobacco advertisements to points of sale only ¹²12. Iglesias R, Jha P, Pinto M, Costa e Silva VL, Godinho J. Tobacco control in Brazil. Washington, DC: International Bank for Reconstruction and Development/World Bank; 2007.. Since the time of this study, Brazil has passed new tobacco control measures, including Article 49 of Law 12.546¹³13. Presidência da República. Lei nº 12.546, de 14 de dezembro de 2011. Diário Oficial da União 2011; 15 dez., which requires warnings on 30% of the front of a cigarette pack in addition to the 100% warning covering the back of the pack, prohibits the advertisements of cigarettes everywhere including points of sale, and bans smoking in all enclosed workplaces and public places. However, it does not prohibit smoking imagery in media ¹⁴14. Campaign for Tobacco Free Kids. Tobacco control laws: country details for Brazil, 2015. http://www.tobaccocontrollaws.org/legislation/country/brazil/summary (acessado em 29/Nov/2015).
http://www.tobaccocontrollaws.org/legisl... ^,1515. Jurberg C. Brazil and tobacco use: a hard nut to crack. Bull World Health Organization 2009; 87:812-3.^,1616. Campaign for Tobacco Free Kids. Brazil takes crucial step toward becoming world's most populous smoke-free country, 2014. http://www.tobaccofreekids.org/tobacco_unfiltered/post/2014_06_06_brazil (acessado em 29/Nov/2015).
http://www.tobaccofreekids.org/tobacco_u... .

The association between exposure to smoking imagery and advertising in movies, television, magazines, newspapers, and the internet, and its effect on smokers has been studied extensively in developed nations ¹⁷17. Centers for Disease Control and Prevention. Smoking in top-grossing movies: United States, 1991-2009. MMWR Morb Mortal Wkly Rep 2010; 59:1014-7.^,1818. Sargent JD, Morgenstern M, Isensee B, Hanewinkel R. Movie smoking and urge to smoke among adult smokers. Nicotine Tob Res 2009; 11:1042-6.^,1919. Carter BL, Robinson JD, Lam CY, Wetter DW, Tsan JY, Day SX, et al. A psychometric evaluation of cigarette stimuli used in a cue reactivity study. Nicotine Tob Res 2006; 8:361-9.^,2020. Pucci LG, Siegel M. Exposure to brand-specific cigarette advertising in magazines and its impact on youth smoking. Prev Med 1999; 29:313-20.^,2121. Sims TH. Tobacco as a substance of abuse. Pediatrics 2009; 124:e1045-53.^,2222. Ribisl KM. The potential of the internet as a medium to encourage and discourage youth tobacco use. Tob Control 2003; 12:i48-59., where almost half of popular films contained tobacco imagery. A positive association has been seen between exposure to smoking imagery and initiation among non-smokers. Dalton et al. ²³23. Dalton MA, Sargent JD, Beach ML, Titus-Ernstoff L, Gibson JJ, Ahrens MB, et al. Effect of viewing smoking in movies on adolescent smoking initiation: a cohort study. Lancet 2003; 362:281-5. observed that 10% of adolescents aged 10-14 years exposed to smoking in films initiated smoking within a 13-26 month follow up period. These findings are consistent with other studies ²⁴24. Sargent JD, Beach ML, Adachi-Mejia AM, Gibson JJ, Titus-Ernstoff LT, Carusi CP, et al. Exposure to movie smoking: its relation to smoking initiation among US adolescents. Pediatrics 2005; 116:1183-91.^,2525. Millett C, Glantz S. Assigning an 18 rating to movies with tobacco imagery is essential to reduce youth smoking. Thorax 2010; 65:377-8.^,2626. Dal Cin S, Stoolmiller M, Sargent JD. When movies matter: exposure to smoking in movies and changes in smoking behavior. J Health Commun 2012; 17:76-89..

There is less information about the associations between exposure to smoking imagery in media and trying to quit and quitting among current smokers. In Brazil, there is one television for every 4.5 persons. Telenovelas, a very popular type of soap opera, are the most frequently watched television programs in Brazil, inextricably a part of Brazilian life and culture. Brazilians watch an average of 3 to 4 telenovelas daily, smoking is commonly portrayed in these, and one study showed that 47.9% of Brazilian adults noticed an actor or character smoking in telenovelas 30 days prior to the survey ²⁷27. Tufte T. Living with the rubbish queen: telenovelas, culture and modernity in Brazil. Luton: University of Luton Press; 2000.^,2828. Instituto Nacional De Câncer; Pan American Health Organization. Global Adult Tobacco Survey: Brazil report. Rio de Janeiro: Instituto Nacional de Câncer/Pan American Health Organization; 2010.. This study uses cross-sectional data from the Brazilian 2008 Global Adult Tobacco Survey (GATS) to evaluate the associations between exposures to smoking imagery in various media on trying to quit and quitting smoking.

Materials and methods

Study design

This is a cross-sectional study of Brazilian adults, ages 15 years and older, surveyed in 2008, which evaluated the associations between exposure to smoking in Brazilian television and domestic and international films and trying to quit and quitting smoking.

Questionnaire

In February 2007, the World Health Organization (WHO) and US Centers for Disease Control and Prevention (CDC) launched the GATS as part of the Global Tobacco Surveillance System to monitor and measure tobacco use in 14 low- and middle-income countries ¹1. World Health Organization. Tobacco fact sheet 339. Geneva: World Health Organization; 2014.. The countries studied account for 61% of the world’s adult population and 62% of the world’s adult smokers ²⁹29. Kalsbeek WD, Bowling JM, Hsia J, Mirza S, Palipudi KM, Asma S. The Global Adult Tobacco Survey (GATS): sample design and related methods. In: Proceedings of the Section on Survey Methods, Joint Statistical Meetings. Alexandria: American Statistical Association; 2010. p. 3082-96.. GATS has subsequently expanded to cover a total of 19 low- and middle-income countries ³⁰30. World Health Organization. Global Adult Tobacco Survey (GATS). Geneva: World Health Organization; 2014.. In Brazil, GATS was part of the Brazilian National Household Sample Survey (PNAD) ²⁸28. Instituto Nacional De Câncer; Pan American Health Organization. Global Adult Tobacco Survey: Brazil report. Rio de Janeiro: Instituto Nacional de Câncer/Pan American Health Organization; 2010..

GATS Brazil uses a standardized core questionnaire that is approved by the GATS Collaborative Group of international experts. The survey instrument covers socio-demographic characteristics; tobacco and smokeless tobacco usage; several cessation-related behaviors; secondhand smoke exposures; economic issues; media exposures to tobacco control and popular imagery; and knowledge, attitudes, and perceptions about tobacco use. Some changes were made to the original GATS questionnaire to better reflect the socio-cultural characteristics of the Brazilian population ²⁸28. Instituto Nacional De Câncer; Pan American Health Organization. Global Adult Tobacco Survey: Brazil report. Rio de Janeiro: Instituto Nacional de Câncer/Pan American Health Organization; 2010.. For GATS Brazil, portable handheld devices were used to collect data. Details of the interview process and data compilation are given elsewhere ²⁸28. Instituto Nacional De Câncer; Pan American Health Organization. Global Adult Tobacco Survey: Brazil report. Rio de Janeiro: Instituto Nacional de Câncer/Pan American Health Organization; 2010..

Study population

GATS Brazil included both males and females aged 15 years and older living in private or collective households throughout Brazil. Residents were defined as Brazilian citizens or non-citizens who had lived in Brazil for at least half the time during the previous year and who consider the selected household to be their primary residence. People living in embassies, consulates, and legations were excluded, as were those living in institutional households including barracks, prisons, schools, orphanages, nursing homes, hospitals, convents, or monasteries ²⁸28. Instituto Nacional De Câncer; Pan American Health Organization. Global Adult Tobacco Survey: Brazil report. Rio de Janeiro: Instituto Nacional de Câncer/Pan American Health Organization; 2010..

PNAD employs stratified multistage cluster sampling in which probability-proportional-to-size random selection methods are used to select household samples in several stages in order to adequately represent the population. PNAD had three selection stages: municipalities in the first, census tracts in the second, and private and collective households in the third. The final stage in GATS Brazil randomly selected one resident 15 years of age or older from each household ²⁸28. Instituto Nacional De Câncer; Pan American Health Organization. Global Adult Tobacco Survey: Brazil report. Rio de Janeiro: Instituto Nacional de Câncer/Pan American Health Organization; 2010..

Because of the complex sampling design involving clustering and stratification, sample weights were used during data analysis to obtain accurate point estimates and variances that reflect tobacco use patterns in the total population ³⁰30. World Health Organization. Global Adult Tobacco Survey (GATS). Geneva: World Health Organization; 2014.. Sample weights were designed to adjust for non-response (empty household, refusal to participate, etc.); the non-response rate varied by gender, and thus weighting was adjusted by gender as well ²⁸28. Instituto Nacional De Câncer; Pan American Health Organization. Global Adult Tobacco Survey: Brazil report. Rio de Janeiro: Instituto Nacional de Câncer/Pan American Health Organization; 2010..

GATS Brazil sought to interview 40,000 individuals, representative of Brazil’s five geographical regions ²⁸28. Instituto Nacional De Câncer; Pan American Health Organization. Global Adult Tobacco Survey: Brazil report. Rio de Janeiro: Instituto Nacional de Câncer/Pan American Health Organization; 2010.. The final sample included 51,011 households, representing one-third of households. The household response rate was 95%, the person response rate was 98.9%, and the overall response rate was 94%. There were a total of 39,425 completed interviews including 33,680 in urban areas and 5,745 in rural areas ²⁸28. Instituto Nacional De Câncer; Pan American Health Organization. Global Adult Tobacco Survey: Brazil report. Rio de Janeiro: Instituto Nacional de Câncer/Pan American Health Organization; 2010..

Variables

The outcome variables of the study included: tried to stop smoking in last 12 months (yes, no); and smoking status (current smoker, former smoker, and never smoker). Categories for smoking status included “daily” and “less than daily” smokers as well as smoking any tobacco product.

The key exposure variables were “noticed an actor or character smoking on TV, in national films, in international films, or in stage play, in the last 30 days (yes, no)”. The “no” category also included “not attend” and “did not know/remember”.

Covariates included “had seen or heard information about the dangers of smoking on television, on the radio, in newspapers or magazines, on billboards, or on fliers (yes, no)”, of which the latter three were collapsed into “other” to prevent over adjusting (these variables were found to be highly correlated); “had seen warning labels on cigarette packages (yes, no)”; “had seen signs promoting cigarettes in sales points, in national films, in international films, on the internet, or elsewhere (yes, no)”, which were also collapsed into “any of the above”. The “no” category also included “has not seen/heard” and “did not know/remember”. Other confounders included whether participants believe smoking/secondhand smoke causes serious illness, stroke, heart attack, or cancer (yes, no), which were collapsed into “any of the above”. The “no” category also included “did not know”. Participants also reported whether smoking was allowed inside the home (allowed, never allowed). The “allowed” category also included “is usually not allowed, with exceptions” and “there is no standard”. Also included was whether participants believed advertising cigarettes in media was prohibited or not. The “not totally prohibited” category also included “did not know”.

Other covariates included: sex, age group (15-24, 25-44, 45-64, and 65+), literacy (yes, no), highest level of school completed (< middle, middle to secondary, and some university), employment status (employed, unemployed), and self-reported race/skin color (Asian, Black, Brown, Indigenous, and White).

Analysis

Descriptive frequencies are reported for each exposure variable stratified by smoking status (former, current, or never smoker). Quit ratios were calculated by dividing former smoking prevalence by prevalence of ever having smoked (former + current). The odds ratio (OR) was used to evaluate the magnitude of the associations between exposures of interest (whether participants noticed an actor smoking in media, whether they had seen warnings about dangers of smoking in media or on cigarette packages, whether they had seen signs promoting cigarettes in media, their rule about smoking at home, their beliefs that smoking or secondhand smoke causes illness, stroke, heart attack, or cancer, their understanding of whether cigarette advertising is prohibited in media, gender, age, literacy, education, employment and race) and outcomes (trying to quit and quitting). Statistical significance was evaluated through the chi-square test. OR and 95% confidence intervals (95%CI) were calculated using Proc Logistic in SAS V.9.3 (SAS Inst., Cary, USA). The “surveyfreq” and “surveylogistic” procedures were used to account for cluster, strata, and weight factors.

Variables found to be significant from bivariate analyses at p < 0.10 were included in step-wise multivariable logistic regression models to evaluate associations with the outcomes of interest. Variables that were associated with outcomes at p < 0.05 were retained in the final model. Adjusted OR (aOR) and 95%CI are reported.

The order of variables included in the models was determined by significance and relevance. When there was a tie for significance between variables, the more relevant variable to the research question was entered first. After all significant variables from the bivariate analysis were introduced, interaction terms that were cited in the literature ³¹31. Pechmann C, Shih CF. Smoking scenes in movies and antismoking advertisements before movies: effects on youth. Journal of Marketing 1999; 63:1-13.^,3232. Laaksonen M, Rahkonen O, Karvonen S, Lahelma E. Socioeconomic status and smoking: analysing inequalities with multiple indicators. Eur J Public Health 2005; 15:262-9. were assessed.

Results

Of the 39,425 participants surveyed, 17.8% were current smokers, 18.8% were former smokers, and 63.4% were never smokers.

Tried to quit

Trying to quit was associated with noticing an actor smoking in a telenovela (OR = 1.31, 95%CI: 1.17; 1.47), a Brazilian film (OR = 1.38, 95%CI: 1.21; 1.56), or an international film (OR = 1.17, 95%CI: 1.04; 1.31, Table 1). However, after adjusting for noticing an actor smoking in a national film, the belief that smoking causes serious illness, the rule about smoking at home, seeing information about the dangers of smoking on television, gender, and race, trying to quit was not associated with noticing an actor smoking in a telenovela (aOR = 1.10, 95%CI: 0.96; 1.25) or an international film (aOR = 0.91, 95%CI: 0.78; 1.07, Table 2). Therefore, we cannot reject the null hypothesis that there is no association between trying to quit and exposure to smoking imagery in telenovelas.

The multivariable analysis also showed a significant association between trying to quit and noticing an actor smoking in a Brazilian film (aOR = 1.28, 95%CI: 1.08; 1.51) for adults aged 15 and older. In addition, the analysis showed that trying to quit was associated with seeing information about the dangers of smoking on television, the belief that smoking causes serious illness, the rules prohibiting smoking at home, the belief that advertising cigarettes in media is prohibited, female gender, and brown race. Interactions between seeing an actor smoking in a telenovela, Brazilian film, or international film, and seeing or hearing information about the dangers of smoking on television were not significant at p < 0.05. Other variables significant at p < 0.10 from bivariate analyses can be found in Table 1.

Smoking status

Being a former smoker compared to a current smoker was negatively associated with noticing an actor smoking in a telenovela (OR = 0.86, 95%CI: 0.79; 0.93), a Brazilian film (OR = 0.80, 95%CI: 0.73; 0.88), or an international film (OR = 0.78, 95%CI: 0.72; 0.85, Table 3). However, after adjusting for seeing information about the dangers of smoking in newspapers, magazines, billboards, or fliers, seeing warning labels on cigarette packages, the belief that smoking tobacco causes serious illness, the rule about smoking at home, age, gender, the highest level of school completed, race, and employment status, having quit smoking was not associated with noticing an actor smoking in a telenovela (aOR = 1.01, 95%CI: 0.91; 1.12), a Brazilian film (aOR = 0.97, 95%CI: 0.85; 1.10), or an international film (aOR = 0.94, 95%CI: 0.84; 1.06, Table 2). Therefore, we cannot reject the null hypothesis that there is no association between smoking status and exposure to smoking imagery in telenovelas. The multivariable analyses also found that having quit smoking was negatively associated with seeing information about the dangers of smoking in newspapers, magazines, billboards, or fliers, seeing warning labels on cigarette packages, black and brown races and employment, and positively associated with the belief that smoking causes serious illness, rules that prohibited smoking at home, older age, female gender, and higher education. Interactions between seeing an actor smoking in a telenovela, Brazilian film, or international film, and employment were not significant at p < 0.05. Other variables significant at p < 0.10 from bivariate analyses can be found in Table 3.

The quit ratios for smokers who noticed an actor smoking in a telenovela, a Brazilian film, or an international film were 49.3%, 47.2%, and 47.4%, respectively, compared to 53.3%, 52.8%, and 53.5% among those who did not.

Discussion

This study sought to determine whether trying to quit and quitting were associated with noticing an actor smoking in a telenovela, movies, or plays. Before adjusting for multiple covariates, there was a significant association between trying to quit and quitting, and seeing an actor smoking in these various media. After adjusting for covariates, however, most of these associations were no longer significant, except for the association between trying to quit and noticing an actor smoking in a Brazilian film. The analyses revealed significant associations with other variables that were included in the final models: rules prohibiting smoking at home, the belief that smoking causes serious illness, and seeing or hearing information about the dangers of smoking in media. These conditions appear to have a more significant influence on adult smokers who are trying to quit than only media exposure to smoking.

These results are in accordance with research ³³33. Clark PI, Schooley MW, Pierce B, Schulman J, Schmitt CL, Hartman AM. Impact of home smoking rules on smoking patterns among adolescents and young adults. Prev Chronic Dis 2006; 3:A41.^,3434. Lee CW, Kahende J. Factors associated with successful smoking cessation in the United States, 2000. Am J Public Health 2007; 97:1503.^,3535. Mills AL, Messer K, Gilpin EA, Pierce JP. The effect of smoke-free homes on adult smoking behavior: a review. Nicotine Tob Res 2009; 11:1131-41.^,3636. Farkas AJ, Gilpin EA, Distefan JM, Pierce JP. The effects of household and workplace smoking restrictions on quitting behaviours. Tob Control 1999; 8:261-5.^,3737. Gilman SE, Rende R, Boergers J, Abrams DB, Buka SL, Clark MA, et al. Parental smoking and adolescent smoking initiation: an intergenerational perspective on tobacco control. Pediatrics 2009; 123:e274-81.^,3838. Pizacani BA, Martin DP, Stark MJ, Koepsell TD, Thompson B, Diehr P. A prospective study of household smoking bans and subsequent cessation related behaviour: the role of stage of change. Tob Control 2004; 13:23-8. that suggests that the risk of being a current smoker or having ever smoked is significantly lower in homes where smoking is not permitted. Engaging family or household members in creating a smoke-free environment is one of the most effective means of reducing smoking ³⁵35. Mills AL, Messer K, Gilpin EA, Pierce JP. The effect of smoke-free homes on adult smoking behavior: a review. Nicotine Tob Res 2009; 11:1131-41.^,3939. Park EW, Tudiver F, Schultz JK, Campbell T. Does enhancing partner support and interaction improve smoking cessation? A meta-analysis. Ann Fam Med 2004; 2:170-4.^,4040. Barreto SM, Giatti L, Casado L, de Moura L, Crespo C, Malta D. Contextual factors associated with smoking among Brazilian adolescents. J Epidemiol Community Health 2012;66:723-9.^,4141. Abreu MN, Caiaffa WT. Influência do entorno familiar e do grupo social no tabagismo entre jovens brasileiros de 15 a 24 anos. Rev Panam Salud Pública 2011; 30:22-30.^,4242. Barreto SM, Figueiredo RC, Giatti L. Socioeconomic inequalities in youth smoking in Brazil. BMJ Open 2013; 3:e003538..

This study also confirms that the belief that smoking and secondhand smoke cause serious illness is a significant positive influence on trying to quit. Our results indicate that trying to quit is almost three times more likely for someone who believes smoking causes serious illness than for someone who does not. This finding is also consistent with previous studies ⁴³43. McCaul KD, Hockemeyer JR, Johnson RJ, Zetocha K, Quinlan K, Glasgow RE. Motivation to quit using cigarettes: a review. Addict Behav 2006; 31:42-56.^,4444. Gallus S, Muttarak R, Franchi M, Pacifici R, Colombo P, Boffetta P, et al. Why do smokers quit? Eur J Cancer Prev 2013; 22:96-101.^,4545. Cummings KM, Hyland A, Giovino GA, Hastrup JL, Bauer JE, Bansal MA. Are smokers adequately informed about the health risks of smoking and medicinal nicotine? Nicotine Tob Res 2004; 6 Suppl 3:S333-40. that show health concern as the main motive for cessation.

Our results also suggest that seeing or hearing about the dangers of smoking in various media is associated with trying to quit. This further supports previous research ⁴⁶46. Durkin SJ, Brennan E, Wakefield MA. Mass media campaigns to promote smoking cessation among adults: an integrative review. Tob Control 2012; 21:127-38.^,4747. Durkin SJ, Biener L, Wakefield MA. Effects of different types of antismoking ads on reducing disparities in smoking cessation among socioeconomic subgroups. Am J Public Health 2009; 99:2217. which demonstrated that mass media campaigns promote quitting, particularly those messages displaying negative health effects and that are emotionally evocative. Increasing exposure to anti-smoking media reinforces beliefs about the harms of smoking and increases smoking quit and intention to quit rates ⁴³43. McCaul KD, Hockemeyer JR, Johnson RJ, Zetocha K, Quinlan K, Glasgow RE. Motivation to quit using cigarettes: a review. Addict Behav 2006; 31:42-56.^,4848. Hyland A, Wakefield M, Higbee C, Szczypka G, Cummings KM. Anti-tobacco television advertising and indicators of smoking cessation in adults: a cohort study. Health Educ Res 2006; 21:348-54.^,4949. Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.^,5050. Wakefield MA, Durkin SJ, Spittal MJ, Siahpush M, Scollo M, Simpson JA, et al. Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence. Am J Public Health 2008; 98:1443.^,5151. Davis RM, Gilpin EA, Loken B. The role of the media in promoting and reducing tobacco use. Bethesda: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; 2008. (Tobacco Control Monograph, 19)..

Trying to quit was associated with seeing an actor smoking in Brazilian films. Although this finding may appear counterintuitive, a closer examination of relevant studies may reveal an explanation. Many studies ³⁶36. Farkas AJ, Gilpin EA, Distefan JM, Pierce JP. The effects of household and workplace smoking restrictions on quitting behaviours. Tob Control 1999; 8:261-5.^,4646. Durkin SJ, Brennan E, Wakefield MA. Mass media campaigns to promote smoking cessation among adults: an integrative review. Tob Control 2012; 21:127-38.^,5252. Charlesworth A, Glantz SA. Smoking in the movies increases adolescent smoking: a review. Pediatrics 2005; 116:1516-28.^,5354. Morgenstern M, Sargent JD, Engels RC, Scholte RH, Florek E, Hunt K, et al. Smoking in movies and adolescent smoking initiation: longitudinal study in six European countries. Am J Prev Med 2013; 44:339-44.^,5454. Song AV, Ling PM, Neilands TB, Glantz, SA. Smoking in movies and increased smoking among young adults. Am J Prev Med 2007; 33:396-403.^,5555. Tickle JJ, Sargent JD, Dalton MA, Beach ML, Heatherton TF. Favourite movie stars, their tobacco use in contemporary movies, and its association with adolescent smoking. Tob Control 2001; 10:16-22.^,5656. Distefan JM, Pierce JP, Gilpin EA. Do favorite movie stars influence adolescent smoking initiation? Am J Public Health 2004; 94:1239.^,5757. Pizacani BA, Martin DP, Stark MJ, Koepsell TD, Thompson B, Diehr P. A prospective study of household smoking bans and subsequent cessation related behaviour: the role of stage of change. Tob Control 2004; 13:23-8. suggest a dose-response relationship between smoking imagery in films and smoking initiation among adolescents and young adults. Other studies ³³33. Clark PI, Schooley MW, Pierce B, Schulman J, Schmitt CL, Hartman AM. Impact of home smoking rules on smoking patterns among adolescents and young adults. Prev Chronic Dis 2006; 3:A41.^,5858. Lee CW, Kahende J. Factors associated with successful smoking cessation in the United States, 2000. Am J Public Health 2007; 97:1503.^,5959. Tong C, Bovbjerg DH, Erblich J. Smoking-related videos for use in cue-induced craving paradigms. Addict Behav 2007; 32:3034-44. linked exposure to smoking in films and craving among current smokers. This is the first study to our knowledge to focus on trying to quit, quitting, and quit ratios for adults, and the results suggest that exposure to smoking in media for adult smokers may have a different implication than exposure to smoking imagery for adolescents. Adults may be more likely to associate smoking imagery with serious health problems; they believe that smoking causes serious health illness, and they may be reminded of this when they see someone smoking in a film, which, in turn, makes them want to quit. They may, in fact, notice smoking more readily in films if they intend or have been trying to quit. Smokers who have no intention to quit may not notice smoking imagery since it is part of their social norm. However, the quit ratios were higher for those who did not notice an actor smoking than those who did. People who have already quit smoking may be less likely to notice smoking imagery than current smokers who are trying to quit.

After adjusting for other covariates, the exposure to smoking imagery in telenovelas and international films was not statistically significant. Interestingly, however, exposure to smoking in Brazilian films did have a significant association. One explanation for the lack of association with international film imagery is that Brazilians may be able to identify more with films from their own country. However, this would not explain why there was no similar finding for Brazilians watching telenovelas, which are very popular soap operas watched daily by a large percentage of the Brazilian population ⁶⁰60. Thomas E. Telenovelas: a Brazilian passion. Paris: Institut National de L'audiovisuel; 2011.^,6161. La Ferrara E, Chong A, Duryea S. Soap operas and fertility: evidence from Brazil. American Economic Journal: Applied Economics 2012; 4:1-31.. One possible explanation for the difference in reaction to smoking imagery in telenovelas versus smoking in Brazilian films may be the composition of the population watching the imagery. While this was not examined as a part of this study, there may be differences in socioeconomic status between the population viewing telenovelas and the population attending the theater to watch Brazilian films. A report by the Motion Picture Association of America ⁶²62. Women in Film & Television Vancouver. Theatrical market statistics. Washington DC: Motion Picture Association of America; 2009. found that people who attend theaters to watch films tend to be of a higher socioeconomic status than those who are limited to television viewing. Another factor that might play a role in explaining this finding is the frequency with which these two types of media are being viewed. Telenovelas appear daily on television ⁶⁰60. Thomas E. Telenovelas: a Brazilian passion. Paris: Institut National de L'audiovisuel; 2011.^,6161. La Ferrara E, Chong A, Duryea S. Soap operas and fertility: evidence from Brazil. American Economic Journal: Applied Economics 2012; 4:1-31.. People are therefore far more likely to see them frequently than they are to see an actor smoking in a Brazilian film shown in a theater.

As discussed above, although previous studies suggest that smoking imagery in the media is associated with initiation in adolescents and craving in current smokers, it may concomitantly be associated with a desire to quit among adult smokers if that population is also exposed to smoking warnings and develops a belief that smoking causes illness.

The findings of this study are subject to several limitations. The use of cross-sectional survey data limits our ability to make causal inferences between the exposure variables and trying to quit and quitting. The negative association between being a former smoker and noticing smoking imagery in telenovelas differs from the positive association between attempts to quit and noticing smoking imagery for current smokers. Other potential limitations to the data include self-reporting, recall, and survival biases ⁹9. Szklo AS, Levy D, Souza MC, Szklo M, Figueiredo VC, Perez C, et al. Changes in cigarette consumption patterns among Brazilian smokers between 1989 and 2008. Cad Saúde Pública 2012; 28:2211-5.^,6363. Almeida L, Szklo A, Sampaio M, Souza M, Martins LF, Szklo M, et al. Global Adult Tobacco Survey data as a tool to monitor the WHO Framework Convention on Tobacco Control (WHO FCTC) implementation: the Brazilian case. Int J Environ Res Public Health 2012; 9:2520-36. Classification errors leading to residual confounding may also have influenced the associations described ⁶⁴64. Fewell Z, Smith GD, Sterne JA. The impact of residual and unmeasured confounding in epidemiologic studies: a simulation study. Am J Epidemiol 2007; 166:646-55.. On the other hand, the study utilized the GATS data set, which provides a representative large sample. Additional longitudinal and qualitative studies are needed in order to understand the potential associations between smoking imagery in entertainment media and quitting behavior.

Conclusions

This study showed the most influential factors on trying to quit and quitting smoking were rules about not smoking at home, the belief that smoking causes serious illness, and seeing or hearing about the dangers of smoking in media. In addition, quit ratios were higher for those who did not notice an actor smoking than those who did. Interventions on smoking cessation in Brazil should focus on advertisements explaining that cigarettes are harmful and on education on the adverse health effects of smoking. More research is needed to understand any cause and effect relationships, including studies that can measure a dose-response for exposures and outcomes.

Recognizing that the present study is cross-sectional and focused only on Brazil, further studies to compare data between countries might help determine whether the outcomes are similar or vary across countries. For example, exposure to telenovelas, pervasive in Brazilian households, may be less important in other countries or regions of the world. The GATS data used here are also available for 19 other low and middle income countries, which might allow for fruitful comparisons of smoking and quitting patterns across nations ³⁰30. World Health Organization. Global Adult Tobacco Survey (GATS). Geneva: World Health Organization; 2014..

Acknowledgments

The research project was conceived by Centre for Studies on Tobacco and Health (CETAB), which is part of the Oswaldo Cruz Foundation, Rio, Brazil.

References

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