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 Unpublished studies were solicited from researchers.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.