As far as we have come in the 50 years since the U.S. Surgeon General first warned of the dangers of smoking, many obstacles remain.
More laws banning smoking would help. So would higher taxes. Support for both could be achieved with wider awareness of how severely nonsmokers are affected by cigarettes: Secondhand smoke causes up to 75,000 deaths from heart disease and up to 129,000 heart attacks each year, while long-term exposure can hike risk for coronary heart disease by 30 percent.
As the nation's largest heart-health organization, the American Heart Association is committed to making a difference. We have worked with the American Cancer Society, American Lung Association, Americans for Non-Smokers Rights, the Campaign for Tobacco-Free Kids, and many more to continue battling the leading preventable cause of death: tobacco use.
Another part of the ongoing battle is Hollywood's continued glamorization of smoking. Every time a star lights a cigarette, a negative message is sparked.
That is the subject of the rest of this column, penned by leaders of Legacy, the nation's largest public health foundation devoted to the issue of tobacco use prevention and cessation. Legacy was created as part of the 1998 Master Settlement Agreement between the major tobacco companies, 46 U.S. states, the District of Columbia and five U.S. territories, and I proudly serve on Legacy's board of directors.
While their focus is on one recent commercial, it clearly shows a systematic pattern that is far more part of the problem at a time when we could use more solutions.
The first "House of Cards" Season 2 trailer released by Netflix last month reveals very little about the upcoming season: no dialogue, no indication of future plot lines, not even the title of the show. The promo, in black and white, is simply 30 seconds of Robin Wright smoking a cigarette.
In recent years, we have seen some promising trends in the portrayal of smoking in entertainment media, including a decline in tobacco use in top-grossing movies from 2005-2010. However, smoking imagery in movies and TV shows, including those popular among youth and young adults, persists, and "House of Cards," a Netflix-original show and the epitome of Internet-age television, is yet another alarming example.
Decades of research have shown that smoking imagery in television and movies influences youth uptake of smoking. The National Cancer Institute (NCI) has concluded that there is evidence for a causal relationship between exposure to smoking imagery in movies and youth smoking initiation, with studies showing that youth with the most exposure to onscreen tobacco imagery are about twice as likely to start smoking.
The portrayal of smoking in the "House of Cards" episodes and its recent trailer is of serious public health concern, especially given the series' popularity and accessibility to anyone with a Netflix account, which ensures broad exposure to smoking imagery. Within just 12 days of the show's launch early this year, a Cowen research survey indicated 10 percent of Netflix subscribers had watched the show. With Netflix subscribers in the U.S. at 31.1 million and rising, the number of smoking depictions from the show -- and, now, its second-season trailer -- may total well into the millions.
The trailer's sole focus on one of its main characters smoking is indicative of how deeply smoking is part of the identity of the show. At the end of each day, Washington, D.C. power couple Frank and Claire Underwood share a cigarette, a symbol of intimacy in their relationship. This sharing of a cigarette by characters who do not smoke otherwise ignores the reality of the powerful addictive nature of cigarettes. Rather, smoking is portrayed as a bridge to intimacy and stress relief -- ironic, given the toll of tobacco-related disease. Also disturbing is that the Underwoods reflect modern-day, high-income, influential individuals, displaying one of the most positive portrayals of smoking in recent entertainment history (excluding examples such as "Mad Men," which reflect historically high rates of smoking). Media coverage of the unusual trailer helps further perpetuate positive perceptions of smoking, with headlines such as AdWeek's "Netflix promo leaves you craving more" and the popular blog We Got This Covered's "Robin Wright is smoking hot in first teaser for `House of Cards' Season 2."
Unlike what is portrayed on the show, smoking is addictive, extraordinarily harmful and has a disproportionate impact on those with low incomes and limited education. Although the smoking rate in the U.S. has reduced by more than half since the 1960s, tobacco-related disease still kills more than 430,000 people each year. Approximately 88 percent of adults who smoke started smoking before the age of 18, making the teenage years a critical time in which initiation can be influenced by different factors, including smoking on TV shows.
Despite 50 years of social norm change since the U.S. Surgeon General released the first landmark Report on Smoking and Health in 1964, this kind of promotion threatens to normalize a product that kills more Americans than AIDS, alcohol, car accidents, murders, suicides, drugs and fires combined.
Given the conclusive evidence that smoking imagery portrayed across entertainment media impacts youth and young adult smoking initiation, positive portrayals of tobacco use threaten to reverse the critical progress the U.S. has made over the past five decades in reducing smoking. We call on Netflix and others in the entertainment industry to minimize the mythology around smoking -- it's a deadly addiction, and there's nothing glamorous about that.
Robin Koval, President and CEO, Legacy
Vinu Ilakkuvan, MSPH, Research Associate, Legacy
Ollie Ganz, MSPH, Research Associate, Legacy