Video game warnings fall far short in rating tobacco content

September 14, 2015

Video games are not adequately rated for tobacco content, according to a new UC San Francisco study that found video gamers are being widely exposed to tobacco imagery.

The researchers concluded that a national ratings board set up more than 20 years ago is not a reliable source for learning whether video games contain tobacco imagery.

The study will be published online September 14 in Tobacco Control.

"Parents should stop relying on the ratings to screen for tobacco use in buying video games for their kids," said first author Susan Forsyth, a PhD candidate at the UCSF School of Nursing.

Video games are a ubiquitous part of adolescent life in many countries. In the U.S., 88 percent of youth 8 to 18 years old play video games at least occasionally, according to a national study. Despite the widespread practice, there has been little research on whether smoking content is present in the games and whether games are being adequately rated for tobacco content.

Previous research has found that smoking imagery in movies can lead youths to begin smoking. In the video game study, the researchers sought to assess whether tobacco content was appropriately labelled. "The presence of tobacco imagery in (video) games exposes players to products and behaviors within an immersive...environment, with unknown effects on real-world smoking behavior," the authors wrote.

The Entertainment Software Ratings Board (ESRB) was established in 1994 by the video game industry as a voluntary, self-regulating body to assist buyers in determining age-appropriate content. Much like movie ratings, video game ratings assess the level of violence and tobacco content in games.

For the study, the researchers interviewed 65 gamers between 13 and 50 years old on their favorite games and whether the games contained smoking imagery. Tobacco content included visible smoking equipment, characters mentioning smoking or characters smoking a cigarette, pipe, cigar, or e-cigarette.

The authors found that game ratings do not accurately reflect tobacco content. While 8 percent of the games received tobacco warnings, 42 percent actually had tobacco content. Among games rated "M" for "mature," 75 percent contained verified tobacco content - but the ESRB provided warnings on only 4 percent of the games.

In one popular series, Metal Gear, the ratings board gave the game no tobacco content descriptor, yet it had extensive smoking throughout.

As a result, adolescents are being exposed to significantly more tobacco imagery than previously thought, the researchers said.

"The ratings board needs to stop pretending that it's providing accurate ratings," said senior author Ruth E. Malone, RN, PhD, a professor at the UCSF School of Nursing and chair of the UCSF Department of Social and Behavior Sciences. "And it should more thoroughly and consistently screen material for content and accurately report it."
Forsyth is funded by a dissertation award from the Tobacco-Related Disease Research Program grant #22DT-0003.

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About UCSF: UCSF is a leading university dedicated to transforming health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. Founded in 1864 as a medical college, UCSF now includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with world-renowned programs in the biological sciences, a preeminent biomedical research enterprise and top-tier hospitals, UCSF Medical Center and UCSF Benioff Children's Hospitals. Please visit

University of California - San Francisco

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