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Am Fam Physician. 2004;69(11):2545-2555

“Good evening and welcome to the six o'clock news. Tonight we're going to skip our usual sensationalistic stories and inform you of something truly important. Did you know that your children are exposed to more than 45 hours each week of various forms of electronic media, such as television and radio? Did you know that before they reach legal drinking age, your children will watch 20,000 beer commercials, most of which are specifically aimed at youth? Are you aware of the American Academy of Pediatrics' recommendation that children younger than two years watch no television at all? Did you know that mass media exposure has been linked to problems such as obesity, poor academic achievement, suicide, and post-traumatic stress disorder? Now that you're aware, please tune in again tomorrow night, when we'll …”

We are unlikely to receive a message like this from our primary news sources. Nonetheless, mass media exposure has been linked to multiple health-related issues, and family physicians should learn more about the influence of the media on public health and relay corrective messages to their patients and communities.

Instead of being just another chore to be added to the massive list of things that must be done at each patient visit, media education can be rewarding for family physicians and easily integrated into routine visits. Because media messages are so familiar, they can be useful springboards to health education about lifestyles and health-related issues. The following list sets out salient links between major health issues and the media that can be discussed with patients.


Most physicians know that tobacco use is the number one cause of morbidity and mortality in the United States,1 yet many know relatively little about the influence of the media on tobacco use, especially among American youth. For example, 86 percent of U.S. teens smoke the top three advertised cigarette brands—Marlboro, Camel, and Newport—whereas, overall, these three brands account for only 32 percent of total cigarette sales.2 Eighty-nine percent of terminally ill smokers started smoking before they were 19 years old,2 evidence of how the successful recruitment of today's youth will continue to contribute significantly to the death toll. This is no mystery to the tobacco companies, whose insider documents have revealed their interest in maintaining adolescent consumers. In addition, tobacco companies' promotional activities have been shown to increase smoking among adolescents.3 Finally, youth who watch movies that feature smoking are significantly more likely to smoke themselves.4


The top three causes of death among persons 15 to 24 years of age are accidents, homicide, and suicide, each of which involves alcohol 20 to 40 percent of the time.5 In spite of these statistics, alcohol advertising continues to target young people. In fact, underage persons are exposed to 45 percent more beer ads and 27 percent more liquor ads than adults.6

Alcohol commercials often employ youthful images and themes; hence, the preponderance of cartoon characters, animals, and “bathroom humor” in alcohol advertisements.7 These advertisements have been associated with increased drinking and problems associated with drinking among young people.8


Studies have directly linked obesity with television viewing.9 Three major factors contribute to what is now a national epidemic of obesity: a sedentary lifestyle encouraged by sitting still for literally thousands of hours during childhood, poor food choices based on advertising messages rather than nutritional value, and eating snacks in front of a television. Overall, the prevalence of adolescent obesity rises about 2 percent for each hour of television viewed per week above the norm.10 Furthermore, snack-food companies and fast-food chains aggressively market directly to children in the hope of recruiting lifelong customers. McDonald's, for example, uses a clown to advertise its establishment and operates more playgrounds than any other entity in the United States.11 From a nutritional standpoint, however, their food generally is not ideal for children. According to the McDonald's Web site, for example, a “Happy Meal” contains about 800 calories with 30 g of fat. Once a youngster graduates to an “Extra Value Meal,” he or she will consume about 1,400 calories and 60 g of fat.12


We can begin to appreciate the toll of violence if we compare our country with other industrialized nations. In 1998, the United States had 35 times as many per capita gun deaths as England and 285 times as many as Japan.13 In addition to the highest worldwide morbidity and mortality rate related to violence,14 the United States has the most violent media in the world.14 An average American youth will witness about 200,000 violent episodes, including 16,000 murders on television alone before the age of 18.15

In addition to the sheer volume of violence, the entertainment media present violence in skewed, unrealistic contexts. For instance, “good guys” often use powerful weapons yet sustain no negative consequences from them,16 whereas a household gun in real life is six times more likely to injure a family member than an intruding criminal.17 Theorists believe that this skewed presentation of media violence desensitizes children and teaches them to be aggressive, contributing significantly to the epidemic of violence in this country.16 Longitudinal studies show that exposure to media violence is an important cause of societal violence.18


The media also present a skewed version of sexuality—one that places a priority on sensationalism while avoiding the real-life consequences and complexities of sexual activity. One study19 found that fewer than 165 of the 14,000 sexual references in a television season involved responsible behavior. The result is an unrealistic portrayal of sexuality and responsibility that likely has contributed to the epidemics of sexually transmitted infections and unwanted teen pregnancies in this country.

Mental Health

News coverage of suicides has been linked to increased suicide rates.20 News reports also can have significant traumatic impact. After the events of September 11, 2001, one study21 showed that increased television viewing was more strongly linked with symptoms of post-traumatic stress disorder than any other factor, including actually having been in the World Trade Center on that day. Other advertisements and television programs can contribute to poor self-esteem by repeatedly presenting viewers with the unrealistic physical characteristics of their models. A study22 of the media and its impact on eating disorders concluded that the media have a “significant impact” on the development of these conditions.

Cognitive Development

The American Academy of Pediatrics recommends that children under the age of two years not watch television because the lower level of human interaction that results may negatively affect brain growth and development.23 In older children, excessive television viewing has been shown to negatively affect school performance.24 Further study is necessary to elucidate the precise nature of the relationship between media exposure and cognitive development.

What?What media do you use—television, music videos, music, Internet, video games, movies, radio?
What types of programs do you watch or listen to?
What are the violent and sexual contents?
What are the educational contents?
Where?Where are the televisions, radios, and computers in the home?
Are they in public places or in children's bedrooms?
When?When do you use media? Day or night? Weekdays or weekend?
Do you watch during meals?
How many total hours are involved each day?
How?Do you videotape programs, so that advertisements can be moved through quickly and so there is time for discussion during the program?
Do adults watch with children?
Are there rules regarding daily usage? Who makes the rules?
Are media-limiting tools such as the “V-chip” used?
Why?What is your motivation for using these media? Is it something truly important to you, or is it just for convenience?
What else could you do during “media time”?

Role of Physicians

Family physicians are in a powerful position to address harmful lifestyle behaviors and influence their patients. Physicians who are educated about the health risks of media exposure can appropriately screen patients with a “media history” (see Table 1) and incorporate counseling about media use into their preventive services (see Table 2 on page2553). In addition, physicians can model appropriate behavior by limiting television use in the practice waiting room and substituting educational material for it.

IssueCounseling points
TobaccoCut down on television in general because people who watch more television are more likely to smoke.25
Tobacco companies target teenagers, because they are potential lifelong customers, by presenting smoking as a “rebellious choice.” Choose instead to rebel against the tobacco industry by refusing to buy their products.
Watching movies with glamorous smoking leads to increased smoking. One study found that smoking in movies was responsible for over half (52.2%) of adolescent smoking initiation.4 Because it is not always easy to tell in advance which movies show smoking, it has been suggested that such films automatically be rated “R.”26
AlcoholAlcohol ads target youth by use of theme, characters, and images7—probably because alcohol companies know that younger people who begin to drink will be more likely to become alcoholics and, hence, lifelong customers.27
The top causes of death among youth—car accidents, other accidents, suicide, and homicide—are all significantly influenced by alcohol.5 In spite of this, alcohol advertisers place ads so that underage drinkers will see significantly more beer and liquor ads than do people of legal drinking age.6
Many alcohol ads have inappropriate references to driving and water sports. Others portray scrounging money to buy alcohol, hiding alcohol from authority figures, and other behaviors associated with alcoholism.28 Look for these themes and references the next time you see beer or liquor commercials.
ViolenceThe United States has more per capita violence13 and more violent media14 than any country in the world.
Media violence is more dangerous when it glamorizes violence and does not show accurate physical and emotional consequences.16 Record programs on video tape and watch with children to facilitate discussion of the true consequences of violence.
Reduce the amount of violence watched or discussed in the media because this type of viewing tends to increase both aggression and anxiety in the general population.16,21
SexualityThe United States has more unwanted teenage pregnancies than any industrialized nation in the world29 and an epidemic proportion of sexually transmitted infections each year.30
Mass media sexual references rarely involve responsibility, complexity, or consequences.19 Record programs on video tape and watch with children so that the consequences and complexities of sexual behavior can be discussed.
ObesityWatching television increases obesity by decreasing physical activity and encouraging poor eating habits.9 In fact, the prevalence of obesity goes up 2 percent for each hour of television viewed above the norm.10
For 30 minutes a day of what would have been television time, substitute an activity of your choice (it can be as simple as walking, gardening, dancing, or biking).
Emotional issuesRepeatedly watching news reports of disasters has been linked to post-traumatic stress disorder.21,31 Similarly, highly publicized news stories about suicide have been linked to increased suicide rates.20 Substitute stress-relieving activities such as stretching or reading in place of sensationalistic or excessive news programs.
Children exposed to television and magazines report poor self-esteem and disordered eating in response to comparing themselves with models.22 Teach youth that the models in most mass media are literally unreal; multiple digital effects are used to significantly alter their true bodies and features.
Cognitive issuesBecause of the risk of poor cognitive development, the American Academy of Pediatrics recommends no television for children under 2 years of age.23
Electronic media use also should be limited to 1 to 2 hours a day in school-aged youth, because excessive electronic media use has been linked to poor school performance.32 When children impose their own restrictions and create their own schedules, they are more likely to comply with limited hours.
General suggestionsLimit electronic media use to no more than 1 to 2 hours each day.33
Prerecord television programs and watch with youth to discuss and evaluate the programs together. Avoid “channel surfing.”
Keep television sets and other electronic media out of children's bedrooms.33
Find out how you can become involved in media literacy programs that help viewers actively access, analyze, evaluate, and produce media instead of merely being passive consumers.34

Physicians also can become involved in community media literacy projects, which acknowledge the profound effect of the media on young people and teach them to analyze and evaluate advertisements, television shows, and movies. Studies have shown that children who have been exposed to this behind-the-scenes approach are more likely to understand that some media messages are misleading, and they are less likely to be affected by those messages.35,36 More research is necessary to determine if such community programs can significantly alter harmful health behaviors in a population.

So stay tuned. Perhaps through our understanding of the effects of the media on health and lifestyles, family physicians can provide the media with better news stories to report.

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Copyright © 2004 by the American Academy of Family Physicians.

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