ii Copyright 2016 By Susan Forsyth iii Funding Acknowledgement This dissertation was supported by: • The University of California, San Francisco Graduate Dean’s Health Science Fellowship • The Eugene Cota Robles Doctoral Fellowship • Dissertation award from the Tobacco-Related Disease Research Program (TRDRP), grant #22DT-0003. iv Acknowledgments I would first like to thank the participants who gave freely of their time and stories. Without them this dissertation would never have been written. I knew almost nothing about video games before I started this and their patient explanations of things most obvious was greatly appreciated. I would also like to thank my advisor, Dr. Ruth Malone. In 2008, when I sat in my first graduate class, I was not sure if I even belonged. Dr. Malone encouraged me and helped me believe in myself as a person and as a scholar. She opened doors for me that I did not know even existed. Ruth has mentored me for the last eight years, and for this I am honored and grateful. I would also like to thank my dissertation committee, Dr. Ruth Malone (chair), Dr. Kit Chesla and Dr. Roberta Rehm. Their gentle and careful guidance has seen me safely through one of the most challenging journeys of my life. I would like to thank my qualifying exam committee, Dr. Christine Kennedy (chair), Dr. Ruth Malone, Dr. Roberta Rehm and Dr. Susan Kools. Through your expertise and direction this project was shaped into what it is today. I would also like to thank Dr. Lisa Bero and Dr. Donna Odierna. I joined their reasearch group for ten weeks and stayed five years. They showed me what it was like to work on big grants and do challenging work while having fun. I am grateful for their compassion and their generosity of time and knowledge. Without my writing group, this dissertation would not have materialized. Thank you Leslie Dubbin, Kate Horton and Quinn Grundy. Your comments, insights and editing helped me develop as a writer in so many ways. Also knowing that I had to produce something for the next meeting kept me working. v I owe heaps of thanks to my family. My daughter Anna, who is my reason, my daily amazement and for whom I try. Mommy’s homework is finally done! (For now.) I thank my wonderful husband Dan, for his quiet support, his belief in me, and for the hours of Anna care allowing me to work. Thank you Becky and John, for all of it and for your love. Thank you to my family for being there: David, Rhonda, Chris, Andrea, Larry, Michelle, Jackson, Fiona, Tim, Liam, Cameron, Joel, Lin, Monica, Michael, Adam, Jennie, Val, Suzanne, Matt, Patrick, Francis, Erik and Ralph. You are my center. And to the missing ones. My mother and father, Jim and Fran Forsyth and my sisters, Joan and Sara Forsyth. I miss you each day. I hope I have made you proud. **************************** The text of chapter two and chapter five of this dissertation are reprints of the material as they appear in Nicotine and Tobacco Research and Tobacco Control . The co-author listed in this publication directed and supervised the research that forms the basis for the dissertation/thesis. For these chapters I have maintained the format of the papers as they were accepted for publication. Forsyth S.R & Malone R.E. (2015) Tobacco imagery in video games: ratings and gamer recall. Tobacco Control; [epub ahead of print]. doi:10.1136/ tobaccocontrol-2015- 052286. Forsyth, S. R., & Malone, R. E. (2015). Smoking in video games: A systematic review. Nicotine and Tobacco Research, published online July 25 2015, doi:10.1093/ntr/ntv160 vi Virtually Smoking: Exploring Player Perception of Tobacco Content in Video Games Susan Forsyth Abstract Purpose: The purpose of this qualitative study was to explore the experience of play for adolescent and young adult video game players, perceptions of tobacco content in games, and to understand why game designers inserted tobacco content into the play experience. Background: Viewing smoking in movies causes adolescents to start to smoke. Little research has been done examining whether tobacco content in video games may have similar effects. Teens play video games for an average of 1.4 hours a day, 83% of teens have a dedicated gaming console at home, and on any given day, 56% of teens play video games. Methods: Four data collection strategies were used: interviews including in-person interviews with adolescents (n=20), online interviews with adults (n=41) in-person/video phone interviews with game designers (n=5), observation of gameplay (40 hours), watching movies made from gameplay (n=350 hours) and examining relevant artifacts, including: game ratings and commentary websites, game wikis, written material about video gaming and specific games. Data were collected and analyzed using an interpretive phenomenological approach. Results: Game players valued playing because of the games’ ability to transport them into worlds where they experienced freedom, power, stress relief and relaxation. Far from being isolating, games also served as places to gather, make community and create, hone and extend identity. The Entertainment Software Ratings Board (ESRB) did not rate games with tobacco content accurately. Only 8% (9/118) of the games examined had vii received ESRB tobacco-related content descriptors, but 42% (50/118) contained such content. Participant recall of tobacco content increased when players were actively involved with the tobacco product. Players and designers implicitly understood that insertion of tobacco content allowed messages to be rapidly conveyed about characters, including tobacco-industry groomed tropes such as being cool, rebellious, world-weary, stressed, “badass”, masculine or feminine, tough and normal. Conclusion: Tobacco content is present in games played by adolescents and imbued with meaning. Game companies are uniquely positioned to inculcate game-normative values among players, including continuing the normalization of smoking and its associated tropes. viii Table of Contents Chapter One: Introduction 1 Chapter Two: Smoking in Video Games: A Systematic Review 26 Chapter Three: Methods and Methodological Processes 61 Chapter Four: “It feels more real”: An Interpretive Phenomenological 85 Study of the Meaning of Video Games in Adolescent and Young Adult Lives Chapter Five: Tobacco Imagery in Video Games: Ratings and Gamer 152 Recall Chapter Six: “Playing the Movies”: Tobacco Content in Video Games and 169 Gamer Perception Chapter Seven: Conclusion 216 Appendices Appendix A: Data Collection Tool for the Systematic Review 229 (Chapter 2) Appendix B: Games Played by Adolescent Players Interviewed In- 230 person (Chapter 4) Appendix C: Video Games with Verified Smoking Content 262 (Chapter 5) Appendix D: All Games Recalled by Participants and Tobacco 274 Recall (Chapter 6) Appendix E: Role of Tobacco in Video Games/Verification of 280 Tobacco Content (Chapter 6) Appendix F: Consents 317 Appendix G: Recruitment Flyers 329 List of Tables Chapter Two: Smoking in Video Games: A Systematic Review ix Table One: List and characteristics of included studies by domain 56 Chapter Four: “It feels more real”: An Interpretive Phenomenological Study of the Meaning of Video Games in Adolescent and Young Adult Lives Table One: Demographics of Individual Adolescent Study 145 Participants Table Two: Demographics of Individual Game Designer 146 Participants Table Three: Games Played by ESRB Rating 147 Table Four: Games Discussed by Participants by Genre 148 Table Five: Game Content 151 Chapter Five: Tobacco Imagery in Video Games: Ratings and Gamer Recall Table One: Tobacco content in video games by ESRB rating 161 Table Two: Comparison of ESRB tobacco content labels, verified 162 tobacco content and participant recall in video games Chapter Six: “Playing the Movies”: Tobacco Content in Video Games and Gamer Perception Table One: Tobacco Intensity Scale for Video Games 179 Table Two: Gamer Study Participants 208 Table Three: Game Designer Participants 210 Table Four: Unique Games Identified by Participants 211 Table Five: Total Games Identified by Participants 212 Table Six: Typology of Tobacco imagery in Unique Games and in 213 Total Recalled Video Games Table Seven: Tobacco intensity Score by Unique Games and 214 Recalled Games x List of Figures Chapter Two: Smoking in Video Games: A Systematic Review Figure 1: PRIMSA 2009 Flow diagram 60 Chapter Six: “Playing the Movies”: Tobacco Content in Video Games and Gamer Perception Figure 1: Tobacco intensity level and gamer recall 215 1 Chapter One Introduction Chris is sitting in a chair, alert and intensely focused, staring at the television screen, but he is not watching TV, he is playing a video game. It is after dinner, his mother is in the kitchen and his father sits chatting with me on the couch. Chris is holding a video game controller and, without looking, his fingers move rapidly, pushing buttons and moving toggle sticks. On the screen is Lara Croft, a strong, big-breasted woman wearing a tight shirt and shorts, holding two large pistols, one in each hand. Chris is piloting her through a series of rooms where enemies are lurking. He shoots enemy after enemy, shouting, “Yeah!” after each one. His body sways in relationship to the movement on screen. In a fire-fight, Chris’s Lara is killed. His face falls, he slumps, leans back and with frustration yells, “It cheats, the game cheats, I know it does!” Chris’s father calmly remarks, “It’s just a game,” and Chris shouts back, “No, it’s not” as he restarts his play to try again. ***************** In the last 50 years there has been a fundamental shift in how US adolescents spend their leisure time. Since the 1970’s, more and more experiences of play have been mediated electronically via video games. Children and adolescents now use technology to play games with themselves and others, to explore virtual worlds, exchange ideas and feelings and fill time (Turkle, 1997, 2012).