MEDICINE AND THE MEDIA

Violence in E-Rated Video Games Kimberly M. Thompson, ScD Kevin Haninger

Context Children’s exposure to violence, alcohol, tobacco and other substances, and sexual messages in the media are a source of public health concern; however, content in video games commonly played by children has not been quantified.

C

Objectives To quantify and characterize the depiction of violence, alcohol, tobacco and other substances, and sex in video games rated E (for “Everyone”), analogous to the G rating of films, which suggests suitability for all audiences.

REATED IN 1994, THE ENTERtainment Software Rating Board (ESRB) rates video games according to the categories listed in the BOX and using content descriptors, which game manufacturers display on the game box to inform consumer choices.1 Analogous to the G rating of films,2 the E rating (for “Everyone”) of video games suggests suitability for all audiences, but the E rating does not mean violence-free. Studies on children’s use of various media document the popularity of video games as a major source of entertainment. A recent study found that 70% of children (age, 2-18 years) live in homes that have at least 1 video game console, 33% of children have video game consoles in their bedrooms, and 30% of children in the study played video games the previous day.3 Children in the study reported playing video games for 20 min/d on average, although older children (age, 8-18 years) accounted for most of this use (average, 27 min/d), with boys spending significantly more time playing video games than girls and white children playing video games for significantly less time than black or Hispanic children.3 Unfortunately, little information exists about the ratings and genres of the games that children play as a function of their age, sex, family income level, and ethnicity, although some differences in preferences exist.3 Overall, children appear to play relatively more games in the action, adventure, and sports genres,3 but this may simply reflect the types of games available.

Design We created a database of all existing E-rated video games available for rent or sale in the United States by April 1, 2001, to identify the distribution of games by genre and to characterize the distribution of content descriptors associated with these games. We played and assessed the content of a convenience sample of 55 E-rated video games released for major home video game consoles between 1985 and 2000. Main Outcome Measures Game genre; duration of violence; number of fatalities; types of weapons used; whether injuring characters or destroying objects is rewarded or is required to advance in the game; depiction of alcohol, tobacco and other substances; and sexual content. Results Based on analysis of the 672 current E-rated video games played on home consoles, 77% were in sports, racing, or action genres and 57% did not receive any content descriptors. We found that 35 of the 55 games we played (64%) involved intentional violence for an average of 30.7% of game play (range, 1.5%-91.2%), and we noted significant differences in the amount of violence among game genres. Injuring characters was rewarded or required for advancement in 33 games (60%). The presence of any content descriptor for violence (n = 23 games) was significantly correlated with the presence of intentional violence in the game (at a 5% significance level based on a 2-sided Wilcoxon rank-sum test, t53 = 2.59). Notably, 14 of 32 games (44%) that did not receive a content descriptor for violence contained acts of violence. Action and shooting games led to the largest numbers of deaths from violent acts, and we found a significant correlation between the proportion of violent game play and the number of deaths per minute of play. We noted potentially objectionable sexual content in 2 games and the presence of alcohol in 1 game. Conclusions Content analysis suggests a significant amount of violence in some Erated video games. The content descriptors provide some information to parents and should be used along with the rating, but the game’s genre also appears to play a role in the amount of violent play. Physicians and parents should understand that popular E-rated video games may be a source of exposure to violence and other unexpected content for children and that games may reward the players for violent actions. www.jama.com

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The health implications of exposure to video games and other media with violent content remain uncertain, but considerable concern about the potential impacts of children experi-

encing media violence exists within the broad medical community. 4 , 5 Although several recent studies repeat concerns about the content of video games6-10 and the marketing of violent

Author Affiliations: Harvard School of Public Health, Harvard University, Boston, Mass. Corresponding Author and Reprints: Kimberly M. Thompson, ScD, Harvard School of Public Health,

Harvard Center for Risk Analysis, 718 Huntington Ave, Boston, MA 02115 (e-mail: [email protected]). Medicine and the Media Section Editor: Annette Flanagin, RN, MA, Managing Senior Editor.

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Box. Entertainment Software Rating Board (ESRB) Ratings and Descriptions 1. Early Childhood (EC) Titles rated EC have content suitable for children ages 3 and older and do not contain any material that parents would find inappropriate. 2. Everyone (E)* Titles rated E have content suitable for persons ages 6 and older. These titles will appeal to people of many ages and tastes. They may contain minimal violence, some comic mischief (for example, slapstick comedy), or some crude language. 3. Teen (T) Titles rated T have content suitable for persons ages 13 and older. Titles in this category may contain violent content, mild or strong language, and/or suggestive themes. 4. Mature (M) Titles rated M have content suitable for persons ages 17 and older. These products may include more intense violence or language than products in the Teen category. In addition, these titles may also include mature sexual themes. 5. Adults Only (AO) Titles rated AO have content suitable only for adults. These products may include graphic depictions of sex and/or violence. Adults Only products are not intended to be sold or rented to persons under the age of 18. 6. Rating Pending (RP) Product has been submitted to the ESRB and is awaiting final rating. *Prior to 1998, the “Everyone (E)” rating was named “Kids to Adults (K-A).”

entertainment to children,11 more research on the impact of violent interactive entertainment, including video games, is needed.4,5,9 Remarkably, no quantitative analysis exists on content in E-rated video games or on the relationship between game content and the ESRB content descriptors. This study focuses on providing quantitative information to physicians and parents about the content of E-rated video games. METHODS Video game console systems continue to evolve12,13 with 3 manufacturers presently dominating the market: Nintendo, maker of Nintendo 64 (N64); Sony, maker of PlayStation (PS) and PlayStation 2 (PS2); and Sega, maker of Dreamcast (DC). Popular arcade games featuring different types of game play (eg, Space Invaders, Pole Position, Donkey Kong) served as the first home video games and gave rise to the modern video game market with its wide variety of games of different genres.14 We created a database of information about the universe of E-rated games avail592

able for rent or sale in the United States by April 1, 2001 (accessible at http: //www.kidsrisk.harvard.edu) because we expected that the level of violence in video games might depend on genre. The process involved using data from the ESRB1 and several Internet sites15-18 to identify all 672 E-rated console games, verify that each game was released in the United States, determine each game’s content descriptor(s), and classify each game by 1 of 11 primary genres: action, adventure, casino, fighting, puzzle, racing, role-playing, shooting, simulation, sports, and strategy. A small number of games (n=9) could not be classified by these genres and were labeled as “other.” Unfortunately, the subjective process of characterizing game play, as well as the complexity introduced by the growing presence of games of hybrid genres, have prevented a universal system for classifying video games by genre. For example, one of the most popular games in our sample, The Legend of Zelda: Ocarina of Time, is classified as action, adventure, or role-playing on different Internet sites.15,17,18 In such cases, we

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selected the genre that was most commonly used to describe the game. Using the database, we then performed statistical analyses to summarize the distribution of games by genre and content descriptors. To quantitatively assess the content of games, we selected 55 E-rated video games that represented the distribution of content descriptors and genres and that were available for play on one of the current major home video game consoles in the United States (DC, N64, PS, or PS2). We designed the study to include several games on each console and to play a mixture of both the highly popular games as well as ones that did not receive widespread consumer interest. To explore the possibility of trends in series of video games, we also selected 2 of the most popular series by sales for study: The Legend of Zelda series in the adventure genre and the Super Mario Bros. series in the action genre. We played all of the games in these series, including games released for older consoles like Nintendo Entertainment System and Super Nintendo Entertainment System. Since the 2 oldest games in The Legend of Zelda series were released prior to the creation of the ESRB and have not been rated, we did not include them in our analysis of E-rated games even though we are confident that these games would receive E ratings. Finally, for historical comparison, we assessed the content of 8 classic arcade games that have been rereleased as E-rated compilations or paired with E-rated remakes of the original games. Overall, we played a total of 65 games. For consistency, an undergraduate student with considerable video gaming experience played all of the games and recorded all game play directly onto videocassettes for later coding. The student played each game to its conclusion or for at least 90 minutes, whichever occurred first. Some action and adventure games that allow the player to save game progress are designed for very long play times; consequently, not playing these games to their conclu-

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sion means that some content is missed. In particular, some games may become more difficult as the player advances and they may offer additional weapons or other more mature content. However, in our effort to strike a reasonable balance between playing more games and playing individual games for longer times, we determined that playing the game to its conclusion or for at least 90 minutes allowed us to obtain a reasonably good sample of game play for any single game. Video games often start with an introduction and setup, which the player may elect to bypass. Consequently, we did not include introductions and game setup in our coding or calculations of the duration of game play, although we did generally observe them. For consistency, we defined the beginning of game play as the first scene where autonomous movement occurred. With the game play recorded on videocassettes for consistency, one author (K.H.), who also has considerable video gaming experience, reviewed and coded all of the games using a standard coding instrument (available on request) and entered the data into a database constructed with Microsoft Access (version 2000, Microsoft Corp, Redmond, Wash). The first author and the game player each independently coded a subset of 10 games to assess intercoder reliability. We discussed all instances of games that presented difficulty in coding with verification of game details from the undergraduate student who played the games. We performed descriptive and statistical analyses using Microsoft Access and Excel (version 2000, Microsoft Corp) to compare our sample to the universe of Erated games. We calculated intercoder reliability using the k statistic comparing the duration of violence coded by both the game player and the primary coder (K.H.) in each 10-second interval for 30 minutes of game play (or until the end of the game) for 10 games.19 We defined violence as acts in which the aggressor causes or attempts to cause physical injury or death to another character. We did not include accidental actions that led to unintentional physical

harm, the effects of natural disasters, or the presence of dangerous obstacles that could not be attributed to the actions of a particular character. A violent incident was defined as an uninterrupted display of violence by a character or a group of characters. We defined characters broadly, including personified objects that attacked either the player or other characters. We did not code as violence any intentional acts of physical force that represent normal play in a sports game (eg, tackling in football or checking in hockey), because the intention of the player is technically to stop the other player without causing injury. We did code excessive physical contact in sports games, such as punching or otherwise attacking another player (eg, after the football play was over). To quantify the amount of violence, we manually recorded the starting and ending times of each incident of violence toward other characters (hours, minutes, and seconds from the beginning of the tape). In video games, characters often engage in a series of violent acts that are punctuated by brief periods of time spent running toward the next encounter. For consistency, we established a rule that a series of violent acts would be coded as 1 violent incident only if individual acts of violence were separated by fewer than 10 seconds of nonviolent behavior. For each violent incident, we recorded the type of weapons used for violence, whether the violent incident resulted in injury, and the number of character deaths attributable to the violent incident. In addition, for each game, we noted whether injuring characters or destroying objects is rewarded or is necessary to advance in the game, whether the player could select weapons, and whether any of the following content was present: alcohol, tobacco, illegal drugs, profanity, and sex. Finally, we also looked for the presence of music from explicitcontent–labeled recordings, because a recent Federal Trade Commission report found that 2 music companies had approved the use of music with parental advisory labels in E-rated video games.10

©2001 American Medical Association. All rights reserved.

RESULTS Our analysis of the universe of E-rated video games led to a database of 672 games with 99% of these games available for play on at least 1 of the major home consoles in our study (DC, N64, PS, or PS2). Of these 672 games, our sample included 55 games (8.2%). Half (28 of 55 games) appeared on the monthly list that ranks the 25 bestselling games in the United States by units sold (regardless of ratings).20 In the context of coding, we found good agreement between the author who coded all of the games and the student who played them (k=0.90). TABLE 1 shows the comparison of the 58 content descriptors for the 55 nonarcade games played in our sample vs the 710 content descriptors for the universe of 672 E-rated games. Overall, the sample has a similar distribution to the universe of content descriptors. Our sample does not include any of the 20 games that received content ratings for animated blood, realistic violence, violence, mild violence, suggestive themes, informational, strong language, suitable for all users, or edutainment. Based on analysis of the 672 E-rated video games released for home consoles, 384 games (57%) did not receive any content descriptors. TABLE 2 shows the comparison of genres for the 55 games in our sample and the universe of E-rated games. Based on analysis of the 672 E-rated video games released for home consoles, games in the sports (28%), racing (26%), and action (23%) genres account for most of the games.3 Again, our sample has a similar distribution to the universe of E-rated games, although our effort to explore trends in 2 series of video games contributed to our oversampling of games from the action and adventure genres. TABLE 3 summarizes the content of violence in our sample of video games. We report the percentage of game play depicting violence because comparisons of the absolute durations of violence for the games would be meaningless given the differences in game play durations that resulted from the

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Table 1. Summary of Content Descriptors for Games in Study Sample Compared With All E-Rated Video Games Games in Sample (%)*

All E-Rated Games (%)*

No descriptors

30 (54.5)

384 (57.1)

Animated violence Mild animated violence

11 (20.0) 12 (21.8)

143 (21.3) 82 (12.2)

Comic mischief

1 (1.8)

45 (6.7)

Mild language

2 (3.6)

24 (3.6)

Gaming Use of tobacco and alcohol

1 (1.8) 1 (1.8)

7 (1.0) 5 (0.7)

Animated blood

0 (0)

5 (0.7)

Realistic violence Violence

0 (0) 0 (0)

4 (0.6) 2 (0.3)

Mild violence

0 (0)

2 (0.3)

Suggestive themes

0 (0)

2 (0.3)

Informational Strong language

0 (0) 0 (0)

2 (0.3) 1 (0.1)

Edutainment Suitable for all users

0 (0) 0 (0)

1 (0.1) 1 (0.1)

Content Descriptors

*Totals for these columns sum to 58 and 710, respectively, because some games received more than 1 content descriptor.

Table 2. Summary of Genres for Games in Study Sample Compared With All E-Rated Video Games Content Descriptors

Games in Sample (%)

All E-Rated Games (%)

Action Sports Racing Adventure Puzzles Fighting Shooting Role-playing Strategy Simulation Casino Other

22 (40.0) 12 (21.8) 9 (16.4) 3 (5.5) 2 (3.6) 2 (3.6) 1 (1.8) 1 (1.8) 1 (1.8) 1 (1.8) 1 (1.8) 0 (0)

154 (22.9) 189 (28.1) 176 (26.2) 19 (2.8) 44 (6.5) 12 (1.8) 25 (3.7) 20 (3.0) 13 (1.9) 6 (0.9) 5 (0.7) 9 (1.3)

student completing some games relatively quickly and requiring at least 90 minutes (mean game play, 57 minutes; range, 6.6-136 minutes) for other games. In our sample of 55 games played, we found 20 games that did not include violent game play, and 35 games (64%) that involved intentional violence, with an average of 30.7% of the game duration representing violent game play for these games (range, 1.5%-91.2%). We found that injuring characters was rewarded or required for advancement in 33 (60%) games. Separating the 55 games into 2 groups, 1 group containing 23 games that received a content descriptor for violence and 1 group containing 32 games that did not receive a content de594

scriptor for violence, we found that the games with a violence descriptor contained significantly more violence (at a 5% significance level based on a 2-sided Wilcoxon rank-sum test, t53 = 2.59). Remarkably, we also found that 14 of the 32 games (44%) that received no content descriptors contained acts of violence an average of 37% of the game duration (range, 3%-88%). All of the games we played in the action (n=22), adventure (n=3), fighting (n=2), shooting (n=1), strategy (n=1), and simulation (n=1) genres included violence, while only 2 of the sports games (17%) included violence not associated with normal game play. Given the relatively small sample size, however, we caution against overgeneralization of these particular results. In the sample of 55 games played, 27 games (49%) depicted deaths from violence. Not surprisingly, the shooting game showed the highest numbers of deaths per minute (23.8). In all 22 of the action games, we found that injuring characters was rewarded or was required to advance in the game. Nearly all of the action games (21/22 [95%]) depicted deaths from violence, with an average (arithmetic mean) of 2.3 deaths per minute (range, 0 deaths per minute for Paperboy to 8.4 deaths per minute for Rat Attack).

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We observed that each successive game within The Legend of Zelda series had progressively less violence (FIGURE) and fewer deaths per minute; a less clear trend was demonstrated for the Super Mario Bros. series. One explanation that is consistent with our experience is that successive games in series may tend to involve more complexity in character development and engage the player in more exploration and discovery activities that will help him/her achieve a goal. However, this trend of less violence may be offset by the tendency for successive games to portray violence more graphically and more realistically as technology advances. The limited evidence of these 2 series should not be overgeneralized. Although damage to objects was not coded as violence in our analysis, we found that games rewarded characters for destroying objects or required object destruction for advancement in 29 of 55 games (53%). Table 3 indicates that 32 of 55 games (58%) in our sample depicted weapons other than the body and that the player could select weapons in 16 (50%) of these 32 games. A total of 30 of 55 games (55%) used the body as a weapon, 27 games (49%) used projectiles, 16 games (29%) used magic, 13 games (24%) used guns, 6 games (11%) used a knife or sword, 2 games (4%) used toxic substances (poisons), 17 games (33%) used explosives, and 26 games (47%) used other weapons (eg, fire, hammers, snowboard). This is not an exhaustive list of the weapons that might be encountered in the games because of the limited amount of time that each game was played; consequently, it should be viewed as a subset of the weapons depicted in these games. In addition to coding for violence, we also noted other content in the games that might have led the ESRB to assign content descriptors to the game. For example, Goemon’s Great Adventure and NFL Blitz 2000 received ESRB content descriptors for “mild language.” We found the word “damn” printed on the screen in Goemon’s Great Adventure and noted that the players taunt each other in NFL Blitz 2000. Although none of the

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Table 3. Summary of Violent Content in Games Played by Genre*

Game Title Action 40 Winks†‡ Donkey Kong 64†‡§ Gex 3: Deep Cover Gecko†‡ Goemon’s Great Adventure†‡ Mario Party†‡ Monkey Magic†‡§ Nuclear Strike 64†‡§ Paperboy†‡ Q*bert† Rat Attack† Rayman 2: The Great Escape† Sonic Adventure†‡ Spyro 2: Ripto’s Rage†‡ The Smurfs† Toy Story 2: Buzz Lightyear to the Rescue†‡§ Kirby 64: The Crystal Shards†‡§ Super Mario Bros.†‡\ Super Mario Bros. 2†‡\ Super Mario Bros. 3†‡§\ Super Mario World†‡§\ Yoshi’s Island: Super Mario World 2†‡§\ Super Mario 64†‡\ Sports 1080° Snowboarding NHL ’99† FIFA 2000 Mario Golf 64 NBA2K NFL Blitz 2000 NFL2K Sega Bass Fishing All Star Baseball 2001 Tee Off Golf Tony Hawk’s Pro Skater‡ Triple Play 2001 Racing Gran Turismo Barbie Race and Ride Crash Team Racing†‡§ Demolition Racer†‡ Hydro Thunder Lego Racers†‡§ Speed Devils Supercross 2000 Ridge Racer V Adventure The Legend of Zelda†‡§ Zelda II: The Adventure of Link†‡§ The Legend of Zelda: A Link to the Past†‡§\ The Legend of Zelda: Ocarina of Time†‡§ The Legend of Zelda: Majora’s Mask†‡§

Year System

Content Descriptors

Length, Seconds

Deaths Violence, Violence, Deaths, per Seconds % No. Minute

Weapons

1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999

PS N64 N64 N64 N64 PS N64 N64 PS PS N64 DC PS PS PS

AV MAV CM, MAV MAV, ML No descriptors AV AV MAV No descriptors No descriptors MAV MAV MAV No descriptors AV

1559 4243 6754 5656 4619 7203 2007 2318 1375 1465 5113 5454 6137 2622 6447

194 312 905 2325 484 732 1830 244 458 1004 547 181 932 459 1254

12.4 7.4 13.4 41.1 10.5 10.2 91.2 10.5 33.3 68.5 10.7 3.3 15.2 17.5 19.5

34 55 75 739 4 81 179 0 30 205 25 1 80 26 100

1.31 0.78 0.67 7.84 0.05 0.67 5.35 0 1.31 8.40 0.29 0.01 0.78 0.59 0.93

B, P, O B, G, P, E, O B, G, P, M, O B, K, G, P, M, O B, G, P, E, O B, K, P, E, M, O G, P, E B, P, O B B, O B, G, P, E B, P, E, O B, M, O B, P, E, M B, G, P, E, O

2000 1985 1988 1990 1991 1995 1996

N64 NES NES NES SNES SNES N64

No descriptors No descriptors No descriptors No descriptors No descriptors No descriptors No descriptors

6173 2138 2877 4107 4078 5375 5414

4424 883 1203 1229 1629 1427 341

71.7 41.3 41.8 29.9 39.9 26.5 6.3

483 171 160 147 177 265 21

4.69 4.80 3.34 2.15 2.60 2.96 0.23

B, G, P, E, M, O B, G, P, O B, K, P, E, O B, G, P, M, O B, G, P, M, O B, P, M, O B, P, E

1998 1998 1999 1999 1999 1999 1999 1999 2000 2000 2000 2000

N64 N64 PS N64 DC N64 DC DC N64 DC N64 PS

No descriptors AV No descriptors No descriptors No descriptors AV, ML No descriptors No descriptors No descriptors No descriptors AV No descriptors

1477 1467 1806 636 1693 1033 3138 2053 2605 4257 3384 2390

0 22 0 0 0 115 0 0 0 0 0 0

0 1.5 0 0 0 11.1 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0

1998 1999 1999 1999 1999 1999 1999 1999 2000

PS PS PS PS DC N64 DC N64 PS2

No descriptors No descriptors MAV No descriptors MAV No descriptors No descriptors No descriptors No descriptors

6833 3174 1467 1772 1802 1777 4939 3552 1566

0 0 518 824 0 849 0 0 0

0 0 35.3 46.5 0 47.8 0 0 0

0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0

1987 1988 1992 1998 2000

NES NES SNES N64 N64

NA¶ NA¶ MAV AV AV

5477 5374 5832 8133 5598

3748 2470 2074 945 181

68.4 46.0 35.6 11.6 3.2

869 300 286 61 15

9.52 3.35 2.94 0.45 0.16

B

B

P, E, M, T, O E, O P, E, O

B, K, P, E, O B, K, P, E, M, O B, K, P, E, M, O B, K, P, M, O B, K, P, M, O Continued

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Table 3. Summary of Violent Content in Games Played by Genre* (cont)

Game Title Fighting Monster Rancher 2†‡§ Pokemon Stadium†§ Puzzle Fantavision Who Wants to Be a Millionaire? Shooting Centipede†‡ Role-Playing Harvest Moon 64‡ Strategy Worms Armageddon†‡§ Simulation Pokemon Snap Casino Caesars Palace 2000 Arcade Centipede (1981)†‡ Dig Dug (1982)† Galaga (1982)†‡ Galaxian (1979)†‡ Ms. Pac-Man (1981)† Pac-Man (1980)† Pole Position (1982) Q*bert (1982)†

Content Descriptors

Length, Seconds

Violence, Seconds

Violence, % 21.0 73.9

0 0

0 0

0 0

0 0

0 0

Year

System

1999 2000

PS N64

AV MAV

3831 1726

806 1276

2000 2000

PS2 PS

No descriptors No descriptors

905 1202

0 0

1999

DC

MAV

394

335

1999

N64

TA

7141

0

2000

N64

AV

2564

1999

N64

No descriptors

2000

PS

GA

1999 1999 1999 1999 1999 1999 1999 1999

DC N64 N64 N64 N64 N64 N64 PS

MAV No descriptors No descriptors No descriptors No descriptors No descriptors No descriptors No descriptors

85.0

Deaths, No.

156

Deaths Per Minute

23.76

Weapons B, P, M, O B, P, M, T, O

B, G

0

0

1970

76.8

22

0.51

G, P, E, O

1689

51

3.0

2

0.07

B, E, M

1765

0

0

0

0

203 228 85 160 276 358 143 179

188 153 85 160 150 221 0 60

92.6 67.1 100 100 54.3 61.7 0 33.5

124 30 88 92 6 17 0 6

0

36.65 7.89 62.12 34.50 1.30 2.85 0 2.01

B, G B, O B, G, O B, G B B B

*PS indicates PlayStation; N64, Nintendo 64; DC, Dreamcast; NES, Nintendo Entertainment System; SNES, Super Nintendo Entertainment System; PS2, PlayStation 2. Entertainment Software Rating Board (ESRB) content descriptors are AV, animated violence; MAV, mild animated violence; CM, comic mischief; ML, mild language; GA, gaming; and TA, use of tobacco and alcohol. Weapons are B, body; K, knife; G, gun; P, projectile; E, explosive; M, magic; T, toxic substance; and O, other. †Injuring other characters is rewarded or is necessary to advance in the game. ‡Destroying objects is rewarded or is necessary to advance in the game. §Players can select their weapons. \This game is rated Kids to Adults (K-A) by the ESRB. ¶This game was released prior to the creation of the ESRB and has not been rated (NA indicates not applicable).

Figure. Trend in the Percent of Violence in 2 Video Game Series 80 Super Mario Bros. Series The Legend of Zelda Series

70

Violence, %

60 50 40 30 20

also noted sexual innuendo in Gex 3: Deep Cover Gecko. Finally, in Harvest Moon 64, which received a content rating “use of tobacco and alcohol,” the player can choose to purchase and consume beer, wine, or liquor resulting in a red face and a fall to the floor. We did not find any depiction of tobacco in our play of that game or find any music with parental advisories in any of the games played in our sample.

10 0 1985

1990

1995

2000

Year of Game Release

games received a content descriptor for “suggestive themes,” we noted the provocative leather outfit worn by Ai Fukami in Ridge Racer V, the screen shot between her thighs, and the phrases “curb your desire” and “push it to the limit” in the introduction.21 We 596

COMMENT The first public outcry over violence in video games occurred in 1976, when Exidy Games withdrew from the market Death Race 2000, a game that awarded players points for running over stick figures.12,13 In the 1980s, the US government began using video games for military training purposes, and recently Grossman and DeGaetano22 publicized the use of off-the-shelf video

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games in military battle training. Controversy and concern about the effects of video games on children continue,4-10 although much remains to be learned. With all of the questions about the impact of violence in video games on children, this is the first study to our knowledge to quantify the amount of violence in E-rated video games and to show that many E-rated games do involve violence, killing, and the use of weapons in the course of normal play. No games provide messages about not using violence, and some games reward or require violence and the destruction of objects. The video game genre, ESRB rating, and ESRB content descriptors provide important information about the content of the game, and overall illustrate the considerable variability that exists in the universe of E-rated games. One

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VIOLENCE IN E-RATED VIDEO GAMES

implication of this finding is that studies that assess video game content with a mix of games of different ratings and genres might produce very different results than studies that focus on a single rating and genre; future researchers will need to carefully consider the process of selecting the games for their samples. Clearly, efforts to standardize definitions for genres would be both challenging and helpful. The content descriptors appear to provide limited information about violence. We found that receiving any content descriptor for violence (animated violence, mild animated violence, etc) provided a good indication of violence in the game, but the absence of a descriptor did not mean violence-free. The definition for the E rating states that the game “may contain minimal violence,” yet our experience shows that many E-games contain a significant amount of violence and demonstrates ambiguity in what constitutes “minimal violence.” We did not see how the ESRB distinguishes between different content descriptors for violence and we believe that efforts to standardize the definitions of content descriptors would be helpful. Another approach to consider would be to have content descriptors that provide information about the amount of violence using a scale instead of noting simply its presence. This might help consumers distinguish among games that receive the same descriptors but contain very different amounts of violence (eg, Nuclear Strike 64 vs 40 Winks or Rat Attack vs The Smurfs). We also noted some inconsistencies between games that received a content descriptor and games that did not. Currently, the ESRB rates games based on information and excerpts submitted by the game manufacturer, but does not play the game before assigning the rating. While giving the same materials to raters may promote consistency, our experience playing the games leads us to believe that the ESRB raters should play the finished game, including the introduction, before assigning a rating.

Remarkably, we found some nearly identical games that received different ratings on different consoles (eg, Nuclear Strike 64 and Gex 3: Deep Cover Gecko are E-rated on N64 but rated T for “Teen” on PS), which may make game selection more confusing. We believe that the ESRB should avoid assigning different ratings of the same game on different platforms and should assign the highest rating to all of the games of the same title to avoid inadvertently misleading consumers who may not appreciate the differences between platforms. A few important limitations exist in this study. First, the sample of games represents only a small subset of the available E-rated games. Second, the results depend on the actual game play that we recorded and the methods we used for coding information, which include subjective judgment in the definitions and their implementation. While our approach of having a single person play all of the games and another independent person code all of the games reduces variability in both the game play and the coding, it may have limited the representativeness of the game play for different types and skill levels of players and accuracy in the coding. However, our method of recording the game play on videocassette and recording actual screen times for incidents provided opportunity for validation of the coding, which showed excellent reliability between coders. Third, our use of a broad definition of violence focused on the intention of the character may differ from other similarly legitimate definitions. For example, the sports and racing games, essentially all of which receive an E rating, provided the greatest challenges to coding because they contain intended acts of physical contact like checking in hockey and tackling in football that are not intended to cause injury, although other studies or coders might deem these acts to be “violent.” Despite these limitations, this study provides important and useful information to physicians and parents about the content of E-rated games. Parents should

©2001 American Medical Association. All rights reserved.

be aware of games’ ratings, content descriptors, and genres, and parents whose children play games should actively participate in game selection and engage their children in discussion of the game content. Several Internet sites also provide helpful information for parents who want to better understand the content of video games. In addition to the ESRB Web site, the National Institute on Media and the Family’s KidScore media evaluation system offers information to parents about many types of content in video games.23 We compared the 24 games in our sample that also appear in the KidScore database and noted a few differences. In particular, 2 games (Crash Team Racing and Kirby 64: The Crystal Shards) that received “green lights” in the KidScore database contained significant amounts of violence in our sample. Also, we noted that the KidScore database did not note any sexual content or nudity in Ridge Racer V. Collaborative efforts among industry, parents, physicians, advocacy groups, and the research community to standardize media rating systems and to develop a universal rating system should be pursued.24 Our content analysis suggests that many E-rated video games contain a significant amount of violence and that an “E” rating does not automatically signify a level of violence acceptable for very young game players. Physicians and parents should understand that popular Erated video games may be a source of exposure to violence for children that rewards them for violent actions and that they may contain other content that is not expected given the E rating. We believe that physicians, particularly pediatricians, should consider asking patients about their experience with video games and the medical and public health communities should play an active role in informing parents about the content in video games. Author Contributions: Study concept and design, obtained funding, administrative, technical, or material support, and study supervision: Thompson. Acquisition of data, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content, and statistical expertise: Thompson, Haninger.

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VIOLENCE IN E-RATED VIDEO GAMES Funding/Support: This research was partially supported by a gift to the Harvard School of Public Health from Mitchell Dong, BA, and Robin LaFoley Dong. Acknowledgment: We thank Seamus Ryan, BA, for playing the video games and coding a subset of them as part of a summer internship and Fumie Yokota, MS, for helpful comments and assistance in organizing and managing the data. REFERENCES 1. Entertainment Software Rating Board. Video and computer game ratings database. Available at: http: //www.esrb.org/esrb.asp. Accessed April 1, 2001. 2. Yokota F, Thompson KM. Violence in G-rated animated feature films. JAMA. 2000;283:2716-2720. 3. Roberts DF, Foehr UG, Rideout VJ, Brodie M. Kids & Media @ the New Millennium. Menlo Park, Calif: Kaiser Family Foundation; 1999. 4. American Academy of Pediatrics, American Medical Association, American Academy of Child & Adolescent Psychiatry, American Psychological Association, American Academy of Family Physicians, and the American Psychiatric Association. Joint Statement on the Impact of Entertainment Violence on Children, Congressional Public Health Summit, July 26, 2000. Available at: http://www.aap.org/advocacy/releases /jstmtevc.htm. Accessed March 1, 2001. Accessibility verified June 27, 2001.

5. American Academy of Pediatrics, Committee on Communications. Media violence. Pediatrics. 1995; 95:949-951. 6. Robinson TN, Wilde ML, Navracruz LC, et al. Effects of reducing children’s television and video game use on aggressive behavior: a randomized controlled trial. Arch Pediatr Adolesc Med. 2001;155:17-23. 7. Anderson CA, Dill KE. Video games and aggressive thoughts, feelings, and behavior in the laboratory and in life. J Pers Soc Psychol. 2000;78:772-790. 8. Dill KE, Dill JC. Video game violence: a review of the empirical literature. Aggression Violent Behav. 1998;3:407-428. 9. Singer DG, Singer JL. Handbook of Children and the Media. Thousand Oaks, Calif: Sage Publications; 2001. 10. Villani S. Impact of media on children and adolescents: a 10-year review of the research. J Am Acad Child Adolesc Psychiatry. 2001;40:392-401. 11. Federal Trade Commission. Marketing violent entertainment to children: a review of self-regulation and industry practices in the motion picture, music recording, & electronic game industries. Available at: http: //www.ftc.gov/opa/2000/09/youthviol.htm. Accessed March 1, 2001. 12. Herman L, Horwitz J, Kent S. The history of video games. Available at: http://www.videogames.com /features/universal/hov/index.html. Accessed March 16, 2001. 13. Hunter W. The dot eaters: videogame history 101.

Available at: http://www.emuunlim.com/doteaters. Accessed March 16, 2001. 14. Wolf MJP. The Medium of the Video Game. Austin: University of Texas Press; 2000. 15. IGN Games. Available at: http://games.ign .com. Accessed April 1, 2001. 16. CNET GameSpot. Available at: http://gamespot .com/gamespot. Accessed April 1, 2001. 17. GamePro. Available at: http://www.gamepro .com. Accessed April 1, 2001. 18. Daily Radar. Available at: http://www.dailyradar .com. Accessed May 30, 2001. 19. Cohen J. A coefficient of agreement for nominal scales. Educ Psychological Meas. 1960;20:37-46. 20. NPD data. NPD group essential market information. Available at: http://www.npd.com. Accessed June 1, 2001. 21. Daily Radar. New Ridge Racer V babe revealed. Available at: http://www.dailyradar.com/features /game_feature_page_180_1.html. Accessed March 16, 2001. 22. Grossman D, DeGaetano G. Stop Teaching Our Kids to Kill. New York, NY: Crown Publishers; 1999. 23. National Institute on Media and the Family. KidScore. Available at: http://www.mediafamily.org /kidscore/index.shtml. Accessed June 1, 2001. 24. Walsh DA, Gentile DA. A validity test of movie, television, and video-game ratings. Pediatrics. 2001; 107:1302-1308.

We are an intelligent species and the use of our intelligence quite properly gives us pleasure. In this respect the brain is like a muscle. When it is in use we feel very good. Understanding is joyous. —Carl Sagan (1934-1996)

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LETTERS

Table. Relationship Between Income Adequacy and the Prevalence of Asthma Among Canadians Aged 12 or More Years* Income Adequacy

No. (%)

Asthma Cases

AOR† (95%CI)

7586 (8.0) 19 241 (6.0)

529 1241

1.30 (1.00-1.68) Reference

High

38 431 (5.1)

2242

0.74 (0.63-0.87)

Unknown

19 053 (5.2)

1111

0.89 (0.76-1.05)

10 761 (10.4) 20 938 (8.0)

1178 1702

1.26 (1.08-1.47) Reference

High

36 495 (7.1)

2765

0.79 (0.70-0.91)

Unknown

20 527 (7.4)

1579

0.97 (0.83-1.11)

18 347 (9.4) 40 179 (7.1)

1707 2943

1.27 (1.11-1.45) Reference

High

74 926 (6.1)

5007

0.77 (0.69-0.86)

Unknown

39 580 (6.4)

2690

0.93 (0.84-1.04)

Men Low Middle

Women Low Middle

Total Low Middle

*AOR indicates adjusted odds ratio; CI, confidence interval. †Adjusted for sex, age, history of allergy, household size, and number of bedrooms.

terparts with high incomes; however, there was no significant difference observed between middle- and high-income categories.2 A much larger sample size of the second cycle of NPHS allowed us to further explore whether the prevalence of asthma increases consistently with decreasing income. Methods. We analyzed the cross-sectional data of the NPHS, conducted by Statistics Canada in the period 1996 through 1997. The design and execution of the survey have been detailed elsewhere.3 A total of 173 032 respondents aged 12 years or older who responded to the question about asthma were included in this analysis. Respondents who answered the following question affirmatively were considered as having asthma: “Do you have asthma diagnosed by a health professional?” Based on total household income adjusted for the number of household members, subjects were classified into 3 income categories: low (,$15 000/y for 1 or 2 people; $10 000$14 999 for 3 or 4 people; $15 000-$29 999 for 5 or more people), middle ($15000-$29999 for 1 or 2 people; $20000$39 999 for 3 or 4 people; $30 000-$59 999 for 5 or more people), and high ($30 000-$59 999 for 1 or 2 people; $40 000-$79 999 for 3 or 4 people; $$60 000 for 5 or more people) (all currencies expressed in Canadian dollars). Other variables included in the analysis were sex, age, history of allergy, household size, and number of bedrooms. Point estimates were weighted according to the demographic profile of the Canadian population, and the Rao-Wu bootstrap method was used to estimate the standard errors of these estimates to take into account the complex survey design.4 Logistic regression models were used to evaluate the association between income adequacy and the prevalence of asthma after adjusting for covariates. Model parameters were estimated by the method of maximum likelihood, and were tested for significance using the Wald statistic. Results. Of 84 311 men and 88 721 women 12 years of age or older, 5.7% (95% confidence interval[CI], 5.4%-6.0%) of men 920

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and 7.9% (95% CI, 7.5%-8.3%) of women reported having asthma. The prevalence of asthma was higher for the age group 12 through 24 years (10.5%) compared with other age groups (25-39 years, 6.6%; 40-54 years, 5.1%; 55-69 years, 5.6%; $70 years, 6.0%). The prevalence of asthma increased with decreasing household income in both men and women (TABLE). After adjusting for sex, age, history of allergy, household size, and number of bedrooms, individuals with low incomes had a higher risk of asthma while those with high incomes had a lower risk, compared with those having middle incomes. The results were consistent for men and women. Comment. This analysis indicates that the risk of asthma increases with decreasing income adequacy in both sexes. We consider income adequacy, as measured at the household level, to be an indicator of familial resources and standard of living.5 There exist several mechanisms whereby income adequacy may influence asthma. Poor inner city housing may increase exposure to cockroach and mouse antigens. The prevalence of cigarette smoking is inversely related to income. Other unexplored possibilities include living in more polluted neighborhoods and differences in dietary habits. Our results suggest that asthma control and prevention programs should target lower income families to a greater extent than higher income families. However, it is not yet known if income is related to new development of asthma, exacerbations of preexisting asthma, or both. Yue Chen, MD, PhD Mei Tang, MSc Daniel Krewski, PhD Department of Epidemiology and Community Medicine University of Ottawa Ottawa, Ontario Robert Dales, MD, MSc Department of Medicine University of Ottawa Funding/Support: This work was supported by the Canadian Population Health Initiative. Dr Chen is the holder of a Canadian Institutes of Health Research investigator award. 1. Krahn MD, Berka C, Langlois P, Detsky AS. Direct and indirect costs of asthma in Canada, 1990. CMAJ. 1996;154:821-831. 2. Chen Y, Dales R, Krewski D, Breithaupt K. Increased effects of smoking and obesity on asthma among female Canadians. Am J Epidemiol. 1999;150:255262. 3. Peaudet MP, Chen J, Pe´rez C, Ross N, Wikins K. National Population Health Survey Overview, 1996/1997. Ottawa, Ontario: Health Statistics Division, Statistics Canada; 1998:1-14. Catalogue 82-567. 4. Rao JNK, Wu CFJ. Resampling inference with complex survey data. J Am Stat Assoc. 1998;83:231-241. 5. Krieger N, Williams DR, Moss NE. Measuring social class in US public health research. Annu Rev Public Health. 1997;18:341-378.

CORRECTION Incorrect Wording: In the Medicine and the Media article entitled “Violence in E-Rated Video Games” published in the August 1, 2001, issue of THE JOURNAL (2001; 286:591-598), there was an incorrect word in a sentence. On page 596, at the bottom of the first column, the part of the sentence that read “curb your desire” should have read “control your desire.”

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