This June, US Surgeon General Vivek Murthy penned a strongly worded op-ed in the New York Times calling for social media warning labels. “It is time to require a surgeon general’s warning label on social media platforms, stating that social media is associated with significant mental health harms for adolescents,” he wrote. Such a warning, he said, “would regularly remind parents and adolescents that social media has not been proved safe.”
A surgeon general’s warning label, which Murthy noted requires congressional action, could liken popular digital platforms—Instagram, TikTok, and Discord, for example—to tobacco and alcohol, for which there is substantial evidence of harm.
The associations between social media and worsening adolescent mental health are stacking up, too, Murthy said in a recent 2-part interview with JAMA Editor in Chief Kirsten Bibbins-Domingo, PhD, MD, MS. He emphasized that although far more research on the platforms’ pitfalls and benefits is needed, the cost of inaction was too high to delay. Murthy also shared concrete strategies for clinicians and parents to help safeguard young people’s well-being in the era of social media.
The following interview has been edited for clarity and length.
Dr Bibbins-Domingo:When I think of surgeon general warning labels, I think of tobacco. What is it that made [you want] warning labels for social media?
Dr Murthy:One of the first issues I started hearing about during my second term as Surgeon General was about social media. This was coming from parents in particular. The most common question they were asking me was, “Is social media safe for my kids?” And it wasn’t because of how it was impacting their sleep and their learning. They were seeing how it impacted their [kids’] self-esteem.
They were seeing at times their kids bullied and harassed online and they were wondering, “Are you sure this is okay?” At the same time, parents would often say to me, “If it’s out there and if it’s free and available for my kids to use, it must be safe, right? Somebody must have checked it out and made sure it was okay?”
That is actually what prompted me to go on this journey. The first pitstop there was after the conversations to issue a Surgeon General’s Advisory last year on social media and youth mental health. There are 2 really important things that came from that that ultimately led to this recent announcement about a warning label.
The first was the answer to the parents’ question. There actually wasn’t enough data for us to say with confidence that social media was safe for kids. The second thing that we were finding is that there was actually increasing evidence of harm, and that evidence was coming through multiple channels.
In the data, we were seeing an association between social media use and youth mental health harms. Now, there’s an important debate in the scientific community about the size of that association. What is the significance of that association? Is it greater in some subgroups than others?
It certainly does look like it is greater among girls than boys, for example, when you’re looking at adolescents. Be that as it may, the association was there in multiple studies.
What we were also seeing were data points that told us, for example, that adolescents using social media 3 hours or more a day was associated with a doubling of risk of anxiety and depression symptoms.
But what was also interesting was data that was coming from young people themselves. We had survey data that were telling us that young people were actually concerned about the harms of social media. It didn’t mean that they didn’t acknowledge some benefits—they did—but they also knew that there were harms.
Nearly half of adolescents were saying on surveys that social media use made them feel worse about their body image. A third of adolescents were saying they felt addicted to social media. A third were saying that they were staying up past midnight or later on school nights and using their devices, and much of that was social media use.
And then finally you think about the case studies, if you will, the many examples—hundreds of circumstances, if not more, where parents have reported that after being bullied on social media or harassed or exploited or extorted, their child engaged in self-harm and in some cases took their own lives.
I have actually sat with parents who have lost a child after they were harassed and bullied on social media. I’ve talked to parents who told me that when their child went through an emotionally difficult episode and perhaps posted about that, the algorithm started feeding them more and more disturbing content, including walking them through how to take their own life as a solution to their pain.
These are circumstances that should never happen. And here’s the thing I would urge us to think about: Can you imagine if a medication for kids was put onto the market and hundreds of children died after taking it? What would we do? Well, we would understandably pump the brakes. We’d say we’ve got to investigate and understand what is going on here. Who is being harmed by this? What are the circumstances under which harm is taking place? We actually do that all the time with medications.
The thing that I find stunning and extremely disturbing is, why is it that of all the various things kids use—medications, car seats, cars when they get older, food—we have been largely negligent in acknowledging the harms of social media that are being reported day in and day out by parents and by kids themselves. We have responded with very little in the way of investigations, regulations, safety standards. That is actually a lot of what I called for last year in my advisory: real measures with teeth that Congress needs to pass to make social media safer.
The warning label is important, not as a solution to make social media safer, because it doesn’t do that, but as a warning to help parents and kids understand what we are seeing increasingly in the data: that there isn’t clear evidence of safety and that there is a growing association between social media use and youth mental health harms.
Dr Bibbins-Domingo:There’s so much to unpack there. Warning labels for tobacco differ in a few ways. When I think of the literature on the harms from tobacco, we know from decades of research that tobacco is harmful. There’s a litany of adverse health consequences that result from even a small amount of tobacco use. When I think about the literature on harms from social media, it is more an emerging literature. We understand there are some harms, but we don’t know much about how much social media and in whom social media might be particularly dangerous. How do I think about a warning, when we still have so much still to know about social media and its adverse consequences for teens?
Dr Murthy:This is a really important question and I think it gets at what is often challenging about public health, which is that sometimes you have to make decisions without a hundred percent of all the information that you would want. And this is actually one of the reasons why I think we have to look at it in a real-world context.
If we’re talking about trying to meet a threshold of every research question being answered, it’ll take a long time to get there and there’s a cost to inaction. And in this work, unfortunately the cost is often measured in lives lost. What we’ve got to do is understand if we have enough information to act.
There are plenty of circumstances where we recognize a product may have benefit and also harm and then we’ve got to make a tough decision there, right? Tobacco is an interesting example of where there really doesn’t seem to be any redeeming benefits. But think about opioid medications, for example, which we know have some benefits to treating pain, but we also know have substantial risks in terms of addiction. Many of us in medicine have seen that, living on the front lines of the opioid epidemic.
In this case, I think the decision that we have to make is to, number one, look at this from a safety-first perspective and ask the question, “Do we have enough data to tell us this is safe?” The lack of that data alone should be a red flag that should cause us to warn parents. Because many parents rightly and understandably assume that because it’s out there and free and available to use, that it must be safe and that somebody must have checked it out, and that’s not the case.
But the second thing that we’ve got to do is look at the accumulating evidence of harm. Are there open questions to answer? Absolutely. We want to know with greater detail and clarity which adolescents tend to benefit vs which ones are harmed. What particular types of use are beneficial vs what types of use are harmful? Are there times of the day where using social media seems to be better than other times of the day?
These are all important questions that would be great to be able to address. And that’s why we’ve got to invest more in research. It’s also why we have to require data transparency from the companies themselves because researchers tell me all the time that they cannot get full access to the data that the platforms have on their impact on youth mental health. That in my mind is highly problematic. I don’t want to feel as a parent that somehow the companies are hiding data from me about safety. That should be unacceptable.
But in this case, I think that we have well passed the threshold. If we apply the same principle to medications, we know there are plenty of medications that have benefits, but when we see evidence of harm crop up, we push the brakes, we investigate, we try to understand the origins of that. And even if it’s a minority of people who are being harmed, if the harm is significant enough, a lot of times we will put restrictions on the medication, and sometimes pull it entirely from the market. The threshold is not: are the vast majority of people being harmed by this drug? That is not the threshold that we use with other products, whether it’s car seats, cars, food, or medication.
And keep in mind this, too. Just this year, we had a door plug come off a Boeing plane. Thankfully, nobody was killed. We grounded hundreds of planes to investigate. We had 2 people who died after listeria infection was detected in dairy products. We pulled countless numbers of dairy products from the shelf to investigate. We [use] these thresholds because we have rightly as a society said that safety matters. The peculiar thing to me is why we have not taken action here when we have far exceeded that threshold.
In my mind, we have to think in a more nimble way about public health, about warning people about concerns when we see them. I know that there is sometimes a risk aversion to being wrong and a desire to make sure we’ve got an answer to every question before we act. This is where I think that the mindset of clinicians becomes important in this conversation because we know that the downside, the risk of not acting, could be someone’s life.
If someone comes in with plummeting blood pressures who’s febrile and who’s got a rash that looks like cellulitis, I want to treat that as sepsis. I want to get fluids in. I want to get antibiotics on board. I want to consider other types of shock as well—cardiogenic shock, anaphylactic shock—and perhaps treat those if I think there’s a possibility. But I’m not going to wait 48 hours for the blood cultures to come back before getting antibiotics on board and getting fluids in, because the cost of that inaction could be someone’s life. And so that’s why I think we’ve got to act now.
Dr Bibbins-Domingo:What I appreciate also is that saying there will be warning labels has gotten people’s attention. It’s gotten a lot of people talking about this issue. What I worry about, of course, is that now parents and patients are going to come to me and to other clinicians and ask, “Well, what should we do?” So what practical advice do you give? And what practical advice can you help our clinicians with as they try to advise patients with regard to social media and its risks?
Dr Murthy:That’s so important, and I’m glad you asked that question. I get a lot of these questions every day. So here’s generally what I tell folks when it comes to your kids. One of the most important things you can do as a first step is to start having open conversations with them about social media’s impact on their health and well-being. A lot of times our kids have great insights into how social media is making them feel, but they may not be expressing that to you.
They also may not know when to raise a flag and say, “Hey, something is wrong here.” But we want our kids to know that if they’re approached by strangers in ways that make them feel uncomfortable—as 6 out of 10 adolescent girls are on social media—and certainly if people are trying to bully or extort them or exploit them, that’s an important time to raise a flag and to tell a parent.
The second thing that’s really important for us to do with our kids is to think about the timing of when we introduce social media into their lives. Now, I wish I could tell you there was an RCT [randomized clinical trial] out there that tested all the different ages and told us the best stage. That doesn’t exist. And we also know that kids differ in terms of their level of maturity and when they may be ready.
I’ll tell you, here’s what my wife and I are planning to do for our kids and what I recommend to others. Number one is to wait until after middle school to consider using social media or giving your kid a social media account. The reason for this is because adolescence, early adolescence in particular, is a unique phase of development where we know that children are more prone to being affected by social suggestion and social comparison, and where their impulse control isn’t as fully developed. We want to protect them during that time.
I will say, this is not easy, right? It’s very easy for me to say this, but what if you’re the parent whose child is coming up to you and saying, “Everybody else has a social media account. Do you want me to be alone and left out? I need to have one, too.”
That’s a very, very difficult circumstance to be in, which is why the other thing I recommend parents do is to actually talk to other parents and build partnerships around how to manage social media. If a few families are all waiting until after middle school, that makes it a lot easier for you as a parent, but also your kid knows that they’re not alone.
One last thing I’d recommend: if your child is already on social media, consider creating tech-free zones in their days to protect sleep, in-person interaction, and physical activity. One of the things I worry about with children is that social media use is robbing them of those critical areas that they need for healthy development.
On average right now, adolescents are using social media for 4.8 hours a day. That’s not all screentime; that is just social media—4.8 hours a day. And that’s gone up since I issued the advisory last year. So these numbers are on the move, and not in the right way.
[Parents] could say, for example, “An hour before bedtime, we’re all putting our devices in the kitchen and then we’ll get them back in the morning.” That helps protect quality and quantity of sleep. You could say, “Mealtimes are social time where we’re all together. That’s going to be device-free time where we focus on talking to one another.” These are some steps I’d recommend for parents.
And finally, if you’re going to make that decision to delay, as my wife and I are going to make for our kids, I would reassess in high school based on their maturity, based on where the data are at that point about safety, and based on whether the kinds of safety standards that I recommended in my advisory last year have actually been put in place by Congress. Because that’s ultimately what we need to make social media safer for our kids.
Maybe one last thing I will add for the clinicians out there who have kids or who are seeing kids and engaging with their parents….I would encourage clinicians to raise the question with your patients about social media use, so you understand how it’s making young people feel but also so that you’re having this conversation with parents.
A lot of parents are actually living in a great deal of guilt and shame as they struggle to manage social media for their kids. They’re not talking to other parents about it. They’re assuming that other parents have figured this out because no one else seems to be having issues. So many parents are having to manage a tech that they didn’t grow up with that’s rapidly evolving. They feel like they’re falling behind, and just having the opportunity to express this to a clinician, having the opportunity to know that they’re not the only ones struggling, that can be immensely helpful to parents.
Dr Bibbins-Domingo:So we’re creating these old-fashioned types of networks so that we can better understand how to combat these new digital networks.
Dr Murthy:That’s right. We want to live in a world where social media augments our in-person interactions, not one where it completely substitutes for them, and that’s ultimately what we need to get back to.
In part 1 of this interview, the Surgeon General discusses why he recently declared firearm violence a public health crisis. Read or watch the interview here.
Published Online: August 9, 2024. doi:10.1001/jama.2024.14245
Conflict of Interest Disclosures: Dr Murthy has had numerous financial relationships with academic, nonprofit, commercial, and governmental entities. His financial disclosure report and ethics agreement can be requested online.
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