While many parents and others shopping for young people know to look out for violence and sexual content in video games, they may not be aware of something else found in many popular games that is raising serious public health concerns. So how do you know if you’re selecting a safe video game for kids?

Research shows that exposure to images of tobacco — its use still the leading cause of preventable death and disease in the U.S. — can influence young people to start smoking. In fact, 44 percent of adolescents who start smoking do so because of smoking images they see in movies. Tobacco use in video games is likely to promote youth smoking in similar ways and may even pose additional concerns since video games are more active and intense experiences. Some games even include storylines or elements where tobacco use benefits a player.

Despite the risk, tobacco content in video games is not a well-known issue. Here are some important things to be aware of so you can avoid games with tobacco content.

Many youth- and teen-rated games include tobacco.

Just because a game is rated appropriate for youth and teens does not mean it is free of tobacco imagery. While a methodical review of games on the U.S. market has yet to be conducted, it is clear from past research that tobacco use is frequently depicted in video games geared toward young people.

For example, between 1994 and 2011, 60 out of 78 large video game publishers included tobacco imagery in at least one, and often more, of their games rated appropriate for youth. A 2012 paper on the prevalence of tobacco in games found a significant increase in tobacco content in games rated for young adolescents since 2005.

More recently, Truth Initiative, the national public health organization behind the tobacco public education campaign truth, conducted a partial review of 2016 releases from top publishers and found more than a dozen video games with tobacco imagery, including at least five rated “Teen.”

Warnings and content descriptors are not always reliable.

Video game content descriptors often fail to mention tobacco use, making it difficult for parents to use them to monitor for tobacco imagery.

A 2015 survey by the University of California, San Francisco, confirmed tobacco content in 42 percent of the video games that participants reported playing; however, only 8 percent of these games had tobacco warnings from the Entertainment Software Rating Board, the gaming industry’s self-regulatory organization that rates video games and apps.

In its report, “Played: Smoking and Video Games,” Truth Initiative called on the ESRB to consistently identify and disclose if any game contains tobacco use or tobacco references. The organization is also urging game developers and publishers to stop including tobacco use and tobacco images in their games, particularly those marketed to or played by youth, regardless of their ESRB rating. Research suggests that pressure on movie producers has succeeded in decreasing tobacco imagery in youth-rated movies, and the same efforts should be used to influence game developers and publishers.

Even as national smoking rates have declined to record lows, smoking continues to be portrayed positively on screens. Glamorizing and re-normalizing smoking, and making it appear “cool,” could threaten the progress the U.S. has made in decreasing tobacco use, which kills 1,300 Americans every day.

For more on the topic of tobacco in video games, visit truthinitiative.org.