Reducing the volume, exposure and negative impacts of advertising for foods high in fat, sugar and salt to children: A systematic review of the evidence from statutory and self-regulatory actions and educational measures

PURPOSE

To identify and review evidence on 1) the effectiveness of statutory and self-regulatory actions to reduce the volume, exposure or wider impact of advertising for foods high in fat, sugar and salt (HFSS) to children, and 2) the role of educational measures.

DESIGN/METHODOLOGY/APPROACH

A systematic review of three databases (Medline, CINAHL and PsycINFO) and grey literature was carried out. Relevant evidence included studies evaluating advertising bans and restrictions, advertising literacy programmes and parental communication styles. Relevant media included TV, internet, radio, magazines and newspaper advertising. No studies were excluded based on language or publication date.

FINDINGS

Forty-seven publications were included: 19 provided evidence for the results of statutory regulation, 25 for self-regulation, and six for educational approaches. Outcome measures varied in approach, quality and results. Findings suggested statutory regulation could reduce the volume of and children's exposure to advertising for foods HFSS, and had potential to impact more widely. Self-regulatory approaches showed varied results in reducing children's exposure. There was some limited support for educational measures.

DISCUSSION

Consistency in measures from evaluations over time would assist the development and interpretation of the evidence base on successful actions and measures to reduce the volume, exposure and impact of advertising for foods HFSS to children.

Do alcohol advertisements for brands popular among underage drinkers have greater appeal among youth and young adults?

BACKGROUND

No previous study has determined whether there are differences in the youth appeal of alcohol advertisements for popular versus unpopular brands among underage drinkers. This paper provides a systematic investigation of the differential appeal of brand-level alcohol advertisements among underage youth and young adults in the United States.

METHODS

We examined 3 issues of 8 magazines popular among underage youth. From the advertised alcohol brands, we selected the ads for the top 10 and bottom 10 brands by prevalence of underage youth consumption, based on the results of a previous national survey. We assessed the ads' appeal using a sample of 211 students recruited from 1 graduate and 2 undergraduate courses at Boston University. Respondents rated the appeal of each advertisement on 4 dimensions: physical and social appeal, appeal to underage youth, perceived effectiveness, and liking. Using random-effects linear regression, we compared the appeal of advertisements for popular versus unpopular brands.

RESULTS

On each dimension, the ads for popular youth alcohol brands were rated as significantly more appealing than the ads for unpopular brands. The magnitude of this difference was 0.26 standard deviation for the physical and social appeal score, 0.25 for the appeal to underage youth score, 0.21 for the perceived effectiveness score, and 0.16 for the liking score.

CONCLUSIONS

Advertising for alcohol brands that are popular among youth contain elements that are more likely to appeal to underage youth and young adults than ads for brands that are relatively unpopular among young drinkers.

Bringing comfort and convenience to the colonial table: Delhaize Frères & Cie's Colonial Department in the 1920s and 1930s

The paper explores the role of convenient shopping in establishing a sense of comfort for Europeans in a colonial environment. So far, there has been little investigation into how Belgian retailers tried to gain a firm foothold in the Congo, how they presented themselves and promoted their wares. This paper examines the activities of the colonial department of Delhaize Frères & Cie 'Le Lion', Belgium's first and largest food multiple. It examines how this large grocery chain tried to establish itself in the Congo, what motivations it had to extend its business to the colony, what audience it wished to reach, what products and services it had to offer and what sales and marketing strategies were used. It appears that convenient shopping was one of the key selling points Delhaize's advertising, while also characterising its products as indispensable for Europeans' comfort, moral respectability and homely warmth in a so-called primitive, backward environment.

The effects of TV unhealthy food brand placement on children. Its separate and joint effect with advertising

This paper examines the effect of unhealthy food brand placement on children across different age groups (9, 12 and 15 year-old children). Results show that both brand awareness, and the behavioral disposition (toward junk food and McDonald's) increased when children were exposed to this marketing technique (in comparison with the control group). In the case of age, older groups (12-15) performed better in brand awareness, but scored lower in behavioral disposition than the 9-year-old group. Moreover, the joint use of advertising and placement (synergy) increased the effect of these communication tactics on children. Results are discussed in terms of previous results of the studies providing evidence of the influence of promotional tools of junk food on children.

The impact of medical tourism and the code of medical ethics on advertisement in Nigeria

Advances in management of clinical conditions are being made in several resource poor countries including Nigeria. Yet, the code of medical ethics which bars physician and health practices from advertising the kind of services they render deters these practices. This is worsened by the incursion of medical tourism facilitators (MTF) who continue to market healthcare services across countries over the internet and social media thereby raising ethical questions. A significant review of the advertisement ban in the code of ethics is long overdue. Limited knowledge about advances in medical practice among physicians and the populace, the growing medical tourism industry and its attendant effects, and the possibility of driving brain gain provide evidence to repeal the code. Ethical issues, resistance to change and elitist ideas are mitigating factors working in the opposite direction. The repeal of the code of medical ethics against advertising will undoubtedly favor health facilities in the country that currently cannot advertise the kind of services they render. A repeal or review of this code of medical ethics is necessary with properly laid down guidelines on how advertisements can be and cannot be done.

Awareness of pro-tobacco advertising and promotion and beliefs about tobacco use: findings from the Tobacco Control Policy (TCP) India Pilot Survey

Tobacco companies are utilizing similar strategies to advertise and promote their products in developing countries as they have used successfully for over 50 years in developed countries. The present study describes how adult smokers, smokeless tobacco users, and non-users of tobacco from the Tobacco Control Project (TCP) India Pilot Survey, conducted in 2006, responded to questions regarding their perceptions and observations of pro-tobacco advertising and promotion and beliefs about tobacco use. Analyses found that 74% (n = 562) of respondents reported seeing some form of pro-tobacco advertising in the last six months, with no differences observed between smokers (74%), smokeless tobacco users (74%), and nonsmokers (73%). More than half of respondents reported seeing pro-tobacco advertising on store windows or inside shops. Overall, this study found that a significant percentage of tobacco users and non-users in India report seeing some form of pro-tobacco advertising and promotion messages. Additional analyses found that smokers were more likely to perceive tobacco use as harmful to their health compared with smokeless tobacco users and non-users (p < 0.01). The findings from this study reiterate the need for stronger legislation and strict enforcement of bans on direct and indirect advertising and promotion of tobacco products in India.

The role of attentional bias in the effect of food advertising on actual food intake among children

This study examined the potential moderating role of attentional bias (i.e., gaze duration, number of fixations, latency of initial fixation) in the effect of advergames promoting energy-dense snacks on children's snack intake. A randomized between-subject design was conducted with 92 children who played an advergame that promoted either energy-dense snacks or nonfood products. Eye movements and reaction times to food and nonfood cues were recorded to assess attentional bias during playtime using eye-tracking methods. Children could eat freely after playing the game. The results showed that playing an advergame containing food cues increased total intake. Furthermore, children with a higher gaze duration for the food cues ate more of the advertised snacks. In addition, children with a faster latency of initial fixation to the food cues ate more in total and ate more of the advertised snacks. The number of fixations on the food cues did not increase actual snack intake. Food advertisements are designed to grab attention, and this study shows that the extent to which a child's attention is directed to a food cue increases the effect of the advertisement.

The art of consultation

Sophisticated marketing and practice-enhancing strategies can help bring patients to a surgeon's practice. However, the ability to retain these patients and also convert the consultations into surgical procedures depends on the art of consultation. This very important aspect of clinical practice is seldom taught in the medical school. In this paper, the author discusses many aspects of the art of consultation, which he has learned in his practice over the years.

Defining strategies for promoting product through 'drink responsibly' messages in magazine ads for beer, spirits and alcopops

BACKGROUND

Neither federal regulations nor industry voluntary codes require 'responsibility' statements in alcohol advertising. Stand alone 'public service' responsibility campaigns have been found to convey pro-drinking themes. We analyzed responsibility statements placed in conventional alcohol advertising to consider how responsible drinking is presented, and potential communicative goals for responsibility messages.

METHODS

We conducted a descriptive textual analysis of 'drink responsibly' messages appearing in all advertisements pertaining to beer, spirits and alcopop products placed in U.S. national, newsstand magazines from 2008 to 2010 (N=1795). We coded advertisements for presence, prominence and content of responsibility messages. Using a qualitative approach, we created a taxonomy of product promotional elements within the responsibility messages.

RESULTS

Analysis revealed that 87% of the advertisements included a responsibility message (N=1555); responsibility messages were less prominent than any included tagline (product slogan). Messages never defined responsible drinking or promoted abstinence. No link was made between warnings and activities conveyed in the advertisements. There were 197 unique responsibility messages, 88% of which (N=174) were promotional of the advertised product. Responsibility promotional content was categorized into 5 strategies: Product name, Consumption information, Product qualities, Product promise, Qualities of the drinker.

CONCLUSIONS

Responsibility messages were overwhelmingly used to promote product rather than convey relevant public health information. Based on this analysis, existing responsibility messages are largely ineffective at conveying relevant public health information, and should be supplemented by or replaced with prominently placed, externally developed, cognitively tested warnings that do not reinforce marketing messages.

The relationship between brand-specific alcohol advertising on television and brand-specific consumption among underage youth

BACKGROUND

Being able to investigate the relationship between underage drinkers' preferences for particular brands and their exposure to advertising for those brands would represent a significant advance in alcohol marketing research. However, no previous national study has examined the relationship between underage youth exposure to brand-specific alcohol advertising and consumption of those brands.

METHODS

We conducted a cross-sectional, Internet-based survey of a national sample of 1,031 youth, ages 13-20, who had consumed at least 1 drink of alcohol in the past 30 days. We ascertained all alcohol brands consumed by respondents in the past 30 days. The main outcome measure was brand-specific consumption during the past 30 days, measured as a dichotomous variable. The main predictor variable was exposure to brand-specific alcohol advertising on television. The respondents reported which of 20 television shows popular with youth they had watched during the past 30 days. For each respondent, we calculated a standard measure of potential exposure to the brand-specific alcohol advertising that aired on those shows during the preceding 12 months, based on Nielsen (New York, NY) estimates of the youth audience for each show's telecasts.

RESULTS

Compared to no brand-specific advertising exposure, any exposure was associated with an increased likelihood of brand-specific consumption (adjusted odds ratio 3.02; 95% confidence interval: 2.61-3.49) after controlling for several individual- and brand-level variables. When measured as a continuous variable, the relationship between advertising exposure and brand consumption was nonlinear, with a large association at lower levels of exposure and diminishing incremental effects as the level of exposure increased.

CONCLUSIONS

There is a robust relationship between youth's brand-specific exposure to alcohol advertising on television and their consumption of those same alcohol brands during the past 30 days. This study provides further evidence of a strong association between alcohol advertising and youth drinking behavior.

Children's knowledge of packaged and fast food brands and their BMI. Why the relationship matters for policy makers

Studies regarding the advancing challenges of obesity in many countries are beginning to converge on the importance of early food exposure and consumption patterns. Across two studies (Study 1, 34 boys, 35 girls; Study 2, 40 boys, 35 girls, ages 3-6), child knowledge of brands offering products high in sugar, salt and fat was shown to be a significant predictor of child BMI, even after controlling for their age and gender and when also considering the extent of their TV viewing. Additionally, two different collage measures of brand knowledge (utilized across the two studies) performed similarly, suggesting that this measure may be serving as a surrogate indicator of an overall pattern of product exposure and consumption. Policy implications are discussed.

Cosmetic websites Scotland: legal or lurid

BACKGROUND

The provision of cosmetic interventions and their advertising have recently come under intense scrutiny in the wake of the PIP scandal and Keogh report.

AIM

A study of Scottish websites offering esthetic procedures was conducted to determine adherence to the advertising standards and regulations currently in place.

METHODS

Regulations are provided by the Advertising Standards Authority, Committee on Advertising Practice, Independent Healthcare Advisory Services and General Medical Council. An Internet search was then conducted to search for providers of non-surgical and surgical cosmetic procedures.

RESULTS

Overall 125 websites were reviewed. 109 local and 16 national with 17 websites associated with cosmetic surgeons. 26 websites failed to adhere to regulations. Failure was related to advertising of POM on the homepage or dropdown menu (20), offering enticements inappropriately (6). 26.6% of websites did not display qualifications of the practitioners. Only 16.6% of websites described the specific and the non-specific side effects of "anti-wrinkle injections" and only 12.5% mentioned alternative treatments.

CONCLUSIONS

The majority of websites reviewed adhered to current advertising standards. Plastic surgeons provide a small percentage of cosmetic procedures. Greater regulation at the point of product entry and of all esthetic practitioners is required.

Associations between national gambling policies and disordered gambling prevalence rates within Europe

Policymakers and other interested stakeholders currently are seeking information about the comparative effectiveness of different regulatory approaches to minimising gambling-related harm. This study responds to this research gap by exploring associations between gambling policies and disordered gambling prevalence rates. We gathered information about gambling policies for thirty European jurisdictions and past-year prevalence rates for disordered gambling for twelve of these jurisdictions. We present policy trends and prevalence rates and then describe the level of association between policy and prevalence. We observe one statistically significant association between policy and prevalence: rates of sub-clinical (i.e., Level 2) disordered gambling were higher within environments that mandated less strict regulation of advertising for online gambling. Finally, we discuss the implications of our research in the context of the current process regarding the pan-European regulation of gambling. Our findings do not offer evidence for certain assumptions made in the past by the European judiciary.

Competitiveness measurement system in the advertising sector

In this paper a new approach to find indicators that can be used to measure companies’ competitiveness and performance in an efficient and reliable way is presented.

The aim is to assist managers of companies within a specific industrial sector by providing information about their relative position in the market so as to define better action plans that may improve the company’s performance.

The approach combines the use of the Analytic Network Process, a multicriteria decision method, with the Balanced Scorecard. It allows the definition of a number of competitiveness indicators based on the performance and setting of the advertising sector. In this way it is possible to obtain a Competitiveness Index that allows a company to know its relative position with respect to other companies in the sector, and establish a ranking of the companies ordered by their competitiveness level.

A case study in the advertising industry of Venezuela is provided. Results show that improvement plans for the agencies analyzed should promote creativity, innovation and the use of new technologies, as a particular form of innovation. These factors were considered to be the most relevant indicators in the advertising sector.

The participating experts agreed that the methodology is useful and an improvement over current competitiveness assessment methods.

Efficiency improvement of dentistry clinics: introducing an intervening package for dentistry clinics, isfahan, iran

BACKGROUND

In Isfahan, the second metropolitan in Iran, there are 1448 dentistry treatment centers that most of them are inefficient. Today, efficiency is the most important issue in health care centers as well as dentistry clinics. The goal of this research is to investigate the affordability and efficiency of dentistry clinics in Isfahan province, Iran.

METHODS

The current work is a quantitative research, designed in three methodological steps, including two surveys and experimental studies, for understanding current deficiencies of Iranian dentistry clinics. First, we ran a survey. Then, we analyzed the results of the questionnaires which guided us to find a particular intervening package to improve the efficiency of the clinics. At the second step, we chose an inefficient clinic named Mohtasham (Iran, Isfahan) to evaluate our intervening package.

RESULTS

Based on what the interviewees answered, we mention the most important issues to be considered for improving the efficiency of dental clinics in Isfahan. By considering mentioned problematic issues, an intervening package was designed. This intervening package was applied in Mohtasham clinic, since June 2010. It improved the clinic's income from 16328 US$ with 4125 clients in 2010, to 420,000 US$ with 14784 patients in 2012.

CONCLUSIONS

The proposed intervening package changed this clinic to an efficient and economic one. Its income increased 5.08 times and its patient's numbers grew 4.01 times simultaneously. In other words, Mohtasham's experience demonstrates the reliability of the package and its potentiality to be applied in macro level to improve other dentistry clinics.

Content analysis of Islamic Republic of Iran television food advertising related to oral health: appeals and performance methods

BACKGROUND

Today, electronic mass media such as television (TV), influence behavioral patterns of their audiences. This study aimed to evaluate what messages on food advertisements related to oral health were transmitted (appeals) and how they were transferred (performance methods & artistic techniques) in Islamic Republic of Iran Broadcasting (IRIB).

METHODS

In this cross sectional study, broadcasted advertisements on 4 important channels of Iran TV were recorded for a week from 8 am to 12 pm in 2012. The content and volume of food advertisements were investigated using a researcher-made check list. Advertisement group (food, non-food), food group (non-cariogenic, cariogenic), advertisement appeals (rational, emotional, and humor content), advertisement performance methods (hard-sell, soft-sell, presenting confirmation of Ministry of Health and Medical Education), and artistic technique were assessed. For variable comparison in groups a chi squared test and t-tests were used via SPSS software.

RESULTS

Frequency of food advertisements (14.9%) were less than non-food advertising. Non-cariogenic food advertisements had higher frequency (12.09% (compared to cariogenic food (2.8%(. Rational appeal in advertising of non-cariogenic food had the most frequency (64.9%). In contrast emotional appeal for cariogenic food was used more frequently (85.5%). For cariogenic foods, a soft-sell approach was used more frequently (95.5%). The most common artistic technique used in food advertising was music. Chemical and mechanical dental plaque control materials had a very low frequency (0.2%).

CONCLUSIONS

Advertising of cariogenic foods in Iran TV has low frequency.

Trends in exposure to pro-tobacco advertisements over the Internet, in newspapers/magazines, and at retail stores among U.S. middle and high school students, 2000-2012

BACKGROUND

Most tobacco use begins during youth. Thus, this study assessed the prevalence, trends, and correlates of pro-tobacco advertising among United States students in grades 6-12 during 2000-2012.

METHODS

Data from the 2000-2012 National Youth Tobacco Survey were analyzed to assess self-reported exposure to pro-tobacco advertisements through three media: over the Internet, in newspapers/magazines, and at retail stores. Trends during 2000-2012 were assessed in a binary logistic regression model (P<0.05).

RESULTS

Among all middle and high school students, the overall prevalence of exposure to Internet pro-tobacco advertisements increased from 22.3% to 43.0% during 2000-2012 (P<0.001 for linear trend). During the same period, declines were observed in the overall prevalence of exposure to pro-tobacco advertisements in newspapers/magazines (65.0% to 36.9%) and at retail stores (87.8% to 76.2%) (P<0.001 for all linear trends).

CONCLUSION

Exposure to pro-tobacco advertisements over the Internet increased significantly during 2000-2012 among United States middle and high school students, while a decline in exposure to advertisements in newspapers or magazines, and at retail stores occurred during the same period. However, over two-thirds of students still reported retail store exposure to pro-tobacco advertisements in 2012. Enhanced and sustained efforts would be beneficial to reduce even more exposure to all forms of pro-tobacco advertisements among youths.

The impact of initiatives to limit the advertising of food and beverage products to children: a systematic review

In response to increasing evidence that advertising of foods and beverages affects children's food choices and food intake, several national governments and many of the world's larger food and beverage manufacturers have acted to restrict the marketing of their products to children or to advertise only 'better for you' products or 'healthier dietary choices' to children. Independent assessment of the impact of these pledges has been difficult due to the different criteria being used in regulatory and self-regulatory regimes. In this paper, we undertook a systematic review to examine the data available on levels of exposure of children to the advertising of less healthy foods since the introduction of the statutory and voluntary codes. The results indicate a sharp division in the evidence, with scientific, peer-reviewed papers showing that high levels of such advertising of less healthy foods continue to be found in several different countries worldwide. In contrast, the evidence provided in industry-sponsored reports indicates a remarkably high adherence to voluntary codes. We conclude that adherence to voluntary codes may not sufficiently reduce the advertising of foods which undermine healthy diets, or reduce children's exposure to this advertising.

Pharmaceutical advertising and Medicare Part D

We explore how and to what extent prescription drug insurance expansions affect incentives for pharmaceutical advertising. When insurance expansions make markets more profitable, firms respond by boosting advertising. Theory suggests this effect will be magnified in the least competitive drug classes, where firms internalize a larger share of the benefits from advertising. Empirically, we find that the implementation of Part D coincides with a 14-19% increase in total advertising expenditures. This effect is indeed concentrated in the least competitive drug classes. The additional advertising raised utilization among non-elderly patients outside the Part D program by about 3.6%. This is roughly half of the direct utilization effect of Part D on elderly beneficiaries. The results suggest the presence of considerable spillover effects from publicly subsidized prescription drug insurance on the utilization and welfare of consumers outside the program.

Prevalence of infant formula advertisements in parenting magazines over a 5-year span

Marketing of infant formula contributes to a decreased likelihood to breastfeed. This study established the prevalence of infant formula advertisements in two popular US parenting magazines and explored trends in infant formula advertisement prevalence from 2007 to 2012.

METHODS

Advertisements were analyzed using a comprehensive coding schematic.

RESULTS

We established a high proportion of 0.43 advertisements per page of content in both magazines and observed a significant increase in infant formula advertisement prevalence beginning in 2009.

CONCLUSIONS

Infant formula companies use aggressive marketing in parenting magazines. Nurses who are well-trained in breastfeeding best practices can offer new mothers evidence-based information on the benefits of breastfeeding.

Nutritional quality of foods marketed to children in Honduras

Evidence suggests that exposure to advertising of unhealthy foods may contribute to increased rates of obesity in children. This study examined the extent to which television stations marketed unhealthy foods to children during after-school programming aired over one week in La Ceiba, Honduras. Content analysis was performed on four television stations, including one broadcast station and three cable networks. Eighty hours of programming were recorded and analyzed. Advertised products were categorized as food or non-food items, with food items further classified as healthy or unhealthy. Advertisements were coded as those aimed at children, adults, or both, and chi-square tests were used to compare the proportion of unhealthy advertisements by target audience. A total of 2271 advertisements aired during the observation period, with 1120 marketing products (49.3%). Of those, 397 (35.4%) promoted foods-30.2% were for healthy foods and 69.8% for unhealthy foods. The unhealthy foods were all advertised on cable networks and not the broadcast station. Children appeared to be targeted more than adults in advertisements for unhealthy foods (92.1%, p<0.001). Cable television programming during after-school hours advertised primarily unhealthy foods. Exposure to these advertisements may promote consumption of unhealthy foods by children, increasing their risk of obesity.

The ethics of distress: toward a framework for determining the ethical acceptability of distressing health promotion advertising

Distressing health promotion advertising involves the elicitation of negative emotion to increase the likelihood that health messages will stimulate audience members to adopt healthier behaviors. Irrespective of its effectiveness, distressing advertising risks harming audience members who do not consent to the intervention and are unable to withdraw from it. Further, the use of these approaches may increase the potential for unfairness or stigmatization toward those targeted, or be considered unacceptable by some sections of the public. We acknowledge and discuss these concerns, but, using the public health ethics literature as a guide, argue that distressing advertising can be ethically defensible if conditions of effectiveness, proportionality necessity, least infringement, and public accountability are satisfied. We do not take a broad view as to whether distressing advertising is ethical or unethical, because we see the evidence for both the effectiveness of distressing approaches and their potential to generate iatrogenic effects to be inconclusive. However, we believe it possible to use the current evidence base to make informed estimates of the likely consequences of specific message presentations. Messages can be pre-tested and monitored to identify and deal with potential problems. We discuss how advertisers can approach the problems of deciding on the appropriate intensity of ethical review, and evaluating prospective distressing advertising campaigns against the conditions outlined.

A new method for evaluating compliance with industry self-regulation codes governing the content of alcohol advertising

BACKGROUND

This study evaluated the use of a modified Delphi technique in combination with a previously developed alcohol advertising rating procedure to detect content violations in the U.S. Beer Institute Code. A related aim was to estimate the minimum number of raters needed to obtain reliable evaluations of code violations in television commercials.

METHODS

Six alcohol ads selected for their likelihood of having code violations were rated by community and expert participants (N = 286). Quantitative rating scales were used to measure the content of alcohol advertisements based on alcohol industry self-regulatory guidelines. The community group participants represented vulnerability characteristics that industry codes were designed to protect (e.g., age <21); experts represented various health-related professions, including public health, human development, alcohol research, and mental health. Alcohol ads were rated on 2 occasions separated by 1 month. After completing Time 1 ratings, participants were randomized to receive feedback from 1 group or the other.

RESULTS

Findings indicate that (i) ratings at Time 2 had generally reduced variance, suggesting greater consensus after feedback, (ii) feedback from the expert group was more influential than that of the community group in developing group consensus, (iii) the expert group found significantly fewer violations than the community group, (iv) experts representing different professional backgrounds did not differ among themselves in the number of violations identified, and (v) a rating panel composed of at least 15 raters is sufficient to obtain reliable estimates of code violations.

CONCLUSIONS

The Delphi technique facilitates consensus development around code violations in alcohol ad content and may enhance the ability of regulatory agencies to monitor the content of alcoholic beverage advertising when combined with psychometric-based rating procedures.