Awareness of and reactions to health and environmental harms of red meat among parents in the United States

OBJECTIVE

Evidence of the health and environmental harms of red meat is growing, yet little is known about which harms may be most impactful to include in meat reduction messages. This study examined which harms consumers are most aware of and which most discourage them from wanting to eat red meat.

DESIGN

Within-subjects randomised experiment. Participants responded to questions about their awareness of, and perceived discouragement in response to, eight health and eight environmental harms of red meat presented in random order. Discouragement was assessed on a 1-to-5 Likert-type scale.

SETTING

Online survey.

PARTICIPANTS

544 US parents.

RESULTS

A minority of participants reported awareness that red meat contributes to health harms (ranging from 8 % awareness for prostate cancer to 28 % for heart disease) or environmental harms (ranging from 13 % for water shortages and deforestation to 22 % for climate change). Among specific harms, heart disease elicited the most discouragement (mean = 2·82 out of 5), followed by early death (mean = 2·79) and plants and animals going extinct (mean = 2·75), though most harms elicited similar discouragement (range of means, 2·60-2·82). In multivariable analyses, participants who were younger, identified as Black, identified as politically liberal, had higher general perceptions that red meat is bad for health and had higher usual red meat consumption reported being more discouraged from wanting to eat red meat in response to health and environmental harms (all P < 0·05).

CONCLUSIONS

Messages about a variety of health and environmental harms of red meat could inform consumers and motivate reductions in red meat consumption.

Purchases of Nontaxed Foods, Beverages, and Alcohol in a Longitudinal Cohort After Implementation of the Philadelphia Beverage Tax

BACKGROUND

Evidence suggests that sweetened beverage taxes reduce taxed beverage purchases, but few studies have used individual-level data to assess whether these taxes affect purchases of nontaxed foods, beverages, and alcohol. Additionally, research has not examined whether sweetened beverage taxes influence restaurant purchases.

OBJECTIVES

We assessed changes in individuals' purchases of taxed beverage types; low-calorie/low-added-sugar nontaxed beverages; high-calorie/high-added-sugar nontaxed beverages, foods, and alcohol; and beverages from restaurants following implementation of the 1.5 cent-per-ounce Philadelphia sweetened beverage tax.

METHODS

A longitudinal cohort of adult sugar-sweetened beverage consumers in Philadelphia (n = 306; 67% female; mean age: 43.9 years) and Baltimore (n = 297; comparison city without a beverage tax; 58% female; mean age: 41.7 years) submitted all food and beverage receipts during 2-week periods at baseline and at 3, 6, and 12 months posttax. Difference-in-differences analyses compared changes in purchases from pre- to posttax in Philadelphia to changes in Baltimore.

RESULTS

Purchases of taxed juice drinks [ratio of incidence rate ratios (RIRR) = 0.62; 95% CI, 0.42-0.91], but not other taxed beverage types, decreased in Philadelphia compared to Baltimore following the tax. Analyses did not find changes in purchases of low-calorie/low-added-sugar nontaxed beverages, such as water or milk. Additionally, analyses did not find increases in purchases of most high-calorie/high-added-sugar nontaxed products, including alcohol, juice, candy, sweet snacks, salty snacks, and desserts. Purchases of beverage concentrates increased in Philadelphia (RIRR = 2.22; 95% CI, 1.39-3.54).

CONCLUSIONS

In this difference-in-differences analysis, the Philadelphia beverage tax was associated with reduced purchases of taxed juice drinks. Purchases of beverage concentrates increased after the tax, but no increases were observed for other high-calorie/high-added-sugar nontaxed foods, beverages, or alcohol.

Sugar-Sweetened Beverage Pricing Policies: Simulation of Minimum Price Laws and Taxes in New York City

INTRODUCTION

Minimum price laws, which set a price below which a product cannot be sold, are a promising but understudied strategy for reducing the consumption of sugar-sweetened beverages. New York City has implemented a minimum price law for tobacco products and could consider this policy for sugar-sweetened beverages. This study projects the impacts of a sugar-sweetened beverage minimum price law among New York City adults, with effects of a sugar-sweetened beverage excise tax examined for comparison.

METHODS

In 2020-2021, a microsimulation model of dietary behaviors and body weight was developed using population-based survey data, research on responsiveness to and avoidance of price increases, and a validated weight change model. Analyses applied the model to simulate the impacts of implementing a minimum price law (8 or 10 cents/ounce price floors) or an excise tax (1 or 2 cents/ounce tax rates) on diet and body weight among New York City adults for more than 5 years. Sensitivity analyses varied assumptions about price responsiveness, caloric compensation, and avoidance.

RESULTS

A sugar-sweetened beverage minimum price law with an 8 cents/ounce floor would reduce average sugar-sweetened beverage intake by 16.5 calories/day (95% uncertainty interval= -17.2, -15.8) and obesity prevalence by 0.86 percentage points (95% uncertainty interval= -1.03, -0.69). Benefits were similar for a minimum price law with a 10 cents/ounce floor and for 1 and 2 cents/ounce taxes (range of obesity reductions: -0.84 to -1.24 percentage points). Benefits persisted in sensitivity analyses and were larger for Black and Hispanic than for White and Asian adults and for adults with lower than for those with higher income.

CONCLUSIONS

Excise taxes and minimum price laws for sugar-sweetened beverages could both reduce New York City adults' sugar-sweetened beverage consumption and obesity prevalence and narrow sociodemographic disparities in obesity.

Influence of the San Francisco, CA, Sugar-Sweetened Beverage Health Warning on Consumer Reactions: Implications for Equity from a Randomized Experiment

BACKGROUND

In 2020, San Francisco, CA, amended an ordinance requiring warning labels on advertisements for sugary drinks to update the warning message. No studies have evaluated consumer responses to the revised message.

OBJECTIVES

To evaluate responses to the 2020 San Francisco sugary drink warning label and to assess whether these responses differ by demographic characteristics.

DESIGN

Randomized experiment.

PARTICIPANTS AND SETTING

During 2020, a convenience sample of US parents of children aged 6 months to 5 years (N = 2,160 included in primary analyses) was recruited via an online panel to complete a survey. Oversampling was used to achieve a diverse sample (49% Hispanic/Latino[a], 34% non-Hispanic Black, and 9% non-Hispanic White).

METHODS

Participants were randomly assigned to view a control label ("Always read the Nutrition Facts Panel") or the 2020 San Francisco sugary drink warning label ("SAN FRANCISCO GOVERNMENT WARNING: Drinking beverages with added sugar(s) can cause weight gain, which increases the risk of obesity and type 2 diabetes."). Messages were shown in white text on black rectangular labels.

MAIN OUTCOME MEASURES

Participants rated the labels on thinking about health harms of sugary drink consumption (primary outcome) and perceived discouragement from wanting to consume sugary drinks. The survey was available in English and Spanish.

STATISTICAL ANALYSES PERFORMED

Ordinary least squares regression.

RESULTS

The San Francisco warning label elicited more thinking about health harms (Cohen's d = 0.24; P < 0.001) than the control label. The San Francisco warning label also led to more discouragement from wanting to consume sugary drinks than the control label (d = 0.31; P < 0.001). The warning label's influence on thinking about harms did not differ by any participant characteristics, including age, gender, race/ethnicity, education, income, or language of survey administration (all P values for interactions > 0.12).

CONCLUSIONS

San Francisco's 2020 sugary drink warning label may be a promising policy for informing consumers and encouraging healthier beverage choices across groups with diverse demographic characteristics.

The impact of pictorial health warnings on purchases of sugary drinks for children: A randomized controlled trial

BACKGROUND

Pictorial warnings on tobacco products are promising for motivating behavior change, but few studies have examined pictorial warnings for sugary drinks, especially in naturalistic environments. This study aimed to examine the impact of pictorial warnings on parents' purchases of sugary drinks for their children in a naturalistic store laboratory.

METHODS AND FINDINGS

Parents of children ages 2 to 12 (n = 325, 25% identifying as Black, 20% Hispanic) completed a shopping task in a naturalistic store laboratory in North Carolina. Participants were randomly assigned to a pictorial warnings arm (sugary drinks displayed pictorial health warnings about type 2 diabetes and heart damage) or a control arm (sugary drinks displayed a barcode label). Parents selected 1 beverage and 1 snack for their child, as well as 1 household good; one of these items was selected for them to purchase and take home. The primary outcome was whether parents purchased a sugary drink for their child. Secondary outcomes included reactions to the trial labels, attitudes toward sugary drinks, and intentions to serve their child sugary drinks. Pictorial warnings led to a 17-percentage point reduction in purchases of sugary drinks (95% CI for reduction: 7% to 27%), with 45% of parents in the control arm buying a sugary drink for their child compared to 28% in the pictorial warning arm (p = 0.002). The impact of pictorial warnings on purchases did not differ by any of the 13 participant characteristics examined (e.g., race/ethnicity, income, education, and age of child). Pictorial warnings also led to lower calories (kcal), purchased from sugary drinks (82 kcal in the control arm versus 52 kcal in the pictorial warnings arm, p = 0.003). Moreover, pictorial warnings led to lower intentions to serve sugary drinks to their child, feeling more in control of healthy eating decisions, greater thinking about the harms of sugary drinks, stronger negative emotional reactions, greater anticipated social interactions, lower perceived healthfulness of sugary drinks for their child, and greater injunctive norms to limit sugary drinks for their child (all p < 0.05). There was no evidence of difference between trial arms on noticing of the labels, appeal of sugary drinks, perceived amount of added sugar in sugary drinks, risk perceptions, or perceived tastiness of sugary drinks (all p > 0.05).

CONCLUSIONS

Pictorial warnings reduced parents' purchases of sugary drinks for their children in this naturalistic trial. Warnings on sugary drinks are a promising policy approach to reduce sugary drink purchasing in the US.

TRIAL REGISTRATION

The trial design, measures, power calculation, and analytic plan were registered before data collection at www.clinicaltrials.gov NCT04223687.

Storybooks About Healthy Beverage Consumption: Effects in an Online Randomized Experiment With Parents

INTRODUCTION

Parents spend substantial time reading to their children, making storybooks a promising but understudied avenue for motivating parents to serve their children healthier beverages. This study examines parents' reactions to messages promoting healthy beverage consumption embedded in a children's storybook.

METHODS

In 2020, a total of 2,164 demographically diverse parents of children aged 6 months to 5 years participated in an online survey. Participants were randomized to view control messages (school readiness) or 1 of 3 beverage message topics (sugary drink discouragement, water encouragement, or combined discouragement and encouragement) presented as pages from the storybook Potter the Otter. Survey items assessed parents' reactions to the messages and their perceptions, beliefs, and intentions regarding sugary drinks and water. Data were analyzed in 2021.

RESULTS

Compared with control messages, exposure to the beverage messages led to higher discouragement from serving children sugary drinks and higher encouragement to serve children more water (p<0.001). The beverage messages also elicited more thinking about beverages' health impacts and led to stronger perceptions that sugary drinks are unhealthy (p<0.001). Moreover, the beverage messages led to higher intentions to limit serving children sugary drinks and higher intentions to serve children more water (p≤0.02). Parents' reactions to the beverage messages did not differ by most demographic characteristics. Few differences in outcomes were observed among the 3 beverage message topics.

CONCLUSIONS

Embedding beverage messages in storybooks is a promising, scalable strategy for motivating parents from diverse backgrounds to serve children more water and fewer sugary drinks.

Differences in Dietary Quality by Sexual Orientation and Sex in the US: NHANES 2011-2016

BACKGROUND

There are persistent disparities in weight- and diet-related diseases by sexual orientation. Lesbian and bisexual females have a higher risk of obesity and cardiovascular disease compared to heterosexual females. Gay and bisexual males have a higher risk of diabetes and cardiovascular disease compared to heterosexual males. However, it remains unknown how sexual orientation groups differ in their dietary quality.

OBJECTIVE

This study aimed to determine whether dietary quality differs by sexual orientation and sex among US adults.

DESIGN

This was a cross-sectional study of 24-h dietary recall data from a nationally representative sample of adults aged 20-65 participating in the 2011-2016 National Health and Nutrition Examination Survey (NHANES).

PARTICIPANTS/SETTING

Study participants were adults (n=8,851) with complete information on dietary intake, sexual orientation, and sex.

MAIN OUTCOME MEASURES

The main outcome measures were daily energy intake from 20 specific food and beverage groups and Healthy Eating Index-2015 (HEI-2015) scores for sexual orientation groups (heterosexual vs. gay/lesbian/bisexual (GLB)).

STATISTICAL ANALYSES PERFORMED

Ordinary least squares regressions were used to calculate adjusted means for each food and beverage group and HEI-2015, stratified by sex and controlling for covariates (e.g., age, race/ethnicity) and survey cycles (2011-2012; 2013-2014; 2015-2016).

RESULTS

Among males, red and processed meat/poultry/seafood (p=0.01) and sandwiches (p=0.02) were smaller contributors to energy intake for gay/bisexual males compared to heterosexual males. Among females, cereals (p=0.04) and mixed dishes (p=0.02) were smaller contributors to energy intake for lesbian/bisexual females compared to heterosexual females. Gay/bisexual males had significantly higher total HEI-2015 scores than heterosexual males (53.40 ± 1.36 vs. 49.29 ± 0.32, difference=4.14, p=0.004). Lesbian/bisexual females did not differ in total or component HEI-2015 scores from heterosexual females.

CONCLUSIONS

While GLB groups were similar for a variety of dietary outcomes compared to heterosexual groups, gay and bisexual males displayed healthier dietary quality for processed meat (by consuming smaller amounts) and overall dietary quality (according to HEI-2015) compared to heterosexual males.

Changes in Calorie Content of Menu Items at Large Chain Restaurants After Implementation of Calorie Labels

IMPORTANCE

Calorie labeling on menus is required in US chain food establishments with 20 or more locations. This policy may encourage retailers to offer lower-calorie items, which could lead to a public health benefit by reducing customers' calorie intake from prepared foods. However, potential reformulation of restaurant menu items has not been examined since nationwide enforcement of this policy in 2018.

OBJECTIVE

To examine the calorie content of menu items at large chain restaurants before and after implementation of federally mandated menu calorie labels.

DESIGN, SETTING, AND PARTICIPANTS

This pre-post cohort study used restaurant menu data from MenuStat, a database of nutrition information for menu items offered in the largest chain restaurants in the US, collected annually from 2012 to 2019. The study comprised 35 354 menu items sold at 59 large chain restaurants in the US. Statistical analysis was conducted from February 4 to October 8, 2021.

INTERVENTION

Nationwide implementation of menu calorie labeling.

MAIN OUTCOMES AND MEASURES

Changes in menu items' calorie content after restaurant chains implemented calorie labels were estimated, adjusting for prelabeling trends. All menu items, continuously available items, items newly introduced to menus, and items removed from menus were examined separately.

RESULTS

Among the 59 restaurant chains included in the study, after labeling, there were no changes in mean calorie content for all menu items (change = -2.0 calories; 95% CI, -8.5 to 4.4 calories) or continuously available items (change = -2.3 calories; 95% CI, -11.5 to 6.3 calories). Items that were newly introduced after labeling, however, had a lower mean calorie content than items introduced before labeling (change = -112.9 calories; 95% CI, -208.6 to -25.2 calories), although there was heterogeneity by restaurant type. Items removed from menus after labeling had similar calorie content as items removed before labeling (change = 0.5 calories; 95% CI, -79.4 to 84.0 calories).

CONCLUSIONS AND RELEVANCE

In this cohort study of large chain restaurants, implementing calorie labels on menus was associated with the introduction of lower-calorie items but no changes in continuously available or removed items.

Testing front-of-package warnings to discourage red meat consumption: a randomized experiment with US meat consumers

BACKGROUND

Reducing red meat is a strategy to improve public health and mitigate climate change in the United States and other high-income countries. Policies requiring warnings on the front of red meat packages are a promising intervention to shift consumers towards healthier and more sustainable food choices. We aimed to explore participants' reactions to health and environmental warning messages about red meat.

METHODS

Between June and July 2020, we recruited a national convenience sample of US red meat consumers (n = 1,235; mean age 44 years) for an online survey. Participants were randomly assigned to one of four label conditions: no-label control, health warning, environment warning, and combined health and environment warning (both warnings shown side-by-side). Participants viewed three types of burritos (red meat [steak], chicken, and vegetarian) and selected their preferred item (primary outcome), the item they perceived to be most damaging to health, and the item they perceived to be most damaging to the environment (secondary outcomes). Participants then viewed their assigned warning on a series of other red meat products (no-label control participants were randomly re-assigned to one of the warning conditions) and rated the warnings on perceived message effectiveness, believability, negative emotions, perceived risk, attention, and learning something new. Finally, participants reported their intentions to reduce red meat consumption.

RESULTS

There were no significant differences in selection of the steak burrito between label conditions or in selection of the item most damaging to the environment. Those exposed to the health warning were more likely to select the steak burrito as most damaging to health compared to those exposed to other label conditions (health 73 %, combined 64 %, environment 60 %, no-label control 63 %, p < 0.05). The combined and health warnings elicited higher perceived message effectiveness ratings than the environment warning (combined mean 2.91, health 2.84, environment 2.61, p < 0.05).

CONCLUSIONS

Warnings did not have a significant effect on item preference in the choice experiment. However, combined and health warnings performed better than the environment warning across a variety of warning label reaction measures. More research will be needed to understand whether warnings elicit behavioral change in real-world environments.

TRIAL REGISTRATION

Analyses and hypotheses were preregistered on https://aspredicted.org/ph7mb.pdf on 23 June 2020.

Calorie Labeling and Product Reformulation: A Longitudinal Analysis of Supermarket-Prepared Foods

INTRODUCTION

The 2010 Affordable Care Act required chain retail food establishments, including supermarkets, to post calorie information for prepared (i.e., ready to eat) foods. Implementation of calorie labeling could spur companies to reduce the calorie content of prepared foods, but few studies have explored this. This study evaluates the changes in the calorie content of prepared foods at 2 large U.S. supermarket chains after they implemented calorie labels in April 2017.

METHODS

The chains (≈1,200 stores) provided data on the calorie content and labeling status of all items sold between July 2015 and January 2019. In 2021, analyses used a difference-in-differences approach to examine the changes in the calorie content of prepared bakery, entree, and deli items introduced before calorie labeling to those introduced after the labeling compared with changes in similar foods not subject to the new labeling requirement. Primary analyses examined continuously available items; exploratory analyses examined items newly introduced to the marketplace.

RESULTS

Relative to changes in comparison foods not subject to the labeling requirement, continuously available prepared bakery items decreased by 7.7 calories per item after calorie labels were implemented (95% CI= -12.9, -2.5, p=0.004, ≈0.5% reduction). In exploratory analyses, prepared bakery items introduced after calorie labeling contained 440 fewer calories per item than those introduced before calorie labeling (95% CI= -773.9, -106.1, p=0.01, ≈27% reduction), driven by reductions in product size. No changes were observed in the calorie content of continuously available or newly introduced prepared entrees or deli items.

CONCLUSIONS

Implementing calorie labels could encourage product reformulation among some types of prepared supermarket foods. These supply-side changes could lead to reductions in caloric intake.

Using a Naturalistic Store Laboratory for Clinical Trials of Point-of-Sale Nutrition Policies and Interventions: A Feasibility and Validation Study

Point-of-sale policies such as warnings and taxes are promising tools for improving the nutritional quality of food purchases. Research studies conducted in naturalistic store laboratories could improve the quality of evidence about point-of-sale interventions by allowing for realistic exposure in a controlled setting. This study aimed to assess whether purchasing behavior in a naturalistic store laboratory setting was similar to real-life purchasing behavior and to evaluate participants’ perceptions of store realism and the acceptability of research study protocols in this setting. In a longitudinal observational study in 2019, Latinx parents in North Carolina (n = 61) attended five weekly visits at the UNC Mini Mart, a naturalistic store laboratory that resembled a small convenience store. At each visit, participants purchased a week’s supply of beverages. Purchases of beverages in the Mini Mart were compared to participants’ purchases from receipts submitted the week prior to the study. Analyses compared the percentage of participants buying sugary drinks and non-sugary drinks in the Mini Mart vs. in real stores using Chi-Square tests with Fisher’s p. The percentage of parents who purchased sugary drinks in the Mini Mart (93%) was not significantly different from the percentage who purchased sugary drinks during the week before the study (74%, p = 0.28). The percentage purchasing non-sugary drinks was similar in the two settings (85% in the Mini Mart vs. 85% from receipts, p = 0.33). Nearly all participants reported that their Mini Mart purchases were similar to real-life purchases (96%); the Mini Mart felt like a real store (94%); they could find all the beverages they were looking for (92%); and they could imagine doing their real-life beverage shopping in the Mini Mart (92%). Moreover, retention was high, with 97% of participants attending the final study visit. These results indicate that naturalistic store laboratories are a promising method for increasing the ecological validity of trials to evaluate point-of-sale interventions.

Implementation of a workplace physical activity intervention in child care: process evaluation results from the Care2BWell trial

Care2BWell was designed to evaluate the efficacy of Healthy Lifestyles (HL), a worksite health promotion intervention to increase child care workers' physical activity. The purpose of this study was to use process evaluation to describe the implementation of HL and determine if different levels of implementation are associated with changes in workers' physical activity. Data were collected from 250 workers randomized to HL, a 6 month, multilevel intervention that included an educational workshop followed by three 8 week campaigns that included self-monitoring and feedback, raffle incentive, social support, and center director coaching. Process evaluation data collection included direct observation, self-reported evaluation surveys, website analytics and user test account data, tracking databases and semi-structured interviews. Implementation scores were calculated for each intervention component and compared at the center and individual levels. Nearly a third of workers never self-monitored and few (16%) met self-monitoring goals. Only 39% of centers engaged with the social support component as intended. Raffle and social support components were perceived as the least useful. Implementation varied widely by center (25%-76%) and individual workers (0%-94%). No within- or between-group differences for high compared to low implementation groups for change in physical activity were evident. Interview themes included limited sustainability, competing priorities, importance of social support, and desire for a more intensive, personalized intervention. Wide variation in implementation may explain limited effects on intervention outcomes. Future worksite interventions designed for child care workers can use these findings to optimize health promotion in this setting.

Health Warnings and Beverage Purchase Behavior: Mediators of Impact

BACKGROUND

To reduce diet-related chronic disease, policymakers have proposed requiring health warnings on sugar-sweetened beverages (SSBs). Health warnings reduced purchases of these products by 22% in our recent randomized controlled trial, but the mechanisms remain unclear.

PURPOSE

We sought to identify the psychological mechanisms that explain why SSB health warnings affect purchase behavior.

METHODS

In 2018, we recruited 400 adult SSB consumers to complete a shopping task in a naturalistic convenience store laboratory in North Carolina, USA. We randomly assigned participants to either a health warning arm (all SSBs in the store displayed a text health warning) or to a control arm (SSBs displayed a control label). Participants selected items to purchase with cash.

RESULTS

Compared to control labels, health warnings elicited more attention, negative affect, anticipated social interactions, and thinking about harms (range of ds = 0.63-1.34; all p < .001). Health warnings also led to higher injunctive norms about limiting SSB consumption (d = 0.27, p = .008). Except for attention, all of these constructs mediated the effect of health warnings on SSB purchases (all p < .05). In contrast, health warnings did not influence other attitudes or beliefs about SSBs or SSB consumption (e.g., healthfulness, outcome expectations, and response efficacy).

CONCLUSIONS

Health warnings on sugar-sweetened beverages affected purchase behavior by eliciting negative emotions, increasing anticipated social interactions, keeping SSBs' harms at top of mind, and shifting norms about beverage consumption. Results are consistent with recent studies of why tobacco warnings influence quitting behavior, pointing toward a general framework for understanding how health warnings affect behavior.

CLINICAL TRIALS REGISTRATION

NCT #03511937.

Barriers and facilitators to achieving food security during the COVID-19 pandemic

The COVID-19 pandemic has considerably increased food insecurity. To identify where intervention and policy solutions are most needed, we explored barriers to obtaining food and predictors of experiencing food insecurity due to the COVID-19 pandemic. Between May and July 2020, we conducted cross-sectional online surveys with two convenience samples of U.S. adults (Study 1: n = 2,219, Study 2: n = 810). Roughly one-third of participants reported experiencing food insecurity due to the COVID-19 pandemic (Study 1: 32%, Study 2: 35%). Between one-third and half reported using the charitable food system (Study 1: 36%, Study 2: 46%). The majority of participants experienced barriers to getting food (Study 1: 84%, Study 2: 88%), of which the most commonly reported were not having enough money to buy food (Study 1: 48%; Study 2: 53%) and worrying about getting COVID-19 at the store (Study 1: 50%; Study 2: 43%). Higher education was associated with greater risk of food insecurity in both studies (all p < 0.05). Receipt of aid from SNAP buffered against the association between financial struggles and food insecurity in Study 1 (p = 0.03); there was also some evidence of this effect in Study 2 (p = 0.05). Our findings suggest that food insecurity might be reduced by mitigating financial struggles (e.g., by increasing access to SNAP) and by addressing barriers to obtaining food (e.g., by expanding accessibility of food delivery programs).

Awareness of and reactions to the health harms of sugary drinks: An online study of U.S. parents

Evidence about the health problems associated with sugary drink consumption is well-established. However, little is known about which sugary drink health harms are most effective at changing consumers' behavior. We aimed to identify which harms people were aware of and most discouraged them from wanting to buy sugary drinks. Participants were a national convenience sample of diverse parents (n = 1,058), oversampled for Latino parents (48%). Participants rated a list of sugary drink-related health harms occurring in children (7 harms) and in adults (15 harms). Outcomes were awareness of each harm and how much each harm discouraged parents from wanting to purchase sugary drinks. Most participants were aware that sugary drinks contribute to tooth decay in children (75%) and weight gain in both children (73%) and adults (69%). Few participants were aware that sugary drinks contribute to adult infertility (16%), arthritis (18%), and gout (18%). All health harms were rated highly in terms of discouraging parents from wanting to buy sugary drinks (range: 3.59-4.11 on a 1-5 scale), with obesity, pre-diabetes, and tooth decay eliciting the highest discouragement ratings. Harm-induced discouragement was higher for participants who were aware of more health harms (B = 0.05, p < 0.0001), identified as female (B = 0.15 compared to male, p = 0.02), or had an annual household income of $50,000 or more (B = 0.16 compared to less than $50,000, p = 0.03). These findings suggest health messages focused on a variety of health harms could raise awareness and discourage sugary drink purchases.

COVID-19 and Parent Intention to Vaccinate Their Children Against Influenza

OBJECTIVES

Evaluate if the coronavirus disease 2019 (COVID-19) pandemic influences parents' intentions to have their children receive the 2020-2021 seasonal influenza vaccination.

METHODS

In May 2020, we recruited 2164 US parents and guardians of children ages 6 months to 5 years to complete a brief online survey that examined parental behavior and decision-making in response to experimental stimuli and real-world events. We estimated a multivariate multinomial logistic regression (controlling for key demographics) to assess the relationship between a child's 2019-2020 influenza vaccination status and the COVID-19 pandemic's influence on a parent's intentions for their child's 2020-2021 influenza vaccination.

RESULTS

Changes in vaccination intentions significantly differed between parents whose children received the 2019-2020 influenza vaccine compared with those whose children did not (P < .001). Specifically, among parents whose children did not receive the 2019-2020 vaccine, 34% (95% confidence interval [CI]: 30%-37%) reported that the COVID-19 pandemic made them less likely to have their child receive the 2020-2021 vaccine. Among those whose children did receive the 2019-2020 vaccine, this figure was just 24% (95% CI: 22%-27%). Conversely, only 21% (95% CI: 18%-24%) of parents whose children did not receive the 2019-2020 vaccine reported that the COVID-19 pandemic made them more likely to have their child receive the 2020-2021 vaccine, compared with 39% (95% CI: 36%-41%) of parents whose children did receive the 2019-2020 vaccine.

CONCLUSIONS

The COVID-19 pandemic alone does not appear sufficient to encourage the uptake of pediatric seasonal influenza vaccination. Instead, the COVID-19 pandemic may exacerbate polarity in vaccination uptake.

Reactions to messages about smoking, vaping and COVID-19: two national experiments

Introduction

The pace and scale of the COVID-19 pandemic, coupled with ongoing efforts by health agencies to communicate harms, have created a pressing need for data to inform messaging about smoking, vaping, and COVID-19. We examined reactions to COVID-19 and traditional health harms messages discouraging smoking and vaping.

Methods

Participants were a national convenience sample of 810 US adults recruited online in May 2020. All participated in a smoking message experiment and a vaping message experiment, presented in a random order. In each experiment, participants viewed one message formatted as a Twitter post. The experiments adopted a 3 (traditional health harms of smoking or vaping: three harms, one harm, absent) × 2 (COVID-19 harms: one harm, absent) between-subjects design. Outcomes included perceived message effectiveness (primary) and constructs from the Tobacco Warnings Model (secondary: attention, negative affect, cognitive elaboration, social interactions).

Results

Smoking messages with traditional or COVID-19 harms elicited higher perceived effectiveness for discouraging smoking than control messages without these harms (all p <0.001). However, including both traditional and COVID-19 harms in smoking messages had no benefit beyond including either alone. Smoking messages affected Tobacco Warnings Model constructs and did not elicit more reactance than control messages. Smoking messages also elicited higher perceived effectiveness for discouraging vaping. Including traditional harms in messages about vaping elicited higher perceived effectiveness for discouraging vaping (p <0.05), but including COVID-19 harms did not.

Conclusions

Messages linking smoking with COVID-19 may hold promise for discouraging smoking and may have the added benefit of also discouraging vaping.

Demographic Groups Likely Affected by Regulating Sugar-Sweetened Beverage Portion Sizes

INTRODUCTION

Sugar-sweetened beverages are a key driver of obesity. Portion-size regulations typically limit the volume of unsealed sugar-sweetened beverage containers to 16 fluid ounces. These regulations could reduce sugar-sweetened beverage consumption, but whom these policies would affect remains unknown. This study evaluates demographic groups likely affected by hypothetical national portion-size regulations modeled on policy language and scopes from New York City and California.

METHODS

Data from adults (aged 18-65 years, n=6,594) in the National Health and Nutrition Examination Survey (2013‒2016) were used to classify individuals as likely affected if they consumed a sugar-sweetened beverage larger than 16 fluid ounces from a potentially regulated food source during at least 1 eating occasion. Two classifications of affected food sources were evaluated: (1) excluding convenience stores (New York City scope) and (2) including convenience stores (California scope). In 2020, analyses were conducted using logistic regression to examine associations between affected status and age (<35 and ≥35 years), sex, race/ethnicity (white, non-Hispanic, black, non-Hispanic, andHispanic), education (without college degree and with college degree), and income (≤185% and >185% of the federal poverty line).

RESULTS

Portion-size regulations would affect 8.87% of adults (New York City scope) and 14.71% of adults (California scope). Regulations had a greater potential effect on adults who were aged <35 years, male, and without a college degree (all p<0.05). Differences between demographic groups would be larger in magnitude using California's policy scope.

CONCLUSIONS

Portion-size regulations would likely have a greater effect on younger, male, and less-educated adults. Policy effects would likely be larger if these regulations are written to encompass more food sources.

Reactions to graphic and text health warnings for cigarettes, sugar-sweetened beverages, and alcohol: An online randomized experiment of US adults

We aimed to examine reactions to graphic versus text-only warnings for cigarettes, SSBs, and alcohol. A convenience sample of US adults completed an online survey in 2018 (n = 1352 in the analytic sample). We randomly assigned participants to view a: 1) text-only warning without efficacy information (i.e., message intended to increase consumers' confidence in their ability to stop using the product), 2) text-only warning with efficacy information, 3) graphic warning without efficacy information, or 4) graphic warning with efficacy information. Participants viewed their assigned warning on cigarettes, SSBs, and alcohol, in a random order. Across product types, graphic warnings were perceived as more effective than text-only warnings (p < .001) and led to lower believability, greater reactance (i.e., resistance), more thinking about harms, and lower product appeal (all p < .05); policy support did not differ. Compared to SSB and alcohol warnings, cigarette warnings led to higher perceived message effectiveness, believability, fear, thinking about harms, policy support, and greater reductions in product appeal (all p < .05). The efficacy information did not influence any outcomes. Graphic warnings out-performed text-only warnings on key predictors of behavior despite causing more reactance.

Implementation of the First US Sugar-Sweetened Beverage Tax in Berkeley, CA, 2015-2019

Objectives. To identify lessons learned from implementation of the nation's first sugar-sweetened beverage (SSB) excise tax in 2015 in Berkeley, California.Methods. We interviewed city stakeholders and SSB distributors and retailers (n = 48) from June 2015 to April 2017 and analyzed records through January 2019.Results. Lessons included the importance of thorough and timely communications with distributors and retailers, adequate lead time for implementation, advisory commissions for revenue allocations, and funding of staff, communications, and evaluation before tax collection begins. Early and robust outreach about the tax and programs funded can promote and sustain public support, reduce friction, and facilitate beverage price increases on SSBs only. No retailer reported raising food prices, indicating that Berkeley's SSB tax did not function as a "grocery tax," as industry claimed. Revenue allocations totaled more than $9 million for public health, nutrition, and health equity through 2021.Conclusions. The policy package, context, and implementation process facilitated translating policy into public health outcomes. Further research is needed to understand long-term facilitators and barriers to sustaining public health benefits of Berkeley's tax and how those differ from facilitators and barriers in jurisdictions facing significant industry-funded repeal efforts.

The impact of front-of-package claims, fruit images, and health warnings on consumers' perceptions of sugar-sweetened fruit drinks: Three randomized experiments

We aimed to examine the impact of claims, fruit images, and health warnings on consumers' perceptions of fruit-flavored drinks with added sugar (i.e., "fruit drinks"). We conducted three 2x2x2 randomized experiments with online convenience samples of U.S. adults (Study 1 n = 2139 in 2018, current e-cigarette users and smokers; Study 2 n = 670 in 2018, current e-cigarette users; Study 3 n = 1006 in 2019, general sample). Participants viewed a fruit drink that differed in the presence of a "100% Vitamin C" claim, a fruit image, or a health warning. On average across the three studies, consumers who saw a claim on a fruit drink believed that the drink was more healthful than those who did not see the claim (mean average differential effect (ADE) = 0.66, p < .001); they were also more interested in consuming the drink (mean ADE = 0.38, p = .001). The health warning decreased perceived product healthfulness (mean ADE = -0.65, p < .001) and consumption interest (mean ADE = -0.49, p < .001). The fruit image had no effect on perceived product healthfulness (mean ADE = 0.03, p = .81) or purchase intentions (mean ADE = -0.04, p = .77). In Study 1 and Study 2, there were no interactions between claims, images, or warnings (all p > .05). In Study 3, the "100% Vitamin C" nutrition claim only increased perceived product healthfulness when the drink did not also have a health warning (interaction p < .05). These findings suggest that 100% Vitamin C claims increase the appeal of fruit drinks, whereas health warnings decrease the appeal. Together, these studies support policies to restrict marketing and require health warnings on sugar-sweetened beverage packaging.

Sugar-Sweetened Beverage Health Warnings and Purchases: A Randomized Controlled Trial

INTRODUCTION

Five U.S. states have proposed policies to require health warnings on sugar-sweetened beverages, but warnings' effects on actual purchase behavior remain uncertain. This study evaluated the impact of sugar-sweetened beverage health warnings on sugar-sweetened beverage purchases.

STUDY DESIGN

Participants completed one study visit to a life-sized replica of a convenience store in North Carolina. Participants chose six items (two beverages, two foods, and two household products). One item was randomly selected for them to purchase and take home. Participants also completed a questionnaire. Researchers collected data in 2018 and conducted analyses in 2019.

SETTING/PARTICIPANTS

Participants were a demographically diverse convenience sample of 400 adult sugar-sweetened beverage consumers (usual consumption ≥12 ounces/week).

INTERVENTION

Research staff randomly assigned participants to a health warning arm (sugar-sweetened beverages in the store displayed a front-of-package health warning) or a control arm (sugar-sweetened beverages displayed a control label).

MAIN OUTCOME MEASURES

The primary trial outcome was sugar-sweetened beverage calories purchased. Secondary outcomes included reactions to trial labels (e.g., negative emotions) and sugar-sweetened beverage perceptions and attitudes (e.g., healthfulness).

RESULTS

All 400 participants completed the trial and were included in analyses. Health warning arm participants were less likely to be Hispanic and to have overweight/obesity than control arm participants. In intent-to-treat analyses adjusting for Hispanic ethnicity and overweight/obesity, health warnings led to lower sugar-sweetened beverage purchases (adjusted difference, -31.4 calories; 95% CI= -57.9, -5.0). Unadjusted analyses yielded similar results (difference, -32.9 calories; 95% CI= -58.9, -7.0). Compared with the control label, sugar-sweetened beverage health warnings also led to higher intentions to limit sugar-sweetened beverage consumption and elicited more attention, negative emotions, thinking about the harms of sugar-sweetened beverage consumption, and anticipated social interactions. Trial arms did not differ on perceptions of sugar-sweetened beverages' added sugar content, healthfulness, appeal/coolness, or disease risk.

CONCLUSIONS

Brief exposure to health warnings reduced sugar-sweetened beverage purchases in this naturalistic RCT. Sugar-sweetened beverage health warning policies could discourage sugar-sweetened beverage consumption.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT03511937.