How to improve food choices through vending machines: The importance of healthy food availability and consumers’ awareness

Comparison of Sales From Vending Machines With 4 Different Food and Beverage Messages: A Randomized Trial

Importance

Point-of-sale food messaging can encourage healthier purchases, but no studies have directly compared multiple interventions in the field.

Objective

To examine which of 4 food and beverage messages would increase healthier vending machine purchases.

Design, Setting, and Participants

This randomized trial assessed 13 months (February 1, 2019, to February 29, 2020) of vending sales data from 267 machines and 1065 customer purchase assessments from vending machines on government property in Philadelphia, Pennsylvania. Data analysis was performed from March 5, 2020, to November 8, 2022.

Interventions

Study interventions were 4 food and beverage messaging systems: (1) beverage tax posters encouraging healthy choices because of the Philadelphia tax on sweetened drinks; (2) green labels for healthy products; (3) traffic light labels: green (healthy), yellow (moderately healthy), or red (unhealthy); or (4) physical activity equivalent labels (minutes of activity to metabolize product calories).

Main Outcomes and Measures

Sales data were analyzed separately for beverages and snacks. The main outcomes analyzed at the transaction level were calories sold and the health status (using traffic light criteria) of each item sold. Additional outcomes were analyzed at the monthly machine level: total units sold, calories sold, and units of each health status sold. The customer purchase assessment outcome was calories purchased per vending trip.

Results

Monthly sales data came from 150 beverage and 117 snack vending machines, whereas 1065 customers (558 [52%] male) contributed purchase assessment data. Traffic light labels led to a 30% decrease in the mean monthly number of unhealthy beverages sold (mean ratio [MR], 0.70; 95% CI, 0.55-0.88) compared with beverage tax posters. Physical activity labels led to a 34% (MR, 0.66; 95% CI, 0.51-0.87) reduction in the number of unhealthy beverages sold at the machine level and 35% (MR, 0.65; 95% CI, 0.50-0.86) reduction in mean calories sold. Traffic light labels also led to a 30-calorie reduction (b = -30.46; 95% CI, -49.36 to -11.56) per customer trip in the customer purchase analyses compared to physical activity labels. There were very few significant differences for snack machines.

Conclusions and Relevance

In this 13-month randomized trial of 267 vending machines, the traffic light and physical activity labels encouraged healthier beverage purchases, but no change in snack sales, compared with a beverage tax poster. Corporations and governments should consider such labeling approaches to promote healthier beverage choices.

Trial Registration

ClinicalTrials.gov Identifier: NCT06260176.

Effectiveness of visual nudges for encouraging healthier beverage choices from vending machines

ISSUES ADDRESSED

Research suggests visual nudging techniques can subtly encourage healthier consumption. Two experiments explored the effect of four visual primes for nudging drink choices from a vending machine display.

METHODS

Participants (17-25 years) were randomly assigned to view vending machine advertising posters containing pictorial nudges of water, soft drink, general health (runner), or a text-only control, for nudging vending machine choices. Participants then selected an item from a vending machine display containing drinks only (Experiment 1; n = 164), or both drinks and snack foods (Experiment 2, n = 684).

RESULTS

In both experiments, nudging condition predicted beverage choice. Specifically, the water image nudged healthier beverage choices in both experiments. However, there was no effect on food choice in Experiment 2. Furthermore, in both experiments, liking and habitual consumption of chosen items were also significant predictors of choice, but condition predicted beverage choice over and above these.

CONCLUSION

A water prime may be an effective means of encouraging healthier beverage choices in a vending machine environment. SO WHAT?: Findings have the potential to inform strategies for encouraging healthier beverage choices from vending machine environments.

Perception about the effectiveness of different vending machine interventions to promote healthier snack selection among college students

OBJECTIVE

Evaluate college students' perception of the effectiveness of different vending machine (VM) interventions for improving snack selection.

PARTICIPANTS

A total of 194 college students with the age of ≥18 years.

METHOD

A cross-sectional survey among a purposive sampling near VM.

RESULTS

Most students use VM frequently or occasionally (63.4%). The intervention perceived as most helpful for choosing healthier snacks was labeling (on or near) which snack is healthy (score 3.83/5) followed by lowering the price of healthy options (score 3.33/5), while the least helpful was having posters nearby explaining which snacks are healthier (2.35/5). Participants suggested including snacks high in protein (58.8%) and low in sugar (56.2%). Most would like to see more healthy options in VM (83.5%) and will purchase them if available (67%).

CONCLUSIONS

Lowering the price for healthy snacks and including labels to indicate which are healthy may be the interventions to test for improving snack intake among college students.

Emotional response to healthier foods: Influence of culture and health consciousness

Sugar, salt, and fat content in processed products are important concerns for consumers. Hence, alternative "healthy" versions of conventional foods such as chocolate, potato chips, and yogurt are offered. This work aimed to define the emotional response of consumers from different cultural backgrounds (Spain vs. Brazil) evoked by healthier versions of conventional products and the relationship between hedonic responses and health consciousness. A total of 186 Brazilian and 152 Spanish consumers participated in this online cross-cultural study. Participants answered a Health Consciousness Questionnaire and an emotional check-all-that-applies questionnaire using picture stimuli of conventional chocolate, potato chips, and yogurt and their healthier versions with less sugar, salt, and fat content, respectively. The Brazilians' emotional responses were more diverse for all stimuli compared to the Spaniards'. However, participants from both cultures rated an average of "slightly agree" on the health consciousness scale; a higher level of consumption, liking, and willingness to buy; and a higher frequency of positive emotional terms for the stimuli of conventional products compared to their healthier versions. A higher frequency of evocation of "active" is strongly associated with higher levels of health consciousness. Strategic actions by the food industry and government must consider cultural, emotional, and health-conscious factors to encourage the consumption of healthier foods. PRACTICAL APPLICATION: Food manufacturers can use the information obtained from this study to create healthier versions of their products that appeal to consumers' emotional responses and health consciousness levels. The findings can assist in designing strategic actions to promote healthier food consumption by emphasizing the benefits of healthier food choices and making them more appealing to consumers. The methodology employed in this study can also be applied to further studies aimed to assess emotional responses to food stimuli across different cultures.

Exploring the pathways from the power of food to food cravings in a sample of Brazilian young adults

The present study has three main objectives: a) to analyse, for the first time, the factor structure of the Control of Eating Questionnaire (CoEQ) in a Brazilian sample; b) to explore, through in-depth interviews, motivators and consequences of food cravings among participants with high scores on the CoEQ; and c) to analyse whether and how the power of food is related to food cravings. The study involved 335 young adults aged 18-30 years, balanced for sex. The CoEQ and the Power of Food Scale (PFS) were used in an online survey. The CoEQ and PFS were subjected to confirmatory factor analysis. Semi-structured interviews were also conducted with a subsample (n = 20) with high CoEQ scores. The Socratic questioning method was used for the interviews. The interviews were transcribed and analysed according to thematic content analysis. The PFS and the CoEQ showed adequate factor structure with reliable factors. The results of the qualitative analysis showed that both food availability and seeking relief from stressors serve as motives for food cravings. Concern for health and weight gain were cited as consequences of cravings, as was seeking distraction to cope with these cravings. It was found that the PFS aggregate factor was a significant influencing factor for craving control (β = 0.604; p < 0.001), craving for savoury (β = 0.382; p < 0.001), craving for sweet (β = 0.414; p < 0.001) and positive mood (β = -0.198; p < 0.001). The findings suggest that the relationship between food cravings and the power of food is significant in today's obesogenic environment.

Innovative Strategies to Fuel Organic Food Business Growth: A Qualitative Research

This study aimed to identify the factors affecting consumer behavior and customer loyalty toward organic food. Whether consumers seek organic food for a healthy body or more as food for thought continues to be debated. However, since consumers’ purchase habits are based on their honest life experiences, which shape the building of a brand, this study reviewed the extant literature to understand the factors influencing the purchasing behavior for organic food. The follow-up problems highlighted in the research are related to organic business marketing strategy. Based on our methodology, we conducted semi-structured interviews to gain themes for qualitative research. The study found that availability, variety, and taste were the top three factors affecting consumers’ purchase decisions; surprisingly, neither price nor health-consciousness was the first concern. Using market-led innovation as an innovative lens to understand customer loyalty, this research highlights sustainable and advantageous business practices in the organic food market to enrich the literature on organic food purchasing behavior from multiple stakeholders.

College Students' Perception of Snacks Sold in Vending Machines in the US: A Mixed-Methods Study

Introduction: Food in vending machines in US colleges contain limited nutritious foods available for purchase, which could affect the food choices made by students leading to poor diet quality. Interventions to improve college foodscapes usually follow a top-down approach and fail to affect dietary behavioral changes ultimately. This research aims to uncover what students want and ways to achieve change.

Methods: The mixed-methods approach included peer-led qualitative focus group discussions and a brief quantitative questionnaire on satisfaction from foods available in vending machines. A convenience sample of 20 students (15 females) was recruited from a Hispanic serving institution for this study.

Results: Vending machines were perceived as convenient, plentiful, and unhealthy. Students expressed dissatisfaction with both the variety and nutritional quality of snacks in vending machines. Suggestions for improvement included more fresh items (fruits and vegetables) and refrigerated items with higher protein content (low-fat yogurt, hummus, and peanut butter). To implement these improvements, participants discussed the cost and feasibility of perishable items. Increasing awareness and partnering strategies were proposed to mediate potential cost and buy-in obstacles as was elevating the appeal of healthy vending machines with technological enhancements that draw customers in and educate.

Conclusion and Implication for Practice: This group of college students was eager for positive changes in foods sold in vending machines and understand the major difficulties. The suggested changes may help this and other colleges develop policies to regulate the foods in vending machines to promote overall health and help prevent chronic diseases in the future.

Consumption, Attitudes, and Trends of Vending Machine Foods at a University Campus: A Cross-Sectional Study

Vending machines (VMs) have been identified as an obesogenic factor, offering mainly energy-dense and nutrient-poor foods, with limited healthy options available. This cross-sectional study aimed to assess consumption trends and attitude toward vending machine (VM) foods in a university setting. A web-based survey was conducted among 1250 students and staff. Most participants reported weight gain (43.4%) and poorer food choices (53.4%) since joining the university. Participants described VM foods as expensive (53.7%) and lacking variety (34.3%). Over 81% demanded the availability of healthier options. About 75% of participants were VMs users. The most frequently purchased VM items were water, chocolate, and chips. Males reported consuming nuts, soda, iced tea, and energy drinks more frequently than females (p < 0.005). The main reasons for using the VM were hunger and lack of time. Over 40% nominated fresh fruits, baked chips, sandwiches, and dry roasted nuts to be provided in the VMs as healthier food options. Males and those responsible for buying their own food were more likely to select healthier options (p = 0.001). Findings can be used to inform stakeholders of current vending behaviors and to plan tailored interventions to improve the nutritional quality of vended items and promote healthier food choices.

Favorable Commercial and Health Behavior Impacts of a Healthy Vending Policy at an Australian University

BACKGROUND

The World Health Organization recognizes universities as an important health-promotion setting, including in healthy food provision. Previous research shows that healthy food retail interventions also need to consider commercial sustainability, including financial outcomes, and should take a holistic approach to consumer experience.

OBJECTIVE

Our aim was to determine the health behavior and commercial outcomes of a multicomponent traffic light-based healthy vending policy implemented as one part of a holistic university food policy. The hypothesis was that purchases of less healthy "red" beverages would decrease compared with predicted sales, that purchases of healthier "green" and "amber" alternatives would increase, and that there would be no change in revenue.

DESIGN

A quasi-experimental design evaluated a real-world food policy using monthly aggregated sales data to compare pre-intervention (January 2016 to March 2018) and post-intervention period sales (December 2018 to December 2019).

PARTICIPANTS/SETTING

Electronic sales data were collected from 51 beverage vending machines across 4 university campuses in Victoria, Australia.

INTERVENTION

A multicomponent policy was implemented between April and November 2018. Beverages were classified using a voluntary state government traffic light framework. Policy included display ≤20% red beverages and ≥50% green beverages; machine traffic light labeling; health-promoting machine branding; review of machine placement; and recycled bottle packaging.

MAIN OUTCOME MEASURES

Changes in red, amber, and green volume sales, and revenue compared with predicated sales.

STATISTICAL ANALYSES PERFORMED

Interrupted time series analysis of sales data compared post-policy sales with predicted sales.

RESULTS

In the 13^th month post-policy implementation, there was a 93.2% (95% CI +35.9% to +150.5%) increase in total beverage volume sold and an 88.6% (95% CI +39.2% to +138.1%) increase in revenue. There was no change in red beverage volume sold, but increases in green (+120.8%; 95% CI +59.0% to +182.6%) and amber (+223.2%; 95% CI +122.4% to +323.9%) volume sold.

CONCLUSIONS

Sustained behavior change and commercial outcomes suggest that holistic vending interventions can effectively promote healthier beverage sales.

Street Food Stand Availability, Density, and Distribution Across Income Levels in Mexico City

Street food stands (SFS) are an understudied element of the food environment. Previous SFS studies have not used a rigorous approach to document the availability, density, and distribution of SFS across neighborhood income levels and points of access in Mexico City. A random sample (n = 761) of street segments representing 20 low-, middle-, and high-income neighborhoods were assessed using geographic information system (GIS) and ground-truthing methods. All three income levels contained SFS. However, SFS availability and density were higher in middle-income neighborhoods. The distribution of SFS showed that SFS were most often found near homes, transportation centers, and worksites. SFS availability near schools may have been limited by local school policies. Additional studies are needed to further document relationships between SFS availability, density, and distribution, and current structures and processes.

The health benefits and cost-effectiveness of complete healthy vending

Vending machines contribute to growing levels of obesity. They typically contain energy dense, high fat snacks and attempts at persuading consumers to switch to healthier snacks sold within the same machine have had limited success. This study explored the health benefits and cost effectiveness of the complete replacement of regular snacks with healthy items. Two vending machines were manipulated in a 6-month trial, with a healthy and regular range of products alternated between the two machines every fortnight. Healthy vending resulted in a 61% drop in calories sold relative to regular vending, significant with time and product range as random factors. There was no evidence of compensatory behaviour from nearby shop sales nor in multi-item purchases from vending machines. The impact on profit was less clear. Sales dropped by 30% during healthy vending but variability across product range meant that the change was not significant. Overall our results demonstrate that complete healthy vending can be introduced in hospitals without a catastrophic loss in sales nor compensatory behaviours that offset the public health gains of consuming healthier products.

Healthy Behaviors through Behavioral Design-Obesity Prevention

Evidence for behavior modification for improved health outcomes was evaluated for nutrition, physical activity (PA), and indoor environmental quality (IEQ). The databases searched included LISTA, PubMed, and Web of Science, with articles rated using an a priori baseline score of 70/100 to establish inclusion. The initial search produced 52,847 articles, 63 of which were included in the qualitative synthesis. Thirteen articles met inclusion for nutrition: cafeteria interventions, single interventions, and vending interventions. Seventeen articles on physical activity were included: stair use, walking, and adjustable desks. For IEQ, 33 articles met inclusion: circadian disruption, view and natural light, and artificial light. A narrative synthesis was used to find meaningful connections across interventions with evidence contributing to health improvements. Commonalities throughout the nutrition studies included choice architecture, increasing the availability of healthy food items, and point-of-purchase food labeling. Interventions that promoted PA included stair use, sit/stand furniture, workplace exercise facilities and walking. Exposure to natural light and views of natural elements were found to increase PA and improve sleep quality. Overexposure to artificial light may cause circadian disruption, suppressing melatonin and increasing risks of cancers. Overall, design that encourages healthy behaviors may lower risks associated with chronic disease.

Prompting consumers to make healthier food choices in hospitals: a cluster randomised controlled trial

BACKGROUND

Hospitals in the UK offer snacks for sale to patients, staff and visitors. Despite the NHS's health promoting role, and tightening of regulations around which foods can be sold in hospitals, many snacks purchased in this setting are unhealthy. The present project tests the effectiveness of theory-based point of purchase prompts (PPPs; a form of cognitive nudge) designed to make it cognitively easier for consumers to compare available products and choose healthier options.

METHODS

Hospital shops in Scotland (n = 30) were recruited into a cluster randomised controlled trial to test whether a PPP could reduce the average calorie, fat and/or sugar content of purchased snacks. Inclusion criteria stated that eligible sites; sold food; were located in a hospital; and were accessible to staff, patients and visitors. The PPP intervention was a theory-based sign (tailored to the available range in each location) designed to cognitively simplify healthier snack choices by facilitating cross-product comparison. Shops were randomised to display PPPs (intervention; n = 15) or not (control; n = 15) using block randomisation controlling for shop size. Data on all snacks purchased from participating shops were obtained from retailers for a 12-week baseline and 12-week follow-up period. Primary outcomes were the average calorie (kcals), fat(g) and sugar(g) content of snacks purchased each day. Secondary outcomes were the average customer spend per item purchased (£,p) and the total number of snacks purchased daily. Shop staff were not blinded to group assignment but data providers were. Data were analysed using mixed effects multi-level regression models.

RESULTS

Data from > 1 million snack purchases were analysed. Snacks purchased from intervention sites were on average significantly lower in calorie (γ = - 1.84, p < .001) and sugar (γ = - 0.18, p = .030) at follow up relative to baseline but only the reduction in calories was significantly different to control. Average spend per item also reduced significantly in intervention (but not control) sites (γ = - 0.89, p < .001). The intervention had no effect on the fat content of snacks or the number of snacks sold.

CONCLUSIONS

Simple, theory-based point of purchase prompts can produce small but statistically significant reductions in the energy content of snack purchases from hospital shops.

TRIAL REGISTRATION

Retrospectively registered (8/Oct/2018) with ISRCTN (ID: ISRCTN90365793 ).

Effectiveness of Nutrition Interventions in Vending Machines to Encourage the Purchase and Consumption of Healthier Food and Drinks in the University Setting: A Systematic Review

University food environments typically offer an abundance of unhealthy foods, including through vending machines. This review evaluated the effectiveness of nutrition interventions in vending machines in the university setting. Ten databases were searched for experimental studies published up to July 2019, evaluating nutrition interventions that aimed to encourage the purchase or consumption of healthier foods and drinks in vending machines in the university setting. In total, 401 articles were identified, and 13 studies were included. Studies were pre-post test (n = 7, 54%), randomized controlled trials (RCTs) (n = 5, 38%), and non-randomized controlled trial (n = 1, 8%). Most studies were from the USA (n = 10, 77%) and were published between 2014 and 2018 (n = 9, 69%). Eight interventions (62%) reported positive change in outcomes, including increased number/proportion of sales or revenue from healthier items (n = 6), improved adherence to guidelines for the ratio of healthy/unhealthy products available (n = 1), and improved consumer perception of items available (n = 1). Effective interventions involved the promotion, reduced pricing, increased availability, and/or optimized product placement of healthier items within vending machines. Strategies to improve the nutritional quality of food and drinks in vending machines are warranted. This may be achieved by making healthier options more available and promoting them; however, more robust intervention studies are needed to determine effectiveness.

Investigating business outcomes of healthy food retail strategies: A systematic scoping review

Large changes to food retail settings are required to improve population diet. However, limited research has comprehensively considered the business implications of healthy food retail strategies for food retailers. We performed a systematic scoping review to identify types of business outcomes that have been reported in healthy food retail strategy evaluations. Peer-reviewed and grey literature were searched. We identified qualitative or quantitative real-world food or beverage retail strategies designed to improve the healthiness of the consumer nutrition environment (eg, changes to the "marketing mix" of product, price, promotion, and/or placement). Eligible studies reported store- or chain-level outcomes for measures of commercial viability, retailer perspectives, customer perspectives, and/or community outcomes. 11 682 titles and abstracts were screened with 107 studies included for review from 15 countries. Overall item sales, revenue, store patronage, and customer level of satisfaction with strategy were the most frequently examined outcomes. There was a large heterogeneity in outcome measures reported and in favourability for retailers of outcomes across studies. We recommend more consistent reporting of business outcomes and increased development and use of validated and reliable measurement tools. This may help generate more robust research evidence to aid retailers and policymakers to select feasible and sustainable healthy food retail strategies to benefit population health within and across countries.

Nudging to get our food choices on a sustainable track

Food production is one of the major contributors to environmental damage. Adaptations in our food choices are needed to preserve resources for the needs of future generations. More sustainable consumption patterns have been encouraged by economic incentives, laws, education and communication campaigns. Nonetheless, consumers still find difficulties in trying to change their current food habits. This review takes a behavioural approach in encouraging sustainable food choices among consumers. From a nudging perspective, many behavioural changes can be encouraged in a non-obtrusive way by adapting the complex food environment in which consumers are operating. These interventions do not restrict consumers' choices but rather adapt the choice architecture wherein food decisions are made. Drawing on the literature from diverse theoretical perspectives, we provide an overview of the application of nudging for more sustainable food choices and highlight where more research is needed. More specifically, we discuss research that used nudging to engender cognitive impact (i.e. the use of labels or visibility enhancements), affective responses (i.e. sensorial and social influence cues) and behavioural effects (i.e. adjustments in convenience and product size). We conclude that this review only shows the tip of the iceberg of the research on nudging and sustainable consumption that is likely forthcoming in the next few years, following the successes of nudging applications in other domains. Nonetheless, each individual nudging intervention requires careful examination. Personal predispositions towards the environment should be considered when designing interventions, demonstrating the complementarity of nudging with education on sustainable consumption.

Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health

BACKGROUND

Frequent consumption of excess amounts of sugar-sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB.

OBJECTIVES

To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar-sweetened beverages and sugar-sweetened milk, diet-related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes.

SEARCH METHODS

We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors.

SELECTION CRITERIA

We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet-related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) and interrupted-time-series (ITS) studies, implemented in real-world settings with a combined length of intervention and follow-up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB-specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta-analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented 'Summary of findings' tables.

MAIN RESULTS

We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow-up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non-randomised designs. The studies examine a broad range of interventions, and we present results for these separately.Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied.Nutrition standards in public institutions (16 studies): We found low-certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low-certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied.Economic tools (7 studies): We found moderate-certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low-calorie beverages reported effects on SSB sales varied.Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied.Retail and food service interventions (7 studies): We found low-certainty evidence that healthier default beverages in children's menus in chain restaurants are associated with decreasing SSB sales, and moderate-certainty evidence that in-store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low-certainty evidence that urban planning restrictions on new fast-food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied.Intersectoral approaches (8 studies): We found moderate-certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate-certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied.Home-based interventions (7 studies): We found moderate-certainty evidence that improved availability of low-calorie beverages in the home environment is associated with decreased SSB intake, and high-certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs.Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low-calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes.We analysed interventions targeting sugar-sweetened milk separately, and found low- to moderate-certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar-sweetened milk. We found low-certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar-sweetened milk consumption.

AUTHORS' CONCLUSIONS

The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high-quality evaluations using appropriate study designs, with a particular focus on the long-term effects of approaches suitable for large-scale implementation.