Ethical Considerations for Food and Beverage Warnings

Understanding the role of the state in dietary public health policymaking: a critical scoping review

Despite evidence that dietary population health interventions are effective and widely accepted, they remain the topic of intense debate centring on the appropriate role of the state. This review sought to identify how the role of the state in intervening in individuals' food practices is conceptualized across a wide range of literatures. We searched 10 databases and 4 journals for texts that debated dietary population health interventions designed to affect individuals' health-affecting food practices. Two co-authors independently screened these texts for eligibility relative to inclusion and exclusion criteria. Thirty-five texts formed our final corpus. Through critical reflexive thematic analysis (TA), we generated 6 themes and 2 subthemes concerning choice, responsibility for health, balancing benefits and burdens of intervention, the use of evidence, fairness, and the legitimacy of the state's actions. Our analysis found that narratives that aim to prevent effective regulation are entrenched in academic literatures. Discourses that emphasized liberty and personal responsibility framed poor health as the result of 'lifestyle choices'. Utilitarian, cost-benefit rationales pervaded arguments about how to best balance the benefits and burdens of state intervention. Claims about fairness and freedom were used to evoke powerful common meanings, and evidence was used politically to bolster interests, particularly those of the food industry. This review identifies and critically analyses key arguments for and against population dietary public health policies. Our findings should motivate public health researchers and practitioners to avoid unreflexively embracing framings that draw on the languages and logics of free market economics.

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.

Developing sugar-sweetened beverage warning labels for young adults

OBJECTIVE

There is a lack of qualitative research developing sugar-sweetened beverage (SSB) warning labels with their intended end users. We sought to identify promising SSB warning elements for improving label effectiveness and for future testing in policy and institutional settings.

DESIGN

Mixed methods design using ten focus groups, a design task and a survey. The design task was used to generate ideas for an icon that would dissuade SSB consumption. The survey and focus group guide assessed participant perceptions of SSB warning label mock-ups of text (loss frame, gain frame and loss frame with attribution), colour and icon options.

SETTING

Three large public universities in California from February to March 2018.

PARTICIPANTS

Young adult SSB consumers (n 86) enrolled in one of three diverse California public universities.

RESULTS

Participants perceived the following elements as most effective for reducing SSB consumption: loss-frame text with attribution to a credible source, yellow and red colour for label background and an image or icon to accompany the text. Preferred images included sugar near or inside of an SSB, intuitive shapes like a triangle with exclamation mark or octagon and a visual indicator of SSB sugar content compared with recommended limits. Support was high for using SSB warning labels in university cafeterias and on bottles/cans.

CONCLUSIONS

Loss-frame text with a credible source, yellow or red label colour and icons could potentially enhance effectiveness of SSB warning labels and warrant further testing.

The ethics of excise taxes on sugar-sweetened beverages

Sugar-sweetened beverage (SSB) taxation has emerged as a priority policy for promoting health and funding investments in communities most affected by diet-related disease. There are now 8 U.S. jurisdictions and over 40 countries that have implemented SSB taxes. Evaluations show that these policies reduce SSB consumption and purchasing while raising revenues to fund public health, education, and equity. However, there have been few analyses of the ethical considerations of SSB taxation. Using a framework for evaluating the ethics of public health interventions, this paper considers the ethical aspects of SSB excise taxes with respect to: physical health, psychosocial well-being, equality, informed choice, liberty, social and cultural values, and responsibility. Available evidence suggests there is a strong ethical case for levying SSB excise taxes on manufacturers and distributors. SSB excise taxes reduce consumption and purchasing of SSBs and are expected to meaningfully reduce obesity and diet-related morbidity and mortality. Because SSB taxes are specific to a product and its manufacturers, they are unlikely to harm psychosocial health by stigmatizing people who are overweight. SSB excise taxes should lead to greater equality because the health and social benefits are progressive (i.e., low-income individuals are likely to accrue the largest benefits from the tax, even more so when revenues are spent on health and social equity). Meanwhile, the average consumer cost burden that would result if distributors raise SSB prices in reponse to the tax is minimally regressive. Regarding liberty, SSB taxes do not eliminate the option of buying SSBs, but if SSB distributors raise SSB prices, it becomes somewhat more expensive to continue purchasing the same amount of SSBs. Meanwhile, the taxes expand beverage options by funding drinking water availability and prompting industry to expand offerings of unsweetened drinks and SSBs containing less sugar. Furthermore, by averting poor health, SSB taxes should expand overall freedom to pursue one's goals. Informed choice could be facilitated by seeing a higher SSB shelf price (which indicates a drink contains added sugar) and exposure to nutrition education funded with tax revenues. SSB taxation is unlikely to negatively interfere with social or cultural values because taxation would not eliminate having SSBs for special occasions, and SSBs are not a staple of traditional diets. Lastly, SSB taxation attributes responsibility for health in a manner that reflects industry's contribution to obesity and the multisectoral solutions that are needed to prevent diet-related disease.

Food marketing to children in the United States: Can industry voluntarily do the right thing for children's health?

Food marketing is a major contributor to high rates of obesity and diet-related disease among children. Researchers, advocates, and policymakers have called for improvements in the nutrition quality of foods marketed to children to improve children's health. In the United States, for over 10 years, the food and beverage industry has responded with self-regulatory initiatives, touting the success of these efforts. However, public health researchers have documented very limited improvements. As a product of conference proceedings, we briefly summarize US self-regulation of food and beverage marketing to children, argue that reliance on industry self-regulation limits meaningful change, and explain why existing food companies cannot market truly healthy foods to children. After over a decade of self-regulation, industry continues to exploit loopholes and bombard children with marketing for foods that can negatively impact their health. Still, the political will to advocate for effective government regulation remains a challenge. Shifts in parents' attitudes toward supporting policies to protect children from food marketing and local government actions to improve the food environment are promising indicators of increasing demand for action. However, sustained and well-publicized research and advocacy are necessary to generate broader support to enact such policies at the state and federal level in order to effectively address this public health crisis.