Designing warnings for sugary drinks: A randomized experiment with Latino parents and non-Latino parents

The impact of an eco-score label on US consumers' perceptions of environmental sustainability and intentions to purchase food: A randomized experiment

Front-of-package labels indicating a product's environmental footprint (i.e., eco-score labels) offer promise to shift consumers towards more sustainable food choices. This study aimed to understand whether eco-score labels impacted consumers' perceptions of environmental sustainability and intentions to purchase sustainable and unsustainable foods. US parents (n = 1,013) completed an online experiment in which they were shown 8 food products (4 sustainable and 4 unsustainable). Participants were randomized to a control (n = 503, barcode on product packaging) or eco-score label group (n = 510, eco-score label on product packaging). The eco-score label was color-coded with a grade of A-F based on the product's environmental footprint, where "A" indicates relative sustainability and "F" indicates relative unsustainability. Participants rated each product's environmental sustainability and their future likelihood of purchase. We used multilevel mixed-effects linear regression models and examined moderation by product category and sociodemographic characteristics. The eco-score label lowered perceived sustainability of unsustainable products by 13% in relative terms or -0.4 in absolute terms (95% CI -0.5, -0.3; p<0.001). The eco-score label increased perceived sustainability of sustainable products by 16% in relative terms or 0.6 in absolute terms (95% CI 0.5, 0.7, p<0.001). Effects on purchase intentions were smaller, with a 6% decrease for unsustainable products (p = 0.001) and an 8% increase for sustainable products (p<0.001). For unsustainable products, the effect of eco-score labels on sustainability perceptions was greater for older adults, men, participants with higher educational attainment, and participants with higher incomes. For sustainable products, the effect of ecolabels on sustainability perceptions was greater for those with higher educational attainment. Eco-score labels have the potential to direct consumers towards more sustainable products. Future studies should investigate eco-score label effectiveness on behavioral outcomes.

Understanding Whether Price Tag Messaging Can Amplify the Benefits of Taxes: An Online Experiment

INTRODUCTION

Excise taxes on unhealthy products like sugary drinks and tobacco can reduce purchases of these products. However, little research has investigated whether messages at the point of purchase, such as enhanced price tags, can increase the effects of taxes by heightening psychological reactions. This study aimed to examine whether including messages about taxes on price tags could amplify the benefits of excise taxes on unhealthy products.

METHODS

In 2022, an online study recruited 1,013 U.S. parents to view seven price tag messages (e.g., "includes a 19% sugary drink tax") and a control (i.e., standard price tag with the tax included in the price) displayed in random order alongside sugary drinks. Participants were randomly assigned to view a caution-symbol icon or no icon on price tags. Analyses were conducted in 2023.

RESULTS

All seven messages discouraged parents from buying sugary drinks for their children compared to control (average differential effects [ADEs] ranged from 0.28 to 0.48, all p<0.001). All messages led to greater attention to the price tag (ADEs ranged from 0.24 to 0.41, all p<0.001) and greater consideration of the cost of sugary drinks (ADEs ranged from 0.31 to 0.50, all p<0.001). Icons elicited higher cost consideration than text-only price tags (ADE=0.15, p<0.010), but not discouragement (p=0.061) or attention (p=0.079).

CONCLUSIONS

Messaging on price tags could make excise taxes more effective. Policymakers should consider requiring messaging on price tags when implementing taxes.

A multi-country comparison of jurisdictions with and without mandatory nutrition labelling policies in restaurants: analysis of behaviours associated with menu labelling in the 2019 International Food Policy Study

OBJECTIVE

To examine differences in noticing and use of nutrition information comparing jurisdictions with and without mandatory menu labelling policies and examine differences among sociodemographic groups.

DESIGN

Cross-sectional data from the International Food Policy Study (IFPS) online survey.

SETTING

IFPS participants from Australia, Canada, Mexico, United Kingdom and USA in 2019.

PARTICIPANTS

Adults aged 18-99; n 19 393.

RESULTS

Participants in jurisdictions with mandatory policies were significantly more likely to notice and use nutrition information, order something different, eat less of their order and change restaurants compared to jurisdictions without policies. For noticed nutrition information, the differences between policy groups were greatest comparing older to younger age groups and comparing high education (difference of 10·7 %, 95 % CI 8·9, 12·6) to low education (difference of 4·1 %, 95 % CI 1·8, 6·3). For used nutrition information, differences were greatest comparing high education (difference of 4·9 %, 95 % CI 3·5, 6·4) to low education (difference of 1·8 %, 95 % CI 0·2, 3·5). Mandatory labelling was associated with an increase in ordering something different among the majority ethnicity group and a decrease among the minority ethnicity group. For changed restaurant visited, differences were greater for medium and high education compared to low education, and differences were greater for higher compared to lower income adequacy.

CONCLUSIONS

Participants living in jurisdictions with mandatory nutrition information in restaurants were more likely to report noticing and using nutrition information, as well as greater efforts to modify their consumption. However, the magnitudes of these differences were relatively small.

Natural Claims on Sugary Fruit Drinks: A Randomized Experiment With U.S. Parents

INTRODUCTION

Natural claims on food are largely unregulated in the U.S. This study examined the effects of natural claims on a fruit-flavored drink with added sugar (i.e., fruit drink).

METHODS

In 2019, U.S. parents of children aged 2-12 years (N=1,078) recruited from an online survey panel were randomized to one of three arms: natural claim on a fruit drink, 100% all-natural claim, or a no-claim control. Parents reported their intentions and perceptions regarding fruit drinks using 1-5 response scales. Analysis occurred in 2022-2023.

RESULTS

Both natural claims led parents to have higher intentions to purchase a fruit drink for their child than the control (average differential effect=0.20-0.24, both p<0.05). The natural claim (but not the 100% all-natural claim) also led parents to think that the fruit drink was healthier for their children (average differential effect=0.22, p=0.024). Claims made parents less likely to think that the drink contained added sugar (average differential effect= -0.08 to -0.12, both p<0.05) and led to lower estimated amounts of added sugar in teaspoons (average differential effect= -1.77 to -2.09, both p<0.05). Mediation analyses revealed that the claims led to higher intentions to purchase the fruit drink by increasing perceived healthfulness of the fruit drink and by leading parents to believe that there was no added sugar in the fruit drink.

CONCLUSIONS

Natural claims could increase interest in and perceived healthfulness of fruit drinks. Misperceptions about the nutritional content caused by claims appear to be driving greater purchase intentions. These findings suggest a need for stronger regulation around natural claims to prevent consumer misunderstanding.

Toddler Milk Perceptions and Responses to Front-of-Package Claims and Product Warnings: A Qualitative Study of Caregivers of Toddlers

BACKGROUND

Toddler milk products are ultraprocessed milk-based beverages promoted for children aged 9 through 36 months. They often contain added sugars, which may contribute to unhealthy dietary habits. Aggressive promotion of toddler milk, particularly to the Latinx population, has likely led to rapid rises in sales.

OBJECTIVE

The study aims were to qualitatively explore caregivers' experiences with, beliefs about, and attitudes toward toddler milk; to explore caregivers' reactions to health claims and product warnings on toddler milk packaging; and explore whether perceptions of toddler milk differ by Latinx ethnicity.

DESIGN

Focus group discussions and in-depth interviews were conducted.

PARTICIPANTS

Fifteen online in-depth interviews and 4 online focus groups with US caregivers of children aged 9 through 36 months who reported serving toddler milk to their children were conducted in 2021.

STATISTICAL ANALYSES PERFORMED

Audio files were transcribed, coded, and analyzed in NVivo. A thematic analysis with a hybrid analytical approach of deductive and inductive coding was conducted.

RESULTS

Caregivers struggled to discern toddler milk from infant formula and perceived formula as a larger term that included toddler milk. Participants described offering toddler milk to their children for its convenience, nutritional profile, and perceived benefits tied to health claims present on the labels. Participants reported that health claims on toddler milk packaging attracted their attention; most participants did not express skepticism about the veracity of the claims. An "added sugar" warning increased understanding of the presence of added sugar in a toddler milk product. Latinx and non-Latinx participants largely reported similar perceptions, beliefs, and patterns of provision of toddler milk.

CONCLUSIONS

Health claims may lead caregivers to perceive toddler milk as a nutritionally adequate product. Research is needed to investigate caregiver-directed interventions for informing caregivers about the distinction between infant formula and toddler milk.

Development of the UNC Perceived Message Effectiveness Scale for Youth

PURPOSE

Tobacco prevention media campaigns are an important tool to address youth tobacco use. We developed a theory-based perceived message effectiveness (PME) Scale to use when vetting messages for campaigns.

METHODS

Participants were a national sample of N=623 US adolescents (ages 13-17 years) recruited from a national probability-based panel. In an online experiment, we randomised adolescents to view tobacco prevention ads. All participants viewed an ad on smoking or vaping from the US Food and Drug Administration's The Real Cost campaign and a control video, in a random order. After ad exposure, we assessed PME using nine candidate items and constructs for convergent and criterion validity analyses. We used confirmatory factor analysis and examined information curves to select the scale items.

RESULTS

A brief PME scale with three items (α=0.95) worked equally well for demographically diverse adolescents with different patterns of tobacco use. The Real Cost ads generated higher PME scores than the control videos for both vaping and smoking (convergent validity; p<0.05). Higher PME scores were associated with greater attention, fear, cognitive elaboration and anticipated social interactions (convergent validity; r=0.31-0.66), as well as more negative attitudes toward and lower susceptibility to vaping and smoking (criterion validity; r=-0.14 to -0.37). A single-item PME measure performed similarly to the three-item version.

CONCLUSIONS

The University of North Carolina PME Scale for Youth is a reliable and valid measure of the potential effectiveness of vaping and smoking prevention ads. Employing PME scales during message development and selection may help youth tobacco prevention campaigns deploy more effective ads.

Effects of pictorial warnings on parents' purchases and perceptions of sugar-sweetened beverage categories

BACKGROUND

Sugar-sweetened beverage (SSB) consumption remains high among US children. Warning labels on SSBs hold promise for reducing consumption, but their impact may differ by SSB category.

OBJECTIVES

This study examined the effects of pictorial warnings on parents' beverage purchases and perceptions across SSB categories.

METHODS

Parents of children ages 2-12 (n = 326) visited a convenience store laboratory in North Carolina. Participants were randomly assigned to see SSBs carrying either pictorial warning labels or control labels. Parents purchased a beverage for their child and completed a survey.

RESULTS

Responses from parents in the control arm suggest underlying perceptions of flavoured milk (2.8 on scale ranging from 1 to 5), flavoured water (2.6), and fruit-flavoured drinks (2.5) as the most healthful SSB categories. Compared to the control, pictorial warnings led to the largest reductions in purchases of fruit drinks (-61%), soda (-36%) and flavoured milk (-32%). Warnings also lowered the perceived healthfulness of flavoured water (d = -0.34), flavoured milk (d = -0.28), sports drinks (d = -0.25), and a reduction in intentions to give one's child sports drinks (d = -0.30), flavoured water (d = -0.24) and sweet tea (d = -0.22, all p < 0.05).

CONCLUSIONS

Warning labels may have heterogeneous effects across SSB categories. Future research should assess the psychological mechanisms underlying these heterogeneous effects.

How pictorial warnings change parents' purchases of sugar-sweetened beverage for their children: mechanisms of impact

BACKGROUND

Pictorial health warnings on sugar-sweetened beverages (SSBs) are a promising policy for preventing diet-related disease in children. A recent study found that pictorial warnings reduced parents' purchases of SSBs for their children by 17%. However, the psychological mechanisms through which warnings affect parental behavior remain unknown. We aimed to identify the mechanisms that explain how pictorial warnings affect parents' SSB purchasing behavior for their children using secondary data from a randomized trial.

METHODS

In 2020-2021, parents of children ages 2 to 12 years (n = 325) completed a shopping task in a convenience store laboratory in North Carolina, USA. Participants were randomly assigned to a pictorial warnings arm (SSBs displayed pictorial health warnings about type 2 diabetes and heart damage) or a control arm (SSBs displayed a barcode label). Parents then bought a beverage for their child and took a survey measuring 11 potential psychological mediators, selected based on health behavior theories and a model explaining the impact of tobacco warnings. We conducted simple mediation analyses to identify which of the 11 mechanisms mediated the impact of exposure to pictorial warnings on purchasing any SSBs for their children.

RESULTS

Two of the 11 constructs were statistically significant mediators. First, the impact of pictorial warnings on the likelihood of purchasing any SSB was mediated by parents' perceptions that SSBs were healthier for their child (mediated effect= -0.17; 95% CI = - 0.33, - 0.05). Second, parents' intentions to serve SSBs to their children also mediated the effect of warnings on likelihood of purchasing any SSB (mediated effect= -0.07, 95% CI=-0.21, - 0.003).

CONCLUSIONS

Pictorial warnings reduced parents' purchases of SSBs for their children by making parents think SSBs are less healthful for their children and reducing their intentions to serve SSBs to their children. Communication approaches that target healthfulness perceptions and intentions to serve SSBs may motivate parents to buy fewer SSBs for their children.

Impact of Health, Environmental, and Animal Welfare Messages Discouraging Red Meat Consumption: An Online Randomized Experiment

BACKGROUND

Reducing red meat consumption is a key strategy for curbing diet-related chronic diseases and mitigating environmental harms from livestock farming. Messaging interventions aiming to reduce red meat consumption have focused on communicating the animal welfare, health, or environmental harms of red meat. Despite the popularity of these 3 approaches, it remains unknown which is most effective, as limited studies have compared them side by side.

OBJECTIVE

Our aim was to evaluate responses to red-meat-reduction messages describing animal welfare, health, or environmental harms.

DESIGN

This was an online randomized experiment.

PARTICIPANTS

In August 2021, a convenience sample of US adults was recruited via an online panel to complete a survey (n = 2,773 nonvegetarians and vegans were included in primary analyses).

INTERVENTION

Participants were randomly assigned to view 1 of the 4 following messages: control (neutral, non-red meat message), animal welfare, health, or environmental red-meat-reduction messages.

MAIN OUTCOME MEASURES

After viewing their assigned message, participants ordered hypothetical meals from 2 restaurants (1 full service and 1 quick service) and rated message reactions, perceptions, and intentions.

STATISTICAL ANALYSES PERFORMED

Logistic and linear regressions were performed.

RESULTS

Compared with the control message, exposure to the health and environmental red-meat-reduction messages reduced red meat selection from the full-service restaurant by 6.0 and 8.8 percentage points, respectively (P = .02 and P < .001, respectively), while the animal welfare message did not (reduction of 3.3 percentage points, P = .20). None of the red-meat-reduction messages affected red meat selection from the quick-service restaurant. All 3 red-meat-reduction messages elicited beneficial effects on key predictors of behavior change, including emotions and thinking about harms.

CONCLUSIONS

Red-meat-reduction messages, especially those describing health or environmental harms, hold promise for reducing red meat selection in some types of restaurants. Additional interventions may be needed to discourage red meat selection across a wider variety of restaurants, for example, by making salient which menu items contain red meat.

Should messages discourage sugary drinks, encourage water, or both? A randomized experiment with U.S. parents

Campaigns to improve beverage consumption typically focus on discouraging unhealthy beverages (e.g., soda), encouraging healthy beverages (e.g., water), or both. It remains unclear which of these strategies is most effective. We recruited a national convenience sample of U.S. parents of children ages 2-12 (n = 1078, 48% Latino[a]) to complete an online survey in 2019. We randomly assigned participants to view: 1) a control message, 2) a soda discouragement message, 3) a water encouragement message, or 4) both soda discouragement and water encouragement messages shown side-by-side in random arrangement. Intervention messages mimicked New York City's "Pouring on the Pounds" campaign. Participants rated messages on perceived effectiveness for discouraging soda consumption and encouraging water consumption (1-5 response scales) and reported feelings and intentions about drinking soda and water (1-7 scales). Compared to those with no exposure, participants who viewed the soda discouragement message reported higher perceived discouragement from drinking soda (Average Differential Effect [ADE] = 1.18), more negative feelings toward drinking soda (ADE = 0.83) and stronger intentions to avoid drinking soda (ADE = 0.45) (ps < 0.001). The soda discouragement message also exerted beneficial effects on perceived effectiveness, feelings, and intentions related to water consumption (ADEs = 0.33-0.68; ps < 0.001). Exposure to the water encouragement message had beneficial effects on outcomes related to water consumption (ADEs = 0.28-0.81, ps < 0.001), but limited impact on outcomes related to soda consumption. Across outcomes, results indicated diminishing returns from exposure to both message types. Messaging campaigns discouraging unhealthy beverages may be more promising for improving beverage consumption than messages only promoting healthier beverages.

Designing Effective Alcohol Warnings: Consumer Reactions to Icons and Health Topics

Introduction

New warning labels for alcohol could reduce alcohol-related health harms. This study examined consumer responses to alcohol warnings with different designs.

Methods

A national sample of 3,051 U.S. adults completed an online survey in August 2021. Participants were randomized to 1 of 4 warning topics (addiction, liver damage, early death, or colon cancer). Participants viewed 3 labels, presented in random order: 2 types of warning labels (text-only and icon) showing a newly developed warning message about their assigned topic and a text-only control label showing a neutral message. Participants rated each label on effectiveness at discouraging alcohol consumption (primary outcome) and attention (secondary outcome) using 1 to 5 Likert-type scales. Participants also rated warnings with different causal language variants (e.g., "increases risk of," "contributes to") and marker words (e.g., "WARNING," "SURGEON GENERAL WARNING").

Results

Both the text-only and icon warnings were perceived as more effective (Average Differential Effects [ADEs]=0.79 and 0.86, respectively) and more attention-grabbing (ADEs=0.43 and 0.69, respectively) than control labels (all ps<0.001). The icon warnings were rated as more effective and attention-grabbing than the text-only warnings (ADEs=0.07 and 0.27, respectively, both ps<0.001). Although all warning topics outperformed the control messages, warnings about addiction were rated as less effective and attention-grabbing than the other topics. A majority (60%) of participants selected "increases risk of" as the most discouraging causal variant and a plurality (47%) selected "SURGEON GENERAL WARNING" as the most discouraging marker word.

Conclusions

New alcohol warnings could discourage alcohol consumption, especially if warnings include icons.

Effect of Front-of-Package Information, Fruit Imagery, and High-Added Sugar Warning Labels on Parent Beverage Choices for Children: A Randomized Clinical Trial

IMPORTANCE

Fruit drinks are widely consumed by young children, and many parents mistakenly believe that these drinks are healthy, potentially due to front-of-package claims and imagery. Research is needed on the influence of this marketing and how labeling regulations could change behavior.

OBJECTIVE

To assess the effects of a front-of-package 100% vitamin C claim, fruit imagery, percentage juice and teaspoons of added sugar disclosures, and high-added sugar warnings on parents' choices, knowledge, and perceptions of beverages.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted May to July 2021 as a single-exposure (no follow-up) online survey of primary caregivers of children ages 0 to 5 years throughout the US.

INTERVENTIONS

Participants were shown no-, low-, and high-added sugar beverages and asked to choose 1 for their child. Participants were randomized to see high-added sugar beverages with 1 of 7 front-of-package conditions: (1) claim and imagery (control); (2) no claim; (3) no imagery; (4) no claim or imagery; (5) claim, imagery, and percentage juice disclosure; (6) claim, imagery, and warning; or (7) claim, imagery, warning, and teaspoons of added sugar disclosure.

MAIN OUTCOMES AND MEASURES

Primary outcomes were type of beverage chosen (eg, high-added sugar beverage) and resulting calories and added sugar (in grams). Secondary outcomes were fruit drink knowledge (added sugar and percent juice) and perceptions.

RESULTS

There were 5005 participants included in the final analysis (mean [SD] age, 31.5 [8.3] years; 3587 female participants [71.7%]), including 714 participants in group 1, 717 participants in group 2, 710 participants in group 3, 717 participants in group 4, 708 participants in group 5, 729 participants in group 6, and 710 participants in group 7. Compared with participants in the control group, who had a mean (standard error [SE]) of 9.4 (0.5) g of added sugar and 81.9 (1.6) kcal in chosen beverages, only participants who saw warnings with teaspoons of added sugar disclosures had significantly reduced added sugar (-1.3 g; 95% CI, -2.6 to -0.1 g [-14.2%; 95% CI, -26.7% to -1.8%]; P = .04) and calories (-5.3 kcal; 95% CI, -9.8 to -0.9 kcal [-6.5%; 95% CI, -11.8% to -1.3%]; P = .02) in selected beverages. In warning conditions (ie, 6 and 7) compared with the control group (mean [SE] 41.0% [1.8%]), the proportion of participants choosing high-added sugar beverages was significantly reduced, by 5.5 percentage points (95% CI, 0.5 to 10.5 percentage points [13.4%; 95% CI, 1.2% to 25.6%]; P = .03) and 6.4 percentage points (95% CI, 1.4 to 11.4 percentage points [15.6%; 95% CI, 3.3% to 27.8%]; P = .01), respectively. The no claim or imagery condition (4) significantly reduced the proportion of parents choosing high-added sugar beverages (-7.6 percentage points; 95% CI, -12.6 to -2.6 percentage points [-18.4%; 95% CI, -30.6% to -6.3%]; P = .003). Percentage juice disclosures did not affect beverage choice.

CONCLUSIONS AND RELEVANCE

These findings suggest that added sugar warnings and prohibitions of front-of-package claims and imagery may reduce parents' purchases of high-added sugar beverages for their young children but that percentage juice disclosures may not change behavior.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04811690.

Perceived effect of warning label on parental food purchasing and drivers of food selection among South African parents–An exploratory study

Household food purchasing decision is a complex process influenced by factors such as marketing, cost, children food preference and parental choices. Most food products targeted toward children are unhealthy and are aggressively marketed to increase desirability among parents and children making healthier food selection even harder. The warning label (WL) is identified as a simple front-of-package labeling format that assist consumers to easily identify unhealthy foods and reduce their purchasing. This was a qualitative study that aimed to investigate the perceived effect of the warning label (WL) on parental food purchasing and drivers of food selection among parents. The study was conducted in a mainly rural part of South Africa, in Limpopo Province. Data were collected from 44 adult participants, all parents with children aged below 16 years selected using the snowball sampling method. Seven focus groups diversified according to age, literacy, income and urbanicity were utilized for data collection. Using a focus group discussion guide, parents were shown images of six products (crisps, soda, juice, biscuits, cereals, and yogurt) superimposed with the WL and questions asked were based on those images. Thematic analysis revealed that although some parents felt undeterred by the WL, some felt they would alter their food purchasing in the presence of the WL. Other parents felt they would reduce the frequency or the amount purchased or completely stop purchasing labeled products for their children. Motives behind perceived behavior modification included children's health being perceived as a priority and labeled products being viewed as unhealthy. Factors such as pressure from children, taste, poor nutrition knowledge and affordability seemed to influence parental food selection. These findings have important policy implications by providing evidence to policymakers that the WL may alter parental food purchasing and also provide insight into drivers of food selection among South African parents.

Do sugar warning labels influence parents' selection of a labeled snack for their children? A randomized trial in a virtual convenience store

Despite growing evidence that warning labels reduce purchases of sugary drinks, less is known about warnings' impact on purchases of sugary snacks. This paper aimed to experimentally test whether a front-of-package label warning about high sugar content ("sugar warning label") would reduce parents' likelihood of selecting a labeled snack versus a non-labeled snack for their child in a food store setting. Participants (n = 2,219 parents of at least one child aged 1-5y) were recruited via an online panel and asked to complete a shopping task in a virtual convenience store. Participants were randomized to one of three labeling conditions: barcode control, text-only sugar warning label, or pictorial sugar warning label. Participants viewed two granola snacks, one labeled and one unlabeled, and selected one for purchase. A post-shopping survey measured secondary outcomes. Predictions and analyses were preregistered on www.clinicaltrials.gov (NCT04381481). Participants exposed to the text or pictorial sugar warning labels were less likely to select the labeled snack than those in the barcode control group (21%, 18%, and 34% respectively; p < 0.001 for both comparisons of warning to control). Relative to the barcode control label, the text and pictorial sugar warning labels resulted in greater attention, anticipated social interactions, negative affect, cognitive elaboration, and perceived message effectiveness, as well as lower perceptions of healthfulness, appeal, and intentions to purchase or consume the product (p < 0.001 for all comparisons of warnings to control). There were no differences in outcomes between text and pictorial sugar warning labels. In conclusion, text and pictorial sugar warning labels reduced parents' likelihood of selecting a labeled granola snack for their children. These results contribute to a growing body of evidence showing that warning labels influence food purchasing behaviors.

Front-of-Package Labels on Unhealthy Packaged Foods in India: Evidence from a Randomized Field Experiment

Policies to require front-of-package labels (FOPLs) on packaged foods may help Indian consumers to better identify foods high in nutrients of concern, including sugar, saturated fat, and sodium, and discourage their consumption, which are outcomes that are critical for preventing rises in diet-related non-communicable disease. The objective was to test whether FOPLs helped Indian consumers identify “high-in” packaged foods and reduce intentions to purchase them. We conducted an in-person randomized experiment (n = 2869 adults between ages 18 and 60 years old) in six states of India in 2022. Participants were randomized to one of five FOPLs: a control label (barcode), warning label (octagon with “High in [nutrient]”), Health Star Rating (HSR), Guideline Daily Amount (GDA), or traffic light label. Participants then viewed a series of packaged foods high in sugar, saturated fat, or sodium with the assigned FOPL, and rated product perceptions and label reactions. Fewer than half of participants in the control group (39.1%) correctly identified all products high in nutrient(s) of concern. All FOPLs led to an increase in this outcome, with the biggest differences observed for the warning label (60.8%, p < 0.001), followed by the traffic light label (54.8%, p < 0.001), GDA (55.0%, p < 0.001), and HSR (45.0%, p < 0.01). While no FOPLs led to a reduction in intentions to purchase the packaged foods, the overall pattern of results suggested that warning labels are the most effective FOPL to help Indian consumers identify unhealthy foods.

Perceived effectiveness of added-sugar warning label designs for U.S. restaurant menus: An online randomized controlled trial

Added-sugar consumption in the U.S. exceeds recommended limits. Policymakers are considering requiring restaurants to use menu warning labels to indicate items high in added sugar. We sought to determine whether icon-only and icon-plus-text added-sugar menu labels were (1) perceived as more effective at potentially reducing consumption of items high in added sugar and (2) increased knowledge of menu items' added-sugar content relative to control labels, and if effects differed by label design. A national sample of U.S. adults (n = 1327) participated in an online randomized experiment. Participants viewed menu items with either a control label, 1 of 6 icon-only labels, or 1 of 18 icon-plus-text labels with 3 text variations. For their assigned label, participants provided ratings of perceived message effectiveness (a validated scale of a message's potential to change behavior). Participants were also asked to classify menu items by their added-sugar content. The icon-only and icon-plus-text labels were perceived as more effective than the control label (means: 3.7 and 3.7 vs. 3.1, respectively, on a 5-point scale; p < 0.001). The icon-only and icon-plus-text groups each correctly classified 71% of menu items by added-sugar content vs. 56% in the control group (p < 0.001). All icons and text variations were perceived as similarly effective. In conclusion, relative to a control label, icon-only and icon-plus-text added-sugar menu labels were perceived as effective and helped consumers identify items high in added sugar. Menu warning labels may be a promising strategy for reducing added-sugar consumption from restaurants, but research on behavioral effects in real-world settings is needed. Clinical Trials Identifier:NCT04637412.

Developing health and environmental warning messages about red meat: An online experiment

INTRODUCTION

The United States has among the highest per capita red meat consumption in the world. Reducing red meat consumption is crucial for minimizing the environmental impact of diets and improving health outcomes. Warning messages are effective for reducing purchases of products like sugary beverages but have not been developed for red meat. This study developed health and environmental warning messages about red meat and explored participants' reactions to these messages.

METHODS

A national convenience sample of US red meat consumers (n = 1,199; mean age 45 years) completed an online survey in 2020 for this exploratory study. Participants were randomized to view a series of either health or environmental warning messages (between-subjects factor) about the risks associated with eating red meat. Messages were presented in random order (within-subjects factor; 8 health messages or 10 environmental messages). Participants rated each warning message on a validated 3-item scale measuring perceived message effectiveness (PME), ranging from 1 (low) to 5 (high). Participants then rated their intentions to reduce their red meat consumption in the next 7 days.

RESULTS

Health warning messages elicited higher PME ratings than environmental messages (mean 2.66 vs. 2.26, p<0.001). Health warning messages also led to stronger intentions to reduce red meat consumption compared to environmental messages (mean 2.45 vs. 2.19, p<0.001). Within category (health and environmental), most pairwise comparisons of harms were not statistically significant.

CONCLUSIONS

Health warning messages were perceived to be more effective than environmental warning messages. Future studies should measure the impact of these messages on behavioral outcomes.

Impact of front-of-pack labels on the perceived healthfulness of a sweetened fruit drink: a randomised experiment in five countries

OBJECTIVE

Front-of-pack (FOP) nutrition labelling is a globally recommended strategy to encourage healthier food choices. We evaluated the effect of FOP labels on the perceived healthfulness of a sweetened fruit drink in an international sample of adult consumers.

DESIGN

Six-arm randomised controlled experiment to examine the impact of FOP labels (no label control, Guideline Daily Amounts (GDA), Multiple Traffic Lights, the Health Star Ratings (HSR), Health Warning Labels, and 'High-in' Warning Labels (HIWL)) on the perceived healthfulness of the drink. Linear regression models by country examined healthfulness perceptions on FOP nutrition labels, testing for interactions by demographic characteristics.

SETTING

Online survey in 2018 among participants from Australia, Canada, Mexico, United Kingdom (UK) and United States.

PARTICIPANTS

Adults (≥18 years, n 22 140).

RESULTS

Compared with control, HIWL had the greatest impact in lowering perceived healthfulness (β from -0·62 to -1·71) across all countries. The HIWL and the HSR had a similar effect in Australia. Other labels were effective in decreasing the perceived healthfulness of the drink within some countries only, but to a lower extent. The GDA did not reduce perceived healthfulness in most countries. In the UK, the effect of HIWL differed by age group, with greater impact among older participants (> 40 years). There were no other variations across key demographic characteristics.

CONCLUSIONS

HIWL, which communicates clear, non-quantitative messages about high levels of nutrients of concern, demonstrated the greatest efficacy to decrease the perceived healthfulness of a sweetened fruit drink across countries. This effect was similar across demographic characteristics.

Designing Environmental Messages to Discourage Red Meat Consumption: An Online Experiment

Reducing red meat consumption in high-consuming countries is critical for mitigating climate change and preventing chronic disease. This study tested the effectiveness of messages conveying the worsening or reduction of environmental harms at discouraging red meat consumption. 1078 U.S. adults viewed seven messages in an online survey highlighting the reduction or worsening of environmental harms associated with eating red meat (between-subjects factor) and rated the messages on how much they discouraged them from wanting to buy beef. Each message highlighted a different environmental harm: deforestation, climate change, water shortages, biodiversity loss, carbon footprint, greenhouse gas emissions, or environment (within-subjects factor). No statistically significant difference was found between the reduction and worsening of environmental harms conditions for most topics, though the worsening of harms frame slightly outperformed the reduction of harms frame for the ‘environment’ topic. ‘Environment’ was also the message topic that elicited the strongest response from participants overall. Latino participants, those with more than a high school degree, and those who consume beef once a week or less rated messages as more effective than non-Latino participants, those who completed high school or less, and those who consumed beef more than once a week. Future research should explore the effect of messages on behavioral outcomes.

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.

Caregivers' Understanding of Ingredients in Drinks Served to Young Children: Opportunities for Nutrition Education and Improved Labeling

BACKGROUND

Against expert recommendations, sugar-sweetened beverages, especially fruit drinks, are consumed by young children. Misperceptions about drink ingredients and healthfulness can contribute to caregivers' provision.

OBJECTIVES

To assess caregivers' reasons for serving sweetened fruit-flavored drinks and unsweetened juices to their young children (1-5 y) and perceptions of product healthfulness and drink ingredients.

METHODS

A cross-sectional online survey assessed participants' (n = 1614) perceptions of sweetened fruit-flavored drinks (fruit drinks and flavored water) and unsweetened juices (100% juice and water/juice blends) provided to their child in the past month, including product healthfulness, reasons for providing, and knowledge of product ingredients [added sugar, nonnutritive sweeteners (NNSs), percentage juice]. One-factor ANOVA compared perceived healthfulness of drink categories and types of sugar and NNSs, and differences between participants who could compared with those who could not accurately identify drink ingredients.

RESULTS

Participants' top reasons for providing sweetened drinks included child liking it, being inexpensive, child asking for it, and being a special treat. Participants perceived 100% juice as healthiest, followed by juice/water blends, flavored waters, and, lastly, fruit drinks (P < 0.05). Many participants inaccurately believed the fruit drink or flavored water they served their child most often did not contain NNSs (59.0% and 64.9%) and/or added sugars (20.1% and 42.2%), when in fact they did, and 81.3-91.1% overestimated the percentage juice in the drink. Perceived healthfulness of fruit drinks was associated with caregivers' belief that the drink contained added sugar (P < 0.05), but not with their belief that it contained NNS; increased accuracy was associated with decreased perceived healthfulness (P < 0.05).

CONCLUSIONS

Inaccurate understanding of added sugar, NNSs, and percentage juice in drinks served to young children was common and could contribute to sugary drink provision. Public health efforts should seek to improve labeling practices and revise nutrition education messages.

Text Messages to Curb Sugar-Sweetened Beverage Consumption among Pregnant Women and Mothers: A Mobile Health Randomized Controlled Trial

Racial, ethnic, and socioeconomic disparities in childhood obesity in the United States (U.S.) originate in early life. Maternal sugar-sweetened beverage (SSB) consumption is an early life risk factor for later offspring obesity. The goal of this study was to test the effects of policy-relevant messages delivered by text messages mobile devices (mHealth) on maternal SSB consumption. In this three-arm 1-month randomized controlled trial (RCT), pregnant women or mothers of infants in predominantly Hispanic/Latino New York City neighborhoods were randomized to receive one of three text message sets: graphic beverage health warning labels, beverage sugar content information, or attention control. The main outcome was change in maternal self-reporting of average daily SSB consumption from baseline to one month. Among 262 participants, maternal SSB consumption declined over the 1-month period in all three arms. No intervention effect was detected in primary analyses. In sensitivity analyses accounting for outliers, graphic health warning labels reduced maternal SSB consumption by 28 kcal daily (95% CI: −56, −1). In this mHealth RCT among pregnant women and mothers of infants, graphic health warning labels and beverage sugar content information did not reduce maternal SSB consumption.

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.