Decreases in purchases of energy, sodium, sugar, and saturated fat 3 years after implementation of the Chilean food labeling and marketing law: An interrupted time series analysis.

BACKGROUND: In 2016, Chile implemented a multiphase set of policies that mandated warning labels, restricted food marketing to children, and banned school sales of foods and beverages high in nutrients of concern ("high-in" foods). Chile's law, particularly the warning label component, set the precedent for a rapid global proliferation of similar policies. While our initial evaluation showed policy-linked decreases in purchases of high-in, a longer-term evaluation is needed, particularly as later phases of Chile's law included stricter nutrient thresholds and introduced a daytime ban on advertising of high-in foods for all audiences. The objective is to evaluate changes in purchases of energy, sugar, sodium, and saturated fat purchased after Phase 2 implementation of the Chilean policies. METHODS AND FINDINGS: This interrupted time series study used longitudinal data on monthly food and beverage purchases from 2,844 Chilean households (138,391 household-months) from July 1, 2013 until June 25, 2019. Nutrition facts panel data from food and beverage packages were linked at the product level and reviewed by nutritionists. Products were considered "high-in" if they contained added sugar, sodium, or saturated fat and exceeded nutrient or calorie thresholds. Using correlated random-effects models and an interrupted time series design, we estimated the nutrient content of food and beverage purchases associated with Phase 1 and Phase 2 compared to a counterfactual scenario based on trends during a 36-month pre-policy timeframe. Compared to the counterfactual, we observed significant decreases in high-in purchases of foods and beverages during Phase 2, including a relative 36.8% reduction in sugar (-30.4 calories/capita/day, 95% CI -34.5, -26.3), a 23.0% relative reduction in energy (-51.6 calories/capita/day, 95% CI -60.7, -42.6), a 21.9% relative reduction in sodium (-85.8 mg/capita/day, 95% CI -105.0, -66.7), and a 15.7% relative reduction in saturated fat (-6.4 calories/capita/day, 95% CI -8.4, -4.3), while purchases of not-high-in foods and drinks increased. Reductions in sugar and energy purchases were driven by beverage purchases, whereas reductions in sodium and saturated fat were driven by foods. Compared to the counterfactual, changes in both high-in purchases and not high-in purchases observed in Phase 2 tended to be larger than changes observed in Phase 1. The pattern of changes in purchases was similar for households of lower versus higher socioeconomic status. A limitation of this study is that some results were sensitive to the use of shorter pre-policy time frames. CONCLUSIONS: Compared to a counterfactual based on a 36-month pre-policy timeframe, Chilean policies on food labeling, marketing, and school food sales led to declines in nutrients of concern during Phase 2 of implementation, particularly from foods and drinks high in nutrients of concern. These declines were sustained or even increased over phases of policy implementation.

Outcomes of implementing the International Code of Marketing of Breast-milk Substitutes as national laws: a systematic review.

BACKGROUND: The International Code of Marketing of Breast-milk Substitutes, or 'the Code,' sets standards to regulate marketing of commercial milk formula (CMF) to protect breastfeeding. World Health Organization member states are advised to legislate the Code into national law, but understanding of its implementation outcomes is limited. This systematic review aimed to examine implementation outcomes in countries implementing the Code as national law. METHODS: We systematically searched five academic databases in September 2022 for articles published in English from 1982 to 2022. We double-screened titles/abstracts and then full texts for eligible articles reporting implementation outcomes of the Code in 144 eligible countries. We used the Mixed Methods Appraisal Tool for quality assessment and synthesized data thematically. We applied the Proctor et al. framework to guide synthesis of implementation outcomes, organizing our findings according to its taxonomy. RESULTS: We included 60 eligible articles of the 12,075 screened, spanning 28 countries. Fifty-seven articles focused on legal compliance, 5 on acceptability, and 1 on feasibility. Compliance was assessed across multiple sources, including mothers, health workers, media, points of sale, and product labels. Maternal exposure to CMF promotion remained widespread, with reports of mothers receiving free samples and coupons, and encountering media advertisements. Compliance of health workers varied across countries, with many reporting contact with CMF companies despite legal prohibitions. Public hospitals generally showed better adherence to the national law than private ones. While implementing the Code as national law effectively regulated the promotion of CMF for infants aged 0-12 months in public settings and in the media, it remains insufficient in addressing the promotion of unregulated products like growing-up milk, which are often marketed through emerging strategies such as cross-promotion and digital advertising. Point-of-sales compliance was inconsistent, with many countries reporting non-compliant price-related promotions. CONCLUSION: To enhance legal compliance, robust monitoring and reporting systems are necessary. Utilizing technology-assisted solutions for monitoring compliance can be an option for countries with limited human resources. Adequate training for health workers and communication strategies targeting shop managers about national law are also essential in enhancing their acceptability and compliance.

The effect of the implementation of the international code of marketing of breast-milk substitutes on child mortality in Ghana and Tanzania.

OBJECTIVE: The International Code of Marketing of Breast-Milk Substitutes is an important instrument to protect and promote appropriate infant and young child feeding and the safe use of commercial milk formulas. Ghana and Tanzania implemented the Code into national legislation in 2000 and 1994, respectively. We aimed to estimate the effects of the Code implementation on child mortality (CM) in both countries. SETTING: The countries analysed were Ghana and Tanzania. PARTICIPANTS: For CM and HIV rates, data from the Institute for Health Metrics and Evaluation from up to 2019 were used. Data for income and skilled birth rates were retrieved from the World Bank, for fertility from the World Population Prospects, for vaccination from the Global Health Observatory and for employment from the International Labour Organization. DESIGN: We used the synthetic control group method and performed placebo tests to assess statistical inference. The primary outcomes were CM by lower respiratory infections, mainly pneumonia, and diarrhoea and the secondary outcome was overall CM. RESULTS: One-sided inference tests showed statistically significant treatment effects for child deaths by lower respiratory infections in Ghana (P = 0·0476) and Tanzania (P = 0·0476) and for diarrhoea in Tanzania (P = 0·0476). More restrictive two-sided inference tests showed a statistically significant treatment effect for child deaths by lower respiratory infections in Ghana (P = 0·0476). No statistically significant results were found for overall CM. CONCLUSION: The results suggest that the implementation of the Code in both countries had a potentially beneficial effect on CM due to infectious diseases; however, further research is needed to corroborate these findings.

Controversial FDA Decision Authorizes Menthol-Flavored E-Cigarettes Despite Risks to Youth.

This Medical News story examines the controversy surrounding the FDA's first authorization of flavored e-cigarettes, in this case menthol.

Inhibitors and Supporters of Policy Change in the Regulation of Unhealthy Food Marketing in Australia.

BACKGROUND: Evidence on the impact of policies that regulate unhealthy food marketing demonstrates a need for a shift from pure industry self-regulation toward statutory regulation. Institutional rules, decision-making procedures, actor practices, and institutional norms influence the regulatory choices made by policy-makers. This study examined institutional processes that sustain, support, or inhibit change in the food marketing regulation in Australia using the three pillars of institutions framework - regulatory, normative, and cultural cognitive pillars. METHODS: This was a qualitative study. Twenty-four in-depth semi-structured interviews were conducted with industry, government, civil society, and academic actors who are involved in nutrition policy in Australia. RESULTS: The regulatory pillar was perceived to inhibit policy change through the co-regulation and self-regulation frameworks that assign rulemaking, monitoring and enforcement to industry bodies with minimal oversight by regulatory agencies and no involvement of health actors. The normative pillar was perceived to provide pathways for comprehensive statutory regulation through institutional goals and norms for collaboration that centre on a whole-of-government approach. The framing of food marketing policies to highlight the vulnerability of children is a cultural cognitive element that was perceived to be essential for getting support for policy change; however, there was a lack of shared understanding of food marketing as a policy issue. In addition, government ideologies that are perceived to be reluctant to regulate commercial actors and values that prioritize economic interest over public health make it difficult for health advocates to argue for statutory regulation of food marketing. CONCLUSION: Elements of all three pillars (regulatory, normative, and cultural-cognitive) were identified as either inhibitors or pathways that support policy change. This study contributes to the understanding of factors that inhibit policy change and potential pathways for implementing comprehensive statutory regulation of unhealthy food marketing.

"It's changing our lives, not for the better. It's important that we have a say". The role of young people in informing public health and policy decisions about gambling marketing.

BACKGROUND: Marketing has a significant impact on the normalisation of gambling for youth across the globe. This has included shaping positive attitudes towards gambling, as well as increasing the social and cultural acceptance of gambling - particularly aligned with valued activities such as sport. Because of this, public health experts argue that gambling marketing poses a significant risk to the health and wellbeing of youth. While young people are increasingly exposed to, and impacted by marketing for gambling products, they are rarely consulted about policy issues and options. This study aimed to explore young Australians' perceptions of current policy responses to gambling advertising, whether they thought young people should be involved in discussions and decisions about gambling marketing regulations, and their perceptions of the duty of governments to protect young people from gambling industry marketing strategies. METHODS: Qualitative focus groups (n = 22) were held with n = 64, 12-17 year olds in the Australian states of Victoria and New South Wales. Participants were asked to reflect on current gambling policies, particularly relating to marketing, what they thought should be done about gambling marketing, and if and how young people should be included in public health responses to gambling. An interpretivist 'Big Q' approach to reflexive thematic analysis was used. RESULTS: Young people highlighted the need for more effective regulations around the content and frequency of gambling marketing. They also wanted to see more realistic representations of the negative impacts of gambling to counter persistent positive commercial marketing messages. Most thought that young people should be given an opportunity to have a say about responses to gambling due to their unique experiences. Participants identified mechanisms to increase young people's engagement in decision making, such as direct lines of communication to different levels of government, involvement in research, and diversifying ways of engagement. Specific recommendations included more regulatory action such as bans on gambling advertising. CONCLUSIONS: Creating formal structures that facilitate the inclusion of young people's perspectives in decisions made about gambling can result in more innovative and effective strategies to prevent the harms from gambling industry products, promotions, and practices.

Is It Time to Ban Flavored Cigarettes in Asia-Pacific Countries? A Scoping Review.

Flavored cigarettes encourage youth smoking and deter quitting. No country in Asia-Pacific, a region with some of the world's highest smoking rates, has regulated tobacco flavors. We examined market data, academic literature, and gray literature to describe what is known on flavored cigarettes in the Asia-Pacific region. Of the 12 countries for which market data were available, ten had substantial flavored cigarette market shares ranging from 10% to 97%. With no regulations and growing markets for flavor capsule variants, the tobacco industry's ongoing promotion of flavored cigarettes, which targets primarily youth and women, is expected to drive further increases in smoking prevalence. There are significant research and monitoring gaps on the industry's marketing tactics and use of flavored cigarettes in the region. Given the large market shares, Asia-Pacific countries stand to benefit substantially from a tobacco flavors ban.

Corporate social responsibility, policy framing and strategic marketing: understanding the alcohol industry's use of social media in Uganda.

BACKGROUND: Sub-Saharan Africa is important to the future of alcohol and global health because the alcohol market there is expanding rapidly in a relatively young population. This entails a corresponding contest about whether the policy measures adopted will be shaped by scientific evidence or by industry interference in alcohol policy. This study examines how alcohol industry actors use social media. METHODS: Uganda was selected for study because of high levels of alcohol harm and recent alcohol policy debates. Data on the X (formerly Twitter) activity of the Ugandan companies of AB InBev and Diageo, who are the two main brewers, and the trade association including both, were collected, coded and thematically analysed. RESULTS: X is used overwhelmingly by alcohol industry actors in Uganda to promote corporate social responsibility (CSR) and alcohol policy framing content. There is little direct product marketing. The framing of policy problems and solutions, and of the actors involved in policymaking and CSR resembles that used elsewhere in the political strategies of the transnational alcohol corporations. Content which appears more emphasised in Uganda includes material on farmers, illicit trade and contribution to the economy. As elsewhere, it avoids giving attention to the policy measures which would make a difference to the levels of alcohol harms endured by Uganda. Rhetorically, X is thus used to create a parallel universe, in which the actual harms and what is known about how to reduce them are conspicuous by their absence. CONCLUSIONS: The alcohol industry presents itself as indispensable to Uganda's future and appears to have developed relationships with politicians, partnerships with government, and built a coalition with farmers. This means the alcohol industry may be well positioned to oppose public health policy measures, even though their arguments lack substance and are at odds with the evidence.

Abortion pill marketing and sourcing on twitter following Dobbs v. Jackson supreme court ruling.

OBJECTIVE: This study examines abortion-related discourse on Twitter (X) pre-and post-Dobbs v. Jackson ruling, which eliminated the constitutional right to abortion. STUDY DESIGN: We used a custom data collection tool to collect tweets directly from Twitter using abortion-related keywords. We used the BERTopic language model and examined the top 30 retweeted and top 30 textually similar tweets from relevant topic clusters using an inductive coding approach. We also conducted statistical testing to assess potential associations between abortion themes. RESULTS: 166,799 unique tweets were collected from December 2020-December 2022. 464 unique tweets were coded for abortion-related themes with 154 identified as relevant. Of these, 66 tweets marketed abortion pills, 17 tweets were identified as offering consultations, and 91 tweets were relevant to self-managed abortion. All marketing and consultation tweets were posted post-Dobbs decision and 7 (7.69%) of self-managed tweets were posted pre-Dobbs versus 84 (92.30%) posted post-Dobbs. A positive association was found between tweets offering a medical consultation with tweets marketing abortion pills and discussing self-managed abortion. CONCLUSION: This study detected online marketing of abortion pills, consultations and discussions about self-managed abortion following the Dobbs v. Jackson ruling. These results provide more context to the type of abortion-related information that is available online.

This study examined tweets occurring both pre and post Dobbs decision and identified relevant discussions about self-managed abortion services, marketing and sale of abortion pills, and offering purported medical consultations. These findings indicate that abortion-related tweets, particularly those marketing abortion medications, increased after the Dobbs v. Jackson ruling. These findings highlight the evolving abortion information environment in the United States on Twitter, which represents a platform where health and politicised issues are commonly discussed.

The impacts of alcohol marketing and advertising, and the alcohol industry's views on marketing regulations: Systematic reviews of systematic reviews.

ISSUES: Advertising and marketing affect alcohol use; however, no single systematic review has covered all aspects of how they affect alcohol use, and how the alcohol industry views alcohol marketing restrictions. APPROACH: Two systematic reviews of reviews were performed according to the Preferred Reporting Items on 2 February 2023. Results were analysed using a narrative synthesis approach. KEY FINDINGS: Twenty-three reviews were included in the systematic reviews. The first systematic review examined youth and adolescents (11 reviews), digital or internet marketing (3 reviews), alcohol marketing's impact on cognition (3 reviews), and alcohol marketing and policy options (2 reviews). The second systematic review focused on alcohol industry (i.e., importers, producers, distributors, retailers and advertising firms) response to advertising restrictions (four reviews). The reviews indicated that there is evidence that alcohol marketing (including digital marketing) is associated with increased intentions to drink, levels of consumption and harmful drinking among youth and young adults. Studies on cognition indicate that advertisements focusing on appealing contexts and outcomes may be more readily accepted by adolescents, and may be less easily extinguished in this population. The review of the alcohol industry found a strong desire to self-regulate alcohol advertising. IMPLICATIONS: We found alcohol advertising and marketing is associated with increased drinking intentions, consumption and harmful drinking. Thus, policies which restrict advertising may be an effective way to reduce alcohol use. CONCLUSION: More research is needed to assess all aspects of the observed associations, especially as to how marketing policies impact women and people with alcohol dependence.

Drug Promotions Between Ethics, Regulations, and Financial Interests.

BACKGROUND: The promotion of the latest medicines produced by the pharmaceutical industry is an important issue both from an ethical point of view (the level of accessibility, the way research is carried out) and from the point of view of marketing and especially from the lobbying issues raised. AREAS OF UNCERTAINTY: The ethical dilemmas raised by the promotion of new drugs revolve between the need to discover new molecules important for treating a wide range of diseases and the need to establish a battery of ethical rules, absolutely necessary for regulations in the field to be compliant with all ethical principles. DATA SOURCES: A literature search was conducted through PubMed, MEDLINE, Plus, Scopus, and Web of Science (2015-2023) using combinations of keywords, including drugs, medical publicity, and pharma marketing plus ethical dilemma. ETHICS AND THERAPEUTIC ADVANCES: The promotion of medicines is governed by advertising laws and regulations in many countries, including at EU level, based on the need for countries to ensure that the promotion and advertising of medicines is truthful, based on information understood by consumers. The ethical analysis of the issues raised is more necessary and complex as the channels used for promotion are more accessible to the population, and the information, easier to obtain, can be the cause of increased self-medication and overeating. Large amounts of money invested in the development of new molecules, but also the risk of scientific fraud through manipulation of data during clinical trials, selective or biased publication of information can have repercussions on the health of the population. CONCLUSIONS: The development of new pharmaceutical molecules is necessary to intervene and treat as many conditions as possible, but marketing must not neglect the observance of ethical principles. The promotion of medicines should be the attribute especially of the medical staff, which should also be a mandatory part of the mechanism for approving the marketing methods and means used by the pharmaceutical companies.

Tobacco Control in Denmark: How the Ugly Duckling Turned into a Swan.

INTRODUCTION: The implementation of tobacco control policies has been a neglected topic in tobacco research. A comprehensive Tobacco Action Plan including plain packaging, a point-of-sale display ban, a ban on characterizing flavors (in products other than cigarettes), a strengthening of the promotion and marketing ban, a ban on the sale of novel nicotine products to minors, smoke-and nicotine-free-school hours in all-schools with minors, and a significant increase in tobacco tax, was adopted in Denmark in 2019. AIMS AND METHODS: Eleven people involved or very close to the advocacy process were invited, two did not respond and nine attended our research center. We used the nominal group technique, a consensus method, to identify the most important driving factors for passing the Tobacco Action Plan. RESULTS: The round-robin identified 39 driving factors merged into 13 in the clarification phase. In the ranking phase, participants agreed on seven factors that they perceived have strongly influenced the political will to strengthen national tobacco control comprehensively. The most important factors were national data and evidence, a nationwide alliance with broad partnerships, a strict focus on young people, continuous media coverage, intensive lobbying by many different advocates, making it a community agenda-not a political one, and effective professional campaigns. CONCLUSIONS: Our findings agree with experiences from other countries that significantly improved tobacco control. The Danish strategy, including a nationwide alliance with broad partnerships, had a high influence on the political agenda. IMPLICATIONS: In this study, there was a consensus that seven factors strongly influenced the political will to comprehensively strengthen the national tobacco control in Denmark in a short time: national data and evidence; a nationwide alliance with broad partnerships; a strict focus on children and young people; continuous media coverage; intensive lobbying by many different advocates; making it a community agenda-not a political one, and effective professional campaigns. This is consistent with findings from other countries.

Should tobacco sales be restricted to state-run alcohol outlets? Perspectives from 10 US alcohol control states.

BACKGROUND AND AIMS: The ubiquity of tobacco retailers helps to sustain the tobacco epidemic. A tobacco retail reduction approach that has not been tried is transitioning tobacco sales to state-controlled alcohol stores (TTS), which are limited in number and operate under some restrictions, e.g. regarding opening hours or marketing materials. This study summarizes policy experts' and advocates' views of TTS, including (1) advantages and disadvantages; (2) feasibility; and (3) potential implementation obstacles. DESIGN: This study was a qualitative content analysis of semi-structured interviews. SETTING: Ten US states with alcoholic beverage control systems were included. PARTICIPANTS: The participants comprised a total of 103 tobacco control advocates and professionals, public health officials, alcohol policy experts and alcohol control system representatives, including two tribal community representatives. MEASUREMENTS: Interviewees' perspectives on their state's alcoholic beverage control agency (ABC, the agency that oversees or operates a state alcohol monopoly) and on TTS were assessed. FINDINGS: Interviewees thought TTS offered potential advantages, including reduced access to tobacco products, less exposure to tobacco advertising and a greater likelihood of successful smoking cessation. Some saw potential long-term health benefits for communities of color, due to the smaller number of state alcohol stores in those communities. Interviewees also raised concerns regarding TTS, including ABCs' limited focus on public health and emphasis on revenue generation, which could conflict with tobacco use reduction efforts. Some interviewees thought TTS could enhance the power of the tobacco and alcohol industries, increase calls for alcohol system privatization or create difficulties for those in recovery. CONCLUSIONS: In the United States, transitioning tobacco sales to state-controlled alcohol stores (TTS) could have a positive public health impact by reducing tobacco availability, marketing exposure and, ultimately, tobacco use. However, tensions exist between alcohol control system goals of providing revenue to the state and protecting public health. Should a state decide to pursue TTS, several guardrails should be established, including building into the legislation an explicit goal of reducing tobacco consumption.