Marketing of commercial milk formula: a system to capture parents, communities, science, and policy.

Despite proven benefits, less than half of infants and young children globally are breastfed in accordance with the recommendations of WHO. In comparison, commercial milk formula (CMF) sales have increased to about US$55 billion annually, with more infants and young children receiving formula products than ever. This Series paper describes the CMF marketing playbook and its influence on families, health professionals, science, and policy processes, drawing on national survey data, company reports, case studies, methodical scoping reviews, and two multicountry research studies. We report how CMF sales are driven by multifaceted, well resourced marketing strategies that portray CMF products, with little or no supporting evidence, as solutions to common infant health and developmental challenges in ways that systematically undermine breastfeeding. Digital platforms substantially extend the reach and influence of marketing while circumventing the International Code of Marketing of Breast-milk Substitutes. Creating an enabling policy environment for breastfeeding that is free from commercial influence requires greater political commitment, financial investment, CMF industry transparency, and sustained advocacy. A framework convention on the commercial marketing of food products for infants and children is needed to end CMF marketing.

The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress.

Despite increasing evidence about the value and importance of breastfeeding, less than half of the world's infants and young children (aged 0-36 months) are breastfed as recommended. This Series paper examines the social, political, and economic reasons for this problem. First, this paper highlights the power of the commercial milk formula (CMF) industry to commodify the feeding of infants and young children; influence policy at both national and international levels in ways that grow and sustain CMF markets; and externalise the social, environmental, and economic costs of CMF. Second, this paper examines how breastfeeding is undermined by economic policies and systems that ignore the value of care work by women, including breastfeeding, and by the inadequacy of maternity rights protection across the world, especially for poorer women. Third, this paper presents three reasons why health systems often do not provide adequate breastfeeding protection, promotion, and support. These reasons are the gendered and biomedical power systems that deny women-centred and culturally appropriate care; the economic and ideological factors that accept, and even encourage, commercial influence and conflicts of interest; and the fiscal and economic policies that leave governments with insufficient funds to adequately protect, promote, and support breastfeeding. We outline six sets of wide-ranging social, political, and economic reforms required to overcome these deeply embedded commercial and structural barriers to breastfeeding.

Development and validation of the Alcohol Message Perceived Effectiveness Scale.

To assist intervention developers assess the likely effectiveness of messages designed to encourage greater use of protective behavioral strategies, this study developed and tested the Alcohol Message Perceived Effectiveness Scale (AMPES). Recommendations from the message effectiveness literature were used to guide AMPES development. The resulting scale was administered in online surveys at two time points to Australian drinkers aged 18-70 years (3001 at Time 1 and 1749 at Time 2). An exploratory factor analysis identified the presence of two factors ('effect perceptions' and 'message perceptions') that accounted for 71% of the variance in scores. Internal consistency of scores was good for the overall scale (ω = 0.83) and 'effect perceptions' factor (ω = 0.85), but suboptimal for the 'message perceptions' factor (α = 0.60). Scores on both factors significantly predicted enactment of protective behavioral strategies. The AMPES appears to be an appropriate tool to assess perceived message effectiveness and assist in the development of public health messages designed to reduce alcohol consumption.

"Using information to shape perception": tobacco industry documents study of the evolution of Corporate Affairs in the Miller Brewing Company.

BACKGROUND: The Miller Brewing Company (MBC) was wholly owned by Phillip Morris (PM), between 1970 and 2002. Tobacco industry document studies identify alliances between the alcohol and tobacco industries to counter U.S. policies in the 1980s and 1990s. This investigation sought to study in-depth inter-relationships between MBC and PM, with a particular focus on alcohol policy issues. We used the Truth Tobacco Industry Documents library to trace the evolution of corporate affairs and related alcohol policy orientated functions within and between MBC and PM. RESULTS: MBC was structured and led by PM senior executives from soon after takeover in 1970. Corporate Affairs sought to influence public perceptions of alcohol to align them with business interests. Alcohol education was specifically designed to prevent the adoption of policies inimical to those interests (e.g., raising excise taxes). Strategic consideration of alcohol policy issues was integrated within company-wide thinking, which sought to apply lessons from tobacco to alcohol and vice versa. PM directly led key alcohol industry organisations nationally and globally, which have successfully delayed the adoption and implementation of known effective policy measures in the U.S. and worldwide. CONCLUSIONS: PM has been a key architect of alcohol industry political strategies. This study builds on earlier work on alcohol companies in the tobacco documents, and offers historical data on how tobacco companies have used commercial involvements in other sectors to influence wider public health policy. We are only beginning to appreciate how multi-sectoral companies internally develop political strategies across product categories. Global health and national governmental policy-making needs to be better protected from business interests that fundamentally conflict with public health goals.

A randomized controlled trial of the effectiveness of combinations of 'why to reduce' and 'how to reduce' alcohol harm-reduction communications.

INTRODUCTION: Alcohol is a major source of harm worldwide. The aim of this study was to experimentally assess the effects of exposing Australian adult drinkers to combinations of 'why to reduce' and 'how to reduce' alcohol harm-reduction messages. METHODS: Three online surveys were administered over six weeks: Time 1 at baseline (n = 7,995), Time 2 at three weeks post-baseline (n = 4,588), and Time 3 at six weeks post-baseline (n = 2,687). Participants were randomly assigned to one of eight conditions: (1) a control condition; (2) a 'why to reduce' television advertisement; (3-5) one of three 'how to reduce' messages referring to the following protective behavioral strategies (PBSs): Keep count of your drinks, Decide how many drinks and stick to it, It's okay to say no; and (6-8) the television advertisement combined with each PBS message individually. Intention-to-treat analyses were conducted to determine effects of condition assignment on changes over time in attempts to reduce alcohol consumption and amount of alcohol consumed. RESULTS: Participants assigned to the 'TV ad' and 'TV ad + Keep count of your drinks PBS' conditions reported significant increases in attempts to reduce alcohol consumption. Only participants assigned to the 'TV ad + Keep count of your drinks PBS' condition exhibited a significant reduction in alcohol consumed (-0.87 drinks per person per week). CONCLUSIONS: Well-executed 'why to reduce' alcohol harm-reduction advertisements can encourage drinkers to attempt to reduce their alcohol consumption. These ads may be effectively supplemented by specific 'how to reduce' messages designed to encourage drinkers to monitor their intake.

Attitudinal factors associated with drink counting.

INTRODUCTION: 'Count your drinks' is a protective behavioural strategy (PBS) that has been found to be effective in reducing alcohol consumption. Previous research has shown that females, older people and low-risk drinkers are more likely to use this strategy, but little is known about the attitudinal factors associated with engaging in drink counting. This information is important for developing effective interventions to encourage use of this PBS. The aim of this paper was to assess whether the following attitudinal factors are associated with frequency of enactment of the 'Count your drinks' PBS: (i) perceived ease of use; (ii) perceived effectiveness; (iii) personal relevance; and (iv) believability. METHODS: A total of 683 Australian drinkers completed an online survey assessing demographic variables, alcohol consumption, frequency of drink counting and attitudes to the 'Count your drinks' PBS. A hierarchical regression analysis was used to determine whether the attitudinal factors were associated with frequency of enactment after controlling for demographic and alcohol-related factors. RESULTS: Attitudes to the 'Count your drinks' PBS accounted for 28% of the variance in reported frequency of drink counting. Perceptions of personal relevance, ease of use and effectiveness were found to be significantly associated with frequency of enactment. DISCUSSION AND CONCLUSIONS: Interventions designed to encourage drinkers to count their drinks should aim to increase the perceived personal relevance, ease of use and effectiveness of this strategy.

Maximising the impact of global and national physical activity guidelines: the critical role of communication strategies.

OBJECTIVES: Physical activity guidelines are evidence-based statements on recommended physical activity levels for good health. Guidelines, in isolation, are unlikely to increase population levels of physical activity; appropriate and effective communication is fundamental to maximising their impact. The aim of this paper is to provide a planning framework for physical activity guideline communication, including an overview of key audiences, aims and approaches. METHODS: All authors considered and agreed on the three broad issues to address by consensus. We identified key sources of evidence through scoping of the literature and our knowledge of the research area. RESULTS: Whether guidelines are global or national, communication of the physical activity guidelines should be informed by: (1) a situational analysis that considers the context in which the communication will take place and (2) a stakeholder analysis to determine the key target audiences for the communication and their values, needs and preferences. Audiences include policy-makers within and outside the health sector, other key stakeholders, the general public, specific population subgroups, health professionals and non-health professionals with a role in physical activity promotion. The aims and approach to communication will differ depending on the target audience. CONCLUSION: Communication to raise awareness and knowledge of the physical activity guidelines must be supported by policies, environments and opportunities for physical activity. Besides the intrinsic value of the physical activity guidelines, it is essential that substantial effort is put in to diligently planning, funding and implementing their communication from the outset.

Selling second best: how infant formula marketing works.

BACKGROUND: Despite the clear policy intent to contain it, the marketing of formula milk remains widespread, powerful and successful. This paper examines how it works. METHODS: The study comprised a mix of secondary analysis of business databases and qualitative interviews with marketing practitioners, some of whom had previously worked in formula marketing. RESULTS: The World Health Assembly Code aims to shield parents from unfair commercial pressures by stopping the inappropriate promotion of infant formula. In reality marketing remains widespread because some countries (e.g. the USA) have not adopted the Code, and elsewhere industry has developed follow-on and specialist milks with which they promote formula by proxy. The World Health Assembly has tried to close these loopholes by extending its Code to these products; but the marketing continues. The campaigns use emotional appeals to reach out to and build relationships with parents and especially mothers. Evocative brands give these approaches a human face. The advent of social media has made it easier to pose as the friend and supporter of parents; it is also providing companies with a rich stream of personal data with which they hone and target their campaigns. The formula industry is dominated by a small number of extremely powerful multinational corporations with the resources to buy the best global marketing expertise. Like all corporations they are governed by the fiduciary imperative which puts the pursuit of profits ahead of all other concerns. This mix of fiscal power, sophisticated marketing, and single-mindedness is causing great harm to public health. CONCLUSIONS: Formula marketing is widespread and using powerful emotional techniques to sell parents a product that is vastly inferior to breast milk. There is an urgent need to update and strengthen regulation.

Hostage to fortune: an empirical study of the tobacco industry's business strategies since the advent of e-cigarettes.

The tobacco market has been transformed by the arrival of e-cigarettes and array of alternative nicotine delivery systems (ANDS). Public health has struggled to cope with these changes and clear divisions are apparent, but less is known about the tobacco industry (TI) response. This first empirical study to examine TI and independent ANDS companies' business strategies fills this gap. Primary data were collected through 28 elite interviews with senior/influential TI and independent stakeholders, triangulated with a documentary analysis of company reports, investor analyses, market research, and consultation responses (1022 documents). A deliberately emic analysis shows that tobacco multinationals were initially disconcerted by ANDS, but logic provided by the fiduciary imperative is enabling them to turn a potential threat into profitable opportunities. Interviewees argue market changes played to their strengths: customer links, expertise in nicotine, and enormous financial resources. This enabled portfolio diversification in which combustible and ANDS coexist; providing potential to develop robust scientific and regulatory positions and hope of retrieving corporate reputations. The principal threat for major tobacco players comes from the independent sector, which is prepared and able to satisfy bespoke consumer needs. Multinationals by contrast need to turn ANDS into a genuinely mass-market product appealing to its global customers. They are making progress. Given the continued buoyancy of the combustibles market, they have extensive resources to continue their efforts. Disruptive innovations are not unique to tobacco control. Equivalent technological solutions - with concomitant business opportunities - are emerging in obesity and alcohol fields with implications for public health.

Impact of a ban on the open display of tobacco products in retail outlets on never smoking youth in the UK: findings from a repeat cross-sectional survey before, during and after implementation.

BACKGROUND: In the UK, a ban on the open display of tobacco products at the point of sale (POS) was phased in between 2012 and 2015. We explored any impact of the ban on youth before, during and after implementation. METHODS: A repeat cross-sectional in-home survey with young people aged 11-16 years old in the UK was conducted preban (2011, n=1373), mid-ban (2014, n=1205) and postban (2016, n=1213). The analysis focuses on the never-smokers in the sample (n=2953 in total). Preban, we quantified the associations of noticing cigarettes displayed at POS and cigarette brand awareness with smoking susceptibility. We measured any change in noticing cigarettes displayed at POS, cigarette brand awareness and smoking susceptibility between preban, mid-ban and postban. Postban, we assessed support for a display ban, perceived appeal of cigarettes and perceived acceptability of smoking as a result of closed displays. RESULTS: Preban, noticing cigarettes displayed at POS (adjusted OR [AOR]=1.97, 95% CI 1.30 to 2.98) and higher brand awareness (AOR=1.15, 95% CI 1.03 to 1.29) were positively associated with smoking susceptibility. The mean number of brands recalled declined from 0.97 preban to 0.69 postban (p<0.001). Smoking susceptibility decreased from 28% preban to 23% mid-ban and 18% postban (p for trend <0.001). Postban, 90% of never-smokers supported the display ban and indicated that it made cigarettes seem unappealing (77%) and made smoking seem unacceptable (87%). CONCLUSIONS: Both partial and full implementation of a display ban were followed by a reduction in smoking susceptibility among adolescents, which may be driven by decreases in brand awareness.

Remembering who owns the river.

We have discovered the elixir of life. For the first time in human existence we now know how we can avoid disease, make our lives healthier and more fulfilled, and even fend off the grim reaper himself (at least for a while). We may not have joined the immortals - many traps and snares continue to prey on us - but we are beginning to learn some of their secrets. Why then are we failing to grasp these heady opportunities? WHO data show that nine out of ten of we Europeans are dying of lifestyle diseases; that is diseases caused by our own choices - self-inflicted diseases. Despite the all too familiar consequences for our bodies, we continue to smoke the tobacco, swallow the junk food and binge on the alcohol that is killing us. Yes, there are systemic drivers at work - commercial marketing, corporate power, inequalities, addiction - but we don't have to collaborate. No one holds a gun to our heads and commands us to eat burgers or get drunk and incapable. This paper argues that public health progress - and human progress more widely - depends on us solving the conundrum of this self-inflicted harm. The urgency of this task increases when we consider our irresponsible consumption behaviour more widely, and that it is not just harming our own health but everyone else's too. Most egregiously anthropomorphic climate change is being caused by the free choices we in the wealthy global north make to drive SUVs, go on intercontinental holidays and accumulate a foolish excess of stuff. It need not be so. Historical experience and two millennia of thinking show we are capable of better. We have moral agency and we can make the right choice even when it is the difficult one. Indeed, it is this capacity and desire ' to follow after wisdom and virtue', to rebel against injustice and malignancy, that makes us human and cements our collective identity. In the last century this realisation was focused by the terrible events of the Second World War and resulted in the formation of the United Nations and the Universal Declaration of Human Rights. Importantly these rights do not just protect us from oppression but enshrine in international law our entitlement to be an active participant in the process of progressive social change.

Public attitudes towards alcohol control policies in Scotland and England: Results from a mixed-methods study.

The harmful effects of heavy drinking on health have been widely reported, yet public opinion on governmental responsibility for alcohol control remains divided. This study examines UK public attitudes towards alcohol policies, identifies underlying dimensions that inform these, and relationships with perceived effectiveness. A cross-sectional mixed methods study involving a telephone survey of 3477 adult drinkers aged 16-65 and sixteen focus groups with 89 adult drinkers in Scotland and England was conducted between September 2012 and February 2013. Principal components analysis (PCA) was used to reduce twelve policy statements into underlying dimensions. These dimensions were used in linear regression models examining alcohol policy support by demographics, drinking behaviour and perceptions of UK drinking and government responsibility. Findings were supplemented with a thematic analysis of focus group transcripts. A majority of survey respondents supported all alcohol policies, although the level of support varied by type of policy. Greater enforcement of laws on under-age sales and more police patrolling the streets were strongly supported while support for pricing policies and restricting access to alcohol was more divided. PCA identified four main dimensions underlying support on policies: alcohol availability, provision of health information and treatment services, alcohol pricing, and greater law enforcement. Being female, older, a moderate drinker, and holding a belief that government should do more to reduce alcohol harms were associated with higher support on all policy dimensions. Focus group data revealed findings from the survey may have presented an overly positive level of support on all policies due to differences in perceived policy effectiveness. Perceived effectiveness can help inform underlying patterns of policy support and should be considered in conjunction with standard measures of support in future research on alcohol control policies.

Adolescents' Perceptions of an On-cigarette Health Warning.

INTRODUCTION: In most countries, health warnings have been on cigarette packs for decades. We explored adolescents' perceptions of a health warning on cigarettes. METHODS: Data come from the 2014 wave of a cross-sectional in-home survey with 11- to 16-year olds (N = 1205) from across the UK, with participants recruited from the general population using random location quota sampling. Participants were shown an image of a standard cigarette which displayed the warning "Smoking kills" and asked whether they thought this would (not) put people off starting to smoke, (not) make people want to give up smoking, and whether all cigarettes should (not) have health warnings on them. RESULTS: Most (71%) thought that an on-cigarette warning would put people off starting, although this decreased with age. Never smokers were more likely than current smokers to think that it would put people off starting. Approximately half (53%) thought that an on-cigarette warning would make people want to give up smoking, with this higher for never smokers and experimenters/past smokers than for current smokers. Most (85%) supported a warning on all cigarettes. There was support among each smoking group, although this was higher for never smokers and experimenters/past smokers than for current smokers, and higher for those indicating that most of their close friends do not smoke than for those indicating that most of their close friends do smoke. CONCLUSIONS: The perception among adolescents that an on-cigarette warning could deter smoking, and the high support for a warning on all cigarettes, warrants further research. IMPLICATIONS: Research on dissuasive cigarettes is at a nascent stage. This is the first study to explore how adolescents perceive a health warning ("Smoking kills") on cigarettes. Almost three quarters of participants indicated that on-cigarette health warnings would deter people from starting to smoke, and 85% supported the inclusion of a warning on all cigarettes. While further research is clearly needed, these findings suggest that the inclusion of health warnings on cigarettes is considered appropriate by young people and may have a dissuasive effect.

Teenage perceptions of electronic cigarettes in Scottish tobacco-education school interventions: co-production and innovative engagement through a pop-up radio project.

AIMS: This article thematically analyses spontaneous responses of teenagers and explores their perceptions of electronic cigarettes (e-cigarettes) with a focus on smoking cessation from data collected for research exploring Scottish secondary school students' recall of key messages from tobacco-education interventions and any influence on perceptions and behaviours. METHODS: E-cigarettes were not included in the research design as they did not feature in interventions. However, in discussions in all participating schools, e-cigarettes were raised by students unprompted by researchers. Seven of 19 publicly funded schools in the region opted to participate. Groups of 13- to 16-year-olds were purposely selected to include a range of aptitudes, non-smokers, smokers, males and females. A total of 182 pupils took part. Data were generated through three co-produced classroom radio tasks with pupils (radio quiz, sitcom, factual interviewing), delivered by a researcher and professional broadcast team. All pupils were briefly interviewed by a researcher. Activities were recorded and transcribed verbatim and the researcher discussed emerging findings with the broadcast team. Data were analysed using NVivo and transcripts making reference to e-cigarettes examined further using inductive thematic analysis. RESULTS: Key themes of their impressions of e-cigarettes were easy availability and price; advertising; the products being safer or healthier, addiction and nicotine; acceptability and experiences of use; and variety of flavours. CONCLUSIONS: This was a qualitative study in one region, and perception of e-cigarettes was not an a priori topic. However, it provides insights into youth perceptions of e-cigarettes. How they discerned e-cigarettes reflects their marketing environment. The relative harmlessness of nicotine, affordability of e-cigarettes, coolness of vaping, absence of second-hand harms and availability of innovative products are all key marketing features. Conflicting messages on safety, efficacy, potential 'gateway' to smoking and nicotine may be contributing to teenagers' confusion. The allure of 'youthful cool' to vaping offers no public health gain, so children should be protected from misleading promotion. Consistent tobacco-education initiatives need to account for this popular trend.

Adolescents' responses to the promotion and flavouring of e-cigarettes.

OBJECTIVES: The purpose of the study is to examine adolescents' awareness of e-cigarette marketing and investigate the impact of e-cigarette flavour descriptors on perceptions of product harm and user image. METHODS: Data come from the 2014 Youth Tobacco Policy Survey, a cross-sectional in-home survey conducted with 11-16 year olds across the UK (n = 1205). Adolescents' awareness of e-cigarette promotion, brands, and flavours was assessed. Perceptions of product harm, and likely user of four examples of e-cigarette flavours was also examined. RESULTS: Some participants had tried e-cigarettes (12 %) but regular use was low (2 %) and confined to adolescents who had also smoked tobacco. Most were aware of at least one promotional channel (82 %) and that e-cigarettes came in different flavours (69 %). Brand awareness was low. E-cigarettes were perceived as harmful (M = 3.54, SD = 1.19) but this was moderated by product flavours. Fruit and sweet flavours were perceived as more likely to be tried by young never smokers than adult smokers trying to quit (p < 0.001). CONCLUSIONS: There is a need to monitor the impact of future market and regulatory change on youth uptake and perceptions of e-cigarettes.

Lay epidemiology and the interpretation of low-risk drinking guidelines by adults in the United Kingdom.

AIMS: To explore how the concept of lay epidemiology can enhance understandings of how drinkers make sense of current UK drinking guidelines. METHODS: Qualitative study using 12 focus groups in four sites in northern England and four sites in central Scotland. Participants were 66 male and female drinkers, aged between 19 and 65 years, of different socio-economic backgrounds. Data were analysed thematically using a conceptual framework of lay epidemiology. RESULTS: Current drinking guidelines were perceived as having little relevance to participants' drinking behaviours and were generally disregarded. Daily guidelines were seen as irrelevant by drinkers whose drinking patterns comprised heavy weekend drinking. The amounts given in the guidelines were seen as unrealistic for those motivated to drink for intoxication, and participants measured alcohol intake in numbers of drinks or containers rather than units. Participants reported moderating their drinking, but this was out of a desire to fulfil work and family responsibilities, rather than concerns for their own health. The current Australian and Canadian guidelines were preferred to UK guidelines, as they were seen to address many of the above problems. CONCLUSIONS: Drinking guidelines derived from, and framed within, solely epidemiological paradigms lack relevance for adult drinkers who monitor and moderate their alcohol intake according to their own knowledge and risk perceptions derived primarily from experience. Insights from lay epidemiology into how drinkers regulate and monitor their drinking should be used in the construction of drinking guidelines to enhance their credibility and efficacy.

Public health and the value of disobedience.

The writings of a sixteenth century French teenager may seem a stretch for a public health readership, but Etienne de la Boétie's treatise on Voluntary Servitude explains why unjust systems prevail and how they can be changed. They prevail, he shows, because we let them (the losers always vastly outnumber the winners); and they change when we retract our permission (as Ghandi demonstrated). These vital insights have inspired progress down the centuries--the enlightenment philosophers, the French Revolution, Tolstoy, the American civil rights movement as well as the Indian struggle against the British Empire. In an era when widening inequalities have become all too apparent, and the harm this does to the commonweal much better understood, this paper argues that La Boétie's analysis retains all its power and can inspire a new vision for public health.