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.

"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.

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.

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.

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.

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.

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.

Adolescents' response to pictorial warnings on the reverse panel of cigarette packs: a repeat cross-sectional study.

BACKGROUND: The UK (UK) became the third country in the European Union to require pictorial warnings on the back of cigarette packs, in October 2008. METHODS: A repeat cross-sectional survey was conducted with 11-16-year-olds in the UK between August and September 2008 (N=1401) and August and September 2011 (N=1373). At both waves the same text warnings appeared on the front and back of packs, with the only difference being the inclusion of images on the back of packs to support the text warnings in 2011. Warning related measures assessed were salience (noticing, looking closely at warnings), depth of processing (thinking about warnings, discussing them with others), comprehension and credibility (warning comprehensibility, believability and truthfulness), unaided recall, persuasiveness (warnings as a deterrent to smoking), avoidance techniques (eg, hiding packs) and a behavioural indicator (forgoing cigarettes due to warnings). RESULTS: For never smokers, warning persuasiveness and thinking about what warnings are telling them when the pack is in sight significantly increased from 2008 to 2011, but warning comprehensibility significantly decreased. For experimental smokers, there was a significant increase from 2008 to 2011 for warning persuasiveness, believing warnings and considering them truthful. For regular smokers, there were no significant changes from 2008 to 2011, except for an increase in hiding packs to avoid warnings and a decrease in warning salience. CONCLUSIONS: Including pictorial images on the back of cigarette packaging improved warning persuasiveness for never and experimental smokers, but had a negligible impact on regular smokers. The findings have implications for warning design.

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.

Adolescent perceptions of cigarette appearance.

BACKGROUND: To reduce the possibility of cigarette appearance misleading consumers about harm caused by the product, the European Commission's draft Tobacco Products Directive proposed banning cigarettes <7.5 mm in diameter. It appears however, following a plenary vote in the European Parliament, that this will not be part of the final Tobacco Products Directive. To reduce the appeal of cigarettes, the Australian Government banned the use of branding on cigarettes and stipulated a maximum cigarette length as part of the Tobacco Plain Packaging Act. We explored the role, if any, of cigarette appearance on perceptions of appeal and harm among adolescents. METHODS: Focus group research with 15-year-olds (N = 48) was conducted in Glasgow (Scotland) to explore young people's perceptions of eight cigarettes differing in length, diameter, colour and decorative design. RESULTS: Slim and superslim cigarettes with white filter tips and decorative features were viewed most favourably and rated most attractive across gender and socio-economic groups. The slimmer diameters of these cigarettes communicated weaker tasting and less harmful looking cigarettes. This was closely linked to appeal as thinness implied a more pleasant and palatable smoke for young smokers. A long brown cigarette was viewed as particularly unattractive and communicated a stronger and more harmful product. CONCLUSION: This exploratory study provides some support that standardising cigarette appearance could reduce the appeal of cigarettes in adolescents and reduce the opportunity for stick design to mislead young smokers in terms of harm.

Systematic reviews of the evidence on the nature, extent and effects of food marketing to children. A retrospective summary.

A 2009 systematic review of the international evidence on food and beverage marketing to children is the most recent internationally comprehensive review of the evidence base. Its findings are consistent with other independent, rigorous reviews conducted during the period 2003-2012. Food promotions have a direct effect on children's nutrition knowledge, preferences, purchase behaviour, consumption patterns and diet-related health. Current marketing practice predominantly promotes low nutrition foods and beverages. Rebalancing the food marketing landscape' is a recurring policy aim of interventions aimed at constraining food and beverage promotions to children. The collective review evidence on marketing practice indicates little progress towards policy aims has been achieved during the period 2003-2012. There is a gap in the evidence base on how substantive policy implementation can be achieved. We recommend a priority for future policy relevant research is a greater emphasis on translational research. A global framework for co-ordinated intervention to constrain unhealthy food marketing which has received high level support provides valuable insight on some aspects of immediate implementation research priorities.

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.

The International Alcohol Control (IAC) study-evaluating the impact of alcohol policies.

BACKGROUND: This paper describes a new multicountry collaborative project to assess the impact of alcohol control policy. Longitudinal surveys of drinkers in a number of participating countries and analysis of the policy context allow for the assessment of change over time within countries and comparison between countries. The design of the study is modeled on the International Tobacco Control study and aims to assess the impact of alcohol policies in different cultural contexts on policy-related behaviors and alcohol consumption. A survey instrument and protocol for policy analysis have been developed by the initial participating countries: England, Scotland, Thailand, South Korea, and New Zealand. The first round of data collection is scheduled for 2011-2012. MEASUREMENTS: The survey instrument (International Alcohol Control [IAC] survey) measures key policy relevant behaviors: place and time of purchase, amounts purchased and price paid; ease of access to alcohol purchase; alcohol marketing measures; social supply; perceptions of alcohol affordability and availability and salience of price; perceptions of enforcement; people's experiences with specific alcohol restrictions; support for policy and consumption (typical quantity, frequency using beverage and location-specific measures). The Policy Analysis Protocol (PoLAP) assesses relevant aspects of the policy environment including regulation and implementation. RESULTS: It has proved feasible to design instruments to collect detailed data on behaviors relevant to alcohol policy change and to assess the policy environment in different cultural settings. CONCLUSIONS: In a policy arena in which the interest groups and stakeholders have different perceptions of appropriate policy responses to alcohol-related harm, a robust methodology to assess the impact of policy will contribute to the debate.

The association between point-of-sale displays and youth smoking susceptibility.

INTRODUCTION: According to tobacco industry documents, tobacco displays within the retail environment assume a much greater importance with the loss of other marketing channels. The impact of these displays upon young people and their future intentions to smoke (susceptibility) is, therefore, of significant interest to public health. METHODS: A cross-sectional in-home survey was conducted in 2008 with young people (N = 1,401) aged 11-16 years, recruited from across the United Kingdom. We examine the salience of and attraction to cigarette displays at point-of-sale (POS), among youth, and whether this is associated with susceptibility. We concentrate exclusively on the 956 never-smokers. RESULTS: Logistic regression, controlling for known risk factors of youth smoking, found that noticing cigarette displays was associated with higher levels of susceptibility (odds ratio [OR] = 1.77, p < .05) and greater attraction to displays was associated with higher susceptibility (OR = 1.07, p < .001). CONCLUSIONS: It is difficult, if not impossible, to safeguard young people from exposure to displays of tobacco at POS. That these displays were associated with increased susceptibility suggests that moves to place tobacco out of sight in the United Kingdom, and elsewhere, are justified.

Young people's perceptions of cigarette packaging and plain packaging: an online survey.

INTRODUCTION: In the United Kingdom, with most marketing channels prohibited, packaging is one of the few remaining ways that tobacco companies can promote their products. METHODS: An online survey with young people aged 10-17 years (N = 658) was used to explore why youth choose cigarettes, perceptions of pack color, and perceptions of plain (nonbranded) cigarette packaging. Young people were also shown an image of 3 plain packs, which differed by shape and method of opening, and asked which they liked most and thought others their age would smoke. RESULTS: Price and what significant others smoke were key factors for choosing cigarettes, with packaging also an important influence. More than a third of the sample associated lighter pack color with weak tasting and less harmful cigarettes. Plain packs were rated negatively as were perceptions of plain pack users. One in 3 showed a preference for either a narrow "perfume type" plain pack or a plain "slide" pack that opened from the side, and 1 in 3 also thought that young people would smoke these packs. CONCLUSIONS: Packaging appears to both attract young people and mislead them about product strength and relative harm. Innovative pack construction (novel pack shape and method of opening) and the use of color are instrumental in these effects. The findings therefore suggest that any move to plain packaging should not only consider the benefits of removing branding (including color) but also of standardizing pack construction in terms of shape and method of opening.

Support for removal of point-of-purchase tobacco advertising and displays: findings from the International Tobacco Control (ITC) Canada survey.

BACKGROUND: Although most countries now have at least some restrictions on tobacco marketing, the tobacco industry meet these restrictions by re-allocating expenditure to unregulated channels, such as at point-of-purchase. METHODS: Longitudinal data from 10 Canadian provinces in the International Tobacco Control Survey was analysed to examine adult smokers' support for a ban on tobacco advertising and displays in stores and whether this support is associated with noticing either advertising or displays in stores, and quit intentions, over time. In total, there were 4580 respondents in wave 5 (October 2006 to February 2007), wave 6 (September 2007 to February 2008) and wave 7 (October 2008 to June 2009). The surveys were conducted before, during and in some cases after the implementation of display bans in most Canadian provinces and territories. RESULTS: Smokers in all provinces showed strong support for a ban on tobacco displays over the study period. Levels of support for an advertising and display ban were comparable between Canadian provinces over time, irrespective of whether they had been banned or not. Noticing tobacco displays and signs in-store was demonstrably less likely to predict support for display (OR=0.73, p=0.005) and advertising (OR=0.78, p=0.02) ban, respectively. Smokers intending to quit were more likely to support advertising and display bans over time. CONCLUSION: This study serves as a timely reminder that the implementation of tobacco control measures, such as the removal of tobacco displays, appear to sustain support among smokers, those most likely to oppose such measures.

Young adult smokers' perceptions of illicit tobacco and the possible impact of plain packaging on purchase behaviour.

Plain (unbranded) packaging for cigarettes is at the top of the tobacco control agenda in both Australia and Europe. The evidence suggests that it will benefit public health by decreasing the appeal of tobacco products and increasing the power of the health warning. The tobacco industry instead argues that plain packaging would make it easier to counterfeit cigarettes, which would both confuse consumers and reduce price; thereby increasing consumption. Using focus group research we examined young adult smokers (N = 54) perceptions of, and ability to recognize, illicit tobacco and the possible impact of plain packaging on illicit tobacco purchasing behaviour. We found that the pack has no impact on the decision to buy illicit tobacco. Smokers were easily able to identify counterfeit cigarettes, not least by the pack, and buy it knowingly and in the full expectation that it will be inferior in quality. Illicit tobacco purchase, including that for counterfeit tobacco, was instead driven by availability and price. Given the extremely low manufacturing cost, per pack, of certain types of illicit cigarettes, it is difficult to envisage how plain packaging would alter the price of illicit tobacco in any meaningful way. The findings therefore suggest that a move to plain packaging would have no impact on young adult smokers' purchase behaviour.

Young adult smokers' perceptions of plain packaging: a pilot naturalistic study.

AIMS: To explore the impact, if any, that using plain (non-branded) cigarette packs in real-life settings has on young adult smokers. METHODS: Naturalistic-type research was employed, where smokers used brown 'plain' packs for 2 weeks and their regular packs for 2 weeks, in real-life settings. Participants were recruited in Glasgow, Scotland. Of the 140 smokers aged 18-35 years who participated in the naturalistic study, 48 correctly completed and returned all questionnaires. Over the 4-week study period, participants completed a questionnaire twice a week assessing pack perceptions and feelings, feelings about smoking, salience of health warnings and smoking-related behaviours. A subsample of 18 participated in a post-study interview, which employed a semistructured topic guide to assess perceptions and experiences of using plain packs. RESULTS: Trends in the data show that in comparison with branded packaging, plain packaging increased negative perceptions and feelings about the pack and about smoking. Plain packaging also increased avoidant behaviour (hiding the pack, covering the pack), certain smoking cessation behaviours, such as smoking less around others and forgoing cigarettes, and thinking about quitting. Almost half (n=8) of those in the post-study interview, predominantly women (n=6), reported that the use of plain packs had either increased avoidant behaviour or reduced consumption. CONCLUSIONS: This pilot naturalistic study suggests that plain packaging could potentially help reduce tobacco consumption among some young adult smokers, and women in particular. Employing an innovative research methodology, the findings of this study are consistent with, and indeed support, past plain packaging research.