Food Environment After Implementation of a Healthy Checkout Policy.

Importance: In March 2021, Berkeley, California, became the world's first jurisdiction to implement a healthy checkout policy, which sets nutrition standards for foods and beverages in store checkouts. This healthy checkout ordinance (HCO) has the potential to improve customers' dietary intake if stores comply by increasing the healthfulness of foods and beverages at checkouts. Objectives: To compare the percentage of checkout products that were HCO compliant and that fell into healthy and unhealthy food and beverage categories before and 1 year after HCO implementation in Berkeley relative to comparison cities. Design, Setting, and Participants: In this cohort study in which Berkeley implemented an HCO and other cities did not, a difference-in-differences analysis was conducted of 76 258 product facings at checkouts of 23 stores in Berkeley and 75 stores in 3 comparison cities in California. Data were collected in February 2021 (approximately 1 month before implementation of the HCO) and 1 year later in February 2022 and analyzed from October 2023 to May 2024. Exposure: The HCO, which permits only the following products at checkouts in large food stores: nonfood and nonbeverage products, unsweetened beverages, and foods with 5 g or less of added sugars per serving and 200 mg or less of sodium per serving in the following categories: sugar-free gum and mints, fruit, vegetables, nuts, seeds, legumes, yogurt or cheese, and whole grains. Main Outcomes and Measures: A product facing's (1) HCO compliance and (2) category, including healthy compliant categories and unhealthy noncompliant categories, determined using a validated photograph-based tool to assess product characteristics. Results: Of the 76 258 product facings at store checkouts, the percentage that were HCO compliant increased from 53% (4438 of 8425) to 83% (5966 of 7220) in Berkeley, a 63% increase relative to comparison cities (probability ratio [PR], 1.63; 95% CI, 1.41-1.87). The percentage of food and beverage checkout facings that were HCO compliant increased in Berkeley from 29% (1652 of 5639) to 62% (2007 of 3261), a 125% increase relative to comparison cities (PR, 2.25; 95% CI, 1.80-2.82). The percentage of Berkeley food and beverage facings consisting of candy, sugar-sweetened beverages, and other sweets significantly decreased (candy: from 30% [1687 of 5639] to 6% [197 of 3261]; PR, 0.21; 95% CI, 0.10-0.42; sugar-sweetened beverages: from 11% [596 of 5639] to 5% [157 of 3261]; PR, 0.41; 95% CI, 0.23-0.75; other sweets: from 7% [413 of 5639] to 3% [101 of 3261]; PR, 0.37; 95% CI, 0.15-0.88), while the percentage consisting of unsweetened beverages (from 4% [226 of 5639] to 19% [604 of 3261]; PR, 4.76; 95% CI, 2.54-8.91) and healthy foods (from 6% [350 of 5639] to 20% [663 of 3261]; PR, 2.90; 95% CI, 1.79-4.72) significantly increased. Conclusions and Relevance: This cohort study of the first healthy checkout policy found substantial improvements in the healthfulness of food environments at checkouts 1 year after implementation of the policy. These results suggest that healthy checkout policies have the potential to improve the healthfulness of store checkouts.

Evaluation of Fast-Food Restaurant Kids' Meal Beverage Offerings 1 Year After a State-Level Healthy Beverage Default Policy.

Introduction: Ordering from kids' menus and children's restaurant consumption is associated with greater purchasing and intake, respectively, of sugar-sweetened beverages. In response, policymakers have enacted strategies to improve the healthfulness of kids' meal offerings. This study investigated restaurant kids' meal beverage offerings and compliance with an Illinois healthy beverage default act, effective from January 1, 2022. Methods: Using a pre-post intervention (Illinois)-comparison (Wisconsin) site research design, fast-food restaurant audit data were collected before and 1 year after the Illinois Healthy Beverage Default Act from 6 platforms: restaurant interior and drive-thru menu boards and websites/applications and 3 third-party ordering platforms (DoorDash, Uber Eats, and Grubhub). Analyses included 62-110 restaurants across platforms. Difference-in-differences-weighted logistic regression models with robust SEs, clustered on restaurants, were estimated to assess pre to 1-year postpolicy changes in overall compliance for each audit setting in Illinois relative to that in Wisconsin. Results: This study found no statistically significant (p<0.05) changes in the compliance of kids' meal beverage default offerings associated with the enactment of the Illinois Healthy Beverage Default Act in Illinois relative to that in Wisconsin at fast-food restaurants. There were some observed differences in results in the restaurants' physical locations versus online that are worth noting. That is, after the enactment of the Illinois Healthy Beverage Default Act, the results showed greater odds of fast-food restaurants exclusively offering healthy beverage defaults with kids' meals on restaurant interior (OR=1.83, 95% CI=0.93, 3.58) and drive-thru (OR=2.38, 95% CI=0.95, 5.96) menus, with weak statistical significance (p<0.10). However, the policy was not associated with either meaningful or statistically significant changes in healthy beverage default offerings on restaurant websites or third-party online ordering platforms. Conclusions: This study found limited evidence of changes in kids' meal beverage offerings attributable to the Illinois Healthy Beverage Default Act. Future investigations of communication channels that support awareness and implementation and the resources required for implementation and enforcement may provide insight that is key to improving compliance.

Analysis of social media compliance with cannabis advertising regulations: evidence from recreational dispensaries in Illinois 1-year post-legalization.

BACKGROUND: In the USA, an increasing number of states have legalized commercial recreational cannabis markets, allowing a private industry to sell cannabis to those 21 and older at retail locations known as dispensaries. Research on tobacco and alcohol suggests this new industry will use aggressive marketing tactics to attract new users and promote greater intensity of use. Of concern is that cannabis company advertising campaigns may be appealing to youth, promote false or misleading health claims, and disproportionately target low-income and minority communities. In this study, we evaluated recreational cannabis dispensary compliance with advertising regulations on social media in the state of Illinois. METHODS: Primary data were collected from a census of recreational dispensary Facebook and Twitter business pages during the first year of recreational sales in 2020. A quantitative content analysis was conducted to systematically analyze the data; a codebook that detailed a protocol for classifying posts was developed prior to the analysis using advertising regulations outlined in the Illinois Cannabis Regulation and Tax Act. Violations of advertising regulations were organized into three categories: advertisements that may be appealing to youth (< 21 years old), advertisements that make health claims, and other advertising violations. The data were analyzed cross-sectionally and longitudinally. Additionally, differences in compliance were assessed by dispensary and neighborhood characteristics. RESULTS: The results of the analysis revealed substantial and persistent non-compliance throughout the entire study period. Overall, nearly one third of posts had at least one violation and approximately one in ten posts met the criteria for appealing to youth or contained health claims. The majority of posts with health claims included health claims that were not qualifying conditions for medical cannabis access in the state of Illinois. No differences in compliance by neighborhood and dispensary characteristics were found. CONCLUSIONS: The findings from this study suggest that systematic monitoring and enforcement is needed to ensure compliance with advertising regulations.