Countermarketing Versus Health Education Messages About Sugar-Sweetened Beverages: An Online Randomized Controlled Trial of US Adults.

Objectives. To test whether countermarketing messages for sugary drinks lead to lower intentions to consume sugary drinks and less perceived weight stigma than health education messages. Methods. In August 2023, we conducted an online randomized controlled trial with US adults (n = 2169). We assessed the effect of countermarketing messages, health education messages, and neutral control messages on intentions to consume sugary drinks and perceived weight stigma. Results. Both countermarketing messages (Cohen d = -0.20) and health education messages (d = -0.35) led to lower intentions to consume sugary drinks than control messages (Ps < .001). However, both types of messages elicited more perceived weight stigma than control messages (ds = 0.87 and 1.29, respectively; Ps < .001). Countermarketing messages were less effective than health education messages at lowering intentions to consume sugary drinks (d for countermarketing vs health education = 0.14) but also elicited less perceived weight stigma than health education messages (d = -0.39; Ps < .01). Conclusions. Countermarketing messages show promise for reducing sugary drink consumption while eliciting less weight stigma than health education messages, though they may need to be refined further to minimize weight stigma and maximize effectiveness. Clinical Trial Number. ClinicalTrials.gov NCT05953194. (Am J Public Health. Published online ahead of print October 3, 2024:e1-e11. https://doi.org/10.2105/AJPH.2024.307853).

"Warning: ultra-processed": an online experiment examining the impact of ultra-processed warning labels on consumers' product perceptions and behavioral intentions.

BACKGROUND: Nutrient content and degree of processing are complementary but distinct concepts, and a growing body of evidence shows that ultra-processed foods (UPFs) can have detrimental health effects independently from nutrient content. 10 + countries currently mandate front-of-package labels (FOPL) to inform consumers when products are high in added sugars, saturated fat, and/or sodium. Public health advocates have been calling for the addition of ultra-processed warning labels to these FOPLs, but the extent to which consumers would understand and be influenced by such labels remains unknown. We examined whether the addition of ultra-processed warning labels to existing nutrient warning labels could influence consumers' product perceptions and purchase intentions. METHODS: In 2023, a sample of adults in Brazil (n = 1,004) answered an open-ended question about the meaning of the term "ultra-processed," followed by an online experiment where they saw four ultra-processed products carrying warning labels. Participants were randomly assigned to view either only nutrient warning labels or nutrient plus ultra-processed warning labels. Participants then answered questions about their intentions to purchase the products, product perceptions, and perceived label effectiveness. RESULTS: Most participants (69%) exhibited a moderate understanding of the term "ultra-processed" prior to the experiment. The addition of an ultra-processed warning label led to a higher share of participants who correctly identified the products as UPFs compared to nutrient warning labels alone (Cohen's d = 0.16, p = 0.02). However, the addition of the ultra-processed warning label did not significantly influence purchase intentions, product healthfulness perceptions, or perceived label effectiveness compared to nutrient warning labels alone (all p > 0.05). In exploratory analyses, demographic characteristics and prior understanding of the concept of UPF did not moderate the effect of ultra-processed warning labels. CONCLUSIONS: Ultra-processed warning labels may help consumers better identify UPFs, although they do not seem to influence behavioral intentions and product perceptions beyond the influence already exerted by nutrient warning labels. Future research should examine how ultra-processed warning labels would work for products that do and do not require nutrient warnings, as well as examine the benefits of labeling approaches that signal the health effects of UPFs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05842460. Prospectively registered March 15th, 2023.

Understanding Potential Mechanisms of Vaping Prevention Messages: A Mediation Analysis of the Real Cost Campaign Advertisements.

The U.S. Food and Drug Administration (FDA) developed a public education campaign, The Real Cost, that reduced youth susceptibility to tobacco product use. We sought to identify the mechanisms that may underlie the impact of The Real Cost ads on susceptibility to vaping to inform youth tobacco prevention campaigns. Our online randomized controlled trial (clinicaltrials.gov, identifier NCT04836455) examined a large sample of U.S. adolescents (n = 1,348) who had multiple exposures to Real Cost ads or control videos over a 3-week period in 2021. To examine potential mediating pathways between The Real Cost ads and susceptibility to vaping, we examined theory-based psychosocial and message-related variables. The largest impact of The Real Cost ads on susceptibility was via more negative attitudes toward vaping (ßa*ßb = -0.16; 95% confidence interval [CI] = [-0.25, -0.06]). Other mediation paths were via improved health harm risk beliefs (ßa*ßb = -0.08; 95% CI = [-0.13, -0.04]), addiction risk beliefs (ßa*ßb = -0.04; 95% CI = [-0.06, -0.01]), injunctive norms against vaping (ßa*ßb = -0.05; 95% CI = [-0.09, -0.02]), negative affect (ßa*ßb = -0.05; 95% CI = [-0.08, -0.02]), and cognitive elaboration (ßa*ßb = -0.03; 95% CI = [-0.05, -0.003]). Our findings suggest that ads that target negative attitudes may decrease susceptibility to vaping among youth. Our findings also introduce normative pressure as a novel factor that may be important for vaping prevention messages.

Health harms that discourage alcohol consumption: A randomized experiment of warning messages.

BACKGROUND: Health warnings about alcohol consumption could inform consumers and discourage alcohol consumption, but little is known about what topics these warnings should address. We sought to identify promising topics for alcohol warnings. METHODS: In January 2024, we recruited a convenience sample of 2,522 US adults ages ≥ 21 years. In an online within-subjects experiment, participants viewed messages about 6 topics (5 warning topics selected from a pool of 16 topics [e.g., liver disease, liver cancer] and 1 control topic [i.e., recycling or reselling products]) shown in random order. For each topic, participants viewed and rated 2 statements about that topic on perceived message effectiveness (primary outcome) and reactance (secondary outcome). RESULTS: The 16 warning topics elicited higher perceived message effectiveness than the control topic (ps < 0.001). Among the warning topics, liver disease, most cancer types, dementia or mental decline, and hypertension elicited the highest perceived message effectiveness, while breast cancer, sleep, and drinking guidelines elicited the lowest. Fourteen of the 16 warning topics (all except for fetal harms and impaired driving) elicited more reactance than the control topic (ps < 0.001). Warning topics that elicited high perceived message effectiveness generally elicited high reactance, except for messages about liver disease and liver cancer, which elicited high perceived message effectiveness but only moderate reactance. DISCUSSION: Warning messages about a variety of topics hold promise for discouraging alcohol consumption. Messages about liver disease, most cancer types, dementia or mental decline, and hypertension are perceived as especially effective; however, none of these topics are included in the current US alcohol warning.

Examining the 2021 Cash Value Benefit Increase and WIC Participant Food Purchases.

INTRODUCTION: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutritious foods to more than six million low-income families. In June 2021, WIC increased the amount of money provided for fruits and vegetables (FV), but studies have not investigated whether this increase changed WIC participant FV purchases. The objective was to estimate the association between the FV funding increase and WIC shopper FV purchases. METHODS: This evaluation uses longitudinal food transaction data from 496 stores in a grocery store chain in North Carolina between June 2020 and April 2022 and a propensity score weighted difference-in-differences (DID) approach to estimate the association between the FV funding increase and FV and other food group purchases. Analyses were conducted in 2023 and 2024. RESULTS: WIC shoppers' WIC-eligible FV purchases increased by $12.4 per shopper per month (adjusted confidence interval [ACI], $12.0-$12.9) after the FV benefit increase, which was $9.3 (ACI, $8.7-$10.0) more than non-WIC shoppers. The monthly volume and unique varieties of FV purchased also increased more among WIC shoppers relative to non-WIC shoppers (DID 67.1 ounces [ACI, 61.9-72.3] and DID 2.1 varieties [ACI, 2.0-2.3]). There were also increases in the volume of processed foods (DID 22.0 ounces [ACI, 17.2, 26.9]) and sugar-sweetened beverages (DID 49.1 ounces [ACI, 33.4, 64.9]) purchased among WIC shoppers relative to non-WIC shoppers. CONCLUSIONS: Increased WIC FV funding was associated with greater FV purchases. Research is needed to understand the effects of this policy on total dietary intake.

Online retail nudges to help parents with lower-income choose healthy beverages for their children: A randomized clinical trial.

BACKGROUND: Nudges offer a promising tool to reduce sugary drink intake among children who are most at risk for diet-related disease. OBJECTIVE: To examine the impact of online store nudges on purchases of sugary drinks for children in lower-income households. METHODS: Caregivers with lower-income were recruited to an online shopping experiment and instructed to spend $10-$30 on three beverages for their child aged 1-5 years. Participants were randomized to navigate an online supermarket in its standard version (n = 1106) or a version with nudges (n = 1135), including a product placement nudge (i.e. placing healthy beverages in prominent positions) and a swap nudge (i.e. offering a swap of water, plain milk and/or 100% fruit juice upon selection of sugary drinks). RESULTS: On average, participants purchased 1887 (SD = 2113) and 620 (SD = 1528) calories from sugary drinks per basket in the control and experimental conditions, respectively. Model-based results indicate that those in the experimental condition purchased 1267 (95% CI: 1419, 1114) fewer calories from sugary drinks, and fewer grams of total sugar (ß = -253.5 g (95% CI: -286.3, -220.6)) and added sugar (ß = -287.8 g (95% CI: -323.1, -252.5)) purchased from sugary drinks. CONCLUSION: Nudges may be an effective, acceptable, scalable strategy for leading caregivers in lower-income households to purchase fewer sugary drinks for their children.

Impact of nutrient warning labels on Colombian consumers' selection and identification of food and drinks high in sugar, sodium, and saturated fat: A randomized controlled trial.

OBJECTIVE: This study assessed the impact of nutrient warnings on product selection and ability to identify food products high in nutrients of concern in Colombia. METHODS: In an online experiment (May-June 2023), Colombian adults were randomized to a nutrient warning, guideline daily amounts (GDA), Nutri-Score, or no-label condition (n = 8,004). Participants completed selection tasks between two fruit drinks labeled according to their condition, one high in sugar and one not. Next, participants answered questions about products high in sugar, sodium, and/or saturated fat ("high-in" product). Finally, they selected which label would most discourage them from consuming a high-in product. RESULTS: Fewer participants (17%) exposed to the nutrient warning indicated they would purchase the high-sugar fruit drink compared to Nutri-Score (27%, Holm-adjusted (adj) p<0.001) and no label conditions (31%, adj p<0.001); there were no differences between the nutrient warning and GDA label (14%, adj p = 0.087). Compared to the nutrient warning, the GDA label was slightly more effective at helping consumers identify which drink was high in sugar (89% versus 92%, adj p<0.001), while the Nutri-Score and no-label conditions were less effective. Compared to all other conditions, nutrient warnings were more effective at helping participants identify that products were high in nutrients of concern, were more effective at decreasing intentions to purchase these high-in products and were perceived as more effective. Nutrient warnings were most often selected as the label that most discouraged consumption. CONCLUSIONS: Nutrient warnings are a promising policy to help consumers identify and discourage consumption of products high in nutrients of concern. TRIAL REGISTRATION: Trial Registration: NCT05783726.

Examining the effects of brand and licensed characters on parents' perceptions of Children's breakfast cereals.

Brand and licensed characters frequently appear on children's breakfast cereal boxes and are known to affect children's product perceptions, selection, and consumption. However, less is known about their impact on parents' perceptions of foods they purchase for their child. The present study assessed the impact of brand and licensed characters featured on three children's breakfast cereal packages on parents' intentions and perceptions in an online experiment. Parents of children aged 2-12 years (n = 1013) were randomized into one of two conditions: breakfast cereals containing brand and licensed characters or breakfast cereals without any characters. Within each condition, participants viewed three breakfast cereal brands in random order per their assigned condition and reported their purchase intentions, healthfulness perceptions, and perceptions of appeal to children using 5-point Likert scales. No significant differences in purchase intentions (p = 0.91), perceived healthfulness (p = 0.52) or perceived child appeal (p = 0.59) were observed between the experimental and control groups. However, exploratory moderation analyses revealed that educational attainment moderated the impact of experimental condition on purchase intentions (p for interaction = 0.002) such that participants with a bachelor's degree in the character condition reported 0.36 points lower purchase intentions compared to the control with no difference between conditions for those with an associate's degree/trade school or high school degree or less. This study did not find an impact of brand and licensed characters on children's breakfast cereals, suggesting that their primary appeal is directly to children. Parents with higher educational attainment may be skeptical of characters on cereal brands. Additional research on the impact of brand and licensed characters on other products, in real-world settings, is needed.

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

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

Uncontrolled vaping and restraint strategies: A qualitative study.

INTRODUCTION: Little is known about uncontrolled vaping, defined as vaping more than the user prefers. We sought to understand e-cigarette users' experiences with uncontrolled vaping and how they restrain their vaping. METHODS: Participants were 24 US adult e-cigarette users recruited in 2021. We conducted semi-structured qualitative interviews about uncontrolled vaping and restraint strategies and analyzed findings based on behavioral categories described in the Process Model of Self-Control. RESULTS: While most participants (21 of 24) described experiences of uncontrolled vaping, some expressed ambivalence about how much they vaped. To restrain vaping, willpower was rarely used and was not perceived as effective. Distraction, deployment of attention away from the urge to vape, and reappraisal, thinking differently about vaping such as reminding oneself of health consequences, were common and helped some participants limit use in the moment of wanting to vape. Participants described using both situation selection, choosing to be in situations where e-cigarette use was less possible, and situation modification, modifying their circumstances to restrict opportunities to vape. DISCUSSION: Uncontrolled vaping is not yet a well-defined concept for many e-cigarette users. E-cigarette users employed proactive situational strategies that required planning ahead to restrain use and found these strategies more effective compared to reactive strategies. Tobacco control programs and interventions should consider leveraging restraint strategies that people who vape are naturally using and perceive to be effective.

How Promising Are "Ultraprocessed" Front-of-Package Labels? A Formative Study with US Adults.

High levels of food processing can have detrimental health effects independent of nutrient content. Experts and advocates have proposed adding information about food processing status to front-of-package labeling schemes, which currently exclusively focus on nutrient content. How consumers would perceive "ultraprocessed" labels has not yet been examined. To address this gap, we conducted a within-subjects online experiment with a convenience sample of 600 US adults. Participants viewed a product under three labeling conditions (control, "ultraprocessed" label, and "ultraprocessed" plus "high in sugar" label) in random order for a single product. The "ultraprocessed" label led participants to report thinking more about the risks of eating the product and discouraging them from wanting to buy the product more than the control, despite not grabbing more attention than the control. The "ultraprocessed" plus "high in sugar" labels grabbed more attention, led participants to think more about the risks of eating the product, and discouraged them from wanting to buy the product more than the "ultraprocessed" label alone. "Ultraprocessed" labels may constitute promising messages that could work in tandem with nutrient labels, and further research should examine how they would influence consumers' actual intentions and behaviors.

Special Supplemental Nutrition Program for Women, Infants, and Children Participant Grocery Store Purchases during the COVID-19 Pandemic in North Carolina.

Background: Families participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) experienced barriers to accessing healthy food during the COVID-19 pandemic, but we do not yet understand how WIC participant food purchases shifted during the pandemic. Objectives: We aimed to describe the association between the initial shock of the pandemic in March 2020 and WIC shoppers' food purchases and changes in purchases before and during the pandemic at a top grocery chain and examine differences in these relationships by duration of WIC use. Methods: We used longitudinal food transaction data from WIC shoppers (n = 2,989,116 shopper-month observations from 175,081 unique WIC shoppers) from 496 stores in a top grocery store chain in North Carolina between October 2019 and May 2021. We used an interrupted time series design to describe the following: 1) the relationship between the initial shock of the pandemic and WIC shopper food purchases and 2) differences in purchases before and during the pandemic. To assess differences in purchases between shoppers consistently using WIC electronic benefit transfer (EBT) cards and shoppers starting or stopping WIC EBT use during the pandemic, we used models stratified by WIC group. Primary outcomes were share (%) of total calories purchased from fruits, vegetables, nuts, and legumes (FV), processed foods, and sugar-sweetened beverages (SSBs). Results: We observed small decreases in the share of total calories from FV (-0.4%) and small increases in the share of calories from processed food (1.1%) and SSBs (0.5%) purchased at this retailer when comparing the pre and post March 2020 periods. Compared with shoppers that started or stopped using WIC benefits during the pandemic, shoppers that used WIC benefits consistently had slightly higher FV and lower processed food and SSB purchases at this retailer. Conclusions: Future studies should examine whether additional supports for nutrient-dense food choices may be needed for families with low incomes in public health emergencies.

A Qualitative Exploration of Spanish-Speaking Latina Women's Experiences Participating in WIC Before and During the COVID-19 Pandemic.

BACKGROUND: More than one-third of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants identify as Latino, but participation has been declining and individuals who speak predominantly Spanish face additional barriers to participation. During the COVID-19 pandemic, there were changes in WIC eligibility and benefits that may have been differentially accessible to Spanish-speaking Latina participants due to factors such as language barriers and lack of awareness of changes. Understanding Spanish-speaking Latinas' experiences with the WIC program generally and during the pandemic can inform efforts to equitably implement future emergency food response policies and improve the WIC program and Latina participant enrollment more broadly. OBJECTIVE: This study aimed to understand the perceptions and experiences of Spanish-speaking Latina WIC participants with the WIC program generally and with COVID-19 pandemic-related policy changes made to the WIC program. DESIGN: Qualitative in-depth interviews were conducted virtually in Spanish in August 2022 using a semi-structured guide. PARTICIPANTS/SETTING: Study participants were 18 Spanish-speaking Latina adult WIC participants living in North Carolina recruited using convenience sampling. ANALYSIS: All interviews were recorded, transcribed, and coded in Spanish. Thematic analysis with inductive coding was used to derive key themes. RESULTS: Perceptions about the WIC program in this sample were mixed. Participants felt positively about the healthfulness of foods included in the WIC food packages but expressed concern about the monthly benefit amounts being too low and the cultural appropriateness of food options. Pandemic policy changes, such as remote appointments and the Cash Value Benefit increase were perceived positively; however, barriers to using benefits during this time included limited communication from WIC agencies, food shortages, and concerns about not being granted US citizenship or permanent resident status due to use of WIC (ie, public charge rule). Social networks played an important role in learning about and enrolling in WIC and navigating food shortages during the pandemic. CONCLUSIONS: Concerns about the cultural appropriateness of foods provided, communication challenges, and the public charge rule emphasized the need for resources dedicated in the WIC program to improving Spanish-speaking Latina women's experiences with WIC.

The impact of "pinkwashed" alcohol advertisements on attitudes and beliefs: A randomized experiment with US adults.

OBJECTIVE: To examine the impact of alcohol advertisements related to breast cancer awareness or charities (i.e., pinkwashed ads) on attitudes and beliefs. METHODS: In 2023, an online experiment randomized 602 US adults to view three pinkwashed ads for beer, wine, and liquor, or three standard ads for the same products. RESULTS: Breast cancer risk perceptions (average differential effect [ADE] = 0.03; p = 0.58)) and intentions to purchase the advertised product (ADE = -0.01, p = 0.95) did not differ by ad type. When informed about the link between alcohol and breast cancer, participants who viewed pinkwashed ads reported the ads were more misleading (ADE = 0.51, p < 0.001) and had stronger support for requiring alcohol breast cancer warnings (ADE = 0.23, p < 0.001). The pinkwashed ads for beer (but not for wine or liquor) led to greater: perceived product healthfulness (ADE = 0.16, p = 0.03), perceived social responsibility of the company (ADE = 0.18, p = 0.02), and favorable brand attitudes (ADE = 0.14, p = 0.03). CONCLUSIONS: Informing the public about pinkwashing increases perceptions of misleadingness and support for alcohol policies. POLICY IMPLICATIONS: Exposing the industry practice of pinkwashing could be a promising theme for campaigns to reduce alcohol consumption and increase support for alcohol policies.

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

INTRODUCTION: Excise taxes on unhealthy products like sugary drinks and tobacco can reduce purchases of these products. However, little research has investigated whether messages at the point of purchase, such as enhanced price tags, can increase the effects of taxes by heightening psychological reactions. This study aimed to examine whether including messages about taxes on price tags could amplify the benefits of excise taxes on unhealthy products. METHODS: In 2022, an online study recruited 1,013 U.S. parents to view seven price tag messages (e.g., "includes a 19% sugary drink tax") and a control (i.e., standard price tag with the tax included in the price) displayed in random order alongside sugary drinks. Participants were randomly assigned to view a caution-symbol icon or no icon on price tags. Analyses were conducted in 2023. RESULTS: All seven messages discouraged parents from buying sugary drinks for their children compared to control (average differential effects [ADEs] ranged from 0.28 to 0.48, all p<0.001). All messages led to greater attention to the price tag (ADEs ranged from 0.24 to 0.41, all p<0.001) and greater consideration of the cost of sugary drinks (ADEs ranged from 0.31 to 0.50, all p<0.001). Icons elicited higher cost consideration than text-only price tags (ADE=0.15, p<0.010), but not discouragement (p=0.061) or attention (p=0.079). CONCLUSIONS: Messaging on price tags could make excise taxes more effective. Policymakers should consider requiring messaging on price tags when implementing taxes.

Toddler milk: a scoping review of research on consumption, perceptions, and marketing practices.

Toddler milk is an ultra-processed beverage consisting primarily of powdered milk, caloric sweeteners, and vegetable oil. Pediatric health authorities do not support the use of toddler milk, and emerging evidence suggests that toddler-milk marketing practices may mislead consumers. However, studies have not synthesized the extent of toddler-milk marketing practices or how these practices affect parents' decisions about whether to serve toddler milk. We aimed to summarize the literature about toddler milk to identify what is known about: (1) parents' toddler-milk purchasing and feeding behaviors, (2) toddler-milk marketing, and (3) how marketing practices influence parents' beliefs and perceptions about toddler milk. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), we systematically searched 8 databases (PubMed, APA PsycINFO, Scopus, Cochrane Central, Embase, CINAHL, Communication & Mass Media Complete, and Business Source Premier). We identified 45 articles about toddler milk. Studies were conducted in 25 countries across 6 continents. Five types of findings emerged: (1) consumption and feeding behaviors, (2) demographic correlates of toddler-milk purchasing and consumption, (3) misperceptions and beliefs, (4) increased sales, and (5) increased marketing and responses to marketing. The included articles suggested that toddler-milk sales are growing rapidly worldwide. Findings also revealed that toddler-milk packages (eg, labels, branding) resemble infant formula packages and that toddler-milk marketing practices may indirectly advertise infant formula. Purchasing, serving, and consumption of toddler milk were higher in Black and Hispanic populations than in non-Hispanic White populations, and parents with higher educational attainment and income were more likely to offer toddler milk to their children. Findings suggest a need for policies to prevent cross-marketing of toddler milk and infant formula, reduce provision of toddler milk to infants and toddlers, and prevent caregivers from being misled about toddler-milk healthfulness.

Impact of taxes and warning labels on red meat purchases among US consumers: A randomized controlled trial.

BACKGROUND: Policies to reduce red meat intake are important for mitigating climate change and improving public health. We tested the impact of taxes and warning labels on red meat purchases in the United States. The main study question was, will taxes and warning labels reduce red meat purchases? METHODS AND FINDINGS: We recruited 3,518 US adults to participate in a shopping task in a naturalistic online grocery store from October 18, 2021 to October 28, 2021. Participants were randomized to one of 4 conditions: control (no tax or warning labels, n = 887), warning labels (health and environmental warning labels appeared next to products containing red meat, n = 891), tax (products containing red meat were subject to a 30% price increase, n = 874), or combined warning labels + tax (n = 866). We used fractional probit and Poisson regression models to assess the co-primary outcomes, percent, and count of red meat purchases, and linear regression to assess the secondary outcomes of nutrients purchased. Most participants identified as women, consumed red meat 2 or more times per week, and reported doing all of their household's grocery shopping. The warning, tax, and combined conditions led to lower percent of red meat-containing items purchased, with 39% (95% confidence interval (CI) [38%, 40%]) of control participants' purchases containing red meat, compared to 36% (95% CI [35%, 37%], p = 0.001) of warning participants, 34% (95% CI [33%, 35%], p < 0.001) of tax participants, and 31% (95% CI [30%, 32%], p < 0.001) of combined participants. A similar pattern was observed for count of red meat items. Compared to the control, the combined condition reduced calories purchased (-312.0 kcals, 95% CI [-590.3 kcals, -33.6 kcals], p = 0.027), while the tax (-10.4 g, 95% CI [-18.2 g, -2.5 g], p = 0.01) and combined (-12.8 g, 95% CI [-20.7 g, -4.9 g], p = 0.001) conditions reduced saturated fat purchases; no condition affected sodium purchases. Warning labels decreased the perceived healthfulness and environmental sustainability of red meat, while taxes increased perceived cost. The main limitations were that the study differed in sociodemographic characteristics from the US population, and only about 30% to 40% of the US population shops for groceries online. CONCLUSIONS: Warning labels and taxes reduced red meat purchases in a naturalistic online grocery store. Trial Registration: http://www.clinicaltrials.gov/ NCT04716010.

Implementation costs of sugary drink policies in the United States.

To support implementation of important public health policies, policymakers need information about implementation costs over time and across stakeholder groups. We assessed implementation costs of two federal sugar-sweetened beverage (SSB) policies of current policy interest and with evidence to support their effects: excise taxes and health warning labels. Our analysis encompassed the entire policy life cycle using the Exploration, Preparation, Implementation, and Sustainment framework. We identified implementation actions using key informant interviews and developed quantitative estimates of implementation costs using published literature and government documents. Results show that implementation costs vary over time and among stakeholders. Explicitly integrating implementation science theory and using mixed methods improved the comprehensiveness of our results. Although this work is specific to federal SSB policies, the process can inform how we understand the costs of many public health policies, providing crucial information for public health policy making.

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

Introduction: New warning labels for alcohol could reduce alcohol-related health harms. This study examined consumer responses to alcohol warnings with different designs. Methods: A national sample of 3,051 U.S. adults completed an online survey in August 2021. Participants were randomized to 1 of 4 warning topics (addiction, liver damage, early death, or colon cancer). Participants viewed 3 labels, presented in random order: 2 types of warning labels (text-only and icon) showing a newly developed warning message about their assigned topic and a text-only control label showing a neutral message. Participants rated each label on effectiveness at discouraging alcohol consumption (primary outcome) and attention (secondary outcome) using 1 to 5 Likert-type scales. Participants also rated warnings with different causal language variants (e.g., "increases risk of," "contributes to") and marker words (e.g., "WARNING," "SURGEON GENERAL WARNING"). Results: Both the text-only and icon warnings were perceived as more effective (Average Differential Effects [ADEs]=0.79 and 0.86, respectively) and more attention-grabbing (ADEs=0.43 and 0.69, respectively) than control labels (all ps<0.001). The icon warnings were rated as more effective and attention-grabbing than the text-only warnings (ADEs=0.07 and 0.27, respectively, both ps<0.001). Although all warning topics outperformed the control messages, warnings about addiction were rated as less effective and attention-grabbing than the other topics. A majority (60%) of participants selected "increases risk of" as the most discouraging causal variant and a plurality (47%) selected "SURGEON GENERAL WARNING" as the most discouraging marker word. Conclusions: New alcohol warnings could discourage alcohol consumption, especially if warnings include icons.

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

INTRODUCTION: Natural claims on food are largely unregulated in the U.S. This study examined the effects of natural claims on a fruit-flavored drink with added sugar (i.e., fruit drink). METHODS: In 2019, U.S. parents of children aged 2-12 years (N=1,078) recruited from an online survey panel were randomized to one of three arms: natural claim on a fruit drink, 100% all-natural claim, or a no-claim control. Parents reported their intentions and perceptions regarding fruit drinks using 1-5 response scales. Analysis occurred in 2022-2023. RESULTS: Both natural claims led parents to have higher intentions to purchase a fruit drink for their child than the control (average differential effect=0.20-0.24, both p<0.05). The natural claim (but not the 100% all-natural claim) also led parents to think that the fruit drink was healthier for their children (average differential effect=0.22, p=0.024). Claims made parents less likely to think that the drink contained added sugar (average differential effect= -0.08 to -0.12, both p<0.05) and led to lower estimated amounts of added sugar in teaspoons (average differential effect= -1.77 to -2.09, both p<0.05). Mediation analyses revealed that the claims led to higher intentions to purchase the fruit drink by increasing perceived healthfulness of the fruit drink and by leading parents to believe that there was no added sugar in the fruit drink. CONCLUSIONS: Natural claims could increase interest in and perceived healthfulness of fruit drinks. Misperceptions about the nutritional content caused by claims appear to be driving greater purchase intentions. These findings suggest a need for stronger regulation around natural claims to prevent consumer misunderstanding.