Philadelphia Beverage Tax's Impact on Beverage Ad Expenditures and Number of Ads Purchased.

INTRODUCTION: On January 1, 2017, Philadelphia implemented a beverage excise tax. The study's objective was to determine whether beverage advertising expenditures and the number of beverage ads purchased changed in Philadelphia compared to Baltimore because of this tax. METHODS: Monthly beverage ad expenditures and the number of beverage ads purchased by brand from January 2016 through December 2019 were obtained. Ads were coded as being for taxed or not taxed beverages and analyzed in 2023. The primary outcomes were quarterly taxed beverage ad expenditures and number of ads purchased. A controlled interrupted time series design on segmented linear regression models was used. Models (aggregated and stratified by internet, spot TV, and local radio) compared whether levels and trends in the outcomes changed from pre- to post-tax in Philadelphia compared to Baltimore. RESULTS: There were no significant differences in taxed beverage advertising expenditures between Philadelphia and Baltimore for trends pretax, at implementation, or post-tax. There were 0.13 (95% CI: -0.25, -0.003) fewer quarterly taxed beverage ads purchased per 100 households in Philadelphia versus Baltimore at baseline. Among internet advertising, there were 0.42 (95% CI: -0.77, -0.06) fewer quarterly taxed beverage ads purchased per 100 households in Philadelphia versus Baltimore immediately post-tax. For spot TV ads, the percentage of taxed beverages ads purchased per quarter was greater at baseline in Philadelphia by 28.0 percentage points (95% CI: 1.9, 54.1). CONCLUSIONS: This study found little evidence of changes in mass media advertising on the examined platforms between 2016 and 2019 due to the Philadelphia beverage tax.

Impact of the Philadelphia Beverage Tax on Perceived Beverage Healthfulness, Tax Awareness, and Tax Opinions.

OBJECTIVE: To assess the impact of the Philadelphia Beverage Tax on perceived beverage healthfulness, and awareness and opinions of the tax. DESIGN: Natural experiment SETTING: Small independent stores in Philadelphia (n = 61) and Baltimore (untaxed control site; n = 65) PARTICIPANTS: Shoppers in Philadelphia (n = 2,731) and Baltimore (n = 4,600) pre- and post-tax implementation. MAIN OUTCOME MEASURES: Perceptions of 4 beverages (unhealthy vs healthy/neutral), tax awareness, and tax opinions (oppose vs favor/neutral). ANALYSIS: Mixed-effects linear probability models estimated changes in perceived beverage healthfulness in Philadelphia, relative to Baltimore, following a difference-in-differences approach. Mixed-effects linear probability models estimated pre-post changes in tax awareness and opinions in Philadelphia-only. RESULTS: The probability of perceiving taxed beverages as unhealthy increased 2-years post-tax relative to Baltimore (regular soda: 5.7% [95% confidence interval (CI), 0.9-10.6], P = 0.02; diet soda: 7.7% [95% CI, 1.5-13.8], P < 0.001; sports drinks: 6.4% [95% CI, 0.4-12.4], P = 0.04), with similar changes at 1-year post-tax, whereas perceived healthfulness of untaxed 100% fruit juice did not change. Tax awareness was high at baseline (72%) and increased post-implementation; however, the probability of opposing the tax (22%) also increased over time. CONCLUSIONS AND IMPLICATIONS: Decreases in the perceived healthfulness of taxed beverages suggest the tax had a health-signaling effect. Consumer awareness and health education efforts could complement tax policies to enhance understanding of health risks.

Advertising and Stocking at Small Retailers: A Sweetened Beverage Excise Tax in Philadelphia.

INTRODUCTION: In 2017, Philadelphia enacted a $0.015 per ounce excise tax on SBs that covered both sugar-sweetened beverages and artificially-sweetened beverages, which reduced purchasing and consumption. This study assessed whether the tax also changed beverage advertising or stocking practices that could influence consumer behavior among stores in Philadelphia, Baltimore, and Philadelphia-adjacent counties not subject to the tax. METHODS: Using a longitudinal difference-in-differences approach, beverage advertising and availability changes were evaluated from 4-month pretax to 6-, 12-, and 24-month post-implementation in small independent stores in Philadelphia (n=34) and Philadelphia-adjacent counties (n=38) versus Baltimore (n=43), a demographically similar city without a tax. Mixed effects models tested whether beverage advertising/availability increased in Philadelphia and surrounding counties after implementation versus Baltimore, included store-level random intercepts, and were stratified by beverage tax status, type, size, and store ZIP code income. Data were collected from 2016 to 2018, and analyses were performed in 2022-2023. RESULTS: SB advertising increased post-tax in Philadelphia (6 months= +1.04 advertisements/store [95% CI=0.27, 1.80]; 12 months= +1.54 [95% CI=0.57, 2.52]; 24 months= +0.91 [95% CI=0.09, 1.72]) relative to Baltimore. This was driven by increased advertising of sweetened beverages in low-income ZIP codes. Marketing of SBs increased significantly in Philadelphia-adjacent counties relative to Baltimore. Although SB availability in Philadelphia did not change, it increased in surrounding county stores (6 months= +0.20 [95% CI=0.15, 0.25]; 12 months= +0.08 [95% CI=0.03, 0.12]) relative to Baltimore. CONCLUSIONS: Marketing of SBs, especially in low-income neighborhoods and in surrounding counties, increased following Philadelphia's beverage tax among small, independent retailers. These increases in advertising might have dampened the tax's effect on purchasing behaviors, although estimated effects on sales remained large.

Effects of 4 Interpretive Front-of-Package Labeling Systems on Hypothetical Beverage and Snack Selections: A Randomized Clinical Trial.

Importance: Policymakers and researchers have proposed a variety of interpretative front-of-package food labeling systems, but it remains unclear which is most effective at encouraging people to choose healthier foods and beverages, including among people with less education. Objective: To test the effects of 4 interpretative front-of-package food labeling systems on the healthfulness of beverage and snack selections, overall and by education level. Design, Setting, and Participants: This randomized clinical trial of a national sample of US adults 18 years and older was conducted online from November 16 to December 3, 2022. Intervention: Participants were randomized to view products with 1 of 5 food labeling systems, including control (calorie labels only) or 1 of 4 interpretative labeling systems: green ("choose often") labels added to healthy foods; single traffic light labels added to healthy, moderately healthy, and unhealthy foods; physical activity calorie equivalent labels added to all products; and nutrient warning labels added to products high in calories, sugar, saturated fat, or sodium. All conditions had calorie labels on all products. Main Outcomes and Measures: Participants selected 1 of 16 beverages and 1 of 16 snacks that they wanted to hypothetically purchase. The primary outcomes were calories selected from beverages and from snacks. Secondary outcomes included label reactions and perceptions. Results: A total of 7945 participants completed the experiment and were included in analyses (4078 [51%] female, 3779 [48%] male, and 88 [1%] nonbinary or another gender; mean [SD] age, 47.5 [17.9 years]). Compared with the control arm, exposure to the green (average differential effect [ADE], -34.2; 95% CI, -42.2 to -26.1), traffic light (ADE, -31.5; 95% CI, -39.5 to -23.4), physical activity (ADE, -39.0; 95% CI, -47.0 to -31.1), or nutrient warning labels (ADE, -28.2; 95% CI, -36.2 to -20.2) led participants to select fewer calories from beverages (all P < .001). Similarly, compared with the control label, exposure to the green (ADE, -12.7; 95% CI, -17.3 to -8.2), traffic light (ADE, -13.7; 95% CI, -18.2 to -9.1), physical activity (ADE, -18.5; 95% CI, -23.1 to -13.9), or nutrient warning labels (ADE, -14.2; 95% CI, -18.8 to -9.6) led participants to select fewer calories from snacks (all P < .001). These effects did not differ by education level. The green labels were rated as less stigmatizing than the other interpretative systems but otherwise generally received the least favorable label reactions and perceptions (eg, elicited less attention, were perceived as less trustworthy), while the nutrient warnings and physical activity labels received the most favorable ratings. Conclusions and Relevance: In this randomized clinical trial of front-of-package food labeling systems, all 4 interpretative labeling systems reduced calories selected from beverages and from snacks compared with calorie labels, with no differences by education level. Trial Registration: ClinicalTrials.gov Identifier: NCT05432271.

Philadelphia Beverage Tax and Association With Prices, Purchasing, and Individual-Level Substitution in a National Pharmacy Chain.

Importance: Taxes on sweetened beverages are being implemented around the globe; an understanding of these taxes on individual-level behavior is necessary. Objective: To evaluate the degree to which the sweetened beverage tax in Philadelphia, Pennsylvania, was associated with changes in beverage prices and individual-level purchasing over time at a national pharmacy chain in Philadelphia compared with Baltimore, Maryland. Design, Setting, and Participants: Using a difference-in-differences approach and generalized linear mixed models, this cohort study examined beverage purchases made by loyalty cardholders at a national chain pharmacy retailer with stores in Philadelphia and Baltimore (control city) from before tax to after tax. Beverage sales (in US dollars) were linked by unique loyalty card numbers to enable longitudinal analyses. Data were collected from January 1, 2015, through December 31, 2017 (2 years before tax and 1 year after tax); data analyses were conducted from January through October 2022. Exposure: Implementation of Philadelphia's 1.5 cents/oz tax on sweetened beverages. Main Outcomes and Measures: The outcomes were the change in mean beverage price per-ounce and mean beverage volume purchased per cardholder transaction. Individual-level point-of-sale scanner data from all beverage purchases were analyzed. Results: A total of 1188 unique beverages were purchased from the same stores before tax and after tax. There were 231 065 unique cardholders in Philadelphia and 82 517 in Baltimore. Mean prices of taxed beverages (n = 2 094 220) increased by 1.6 (95% CI, 1.3-2.0) cents/oz (106.7% pass-through) in Philadelphia compared with Baltimore from before tax to after tax. Philadelphia cardholders purchased 7.8% (95% CI -8.1% to -7.5%) fewer ounces of taxed beverages and 1.1% (95% CI, 0.6%-1.7%) more ounces of nontaxed beverages per transaction. Taxed beverages made up a smaller percentage of cardholders' overall beverage purchases after tax (-13.4% [95% CI, -14.2% to -12.6%]), while nontaxed beverages made up a larger share (9.3% [95% CI, 7.7%-10.7%]). Conclusions and Relevance: In this longitudinal cohort study of the Philadelphia beverage tax, the tax was completely passed through to prices and was associated with a 7.8% decline in ounces of taxed beverages purchased at a national pharmacy chain.

Developing Effective Strategies for Obesity Prevention.

Nutrition policies can work with clinical treatments to address the obesity epidemic. The United States has passed beverage taxes at the local level and calorie labeling mandates at the federal level to encourage healthier consumption. Nutritional changes to federal nutrition programs have been either implemented or suggested; evidence shows that the changes that have been implemented have resulted in improvements in diet quality and are cost-effective in decreasing the increase in obesity prevalence. A comprehensive policy agenda that addresses risk of obesity on multiple levels of the food supply will have meaningful long-term effects on obesity prevalence.

Naming Matters: Prompting Smaller Portions in an Online RCT.

INTRODUCTION: Large portions, which can lead people to eat more, are becoming increasingly common in U.S. restaurants. This study tested whether portion-size descriptions on menus and different pricing strategies influence the selection of smaller portion sizes. STUDY DESIGN: This was a 4 × 2 between-subjects online randomized controlled experiment. SETTING/PARTICIPANTS: This was an online simulated menu-ordering study conducted in 2021 among 2,205 U.S. adults. INTERVENTION: Adults viewed a fast-casual and full-service menu with entrées available in 2 sizes and ordered an entrée from each. Participants were randomized to view 1 of 4 portion-size descriptors (smaller/larger portion): (1) no descriptor/large (control), (2) standard/large, (3) just right/large, and (4) no descriptor/hearty. Participants were also randomized to either linear (i.e., reduced price=50% larger portion's price) or nonlinear pricing (i.e., reduced price=70% larger portion's price) (4 × 2 factorial design). MAIN OUTCOME MEASURES: In 2022, logistic regression models were used to analyze whether the interventions increased the likelihood of choosing a reduced portion. RESULTS: Regardless of pricing scheme, participants in the standard/large condition selected reduced portions by 10 (95% CI=0.04, 0.16) and 13 (95% CI=0.07, 0.18) percentage points more than those in the control condition (fast-casual and full-service menus, respectively). Selection of reduced portions in the just right/large condition increased by 9 (95% CI=0.04, 0.15) and 8 (95% CI=0.02, 0.14) percentage points. For the fast-casual menu, keeping portion-size descriptors constant, participants ordered a reduced portion by 5 percentage points more with nonlinear pricing than with linear pricing. CONCLUSIONS: Portion-size descriptions on restaurant menus, even with nonlinear pricing, are a low-cost strategy to promote the selection of lower-calorie, smaller portions without restricting choice.

A Descriptive Analysis of Redemption Patterns by Vendor Type Among: WIC Participants in Massachusetts.

BACKGROUND: The retail environment is an important determinant of food package redemption in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). OBJECTIVE: The objectives of this study were to describe where Massachusetts WIC households redeemed their food benefits each month and monthly variations in benefit redemption depending on a household's most frequently used vendor type each month. DESIGN: These were cross-sectional and longitudinal analyses of administrative data provided by Massachusetts WIC. PARTICIPANTS/SETTING: Monthly redemption data for 209,973 households shopping at approximately 1,000 unique vendors between January 2015 and August 2019 were analyzed. MAIN OUTCOME MEASURES: Outcomes were mean monthly percentage of households that relied on each vendor type when redeeming benefits and mean monthly percent redemption for each benefit category. STATISTICAL ANALYSES PERFORMED: For each month, households were classified as using 1 of 8 vendor types. The monthly percentage of households redeeming at each vendor type was calculated, as well as the monthly percent redemption for each benefit category by vendor type. The averages of these monthly percentages were computed for 2015 and 2019. Data from months when households did not redeem any benefits were excluded from primary analyses because it was not possible to determine their vendor type for that month. RESULTS: On average across months in 2019, the majority of Massachusetts WIC households (63%) relied on large vendors only (ie, superstores, supermarkets, and large grocery stores) when redeeming benefits, and 5% relied on small grocery or convenience stores only. Between 2015 and 2019, mean monthly reliance on small grocery and convenience stores decreased by 3.1 and 0.7 percentage points, respectively. Compared with other vendor types, households that redeemed benefits at superstores only had, in an average month, lower redemption levels for most benefit categories. For example, in the 2019 mean across months, percent redemption of breakfast cereal was 53% among households redeeming at superstores only compared with 74% for those redeeming at small grocery stores only. By contrast, households that relied on small grocery stores only had, in an average month, lower redemption levels for yogurt and cash value benefit compared with other vendor types; for example, in the 2019 mean across months, percent redemption of yogurt was 34% among households redeeming at small grocery stores only compared with 62% among those redeeming at supermarkets only. CONCLUSIONS: Results suggest that retail-based efforts to increase redemption should consider vendor-type reliance. Strategies to increase redemption may be especially important for WIC shoppers relying on superstores.

Child-Directed Marketing, Health Claims, and Nutrients in Popular Beverages.

INTRODUCTION: Fruit drinks are a major source of added sugar in children's diets. This study describes the associations between front-of-package child-directed marketing (i.e., sports, fantasy, or child-directed imagery; child-directed text) and (1) health-related claims and (2) nutrient content of fruit drinks, 100% juices, and flavored waters. METHODS: Beverage purchase data from a national sample of 1,048 households with children aged 0-5 years were linked with front-of-package label and nutrition data to conduct a content analysis on fruit drinks (n=510), 100% juices (n=337), and noncarbonated flavored waters (n=40) in 2019-2020. Unstratified and stratified regression models assessed the differences in the prevalence of claims (macronutrient, micronutrient, natural/healthy, and fruit and juice), non-nutritive sweeteners, and nutrient content (calories, total sugar, and percent daily value of vitamin C) between drinks with and those without child-directed marketing in 2021. RESULTS: Fruit drinks with child-directed marketing were more likely to show front-of-package micronutrient claims (OR=2.1, 95% CI=1.5, 3.1) and contained more vitamin C (18.5% daily value, 95% CI=1.6, 35.5) than fruit drinks without child-directed marketing. 100% juices with child-directed marketing contained less vitamin C (-35.6% daily value, 95% CI= -57.5, -13.8) and 3.0 (95% CI= -5.5, -0.4) fewer grams of sugar than 100% juices without child-directed marketing. Flavored waters with child-directed marketing contained less vitamin C (-37.9% daily value, 95% CI= -68.1, -7.6) than flavored waters without child-directed marketing. CONCLUSIONS: The combination of child-directed marketing with health-related claims may mislead parents into believing that fruit drinks are healthy and appealing to their children, highlighting the need for government regulation of sugary drink marketing.

Front-of-package claims & imagery on fruit-flavored drinks and exposure by household demographics.

Young children regularly consume sugary fruit drinks, in part because parents may falsely believe they are healthful due to front-of-package (FOP) claims and imagery. The goal of this study was to assess: 1) the prevalence of FOP claims/imagery on fruit-flavored beverages purchased by U.S. households with 0-5-year-olds, and 2) proportional differences in beverages purchased with FOP claims/imagery across household demographic groups. A content analysis of FOP claims/imagery (e.g., nutrient claims, fruit imagery) on beverages (n = 1365) purchased by households with 0-5-year-olds was conducted by linking beverage sales with FOP marketing data. Results were merged with purchasing data from a nationally representative sample of households (FoodAPS), and survey-weighted logistic regression was used to assess differences in the proportions of 100% juices and fruit drinks with specific FOP claims/imagery purchased by household race/ethnicity, income, and SNAP/WIC participation. The most common claims on fruit-flavored beverages included nutrient claims (fruit drinks: 73%; 100% juices: 68%; flavored waters: 95%), which most commonly highlighted vitamin C (35-41% across beverage categories) and the absence of sugar (31-48%). Most beverages also contained implied-natural claims (fruit drinks: 60%; 100% juices: 64%; flavored waters: 95%) and natural imagery (fruit drinks: 97%; 100% juices: 96%; flavored waters: 73%). A large proportion of fruit drinks and 100% juices purchased by households across all demographic groups contained FOP claims and imagery, with a few minor differences between racial/ethnic groups. In conclusion, most fruit drinks, 100% juices, and flavored waters purchased by households with 0-5-year-olds contained FOP claims and imagery that may lead consumers to believe the beverages are healthy and natural. FDA regulations should ensure parents are not misled by this marketing.

Purchases of Nontaxed Foods, Beverages, and Alcohol in a Longitudinal Cohort After Implementation of the Philadelphia Beverage Tax.

BACKGROUND: Evidence suggests that sweetened beverage taxes reduce taxed beverage purchases, but few studies have used individual-level data to assess whether these taxes affect purchases of nontaxed foods, beverages, and alcohol. Additionally, research has not examined whether sweetened beverage taxes influence restaurant purchases. OBJECTIVES: We assessed changes in individuals' purchases of taxed beverage types; low-calorie/low-added-sugar nontaxed beverages; high-calorie/high-added-sugar nontaxed beverages, foods, and alcohol; and beverages from restaurants following implementation of the 1.5 cent-per-ounce Philadelphia sweetened beverage tax. METHODS: A longitudinal cohort of adult sugar-sweetened beverage consumers in Philadelphia (n = 306; 67% female; mean age: 43.9 years) and Baltimore (n = 297; comparison city without a beverage tax; 58% female; mean age: 41.7 years) submitted all food and beverage receipts during 2-week periods at baseline and at 3, 6, and 12 months posttax. Difference-in-differences analyses compared changes in purchases from pre- to posttax in Philadelphia to changes in Baltimore. RESULTS: Purchases of taxed juice drinks [ratio of incidence rate ratios (RIRR) = 0.62; 95% CI, 0.42-0.91], but not other taxed beverage types, decreased in Philadelphia compared to Baltimore following the tax. Analyses did not find changes in purchases of low-calorie/low-added-sugar nontaxed beverages, such as water or milk. Additionally, analyses did not find increases in purchases of most high-calorie/high-added-sugar nontaxed products, including alcohol, juice, candy, sweet snacks, salty snacks, and desserts. Purchases of beverage concentrates increased in Philadelphia (RIRR = 2.22; 95% CI, 1.39-3.54). CONCLUSIONS: In this difference-in-differences analysis, the Philadelphia beverage tax was associated with reduced purchases of taxed juice drinks. Purchases of beverage concentrates increased after the tax, but no increases were observed for other high-calorie/high-added-sugar nontaxed foods, beverages, or alcohol.

A qualitative study on retailer experiences with Philadelphia's sweetened beverage tax.

The Philadelphia Beverage Tax was implemented on January 1, 2017 for some sugar- and artificially-sweetened beverages. Few qualitative studies have assessed retailers' reactions to beverage taxes. We aimed to understand food retailers' knowledge and attitudes about the Philadelphia beverage tax and how they responded to it with the goal of informing the framing and implementation of beverage taxes in other interested jurisdictions. Researchers conducted semi-structured interviews with retailers within Philadelphia before (n = 15) and after (n = 11) the Philadelphia Beverage Tax was implemented. Purposeful sampling was used to recruit participants with different store locations and customer base characteristics. A priori codes based on the interview guide were used to organize data, and analytic memos were developed and reviewed to identify themes that emerged within the data using a grounded theory approach. Five themes emerged: (a) concerns about the tax purpose, amount, and use of revenue; (b) concerns about the tax's impact on finances and business operations; (c) business strategies implemented to lessen financial burden of the tax; (d) perceptions of customer responses to the tax based on income; and (e) confusion around tax implementation. Results highlighted ways to improve implementation. Retailers in Philadelphia implemented various strategies to offset negative effects on taxed beverage sales. Cities implementing a beverage tax would benefit from investment in educational outreach and support to business owners prior to tax implementation and ensure transparency in how tax revenue will be spent.

Prior research has shown that while retailers worry about the impact a beverage tax would have on sales, many pass the tax onto consumers as a strategy to mitigate loss. This paper uncovers additional retailer concerns that can inform the framing and implementation of beverage taxes in other interested jurisdictions. Retailers especially desired transparency in governmental tax revenue spending. Increased investment in educational outreach to retailers about the tax may help address misconceptions and improve implementation.

A content analysis of marketing on the packages of dietary supplements for weight loss and muscle building.

Most dietary supplements for weight loss and muscle growth lack scientific evidence in support of product claims and contain ingredients that can be harmful to health. Many people, however, still use these products. This paper aims to address a gap in the knowledge of the number and types of marketing claims appearing on dietary supplements for weight loss and muscle building and how they relate to the presence of an FDA disclaimer. We identified all products (n = 110) found in the weight loss and muscle building section of three stores (a pharmacy, supermarket, and superstore) in the Boston, MA area during 2013. We performed a content analysis to assess the presence of marketing claims displayed on product packaging, including claims about weight loss, safety, quality, and scientific evidence. Warnings and the FDA disclaimer were also coded. We found that, on average, products displayed 6.5 claims. Among weight loss- and muscle building- related claims, claims about reducing weight, BMI, or body fat were most common (60.9%), followed by protein claims (40.0%). Nearly half of the products made claims that scientific research supported product use. Products with the FDA disclaimer (53.6%) or a warning for vulnerable populations (56.4%) had a higher average number of claims compared to products without the disclaimer or warning (p < 0.001). Dietary supplements for weight loss and muscle building displayed many marketing claims promising weight loss despite a lack of scientific evidence that such products can be used safely and effectively. Greater FDA regulation of these marketing claims are needed.

Association of a Sweetened Beverage Tax With Purchases of Beverages and High-Sugar Foods at Independent Stores in Philadelphia.

Importance: The relationship between a sweetened beverage tax and changes in the prices and purchases of beverages and high-sugar food is understudied in the long term and in small independent food retail stores where sugar-sweetened beverages are among the most commonly purchased items. Objective: To examine whether a 1.5 cent-per-fluid-ounce excise tax on sugar- and artificially sweetened beverages Philadelphia, Pennsylvania, was associated with sustained changes in beverage prices and purchases, as well as calories purchased from beverages and high-sugar foods, over 2 years at small independent stores. Design, Setting, and Participants: This cross-sectional study used a difference-in-differences approach to compare changes in beverage prices and purchases of beverages and high-sugar foods (candy, sweet snacks) at independent stores in Philadelphia and Baltimore, Maryland (a nontaxed control) before and 2 years after tax implementation, which occurred on January 1, 2017. Price comparisons were also made to independent stores in Philadelphia's neighboring counties. Main Outcomes and Measures: Changes in mean price (measured in cents per fluid ounce) of taxed and nontaxed beverages, mean fluid ounces purchased of taxed and nontaxed beverages, and mean total calories purchased from beverages and high-sugar foods. Results: Compared with Baltimore independent stores, taxed beverage prices in Philadelphia increased 2.06 cents per fluid ounce (95% CI, 1.75 to 2.38 cents per fluid ounce; P < .001), with 137% of the tax passed through to prices 2 years after tax implementation, while nontaxed beverage prices had no statistically significant change. A total of 116 independent stores and 4738 customer purchases (1950 [41.2%] women; 4351 [91.8%] age 18 years or older; 1006 [21.2%] White customers, 3185 [67.2%] Black customers) at independent stores were assessed for price and purchase comparisons. Purchases of taxed beverages declined by 6.1 fl oz (95% CI, -9.9 to -2.4 fl oz; P < .001), corresponding to a 42% decline in Philadelphia compared with Baltimore; there were no significant changes in purchases of nontaxed beverages. Although there was no significant moderation by neighborhood income or customer education level, exploratory stratified analyses revealed that declines in taxed beverage purchases were larger among customers shopping in low-income neighborhoods (-7.1 fl oz; 95% CI, -13.0 to -1.1 fl oz; P = .001) and individuals with lower education levels (-6.9 fl oz; 95% CI, -12.5 to -1.3 fl oz; P = .001). Conclusions and Relevance: This cross-sectional study found that a tax on sweetened beverages was associated with increases in price and decreases in purchasing. Beverage excise taxes may be an effective policy to sustainably decrease purchases of sweetened drinks and calories from sugar in independent stores, with large reductions in lower-income areas and among customers with lower levels of education.

Availability and Nutrient Composition of Vegetarian Items at US Fast-Food Restaurants.

BACKGROUND: Consumer demand for vegetarian options is growing. Fast-food restaurants have responded by adding high-profile vegetarian offerings, but little is known about the overall availability or nutrient profile of vegetarian options at these establishments, or how these items compare with nonvegetarian items. OBJECTIVE: The purpose of this study was to quantify trends in the availability and nutrient profile of vegetarian items in US fast-food restaurants from 2012 to 2018. DESIGN: This study was a longitudinal analysis of secondary data. We used nutrient data from the MenuStat database for menu offerings at 36 large US fast-food chain restaurants (2012 to 2018). Vegetarian items were identified through automated key word searches and item description hand-coding. OUTCOME MEASURES: Annual counts and proportions of vegetarian and nonvegetarian items by category, and annual trends and differences in predicted mean calories; saturated, unsaturated, and trans fats; sugar; nonsugar carbohydrates; protein; sodium between and within vegetarian and nonvegetarian items. STATISTICAL ANALYSIS PERFORMED: We report counts and proportions of vegetarian items by menu category, then use Tobit regression models to examine annual trends and differences in predicted mean nutrients between and within vegetarian and nonvegetarian items. Sensitivity analyses were calorie-adjusted. RESULTS: The annual proportion of vegetarian items remained consistent (approximately 20%), and counts increased (2012, n = 601; 2018, n = 713). Vegetarian items had significantly fewer calories (2018: -95 kcal) and, even after adjustment for calories, lower saturated fat (-1.6 g), unsaturated fat (-1.8 g), protein (-3.8 g), and sodium (-62 mg) annually (P < .05) compared with nonvegetarian items. Vegetarian items were significantly higher in sugar (2018: +2.0 g; P < .01) and nonsugar carbohydrates (2018: +9.7 g; P < .01), after calorie adjustment, compared with nonvegetarian items. CONCLUSIONS: Vegetarian items were generally lower in several overconsumed nutrients of public health concern (eg, sodium and saturated fat) than nonvegetarian items, but nutrient changes suggest surveillance remains important as vegetarian options increase in popularity.

Messages Promoting Healthy Kids' Meals: An Online RCT.

INTRODUCTION: Calorie labeling is now required on all large U.S. chain restaurant menus, but its influence on consumer behavior is mixed. This study examines whether different parent-targeted messages encourage parents to order lower-calorie meals for their children in a hypothetical online setting. METHODS: An online RCT was conducted with sociodemographically diverse primary caregivers of children aged 6-12 years (data collected and analyzed in 2017-2019). Participants (N=2,373) were randomized to see 1 of 4 messages: (1) nonfood control, (2) kids' meals are the right size for children, (3) doctors recommend a 600 kcal per meal limit for kids, or (4) 600 kcal per meal is a generally recommended limit for kids. Participants ordered hypothetical meals for their children and themselves and rated meal and message perceptions. RESULTS: There were no significant differences between conditions in calories ordered for children at either restaurant, although all 3 food message conditions ordered fewer calories for their children than the control (full service: 27-68 fewer kcal, fast food: 18-64 fewer kcal). The general 600 kcal/meal limit message consistently performed best across outcomes, encouraging parents to order the fewest calories for their children at both restaurants (5%-7% fewer) and significantly increasing their understanding of calorie recommendations for kids' meals. It also significantly reduced fast-food calories parents ordered for themselves compared with the control (-106 kcal, p=0.042). CONCLUSIONS: Although no statistically significant differences were detected, messages with specific calorie recommendations for kids led parents to order lower-calorie restaurant meals for their children, suggesting that additional real-world studies with larger sample sizes are warranted.

Prevalence and nutrient composition of menu offerings targeted to customers with dietary restrictions at US fast casual and full-service restaurants.

OBJECTIVE: To examine the prevalence and nutrient composition of menu offerings targeted to customers with dietary restrictions at US fast casual and full-service chain restaurants. DESIGN: We used 2018 data from MenuStat, a database of nutrient information for menu items at large US chain restaurants. Five alternative diets were examined: gluten-free, low-calorie, low-carbohydrate, low-fat and vegetarian. Diet offerings were identified by searching MenuStat item descriptions and reviewing online menus. For each diet, we reported counts and proportions. We used bootstrapped multilevel models to examine differences in predicted mean kilojoules, saturated fat, Na and sugars between diet and non-diet menu items. SETTING: Forty-five US fast casual and full-service chain restaurants in 2018 (including 6419 items in initial analytic sample across small plates, salads and main dishes). PARTICIPANTS: None. RESULTS: The most prevalent diets were gluten-free (n 631, 9·8 % of menu items), low-calorie (n 306, 4·8 %) and vegetarian (n 230, 3·6 %). Compared with non-diet counterparts, low-calorie main dishes had significantly lower levels of all nutrients examined and vegetarian main dishes had significantly lower levels of all nutrients except saturated fat. Gluten-free small plates had significantly fewer kilojoules, grams of saturated fat and milligrams of Na compared with non-diet small plates. CONCLUSIONS: A small proportion of fast casual and full-service restaurant menus are targeted towards customers with dietary restrictions. Compared with non-diet items, those classified as gluten-free, low-calorie or vegetarian generally have healthier nutrient profiles, but overall nutrient values are still too high for most menu items, regardless of dietary label.

A Qualitative Study of Parents With Children 6 to 12 Years Old: Use of Restaurant Calorie Labels to Inform the Development of a Messaging Campaign.

BACKGROUND: US law mandates that chain restaurants with 20 or more locations post calorie information on their menus to inform consumers and encourage healthy choices. Few qualitative studies have assessed how parents perceive and use this information when ordering for their children and what types of accompanying messages might increase use of calorie labels when ordering food. OBJECTIVE: We aimed to better understand parents' perceptions and use of calorie labeling and the types of messages that might increase use. DESIGN: We conducted 10 focus groups (n = 58) and 20 shop-along interviews (n = 20). Focus group participants discussed their hypothetical orders and restaurant experiences when dining with their children, and shop-along participants verbalized their decision processes while ordering at a restaurant. Both groups gave feedback on 4 public service messages aimed to increase healthier ordering for children. All interviews were voice-recorded and transcribed. PARTICIPANTS/SETTING: Participants were primary caregivers of at least 1 child between 6 and 12 years who reported having less than a college education at the time of screening and who commonly ate at chain restaurants. Focus groups were conducted in a conference room, and shop-alongs were conducted in quick-serve and full-service chain restaurants around Philadelphia between August 2016 and May 2017. ANALYSES: A modified grounded theory approach was used to extract themes from transcripts. RESULTS: Thematic analysis of transcripts revealed 5 key themes: (1) parents' use of calorie labels; (2) differences across restaurant settings; (3) nonjudgmental information; (4) financial value and enjoyment of food; and (5) message preferences. These themes suggested that nonjudgmental, fact-based messages that highlight financial value, feelings of fullness, and easy meal component swaps without giving up the treatlike aspect of eating out may be particularly helpful for consumers. CONCLUSIONS: These findings can inform current US Food and Drug Administration campaign efforts to support consumer use of calorie labels on menus.

One-year changes in sugar-sweetened beverage consumers' purchases following implementation of a beverage tax: a longitudinal quasi-experiment.

BACKGROUND: Few longitudinal studies examine the response to beverage taxes, especially among regular sugar-sweetened beverage (SSB) consumers. OBJECTIVE: This study aimed to examine changes in objectively measured beverage purchases associated with the Philadelphia beverage tax on sugar-sweetened and artificially sweetened beverages. METHODS: A longitudinal quasi-experiment was conducted with adult sugar-sweetened beverage (SSB) consumers in Philadelphia (n = 306) and Baltimore (n = 297; a nontaxed comparison city). From 2016 to 2017 participants submitted all food and beverage receipts during a 2-wk period at: baseline (pretax) and 3, 6, and 12 mo posttax (91.0% retention; data analyzed in 2019). Linear mixed effects models were used to assess the difference-in-differences in total purchased ounces (fl oz) of taxed beverages in a 2-wk period in Philadelphia compared with Baltimore. Secondary analyses: 1) excluded weeks that contained major holidays at baseline and 12 mo (42% of measured weeks at baseline and 12 mo) because policy implementation timing necessitated data collection during holidays when SSB demand may be more inelastic, and 2) aggregated posttax time points to address serial correlation and low power. RESULTS: There were no statistically significant changes in purchased ounces of taxed beverages in Philadelphia compared with Baltimore in the primary analysis. After excluding holiday purchasing, the tax was associated with statistically significant reductions of taxed beverage purchases at 3 and 6 mo (-157.1 ounces, 95% CI: -310.1, -4.1 and -175.1 ounces, 95% CI: -328.0, -22.3, respectively) but not 12 mo. Analyses aggregating all 6 wk of posttax time points showed statistically significant reductions (-203.7 ounces, 95% CI: -399.6, -7.8). CONCLUSIONS: A sweetened beverage tax was not associated with reduced taxed beverage purchases among SSB consumers 12 mo posttax in the full sample. Both secondary analyses excluding holiday purchasing or aggregating posttax time periods found reductions in taxed beverage purchases ranging from -4.9 to -12.5 ounces per day. Larger longitudinal studies are needed to further understand tax effects.

Health Promotion and Healthier Products Increase Vending Purchases: A Randomized Factorial Trial.

BACKGROUND: The current food environment has a high prevalence of nutrient-sparse foods and beverages, most starkly seen in vending machine offerings. There are currently few studies that explore different interventions that might lead to healthier vending machine purchases. OBJECTIVE: To examine how healthier product availability, price reductions, and/or promotional signs affect sales and revenue of snack and beverage vending machines. DESIGN: A 2×2×2 factorial randomized controlled trial was conducted. PARTICIPANTS/SETTING: Students, staff, and employees on a university campus. INTERVENTION: All co-located snack and beverage vending machines (n=56, 28 snack and 28 beverage) were randomized into one of eight conditions: availability of healthier products and/or 25% price reduction for healthier items and/or promotional signs on machines. Aggregate sales and revenue data for the 5-month study period (February to June 2015) were compared with data from the same months 1 year prior. Analyses were conducted July 2015. MAIN OUTCOME MEASURES: The change in units sold and revenue between February through June 2014 and 2015. STATISTICAL ANALYSES PERFORMED: Linear regression models (main effects and interaction effects) and t test analyses were performed. RESULTS: The interaction between healthier product guidelines and promotional signs in snack vending machines documented increased revenue (P<0.05). Beverage machines randomized to meet healthier product guidelines documented increased units sold (P<0.05) with no revenue change. Price reductions alone had no effect, nor were there any effects for the three-way interaction of the factors. Examining top-selling products for all vending machines combined, pre- to postintervention, we found an overall shift to healthier purchasing. CONCLUSIONS: When healthier vending snacks are available, promotional signs are also important to ensure consumers purchase those items in greater amounts. Mitigating potential loss in profits is essential for sustainability of a healthier food environment.