Policies that require front-of-package (FoP) nutrient warnings are becoming increasingly common across the globe as a strategy to discourage excess consumption of sugary drinks and ultra-processed food. However, a better understanding of the pathway through which FoP nutrient warnings work, as well as a review of how outcomes being measured in recent studies map onto this pathway, are needed in order to inform policy on the most effective FoP label design for reducing purchases of ultra-processed foods. This scoping review describes a conceptual model for how FoP nutrient warnings affect consumer behavior, examines which of these outcomes are currently being measured, and summarizes evidence from randomized controlled experiments. Twenty-two studies which experimentally tested nutrient warnings against a control label or other labeling systems were included for full-text review. Our conceptual model includes attention; comprehension, cognitive elaboration, and message acceptance; negative affect and risk perception; behavioral intentions, and behavioral response, along with other elements such as external factors and interpersonal communications. We found that many studies focused on outcomes such as attention, comprehension, and behavioral intentions, but considerable gaps in the evidence remain, particularly for intermediary steps on the pathway to behavioral change, such as negative affect and social interactions. FoP nutrient warnings were visually attended to by consumers, easy to understand, helped consumers identify products high in nutrients of concern, and discouraged them from purchasing these products, although other labeling systems were perceived as containing more information and performed better at helping consumers rank the healthfulness of products. More research is needed to understand whether and how nutrient warnings work in the real world to discourage consumer purchases of sugary drinks and ultra-processed food.

Background: In South Africa, the increased consumption of sugary drinks has been associated with increased obesity rates. Mass media campaigns can play a crucial role in improving knowledge, shifting attitudes, and building support for government action on reducing sugary drink consumption. No study to date has evaluated the effectiveness of mass media campaigns on the health harms of sugary drinks in South Africa. Objective: The purpose of this study was to evaluate the impact of a mass media campaign on knowledge and attitudes around sugary drinks and on public support for a proposed tax on sugary drinks in South Africa. Methods: The “Are You Drinking Yourself Sick?” campaign aired in South Africa from October 2016 to June 2017 to shift attitudes toward sugary drinks, build personal risk perceptions of the health harms of consuming sugary drinks, and build public support for a proposed tax on sugary drinks. Campaign impact was measured in representative cross-sectional household surveys of adults ages 18 to 56. The surveys were conducted just prior to the launch of the campaign (N = 1000), from October 7 to 10, 2016, and immediately following its conclusion (N = 1000), from July 12 to 21, 2017. Campaign impact was assessed by comparing changes from the pre-campaign to the post-campaign period on key outcome indicators. In addition, the effect of campaign awareness was analyzed in logistic regression analysis of the post-campaign data. Results: The campaign was recalled by 55% of survey respondents, and 78% of campaign-aware respondents said that the campaign’s main message was “drinking sugary drinks can make you sick.” There were significant changes from the pre- to the post-campaign period in knowledge that sugary drink consumption can lead to obesity and related health problems and that sugary drinks contribute toward the obesity problem in South Africa. Campaign awareness was also significantly associated with increases in knowledge about the harms of sugary drinks, and in particular, on government action, including the proposed tax on sugary drinks. Discussion: Media campaigns are an effective intervention for obesity prevention. In addition to improving knowledge and shifting attitudes, media campaigns can effectively build public support for strong government action and therefore must be a component of a comprehensive obesity prevention approach.

Policies to require warnings on the front of food and drinks high in nutrients of concern (e.g., added sugar, sodium, or saturated fat) are becoming increasingly common as an obesity prevention strategy. Colombia, a country with growing prevalence of obesity, is considering implementing a similar policy. The objective of this study was to assess perceptions and reactions to different warning designs. We conducted a randomized experiment in an online panel of adults age > 18y (n = 1997). Participants were randomized to view one of four labels: a control label (barcode), an octagon warning, a circle warning, and a triangle warning. Participants viewed their randomly assigned label on a series of products and answered questions (continuous outcomes ranged from 1–4). Compared to the control, all warnings led to higher perceived message effectiveness (increase in mean from 1.79 in the control to 2.59–2.65 in the warning conditions, p < 0.001), a higher percentage of participants who correctly identified products high in nutrients of concern (from 48% in the control condition to 84–89% in the warning conditions, p < 0.001), and reduced intentions to purchases these products (decrease in mean from 2.59 to 1.99–2.01 in the warning conditions, p < 0.001). Relative to the control, warnings performed similarly across education levels, suggesting this policy would be equitable in Colombia. Looking at differences by warning type, the pattern of results suggested that the octagon warnings performed best. After viewing all label types, 49% of participants selected the octagon warning as the one that most discouraged them from consuming products high in nutrients of concern, while 21% and 27% selected the circle and triangle warning. Colombian policymakers should consider the octagon warning as part of a front-of-package labeling policy to help consumers identify and reduce consumption of foods and drinks high in nutrients of concern.

Policies to require front-of-package labels (FOPLs) on packaged foods may help Indian consumers to better identify foods high in nutrients of concern, including sugar, saturated fat, and sodium, and discourage their consumption, which are outcomes that are critical for preventing rises in diet-related non-communicable disease. The objective was to test whether FOPLs helped Indian consumers identify “high-in” packaged foods and reduce intentions to purchase them. We conducted an in-person randomized experiment (n = 2869 adults between ages 18 and 60 years old) in six states of India in 2022. Participants were randomized to one of five FOPLs: a control label (barcode), warning label (octagon with “High in [nutrient]”), Health Star Rating (HSR), Guideline Daily Amount (GDA), or traffic light label. Participants then viewed a series of packaged foods high in sugar, saturated fat, or sodium with the assigned FOPL, and rated product perceptions and label reactions. Fewer than half of participants in the control group (39.1%) correctly identified all products high in nutrient(s) of concern. All FOPLs led to an increase in this outcome, with the biggest differences observed for the warning label (60.8%, p < 0.001), followed by the traffic light label (54.8%, p < 0.001), GDA (55.0%, p < 0.001), and HSR (45.0%, p < 0.01). While no FOPLs led to a reduction in intentions to purchase the packaged foods, the overall pattern of results suggested that warning labels are the most effective FOPL to help Indian consumers identify unhealthy foods.

Background: The use of e-cigarettes is proliferating globally, especially among youth and even children. Marketing is a known risk factor for e-cigarette initiation, yet little is known of e-cigarette marketing on social media in low- and middle-income countries. This study compares e-cigarette social media marketing in India, Indonesia, and Mexico, three such countries with different regulatory environments.Methods: Instances of e-cigarette marketing on social media platforms were identified via the Tobacco Enforcement and Reporting Movement (TERM), a digital tobacco marketing monitoring system. Through systematic keyword-based searches, all tobacco marketing posts observed between 15 December 2021 and 16 March 2022 were included in the analysis. The final sample included 1,437 e-cigarette-related posts on Instagram, Facebook, Twitter, YouTube, and TikTok, which were systematically content analyzed by independent coders after inter-reliability (Cohen's Kappa K > 0.79) was established using a theory-derived codebook. The final data is represented in percentages and frequencies for ease of presentation.Results: We observed e-cigarette marketing online in all countries studied, yet there was variation in the volume of marketing and types of accounts identified. In India, where e-cigarettes were comprehensively banned, we identified 90 (6%) posts; in Mexico, where e-cigarettes were partially restricted, 318 (22%) posts were observed; and in Indonesia, where there were no restrictions, 1,029 (72%) posts were observed. In both India and Mexico, marketing originated from retailer accounts (100%), whereas in Indonesia, it was primarily product brand accounts (86%). Across countries, e-cigarettes were mostly marketed directly to sell products (India: 99%, Indonesia: 69% and Mexico: 93%), though the sales channels varied. Product features, including e-liquid flavors, device colors and technical specifications, was the most prominent message framing (India: 86%; Mexico: 73%; Indonesia: 58%). Harm reduction messaging was most popular in Mexico (8%) and was not common in Indonesia (0.3%) or India (0%).Conclusion: Our study provides important insights for tobacco control stakeholders on the evolving nature of e-cigarette marketing in low- and middle-income countries. It underscores the presence of e-cigarette marketing, including in countries where comprehensive regulations exist, and suggests the importance of continuous monitoring to keep up with industry practices and strengthen tobacco control stakeholder efforts to counter them.

This study aimed to evaluate the effect of different labels on participants identifying products high in nutrients of concern; identifying unhealthy products, and intention to purchase unhealthy products. This blinded randomised controlled trial included a representative sample of South African households (n = 1951). Per household we selected a member primarily responsible for food purchases. Participants were randomised into the Warning Label (WL), Guideline Dietary Amounts (GDA) or Multiple Traffic Light (MTL) arms. Each participant answered questions in a no label condition (control) followed by same questions in the label condition (experiment). Complete data were collected and analysed for 1948 participants (WL = 33.7%, GDA = 32.1% and MTL = 34.2%). The probability of correctly identifying products high in nutrients of concern and identifying products as being unhealthy was higher with the WL compared to the GDA or MTL for most items. There was no difference in performance between the GDA and the MTL when considering all items together. A higher percentage of participants reported a lower intention to purchase an unhealthy product after exposure to the WL compared to MTL for 5 out of 6 products; 2 out of 6 products for the WL compared to GDA and 2 out of 6 products for GDA compared to MTL. Compared to the control condition, exposure to each of the labels resulted in better identification of nutrients of concern, unhealthy products and a lower intention to purchase when considering all specific outcome items together. The WL showed a higher potential to enable South African consumers to identify products high in nutrients of concern, identify unhealthy products and discourage purchasing of unhealthy products.