The health, cost and equity impacts of restrictions on the advertisement of high fat, salt and sugar products across the transport for London network: a health economic modelling study

BACKGROUND

Policies aimed at restricting the marketing of high fat, salt and sugar products have been proposed as one way of improving population diet and reducing obesity. In 2019, Transport for London implemented advertising restrictions on high fat, salt and sugar products. A controlled interrupted time-series analysis comparing London with a north of England control, suggested that the advertising restrictions had resulted in a reduction in household energy purchases. The aim of the study presented here was to estimate the health benefits, cost savings and equity impacts of the Transport for London policy using a health economic modelling approach, from an English National Health Service and personal social services perspective.

METHODS

A diabetes prevention microsimulation model was modified to incorporate the London population and Transport for London advertising intervention. Conversion of calorie to body mass index reduction was mediated through an approximation of a mathematical model estimating weight loss. Outcomes gathered included incremental obesity, long-term diabetes and cardiovascular disease events, quality-adjusted life years, healthcare costs saved and net monetary benefit. Slope index of inequality was calculated for proportion of people with obesity across socioeconomic groups to assess equity impacts.

RESULTS

The results show that the Transport for London policy was estimated to have resulted in 94,867 (4.8%) fewer individuals with obesity, and to reduce incidence of diabetes and cardiovascular disease by 2,857 and 1,915 cases respectively within three years post intervention. The policy would produce an estimated 16,394 additional quality-adjusted life-years and save £218 m in NHS and social care costs over the lifetime of the current population. Greater benefits (e.g. a 37% higher gain in quality-adjusted life-years) were expected to accrue to individuals from the most socioeconomically deprived groups compared to the least deprived.

CONCLUSIONS

This analysis suggests that there are considerable potential health and economic gains from restricting the advertisement of high fat, salt and sugar products. The population health and economic impacts of the Transport for London advertising restrictions are likely to have reduced health inequalities in London.

A scoping review of outdoor food marketing: exposure, power and impacts on eating behaviour and health

BACKGROUND

There is convincing evidence that unhealthy food marketing is extensive on television and in digital media, uses powerful persuasive techniques, and impacts dietary choices and consumption, particularly in children. It is less clear whether this is also the case for outdoor food marketing. This review (i) identifies common criteria used to define outdoor food marketing, (ii) summarises research methodologies used, (iii) identifies available evidence on the exposure, power (i.e. persuasive creative strategies within marketing) and impact of outdoor food marketing on behaviour and health and (iv) identifies knowledge gaps and directions for future research.

METHODS

A systematic search was conducted of Medline (Ovid), Scopus, Science Direct, Proquest, PsycINFO, CINAHL, PubMed, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and a number of grey literature sources. Titles and abstracts were screened by one researcher. Relevant full texts were independently checked by two researchers against eligibility criteria.

RESULTS

Fifty-three studies were conducted across twenty-one countries. The majority of studies (n = 39) were conducted in high-income countries. All measured the extent of exposure to outdoor food marketing, twelve also assessed power and three measured impact on behavioural or health outcomes. Criteria used to define outdoor food marketing and methodologies adopted were highly variable across studies. Almost a quarter of advertisements across all studies were for food (mean of 22.1%) and the majority of advertised foods were unhealthy (mean of 63%). The evidence on differences in exposure by SES is heterogenous, which makes it difficult to draw conclusions, however the research suggests that ethnic minority groups have a higher likelihood of exposure to food marketing outdoors. The most frequent persuasive creative strategies were premium offers and use of characters. There was limited evidence on the relationship between exposure to outdoor food marketing and eating behaviour or health outcomes.

CONCLUSIONS

This review highlights the extent of unhealthy outdoor food marketing globally and the powerful methods used within this marketing. There is a need for consistency in defining and measuring outdoor food marketing to enable comparison across time and place. Future research should attempt to measure direct impacts on behaviour and health.

Tobacco industry thwarts ad ban legislation in India in the 1990s: Lessons for meeting FCTC obligations under Articles 13 and 5.3

Bans on tobacco advertising are important for reducing tobacco-caused disease. Previously secret internal tobacco industry documents and organizational and newspaper websites related to tobacco control efforts in India during 1990s were analyzed. The Ministry of Health and Family Welfare, World Health Organization, Indian Council of Medical Research, and civil society played important roles in pushing for tobacco control legislation beginning in the 1980s. Guided by transnational tobacco companies, especially British American Tobacco, Philip Morris International, and RJ Reynolds, Indian cigarette companies formed the Tobacco Institute of India (TII). Following the industry's global strategy, TII proposed voluntary advertising codes, used diplomatic channels and high level political and judicial lobbying, and allied with other industry, sports and trade groups to delay legislation for ten years. TII argued for the social and economic importance of tobacco and that laws were unnecessary, unconstitutional, and would hurt the economy. These early global strategies were continuing in 2022 to delay and evade legislative efforts to ban tobacco advertising. Understanding these strategies can inform public health efforts to counter industry efforts to thwart the WHO Framework Convention on Tobacco Control in 2022 not only in India, where the Ministry of Health and Family Welfare has proposed strengthening India's tobacco control law, but globally.

Intention to purchase alternative tobacco products as a function of smoking status and responses to advertising, packaging, and sensory experiences

INTRODUCTION

Tobacco manufacturers design and marketed products with appealing sensory characteristics to drive product uptake and continued use. We assessed smokers' and non-smokers' cognitive, affective, and sensory responses to Camel Snus (CS) and Nicotine gum (NG) to gauge future intentions to use.

METHOD

In a single laboratory session, 348 participants (including current smokers and nonsmokers in Buffalo, NY and Boston, MA) were exposed to CS and NG products in counterbalanced order. Exposure involved a cumulative set of 3 steps in which participants i) viewed an advertisement; ii) viewed the packaging, and iii) touched and smelled the product, without actual use. Current daily and non-daily smokers were invited to undertake a fourth exposure step by sampling the product. Following product exposure, participants completed perception measures and reported future intentions to use either product at the end of the survey. After each exposure, participants' reported feelings of valence and arousal.

RESULTS

Smokers reported greater preference to try NG (63.8%) compared with CS (17.4%) or neither (18.8%), whereas majority of nonsmokers preferred neither product (64.3%) (p < 0.01). Of those offered to sample the products, 78.3% daily smokers and 68.4% non-daily smokers opted to sample. When asked about intentions to try, a greater proportion of smokers stated a preference to try NG over CS, as did the small number of nonsmokers who expressed a preference.

CONCLUSION

Intentions to try CS were low despite different levels of exposure to product, and this low product appeal and interest in use may translate to limited potential of CS to serve as a reduced harm product for smokers.

Ethnic differences in fast-food advertising exposure and body mass index among Asian American/Pacific Islander and White young adults

BACKGROUND

Fast-food advertising (FFA) is a potential contributor to obesity. Few studies have examined the relationship between FFA exposure and body mass index (BMI) among young adults. Furthermore, these studies have rarely examined ethnic differences in the relationship between FFA exposure and BMI, specifically across Asian American/Pacific Islander (AAPI) subgroups.

OBJECTIVE

This study aimed to investigate ethnic differences in the association between FFA exposure and BMI in a sample of predominantly AAPI young adults.

METHODS

Cross-sectional data were collected in 2018 from 2622 young adult college students (ages 18-25 years; 54% women) on O'ahu, Hawai'i. FFA exposure was assessed using a cued-recall measure. Multiple regression and analysis of covariance were used to analyze the data.

RESULTS

A significant association was found between higher FFA exposure and higher BMI (p < 0.05; 2-tailed) in the entire sample, adjusting for ethnicity, other demographic variables, and levels of physical activity. However, when examined by ethnic group, the association between FFA exposure and BMI was not statistically significant. A statistically significant main effect of ethnicity on BMI was found. Native Hawaiian/other Pacific Islanders (NHPI) reported the highest mean BMI [27.07 (SD ± 7.74) kg/m2] compared with the other four ethnic groups (p < 0.001). The effect of ethnicity on FFA exposure was not found to be statistically significant.

CONCLUSION

FFA exposure appears to adversely influence BMI in a population of predominantly AAPI young adults. Although we did not find ethnic differences in FFA exposure or in the association between FFA exposure and BMI, the current data make a case for similar future investigation with larger subgroup sample sizes. Regulations that curtail FFA exposure among young adults may be needed.

Who Cares More About the Environment, Those with an Intrinsic, an Extrinsic, a Quest, or an Atheistic Religious Orientation?: Investigating the Effect of Religious Ad Appeals on Attitudes Toward the Environment

There is a consensus among scientists that climate change is an existing, growing, and human-made threat to our planet. The topic is a divisive issue worldwide, including among people of faith. Little research has focused on the relationship between (non)religious belief and climate change. Hence, in Studies 1 and 2, the authors explore the impact of religious/non-religious orientations: intrinsic (religion as an end in itself), extrinsic (religion as a means to an end), quest (a journey toward religious understanding), and non-religious orientation (i.e., atheistic) on consumer attitudes toward the environment, focusing on recycling advertisements with (non)religious cues. Further, in Study 3, we examine the underlying causal mechanism of environmental identity and the moderating effect of political views on consumers' lack of belief in climate change. The results show that religious people are less committed to the environment and climate change and that atheism positively affects recycling and climate change identity. The findings offer practical implications in that advertising campaigns need to be endorsed by religious leaders and channeled within the confines of the religious institutions they represent.

What factors are important to new patients when selecting an orthopedic oncologist?

BACKGROUND

Understanding how patients choose a provider may improve the overall experience by identifying ways to tailor a clinical practice.

AIM

To identify factors that patients consider important when choosing an orthopedic oncologist.

METHODS

New patients presenting to an orthopedic oncology clinic within a tertiary academic medical center from January 2019 to August 2020 were invited to complete an anonymous survey. The questionnaire consisted of 27 items including a Likert-type assessment of the importance of selection factors.

RESULTS

A total of 101 new patients with a median age of 66 years (range, 14 years to 91 years) responded. Most were referred by another doctor (n = 63, 62.4%), and of the referring providers, the most frequent specialty was orthopedic surgery (n = 32, 51%). Using a Likert-type scale with 1 representing ‘least important’ and 5 representing ‘most important’, the most important factor was the hospital reputation (mean, 4.65; SD, 0.85). Additional factors of importance were the number of years in practice (3.87 ± 1.3) and a primary care provider referral (3.71 ± 1.6). Patients younger than 40 years old found social media (P = 0.016) and internet presence (P = 0.035) of their surgeon to be more important than older patients. In contrast, older patients considered care within an academic center to be of greater importance than younger patients (P = 0.014).

CONCLUSION

This investigation suggests a primary care referral, as well as hospital and physician reputation, are among the most important factors when selecting an orthopedic oncologist. Furthermore, social media utilization appears to be more important for younger patients.

Optimize Your First Impression: A Comparison of the Aesthetic Websites of Private Practices and Academic Institutions

BACKGROUND

An aesthetic surgery offering within academic programs has positive financial and educational implications. To compete with private practices, academic institutions must view their website as integral to patient recruitment.

OBJECTIVE

This study examines the aesthetic surgery websites of academic and private practices to compare objective website characteristics.

METHODS

Integrated plastic surgery programs with an aesthetic surgery website were matched with nearby private practices offering cosmetic surgery. Data was collected from websites, including information about procedures, media, surgeon characteristics, design, reputation, finances, and readability, and compared using Chi-square and T tests.

RESULTS

The websites of 68 academic institutions (AP) and 68 location-matched private practices (PP) were examined. Fourteen (17.07%) programs did not have a website. Private practice websites provided information about a greater number of procedures (mean AP 21.82, PP 27.04, p = 0.013), preparation for surgery (AP 52.94%, PP 83.82%, p < 0.001), and expectations after surgery (AP 70.59%, PP 88.24%, p = 0.01). Board certification was listed more frequently for private practices (AP 87%, PP 98%, p = 0.01). Academic websites were more likely to discuss research (AP 76%, PP 57.35%, p = 0.02). There was no significant difference in the readability of AP and PP websites (mean SMOG AP 7.70, PP 7.19, p = 0.06).

CONCLUSIONS

This work demonstrates a significant content gap between private and academic aesthetic websites and serves as an action item for institutions to enhance their online presence. In a field traditionally associated with high overhead costs, website modifications represent a cost-effective way for academic practices to increase their appeal in the cosmetic surgery market.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Population exposure to alcohol and junk food advertising during the 2018 FIFA world cup: implications for public health

BACKGROUND

Advertising alcoholic drinks and food high in fat, sugar, and salt (HFSS) is a driver of alcohol use and HFSS consumption, among children and young people. Whilst advertising legislation and broadcasting regulation protect children from alcohol and HFSS imagery, the 2018 FIFA World Cup, which attracted a global audience, was sponsored and partnered by alcohol and HFSS brands. This study investigated the exposure of viewers to HFSS and alcohol imagery in a selection of group matches, and the final match, of the FIFA 2018 World Cup.

METHODS

The frequency and duration of appearances (to the nearest second) of branding from two sponsors (McDonald's and Budweiser), one official partner (Coca-Cola) and the official sports drink (Powerade) were recorded during all active play in live coverage of a sample of 13 matches (Six in Group A, which included the host nation, Russia, which has stringent alcohol promotion regulations in place; six in Group G, which featured England; and the final) broadcast in the UK. We used census and viewing data to calculate gross and per capita impressions generated by this imagery in the UK population.

RESULTS

The 13 matches included 1262 min of active play and a total of 1806 appearances of alcohol and HFSS food advertisements, delivering approximately 7.5 billion branded HFSS impressions, including 759 million to children (age < 16 years), and 3.3 billion alcohol impressions, including 385 million to children, in the UK. Appearances of HFSS and alcohol brands were not statistically different between the games in either group.

CONCLUSION

UK advertising legislation and broadcasting regulations intended to prevent exposure to alcohol and HFSS imagery and advertising in UK television was circumvented completely by sponsorship arrangements in the 2018 FIFA World Cup. Preventing this exposure therefore requires revision of existing advertising and broadcasting controls to include sponsorship.

Messages in prescription drug advertising for four chronic diseases, 2003-2016: A content analysis

The objective of this study was to examine the frequency and content of messages related to pharmacological and evidence-based, non-pharmaceutical treatments in direct-to-consumer advertising (DTCA) for prescription drugs treating four chronic diseases in the United States. We used content coding to identify theory-informed categories of messages appearing in a large sample of heart disease, diabetes, depression, and osteoarthritis advertisements, appearing on national and local television between 2003 and 2016 (N = 11,347,070). The data were originally accessed in 2019 and analyzed in 2020-2021. The central message in all pharmaceutical DTCA was drug efficacy. Advertisements for diabetes and heart disease, but not depression or osteoarthritis, contained general (not central) messages about diet and exercise. Advertisements for heart disease primarily portrayed diet and exercise as insufficient for controlling the target health condition. No advertisements in our sample portrayed changes in diet or physical activity as an alternative to drugs. Pharmaceutical DTCA across health conditions employ similar strategies to promote use of the advertised drug but vary widely in whether and how they describe non-pharmaceutical treatments that complement or serve as alternatives to medications. Regulators should consider the potential spillover effects of non-pharmaceutical messages in pharmaceutical DTCA when considering future regulatory endeavors.

You've got mail: Drinks are on sale! A study to assess volume and content of direct marketing received from online alcohol retailers in Australia

BACKGROUND

Customers of online alcohol retailers are exposed to marketing displayed on alcohol retailers' websites and may also receive direct marketing via email and text message once contact details are provided in an online sale. To date, this direct marketing activity from online alcohol retailers has not been studied. This study aims to document the quantity and content of marketing material received by customers of online alcohol retailers in Australia, and whether the material complies with relevant regulation.

METHODS

A cross-sectional study of direct marketing from the 100 most popular online alcohol retailers in Australia. Marketing material received via email and text message was collected for three-months from March to June 2021. Email and text messages were coded for 17 variables in four categories: primary purpose of the communication; compliance with relevant regulations; marketing themes and practices used; and offers, promotions, and discounts.

RESULTS

We received 1496 emails from 85 of the 100 retailers. Of the retailers who sent emails, the number sent varied widely (Mdn=8; IQR=2-21). Seven retailers sent a total of 18 text messages. The primary purpose of most emails (67.4%) was to advertise a special or offer a discount. Almost all emails (98.6%) complied with spam legislation to include an unsubscribe link, but around half (46.5%) of emails from retailers in jurisdictions where the inclusion of a liquor license number is mandatory, failed to include one. The most common marketing theme was to link specific times or events to drinking (18.8%). Almost half (48.5%) of emails advertised free or discounted delivery for purchasing over a specified threshold.

CONCLUSION

Most online alcohol retailers in Australia are engaging in direct marketing to their customers via email. More research is needed to understand how these emails may influence purchasing and consumption.

Can nudging overcome procrastinating on preventive health investments?

A fundamental puzzle about human behavior is low investment in preventive health inputs. Present-biased preferences have frequently been put forth as a theoretical explanation for this, but with limited empirical evidence supporting it, especially in developing countries. We extend our previous analysis of a field experiment testing advertising strategies to increase demand for a potentially life-saving preventive health technology, voluntary medical male circumcision. Offering compensation of US$10 conditional on a complement to the procedure, a short counseling session at a providing clinic, tripled uptake of the procedure. This is consistent with the idea that subsidizing a complement encouraged procrastinating men with latent demand to invest in preventive health. In addition, framing the basic advertisement using the statement "Are you tough enough?" doubled uptake.

Tobacco and cannabis use advertisements targeting adolescents and young adults on Snapchat in 2019

Social media platforms offer opportunities for targeted health communication ads to improve tobacco and cannabis prevention efforts. This study described tobacco and cannabis-related ads targeted towards adolescents and young adults on Snapchat. Data comprised of publicly available tobacco (n = 70) and cannabis-related (n = 64) ads from Snapchat in 2019. Identified themes included: Health consequences (Health effects of tobacco or cannabis use), Financial & legal consequences (Adverse financial or legal implications of substance use), Quitting (Resources for cessation), Industry tactics(Tobacco industry misleads individuals), Policy advocacy (Cannabis law reforms or legalization). Ad performance metrics included average Ad Impressions (number of views per ad) and Ad Spend (cost per ad). Ads were also categorized by Sponsoring Organizations (Government or Advocacy organizations). Health Consequences was the predominant theme followed by Quitting among tobacco-related ads. Government organizations sponsored most tobacco-related ads. Tobacco-related ads targeting adolescents received mean = 4,122,071 impressions and cost mean = $10,385.6 per ad. Tobacco-related ads targeting young adults received mean = 2,151,217 impressions and cost mean = $5,382.1 per ad. Health Consequences was a predominant theme among cannabis-related ads followed by Policy Advocacy. Advocacy organizations sponsored most cannabis-related ads targeting young adults. Cannabis-related ads targeting adolescents received mean = 415,293.8 impressions and cost mean=$793.92 per ad. Cannabis-related ads targeting young adults received mean = 293,267.7 impressions, and cost mean = $740.58. Government and advocacy organization sponsored ads reached millions of adolescents and young adults on Snapchat. Prevention campaigns may consider these number of impressions and cost per ad by theme when designing platform specific ads in the future.

Constructing the Gendered Risk of Illness in Lyrica Ads for Fibromyalgia: Fear of Isolation as a Motivating Narrative for Consumer Demand

Direct-to-consumer television advertisements for Lyrica in the United States create narratives of gendered domestic normalcy to which women with fibromyalgia are encouraged to aspire through pharmaceutical intervention. This paper unpacks images and narratives within these advertisements to demonstrate that they rely on metaphors that represent gendered expectations in order to evoke guilt and provoke a desire for what Joseph Dumit calls "health as risk reduction," and what I argue is an attempt to show disability being erased. Following Stuart Hall's Encoding/Decoding model of communication, viewers play a role in constructing societal expectations for women with chronic pain and for themselves.

The high frequency of alcohol advertising during televised English Premier League football games shown in Ethiopia

Background

Excessive alcohol consumption is an important risk factor for increased morbidity, mortality and other social harms globally. Televised sport allows the promotion of alcoholic drinks to a large and often young audience, and thus can be used to develop new markets for alcohol in low- and middle-income countries. This study aimed to analyse the alcohol advertising displayed during televised English Premier League (EPL) games, which is widely viewed in Ethiopia, and are particularly popular among young people.

Methods

Nineteen live televised EPL football matches broadcast in Ethiopia on the SuperSport channels over 4 weeks of the 2018/19 season were digitally recorded from the digital satellite television. Exposure to alcohol advertising was measured by calculating the total elapsed time duration with the alcohol content from the pre-match to the end of the post-game period of the broadcast.

Results

Data were available for a total of 2451 min broadcast time. Alcohol advertising accounted for 205.2 min (8.4%) with a mean duration of 10.8 min per match (range 5.5 to 22.6). The dominant format of alcohol advertisement was the display of logos associated with an alcoholic drink on the television (TV) screen, which accounted for approximately 43% of the total alcohol advertising time. This was followed by pitch side virtual display (17.7%) and a glass of alcohol drink on the TV screen (17.6%). Over three quarters of alcoholic drink advertising (77.7%) was during active football playing time. None of the advertisements on the televised football games showed cigarettes.

Conclusion

There is a high frequency of exposure to alcohol advertising during televised EPL matches in Ethiopia. It is important to ensure that the newly introduced domestic ban on alcohol advertising is also applied to foreign satellite broadcasters. This is likely to have relevance to other sub-Saharan African countries in promoting public health strategies to reduce harm from alcohol consumption.

Outcomes of exposure to healthy weight and lifestyle advertising: An experimental study of adults from the United Kingdom

Mass media advertising promoting healthy weight and lifestyles represents an important approach to the prevention of non-communicable diseases. However, concerns have been raised that advertisements promoting a healthy weight may be stigmatizing and contribute to negative outcomes. This study explored the potential negative and positive cognitive, psychological, and behavioral intention outcomes of exposure to different public health campaign advertisements that promote positive behavior change and healthy weight. A total of 1,098 adult residents of the United Kingdom (50% female, Mage = 35.21 years) viewed one of four video advertisements: one control advertisement and three healthy weight and lifestyle advertisements that differed in message content (negative health impacts, support/encouragement, and social norms) and execution style (graphic, animation, and depicted scene). Participants then responded to items assessing a variety of cognitive, psychological, and behavioral intention outcomes. Compared to those in the control condition, those exposed to a healthy weight and lifestyle advertisement reported significantly higher scores for (i) perceptions of weight stigma, (ii) negative emotions, and (iii) intentions to engage in adaptive lifestyle behaviors. There were no differences observed between conditions for maladaptive behavioral intentions, internalized weight bias, anti-fat attitudes, and body dissatisfaction. The advertisement featuring a supportive/encouraging message and animation style performed most favorably. Results suggest that healthy weight and lifestyle advertisements have the potential to promote positive behavior change but may be associated with some negative outcomes. Of the assessed communication approaches, a supportive/encouraging message with animation style appears least likely to induce negative emotions and is preferred for minimizing weight stigma.

Dissemination of Consumer Law and Policy in Brazil: The Impact of EU Law

This paper analyses the influence of European Law on Brazilian Consumer Law. It starts by describing the general features of Brazilian Consumer Protection law, including the constitutional dimension of consumer protection, and the introduction of the Brazilian Consumer Protection and Defence Code (CDC). It also highlights product liability, product safety, and product warranties. Some of these topics are illustrated by the case of the telecommunications sector.

An analysis of food and beverage advertising on bus shelters in a deprived area of Northern England

OBJECTIVE

To quantify the extent of food and beverage advertising on bus shelters in a deprived area of the UK, to identify the healthfulness of advertised products, and any differences by level of deprivation. The study also sought to assess the creative strategies used and extent of appeal to young people.

DESIGN

Images of bus shelter advertisements were collected via in person photography (in 2019) and Google Street View (photos recorded in 2018). Food and beverage advertisements were grouped into one of seventeen food categories and classified as healthy/less healthy using the UK Nutrient Profile Model. The deprivation level of the advertisement location was identified using the UK Index of Multiple Deprivation.

SETTING

Middlesbrough and Redcar and Cleveland in South Teesside.

PARTICIPANTS

N/A.

RESULTS

Eight hundred and thirty-two advertisements were identified, almost half (48·9 %) of which were for foods or beverages. Of food and non-alcoholic beverage adverts, 35·1 % were less healthy. Most food advertisements (98·9 %) used at least one of the persuasive creative strategies. Food advertisements were found to be of appeal to children under 18 years of age (71·9 %). No differences in healthiness of advertised foods were found by level of deprivation.

CONCLUSIONS

Food advertising is extensive on bus shelters in parts of the UK, and a substantial proportion of this advertising is classified as less healthy and would not be permitted to be advertised around television programming for children. Bus shelter advertising should be considered part of the UK policy deliberations around restricting less healthy food marketing exposure.

INTRODUCTION Commercial Speech and the Commercial Determinants of Health

This article introduces a symposium that aims to identify and critically assess the legal strategies of the tobacco, alcohol, and food and beverage industries which rest on freedom of expression arguments.

The Right to Free Commercial Speech in South Africa and its Tension with Public Health Interventions

Marketing restrictions to promote public health invoke competing rights, including the right to free commercial speech which for-profit entities use to protect their freedom to market products without undue regulation. The right to free commercial speech in South Africa has been developed through case law since the adoption of the first democratic constitution in South Africa in 1996. This article examines the impact of this recent judgment and the lessons for policy makers to ensure effective regulation of marketing practices in South Africa.

Commercial Speech and the Prohibition of Tobacco Advertising: The Colombian Constitutional Court Approach

This article argues that the decision by the Columbian high court to totally ban the advertising and promotion of tobacco products is sound and could indeed be applied to other types of harmful products.

The Influence of the Commercial Speech Doctrine on the Development of Tobacco Control Measures

Among the attempts to oppose tobacco control legislation, the tobacco industry has alleged violations of its right to commercial speech. While the disputes that took place in some jurisdictions like the United States (US), Canada, or the European Union (EU) have been already analyzed, much less is known about how, globally, this doctrine has influenced the adoption of tobacco control measures. This article contributes to filling this gap by illustrating how the commercial speech doctrine influenced the negotiations of the Framework Convention on Tobacco Control (FCTC). Moreover, using the Tobacco Control Database of Campaign for Tobacco-Free Kids, it shows that arguments on commercial speech have been used to challenge tobacco control measures in an increasing number of countries.

Adolescent exposure to cannabis marketing following recreational cannabis legalization in Canada: A pilot study using ecological momentary assessment

Objective

The goal of this pilot study was to assess the feasibility of a 9-day, smartphone-based ecological momentary assessment (EMA) protocol for tracking the frequency of Canadian adolescents' exposures to cannabis marketing, their reactions to such exposures, and the context in which exposures occur in the real-world and in real-time.

Method

Participants were n = 18 adolescents between the ages of 14 and 18 years of age. They used an EMA application to capture and describe cannabis marketing exposures through photographs and brief questionnaires assessing marketing channel and context. Participants also rated their reactions to each exposure in real-time.

Results

Results showed that participants were generally compliant with the protocol. Participants recorded 40 total exposures to cannabis marketing, representing an average of 2.2 (SD 2.3) exposures per participant during the 9-day study. Exposures tended to occur in the afternoon (45.0%) or evening (37.5%), and while participants were at home (70%) and alone (52.5%). Most exposures occurred through promotion by public figures (27.5%) or explicitly marked internet ads (27.5%).

Conclusion

This is the first study to demonstrate the feasibility and utility of EMA to capture adolescent exposures to cannabis marketing as it occurs in participants' natural environments. Our research offers an early look at the predictable wave of cannabis advertising targeting youth and a promising approach for studying its impacts in a post-legalization context, as well as a strategy for assessing policies, such as advertising restrictions, intending to mitigate the harms of early cannabis use among youth.

Prevalence of low-calorie sweeteners and related front-of-package claims in the Brazilian packaged food supply

BACKGROUND

Low-calorie sweeteners (LCS) are increasingly being used worldwide, including in foods and beverages commonly consumed by children.

OBJECTIVE

To examine the prevalence of LCS in packaged foods and beverages sold in Brazil, whether LCS are added to products with advertising directed to children, and whether foods and beverages with LCS include front-of-package (FoP) LCS-related health and nutrition claims.

DESIGN

Cross-sectional study.

SETTING

A sample (n = 11,434) of packaged foods and beverages sold by the top five largest Brazilian food retailers was examined to identify LCS and added sugars and a subsample (n = 3,491) was examined to determine the presence of advertising directed to children and FoP LCS-related claims in foods and beverages with LCS.

MAIN OUTCOME AND MEASURES

The prevalence of foods and beverages with different types of LCS in the Brazilian food supply, among ultra-processed foods and beverages and among foods and beverages with added sugars were measured. Foods and beverages with advertising directed to children were checked to see if these products had LCS, and how many products with LCS had FoP labels with LCS-related claims.

STATISTICAL ANALYSES

Mean and 95% confidence intervals were used to determine the overall prevalence of foods and beverages with LCS and in the different assessed stratifications.

RESULTS

The prevalence of LCS was 9.3% (95% CI 8.8, 9.9) in Brazilian packaged foods and beverages, 14.6% (95% CI 13.8, 15.4) in ultra-processed products alone, and 5.7% (95% CI 4.2, 7.7) in foods and beverages with advertising directed to children. About 83% of food and beverage with LCS were also sweetened with added sugars. LCS were most frequently added to nonalcoholic sweetened beverages, breakfast cereals, and granola bars. Forty percent of foods and beverages with LCS did not present any front-of-package LCS-related claim.

CONCLUSION

This study shows that LCS are present in 15% of ultra-processed foods and beverages in Brazil, largely used in combination with added sugars, and are found in foods and beverages with advertising directed to children. Clearer FoP information regarding the presence of LCS, in particular in products with advertising directed to children, can help consumers make more informed choices regarding LCS consumption.

'Pretty in Pink' and 'Girl Power': An analysis of the targeting and representation of women in alcohol brand marketing on Facebook and Instagram

BACKGROUND

Alcohol marketing helps shape how gender roles and relations are understood, and the gendered nature of drinking learned. In recent years, changes in how women are presented and addressed in marketing, including alcohol marketing, have been observed. This reflects the shifting social, political and regulatory context, in which increased attention has been given to gender inequality and the damaging impact of gender stereotypes. Research is yet to explore the gendered nature of alcohol marketing within this contemporary context.

METHODS

A quantitative content and qualitative thematic analysis of alcohol marketing posts (N = 2600) by 20 alcohol brands on Facebook and Instagram pages over an 18 month period (1st January 2019-30th June 2020) was conducted. Marketing strategies were identified, and the way in which posts targeted, represented and engaged women analysed.

FINDINGS

New (e.g. 'influencer' collaborations) and established (e.g. competitions) strategies were being used to target both women and men. Drinking was presented as a feminine practice and as an important component of 'doing' a combination of traditional, post-feminist and feminist femininities. Women were assigned a range of gender roles that acknowledged their individual pleasures and achievements, and traditional gender roles and stereotypes were both reinforced and rejected to promote alcohol use. An important move away from sexualising and demeaning women to the appropriation of feminist and equality messages was observed, which may appeal to a wider range of women, including those embracing feminist identities.

CONCLUSION

Alcohol brand marketing encourages alcohol use to women through both perpetuating and challenging gender stereotypes. Claims by brands of a commitment to equality are at odds with the harms related to alcohol consumption that contribute to the widening of health and social inequalities. It is important that future work on women's drinking and alcohol marketing is situated within the shifting social-political climate in which traditional, post-feminist and new fourth wave feminist rhetoric and femininities co-exist.