Perceived effectiveness of added-sugar warning label designs for U.S. restaurant menus: An online randomized controlled trial

How and why researchers and advocates should engage with state and local food policymaking

Unhealthy diets contribute to one in every five deaths in the United States, yet federal policy action to improve dietary quality has been limited. We argue that researchers and advocates should engage in state and local food policymaking, which offers an important complementary avenue for creating healthier food environments and improving diet quality. We outline key questions researchers can address to inform local and state policymaking and provide practical tips on how they can engage with the policy process. Finally, we present a case study of researcher engagement with the New York City Sweet Truth Act policy process.

Examining the Longitudinal Relationship Between Perceived and Actual Message Effectiveness: A Randomized Trial

We sought to examine the relationship between perceived message effectiveness (PME) and actual message effectiveness (AME) in a 3-week randomized trial of vaping prevention advertisements. Participants were US adolescents (n = 1,514) recruited in 2021. We randomly assigned them to view The Real Cost vaping prevention ads or control videos online. Participants viewed three videos at Visit 1, again at Visits 2 and 3, and completed a survey at each visit that assessed AME (susceptibility to vaping) and two types of PME - effects perceptions (potential for behavioral impact) and message perceptions (potential for message processing). At Visit 4, AME was measured. Compared to control, The Real Cost ads led to improved AME (lower susceptibility to vaping at Visit 4, p < .001). This was anticipated by The Real Cost ads eliciting higher PME ratings (higher effects and message perceptions at Visit 1, both p < .001). Furthermore, PME (both effects and message perceptions) at Visit 1 predicted susceptibility to vaping at Visits 1, 2, 3, and 4 (all p < .001). Finally, effects perceptions fully mediated the impact of The Real Cost ads on susceptibility to vaping (β = -.30; p < .001), while message perceptions only partially mediated the effect (β = -.04; p = .001). Our findings indicate a relationship between PME and AME, especially effects perceptions, and suggest that PME may be useful in message pre-testing to select messages with greater behavior change potential.

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

INTRODUCTION

Excise taxes on unhealthy products like sugary drinks and tobacco can reduce purchases of these products. However, little research has investigated whether messages at the point of purchase, such as enhanced price tags, can increase the effects of taxes by heightening psychological reactions. This study aimed to examine whether including messages about taxes on price tags could amplify the benefits of excise taxes on unhealthy products.

METHODS

In 2022, an online study recruited 1,013 U.S. parents to view seven price tag messages (e.g., "includes a 19% sugary drink tax") and a control (i.e., standard price tag with the tax included in the price) displayed in random order alongside sugary drinks. Participants were randomly assigned to view a caution-symbol icon or no icon on price tags. Analyses were conducted in 2023.

RESULTS

All seven messages discouraged parents from buying sugary drinks for their children compared to control (average differential effects [ADEs] ranged from 0.28 to 0.48, all p<0.001). All messages led to greater attention to the price tag (ADEs ranged from 0.24 to 0.41, all p<0.001) and greater consideration of the cost of sugary drinks (ADEs ranged from 0.31 to 0.50, all p<0.001). Icons elicited higher cost consideration than text-only price tags (ADE=0.15, p<0.010), but not discouragement (p=0.061) or attention (p=0.079).

CONCLUSIONS

Messaging on price tags could make excise taxes more effective. Policymakers should consider requiring messaging on price tags when implementing taxes.

Online RCT of Icon Added-Sugar Warning Labels for Restaurant Menus

INTRODUCTION

To reduce added-sugar consumption, jurisdictions are considering requiring restaurant menu labels to identify high-added-sugar items. This study examined the impacts of added-sugar warning labels on hypothetical choices, knowledge of items' added-sugar content, and perceptions of high-added-sugar items.

STUDY DESIGN

The design was an online RCT.

SETTING/PARTICIPANTS

National sample of adults (N=15,496) was recruited to approximate the U.S. distribution of sex, age, race, ethnicity, and education.

INTERVENTION

Participants viewed fast-food and full-service restaurant menus displaying no warning labels (control) or icon-only added-sugar warning labels next to high-added-sugar items (containing >50% of the daily recommended limit).

MAIN OUTCOME MEASURES

The main outcome measures were hypothetical ordering of ≥1 high-added-sugar item, grams of added sugar ordered, and knowledge of items' added-sugar content assessed in 2021 and analyzed in 2021-2022.

RESULTS

Warning labels reduced the relative probability of ordering ≥1 high-added-sugar item by 2.2% (probability ratio=0.978, 95% CI=0.964, 0.992; p=0.002); improved knowledge of added-sugar content (p<0.001); and led to a nonstatistically significant reduction of 1.5 grams of added sugar ordered, averaged across menus (p=0.07). The label modestly reduced the appeal of high-added-sugar items, increased perceptions that consuming such items often will increase Type 2 diabetes risk, increased perceived control over eating decisions, and increased injunctive norms about limiting consumption of high-added-sugar items (ps<0.001). However, in the warning condition, only 47% noticed nutrition labels, and 21% recalled seeing added-sugar labels. When restricting the warning condition to those who noticed the label, the result for grams of added sugar ordered was significant, with the warning condition ordering 4.9 fewer grams than the controls (95% CI= -7.3, -2.5; p<0.001).

CONCLUSIONS

Added-sugar warning labels reduced the probability of ordering a high-added-sugar menu item and increased participants' knowledge of whether items contained >50% of the daily value for added sugar. The modest magnitudes of effects may be due to low label noticeability. Menu warning labels should be designed for noticeability.

REGISTRATION

This study was registered at AsPredicted.org #65655.

Effect of Climate Change Impact Menu Labels on Fast Food Ordering Choices Among US Adults: A Randomized Clinical Trial

IMPORTANCE

There is increasing interest in strategies to encourage more environmentally sustainable food choices in US restaurants through the use of menu labels that indicate an item's potential impact on the world's climate. Data are lacking on the ideal design of such labels to effectively encourage sustainable choices.

OBJECTIVE

To test the effects of positive and negative climate impact menu labels on the environmental sustainability and healthfulness of food choices compared with a control label.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial used an online national US survey conducted March 30 to April 13, 2022, among a nationally representative sample of adults (aged ≥18 years) from the AmeriSpeak panel. Data were analyzed in June to October 2022.

INTERVENTIONS

Participants were shown a fast food menu and prompted to select 1 item they would like to order for dinner. Participants were randomized to view menus with 1 of 3 label conditions: a quick response code label on all items (control group); green low-climate impact label on chicken, fish, or vegetarian items (positive framing); or red high-climate impact label on red meat items (negative framing).

MAIN OUTCOMES AND MEASURES

The main outcome was an indicator of selecting a sustainable item (ie, one without red meat). Secondary outcomes included participant health perceptions of the selected item and the Nutrition Profile Index (NPI) score of healthfulness.

RESULTS

Among 5049 participants (2444 female [51.6%]; 789 aged 18-29 years [20.3%], 1532 aged 30-44 years [25.9%], 1089 aged 45-59 years [23.5%], and 1639 aged ≥60 years [30.4%]; 142 Asian [5.3%], 611 Black [12.1%], and 3197 White [63.3%]; 866 Hispanic [17.2%]), high- and low-climate impact labels were effective at encouraging sustainable selections from the menu. Compared with participants in the control group, 23.5% more participants (95% CI, 13.7%-34.0%; P < .001) selected a sustainable menu item when menus displayed high-climate impact labels and 9.9% more participants (95% CI, 1.0%-19.8%; P = .03) selected a sustainable menu item when menus displayed low-climate impact labels. Across experimental conditions, participants who selected a sustainable item rated their order as healthier than those who selected an unsustainable item, according to mean perceived healthfulness score (control label: 3.4 points; 95% CI, 3.2-3.5 points vs 2.5 points; 95% CI, 2.4-2.6 points; P < .001; low-impact label: 3.7 points; 95% CI, 3.5-3.8 points vs 2.6 points; 95% CI, 2.5-2.7 points; P < .001; high-impact label: 3.5 points; 95% CI, 3.3-3.6 points vs 2.7 points; 95% CI, 2.6-2.9 points; P < .001). Participants in the high-climate impact label group selected healthier items according to mean (SE) NPI score (54.3 [0.2] points) compared with those in the low-climate impact (53.2 [0.2] points; P < .001) and control (52.9 [0.3] points; P < .001) label groups.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial's findings suggest that climate impact menu labels, especially negatively framed labels highlighting high-climate impact items (ie, red meat), were an effective strategy to reduce red meat selections and encourage more sustainable choices.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05482204.