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

Local-scale deprivation is associated with the spatial distribution of poor diet quality in adults: A cross-sectional population-based study in Switzerland

Poor diet quality is linked to non-communicable diseases and mortality. Area deprivation is an important determinant of diet. Whether small area deprivation influences the spatial distribution of diet quality remains unknown. We aimed to assess the spatial dependence of diet quality and its association with local-scale deprivation in adults. We used data from the 2016-2019 waves of the population-based Bus Santé Study in Geneva (n = 4453). We assessed diet quality through the Alternate Healthy Eating Index (AHEI), and its spatial dependence through the Local Indicators of Spatial Association (LISA or Local Moran's I). Bivariate LISA analyses and Geographically Weighted Regression models were used to assess associations with sociodemographic variables and small-area deprivation. We used regression models of diet and metabolic health variables to confirm the validity of the low diet quality spatial clustering. We included 4248 participants (mean age 47 ± 14, 50·7% women). We found a mean AHEI score of 35·2 (SD 10·8). 40% of the participants fell into a low diet quality category. Diet quality was spatially patterned across the Canton of Geneva, with identified clusters of lower diet quality (mean AHEI score 27·8 ± 6·24) and higher diet quality (mean AHEI score 43·8 ± 6·8). Clusters of low diet quality persisted after adjusting for individual-level variables. The largest low diet quality cluster was associated with higher local deprivation. Our study sheds light on the role of local-scale deprivation as an independent contextual determinant of diet in a high-income European city.

The global prevalence of emotional eating in overweight and obese populations: A systematic review and meta-analysis

This systematic review aims to investigate the current prevalence of emotional eating and its associated factors in overweight and obese populations. We included studies that (1) reported prevalence of emotional eating; (2) were in the context of weight gain or overweight and obesity; (3) used a validated psychometric tool to assess emotional eating; (4) were published as an internationally referred journal article and (5) were reported in the English language. Articles were searched on eight electronic databases (CINAHL, EMBASE, PsychINFO, ProQuest, PubMed, Scopus, The Cochrane Library and Web of Science) from the journals' inception to 11 April 2024. A total of 18 studies, representing a total of 21,237 people, were included in the review. Our study suggested that emotional eating is significantly prevalent at 44.9%. High heterogeneity observed (I2: 98.7%) can be attributed to differences in measurement tools for emotional eating, but not differences in geographical regions. By providing insight to the current prevalence of emotional eating and its relevant factors, this study outlines the steps to take in future research and practice to tackle emotional eating and related health issues like obesity. There is a need to develop standardized measurement tools for emotional eating, and further investigate sociodemographic factors.

Voicing residents' perception of (commercial) food cues in outdoor public spaces: a photovoice study

BACKGROUND

(Commercial) food cues in outdoor public spaces are environmental drivers of unhealthy diets. This study aimed to explore residents' perceptions of food cues in outdoor public spaces in relation to their perceived food environment, eating behaviour, and their opinion on governmental outdoor food cue regulations.

METHODS

A photovoice study, consisting of a photography assignment followed by semi-structured interviews, was conducted among 15 adult residents of the municipality of Wageningen, the Netherlands. Participants had one week to take photographs of outdoor food cues they encountered in their municipality, using a mobile app "myfoodenvironment", that were central to the interview afterwards.

RESULTS

Participants mainly noticed unhealthy food cues, which they viewed as constant 'reminders' that unhealthy food was easily accessible and affordable. Their views varied on the extent to which food cues affected their own eating behaviour, but generally believed that food cues affected that of others. Participants identified several factors that amplify outdoor food cues' influence on eating behaviour, including hunger, fatigue and attractiveness of the cues. The findings revealed support for government regulation of food cues, while acknowledging the complexity of this issue and the diverse perspectives on how such regulations should be designed (e.g., where, for whom), with one notable counterargument being concerns about feeling patronized by such policies.

CONCLUSIONS

Current findings may inform health professionals and (local) policy makers about the unhealthy food cues encountered by residents in outdoor public spaces, which unconsciously influence their eating behaviour, while also providing insights into designing food cue regulations that attract policy support by balancing public health goals with considerations of consumer autonomy and citizen preferences.

The use of social media to promote unhealthy food and beverage consumption among Indonesian children

BACKGROUND

Rates of childhood overweight and obesity are rising across most low and middle-income countries (LMICs), including Indonesia, the largest country in Southeast Asia. Marketing of unhealthy food and beverages to children is a key driver, yet evidence on digital marketing strategies used in LMICs remains scarce. This study examines the techniques used to advertise unhealthy food and beverages to children on social media in Indonesia.

METHODS

We retrieved 295 ads on three social media platforms (Facebook, Instagram, and Twitter) from 20 food brands with the highest market share in Indonesia across four food categories (snacks, processed foods, soft drinks, and fast food). Marketing techniques used in the ads were coded based on a pre-developed codebook outlining techniques often used to target children and assessed qualitatively through content analysis. The healthfulness of the products advertised was also evaluated, based on the WHO nutrient profile model for Southeast Asia.

RESULTS

The ads analysed employed frequently marketing techniques used to target children. The most common marketing techniques across the three platforms were the inclusion of social media features (21.3%), branded products (19.6%), emotional cues and appeal of fun (10.1%), images of children, teens, or adults (9.0%) and special offers (6.6%). Notably, 85% of the brands analysed promoted at least one food unsuitable for marketing to children based on the WHO model.

CONCLUSIONS

Food and beverage brands in Indonesia purposely and frequently employ various techniques on social media to target children with ads for food and beverages that, based international nutritional standards, are unsuitable for promotion to this age group. This represents a threat to the nutritional status, health, and well-being of Indonesian children, and calls for stricter regulations on the marketing of these products in the country.

Does outdoor advertising correlate with retail food purchases made by adolescents? A cross-sectional study in Canada

Food marketing plays a substantial role in shaping adolescent diets, having wide-ranging ramifications for health behaviours and outcomes throughout the life course. Yet, there remains a dearth of research about how outdoor advertising as a specific channel of food marketing affects purchasing behaviours. We examine self-reported purchases made at retail food outlets by adolescents as it relates to the availability of outdoor food and beverage advertising around each participant's home, school, and along the journey to and from school. We also consider the impacts of sociodemographics and consumption attitudes on purchasing, as compared to the geographic availability of outdoor advertising. Data are drawn from a survey completed by 545 adolescents in 2018 across four secondary schools in the Middlesex-London region of Ontario, Canada. The availability of outdoor advertising in the home and school environment is marginally correlated with self-reported purchases made at fast food, table-based, grocery, and variety retail outlets. However, consumption attitudes, cultural background, and gender are significantly correlated with purchases, with substantially larger effect sizes. The overall results were consistent between estimating the availability of outdoor advertising in the immediate area surrounding the home and along the journey to and from school. There is considerable health promotion policy interest in regulating outdoor advertising around child-serving locations. However, scarce health promotion resources would be better allocated to educational programming that addresses the substantial role of consumption attitudes in affecting adolescent purchasing behaviour, as compared to the considerably weaker impact of outdoor food advertising observed in our analysis.

Children's views on outdoor advertising of unhealthy food and beverages near schools

Children are often exposed to unhealthy outdoor food advertisements during the school commute. This exposure can have negative public health consequences given childhood weight gain has been linked to the marketing of energy-dense and nutrient-poor foods. This study aimed to explore schoolchildren's lived experiences and attitudes towards outdoor advertising surrounding their schools. Seven focus groups with children aged 10-16 years (n = 47) attending schools located in areas with high densities of unhealthy outdoor advertising were conducted in Perth, Western Australia, between July and October 2023. Study participants were aware of outdoor advertising of unhealthy food and beverages near their school, with many reporting that it impacted their food preferences and diet. Many participants felt it was unethical to advertise unhealthy food and beverages around schools and strongly supported restricting alcohol advertising within school precincts. Participants suggested a range of strategies to manage outdoor advertising of unhealthy food and beverages, including banning advertisements on public transport. These findings have the potential to impact State and local government policies affecting children's exposure to unhealthy outdoor advertising, serving as a crucial strategy in the fight against childhood obesity and the harmful effects of alcohol.

Temptation at every corner: exploring public perceptions of food cues and policy support for governmental food cue regulation in outdoor public spaces

BACKGROUND

Unhealthy visual food cues in outdoor public spaces are external drivers of unhealthy diets. Food cues are visible situations associated with food-related memories. This study aimed to gain insight into the (un)healthy food cues residents notice in outdoor public spaces in Dutch municipalities. It also aimed to explore residents' perceptions of food cues' influence on eating behaviour to gain insight into the acceptability of food cues and support for governmental food cue regulation.

METHODS

An exploratory study was conducted among 101 adults who photographed outdoor visual food cues in their municipality and answered survey questions about the food cues using a bespoke app ('myfoodenvironment'). Participant and food cue characteristics were analysed. Associations between those characteristics, perceived influence on eating behaviour, acceptability of food cues and support for regulation were analysed.

RESULTS

Participants took 461 photographs of food cues. Most food cues visualised food (73.8%), 54.4% of which showed only unhealthy food. Food cues photographed by participants with a high level of education and those located near a food service outlet were more often perceived as stimulating others to eat compared to those photographed by participants with a middle education level and located near a food store or along the road (Fisher's exact test: p < 0.001 and p = 0.001, respectively). For most photographs, participants found the presence of food cues acceptable and were opposed to governmental cue regulation. However, when food cues visualised healthy food, they were more likely to be found acceptable than when visualising unhealthy food (χ2 (4; N = 333) = 16.955; p = 0.002). Besides, when food cues visualised unhealthy food, participants were less likely to oppose governmental regulation of those types of cues, than when visualising healthy food (Fisher's exact test: p = 0.002).

CONCLUSIONS

Unhealthy food cues in outdoor public spaces were predominantly photographed by the participants. Yet, for most photographs, participants found the food cues acceptable and opposed governmental food cue regulation, although acceptance was higher for healthy food cues and opposition was lower for unhealthy food cues. These findings can serve as input for policymakers to develop governmental food cue regulations that may gain public support.

Associations between exposure to advertising of foods high in fats, salt and sugar and purchase of energy and nutrients: a cross-sectional study

OBJECTIVE

To assess associations between self-reported advertising exposure to foods high in fats, salt and sugar and household purchases of energy, nutrients and specific product categories.

DESIGN

A cross-sectional design was used. Advertising exposure data were gathered using a questionnaire administered to the main shopper of each household, and purchase data from supermarkets and other stores for these households were accessed for a 4-week period during February 2019.

SETTING

Households in London and the North of England.

PARTICIPANTS

Representative households (N 1289) from the Kantar Fast Moving Consumer Goods Panel. Main shoppers were predominantly female (71 %), with a mean age of 54 years (±13).

RESULTS

Linear regression models identified that exposure to foods high in fats, salt and sugar advertising through traditional mediums (including broadcast and print), but not digital, transport, recreational or functional mediums, was associated with greater purchases of energy (9779 kcal; 95 % CI 3515, 16 043), protein (416 g; 95 % CI 161, 671), carbohydrate (1164 g; 95 % CI 368, 1886) and sugar (514 g; 95 % CI 187, 841). Generalised linear models showed that individuals who reported exposure to sugary drink advertising were more likely to purchase sugary drinks (1·16; 95 % CI 2·94, 4·99) but did not purchase more energy or nutrients from sugary drinks. There was no evidence of associations between exposure to advertising for sugary cereals or sweet snacks and purchases from these categories.

CONCLUSIONS

There was a strong influence of traditional advertising and sugar-sweetened beverage advertising on household food and drink purchases, thus supporting the need for advertising restrictions across traditional formats and for sugary drinks specifically.

Perceptions of Food Marketing and Media Use among Canadian Teenagers: A Cross-Sectional Survey

Despite the prevalence of digital food marketing to teenagers and its potential impact on food preferences and consumption, little is known about the specific food advertisements teenagers see in Canada and how they perceive them. Further, few studies consult teenagers directly about their perceptions of teen-specific food marketing content. To shed light on such issues, this study examines perceptions of food marketing and self-reported media use of Canadian teenagers via an online survey. Four hundred and sixty-four teenagers (ages 13-17) participated. Overall, teenagers identified Instagram and TikTok as the most popular social media platforms. The top food or beverage brands that teens felt specifically targeted them were McDonald's, Starbucks, Coca-Cola and Tim Hortons, while Instagram was deemed the most important media platform when it comes to teen-targeted food marketing. Teens deemed "celebrity" and "visual style" as the most important (food and beverage) advertising techniques when it comes to persuading teenagers to buy. Overall, the study provides insights into teen media use and brand preference, including the brands teens feel target them most directly and what they consider to be salient in terms of the food advertising they see. It also provides valuable details for researchers seeking to further identify and measure elements of teen-targeted food marketing.

Encouraging online consumers into making better food choices: The power of nature exposure on healthy food choices

BACKGROUND

online environments can influence food desire and choices. We tested if online calming nature and stressful street environments can affect desire for healthy and unhealthy foods.

METHOD

we asked 238 participants (40 ± 14 yrs) to rate their desire (100 mm VAS) for 7 low calorie nutrient rich foods (Healthy) and 7 high calorie nutrient poor foods (Unhealthy), and perceived stress (state anxiety in STAI), before and after imagining themselves in a control, nature park, or busy street condition.

RESULTS

participants who imagined themselves being in a nature park had a significant higher desire for Healthy foods, than participants in the busy street condition (p < 0.05). Participants in the busy street condition decreased their desire for Healthy foods after they imagined themselves in a busy street (p < 0.05)). However, perceived stress did not impact the association between condition and desire for low calorie foods nor high calorie foods.

CONCLUSION

this study suggests that online environments can have an impact on healthy food desires, which could be of importance for the increased number of food choices which are made in online environments.

A scoping review on the associations between early childhood caries and sustainable cities and communities using the sustainable development goal 11 framework

BACKGROUND

Early childhood caries (ECC) is a multifactorial disease in which environmental factors could play a role. The purpose of this scoping review was to map the published literature that assessed the association between the Sustainable Development Goal (SDG) 11, which tried to make cities and human settlements safe, inclusive, resilient and sustainable, and ECC.

METHODS

This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. In July 2023, a search was conducted in PubMed, Web of Science, and Scopus using tailored search terms related to housing, urbanization, waste management practices, and ECC. Studies that solely examined ECC prevalence without reference to SDG11 goals were excluded. Of those that met the inclusion criteria, a summary highlighting the countries and regions where the studies were conducted, the study designs employed, and the findings were done. In addition, the studies were also linked to relevant SDG11 targets.

RESULTS

Ten studies met the inclusion criteria with none from the African Region. Six studies assessed the association between housing and ECC, with findings suggesting that children whose parents owned a house had lower ECC prevalence and severity. Other house related parameters explored were size, number of rooms, cost and building materials used. The only study on the relationship between the prevalence of ECC and waste management modalities at the household showed no statistically significant association. Five studies identified a relationship between urbanization and ECC (urbanization, size, and remoteness of the residential) with results suggesting that there was no significant link between ECC and urbanization in high-income countries contrary to observations in low and middle-income countries. No study assessed the relationship between living in slums, natural disasters and ECC. We identified links between ECC and SDG11.1 and SDG 11.3. The analysis of the findings suggests a plausible link between ECC and SDG11C (Supporting least developed countries to build resilient buildings).

CONCLUSION

There are few studies identifying links between ECC and SDG11, with the findings suggesting the possible differences in the impact of urbanization on ECC by country income-level and home ownership as a protective factor from ECC. Further research is needed to explore measures of sustainable cities and their links with ECC within the context of the SDG11.

Associations between everyday exposure to food marketing and hunger and food craving in adults: An ecological momentary assessment study

Food marketing in television and digital media negatively affects appetitive sensations and eating behaviour in children, but effects are less well understood for outdoor food advertising and adults. This research used Ecological Momentary Assessment (EMA) to explore associations between exposures to food advertising in various contexts (television, digital, outdoors) and adults' hunger and craving for highly advertised food categories. Over one week, participants provided ratings of cravings for types of food (fast food, soft drinks, snacks/confectionery, other) and hunger on a smartphone app up to six times per day when they saw a food advertisement (reactive assessment) and at random intervals (random assessment). Fifty-four participants (70.4 % female; 21.24 ± 3.84 years) provided 1223 assessments (24.7 % reactive, 75.3 % random). Data were analysed in R using multilevel multivariable linear regression models. Participants reported feeling hungrier (X2(1) = 5.85, p = .016, ΔAIC = 3.9) and having stronger cravings (X2(1) = 20.64, p < .001, ΔAIC = 318.6) after seeing food advertisements vs. random assessments. This was driven by greater hunger following television advertising exposure vs. random assessments (β = 1.58, SE = 0.61, p = .010, 95 %CIs 0.38 to 2.78), food advertising via digital devices or outdoors was not associated with hunger. Participants experienced stronger craving after seeing a food advertisement on television (β = 0.52, SE = 0.19, p = .006, 95 %CIs 0.15 to 0.89), outdoors (β = 0.39, SE = 0.12, p < .001, 95 % CIs 0.16 to 0.62) and in digital media (β = 0.36, SE = 0.14, p = .012, 95 % CIs 0.08 to 0.64), vs. random assessments. Cravings were (largely) specific to the advertised food category. EMA can be effective for assessing food marketing associations in adults. The current study provides evidence that food marketing is associated with hunger and craving in adults, which may, with replication, have implications for public health policy.

Exposure and power of TV food advertising during the COVID-19 pandemic in Brazil: a content analysis

BACKGROUND

With the COVID-19 pandemic and the restrictions imposed to contain the spread of SARS-CoV-2, the Brazilian population has increased the time spent at home and watching television (TV). Since food advertising exposure is a key driver of food choices, this study described the content of food advertisements (ads) on Brazilian TV during the COVID-19 pandemic.

METHODS

This is an exploratory study. A total of 684 h of TV programming comprised of three free-to-air channels and two pay-per-view channels was recorded from 06 a.m. to 12 a.m. for eight non-consecutive days in June 2020. A content analysis of all the food-related ads was carried out. The data collection process followed INFORMAS Protocol for TV food advertising monitoring.

RESULTS

The sample was composed of 7,083 ads, 752 (10.6%) of which were food-related and 487 (6.9%) were promoting ultra-processed foods. The content analysis indicated seven thematic categories, all of them with reference to the COVID-19 pandemic: brand and product differentials (79.8%); visual and sound effects (70.2%); thematic campaigns (56.0%); digitization (22.9%); convenience (16.5%); economic benefits (11.9%); and commensality and social interaction (6.1%). Ads content varied according to the day of the week, the time of the day, the length of the ad, and the channel type.

CONCLUSIONS

The thematic of food advertising on Brazilian TV during the COVID-19 pandemic is aligned with the country's health crisis context and varied during the programming.

Characterizing restrictions on commercial advertising and sponsorship of harmful commodities in local government policies: a nationwide study in England

BACKGROUND

Commercial advertising and sponsorship drive the consumption of harmful commodities. Local authorities (LAs) have considerable powers to reduce such exposures. This study aimed to characterize local commercial policies across all English LAs.

METHODS

We conducted a census of all English LAs (n = 333) to identify local commercial policies concerning advertising and sponsorship of tobacco, alcohol, less healthy foods and gambling, through online searches and Freedom of Information requests. We explored policy presence, commodity frequency and type, and associations with LA characteristics (region, urban/rural and deprivation).

RESULTS

Only a third (106) of LAs in England had a relevant policy (32%). These included restrictions on tobacco (91%), gambling (79%), alcohol (74%) and/or less healthy foods (24%). Policy prevalence was lowest in the East of England (22%), North East (25%) and North West (27%), higher in urban areas (36%) than rural areas (28%) and lower in the least (27%) compared with the most (38%) deprived areas. Definitions in policies varied, particularly for alcohol and less healthy foods.

CONCLUSIONS

English LAs currently underutilize their levers to reduce the negative impacts of harmful commodity industry marketing, particularly concerning less healthy foods. Standardized guidance, including clarity on definitions and application, could inform local policy development.

Within-store fast food marketing: The association between food swamps and unhealthy advertisement

Previous studies have linked food consumption outside the home and fast food to poor diet quality and living within a food swamp to an increased likelihood of obesity. A growing amount of research has linked food marketing to food choice. Still, limited information is available on how this dynamic may work within fast food establishments and if the marketing strategies used may vary by neighborhood food swamp status. Utilizing the Environment Assessment (EAT) Tool, we examined the within-store marketing environment of fast food restaurants to understand the factors potentially influencing food choice. A cross-sectional study design surveyed fast food outlets (n = 170) for unhealthy advertisements. Each fast-food outlet was assigned an FSI score based on its geographic location and proximity to unhealthy outlets. Outlets were assessed for associations between food swamp status and unhealthy advertisements. Poisson Regression was performed to assess the relationship between unhealthy advertisements and FSI score. Low FSI had a mean unhealthy advertisement score of 36.79 (11.06). Moderate and High FSI had mean unhealthy advertisement scores of 33.03 (14.67) and 31.71 (12.63), respectively. The number of unhealthy advertisements did not differ by food swamp categories (Moderate FSI IRR: 0.90, 95% CI: 0.74-1.09; High FSI IRR: 0.86, 95% CI: 0.73-1.01 vs. low FSI). Differences in marketing environments by food swamp status were not observed. Future research should examine other factors of the food swamp environment and additional factors such as television or social media to understand its association with food choice.

Nutritional Strategies to Prevent Weight Gain and Obesity

It has now been 25 years since the World Health Organisation (Geneva, Switzerland) drew attention to the obesity epidemic (later becoming a pandemic) [...].

School-Level Socioeconomic Status and Nutrient Content of Outdoor Food/Beverage Advertisements

We examined if areas around schools with more students of lower socioeconomic status (SES) have more total food/beverage advertisements and/or more advertisements with poorer nutritional content as compared to areas around schools with fewer students with lower SES. All outdoor food/beverage advertisements within a half-mile radius of 47 middle and high schools in the United States were objectively documented in 2012 and coded for nutritional content. The total number of advertisements and the macronutrient and micronutrient contents (total calories, fat (g), protein (g), carbohydrate (g), sugar (g), and sodium (mg)) of food and beverage items depicted in the advertisements were calculated. In total, 9132 unique advertisements were recorded, with 3153 ads displaying food and beverages that could be coded for nutrient content. Schools located in areas of lower SES (≥60% students receiving free/reduced-price lunch) had significantly more advertisements displaying food and beverages that could be coded for nutrient content (z = 2.01, p = 0.04), as well as advertisements that contained more sodium (z = 2.20, p = 0.03), as compared to schools located in areas of higher SES. There were no differences in calorie, fat, protein, carbohydrate, or sugar content. Policies to reduce the prevalence of outdoor food and beverage advertising are warranted.

Opportunities to improve population health: possibilities for healthier food environments

The recent Covid-19 pandemic highlighted stark social inequalities, notably around access to food, nutrition and to green or blue space (i.e. outdoor spaces with vegetation and water). Consequently, obesity is socio-economically patterned by this inequality; and while the environmental drivers of obesity are widely acknowledged, there is currently little upstream intervention. We know that living with obesity contributes to increasing health inequalities, and places healthcare systems under huge strain. Our environment could broadly be described obesogenic, in the sense of supporting unhealthful eating patterns and sedentary behaviour. Evidence points to the existence of nearly 700 UK obesity policies, all of which have had little success. Obesity prevention and treatment has focused on educational and behavioural interventions targeted at individual consumers. A more sustainable approach would be to try and change the environments that promote less healthy eating and high energy intake as well as sedentary behaviour. Approaches which modify the environment have the potential to assist in the prevention of this complex condition. This review paper focuses on the role of wider food environments or foodscapes. While there is an imperfect evidence base relating to the role of the foodscape in terms of the obesity crisis, policy, practice, civic society and industry must work together and take action now, in areas where current evidence suggests change is required. Despite the current cost-of-living crisis, shaping the foodscape to better support healthful eating decisions has the potential to be a key aspect of a successful obesity prevention intervention.

Is it ethical to advertise unhealthy foods to children?

The marketing of foods and non-alcoholic beverages (hereafter: food) high in fats, salt and/or sugar (HFSS) has been strongly implicated in the rising levels of childhood obesity worldwide. Multiple ethical concerns arise from the practice of exposing children to such marketing and efforts to monitor and restrict it through regulatory policies. There is considerable evidence that exposure to powerful food marketing messages affects children's food behaviours in ways that are detrimental to good dietary health. Children are particularly vulnerable to being exploited and deceived by food marketing messages based on their cognitive and developmental immaturity. HFSS food marketing also affects numerous child rights enshrined within the UN Convention on the Rights of the Child (of which the UK is a signatory) including the right to the enjoyment of the highest attainable standard of health. The debate has become somewhat polarised between the public health community's evidence-based assertion that all marketing is inherently exploitative and the rebuttal from food and marketing industry stakeholders that provided the marketing is 'accurate and truthful' and there is no ethical need to regulate. This polarisation is reflected in the complexity of policymaking decisions regarding the rationale for mandatory government-led policies or industry self-regulation. There are also ethical considerations inherent in the monitoring of children's food marketing exposure, particularly in the digital sphere, by researchers for the purposes of informing policy design, scope and implementation. This review paper will explore the latest evidence on these issues and consider the implications for public health research, policy, and practice.

Assessing exposure to outdoor advertisement for products high in fat, salt and sugar (HFSS); is self-reported exposure a useful exposure metric?

BACKGROUND

Exposure to advertising of unhealthy commodities such as fast-food and gambling is recognised as a risk factor for developing non-communicable diseases. Assessment of the impact of such advertisement and the evaluation of the impact of any policies to restrict such advertisements on public health are reliant on the quality of the exposure assessment. A straightforward method for assessing exposure is to ask people whether they noticed any such advertisements in their neighbourhoods. However, the validity of this method is unclear. We assessed the associations between measured exposure to outdoor advertising, self-reported exposure, and self-reported consumption.

METHODS

We collected exposure information in January-March 2022 using two methods: (i) through a resident survey investigating advertising and consumption of unhealthy products, distributed across Bristol and neighbouring South Gloucestershire, and (ii) through in-person auditing. Self-reported exposure was obtained from the resident survey (N = 2,560) and measured exposure from photos obtained for all Council owned advertisement sites (N = 973 bus stops). Both data sources were geographically linked at lower-super-output-area level. Reporting ratios (RRs), 95% confidence intervals (CIs), and Cohen's kappas, are presented.

RESULTS

24% of advertisements displayed food and/or drink advertising. Bristol respondents in neighbourhoods displaying food/drink adverts were more likely to also report seeing these adverts compared to those in neighbourhoods without food/drink adverts (59% vs. 51%, RR = 1.15, 95%CI 1.01-1.31). There was no such association in South Gloucestershire (26% vs. 32%, RR = 0.82, 95%CI 0.58-1.14). Respondents in both Bristol and South Gloucestershire who recalled seeing advertising for unhealthy food and drink products were more likely to consume them (e.g. for fast-food: 22% vs. 11%, RR = 2.01, 95%CI 1.68-2.42). There was no such association between measured food and drink adverts in respondents' local areas and self-reported consumption of HFSS product (90.1% vs. 90.7%, RR = 0.99, 95%CI 0.96-1.03).

CONCLUSIONS

Self-reported outdoor advertisement exposure is correlated with measured exposure, making this a useful methodology for population studies. It has the added advantage that it correlates with consumption. However, given that measurement error can be significant and self-reported exposure is known to be susceptible to various biases, inferences from studies using this exposure metric should be made with caution.