key: cord-0779073-w0mu7y98
authors: Nanchahal, Kiran; Vasiljevic, Milica; Petticrew, Mark
title: A content analysis of the aims, strategies, and effects of food and nonalcoholic drink advertising based on advertising industry case studies
date: 2021-09-15
journal: Obes Sci Pract
DOI: 10.1002/osp4.561
sha: 7c023057d8979cff0dfce6901a35a29277c38861
doc_id: 779073
cord_uid: w0mu7y98

BACKGROUND: Placing limitations on advertising of food and nonalcoholic drinks to children is an effective strategy in addressing childhood obesity. The industry maintains that further restrictions are unnecessary. AIMS: To ascertain whether the advertising campaigns were successful according to the industry evaluations and more specifically the effects of marketing on children. MATERIALS & METHODS: A total of 117 case studies (1980–2016) published by the advertising industry which evaluate the effects of advertising campaigns were reviewed. This industry data source had been previously used to analyze the effects of alcohol advertising campaigns. The nutrition profile of the products was assessed by applying the World Health Organisation Nutrition Profile model designed to restrict the marketing of foods and beverages to children. RESULTS: The food and drink industry advertising campaigns target specific consumers including children, use several persuasive marketing techniques (utilizing celebrities and gamification), often position unhealthy products as healthy, and lead to increased sales of the advertised product with good returns on investment. The health‐related claims made, and aspects of the campaigns related to the marketing of the products to children are summarized. DISCUSSION: Our analysis of food and non‐alcoholic drinks case studies aligns with similar analyses of tobacco and alcohol advertising CONCLUSION: This analysis, based on internal industry data, presents important evidence on the effects of advertising on consumption‐related outcomes and the mechanisms by which they are achieved.

The obesogenic food environment is implicated as a contributory causal factor of the worldwide obesity epidemic with the global shift in the food system toward ultra-processed foods high in sugars and saturated fat being a major driver. 1, 2 Increases in ultra-processed food and drink volume sales per capita are positively associated with population-level body mass index (BMI) trajectories worldwide, with evidence supporting the link between food marketing and individual weight outcomes. 3, 4 One influence on people's food choices is marketing by the food and beverage industry, with people across the world living in media saturated environments. 5, 6 A recent report found producers of the top 18 UK brands (largely crisps, confectionery, and sugary drinks) spent more than £143m (€160m; $190m) on advertising in 2016, about 27.5 times the £5.2m spent by the UK government's healthy eating campaign (Change4Life). 7 The International Network for Food and Obesity/Noncommunicable Diseases Research, Monitoring and Action Support (INFORMAS) defines the food environment as "the collective physical, economic, policy and sociocultural surroundings, opportunities and conditions that influence people's food and beverage choices and nutritional status." 8 The Eatwell Guide to a healthy diet states that foods high in fat, sugar, and salt (HFSSS) are not part of a healthy diet and are considered unhealthy in the context of this study. 9 The food industry influences obesity-related dietary behaviors in children by promoting HFSS products using "persuasive marketing techniques, such as attractive product packing, toys, and emotional appeals to forge longlasting relations with children and create brand loyalty in the short and long run." 10 Globally, children are exposed to a large volume of TV advertisements for unhealthy foods and beverages, despite the implementation of food industry codes of practice. 11 Children aged 2-14 years exposed to food advertising on TV and advergames consumed an average of 60.0 and 53.2 kcal, respectively, more than children exposed to non-food advertising. 12 The contribution of TV food advertising exposure to the prevalence of obesity among 6-to 11-year-old children is estimated as 16%-40% in the United States, 10%-28% in Australia and Italy, and 4%-18% in Great Britain, Sweden and the Netherlands, with moderately strong evidence to support the reduction of food promotion to children as an obesity prevention measure. 13, 14 A review on the effects of food advertising on adults reported a significant association with food choices while studies in children found that unhealthy dietary marketing leads to increased preference and intake of energy-dense, nutrition-poor (EDNP) food and beverages, even with short-term exposure. [15] [16] [17] [18] Norman systematically examined the evidence on food marketing exposure and children's behavior, concluding that there was compelling evidence for a causal relationship between them, particularly for food preferences, choices, and short-term consumption among 3-12 year-olds. 19 Restrictions have been placed on the marketing of food and drink to children in several countries, with evidence suggesting that statutory regulation is more effective than self-regulatory approaches. 20 Cost-effectiveness and multi-state life table modeling studies in Australia and the United Kingdom on the effects of restricting HFSS advertising on children suggest a reduction in energy intake, BMI, prevalence of overweight and obesity, as well as health-related costs. 21, 22 The UK government launched consultations on the extension of restrictions on advertising of HFSS products as part of its contribution to dealing with childhood obesity and more recently an obesity strategy for England in the context of the COVID-19 pandemic. [23] [24] [25] The effects of advertising are disputed by the industry stating that "There is no scientific consensus that food advertising causes obesity" and that "Food advertising is, at most, a marginal factor in determining children's food choices." 26 The Food and Drink Federation has raised objections to the UK government proposals on the grounds that they will have little impact on levels of obesity or sale of products stating that, "the proposed extension to advertising restrictions which call for a restriction on advertising before 9pm on both TV and the internet is predicted to make a 2-calorie [daily] difference to children's intakes." 27 A hitherto-untapped source of evidence on the impact of specific advertising campaigns on consumption has been identified and used it to show the effects of alcohol advertising on consumption-related outcomes, and mechanisms by which they achieve those effects. 28 This derives from a series of evaluative advertising industry case studies reporting on the effectiveness of advertising campaigns for food, alcohol, and nonalcoholic beverages as well as food outlets. some studies present evidence on dose-response effects and qualitative data (from focus groups). To our knowledge, these case studies have not been systematically examined outside the food and advertising industries. They therefore represent a key overlooked source of evidence on the effects of food and beverage advertising.

The main aims of the study were to describe the target audience; objectives and strategies used in the marketing campaigns for food, nonalcoholic beverages and fast-food outlets; the effects of advertising on awareness, penetration, sales, return on (marketing) investment (RO(M)I); and strategies used and effects on children.

A total of 117 case studies reporting on campaigns conducted between 1980 and 2014 related to food, nonalcoholic beverages, and NANCHAHAL ET AL.

-209 fast-food outlets published across 23 volumes of the Advertising Series were identified. There are no case studies available after 2016 in the public domain. The case studies report on the evaluations of advertising campaigns for products ranging from those used in cooking (e.g., margarine, cooking oil, and stock pots), breakfast cereals, milk, bread, cheese, ready-made meals (e.g., frozen pizza and jacket potato), chocolate, and drinks to fast-food outlets. Although the regulatory environment has changed since the 1980s, obesity was already a public health concern in the 1970s with the Health Education Council, a centralized nongovernmental body responsible for health education services, launching a campaign to increase public awareness of the health problems caused by overeating in 1978. 29 Furthermore, the impact of advertising on children's eating habits was being reported by the early 1980s. 30 These case studies have not been previously analyzed so it is important to include all of the data and examine the industry claim that advertising does not affect behavior (and indirectly, consumption). Moreover, this analysis focuses on the strategies and mechanisms of action of advertising campaigns rather than obesity per se.

The information about the advertised products contained in the case studies was systematically assessed. The nutritional profile of foods and nonalcoholic beverages within each report was evaluated by applying the World Health Organisation (WHO) Regional Office for Europe nutrient profile (NP) model designed for the purpose of restricting the marketing of foods and beverages to children. 31 The model classifies products into 16 food and 4 nonalcoholic beverage categories and designates them as "permitted" or "not permitted" to be advertised to children. Certain categories are not permitted regardless of their nutritional composition-including chocolate and confectionery, cakes and sweet biscuits, juices, and energy drinks. Conversely, unprocessed meat, fish, fresh/frozen fruit, and vegetables are permitted to be marketed without restriction. For other categories, threshold criteria per 100 g/mL for total fat, saturated fat, trans fat, total sugar, added sugar, non-sugar sweeteners, salt, and/or energy apply. Advertisements for coffee, tea, nutritional supplements, baby and toddler food, and food outlets are not covered by the WHO NP model. Nutritional information was obtained from producers; websites in the first instance, if not then the supermarkets stocking the products, and finally from food composition websites.

Additional data from each case study was extracted on the following variables where available: the volume of sales, year(s) of the marketing campaign, country; descriptive information on the nature of the food or beverage product, company, retailer, or outlet promoted (brand/company name and description); target audience, objectives of the campaign, strategy used (including promotional characters, such as company-owned characters or mascots, thirdparty licensed characters, entertainment, or sports celebrities); health-related claims made, advertising/media spend, return on investment (ROI/ROMI), awareness (index or proportion aware (%)), penetration (%), trial (%), additional volume sales (%), sales attributable to advertising (%), value/brand share, number of new customers, additional units, or weight (kg) sold. Awareness was reported either using the awareness index (a measure of advert quality representing the level of claimed recall of the advert) or change in proportion aware associated with the advertising campaign. Penetration represented a measure of the popularity of a product in terms of usage or purchase. Marketing to children was assessed according to whether a specific target audience was mentioned in the case study report which directly or implicitly included children using terms such as housewives, families, parents or mums with children, children and teenagers or age range including under 18-year-olds.

The aim was to ascertain whether the advertising campaigns Furthermore, the case studies do not always present the full raw data necessary for such calculations to be presented here.

A total of 117 case studies on food, nonalcoholic beverages, and fastfood restaurants published 1980-2014 with the advertising campaigns covering a period between 1979 and 2016 (Table S1) were evaluated. These included 11 case studies that could not be assigned a permitted or not code (five food outlets, three tea/coffee, one baby meals, and two margarines no longer produced). Of the remaining campaigns, only about one in five of the products were currently permitted to be marketed to children according to the WHO NP model ( Table 1 ). The majority of campaigns were based in the United Kingdom, although other countries were also represented, including Denmark, India, and Malaysia, while some had a global reach.

T A B L E 1 Target audience according to whether currently permitted to be marketed to children or not 

About one in 10 campaigns mentioned targeting specific socioeco- 

The aims and objectives of the campaigns included: to clarify the benefits of the product (e.g., Actimel), demonstrate that a product can 

The advertisers used various strategies to increase sales and con- 

Specific health-related claims were made in 34 reports, including mentioning health-related ingredients, nutrient content, or comparison (e.g., low fat), general health, functional (e.g., digestion), 23

(67.6%) are not currently permitted to be marketed to children.

The advertising suggested that the product is tasty and fun to eat, and implied, on a covert level, that meatballs have 'food value'. The idea succeeded in distancing meatballs from their gimmicky/junky image. 

Many case studies reported an increase in awareness of the product either using the awareness index (a measure of ad quality representing the level of claimed recall of the advert) or change in proportion aware associated with the advertising campaign.

For example, the advertising boosted awareness from 41% to 61%

(Kia-Ora, 1983-1986) or awareness index increased from 8 to 18 and, pass from older to younger siblings:

The way in which older and younger children react to our advertising is broadly analogous with other markets in which products find favour initially with a group NANCHAHAL ET AL. Dairylea's Strip Cheese met children's desire for food that they can play with-the fun factor was at the forefront and the advertising reflected this …. (Dairylea, 1996 (Dairylea, -1999 Others relied on recruiting children as the mechanism to drive sales:

Children are known to be a notoriously fickle target group: 'faddish' about food, they can be strongly motivated to ask for a particular product through involving advertising …. Parents appeared more willing to provide cereals their children asked for-including relatively more expensive, 'pre-sweetened' brands. (Coco Pops, 1981 -1983 What is also certain, is that not just 'any' advertising There are striking similarities in the way the food, alcohol, and tobacco industries have responded to public mistrust, unfavorable scientific evidence, and calls for regulatory action. Our analysis of industry case studies aligns with similar analyses of tobacco and alcohol advertising. 28, 55 Food and drink companies and advertisers have issued statements declaring their concern with the public's well-being, and claiming that no further regulation is needed:

Members of the Food and Drink Federation take their responsibility to tackle public health issues very seriously. Members are committed to playing a positive role in addressing these issues, particularly in relation to the rising obesity levels. 27 We have always supported the aim of tackling the problem of obesity in the UK but we have always made the case that the introduction of further restrictions on advertising will not help achieve that aim. 56 One similarity between tobacco, alcohol, and food companies is the introduction and marketing of "safer" or "healthier" products.

These products include those with reduced amounts of ingredients thought to cause harm (e.g., sugar, fat, salt, and alcohol) and

products supplemented or fortified with ingredients purported to improve health (e.g., vitamins and minerals, oat bran, and whole grains). As with a number of food advertising campaigns analyzed in this study, the marketing of low(er) strength alcohol products used marketing messages that suggested additional consumption occasions with added implications for health. 55 The tobacco industry also marketed cigarettes on the basis of spurious health claims, and even marketed "health-image" cigarettes. 57 As with the food and drink industry, the tobacco industry emphasized personal responsibility, made self-regulatory pledges, lobbied against government action, introduced "safer" products, and marketed to children, arguing that this did not lead to smoking uptake. The food and drink industry differs from tobacco companies in important ways, but there "are significant similarities in the actions that these industries have taken in response to concern that their products cause harm." 58 An examination of the strategies used by the US Sugar Association found that their overarching narrative was that restricting sugar, which it claimed was a valuable food that makes healthy foods more palatable, would cause harm but that this defense did not meet criteria for truthfulness or sincerity. 59 The nonalcoholic beverage industry uses similar tactics-lobbying policymakers and aiming to shift attention and blame away from sugar-sweetened beverages in the debate about obesity. 60 Tangcharoensathien reviewed aggressive market promotion and industry interference in government policies and classified them into four groups of tactics: "(a) interfering with the legislative process;

(b) using front groups to act on their behalf; (c) questioning the evidence of tobacco harm and the effectiveness of harm-reduction interventions; and (d) appearing responsible in the eyes of the public, journalists and policy-makers." Tobacco, alcohol, and unhealthy food and drink industries use similar tactics to aggressively interfere in policies. 61 A major strength of this study is that we used a previously overlooked source of industry's own evidence on the impact of food and nonalcoholic beverage advertising on consumption. The findings are also consistent with findings of an analysis of alcohol industry advertising campaigns using the same source of industry data. 28 A key limitation is that these case studies are not a representative sample of advertising industry evaluations as the majority are based on award winning campaigns, and many are from the 1980s and 1990s. A limitation regarding advertising aimed at consumption by children is that our use of the WHO NP model is retrospective, and we cannot be certain that the product advertised would have been "permitted" or not at the time the advertising campaign was run. The formulation of the products may also have changed since the campaigns included here. Moreover, several of the reports are very brief, often just two pages, with insufficient detail provided to code all the variables studied here.

There is an urgent need to consider obesity in a much wider context of common underlying societal and political drivers, including the commercial determinants of health with part of the solution being restrictions on marketing of HFSS and EDNP foods with our analyses

showing the role that this plays in promoting unhealthy diets, especially to children. These findings provide additional evidence from within the food and nonalcoholic drinks industry to support calls for restrictions on advertising as a means of addressing obesity and its health implications in children and adults.

NANCHAHAL ET AL.

The global obesity pandemic: shaped by global drivers and local environments

Global changes in food supply and the obesity epidemic

A hierarchy of unhealthy food promotion effects: identifying methodological approaches and knowledge gaps

Global trends in ultraprocessed food and drink product sales and their association with adult body mass index trajectories

Creating healthy food and eating environments: policy and environmental approaches

ObesiTV: how television is influencing the obesity epidemic

Spending on junk food advertising is nearly 30 times what government spends on promoting healthy eating

INFORMAS (International Network for Food and Obesity/Non-Communicable Diseases Research, Monitoring and Action Support): overview and key principles

Beyond food promotion: a systematic review on the influence of the food industry on obesity-related dietary behaviour among children

Global benchmarking of children's exposure to television advertising of unhealthy foods and beverages across 22 countries

The effect of screen advertising on children's dietary intake: a systematic review and meta-analysis

The influence of the food environment on overweight and obesity in young children: a systematic review

Television food advertising and the prevalence of childhood overweight and obesity: a multicountry comparison

Food advertising to children and its effects on diet: review of recent prevalence and impact data

Influence of unhealthy food and beverage marketing on children's dietary intake and preference: a systematic review and metaanalysis of randomized trials

Advertising as a cue to consume: a systematic review and meta-analysis of the effects of acute exposure to unhealthy food and nonalcoholic beverage advertising on intake in children and adults

The effects of food advertising on food-related behaviours and perceptions in adults: a review

The impact of marketing and advertising on food behaviours: evaluating the evidence for a causal relationship

Reducing the volume, exposure and negative impacts of advertising for foods high in fat, sugar and salt to children: a systematic review of the evidence from statutory and self-regulatory actions and educational measures

The potential costeffectiveness and equity impacts of restricting television advertising of unhealthy food and beverages to Australian children

The potential health impact of restricting less-healthy food and beverage advertising on UK television between 05.30 and 21.00 hours: a modelling study

tackling-obesity-government-strategy/tackling-obesity-empoweringadults-and-children-to-live-healthier-lives 24. Introducing a Total Online Advertising Restriction for Products High in Fat, Sugar and Salt (HFSS). GOV.UK; 2020. Access

Introducing Further Advertising Restrictions on TV and Online for Products High in Fat

Understanding Food Advertising

Advertising and Promotions 2020

Recruiting the "heavy-using loyalists of tomorrow": an analysis of the aims, effects and mechanisms of alcohol advertising, based on advertising industry evaluations

Wellcome Trust-Funded Monographs and Book Chapters 'Look after yourself': visualising obesity as a public health concern in 1970s and 1980s Britain

The development of children's eating habits: the role of television commercials

World Health Organization. WHO Regional Office for Europe Nutrient Profile Model

An audit of food and beverage advertising on the Sydney metropolitan train network: regulation and policy implications

Socioeconomic differences in outdoor food advertising at public transit stops across Melbourne suburbs

Unhealthful foodand-beverage advertising in subway stations: targeted marketing, vulnerable groups, dietary intake, and poor health

Food and beverage TV advertising to young children: measuring exposure and potential impact

Television food advertising to children: a global perspective

The impact of initiatives to limit the advertising of food and beverage products to children: a systematic review

Food advertisements on UK television popular with children: a content analysis in relation to dental health

A path analysis model of factors influencing children's requests for unhealthy foods

Children's food and beverage promotion on television to parents

Persuasive techniques used in television advertisements to market foods to UK children

Healthy characters? An investigation of marketing practices in children's food advertising

Weekday and weekend food advertising varies on children's television in the USA but persuasive techniques and unhealthy items still dominate

Food marketing influences children's attitudes, preferences and consumption: a systematic critical review

Children's exposure to television food advertising Contributes to strong brand attachments

A systematic review of persuasive marketing techniques to promote food to children on television

Influence of food companies' brand mascots and entertainment companies' cartoon media characters on children's diet and health: a systematic review and research needs

Teaching children about good health? Halo effects in child-directed advertisements for unhealthy food

The health halo trend in UK television food advertising viewed by children: the rise of implicit and explicit health messaging in the promotion of unhealthy foods

Content analysis of advertisements related to oral health in children: a systematic review and meta-analysis

Prime Minister for a day: children's views on junk food marketing and what to do about it

The effects of digital marketing of unhealthy commodities on young people: a systematic review

Fast food, beverage, and snack brands on social media in the United States: an examination of marketing techniques utilized in 2000 brand posts

Digital marketing of unhealthy foods to Australian children and adolescents. Health Promot Int

Marketing messages accompanying online selling of low/er and regular strength wine and beer products in the UK: a content analysis

How Will the UK Government's Junk Food Ad Ban Impact the Marketing Sector

The Cigarette Papers

The perils of ignoring history: big tobacco played dirty and millions died. How similar is big food? Milbank Q

In defense of sugar: a critical analysis of rhetorical strategies used in the Sugar Association's award-winning 1976 public relations campaign

Public meets private: conversations between Coca-Cola and the CDC

Addressing NCDs: challenges from industry market promotion and interferences

A content analysis of the aims, strategies, and effects of food and nonalcoholic drink advertising based on advertising industry case studies

The authors would like to thank Sian Thomas for helping with extracting the data from the case studies.

Mark Petticrew is a co-investigator in the SPECTRUM consortium which is funded by the UK Prevention Research Partnership 

https://orcid.org/0000-0001-8812-7628