The impact of pictorial health warnings on purchases of sugary drinks for children: A randomized controlled trial

Abstract

Background Pictorial warnings on tobacco products are promising for motivating behavior change, but few studies have examined pictorial warnings for sugary drinks, especially in naturalistic environments. This study aimed to examine the impact of pictorial warnings on parents’ purchases of sugary drinks for their children in a naturalistic store laboratory. Methods and findings Parents of children ages 2 to 12 (n = 325, 25% identifying as Black, 20% Hispanic) completed a shopping task in a naturalistic store laboratory in North Carolina. Participants were randomly assigned to a pictorial warnings arm (sugary drinks displayed pictorial health warnings about type 2 diabetes and heart damage) or a control arm (sugary drinks displayed a barcode label). Parents selected 1 beverage and 1 snack for their child, as well as 1 household good; one of these items was selected for them to purchase and take home. The primary outcome was whether parents purchased a sugary drink for their child. Secondary outcomes included reactions to the trial labels, attitudes toward sugary drinks, and intentions to serve their child sugary drinks. Pictorial warnings led to a 17-percentage point reduction in purchases of sugary drinks (95% CI for reduction: 7% to 27%), with 45% of parents in the control arm buying a sugary drink for their child compared to 28% in the pictorial warning arm (p = 0.002). The impact of pictorial warnings on purchases did not differ by any of the 13 participant characteristics examined (e.g., race/ethnicity, income, education, and age of child). Pictorial warnings also led to lower calories (kcal), purchased from sugary drinks (82 kcal in the control arm versus 52 kcal in the pictorial warnings arm, p = 0.003). Moreover, pictorial warnings led to lower intentions to serve sugary drinks to their child, feeling more in control of healthy eating decisions, greater thinking about the harms of sugary drinks, stronger negative emotional reactions, greater anticipated social interactions, lower perceived healthfulness of sugary drinks for their child, and greater injunctive norms to limit sugary drinks for their child (all p < 0.05). There was no evidence of difference between trial arms on noticing of the labels, appeal of sugary drinks, perceived amount of added sugar in sugary drinks, risk perceptions, or perceived tastiness of sugary drinks (all p > 0.05). Conclusions Pictorial warnings reduced parents’ purchases of sugary drinks for their children in this naturalistic trial. Warnings on sugary drinks are a promising policy approach to reduce sugary drink purchasing in the US. Trial registration The trial design, measures, power calculation, and analytic plan were registered before data collection at www.clinicaltrials.gov NCT04223687.

Effect of Front-of-Package Information, Fruit Imagery, and High–Added Sugar Warning Labels on Parent Beverage Choices for Children

“…Some options include restricting nutrient content claims or fruit imagery on products with high levels of added sugar, requiring FOP percentage juice content disclosures 19 (in addition to currently mandated back-of-pack disclosures 20 ), or requiring added-sugar warnings if these added sugars exceed a predetermined level. Evidence suggests that added-sugar warnings may reduce SSB purchases, [21][22][23][24][25] and the US Congress has introduced a bill to mandate such warnings. 26 Combining warnings with quantitative added-sugar disclosures (eg, teaspoons of added sugar/serving) may further discourage SSB consumption.…”

Addressing Sugar-Sweetened Beverage Consumption in North Carolina

“…One approach is having pictorial warnings on SSB containers to decrease the consumption of SSB. A recent study in North Carolina aimed to examine the impact of pictorial warnings based on parents' purchases of SSB for their children in a realistic store laboratory [10]. The study showed success in limiting parents' SSB purchases for their children by giving them a sense of feeling more in control of making healthier decisions [10].…”

“…A recent study in North Carolina aimed to examine the impact of pictorial warnings based on parents' purchases of SSB for their children in a realistic store laboratory [10]. The study showed success in limiting parents' SSB purchases for their children by giving them a sense of feeling more in control of making healthier decisions [10]. Another approach is for North Carolina to adopt more kids' meal policies like the nearly 24 states and localities that have already done so [11].…”

Exploring the effects of added sugar labels on food purchasing behaviour in Australian parents: An online randomised controlled trial

“…However, labels were noted to have a greater effect on consumers’ understanding of sugar content than on the healthiness of choices. Recent findings suggest that graphical tobacco-style pictorial labels may be more effective than text- or icon-based warnings among parents [ 29 ] and young adults [ 21 ]. No jurisdictions currently require such pictorial warning labels, and the current study chose to focus on policy-relevant labels under consideration by the Australian government.…”