Introduction
Five U.S. states have proposed policies to require health warnings on sugar-sweetened
beverages, but warnings’ effects on actual purchase behavior remain uncertain. This
study evaluated the impact of sugar-sweetened beverage health warnings on sugar-sweetened
beverage purchases.
Study design
Participants completed one study visit to a life-sized replica of a convenience store
in North Carolina. Participants chose six items (two beverages, two foods, and two
household products). One item was randomly selected for them to purchase and take
home. Participants also completed a questionnaire. Researchers collected data in 2018
and conducted analyses in 2019.
Setting/participants
Participants were a demographically diverse convenience sample of 400 adult sugar-sweetened
beverage consumers (usual consumption ≥12 ounces/week).
Intervention
Research staff randomly assigned participants to a health warning arm (sugar-sweetened
beverages in the store displayed a front-of-package health warning) or a control arm
(sugar-sweetened beverages displayed a control label).
Main outcome measures
The primary trial outcome was sugar-sweetened beverage calories purchased. Secondary
outcomes included reactions to trial labels (e.g., negative emotions) and sugar-sweetened
beverage perceptions and attitudes (e.g., healthfulness).
Results
All 400 participants completed the trial and were included in analyses. Health warning
arm participants were less likely to be Hispanic and to have overweight/obesity than
control arm participants. In intent-to-treat analyses adjusting for Hispanic ethnicity
and overweight/obesity, health warnings led to lower sugar-sweetened beverage purchases
(adjusted difference, −31.4 calories; 95% CI= −57.9, −5.0). Unadjusted analyses yielded
similar results (difference, −32.9 calories; 95% CI= −58.9, −7.0). Compared with the
control label, sugar-sweetened beverage health warnings also led to higher intentions
to limit sugar-sweetened beverage consumption and elicited more attention, negative
emotions, thinking about the harms of sugar-sweetened beverage consumption, and anticipated
social interactions. Trial arms did not differ on perceptions of sugar-sweetened beverages’
added sugar content, healthfulness, appeal/coolness, or disease risk.
Conclusions
Brief exposure to health warnings reduced sugar-sweetened beverage purchases in this
naturalistic RCT. Sugar-sweetened beverage health warning policies could discourage
sugar-sweetened beverage consumption.
Trial registration
This study is registered at www.clinicaltrials.gov NCT03511937.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of Preventive MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
- Trends in beverage consumption among children and adults, 2003‒2014.Obesity (Silver Spring). 2018; 26: 432-441
- Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association.Circulation. 2011; 123: 933-944
- Dietary Guidelines for Americans 2015–2020.8th edition. Published 2015http://health.gov/dietaryguidelines/2015/guidelines/Date accessed: November 10, 2016
- Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis.Am J Clin Nutr. 2013; 98: 1084-1102
- Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk.Circulation. 2010; 121: 1356-1364
- Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction.BMJ. 2015; 351: h3576
- Resolved: there is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases.Obes Rev. 2013; 14: 606-619
- Interventions to reduce consumption of sugar-sweetened beverages or increase water intake: evidence from a systematic review and meta-analysis.Obes Rev. 2017; 18: 1350-1363
- The global obesity pandemic: shaped by global drivers and local environments.Lancet. 2011; 378: 804-814
- Patchy progress on obesity prevention: emerging examples, entrenched barriers, and new thinking.Lancet. 2015; 385: 2400-2409
- Smart food policies for obesity prevention.Lancet. 2015; 385: 2410-2421
- The surgeon general's call to action to prevent and decrease overweight and obesity.Office of the Surgeon General, Rockville, MD2001www.ncbi.nlm.nih.gov/books/NBK44206/Date accessed: January 17, 2018
- Sugar-sweetened beverages: safety warnings.Published 2019http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201920200SB347Date accessed: February 27, 2019
- Concerning mitigation of the adverse impacts of sugar-sweetened beverages.Published 2016http://app.leg.wa.gov/billsummary?BillNumber=2798&Year=2016Date accessed: June 24, 2019
- Relating to health.Published 2017www.capitol.hawaii.gov/measure_indiv.aspx?billtype=HB&billnumber=1209&year=2017Date accessed: June 24, 2019
- An act related to health and safety warnings on sugar-sweetened beverages.Published 2017https://legislature.vermont.gov/bill/status/2018/H.433Date accessed: July 3, 2019
- Requires sugar-sweetened beverages to be labeled with a safety warning.Published 2017www.nysenate.gov/legislation/bills/2017/S162Date accessed: June 24, 2019
- Growing momentum for sugar-sweetened beverage campaigns and policies: costs and considerations.Am J Public Health. 2017; 107: 835-838
- The influence of sugar-sweetened beverage health warning labels on parents’ choices.Pediatrics. 2016; 137e20153185
- The influence of sugar-sweetened beverage warnings: a randomized trial of adolescents’ choices and beliefs.Am J Prev Med. 2016; 51: 664-672
- Effects of plain packaging, warning labels, and taxes on young people's predicted sugar-sweetened beverage preferences: an experimental study.Int J Behav Nutr Phys Act. 2016; 13: 95
- Does changing behavioral intentions engender behavior change? A meta-analysis of the experimental evidence.Psychol Bull. 2006; 132: 249-268
- The effect of graphic warnings on sugary-drink purchasing.Psychol Sci. 2018; 29: 1321-1333
- The impact of price and nutrition labelling on sugary drink purchases: results from an experimental marketplace study.Appetite. 2018; 121: 129-137
- Development of a brief questionnaire to assess habitual beverage intake (BEVQ-15): sugar-sweetened beverages and total beverage energy intake.J Acad Nutr Diet. 2012; 112: 840-849
- Hiding the tobacco power wall reduces cigarette smoking risk in adolescents: using an experimental convenience store to assess tobacco regulatory options at retail point-of-sale.Tob Control. 2016; 25: 679-684
- Placing antismoking graphic warning posters at retail point-of-sale locations increases some adolescents’ susceptibility to future smoking.Nicotine Tob Res. 2019; 21: 220-226
- Monitoring foods and nutrients sold and consumed in the United States: dynamics and challenges.J Acad Nutr Diet. 2012; 112: 41-45.e4
- Trends in sugar-sweetened beverage consumption among youth and adults in the United States: 1999‒2010.Am J Clin Nutr. 2013; 98: 180-188
- Increasing consumption of sugar-sweetened beverages among U.S. adults: 1988–1994 to 1999‒2004.Am J Clin Nutr. 2008; 89: 372-381
- How should sugar-sweetened beverage health warnings be designed? A randomized experiment.Prev Med. 2019; 121: 158-166
- Understanding why pictorial cigarette pack warnings increase quit attempts.Ann Behav Med. 2019; 53: 232-243
- Effect of pictorial cigarette pack warnings on changes in smoking behavior: a randomized clinical trial.JAMA Intern Med. 2016; 176: 905-912
- Pictorial cigarette pack warnings: a meta-analysis of experimental studies.Tob Control. 2015; 25: 341-354
- Introductory Econometrics: A Modern Approach.5th ed. South-Western, Cengage Learning, Mason, OH2013
- Quick assessment of literacy in primary care: the newest vital sign.Ann Fam Med. 2005; 3: 514-522
- Cost effectiveness of a sugar-sweetened beverage excise tax in the U.S.Am J Prev Med. 2015; 49: 112-123
- A penny-per-ounce tax on sugar-sweetened beverages would cut health and cost burdens of diabetes.Health Aff (Millwood). 2012; 31: 199-207
- Ending SNAP subsidies for sugar-sweetened beverages could reduce obesity and type 2 diabetes.Health Aff (Millwood). 2014; 33: 1032-1039
R.J. Reynolds Tobacco Co. v. Food and Drug. Admin, 696 F.3d 1205 (D.C. Cir. 2012).
- The impact of strengthening cigarette pack warnings: systematic review of longitudinal observational studies.Soc Sci Med. 2016; 164: 118-129
- Commentary: soda taxes, obesity, and the shifty behavior of consumers.Prev Med. 2011; 52: 417-418
- Quantification of the effect of energy imbalance on bodyweight.Lancet. 2011; 378: 826-837
- Fruit juice: just another sugary drink?.Lancet Diabetes Endocrinol. 2014; 2: 444-446
- Targeting overconsumption of sugar-sweetened beverages vs. overall poor diet quality for cardiometabolic diseases risk prevention: place your bets.Nutrients. 2017; 9: 600
- Communicating about cigarette smoke constituents: an experimental comparison of two messaging strategies.J Behav Med. 2017; 40: 352-359
- Nutrition warnings as front-of-pack labels: influence of design features on healthfulness perception and attentional capture.Public Health Nutr. 2017; 20: 3360-3371
- The science on front-of-package food labels.Public Health Nutr. 2013; 16: 430-439
- Impact of food labelling systems on food choices and eating behaviours: a systematic review and meta-analysis of randomized studies.Obes Rev. 2016; 17: 201-210
Article info
Publication history
Published online: October 02, 2019
Identification
Copyright
© 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
