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5 Emerging Policy Initiatives and Communication Strategies I n the final panel of the workshop, five speakers discussed several prom- ising innovative approaches to reducing or countering the marketing of unhealthy foods to children. Monifa Bandele, campaign director of MomsRising, described the power of advocacy spurred by online com- munications to change policy. Terry Huang, professor and chair of the Department of Health Promotion in the College of Public Health, Univer- sity of Nebraska Medical Center, talked about one of the few antiobesity efforts aimed directly at Hispanics. Cheryl Healton, founding president and chief executive officer of Legacy, drew parallels between the food and tobacco industries, which suggest that similar confrontational approaches may prove useful to counter the marketing of unhealthy foods. Samantha Graff, research director at ChangeLab Solutions, reviewed the legal issues involved in food marketing and opportunities to take advantage of previous legal decisions. Finally, Tim Lobstein, director of policy and programmes at the International Association for the Study of Obesity (IASO), described international efforts to limit food marketing, which could inform such ini- tiatives in the United States. PARENT-LED COMMUNICATION STRATEGIES Summary of presentation by Monifa Bandele MomsRising is, according to its website (http://www.momsrising.org), “a transformative online and on-the-ground multicultural organization of more than a million members and over a hundred aligned organizations 33

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34 CHANGE IN FOOD MARKETING TO CHILDREN AND YOUTH working to increase family economic security, to end discrimination against women and mothers, and to build a nation where both businesses and families can thrive.” With more than 1,000 bloggers, MomsRising is one of the most popular websites for women in the United States. It has collected thousands of stories from its members about health, economic security, and other issues, and these stories are having a powerful influence on industry, legislators, and administrators, according to Bandele. Research has demonstrated that a single story told by a woman can be more powerful than a wealth of data in drawing the interest of leaders and the media, and Bandele argued that decision makers can ignore data, but they cannot ignore real stories from women. Furthermore, the stories energize other members of MomsRising to tell their own stories and become more active. The resulting dialogue changes the nature of how information is perceived, with the messenger becoming important as well as the message. Major Achievements MomsRising has produced a long list of achievements, said Bandele, including the following: • It mobilized its members to prevent the loss of unemployment insurance in February 2011, which would have cost more than 2 million families their benefits. • It helped pass paid-sick-day legislation in Connecticut, Philadelphia, ­ and Seattle. • It played a major role in pressuring the Internal Revenue Service to reverse its previous decision and keep the cost of breast pumps tax deductible. • Its food team targeted four major supermarket chains to remove meat made of “pink slime”1 from their shelves. • Its toxics team successfully pressed the Food and Drug Administra- tion (FDA) to prohibit bisphenol A in products for babies. • Its members’ strong support for the Breastfeeding Promotion Act helped ensure that one of the act’s key provisions, the right to pump breast milk at work, passed as part of the Patient Protection and Affordable Care Act. 1  “Pink slime” is the term used for a mixture of mechanically separated and disinfected beef products approved for human consumption in the United States in 2001.

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EMERGING POLICY INITIATIVES AND COMMUNICATION STRATEGIES 35 Key Principles MomsRising has an integrated model that rests on four key principles: 1. Stay nimble and responsive. 2. Constantly test. 3. Maintain the dialogue. 4. Open as many engagement avenues as possible. Working closely with policy partners, MomsRising makes sure it has access to a trusted expert on an issue who can provide advice on the right course of action. The organization also tries to identify the one thing that will make a difference to a busy mother. For example, it offers one-click advocacy whereby someone can sign a letter or contribute to a quick poll. It mobilizes members who have the time available to compile the input from other members and convey that information to legislators, businesses, and other decision makers. It uses the full range of media, from social media to traditional newspapers. And it provides on-the-ground engagement by convening members in key regions to demonstrate the presence of mothers and their concerns. Lessons Learned Bandele listed several lessons she has learned from her experience with MomsRising: • Provide multiple ways to engage and dialogue. • Be creative and experiment. • Be ready to act fast, and learn quickly from experience and failure. • Use the voices of real people to change what policy makers think is possible. • Use metrics to keep the organization on track with goals. • Keep it fun. “Being able to provide these levels of engagement has been hugely popular with people who want to make a better world for themselves and for their families.” —Monifa Bandele

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36 CHANGE IN FOOD MARKETING TO CHILDREN AND YOUTH YOUTH-LED COMMUNICATION STRATEGIES Summary of presentation by Terry Huang Public health interventions that are adopted for minority or low-resource communities often fail because they are not responsive to the level of com- munity readiness. For example, Huang’s research showed that one-quarter of Latinos in Douglas County in South Omaha, Nebraska, do not see childhood obesity as a big problem, compared with just 6 percent of whites (personal communication, T. Huang, University of Nebraska Medical Center, Janu- ary 31, 2013). In addition to the lack of awareness, low levels of perceived leadership, a poor community climate, and low resource levels in South Omaha contribute to limited community readiness to address the problem (Frerichs et al., 2012). SaludableOmaha is a program in South Omaha aimed at combin- ing youth advocacy with social marketing and partnerships to create a Latino health movement. Its core goals are empowering families to make healthy choices and creating an environment that is conducive to healthy lifestyles. The program is youth driven and depends on the participation of the community to provide community ownership and sustainability. S ­ aludableOmaha sees the “ABLE” part of Saludable as referring to Atti- tude, Balance, Leadership, and Energy. Strategies SaludableOmaha has a multipronged strategy: • Facebook pages and an interactive, multimedia-driven website pro- vide an online presence. As part of this effort, SaludableOmaha is adding a youth blog to its online presence, as well as an expert blog where parents can ask questions and access information. • The program has a school project addressing health and nutri- tion issues. For example, a student-led Green Is Go campaign has worked with school leadership to educate food service staff on what they should be telling students to eat, as well as to create­ t ­raffic-light labels for the foods offered in the cafeteria. This cam- paign now is being expanded into other sources of food for stu- dents, such as concession stands and convenience stores. Students also are planning to extend the campaign to elementary and middle schools. • A neighborhood campaign is extending the project into school- based health centers, education centers, and local businesses. The goal is to reach 25 local restaurants or grocery stores and pro-

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EMERGING POLICY INITIATIVES AND COMMUNICATION STRATEGIES 37 vide them with a short menu of strategies. With one change, they become Saludable activists. With the implementation of two or more changes, they become super-activists and receive a certificate they can post in their place of business. • As with MomsRising, digital technologies are central to the project. SaludableOmaha combines art, media, and science to catalyze a social movement in Omaha’s Latino community. Students design projects, create logos, engage in branding, and otherwise develop strategies to capitalize on their unique talents. • To make the program sustainable, SaludableOmaha worked with Omaha South High School to incorporate the program into its established service learning curriculum. Students have the option of working with SaludableOmaha to develop strategies and initiatives throughout the academic year. In this way, the program has been seeking to embed itself into the school environment without asking the school board to create a new curriculum. • SaludableOmaha also has established links with local wellness organizations such as Live Well Omaha, the primary umbrella organization in the county that, along with the county health department, serves as a leader in public health initiatives. Becoming part of the existing infrastructure and institutional climate will be key to the program’s long-term viability. Challenges Huang listed several challenges faced by SaludableOmaha: • Thus far the program has been conducted on a shoestring. It needs to become part of a larger network to be financially sustainable, because this kind of project is difficult to support through existing funding mechanisms. • The program is resource intensive. Managing social marketing and social media requires considerable effort on a daily basis. • For a host of reasons, it can be difficult to capture the attention and time of minority youth. “There is a dearth of interventions that focus specifically on ­ atino L youth and Latino families in the realm of obesity prevention.” —Terry Huang

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38 CHANGE IN FOOD MARKETING TO CHILDREN AND YOUTH LESSONS LEARNED FROM THE TRUTH® ANTITOBACCO CAMPAIGN Summary of presentation by Cheryl Healton Comparisons Between the Tobacco and Food Industries Camel cigarettes, once smoked mainly by men, have more recently been marketed as a “light and luscious” brand to attract female smokers. This campaign has produced a 10 percent increase in brand affinity for young girls and no change in brand affinity for boys, said Healton. In a Tysons Chicken Nuggets ad, a succession of cute and very young children say • “I don’t like tuna salad, lima beans, or casserole.” • “Mushrooms look like aliens.” • “Spinach? Not a big fan.” • “They just look like dirty socks.” • “I don’t like any of those stuff.” Both ads appear to be to targeted to attract a young audience to a product brand. The chicken nugget ad not only sells its own product but unsells vegetables. Extensive formative research is used to develop products and ad campaigns like these that appeal to targeted audiences, said Healton. Advertising and sponsorship by the food industry are prevalent and largely unchallenged by the public. Furthermore, the number of unhealthy food products still being marketed points to a problem that voluntary efforts alone will not fix in the foreseeable future. In general, brands are a means of self-expression for youth. Young p ­ eople are particularly sensitive to the message they convey to peers through brand choices. Furthermore, the locking in of brand identity hap- pens largely between ages 12 and 17, which is just above the cutoff age for restrictions on food marketing to children. The desire for self-expression heightens the need for personal choice. The tobacco industry frames smok- ing as a personal choice, and according to Healton, the food industry is follow­ng this lead (the food industry does not face issues such as second- i hand smoke, which can harm other people). Framing the consumption of foods and beverages that contribute to poor diet and obesity as a personal choice dampens the public will to enact policies that would reduce the development, marketing, and consumption of these products. Food industry executives are involved with shaping relevant policy, such as nutrition guidelines. Industry language often is adopted verbatim, argued Healton, and for a variety of reasons, government officials may value business interests over the public health. In addition, research has

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EMERGING POLICY INITIATIVES AND COMMUNICATION STRATEGIES 39 shown that the results of studies sponsored by the food industry tend to favor the industry (Vartanian et al., 2007). Here again there are parallels with the tobacco industry, which has sought to influence science and per- ceptions of science. Tobacco companies notoriously bought a great deal of biased science for the purpose of creating a debate about the health effects of tobacco (Hirschhorn et al., 2001). Finally, selling tobacco is profitable to the tobacco industry, just as selling food is profitable to the food industry, said Healton. The tobacco industry realizes it needs to create young adult smokers if it is to survive. Similarly, as Brownell and Warner (2009) have written, “If consumers’ demand for food were to reflect what they needed to maintain a healthy weight, the market would contract.” A Countermarketing Campaign Healton advocated for a large national food countermarketing cam- paign that would be funded by a variety of mechanisms and be indepen- dent of the food industry. As an example, she cited the truth® campaign, a branded national smoking prevention campaign designed to reach at‑risk youth aged 12-17, primarily through edgy television ads with an anti- tobacco industry theme. For example, the first ad piled 1,200 body bags around Philip Morris’s downtown headquarters in New York City. A simi- lar ad would be legitimate if it piled 500 body bags around a multinational food company, representing the number of people who die in the United States alone every day from obesity, said Healton. The truth® campaign was financed through the master settlement agree- ment between the state attorneys general and the tobacco industry. As part of the settlement, a foundation was created to undertake a public education campaign. In its first 4 years, that campaign cost more than $500 million. However, such a campaign might be less expensive today because of the Internet, which costs less than television to reach young people. The truth® campaign created a brand that competed head to head with industry brands. It spoke to teens in their own voices and did not talk down to them. It highlighted the actions of the tobacco industry in marketing cigarettes, including the failure to be truthful about cigarettes’ addictiveness and health effects. It capitalized on the natural rebelliousness of teens to encourage them to define themselves in opposition to the tobacco industry. The campaign engaged in strong and ongoing evaluation. According to a 2002 article in the American Journal of Public Health (Farrelly et al., 2002), 75 percent of all U.S. youth aged 12‑17 could accurately describe a truth® ad, and awareness was linked to attitude and belief change. Farrelly ­ and colleagues (2005) also found that 22 percent of the U.S. decline in youth smoking from 1999 to 2002 could be attributed to the campaign,

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40 CHANGE IN FOOD MARKETING TO CHILDREN AND YOUTH resulting in 300,000 fewer smokers in the United States. A later study found an even more substantial effect and documented a particularly strong effect in African American and Hispanic youth (Farrelly et al., 2009). Hard-hitting campaigns should expect to be sued, said Healton. The truth® campaign was in litigation for more than 5 years at a cost of more than $17 million, and won unanimously in the Delaware Supreme Court. The same kind of campaign directed at healthy eating could have similar effects, Healton said. She listed several essential elements of such a campaign: • Effective media campaigns need to be based on scientific evidence. • The target audience needs to be narrowly defined. • Campaigns need to conduct formative research with the target audience and pretest messages. • Campaigns should consider using new media channels, including online, mobile, and gaming media. Efforts to prevent smoking have obvious differences from efforts to pre- vent obesity; most obviously, people need to eat but do not need to smoke. Nevertheless, the antitobacco movement offers important lessons for obesity prevention, Healton concluded. “Right now the tactics that are being utilized in relation to the communication between us, as a nation, and big food . . . have been constrained and polite. . . . But there are other directions that theoretically they could go.” —Cheryl Healton LEGAL AND POLICY CHALLENGES AND OPPORTUNITIES Summary of presentation by Samantha Graff Americans have long taken for granted that the government can regu- late commercial activity to protect children’s welfare, individual privacy, principles of fair play, food and product safety, public health, and other important elements of common well-being. Recently, however, industry advocates have successfully advanced a novel interpretation of the First Amendment in the courts against government policies addressing the per- vasive marketing of products that lead to lifelong illness and early death. This troubling trend in constitutional law has occurred during the same

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EMERGING POLICY INITIATIVES AND COMMUNICATION STRATEGIES 41 period that obesity and other chronic diseases have emerged as a public health crisis, observed Graff. Historically, the First Amendment has been construed as a way of pro- tecting unpopular voices from government retribution, not as a way for cor- porations to flood the airwaves with their promotions and points of view. But in the 1970s the Supreme Court extended First Amendment protection to advertising, or in legal terms, “commercial speech.” The rationale was that advertising conveys important information to con­ umers and is neces- s sary to the smooth functioning of a free market economy. Over the past two decades, the commercial speech doctrine has evolved to afford nearly the same level of First Amendment protection to corporate commercial speech as it does to individual political and artistic expression. Graff discussed five challenges that the commercial speech doctrine poses for public health, along with some opportunities to address them. The Concept of the Rational Consumer The first challenge involves the Supreme Court’s justification for extend- ing strong First Amendment protection to advertising. This justification holds that truthful advertising is essential to the smooth operation of the free enterprise system because it relays concrete information that consumers use to make “intelligent and well-informed” purchasing decisions. In other words, the commercial speech doctrine is built on a rational choice theory of human behavior. This view led the majority of Supreme Court justices to reject what they characterized as “paternalistic” government efforts to protect the public welfare. The premise is that the government should not meddle in what commercial speakers have to say to consumers because adults are perfectly capable of digesting all of this information to make logical economic decisions. False and “inherently misleading” advertising is not protected because— in the words of the Supreme Court—“the public and private benefits from commercial speech derive from confidence in its accuracy and reliability.” However, suggested Graff, the legal construction of what counts as “inher- ently misleading” advertising is markedly narrow, given that most advertis- ing is practically synonymous with emotional manipulation. The fallacy in this approach is becoming clearer, said Graff, as research on how humans actually make decisions converges from fields including neuroscience, behavioral economics, developmental psychology, and addic- tion studies. If scientists strategically translated and disseminated findings from this research, they might eventually force courts to question the valid- ity of the theory buttressing the commercial speech doctrine.

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42 CHANGE IN FOOD MARKETING TO CHILDREN AND YOUTH Protecting Children and Adolescents The second challenge centers on the question of how the commercial speech doctrine treats regulations aimed at protecting children. Although there is little to no First Amendment case law addressing restrictions on child-targeted advertising, the Supreme Court has indicated in other settings that government paternalism is appropriate when it comes to commercial regulations aimed at protecting children. Studies on children’s cognitive development show that any advertising targeting children under 12 should be unprotected because it is by definition inherently misleading, Graff said. By this reasoning, government can ban harmful commercial advertising—or for that matter any commercial advertising—directed to younger children. The conundrum is that the Supreme Court has made clear that regula- tions designed to protect children cannot place excessive limits on adver- tising to adults. In the 2001 Supreme Court case Lorillard v. Reilly, for example, a ban on tobacco advertising near schools and playgrounds was struck down as too broad because it unduly restricted the ability of tobacco companies to convey their messages to adults. Within certain child-oriented domains, the First Amendment does per- mit policy makers to limit child-targeted advertising. School authorities have considerable leeway to set policies establishing what commercial mes- sages, if any, should be allowed on school property. If school districts resort to advertising revenues, they can at least exclude ads for unhealthy foods and beverages. Graff also noted that it is politics, not the First Amendment, that stands in the way of well-tailored restrictions on advergames aimed at children, ads and product placements on children’s television, and the use of cartoon characters to promote obesogenic foods. The ability of advertisers to have unimpeded access to teens remains an open question. On the one hand, in a recent case involving age restric- tions on extremely violent video games, the Supreme Court said that minors have free speech rights to be exposed to offensive digital images and ideas. The Court could apply the same approach to the right of adolescents to be exposed to commercial advertising. On the other hand, Graff explained that a growing body of research has led to recognition that adolescents merit special protection from digital marketing tactics that exploit their cognitive vulnerabilities. Graff concluded that this is another area in which a burgeoning body of scientific research may be on the verge of shaping new legal principles. Evidence and Regulation The third challenge involves the type and amount of scientific data the government must be able to muster to justify a commercial speech

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EMERGING POLICY INITIATIVES AND COMMUNICATION STRATEGIES 43 regulation. An example can be found in a recent federal appeals court case regarding the new tobacco control law requiring cigarette packs to include large graphic health warnings issued by the FDA. In selecting nine images that would effectively convey the negative health effects of smoking, the FDA relied on evidence, including international studies, showing that graphic warnings cause people to think more about quitting, as well as an FDA consumer study focused on the salience measures reported for a set of 36 proposed images. The appeals court struck down the FDA’s chosen images, interpreting Supreme Court precedent as requiring that the FDA quantify “with statistical precision” how much the graphic warnings would reduce smoking rates. Even under such stringent standards, policy makers might succeed if they considered their stated goals, Graff said. If the government cannot show that a particular regulation will reduce childhood obesity rates, for example, it may be able to show that the regulation will protect children’s privacy or some aspect of their psychological well-being. Scientists study- ing the impact of contemporary food marketing on children could make a major contribution by identifying and explaining the types of “upstream” harms caused by this marketing. Researchers also could try to influence courts’ perspective on evidence by publicizing the need to take a risk fac- tors approach to complex, multicausal problems such as childhood obesity. Nonexpressive Business Activities Versus Protected Speech The fourth challenge involves determining what types of commercial products and activities fall under the protective umbrella of the First Amend- ment. In recent decades, industry advocates have endeavored to characterize nonexpressive business practices as protected speech. For example, the new federal tobacco control law limits where tobacco samples can be distributed so as to ensure that an addictive, deadly product does not end up in the hands of children. One court viewed this as a simple restriction on where a product may be circulated in commerce, but another found that a tobacco sampling regulation must be treated with greater suspicion as a government limitation on protected commercial speech. The Supreme Court has recently indicated a shift toward applying stringent First Amendment review to what would appear to be ordinary business regulations. Still, the question of which commercial practices count as protected speech remains far from settled, and Graff urged that policy makers not be dissuaded from addressing food marketing simply because companies may raise First Amendment objections. In addition, corporate free speech rights probably will not be implicated in zoning restrictions on the location of chain restaurants, in laws requiring different sizes of a bev- erage product to have the same per ounce price, in laws setting minimum

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44 CHANGE IN FOOD MARKETING TO CHILDREN AND YOUTH nutrition standards for children’s restaurant meals, in laws prohibiting children from buying highly caffeinated energy drinks, or in a portion-size restriction on sugar-sweetened beverages. Public Health Messages Finally, at the same time that corporate speakers have been securing the First Amendment right to amplify their messages, they have been work- ing to stifle government messages regarding public health. Graff described three cases in which the affected industries painted simple informational messages coming from the government as coercive violations of corporate free speech rights: the first involved draft recommendations on food mar- keted to children from a federal Interagency Working Group on Food Marketed to Children, the second pertained to the FDA’s graphic tobacco ­ warnings depicting the hazards of smoking, and the third was in regard to a local law requiring that campaign flyers disclose major funding from out-of-city contributors. Graff posed the question of what is to keep the government’s mes- sages from being drowned out. She noted that there is growing momentum in the public health field to pursue taxes on sugar-sweetened beverages, with revenues earmarked in part for countermarketing campaigns. These revenues will not match industry marketing budgets, but strategic, hard- hitting counter­ arketing campaigns can be extremely effective, Graff said. m Government agencies also can use their enforcement powers to shine a light on dubious food marketing practices. Often even the prospect of an investigation will inspire reform. Finally, government can lead by example. The First Amendment leaves policy makers leeway to determine what types of promotional activities are allowed on government property—if not through their regulatory power then through their procurement power. By setting nutrition and marketing standards for products served or sold in places such as schools, parks, and hospitals, the government can carve out safe spaces for children to experi- ence what a healthy environment looks and feels like. Achieving a Healthy Balance In conclusion, Graff noted that the current legal and political climates pose formidable challenges for government efforts to address the pervasive marketing of obesogenic foods and beverages to youth. Nonetheless, she suggested, the U.S. constitutional system is designed to balance compet- ing interests and adapt to new technological developments, scientific dis­ coveries, and social norms.

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EMERGING POLICY INITIATIVES AND COMMUNICATION STRATEGIES 45 “In the same two decades that obesity and other chronic diseases were emerging as a public health crisis, government efforts to mitigate the crisis have confronted a troubling trend in constitu- tional law.” —Samantha Graff INTERNATIONAL DEVELOPMENTS Summary of presentation by Tim Lobstein The marketing of foods and beverages to children is a prominent issue in many countries other than the United States. Many international orga- nizations have developed policy statements and reports in this area, while a number of countries and industry organizations have taken action to limit such marketing. Policy Statements and Reports International organizations have developed the following policy state- ments and reports regarding the marketing of foods and beverages to children. • For the World Health Organization (WHO) consultation on a global strategy for diet and health, the International Association of Consumer Food Organizations developed a statement titled Broad- casting Bad Health: Why Food Marketing to Children Needs to Be Controlled (IACFO, 2003). • Consumers International (2004) produced a report titled The Junk Food Generation that includes a multicountry survey of the influ- ence of television advertising on children. • According to a WHO (2004) report titled Marketing Food to Children: The Global Regulatory Environment, “some experts have suggested that the marketing of such [high-fat, -sugar, and -salt] foods contributes to an ‘obesogenic’ environment that makes healthy food choices more difficult, especially for children.” • The International Obesity Task Force released a set of principles in 2006 regarding the rights and protection of children and restraints that should be placed on targeted marketing (Swinburn et al., 2008). • According to the report of a WHO Forum and Technical Meeting held in 2006 titled Marketing of Food and Non-Alcoholic Bever-

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46 CHANGE IN FOOD MARKETING TO CHILDREN AND YOUTH ages to Children, “action is essential” to control advertising to children (WHO, 2006). • In 2008 the International Food and Beverage Association issued a set of international pledges stating that companies adhering to the pledges would not market certain products to children under 12 (IFBA, 2008). • The International Association for the Study of Obesity (IASO) and Consumers International released a report in 2008 titled Recom- mendations for an International Code on Marketing of Foods and Non-Alcoholic Beverages to Children (IASO-CI, 2008). • Following up on those recommendations, WHO (2012) issued the report A Framework for Implementing the Set of Recommendations on the Marketing of Food and Non-Alcoholic Beverages to Children. • A United Nations high-level meeting on noncommunicable diseases held in 2011 cited the WHO recommendations on food and drink marketing to children (WHO, 2006) in its Political Declaration, which was followed up in 2012 by an advisory document on how to implement the recommendations (WHO, 2012). • In 2011 the Pan American Health Organization issued the report Recommendations from a Pan American Health Organization Expert Consultation on the Marketing of Food and Non-Alcoholic Beverages to Children in the Americas (PAHO, 2011). Country Actions Actions by particular countries have been less dramatic than the above policy statements and reports, according to Lobstein, but some actions have been notable: • Since the 1990s, Sweden and the province of Quebec in Canada have had a ban on all promotions of any products to young chil- dren, although cross-border marketing has been a problem. • In 2006 the United Kingdom formulated a ban on high-fat, -sugar, and -salt foods advertised on children’s television programming. The ban included a definition of such foods that acts, in effect, as a statutory definition of junk food. More recently, this ban has been extended to other media, including websites. • Ireland has introduced proposals similar to those in the United Kingdom, with the exception that the advertising of cheese would still be permitted. • France has banned vending machines in all state schools and has required statements such as “eat more fruits and vegetables” in food ads in all media.

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EMERGING POLICY INITIATIVES AND COMMUNICATION STRATEGIES 47 • South Korea has banned energy-dense, nutrient-poor foods on television ads aimed at children. • Chile has introduced a ban on junk food ads, although the ban is currently being challenged in court. • Singapore has promised to introduce guidelines regarding junk food ads, although the guidelines may be voluntary. • Norway has proposed a ban on ads for high-fat, -sugar, and -salt foods directed to anyone under 18. IASO issues a regular roundup of obesity-related news, including market­ ing news, on its website at http://www.iaso.org/resources/obesity-news. Industry Actions Like the Children’s Food and Beverage Advertising Initiative (CFBAI), the International Food and Beverage Alliance has issued pledges to limit marketing to children. This policy has improved over time, although it still has uncertain definitions and other limitations. It is not clear whether the policy covers all advertising, including integrated marketing techniques (discussed in Chapter 4). Also, the policy defines “advertising to children under 12 years” as advertising in child-directed media for which 35 percent or more of the audience is under age 12, which, Lobstein asserted, occurs only occasionally during peak periods of children’s television viewing. An IASO (2012) report on changes in Europe showed a decline of 29 percent in children’s exposure to television ads for noncompliant foods from the first quarter of 2005 to the first quarter of 2011. But this is not enough, said Lobstein, especially given the weak definitions of what foods can and cannot be advertised to children. In a comparison of 34 children’s products that industry still allows itself to advertise, IASO found that the UK and Irish restrictions would ban all but 6, the Norwegian proposals would ban all but 3, the proposals from the interagency working group in the United States would ban all but 2, and an industry-supported forum in Denmark would ban all 34. The Danish ­ forum is a coregulatory body involving both government and industry, which could serve as a model for such bodies elsewhere. Recent studies of the voluntary pledge initiatives found no significant improvements in food and beverage advertising to children in Australia (King et al., 2012), Canada (Potvin Kent et al., 2011), Germany (Effertz and Wilcke, 2012), or Spain (Romero-Fernández et al., 2010). By con- trast, improvements have been identified in South Korea and the United Kingdom, both of which introduced statutory regulations rather than voluntary pledges. In addition, red, amber, or green lights on products in the United Kingdom according to various levels of fat, sugar, and salt

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48 CHANGE IN FOOD MARKETING TO CHILDREN AND YOUTH have changed purchasing behaviors and companies’ attitudes toward reformulation. Reflections Lobstein offered several reflections based on his work in this area: • Countries are moving toward consensus on the definition of junk food, as demonstrated by the legally established definition in the United Kingdom. • Consensus also is building on what leads to behavior change, with the recognition that much decision making is noncognitive and not rational. • No method exists to “immunize” children against the impact of advertising, given its subconscious effects on behavior. Media lit- eracy is not a defense against exposure. • Discussion of the rights of children could be extended to the pro- tection of children from commercialization, which is an approach that could attract support from church and community groups. “Things have moved quite a lot outside of the United States, both in policies and regulatory practices.” —Tim Lobstein