THE EXTENT, NATURE AND EFFECTS OF FOOD PROMOTION TO CHILDREN: A REVIEW OF THE EVIDENCE TECHNICAL PAPER PREPARED FOR THE WORLD HEALTH ORGANIZATION Gerard Hastings, Laura McDermott, Kathryn Angus, Martine Stead and Stephen Thomson Institute for Social Marketing, University of Stirling & The Open University, United Kingdom July 2006 WHO Library Cataloguing-in-Publication Data The extent, nature and effects of food promotion to children [electronic resource] : a review of the evidence : technical paper / CONTENTS prepared for the World Health Organization ; Gerard Hastings ... [et al.]. 1 electronic document. 1.Food. 2.Marketing. 3.Child. 4.Advertising. 5.Diet - trends. I.Hastings, Gerard. II.World Health Organization. EXECUTIVE SUMMARY 1 Background 1 ISBN 978 92 4 159524 7 (NLM classification: QT 235) Review methods 1 Extent and nature of food promotion to children 1 Food promotion and marketing in developing countries and emerging markets 1 The effects of food promotion to children 2 Discussion 2 Preliminary recommendations 3 1. INTRODUCTION 5 2. REVIEW QUESTIONS 6 3. REVIEW METHODS 7 3.1 The systematic review process 7 3.2 The search strategy 7 3.2.1 Reference lists from previous systematic reviews 7 3.2.2 Update of database searches 7 3.3 Initial relevance assessment 9 3.4 Assessment of study quality 9 3.5 Other evidence of the extent and nature of food promotion in developing countries 10 4. THE EVIDENCE BASE 11 4.1 The extent and nature of food promotion to children 11 4.1.1 What promotional channels are used by food marketers to reach children? 4.1.2 What food items are promoted to children 12 4.1.3 What creative strategies used by food marketers to target children? 4.1.4 Conclusion 14 4.2 Food promotion and marketing in developing countries and rapidly growing markets 4.2.1 Introduction 15 4.2.2 what marketing strategies are being used to promote foods in developing countries? 4.2.3 Conclusion 19 4.3 The effects of food promotion to children 19 © World Health Organization 2007 4.3.1 How do children respond to food promotion? 19 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 4.3.2 Is there a casual link between food promotion and children’s 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). food knowledge, attitudes and behaviour? Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should 4.3.3 Conclusion 27 be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: [email protected]). 4.4 What is the extent of food promotion’s influence relative to other factors? The designations employed and the presentation of the material in this publication do not imply the expression of any opinion 4.5 Does food promotion affect total category sales, brand switching or both? whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its ANNEX 1. RECORD OF SEARCHEs 46 authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. ANNEX 2. SEARCH METHODS FOR ADDITIONAL DESK RESEARCH ON FOOD MARKETING IN The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended DEVELOPING COUNTRIES AND RAPIDLY GROWING MARKEts 55 by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. ANNEX 3. DATA ExtRACTION TABLE: THE ExtENT AND NAtuRE OF FOOD PROMOTION TO CHILDREN 57 All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. ANNEX 4. FOOD MARKETING IN THE DEVELOPING WORLD: THE NutRITION TRANSITION 79 However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for ANNEX 5. DATA ExtRACTION TABLE: THE EFFECts OF FOOD PROMOTION TO CHILDREN 83 damages arising from its use. The named authors alone are responsible for the views expressed in this publication. EXECUTIVE SUMMARY Background This document describes a review of the extent and nature of food promo- tion to children and its effects on their food knowledge, preferences and behaviour. The review was undertaken by the Institute for Social Marketing at Stirling, and the Open University, United Kingdom of Great Britain and Northern Ireland, on behalf of the World Health Organization in preparation for the WHO meeting of stakeholders on “Marketing food and non-alcoholic beverages to children” held in Oslo (2–4 May 2006). Review methods Systematic methods were used to identify relevant literature for the review. The reference lists of two previous systematic reviews on food promotion to children (Hastings et al., 2003; McDermott et al., 2004) were examined to identify relevant studies. Systematic searches were also undertaken on a range of academic databases. The titles and abstracts yielded by the searches were assessed according to pre-defined relevance criteria for the review. This process helped identify 63 studies on the extent and nature of food promotion to children and 70 on its effects. Extent and nature of Studies examining the extent and nature of food promotion to children food promotion to showed that it is dominated by television advertising, and the great major- children ity of this promotes the so-called ‘Big Four’ of pre-sugared breakfast cereals, soft-drinks, confectionary and savoury snacks. In the last ten years, advertising for fast-food outlets has rapidly increased, turning the ‘Big Four’ into the ‘Big Five’. There is some evidence that the dominance of television has recently begun to wane. The importance of strong, global branding reinforces a need for multifaceted communications combining television with merchandising, ‘tie-ins’ and point of sale activity. The advertised diet contrasts sharply with that recommended by public health advisers, and themes of fun and fantasy or taste, rather than health and nutrition, are used to promote it to children. Meanwhile, the recom- mended diet gets little promotional support. 1 THE EXTENT, NATURE AND EFFECTS OF FOOD PROMOTION TO CHILDREN: A REVIEW OF THE EVIDENCE EXECUTIVE SUMMARY of these more complex studies was undertaken in the developing world, Food promotion Because there was little evidence from the published academic literature other research shows that children everywhere respond to food promotion and marketing in on the extent and nature of food promotion in developing countries, addi- in similar ways. There is, therefore, reason to believe that children in the developing countries tional searches were undertaken on a range of other business and media developing world will be just as vulnerable to food promotion. Indeed three resources. Although data are sparse, it is clear that children in developing factors suggest they may well be more so: and emerging and emerging economies are being widely and effectively targeted by fast- markets food marketing which deploys much the same techniques as in developed 1. They are likely to be less sophisticated about modern marketing and economies. Cultural and political developments make this possible, as do branding because it is such a new phenomenon to them. In China, for more engineered changes such as parties to celebrate ‘solar birthdays’. In example, the economy has only just opened up to developed-country both cases children are a key target group, not just in their own right but influence. also as a bridgehead into wider society. 2. Firms in developed countries see children as a bridgehead for entering developing economies because they are more flexible and responsive than their parents. The effects of food Survey evidence shows that children in both the developed and developing promotion to children world have extensive recall of food advertising. Food adverts are among their 3. They also represent a very real direct and indirect market; even in favourite types of advertising, with the most popular being for chocolate, relatively poor countries they have disposable income from an early sweets, soft drinks and other foods high in fat, sugar and salt (e.g. snacks age and are known to have a big influence on family consumption and fizzy drinks). Surveys in countries as varied as Bahrain, Chile, India and behaviour. Venezuela, as well as in highly developed markets like the United Kingdom This review therefore confirms that global action is needed on the marketing and the United States of America, show that children are interested in of food to children. trying advertised foods and often ask their parents to buy them. Parents – especially those from disadvantaged backgrounds – frequently yield to Preliminary The public health response needs to build on the following principles. These such requests. Disadvantaged mothers also attribute more importance to reflect the work of the authors and have not been endorsed by WHO governing advertised food products and credibility to food adverts than their more recommendations bodies: privileged peers. from the authors Evidence from more complex studies (capable of establishing causality) ■ The problem extends beyond advertising and promotion, encompassing shows that this promotional activity is having an effect on children. Whilst product design, pricing strategies, distribution and point-of-sale activ- it does not seem to influence their general perceptions of what constitutes ity. This is about food marketing not just food promotion.