A ban on marketing of foods/beverages to children: the who, why, what and how of a population health intervention.

Dutton, Daniel J. ; Campbell, Norman R.C. ; Elliott, Charlene 等

To achieve significant and sustained reduction in various health risk factors, the need for population-level intervention (i.e., intervention [policy or program] operating within or outside the health sector, that targets a whole population (1,2) is increasingly recognized. One current example is diet. Approximately 40% of deaths from non-communicable diseases worldwide are attributed to excess consumption of saturated fats, trans fats, sugar and salt. (3) This applies to children as well: Canadian children, on average, do not eat enough fibre (4) or fruits and vegetables (5) and consume too much sodium. (6) Accordingly, it has been predicted that the current generation of children could live a shorter life span than their parents; this would be unprecedented. (7)

Several population-level interventions have been suggested, one of which is banning marketing to children (e.g., ref. 8). Marketing to children includes traditional forms of marketing, such as television or print advertisements, as well as internet or cellular phone-based promotion, games and contests, and in-store promotions targeting children. (9) A reasonable evidence base exists to support a ban on marketing to children, although much of the evidence to date pertains to television advertising. Advertisements appear to have a strong influence on children's preference, according to a review commissioned by the World Health Organization (WHO), which included both observational and controlled experimental trials. This review concluded that children exposed to advertising exhibit preferences towards food they see advertised, a tendency towards purchasing and requesting the foods they see advertised, and a greater consumption of those foods. (10) Cecchini et al. (11) estimated that, among various interventions used to tackle unhealthy diet and physical inactivity, the largest overall gains in disability-adjusted life years (DALYs) in a developed country would come from regulation of food advertisements to children, the benefits of which would accrue over the lifetime of the children.

One clear lesson from the history of public health is that even a robust evidence base often is not sufficient to ensure the adoption and implementation of specific policies -- particularly those that are upstream in nature. (12) To achieve the desired population-level impact, interventions will need to have a significant structural or regulatory component, (13) due to inherent weaknesses of a voluntary, company-initiated approach. However, the current political environment in Canada is not supportive of this: in a regime characterized by active and passive encouragement of market forces, (14) government action to regulate private industry and potentially restrict profits by corporations is unpalatable to some. This is illustrated by the federal government's preference for voluntary rather than regulatory approaches in dietary policy. (8) That government has identified diet-related health issues as a priority (http://www.phacaspc.gc.ca/media/nr-rp/2011/2011_0307-eng.php) yet fails to implement policy that would have the desired impact, makes the government potentially vulnerable to a health lobby. There is opportunity for the health community to unite around a call for population-level interventions that require regulation and enforcement, such as banning marketing to children. However, for such a call to have credibility, the health community needs to be cognizant of the issues and challenges, some of which we outline here.

The who: Creating a health lobby

There is opportunity for health organizations (including professional organizations in public health and health care, and nonprofit groups) to unite in favour of banning marketing to children. While some in the public health community may readily support this, other health organizations may encounter challenges. For example, the disease-specific focus of some federal or provincial non-governmental organizations lends itself to a 'downstream' orientation whereby the organization's funding is predominantly for biomedical and/or clinical research activities. For these organizations, supporting a call for banning marketing to children may be viewed as "too upstream" to be consistent with the organization's mandate. Ultimately, these organizations are accountable to their donor base, so support for a ban may be achieved through increased support for upstream policies from the general public, which includes the donor base, as well as organizational leadership. To secure the buy-in of these organizations, it may be necessary to actively promote the value (i.e., evidence base, potential impact) of such population health interventions. Such promotion, or education, could occur via communication (e.g., newsletters) to membership, as well as through conventional channels such as increased media attention to the determinants of health through newspapers and other mainstream media.

The why: "Health" may not be the most effective rationale

Although an evidence base exists to support banning marketing to children for health reasons, health communications scholars have argued that "health" may not be the most effective rationale. In particular, the "health pitch" has been shown to be vulnerable to manipulation by industry. (15) For example, towards ostensibly aligning with health goals, some companies have been keen to brand their foods as "healthier" than alternatives by emphasizing particular characteristics of their product, though in a misleading manner. For example, a company may emphasize elevated levels of desirable content (such as fibre), while other characteristics of the product may be questionable from a nutrition point of view; alternatively, they may advertise decreased levels of less desirable content (such as sodium) "per serving", which is achieved by reducing serving size rather than through product reformulation. That health branding is vulnerable to manipulation reflects attributes of the regulatory system (i.e., manipulation would not occur if the system was designed to disallow it), and regulatory systems in turn are often developed in conjunction with industry, thus raising the broader issue of potential conflict of interest when industry is involved in the development of government-set regulations. While the expertise and advocacy of the health sector is integral to the proposed ban, an important complement is the ethical case for a ban: children are a vulnerable group. Health professionals, who are understandably accustomed to viewing health as sufficient rationale to implement an activity such as a ban, may need prompting to look beyond 'health' as the only or most important rationale, and endorse the critical role of the ethical case. Further, privileging the ethical case may appeal to sectors of the general population who are not as convinced by a health rationale. There is a precedent for the value of privileging the ethical case: under sections 248 and 249 of the Consumer Protection Act, Quebec has banned advertising to children since 1980. (16) The ban was challenged by industry, but the Supreme Court of Canada upheld the ban on the basis that children are unable to critically assess advertising (which may be coercive or misleading), and thus advertising to children is not ethically defensible. (17) For a health lobby to be effective, health and health care professionals need to recognize and emphasize the ethical rationale of a ban, in addition to the health rationale. Privileging the ethical justification for a ban would also solve some of the problems with the vulnerability of existing initiatives, as noted above, to manipulation of what constitutes "healthier".

The what and how: The nuts and bolts of the intervention, and jurisdictional issues

Banning "marketing" to children is, in fact, complex. Other well-known public health bans have focused more on single products (e.g., cigarettes) or mediums (e.g., television) than on target audiences. While we can avoid the complexity posed by the large diversity of products (foods/beverages) by calling for a complete ban on all products, questions remain about how to operationalize marketing to a target audience. For example, how do we determine the audience targeted by marketing, including their age? How do we ensure that all important media (i.e., television, internet, cell phones, video games, etc.) are included?

The Quebec case is instructional. Although there are guidelines on what constitutes advertising to children, (17) the guidelines are open to interpretation. Monitoring of the Quebec ban comes mostly in the form of complaints by advocacy groups that direct attention to potential violations of the ban, and the onus is on the complainants to emphasize that the delivery and/or content of the advertisement is directed at children (such as the Coalition Poids http://www.cqpp.qc.ca/en). While it is operationally easy to extend the Quebec model to every other province in Canada, it is not clear that a grassroots monitoring approach would be appropriate or effective at the national level. Without comprehensive national rules, regional discrepancies could give rise to both unequal enforcement of such a ban as well as differential interpretations across regions of what counts under the ban, which would lead to future national enforcement difficulties. The need for a national policy and enforcement is consistent with discussion of jurisdictional issues in public health generally: while public health delivery is largely a provincial responsibility, a coordinated central response federally is necessary for successful intervention, especially when the costs of the intervention are likely to be unequal across provinces. (18)

CONCLUSION

The Canadian government has identified certain diet-related health issues as priorities, yet their actions are insufficient to achieve meaningful change to the food environment. There is an opportunity for the health community to unite around population-level interventions such as a ban on marketing to children, and such a lobby could potentially be very powerful in the face of government hypocrisy. For a health lobby to be effective, there is need for cognizance of key issues and challenges, some of which we outline here. However these challenges should not be seen as reasons not to proceed, considering what is at stake. The present and predicted future of diet-related illness in Canadian children is such that population-level intervention is necessary and becoming increasingly urgent. Although the action suggested, and issues raised, in this commentary may be known to experts with regard to the relationship between health and marketing in children, we propose that this relatively small number of experts will be limited in their ability to enact change unless they have the active support of the general health community.

Acknowledgements: Daniel J. Dutton is funded through a traineeship from the Population Health Intervention Research Network, via the Population Health Intervention Research Centre at the University of Calgary. Charlene Elliott acknowledges the generous support of the CIHR Canada Research Chairs Program. Lindsay McLaren is funded by a Population Health Investigator Award from Alberta Innovates--Health Solutions. We thank Prof. J.C. Herbert Emery for helpful comments on an earlier version of the commentary.

Conflict of Interest: Dr. Norman R.C. Campbell received financial travel support from Boehringer Ingelheim to attend hypertension meetings in 2010. Otherwise, the authors have no conflicts of interest to declare.

Received: August 4, 2011

Accepted: November 5, 2011

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Daniel J. Dutton, MA, [1] Norman R.C. Campbell, MD, [2] Charlene Elliott, PhD, [3] Lindsay McLaren, PhD [1]

Author Affiliations

[1.] Department of Community Health Sciences, University of Calgary, Calgary, AB

[2.] Libin Cardiovascular Institute of Alberta, Department of Medicine, University of Calgary, Calgary, AB

[3.] Department of Communication and Culture, University of Calgary, Calgary, AB

Correspondence: Lindsay McLaren, Department of Community Health Sciences, University of Calgary, TRW3, 3280 Hospital Dr. NW, Calgary, AB T2N 4Z6, Tel: 403-210-9424, Fax: 403-270-7307, E-mail: lmclaren@ucalgary.ca