European Journal of Clinical Nutrition (2014) 68, 753–759 © 2014 Macmillan Publishers Limited All rights reserved 0954-3007/14 www.nature.com/ejcn
PUBLIC HEALTH NUTRITION HIGHLIGHTS REVIEW
Obesity and industry self-regulation of food and beverage marketing: a literature review K Ronit1 and JD Jensen2 OBJECTIVE: Obesity is a growing concern at national and international levels, and it is increasingly recognised that the industry has a role in and hence needs to be involved in halting the obesity epidemic. The objective of this study is to describe, analyse and evaluate research on industry self-regulation regarding food and beverage marketing and nutrition labelling. SUBJECTS/METHODS: Five databases were searched for combinations of the search terms—obesity, nutrition, food, beverages, industry, self-regulation, labelling, advertising and marketing—and papers were selected on the basis of paper titles and, subsequently, on the basis of abstracts. RESULTS: Of the 4978 identified publications, 22 were included in the final review. The studies show that commitments in industry self-regulation schemes tend to be relatively vague and permissive, that the measurable effects of the self-regulations tend to be relatively small and that some extent of public regulation may catalyse the effectiveness of industry self-regulation. CONCLUSIONS: Although the reviewed studies vary in terms of analytic units and methods applied, they generally stress an ineffectiveness of existing self-regulation schemes. Food industry self-regulation in relation to obesity prevention is an emerging field of research, and further research is needed in such schemes’ definitions of regulatory standards, their monitoring and sanctioning mechanisms, and their interactions with public regulation, if industry self-regulation of marketing behaviour is to become an effective and credible approach. European Journal of Clinical Nutrition (2014) 68, 753–759; doi:10.1038/ejcn.2014.60; published online 9 April 2014 Keywords: food marketing; industry self-regulation; compliance; regulatory effectiveness
INTRODUCTION In many international forums, increasing attention is directed towards obesity as a serious lifestyle disease. Obesity is not only common in many affluent countries, giving rise to stronger priorities in health policy, but is also rapidly spreading to many low- and middle-income countries, putting a double burden on their already small health-care budgets.1–2 As the special agency for global health, the WHO has, especially since the late 1990 s, been engaged in combating obesity and the various chronic and non-communicable diseases typically associated with obesity, such as cancers, cardiovascular diseases, chronic respiratory diseases and diabetes.3 Obesity has also been elevated to a concern for the United Nations with the obesity epidemic highlighted at the first United Nations High-Level Meeting on Non-Communicable Diseases in September 2011. On that occasion, the UN Secretary General stated that '…industry and the private sector must be engaged. Their role is critical in populationwide behavioural interventions. For example, initiatives by the food industry in reformulation to healthier products and in exercising responsible marketing are crucial', and it was further noted that 'marketers can comply with recommendations against the marketing of food and non-alcoholic beverages to children', and provide products that 'follow relevant nutrition facts and labelling standards',4 topics that have also been a focus area for the WHO,5 and in academic research.6 More precise recommendations have been developed by the scientific community, and the
International Association for the Study of Obesity has issued the Sydney Principles7 to guide the private sector’s marketing, in particular to protect against the effects of unhealthy food marketing on children’s diets.8 These different organisations, therefore, envisage an active role for the industry. Given the serious and global character of the epidemic, global initiatives spanning relevant industries, preferably based on binding rules, and targeted at all consumers, but especially with a view to reach children and young people, are recommended.7,8 Encouraged by governments and international organizations (and possibly also triggered by industry concerns about potential upcoming public regulations), a rich variety of self-regulation initiatives (that is, regulations where companies or groups of companies commit themselves to follow specific rules or standards) have emerged in the industries. On one hand, industry self-regulation of marketing activities can be expected to be more flexible and better targeted towards specific conditions in the respective companies or industries in specific contexts, and hence be more cost-effective.9 For example, one company may find that reduction in the frequency of advertising adjacent to childrentargeted TV shows to be the least costly way to reduce children’s exposure to marketing, whereas another company may consider abolishing the use of licensed characters as the least-cost way to reduce exposure. On the other hand, self-regulation also implies higher reliance on the food industry's practices and ethics in defining and interpreting the norms and benchmarks for
1 Department of Political Science, University of Copenhagen, Copenhagen Ø, Denmark and 2Department of Food and Resource Economics, University of Copenhagen, Frederiksberg C, Denmark. Correspondence: Associate Professor JD Jensen, Department of Food and Resource Economics, University of Copenhagen, Rolighedsvej 25, DK-1958 Frederiksberg C, Denmark. E-mail: [email protected] Received 16 October 2013; revised 3 March 2014; accepted 4 March 2014; published online 9 April 2014
Obesity and industry self-regulation K Ronit and JD Jensen
754 self-regulation, including the monitoring of compliance with regulation and the use of sanctions to foster compliance. If these practices and performances are not transparent, there is a risk of sliding standards and lack of compliance.10 The general challenge of industry to curb obesity has also been discussed in academic publications for more than a decade,11–12 in which self-regulation is examined as one of the ways to regulate industry activities,13 particularly marketing to vulnerable groups such as children14–17 in Western countries18 as well as in other parts of the world, such as China.19 The provision of transparent and credible production information in terms of nutrition labelling has also attracted some interest in the literature.10,19 The purpose of this paper is to describe, analyse and evaluate research on industry self-regulation regarding nutrition labelling and food and beverage marketing to consumers. In particular, it is the aim of this review to evaluate alternative approaches and designs of industry self-regulation as well as the measurable performance of these regulations in terms of reducing companies’ promotion of energy-dense foods and beverages, in general, and with regard to special vulnerable consumer groups in particular. This objective is pursued via a systematic review of the literature on business self-regulation related to obesity prevention. MATERIALS AND METHODS The relationship between obesity and the self-regulation of marketing activities is complex and crosses several disciplinary boundaries, from health sciences to different branches of social science. At one end of the spectrum, there is a quite voluminous literature addressing a huge variety of physiological aspects of obesity, but it is not concerned with, for example, how industry behaves.20 At the other end of the spectrum, there is the significant research on the tools employed by industry to reach consumers,21 which, however, does not take a strong interest in food and beverages and the consequences of industry activities on public health—for example, obesity as a lifestyle disease. Much of the academic interest in the role of food marketing in public health seems to occur among scientists from the public health research community,22,23 although researchers from the broader social sciences have also displayed interest in this area of study. On the basis of a preliminary review of the relevant literature, the following search terms were identified: obesity, nutrition, food, beverages, industry, self-regulation, labelling, advertising and marketing. A flexible search procedure that included four or three search words in a variety of combinations was adopted: Obesity AND Nutrition AND industry AND selfregulation; Obesity AND food AND industry AND self-regulation; Obesity AND beverages AND industry AND self-regulation; Nutrition AND industry AND advertising; Nutrition AND Industry AND labelling; Nutrition AND Industry AND marketing; Food AND industry AND advertising; Food AND industry AND labelling; Food AND industry AND marketing; Beverages AND industry AND advertising; Beverages AND industry AND labelling and, finally, Beverages AND industry AND marketing. The following five databases were included in our literature search: Web of Science (Knowledge), Medline, PubMed, Science Direct and Social Science Research Network. The combination of different databases, with strengths in different clusters of disciplines, increases the likelihood that primary contributions that constitute the small and emergent field of obesity and industry self-regulation from different scientific disciplines would be found and properly evaluated. The search was conducted in May 2013. In order to focus on studies that are scientifically recognised, only full original academic papers published in English and containing concrete assessments of the organisation and performance of food and beverage industry self-regulation were included in the review. It is acknowledged that a considerable amount of ‘grey’ literature has also been prepared and published as reports from, for example, public health organisations, industry associations, and so on. Although many of these studies may represent valuable data and methods, there is also a risk of different biases in such reports. When exclusion criteria were defined for publication date, they limited the search to papers published from 1995 to 2013, a time when stronger scholarly attention was directed towards the challenge of obesity. No criterion was established for geographic coverage or research design. Obesity is today seen as a global problem and, hence, papers examining the situation in different cultural contexts are relevant to include in our review. European Journal of Clinical Nutrition (2014) 753 – 759
RESULTS The number of hits from the five databases totalled 4978 (1307, 2462, 704, 365 and 140, respectively), including duplicates between the different combinations of the search terms. On the basis of a review of the paper titles (the titles’ wording regarding self-regulation, marketing and labelling, food and beverages), 121 publications were found relevant for further scrutiny, and abstracts from these papers were carefully studied by the authors with a respect to obesity, nutrition, performance/effectiveness and organisation to identify a smaller group of core papers. In the next step, papers considered relevant to the study aims were read in-depth and, finally, 22 papers were included in our literature review. Table 1 presents the characteristics and main findings of the 22 included studies, which fall into three categories (although some of the studies address more than one of these categories): studies of the content of industry self-regulation schemes, studies of the effects of industry self-regulation schemes, and studies of the interactions between self-regulation schemes and public regulation—for example, a perceived threat of public regulation may catalyse the development of private schemes. These core papers use different research methods. Furthermore, they display a variety of companies, associations and other entities engaged in self-regulation at different territorial levels and jurisdictions and addressing different segments of consumers and different marketing tools. It is interesting to note that, although scholarly attention has been directed towards the practices of business in relation to the obesity epidemic since the 1990s, and in some respects even earlier, most of the contributions are quite recent. The ambition in most of the contributions reviewed is to offer a broad (industry) picture of self-regulation, in some cases by considering a selected group of (typically large) companies27,28,33,38 and comparing the marketing activities of corporations participating in an industry self-regulation scheme with those of non-participating firms,30,31,39 and in other cases by studying the performance of the industry at a more general level on the basis of aggregated data.36,38 Whereas most reviewed studies refer to the food and beverage industry in general, some studies concentrate on particular industries, such as 'breakfast cereals'38 or the 'quick-service restaurant industry',32 some studies pinpoint certain products or substances, such as 'sugar sweetened beverages',28,37,42 and some provide comparisons between different subsectors of the food and beverage industry—for example, different sub-sectors’ rate of food advertising during children’s peak TV viewing time35 or compliance with industrywide self-regulation schemes.37 Content of industry self-regulation schemes Studies in this category pay attention to the behaviour of corporations participating in self-regulatory schemes in terms of restrictions on nutritional values of the products marketed to children, different marketing media (for example, television, internet, computer games, smart phones) and different marketing tools (for example, character licensing). The reviewed studies show that some basic challenges are facing the industries as a whole, with many similarities between the different areas of food and beverages. For example, Hawkes and Harris41 found that the majority of industry self-regulation pledges regarding food marketing behaviour in 2009 covered the food industry broadly across commodity categories. Two broad sets of marketing activities tend to be regulated by private regulations and have attracted special attention in research—namely, front-of-package labelling of products10,25,28,40,41 and advertising of products through television.13,37,39 Whereas labelling is directed towards the adult population who are supposed to read and interpret the information on the front of packages to make an informed choice © 2014 Macmillan Publishers Limited
Research methods
Study
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Compare US self-regulation schemes USA. Industry with eight 'objective' standards for meaningful self-regulation
29
Comparing advertising intensity towards children for pledgers and non-pledgers
Examine the impact of selfregulatory pledges on food and drink advertising to children on commercial television
34
35
Australia. Industry
Voluntary assignment to pledge Voluntary compliance
Advertising to children
Australia. Focus on Voluntary assignment to pledge Advertising to single firms (members Mainly voluntary but also industry children and free-riders) association’s actions to enhance compliance
Change in non-core food advertisements
Advertisements’ compliance with nutritional standards
Marketing activities of Not lower marketing intensity pledgers versus non-pledgers for pledgers
Advertising to children
Compare advertisement intensity for Canada. Signatories of Voluntary assignment to pledge. Voluntary compliance pledgers and non-pledgers industry pledge. Mainly firms
33
Frequency of non-core food advertising has remained essentially unchanged between 2006 and 2011
Effect of pledging was found but effect was limited
Unhealthy foods constitute a smaller share of total ads after initiative, but absolute exposure effect is limited
Firms classify fewer products as unhealthy compared with objective classification. Suppliers of unhealthy foods tend to use 'per-portion' nutrition facts rather than 'per 100 g' Compliance with alternative nutritional standards
Compliance with alternative nutrition standards
Evaluate exposure to advertisements Australia. Mainly focus Restriction on marketing based on industry- Advertising to before and after self-regulation on industry but firms led nutrient profiling. children initiative in 2009 are also included Voluntary actions; not how to punish noncompliers
Restriction on marketing based on industry- Marketing, especially led nutrient profiling. advertising to Voluntary compliance children
Change in core and non-core The industry’s voluntary food advertising. agreement has failed to fulfil Documentation of marketing its declared purpose techniques
The considered self-regulation schemes do not comply with the objective standards
A significant share of labelled products are not healthy from objective criteria
Firms are prone to state relatively loose evaluation criteria
32
Australia. Firms
Advertising to children
Compliance with eight standards for self-regulation
Mainly advertising to Various existing self-regulatory pledges. Mainly voluntary - few measures to enhance general consumers compliance EU pledge. Voluntary compliance
Share of products compliant with NPM criteria
Different indicators of industry progress
Commitments are permissive and vague
The DIG kJ label performed poorly in comparison with the other labels
Compare firms' categorisation of unhealthy foods with 'objective' categorisations
Germany. Industry
Adults’ assessment of DIG’s interpretability, noticeability and usefulness, compared with other labels
Labelling towards consumers in general
SmartChoice label according to industrydefined criteria. Voluntary compliance
Advertising to children and adolescents
Key results
Products compliant with NPM Government-led schemes are criteria more restrictive compared with industry-led schemes
Outcome measures
Marketing to children Assessment of firms’ commitments on marketing to children
Labelling for general consumers
Advertising to children
Tools and segment: all/selected groups
31
Effect evaluation of self-regulation schemes 30 Examine effectiveness of selfadministered voluntary restrictions on promotion of less healthy food
Review of products labelled with SmartChoice label compared with "objective" (Nutrient Profiling Model - NPM) health criteria
28
USA. Firms and product names
USA. Firms’ behaviour Product reformulation, restrictions on TV and industry advertising, labelling. programs Voluntary—but some mechanisms to make firms comply are studied
Assess firms' evaluation criteria for self-regulation against 'objective' criteria
27
Australian Responsible Marketing to Children Initiative. voluntary compliance
Australia. Firms (mainly) and industry
Assess principles and commitments of signatory companies to responsible marketing
26
Nutrition labelling based on industrydefined nutrient profiles. Voluntary—few measures to enhance compliance
Evaluation of a voluntary daily-intake Australia Consumers’ guide label (DIG kj) against other perception of labels nutrition labels
Restriction on advertising based on industry-led nutrient profiling voluntary compliance
Regulation and compliance with regulation
25
Industry compliance with self-regulation schemes 22 Compare industry-led nutrient USA and EU. Industry profiling schemes with governmentled schemes
Coverage: national/international and scope
Selected papers and their major findings
Table 1.
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Assess the effectiveness of coregulatory system in limiting children’s exposure to unhealthy television food advertising
Compare advertisements' compliance with standards for marketing to children for pledgers and non-pledgers
Compare marketing of self-defined unhealthy products with objectively defined unhealthy products
36
37
38
USA. Firms
Spain. Industry and firms and products
Australia. Industry
Coverage: national/international and scope
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Review of pledges wrt content and coverage
Review of sanctioning procedure for New Zealand. Industry Self-regulation of food advertising and not complying with stated pledges treatment of complaints Some mechanisms of self-regulation to make regulation binding (compliers and adjudication)
Assess industry pledges and the role USA. Industry, firms of US legislation regarding beverage and public regulation sales in schools
Review of documents related to two Australia. Industry self-regulatory initiatives towards food and beverage marketing to children
9
42
17
Content of pledges
Advertising to children
Abbreviations: DIG, daily intake guide; NPM, nutrient profiling model; wrt, with respect to.
Self-regulation of food advertising to children. Voluntary codes
Advertising to children
Fair and transparent enforcement of self-regulation requires objective bodies
A number of limitations and inconsistencies in the pledges were found
There is huge variation in the regulations, standards and guidelines on public as well as private nutrition labelling around the world
Growth in regulation of marketing to children: selfregulation, public campaigns and government regulation, but only to a little extent based on evidence
Large variation in regulation environments in different countries
Self-regulation is less effective than that claimed by firms
About half of the advertisements do not comply with all standards
Many breaches of mandatory as well as voluntary regulations
Key results
Evaluation of transparency and accountability
Both schemes establish transparency and accountability mechanisms, but too little stakeholder involvement, and are thus unlikely to reflect public health concerns properly
Extent and content of public Industry pledges have little and private regulations substance when it comes to complying with the pledges
Advertising to general Arguments in treatment of consumers complaint and decision
Legislation and policy documents
Labelling for general consumers
Voluntary pledges on beverages sales in Marketing to school schools. children Voluntary compliance, but some public and industry measures to enhance compliance
Assignment to voluntary pledges. Global, regional and national. Mainly focus Voluntary pledges but some public and industry measures to enhance compliance on industry pledges but firms are also covered
Interaction between public and private regulation. Voluntary pledges and some public and industry measures to enhance compliance
41
Global. Industry
Overview and analysis on regulations, standards, and guidelines on nutrition labelling
40
Legislation and policy documents
Nutritional value of products exposed to children
Advertisements’ compliance with pledge standards
Compliance with alternative nutritional standards
Outcome measures
Focus on some mechanisms of industry self- Different marketing Content and bindingness of regulation. tools to young people government and industry-led Some industry measures to enhance regulations compliance
Policy recommendation
Comparative —selected countries. Industry
Advertising to young people
Advertising to children
Advertising to children
Tools and segment: all/selected groups
Interaction between public and private Advertising to regulation. children Voluntary pledges and industry measures to enhance compliance
Restriction on advertising based on industry-led nutrient profiles. Voluntary compliance—few measures to enhance compliance
Pledge on food marketing to youth. Voluntary compliance
Mandatory and voluntary advertising regulations. Influence of mandatory regulation on compliance in self-regulation
Regulation and compliance with regulation
18
Interrelations between industry self-regulation and public regulation 39 Policy review Global and comparative Industry, also related to public regulation
Research methods
(Continued )
Study
Table. 1.
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Obesity and industry self-regulation K Ronit and JD Jensen
(and where the basic regulation issue is to extend and ensure adequate quality of information), television advertising is mainly studied in relation to children and young people, where the key concern of regulation is to structure and limit advertising activities. Regarding front-of-package labelling, the main research questions have been whether labelling provides appropriate nutritional information to consumers, the definition of standards underlying these labels29 and whether companies comply with the guidelines that they have adopted. Two studies25,29 suggest that industrydefined criteria are relatively permissive and vague, and one study suggests that labelling can also be used to manipulate a consumer's perception of the product's nutritional value—for example, by selective use of nutritional indicators or units of measurement, and that self-regulation can also address such behaviour.10 In addition , with regard to TV advertising, industry self-regulation schemes are found to be relatively vague in terms of stated commitments 24,26 and evaluation criteria.27 Other types of marketing tools are also used in food marketing and might also be addressed in regulations to protect consumers, such as use of names and licensed characters (for example, cartoons) on the packaging of foods.29 The literature offers a number of examples of self-regulation, in terms of voluntary pledges, in which food companies promise to abstain from using such characters in their product promotion.33,35 Other types of tools addressed in self-regulation schemes include product placement (in TV shows, computer games, websites, social networks and so on), premium offers and promotion or sales in schools.34,39 Enrolment in the various self-regulation initiatives studied is to a very high degree voluntary, and companies can join or leave them without heavy sanctions being imposed, should they not observe the self-imposed restrictions.27 However, companies can also violate the initiatives without leaving them and without being punished.33 Much, therefore, hinges on the commitment of the individual companies, and many studies observe a conflict between basic commitment and actual non-compliance, and it is possible for companies to exploit 'the fine print'.26 Effect evaluation of self-regulation schemes Most studies addressing the effectiveness of industry self-regulation report on domestic experiences with food industry and self-regulation at a national level, whereas a few address the issue at international levels.39,41,43 According to our findings, a considerable body of scientific studies addresses experiences with self-regulation of food marketing practices in Australia;9,13,25,31,32,34 however, there is also an emerging tradition in North America27,33,38 and in Europe.30,37 Often, reported cases refer to local and state experiences rather than nationwide practices.34,35,42 A significant number of the studies analyse industry initiatives addressing marketing towards children and adolescents15,38 or primarily children.26,31,33,41 In particular, many studies address the extent to which the industry observes the rules and restrictions it has imposed on itself. Several of the reviewed studies offer examples that industry has severe difficulties complying with its own commitments on advertising to children, and various loopholes and transgressions are reported—transgressions that cannot be observed by children as a specific consumer group31,33,39,41—for example, setting thresholds for 'negative' nutrients relatively high.31 Hence, most of the studies found that the effects of self-regulation were limited.30,32–38 Relations between industry self-regulation and public regulation Processes of creating incentives in the various industry self-regulation schemes to enhance compliance are only discussed © 2014 Macmillan Publishers Limited
to a limited extent in the reviewed literature in our study.13,15,29,34 If the initiatives are weak from the beginning, and no sanctions are envisioned to punish transgressors, it is no surprise that compliance is low. Hawkes and Harris,41 however, provide interesting insights into the complex mechanisms between companies and the initiatives and distinguish between the collective self-regulation pledges that companies can join, and within-pledge commitments issued by single corporations, regarding self-regulation of marketing to children. In particular, studies found differences in criteria underlying the different pledges (with some companies committing to different pledges with different standards), but also some development in the pledges over time, in the direction of becoming more restrictive, was noted. Studies also found substantial variation in individual companies' participation in collective pledges, with some of the most active participating in 11 out of 13 pledges. Although corporations participating in the pledges tend to be among the largest in their respective markets, there are, however, still many relevant suppliers who do not participate. Horizontal pressures operating between companies to discipline non-complying companies seem to be fairly weak in the studied self-regulation schemes. Examples of such horizontal pressures could be peer pressure, in which compliance was monitored (and possibly sanctioned) by peers and competitors, or active accountability with respect to such pledges in companies’ own individual corporate social responsibility schemes. However, companies have not delegated real power to monitor and, if need be, sanction non-compliers. Only exception is, for instance, adjudication discussed in the analyses of self-regulation.9 Further insights can be achieved by exploring the performance of and linkages between self-regulation and public regulation (such as general mandatory rules or standards, or various forms of partnerships between industry and government)24,36,39,40,42—for instance, because public regulation can influence and pose an alternative to self-regulation and in this way assist in stimulating compliance. For example, Mello et al.42 found that an industry selfregulation on beverage marketing, where three of the major soft drink sellers in the United States committed themselves to phase out soft-drink sales in schools, was catalysed by a latent possibility of public regulation, which might be more burdensome for the companies than voluntary regulation, a point that has also been mentioned in other studies outside the focus of the present review.22,43 Whereas regulation of markets across borders can be a serious challenge for public regulation,39 self-regulation efforts through multinational corporations, and especially through international industry associations, may be better suited to deal with this aspect of globalisation.40,43 Hawkes and Harris41 studied some of the attempts to develop encompassing initiatives through international industry associations and found that the participation of companies in global commitments is relatively low. DISCUSSION Food industry self-regulation in relation to obesity prevention is an emerging field of research and, although studies generally note some progress in the implementation of such schemes41 and important achievements have been made in some of the studied cases, there is still need for research in a number of areas, if self-regulation is to become an effective and credible approach. Self-regulation initiatives tend to be based on voluntary participation, where companies have a strong say in formulating the standards and benchmarks of the regulation, which implies a risk of setting the standards at a relatively low level. Given such pitfalls, several papers9,32,40 reach the conclusion that stronger tools are needed to regulate the industry, and that some degree of government intervention may be needed to solve this challenge. European Journal of Clinical Nutrition (2014) 753 – 759
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758 There is need for more research in potential mechanisms for selfregulation in this area, including the effectiveness of alternative benchmarking, such as the UK-based Nutrient Profiling Model,24,28 and formulation of appropriate and generally recognisable and verifiable standards for marketing in media other than television, such as internet, computer games, smart phones and so on. The voluntary participation in industry self-regulation schemes is a major weakness, a view shared by all scholarly contributions. Only some firms sign up, and there are many examples of firms joining self-regulation schemes and committing themselves to comply with the rules in these schemes but nevertheless manipulating and evading the rules, for example, by applying different definitions of 'children' (for example, Hawkes and Harris41), with self-stated commitments being less binding, the narrower the definition of 'children', or companies may be rather selective in their choice of specific commitments, they sign up to.24 The studies show that currently there is no strong power to make firms comply and punish recalcitrant behaviour. Hence, there is a need for more research on the role of associations or other entities in monitoring and enforcing self-regulation. Industry self-regulation can be considered a strategy for industry to prevent the introduction of more binding and less flexible public regulation, which would imply a higher cost to the industry. Parts of the literature suggest that self-regulation comes close to 'regulatory capture'. In the regulation literature, reference is made to 'regulatory capture' when a special interest, in our case the food and beverage industry, manages to instrumentalize public regulation in ways that are mainly beneficial to private interests.45 This is a key problem with regard to public health and the prevention of obesity46 and it is spelled out in many ways through the interaction between government and industry in and beyond the food sector.42,47,48 To the extent that current self-regulation is considered 'too weak' in the general public and among policy makers, it may therefore be in the self-interest of the industry to improve these initiatives and replace voluntary elements with more binding rules. Some contributions in the literature study how a combination of public and private regulation can operate in practice as a solution for effective regulation;13,42 however, there is need for a more profound understanding of how public regulation might enhance and sustain self-regulation. In theory, industry self-regulation may be superior to the efforts of single companies, simply because industry-level rules are more encompassing, standardised and make it easier for consumers to identify non-compliance than a plethora of incomparable rules and activities. The food industry is, however, very heterogeneous, displaying differences in firm structures, regulatory challenges and demand for regulation. For example, companies may be able to state more ambitious commitments if they have opportunities to substitute some of their products with other and healthier products. In addition, companies in markets with fierce competition may be more reluctant to state ambitious goals compared with companies facing less competition.17,27 Such factors may provide industries with different opportunities and different approaches to self-regulation and influence the firms’ coping with self-regulatory schemes. Whereas studies based on aggregate data can be considered representative for large parts of the industry (or a subsector), studies of individual companies or company behaviour within individual self-regulation schemes tend to focus on the way single companies cope with, implement and comply with self-regulation. Several of the studies reviewed in this paper suggest that a lack of compliance with self-regulation schemes appears in some industries (for example, sugared drinks); however, it should be recognised that conclusions based on this observation may be subject to serious selection bias, as the level of marketing activities in an unregulated industry—as well as the coverage in the literature—also differs substantially between different European Journal of Clinical Nutrition (2014) 753 – 759
subsectors of the food and beverage industry. Although the combination of sector-level and company-level analytical approaches yields insights into both the overall performance of food industry self-regulation and the mechanisms at the company level, there is still need for development of analytical strategies to understand the relationships between a companies’ product portfolios and market orientations, the degree of competition in the respective markets and the design and effectiveness of selfregulation schemes—for example, whether self-regulation is more likely to be more effective in some markets than in others. Taking into account the international structure of the food and beverage industry, with corporations being active in several jurisdictions, public regulation of industry behaviour can be a challenge. Appropriately designed industry self-regulation may constitute an answer to this challenge because corporate policies may be easier to implement across jurisdictions than are public policies. For such self-regulation schemes to work effectively and appropriately, precise definitions of regulation items, transparent monitoring schemes and the development of appropriate sanctions in cases of non-compliance are however required. The reviewed literature suggests some room for improvement in these respects. The reviewed studies with an international orientation mainly analyse the general performance of Western corporations.40,41 Some of the studies, including the behaviour of large international corporations, or of significant international business associations, provide important experiences with self-regulation, and some of these experiences can be used to understand the global situation. However, in relation to understanding industry self-regulation on a global scale—for example, in the development of policies and recommendations within the framework of intergovernmental bodies, such as the WHO—there is a need for more knowledge on market structures, income levels and cultural factors in the meeting between domestic consumers and foreign companies, implications of multinational corporations being present in many markets and meeting many segments of consumers. Thus, it is necessary to further develop such international perspectives—for example, by studying otherwise neglected countries and regions that struggle with obesity problems. CONCLUSIONS Against a backdrop of growing prevalence of obesity and an increasing concern for the role of food industry in this development from national governments, non-governmental organisations and international bodies, such as the United Nations and the World Health Organization, the present study has reviewed the scientific literature on the opportunities and challenges related to industry self-regulation in the food industry. Although the reviewed studies vary in terms of analytic units and methods applied, rendering comparisons and general conclusions difficult, the studies generally stress the ineffectiveness of existing self-regulation and the perils of surrendering the role of regulating food and beverage markets to the industry. The studies show that commitments in industry self-regulation schemes tend to be relatively vague and permissive, that the measurable effects of the self-regulations tend to be relatively small and that some extent of public regulation might enhance the effectiveness of industry self-regulation. Food industry self-regulation with regard to obesity is an emerging field of research and, although the reviewed studies show important achievements in a number of research areas, a number of issues still call for further research on companies’ incentives to participate in self-regulation schemes, mechanisms involved in the formulation of rules and standards, mechanisms in monitoring and enforcing compliance, the role of industry and market structures, and the interaction between industry self-regulation and public regulation. © 2014 Macmillan Publishers Limited
Obesity and industry self-regulation K Ronit and JD Jensen
759 CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGEMENTS This study was prepared as part of the cross-disciplinary UNIK—Food, Fitness & Pharma research center at the University of Copenhagen. The activity was financed by a research grant from the Danish Ministry of Science and Innovation. Preparation of the manuscript was financed by a research grant from the Danish Ministry of Science and Innovation.
REFERENCES 1 Prentice AM. The emerging epidemic of obesity in developing countries. Int Journ Epid 2006; 35: 93–99. 2 WHO. Preventing Chronic Disease. A Vital Investment 2005: World Health Organization: Geneva, 2005. 3 WHO Obesity: preventing and managing the global epidemic. Report of a WHO Consultation on Obesity.1998, WHO: Geneva. Geneva. 3–5 June 1997. 4 United Nations. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases. General Assembly. Sixty-Sixth Session. 2011. Agenda Item 117 A/66/L.1 (16 September 2011). 5 World Health Organization Set of recommendations on the marketing of foods and non-alcoholic beverages to children. 2010. Available at: http://www. who.int/dietphysicalactivity/publications/recsmarketing/en/index.html (accessed 25 September 2013). 6 Cairns G, Angus K, Hastings G, Caraher M. Systematic reviews of the evidence on the nature, extent and effects of food marketing to children. A retrospective summary. Appetite 2013; 62: 209–215. 7 International Association for the Study of Obesity The Sydney Principles: Guiding Principles for Achieving a Substantial Level of Protection for Children Against the Commercial Promotion of Foods and Beverages. IASO: London. 8 Swinburn B, Sacks G, Lobstein T, Rigby N, Baur LA, Brownell KD et al. The Sydney principles for reducing the commercial promotion of foods and beverages to children. Public Health Nutr 2008; 11: 9. 9 Hoek J, King B. Food advertising and self-regulation: a view from the trenches. Austr N Z J Public Health 2008; 32: 261–265. 10 Brownell KD, Koplan JP. Front-of-package nutrition labeling: an abuse or trust by the food industry?”. N Engl J Med 2011; 364: 25. 11 Seidell JC. Prevention of obesity: the role of the food industry. Nutr Metab Cardiovasc Dis 1999; 9, 45–50. 12 Yach D, Khan M, Bradley D, Hargrove R, Kehoe S, Mensah G. The role and challenges of the food industry in addressing chronic disease. Global Health 2010; 28: 10. 13 Reeve B. The regulatory pyramid meets the food pyramid: can regulatory theory improve controls on television food advertising to Australian children?”. J Law Med 2011; 19: 128–146. 14 Kelly B. To quell obesity, who should regulate food marketing to children. Global Health 2005; 14: 9. 15 Hawkes C. Regulating food marketing to young people worldwide: trends and policy drivers. Am J Public Health 2006; 97: 11. 16 Lobstein T. Food and drink marketing to children. Public Health Nutr 2009; 12: 882. 17 Reeve B. Private Governance, public purpose? Assessing transparency and accountability in self-regulation of food advertising to children. J Bioeth Inq 2013; 10: 149–163. 18 Nestle M. Food marketing and children obesity – a matter of policy”. N Engl J Med 2006; 354: 2527–2529. 19 Hawkes C. The agro–food industry growth and obesity in China: what role for regulating food advertising and promotion and nutrition labeling? Obes Rev 2008; 9: 1. 20 Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. J Am Med Assoc 1999; 282: 1523–1529. 21 McGregor SLT. Transdisciplinary consumption. Integral Rev 2013; 9: 413–438. 22 Panjwani C, Caraher M. The Public Health Responsibility Deal: brokering a deal for public health, but on whose terms? Health Policy 2013, 114: 163–173.
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23 Slining MM, Ng SW, Popkin BM. Food companies' calorie-reduction pledges to improve U.S. diet. Am J Prev Med 2013; 44: 174–184. 24 Brinsden H, Lobstein T. Comparison of nutrient profiling schemes for restricting the marketing of food and drink to children. Pediatr Obes 2013; 8: 325–337. 25 Carter O, Mills B, Phan T. An independent assessment of the Australian food industry’s daily intake guide ‘Energy Alone’ label. Health Promot J Austr 2011; 22: 63–67. 26 Hebden L, King L, Kelly B, Chapman K, Innes-Hughes C. Industry self-regulation of food marketing to children: reading the fine print. Health Promot J Austr 2010; 21: 3. 27 Kraak V, Story M, Wartella EA, Ginter J. Industry progress to market a healthful diet to american children and adolescents. Am J Prev Med 2011; 41:322–333. 28 Roberto CA, Bragg MA, Livingston KA, Harris JL, Thompson JM, Seamans MJ et al. Choosing front-of-package food labeling nutritional criteria: how smart were “smart choices”? Public Health Nutr 2012; 15: 2. 29 Sharma L, Teret SP, Brownell KD. The food industry and self-regulation: standards to promote success and to avoid public health failures. Am J Public Health 2010; 100: 2. 30 Effertz T, Wilcke AC. Do television food commercials target children in Germany? Public Health Nutr 2011; 15: 1466–1473. 31 Hebden L, King L, Kelly B, Chapman K, Innes-Hughes C, Gunatillaka N. Regulating the types of food and beverages marketed to Australian children: how useful are food industry commitments? Nutr Diet 2010; 67: 4. 32 Hebden L, King L, Grunseit A, Kelly B, Chapman K. Advertising of fast food to children on Australian television: the impact of industry self-regulation. Med J Australia 2011; 195: 1. 33 Kent MP, Dubois L, Wanless A. Self-regulation by industry of food marketing is having little impact during children’s preferred television. Int J Pediatr Obes 2011; 6: 5–6. 34 King L, Hebden L, Grunseit A, Kelly B, Chapman K, Venngopal K. Industry self-regulation of television food advertising: responsible or responsive? Int J Pediatr Obes 2011; 6: 2. 35 King L, Hebden L, Grunseit A, Kelly B, Chapman K. Building the case for independent monitoring of food advertising on Australian television. Public Health Nutr 2012; 16: 2249–2254. 36 Roberts M, Pettigrew S, Chapman K, Miller C, Quester P. Compliance with children's television food advertising regulations in Australia. BMC Public Health 2012; 12: 846. 37 Romero-Fernandez MM, Royo-Bordonada MA, Rodrigues-Artalejo F. Compliance with self-regulation of television food and beverage advertising aimed at children in Spain. Public Health Nutr 2010;13:1013–1021. 38 Schwartz MB, Ross C, Harris JL, Jernigan DH, Siegel M, Ostroff J et al. Breakfast cereals industry pledges to self-regulate advertising to youth will they improve the marketing landscape? J Public Health Pol 2010; 31: 1. 39 Caraher M, Landon J, Dalmeny K. Television advertising and children: lessons from policy development. Public Health Nutr 2006; 9: 5. 40 Hawkes C. Government and voluntary policies on nutrition labeling: a global overview. In: Albert J (ed). Innovations in Food Labeling. Woodhead Publishing Ltd: Cambridge, 2010. Woodhead Food Series No. 184. 41 Hawkes C, Harris JL. An analysis of the content of food industry pledges to marketing to children. Public Health Nutr 2011;14: 8. 42 Mello MM, Pomeranz J, Moran P. The interplay of public health law and industry self-regulation: the case of sugar sweetened beverage sales in schools. Am J Public Health 2008; 98: 4. 43 Bryden A, Petticrew M, Mays N, Eastmure E, Knai C. Voluntary agreements between government and business-A scoping review of the literature with specific reference to the Public Health Responsibility Deal. Health Policy 2013; 110: 186–197. 44 Hawkes C. Uneven dietary development: linking the policies and processes of globalization with the nutrition transition, obesity and diet-related chronic diseases. Global Health 2006; 2: 4. 45 Stigler G. The theory of economic regulation. Bell J Econ Manage Sci 1971; 2: 3–21. 46 Acs Z, Lyles A. (eds). Obesity. Business and Public Policy. Edward Elgar: Cheltenham, 2007. 47 Miller D, Harkins C. Corporate strategy, corporate capture: food and alcohol industry lobbying and public health. Crit Soc Pol 2010; 30: 564–589. 48 Babor TF, Robaina K. Public Health, Academic Medicine, and the Alcohol Industry’s Corporate Social Responsibility Activities. Am J Public Health 2013; 103: 206–214.
European Journal of Clinical Nutrition (2014) 753 – 759
PUBLIC HEALTH NUTRITION HIGHLIGHTS REVIEW
Obesity and industry self-regulation of food and beverage marketing: a literature review K Ronit1 and JD Jensen2 OBJECTIVE: Obesity is a growing concern at national and international levels, and it is increasingly recognised that the industry has a role in and hence needs to be involved in halting the obesity epidemic. The objective of this study is to describe, analyse and evaluate research on industry self-regulation regarding food and beverage marketing and nutrition labelling. SUBJECTS/METHODS: Five databases were searched for combinations of the search terms—obesity, nutrition, food, beverages, industry, self-regulation, labelling, advertising and marketing—and papers were selected on the basis of paper titles and, subsequently, on the basis of abstracts. RESULTS: Of the 4978 identified publications, 22 were included in the final review. The studies show that commitments in industry self-regulation schemes tend to be relatively vague and permissive, that the measurable effects of the self-regulations tend to be relatively small and that some extent of public regulation may catalyse the effectiveness of industry self-regulation. CONCLUSIONS: Although the reviewed studies vary in terms of analytic units and methods applied, they generally stress an ineffectiveness of existing self-regulation schemes. Food industry self-regulation in relation to obesity prevention is an emerging field of research, and further research is needed in such schemes’ definitions of regulatory standards, their monitoring and sanctioning mechanisms, and their interactions with public regulation, if industry self-regulation of marketing behaviour is to become an effective and credible approach. European Journal of Clinical Nutrition (2014) 68, 753–759; doi:10.1038/ejcn.2014.60; published online 9 April 2014 Keywords: food marketing; industry self-regulation; compliance; regulatory effectiveness
INTRODUCTION In many international forums, increasing attention is directed towards obesity as a serious lifestyle disease. Obesity is not only common in many affluent countries, giving rise to stronger priorities in health policy, but is also rapidly spreading to many low- and middle-income countries, putting a double burden on their already small health-care budgets.1–2 As the special agency for global health, the WHO has, especially since the late 1990 s, been engaged in combating obesity and the various chronic and non-communicable diseases typically associated with obesity, such as cancers, cardiovascular diseases, chronic respiratory diseases and diabetes.3 Obesity has also been elevated to a concern for the United Nations with the obesity epidemic highlighted at the first United Nations High-Level Meeting on Non-Communicable Diseases in September 2011. On that occasion, the UN Secretary General stated that '…industry and the private sector must be engaged. Their role is critical in populationwide behavioural interventions. For example, initiatives by the food industry in reformulation to healthier products and in exercising responsible marketing are crucial', and it was further noted that 'marketers can comply with recommendations against the marketing of food and non-alcoholic beverages to children', and provide products that 'follow relevant nutrition facts and labelling standards',4 topics that have also been a focus area for the WHO,5 and in academic research.6 More precise recommendations have been developed by the scientific community, and the
International Association for the Study of Obesity has issued the Sydney Principles7 to guide the private sector’s marketing, in particular to protect against the effects of unhealthy food marketing on children’s diets.8 These different organisations, therefore, envisage an active role for the industry. Given the serious and global character of the epidemic, global initiatives spanning relevant industries, preferably based on binding rules, and targeted at all consumers, but especially with a view to reach children and young people, are recommended.7,8 Encouraged by governments and international organizations (and possibly also triggered by industry concerns about potential upcoming public regulations), a rich variety of self-regulation initiatives (that is, regulations where companies or groups of companies commit themselves to follow specific rules or standards) have emerged in the industries. On one hand, industry self-regulation of marketing activities can be expected to be more flexible and better targeted towards specific conditions in the respective companies or industries in specific contexts, and hence be more cost-effective.9 For example, one company may find that reduction in the frequency of advertising adjacent to childrentargeted TV shows to be the least costly way to reduce children’s exposure to marketing, whereas another company may consider abolishing the use of licensed characters as the least-cost way to reduce exposure. On the other hand, self-regulation also implies higher reliance on the food industry's practices and ethics in defining and interpreting the norms and benchmarks for
1 Department of Political Science, University of Copenhagen, Copenhagen Ø, Denmark and 2Department of Food and Resource Economics, University of Copenhagen, Frederiksberg C, Denmark. Correspondence: Associate Professor JD Jensen, Department of Food and Resource Economics, University of Copenhagen, Rolighedsvej 25, DK-1958 Frederiksberg C, Denmark. E-mail: [email protected] Received 16 October 2013; revised 3 March 2014; accepted 4 March 2014; published online 9 April 2014
Obesity and industry self-regulation K Ronit and JD Jensen
754 self-regulation, including the monitoring of compliance with regulation and the use of sanctions to foster compliance. If these practices and performances are not transparent, there is a risk of sliding standards and lack of compliance.10 The general challenge of industry to curb obesity has also been discussed in academic publications for more than a decade,11–12 in which self-regulation is examined as one of the ways to regulate industry activities,13 particularly marketing to vulnerable groups such as children14–17 in Western countries18 as well as in other parts of the world, such as China.19 The provision of transparent and credible production information in terms of nutrition labelling has also attracted some interest in the literature.10,19 The purpose of this paper is to describe, analyse and evaluate research on industry self-regulation regarding nutrition labelling and food and beverage marketing to consumers. In particular, it is the aim of this review to evaluate alternative approaches and designs of industry self-regulation as well as the measurable performance of these regulations in terms of reducing companies’ promotion of energy-dense foods and beverages, in general, and with regard to special vulnerable consumer groups in particular. This objective is pursued via a systematic review of the literature on business self-regulation related to obesity prevention. MATERIALS AND METHODS The relationship between obesity and the self-regulation of marketing activities is complex and crosses several disciplinary boundaries, from health sciences to different branches of social science. At one end of the spectrum, there is a quite voluminous literature addressing a huge variety of physiological aspects of obesity, but it is not concerned with, for example, how industry behaves.20 At the other end of the spectrum, there is the significant research on the tools employed by industry to reach consumers,21 which, however, does not take a strong interest in food and beverages and the consequences of industry activities on public health—for example, obesity as a lifestyle disease. Much of the academic interest in the role of food marketing in public health seems to occur among scientists from the public health research community,22,23 although researchers from the broader social sciences have also displayed interest in this area of study. On the basis of a preliminary review of the relevant literature, the following search terms were identified: obesity, nutrition, food, beverages, industry, self-regulation, labelling, advertising and marketing. A flexible search procedure that included four or three search words in a variety of combinations was adopted: Obesity AND Nutrition AND industry AND selfregulation; Obesity AND food AND industry AND self-regulation; Obesity AND beverages AND industry AND self-regulation; Nutrition AND industry AND advertising; Nutrition AND Industry AND labelling; Nutrition AND Industry AND marketing; Food AND industry AND advertising; Food AND industry AND labelling; Food AND industry AND marketing; Beverages AND industry AND advertising; Beverages AND industry AND labelling and, finally, Beverages AND industry AND marketing. The following five databases were included in our literature search: Web of Science (Knowledge), Medline, PubMed, Science Direct and Social Science Research Network. The combination of different databases, with strengths in different clusters of disciplines, increases the likelihood that primary contributions that constitute the small and emergent field of obesity and industry self-regulation from different scientific disciplines would be found and properly evaluated. The search was conducted in May 2013. In order to focus on studies that are scientifically recognised, only full original academic papers published in English and containing concrete assessments of the organisation and performance of food and beverage industry self-regulation were included in the review. It is acknowledged that a considerable amount of ‘grey’ literature has also been prepared and published as reports from, for example, public health organisations, industry associations, and so on. Although many of these studies may represent valuable data and methods, there is also a risk of different biases in such reports. When exclusion criteria were defined for publication date, they limited the search to papers published from 1995 to 2013, a time when stronger scholarly attention was directed towards the challenge of obesity. No criterion was established for geographic coverage or research design. Obesity is today seen as a global problem and, hence, papers examining the situation in different cultural contexts are relevant to include in our review. European Journal of Clinical Nutrition (2014) 753 – 759
RESULTS The number of hits from the five databases totalled 4978 (1307, 2462, 704, 365 and 140, respectively), including duplicates between the different combinations of the search terms. On the basis of a review of the paper titles (the titles’ wording regarding self-regulation, marketing and labelling, food and beverages), 121 publications were found relevant for further scrutiny, and abstracts from these papers were carefully studied by the authors with a respect to obesity, nutrition, performance/effectiveness and organisation to identify a smaller group of core papers. In the next step, papers considered relevant to the study aims were read in-depth and, finally, 22 papers were included in our literature review. Table 1 presents the characteristics and main findings of the 22 included studies, which fall into three categories (although some of the studies address more than one of these categories): studies of the content of industry self-regulation schemes, studies of the effects of industry self-regulation schemes, and studies of the interactions between self-regulation schemes and public regulation—for example, a perceived threat of public regulation may catalyse the development of private schemes. These core papers use different research methods. Furthermore, they display a variety of companies, associations and other entities engaged in self-regulation at different territorial levels and jurisdictions and addressing different segments of consumers and different marketing tools. It is interesting to note that, although scholarly attention has been directed towards the practices of business in relation to the obesity epidemic since the 1990s, and in some respects even earlier, most of the contributions are quite recent. The ambition in most of the contributions reviewed is to offer a broad (industry) picture of self-regulation, in some cases by considering a selected group of (typically large) companies27,28,33,38 and comparing the marketing activities of corporations participating in an industry self-regulation scheme with those of non-participating firms,30,31,39 and in other cases by studying the performance of the industry at a more general level on the basis of aggregated data.36,38 Whereas most reviewed studies refer to the food and beverage industry in general, some studies concentrate on particular industries, such as 'breakfast cereals'38 or the 'quick-service restaurant industry',32 some studies pinpoint certain products or substances, such as 'sugar sweetened beverages',28,37,42 and some provide comparisons between different subsectors of the food and beverage industry—for example, different sub-sectors’ rate of food advertising during children’s peak TV viewing time35 or compliance with industrywide self-regulation schemes.37 Content of industry self-regulation schemes Studies in this category pay attention to the behaviour of corporations participating in self-regulatory schemes in terms of restrictions on nutritional values of the products marketed to children, different marketing media (for example, television, internet, computer games, smart phones) and different marketing tools (for example, character licensing). The reviewed studies show that some basic challenges are facing the industries as a whole, with many similarities between the different areas of food and beverages. For example, Hawkes and Harris41 found that the majority of industry self-regulation pledges regarding food marketing behaviour in 2009 covered the food industry broadly across commodity categories. Two broad sets of marketing activities tend to be regulated by private regulations and have attracted special attention in research—namely, front-of-package labelling of products10,25,28,40,41 and advertising of products through television.13,37,39 Whereas labelling is directed towards the adult population who are supposed to read and interpret the information on the front of packages to make an informed choice © 2014 Macmillan Publishers Limited
Research methods
Study
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Compare US self-regulation schemes USA. Industry with eight 'objective' standards for meaningful self-regulation
29
Comparing advertising intensity towards children for pledgers and non-pledgers
Examine the impact of selfregulatory pledges on food and drink advertising to children on commercial television
34
35
Australia. Industry
Voluntary assignment to pledge Voluntary compliance
Advertising to children
Australia. Focus on Voluntary assignment to pledge Advertising to single firms (members Mainly voluntary but also industry children and free-riders) association’s actions to enhance compliance
Change in non-core food advertisements
Advertisements’ compliance with nutritional standards
Marketing activities of Not lower marketing intensity pledgers versus non-pledgers for pledgers
Advertising to children
Compare advertisement intensity for Canada. Signatories of Voluntary assignment to pledge. Voluntary compliance pledgers and non-pledgers industry pledge. Mainly firms
33
Frequency of non-core food advertising has remained essentially unchanged between 2006 and 2011
Effect of pledging was found but effect was limited
Unhealthy foods constitute a smaller share of total ads after initiative, but absolute exposure effect is limited
Firms classify fewer products as unhealthy compared with objective classification. Suppliers of unhealthy foods tend to use 'per-portion' nutrition facts rather than 'per 100 g' Compliance with alternative nutritional standards
Compliance with alternative nutrition standards
Evaluate exposure to advertisements Australia. Mainly focus Restriction on marketing based on industry- Advertising to before and after self-regulation on industry but firms led nutrient profiling. children initiative in 2009 are also included Voluntary actions; not how to punish noncompliers
Restriction on marketing based on industry- Marketing, especially led nutrient profiling. advertising to Voluntary compliance children
Change in core and non-core The industry’s voluntary food advertising. agreement has failed to fulfil Documentation of marketing its declared purpose techniques
The considered self-regulation schemes do not comply with the objective standards
A significant share of labelled products are not healthy from objective criteria
Firms are prone to state relatively loose evaluation criteria
32
Australia. Firms
Advertising to children
Compliance with eight standards for self-regulation
Mainly advertising to Various existing self-regulatory pledges. Mainly voluntary - few measures to enhance general consumers compliance EU pledge. Voluntary compliance
Share of products compliant with NPM criteria
Different indicators of industry progress
Commitments are permissive and vague
The DIG kJ label performed poorly in comparison with the other labels
Compare firms' categorisation of unhealthy foods with 'objective' categorisations
Germany. Industry
Adults’ assessment of DIG’s interpretability, noticeability and usefulness, compared with other labels
Labelling towards consumers in general
SmartChoice label according to industrydefined criteria. Voluntary compliance
Advertising to children and adolescents
Key results
Products compliant with NPM Government-led schemes are criteria more restrictive compared with industry-led schemes
Outcome measures
Marketing to children Assessment of firms’ commitments on marketing to children
Labelling for general consumers
Advertising to children
Tools and segment: all/selected groups
31
Effect evaluation of self-regulation schemes 30 Examine effectiveness of selfadministered voluntary restrictions on promotion of less healthy food
Review of products labelled with SmartChoice label compared with "objective" (Nutrient Profiling Model - NPM) health criteria
28
USA. Firms and product names
USA. Firms’ behaviour Product reformulation, restrictions on TV and industry advertising, labelling. programs Voluntary—but some mechanisms to make firms comply are studied
Assess firms' evaluation criteria for self-regulation against 'objective' criteria
27
Australian Responsible Marketing to Children Initiative. voluntary compliance
Australia. Firms (mainly) and industry
Assess principles and commitments of signatory companies to responsible marketing
26
Nutrition labelling based on industrydefined nutrient profiles. Voluntary—few measures to enhance compliance
Evaluation of a voluntary daily-intake Australia Consumers’ guide label (DIG kj) against other perception of labels nutrition labels
Restriction on advertising based on industry-led nutrient profiling voluntary compliance
Regulation and compliance with regulation
25
Industry compliance with self-regulation schemes 22 Compare industry-led nutrient USA and EU. Industry profiling schemes with governmentled schemes
Coverage: national/international and scope
Selected papers and their major findings
Table 1.
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755
European Journal of Clinical Nutrition (2014) 753 – 759
Assess the effectiveness of coregulatory system in limiting children’s exposure to unhealthy television food advertising
Compare advertisements' compliance with standards for marketing to children for pledgers and non-pledgers
Compare marketing of self-defined unhealthy products with objectively defined unhealthy products
36
37
38
USA. Firms
Spain. Industry and firms and products
Australia. Industry
Coverage: national/international and scope
European Journal of Clinical Nutrition (2014) 753 – 759
Review of pledges wrt content and coverage
Review of sanctioning procedure for New Zealand. Industry Self-regulation of food advertising and not complying with stated pledges treatment of complaints Some mechanisms of self-regulation to make regulation binding (compliers and adjudication)
Assess industry pledges and the role USA. Industry, firms of US legislation regarding beverage and public regulation sales in schools
Review of documents related to two Australia. Industry self-regulatory initiatives towards food and beverage marketing to children
9
42
17
Content of pledges
Advertising to children
Abbreviations: DIG, daily intake guide; NPM, nutrient profiling model; wrt, with respect to.
Self-regulation of food advertising to children. Voluntary codes
Advertising to children
Fair and transparent enforcement of self-regulation requires objective bodies
A number of limitations and inconsistencies in the pledges were found
There is huge variation in the regulations, standards and guidelines on public as well as private nutrition labelling around the world
Growth in regulation of marketing to children: selfregulation, public campaigns and government regulation, but only to a little extent based on evidence
Large variation in regulation environments in different countries
Self-regulation is less effective than that claimed by firms
About half of the advertisements do not comply with all standards
Many breaches of mandatory as well as voluntary regulations
Key results
Evaluation of transparency and accountability
Both schemes establish transparency and accountability mechanisms, but too little stakeholder involvement, and are thus unlikely to reflect public health concerns properly
Extent and content of public Industry pledges have little and private regulations substance when it comes to complying with the pledges
Advertising to general Arguments in treatment of consumers complaint and decision
Legislation and policy documents
Labelling for general consumers
Voluntary pledges on beverages sales in Marketing to school schools. children Voluntary compliance, but some public and industry measures to enhance compliance
Assignment to voluntary pledges. Global, regional and national. Mainly focus Voluntary pledges but some public and industry measures to enhance compliance on industry pledges but firms are also covered
Interaction between public and private regulation. Voluntary pledges and some public and industry measures to enhance compliance
41
Global. Industry
Overview and analysis on regulations, standards, and guidelines on nutrition labelling
40
Legislation and policy documents
Nutritional value of products exposed to children
Advertisements’ compliance with pledge standards
Compliance with alternative nutritional standards
Outcome measures
Focus on some mechanisms of industry self- Different marketing Content and bindingness of regulation. tools to young people government and industry-led Some industry measures to enhance regulations compliance
Policy recommendation
Comparative —selected countries. Industry
Advertising to young people
Advertising to children
Advertising to children
Tools and segment: all/selected groups
Interaction between public and private Advertising to regulation. children Voluntary pledges and industry measures to enhance compliance
Restriction on advertising based on industry-led nutrient profiles. Voluntary compliance—few measures to enhance compliance
Pledge on food marketing to youth. Voluntary compliance
Mandatory and voluntary advertising regulations. Influence of mandatory regulation on compliance in self-regulation
Regulation and compliance with regulation
18
Interrelations between industry self-regulation and public regulation 39 Policy review Global and comparative Industry, also related to public regulation
Research methods
(Continued )
Study
Table. 1.
Obesity and industry self-regulation K Ronit and JD Jensen
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Obesity and industry self-regulation K Ronit and JD Jensen
(and where the basic regulation issue is to extend and ensure adequate quality of information), television advertising is mainly studied in relation to children and young people, where the key concern of regulation is to structure and limit advertising activities. Regarding front-of-package labelling, the main research questions have been whether labelling provides appropriate nutritional information to consumers, the definition of standards underlying these labels29 and whether companies comply with the guidelines that they have adopted. Two studies25,29 suggest that industrydefined criteria are relatively permissive and vague, and one study suggests that labelling can also be used to manipulate a consumer's perception of the product's nutritional value—for example, by selective use of nutritional indicators or units of measurement, and that self-regulation can also address such behaviour.10 In addition , with regard to TV advertising, industry self-regulation schemes are found to be relatively vague in terms of stated commitments 24,26 and evaluation criteria.27 Other types of marketing tools are also used in food marketing and might also be addressed in regulations to protect consumers, such as use of names and licensed characters (for example, cartoons) on the packaging of foods.29 The literature offers a number of examples of self-regulation, in terms of voluntary pledges, in which food companies promise to abstain from using such characters in their product promotion.33,35 Other types of tools addressed in self-regulation schemes include product placement (in TV shows, computer games, websites, social networks and so on), premium offers and promotion or sales in schools.34,39 Enrolment in the various self-regulation initiatives studied is to a very high degree voluntary, and companies can join or leave them without heavy sanctions being imposed, should they not observe the self-imposed restrictions.27 However, companies can also violate the initiatives without leaving them and without being punished.33 Much, therefore, hinges on the commitment of the individual companies, and many studies observe a conflict between basic commitment and actual non-compliance, and it is possible for companies to exploit 'the fine print'.26 Effect evaluation of self-regulation schemes Most studies addressing the effectiveness of industry self-regulation report on domestic experiences with food industry and self-regulation at a national level, whereas a few address the issue at international levels.39,41,43 According to our findings, a considerable body of scientific studies addresses experiences with self-regulation of food marketing practices in Australia;9,13,25,31,32,34 however, there is also an emerging tradition in North America27,33,38 and in Europe.30,37 Often, reported cases refer to local and state experiences rather than nationwide practices.34,35,42 A significant number of the studies analyse industry initiatives addressing marketing towards children and adolescents15,38 or primarily children.26,31,33,41 In particular, many studies address the extent to which the industry observes the rules and restrictions it has imposed on itself. Several of the reviewed studies offer examples that industry has severe difficulties complying with its own commitments on advertising to children, and various loopholes and transgressions are reported—transgressions that cannot be observed by children as a specific consumer group31,33,39,41—for example, setting thresholds for 'negative' nutrients relatively high.31 Hence, most of the studies found that the effects of self-regulation were limited.30,32–38 Relations between industry self-regulation and public regulation Processes of creating incentives in the various industry self-regulation schemes to enhance compliance are only discussed © 2014 Macmillan Publishers Limited
to a limited extent in the reviewed literature in our study.13,15,29,34 If the initiatives are weak from the beginning, and no sanctions are envisioned to punish transgressors, it is no surprise that compliance is low. Hawkes and Harris,41 however, provide interesting insights into the complex mechanisms between companies and the initiatives and distinguish between the collective self-regulation pledges that companies can join, and within-pledge commitments issued by single corporations, regarding self-regulation of marketing to children. In particular, studies found differences in criteria underlying the different pledges (with some companies committing to different pledges with different standards), but also some development in the pledges over time, in the direction of becoming more restrictive, was noted. Studies also found substantial variation in individual companies' participation in collective pledges, with some of the most active participating in 11 out of 13 pledges. Although corporations participating in the pledges tend to be among the largest in their respective markets, there are, however, still many relevant suppliers who do not participate. Horizontal pressures operating between companies to discipline non-complying companies seem to be fairly weak in the studied self-regulation schemes. Examples of such horizontal pressures could be peer pressure, in which compliance was monitored (and possibly sanctioned) by peers and competitors, or active accountability with respect to such pledges in companies’ own individual corporate social responsibility schemes. However, companies have not delegated real power to monitor and, if need be, sanction non-compliers. Only exception is, for instance, adjudication discussed in the analyses of self-regulation.9 Further insights can be achieved by exploring the performance of and linkages between self-regulation and public regulation (such as general mandatory rules or standards, or various forms of partnerships between industry and government)24,36,39,40,42—for instance, because public regulation can influence and pose an alternative to self-regulation and in this way assist in stimulating compliance. For example, Mello et al.42 found that an industry selfregulation on beverage marketing, where three of the major soft drink sellers in the United States committed themselves to phase out soft-drink sales in schools, was catalysed by a latent possibility of public regulation, which might be more burdensome for the companies than voluntary regulation, a point that has also been mentioned in other studies outside the focus of the present review.22,43 Whereas regulation of markets across borders can be a serious challenge for public regulation,39 self-regulation efforts through multinational corporations, and especially through international industry associations, may be better suited to deal with this aspect of globalisation.40,43 Hawkes and Harris41 studied some of the attempts to develop encompassing initiatives through international industry associations and found that the participation of companies in global commitments is relatively low. DISCUSSION Food industry self-regulation in relation to obesity prevention is an emerging field of research and, although studies generally note some progress in the implementation of such schemes41 and important achievements have been made in some of the studied cases, there is still need for research in a number of areas, if self-regulation is to become an effective and credible approach. Self-regulation initiatives tend to be based on voluntary participation, where companies have a strong say in formulating the standards and benchmarks of the regulation, which implies a risk of setting the standards at a relatively low level. Given such pitfalls, several papers9,32,40 reach the conclusion that stronger tools are needed to regulate the industry, and that some degree of government intervention may be needed to solve this challenge. European Journal of Clinical Nutrition (2014) 753 – 759
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758 There is need for more research in potential mechanisms for selfregulation in this area, including the effectiveness of alternative benchmarking, such as the UK-based Nutrient Profiling Model,24,28 and formulation of appropriate and generally recognisable and verifiable standards for marketing in media other than television, such as internet, computer games, smart phones and so on. The voluntary participation in industry self-regulation schemes is a major weakness, a view shared by all scholarly contributions. Only some firms sign up, and there are many examples of firms joining self-regulation schemes and committing themselves to comply with the rules in these schemes but nevertheless manipulating and evading the rules, for example, by applying different definitions of 'children' (for example, Hawkes and Harris41), with self-stated commitments being less binding, the narrower the definition of 'children', or companies may be rather selective in their choice of specific commitments, they sign up to.24 The studies show that currently there is no strong power to make firms comply and punish recalcitrant behaviour. Hence, there is a need for more research on the role of associations or other entities in monitoring and enforcing self-regulation. Industry self-regulation can be considered a strategy for industry to prevent the introduction of more binding and less flexible public regulation, which would imply a higher cost to the industry. Parts of the literature suggest that self-regulation comes close to 'regulatory capture'. In the regulation literature, reference is made to 'regulatory capture' when a special interest, in our case the food and beverage industry, manages to instrumentalize public regulation in ways that are mainly beneficial to private interests.45 This is a key problem with regard to public health and the prevention of obesity46 and it is spelled out in many ways through the interaction between government and industry in and beyond the food sector.42,47,48 To the extent that current self-regulation is considered 'too weak' in the general public and among policy makers, it may therefore be in the self-interest of the industry to improve these initiatives and replace voluntary elements with more binding rules. Some contributions in the literature study how a combination of public and private regulation can operate in practice as a solution for effective regulation;13,42 however, there is need for a more profound understanding of how public regulation might enhance and sustain self-regulation. In theory, industry self-regulation may be superior to the efforts of single companies, simply because industry-level rules are more encompassing, standardised and make it easier for consumers to identify non-compliance than a plethora of incomparable rules and activities. The food industry is, however, very heterogeneous, displaying differences in firm structures, regulatory challenges and demand for regulation. For example, companies may be able to state more ambitious commitments if they have opportunities to substitute some of their products with other and healthier products. In addition, companies in markets with fierce competition may be more reluctant to state ambitious goals compared with companies facing less competition.17,27 Such factors may provide industries with different opportunities and different approaches to self-regulation and influence the firms’ coping with self-regulatory schemes. Whereas studies based on aggregate data can be considered representative for large parts of the industry (or a subsector), studies of individual companies or company behaviour within individual self-regulation schemes tend to focus on the way single companies cope with, implement and comply with self-regulation. Several of the studies reviewed in this paper suggest that a lack of compliance with self-regulation schemes appears in some industries (for example, sugared drinks); however, it should be recognised that conclusions based on this observation may be subject to serious selection bias, as the level of marketing activities in an unregulated industry—as well as the coverage in the literature—also differs substantially between different European Journal of Clinical Nutrition (2014) 753 – 759
subsectors of the food and beverage industry. Although the combination of sector-level and company-level analytical approaches yields insights into both the overall performance of food industry self-regulation and the mechanisms at the company level, there is still need for development of analytical strategies to understand the relationships between a companies’ product portfolios and market orientations, the degree of competition in the respective markets and the design and effectiveness of selfregulation schemes—for example, whether self-regulation is more likely to be more effective in some markets than in others. Taking into account the international structure of the food and beverage industry, with corporations being active in several jurisdictions, public regulation of industry behaviour can be a challenge. Appropriately designed industry self-regulation may constitute an answer to this challenge because corporate policies may be easier to implement across jurisdictions than are public policies. For such self-regulation schemes to work effectively and appropriately, precise definitions of regulation items, transparent monitoring schemes and the development of appropriate sanctions in cases of non-compliance are however required. The reviewed literature suggests some room for improvement in these respects. The reviewed studies with an international orientation mainly analyse the general performance of Western corporations.40,41 Some of the studies, including the behaviour of large international corporations, or of significant international business associations, provide important experiences with self-regulation, and some of these experiences can be used to understand the global situation. However, in relation to understanding industry self-regulation on a global scale—for example, in the development of policies and recommendations within the framework of intergovernmental bodies, such as the WHO—there is a need for more knowledge on market structures, income levels and cultural factors in the meeting between domestic consumers and foreign companies, implications of multinational corporations being present in many markets and meeting many segments of consumers. Thus, it is necessary to further develop such international perspectives—for example, by studying otherwise neglected countries and regions that struggle with obesity problems. CONCLUSIONS Against a backdrop of growing prevalence of obesity and an increasing concern for the role of food industry in this development from national governments, non-governmental organisations and international bodies, such as the United Nations and the World Health Organization, the present study has reviewed the scientific literature on the opportunities and challenges related to industry self-regulation in the food industry. Although the reviewed studies vary in terms of analytic units and methods applied, rendering comparisons and general conclusions difficult, the studies generally stress the ineffectiveness of existing self-regulation and the perils of surrendering the role of regulating food and beverage markets to the industry. The studies show that commitments in industry self-regulation schemes tend to be relatively vague and permissive, that the measurable effects of the self-regulations tend to be relatively small and that some extent of public regulation might enhance the effectiveness of industry self-regulation. Food industry self-regulation with regard to obesity is an emerging field of research and, although the reviewed studies show important achievements in a number of research areas, a number of issues still call for further research on companies’ incentives to participate in self-regulation schemes, mechanisms involved in the formulation of rules and standards, mechanisms in monitoring and enforcing compliance, the role of industry and market structures, and the interaction between industry self-regulation and public regulation. © 2014 Macmillan Publishers Limited
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759 CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGEMENTS This study was prepared as part of the cross-disciplinary UNIK—Food, Fitness & Pharma research center at the University of Copenhagen. The activity was financed by a research grant from the Danish Ministry of Science and Innovation. Preparation of the manuscript was financed by a research grant from the Danish Ministry of Science and Innovation.
REFERENCES 1 Prentice AM. The emerging epidemic of obesity in developing countries. Int Journ Epid 2006; 35: 93–99. 2 WHO. Preventing Chronic Disease. A Vital Investment 2005: World Health Organization: Geneva, 2005. 3 WHO Obesity: preventing and managing the global epidemic. Report of a WHO Consultation on Obesity.1998, WHO: Geneva. Geneva. 3–5 June 1997. 4 United Nations. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases. General Assembly. Sixty-Sixth Session. 2011. Agenda Item 117 A/66/L.1 (16 September 2011). 5 World Health Organization Set of recommendations on the marketing of foods and non-alcoholic beverages to children. 2010. Available at: http://www. who.int/dietphysicalactivity/publications/recsmarketing/en/index.html (accessed 25 September 2013). 6 Cairns G, Angus K, Hastings G, Caraher M. Systematic reviews of the evidence on the nature, extent and effects of food marketing to children. A retrospective summary. Appetite 2013; 62: 209–215. 7 International Association for the Study of Obesity The Sydney Principles: Guiding Principles for Achieving a Substantial Level of Protection for Children Against the Commercial Promotion of Foods and Beverages. IASO: London. 8 Swinburn B, Sacks G, Lobstein T, Rigby N, Baur LA, Brownell KD et al. The Sydney principles for reducing the commercial promotion of foods and beverages to children. Public Health Nutr 2008; 11: 9. 9 Hoek J, King B. Food advertising and self-regulation: a view from the trenches. Austr N Z J Public Health 2008; 32: 261–265. 10 Brownell KD, Koplan JP. Front-of-package nutrition labeling: an abuse or trust by the food industry?”. N Engl J Med 2011; 364: 25. 11 Seidell JC. Prevention of obesity: the role of the food industry. Nutr Metab Cardiovasc Dis 1999; 9, 45–50. 12 Yach D, Khan M, Bradley D, Hargrove R, Kehoe S, Mensah G. The role and challenges of the food industry in addressing chronic disease. Global Health 2010; 28: 10. 13 Reeve B. The regulatory pyramid meets the food pyramid: can regulatory theory improve controls on television food advertising to Australian children?”. J Law Med 2011; 19: 128–146. 14 Kelly B. To quell obesity, who should regulate food marketing to children. Global Health 2005; 14: 9. 15 Hawkes C. Regulating food marketing to young people worldwide: trends and policy drivers. Am J Public Health 2006; 97: 11. 16 Lobstein T. Food and drink marketing to children. Public Health Nutr 2009; 12: 882. 17 Reeve B. Private Governance, public purpose? Assessing transparency and accountability in self-regulation of food advertising to children. J Bioeth Inq 2013; 10: 149–163. 18 Nestle M. Food marketing and children obesity – a matter of policy”. N Engl J Med 2006; 354: 2527–2529. 19 Hawkes C. The agro–food industry growth and obesity in China: what role for regulating food advertising and promotion and nutrition labeling? Obes Rev 2008; 9: 1. 20 Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. J Am Med Assoc 1999; 282: 1523–1529. 21 McGregor SLT. Transdisciplinary consumption. Integral Rev 2013; 9: 413–438. 22 Panjwani C, Caraher M. The Public Health Responsibility Deal: brokering a deal for public health, but on whose terms? Health Policy 2013, 114: 163–173.
© 2014 Macmillan Publishers Limited
23 Slining MM, Ng SW, Popkin BM. Food companies' calorie-reduction pledges to improve U.S. diet. Am J Prev Med 2013; 44: 174–184. 24 Brinsden H, Lobstein T. Comparison of nutrient profiling schemes for restricting the marketing of food and drink to children. Pediatr Obes 2013; 8: 325–337. 25 Carter O, Mills B, Phan T. An independent assessment of the Australian food industry’s daily intake guide ‘Energy Alone’ label. Health Promot J Austr 2011; 22: 63–67. 26 Hebden L, King L, Kelly B, Chapman K, Innes-Hughes C. Industry self-regulation of food marketing to children: reading the fine print. Health Promot J Austr 2010; 21: 3. 27 Kraak V, Story M, Wartella EA, Ginter J. Industry progress to market a healthful diet to american children and adolescents. Am J Prev Med 2011; 41:322–333. 28 Roberto CA, Bragg MA, Livingston KA, Harris JL, Thompson JM, Seamans MJ et al. Choosing front-of-package food labeling nutritional criteria: how smart were “smart choices”? Public Health Nutr 2012; 15: 2. 29 Sharma L, Teret SP, Brownell KD. The food industry and self-regulation: standards to promote success and to avoid public health failures. Am J Public Health 2010; 100: 2. 30 Effertz T, Wilcke AC. Do television food commercials target children in Germany? Public Health Nutr 2011; 15: 1466–1473. 31 Hebden L, King L, Kelly B, Chapman K, Innes-Hughes C, Gunatillaka N. Regulating the types of food and beverages marketed to Australian children: how useful are food industry commitments? Nutr Diet 2010; 67: 4. 32 Hebden L, King L, Grunseit A, Kelly B, Chapman K. Advertising of fast food to children on Australian television: the impact of industry self-regulation. Med J Australia 2011; 195: 1. 33 Kent MP, Dubois L, Wanless A. Self-regulation by industry of food marketing is having little impact during children’s preferred television. Int J Pediatr Obes 2011; 6: 5–6. 34 King L, Hebden L, Grunseit A, Kelly B, Chapman K, Venngopal K. Industry self-regulation of television food advertising: responsible or responsive? Int J Pediatr Obes 2011; 6: 2. 35 King L, Hebden L, Grunseit A, Kelly B, Chapman K. Building the case for independent monitoring of food advertising on Australian television. Public Health Nutr 2012; 16: 2249–2254. 36 Roberts M, Pettigrew S, Chapman K, Miller C, Quester P. Compliance with children's television food advertising regulations in Australia. BMC Public Health 2012; 12: 846. 37 Romero-Fernandez MM, Royo-Bordonada MA, Rodrigues-Artalejo F. Compliance with self-regulation of television food and beverage advertising aimed at children in Spain. Public Health Nutr 2010;13:1013–1021. 38 Schwartz MB, Ross C, Harris JL, Jernigan DH, Siegel M, Ostroff J et al. Breakfast cereals industry pledges to self-regulate advertising to youth will they improve the marketing landscape? J Public Health Pol 2010; 31: 1. 39 Caraher M, Landon J, Dalmeny K. Television advertising and children: lessons from policy development. Public Health Nutr 2006; 9: 5. 40 Hawkes C. Government and voluntary policies on nutrition labeling: a global overview. In: Albert J (ed). Innovations in Food Labeling. Woodhead Publishing Ltd: Cambridge, 2010. Woodhead Food Series No. 184. 41 Hawkes C, Harris JL. An analysis of the content of food industry pledges to marketing to children. Public Health Nutr 2011;14: 8. 42 Mello MM, Pomeranz J, Moran P. The interplay of public health law and industry self-regulation: the case of sugar sweetened beverage sales in schools. Am J Public Health 2008; 98: 4. 43 Bryden A, Petticrew M, Mays N, Eastmure E, Knai C. Voluntary agreements between government and business-A scoping review of the literature with specific reference to the Public Health Responsibility Deal. Health Policy 2013; 110: 186–197. 44 Hawkes C. Uneven dietary development: linking the policies and processes of globalization with the nutrition transition, obesity and diet-related chronic diseases. Global Health 2006; 2: 4. 45 Stigler G. The theory of economic regulation. Bell J Econ Manage Sci 1971; 2: 3–21. 46 Acs Z, Lyles A. (eds). Obesity. Business and Public Policy. Edward Elgar: Cheltenham, 2007. 47 Miller D, Harkins C. Corporate strategy, corporate capture: food and alcohol industry lobbying and public health. Crit Soc Pol 2010; 30: 564–589. 48 Babor TF, Robaina K. Public Health, Academic Medicine, and the Alcohol Industry’s Corporate Social Responsibility Activities. Am J Public Health 2013; 103: 206–214.
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