February 1, 2022

A study published today in the journal PLOS Medicine is the first to examine in a realistic setting whether pictorial health warnings on sugary drinks — like juice and soda — influence which beverages parents buy for their children.

The findings are promising: The warnings reduced parental purchases of sugary drinks for their kids by 17 percentage points.

Researchers at the University of North Carolina at Chapel Hill’s Gillings School of Global Public Health ran the study in a unique laboratory — the “UNC Mini Mart.” The space, housed in UNC’s Center for Health Promotion and Disease Prevention, is set up to mimic a convenience store shopping experience.

Dr. Lindsey Smith Taillie

Dr. Lindsey Smith Taillie

“We created this store because we saw a major need for research that tests the impact of policies in a food store setting that is much more realistic. When people make choices about what food to buy, they are juggling dozens of factors like taste, cost and advertising and are looking at many products at once,” says senior author Lindsey Smith Taillie, PhD, assistant professor in the Department of Nutrition at the Gillings School and a member of UNC’s Carolina Population Center (CPC). “Showing that warnings can cut through the noise of everything else that’s happening in a food store is powerful evidence that they would help reduce sugary drink purchases in the real world.”

Dr. Anna Grummon

Dr. Anna Grummon

Dr. Marissa Hall

Dr. Marissa Hall

Taillie’s co-authors from the Gillings School are lead author Marissa G. Hall, PhD, assistant professor in Gillings’ Department of Health Behavior and a member of both the CPC and UNC’s Lineberger Comprehensive Cancer Center (LCCC); and Anna H. Grummon, PhD, an alumna of the UNC Gillings Department of Health Behavior who is now a David. E. Bell Fellow at Harvard University.

Their positive findings about the effects of image-based warning labels highlight a recent but ever-more-common approach to combatting the global struggle with obesity. Children in the United States and many other countries consume more than the recommended amount of sugary drinks, which increases their risk for obesity and diet-related chronic diseases, including Type 2 diabetes and heart conditions.

There also are pronounced disparities by race/ethnicity, with higher rates of sugary drink consumption and obesity among Black and Latino children compared to non-Latino white children, in part due to structural factors like targeted marketing.

Taillie has conducted research into warning labels and taxes on sugar-sweetened beverages and junk food in Chile, Mexico and South Africa. Hall researches the impact of warnings on tobacco and food products.

In their latest study, 326 parents (25% Black; 20% Latino) of children ages 2 to 12 years old participated in a randomized trial with 1) a picture warning arm (in which drink labels had images representing heart damage and Type 2 diabetes), and 2) a control arm (in which drink labels displayed a barcode).

Sodas with warning labels fill a drink cooler.

Sodas with warning labels fill a drink cooler.

Participants were instructed to choose one drink and one snack for their child, along with one household good — this shopping list was designed to mask the purpose of the study. After shopping, participants completed a survey about their selections and left with their drink of choice and a cash incentive.

The picture warnings led to a 17-percentage point reduction in purchases of sugary drinks, with 45% of parents in the control arm buying a sugary drink for their child compared to 28% in the pictorial warning arm.

The picture warnings also reduced calories purchased from sugary drinks and led to parents feeling more in control of healthy eating decisions and thinking more about the harms of sugary drinks.

The benefits of the picture warnings were similar for parents with different characteristics, including race, ethnicity and socioeconomic status, suggesting picture warnings could be effective across diverse populations. Larger studies are needed, however, to see how well warnings work for the groups at highest risk of diet-related disease.

“We think the paper could be useful for policymakers in the U.S. and globally,” Hall says. “This evidence supports strong front-of-package warnings to reduce children’s sugary drink consumption.”

Other study researchers affiliated with UNC are: Isabella C. A. Higgins, MPP, a doctoral student in the Gillings Department of Health Behavior and trainee at the CPC; Allison J. Lazard, PhD, E. Reese Felts Jr. Distinguished Associate Professor at the UNC Hussman School of Journalism and Media and a member of the LCCC; Carmen E. Prestemon, a project coordinator at the CPC; and Mirian I. Avendaño-Galdamez, a research assistant at the CPC.

Contact the UNC Gillings School of Global Public Health communications team at sphcomm@unc.edu.

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