14 th Meeting of the WHO European Action
Network on Reducing Marketing Pressure on
Children
MEETING REPORT
Bern, Switzerland, 8 – 9 May 2019
WHO European Office for the Prevention and Control of
Noncommunicable Diseases
ABSTRACT
In May 2019, the 14th meeting of the WHO European Action Network on Reducing Marketing Pressure on Children took place in Bern, Switzerland. The Network facilitates cooperation and knowledge sharing between European Member States on reducing marketing of foods high in fat, sugar or salt (HFSS) to children as part of broader efforts to tackle increasing levels of childhood obesity and the high burden of noncommunicable diseases.
Representatives of 11 Member States belonging to the Network participated in the meeting, along with academic experts and representatives of civil society and international organizations, including WHO. Several countries reported on progress in introducing measures to restrict HFSS food marketing to children, and participants heard of new tools, templates and training developed to support Member States in their efforts.
The digital marketing of foods and non-alcoholic beverages to children poses serious challenges. Participants learned about how the digital marketing ecosystem works and of new research to help understand children’s exposure to such marketing and its impact. Continued country cooperation, with technical support from WHO, will be essential to help countries overcome these challenges and reduce marketing pressure on children throughout the European Region.
Document number: WHO/EURO:2021-2678-42434-58873
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CONTENTS
Page
Introduction and background ... 1
Introductory session and opening remarks ... 2
Session 1: Update on country approaches to tackling marketing of foods to children in the WHO European Region, with a focus on digital marketing ... 4
Portugal ... 4
Israel ... 6
Cyprus ... 7
Norway ... 8
Session 2: Update on WHO tools and approaches to monitoring marketing ... 10
Monitoring and restricting digital marketing of unhealthy products to children and adolescents: CLICK tool ... 10
Training unit for the monitoring of food and beverage marketing to children across multiple media ... 11
Presentation of the WHO European Action Network on Reducing Marketing Pressure on Children website ... 12
Thinking out of the box: Opportunities to learn from other countries and other areas to better implement policies ... 13
Building Momentum: Lessons on implementing policies to reduce food marketing to children ... 13
Understanding what marketing means to marketers ... 13
Update on new and promising research ... 15
Impact of social media influencers ... 15
Perceptions of social media marketing among teens and parents ... 16
Update from European Association for the Study of Obesity ... 16
Working group sessions ... 17
Tools and approaches for monitoring of digital marketing to children and young people — how to use them ... 17
Determining the scope of restrictions and provisions ... 17
Closing remarks and next steps ... 18
Annex I: List of participants ... 20
1
Introduction and background
The high levels of childhood obesity and the heavy burden of diet-related noncommunicable diseases (NCDs) across the WHO European Region call for broad policy responses. One important area for action is to reduce marketing pressure on children — especially the marketing of energy-dense, micronutrient-poor, foods and beverages. Such marketing influences children’s knowledge, preferences, attitudes, food choices and dietary behaviours.
A European WHO Action Network on Reducing Marketing Pressure on Children (hereafter referred to as ‘the Network’) was established in 2008, in close collaboration with the WHO Regional Office for Europe, to facilitate country exchange and collaboration on this issue.
Norway initially took on the responsibility of leading and facilitating the network and since 2016 Portugal has taken over this responsibility.
There are currently 30 countries in the WHO European Region participating in the Network.1 In addition, several organizations and institutions take part in the Network as observers.2 Network meetings have been held in Serbia, Slovenia, the United Kingdom, Portugal (twice), Belgium, Denmark, Turkey, Switzerland, Greece, Ireland and Austria.
The long-term goal and objectives of the Network are:
Long term goal
To protect children’s health and wellbeing as a basic human right, through sharing experiences and best practices in order to identify and implement specific actions which will substantially reduce the extent and impact of all marketing to children of high salt, energy-dense, micronutrient-poor foods and beverages.
Objectives
1. To constitute a coalition of committed countries who can identify and demonstrate specific actions to protect children against pressure from marketing of high salt, energy-dense, micronutrient-poor foods and beverages.
2. To share and discuss experiences in work relating to regulation of food and beverage marketing to children and ensure that information is exchanged between the network countries and available to other countries in the Region and globally, including countries in transition.
3. To discuss approaches to control marketing of food and non-alcoholic beverage to children, such as statutory regulation, self-regulation, voluntary measures and co regulation and identify content and principles and contribute to international recommendations on the regulation of marketing of food and non- alcoholic beverage to children.
4. To develop tools and share experiences to support monitoring of food and beverage marketing to children, as well as compliance and impact of control mechanisms in place, and when possible to identify the impact on different socio-economic groups.
5. To discuss and come up with advice on nutrient profiling/profile models as a tool to control the marketing of food and beverages.
1 Albania, Austria, Belgium, Bulgaria, Croatia, Cyprus, Denmark, Estonia, Finland, France, Georgia, Greece, Hungary, Ireland, Israel, Latvia, FYR Macedonia, Malta, Montenegro, the Netherlands, Norway, Poland, Portugal, Serbia, Slovenia, Spain, Sweden, Switzerland, Turkey and the United Kingdom.
2 WHO, European Commission, European Association for the Study of Obesity (EASO), FAO, UN Standing Committee on Nutrition, Consumers International, World Obesity, UNICEF, European Heart Network, World Cancer Research Fund, Bureau Européen des Unions de Consommateurs.
2
6. To follow-up and identify how WHO HQ Recommendations and Network Code can be used to support member states in their work to protect children from food and beverage marketing.
7. To report and contribute to various international meetings such as to the World Health Assembly and Regional Committee (RC) meetings in the WHO European Region.
8. To explore and develop multisectoral competences and knowledge, and health in all policies approach, involving different disciplines and sectors, enabling the Network to achieve comprehensive solutions.
In May 2019 the 14th Network meeting took place in Bern, Switzerland. Representatives of 11 Network countries participated in the meeting, along with international experts and representatives from other relevant organizations (civil society) and collaborating centres.
Introductory session and opening remarks
Liliane Bruggmann, Federal Food Safety and Veterinary Office (FSVO), welcomed participants to Switzerland and the FSVO premises in Bern.
On behalf of WHO Regional Office for Europe, João Breda welcomed all participants and thanked the FSVO for hosting the meeting and Portugal for leading the Network. In his introductory remarks he stressed how effective the WHO European Action Networks had proven to be for supporting Member States. It remains as true as ever that countries need to work closely with each other and with WHO and other UN agencies to drive forward progress and improve the health of the Region’s children.
As Chair of the Network, Maria João Gregório, Directorate General of Health, Portugal, added her welcome to participants. She thanked WHO for its support and Switzerland for hosting the meeting and logistical support. She reminded participants of the Network’s mission to protect child health by sharing experience and best practice in order to implement actions to reduce the impact of food marketing to children. Current challenges include how to tackle digital marketing and how to monitor such marketing, and these are areas where joint working is essential.
Update on WHO’s work on tackling marketing of foods to children, with a focus on digital marketing
João Breda presented an overview of WHO’s work on tackling marketing of foods to children, with a focus on digital marketing. Technical guidance provided to countries by WHO has included, among others, the WHO Set of Recommendations on Marketing of Foods and Non- alcoholic Beverages to Children in 2010 and a framework for their implementation in 2012, as well as a regional nutrient profile model in 2015 and resources on tackling marketing to children in a digital world in 2016.
The challenges continue to be the same as previously: defining the age of the child; defining unhealthy foods; deciding whether to restrict marketing targeted at children or marketing to which children are exposed; and, how to address all forms of marketing. In the European Region, 25 countries report having implemented some measures (29% define which foods and beverages are covered, but only seven countries are using a nutrient profile model; 29% define
3 the age of the children to which measures apply; 9% have a clear definition of marketing techniques covered).
Children and young people are still being exposed to marketing for unhealthy products and it is more important than ever to make further progress on this issue. In the Russian Federation and Kazakhstan, for example, 62% and 72%, respectively, of food advertisements are for products for which marketing to children would not be permitted according to the WHO Regional nutrient profile model.
Digital marketing to children is not only an issue for foods, it is also a challenge in relation to alcoholic drinks, novel tobacco products and e-cigarettes (electronic nicotine delivery systems (ENDS)). Moving forward, these areas can draw lessons from the food area which point to the need for state regulation and a comprehensive approach which protects all children and focuses on what children and young people see, rather than who marketers target. An evaluation of the implementation of the WHO set of recommendations in the WHO European Region highlighted a need for further progress to address brand equity or licensed characters, brand marketing, influencers and vloggers. Adoption of effective nutrient profiling systems is also needed, as well as leveraging of opportunities to tackle cross-border marketing and implementation of effective monitoring and research.3
In June 2018, an expert meeting on monitoring digital marketing of unhealthy products to children and adolescents was held in Moscow. The report of this meeting was published in March 2019, incorporating CLICK, a tool for monitoring children’s exposure to marketing of unhealthy products online.4
Discussion
The discussion noted that transmission by cable/satellite television channels into several countries already poses cross-border challenges, and that these issues are even more challenging in relation to digital content.
The issue of non-alcoholic beer was raised, and the question of whether such products should be treated as sugar-sweetened drinks. There is a concern that alcohol brands are using advertising for their non-alcoholic versions as cross-promotion — particularly to children and young people — for their alcohol-containing products. Some countries have decided to treat non-alcoholic beer in the same way as beer containing alcohol.
There was acknowledgement that children do benefit from participation in the digital world, and restrictions on marketing to children through digital media need to find a balance which
3Evaluating implementation of the WHO Set of Recommendations on the Marketing of Foods and Non-alcoholic Beverages to Children: Progress, challenges and guidance for next steps in the WHO European Region. Copenhagen: World Health Organization Regional Office for Europe; 2018 (http://www.euro.who.int/__data/assets/pdf_file/0003/384015/food- marketing-kids-eng.pdf, accessed 7 July 2021).
4Monitoring and restricting digital marketing of unhealthy products to children and adolescents. Copenhagen: World Health Organization Regional Office for Europe; 2019. (http://www.euro.who.int/__data/assets/pdf_file/0008/396764/Online- version_Digital-Mktg_March2019.pdf?ua=1, accessed 7 July 2021).
4 preserves such benefits. Nonetheless, WHO Guidelines relating to physical activity do recommend limited screen time for children under five.5
The collaboration between the nutrition, alcohol and tobacco sectors was welcomed. Another area which faces similar challenges relates to gaming and gambling. There is also cross-over with some issues to do with violence/sexual violence and sexual health. It was agreed that it is very useful to collaborate with professionals working to address these issues and identify common challenges and possible solutions.
Session 1: Update on country approaches to tackling marketing of foods to children in the WHO European Region, with a focus on digital marketing
Portugal
Maria João Gregório provided an overview of a new law (No. 30/2019) in Portugal, published in April 2019, which introduces restrictions on the marketing and advertising to children under the age of 16 of food and beverages high in energy, salt, sugar, saturated fat and trans fatty acids.
The age limit (under 16 years) was achieved after a long period of discussion. The law covers television, radio, publications, cinema and digital marketing. For broadcast marketing channels, this includes both traditional and on-demand audiovisual programmes and services and HFSS food marketing to children is prohibited in content targeted to children, defined as when 25% or more of the audience is under the age of 16. In cinemas, HFSS food marketing is prohibited during screenings of all movies age-rated under 16 years of age, including all advertisements prior to movies and during breaks. In relation to digital marketing channels, HFSS food marketing is prohibited in content intended for children under 16 years old, internet (websites or social networks) and mobile applications for devices using internet intended for children under 16 years old. Such marketing is also prohibited in specific settings, including schools, school environments (at preschool, primary and secondary levels), public playgrounds and within a 100 m radius of all these places. In addition, HFSS food marketing is prohibited during sports events, recreational and cultural activities promoted by schools.
There are also rules relating to marketing content, stating that food marketing should not, among other things, promote excessive consumption, create a sense of urgency or need for a product, suggest benefits in their exclusive or exaggerated consumption or associate consumption with social status or success, special skills, popularity or intelligence.
Furthermore, marketing should not use characters, figures or personalities that are aimed at children or promote foods as healthy while omitting mention of the harmful effects of such products.
5Guidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/handle/10665/311664, accessed 7 July 2021).
5 The Directorate-General of Health is tasked with defining the nutrient profile model for foods which have a high energy value and are high in salt, sugar, saturated fatty acids and trans fatty acids, within a two-month period. The WHO Nutrient Profile Model should be the reference base for the Portuguese law — this is significantly stricter than the new UK Ofcom model and would restrict 91.8% of HFSS products. One challenge to be addressed is the issue of how to deal with products containing non-sugar sweeteners.
A remaining challenge will be how to define and identify digital marketing of HFSS foods to which children and young people might be exposed (rather than only marketing directed at children). Another issue for consideration is how to handle marketing to parents for child- targeted foods, such as baby foods.
There is a requirement to conduct an impact assessment every five years. This will require the definition of indicators (e.g. food consumption patterns, food communication to children under 16 years) and methodology. This is an area where it will be important to learn lessons from other countries’ experience, and where it is hoped that international cooperation will be helpful.
Discussion
In discussion, it was noted that age limits do differ across the Region and was suggested that agreement on a common age limit for the whole Region could be useful. A word of caution was sounded, that it would be important to take care that this did not result in a harmonization to the youngest age in use. It is important to protect those countries which have already decided that restrictions should apply to marketing to children under 16 or 18 years, and to use these as examples for other policymakers. It was suggested that use of the terminology “children and adolescents up to 18 years of age” is clear, unambiguous and consistent with other definitions for “child” (e.g. in relation to children’s rights). In Portugal, there had been popular support for concept of protecting children up to the age of 16 years.
It was pointed out that the WHO regional nutrient profile model was validated by several countries, on the basis of their food composition databases. Countries are encouraged to use that model, and to make specific adaptions to their own context as required. In relation to non- nutritive sweeteners, Slovenia included products containing such ingredients in their definition of foods for which marketing should be restricted. Experience from Slovenia suggests that agreement of the nutrient profile model in a two-month period should be possible, and that is helpful to repeatedly stress that the nutrient profile model defines products for which marketing to children should be restricted not sales of the product per se.
There was clarification that WHO is developing a guideline on non-nutritive sweeteners, and the systematic review commissioned for the guideline development is available.
Another challenging area is that of energy drinks, and this is an area where some countries have taken regulatory action while in others lack of consumption data has hindered progress. It was noted that only around 30% of Member States in the Region have up-to-date dietary intake data. There may, however, be other useful data sources — some countries in the WHO European Childhood Obesity Surveillance Initiative (COSI), for example, collect data on sugar-sweetened beverage consumption and the European Food Safety Agency (EFSA) may have data.
6 In relation to monitoring, it was noted that a lot of development work has been done and various countries have found the Nordic Protocol to be very helpful.
On the final question of marketing to parents of foods for babies or toddlers, this is an important area of concern. WHO is publishing a study revealing high levels of sugars in many products, some high levels of salt and frequent use of misleading claims. It is also publishing a proposed nutrient profile model for commercial baby and toddler foods.6
Israel
Carmit Safra, Ministry of Health and School of Public Health, Haifa University, Israel, presented an update on regulation of marketing to children in Israel.
In 2016, a regulation committee involving many stakeholders was formed. This committee asked citizens questions on a number of issues, and feedback from the public indicated clear demand for regulation of advertising and marketing.
Policy action has been action to ease decision-making with accessible information and to encourage reformulation, mainly through adoption, in two phases, of warning labels for foods high in saturated fats (> 3%), total sugars (>10%) and sodium (> 400 mg/100g). The nutrient criteria are much stricter than the criteria of the EU Pledge on marketing. In addition, a positive front-of-pack health logo is being adopted, to nudge food choices towards the national nutrition recommendations. This is to ensure that consumers do not think that any product which does not have any warning labels is necessarily healthy. These measures, however, are insufficient to counteract the influence of advertising and marketing.
A multistakeholder committee was formed, therefore, to address marketing to children. The committee met seven times over the year and recommended regulation to the Minister of Health, with a holistic approach covering multiple platforms (TV, web and social media) and messages (marketing, adverts, advergames, bloggers and food packaging). They also recommended incorporating a robust monitoring system. Meanwhile, the industry was proposing adoption of the EU Pledge as a response.
An age limit of 18 years was recommended, on the basis of a child rights approach. It is proposed to restrict marketing of foods carrying warning labels, and there remains a question about foods with non-nutritive sweeteners. The regulatory frame for the legislation is challenging — while the warning label legislation was suggested, this does not cover unpackaged foods (including restaurants, fast food), so a different framework is required. The recommendation is to limit children’s exposure by prohibiting all marketing of foods with warning labels from 6 am to 8 pm. The scope should be as wide as possible, in terms of platforms and messages. It is clear that monitoring is essential.
Discussion
6Both reports have since been published and are available at: http://www.euro.who.int/en/health-topics/disease-
prevention/nutrition/publications/2019/commercial-foods-for-infants-and-young-children-in-the-who-european-region-2019 and http://www.euro.who.int/__data/assets/pdf_file/0004/406453/Ending_Final_3June2019.pdf?ua=1
7 This presents a very useful example for other Member States in the European Region but outside the European Union. It sends a strong message and, encouragingly, there is no indication of any signs that the government will soften the measures.
There was discussion of the scope for joint working to adapt the nutrient profile model for national marketing restrictions. This is an area of work that could be tackled through the Joint Action on nutrition.
Cyprus
Eliza Markidou, Ministry of Health, gave an update on the situation in Cyprus. After five years of advocacy, and since the first results of COSI in Cyprus shocked politicians about the very high prevalence of childhood overweight and obesity, the President has announced a plan for childhood obesity. It covers marketing to children, reformulation and promotion of the Mediterranean diet.
In June 2018 a stakeholder conference was held, involving a number of different ministries, to share experience from other countries as well as the WHO Set of Recommendations and the EU Pledge. Multinational industries claim that they are already following the Pledge. Local industry has also pledged to work on reformulation and marketing to children.
The Ministry of Health has been working on the issue of marketing to children, and on the issues of deciding age limits, nutrient criteria and how to reduce exposure during family viewing programmes. The aim is to have these issues resolved by the end of summer 2019, and to publish a law in autumn 2019.
Discussion
There was clarification that the work on reformulation has resulted in reduced salt in cheeses, hams, sausages, crisps and nuts, reduced sugars in biscuits and reduced fat in traditional cheeses. In discussion on traditional diets, there was clarification that traditional diets do sometimes include regular fasting, and that there has been a resurgence in that habit.
The criteria for defining whether to restrict marketing for child audiences or children’s programming are still to be decided. One proposal is to prohibit marketing during programmes for which more than 25% of the audience are children. The concept of restrictions during family viewing, rather than only children’s programming, came up in discussion of the revision of the EU Audio Visual Media Services Directive (AVMSD). This was not upheld and incorporated into the Directive, but there remains the scope for countries to go further than is set out in the Directive. The European Heart Network is trying to establish a Healthy Marketing Alliance to improve communication on marketing issues and help encourage Member States to take action and go further than the Directive.
8 Norway
Henriette Øien, Norwegian Directorate of Health, provided an update on the situation in Norway.
Marketing of unhealthy foods and beverages to children is included in the Norwegian action plan for a healthier diet from 2017 to 2021, under the action area ‘Healthy choices’. Following the discussions at the 13th Network meeting in 2018, there has also been some action in relation to marketing of foods for infants and young children. Norway tested the proposed WHO nutrient profile model for commercial foods for infants and young children.
The self-regulatory body, the MFU, which was established in 2014, is still active and the Norwegian Directorate of Health is represented in that body. It published guidance in 2016 that there should be no marketing to children under 13 years of age, and that there should be caution in relation to children aged between 13 and 18 years. The MFU has also launched a guide to social media. There is regular dialogue between the MFU, the Ministry of Health (and Directorate of Health) and other government ministries.
Bente Øverbø, Norwegian Institute of Public Health, provided an update on monitoring and evaluation. In partnership with Oslo Metropolitan University, new methodologies are being developed to measure children’s reactions to marketing.
An evaluation of the MFU is being conducted in 2019. This will include a survey of consumer awareness and engagement, as well as an evaluation of the system’s function by a variety of stakeholders.
Kaja Lund-Iversen, Norwegian Consumer Council, informed the Network about a report on digital marketing published in March 2019. This followed on from a May 2017 report on the marketing of unhealthy food and beverages in social media — a focus group study with teenagers 13 and 15 years of age.7 This report identified that children do not always recognize promotional material as marketing.
The 2019 report is entitled Young and exposed to unhealthy marketing — a monitoring survey of digital food marketing with focus on influencers.8 For this report, Norwegian YouTubers and influencers were monitored throughout 2018. In total, 16 channels popular among children and adolescents were identified and, of these, 11 promoted food. Two-thirds of the promotional videos were for Coca Cola. In the monitoring of Facebook, which is less popular with children, there were a lot of competitions, use of peers and youth culture and everyday life and role models.
7The marketing of unhealthy food and beverages in social media — a focus group study of 13 and 15-year-olds. Oslo:
Norwegian Consumer Council; 2017 (https://fil.forbrukerradet.no/wp-content/uploads/2017/05/report-marketing-in-some- final-norwegian-consumer-council-may2017.pdf, accessed 7 July 2021).
8Young and exposed to unhealthy marketing — Digital food marketing using influencers. Oslo: Norwegian Consumer Council; 2019 (https://fil.forbrukerradet.no/wp-content/uploads/2019/02/young-and-exposed-to-unhealthy-marketing- digital-food-marketing-using-influencers-report-february-2019.pdf, accessed 7 July 2021).
9 Despite the existence of the MFU, the Norwegian Consumer Council filed seven complaints between 2014 and 2019, and several of these have been upheld. Other complaints were judged to be outside the scope of MFU or deemed not to be targeted to children.
She also described some other initiatives relating to marketing to children. The Trans-Atlantic Consumer Dialogue (TACD) issued a Resolution on the protection of children from digital food marketing, with 11 policy recommendations, in May 2019.9 The Norwegian Cancer Society has challenged the authorities to make a legal assessment of the authorities’ obligation under the Convention on the Rights of the Child (CRC) to protect children from marketing of unhealthy food and drink. It has sent the authorities its own legal assessment and concludes that the State does not fulfil its obligations. The Norwegian Consumer Council and the NCD Alliance have sent a joint letter to the Ministry of Health and Care Services and the Ministry of Children and Equity to request that the upcoming evaluation of the MFU includes a survey of digital marketing that children and adolescents are exposed to and that it considers the self- regulation runs contrary to the WHO Set of recommendations and the State’s obligations under the CRC.
Discussion
There was discussion of the potential value in developing a harmonized protocol for independent evaluation of regulation of marketing. Such evaluations can be important tools to help advocated for improvements to legislation or codes and for highlighting where voluntary measures are not working well. It would also be interesting to compare the use and level of sanctions for violations. It was also suggested that a comprehensive review of the effectiveness of voluntary versus mandatory approaches would be useful, and WHO would be happy to develop this work.
Other issues which came up in discussion include:
• the impact of mass privatization and the concentration of resources and services in the hands of a small number of individuals/corporations;
• potential for working with YouTube influencers as social marketers for positive messages, as for example, consumer organisations in Finland and Norway have been doing in relation to healthy eating and WHO has done in relation to breastfeeding in Russia;
• other possibilities to work with digital platforms to promote targeted public health messages may be worth exploring.
9TACD publishes policy resolution on the protection of children from digital food marketing. Trans Atlantic Consumer Dialogue; 2019 (https://tacd.org/tacd-publishes-policy-resolution-on-the-protection-of-children-from-digital-food- marketing/, accessed 7 July 2019).
10
Session 2: Update on WHO tools and approaches to monitoring marketing
Monitoring and restricting digital marketing of unhealthy products to children and adolescents: CLICK tool
Kremlin Wickramasinghe, WHO European Office for Prevention and Control of Noncommunicable Diseases, presented an overview of the new CLICK tool to help monitor and restrict digital marketing of unhealthy products to children and adolescents.
As highlighted previously, an expert meeting on monitoring of digital marketing of unhealthy products to children and adolescents was held in Moscow in June 2018. The report of this meeting was launched in London in March 2019. At the same time, a proposed new tool — CLICK, a tool for monitoring children’s and adolescents’ exposure — was presented.
For taking the issue forward there was an emphasis on measuring (and preventing) actual exposure (i.e., what children see) rather than media “targeted at children”. One of the challenges is the “programmatic” system of advertising, involving automated buying and selling of targeted advertising impressions. Because of this complex ecosystem and bidding process, involving many different actors, neither the brand, the media agency or the publisher can say with certainty which ads have been served and to whom.
The CLICK tool involves five steps, from mapping the ecosystem and understanding the landscape through to investigating exposure, capturing examples on screen and sharing knowledge (Fig 1).
Figure 1 CLICK: A tool for monitoring children’s exposure to marketing of unhealthy products online
Beyond monitoring there are some other important issues on the agenda, where cooperation could be useful:
11
• Age verification of online users — it would be helpful to know the current state of age verification practices and technology;
• Tagging of marketing campaigns — it could be possible for governments to collaborate and make it a requirement for campaigns to be tagged if they are shown in those countries;
• Data on digital marketing — governments can request that companies provide data on advertising practices “on a scheduled basis”. This is drawing on the experience of Canada in relation to tobacco advertising, but could be applied to HFSS food marketing.
Discussion
There was discussion about whether this last point could present difficulties, within the European Union, with compliance with the General Data Protection Regulation (GDPR). There was clarification, however, that the only information required in relation to users would be whether they are over or under 18 years of age.
Training unit for the monitoring of food and beverage marketing to children across multiple media
Dr Emma Boyland, University of Liverpool, UK, and Dr Mimi Tatlow-Golden, Open University, UK, presented an overview of a forthcoming new training unit on monitoring marketing to children across multiple media. The training unit under development is intended to support the CLICK tool by providing more detailed practical and technical guidance.
The training unit covers a range of media and platforms, including television, websites and social media. The unit contains the following resources:
• template training programme
• audio-narrated slideshows
• template protocols
• template coding forms and example coding
• guidance for statistical analysis
• publication template and example articles.
The training resources can be adapted to the national context, while still providing some comparability of data between countries.
In terms of outcomes, anyone completing the training should be able to:
1. Understand key scientific theories (child development, marketing effects).
2. Understand research evidence on marketing exposure, power and impact.
3. Apply these principles to the design of a contemporary marketing monitoring study.
4. Measure the extent and nature of marketing in multiple media.
5. Code and analyse collected data.
6. Write an official publication to report the findings.
12 Some of the training is delivered via audio-narrated slideshows. In addition, there are template protocols, covering issues relating to sampling, logistics, coding, the WHO regional nutrient profile model and data handling and processing.
The protocols also take participants through the process of identifying the relevant platform for children and teenagers in their country. Where possible, decision trees are provided for participants to design a bespoke protocol to meet their specific needs. There are also template spreadsheets, with examples of exposure and power variables, and detailed guidance on coding, data analysis and preparation of a publication and its dissemination.
Launch of the complete training module is planned for summer 2019, and it will be disseminated online, together with the CLICK tool. There are points in the development of monitoring protocols where countries are strongly recommended to work with WHO and expert advisers — these points are flagged up in the training module.
Discussion
The development of these tools and the training was very much welcomed by Member State representatives.
Media regulators may already have key data (including, for example, recordings of adverts) and in some countries they have agreed to share detailed data with health colleagues. This is an area where WHO is happy to provide help, if needed, by writing letters to the relevant regulatory authority; any country requiring such help should contact WHO.
There was clarification that there is no fixed time period for completion of the training module or protocol development. It is important to take into account the country context, as well as the available resources, legal constraints and time considerations. It is clear, however, that completion of the training unit will save participants considerable time when designing a monitoring protocol.
Presentation of the WHO European Action Network on Reducing Marketing Pressure on Children website
Maria João Gregório introduced the new Network website: https://whomarketingnetwork.dgs.pt/
Member State representatives were invited to provide a brief description of their country context and the actions in relation to food marketing to children for inclusion on the website.
Information on the relevant activities of observer member organizations from civil society could also be included. WHO will send a template for collecting the relevant information.
Key documents will also be uploaded to the website, including the meeting reports. When providing information Network members should bear in mind that the website is publicly available, although creation of a private area for Network member communication would be possible if there is demand.
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Thinking out of the box: Opportunities to learn from other countries and other areas to better implement policies
Building Momentum: Lessons on implementing policies to reduce food marketing to children
Angela Carriedo, World Cancer Research Fund International (WCRF), presented an overview of a forthcoming report on restricting marketing to children, as part of WCRF’s Building Momentum series. This series of reports aims to help policymakers overcome common barriers to implement evidence-informed nutrition policy.
Previous reports have covered implementation of sugar-sweetened beverage taxes and front- of-pack nutrition labelling. The reports seek to provide practical technical information, as well as lessons learned from countries which have already implemented the measures.
A report on food marketing to children is in preparation. It will be prepared on the basis of a literature review and interviews with key stakeholders. The WCRF team is particularly keen to interview people from the following countries about their experience in relation to restricting food marketing to children: Ireland, UK, Slovenia, Norway, Turkey, Chile, Brazil, Mexico, Canada, Peru and Portugal. Network participants were encouraged to contact Angela or her colleague Fiona Singh with information about implemented policies and if they are willing to be interviewed or provide appropriate contact details.
Understanding what marketing means to marketers
Tobin Ireland, Mobile Value Partners, UK, presented an overview of the basics of the advertising technology ecosystem and some suggestions for how WHO and Member States could restrict digital marketing for HFSS foods to children.
Today global mobile advertising spend is driven by programmatic advertising and data — this is because it performs better by buying access to specific people, in real time, rather than to publisher audiences. This fuels demand for high quality data. There are reinforcing loops in the ad technology ecosystem whereby the more data is consumed (by use of mobile devices), the more data is generated to improve algorithms.
Global adoption of mobile programmatic media buying has been increasingly rapidly since 2016. The global mobile advertising ecosystem is currently in a significant moment of disruption, faced with a number of issues (e.g. squeeze on ad tech economics, brand and data safety, access to high quality data and publisher fight back). Another important issue relates to GDPR compliance and consent — the third-party data market has dried up, since high quality data companies have largely chosen not to give access to their data in the open mobile advertising ecosystem due to concerns about data leakage. The GDPR has also has unintended consequences in that it has consolidated the Google/Facebook/Amazon triopoly.
There is clearly a need for better regulation to tackle different aspects of this advertising/data ecosystem, including food marketing to children, privacy and tax issues. There are a number of pointers that could be explored to help prevent HFSS food marketing to children. These should place the emphasis on measuring targeting rather than actual exposure and be based on
14 the understanding that technology has the potential to be used to positively or negatively target particular consumers (e.g. to prevent display of a HFSS food advert to children). In order to be able to use the available technology properly, there is a need for:
• accurate age data (an age flag);
• flags to highlight HFSS food content (with consistent nutrient profiles);
• up-to-date mapping of local marketing ecosystems, which are fast changing;
• a global framework for a regulatory code of practice — with agreement that there should be no HFSS advertising to children under 18 years;
• monitoring tools to police and enforce compliance at the local level.
It is clear that any solution needs active support and/or regulatory control of the major global tech companies. It is a global problem and a global ecosystem, so local solutions will not work.
It is technically possible to block all ads at the network layer or through a browser or smartphone application. Blocking at the network side is illegal under net neutrality laws, but it is possible through consumer opt-ins in browsers or smartphone apps. It is easier to police restrictions on certain brand categories (e.g. tobacco, guns, pornography), where advertising is blocked to everyone, rather than categories where marketing is restricted to certain population groups (e.g. HFSS foods).
It is clear, however, that with accurate age and brand data — that is, an age flag based on 100%
legally-verified age data, an HFSS food brand flag and an identifier to link the ad impression to the individual — programmatic targeting could be 100% effective. In order to ensure that the HFSS flag is accurate, it is vital that there is global consistency on nutrient criteria and media companies need to add the flag when the campaign is set up. Monitoring of compliance would still be necessary, with enforcement and sanctions. There would need to be engagement with media agencies, demand-side platforms and industry associations to disable bidding on age flag impressions (i.e. showing the ad to under 18s) by HFSS brands. The age flag could also be used in relation to regulating marketing of alcohol, tobacco, gambling and pornography.
It would be preferable to have a default “off” flag, such that ads can only be shown to those who have proved that they are over 18. To accelerate adoption of the age flag, it would be important to have the support of media regulators. It is important to frame this issue as a
“legitimate interest” attribute for ad targeting, so that no explicit consent is required for GDPR compliance.
The next steps to take this forward would include:
1. Mapping of local media ecosystems on a consistent and regular basis;
2. Encourage standard category definitions on global media spend (Food, Drink, Alcohol, Tobacco);
3. Consistent definition of HFSS and decide to share flag with all restricted advertising categories;
4. Consistent age band definition;
5. Identify best national sources of verified age data and how to distribute;
6. Agree default-off and GDPR “legitimate interest” treatment of age flags;
7. Regulatory / engagement with major tech companies;
8. Regulation prohibiting serving of restricted ads to restricted age groups – brands, agencies, demand-side platforms;
15 9. Monitoring tools to detect and track non-compliance (campaign database,
panel).
Discussion
To take forward the first step outlined above, WHO is keen to get information on the local media ecosystems in all countries and has developed a template which Member States can use for data collection. A draft template was presented and will be shared with Member States for feedback, before being sent out for data collection. Member States can then use the template to ask companies for the requested data. Countries are encouraged to participate, because this would be incredibly valuable work, and lay a good foundation for future work.
There was discussion of the economic arguments that media and advertising companies will make in response to any restrictions to HFSS food marketing to children — particularly since food and drink marketing accounts for a sizeable proportion of ad spending. Experience suggests, however, that other advertisers will fill the gap and that revenue does not necessary decrease.
Kremlin Wickramasinghe described some work WHO is doing in relation to using digital media for positive social marketing in relation to use of electronic cigarettes (vaping). There is a pilot project on VK, the Russian-language social media platform, to obtain data about groups interested in vaping. This will be further explored to identify whether and how the data could be used to target public health messages. If successful, this could be a useful precedent for countries to cite as an example which could be followed in other sectors.
Update on new and promising research
Impact of social media influencersEmma Boyland, University of Liverpool, UK, presented preliminary findings of a study on the impact of social media influencers on digital food marketing. Influencers are online personalities with established credibility and huge audiences. They are often referred to as influencers due to the persuasive effect their opinions can have on their audiences. It is known that children are avid users of social media and marketing occurs when influencers feature brands or products in their content.
The University of Liverpool is conducting a series of studies exploring how much food and beverage marketing is done by influencers, the impact of influencer marketing on children’s food intake and on brand choice and children’s attitudes towards this type of marketing. A randomized trial was conducted among 176 children, aged 9-11 years, on social media influencer marketing using mock Instagram profiles of two influencers with unhealthy snacks, healthy snacks and non-food items.10 The study found that those viewing Instagram with unhealthy snacks consumed more calories from unhealthy snacks and more calories overall
10Coates AE, Hardman CA, Halford JCG, Christiansen P, Boyland EJ. Social media influencer marketing and children’s food intake: A randomized trial. Pediatrics, 2019 Apr;143(4).
16 than those in the control group and those exposed to Instagram with healthy snacks. Viewing influencers with healthy snacks did not affect intake.
Perceptions of social media marketing among teens and parents
Mimi Tatlow-Golden, The Open University, UK, presented some initial findings of the Adwareness Study, a joint project by the Open University, University of Liverpool and the Wellcome Trust.
Through six focus groups with 38 young people (6 boys, 32 girls) in North-West England, the study explored a number of questions relating to digital food marketing to children in the surveillance economy:
• How do I know it’s an ad?
• Do I even get food ads?
• What I see…
• How I respond…
• How did I get it?
The research suggests that children are more ad literate than their parents. Nonetheless, their initial response is often that they do not really see digital food ads, but on further probing — with prompts — it is clear that they do. This points to the need for caution in research based on self-reported exposure to advertising and to the value of using prompts for surveys. Reported responses to the ads vary from motivation to buy/consume the product, remembering the advertised product in future and linking/tagging friends who might like the product to ignoring the advert and/or being suspicious of the content. Again, there is a need to be cautious in interpretation of self-reported responses to such questions.
Initially neutral responses to the question ‘How did I get it?’ became more suspicious and critical on further exploration. There appears to be growing awareness of data privacy issues and the lack of individual control over personal data. There also appears to be clear understanding that global/regional entities and governments need to tackle this problem, and the economic rationale for governments to take action on unhealthy food marketing.
Discussion
In discussion, it was suggested that marketing companies may be expanding their focus to include multiple small influencers (with fewer than 1,000 followers), because followers have a greater degree of trust in such influencers than in those with hundreds of thousands or millions of followers. This would be a shift that would resonate with teenagers, who tend to prefer smaller, niche media.
Update from European Association for the Study of Obesity
Nathalie Farpour-Lambert provided a brief update on the European Association for the Study of Obesity (EASO). The Association considers that digital food marketing to children is a very important issue and is very keen to collaborate on this critical topic. EASO is happy to provide support, where possible, and to collaborate on any research proposals.
From EASO’s perspective, it is also important to point out that food marketing — whether traditional or digital — also affects parents and other adults. To date, it has generally only been
17 possible to take measures to restrict marketing to children, but reducing the impact of marketing on adults is an issue where EASO is interested to see more progress.
Working group sessions
Participants split into two working groups to address two specific topics. After the session, a rapporteur for each group presented the conclusions.
Tools and approaches for monitoring of digital marketing to children and young people — how to use them
The first group reported discussions on tools and approached for monitoring. Currently, the only tool in use in the participating countries is the Nordic protocol. In relation to identification of the preeminent digital platform in countries, participants did not have access to data to be able to answer that question. It was noted, however, that — although this varies over time and between countries — YouTube has massive appeal to children in the European Region. It was also noted that richer Member States have greater internet access and that research suggests overweight children have more screen time. A word of caution was noted, however, that screen time should not be used as a proxy for exposure to marketing.
Recommended priorities included:
• improving understanding of the system in each country
• cooperating with other Member States
• mobilizing citizens and civil society on the issue of food marketing to children
• using laws to help gather relevant data.
It was agreed that the training and templates which are being developed by Dr Boyland and Dr Tatlow-Golden for WHO would be immensely valuable. It will then be for governments to conduct or facilitate the monitoring at the national level on a regular basis (every three years was suggested). The support of WHO will be vitally important, to ensure that the data collected are appropriate and comparable. It was also suggested that EU Member States use their power to go beyond the minimum requirements set out in the EU Audio Visual Media Services Directive.
Determining the scope of restrictions and provisions
The second working group discussed the scope of restrictions and provisions. They started by summarizing the restrictions in place: Estonia, Portugal, Norway, UK and Slovenia all have some restrictions relating to food marketing to children in place (although not necessarily specifically related to digital). Some of the techniques used to restrict marketing include designation of protected environments (e.g., schools, playgrounds, cinemas), establishing a watershed in broadcast communications and establishing age limits.
The group discussed the issue of who should impose restrictions (i.e. action at Member State or EU level, or WHO). There was acknowledgement that different age limits across Member States makes harmonization very difficult, and that there needs to be a global discussion and decision on harmonized age limits.
18 The group identified a number of support needs:
• Dissemination, by WHO, of a table comparing age limits across other areas of marketing restrictions (e.g. tobacco, alcohol, GDPR) and across Member States. This could then be used to make a rights-based approach to advocate for restrictions;
• Support from academia to provide evidence on the impact of marketing.
The main priorities for the future were identified as:
• having a harmonized nutrient profile model widely implemented;
• agreement on an appropriate age limit;
• establishing robust monitoring and enforcement, with meaningful sanctions.
In discussion of how companies would react, it was suggested that many food manufacturers might appreciate a level playing field, but discussions are often with industry associations which tend to push for the lowest level of restriction possible. It was suggested that it would be helpful to explain to the general public the distinction between “nanny state” regulation and company manipulation. It is important to communicate that measures relate to protecting children and to protecting people from corporate manipulation.
Closing remarks and next steps
Throughout the meeting a number of action points were suggested:
• joint working to adapt the Regional nutrient profile model for national marketing restrictions in each country;
• development of a harmonized protocol for independent evaluation of regulation of marketing;
• a comprehensive review of the effectiveness of voluntary versus mandatory approaches;
• Member State representatives to contact Angela Carriedo or Fiona Singh at WCRF if they are willing to be interviewed about country experience with marketing to children for the Building Momentum report.
In addition, a number of next steps were agreed:
• Launch and dissemination of the complete training module and package of easy-to-use templates for monitoring protocols.
• WHO to disseminate a template for Member States to provide a brief description of their country context and the actions in relation to food marketing to children for inclusion on the Network website.
• WHO to send a template for Member States to use for collection of data on digital marketing local ecosystems. Member States are encouraged to use this template to ask companies for data.
• The next Network meeting is planned for late May or early June 2020 — precise dates and venue will be communicated in due course.
João Breda thanked participants for their contribution to excellent discussions over two days.
Digital marketing to children is a rapidly evolving field and it is exciting to see that WHO and Member States are at the cutting edge of how governments can respond to protect public health.
The Network continues to be an important tool for implementation of the current regional Food and Nutrition Action Plan.
19 WHO is keen to encourage more interactions between Network members, and with WHO, throughout the year. It is abundantly clear that the challenges ahead will require Member States and WHO to work together more. The WHO Regional Office is happy to commit to continue to support Member States to translate commitments into action on the ground.
He thanked all countries for the continued engagement, Portugal for its leadership of the Network and Switzerland for its generous hosting of the meeting.
In her closing remarks, Maria João Gregório added her thanks to Switzerland for hosting and thanked all participants for a very productive meeting and fruitful exchange of country experience. In conclusion, it is clear that countries need to continue to collaborate in this way.
It is also clear that all countries need a concrete protocol for monitoring marketing, particularly digital marketing, is needed. The new tools and training presented at the meeting pave the way, providing a general framework for countries to develop easy-to-use protocols to better monitor food marketing to children. On behalf of the Network, she thanked WHO for supporting this important work.
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Annex I: List of participants
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR EUROPE WELTGESUNDHEITSORGANISATION REGIONALBÜRO FÜR EUROPA
ORGANISATION MONDIALE DE LA SANTÉ BUREAU RÉGIONAL DE L'EUROPE ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ
ЕВРОПЕЙСКОЕ РЕГИОНАЛЬНОЕ БЮРО
Final list of participants
AUSTRIA (8 May only) Prof Judith Benedics
Federal Ministry of Labour, Social Affairs, Health and Consumer Protection
CYPRUS
Dr Eliza Markidou Clinical Dietitian Nutrition Coordinator Ministry of Health DENMARK Dr Maja Lund
Healthy Diet and Communication Division Ministry of Environment and Food of Denmark Danish Veterinary and Food Administration ESTONIA
Dr Haidi Kanamäe
Head of the Nutrition and Exercise Unit Centre for Health Risk Prevention
National Institute for Health Development Dr Sille Pihlak
Ministry of Social Affairs FINLAND
Dr Heli Kuusipalo Senior researcher
National Institute for Health and Welfare (THL) Nutrition unit
14th Meeting of the WHO European Action Network on Reducing Marketing Pressure on Children
Berne, Switzerland
8-9 May 2019 June 2019
21 ISRAEL
Dr Carmit Safra Nutrition Department
Ministry of Health and School of Public Health Haifa University
LATVIA Dr Lāsma Piķele
Senior Expert on nutrition,
Division of Health promotion and addiction prevention Public Health department
Ministry of Health of Latvia NORWAY
Dr Bente Øverbø
Norwegian Institute of Public Health Ms Henriette Øien
Director
Noncommunicable diseases Norwegian Directorate of Health PORTUGAL
Dr Maria João Gregório Director
National Programme on Healthy Eating Directorate General of Health
Ministry of Health SLOVENIA
Dr Mojca Gabrijelčič Blenkuš Senior Advisor
Health research and health promotion National Institute of Public Health Slovenia SWITZERLAND
Dr Liliane Bruggmann Head of Sector Nutrition
Federal Food Safety and Veterinary Office FSVO Division Food and Nutrition
Sector Nutrition
Dr Didier Lusuardi
Federal Food Safety and Veterinary Office FSVO Division Food and Nutrition
Sector Nutrition
22 Dr Nathalie Voisard
Federal Food Safety and Veterinary Office FSVO Division Food and Nutrition
Sector Nutrition
TEMPORARY ADVISERS Dr Emma Boyland
Senior Lecturer
Department of Psychological Sciences University of Liverpool
Dr Mimi Tatlow-Golden
Lecturer, Developmental Psychology & Childhood Co-Director, CCW@OU: Centre for Children and Young People’s Wellbeing, Faculty of Wellbeing, Education and Language Studies
The Open University Dr Tobin Ireland Mobile Value Partners
REPRESENTATIVES OF OTHER ORGANIZATIONS
European Association for the Study of Obesity Dr Nathalie Farpour Lambert
President
United Kingdom
European Heart Network Ms Marleen Kestens Manager Prevention Belgium
Joint Research Centre - European Commission Ms Evangelia Grammatikaki
Scientific / Technical Project Officer Italy
United Nations Children’s Fund Dr Bernadette Gutmann
Child Rights and Business Specialist Switzerland
23 World Cancer Research Fund International
Ms Angela Carriedo
Policy and Public Affairs Officer Policy and Public Affairs
United Kingdom
Norwegian Consumer Council Ms Kaja Lund-Iversen
Senior adviser on food and nutrition policy Norway
WORLD HEALTH ORGANIZATION
Regional Office for Europe Dr João Breda
Head
WHO European Office for Prevention and Control of Noncommunicable Diseases a.i. Programme Manager
Nutrition, Physical Activity and Obesity Dr Kremlin Wickramasinghe
Technical Officer
WHO European Office for Prevention and Control of Noncommunicable Diseases Ms Olga Zhiteneva
Technical Officer
WHO European Office for Prevention and Control of Noncommunicable Diseases Ms Liza Jane Villas
Programme Assistant
Nutrition, Physical Activity and Obesity
Rapporteur Ms Karen McColl
24 The WHO Regional
Office for Europe
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