12th Meeting of the WHO European Action Network on Reducing Marketing Pressure on Children: Dublin, Ireland, 10–11 May 2017: meeting report

12th Meeting of the WHO European Action Network on Reducing Marketing Pressure on Children Meeting Report Dublin, Ireland 10-11 May 2017 WHO European Action Network on Reducing Marketing Pressure on Children page 2 ABSTRACT In April 2017, the 12 th meeting of the WHO European Action Network on Reducing Marketing Pressure on Children took place in Dublin, Ireland. 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. Meeting participants—including representatives of 15 Network countries—exchanged information on national efforts to reduce marketing pressure on children. New national developments to extend the scope of marketing restrictions beyond broadcast marketing were reported in several Member States, to improve compliance through monitoring arrangements, to adopt the WHO nutrient profile model to define HFSS foods, and to implement evidence-informed policy. New research of relevance was presented, including the findings that children who eat more HFSS foods following exposure to HFSS marketing do not compensate by eating less at the next mealtime, and that inclusion of a ‘protective’ message does not reduce the impact of advergames promoting unhealthy foods to children. The Network meeting explored the wider challenges of food marketing—including digital marketing, advergames and supermarket packaging of foods targeted at children—and identified the definition, measurement and monitoring of digital HFSS marketing to children as key areas for future collaboration. The meeting also considered how to address inappropriate promotion of foods for infants and young children and agreed to extend the remit of the Network beyond the issue of ‘marketing to children’ to include ‘promotion of foods for infants and young children’. Document number: WHO/EURO:2017-2968-42726-59598 © World Health Organization 2017 All rights reserved. This information material is intended for a limited audience only. It may not be reviewed, abstracted, quoted, reproduced, transmitted, distributed, translated or adapted, in part or in whole, in any form or by any means. Meeting report page 3 CONTENTS Page Introductory session ........................................................................................................... 4 Session 1: Addressing inappropriate promotion of foods for young children ............................. 6 Recap of existing guidance from WHO and implications for country action ...................... 6 Findings from the WHO survey on complementary feeding and a snapshot of results from a pilot study in Denmark ............................................................................................. 8 Session 2: Update on efforts to reduce marketing pressure on children within the WHO European Region—focus on political process for change at the national level .......................... 9 Slovenia: success in adopting the nutrient profile model ................................................ 9 Estonia: evidence-informed policy brief on policies to reduce SSBs ............................... 11 Norway: ensuring accountability and compliance via monitoring................................... 13 Ireland: Code of Practice for food advertising, marketing and sponsorship .................... 15 Israel: New public information films on healthy eating................................................. 15 Session 3: Update on new research in the area of marketing to children ............................... 16 Is overconsumption in response to food marketing later compensated for? ................... 16 Does a ‘protective’ message reduce the impact of an advergames promoting unhealthy foods to children? .................................................................................................... 17 How complete a picture of digital marketing to children can we get? ............................ 19 Session 4: Beyond children’s broadcasting—getting to grips with the wider challenges of food marketing 20 How can we improve monitoring of companies’ commitments to limit digital marketing to children ................................................................................................................... 20 United Kingdom: innovation via CAP guidelines on digital marketing ............................. 22 Packaging, supermarket-based marketing and older adolescents .................................. 23 Workshop session: Planning collaborative work for 2017-2018 ............................................. 25 Conclusions and next steps ............................................................................................... 26 Annex 1 28 LIST OF PARTICIPANTS............................................................................................ 28 WHO European Action Network on Reducing Marketing Pressure on Children page 4 Background Increasing levels of childhood obesity and the high burden of non-communicable diseases (NCDs) observed across the WHO European Region calls for broad-based prevention efforts. One important measure 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. In the past decade, the issue of reducing marketing of foods high in fat or salt or sugar (HFSS) to children has become increasingly prominent on the international agenda. International action is essential to ensure that efforts to reduce marketing pressure on children are effective. The establishment of a European WHO Action Network on Reducing Marketing Pressure on Children (hereafter referred to as ‘the Network’) in 2008 reflected the joint interest of several countries in the WHO European Region to take action on this issue. The Network was established in close cooperation with the WHO Regional Office for Europe. 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, and Greece. In April 2017, the 12 th Network meeting took place in Dublin, Ireland. In total, 41 participants attended the meeting, including representatives of 15 Network countries and one WHO Collaborating Centre, as well as observers, temporary advisers, invited speakers and WHO representatives. Introductory session On behalf of the Department of Health, Ireland, Ursula O’Dwyer warmly welcomed participants to Dublin. Marcella Corcoran Kennedy TD, Minister of State for Health Promotion, conveyed a message of support to the Network at the opening of the meeting of the European Action Network on Salt Reduction in the European Region. It is important to build healthy habits for all children and families as part of efforts to prevent childhood obesity. These are the critical habits that will help those children who are a healthy weight now stay a healthy weight and those who are overweight or obese achieve a healthier weight as they grow and develop. In Ireland, intake of HFSS foods is too high and the key messages from the Department of Health’s Healthy Food for Life campaign are to manage treat foods and not have them every day (ideally only once or twice a week), have smaller portion sizes of these and replace sugar sweetened drinks with water. Ireland has a good track record on action to reduce marketing pressure on children in broadcast media, being the first country to ban celebrity endorsement of HFSS foods and drinks and 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, FAO, UN Standing Committee on Nutrition, Consumers International, World Obesity, UNICEF, European Heart Network, World Cancer Research Fund, Bureau Européen des Unions de Consommateurs. Meeting report page 5 banning toys and giveaways with children’s meals. The next focus as part of the Obesity Action Plan is to press for a 9 pm watershed on HFSS food advertising on television and radio. In the last 18 months the Department of Health has been working with the Food Safety Authority Ireland (FSAI) and other key stakeholders on developing a Code of Practice on marketing, product placement and sponsorship of HFSS food for children and adults, including in digital media. The launch of this Code is planned for late 2017. The Minister congratulated Network members on the work and progress achieved to date and thanked FSAI for organising the meetings. She wished participants a fruitful discussion and looked forward to hearing the outcomes of the discussion. On behalf of WHO, João Breda thanked the Irish hosts and Portugal for its leadership of the Network and welcomed all members, observers and other participants. The fact that the Network continues to grow reflects the importance of this issue and the value of the collaboration facilitated by the Network. When the Network was established in 2008 it would have been difficult to imagine the progress that has now been achieved. There are, however, many remaining challenges so continued collaboration is essential. The examples of successes and failures presented at the Network meetings serve to inform, empower and inspire other Member States. Pedro Graça, representing the Network chair, thanked WHO for its support, the Irish hosts and all participants for their engagement. He reminded participants of the long-term goal and objectives of the Network. 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. 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. Portugal has been developing a tool to improve information sharing within the Network. A website has been developed, where members can upload information about their activities, WHO European Action Network on Reducing Marketing Pressure on Children page 6 problems encountered and legislative advances. 3 Countries can also upload (or send to Portugal for uploading) publications and data. It will also be a space for exchange and discussion and, while some areas of the site will remain private, members can agree to make other areas available externally. Session 1: Addressing inappropriate promotion of foods for young children Recap of existing guidance from WHO and implications for country action Dr Laurence Grummer-Strawn, Department of Nutrition for Health and Development, WHO Headquarters, provided an update on the implementation of the WHO Guidance on ending the inappropriate promotion of foods for infants and young children. This differs somewhat from the topics normally covered by the Network, which are focused on marketing to children. This guidance relates to promotion of foods for infants and young children, essentially covering complementary foods for children between 6 and 36 months old. An overview of the Guidance was presented to the Network meeting in April 2016 and since then the Guidance was ‘welcomed with appreciation’ by the World Health Assembly in May 2016. 4 The Guidance clarified the meaning of breast-milk substitute, to include any milk (or products that could be used to replace milk) specifically marketed for feeding infants and young children up to the age of 3 years. This includes follow-up formula and ‘growing-up’ or toddler milks. The Guidance restated that these products are covered by the International Code of Marketing of Breast-milk Substitutes (‘the Code’) if they are marketed or otherwise represented to be suitable, with or without modification, for use as a partial or total replacement for breast milk. In addition, where follow-up formula is otherwise represented in a manner which results in such product being perceived or used as a partial or total replacement for breast milk, such product also falls within the scope of the Code. The new Guidance sets out general principles about how other foods (excluding breast-milk substitutes, follow-on formulas and growing-up milks) for infants and young children may be marketed and specifies, in general terms, foods that should not be promoted. A side workshop on 8 May in Dublin began to explore the next steps for implementation of the Guidance in the European Region. One of the key tasks at Regional and national levels will be to define those specific products that should not be promoted. The Guidance states that only products which meet all relevant national, regional and global standards for composition, safety, quality and nutrient levels and are in line with national dietary guidelines should be promoted. It does not go into any more detail to define such products or those that should not be promoted. This task will involve developing a detailed understanding of the current market—a ‘stocktake’ of what products are on sale and how they are marketed. In addition to the specific nutritional quality of the products, it is useful to explore other issues such as how foods are described, texture and taste/sweetness profiles of products. The next step is likely to involve development of tools such as nutrient profile models in order to be able to define what products are inappropriate and, therefore, should not be promoted. This approach could potentially extend to other ‘softer’ issues such as appropriate flavours, levels of 3 http://whomarketingnetwork.dgs.pt/ 4 For a full copy of the Guidance and the WHA Resolution see http://www.who.int/nutrition/topics/guidance-inappropriate-food- promotion-iyc/en/ Meeting report page 7 sweetness and textures. An in-depth understanding of promotional techniques is also necessary to be able to decide where to focus the most attention. It may be possible to use and adapt some of the Code monitoring tools to monitor promotion of complementary feeding. In order to prevent conflicts of interest between healthcare providers and the baby food industry, the Guidance sets out specific situations that need to be avoided (e.g., no free, reduced price products; no donations or incentives to health care staff; no gifts or coupons to parents, caregivers and families; no education to parents in health facilities; no sponsorship of professional or scientific meetings). These principles now need to be operationalized. For EU Member States, implementation of the Guidance needs to take place within the context of EU measures that cover some of the products within the scope of the Guidance. There is a certain amount of flexibility because not all products are covered by EU legislation. The current EU Regulation does not, for example, cover ‘growing up’ or ‘toddler’ milks. This means that European Union Member States need to think how to deal with these products, since they cannot be managed in the same way as breast-milk substitutes within the EU legislation. The picture for European Member States from outside the European Union is somewhat simpler. Implementation of the Guidance will usually entail a tightening up of existing legislation. In relation to foods marketed to children, the Guidance recommends that implementation of the WHO Set of Recommendations on the Marketing of Foods and Non-Alcoholic Beverages to Children should also pay attention to settings where young children gather. Follow-up formula will be discussed at Codex in December 2017. WHO is very clear that these products should be covered by the Code. The conclusions of the workshop on marketing of complementary foods and implementation of the Guidance in the European Region will feed into further discussions on the development of a work plan on this issue for the Region. Discussion There was recognition that this issue is tremendously important for the European Region. WHO’s Commission on Ending Childhood Obesity also stressed the importance of early nutrition for childhood obesity, one of the most important public health challenges facing Europe. This is likely to be an issue where it is likely to be possible to build political support for action. A related area is nutrition during pregnancy, concerning both mother and offspring. The first 1,000 days—from pregnancy to a child’s second birthday provide a critical window for optimal nutrition. The WHO Regional Office for Europe published a report Good maternal nutrition— the best start in life in 2016. This highlighted that there is scope for Member States to provide a lot more guidance on nutrition before, during and after pregnancy. The Regional office would be willing to help Member States develop a practical approach to nutrition and physical activity in pregnancy. It is important to clearly set out the scope of the products under discussion. The term ‘complementary foods’ is often used as shorthand but the Guidance relates to all foods for infants and young children. There are two key questions to address initially: What is the nutritional composition of foods that are marketed as appropriate for infants and young children? If they are being marketed, is it acceptable? There was support from Member States for the Regional Office taking forward this issue in order to help Member States explore the next steps for implementation of the Guidance. More specifically, some work from the European Region on development of nutrient profile models WHO European Action Network on Reducing Marketing Pressure on Children page 8 would be useful and could also feed into discussions in other WHO Regions. The Regional Office will develop a proposal for an open and transparent process for this work and then consult on this proposal. There are clearly challenges involved in developing a nutrient profile model. This will be particularly difficult for complementary foods—which are, by definition, meant to complement the breastmilk portion of an infant or young child’s diet—but may be more straightforward for snacks or similar products. It is also important to take into account Codex’s work to develop standards and guidelines for some of these products (e.g., new guidelines for formulated complementary foods). There is interest, within the Region, in exploring some of the softer issues highlighted, such as texture, physical properties of food, feeding methods, flavour and sweetness. Given concerns that feeding very young children salty or sugary foods may condition their taste preferences later in life, it would be useful to map the taste/flavour and sweetness of products on the market. It could be argued that some foods are not “nutritionally secure” for children under the age of three years. It was suggested that any products labelled as suitable as being suitable for children under three years of age might require official Ministry of Health approval. It was proposed and agreed that the remit of the Network be amended beyond the issue of ‘marketing to children’ to take this issue of ‘inappropriate promotion of foods for infants and young children’ into account. Findings from the WHO survey on complementary feeding and a snapshot of results from a pilot study in Denmark Nathali Lehmann Hirsch, WHO Regional Office for Europe, presented preliminary results from two studies: namely, a WHO survey of Member State guidelines on infant and young child feeding and a pilot study of foods for infants and young children on the market in Denmark. A questionnaire was sent to Member States to ascertain infant and young child nutrition recommendations in order to establish a regional overview of existing recommendations on infant and young child nutrition, with a special focus on the age of 4 to 12 months. The questionnaire explored a number of areas, including guidelines on infant and young child nutrition, promotion and support of breastfeeding, introduction to complementary feeding, commercially produced complementary food products and national publications related to infant and young child nutrition. The preliminary results suggest that a number of discrepancies exist between countries in a number of areas. A majority, but not all, of Member States have national recommendations on infant and young child nutrition. There are also differences in the recommended duration of exclusive breastfeeding, the age of introduction of complementary feeding and the amount (number of meals, energy content) and type (food groups, nutrient intakes) of complementary foods. In addition, there were marked differences in the types of drinks considered appropriate for infants and young children. A pilot study was conducted to explore the availability and quality of commercially-produced baby and infant food products on the market in Copenhagen, Denmark. This was carried out by researchers visiting all retail stores that might sell food or other edible items in defined low- and high-income areas in Copenhagen and recording 58 indicators concerning products in the baby and infant food aisle (and their point-of-sale promotion) using a user-friendly mobile application. The study collected data on availability by types of store, types of product, age groups, brand and geographical area (low- and high-income areas). Data were also collected on marketing and Meeting report page 9 promotional techniques, including visual aspects of product/packaging and claims. Data were also collected on the sodium and sugar contents by type of product and brand It is now time to consider how to take this forward. In particular, how the database can be expanded to cover other cities and how the data can best be used. The preliminary findings from the pilot study suggest that a sizeable proportion of the baby and infant food products on the market are promoted inappropriately. There are worrying levels of nutrients of concern and a need to consider what the thresholds should be for particular nutrients, possibly as part of a nutrient profile model for complementary foods. Discussion It is notable that the pilot study was conducted in a country that has introduced numerous regulations in this area but still highlighted areas of concern, and uncovered differences between high and low-income areas. It is conceivable that the results would be even more striking in some other, less regulated, countries. Feedback on results from small studies in other countries also suggest cause for concern, with different recommendations on age of introduction. An important issue is confusion over terminology, in particular, what exactly does “from four months” mean?. The methodology is now ready to be adapted and used in other countries. Member States are encouraged to use it to perform studies and it would be helpful if they report the results back to the Regional Office and provide written feedback on the methodology. There was clarification that all the cereal-based products were intended for dilution with water, so the sugar levels were not due to lactose in milk to be added to the product as consumed. There was also clarification that all products, including simple fruit or vegetable purées were included, in order to obtain a full snapshot. Using the ingredients list it should be possible to assess the ‘added sugars’ or ‘free sugars’ and this will be an area for further analysis. The pilot study shows that this is an expanding and evolving market, at least in Denmark. The sizeable differences in availability in the different socio-economic areas suggest that industry may be targeting higher-income consumers first, possibly as a means of attaching high status to the products. It would be interesting to analyse products by nutrient content and cost—these data are available but the analysis has not yet been done. It would also be interesting to track these data over time. The EUROPREVOB project had compared various indicators of the food environment in low-income and high-income areas (including infant feeding) and it could be useful to look at those indicators. It was noted that in-store promotion and packaging are only two aspects of overall promotion and marketing. Media promotion and contact with caregivers, for example, are important aspects of promotion but were not addressed in the pilot study and are not captured by the app. It may be possible to adapt the mobile app to collect information on different types of food (i.e., not only complementary foods). Session 2: Update on efforts to reduce marketing pressure on children within the WHO European Region—focus on political process for change at the national level Slovenia: success in adopting the nutrient profile model Mojca Gabrijelčič Blenkuš, National Institute of Public Health, presented an overview of the long process of implementing EU media law and adopting the WHO Europe nutrient profile model in Slovenia. WHO European Action Network on Reducing Marketing Pressure on Children page 10 In 2011, Slovenia’s draft media law was amended, as part of Slovenia’s harmonization of the EU audiovisual media directive, to include a requirement for codes of conduct to be developed in accordance with Ministry of Health nutrition guidelines. This opened the door to use of a nutrient profile model. Although Slovenia was one of the first countries to test the WHO nutrient profile model in 2012, the country decided not to pursue a single national nutrient profile model. At the end of 2013, the decision was taken to support the preparation of the WHO Europe nutrient profile model and adapt if necessary. In February 2015, the WHO nutrient profile was adopted. The first steps were to translate the model then adapt it to the Slovene context, by making some minor changes to a few categories for the Slovene version of the model. 5 A communication strategy was developed and adopted in March 2015. Following a consultative process, guidelines, based on the nutrient profile model, were prepared in September 2015. In October 2015 a meeting was held with the Slovene Chamber of Advertisers, which had volunteered to liaise with the television operators. Consultation in December 2015 with the Chamber of Advertisers and the Slovene television operators was quite heated, with many comments. The public health working group then prepared a response, which the Ministry of Health sent to different trade bodies. The Slovene guidelines for audiovisual media operators, based on the WHO nutrient profile model, were then launched in July 2016. The private sector also signed a national pledge in September 2015 and this is being evaluated. One lesson learned through the process is that it can be useful to involve food technology expertise to understand feasibility of thresholds. Slovenia also found it useful to have dialogue with industry representatives responsible for marketing at various stages. Another important lesson is the importance of leadership and policy decision-making from a highly engaged Ministry of Health, backed up by the technical expertise of the National Institute of Public Health. The Ministry of Health has been working with the Agency for communication networks and services (ANCS) to check that the MoH guidelines are included in operators’ or advertisers’ codes of conduct. The involvement of the Agency was very important for the interpretation and follow-up, because it brought in interdisciplinary competence. By February 2017 half of the television providers had sent in draft rules. Private television operators had decided not to stop marketing but to add a special written health warning message to adverts instead. The national consumers organisation has been asked to monitor developments; naming and shaming is the only sanction for infringements. Currently, a fine can only be levied on advertisers who do not develop codes of conduct. Between 13 and 26 March 2017 the national consumer organisation’s monitoring found that 57 of a total of 83 adverts (68%) were for foods for which consumption is not to be encouraged. Some private television operators appear to have increased the number of adverts. During this process, discussions started on other forms of marketing, particularly digital and social media marketing. It was decided to join forces with other areas, such as tobacco, alcohol, gaming and gambling, physical activity and others (including mental health) to define a common agenda. In October 2016, the National Institute of Public Health and the Telecommunications Agency organised a workshop. The workshop was shown the presentation of Dr Tatlow Golden and Dr Boyland (as presented to the Network meeting in 2016) along with presentations of the 5 See http://www.mz.gov.si/fileadmin/mz.gov.si/pageuploads/javno_zdravje_2015/prehrana/prehranske_smernice- oglasevanje_072016.pdf Meeting report page 11 marketing approaches in the areas of tobacco, alcohol, nutrition, physical activity and gaming. In each of these areas the following questions were posed: - Are there any rules (regulation, coregulation, self-regulation) for reducing marketing pressure of the products (to children)? - If yes, what kind of rules exist? What channels of marketing do they apply to? Do they apply also for digital marketing? If yes, what kind of digital marketing? - How successful are such rules? What are the main challenges (definition of target group, age limitation, criteria, distribution channels, data privacy, tracking, monitoring, ...)? - What are the key obstacles and key facilitators for improvement of the situation? - What are the most promising steps forward? A further workshop will be held in October 2017 to raise awareness and build capacity among the Slovene health promotion workforce, define common denominators for more efficient work on marketing of ‘lifestyle products’ to children and adolescents, to develop background materials and recommendations, and to produce awareness-raising and educational material for WHO. The workshop will also explore possible links with initiatives in the Slovak Republic. Participants were invited to notify Dr Gabrijelčič Blenkuš with any further ideas for the workshop. Estonia: evidence-informed policy brief on policies to reduce sugar- sweetened beverage consumption Kristina Köhler, Ministry of Social Affairs, described the process of developing an evidence brief for policy to reduce consumption of sugar-sweetened beverages (SSBs) in Estonia. As part of the evidence-informed policy cycle, an evidence brief for policy was developed to inform a deliberative dialogue to support policy choice and implementation. An evidence brief for policy synthesizes the best available research evidence alongside with local evidence to answer a specific policy problem. It is important to note that the policy is evidence informed (rather than based), recognizing that evidence is not the only element that feeds into policymaking. The evidence brief for policy on SSBs was based on initial consideration of 53 systematic reviews, of which 33 were analysed and 19 were finally included, comprising more than 443 study results. The process was started after an initial government request to assess possible restrictions on sales of energy drinks in schools and kindergartens was widened to include sugar- sweetened beverages because of concerns about increasing prevalence of obesity and overweight, particularly among children. Evidence on four different policy areas was examined, with the following conclusions: Regulation of food advertising (33 systematic reviews covering 77 studies)  Regulating advertising of HFSS foods is a policy that can be justified as a precautionary measure, which helps to change social norms of dietary behaviour and appropriate nutrition for children.  Comprehensive, preferably statutory, restrictions on food advertising are recommended to reduce marketing pressure on children. Self-regulation has not produced desired results.  The Government should define the media to be covered by restrictions, products that would be controlled and population groups to be protected. WHO European Action Network on Reducing Marketing Pressure on Children page 12 Labelling and raising awareness about health effects (3 systematic reviews covering 52 studies on counselling and 38 studies on labelling)  Front-of-package labelling as part of nutrient-specific schemes, with text, symbols and colours indicating nutrient levels, allows consumers to select healthier products more easily.  Long-term parental counselling is the only means that has proven to be effective in changing the dietary habits of children in the long term.  Individual, face-to-face or telephone counselling is the most effective way to involve parents in improving their children’s diet. School interventions and nutrition policies (8 systematic reviews covering 111 studies)  Interventions with an educational component alone (no environmental strategy) appear to have little effect in obesity prevention; multicomponent programmes give more favourable results.  Focusing on only one aspect of the food environment, such as vending machines, or for only one product, is likely to be less effective than interventions on multiple aspects of the food environment, such as canteen menus, snack bars and vending machines. Imposing taxes on SSBs and/or subsidizing other food groups (5 systematic reviews, covering 164 studies)  Food taxes and subsidies can influence consumption and raising the price of SSBs is associated with lower demand—10% increase in price reduces consumption by 8-12%.  Imposing substantial taxes on SSBs might improve outcomes such as body weight and chronic disease risk.  To maximize the effect, taxes and subsidies should constitute a minimum of 10–15% of the price increase. Considerations of issues around implementation concluded that all four policy options would help to reduce consumption of SSBs. To achieve better health outcomes, however, they should be implemented in combination and as part of a wider, comprehensive healthy nutrition strategy. The four areas for action have all been integrated into the nutrition and physical activity green paper and a number of further actions are planned. Regulation of food advertising to children has been included and a task force will be formed to address this issue. A task force will also discuss implementation of front-of-pack nutrition labelling. The green paper also includes individual nutrition counselling, and, to this end, health professional training is due to start in autumn 2017. Further awareness-raising work is to be carried out in schools and pre-schools and legislation will be changed to regulate which foods can be sold or brought into schools. Finally, in May 2017 a draft law was adopted to introduce a tax on SSBs. 6 Discussion Estonia was congratulated on its thorough approach and the tremendous value of this process for national policymaking was recognized. This is demonstrated by how quickly the proposal to tax sugary drinks has been adopted. The evidence policy brief has hugely strengthened the political process, and provides an excellent example of the way forward for public health—start strong by compiling all relevant evidence, ready to respond to potential criticisms. At the same time, it is important to be intellectually honest and realistic about the expected impact of individual 6 A tax on sugar-sweetened beverages, graded by sugar content, is due to come into force from 1 January 2018. Meeting report page 13 measures, by taking care to specify intermediate and process outcomes, rather than direct health outcomes in the short term. Experience from Portugal suggests that soft drink companies may respond to taxes by investing more in marketing, resulting in more widespread promotion (especially for diet versions). This reinforces the point that measures are more likely to work synergistically as part of a wider package. In Estonia the tax will be two-tier to also include drinks sweetened with sugar substitutes. The importance of thorough evaluation of the impact was stressed. As the body of evidence grows from real life implementation of measures this will strengthen civil society advocacy and embolden public health policy makers in other countries. There is increasing interest in evaluating policy measures as ‘natural experiments’ to strengthen the evidence base—this requires some advance thinking about the precise methodology for evaluation and WHO is currently exploring this issue further. It would be very useful if all future evaluation were able to document the impact on consumption and also substitution effects. Estonia confirmed that the national nutrition survey will form the baseline for the evaluation and this will be complemented by analysis of baseline sugar levels in soft drinks before implementation of the tax, in order to be able to monitor product reformulation. There was clarification that a task force will consider the topic of HFSS marketing to children in Estonia in more detail. As part of a similar exercise, Israel had seen that there is a huge increase in soft drink advertising just before and during the summer period. It is important to take seasonality into account. Norway: ensuring accountability and compliance via monitoring Knut-Inge Klepp, Norwegian Institute of Public Health, provided an overview on developments in relation to monitoring in Norway. Following a period of intense debate on proposed statutory regulation based on the WHO Set of Recommendations on the marketing of foods and non-alcoholic beverages to children, a self- regulatory system was set up in 2013 for a trial period. The Norwegian Food and Drink Industry Professional Practices Committee (MFU) is a self-regulatory body responsible for a Code and Guidance, which prohibit marketing of HFSS foods to children under 13 years old. The MFU product list is in line with the nutrient profile model in the proposed statutory regulation. The MFU provides industry with confidential pre-judgements on whether marketing complies with the Code, treats complaints about potential violations and ‘names and shames’ those found to contravene the Code. 7 In 2016, the Directorate of Health conducted a four-part evaluation of the MFU. This comprised: 1. A systematic survey of advertising of HFSS food and drinks to children on TV and internet in 2016 (conducted by independent research institutes according to the Nordic Evaluation Model) 2. A self-evaluation by MFU of its work during the time period 2013-2016, including an assessment of achieved results during this period (until March 2016) 3. An assessment of views held by other actors (civil society) (May 2016) 4. An overall assessment by the Directorate of Health. 7 See www.mfu.as for details. WHO European Action Network on Reducing Marketing Pressure on Children page 14 The survey of advertising found that 3% of all television advertising, and 16% of all food and drink television advertising, was for HFSS products that should not be marketed to children according to MFU. A similar survey in 2013 found that 19% of all advertising was for HFSS products. Advertising in social media and internet were registered by a sample of children, and 16% of all advertising and 61% of food and drink advertising was for HFSS foods and drinks. A qualitative content analysis found that few television adverts for unhealthy foods were aired in connection with typical children’s programming and that the advertising identified tended to have relatively little appeal for younger children. On social media, however, the advertising had a form and content that was clearly designed for a younger audience. The MFU has received 189 complaints and reviewed 43 cases (by spring 2017). Their judgements found 19 violations, 14 acceptable and 10 cases were considered to be outside the scope of the MFU. Prejudgement opinions (prior to broadcast of adverts) were delivered for 67 different campaigns. The MFU is proud of its record, which it claims is the world’s most comprehensive regulation and has resulted in, for example, industry changing its behaviour. The voices of other actors, however, strongly challenged these views. A number of criticisms were raised. These include the need to make the code stricter and more inclusive, as well as clearer and easier to understand. The MFU needs to be more visible and better known and the complaint process needs to be improved, as does the website. In addition, the consequences of any violation need to be clarified and sanctions other than ‘naming and shaming’ should be considered. The Directorate of Health’s overall assessment, therefore, was that there are some positive aspects. The MFU’s proactive function, through confidential pre-judgements, has had a preventive effect. In addition, there has been engagement with business and a transparent process. There are also, however, challenges and areas where improvement is needed. The Code is not seen as being comprehensive enough and there are limited consequences of violation. In addition, public awareness and knowledge about the MFU is considered to be too low. The Code and Guidance were revised with effect from September 2016. This has clarified the Code and also made it somewhat stronger by including stricter rules on placement of products, e- commerce, inclusion of all media and addressing the age limit in social media. These revisions have gone some way to addressing the problems, but some of the criticisms still remain. In conclusion, the dialogue between the authorities, the MFU industry actors and other actors (NGOs) on how to improve the MFU should continue and there should be another evaluation in 2 years. Health and consumer authorities need to promote the MFU in order to further increase public awareness, accountability and compliance. The statutory action proposed in 2012 needs to be considered as a relevant alternative to self-regulation during the next MFU evaluation. Discussion There was some discussion about the age limit of 13. The main argument presented by industry against an age limit of 18 is that this would amount to an effective total ban on HFSS advertising. There was discussion of the potential impact of greater media interest in the MFU and the impact of the changes in its code. There are signs that companies are keen not to be ‘named and shamed’, so there may be growing impact. All internet marketing is covered by the MFU, so it is important that people submit complaints about online marketing, Some NGOs have been raising awareness and have mobilized children to report apparent violations. Meeting report page 15 In terms of possible impact on purchase behaviour, it is not possible to attribute any changes in sales patterns specifically to the marketing restrictions or changes in marketing practices. Ireland: Code of Practice for food advertising, marketing and sponsorship Ursula O’Dwyer, Department of Health, gave a brief update on developments in Ireland to help reduce marketing pressure on children. Five years ago the Department of Health decided to draw up a multisectoral Healthy Ireland Framework, endorsed by a whole-of-government approach. Under this framework, the Healthy Weight for Ireland 2016-2025 policy and action plan was developed through a consultative process and a 5 million euro fund has been set up for implementation. One of the key actions in the first year is to develop a Code of Practice for food advertising, marketing and sponsorship. Ireland has a good track record on tackling advertising in broadcast media, through regulatory action by the Broadcast Authority Ireland. The Children’s Communication Code used a nutrient profile model—based on the UK Ofcom model with an exemption for cheese—to assess foods and defines children as being under 18 in most cases. A new Code of Practice has been developed on marketing, product placement and sponsorship of HFSS foods to children and adults. This Code was developed by a working group that included stakeholders from the Department of Health, State agencies and the food manufacturing, retail and advertising trade bodies. The new Code is very similar to the alcohol Code and will cover all sorts of sponsorship, including schools, sporting events etc. Key obstacles encountered include industry resistance to the use of the term ‘HFSS foods’ or ‘high fat, salt or sugar foods’. The term is, however, used in the EU Pledge so its use was finally accepted. There was discussion about whether it was necessary to use a nutrient profile model and, if so, which one. Finally, it was agreed to use the Irish adaptation of the Ofcom model, as it is used in the broadcast Code. The process of developing the Code was difficult, particularly after the final working group meetings, and the requirement for Food and Drink Ireland members to sign up to the Code was challenging. The launch of the Code is planned for late 2017 and it will be reviewed after two years of implementation. The Code that covers broadcasting is currently commencing a review. These reviews are likely to particularly address the questions of age restrictions and which nutrient profile model to use. There may be at that point another opportunity to consider using the WHO Europe nutrient profile model. Israel: New public information films on healthy eating Ronit Endevelt, Ministry of Health, Israel, showed participants three short public information films to raise awareness of the sugar content of sugar-sweetened beverages, the salt content of salty snacks and the health benefits of wholewheat bread. Industry pressure resulted in withdrawal of the second film (salty snacks) after two broadcasts. The Ministry is now responding to consumer feedback about the high price of wholewheat bread to try and encourage development of one standardized type of wholewheat bread at an affordable price. There is a national programme in Israel with collaboration of the Ministry of Health, Education and Sport and other ministries to encourage healthy nutrition and physical activity. The programme is called " it is possible to be healthy". One of the initiatives is to mandate front-of- pack (FOP) labels on foods high in salt, sugar and saturated fat, similar to the Chilean model. In addition, guidelines for voluntary positive FOP labelling, incorporating voluntary the Scandinavian Key Hole, have been developed. WHO European Action Network on Reducing Marketing Pressure on Children page 16 The programme, encouraging better nutrition and increased physical activity, is focused on health and education institutes, and also directed towards better nutrition programmes in the local municipalities and in workplaces. Regarding adverting and marketing of unhealthy foods to children and adolescents, there is a Ministry of Health committee currently working on writing its recommendations. The Ministry of Health is also working hand-in-hand with the Ministry of Education to add nutrition education in schools, for all levels. Teachers in kindergartens and elementary (primary) schools will be suitably trained to carry this out. In middle and high (secondary) schools, nutrition education will be taught by certified nutritionists. Session 3: Update on new research in the area of marketing to children Is overconsumption in response to food marketing later compensated for? Jenny Norman and Bridget Kelly, University of Wollongong, Australia, presented (via a remote link) results of a study on sustained impact of energy-dense food advertising on children’s dietary intake. It has been shown that food marketing influences children’s attitudes, preferences and consumption. While it has been shown that acute exposure to food advertising on television or online directly increases intake afterwards, however, there is a lack of evidence showing a direct and ongoing link between food marketing and children’s energy intake and weight. A research study was conducted, therefore, to fill some of these gaps. The study aimed to investigate the effect of unhealthy food marketing on children’s immediate and later food consumption, from single and multiple media platforms over a period of six days. More specifically it aimed to monitor if increased energy consumed as a result of food advertising is compensated for at a later eating occasion. The within-subject, randomised, crossover, counter-balanced trial was conducted at four University of Wollongong school holiday camps among children aged 7 to 12 years. There were two advertising conditions: experimental (food advertising) and control (non-food advertising). Children arriving at the camp were served breakfast and their intake recorded. At mid-morning they were exposed to the advertising through single or multiple media. All children were shown a television cartoon and those with multi-media exposure also played an advergame. Food and non-food adverts were embedded. Each child was exposed to three days of food advertising and three days of non-food advertising. After the advertising exposure, children were served morning tea and snacks. Children were given 15 minutes’ eating time, and were given more food if they asked for it. At lunchtime, children could again eat as much or as little as they liked in the 30 minutes eating time. All food items were weighed pre and post eating. The study found that a significant increase in snack intake (in kJ) was associated with exposure to the food advertising. There was an increased effect seen among children exposed to the multi- media condition and among children with overweight and obesity. The increased intake at snack time was not compensated for at lunch thus leading to a positive daily energy-gap on days children were exposed to food advertising. Limitations of the study include the relatively short 15-minute period for snack time; sometimes children had asked for extra snacks but had not finished them by the end of the period. The study Meeting report page 17 was also underpowered in the proportion of overweight and obese children. Strengths of the study include the natural setting and that dietary data collection was over a six-day period. This lack of compensation at lunch for children’s increased snack intake suggests that unhealthy food advertising does increase children’s daily energy intake, which, cumulatively over time could lead to the development of overweight. This is a significant contribution to the evidence base, and adds to the case for further restrictions on food advertising to children. Discussion The researchers were congratulated on this important contribution to the overall debate on food advertising to children. There was clarification that there was no attempt to get the parents to assess or measure food intakes later in the day. It was felt that the burden on participants was already considerable and that measuring intakes at home would probably be too prone to error for this specific purpose. Additionally, it was clarified that camp organisers tried to maintain the intensity of physical activities during the camp consistent over the six days. Children were able to choose between high fat savoury and high fat sweet snacks. To date, the analysis has been on results pooled from all data, and no specific analysis by type of food has been done. This may be a subject for further analyses. None of the brands promoted in the advertising were offered as snacks. In this way, care was taken to ensure that the study looked beyond the brand effect of advertising. It seems likely that the children would have consumed more snacks if the time available had been longer and this would have had implications for the results. Other studies, which did not impose a time limit, saw significant results for television advertising alone. An analysis of data on children who had asked for extra snacks but not finished them lead the authors to believe that the ‘television only’ results would have been statistically significant if the children had been given more eating time. To offset any ethical concerns, the study also included a summary sheet for parents offering advice on how to discuss advertising with children. In addition, it was explained that children would not be exposed to more advertising than they would be in one hour of television viewing. In relation to socioeconomic characteristics of the sample, some data on household income were collected and this was somewhat higher than the state average. The research team does not currently have plans to repeat the study, but the study methodology could be repeated—and built on—in other countries. A change that the research team would recommend for any future studies would be to over sample overweight and obese children. Does a ‘protective’ message reduce the impact of an advergames promoting unhealthy foods to children? Frans Folkvord, Radboud University, Netherlands, presented an overview of research exploring whether the impact of food advertising can be mitigated by inclusion of a ‘protective’ message. Advergames are computer games specifically created to function as advertisements to promote brands, where the entertainment content mimics traditional game forms. Advergames promoting foods have been shown to have a particularly strong effect on food intake. Furthermore, children do not recognize them as advertising. The stronger impact of advergames may be due to the WHO European Action Network on Reducing Marketing Pressure on Children page 18 interactive and high involvement and a longer duration of priming (e.g., up to half an hour compared to a 30 second advert). A study was conducted to explore the effect of advergames on intake using a manipulated memory game with four different conditions (unhealthy (confectionery); healthy (fruit); non food (toys) and no game). The between-subject design study randomly assigned 270 children between 8 and 10 years to one of the four groups. Children played the advergames for five minutes, ate snacks (confectionery or fruit) for five minutes then completed a questionnaire and had their BMI measured. Children exposed to the confectionery (Haribo) and the fruit advergames both ate significantly more confectionery (and significantly more total food) than children exposed to the non-food advergames or no advergames. In conclusion, children that played an advergame promoting unhealthy or healthy food had a higher food intake of unhealthy food than children who played the advergames promoting toys or control group. In addition, promoting healthier food did not work in the context of the obesogenic environment. Individual susceptibility factors are important—research shows, for example, that if a child is more impulsive, it is more difficult to resist temptation. A further study was commissioned by the European Commission to explore whether a ‘protective’ message could reduce the impact of an advergames by promoting ad literacy and making children aware of the persuasiveness of the game. The protective message ‘Remember: This game is an advertisement for X’. The study compared online memory games (energy-dense snacks versus non-food) both with and without protective message. The study took place in the Netherlands (n=215) and Spain (n=382). Among the Dutch children, those children exposed to the games with the protective message ate more than those where no protective message was included. Among Spanish children, the protective message had no effect. Very few (c5%) of the children who played the energy-dense advergames with the protective message remembered the text of the message a minority recognized the text of the message. Advertising literacy increased slightly among Dutch children, but did not change in the Spanish children In conclusion, energy dense advergames increase intake. Inclusion of a protective message is not effective—it has no effect, or even has a counteractive effect, on intake. The protective message is not remembered and barely recognized. Future research lines include looking at the impact of social media (e.g., vloggers, Instagram, Facebook) on children’s intake and exploring whether some of the newer marketing techniques can be used to promote healthier foods. Discussion The impact of unhealthy advergames shown in this research reinforces the importance of establishing healthy taste preferences and optimal infant and young children nutrition. It is also very important to consider establishment of healthy preferences in 7-12 year olds. These games and memory games are particularly developed for children up to 12 years old, but the graphics do suggest they would appeal to younger children. There was clarification that future studies may include older children (over 12 years). It will also be important to examine different individual susceptibility factors, such as addiction, socioeconomic status and overweight/obesity. Meeting report page 19 There was discussion about the implications of the apparent finding that advergame promotion of HFSS foods is more effective than television advertising. Will restrictions on HFSS television advertising still have an impact? In fact, marketing is an accumulation of all its different forms and these all need to be tackled. The finding that even advertising of healthy foods can increase intake of unhealthy foods has important implications, and underlines the importance of tackling the unhealthy food environment. This is an area that warrants further research. Marketing through advergames is quite prevalent. In the Netherlands, 80% of the brands which advertise on television also do advergames. Among the children studied, 80% agreed with the statement ‘I play games like this’, although care needs to be taken in interpreting this figure because so few children actually recognise that advergames are advertising. This research suggests that ad literacy can only be achieved through education over time and starting from a very young age. If it is not possible to restrict children’s exposure to such advergames, a great deal more educational effort will need to go into advertising literacy, especially for vulnerable groups. How complete a picture of digital marketing to children can we get? Ed Chatham, Reality Mine, UK, presented an introduction on how passive metering technology can be used to obtain information on digital marketing to children. The new digital landscape has a very pervasive influence on today’s society and mobile technology and social media are the new addiction of the Millennial generation. Younger audiences use mobile devices (tablets and smartphones) the most, and they spend a far greater amount of time on mobile platforms than older users. Therefore, advertisers target young people on mobile devices for unique and incremental penetration of their target audiences. People get addicted to mobile and social media by design, not accident, with the discipline of ‘captology’ and the application of ‘behavioural design’. These include win and reward systems and gamification, and the user experience is designed to encourage addiction. The challenge is that, to be able to do something about it, there is a need to measure the multi-platform marketing to which children are exposed. There are a number of technical challenges associated with measuring this exposure. Surveying people about their digital lives does not work. Cookie and web analytics-based technology only shows that an ad has been seen, not by whom, and social media scraping is cheap but non- conclusive. In addition, the sheer volume of advertising means that even advertisers are not in control of where adverts are placed. RealityMine considers, therefore, that the only way to understand the individual is to monitor the individual with their explicit consent. This is the gold standard of how television, radio and other media are measured globally. The RealityMeter is an app that silently and discreetly measures web, app, search and video consumption and other metrics. There are a number of challenges, particularly in relation to children. These include compliance and data privacy concerns, the ongoing attempts by major internet companies to stop any data interception or measurement techniques, and the challenge of processing and interpreting the vast quantities of data obtained. The app can collect data on web traffic, app use, location and networks. In addition, audio content recognition technology can analyse television or radio communication and cross-check this against the company’s database. It currently collects data on YouTube use and will soon WHO European Action Network on Reducing Marketing Pressure on Children page 20 have data on Netflix and Amazon. The app can be used, therefore, to plot a ‘digital day in the life of’ an individual and the marketing to which they are exposed. Implementation of a passive metering study can be expensive. A major cost is paying respondents to participate. It would be possible to design a pilot study to test whether this methodology provides the kind of data required. This could generate hard evidence on the extent and type of marketing for HFSS foods to which children are exposed. This data would, in turn, be useful for national regulatory action. Discussion There was clarification that RealityMine’s work is mainly for market research agencies that want to measure the total media reach of marketing for industry bodies or advertisers. This enables advertisers to understand what ad space to buy and provides ‘pathway to purchase’ data. Panel participants are paid (they are members of existing panels around the world). RealityMine approaches panel organisers and suggests ‘add-on’ elements. Factors which can affect the participation rate include the fact that the app is a drain on the device battery and can slightly slow down internet activity. People are long-term participants in the panels and behaviour change in response to being monitored appears to be minimal. It would, in theory, be possible to link the data to health data. This type of link—with other data sets—could certainly be very interesting. It was agreed that generating this type of data, about the marketing to which children are exposed, could also be very useful for raising parental awareness and for helping to educate parents on this issue. Session 4: Beyond children’s broadcasting—getting to grips with the wider challenges of food marketing How can we improve monitoring of companies’ commitments to limit digital marketing to children Valerie Verdoodt, KU Leuven, Belgium, explored the role of children’s rights in regulating digital advertising, business responsibilities and recommendations for improved monitoring and enforcement. KU Leuven is a partner in the AdLit inter-disciplinary project 8 , involving various universities in Flanders and various different sectors (advertising industry, policymakers, educators, etc.) to try and empower children and youth to cope with advertising in today’s new media environment.. It is important to recognize that children’s rights are reconfigured by digital marketing. There has been an increased commercialisation of children’s digital worlds, as children are targeted by personalized marketing, and that has an impact on the realization of children’s rights. The UN Committee on the Rights of the Child has already recognized the important role and responsibilities of businesses for realizing children’s rights. More specifically, all businesses should respect and support children’s rights, which implies that an advert should not have an adverse impact on children’s rights. In this regard, children’s rights and principles need to be translated into clear standards and guidelines for companies. When developing digital advertising and marketing aimed at children, companies should conduct children’s rights impact assessments. This can mean balancing different aspects of rights—such as participation, provision and protection. 8 http://adlit.be/english Meeting report page 21 States are responsible for ensuring that companies meet their responsibilities vis-à-vis children’s rights. In practice, this means having a regulatory framework in place to safeguard and protect children’s rights, along with effective monitoring and enforcement. A mapping exercise to examine the current situation on regulating digital advertising aimed at children revealed that advertisers do have a myriad of obligations, but regulation does not automatically mean that children are empowered. There are many abstract provisions and the scope of the existing frameworks is often unclear with regard to new forms of commercial communication, creating confusion. The variety of frameworks enforced by different regulators compounds the confusion and lack of clarity. In addition, there are many unclear definitions and different age groups are covered by legislation. Furthermore, there is little practical guidance for advertisers, combined with very little awareness among consumers. Monitoring and enforcement could be improved by better coordination between regulatory bodies (e.g., self-regulatory bodies, media regulators and data protection authorities). There is also a need to raise consumer awareness of their rights and complaint procedures. The different regulatory bodies need to cooperate and streamline complaint procedures and issue clear guidance. KU Leuven is developing clear guidance documents and tools for parents and children on how to complain. A digital tool for the Belgian advertising industry is being developed to raise awareness of these issues. This digital tool (a checklist) is being specifically developed for companies, in cooperation with the Belgian self-regulatory organisation and other regulatory bodies, but could also be useful for parents and children. The participatory methodology for designing the tool will be a platform for bringing together the various parties around the table. In collaboration with Dr Veronica Donoso, the independent reviewer of the EU Pledge, a review of experiences with monitoring companies’ commitments was conducted to help identify best practices. Drawing on some of the positive aspects identified, it can be concluded that the monitoring of companies’ commitments should be independent and the independent reviewer must be free to criticise. In addition, there should be continuous review of the methodology and assessment. The difficulties with monitoring that are specific to digital advertising marketing are that activities take place in the personal sphere (on phones or tablets) and that the marketing is personalised and/or location-based. Other potential ways in which monitoring can be improved are to consult children when setting up monitoring schemes, ensure close follow-up, apply sanctions when there are breaches and take stronger action in case of repeated breaches. Discussion There was a lively debate between participants regarding interpretation of the UN Convention on the Rights of the Child. Many participants felt that it is clear that anyone under the age of 18 is a child and attributed the confusion about ‘what constitutes a child’ in the context of marketing discussions to the food industry. However, others reflected that while it is correct that anyone under 18 does have access to children’s rights, this does not mean that the implementation of the rights is the same for each age group, in recognition of the ‘evolving capacities of the child.’ In data protection legislation, for example, specific rules are introduced for under 16s (in the General Data Protection Regulation)—an issue that was subject to much debate and remains confusing. Does a child have the right not to be marketed to? A child should fulfil their right to develop into rational adults in an optimal way. There was some discussion about whether commercial communication has any role to play in a young person’s optimal development. There was also some discussion about media or advertising literacy in young people. There is a view that a basic, decent education would better equip young people than any specific media or WHO European Action Network on Reducing Marketing Pressure on Children page 22 advertising literacy education. Others take the view that there is value in empowering children through advertising literacy, although this should be part of a wider educational package. United Kingdom: innovation via CAP guidelines on digital marketing Sharon Egan, Department of Health, England, presented an overview of new rules on digital marketing in the UK. One in five children are overweight or obese when they start school, and by the time they leave primary school one in three are obese or overweight. As well as harming children and young people, the annual cost to the wider economy is around 30 billion euros, more than annual expenditure on, for example, police, fire service and the judicial system. In August 2016 the Government published Childhood Obesity: A Plan for Action, with a set of over 20 ambitious actions focusing on schools, healthier environments and working together. The measures include a sugar levy (revenue from which will be hypothecated for school sports) and actions on reformulation, food labelling, schools and ongoing work to update the Ofcom nutrient profile model in light of latest advice from the UK’s Scientific Advisory Committee on Nutrition (SACN). The Advertising Standards Authority (ASA) is the UK’s independent regulator of advertising across all media. It applies the advertising codes, which are written by the Committees of Advertising Practice (CAP). It is an industry-led, co-regulatory model with the Advertising Standards Agency acting as enforcer. Pre-dating the changes described here, there were some differences in the rules on advertising food and drinks between broadcast and non-broadcast advertising. There were also criticisms that the articles are too vague. Given the growing scale of the obesity problem, developments in online advertising, changes in children’s media habits and concerns about the existing rules controlling food and soft drink advertising, the Advertising Standards Authority decided to consult on changing the rules. Between May and July 2016 a proposal setting out the following actions was issued for consultation:  Introduce a new rule to the UK Code of Non-broadcast Advertising, Direct and Promotional Marketing (the CAP Code) to limit where advertising for HFSS products can be placed in all non-broadcast media, including traditional and online media.  Explore through consultation whether the new rule should prohibit HFSS product advertising in media targeted at or of particular appeal to children under 12 or under 16.  Apply the existing rules prohibiting the use of promotions and licensed characters and celebrities popular with children to HFSS product advertising only (allowing such techniques for promotion of healthier foods) The consultation revealed a strong consensus that more needs to be done and the CAP is introducing a new placement restriction and making amendments to existing rules on the creative content of advertising. The rules will:  Prohibit HFSS advertising from appearing in children’s media (children defined as being under 16)  Prohibit HFSS advertising in other media where children make up a significant proportion of the audience  Prohibit brand advertising (including, branding such as company logo of characters) that has the effect of promoting specific HFSS products even if they are not featured directly. Meeting report page 23 (This will probably apply to brands where more than 50% of the products in a brand are HFSS products.)  Apply to all media, including advertising in online platforms like social networks and techniques such as advergames  Use the Department of Health nutrient profiling model to differentiate between HFSS and non-HFSS products  Allow advertisements for non-HFSS products to use promotions and licensed characters and celebrities popular with children to better promote healthier options. These significant changes will result in a reduction in children’s exposure to advertising for HFSS products. The changes also bring the CAP Code into line with the rules for TV advertising in the Code of Broadcast Advertising. CAP considers that the rule will deliver on its underlying objective of altering the nature and balance of food advertising seen by children. A regulatory statement was issued in December 2016 and the new rules will apply from July 2017. The Advertising Standards Agency will be responsible for enforcement, generally on a reactive basis in response to complaints. There is, therefore, an important role for civil society and NGOs to monitor practice. Some guidance on compliance for industry has been produced by CAP, and more specific online guidance will also be produced this year. Discussion There was some discussion of the possible association between factors that may be associated with prevalence of childhood overweight, such as children’s screen time and concentration of fast food outlets. A new tool has been developed to enable local authorities to map fast food outlets in their areas and explore the associations between density of such outlets, economic deprivation and obesity or overweight. There was clarification that the hypothecation of the sugar levy revenue for promotion of physical activity is unusual in the UK context. The Department of Health effectively argued the case for the revenue to be earmarked for public health purposes. Packaging, supermarket-based marketing and older adolescents Charlene Elliot, University of Calgary, Canada, presented an overview of research on food promotion and children’s health, and the role of supermarket packaging and ‘fun foods’. Childhood obesity levels in Canada have tripled since 1979 and Canadian children and youth spend almost eight hours a day in front of screens. The average child watches about two hours of television per day and sees four to five food and beverage adverts per hour. A study by the Heart and Stroke Association estimated that children see over 25 million food and beverage adverts a year on their favourite websites. Dr Elliot’s first study in this area examined the packaging of 367 supermarket foods targets at children in 2007. Of these, 89% of the products were of poor nutritional quality (HFSS) and 70% were high in sugar. A 2012 study of 354 products found that there were more ‘better-for-you’ fun foods on the market, but almost two-thirds (65%) of these were HFSS products. Of the ‘regular’ fun foods, 91% were HFSS products and 73% of the products were high in sugar. Exploration of the way in which ‘fun foods’ are marketed shows that the traditional concept of children exercising ‘pester power’ no longer really represents the reality of a ‘co-consumer’ model where parents buy products that they think their children will like and find fun. The WHO European Action Network on Reducing Marketing Pressure on Children page 24 ‘funning of food’ is a trend that dates back to the 1950s and 1960s, starting in the breakfast cereal sector. Since the mid-1990s child targeted foods have grown outside the cereal sector. The ‘funning of food’ nowadays addresses various types of product appeal: • 86% of products display a cartoon image on the front of the package • 69% of products contain cartoonish or “crayoned” font • 55% of products have unusual product names and/or flavours • 30% of products offer a game or activity on the back of the package • 22% of products contain licensed characters (e.g., Disney characters, Scooby Doo, SpongeBob SquarePants) • 15% of products urge children to ‘collect points’, ‘enter a contest’, use a coupon for another product (e.g., zoo passes, Lego, branded t-shirts) • 14% of products explicitly reference fun on the front of the package and 20% of products explicitly reference fun on the back or side of the package • ‘Better for you’ products also need to be fun in some way—29% of ‘better for you’ child- targeted products make a direct statement about fun somewhere on the product compared to 23% of ‘regular’ child-targeted products The idea of fun, therefore, is reinforced across the spectrum of foods and has also found its way into adult foods. The gamification of foods is a key trend for both adult and child-targeted foods. A new study is underway, examining 365 products, and preliminary results suggest that ‘fun’ is still very much present in packaging and marketing, with heavy use of licensed characters and ‘collectable’ packaging or products. There are important policy and regulatory implications. Packaging is often exempt from discussions on regulation of marketing, but it is clearly a form of marketing. Research suggests that such marketing affects how children and young people classify food more generally— children consider, for example, confectionery and chicken nuggets to be ‘kids’ food’ while ‘adult food’ is salad, vegetables and meat. Research to explore the brand personality of different foods found that teenagers considered that if broccoli were a person it would have no friends, would not be popular, etc. If ‘junk food’ were a person it would have many friends, would be the life and soul of the party, would sell drugs but probably would not take drugs. Canada is currently looking into implementing a ban on food marketing to children. University of Calgary research exploring teenagers’ perspectives on such a ban found adolescents consistently think of themselves as consumers and cannot conceive of a world where there is no marketing targeted at them. They do recognise that marketers manipulate messages, but consider that this mainly affects younger children and they do not think that a ban is the answer. They were not, however, as ‘savvy’ or aware as they think they are. Children and young people are rarely asked to think about the ethics of marketing, and it would be helpful to bring these issues to the forefront. Discussion There was some discussion of the options for regulatory action on packaging. It is possible to regulate use of cartoon characters and packaging, but there are challenges (not all cartoon characters are child-targeted). Member States should be aware that strict regulation of television and digital marketing may leave the door open to marketing of this kind through packaging. Health Canada is currently looking at the issue of regulating packaging. Meeting report page 25 In Quebec, legislation has protected children from marketing through its ban on all commercial communication to children in place since 1980. Extension of this to the whole of Canada would be a great step forward. There was discussion about whether the ‘funning of food’ should be explored and applied to healthy foods. There are risks however, in perpetuating the idea that food needs to be fun. This can lead to problematic relationships with food—as entertainment and distraction—and should not be normalised. Workshop session: Planning collaborative work for 2017-2018 Three workshops were organised to prompt discussion and identify suggestions for future collaborative work. The discussions were organized around three questions using a world café format, whereby groups rotate and all three groups consider each question and add to the flipchart notes. A rapporteur provided brief feedback from each group. Defining what is marketing to children online: content; indexing? It is important to define online marketing to children as comprehensively as possible. This means that a flexible definition is needed, particularly to be able to anticipate marketers’ potential future developments. More generally, marketing should cover packaging, billboards, digital, sponsorship, point-of-sale marketing, giveaways and toys, price promotions, competitions, personalisation, brand ambassadors and cover locations such as vending machines and schools. Digital marketing should cover advertising, advergaming and product placement in online media. It is clear that a variety of different areas of expertise are needed to be able to set out a comprehensive definition. A number of possible tools to support monitoring and regulation were identified, including geo- gating (used at national level to block particular IP addresses), a watershed or index development, stricter nutrient criteria, and development of specific, clear guidelines (incorporating a checklist). There is a need to increase parental awareness of digital profiling, marketing and the nutrient composition of child-targeted foods. This could be vital to increase public concern and, in turn, generate political will for action. There is a need to identify relevant existing models of regulation and examples of best practice from other Member States because there is still a lack of clarity about how online marketing can be regulated. Advocacy and building the case for national action It can be very difficult to build the case for action if the topic does not get any media coverage, so it is vital to raise awareness of the issue through national media and effective dissemination. It is important to collect scientific evidence and to use this to shape the key messages. It is important to engage stakeholders to establish one strong voice, and this is an area where WHO can provide a lot of support. A strong top-down approach from WHO to Member States can be helpful in many cases. It is always important to stress the ultimate economic impact of HFSS marketing to children. This should be combined with a human rights approach. It also makes sense to involve parents and children in discussions. Windows of opportunity sometimes arise, and it is important to understand these opportunities and use them appropriately. Identification of particularly engaged politicians is also valuable and establishment of broad coalitions is essential. There are lessons to be learned from other areas of public health (e.g., the anti-tobacco lobby). WHO European Action Network on Reducing Marketing Pressure on Children page 26 It is important not to fall for the trap of having to demonstrate an impact on NCD prevalence, it is sufficient to be able to show that marketing impacts on behavioural determinants and consumption. Finally, it was suggested that messages should be framed in a measured way so that advocates are not dismissed as ‘public health zealots’. The Rome Declaration on Nutrition includes a reference to governments protecting consumers, especially children, from ‘inappropriate marketing or publicity for food’ and this provides further support for action. Monitoring composition of infant foods and setting guidelines for their promotion It was agreed that it would be very interesting to replicate the mapping study carried out by the WHO Regional Office for Europe in Copenhagen in other Member States. For this to happen, Member States will need a clear protocol and a very clear guide to the methodology. It will be important to capture all types of retailers including supermarkets, pharmacies and markets. There is a need to look at products across the entire 0-36 months age range, including breast- milk substitutes and growing-up milks. It will be essential to categorize the different products available in different countries well. There is also value in mapping claims made for foods for infants and young children, including nutrient declarations, ingredient lists, health claims, endorsements, visual claims and pricing. For analysis of the results it is important to establish clear criteria and standards. There is a great deal of interest in development of a nutrient profile model for foods for this age group. Some Member States have reference intake values that would be helpful for this process. It is very important to share study results and analyses. Conclusions WHO and the Network Secretariat will consider the feedback from the workshops and identify further topics for the agenda of future Network meetings. In addition, WHO will take on board suggestions for future areas of work to support Member States, such as support on drawing up a definition of marketing to children. Members were encouraged to put forward any other suggestions for future areas of collaboration for the Network. There was some discussion about the importance of the WHO Europe nutrient profile model for Member States’ actions. There was confirmation from Member States and from civil society that this had been a very welcome development. Not only has it been of great value to Member States in their national actions it has also featured at European-level discussions and has been a very important tool for advocacy. One suggestion for a future area of collaborative work relates to methodology for monitoring online marketing to children. Any support from WHO in this area would be extremely welcome. WHO published a protocol for monitoring HFSS marketing via television, a similar protocol could be developed for digital marketing. It would be very helpful to be able to compare marketing exposure etc. in different Member States, where different policy approaches have been adopted. WHO noted the interest in support on developing methodology to capture children’s exposure to digital marketing and indicated that further work in this area is a priority. Conclusions and next steps Pedro Graça made some concluding remarks, drawing out some key conclusions from the proceedings. It is clear that technological developments are resulting in new concerns emerging quickly. The fundamental issue of how marketing influences consumption remains a vital Meeting report page 27 question, and it is still vital to share and exchange new research and experience on this topic, including findings that are not published. WHO’s support continues to be needed to establish frameworks for guidance and regulation. Policymakers are faced with some dilemmas. For example, nutrition education is important for empowering consumers to make healthier choices, but evidence suggests that protective messages do not in fact protect against the effects of online HFSS marketing to children. It is clear that citizens need protecting and empowering in different ways. Technology provides exciting new tools and these generate, in turn, some ethical issues. The perspectives of legal experts and ethicists would be very welcome in future. Another key issue is the development of tools for monitoring digital marketing to children, in order to inform policy action, enforce rules and enable comparisons between countries with different regulatory approaches. Members were encouraged to provide feedback on the new website. 9 This will be a key tool for the sharing of information—whether in the confidential or the public area—and for future development of the Network’s activities. Professor Graça thanked all participants for the very productive discussions throughout the meeting and conveyed gratitude to the Irish hosts. Jo Jewell added thanks on behalf of WHO to the host organisation, all speakers and all participants. In addition, he thanked Portugal for its leadership of the Network and drew the meeting to a close. 9 http://whomarketingnetwork.dgs.pt/the-network/ WHO European Action Network on Reducing Marketing Pressure on Children page 28 Annex 1 LIST OF PARTICIPANTS AUSTRIA Adelheid Weber Austrian Federal Ministry of Health and Women’s Affairs Radetzkystrasse 2 Vienna 1030 BULGARIA Professor Vesselka Duleva Head of Department Food and Nutrition National Center of Public Health and Analyses 15 Acad. Iv. Ev. Geshov Blvd. 1431 Sofia DENMARK Mr Morten Andersen Danish Veterinary and Food administration Stationsparken 31-33 Glostrup 2600 ESTONIA Dr Kristina Köhler Ministry of Social Affairs of Estonia Gonsiori 29 Tallinn 15027 Dr Anneli Sammel Head of department Department of NCD prevention National Institute for Health Development Hiiu 42 Tallinn HUNGARY Dr Zoltán Cserháti National Institute of Pharmacy and Nutrition Albert Florian ut 3/a 1097 Budapest IRELAND Dr Sandra Barnes Department of Health Hawkins House, Hawkins St Dublin Meeting report page 29 Dr Nazih Eldin Obesity Advisor Department of Health Hawkins House, Hawkins St Dublin Ms Ursula O‘Dwyer Nutrition Policy Advisor Department of Health Hawkins House, Hawkins St Dublin ISRAEL Prof Ronit Endevelt Ministry of Health and School of Public Health Haifa University 57 Hailanot st Zur Igal 4486200 LATVIA Dr Inga Birzniece Ministry of Health 72 Brivibas Street LV-1011 Riga MALTA Ms Lucienne Pace Senior Scientific Officer Department for Health Regulation Health Promotion and Disease Prevention Ministry for Health 5B, The Emporium, Triq C. De Brockdorff, Msida NORWAY Prof Knut-Inge Klepp Executive Director Mental and Physical Health Norwegian Institute of Public Health PO Box 4404, Nydalen N-0403 Oslo Dr Britt Lande Senior adviser Division of Public Health Norwegian Directorate of Health PO Box 7000 St Olavs plass N-0130 Oslo WHO European Action Network on Reducing Marketing Pressure on Children page 30 Ms Henriette Øien Norwegian Directorate of Health PO Box 7000 St Olavs plass N-0130 Oslo POLAND Dr Justyna Tyburska-Malina Chief Expert Reproductive Health Unit Department of Mother and Child 15 Miodowa Street Warsaw 00952 PORTUGAL Professor Antonio Pedro Graça Director National Programme on Healthy Eating Directorate General of Health Ministry of Health Alameda D. Afonso Henriques, 45 1049-005 Lisbon SLOVENIA Prof Mojca Gabrijelčič Blenkuš National Institute of Public Health Trubarjeva 2 1000 Ljubljana SWITZERLAND Ms Liliane Bruggmann Federal Food Safety and Veterinary Office FSVO Schwarzenburgstrasse 155 Bern 3003 Ms Elisabeth Guadagnolo Federal Food Safety and Veterinary Office FSVO Schwarzenburgstrasse 155 Bern 3003 UNITED KINGDOM Dr Sharon Egan Department of Health Whitehall SW1A 2NS London Meeting report page 31 TEMPORARY ADVISERS Professor Edward Chatham RealityMine Warren Bruce Court, Warren Bruce Rd Stretford, Manchester, M17 1LB United Kingdom Dr Charlene Elliott University of Calgary 209 Point McKay Terrace NW Calgary, Alberta T3B5B6 Canada Professor Frans Folkvord Behavioural Science Institute Radboud University Nijmegen Nijmegen 6525 GD Netherlands Ms Bridget Kelly Gillott (via Skype) University of Wollongong Northfields Ave Wollongong NSW 2522 Australia Ms Nathali Lehmann Hirsch Vordingborggade 25, 4 tv Copenhagen Denmark Ms Jenny Norman (via Skype) University of Wollongong Northfields Ave Wollongong NSW 2522 Australia Ms Valerie Verdoodt Doctoral Researcher Centre for IT and IP Law, KU Leuven Vlaams Brabant 3000 Belgium OBSERVERS Ms Emma Calvert Bureau Européen des Unions de Consommateurs (BEUC) Rue d’Arlon 80 Brussels 1000 Belgium WHO European Action Network on Reducing Marketing Pressure on Children page 32 Ms Simone Bösch World Cancer Research Fund International Flat F, 122 Christchurch Road London SW2 3DF United Kingdom Ms Marijke Luif World Cancer Research Fund Weesperstraat 105-A Amsterdam 1018VN Netherlands Ms Susanne Løgstrup European Heart Network Rue Montoyer 31 Brussels 1000 Belgium OTHER ORGANIZATIONS European Commission, Directorate General Joint Research Centre Ms Ana Sarasa Renedo Via E. Fermi, 2749. TP127 Ispra 21027 Italy WHO Collaborating Centre for Nutrition and Childhood Obesity National Institute of Health Dr Ricardo Jorge Professor Ana Rito National Institute of Health Dr Ricardo Jorge Av. Padre Cruz 1649-016 Lisbon Ms Mariana Coelho Santos Avenida Padre Cruz, 1649 Lisbon 1649-016 Portugal Meeting report page 33 WORLD HEALTH ORGANIZATION WHO Headquarters Avenue Appia 20 CH-1211 Geneva 27, Switzerland Dr Laurence Grummer-Strawn Technical Officer Nutrition for Health and Development Dr Chizuru Nishida Coordinator Nutrition Policy & Scientific Advice WHO Regional Office for Europe Marmorvej 51 Copenhagen 2100, Denmark Dr João Breda Head WHO European Office for Prevention and Control of Noncommunicable Diseases a.i. Programme Manager Nutrition, Physical Activity and Obesity Mr Jo Jewell Nutrition, Physical Activity and Obesity Ms Inês Morais Nutrition, Physical Activity and Obesity Ms Liza Jane Villas Nutrition, Physical Activity and Obesity Rapporteur Karen McColl The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. 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