Food and drink high in fat, sugar and salt - out of home advertising restrictions: rapid evidence review

Annex

Annex 1: Topic guide

Could you briefly tell us what your role was/is in relation to the advertising policy?

Could you tell us a bit about the product restrictions?

- How was the product defined and delineated? (e.g. Nutrient Profiling Model)

- Does the policy contain restrictions on advertising of other products? (e.g. alcohol, tobacco, gambling, vapes, products/services with high emissions)

- Were there any challenges attached to defining the scope of product restriction?

Could you tell us a bit about the site restrictions?

• What is the structure of the advertising media? Do they include e.g. billboards, bus stops, phone kiosks and taxis as well as transport hubs?
• Was both print and digital media included?
• Were there any challenges with delineating the scope of the site restriction?

Who owns the sites that are being restricted?

• Is the site being leased to a third party?
• How did this affect the ease of implementing the restrictions?

Were there any geographical limitations placed on the restrictions?

• Were there temporary exemptions granted for events or festivals?
• Were any parts of the local authority area exempt (e.g. city centre)?
• Were there areas of focus for the measures? (e.g. schools)

Could you talk a bit about any economic impacts of the measures?

• On advertising companies
• On local authorities
• On local businesses

Were any sites rendered unused or were alternative compliant products advertised instead?

• Could you give some examples of alternative compliant products that were advertised instead?

Could you talk about the reduction in exposure to HFSS products?

• Do you think restricting advertising of HFSS products has been successful?
• How has success been measured?

What challenges (if any) did the local authority face when implementing the restrictions?

• Were there any legal or political issues?
• Were there local or national objections from businesses or interest groups?
• What was the nature of any objections?
• Were there supporters for the measures?
• Who were they?

Were there any unintended consequences of implementing the restrictions that you know of?

• This could be positive or negative (e.g. other local authorities following suit).

Were local people supportive or against the measures?

• Were local people consulted before the measures were implemented?
• How has the public responded since the measures have come in?
• Were local businesses also consulted?
• Was there any engagement with the advertising industry with the implementation of the measures?

What role did evidence play in formulating the policy?

- Did you conduct an evidence review beforehand to help develop the policy/manage stakeholders?

- Which, if any, piece(s) of evidence did you find particular robust/reliable?

Is there anything else you would like to add?

Annex 2: List of peer-reviewed published and grey literature meeting inclusion criteria

Authors: Adblock Bristol (part of national Adfree Cities network, aims to eliminate billboards entirely in Bristol)

Title: How outdoor advertising impacts health and wellbeing (Online article, non-peer reviewed)

Content: Critique of Bristol HFSS advertising policy

Key points:

• In 2018, 3000+ residents signed petition objecting to commercial advertising in parks
• Advertising policy (HFSS, gambling, alcohol and pay-day loans) introduced 2021
• Council owned sites (180 sites, mainly bus stops)
• Advertising Standards Authority (ASA) slow moving
• Call for local and regional authorities to take firmer stand e.g. “No new billboards”

Authors: Advertising Association, British Soft Drinks Association (BSDA), Diabetes UK, Dominoes, Uber eats, Food ethics council, FoodExchange, Clear Channel, Exterion Media, JCDecaux, OUTSMART etc

Title: Response to draft London Food Strategy Freedom of information request (26/07/2019) AND The London Food Strategy. Report to the mayor on consultation on the draft London food strategy

Content: Industry responses to draft London food strategy (in relation to TfL ban)

Key points:

The response to draft London Food Strategy contains a range of views from industry including:

• Advertising association does not agree with ‘unhealthy’ food and drink advertising ban on TfL.
• BSDA ask soft drinks below 5g sugar per 100ml permitted, and fruit and vegetable juice permitted.
• Diabetes UK welcomes HFSS advertising ban.
• Dominoes agrees to restrictions somewhat (e.g. at certain times of day)
• Uber Eats does not agree with TfL ban, but provides further suggestions (e.g. taglines to encourage eating a varied diet).
• Food ethics council welcomes draft London food Strategy.
• FoodExchange likes the idea but does not think it is realistic given financial implications.
• Clear channel – ban is not proportionate or evidence-based.
• Exterion Media – do not agree with ban
• JCDecaux believe current proposal is binary and a more nuanced approach would be more beneficial.
• OUTSMART believes ban is disproportionate, unclear and unworkable.

The London Food strategy reports on a summary of the above and includes:

• The consultation process
• Main issues raised, and proposed strategy changes
• Conclusions and recommendations
• Next steps

Author: East of Scotland Regional Partnership and Obesity Action Scotland. Funded by Scottish Government (Published October 2021)

Title: Outdoor advertising. Policy arrangements in the East of Scotland

Content: Research with the aim of understanding the influence local authorities have on outdoor advertising in the East region of Scotland. Included: City of Edinburgh, Scottish Borders, Fife Council, West Lothian Council

Key points:

• Project involved analysis of local policy documents and interviews with 11 local authority representatives
• Some local authorities have advertising policies but none explicitly mention restricting HFSS products
• The scale of ownership/control varies amongst LAs (e.g. decreased interest from advertising companies in rural areas)
• LAs own and control limited number of advertising sites (e.g. 6 of the total billboards in Edinburgh, administered by JCDecaux, over 300 other hoardings owned by e.g. Global media, Clear Channel, Ocean
• Majority of ad spaces owned by third parties
• A national approach is recommended for consistent approach across all local authorities

In addition, local authorities would benefit from gaining a more thorough understanding of the role of advertising in health-related outcomes.

Author: Fran Bernhardt (2018), Sustain

Title: Healthier Food Advertising Policy Toolkit. How local authorities can restrict junk food advertising.

Content: Document with advice for local authorities wanting to implement HFSS advertising restrictions

Key points:

Goes over history of TfL implementation and timeline:

• Summer 2018 – public consultation on draft plan
• November 2018 - Announcement of policy
• February 2019 – Policy in force

Details of policy

• NPM
• Incidentals
• Exceptions
• Gives examples of alternative advertising that has been used

Reasons the policy won’t lose the council money

• Does not ban brands from advertising
• TfL estate has not lost revenue
• Brands have not lost money due to findings alternative products

Suggested step-by-step process:

• Introducing and researching the policy (e.g. get support from across local councils and steering groups, read up on details of policy)
• Making the case (e.g. with local and national research, establish small team to work on project)
• Policy adoption and implementation (e.g. consider exceptions process, announce and implement the policy
• Policy evaluation and review (e.g. continuous monitoring of policy)
• Industry lobbying – Sustain recommends that industry should be given the chance to feed in to the policy through consultation or written representation, but should not be part of decision-making process.

Case studies

• Bristol
• Royal Borough of Greenwich
• Haringey
• Merton
• Southwark

Author: Lauber et al. (2021)

Title: Corporate political activity in the context of unhealthy food advertising restrictions across Transport for London: a qualitative case study

Content: Peer-reviewed research exploring opposition to TfL ban from food and advertising industry actors. The data used included the freedom of information request on industry responses to the London Food Strategy consultation (included above).

Key points:

• The majority of food and advertising industry respondents, in particular multi-national companies and business associations, opposed the policy
• Most who supported the policy were smaller businesses
• Opposition underplayed potential benefits and exaggerating potential costs and negative impacts
• Opposition challenged claims of policy not being based on enough evidence but only sparingly used evidence in their own claims

Food and advertising companies engaged with the policy through meetings and phonecalls, amplifying opposing voices

Author: Meiksin et al. (2021)

Title: Restricting the advertising of high fat, salt and sugar foods on the Transport for London estate: Process and implementation study

Content: Peer-reviewed journal article including data from interviews with stakeholders on design and implementation of TfL policy

Key points:

• Themes that emerged from the 20 stakeholder interviews:
• Timeline for initiation consultation (May 2018) and announcing (November 2018) was fast-paced
• Operationalising the concept of ‘junk food’. NMP does not account for portion size, it produces a score per 100g. Model allows e.g. fried chicken
• Legal considerations such as inconsistent application of the policy
• Differential impacts on industry stakeholders e.g. those with a narrower product portfolio may be more impacted
• Political factors caused tension between wanting to improve health via the policy while being concerned about loss of revenue
• Public perception and political considerations had to be managed

Author: Ottoway Strategic Management (September, 2022)

Title: London Borough of Lewisham: Child Obesity Trailblazer Programme (COTP)

Content: End of programme evaluation report

Key points:

• Programme designed to tackle obesity using whole systems approach
• Involved steering group with industry (outsmart, sustain)
• Materials for campaign were co-produced with young people, families and organisations
• OOH advertising restrictions were voluntarily introduced by JCDecaux sites and council-owned sites
• Outsmart encouraged other media partners to engage
• Unsold estates were used to deliver health promotion messages
• Other activities: daily mile programme in schools
• Outcomes were limited by covid-19 pandemic, but it was found via surveys that:
• Increased public awareness and understanding of environmental causes of obesity
• Industry, public sector and communities can work together

Author: Scott et al. (2023a)

Title: Assessing exposure to outdoor advertising for products high in fat, salt and sugar (HFSS); is self-reported exposure a useful exposure metric?

Content: Peer-reviewed journal article including data collected via self-report survey on HFSS advertising distributed to Bristol and South Gloucestershire residents. Objective data on (SG) residents. Objective data on quantity of HFSS adverts on bus stops was also collected.

Key points:

• Of 4000 surveys sent out, 1,123 and 1,437 complete responses were obtained from Bristol and SG respectively.
• Bristol respondents living in areas where any food/drink adverts were present were more likely to report seeing HFSS adverts than in areas where adverts were not present. This shows that self-report may be an accurate measure of advertising exposure.
• In SG, there was no evidence of an association between self-reported exposure and objective advertising.
• No association between self-reported advertising exposure and consumption for HFSS product, but associations between exposure to single products and consumption (e.g. fast food, sugary cereal, sugary drinks).
• Measured exposure only obtained from council sites (bus stops) which underestimates actual exposure
• Self-reports may have included when participants travelled outside their local area.
• Possible improvements to survey: capturing dietary intake alongside advertising exposure, considering length of survey and participation rates.

Author: Scott et al. (2023b)

Title: Advertisement of unhealthy commodities in Bristol and South Gloucestershire and rationale for new advertising policy

Content: Peer reviewed journal article involving seven stakeholder interviews about design and implementation of the advertising policy in Bristol. AND a residential survey was also completed by Bristol and South Gloucestershire residents to provide socio-demographic information and exposure data.

Key points:

Themes that emerged from qualitative interviews:

History of the policy:

• before implementation there was a commitment to embed health into all policies, prior campaigns about harms associated with unhealthy advertising and evidence from success of TfL

Planning the policy

• 18 months to develop, first 12 months to draft, last 6 months to engage wider stakeholders

Anticipated impacts

• Reduction in purchase of HFSS products. Uncertainty on the larger impacts but a “step in the right direction”

Initial barriers and facilitators

• Bristol is progressive, therefore there was widespread acceptance of the policy
• TfL set precedence
• Council owns relatively small proportion of advertising, therefore reach and impact questioned
• No dedicated project lead officer to help implement and monitor the policy
• Conflict between policy and stimulating City’s economy through festivals etc.

Quantitative findings:

• 1,110 respondents from Bristol, 1,433 from SG
• 40% respondents reported observing HFSS products, mostly fast-food (53%), sugary drinks (15%), chocolate/sweets (14%).
• SG reported less adverts than Bristol.
• People using bus more often were more likely to see adverts than those who used bus less often.
• Young people saw more adverts than older people
• People living in deprived areas saw more adverts than those living in less deprived areas, especially HFSS

Author: Thomas et al. (2022)

Title: The health, cost and equity impacts of restrictions of high fat, salt and sugar products across the transport for London network: a health economic modelling study

Content: Peer-reviewed journal article. Peer-reviewed journal article modelling potential impact of TfL restrictions on health outcomes

Key points:

Modelling predicts that 12 months after implementation of TfL intervention:

• 4.8% fewer people obese (94,867)
• 1.8% fewer people overweight (49,145)
• Saving NHS £12 million over the life course of the current population

Importantly, HFSS purchasing and obesity still increased, but there was a smaller increase that what would have occurred without the TfL restrictions. Therefore, advertising restrictions may slow growth, but other strategies are also required if obesity levels are to be actively reduced.

Author: Thompson et al. (2021)

Title: Media representations of opposition to the ‘junk food advertising ban’ on the Transport for London (TfL) network: a thematic content analysis of UK news and trade press

Content: Peer reviewed journal article analysing arguments for and against the restrictions using media coverage

Key points:

Arguments in favour of the ban:

• Need to address health and social inequalities
• Public health crisis of childhood obesity
• Economic burden of obesity on health services
• (It was reported in the Guardian that Edinburgh was due to follow suit after TfL)

Arguments against the ban:

• Childhood obesity not appropriate for TfL or Mayor of London to tackle
• Advertising ban ineffective way to tackle obesity
• Justified by:
• Identifying alternative priorities (e.g. youth violence, knife crime smoking, alcohol, body image)
• Doubting evidence/science (e.g. use of nutrient profiling model)
• Emphasising possible costs (e.g. speculation about increase in fares, job losses)
• Downplay intricacies of the ban (e.g. exceptions process, acknowledgement that public health interventions only work for the population exposed to them)

Author: Yau et al. (2022)

Title: Changes in household food and drink purchases following restrictions on the advertisement of high fat, salt and sugar products across the Transport for London network: a controlled interrupted time series analysis

Content: Peer-reviewed journal article evaluating impact of TfL ad restrictions on energy purchases via data from Kantar Fast Moving Goods Panel

Key points:

• Compared average weekly household purchases of HFSS products in London to estimation of what would have happened without policy implementation using a counterfactual scenario
• The counterfactual was created by estimating the pre-implementation trend in London and accounting for the post-implementation changes seen in households in control area (North of England)

Main effects

• After intervention, energy purchased from HFSS products was 6.7% lower (1,001 kal) in London households compared to counterfactual
• Energy purchased from chocolate and confectionary was 19.4% (317.9 kcal) lower.
• Average energy by nutrients was also lower, fat – 57.9g, saturated fat – 26.4g, sugar – 80.7g.
• Sensitivity analysis
• No changes in purchasing detected when date of intervention changed, showing changes robust to time of implementation
• No significant differences when main shopper reported higher public transport use
• Similar results when two weeks leading up to Christmas removed from analysis
• Strengths
• Although the type of analysis cannot rule out the effect of history bias (i.e. other events or interventions happening previously or a the same time), the sensitivity analysis shows that findings specific to time of intervention and only detected for HFSS products.
• The use of a control group and a counterfactual overcomes several biases, and provides more information that a simple adjusted before and after difference model.
• Limitations
• Construction of the counterfactual, whether North of England can be compared with London. However, true counterfactual can never be known as not possible to observe intervention not being implemented in same area. Counterfactual is best possible approximation.
• Lack of out of home purchases due to limited nutritional data available on these.

Note: Where more than one publication relates to the same document, this was counted as one document. For example, a document including original responses from industry on the draft London Food Strategy was included. In addition, a separate document containing the final London Food Strategy Report that summarises industry responses was also included. These were counted as one publication.

Annex 3. Local Authorities and OOH HFSS ad restrictions in the United Kingdom (UK).

Table 1: Local authorities with published evidence of implemented or forthcoming policy as at 13/09/24.

Local Authority: Barnsley (link to policy documentation)

Status: In effect, but no contract with OUTSMART

Restrictions apply to: HHFS products/imagery, including incidentals and brand only. HFSS based on NPM.

Notes: Small estate

Local Authority: Brighton & Hove (link to policy documentation)

Status: Policy signed off 2023, implementation forthcoming (2025)

Restrictions apply to: HFSS products/imagery including incidentals and brand only. HFSS based on NPM.

Notes: Spoken to LA representatives

Local Authority: Bristol (link to policy documentation)

Status: In effect/at renewal

Restrictions apply to: HFSS products/imagery including incidentals and brand only. HFSS based on NPM.

Notes: Published literature on implementation (Scott et al., 2022a) and effectiveness (Scott et al., 2022b)

Local Authority: Greater London (TfL) (link to policy documentation)

Status: In effect

Restrictions apply to: HFSS products/imagery including incidentals and brand only. HFSS based on NPM.

Notes: Published literature on effectiveness (Thomas et al., 2022; Yau et al., 2022), opposition (Thompson et al., 2021) and industry responses (Lauber et al., 2021; SLG report).

Local Authority: Haringey (link to policy documentation)

Status: Policy signed off 2019, no contract with OUTSMART

Restrictions apply to: HFSS products/imagery including incidentals and brand only. HFSS based on NPM.

Notes: Spoke to Haringey representative

Local Authority: Knowsley

Status: In effect, no contract with OUTSMART

Restrictions apply to: HFSS products/imagery including incidentals and brand only. HFSS based on NPM.

Notes: Small estate. Part of Liverpool. Contract with Clear Channel to manage council-owned sites. Knowsley Champions Healthier Choices - Knowsley News (Jan, 2024).

Local Authority: Luton (link to policy documentation)

Status: Likely to be included in 2027 tender but no contract with OUTSMART

Restrictions apply to: HFSS products/imagery including incidentals and brand only. HFSS based on NPM.

Notes: Policy applies to own assets but media owner contracts not impacted (OUTSMART)

Local Authority: Merton (link to policy documentation)

Status: In effect

Restrictions apply to: HFSS products/imagery including incidentals and brand only. HFSS based on NPM.

Notes: n/a

Local Authority: Sefton (link to policy documentation)

Status: In effect, no contract with OUTSMART

Restrictions apply to: HFSS products/imagery including incidentals and brand only. HFSS based on NPM.

Notes: Small estate, possibly no media owner contract

Local Authority: Southwark (link to policy documentation)

Status: In effect

Restrictions apply to: HFSS products/imagery including incidentals and brand only. HFSS based on NPM. Alcohol, gambling

Notes: n/a

Local Authority: Tower Hamlets (link to policy documentation)

Status: In effect, with bus shelters forthcoming in 2031 and info panels forthcoming in 2029.

Restrictions apply to: HFSS products/imagery including incidentals and brand only. HFSS based on NPM.

Notes: n/a

Local Authority: York (link to policy documentation)

Status: Approved at committee (OUTSMART) forthcoming in new contract effective 2025

Restrictions apply to: HFSS products/imagery including incidentals and brand only. HFSS based on NPM.

Notes: n/a

Local Authority: Peterborough (link to policy documentation)

Status: In effect

Restrictions apply to: HFSS products/imagery including incidentals and brand only. HFSS based on NPM.

Notes: Peterborough Youth Council report Peterborough- Youth Petition - Junk Food Advertisement - Petitioner Report

Local Authority: Sheffield (link to policy documentation)

Status: Forthcoming (2030; According to OUTSMART)

Restrictions apply to: HFSS products imagery including incidentals and brand only, Airlines, Airports, Cruise holidays, Fossil Fuel companies, Cars (including hybrid)

Notes: n/a

Note: Status determined from OOH media partner OUTSMART, published policy documents and speaking with Local Authority Representatives. Some councils have a small estate and manage it themselves without an OOH media partner. Nutrient Profiling Model (NPM).