TY - JOUR
AU - Peeters, Anna
AB - Abstract Context Globally, the use of labels or signage targeting SSBs remains in its infancy and there is limited evidence available regarding its ability to decrease purchase and consumption of SSBs. Objective This systematic review aimed to synthesize the evidence on the effect of sugar- or health-related sugar-sweetened beverage (SSB) warning labels or signage on knowledge, attitudes, and beliefs, and SSB purchase and consumption. Data sources Nine databases – Ovid Medline, Emerald Insight, Scopus, Informit, Business Source Complete, CINAHL, Global Health, PsychINFO, and SocIndex – were searched along with grey literature from inception to December 2019. The PRISMA guidelines were applied for reporting this systematic review. Study Selection Studies examining the impact of front of pack (FOP) labels and/or point of sale (POS) signage highlighting added sugar content or its health risks were included. Data extraction Two authors independently extracted data on items, including study details, study design, population characteristics, intervention label details (type, duration, and settings), and outcomes measures. The Effective Public Health Practice Project tool was used to assess the study quality. Data analysis Findings were synthesized narratively. Results Twenty-one studies published between 1992 and 2019 were included. Of these, 16 studies examined the impact of FOP labels and 5 studies examined the impact of POS signage. Both FOP labels and POS signage were associated with improved health knowledge, attitudes, and beliefs regarding SSBs and reduced SSB purchases. Warning labels with diet-related health consequences were found to be particularly effective. Overall quality of studies was assessed as mixed. Conclusion Health- or sugar-related FOP labels and POS signage for SSBs are promising public health measures and may improve consumers’ health behaviors toward reduced SSB purchase and consumption. health behaviors, signage, sugar-sweetened beverage, warning labels BACKGROUND There is substantial evidence that excessive sugar-sweetened beverage (SSB) consumption is associated with preventable health conditions such as excessive weight gain, obesity, type 2 diabetes, dental decay, and some cancers.1–6 SSBs lack essential nutrients, contain free or added sugars, and contribute excess dietary energy to daily diet.7 The World Health Organization (WHO) recommends free or added sugar intake be limited to less than 10% of total energy intake.8 The WHO further provides conditional support on limiting consumption to 5% of total energy intake, asserting that reducing population intake of sugary beverages is an important public health goal. Worldwide, populations consume sugars above the WHO’s recommendations on sugar intake, such as in Brazil, Canada, South Africa, the United Kingdom, and the United States.9 Over half of Australians exceed this recommendation10 and SSBs are the single largest contributor to this free sugar intake (approximately 40%–60% of free sugar intake).7 The top 10% of teenage boys in Australia consume 38 teaspoons of sugar every day.11 Hence, SSBs are recognized as a key target for public health measures to improve population diets and health. In growing recognition of the importance of reducing added sugar consumption, a substantial international body of literature on the effectiveness of a range of public health policies aimed at reducing purchase and consumption of SSBs have been proposed and implemented worldwide. These include sugar taxes,12 food reformulation,13 regulating marketing and advertising,14 and mandating sugar labeling,15 among other measures. As SSBs are just one component of an unhealthy diet, wider public health measures such as subsidizing fruits and vegetables and promoting healthy meals and drinking water have also been implemented to promote uptake of healthy alternatives for a healthy diet.16,17 In terms of sugar labeling on food and drinks, nonnumerical information-based labeling is one commonly implemented public health measure as it offers complementary information (along with other quantitative information) to help increase consumers’ awareness of the nutritional quality of food and the selection of healthier foods. Front-of-package (FOP) labels and point-of-sale (POS) signage constitute 2 formats for displaying nutrition information through symbols, warnings, or rating systems on a food product and at the checkout point, respectively, that have been attracting growing attention worldwide.18Information-based labels include health-related nutrition information to the consumer in the form of written text, graphic pictures, numbers, or symbols, often highlighting the adverse health outcomes. Both FOP labels and POS signage include some form of information-based approaches. For example, Chile has a legislation that requires all foods and beverages high in calories, saturated fat, sodium, or added sugar (such as SSBs) to display a warning message.19,20 The Australian government is currently considering adding sugar labeling, and a number of campaigns such as Australia’s “Rethink Sugary Drink” campaign21 and New York City’s healthy beverages initiative22 have used POS signage targeting SSB consumption. Labeling laws may also encourage manufacturers to consider food reformulation. Retailers in countries such as the United Kingdom and France have introduced reformulation. For example, Tesco (a British multinational grocery and general merchandise retailer) in the United Kingdom23 and Nestlé and Orangina Schweppes in France13 have reduced the added sugars content in their home-brand products. Globally, the use of labels or signage targeting SSBs remains in its infancy and there is limited evidence available regarding its ability to decrease purchase and consumption of SSBs. A greater understanding of the effectiveness of FOP labels and POS signage will aid decision makers in implementing policy and interventions. The aim of this systematic review was to synthesize the available evidence on the effect of sugar- or health-related FOP labels or POS signage on knowledge, attitudes, beliefs, and purchase and consumption of SSBs. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed for reporting this systematic review24 (Appendix S1; please see the Supporting Information online). METHODS Search strategy For this systematic review, both scientific and grey literature databases were searched from their date of inception to December 2019. The following databases were searched: Ovid Medline, Emerald Insight, Scopus, Informit, Business Source Complete, CINAHL, Global Health, PsychINFO, and SocIndex. Grey literature sources included in the search were ProQuest Dissertations, Theses Global, and Trove (database for the National Library of Australia). The internet search engine Google was used to search the following government websites of selected high-income countries: the Australian Government (.gov.au), Australian organizations (.org.au), the U.S. Department of Health (hhs.gov), the UK Government (.gov.uk), and the Canadian Government (.gc.ca). It was predicted that the Google search would return a large volume of websites and therefore the screening process was limited to the first 100 uniform resource locators (URLs) from each website host and, depending on relevancy, the next 100 URLs searched thereafter. These websites were selected to expand the scope of the search to other high-income countries. Reference lists of relevant systematic or narratives reviews were screened for studies that met the eligibility criteria. Reference lists of studies included in the review were hand-searched for additional articles that met the eligibility criteria (backward citation searching). I ncluded studies were searched in both Web of Science and ProQuest Dissertations & Theses Global for any additional articles that met the eligibility criteria (forward citation searching). Database search terms were adapted from the following hedge terms: “food labeling” AND “sugar sweetened beverage” AND “health knowledge, attitudes, practice.” These search terms were identified through an initial search in the Ovid-MEDLINE database and by scoping relevant publications. Search terms were then adapted for the remaining databases. A full list of search terms for each database can be found in Table S1 (please see the Supporting Information online). Where possible, search parameters were limited to only include articles published in the English language and involving people of all ages. There were no limits applied to the year of publication. Study selection A modified PICOS (population, intervention/exposure, comparison, outcome, and study context) criterion was developed for each objective (Table 1). Articles were eligible for inclusion if they examined the use of FOP labels or POS signage that specifically referred to the added sugar content of SSBs or the health risks associated with SSB consumption. Health- or sugar-related labels or signage could be in the form of warning messages, health information, or nutrition information, or could be an interpretive label. Interpretive labels provide health-related nutrition information to the consumer in the form of written text, graphic pictures, numbers, or symbols.25 Studies were included if they assessed the effect of labels or signage on: (i) consumers’ knowledge, attitudes, and beliefs regarding SSBs, or (ii) SSB purchase (intended or actual) and consumption. Studies that evaluated back-of-pack nutrition information panels or calorie labels were excluded as these topics have been previously evaluated in comprehensive reviews.26–29 Studies were also excluded when the labeling or signage did not refer to the added sugar content of SSBs or health risks associated with their consumption. For example, studies examining the impact of simple traffic-light labeling, which classifies a food or beverage as “green” (healthiest), “amber,” or “red” (less healthy) based on specific nutrient criteria were excluded if the amount of added sugar in a product was not explicitly communicated to the consumer. All study designs were eligible for inclusion in the review. Table 1 PICOS criteria for inclusion of studies Parameter . Inclusion criterion . Exclusion criterion . Population Intervention/exposure Comparator/control Outcome Study context All studies that included participants regardless of age, gender, settings, racial, ethnic, cultural or religious groups or geographical location Use of FOP labels or POS signage (in the form of written text, graphic pictures, numbers or symbols) that specifically referred to the added sugar content of SSBs or the health risks associated with SSB consumption. Health- or sugar-related labels or signage could be in the form of warning messages, health information or nutrition information, or be an interpretive label. None -Consumers’ knowledge, attitudes and beliefs regarding SSBs -SSB purchase (intended or actual) and consumption. All studies conducted in any country around the world Restricted to English language publications only. -Studies that evaluated back-of-pack nutrition information panels or calorie labels -When the labeling or signage did not refer to the added sugar content of SSBs or health risks associated with their consumption. For example, studies examining the impact of simple traffic light labeling, None If the amount of added sugar in a product was not explicitly communicated to the consumer No restriction Parameter . Inclusion criterion . Exclusion criterion . Population Intervention/exposure Comparator/control Outcome Study context All studies that included participants regardless of age, gender, settings, racial, ethnic, cultural or religious groups or geographical location Use of FOP labels or POS signage (in the form of written text, graphic pictures, numbers or symbols) that specifically referred to the added sugar content of SSBs or the health risks associated with SSB consumption. Health- or sugar-related labels or signage could be in the form of warning messages, health information or nutrition information, or be an interpretive label. None -Consumers’ knowledge, attitudes and beliefs regarding SSBs -SSB purchase (intended or actual) and consumption. All studies conducted in any country around the world Restricted to English language publications only. -Studies that evaluated back-of-pack nutrition information panels or calorie labels -When the labeling or signage did not refer to the added sugar content of SSBs or health risks associated with their consumption. For example, studies examining the impact of simple traffic light labeling, None If the amount of added sugar in a product was not explicitly communicated to the consumer No restriction Open in new tab Table 1 PICOS criteria for inclusion of studies Parameter . Inclusion criterion . Exclusion criterion . Population Intervention/exposure Comparator/control Outcome Study context All studies that included participants regardless of age, gender, settings, racial, ethnic, cultural or religious groups or geographical location Use of FOP labels or POS signage (in the form of written text, graphic pictures, numbers or symbols) that specifically referred to the added sugar content of SSBs or the health risks associated with SSB consumption. Health- or sugar-related labels or signage could be in the form of warning messages, health information or nutrition information, or be an interpretive label. None -Consumers’ knowledge, attitudes and beliefs regarding SSBs -SSB purchase (intended or actual) and consumption. All studies conducted in any country around the world Restricted to English language publications only. -Studies that evaluated back-of-pack nutrition information panels or calorie labels -When the labeling or signage did not refer to the added sugar content of SSBs or health risks associated with their consumption. For example, studies examining the impact of simple traffic light labeling, None If the amount of added sugar in a product was not explicitly communicated to the consumer No restriction Parameter . Inclusion criterion . Exclusion criterion . Population Intervention/exposure Comparator/control Outcome Study context All studies that included participants regardless of age, gender, settings, racial, ethnic, cultural or religious groups or geographical location Use of FOP labels or POS signage (in the form of written text, graphic pictures, numbers or symbols) that specifically referred to the added sugar content of SSBs or the health risks associated with SSB consumption. Health- or sugar-related labels or signage could be in the form of warning messages, health information or nutrition information, or be an interpretive label. None -Consumers’ knowledge, attitudes and beliefs regarding SSBs -SSB purchase (intended or actual) and consumption. All studies conducted in any country around the world Restricted to English language publications only. -Studies that evaluated back-of-pack nutrition information panels or calorie labels -When the labeling or signage did not refer to the added sugar content of SSBs or health risks associated with their consumption. For example, studies examining the impact of simple traffic light labeling, None If the amount of added sugar in a product was not explicitly communicated to the consumer No restriction Open in new tab After duplicate articles were removed, titles and abstracts were screened independently by 3 authors (N.B., A.G., O.H.) and then 10% of these were cross-checked by 2 other authors (N.A.G. and A.P.). Eighty full texts were then examined against the inclusion and exclusion criteria by 2 authors independently (M.R.B. and A.G.) and then 10% of these were cross-checked by 2 other authors (N.B. and O.H.). Any discrepancies between researchers were discussed and final decisions were made on the included articles. Data extraction Data was extracted from all included articles by 2 authors independently (N.B. and A.G.) and was cross-checked by 2 other authors (N.A.G. and O.H.), and their results were compared. Discrepancies were resolved through discussions between each pair of reviewers. The following data were then collated into a predetermined matrix table: author and year of publication; aim; study design (experimental studies testing interventions—randomized and nonrandomized study designs); country; study population characteristics; intervention label details; intervention period; intervention type (ie, front-of-pack or point-of-sale); intervention setting (eg, vending, supermarket); other intervention components; and outcomes measured. Quality appraisal To ensure credibility, relevance, and value, each included article was critically appraised independently by 3 authors (N.B., A.G., and O.H.) using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool.30 The rating was based on the quality assessment across all 6 domains of the EPHPP tool: selection bias, study design, confounding, blinding, data collection, and withdrawal/dropouts. Data analysis A narrative synthesis of the results was conducted. No grey literature was included in the final included studies as these articles did not meet the eligibility criteria. Hence, there was no need to combine the findings from the gray literature with the academic literature. The data was grouped by label type (FOP labels and POS signage) and outcomes reported, including (i) health-related knowledge, (ii) attitudes/beliefs, and (iii) SSB purchases (intended or actual) and consumption. Differences in the outcomes were only reported if they were described as statistically significant in the respective article. RESULTS The electronic search of the scientific and grey literature databases retrieved a total of 5340 articles. Additionally, 890 URLs were retrieved via Google searches, of which the first 100 websites were searched from each host website (eg, Australian Government). Twenty-one experimental studies were included in the final review and subsequently synthesized narratively (Figure 1).15,31–50 Figure 1  Open in new tabDownload slide Flow diagram of the literature search process. Abbreviation: SSBs, sugar-sweetened beverages Figure 1  Open in new tabDownload slide Flow diagram of the literature search process. Abbreviation: SSBs, sugar-sweetened beverages Study characteristics The 21 experimental studies15,31–50 were published between 1992 and 2019. Of these, 11 were conducted in the United States, 3 in the United Kingdom, 2 each in Australia and Canada, and 1 each in New Zealand, Germany, and Switzerland. The characteristics of the included studies are summarized in Table 2.15,31–50 Table 2 Study characteristics Author(s), year . Study aim . Study design, quality rating . Sample size, country . Study/ target population characteristics . Study setting . Follow-up . Outcome measurement . Studies examining Front-of-pack labels (n=16 studies) Acton et al (2018)46 To examine the effect of FOP nutrition labeling and sugary drink taxation on consumer beverage purchases Experimental study; weak 675 participants; Canada Canadians aged ≥16 y Shopping mall NA Consumer beverage purchases Acton et al (2019)43 To examine the relative impact of different sugar taxes and FOP labeling systems on beverage and snack food purchases Experimental study; moderate 3584 participants; Canada Canadians aged ≥13 y Shopping mall NA Beverage and snack food purchases Adams et al (2014)41 Experiment 1 (not relevant) Experiment 2 To examine whether providing people with concrete representations of SSB sugar content reduces the perceived attractiveness for SSBs Experimental study; weak 74 participants; USA American adults; SSB consumers; mean age 26.89 ± 5.98 y Online choice experiment NA SSB attractiveness index; cumulative change in intended SSB consumption Adams et al (2014)41 Experiment 3 To examine whether providing people with concrete representations of SSB sugar content would reduce the selection of SSBs Experimental study; weak 109 participants; USA University pedestrians, SSB drinkers; mean age 20.54 ± 2.92 y Choice experiment conducted in a university setting NA Intended purchases/selection of SSBs Billich et al (2018)47 To determine whether FOP labels with a graphic warning, text warning, sugar information (with the number of teaspoons of added sugar), or HSR reduces intended choice of SSB in an online choice experiment with young Australian adults Randomized controlled trial; moderate 994 participants; Australia Young adults, aged 18 and 35 y Online choice experiment NA Primary outcomes: proportion of participants who selected a SSB in the hypothetical choice scenario for each of the 5 study groups; Secondary outcomes: participants’ selection of diet drinks and high HSR drinks (for those participants who did not choose SSB in the choice scenario), factors that influenced their decision in the choice scenario, and perceptions about the impact of SSBs on health and wellbeing Bollard et al (2016)36 To assess the effects of plain packaging, warning labels (text and graphic), and a 20% tax on predicted product preferences, beliefs, and SSB purchase probabilities Randomized controlled trial; moderate 604 participants; New Zealand Participants were aged 13–24 y; mean age 18.4 ± 3.4 y; 51% female, 49% male; regular SSB consumers; majority European ethnicity Online choice experiment NA Attitudes toward interventions; preferences for and perceptions (healthiness) of products; probability of purchasing Gray et al (2011)42 To determine whether text-based FOP health-related labeling impacts intent to purchase SSBs Experimental study; weak 130 participants; Australia Individual in each household most responsible for grocery shopping; 79.2% SSB consumers Postal survey NA Comprehension of label; intent to purchase SSBs Mantzari et al (2018)50 The primary aim was to assess the impact on SSB selection of (i) 2 image-based warning labels, and (ii) calorie information labels; secondary aims were to assess (a) the impact of each label on perceptions of SSBs and acceptability of using the different labels on SSBs, and (b) the mediating role of negative emotional arousal on the impact of labels on SSB selection Experimental study; weak 2002 participants; UK Parents of children aged 11–16 y, with a total household SSB consumption of at least 500 mL each week. More than half were white and male and had obtained higher education. Online survey NA Primary outcomes: proportion of participants selecting SSBs; Secondary outcomes: perceptions of SSBs (negative emotional arousal; perceived health risks of drinking SSBs; acceptability of introducing image-based labels and/or calorie information labels on SSBs) Mantzari et al (2019)49 To assess the impact on SSB selection of: an “on-pack” pictorial health warning label depicting an adverse health consequence of excess sugar consumption, and “on-pack” calorie information labels Randomized controlled between-subject study; moderate 401 participants; England Adults aged 40.0 (13.9) y; 56% female, 86% white; 52% lower socioeconomic position Laboratory study NA Proportion of participants choosing SSBs Moran et al (2018)45 To describe and compare parents’ perceptions about the healthful qualities and risks of different categories of sugary drinks when no warning label is present Randomized experimental design; moderate 2381 participants; USA Caregivers of children aged 6–11 y; mean age of parents 36 y Online survey NA Purchase intentions, health beliefs, risk perceptions, and nutrition knowledge Popova et al (2019)44 To analyze how visual attention to the warning label and other product descriptors is associated with aided recall of the warning, perceptions of the product, and purchase intentions Randomized experimental design; moderate 180 participants; USA Participants aged 18–34 y; mean age: 25 y; 79% female, 48% white, 45% black; 53% with some college degree; 35% with income between $25 000 and $49 999; 67% living with overweight and obesity; history of smoking cigarillos or little cigars; 60% drank SSBs at least weekly Unspecified hypothetical choice setting NA Recall of the warning, perceptions of the product, and purchase intentions Roberto (2012)15 To determine which FOP label enables consumers to identify healthier options and promote accurate understanding of nutritional profiles Randomized controlled trial; strong 480 participants; USA Adults’ mean age 36 ± 13 y; 64% females; mean BMI 27.25 ± 7.35 kg/m2 Online choice experiment NA Health knowledge Roberto et al (2012)34 To determine which FOP label options lead to more accurate understanding of nutritional profiles of products Randomized controlled trial; strong 703 participants; USA Representative of the 2011 US Census; mean age: 46.01 ± 16.51 y (69.9%) overweight/obese; 82.4% Caucasian Online nutrient comparison quiz NA Nutrition understanding, label comprehension, interpretation, and preferences Roberto et al (2016)33 To examine how health warning labels on SSBs may influence parents and determine which labels are most impactful on intended SSB purchases Randomized controlled trial; moderate 2381 participants; USA Primary caregivers of children aged 6–11 y; representative of 2010 census; mean age 36.2 y; median BMI 25.8 kg/m2; 67.5% white, 28.2% African-American Vending machine setting described in an online choice experiment NA Health knowledge, Intended SSB purchases, and attitudes toward warning labels Shepherd et al (1992)32 To determine the effect of sugar and fat content information on the assessment of flavored milks, taking account of dietary restraint and general attitudes toward the product Experimental study; weak 80 participants; UK University students Sensory evaluation laboratory NA Perceived healthfulness of SSBs; likelihood of purchasing SSBs, and attitudes toward beverages Siegrist et al (2015)40 To examine how 3 different label formats, (nutrition table, GDA, and TL) influence participants efficiency in judging the healthiness of a product and how FOP labels influence health judgments Experimental study; weak 98 participants; Switzerland Participants aged 16–74 y; mean age: 35 ± 15 y; 69% female Eye-tracking laboratory setting NA Perceived healthiness VanEpps et al (2016)31 To determine whether warning labels affect health knowledge and influence choices Randomized controlled trial; strong 2202 participants; USA Participants aged 12–18-y; mean age 15 y; representative of the 2010 US census; oversample of Hispanics and African-Americans Online choice experiment (vending machine setting) NA Health knowledge, intended SSB purchases, and attitudes toward warning labels Studies examining Point of sale labels (n=5 studies) Bergen et al (2006)39 To examine the effectiveness of intervention promoting more water and diet soft drink consumption instead of full-calorie soft drink Pre- and postexperimental study; strong 8 vending machines; USA College students, professors, and staff members College vending machines 9 wk (total) Mean number of beverages sold; mean weekly dollar sales from each vending machine Bleich et al (2014)38 To identify the most effective modes of communicating SSB caloric information to African-American adolescents, and to examine whether providing caloric information had a persistent effect on behavior after it was removed Randomized controlled trial; strong 6 corner stores, 4516 purchases, and 607 exit interviews; USA Low-income African-American adolescents; exit interview population age range 12–18 y Corner stores 12 wk (total) Total SSBs purchased; total calories purchased; amount of large volume SSB purchased Block et al (2010)37 To determine whether POS strategies (educational posters and/or price increases) can reduce the consumption of sugar-sweetened soft drinks Controlled pre- and postexperimental study; strong 1 cafeteria; 154 survey respondents; USA Hospital staff, patients, and visitors Hospital cafeteria 18 wk (total) Primary outcomes: beverages purchased (soft drinks, diet soft drinks, and water); Secondary outcomes: other beverages purchased (including sugary water), total sales; attitudes toward beverages, and awareness of interventions Donnelly et al (2018)48 To field-test the effectiveness of graphic warning labels (vs text warning labels, calorie labels, and no labels), provide insight into psychological mechanisms driving effectiveness, and assess consumer sentiment Experimental study; moderate Study 1: 2548 (SD = 290.0) bottled drinks purchased Study 2: 200 participants Study 3: 402 participants USA Study 1: not relevant Study 2: 48.8% female, 51.2% male; mean age 33.86 y, SD = 9.74; 80.6% Caucasian; median annual income $50 000–$74 999; 82.6% attended at least some college; Study 3: 49.8% female, 50.2% male; median age 45–54 y; 74.6% Caucasian; median annual income $25 000–$49 999; 55.5% attended at least some college; 28.3% consumed at least one sugary drink per day; mean BMI 28.51 kg/m2, SD = 7.57 Study 1: Hospital cafeteria, Studies 2 and 3: Online survey 14 wk Primary outcomes: percentage of drinks purchased that were sugary drinks Secondary outcomes: beverage calories purchased, overall beverage purchases, share of drink types purchased, and the weight of fountain syrup dispensed. Effertz et al (2014)35 To measure the single and joint effects of pictorial framings and warning labels in SSB advertisements Experimental study; strong 404 participants; Germany Children/ adolescents aged 10–22 y, attending high schools within metropolitan Hamburg Classroom setting NA Intended SSB purchases/product knowledge Author(s), year . Study aim . Study design, quality rating . Sample size, country . Study/ target population characteristics . Study setting . Follow-up . Outcome measurement . Studies examining Front-of-pack labels (n=16 studies) Acton et al (2018)46 To examine the effect of FOP nutrition labeling and sugary drink taxation on consumer beverage purchases Experimental study; weak 675 participants; Canada Canadians aged ≥16 y Shopping mall NA Consumer beverage purchases Acton et al (2019)43 To examine the relative impact of different sugar taxes and FOP labeling systems on beverage and snack food purchases Experimental study; moderate 3584 participants; Canada Canadians aged ≥13 y Shopping mall NA Beverage and snack food purchases Adams et al (2014)41 Experiment 1 (not relevant) Experiment 2 To examine whether providing people with concrete representations of SSB sugar content reduces the perceived attractiveness for SSBs Experimental study; weak 74 participants; USA American adults; SSB consumers; mean age 26.89 ± 5.98 y Online choice experiment NA SSB attractiveness index; cumulative change in intended SSB consumption Adams et al (2014)41 Experiment 3 To examine whether providing people with concrete representations of SSB sugar content would reduce the selection of SSBs Experimental study; weak 109 participants; USA University pedestrians, SSB drinkers; mean age 20.54 ± 2.92 y Choice experiment conducted in a university setting NA Intended purchases/selection of SSBs Billich et al (2018)47 To determine whether FOP labels with a graphic warning, text warning, sugar information (with the number of teaspoons of added sugar), or HSR reduces intended choice of SSB in an online choice experiment with young Australian adults Randomized controlled trial; moderate 994 participants; Australia Young adults, aged 18 and 35 y Online choice experiment NA Primary outcomes: proportion of participants who selected a SSB in the hypothetical choice scenario for each of the 5 study groups; Secondary outcomes: participants’ selection of diet drinks and high HSR drinks (for those participants who did not choose SSB in the choice scenario), factors that influenced their decision in the choice scenario, and perceptions about the impact of SSBs on health and wellbeing Bollard et al (2016)36 To assess the effects of plain packaging, warning labels (text and graphic), and a 20% tax on predicted product preferences, beliefs, and SSB purchase probabilities Randomized controlled trial; moderate 604 participants; New Zealand Participants were aged 13–24 y; mean age 18.4 ± 3.4 y; 51% female, 49% male; regular SSB consumers; majority European ethnicity Online choice experiment NA Attitudes toward interventions; preferences for and perceptions (healthiness) of products; probability of purchasing Gray et al (2011)42 To determine whether text-based FOP health-related labeling impacts intent to purchase SSBs Experimental study; weak 130 participants; Australia Individual in each household most responsible for grocery shopping; 79.2% SSB consumers Postal survey NA Comprehension of label; intent to purchase SSBs Mantzari et al (2018)50 The primary aim was to assess the impact on SSB selection of (i) 2 image-based warning labels, and (ii) calorie information labels; secondary aims were to assess (a) the impact of each label on perceptions of SSBs and acceptability of using the different labels on SSBs, and (b) the mediating role of negative emotional arousal on the impact of labels on SSB selection Experimental study; weak 2002 participants; UK Parents of children aged 11–16 y, with a total household SSB consumption of at least 500 mL each week. More than half were white and male and had obtained higher education. Online survey NA Primary outcomes: proportion of participants selecting SSBs; Secondary outcomes: perceptions of SSBs (negative emotional arousal; perceived health risks of drinking SSBs; acceptability of introducing image-based labels and/or calorie information labels on SSBs) Mantzari et al (2019)49 To assess the impact on SSB selection of: an “on-pack” pictorial health warning label depicting an adverse health consequence of excess sugar consumption, and “on-pack” calorie information labels Randomized controlled between-subject study; moderate 401 participants; England Adults aged 40.0 (13.9) y; 56% female, 86% white; 52% lower socioeconomic position Laboratory study NA Proportion of participants choosing SSBs Moran et al (2018)45 To describe and compare parents’ perceptions about the healthful qualities and risks of different categories of sugary drinks when no warning label is present Randomized experimental design; moderate 2381 participants; USA Caregivers of children aged 6–11 y; mean age of parents 36 y Online survey NA Purchase intentions, health beliefs, risk perceptions, and nutrition knowledge Popova et al (2019)44 To analyze how visual attention to the warning label and other product descriptors is associated with aided recall of the warning, perceptions of the product, and purchase intentions Randomized experimental design; moderate 180 participants; USA Participants aged 18–34 y; mean age: 25 y; 79% female, 48% white, 45% black; 53% with some college degree; 35% with income between $25 000 and $49 999; 67% living with overweight and obesity; history of smoking cigarillos or little cigars; 60% drank SSBs at least weekly Unspecified hypothetical choice setting NA Recall of the warning, perceptions of the product, and purchase intentions Roberto (2012)15 To determine which FOP label enables consumers to identify healthier options and promote accurate understanding of nutritional profiles Randomized controlled trial; strong 480 participants; USA Adults’ mean age 36 ± 13 y; 64% females; mean BMI 27.25 ± 7.35 kg/m2 Online choice experiment NA Health knowledge Roberto et al (2012)34 To determine which FOP label options lead to more accurate understanding of nutritional profiles of products Randomized controlled trial; strong 703 participants; USA Representative of the 2011 US Census; mean age: 46.01 ± 16.51 y (69.9%) overweight/obese; 82.4% Caucasian Online nutrient comparison quiz NA Nutrition understanding, label comprehension, interpretation, and preferences Roberto et al (2016)33 To examine how health warning labels on SSBs may influence parents and determine which labels are most impactful on intended SSB purchases Randomized controlled trial; moderate 2381 participants; USA Primary caregivers of children aged 6–11 y; representative of 2010 census; mean age 36.2 y; median BMI 25.8 kg/m2; 67.5% white, 28.2% African-American Vending machine setting described in an online choice experiment NA Health knowledge, Intended SSB purchases, and attitudes toward warning labels Shepherd et al (1992)32 To determine the effect of sugar and fat content information on the assessment of flavored milks, taking account of dietary restraint and general attitudes toward the product Experimental study; weak 80 participants; UK University students Sensory evaluation laboratory NA Perceived healthfulness of SSBs; likelihood of purchasing SSBs, and attitudes toward beverages Siegrist et al (2015)40 To examine how 3 different label formats, (nutrition table, GDA, and TL) influence participants efficiency in judging the healthiness of a product and how FOP labels influence health judgments Experimental study; weak 98 participants; Switzerland Participants aged 16–74 y; mean age: 35 ± 15 y; 69% female Eye-tracking laboratory setting NA Perceived healthiness VanEpps et al (2016)31 To determine whether warning labels affect health knowledge and influence choices Randomized controlled trial; strong 2202 participants; USA Participants aged 12–18-y; mean age 15 y; representative of the 2010 US census; oversample of Hispanics and African-Americans Online choice experiment (vending machine setting) NA Health knowledge, intended SSB purchases, and attitudes toward warning labels Studies examining Point of sale labels (n=5 studies) Bergen et al (2006)39 To examine the effectiveness of intervention promoting more water and diet soft drink consumption instead of full-calorie soft drink Pre- and postexperimental study; strong 8 vending machines; USA College students, professors, and staff members College vending machines 9 wk (total) Mean number of beverages sold; mean weekly dollar sales from each vending machine Bleich et al (2014)38 To identify the most effective modes of communicating SSB caloric information to African-American adolescents, and to examine whether providing caloric information had a persistent effect on behavior after it was removed Randomized controlled trial; strong 6 corner stores, 4516 purchases, and 607 exit interviews; USA Low-income African-American adolescents; exit interview population age range 12–18 y Corner stores 12 wk (total) Total SSBs purchased; total calories purchased; amount of large volume SSB purchased Block et al (2010)37 To determine whether POS strategies (educational posters and/or price increases) can reduce the consumption of sugar-sweetened soft drinks Controlled pre- and postexperimental study; strong 1 cafeteria; 154 survey respondents; USA Hospital staff, patients, and visitors Hospital cafeteria 18 wk (total) Primary outcomes: beverages purchased (soft drinks, diet soft drinks, and water); Secondary outcomes: other beverages purchased (including sugary water), total sales; attitudes toward beverages, and awareness of interventions Donnelly et al (2018)48 To field-test the effectiveness of graphic warning labels (vs text warning labels, calorie labels, and no labels), provide insight into psychological mechanisms driving effectiveness, and assess consumer sentiment Experimental study; moderate Study 1: 2548 (SD = 290.0) bottled drinks purchased Study 2: 200 participants Study 3: 402 participants USA Study 1: not relevant Study 2: 48.8% female, 51.2% male; mean age 33.86 y, SD = 9.74; 80.6% Caucasian; median annual income $50 000–$74 999; 82.6% attended at least some college; Study 3: 49.8% female, 50.2% male; median age 45–54 y; 74.6% Caucasian; median annual income $25 000–$49 999; 55.5% attended at least some college; 28.3% consumed at least one sugary drink per day; mean BMI 28.51 kg/m2, SD = 7.57 Study 1: Hospital cafeteria, Studies 2 and 3: Online survey 14 wk Primary outcomes: percentage of drinks purchased that were sugary drinks Secondary outcomes: beverage calories purchased, overall beverage purchases, share of drink types purchased, and the weight of fountain syrup dispensed. Effertz et al (2014)35 To measure the single and joint effects of pictorial framings and warning labels in SSB advertisements Experimental study; strong 404 participants; Germany Children/ adolescents aged 10–22 y, attending high schools within metropolitan Hamburg Classroom setting NA Intended SSB purchases/product knowledge Abbreviations: FOP, front of pack; GDA, guideline daily amount; HSR, health star rating; NA, not applicable; POS, point of sale; SD, standard deviation; SSB, sugar-sweetened beverage; TL, Traffic-light Label. Open in new tab Table 2 Study characteristics Author(s), year . Study aim . Study design, quality rating . Sample size, country . Study/ target population characteristics . Study setting . Follow-up . Outcome measurement . Studies examining Front-of-pack labels (n=16 studies) Acton et al (2018)46 To examine the effect of FOP nutrition labeling and sugary drink taxation on consumer beverage purchases Experimental study; weak 675 participants; Canada Canadians aged ≥16 y Shopping mall NA Consumer beverage purchases Acton et al (2019)43 To examine the relative impact of different sugar taxes and FOP labeling systems on beverage and snack food purchases Experimental study; moderate 3584 participants; Canada Canadians aged ≥13 y Shopping mall NA Beverage and snack food purchases Adams et al (2014)41 Experiment 1 (not relevant) Experiment 2 To examine whether providing people with concrete representations of SSB sugar content reduces the perceived attractiveness for SSBs Experimental study; weak 74 participants; USA American adults; SSB consumers; mean age 26.89 ± 5.98 y Online choice experiment NA SSB attractiveness index; cumulative change in intended SSB consumption Adams et al (2014)41 Experiment 3 To examine whether providing people with concrete representations of SSB sugar content would reduce the selection of SSBs Experimental study; weak 109 participants; USA University pedestrians, SSB drinkers; mean age 20.54 ± 2.92 y Choice experiment conducted in a university setting NA Intended purchases/selection of SSBs Billich et al (2018)47 To determine whether FOP labels with a graphic warning, text warning, sugar information (with the number of teaspoons of added sugar), or HSR reduces intended choice of SSB in an online choice experiment with young Australian adults Randomized controlled trial; moderate 994 participants; Australia Young adults, aged 18 and 35 y Online choice experiment NA Primary outcomes: proportion of participants who selected a SSB in the hypothetical choice scenario for each of the 5 study groups; Secondary outcomes: participants’ selection of diet drinks and high HSR drinks (for those participants who did not choose SSB in the choice scenario), factors that influenced their decision in the choice scenario, and perceptions about the impact of SSBs on health and wellbeing Bollard et al (2016)36 To assess the effects of plain packaging, warning labels (text and graphic), and a 20% tax on predicted product preferences, beliefs, and SSB purchase probabilities Randomized controlled trial; moderate 604 participants; New Zealand Participants were aged 13–24 y; mean age 18.4 ± 3.4 y; 51% female, 49% male; regular SSB consumers; majority European ethnicity Online choice experiment NA Attitudes toward interventions; preferences for and perceptions (healthiness) of products; probability of purchasing Gray et al (2011)42 To determine whether text-based FOP health-related labeling impacts intent to purchase SSBs Experimental study; weak 130 participants; Australia Individual in each household most responsible for grocery shopping; 79.2% SSB consumers Postal survey NA Comprehension of label; intent to purchase SSBs Mantzari et al (2018)50 The primary aim was to assess the impact on SSB selection of (i) 2 image-based warning labels, and (ii) calorie information labels; secondary aims were to assess (a) the impact of each label on perceptions of SSBs and acceptability of using the different labels on SSBs, and (b) the mediating role of negative emotional arousal on the impact of labels on SSB selection Experimental study; weak 2002 participants; UK Parents of children aged 11–16 y, with a total household SSB consumption of at least 500 mL each week. More than half were white and male and had obtained higher education. Online survey NA Primary outcomes: proportion of participants selecting SSBs; Secondary outcomes: perceptions of SSBs (negative emotional arousal; perceived health risks of drinking SSBs; acceptability of introducing image-based labels and/or calorie information labels on SSBs) Mantzari et al (2019)49 To assess the impact on SSB selection of: an “on-pack” pictorial health warning label depicting an adverse health consequence of excess sugar consumption, and “on-pack” calorie information labels Randomized controlled between-subject study; moderate 401 participants; England Adults aged 40.0 (13.9) y; 56% female, 86% white; 52% lower socioeconomic position Laboratory study NA Proportion of participants choosing SSBs Moran et al (2018)45 To describe and compare parents’ perceptions about the healthful qualities and risks of different categories of sugary drinks when no warning label is present Randomized experimental design; moderate 2381 participants; USA Caregivers of children aged 6–11 y; mean age of parents 36 y Online survey NA Purchase intentions, health beliefs, risk perceptions, and nutrition knowledge Popova et al (2019)44 To analyze how visual attention to the warning label and other product descriptors is associated with aided recall of the warning, perceptions of the product, and purchase intentions Randomized experimental design; moderate 180 participants; USA Participants aged 18–34 y; mean age: 25 y; 79% female, 48% white, 45% black; 53% with some college degree; 35% with income between $25 000 and $49 999; 67% living with overweight and obesity; history of smoking cigarillos or little cigars; 60% drank SSBs at least weekly Unspecified hypothetical choice setting NA Recall of the warning, perceptions of the product, and purchase intentions Roberto (2012)15 To determine which FOP label enables consumers to identify healthier options and promote accurate understanding of nutritional profiles Randomized controlled trial; strong 480 participants; USA Adults’ mean age 36 ± 13 y; 64% females; mean BMI 27.25 ± 7.35 kg/m2 Online choice experiment NA Health knowledge Roberto et al (2012)34 To determine which FOP label options lead to more accurate understanding of nutritional profiles of products Randomized controlled trial; strong 703 participants; USA Representative of the 2011 US Census; mean age: 46.01 ± 16.51 y (69.9%) overweight/obese; 82.4% Caucasian Online nutrient comparison quiz NA Nutrition understanding, label comprehension, interpretation, and preferences Roberto et al (2016)33 To examine how health warning labels on SSBs may influence parents and determine which labels are most impactful on intended SSB purchases Randomized controlled trial; moderate 2381 participants; USA Primary caregivers of children aged 6–11 y; representative of 2010 census; mean age 36.2 y; median BMI 25.8 kg/m2; 67.5% white, 28.2% African-American Vending machine setting described in an online choice experiment NA Health knowledge, Intended SSB purchases, and attitudes toward warning labels Shepherd et al (1992)32 To determine the effect of sugar and fat content information on the assessment of flavored milks, taking account of dietary restraint and general attitudes toward the product Experimental study; weak 80 participants; UK University students Sensory evaluation laboratory NA Perceived healthfulness of SSBs; likelihood of purchasing SSBs, and attitudes toward beverages Siegrist et al (2015)40 To examine how 3 different label formats, (nutrition table, GDA, and TL) influence participants efficiency in judging the healthiness of a product and how FOP labels influence health judgments Experimental study; weak 98 participants; Switzerland Participants aged 16–74 y; mean age: 35 ± 15 y; 69% female Eye-tracking laboratory setting NA Perceived healthiness VanEpps et al (2016)31 To determine whether warning labels affect health knowledge and influence choices Randomized controlled trial; strong 2202 participants; USA Participants aged 12–18-y; mean age 15 y; representative of the 2010 US census; oversample of Hispanics and African-Americans Online choice experiment (vending machine setting) NA Health knowledge, intended SSB purchases, and attitudes toward warning labels Studies examining Point of sale labels (n=5 studies) Bergen et al (2006)39 To examine the effectiveness of intervention promoting more water and diet soft drink consumption instead of full-calorie soft drink Pre- and postexperimental study; strong 8 vending machines; USA College students, professors, and staff members College vending machines 9 wk (total) Mean number of beverages sold; mean weekly dollar sales from each vending machine Bleich et al (2014)38 To identify the most effective modes of communicating SSB caloric information to African-American adolescents, and to examine whether providing caloric information had a persistent effect on behavior after it was removed Randomized controlled trial; strong 6 corner stores, 4516 purchases, and 607 exit interviews; USA Low-income African-American adolescents; exit interview population age range 12–18 y Corner stores 12 wk (total) Total SSBs purchased; total calories purchased; amount of large volume SSB purchased Block et al (2010)37 To determine whether POS strategies (educational posters and/or price increases) can reduce the consumption of sugar-sweetened soft drinks Controlled pre- and postexperimental study; strong 1 cafeteria; 154 survey respondents; USA Hospital staff, patients, and visitors Hospital cafeteria 18 wk (total) Primary outcomes: beverages purchased (soft drinks, diet soft drinks, and water); Secondary outcomes: other beverages purchased (including sugary water), total sales; attitudes toward beverages, and awareness of interventions Donnelly et al (2018)48 To field-test the effectiveness of graphic warning labels (vs text warning labels, calorie labels, and no labels), provide insight into psychological mechanisms driving effectiveness, and assess consumer sentiment Experimental study; moderate Study 1: 2548 (SD = 290.0) bottled drinks purchased Study 2: 200 participants Study 3: 402 participants USA Study 1: not relevant Study 2: 48.8% female, 51.2% male; mean age 33.86 y, SD = 9.74; 80.6% Caucasian; median annual income $50 000–$74 999; 82.6% attended at least some college; Study 3: 49.8% female, 50.2% male; median age 45–54 y; 74.6% Caucasian; median annual income $25 000–$49 999; 55.5% attended at least some college; 28.3% consumed at least one sugary drink per day; mean BMI 28.51 kg/m2, SD = 7.57 Study 1: Hospital cafeteria, Studies 2 and 3: Online survey 14 wk Primary outcomes: percentage of drinks purchased that were sugary drinks Secondary outcomes: beverage calories purchased, overall beverage purchases, share of drink types purchased, and the weight of fountain syrup dispensed. Effertz et al (2014)35 To measure the single and joint effects of pictorial framings and warning labels in SSB advertisements Experimental study; strong 404 participants; Germany Children/ adolescents aged 10–22 y, attending high schools within metropolitan Hamburg Classroom setting NA Intended SSB purchases/product knowledge Author(s), year . Study aim . Study design, quality rating . Sample size, country . Study/ target population characteristics . Study setting . Follow-up . Outcome measurement . Studies examining Front-of-pack labels (n=16 studies) Acton et al (2018)46 To examine the effect of FOP nutrition labeling and sugary drink taxation on consumer beverage purchases Experimental study; weak 675 participants; Canada Canadians aged ≥16 y Shopping mall NA Consumer beverage purchases Acton et al (2019)43 To examine the relative impact of different sugar taxes and FOP labeling systems on beverage and snack food purchases Experimental study; moderate 3584 participants; Canada Canadians aged ≥13 y Shopping mall NA Beverage and snack food purchases Adams et al (2014)41 Experiment 1 (not relevant) Experiment 2 To examine whether providing people with concrete representations of SSB sugar content reduces the perceived attractiveness for SSBs Experimental study; weak 74 participants; USA American adults; SSB consumers; mean age 26.89 ± 5.98 y Online choice experiment NA SSB attractiveness index; cumulative change in intended SSB consumption Adams et al (2014)41 Experiment 3 To examine whether providing people with concrete representations of SSB sugar content would reduce the selection of SSBs Experimental study; weak 109 participants; USA University pedestrians, SSB drinkers; mean age 20.54 ± 2.92 y Choice experiment conducted in a university setting NA Intended purchases/selection of SSBs Billich et al (2018)47 To determine whether FOP labels with a graphic warning, text warning, sugar information (with the number of teaspoons of added sugar), or HSR reduces intended choice of SSB in an online choice experiment with young Australian adults Randomized controlled trial; moderate 994 participants; Australia Young adults, aged 18 and 35 y Online choice experiment NA Primary outcomes: proportion of participants who selected a SSB in the hypothetical choice scenario for each of the 5 study groups; Secondary outcomes: participants’ selection of diet drinks and high HSR drinks (for those participants who did not choose SSB in the choice scenario), factors that influenced their decision in the choice scenario, and perceptions about the impact of SSBs on health and wellbeing Bollard et al (2016)36 To assess the effects of plain packaging, warning labels (text and graphic), and a 20% tax on predicted product preferences, beliefs, and SSB purchase probabilities Randomized controlled trial; moderate 604 participants; New Zealand Participants were aged 13–24 y; mean age 18.4 ± 3.4 y; 51% female, 49% male; regular SSB consumers; majority European ethnicity Online choice experiment NA Attitudes toward interventions; preferences for and perceptions (healthiness) of products; probability of purchasing Gray et al (2011)42 To determine whether text-based FOP health-related labeling impacts intent to purchase SSBs Experimental study; weak 130 participants; Australia Individual in each household most responsible for grocery shopping; 79.2% SSB consumers Postal survey NA Comprehension of label; intent to purchase SSBs Mantzari et al (2018)50 The primary aim was to assess the impact on SSB selection of (i) 2 image-based warning labels, and (ii) calorie information labels; secondary aims were to assess (a) the impact of each label on perceptions of SSBs and acceptability of using the different labels on SSBs, and (b) the mediating role of negative emotional arousal on the impact of labels on SSB selection Experimental study; weak 2002 participants; UK Parents of children aged 11–16 y, with a total household SSB consumption of at least 500 mL each week. More than half were white and male and had obtained higher education. Online survey NA Primary outcomes: proportion of participants selecting SSBs; Secondary outcomes: perceptions of SSBs (negative emotional arousal; perceived health risks of drinking SSBs; acceptability of introducing image-based labels and/or calorie information labels on SSBs) Mantzari et al (2019)49 To assess the impact on SSB selection of: an “on-pack” pictorial health warning label depicting an adverse health consequence of excess sugar consumption, and “on-pack” calorie information labels Randomized controlled between-subject study; moderate 401 participants; England Adults aged 40.0 (13.9) y; 56% female, 86% white; 52% lower socioeconomic position Laboratory study NA Proportion of participants choosing SSBs Moran et al (2018)45 To describe and compare parents’ perceptions about the healthful qualities and risks of different categories of sugary drinks when no warning label is present Randomized experimental design; moderate 2381 participants; USA Caregivers of children aged 6–11 y; mean age of parents 36 y Online survey NA Purchase intentions, health beliefs, risk perceptions, and nutrition knowledge Popova et al (2019)44 To analyze how visual attention to the warning label and other product descriptors is associated with aided recall of the warning, perceptions of the product, and purchase intentions Randomized experimental design; moderate 180 participants; USA Participants aged 18–34 y; mean age: 25 y; 79% female, 48% white, 45% black; 53% with some college degree; 35% with income between $25 000 and $49 999; 67% living with overweight and obesity; history of smoking cigarillos or little cigars; 60% drank SSBs at least weekly Unspecified hypothetical choice setting NA Recall of the warning, perceptions of the product, and purchase intentions Roberto (2012)15 To determine which FOP label enables consumers to identify healthier options and promote accurate understanding of nutritional profiles Randomized controlled trial; strong 480 participants; USA Adults’ mean age 36 ± 13 y; 64% females; mean BMI 27.25 ± 7.35 kg/m2 Online choice experiment NA Health knowledge Roberto et al (2012)34 To determine which FOP label options lead to more accurate understanding of nutritional profiles of products Randomized controlled trial; strong 703 participants; USA Representative of the 2011 US Census; mean age: 46.01 ± 16.51 y (69.9%) overweight/obese; 82.4% Caucasian Online nutrient comparison quiz NA Nutrition understanding, label comprehension, interpretation, and preferences Roberto et al (2016)33 To examine how health warning labels on SSBs may influence parents and determine which labels are most impactful on intended SSB purchases Randomized controlled trial; moderate 2381 participants; USA Primary caregivers of children aged 6–11 y; representative of 2010 census; mean age 36.2 y; median BMI 25.8 kg/m2; 67.5% white, 28.2% African-American Vending machine setting described in an online choice experiment NA Health knowledge, Intended SSB purchases, and attitudes toward warning labels Shepherd et al (1992)32 To determine the effect of sugar and fat content information on the assessment of flavored milks, taking account of dietary restraint and general attitudes toward the product Experimental study; weak 80 participants; UK University students Sensory evaluation laboratory NA Perceived healthfulness of SSBs; likelihood of purchasing SSBs, and attitudes toward beverages Siegrist et al (2015)40 To examine how 3 different label formats, (nutrition table, GDA, and TL) influence participants efficiency in judging the healthiness of a product and how FOP labels influence health judgments Experimental study; weak 98 participants; Switzerland Participants aged 16–74 y; mean age: 35 ± 15 y; 69% female Eye-tracking laboratory setting NA Perceived healthiness VanEpps et al (2016)31 To determine whether warning labels affect health knowledge and influence choices Randomized controlled trial; strong 2202 participants; USA Participants aged 12–18-y; mean age 15 y; representative of the 2010 US census; oversample of Hispanics and African-Americans Online choice experiment (vending machine setting) NA Health knowledge, intended SSB purchases, and attitudes toward warning labels Studies examining Point of sale labels (n=5 studies) Bergen et al (2006)39 To examine the effectiveness of intervention promoting more water and diet soft drink consumption instead of full-calorie soft drink Pre- and postexperimental study; strong 8 vending machines; USA College students, professors, and staff members College vending machines 9 wk (total) Mean number of beverages sold; mean weekly dollar sales from each vending machine Bleich et al (2014)38 To identify the most effective modes of communicating SSB caloric information to African-American adolescents, and to examine whether providing caloric information had a persistent effect on behavior after it was removed Randomized controlled trial; strong 6 corner stores, 4516 purchases, and 607 exit interviews; USA Low-income African-American adolescents; exit interview population age range 12–18 y Corner stores 12 wk (total) Total SSBs purchased; total calories purchased; amount of large volume SSB purchased Block et al (2010)37 To determine whether POS strategies (educational posters and/or price increases) can reduce the consumption of sugar-sweetened soft drinks Controlled pre- and postexperimental study; strong 1 cafeteria; 154 survey respondents; USA Hospital staff, patients, and visitors Hospital cafeteria 18 wk (total) Primary outcomes: beverages purchased (soft drinks, diet soft drinks, and water); Secondary outcomes: other beverages purchased (including sugary water), total sales; attitudes toward beverages, and awareness of interventions Donnelly et al (2018)48 To field-test the effectiveness of graphic warning labels (vs text warning labels, calorie labels, and no labels), provide insight into psychological mechanisms driving effectiveness, and assess consumer sentiment Experimental study; moderate Study 1: 2548 (SD = 290.0) bottled drinks purchased Study 2: 200 participants Study 3: 402 participants USA Study 1: not relevant Study 2: 48.8% female, 51.2% male; mean age 33.86 y, SD = 9.74; 80.6% Caucasian; median annual income $50 000–$74 999; 82.6% attended at least some college; Study 3: 49.8% female, 50.2% male; median age 45–54 y; 74.6% Caucasian; median annual income $25 000–$49 999; 55.5% attended at least some college; 28.3% consumed at least one sugary drink per day; mean BMI 28.51 kg/m2, SD = 7.57 Study 1: Hospital cafeteria, Studies 2 and 3: Online survey 14 wk Primary outcomes: percentage of drinks purchased that were sugary drinks Secondary outcomes: beverage calories purchased, overall beverage purchases, share of drink types purchased, and the weight of fountain syrup dispensed. Effertz et al (2014)35 To measure the single and joint effects of pictorial framings and warning labels in SSB advertisements Experimental study; strong 404 participants; Germany Children/ adolescents aged 10–22 y, attending high schools within metropolitan Hamburg Classroom setting NA Intended SSB purchases/product knowledge Abbreviations: FOP, front of pack; GDA, guideline daily amount; HSR, health star rating; NA, not applicable; POS, point of sale; SD, standard deviation; SSB, sugar-sweetened beverage; TL, Traffic-light Label. Open in new tab Sixteen included studies examined the impact of FOP labeling15,31–34,36,40–47,49,50 and 5 studies examined the impact of POS labeling.35,37–39,48 Of the 16 studies that examined the impact of FOP labels, 9 were randomized controlled trials (RCTs)15,31,33,34,36,44,45,47,49 and 7 were nonrandomized experimental design studies.32,40–43,46,50 Eight of the FOP studies were conducted online, 3 were conducted in a laboratory setting, one study reported on 2 experiments that were conducted online and in a real-world setting (a university), 2 studies were conducted in a shopping mall, one used an unspecified hypothetical choice setting, and one used a postal survey. Of the 5 studies that examined the impact of POS signage, only one was a RCT (conducted in corner stores), while the remaining 4 were nonrandomized experimental design studies (conducted in colleges, hospitals, classrooms, and online). Only 3 of the 21 studies were lab-based. These studies were purposively included because they tested interventions on human participants and the insights on efficacy and adverse effects of interventions by controlling the variables that could impact the results of the study in the real-world could be helpful. Online studies, such as lab-based studies, were also included as they offer a range of benefits. These include the advantages of reaching and engaging with target population groups, increased interactivity, flexibility for information tailoring, ease of use and application, cost-effectiveness, and anonymity. Of the 5 studies that examined the impact of POS signage, one was a RCT,38 2 were nonrandomized experimental design studies,35,48 and 2 were pre-/post-experimental studies.37,39 Four of the 5 studies that used POS signage measured SSB purchases in real-world settings (vending machine in a college, classroom, corner store, and hospital cafeteria)37–39,48 and one displayed a fictitious SSB advertisement to students in a classroom setting.35 Participants The sample size of the participants recruited ranged from 74 to 3584. The majority of the participants were reported to have attained some form of basic education, and were of Caucasian ethnicity with ages ranging from 16 to 35 years. Some studies described their participants living with overweight and obesity, and some identified their participants to be consuming SSBs from daily to weekly. Outcomes Outcomes measured across studies were participants’ SSB health-related knowledge or awareness of ill-effects of SSBs (n = 10), preference for SSBs (n = 5), and SSB purchases (intended and actual) (n = 15). No study measured SSB consumption as the study outcome. There was overlap in the outcomes across studies as more than one outcome was reported in the included studies. Quality of included studies The overall quality ratings of the included studies using the EPHPP tool are stated in Table 2. Seven studies scored a strong rating, 8 studies scored a moderate rating, and the remaining 6 studies scored a weak rating. While the majority of the studies had an experimental study design (randomized or nonrandomized), only a few studies reported whether or not the study (i) was protected against detection bias and reporting bias through blinding, and (ii) used reliable and valid methods of data collection. A detailed description of the quality assessment for each study is shown in Table S2 (please the Supporting Information online). A summary of study outcomes is presented in Table 3.15,31–50 Table S3 (please see the Supporting Information online) shows details of the intervention and label characteristics (FOP and POS). Table 3 Summary of study outcomes (✓ change in favorable direction; × change in unfavorable direction;—no change) Study and intervention characteristics . Health-related knowledge or awareness in relation to SSBs: . Impact on attitudes . SSB purchases . Author, year . Label type (FOP/POS) . Label/sign . Cause weight gain . Cause diabetes . Cause heart disease . Contribute to poorer health . Are unhealthy choices . SSB sugar/ calorie content . Preferences for SSBs . Intended purchases/choice . Actual purchases/choice . Studies examining front-of-pack labels (n=16 studies) Acton et al (2018)46 FOP Text health warning ✓ ✓ High sugar symbol ✓ ✓ Health star format — Acton et al (2019)43 FOP Text warning label ✓ Multiple traffic light format ✓ Health star rating format ✓ Nutrition table format ✓ Adams et al (2014)41 Experiment 2 FOP Concrete-sugar-image ✓ ✓ Abstract-sugar information ✓ ✓ Experiment 3 Concrete-sugar-image ✓ ✓ Abstract-sugar information ✓ Billich et al (2018)47 FOP Graphic warning label ✓ ✓ Text warning label ✓ Sugar information label ✓ ✓ Health star format ✓ Bollard et al (2016)36 FOP Warning text (inside an orange octagon covering one-eighth of a soft drink can) — ✓ ✓ Gray et al (2011)42 FOP Text-based warning label ✓ Mantzari et al (2018)50 FOP Pictorial disease image label ✓ Pictorial sugar content label ✓ Calorie label ✓ Mantzari et al (2019)49 FOP Pictorial health warning label — Calorie information label — Moran et al (2018)45 FOP Calorie label ✓ California label ✓ ✓ ✓ ✓ ✓ ✓ Weight gain label ✓ ✓ ✓ ✓ ✓ ✓ Preventable label ✓ ✓ ✓ ✓ ✓ ✓ Type 2 diabetes label ✓ ✓ ✓ ✓ ✓ ✓ Popova et al (2019)44 FOP Warning label ✓ ✓ — Roberto (2012)15 FOP Informational text, traffic light symbol — Informational text and traffic light symbol + image of a male and female figure + calories-per-day label — A modified traffic light symbol/ informational text + calories-per-serving label — Roberto et al (2012)34 FOP Informational text + symbols, traffic light ✓ Informational text, facts up front ✓ Roberto et al (2016)33 FOP Warning text (displayed on picture of beverage) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Shepherd et al (1991)32 FOP Informational text ✓ ✓ — Siegrist et al (2015)40 FOP Traffic light format — Guidelines of daily amount format — Nutrition table format — VanEpps et al (2016)31 FOP California label — — — ✓ — ✓ ✓ Weight gain label — — — ✓ — ✓ ✓ Preventable label — ✓ — ✓ ✓ ✓ ✓ Type 2 diabetes label — — — ✓ ✓ ✓ ✓ Studies examining point-of-sale labels (n=5 studies) Bergen et al (2006)39 POS Informational text, motivational posters — Bleich et al (2014)38 POS Informational text ✓ Block et al (2010)37 POS Educational posters and flyers — Donnelly et al (2018)48 POS Calorie label — Text warning label — Graphic warning label ✓ ✓ Effertz et al (2014)35 POS Informational text + graphic, fictitious posters ✓ (young adults) × (older adults) Study and intervention characteristics . Health-related knowledge or awareness in relation to SSBs: . Impact on attitudes . SSB purchases . Author, year . Label type (FOP/POS) . Label/sign . Cause weight gain . Cause diabetes . Cause heart disease . Contribute to poorer health . Are unhealthy choices . SSB sugar/ calorie content . Preferences for SSBs . Intended purchases/choice . Actual purchases/choice . Studies examining front-of-pack labels (n=16 studies) Acton et al (2018)46 FOP Text health warning ✓ ✓ High sugar symbol ✓ ✓ Health star format — Acton et al (2019)43 FOP Text warning label ✓ Multiple traffic light format ✓ Health star rating format ✓ Nutrition table format ✓ Adams et al (2014)41 Experiment 2 FOP Concrete-sugar-image ✓ ✓ Abstract-sugar information ✓ ✓ Experiment 3 Concrete-sugar-image ✓ ✓ Abstract-sugar information ✓ Billich et al (2018)47 FOP Graphic warning label ✓ ✓ Text warning label ✓ Sugar information label ✓ ✓ Health star format ✓ Bollard et al (2016)36 FOP Warning text (inside an orange octagon covering one-eighth of a soft drink can) — ✓ ✓ Gray et al (2011)42 FOP Text-based warning label ✓ Mantzari et al (2018)50 FOP Pictorial disease image label ✓ Pictorial sugar content label ✓ Calorie label ✓ Mantzari et al (2019)49 FOP Pictorial health warning label — Calorie information label — Moran et al (2018)45 FOP Calorie label ✓ California label ✓ ✓ ✓ ✓ ✓ ✓ Weight gain label ✓ ✓ ✓ ✓ ✓ ✓ Preventable label ✓ ✓ ✓ ✓ ✓ ✓ Type 2 diabetes label ✓ ✓ ✓ ✓ ✓ ✓ Popova et al (2019)44 FOP Warning label ✓ ✓ — Roberto (2012)15 FOP Informational text, traffic light symbol — Informational text and traffic light symbol + image of a male and female figure + calories-per-day label — A modified traffic light symbol/ informational text + calories-per-serving label — Roberto et al (2012)34 FOP Informational text + symbols, traffic light ✓ Informational text, facts up front ✓ Roberto et al (2016)33 FOP Warning text (displayed on picture of beverage) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Shepherd et al (1991)32 FOP Informational text ✓ ✓ — Siegrist et al (2015)40 FOP Traffic light format — Guidelines of daily amount format — Nutrition table format — VanEpps et al (2016)31 FOP California label — — — ✓ — ✓ ✓ Weight gain label — — — ✓ — ✓ ✓ Preventable label — ✓ — ✓ ✓ ✓ ✓ Type 2 diabetes label — — — ✓ ✓ ✓ ✓ Studies examining point-of-sale labels (n=5 studies) Bergen et al (2006)39 POS Informational text, motivational posters — Bleich et al (2014)38 POS Informational text ✓ Block et al (2010)37 POS Educational posters and flyers — Donnelly et al (2018)48 POS Calorie label — Text warning label — Graphic warning label ✓ ✓ Effertz et al (2014)35 POS Informational text + graphic, fictitious posters ✓ (young adults) × (older adults) Open in new tab Table 3 Summary of study outcomes (✓ change in favorable direction; × change in unfavorable direction;—no change) Study and intervention characteristics . Health-related knowledge or awareness in relation to SSBs: . Impact on attitudes . SSB purchases . Author, year . Label type (FOP/POS) . Label/sign . Cause weight gain . Cause diabetes . Cause heart disease . Contribute to poorer health . Are unhealthy choices . SSB sugar/ calorie content . Preferences for SSBs . Intended purchases/choice . Actual purchases/choice . Studies examining front-of-pack labels (n=16 studies) Acton et al (2018)46 FOP Text health warning ✓ ✓ High sugar symbol ✓ ✓ Health star format — Acton et al (2019)43 FOP Text warning label ✓ Multiple traffic light format ✓ Health star rating format ✓ Nutrition table format ✓ Adams et al (2014)41 Experiment 2 FOP Concrete-sugar-image ✓ ✓ Abstract-sugar information ✓ ✓ Experiment 3 Concrete-sugar-image ✓ ✓ Abstract-sugar information ✓ Billich et al (2018)47 FOP Graphic warning label ✓ ✓ Text warning label ✓ Sugar information label ✓ ✓ Health star format ✓ Bollard et al (2016)36 FOP Warning text (inside an orange octagon covering one-eighth of a soft drink can) — ✓ ✓ Gray et al (2011)42 FOP Text-based warning label ✓ Mantzari et al (2018)50 FOP Pictorial disease image label ✓ Pictorial sugar content label ✓ Calorie label ✓ Mantzari et al (2019)49 FOP Pictorial health warning label — Calorie information label — Moran et al (2018)45 FOP Calorie label ✓ California label ✓ ✓ ✓ ✓ ✓ ✓ Weight gain label ✓ ✓ ✓ ✓ ✓ ✓ Preventable label ✓ ✓ ✓ ✓ ✓ ✓ Type 2 diabetes label ✓ ✓ ✓ ✓ ✓ ✓ Popova et al (2019)44 FOP Warning label ✓ ✓ — Roberto (2012)15 FOP Informational text, traffic light symbol — Informational text and traffic light symbol + image of a male and female figure + calories-per-day label — A modified traffic light symbol/ informational text + calories-per-serving label — Roberto et al (2012)34 FOP Informational text + symbols, traffic light ✓ Informational text, facts up front ✓ Roberto et al (2016)33 FOP Warning text (displayed on picture of beverage) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Shepherd et al (1991)32 FOP Informational text ✓ ✓ — Siegrist et al (2015)40 FOP Traffic light format — Guidelines of daily amount format — Nutrition table format — VanEpps et al (2016)31 FOP California label — — — ✓ — ✓ ✓ Weight gain label — — — ✓ — ✓ ✓ Preventable label — ✓ — ✓ ✓ ✓ ✓ Type 2 diabetes label — — — ✓ ✓ ✓ ✓ Studies examining point-of-sale labels (n=5 studies) Bergen et al (2006)39 POS Informational text, motivational posters — Bleich et al (2014)38 POS Informational text ✓ Block et al (2010)37 POS Educational posters and flyers — Donnelly et al (2018)48 POS Calorie label — Text warning label — Graphic warning label ✓ ✓ Effertz et al (2014)35 POS Informational text + graphic, fictitious posters ✓ (young adults) × (older adults) Study and intervention characteristics . Health-related knowledge or awareness in relation to SSBs: . Impact on attitudes . SSB purchases . Author, year . Label type (FOP/POS) . Label/sign . Cause weight gain . Cause diabetes . Cause heart disease . Contribute to poorer health . Are unhealthy choices . SSB sugar/ calorie content . Preferences for SSBs . Intended purchases/choice . Actual purchases/choice . Studies examining front-of-pack labels (n=16 studies) Acton et al (2018)46 FOP Text health warning ✓ ✓ High sugar symbol ✓ ✓ Health star format — Acton et al (2019)43 FOP Text warning label ✓ Multiple traffic light format ✓ Health star rating format ✓ Nutrition table format ✓ Adams et al (2014)41 Experiment 2 FOP Concrete-sugar-image ✓ ✓ Abstract-sugar information ✓ ✓ Experiment 3 Concrete-sugar-image ✓ ✓ Abstract-sugar information ✓ Billich et al (2018)47 FOP Graphic warning label ✓ ✓ Text warning label ✓ Sugar information label ✓ ✓ Health star format ✓ Bollard et al (2016)36 FOP Warning text (inside an orange octagon covering one-eighth of a soft drink can) — ✓ ✓ Gray et al (2011)42 FOP Text-based warning label ✓ Mantzari et al (2018)50 FOP Pictorial disease image label ✓ Pictorial sugar content label ✓ Calorie label ✓ Mantzari et al (2019)49 FOP Pictorial health warning label — Calorie information label — Moran et al (2018)45 FOP Calorie label ✓ California label ✓ ✓ ✓ ✓ ✓ ✓ Weight gain label ✓ ✓ ✓ ✓ ✓ ✓ Preventable label ✓ ✓ ✓ ✓ ✓ ✓ Type 2 diabetes label ✓ ✓ ✓ ✓ ✓ ✓ Popova et al (2019)44 FOP Warning label ✓ ✓ — Roberto (2012)15 FOP Informational text, traffic light symbol — Informational text and traffic light symbol + image of a male and female figure + calories-per-day label — A modified traffic light symbol/ informational text + calories-per-serving label — Roberto et al (2012)34 FOP Informational text + symbols, traffic light ✓ Informational text, facts up front ✓ Roberto et al (2016)33 FOP Warning text (displayed on picture of beverage) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Shepherd et al (1991)32 FOP Informational text ✓ ✓ — Siegrist et al (2015)40 FOP Traffic light format — Guidelines of daily amount format — Nutrition table format — VanEpps et al (2016)31 FOP California label — — — ✓ — ✓ ✓ Weight gain label — — — ✓ — ✓ ✓ Preventable label — ✓ — ✓ ✓ ✓ ✓ Type 2 diabetes label — — — ✓ ✓ ✓ ✓ Studies examining point-of-sale labels (n=5 studies) Bergen et al (2006)39 POS Informational text, motivational posters — Bleich et al (2014)38 POS Informational text ✓ Block et al (2010)37 POS Educational posters and flyers — Donnelly et al (2018)48 POS Calorie label — Text warning label — Graphic warning label ✓ ✓ Effertz et al (2014)35 POS Informational text + graphic, fictitious posters ✓ (young adults) × (older adults) Open in new tab Front-of-pack warning labels. Of the 16 studies that used FOP labels, 6 used text warning labels,31,33,42–45 5 used both text and graphic warning labels,36,46,47,49,50 and 5 used sugar informational labels.15,32,34,40,41 Effect of front-of-pack warning labels on health knowledge Three RCTs31,33,45 of strong and moderate quality evaluated the impact of text warning labels on parents’ and adolescents’ health-related knowledge. All 3 studies found that participants exposed to the warning labels relative to those not exposed to the warning labels rated SSBs to be less healthy, and could more accurately estimate nutritional content of SSBs. Roberto et al33 found that compared with the control group (unexposed to a label), parents in the warning-label groups rated SSBs to be less healthy, could more accurately estimate the nutritional content of SSBs, were more likely to report that SSBs would lead to their child living a less healthy life, have less energy, be less likely to focus, or have a higher risk of weight gain, heart disease, and diabetes. Moran and Roberto45 and VanEpps and Roberto31 assessed the impact of similar warning labels on parents and adolescents, respectively. VanEpps and Roberto found that warning labels had less impact on the health knowledge of adolescents. Moran and Roberto found that all the 4 labels (California label, weight gain label, preventable label, and type 2 diabetes label) decreased the ratings of SSB healthiness among parents. However, only 2 labels (preventable warning and yype 2 diabetes warning) decreased the ratings of SSB healthiness among adolescents. In the majority of cases, warning labels had no effect on the proportion of adolescents that reported SSBs would lead to diabetes, weight gain, or heart disease. However, warning labels increased subjective perceptions of added sugar and led to diminished subjective perceptions of SSBs promoting a healthy life, helping one feel energized, or helping one focus at school. Warning labels also led to adolescents having more accurate estimates of the nutritional content of SSBs. One RCT of moderate quality evaluated the impact of a graphic and a text (“high sugar content”) warning label.36 This study found that the participants exposed to both text and graphic warning labels rated SSBs to be significantly less healthy than those in the control group (unexposed to a label). Another RCT44 of strong quality found that participants who viewed the California warning label (similar to the label used above31 modeled after SSB warning labels proposed in California warning: “Drinking beverages with added sugar(s) contributes to obesity, diabetes, and tooth decay”) perceived SSBs to be less healthy and more likely to contribute to diabetes. Popova et al included participants with BMI > 25 and reported that its regression models controlled for BMI. The authors did not conduct any sub-group analysis to conclude any differences in the outcome measure based on overweight and obesity as a result of different labels. The authors also reported that interactions between label condition and weight status were based on self-reported height and weight, which is prone to measurement error. A weak quality experimental study found that viewing a sugar informational label stating “high sugar” was associated with participants’ increased ability to estimate calorie content for high sugar beverage, and decreased both ability to estimate calorie content for low sugar beverage and decreased perceived beverage healthiness.32 In a moderate-quality RCT,47 of participants exposed to graphic warning or sugar information labels, 37% (odds ratio [OR], 1.61; 95%CI, 1.04–2.49) and 36% (OR, 1.57; 95%CI, 1.01–2.44) respectively reported that they considered the healthiness of the drink when making their selection, and this was significantly higher than the control group. Similarly, in a poor-quality experimental study,50 the disease image label and both sugar content image labels (with and without calorie information) increased the perceived health risks of drinking SSBs compared with both the control and calorie information label. One strong-quality RCT34 found that participants who viewed a traffic-light label and “facts up front” label with additional sugar information were more likely than those in the control group to be able to correctly identify which beverage had the most calories. In this study, the authors included participants with BMI > 25 and reported no interactions between label condition and weight status for any of the outcome variables. However, another strong quality RCT which also tested the participants’ perception of healthiness of the food product using the same traffic light label with added sugar information found no significant group differences.15 Similarly, Siegrist et al40 found no association between traffic light or nutritional labels with additional sugar information and participants’ rating of SSB healthiness, in a weak quality study. Effect of front-of-pack warning labels on attitude, beliefs Five studies (2 moderate-quality RCTs33,36 and 3 poor-quality experimental studies32,41,42) evaluated the impact of FOP labels on participants’ attitudes toward SSBs in the form of preference for SSBs. Participants exposed to graphic and text warning labels rated SSBs as less desirable, less tasty, less attractive and of a lower quality than those in the control group.36 In one study, the graphic warning label had a greater impact on participants’ preferences for SSBs than the text warning label.36 However, Roberto et al33 found no association between warning labels and parents’ perceptions of their child’s taste preference for SSBs or the amount they were willing to pay for SSBs. Labels with concrete sugar information (images of each SSB were displayed with a visual representation of the amount of sugar in the beverage – ie, a sugar pyramid representing the amount of sugar in the beverage and a caption that listed the number of sugar grams in the beverage’s “sugar-gram information caption”) also reduced the intention to purchase SSBs and the attractiveness of SSBs.41 Participants exposed to the abstract-information condition (the sugar-gram information caption was provided, but there was no visual representation of the amount of sugar in the beverage – ie, no sugar pyramid) were nearly 3 times more likely to select an SSB than participants exposed to the concrete-information condition.41 In another study,33 participants also strongly believed that warning labels would help change their beliefs about the healthfulness of SSBs and would encourage them to purchase fewer SSBs for their children. Effect of front-of-pack warning labels on purchases of sugar-sweetened beverages Ten studies examined the effect of a range of FOP labels on SSB purchases.31–33,36,42,43,46,47,49,50 Graphic and text warning labels significantly decreased SSB purchases (intended and actual) compared with the control conditions in 6 out of 10 of the studies. Graphic and text warning labels also significantly decreased the likelihood of purchasing SSBs.36 Roberto et al33 demonstrated that warning labels reduced the intended choice of an SSB when compared with calorie labels or no informational text/image. Warning labels significantly reduced the number of participants that selected a coupon to receive a discount on real-world purchases of SSBs, but no difference was observed between participants in the warning-label groups and the control group on the likelihood of future purchases.31,33 One moderate-quality RCT43 found that participants assigned to the “high in sugar” warning-label condition purchased fewer beverages containing sugars than those assigned to the no-label control condition. A moderate-quality RCT47 found that compared to the control group (not exposed to a label), the graphic warning, text warning, sugar information, and health star rating (HSR) labels all significantly reduced selection of SSB in the choice scenario. The HSR is a FOP labeling scheme that provides an overall rating of the nutritional profile of a food or drink from 0.5 (least healthy) to 5 (healthiest) stars. The magnitude of effect was greatest for the graphic warning label (OR, 0.22; 95%CI, 0.14–0.35). Similarly in an online weak-quality experimental study conducted by Mantzari et al,50 compared to the control group, use of all image-based warning labels decreased the odds of selecting SSBs. Contrary to the positive effect of graphic and text-warning labels on the consumer-intended SSB purchases, 4 studies found that the sugar information label had no significant impact on the intended SSB purchases.32,42,46,49 Adolescents reported that viewing a warning label would encourage them to purchase fewer SSBs.31 Among participants who saw labels warning them of the risks of obesity and diabetes associated with SSBs, 35% and 42% stated they would reduce purchases of at least one high-sugar soft drink, respectively.42 In response to the warning labels, 13% of households reported they would no longer purchase any SSBs if an FOP label was in place.42 In contrast, a study by Bollard et al36 revealed no impact of warning labels on intended SSB purchases. Shepherd et al32 found that presenting sugar information had no significant effect on intended purchases of sugar-sweetened flavored milk. Point-of-sale warning signage and its effect on SSB purchases. Five studies examined the association of various POS warning signs on SSB purchases and sales.35,37–39,48 These studies did not assess other outcomes such as health-related knowledge or awareness of SSBs and impact on attitudes toward SSBs. These studies explored the impact of warning labels/signage, and motivational and educational posters on SSB purchases/sales. Effertz et al35 demonstrated that displaying warning signage or labels at the point of sale was associated with an overall decline in purchase intention among participants aged 10–22 years. In another study,39 motivational posters displayed on vending machines at the point of sale, over a 5-week intervention period, resulted in significantly reduced SSB purchases. Another study38 showed that providing sugar content information significantly reduced the number of total beverage calories purchased, the likelihood of buying an SSB, and the likelihood of buying an SSB greater than 16 ounces (P < 0.05). An educational campaign with a poster and informational flyers posted at strategic locations in the cafeteria, all stating the same message – “Lose up to 15–25 pounds in one year and decrease your risk of diabetes by 1/2. Just skip one regular soda per day. For zero calories, try diet soda or water” – had no effect on SSB purchases.37 In a moderate-quality experimental study,48 it was found that graphic warning labels reduced the share of sugary drinks purchased in a cafeteria from 21.4% at baseline to 18.2% and also heightened the negative effect and prompt consideration of health consequences of SSBs. Except one moderate-quality study,48 all the remaining 4 of the 5 studies were strong in quality and had a low risk of bias. DISCUSSION This review demonstrates that health- or sugar-related messages for SSBs, either as FOP or POS, may improve health knowledge, positively impact attitudes and beliefs toward SSBs, and reduce intended and actual SSB purchases. There is moderate-to-strong evidence to support the efficacy of FOP warning labels at improving health knowledge relating to the risks of SSB consumption and reducing intention to choose SSBs by adults in controlled environments. Limited evidence suggests FOP sugar information or interpretive labels increase health knowledge relating to SSBs. There is also limited evidence, albeit of strong quality, that demonstrates POS sugar information signage is an effective strategy to reduce actual purchases of SSBs in real-world settings. The findings from this review suggest that warning labels on SSBs may increase consumers’ perceptions of the risks of unwanted health outcomes associated with SSB consumption, such as obesity, diabetes, and heart disease. Warning labels may also reduce preferences for SSBs (eg, ratings of attractiveness and quality), intended SSB purchases, and selection of coupons to receive a discount on SSBs. This review demonstrates that graphic warning labels were more effective than text-based labels at reducing preferences for, and intended purchases of, SSBs. This could be due to the fact that the use of graphics and colors may have a wider reach as compared to text-based labels as they may help non-native language speakers, youth, and those with reading difficulties to better interpret the healthiness of the product.51 Similar to the findings of this review on the impact of sugar-related warning labels in generating negative feelings toward SSBs, warning labels with regards to smoking have previously shown that implementing graphic warning labels on cigarette packs was associated with generating negative feelings, leading to an increased number of calls to a smoking cessation helpline, increasing the number of times people attempted to quit smoking, and overall decreasing smoking prevalence in certain countries.52,53 Furthermore, the effectiveness of warning labels focusing on health-related consequences of smoking (eg, lung cancer, oral cancer) has successfully led to increased awareness among people on the ill health effects of smoking.53–55 A small number of studies have reflected on the influence of sociodemographic factors on SSB purchase and consumption. Studies found that identical warning labels elicited different effects in adolescents and adults.31,33 Although the labels reduced intended SSB choice for both age groups, the warning labels were less effective in the adolescent group at increasing the perceived risk of adverse health outcomes than with the sample of parents. This difference in effect between adults and adolescents needs to be considered when developing SSB reduction strategies. However, as SSB consumption remains high among adolescents, targeting interventions at this subgroup may be effective. For example, the Australian Rethink Sugary Drink campaign targeted young Australians and was successful in convincing this group to reduce consumption of sugary drinks and replace them with water, reduced-fat milk, or unsweetened options.56 Strengths and limitations There are several strengths to this review. First, a comprehensive search strategy was developed and adapted to a large range of databases to ensure no relevant studies were missed. Second, both academic and grey literature was searched to identify research that may be of interest to policy makers. Third, a variety of study designs, including closed experimental conditions and real-world studies, were included to help build a strong evidence base. While all study designs were considered eligible for inclusion, no observational study met the eligibility criteria. There could be three potential reasons for this: (1) Given that individual-level outcomes (knowledge, attitude, and practices regarding SSBs) were of interest for this review, it is less likely that country-level sugar-related labeling legislations as exposure would be examined in observational studies; (2) In countries that do not have sugar-related labeling legislations, there is no exposed group to assess the impact of sugar-related labeling (front-of-pack labeling or point-of-sale signage) on knowledge, attitude, and practices regarding SSBs; (3) Vice versa, in countries that have introduced sugar-related labeling legislations, it is unlikely that there will be individual-level variations in the exposure to assess the impact of sugar-related labeling (front-of-pack labeling or point-of-sale signage) on knowledge, attitude, and practices regarding SSBs. Observational studies in this regard could only have been identified if there had been a natural experiment where individuals’ knowledge, attitude, and practices regarding SSBs could be assessed before and after a sugar-related labeling legislation had been passed. Next, to maximize the likelihood of identifying relevant studies in this review, no restriction on the sociodemographic composition of the participants was applied. Hence, the studies varied widely in the numbers of participants and their sociodemographic composition. Last, the studies that demonstrated that health- or sugar-related signage was effective at reducing actual or intended SSB purchases were of strong quality and had a low risk of bias. However, the studies included in this review also have several limitations. First, the majority of included studies involved closed experimental conditions such as online experiments. Whilst these studies are able to control for external factors that may influence results, they are less generalizable to real-world settings. The real-world studies in this review demonstrated that POS signage reduced overall SSB purchases for specific populations (one involving low-income, African-American adolescents, and the other college staff and students). Thus, the findings of these studies may therefore not be generalizable to the wider population. Second, the heterogeneity of the included studies makes it difficult to draw firm conclusions about the effect of specific labeling interventions. Third, as only a few studies reflected on the sociodemographic variation in SSB purchase and consumption, a separate subgroup analysis could not be conducted to ascertain whether a specific type of message (warning vs informational) or location of messages (FOP vs POS) may be more effective for particular subgroups. This is an important area of research given the higher consumption of SSBs in lower socioeconomic position groups in countries such as Australia. Further, variables such as overweight and obesity, and sugar consumption, are critical in determining knowledge, attitude, and practices regarding SSBs and should be explored in future studies. Fourth, no eligible studies were found from low- and middle-income countries, although analyses relevant to this study have been conducted in many parts of the world. This may be due to three reasons: (1) the limited number of studies from these countries, (2) the presence of publication bias – ie, a strong bias to publish only studies that show significant results, and (3) articles published in languages other than English. Finally, it is important to note that the included studies were conducted between 1992 and 2019, with the majority being conducted between 2014 and 2019. This could be due to the recent rise in nutrition labeling policies implemented worldwide. Study implications This is the first review to systematically summarize evidence regarding the impact of sugar- or health-related labels or signage on attitudes and beliefs concerning SSBs or on choosing to purchase SSBs. The findings from this study suggest that different label or signage types may be effective in some settings and for some consumers, but less effective for others. There have been limited studies published that test the effectiveness of FOP labels or warning messages (FOP or POS) in real-world environments (eg, convenience stores or vending machines) on actual SSB sales and there is also limited evidence available that assesses the differences between graphic- and text-based warning labels. Three studies measured participants’ support for proposed SSB-related FOP labeling policies and found that participants either agreed or strongly agreed that SSBs should carry a text warning label or the use of a graphic warning label. This is an important finding and requires further investigation to inform sugar labeling policy reforms. Previous research has shown the impact of multiple FOP labels on consumers’ decisions based on, for example, their age, gender, and BMI profiles.57 However, the research has often been quite abstract and used hypothetical scenarios to understand consumer behavior rather than real-life situations. Future research could include subgroup analysis on age, gender, socioeconomic position, strength of habit for SSB consumption, and health status to determine which groups are most influenced. Furthermore, future research could focus on identifying alternative forms of FOP label formats that are specifically tailored to specific subgroups of consumers. This study calls for a universal implementation of labeling laws and policies in order to tackle sugar consumption. Having mandatory FOP and POS labels that are (1) noticeable by consumers,58,59 (2) present clear and precise information that is easily understood by consumers,60 and (3) effectively motivate consumers’ preference and purchase of healthy products61 is likely to be part of the way forward. Some policy makers internationally are already making significant contribution by introducing front-of-pack warning labels on products with high sugar content. For example, countries such as Chile62 and Israel63 currently have labeling legislation in place, while many others such as Canada and Australia are currently reviewing the benefit of front-of-pack warning labels. This review demonstrates that both FOP labels and POS signage have the potential to encourage consumers to choose healthy food options. CONCLUSION This review provides evidence to suggest that health- and sugar-related labels and signage may be effective at improving health knowledge and changing attitudes and beliefs toward SSBs, and reducing intention to choose or purchase SSBs by adults. However, there is only limited evidence that such interventions are successful at reducing actual SSB purchasing and consumption in real-world environments. The evidence described herein suggests that warning labels that refer to diet-related diseases are consistently effective at reducing intended choice and purchase of SSBs and influencing health knowledge and attitudes and beliefs regarding SSBs. Acknowledgments Author contributions. A.G., N.B., and N.A.G. contributed equally to the development of this systematic review manuscript. All other authors provided feedback and suggestions on multiple drafts of the manuscript. Funding. The current study was part of a study funded by NSW Health and did not influence the conception, design, performance, and approval of this work in any way. N.B. is funded by a Research Training Program scholarship through Monash University. K.B. is supported by a Heart Foundation Future Leader Fellowship (102047). M.R.B. and A.P. have received grants from NSW Health during the conduct of the study. T.B.-R. is supported a National Health and Medical Research Council Centre for Research Excellence grant (APP1152968), a grant from The Australian Prevention Partnership Centre and the University of Sydney. Declaration of interest. All the authors (A.G., N.B., N.A.G., M.R.B., O.H., T.B.-R., K.B., A.P.) have no competing interests nothing to declare. Supporting Information The following Supporting Information is available through the online version of this article at the publisher’s website. 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Author notes Adyya Gupta, Natassja Billich and Neetu Abey George contributed equally to this work © The Author(s) 2020. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - The effect of front-of-package labels or point-of-sale signage on consumer knowledge, attitudes and behavior regarding sugar-sweetened beverages: a systematic review
JF - Nutrition Reviews
DO - 10.1093/nutrit/nuaa107
DA - 2020-10-29
UR - https://www.deepdyve.com/lp/oxford-university-press/the-effect-of-front-of-package-labels-or-point-of-sale-signage-on-GU5Y4EM1rf
SP - 1
EP - 1
VL - Advance Article
IS - 
DP - DeepDyve
ER -