Sugary drink warnings: A meta-analysis of experimental studies

Autoři: Anna H. Grummon aff001;  Marissa G. Hall aff003
Působiště autorů: Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts, United States of America aff001;  Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America aff002;  Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, United States of America aff003;  Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America aff004;  Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America aff005
Vyšlo v časopise: Sugary drink warnings: A meta-analysis of experimental studies. PLoS Med 17(5): e32767. doi:10.1371/journal.pmed.1003120
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003120



Policymakers worldwide are considering requiring warnings for sugary drinks. A growing number of experimental studies have examined sugary drink warnings’ impacts, but no research to our knowledge has synthesized this literature. To inform ongoing policy debates, this study aimed to identify the effects of sugary drink warnings compared with control conditions.

Methods and findings

We systematically searched 7 databases on June 21, 2019, and October 25, 2019. We also searched reference lists of relevant articles. Two investigators independently screened titles, abstracts, and full texts to identify peer-reviewed articles that used an experimental protocol to examine the effects of sugary drink warnings compared to a control condition. Two investigators independently extracted study characteristics and effect sizes from all relevant full-text articles. We meta-analyzed any outcome assessed in at least 2 studies, combining effect sizes using random effects meta-analytic procedures. Twenty-three experiments with data on 16,241 individuals (mean proportion female, 58%) were included in the meta-analysis. Most studies took place in Latin America (35%) or the US or Canada (46%); 32% included children. Relative to control conditions, sugary drink warnings caused stronger negative emotional reactions (d = 0.69; 95% CI: 0.25, 1.13; p = 0.002) and elicited more thinking about the health effects of sugary drinks (d = 0.65; 95% CI: 0.29, 1.01; p < 0.001). Sugary drink warnings also led to lower healthfulness perceptions (d = −0.22; 95% CI: −0.27, −0.17; p < 0.001) and stronger disease likelihood perceptions (d = 0.15; 95% CI: 0.06, 0.24; p = 0.001). Moreover, sugary drink warnings reduced both hypothetical (d = −0.32; 95% CI: −0.44, −0.21; p < 0.001) and actual consumption and purchasing behavior (d = −0.17; 95% CI: −0.30, −0.04; p = 0.012). Statistically significant effects were not observed for perceptions of added sugar or positive sugary drink attitudes (p’s > 0.10). Moderation analyses revealed that health warnings (e.g., “Beverages with added sugar contribute to obesity”) led to greater reductions in hypothetical sugary drink purchases than did nutrient warnings (e.g., “High in sugar”; d = −0.35 versus −0.18; Qb = 4.04; p = 0.04). Limitations of this study include that we did not review grey literature and that we were unable to conduct moderation analyses for several prespecified moderators due to an insufficient number of studies.


This international body of experimental literature supports sugary drink warnings as a population-level strategy for changing behavior, as well as emotions, perceptions, and intentions.

Protocol Registry


Klíčová slova:

Behavior – Beverages – Communication in health care – Database searching – Decision making – Emotions – Health care policy – Metaanalysis


1. Singh GM, Micha R, Khatibzadeh S, Lim S, Ezzati M, Mozaffarian D, et al. Estimated global, regional, and national disease burdens related to sugar-sweetened beverage consumption in 2010. Circulation. 2015;132:639–66. doi: 10.1161/CIRCULATIONAHA.114.010636 26124185

2. Singh GM, Micha R, Khatibzadeh S, Shi P, Lim S, Andrews KG, et al. Global, regional, and national consumption of sugar-sweetened beverages, fruit juices, and milk: a systematic assessment of beverage intake in 187 countries. PLoS ONE. 2015;10:e0124845. doi: 10.1371/journal.pone.0124845 26244332

3. Popkin BM, Hawkes C. Sweetening of the global diet, particularly beverages: patterns, trends, and policy responses. Lancet Diabetes Endocrinol. 2016;4:174–86. doi: 10.1016/S2213-8587(15)00419-2 26654575

4. Brownell KD, Frieden TR. Ounces of prevention: the public policy case for taxes on sugared beverages. N Engl J Med. 2009;360:1805–8. doi: 10.1056/NEJMp0902392 19357400

5. Malik V, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98:1084–102. doi: 10.3945/ajcn.113.058362 23966427

6. Malik VS, Popkin BM, Bray GA, Després J-P, Hu FB. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation. 2010;121:1356–64. doi: 10.1161/CIRCULATIONAHA.109.876185 20308626

7. Imamura F, O’Connor L, Ye Z, Mursu J, Hayashino Y, Bhupathiraju SN, et al. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ. 2015;351:h3576. doi: 10.1136/bmj.h3576 26199070

8. Hu F. Resolved: there is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases. Obes Rev. 2013;14:606–19. doi: 10.1111/obr.12040 23763695

9. Bernabé E, Vehkalahti MM, Sheiham A, Aromaa A, Suominen AL. Sugar-sweetened beverages and dental caries in adults: a 4-year prospective study. J Dent. 2014;42:952–8. doi: 10.1016/j.jdent.2014.04.011 24813370

10. Vargas-Garcia E, Evans C, Prestwich A, Sykes-Muskett B, Hooson J, Cade J. Interventions to reduce consumption of sugar-sweetened beverages or increase water intake: evidence from a systematic review and meta-analysis. Obes Rev. 2017;18:1350–63. doi: 10.1111/obr.12580 28721697

11. Roberto CA, Swinburn B, Hawkes C, Huang TT-K, Costa SA, Ashe M, et al. Patchy progress on obesity prevention: emerging examples, entrenched barriers, and new thinking. Lancet. 2015;385:2400–9. doi: 10.1016/S0140-6736(14)61744-X 25703111

12. Hawkes C, Smith TG, Jewell J, Wardle J, Hammond RA, Friel S, et al. Smart food policies for obesity prevention. Lancet. 2015;385:2410–21. doi: 10.1016/S0140-6736(14)61745-1 25703109

13. Frieden TR. A framework for public health action: the Health Impact Pyramid. Am J Public Health. 2010;100:590–5. doi: 10.2105/AJPH.2009.185652 20167880

14. Corvalán C, Reyes M, Garmendia ML, Uauy R. Structural responses to the obesity and non-communicable diseases epidemic: the Chilean Law of Food Labeling and Advertising. Obes Rev. 2013;14:79–87. doi: 10.1111/obr.12099 24102671

15. Global Food Research Program. Front-of-package (FOP) labeling: empowering consumers to make healthy choices. Chapel Hill (NC): Global Food Research Program; 2018 [cited 2020 April 30].

16. Requires sugar-sweetened beverages to be labeled with a safety warning, S00473, New York State Assembly. 2020 Jan 8 [cited 2020 Apr 29].

17. Sugar-sweetened beverages: safety warnings, SB-347, California Legislature. 2019 Feb 19 [cited 2020 Apr 29].

18. Relating to health, HB 1209, Legislature of the State of Hawaii. 2017 [cited 2020 Apr 29].

19. An act related to health and safety warnings on sugar-sweetened beverages, H.89, Vermont General Assembly. 2015 [cited 2020 Apr 29].

20. Concerning mitigation of the adverse impacts of sugar-sweetened beverages, HB 2798, Washington State Legislature. 2016 Jan 20 [cited 2020 Apr 29].

21. Pomeranz JL, Mozaffarian D, Micha R. Can the government require health warnings on sugar-sweetened beverage advertisements? JAMA. 2018;319:227–8. doi: 10.1001/jama.2017.19209 29340685

22. VanEpps EM, Roberto CA. The influence of sugar-sweetened beverage warnings: a randomized trial of adolescents’ choices and beliefs. Am J Prev Med. 2016;51:664–72. doi: 10.1016/j.amepre.2016.07.010 27617366

23. Roberto CA, Wong D, Musicus A, Hammond D. The influence of sugar-sweetened beverage health warning labels on parents’ choices. Pediatrics. 2016;137:e20153185. doi: 10.1542/peds.2015-3185 26768346

24. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement. PLoS Med. 2009;6:e1000097. doi: 10.1371/journal.pmed.1000097 19621072

25. Noar S, Hall M, Francis D, Ribisl K, Pepper J, Brewer N. Pictorial cigarette pack warnings: a meta-analysis of experimental studies. Tob Control. 2015;25:341–54. doi: 10.1136/tobaccocontrol-2014-051978 25948713

26. Acton R, Jones A, Kirkpatrick S, Roberto C, Hammond D. Taxes and front-of-package labels improve the healthiness of beverage and snack purchases: a randomized experimental marketplace. Int J Behav Nutr Phys Act. 2019;16:46. doi: 10.1186/s12966-019-0799-0 31113448

27. Mantzari E, Vasiljevic M, Turney I, Pilling M, Marteau T. Impact of warning labels on sugar-sweetened beverages on parental selection: an online experimental study. Prev Med Rep. 2018;12:259–67. doi: 10.1016/j.pmedr.2018.10.016 30406003

28. Grummon AH, Taillie LS, Golden SD, Hall MG, Ranney LM, Brewer NT. Sugar-sweetened beverage health warnings and purchases: a randomized controlled trial. Am J Prev Med. 2019;57:601–10. doi: 10.1016/j.amepre.2019.06.019 31586510

29. Donnelly G, Zatz L, Svirsky D, John L. The effect of graphic warnings on sugary-drink purchasing. Psychol Sci. 2018;29:1321–33. doi: 10.1177/0956797618766361 29912624

30. Brewer NT, Parada H Jr, Hall MG, Boynton MG, Noar SM, Ribisl KM. Understanding why pictorial cigarette pack warnings increase quit attempts. Ann Behav Med. 2019;53:232–43. doi: 10.1093/abm/kay032 29850764

31. Grummon AH, Brewer NT. Health warnings and beverage purchase behavior: mediators of impact. Ann Behav Med. 2020 Mar 17.

32. Noar SM, Francis DB, Bridges C, Sontag JM, Ribisl KM, Brewer NT. The impact of strengthening cigarette pack warnings: systematic review of longitudinal observational studies. Soc Sci Med. 2016;164:118–29. doi: 10.1016/j.socscimed.2016.06.011 27423739

33. Noar SM, Francis DB, Bridges C, Sontag JM, Brewer NT, Ribisl KM. Effects of strengthening cigarette pack warnings on attention and message processing: a systematic review. Journal Mass Commun Q. 2016;94:416–42. doi: 10.1177/1077699016674188 29975497

34. Wilson DB. Practical meta-analysis effect size calculator. Oslo: Campbell Collaboration; 2020 [cited 2020 April 30].

35. Arrua A, Curutchet MR, Rey N, Barreto P, Golovchenko N, Sellanes A, et al. Impact of front-of-pack nutrition information and label design on children’s choice of two snack foods: comparison of warnings and the traffic-light system. Appetite. 2017;116:139–46. doi: 10.1016/j.appet.2017.04.012 28428151

36. Borenstein M, Hedges L, Higgins J, Rothstein H. Introduction to meta-analysis. Chichester (UK): John Wiley & Sons; 2009.

37. Hedges LV, Olkin I. Statistical methods for meta-analysis. Cambridge (MA): Academic Press; 2014.

38. Berkey CS, Hoaglin DC, Mosteller F, Colditz GA. A random-effects regression model for meta-analysis. Stat Med. 1995;14:395–411. doi: 10.1002/sim.4780140406 7746979

39. Paule RC, Mandel J. Consensus values, regressions, and weighting factors. J Res Natl Inst Stand Technol. 1989;94:197–203. doi: 10.6028/jres.094.020 28053410

40. Veroniki AA, Jackson D, Viechtbauer W, Bender R, Bowden J, Knapp G, et al. Methods to estimate the between-study variance and its uncertainty in meta-analysis. Res Synth Methods. 2016;7:55–79. doi: 10.1002/jrsm.1164 26332144

41. Ang FJL, Agrawal S, Finkelstein EA. Pilot randomized controlled trial testing the influence of front-of-pack sugar warning labels on food demand. BMC Public Health. 2019;19:164. doi: 10.1186/s12889-019-6496-8 30732609

42. Sheeran P, Abraham C, Jones K, Villegas ME, Avishai A, Symes YR, et al. Promoting physical activity among cancer survivors: meta-analysis and meta-CART analysis of randomized controlled trials. Health Psychol. 2019;38:467. doi: 10.1037/hea0000712 30973743

43. Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions. Chichester (UK): John Wiley & Sons; 2011.

44. Ares G, Varela F, Machin L, Antúnez L, Giménez A, Curutchet MR, et al. Comparative performance of three interpretative front-of-pack nutrition labelling schemes: insights for policy making. Food Qual Prefer. 2018;68:215–25.

45. Acton R, Hammond D. The impact of price and nutrition labelling on sugary drink purchases: results from an experimental marketplace study. Appetite. 2018;121:129–37. doi: 10.1016/j.appet.2017.11.089 29146460

46. Billich N, Blake MR, Backholer K, Cobcroft M, Li V, Peeters A. The effect of sugar-sweetened beverage front-of-pack labels on drink selection, health knowledge and awareness: an online randomised controlled trial. Appetite. 2018;128:233–41. doi: 10.1016/j.appet.2018.05.149 29879450

47. Bollard T, Maubach N, Walker N, Mhurchu CN. Effects of plain packaging, warning labels, and taxes on young people’s predicted sugar-sweetened beverage preferences: an experimental study. Int J Behav Nutr Phys Act. 2016;13:95. doi: 10.1186/s12966-016-0421-7 27580589

48. David IA, Krutman L, Fernandez-Santaella MC, Andrade JR, Andrade EB, Oliveira L, et al. Appetitive drives for ultra-processed food products and the ability of text warnings to counteract consumption predispositions. Public Health Nutr. 2018;21:543–57. doi: 10.1017/S1368980017003263 29173214

49. Grummon AH, Hall MG, Taillie LS, Brewer NT. How should sugar-sweetened beverage health warnings be designed? A randomized experiment. Prev Med. 2019;121:158–66. doi: 10.1016/j.ypmed.2019.02.010 30772370

50. Hayward L, Vartanian L. Potential unintended consequences of graphic warning labels on sugary drinks: do they promote obesity stigma? Obes Sci Pract. 2019;5:333–41. doi: 10.1002/osp4.353 31452918

51. Lima M, Ares G, Deliza R. How do front of pack nutrition labels affect healthfulness perception of foods targeted at children? Insights from Brazilian children and parents. Food Qual Prefer. 2018;64:111–9.

52. Machín L, Aschemann-Witzel J, Curutchet MR, Giménez A, Ares G. Does front-of-pack nutrition information improve consumer ability to make healthful choices? Performance of warnings and the traffic light system in a simulated shopping experiment. Appetite. 2018;121:55–62. doi: 10.1016/j.appet.2017.10.037 29102533

53. Mantzari E, Pechey R, Codling S, Sexton O, Hollands GJ, Marteau TM. The impact of ‘on-pack’ pictorial health warning labels and calorie information labels on drink choice: a laboratory experiment. Appetite. 2020;145:104484. doi: 10.1016/j.appet.2019.104484 31626833

54. Nobrega L, Ares G, Deliza R. Are nutritional warnings more efficient than claims in shaping consumers’ healthfulness perception? Food Qual Prefer. 2020;79:103749.

55. Popova L, Nonnemaker J, Taylor N, Bradfield B, Kim A. Warning labels on sugar-sweetened beverages: an eye tracking approach. Am J Health Behav. 2019;43:406–19. doi: 10.5993/AJHB.43.2.16 30808479

56. Temple JL, Ziegler AM, Epstein LH. Influence of price and labeling on energy drink purchasing in an experimental convenience store. J Nutr Educ Behav. 2016;48:54–9.e1. doi: 10.1016/j.jneb.2015.08.007 26404774

57. Brewer NT, Hall MG, Noar SM, Parada H, Stein-Seroussi A, Bach LE, et al. Effect of pictorial cigarette pack warnings on changes in smoking behavior: a randomized clinical trial. JAMA Intern Med. 2016;176:905–12. doi: 10.1001/jamainternmed.2016.2621 27273839

58. Moran AJ, Roberto CA. Health warning labels correct parents’ misperceptions about sugary drink options. Am J Prev Med. 2018;55:e19–27. doi: 10.1016/j.amepre.2018.04.018 29903567

59. Grummon AH, Smith NR, Golden SD, Frerichs L, Taillie LS, Brewer NT. Health warnings on sugar-sweetened beverages: simulation of impacts on diet and obesity among U.S. adults. Am J Prev Med. 2019;57:765–74. doi: 10.1016/j.amepre.2019.06.022 31630966

60. Levy DT, Mays D, Yuan Z, Hammond D, Thrasher JF. Public health benefits from pictorial health warnings on US cigarette packs: a SimSmoke simulation. Tob Control. 2017;26:649–55. doi: 10.1136/tobaccocontrol-2016-053087 27807299

61. Macaskill P, Walter SD, Irwig L. A comparison of methods to detect publication bias in meta-analysis. Stat Med. 2001;20:641–54. doi: 10.1002/sim.698 11223905

62. Lau J, Ioannidis JPA, Terrin N, Schmid CH, Olkin I. The case of the misleading funnel plot. BMJ. 2006;333:597–600. doi: 10.1136/bmj.333.7568.597 16974018

63. Hammond D. Health warning messages on tobacco products: a review. Tob Control. 2011;20:327–37. doi: 10.1136/tc.2010.037630 21606180

64. Zhen C, Wohlgenant MK, Karns S, Kaufman P. Habit formation and demand for sugar-sweetened beverages. Am J Agric Econ. 2011;93:175–93.

65. Taillie LS, Reyes M, Colchero MA, Popkin B, Corvalán C. An evaluation of Chile’s Law of Food Labeling and Advertising on sugar-sweetened beverage purchases from 2015 to 2017: a before-and-after study. PLoS Med. 2020;17:e1003015. doi: 10.1371/journal.pmed.1003015 32045424

66. Ohme R, Reykowska D, Wiener D, Choromanska A. Analysis of neurophysiological reactions to advertising stimuli by means of EEG and galvanic skin response measures. J Neurosci Psychol Econ. 2009;2:21–31.

67. Droulers O, Gallopel-Morvan K, Lacoste-Badie S, Lajante M. The influence of threatening visual warnings on tobacco packaging: measuring the impact of threat level, image size, and type of pack through psychophysiological and self-report methods. PLoS ONE. 2017;12:e0184415. doi: 10.1371/journal.pone.0184415 28910317

68. Hall MG, Mendel JR, Noar SM, Brewer NT. Why smokers avoid cigarette pack risk messages: two randomized clinical trials in the United States. Soc Sci Med. 2018;213:165–72. doi: 10.1016/j.socscimed.2018.07.049 30096636

69. Hall MG, Peebles K, Bach LE, Noar SM, Ribisl KM, Brewer NT. Social interactions sparked by pictorial warnings on cigarette packs. Int J Environ Res Public Health. 2015;12:13195–208. doi: 10.3390/ijerph121013195 26506363

70. Morgan JC, Southwell BG, Noar SM, Ribisl KM, Golden SD, Brewer NT. Frequency and content of conversations about pictorial warnings on cigarette packs. Nicotine Tob Res. 2018;20:882–7. doi: 10.1093/ntr/ntx180 29059415

71. Khandpur N, Swinburn B, Monteiro CA. Nutrient-based warning labels may help in the pursuit of healthy diets. Obesity. 2018;26:1670–1. doi: 10.1002/oby.22318 30358147

72. Vyth EL, Steenhuis IH, Roodenburg AJ, Brug J, Seidell JC. Front-of-pack nutrition label stimulates healthier product development: a quantitative analysis. Int J Behav Nutr Phys Act. 2010;7:65. doi: 10.1186/1479-5868-7-65 20825645

73. Mhurchu CN, Eyles H, Choi YH. Effects of a voluntary front-of-pack nutrition labelling system on packaged food reformulation: the Health Star Rating System in New Zealand. Nutrients. 2017;9:918.

74. Assunta M, Chapman S. “The world’s most hostile environment”: how the tobacco industry circumvented Singapore’s advertising ban. Tob Control. 2004;13:ii51.

75. Gibson L, Brennan E, Momjian A, Shapiro-Luft D, Seitz H, Cappella JN. Assessing the consequences of implementing graphic warning labels on cigarette packs for tobacco-related health disparities. Nicotine Tob Res. 2015;17:898–907. doi: 10.1093/ntr/ntv082 26180214

76. Wang Y, Coxson P, Shen Y-M, Goldman L, Bibbins-Domingo K. A penny-per-ounce tax on sugar-sweetened beverages would cut health and cost burdens of diabetes. Health Aff (Millwood). 2012;31:199–207.

77. Basu S, Vellakkal S, Agrawal S, Stuckler D, Popkin B, Ebrahim S. Averting obesity and type 2 diabetes in India through sugar-sweetened beverage taxation: an economic-epidemiologic modeling study. PLoS Med. 2014;11:e1001582. doi: 10.1371/journal.pmed.1001582 24409102

78. Basu S, Seligman HK, Gardner C, Bhattacharya J. Ending SNAP subsidies for sugar-sweetened beverages could reduce obesity and type 2 diabetes. Health Aff (Millwood). 2014;33:1032–9.

79. Grummon AH, Lockwood BB, Taubinsky D, Allcott H. Designing better sugary drink taxes. Science. 2019;365:989. doi: 10.1126/science.aav5199 31488678

80. Sánchez-Romero LM, Penko J, Coxson PG, Fernández A, Mason A, Moran AE, et al. Projected impact of Mexico’s sugar-sweetened beverage tax policy on diabetes and cardiovascular disease: a modeling study. PLoS Med. 2016;13:e1002158. doi: 10.1371/journal.pmed.1002158 27802278

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