Food marketing to children in Canada: a settings-based scoping review on exposure, power and impact

Abstract

Introduction:

Food marketing impacts children’s food knowledge, behaviours and health. Current regulations in Canada focus on restricting promotional aspects of food marketing with little-to-no consideration of the places where children experience food. Understanding food marketing in children’s everyday settings is necessary to protect children. This scoping review describes the current literature on food marketing to children in Canada by setting.

Methods:

The author searched databases for Canadian research on children’s exposure to food marketing, and the power and impact of food marketing to children (2-17 years) across settings, and on how current regulations may mediate the effect of food marketing on children. Peer-reviewed studies in English, published between 2000 and 2016, were included.

Results:

Twenty-five studies documented children’s exposure to food marketing and its power and/or impact on them in homes (via television, or online) (n = 12), public schools (n = 1), grocery stores (n = 8), fast food restaurants (n = 2), and in general (n = 2). Research trends suggest that unhealthy foods are targeted at children using multiple promotional techniques that overlap across settings. Several research gaps exist in this area, leading to an incomplete, and potentially underestimated, picture of food marketing to children in Canada. Available evidence suggests that current Canadian approaches have not reduced children’s exposure to or the power of food marketing in these settings, with the exception of some positive influences from Quebec’s statutory regulations.

Conclusion:

The settings where children eat, buy or learn about food expose them to powerful, often unhealthy food marketing. The current evidence suggests that “place” may be an important marketing component to be included in public policy in order to broadly protect children from unhealthy food marketing. Organizations and communities can engage in settings-based health promotion interventions by developing their own marketing policies that address the promotion and place of unhealthy food and beverages.

Highlights

• Children’s everyday settings are important places to restrict unhealthy food marketing.

• Research in Canada shows that children (2-17 years) are exposed to food marketing in homes, schools and supermarkets; however, overall exposure is likely underestimated.

• Powerful marketing techniques are often used in promoting less healthy foods to children.

• Multiple exposures to the marketing of unhealthy foods in various settings may adversely shape children’s food culture.

• Current evidence suggests that actions by governments and communities that address all components of marketing (product, place, promotion and price) will more effectively protect children from powerful, unhealthy food marketing in their everyday settings, however more research is needed.

Introduction

Children’s development takes place in their everyday settings.¹ The places where children live, learn and play are critical factors in determining their current and future health.² In fact, the Ottawa Charter for Health Promotion emphasizes the importance of everyday settings in preventing disease.³ To this end, the World Health Organization recommends that the places where children gather be free from unhealthy food and beverage marketing.⁴ “Place” is also a critical factor for marketers, as it is one of the four components of marketing known as the “four Ps” (4Ps): product, promotion, place and price. Corporations strategically mix the 4Ps to reach their target audience effectively and influence attitudes and behaviours.⁵

Food marketing impacts children’s food knowledge, preferences, behaviours and health.⁶ Factors that promote a poor diet are of concern since, according to Statistics Canada, one-quarter of the calories eaten by Canadians aged 4 to 18 years are from “other foods” (e.g. foods to be limited according to Canada’s Food Guide), including soft drinks, fruit drinks, chocolate and chips.⁷ More than half of children in Canada consume fewer than five servings of vegetables and fruit per day.⁸ The impact of food marketing on children’s food preferences and behaviours depends on their exposure to and the power of the marketing messages, where exposure is defined as “the reach and frequency of the marketing message,” and power is “the creative content, design and execution of the marketing message.”⁹,p.11

There are three main mechanisms by which food marketing to children is currently “controlled” in Canada (Table 1): (1) Quebec statutory regulation [Quebec’s Consumer Protection Act (QCPA)¹⁰]; (2) food industry voluntary self-regulation [Canadian Children’s Food and Beverage Advertising Initiative (CAI)¹¹]; and (3) broadcast industry self-regulation (The Broadcast Code for Advertising to Children¹²). Additionally, in 2016, the Canadian Health Minister announced forthcoming federal statutory regulations on food marketing.¹³ School food policies may also regulate food marketing to children; however, current provincial and territorial policies tend to focus on food provision and are limited and inconsistent in their address of food marketing (Table 1).

TABLE 1. Types of regulatory control of food marketing to children in Canada.

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^{19,20,23,24,25,26,27,28,29,30,31,32,33,79}

Current and proposed regulations may control both exposure to and power of food marketing to children by restricting the amount and the use of persuasive promotional techniques (discussed in the Results section of this article). Unfortunately, place, a key component of marketers’ strategies⁵ and of health promotion interventions,¹⁴ is poorly considered in current approaches, with the exception of the CAI restricting some marketing in elementary schools.¹⁵,^* It is reasonable to expect that regulations that ignore this key component of marketing will not generate maximal impact on children’s exposure to or the power of food marketing. Place is often misinterpreted as the location of marketing messages, which is in fact a component of promotion.¹⁶ A more accurate definition of place, from a marketing perspective, is the location where behaviours are performed or related goods and services are acquired.⁵ In the context of food marketing, place may represent where we eat, purchase or learn about food.

Notably, the settings in which children are marketed to are a policy consideration of proposed regulations in Canada;¹⁷ however, no research has explored what these settings are. It is critical to understand food marketing in the context in which children experience it in order to form effective policies. Using a settings-based approach,¹⁸ this review aims to explore the places where children may be exposed to food marketing by reviewing (1) the extent of their exposure to and the power of food marketing by setting; (2) the influence of statutory (QCPA) and voluntary (CAI) regulations on exposure and power;^† and (3) the impact of food marketing on the attitudes, perceptions and behaviours of Canadian children.

Methods

The author systematically searched eight health, psychology and business databases (Table 2) identified by a research librarian for research on the exposure to and power of food marketing to children in Canada, its impact and the influence of regulations in July 2015 and updated the search in September 2016. All references were imported into an online reference manager. The author selected articles based on a priori inclusion criteria (Table 2) through systematic title, abstract and full-text screening (Figure 1). After title and abstract reviewing, three Canadian researchers with expertise in the topic area were consulted to identify missing research and confirm comprehensiveness of search results. The researchers provided 21 new items, but only four^34-37 met the inclusion criteria (Figure 1). This scoping review was limited to peerreviewed, English-language studies using Canadian data. Two French-language articles^38,39 were excluded, as no expert fluent in French was able to review them. The author reviewed all studies and extracted the data.

TABLE 2. Scoping review of food marketing to children in Canada: systematic search criteria and process.

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Figure 1. Flow chart of systematic search strategy.

Results

Twenty-five articles met the inclusion criteria (Figure 1). The literature available examined the exposure to, power of or impact of food marketing to children in Canada in general,^36,40 on television,^34,41-48 online,^49-51 in public schools,⁵² on product packaging in grocery stores^35,37,53-58 and in fast food restaurants^59,60 (Table 3). The majority of articles were based on crosssectional studies (n = 14).^{34,37,42-45,49-56} Two articles reviewed the impact of the QCPA^43,44 and four reviewed that of the CAI^45-47,56 on exposure to and power of food marketing. Table 4 provides a summary of the influence of regulations on exposure and power by setting. Nine studies explored how food marketing impacted food attitudes, preferences and behaviours— three using experimental,^48,59,60 one using cross-sectional⁴⁹ and five using qualitative methods.^{35,36,40,57,58}

TABLE 3. Synthesis of Canadian, English-language literature on exposure to and the power and impact of food marketing to children in Canada, and the influence of the QCPA and the CAI.

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TABLE 4. Summary of influence of current regulation in Canada on exposure to and power of food marketing to children by setting.

Exposure to and power of food marketing to children in Canada

Exposure to food marketing in the home: television

Six articles reviewed exposure to television food marketing.^34,41-45 In these studies, exposure was measured by the proportion of all television advertisements that were for food (overall and unhealthy) and the rate of food advertisements per hour per channel.

One-fifth of advertisements recorded on three popular children’s channels in Canada between 2007 and 2008 were for food (unpublished data by Kelly et al.³⁴). Potvin Kent et al. studied the top 30 hours of television watched by ten to 12 year old children in Ontario and Quebec in 2009, which included general and children’s channels, and found that 24% to 27% of the advertisements children watched were for food.⁴³

The studies reported varying rates of food advertising, from three to seven advertisements per hour per channel^34,41,47 (unpublished data by Kelly et al.³⁴). This variability may be related to differences in study methods, including heterogeneity in the number and type of channels recorded, times and number of days recorded and location and dates of data collection.

Exposure to unhealthy food television advertisements was evaluated by determining the proportion of advertised foods that were high in energy, fat, sugar or salt.^34,42,44 According to Kelly et al., 80% of food advertisements on children’s channels were for “noncore foods” that were high in fat, sodium or energy.³⁴ Using the UK’s Nutrient Profiling system, Adams et al.⁴² found that 66% of all food advertisements on general television in Canada were “less healthy.” Potvin Kent et al.⁴⁴ found that 88% of food advertisements watched by children in Canada were “less healthy” using the same nutrient profiling system.

Influence of regulation on exposure

Potvin Kent et al. researched the impact of statutory regulation in 2009⁴³ and voluntary industry regulation in 2011⁴⁶ in Canada and found that neither were associated with reduced children’s exposure to television food marketing. Specifically, French-speaking children in Quebec and English-speaking children in Quebec and Ontario were found to be exposed to the same rate of food advertisements per hour per channel.⁴³ Potvin Kent and Wanless⁴⁷ estimated that children’s overall exposure to television food advertising increased by 6% in Vancouver and 17% in Toronto between 2006 and 2011, since the introduction of the CAI. Although food advertisements on children’s television from CAI companies decreased by 24% between 2006 and 2011, the same kind of advertisements by non-CAI companies increased by 76%.⁴⁶

Small improvements in the nutritional quality of the advertised foods were associated with the QCPA⁴³ but not the CAI.⁴⁶ Significantly fewer advertisements watched by children were found on French-language television in Quebec for “less healthy” foods than on English-language television in Ontario;⁴⁴ however, 81% of the former were still “less healthy.” On the other hand, there was no significant change in the proportion of “less healthy” foods advertised by CAI companies between 2006 and 2011.⁴⁶

Power of food marketing in the home: television

The power of food marketing is evaluated by the prevalence of child targeting in food advertisements and the use of powerful promotional techniques. On general television (from 7:00 p.m.–11:00 p.m.), 7% of food advertisements were of particular appeal to children (aged 2–17 years) in 2006.⁴² On television watched by French-speaking children (10-12 years) in Quebec in 2009, only 30% of food advertisements were targeted at children, compared to 76% and 65% of advertisements watched by English-speaking children (10-12 years) in Quebec and Ontario, respectively.⁴³ In 2011, approximately onequarter of food advertisements by CAI and non-CAI companies on children’s specialty channels targeted children and teens.⁴⁶

A variety of marketing techniques were used in television food advertisements, including premiums (such as giveaways, vouchers), promotional characters, fun and health appeals.^34,46 Foods advertised with these powerful techniques were often unhealthy.^34,46 For example, Kelly et al.³⁴ found that almost 100% of televised food advertisements that used promotional characters on children’s channels in 2007 and 2008 in Canada were for “non-core” foods, compared to only 80% overall.

Influence of regulation on power

Small improvements in the power of food advertisements were found to be associated with the QCPA⁴³ but not the CAI.⁴⁶ In 2009, the QCPA was associated with fewer food advertisements targeted at Frenchspeaking children in Quebec, but did not prove to fully protect all children in Quebec since English-speaking children view television originating outside Quebec, which is not restricted by Quebec’s law.⁴³ Overall, there was no change in the prevalence of targeting children in food advertisements by CAI or non-CAI companies between 2006 and 2011.⁴⁶ In fact, there is some evidence that it has worsened, since more unhealthy food advertisements targeted children in 2011 than 2006.⁴⁶ For example, between 2006 and 2011 the use of fun and licensed characters to advertise “less healthy” products increased by 38% and 234% by CAI companies, respectively.⁴⁶

Exposure to food marketing in the home: online

Online food marketing in Canada was captured by two studies evaluating marketing to children on food company websites. ^50,51 This evidence does not assess the multitude of emerging electronic marketing techniques used to target children, including viral marketing (online word-ofmouth by consumers), social networking and direct marketing by e-mail.⁴ The author found no studies that assessed these techniques in Canada. Studies from other countries may be informative, since Canadians can access international websites; however, that was beyond the scope of this review. The two included studies focussed on documenting the powerful characteristics of food company websites and were not designed to measure exposure— for example, the proportion of websites visited by children with food marketing. Thus, the available evidence does not reveal children’s exposure to food marketing online, or the impact of regulation on the degree of exposure.

Power of food marketing in the home: online

In 2010, Potvin Kent et al.⁵¹ reviewed websites tied to food or beverages advertised on television watched by ten to 12 year old children to evaluate the impact of the QCPA and the CAI. Of 148 websites, approximately one-third were child-directed, which was defined as having “child-oriented marketing features such as spokescharacters, cartoons, contests, activities, or games directed at children; and [using] simple vocabulary easily understood by children.”⁵¹,p.801 In a separate evaluation of only CAI company websites, 83% contained marketing directed at children under 12 years of age.⁵⁰

Multiple techniques urged children to engage with the food marketing on CAI websites:⁵⁰

• memberships, incentives and leaderboards for repeated and prolonged use of online media;

• “advergames,” music, animation and e-buttons to interact with the product or brand;

• electronic word-of-mouth techniques to share brand or website information; and

• downloadable features (computer wallpaper, growth charts, shopping lists, board games) to embed brands into children’s daily lives.

Influence of regulation on power

No statistical differences in the power of food marketing (e.g., whether or not they targeted children, the type or frequency of promotional techniques used) were found between French- and English-language websites, nor between CAI and non-CAI websites in 2010.⁵¹

Exposure to food marketing in schools

With only one study on marketing in schools conducted in the last decade,⁵² evidence is lacking in this setting. Velazquez et al.⁵² examined the extent of commercial and non-commercial (made by the school or students) food promotions in a representative sample of 23 Vancouver public schools in the 2012/13 school year. Through observation, Velazquez et al.⁵² found that 87% of schools displayed food promotions. Schools had a median of 17 promotions (range = 0–57). Secondary schools had more advertising than elementary schools.⁵²

Velazquez et al.⁵² used British Columbia’s school nutrition guidelines²¹ to assess the healthfulness of observed food and beverage promotions. Over half of schools promoted foods or beverages prohibited by the provincial guidelines.⁵² Almost onequarter of all promotions were for “Choose Least Often” or “Not Recommended” items.⁵² On the other hand, 80% of the schools had promotions for “Choose Most Often” items, which made up 45% of all promotions.

Influence of regulation on exposure

No studies have evaluated the impact of the QCPA or the CAI on exposure to food marketing in schools. The lower levels of food marketing in elementary schools documented by Velazquez et al.,⁵² a setting partially covered by the CAI, may reflect the influence of the CAI; however, this finding more likely reflects the fact that secondary schools have more food services (vending machines and concessions) than elementary schools⁵² and thus more food promotion.

Power of food marketing in schools

Velazquez et al.⁵² found that observable food promotions in schools often involved specific products or brands, and rarely used animated characters, celebrities or premium offers. The rare use of these powerful techniques may be related to the finding that half of promotions recorded were noncommercial promotions created by the students or the school.⁵²

Influence of regulation on power

Not documented.

Exposure to food marketing in supermarkets

Two studies documented the proportion of products that targeted children through product packaging. From 15 randomly audited grocery stores in Ontario, Berry and McMullen found 2755 cereal boxes at child height (defined as 48 inches from the ground, which takes into account the eye level of a child sitting in a shopping cart as well as standing or walking).⁵³ Up to half of breakfast cereal shelf space at child height contained cereal boxes with at least one child-directed feature (described in the “Power of food marketing in supermarkets” section of this article). From the University of Toronto’s Food Label Information Program database, which contains over 10 000 packaged food products collected between 2010 and 2011, Murray found that 415 (4%) targeted children, defined as depicting fun or play, or using cartoons or child-like fonts.⁵⁶ One other study⁵⁵ identified products that were targeted to children only, without collecting a total product denominator. In two supermarkets in Alberta, Elliott found over 350 everyday foods (not junk foods) that targeted children, defined as being designed for children, or displaying cartoons, crossmerchandising, unusual shapes, colours, tastes, or games on its packaging.⁵⁵ The estimates of exposure in these three studies are not complete; true exposure may be underestimated, since none of the studies explored food marketing in checkout areas, store display, or other features of grocery stores.

Overall, most foods marketed to children in supermarkets were high in sugar, fat or sodium⁵⁴ and/or low in desirable nutrients. ⁵⁶ Almost one-quarter of foods marketed to children were labelled “better for you” according to the CAI definition; however, two-thirds of the “better for you” foods were still high in sugar, fat or sodium.³⁷ A significantly greater proportion of some food categories (snacks, beverages, cereals, crackers, pudding and combination dishes not measurable by a cup, such as pizza) were considered “less healthy” according to the UK’s Nutrient Profiling system when they were marketed to children compared to when they were not marketed to children.⁵⁶ Elliott⁵⁵ and Murray⁵⁶ both found that 1% or less of foods marketed to children were vegetables or fruits.

Influence of regulation on exposure

Neither the QCPA nor the CAI explicitly applies to product packaging. No research exists on the impact of the QCPA on product packaging. The impact of the CAI on the overall exposure to product packaging targeted at children is not documented; however, Murray found that the CAI did not impact the nutritional quality of foods marketed to children through product packaging.⁵⁶

Power of food marketing in supermarkets

The majority of grocery store products Elliott reviewed had “fun” features on product packaging, including cartoons and cartoonish fonts.⁵⁴ Murray found that unusual flavours, shapes and colours, characters and graphics or lettering were the most commonly used marketing techniques on products targeting children.⁵⁶ In an analysis of breakfast cereals boxes, 48% had child-oriented colours, 35% had incentives or premium offers and 34% had spokes-characters.⁵³

Similar to research on television food advertisements, powerful marketing techniques on product packaging were associated with poor quality foods.^53,54 In particular, breakfast cereals were more likely to be higher in sugar if their packaging targeted children.⁵³ As well, over twothirds of non-junk, high-sugar products had a nutrition claim, compared to only half of “healthier” products.⁵⁴ Berry and McMullen suggested that the marketing landscape in the cereal aisle in Canada is “health-exploitive,”⁵³,p.334 meaning that it uses child-directed marketing techniques on less healthy products, encouraging their consumption.

Influence of regulation on power

Not documented.

Impact of food marketing on children in Canada

The evidence of a causal impact of food marketing on children’s food attitudes, preferences and behaviours is compelling and has been discussed elsewhere.^6,61,62 Although limited, Canadian studies provide local insight into how children in Canada are impacted by food marketing. Experimental and qualitative studies in Canada have shown that television product placement,⁴⁸ online advertising,⁴⁹product packaging,^35,57,58,60 and toy premiums⁵⁹ can impact Canadian children’s attitudes, preferences, and behaviours.

Hudson and Elliott⁴⁸ found that although only 17% of children (7-12 years) were aware of product placement, children who viewed a television program with unhealthy product placements (vs. no product placement or healthy product placement) were most likely to recall the advertised products. Almost one-quarter of children aged 7 to 13 years said they purchased or requested a food advertised online (most commonly soft drinks, chocolate and candy).⁴⁹

Researchers used focus groups of children aged 5 to 12 years to assess children’s preferences, perceptions and interpretations of packaged foods.^35,57,58 Preferences were commonly influenced by packaging that used themes of fun and was esthetically pleasing or interactive.⁵⁷ When asked to identify healthy products, children created their own, often inaccurate, rationales based on colours,⁵⁷ nutrition or organic claims,^35,57 ingredient lists^35,57 and sometimes nutrition facts tables.^35,57 Results from focus groups with 225 children across Canada revealed that marketing features (colours, words, pictures, spokescharacters and front-of-pack claims) were more regularly used than nutrition facts and ingredient lists in evaluating the healthfulness of packaged foods.⁵⁸

Elliot et al.⁶⁰ investigated whether 6 to 11 year old children’s taste preferences differed based on food packaging design. When compared to food in plain packaging, children preferred the food in McDonald’s packaging; however, this preference was not maintained when food in McDonald’s packaging was compared to colourful or Starbucks packaging. Exploring a method of healthy food promotion, Hobin et al.⁵⁹ assessed the impact of toy premiums on meal choice. Children (aged 6–12 years) who were offered toy premiums with healthy options only (vs. healthy and unhealthy options) were over three times as likely to select the healthy meal.⁵⁹

Finally, evidence from qualitative studies that were not setting-specific show that Canadian children have homogeneous attitudes towards food,^36,40 suggesting that cumulative exposures to food marketing may have a greater impact on children’s food culture than a single exposure in a study. Focus groups conducted in Alberta, Ontario and New Brunswick with children aged 6 to 11 years showed that children distinguished between food for themselves and for others.⁴⁰ They reported that “kids’ food” is junk food, sugary, associated with cartoons, comes in fun shapes or colours and is something you can play with or eat with your hands.⁴⁰,p.133 These symbolic features identified by children mimic the powerful techniques listed in this review and used by the food industry to market to children. Conversely, children saw adult food as plain, unprocessed, healthy, responsible food, and not for them.⁴⁰ As well, adolescents (aged 12-14 years) personify food in a consistent manner across Canada:³⁶ broccoli is “shy, unpopular, and boring,”³⁶,p.87 and milk is “athletic”³⁶,p.87 (except for older boys). They see junk food, on the other hand, as a “party person” who is “funny and fun to hang around with.”³⁶,p.87 Children’s food attitudes may have been socially constructed by commercial food marketing, or the lack thereof, and may partly explain why the children’s diets do not align with Canada’s Food Guide.

Discussion

This scoping review found evidence of multiple exposures to food marketing to children in different settings—at home, at school and in supermarkets. With the exception of television and product packaging, the evidence base is limited. Fast food restaurants represent another setting where food marketing would be expected, but only the impact of promotional techniques used in fast food restaurants^59,60 has been studied in Canada. International research has documented food marketing in other settings (restaurants,⁶³ sports centres⁶⁴ and outside⁶⁵) and thus, this review likely underestimates Canadian children’s exposure. Foods high in energy, fat, sugar and salt were commonly marketed in all settings, which is consistent with findings from other research.⁶ Children were often targeted with powerful promotional techniques that were multiple and varied, and overlapped across settings; food marketers have an arsenal of marketing tools.

With the exception of limited positive influences of the statutory regulation in Quebec on television food advertising, current evidence suggests that statutory and self-regulations in Canada have not improved either children’s exposure to or the power of food marketing; however more research is needed to understand regulations’ impact across settings. Dhar and Baylis estimated that the QCPA has positively impacted population health by reducing weekly household fast food consumption in French-speaking, but not English-speaking, households with children in Quebec since English-speaking households may view non-Quebec food marketing not covered under the QCPA.⁶⁶ Although the influence of regulation in schools has not been measured, a 2004 survey of all Canadian public schools found that prevalence of commercial (food and non-food) advertising was lower in Quebec than the rest of Canada.⁶⁷ Quebec’s statutory regulation, a rights-based approach to child health,⁴ may better influence the settings and context in which children live, compared to industry self-regulation.

The evidence synthesis presented here shows that food attitudes, preferences and behaviours of Canadian children are impacted by exposures to food marketing in a single setting. More important, however, may be the uniformity of food attitudes among Canadian children, which is suggestive of a nonspecific, collective impact of food marketing exposure over time and across place. As children become increasingly immersed in marketing throughout their lives, and as promotional techniques and channels integrate and overlap more often,⁶⁸ it is reasonable to ask whether exposures to unhealthy food marketing have a greater cumulative impact⁶¹ than when viewed separately by promotion type.

The body of evidence presented in this scoping review must be considered within the daily life of an average Canadian child, who watches two to three hours of television, ⁶⁹ uses the computer or plays video games for one to two hours,⁶⁹ sits in school for five to six hours⁷⁰ and whose family shops for groceries almost every second day.⁷¹ In that light, it becomes more obvious that children in Canada (with the exception of some in Quebec) are at risk of exposure to an astounding volume of powerful food marketing. Furthermore, the settings where food marketing occurs that the author has identified in this review are common places for children to eat, buy or learn about food.

The study of Vancouver schools may suggest that children’s exposure to unhealthy food marketing is less frequent and the marketing is less powerful in schools than in other settings, since only one-quarter of foods advertised were unhealthy and powerful promotional techniques were rare.⁵² This finding may be noteworthy, as it may signify that settingsbased policies, such as British Columbia’s mandatory school food policy with food marketing recommendations,^21,22 are more comprehensive and efficient than traditional promotion-focussed regulations. The latter may not reach the extensive food-related commercialization in Canadian public schools previously reported,⁶⁷ including exclusive agreements with Coca-Cola and Pepsi, incentive programs (Campbell’s Labels for Education) and sponsored educational materials (Pizza Hut’s “Book it”, Mr. Christie’s “Smart Cookie”). Unfortunately, the limited research precludes conclusions about the state of marketing in schools, especially since variability in school food policies likely contributes to different food marketing environments in schools across Canada.

Experts have recommended strong, comprehensive statutory regulations with independent monitoring and compliance penalties to effectively reduce children’s exposure to powerful unhealthy food marketing. ^72,73 Nevertheless, those planning interventions must consider how multiple exposures to food marketing interact and socially construct food attitudes and behaviours in children’s everyday settings. The tendency for regulations to focus on the promotional aspects of food marketing⁷⁴ without considering the settings where children eat, buy or learn about food may increase the risk of policies that inadequately intercept marketers’ plans to reach children. Settings as a component in the proposed Canadian food marketing regulations¹⁷ is valuable if the regulations consider settings not as just promotional marketing channels, but as the places where behaviours are performed or related goods and services are acquired⁵ – where children eat, buy and learn about food.

Implications for policy and research

A comprehensive approach to restricting unhealthy food marketing to children that addresses product, promotion, place and price may require action by policy makers, industry and communities.

In the United States, Palaskhappa et al. found that lower childhood obesity prevalence was associated with strong laws regulating the sale of unhealthy foods (OR = 0.68, 95% CI:0.48–0.96) and food advertising in schools (OR = 0.63, 95% CI:0.46–0.86), compared to states with no laws.⁷⁵Furthermore, states with multiple strong school food laws (two or more) compared to states with no laws had reduced risk of obesity in elementary schools and of overweight in middle schools.⁷⁵ The success of this kind of regulation demonstrates that government policy regulating the food industry, if it follows research-based recommendations,⁷³ can be paired with local settings-based initiatives to prohibit unhealthy food marketing in the places where children live, learn and play, such as schools and recreation facilities. The places where we eat, buy and learn about food are critical points of intervention for health promotion, just as they are critical targets for the food industry.

The goal of marketing restrictions should be to improve children’s everyday lives, not just limit the marketing channels used to reach them. Solely focussing on the promotional aspects of food marketing may allow marketers continued access to children by simply switching from one marketing technique to another. The increase in new media marketing techniques and decrease in television marketing observed in the United States after the introduction of industry self-regulation⁶⁸ may be evidence of such a consequence. The sectors that disseminate food marketing (schools, media, retailers, sports organizations, etc.) are key actors in supporting food marketing restrictions.⁹

Using the broadcast industry’s code as an example of sector-based action,¹² organizations and communities can take the lead in place-based interventions by developing their own marketing or sponsorship policies that address the promotion, place and pricing of unhealthy food and beverages. Setting-based health promotion helps to shift the focus from an individualistic risk-factor approach to one that appreciates the complexity of interconnecting environmental and individual factors influencing health.¹⁴ Whole-system approaches, a feature of settings-based interventions, with actions by government, industry and communities may impact culture more widely than traditional reductionist approaches that view issues linearly with single causes and outcomes. ¹⁴ For example, school food polices, which may include multiple aspects of marketing (see Table 1), can be expanded to comprehensively address all 4Ps. In addition to proposed marketing regulations, policy makers may also consider adopting additional supporting interventions that target broader aspects of marketers’ 4Ps, such as product availability through industry reformulation, or food pricing via taxes and subsidies, in a wholesystem intervention to reduce the impact of food marketing. A 4Ps policy strategy may help address unhealthy food marketing in situations where it is not applicable or feasible to introduce a settings-based policy, such as in the business sector.

Further research is needed to fully examine children’s exposure to and the power and impact of food marketing within the settings of children’s everyday lives and consider the influence of all 4Ps. Specifically, more research is needed on how settings, such as schools, recreation centres, daycares, retailers and other spaces, can be targeted when creating policy to protect children from unhealthy food marketing. More research is also needed on children older than 12 years and population subgroups (e.g. by income or ethnicity) to completely understand the state of food marketing to children in Canada and its impact.

Strengths and limitations

The settings-based approach¹⁸ used to conduct this review diverges from the usual siloed media/promotion perspective and provides fresh insight into children’s exposure to food marketing, its power and its impact on their lives. By critiquing the literature through the 4Ps marketing lens, this review bridges the population health and business disciplines and provides a novel perspective on population health interventions and research on food marketing to children.

Restricted to peer-reviewed, Englishlanguage research in Canada, however, the findings in this review may underestimate children’s exposure to and the power of food marketing in Canada. The limited search strategy may have excluded studies that cursorily measured food marketing to children as a part of broader study objectives irrelevant to this review. With only 23 studies (mostly cross-sectional) published over the last decade, the temporal aspects of marketing are not well documented. Due to the mix of study designs, the quality of studies was not evaluated.

Conclusion

Creating environments that support healthy diets for children is a priority in Canada as a strategy to reduce the prevalence of childhood obesity.⁷⁶ However, food marketing in the settings where children eat, buy and learn about food encourages “fun” junk foods inconsistent with healthy diets. The findings from this scoping review suggests that statutory and voluntary regulations are not adequately protecting Canadian children from exposure to powerful unhealthy food marketing. Complementary actions from government, industry and communities, such as strong, enforced and monitored statutory regulations and broadened school food policies, may be needed to address the multifaceted nature of powerful food marketing. With almost seven million children under 18 years⁷⁷ in Canada and 400 000 new births every year,⁷⁸ protecting the places where children live, learn and play from unhealthy food marketing constitutes one of the strategies needed to help reverse the tide of childhood obesity in Canada.

Acknowledgements

Stipend support to Rachel Prowse was provided by the Heart and Stroke Foundation of Canada and the CIHR Training Grant in Population Intervention for Chronic Disease Prevention: A Pan- Canadian Program (PICDP Program) (Grant #53893); the CIHR Doctoral Award – Frederick Banting and Charles Best Canada Graduate Scholarship; and the Women and Children’s Health Research Institute Graduate Studentship, supported by the Stollery Children’s Hospital Foundation. Rachel Prowse would also like to extend appreciation to the PICDP Program for the experiential learning opportunity to collaborate with a third party agency to develop the review objectives. The author would like to thank Dr. Kim Raine for her editorial assistance.

Conflicts of interest

Rachel Prowse has no financial relationships that may pose a conflict of interest.