Ethical Considerations for Food and Beverage Warnings

Abstract

Several countries have implemented warnings on unhealthy foods and beverages, with similar policies under consideration in the U.S. and around the world. Research demonstrating food warnings’ effectiveness is emerging, but limited scholarship has evaluated the ethics of food warning policies. Using a public health ethics framework for evaluating obesity prevention policies, we assessed the ethical strengths and weaknesses of food warnings along multiple dimensions: 1) Health behaviors and physical health, 2) Psychosocial well-being, 3) Social and cultural values, 4) Informed choice, 5) Equality, 6) Attributions of responsibility, 7) Liberty, and 8) Privacy. Our analysis identifies both ethical strengths and weaknesses of food warnings, including that: 1) warnings are likely to generate important benefits including increased consumer understanding and informed choice, healthier purchases, and potential reductions in obesity prevalence; 2) warnings evoke negative emotional reactions, but these reactions are an important mechanism through which food warnings encourage healthier behaviors and promote informed choice; 3) warnings appear unlikely to have ethically unacceptable effects on social and cultural values, attributions of responsibility, liberty, or privacy. Current research suggests we continue to pursue food warnings as a policy option for improving public health while simultaneously conducting additional research on the ethics of these policies. Future research is especially needed to clarify warnings’ effects on stigma and to characterize the balance and distribution of costs of and benefits from implementing food warning policies.

Introduction

Globally, consumption of unhealthy foods (e.g., processed meats, sugar-sweetened beverages) has risen over the last several decades.¹ Poor dietary quality increases risk for premature death and several of the most common chronic diseases, including obesity,^2–4 cardiovascular disease,^5,6 and type 2 diabetes.^6,7 Policy action is needed to reverse these trends and achieve meaningful, population-wide improvements in dietary quality and diet-related disease.^8–11

Policies requiring warnings on unhealthy foods and beverages are emerging as a promising strategy to address poor dietary quality, as research suggests that warnings encourage healthier purchases^12–14 and could spur product reformulation.¹⁵ Food and beverage warnings (hereafter simply “food warnings”) refer to messages on products, menus, or advertisements that either make a direct statement about a product’s health consequences (e.g., “contributes to obesity”) or alert consumers that a product contains an excessive amount of an unhealthy nutrient (e.g., a stop sign logo with the statement “High in sodium”). Food warnings are distinct from numerical nutrition labels such as nutrition facts panels and calorie content labels that provide numerical information only without conveying information about healthfulness. Warnings also exclude traffic light, health star, or Nutri-Score labels because these labels describe positive as well as negative health attributes and typically do not provide statements about excessive amounts of nutrients in products or the health consequences associated with consumption.

Policymakers are increasingly interested in food warning policies. In the U.S., lawmakers in five states have proposed policies to require warnings on sugar-sweetened beverages (SSBs) that describe the health consequences of these products (Figure 1).^16–20 Other countries have already adopted food warnings: in 2016, Chile began requiring front-of-package “high in” warnings on products that exceed recommended levels of sugar, sodium, saturated fat, or calories (Figure 2).²¹ Similar policies have been passed or implemented in Peru, Uruguay, and Israel²² and are under consideration in South Africa,²³ Canada,²⁴ Brazil,²⁵ and elsewhere.

Figure 1.

Mock-up of the sugar-sweetened beverage warning proposed by California in 2019.

Figure 2.

One of the four health warnings implemented in Chile in 2016. The warning text translates to “HIGH IN SODIUM.”

Debates about food warning policies often center on ethical questions such as whether warnings will achieve their public health goals,²⁶ infringe on consumers’ autonomy by appealing to fear,^27,28 exacerbate disparities,²⁹ or increase stigma.³⁰ Answering these and other ethical questions is important to ensure that warning policies properly balance ethics with the goal of improving population health. Anticipating and mitigating potential ethical pitfalls of food warnings can also help preempt opposition to these policies.^31,32 To date, limited scholarship has considered the ethics of food warnings. In this article, we explore potential ethical implications of requiring warnings on foods and beverages.

Framework for Evaluating the Ethical Implications of Food and Beverage Warnings

A variety of frameworks exist for examining ethical dimensions of public health policies.^31,33–35 Recently, Marieke ten Have and colleagues developed a framework for analyzing the ethics of a program or policy aimed at preventing obesity. The framework consists of identifying the policy’s ethical strengths and weaknesses along multiple dimensions (e.g. informed choice, equality), considering ways to minimize weaknesses and maximize strengths, and assessing whether the policy’s ethical weaknesses can be justified.^32,36,37 Our analysis focuses on six components of this framework: 1) health behaviors and physical health, 2) psychosocial well-being, 3) social and cultural values, 4) informed choice, 5) equality, and 6) attributions of responsibility (Table 1). Although the framework also encourages the ethical analyst to examine policies’ effects on liberty and privacy, food warnings have little or no potential impact on liberty or privacy; thus, we do not discuss those in depth here.

Table 1.

Ethical considerations, summary of ethical analysis, current conclusions, and areas for future research for food and beverage warnings.

Ethical consideration Key question	Summary of ethical analysis	Current conclusion	Possible areas for future research
Health behaviors and physical health To what extent do food warnings encourage healthier behaviors and promote physical health?	Warnings promote healthier purchases.12–14 Warnings could prompt industry reformulation, which could improve the healthfulness of the food supply15,44,45 and consumers’ purchases.50 Simulation modeling studies project that implementing warnings could reduce obesity prevalence.40,41	Positive health effects are likely.	What is the trajectory of warnings’ effects on behavior and health over time? To what extent do warnings spur product reformulation? Does reformulation bring additional health benefits? What are warnings’ effects on diabetes, heart disease, and other diet-related diseases? Do warnings have synergistic effects with other nutrition policies such as taxes or marketing restrictions?
Psychosocial well-being To what extent do food warnings promote or diminish positive psychosocial well-being?	Warnings generate short-term negative emotions.12,13,56 However, these emotional responses are productive reactions that help warnings achieve their beneficial effects such as promoting informed choice54,59–62 and changing behavior.52 Warnings may reduce enjoyment by reducing consumption of foods consumers find pleasurable.63 On the other hand, warnings could improve psychosocial well-being if consumers feel happier after making healthier dietary choices.64 Whether warnings’ emotional consequences are ethicallyjustifiable will depend on the magnitude of their long-term costs and benefits as well as their nature, prevalence, intensity, and duration. Graphic warnings depicting images of people with obesity could increase some forms of weight stigma,30 but limited research has examined this question. Food warnings that do not describe obesity may be less likely to increase stigma. Studies have not found that warnings worsen body image30 or contribute to disordered eating,71 but limited research has examined these outcomes.	Negative psychosocial consequences are possible, but may be justifiable.	To what extent to warnings increase stigma? How can warnings be designed to minimize stigma? To what extent do warnings worsen body image? To what extent do warnings affect disordered eating?
Social and cultural values To what extent do food warnings interfere with cultural or social values?	Studies have not examined whether warnings diminish feelings of identity, community, or belonging that consumers may get from eating particular foods. Research has not yet examined whether warnings differentially affect foods that have cultural or social importance to particular groups. Existing food warning policies use objective nutrient profiling systems to determine what products trigger mandatory warnings.73 These systems are unlikely to single out foods from particular cultural or ethnic groups. Warnings do not prevent people from buying or consuming socially or culturally important products.	Interference with social and cultural values is unlikely.	Do current or proposed warning policies require warnings on foods or beverages with cultural or social importance? If so, to what extent do warnings reduce positive feelings of identity, community, or belonging? What groups are most affected?
Informed choice To what extent do food warnings promote consumers’ informed choosing without subjecting them to unacceptable manipulation?	Warnings increase understanding of products’ healthfulness.80–85 Warnings also activate this understanding by making it salient in consumers’ minds at the point of purchase.12,13,56 Warnings evoke emotions, and emotions are part of how warnings change behavior. However, warnings’ emotionality does not make them unacceptably manipulative, because these emotional responses are necessary for warnings to inform,60–62 are appropriate responses that improve reasoning,95,96 and could “level the playing field” against manufacturers’ arguably manipulative narratives about their products.97,98 Warnings may help consumers feel more in control of their eating choices.99	Promotion of informed choice is likely.	How can warnings be designed to maximize their effects on consumers’ understanding of product healthfulness? What types of warnings increase consumers’ feelings of control?
Equality To what extent are the costs and benefits of food warnings fairly distributed?	Warnings have similar effects on consumer understanding,80,81,105 behavioral intentions,80,81 and purchase behaviors12 across diverse groups, suggesting they are unlikely to exacerbate underlying disparities in these outcomes. Warnings could reduce disparities in diet-related diseases,40 but limited research has examined this question.	Increased equality is possible, but more research is needed.	What is the distribution of costs and benefits of warning policies in real-world settings (i.e., in jurisdictions where warnings have been implemented)? How can warnings be designed to maximize their potential to enhance equality?
Attributions of responsibility To what extent do food warnings imply a fair division of who is responsible for dietary behaviors and health?	Because one goal of warnings is to change individual consumer behavior, warnings might suggest to the public that consumers are primarily responsible for their own diet and health.32 Warnings can also be designed to spur reformulation,15,50 which could shift implied responsibility for diet and health toward industry. Limited research has examined these two possibilities.	Acknowledgement of responsibilities of various entities is possible, but more research is needed.	Does proposing or implementing a food warning policy increase the public’s perception that individuals are the primary entity responsible for diet and health? Is this reaction attenuated when policies are explicitly designed to encourage reformulation?
Liberty To what extent do warnings constrain liberty or freedom of choice?	Warnings do not ban consumers from buying or consuming products, so warnings have little or no impact on liberty.	Constraints on liberty are negligible.	Not applicable.
Privacy To what extent do food warnings intrude on privacy?	Warnings do not require the government to gather any personal information from consumers, so warnings have little or no impact on privacy.	Intrusions on privacy are negligible.	Not applicable.

Note. Ethical considerations are drawn from ten Have and colleagues’ ethical framework for evaluating obesity prevention programs and policies.³²

Using the framework, we review available research to identify ethical strengths and concerns of food warnings. Ethical concerns do not necessarily disqualify food warnings from policy consideration. Instead, one must consider whether any ethical downsides of food warnings are reasonable in light of their ethical strengths and their potential to improve population health. Table 1 provides a summary of our analysis, current conclusions, and potential areas for future research.

Health Behaviors and Physical Health

An important first question in evaluating the ethics of food warnings is assessing whether warnings encourage healthier behaviors and/or better physical health. Most research has focused on warnings’ shorter-term impacts on health behaviors like food purchases, rather than their longer-term impacts on health outcomes. Experimental and quasi-experimental evidence indicates that food warnings reduce purchases of the targeted nutrients or products. Two recent studies of U.S. adults found that exposure to sugar-sweetened beverage (SSB) health warnings reduced calories purchased from these beverages by 14% to 22%.^12,13 Another trial of more than 3,500 Canadian adolescents and adults found that participants exposed to “high in” warnings purchased less sugar, saturated fat, and calories from beverages and less sodium and calories from foods.¹⁴ Because food and beverage purchases are predictive of dietary intake,^38,39 these studies suggest that warnings could improve physical health by encouraging healthier diets. Additionally, two recent microsimulation studies projected that SSB warnings’ effects on purchases are large enough to meaningfully reduce obesity prevalence.^40,41

Food warning policies could also spur manufacturers to reformulate products to avoid triggering a mandatory warning.^42,43 While research on food warnings’ effects on reformulation is limited,¹⁵ studies examining other nutrition labeling schemes,^44–46 as well as other nutrition policies like taxes,^47–49 find that implementing these policies can prompt positive changes in products’ overall nutritional profile. Additionally, a recent experiment with 306 Uruguayan adults found that consumers preferred reformulated foods without warnings to non-reformulated foods with warnings,⁵⁰ suggesting that reformulation could encourage healthier purchases.

As food warning policies are enacted, opportunities to explore their effects on physical health in real-world settings will emerge. Several questions will be important to address. First, studies can establish the trajectory of warnings’ effects over time. Warnings that become more or less effective over time may have different effects on long-term health outcomes;⁴⁰ rotating warnings could help ensure sustained effectiveness.⁵¹ Second, research can determine the extent to which food warnings spur product reformulation¹⁵ and whether reformulation enhances warnings’ health benefits. Third, most research on food warnings has focused on obesity; additional research will clarify warnings’ impacts on type 2 diabetes, heart disease, and other diet-related diseases. Additionally, food warnings may be implemented in tandem with other nutrition policies such as taxes or marketing restrictions;²¹ future research can examine whether these policies have synergistic effects on health behaviors and health outcomes. Despite these gaps, a growing body of evidence suggests that food warnings are likely to help consumers make healthier choices and could lead to improvements in population-level health outcomes.

Psychosocial Well-Being

Even if warnings generate unambiguous improvements to health behaviors and physical health, they might simultaneously have negative effects on psychosocial well-being. We focus here on warnings’ potential to generate three kinds of psychosocial effects: negative emotions, stigma, and negative body image and disordered eating behaviors.

Negative emotions.

When consumers view a food warning, they may experience a range of short-term negative emotional responses;^52–56 for example, consumers may feel fear and anxiety in response to the knowledge that a product contributes to health harms. Whether causing these negative emotions is ethically justifiable depends upon their intensity, duration, and prevalence. If the negative emotions caused by warning labels are transient and do not lead to lasting harm, eliciting these emotions may be ethically justifiable, especially given that short-term negative emotions are a ubiquitous part of everyday life.^57,58 An ethical analysis of warnings’ emotional impacts should also recognize the potential beneficial roles of negative emotions. Evidence suggests that experiencing anxiety, fear, or other negative emotions in response to warnings is a productive reaction because these emotions are a key pathway through which warnings encourage healthier behaviors⁵² and promote informed choice^54,59–62 (see also further discussion of emotion and informed choice below).

In addition to their direct effects on emotions, food warnings may also affect emotions indirectly by reducing enjoyable but unhealthy food and beverage consumption.⁶³ Reducing consumption of unhealthy foods could also lead to improvements in psychosocial well-being if consumers feel empowered or happy after making healthier choices.⁶⁴ Warnings’ negative and positive emotional effects should be investigated further, and should be weighed against one another when analyzing warnings’ ethical acceptability.

Stigma.

Scholars have suggested that “information initiatives” like some food warnings could increase stigma toward people with certain health conditions by emphasizing personal responsibility for health outcomes.^65,66 This concern likely applies primarily to food warnings that include health effects statements (e.g., “sugary drinks contribute to obesity”), rather than warnings that signal excess levels of nutrients. To our knowledge, only one study has examined whether food warnings with health effects statements contribute to stigma, focusing specifically on stigma toward people with obesity. In that study, researchers recruited 681 adults and randomized half to view a pictorial SSB warning that described the health consequences of these beverages (“WARNING: Drinking beverages with added sugar(s) contribute to: obesity, diabetes, and tooth decay”) accompanied by images of the bare stomach of a person with obesity, a person injecting their stomach with a needle, and decaying teeth. Exposure to the pictorial warning led to small increases in both bias and disgust toward people with obesity.³⁰ However, the warning did not lead to more negative judgments about people with obesity, nor did it affect participants’ beliefs about the importance protecting the rights of people with obesity. Still, ethicists have raised special concerns about messaging that provokes disgust toward others because of how disgust dehumanize its targets,⁶⁷ and food warnings that do not elicit disgust are likely to be more ethically acceptable.

More research will help to clarify the extent to which food warnings increase stigma (and perhaps particularly disgust) and what types of warnings elicit these responses. For example, text-only warnings or warnings with images of nutrients (e.g., number of teaspoons of sugar in a beverage) might elicit less stigma than warnings showing pictures of people, but this has not been studied. Warnings might also be less likely to generate stigma if they focus on health outcomes other than obesity.⁶⁸ Similarly, “high in” warnings like those required in Chile do not describe health consequences and, therefore, should be less likely to stigmatize.

Body image and disordered eating.

Researchers have raised concerns that obesity prevention interventions, including nutrition labeling, could worsen body image and increase risk of disordered eating.^30,69,70 One experimental study has examined warnings’ effects on body image. In a sample of 561 U.S. adults who considered themselves overweight or obese, researchers found that exposure to an SSB warning accompanied by an image of a person with obesity did not worsen participants’ appearance self-esteem or overall self-esteem.³⁰ To our knowledge, studies have not examined whether food warnings affect disordered eating; however, studies have examined traffic light labels, which share some similarities with “high in” food warnings. In one survey of 1,294 college students, 9% of those surveyed reported that they believed traffic light labels could put people at risk for developing an eating disorder.⁷¹ However, in focus groups with 57 students, very few participants said they knew someone who had changed their eating behaviors in an unhealthy way after these labels were implemented in the students’ cafeterias.⁷¹ Thus, the available limited evidence does not suggest that warnings will have major negative effects on body image or disordered eating.

Social and Cultural Values

Some foods and beverages have important cultural or social value.^32,36 For example, we might eat cake to celebrate a birthday or share a particular meal as part of a family, religious, or cultural tradition.⁶³ Specific foods are linked to cultural, ethnic, national or regional identities, and have special significance for various population groups. If warnings reduce consumption of these foods and beverages, they might also diminish the positive feelings of identity, community, and belonging people experience from consuming these products. Most relevant to our analysis is whether warnings have a disparate effect on some cuisines or cultural groups and whether this is ethically acceptable. In one relevant case, the Italian government claimed that the United Kingdom’s voluntary traffic light labeling scheme unfairly targeted traditional Mediterranean foods such as cheeses and meats.⁷² It is worth noting that in most countries with food warnings, the nutrient profile model used to determine when a product triggers a nutrient-based warning is an objective numerical system that evaluates a product’s nutrient content,⁷³ making it unlikely that the system would “single out” any particular food group based on cultural or ethnic background. Further, warnings do not prevent people from buying or consuming products, so major ethical concerns on this dimension appear unlikely.

Informed Choice

A widely accepted view is that exercising autonomy requires making informed choices and being free of controlling influence by others.ⁱ For food warnings to respect and promote individual autonomy, they must promote consumers’ informed choosing without subjecting them to unacceptable manipulation, recognizing that our food choices are already heavily shaped by external forces including the food environment^39,75,76 and food marketing.^77,78

To exercise informed choice, individuals must first understand their options for how to behave and the consequences of those behaviors.⁷⁹ Food warnings are likely to strengthen informed choice along these dimensions. Randomized experiments demonstrate that exposure to warnings increases consumers’ understanding of the healthfulness and health consequences of foods and beverages.^80–85 One randomized experiment with 387 Uruguayan adults found that warnings improved consumers’ ability to correctly identify products high in unhealthy nutrients.⁸³ Another study with 2,381 U.S. parents showed that warnings helped correct misperceptions about the healthfulness of certain sugary drinks (e.g., sweetened teas) often believed to be healthier than sodas.⁸⁴ Food warnings have also been shown to reduce the time and cognitive effort it takes consumers to evaluate product healthfulness,⁸⁶ suggesting that well-designed food warnings may benefit consumers’ overall autonomy by freeing up cognitive resources to focus on other things.⁷⁴

Food warnings also activate consumers’ understanding of the health consequences of consuming certain foods by making that knowledge salient and accessible when consumers are making choices about what to buy. Experimental studies have demonstrated that food warnings encourage individuals to think more deeply about the health consequences of products when deciding what to buy or consume.^12,13,56 One randomized trial with 400 adults found that participants who saw warnings on SSBs reported thinking more about the harms of SSB consumption than those exposed to a control label,¹² and increased thinking about harms led to healthier beverage purchases.⁸⁷ Because decisions about food are often made without active thinking,⁷⁵ helping consumers keep products’ health consequences at top of mind when making a purchase decision is likely to enhance their capacity to make and carry out informed choices.^39,79

While food warnings increase and activate understanding, they also evoke emotions. Some scholars argue that interventions that change behavior by evoking emotion (in contrast to changing behavior by providing behavior) are unacceptably manipulative.^27,88,89 However, several considerations indicate that food warnings’ emotional effects are not unacceptably manipulative. First, scholars have argued that there is not a dichotomy between conveying information and eliciting emotions,^90–92 but instead, that effectively conveying information requires eliciting emotion. The evidence is consistent with this view. Factual information (such as the information provided in text-only warnings) can and does elicit emotion,^12,56,93,94 and information that does not generate emotion lacks meaning.^60–62 Warnings that do not generate emotions are thus unlikely to effectively inform consumers and in this respect, warnings’ emotionality functions to enhance informed choice. Second, some scholars have argued that eliciting emotion is not manipulative (and thus not ethically problematic) when the emotional response evoked is appropriate and improves reasoning.^95,96 Warnings are likely to meet this standard. Feeling fear, worry, or other negative emotions after seeing a food warning is likely an appropriate response to learning that consuming a product is associated with serious health consequences, and experimental studies find that feeling these emotions improves reasoning about the health consequences of unhealthy products.^54,59 Third, even if food warnings were manipulative, this could be a seen as a form of counter-manipulation that aims to counteract arguably manipulative food marketing that often misrepresents products’ healthfulness⁹⁷ and appeals to emotions⁹⁸ to sell products.

One additional consideration is how consumers feel about food warnings – do they perceive warnings as unacceptably manipulative? Studies typically find high public support for food warning policies,^{80,81,99–102} suggesting that many consumers find warnings acceptable and desirable. Additionally, some studies have directly assessed perceptions of control over one’s eating choices. One study of 1,000 Canadian adults asked participants to rate whether “high in” beverage warnings made them feel more or less “in control” of their eating choices. Most respondents reported that the warnings made them feel more in control; fewer than 5% said the warnings made them feel less in control.⁹⁹ This study offers preliminary evidence that food warnings may not be unethically controlling, or at least may not be perceived as such. While future studies should examine whether this finding extends to other warnings types (e.g., graphic warnings) and in other populations, the balance of available evidence indicates food warnings are likely to promote informed choice without being unacceptably manipulative.

Equality

The principle of equality requires a fair distribution of both goods and burdens.^32,103,104 For warnings to promote equality, they must not disproportionately benefit or burden a particular group unless doing so would reduce morally relevant inequities.¹⁰³ Existing research provides some initial insight into the likely distribution of warnings’ benefits and harms.

Distribution of benefits.

As discussed above, two benefits of food warnings are that they are likely to promote informed choice and discourage unhealthy purchases. Research to date has generally found that food warnings have similar beneficial effects on consumer knowledge and understanding,^80,81,105 behavioral intentions^80,81 (which are predictive of behavioral performance¹⁰⁶) and actual purchase behaviors¹² across diverse demographic groups. These findings are consistent with studies of tobacco warnings, which also find that warnings typically produce similar beneficial responses across groups.^53,55,94 If these patterns hold in response to real-world implementation of food warning policies, warnings would be unlikely to exacerbate underlying disparities in knowledge or dietary behaviors. In this regard, food warnings differ from calorie labels and back-of-package nutrition information panels, which are used more often and understood better among more advantaged groups.^107–109

If food warnings indeed exert similar effects on behavior across groups, they could reduce health disparities (and thus promote equality) in contexts where unhealthy food consumption is highest among more disadvantaged groups. This is because the same proportional reduction in unhealthy food consumption in response to warnings will generate larger absolute reductions among groups with higher baseline consumption of these foods. Consistent with that possibility, one recent simulation study projected that implementing SSB warnings in the U.S. would yield the largest reductions in SSB consumption racial/ethnic minorities and individuals with lower socioeconomic status, a result driven by higher baseline SSB consumption among these groups.⁴⁰ The study also projected larger obesity reductions among racial/ethnic minorities and individuals with lower socioeconomic status. These groups have higher rates of obesity, suggesting that implementing SSB warnings could reduce obesity disparities in the U.S. and thus promote equality along this dimension.

Distribution of costs.

As mentioned above, research to date suggests that the costs of food warnings include possible emotional costs and the potential for increased stigma. Emotional costs (i.e., short-term negative emotions in reaction to warnings, potential lost enjoyment) would largely be concentrated among individuals who consume the products that display warnings. The ethical implications of this distribution of costs will depend in part on whether individuals who consume unhealthy products belong to a group that society especially wants to protect from additional burdens, such as lower-income or otherwise disadvantaged groups. The possibility of greater emotional costs among some groups should be weighed against the likelihood that these groups will also reap the largest health benefits from food warning policies. Further research should explore these tradeoffs in more depth and across different contexts.

Increasing stigma could have negative impacts that extend beyond individuals who consume the products that display warnings. For example, if food warnings do increase stigma toward people with obesity, this would disproportionately affect these individuals. People with diet-related health conditions such as obesity are already burdened by reduced health and by the stigma that chronic diseases often carry; policies that disproportionately harm these groups raise ethical concerns. This concern highlights the importance identifying warning designs that minimize this unintended consequence.

Attribution of Responsibility

Public health policies and programs often communicate ideas about who is responsible for addressing public health problems.^32,110 Encouraging healthier eating and reducing diet-related disease might be framed as the responsibility of individuals, organizations, the government, industry, or some combination of these. Ethical public health policies should promote a fair and just balance of responsibility across these entities. On one hand, warnings are meant to change individual consumers’ behavior and thus could suggest to the public that individual consumers are the primary entity responsible for ensuring healthy dietary intake and avoiding diet-related disease. This may be seen as unjust distribution of responsibility given that diet and health are the result of a variety of factors, many of which are outside of an individual’s control.^8,111,112 On the other hand, warnings may also improve health by prompting industry reformulation.¹⁵ Nutrition policies can be designed specifically to encourage product reformulation;¹¹³ doing so may help shift the balance of implied responsibility to an ethically more favorable equilibrium (i.e., toward shared responsibility between individuals and industry). Additionally, warning policies can be accompanied by mass communication campaigns that emphasize that individuals, organizations, industry, and the government each have a role to play in encouraging healthy eating.¹¹⁴

Conclusions

Four countries have mandated warnings on foods and beverages, with additional jurisdictions in the U.S. and around the world considering similar regulations. This paper drew on the framework developed by Marieke ten Have and colleagues³² – a public health ethics framework for evaluating obesity prevention policies – to probe the ethics of food warning policies. Our analysis of available evidence suggests that food warnings may be ethically defensible, depending upon the nature, magnitude and distribution of their costs and benefits (Figure 3). First, research suggests that food warnings generate important benefits including increased consumer understanding and informed choice, healthier food and beverage purchases, and potential reductions in obesity prevalence. Second, warnings also generate costs, including evoking negative emotions; however, these emotional reactions are an important mechanism through which warnings achieve their beneficial effects. Finally, research to date suggests that warnings are unlikely to have unacceptable effects on social and cultural values, attributions of responsibility, liberty, or privacy.

Figure 3.

Summary of evidence that food warnings may be ethically defensible.

Our analysis also suggested key areas for future research. For example, there is limited research examining whether food warnings perpetuate stigma. Warnings should be designed to minimize stigma. If even well-designed warnings lead to some stigma, this must be weighed against warnings’ benefits, particularly if this cost unfairly burdens certain groups. Research will also help clarify warnings’ effects on equality. Emerging evidence suggests sugary drink warnings may reduce disparities in obesity prevalence in the United States, but additional investigation is needed to characterize the full distribution of food warnings’ costs and benefits across ethically-relevant population subgroups. As additional evidence emerges on these topics, ethical analyses of food warnings should be refined and revised.

Policy action is essential to address the growing burden of diet-related disease worldwide. Our analysis suggests we pursue food warnings as a strategy for improving public health while also conducting additional research to enable a more thorough ethical analysis.