How have media campaigns been used to promote and discourage healthy and unhealthy beverages in the United States? A systematic scoping review to inform future research to reduce sugary beverage health risks

Summary Sugary beverage consumption is associated with many health risks. This study used a proof‐of‐concept media campaign typology to examine U.S. beverage campaigns that promoted healthy beverages and encouraged or discouraged sugary beverages. We used a three‐step systematic scoping review to identify, organize, analyze, and synthesize evidence. Step 1 used Preferred Reporting Items for Systematic Review and Meta‐Analysis Extension for Scoping Reviews (PRISMA‐ScR) guidelines to search four electronic databases and gray literature through 2021. Step 2 categorized relevant media campaigns using a media campaign typology. Step 3 examined campaign evaluation outcomes. We identified 280 campaigns organized into six campaign typology categories. The media landscape was dominated by corporate marketing campaigns for branded sugary beverages (65.8%; n = 184) followed by public awareness (9.6%; n = 27), public policy (8.2%; n = 23), social marketing (7.1%; n = 20), corporate social responsibility (5.7%; n = 16), and countermarketing (3.6%; n = 10) campaigns. Evaluations for 20 unique campaigns implemented over 30 years (1992–2021) across 14 states showed reduced sugary beverage or juice and increased water or low‐fat milk sales and intake. Positive short‐term cognitive and mid–term retail and behavioral changes were reported. There was limited evidence for long‐term policy, social norm, and population health outcomes. Future research is needed to use media campaigns in strategic communications to reduce sugary beverage health risks for Americans.


| INTRODUCTION
Human behaviors are influenced by the images, stories, and textual messages communicated through the mass media. 1 Public health media campaigns use print, broadcast, and social media to influence people's attitudes and behaviors to reduce health risks. 1 Many corporate-funded marketing campaigns deliver competing messages that encourage people to buy and consume sugary beverages that contribute to poor diet quality, dental caries, obesity, type 2 diabetes, and cardiovascular disease in the United States (U.S.) and other countries. [2][3][4][5] Sugary beverage products are the primary source of added sugars in Americans' diets and include carbonated soft drinks (i.e., soda) and sports and energy drinks; sweetened fruit drinks, juices, and nectars; enhanced waters; sweetened teas and coffees; and sweetened cow's milk and plant-based nondairy milks. 2,3 Consumption patterns of sugary beverages vary by age, income, race, and ethnicity. On average, half to two thirds of American adults and nearly two thirds of U.S. children consume at least one sugary beverage each day that contributes 130 or more calories to their daily energy intake. 2,3,6 Neither the World Health Organization nor the U.S. government have issued comprehensive healthy beverage guidelines across the lifespan. 7 Health-oriented media campaigns have used print, broadcast, and social media to support policy, systems, and environmental (PSE) strategies to discourage sugary beverages and promote water, milk, or noncaloric beverages. 7 We developed a proof-of-concept media campaign typology published previously that describes mass media campaigns having different goals, objectives, paradigms, and target populations to promote or discourage behaviors. 7 The campaign typology has six categories including corporate advertising, marketing, or entertainment; corporate social responsibility, public relations, or cause marketing; social marketing; public information, awareness, education, or health promotion; media advocacy or countermarketing; and political or public policy campaigns. 7 No study has summarized evidence for U.S. nonalcoholic beverage campaigns or described how corporate versus government and civil society-funded media campaigns have used print, broadcast, and digital or social media to communicate messages to target populations about healthy and unhealthy beverage products in a crowded media message ecosystem. 7 Figure 1 shows a conceptual model to plan and evaluate media campaigns to support a social change movement to reduce sugary beverage health risks for Americans. 7 In a previous review, we defined social change as a long-term process that fosters collective action to transform social norms, attitudes, and behaviors of populations for a specific issue over years or decades. 7 The Tobacco-Free Generation and Tobacco Endgame concepts 7,8 have used media to build policy support for a social change movement to de-normalize and discourage youth from using tobacco and vaping products. These concepts could F I G U R E 1 A conceptual model to plan and evaluate media campaigns for a social change movement to reduce sugary beverage health risks be adapted to examine evidence for U.S. beverage media campaigns to normalize healthy hydration behaviors and establish a Sugary Beverage-Free Generation. 7 This study addresses these research gaps.

| Study purpose
This study conducted a systematic scoping review of U.S. beverage media campaigns, categorized evidence into a media campaign typology, 7 and addressed other research gaps. First, we provide a summary of U.S. beverage recommendations, consumption, and marketing trends. Thereafter, we describe the results from a systematic search of the published and gray literature for U.S. media campaigns used to influence nonalcoholic beverage behaviors, organize the campaigns chronologically by campaign type into the media campaign typology, and synthesize evidence from published media campaign evaluations. We suggest future research needs to build a social change movement to reduce sugary beverage health risks for Americans.

| TRENDS IN U.S. EXPERT BEVERAGE RECOMMENDATIONS, POPULATION INTAKE, AND MARKETING
The 2020 Dietary Guidelines Advisory Committee (DGAC) report noted that sugary beverages contribute about 30%, 50%, and 60% of added sugars to the diets of U.S. children, adolescents, and adults, respectively. 9 The Dietary Guidelines for Americans (DGA) 2020-2025 report 10 recommended general guidelines for healthy nonalcoholic beverage intake that encourage (1) water and other beverages that contribute beneficial nutrients, including low-fat and nonfat milk or a fortified nondairy soy milk and limited amounts of 100% juice; (2) coffee, tea, and flavored water without added sugars or fats; (3) ≤400 mg of caffeine intake per day; (4) <10% of total daily calories from added sugars; and (5) the replacement of sugary beverages with water or other unsweetened beverages. 10 The DGA 2020-2025 also provided specific healthy beverage targets for infants and toddlers under 2 years of age. 10 However, the DGA report lacked specific recommendations for daily water intake for children over 2 years old, adolescents, or adults and did not address artificially sweetened or functional beverages.
The U.S. Healthy Eating Research (HER) National Program, supported by the Robert Wood Johnson Foundation (RWJF), convened expert panels that published healthy beverage targets for water, milk, and 100% juice for infants and toddlers, children, teens, and adults in 2013, 11 and the guidelines for children birth to age 5 years were updated in 2019. 12 The panel's recommendations were not incorporated into the DGA 2020-2025 for all age groups. 10 The average U.S. adult woman and man consume about 10 cups (8 oz/240 ml) and 12 cups (8 oz/240 ml) of fluids daily, respectively, which are below the recommended Dietary Reference Intake (DRI) of 11.5-15.5 cups of fluids daily. 13 Two thirds of U.S. adults consume a sugary beverage daily. 14 The recommended DRI for children is 4-8 cups of fluids daily. 15 The average U.S. child aged 2-19 years consumes over 5 cups (8 oz/240 ml) of fluids daily and more than half is from water, followed by sugary beverages and milk. 16 Fruit drinks, sweetened juices, and flavored or sweetened skim milk are the leading sources of added sugars in young children's diet, 16 and adolescents overconsume soft drinks, energy drinks, and sports drinks. 2,17 Nestlé, The Coca-Cola Company, and PepsiCo Inc. dominate the U.S. and global beverage brand market and sales for sparkling soft drinks and sugary beverages, water, sweetened and unsweetened juices, dairy and plant-based drinks, coffees, and teas. 18  The U.S. development, marketing, and sales of functional beverages increased between 2013 and 2021. 20 Functional beverages are a nonalcoholic beverage category that promotes their health-enhancing benefits attributed to herbs, vitamins, minerals, amino acids, and prebiotics or probiotics. Functional beverages include energy drinks, sports drinks, enhanced waters and juices, and nondairy plant-based beverages (i.e., almond, cashew, coconut, oat, rice, soy, and blended nut milks) 20 that may contain excessive added sugars. 2,3,6 The volume and U.S. per capita purchasing of beverages with nonnutritive sweeteners (sucralose and stevia) and/or caloric sweeteners (sucrose) increased (2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018). 21 A concurrent trend has been the increased sales of bottled water from supermarkets among high-income populations (2011-2016) and increased intake of both bottled and tap water within the southern and midwestern U.S. states. 22,23 Only a small proportion of Americans consume the DRI-recommended daily water intake. 22 U.S. beverage trends have been driven by the extensive marketing of sugary beverage brands using IMC strategies to build brand loyalty and revenue 17 ; permissive government policies that have supported industry self-regulatory programs 17 ; industry marketing of functional beverages with added sugars 20 that compete with unbranded free tap water; and industry lobbying of legislators that has preempted and opposed state and local laws for pro-sugary beverage taxes and warning labels. 24 *Integrated marketing communications (IMC) strategies include advertising, personal selling, public relations, and sales promotion combined with marketing techniques (i.e., branding, celebrity endorsement, premiums, product placement, point of sale, and sponsorship) delivered across media platforms and diverse settings to influence the diet-related cognitive, behavioral, and health outcomes of individuals and populations.

| Search strategy, evidence selection, and extraction
We conducted a systematic scoping review due to the exploratory nature of the study. The scoping review used five steps described by  26 and PRISMA Extension for Scoping Reviews (PRISMA-ScR) checklists. 27 We did not assess the study quality or risk of bias due to the broad study purpose to apply the media campaign typology to the U.S. context only. Beverage media campaigns implemented in other countries were excluded from the review process for this paper.
To address RQ1, a coinvestigator (K. C. S.) worked with two university research librarians to design a comprehensive search strategy to identify media campaigns that promoted unsweetened water, lowfat and fat-free milk, coffee, tea, or 100% juice and promoted or discouraged branded, nonalcoholic beverages. We used several published review papers to select the search terms and guide the search strategy for beverage campaigns that included Palmedo et al., 28 Freudenberg et al., 29 Huang et al., 30 and Te et al. 31 Table 1 Figure 2 displays the PRISMA flow diagram for the systematic scoping review of evidence for U.S. media campaigns that promote or discourage beverages used to address RQ1. We identified 4271 records from the search. After removing the duplicate records, we screened the titles and abstracts for 3470 records, and we reviewed 527 full-text records. Of the records screened, we identified 172 records that described U.S. beverage media campaigns, and we found 72 additional sources that led to 244 records for 280 unique U.S. media campaigns.   T A B L E 1 Search strategy for the systematic scoping review to examine U.S. media campaigns used to promote or discourage nonalcoholic beverages to Americans Search strategy

Inclusion criteria Exclusion criteria
• Articles or gray literature sources available in the English language that mention one or more specific U.S. media campaign and describe at least one other component of the campaign (e.g., location, length [time frame], developer(s), budget, target audience(s), key message(s), and/or intended outcome(s)) • Articles or gray literature sources that describe campaigns that Have a clear name and/or slogan assigned to them (e.g., Got Milk? campaign, Kick the Can campaign); Promote or discourage specific branded sugary beverage products (i.e., carbonated soft drinks; sports and energy drinks; fruit drinks; and sweetened teas, coffees, and milks) from Nestlé, The Coca-Cola Company, or PepsiCo, Inc a ; Promote or discourage the purchase and/or consumption of water, cow's milk, plant-based milk, or 100% juice, including campaigns for branded water, milk, and juice products; Promote or discourage the purchase and consumption of broad beverage categories (e.g., sugary beverages and milk); and Are community, city-wide, regional, or national in scope.
• Articles or gray literature sources that are not available in the English language • Articles or gray literature sources describing media campaigns that Do not promote or discourage sugary beverages, milk, juice, and/or water purchase or consumption (e.g., alcoholic beverage campaigns and Human Immunodeficiency Virus (HIV) awareness campaigns); Promote or discourage a branded sugary beverage product that is not one of Nestle, Coca-Cola Company, or PepsiCo, Inc's products; Are based in a country other than the United States; Have no name or slogan attached to it (i.e., are "unnamed" or "unbranded"); Are focused at the school level or in one establishment (e.g., a specific hospital or workplace); Promote or discourage breast milk, formula, or other products intended to replace breast milk (e.g., "toddler milks"); and Include changes in beverage behavior as just one component of a multipronged behavior change campaign or intervention (e.g., healthy eating, healthy weight, or obesity prevention campaigns) • Articles that mention media campaign (s)  (campaign) AND (beverage* OR soda* OR cola OR "energy drink" OR "sports drink" OR Pepsi OR Coke OR "Coca-Cola" OR Nestlé OR (water AND (consum* OR drink* OR tap)) OR "carbonated water" OR "bottled water" OR juice OR milk OR tea OR coffee) AND (health OR promot* OR advocacy OR policy OR political OR tax OR media OR communication* OR advertis* OR information* OR aware* OR behavior* OR "public relations" OR marketing OR countermarketing OR countermarketing OR education* OR entertainment OR advocacy OR advocat*) MeSH terms used where applicable: health; "health promotion"; "mass media"; "social marketing"; "health communication"; "public relations"; beverages; "sugar-sweetened beverage"; "artificially sweetened beverage"; "carbonated beverages"; "carbonated water"; "drinking water"; "energy drinks"; coffee; milk Google and Google Scholar (campaign) AND (beverage* OR soda* OR water OR juice OR milk OR tea OR coffee) AND (health OR promot* OR advoc* OR policy OR politic* OR tax OR media OR communic* OR advertis* OR inform* OR aware* OR behav* OR "public relations" OR market* OR educ*) a Search was limited to three largest global branded beverage manufacturers given the large number of advertising campaigns for beverages and three manufacturers that collectively spent the most on advertising and marketing for beverage products in the United States and globally.

| Corporate advertising, marketing, and entertainment campaigns
Corporate advertising, marketing, and entertainment campaigns are used to promote a specific brand or branded product to increase sales, purchase, and consumption. 7 The scoping review identified 184 corporate advertising, marketing, and entertainment campaigns. The majority of these campaigns were used to promote sugary beverage brands by The Coca-Cola Company (n = 81) that ranged from Drink Coca-Cola and Enjoy It (1886) to Real Magic (2021) 33 and PepsiCo (n = 84) that spanned from Exhilarating, Invigorating, Aids Digestion (1903) 34 to Greatest of All Time Camp (2020). 35   promoted branded water products, which differed from the corporate advertising campaigns because the sale of the water was tied to a social or environmental cause, such as providing clean drinking water for people in Africa.
These campaigns have promoted healthy beverage behaviors; supported social, racial, and ethnic justice issues; and promoted environmental sustainability. [43][44][45][46][47] The earliest campaign identified was Danone's Drink 1, Give 10 or 1 L = 10 L for Africa campaign (2008) for Volvic branded water. 48  to promote positive behavior change to increase consumption of unsweetened fluid milk, coffee, tea, or 100% unsweetened juice recommended by the DGA as healthy beverages, rather than to encourage Americans to reduce or stop sugary beverage consumption. We separated the corporate branded water and juice campaigns from social marketing campaigns because the latter promote unbranded water, juice, or milk, and many of the campaigns spanned years or even decades. These campaigns were also supported by or implemented in partnership with government, civil society organizations, or industry trade organizations, which we found to be unique from traditional corporate marketing campaigns that were solely industry funded.   Table 2 were evaluated and the outcomes are described in Table 3. and Table 3 summarize the evaluation results for The Bigger Picture. 86

| Public policy and political campaigns
Public policy or political campaigns catalyze public support or opposition for legislation and laws to restrict sales or access to products or discourage behaviors that harm human health or the environment. 7 We identified 23 relevant campaigns, including pro-sugary beverage tax campaigns (n = 11) and anti-sugary beverage tax and state preemption campaigns (n = 12). Twenty campaigns used print, broadcast, and/or social media to support or oppose a proposed sugary beverage tax in nine cities and the Navajo Nation. 87 The earliest pro-and anti-tax campaigns were in Richmond, CA, called Richmond Fit for Life (pro-tax) and No On N (anti-tax) (2012) 88 where a sugary beverage tax was not enacted.
The Navajo Nation, which covers northeastern Arizona, southeastern Utah, and northwestern New Mexico, successfully enacted the Healthy Diné Nation Act (2014) 89 that was renewed and reauthorized in 2020. 90  to gain public support to prevent future sugary beverage tax laws. 24 We found no published evaluations of outcomes for these public policy campaigns. year, campaign name, typology category, and reported outcomes . Table S2 provides a detailed summary of each campaign's goal, time frame, target audiences, and media strategies; the theory, model, or conceptual framework reported; and short-term cognitive outcomes (i.e., awareness, knowledge, attitudes, beliefs, and intentions), midterm outcomes (i.e., retail and behaviors), and longterm outcomes (i.e., social norms, policies, and population health).    Table S2 for details for each campaign. The most frequent response categories for short-, middle-, and long-term outcomes are reflected by a slightly darker color (i.e., HB knowledge, HB intake, and institutional policy). Healthy beverage (HB); (+)

| U.S. beverage media campaign evaluations
= positive healthy beverage change (e.g., increased water intake and/or reduced sugary beverage or juice intake) and (À) = negative healthy beverage change.
a Wootan et al. 62 evaluated milk sales in four different communities. Two of the four communities found a positive change in the sale healthier milks promoted, and there was no significant change found in the remaining two communities. b Samuels et al. 82 did not conduct a baseline assessment, so it is not possible to report changes in the postcampaign evaluation. Some findings were mixed, for example, respondents were in favor of taxation of sugary beverages (e.g., for generating funds) but also reported that taxation may have limited effectiveness to reduce sugary beverage consumption. CA. This study also documented an increase in parents and youth who reported that drinking more sugary drinks was acceptable or that they needed to balance healthy and unhealthy beverage intake. 51 Cohen et al. 52 found no change in sugary beverage sales in the intervention communities after two years. The two BCI evaluations 51,52 reported a decrease in healthy beverage knowledge of targeted populations. 51 In contrast, evaluations for 10 unique campaigns found a positive knowledge change attributed to the media campaign. 57,63,64,72,73,75,78,79,82,86 Twenty-one studies measured midterm behavioral outcomes including healthy beverage intake, change in retail sales of healthy beverage, or whether a respondent communicated with another person(s) about the campaign or messages. Eleven of 13 studies that reported on sugary beverage consumption found decreased intake [56][57][58][59][60]62,74,[78][79][80]83 for six unique campaigns. The Cavities Get Around campaign evaluation was the only one that reported changes in healthy beverage intake among young children. 73 No changes were reported for San Francisco's Pouring on the Pounds (2010) and Oregon's It Starts Here (2011) campaigns 75,82 (Table 3). Eleven of 12 studies that assessed retail outcomes reported an increase in healthy beverage sales. [55][56][57][58][59][60][61][62][63][64]77 Three studies 57 (Figure 3). However, we found no evaluation for a media campaign that had communicated the benefits of sugary beverage taxes for communities. This is a major knowledge gap to understand how to influence Americans' beverage perceptions and behaviors. Therefore, media campaign planners must use insights from previous campaigns to inform future campaigns.

| Future research
This section builds on the study findings and combines these findings with additional literature to suggest future research needs for media campaigns to reduce sugary beverage health risks for Americans and to support a social change movement to establish a Sugary Beverage-Free Generation (Figure 4).
Third, future research could explore how message framing, graphics, slogans, and IMC strategies may influence media campaign outcomes using the typology. Fourth, funders should provide multi- year grants that will enable campaign planners to adequately fund high-quality evaluations and use conceptual frameworks or theories to plan and evaluate campaigns. Many costs are associated with the packaged strategies for media campaigns that vary depending on context; therefore, cost-effectiveness evaluations are also needed to inform future efforts.
Fifth, future research should examine the public's understanding of how sugary beverage taxes benefit communities, including Black and Latinx youth and parents who may support pro-tax policies when the benefits are communicated effectively. 110,111 A study published after we completed our review reported that culturally tailored countermarketing messages delivered to Latinx parents for 6 weeks in an online simulated store on Facebook, either alone or combined with water promotion messages, had influenced parents to select fewer sweetened fruit drinks and increase water for their children. 112 Whether these behaviors are sustained over time requires further investigation given the challenge for public health messages to compete with highly funded corporate marketing campaigns for sugary beverages. 113 Sixth, future research should apply tobacco control campaign insights 114 to engage and inspire youth activism 115,116 to support a social change movement for a Sugary Beverage-Free Generation.

| CONCLUSION
Public health media campaigns may influence the awareness, attitudes, preferences, behaviors, and health outcomes of individuals and populations. However, these campaigns must be examined within the broader environment. This systematic scoping review of U.S. beverage media campaigns categorized evidence into a proof-ofconcept typology. As the corporate marketing of sugary beverage products targeted to Americans increases across digital platforms, media campaigns that influence awareness and attitudes about the harms of sugary beverages but do not address equity, health disparities, and the commercial determinants of health are unlikely to produce sustainable changes. Six future research needs are described to understand how media campaigns may support a social change movement to promote healthy hydration behaviors and reduce sugary beverage health risks for populations.
The copyright and trademarked images used in this paper are intended for noncommercial educational purposes only and allowed by the U.S. "nominative fair use" doctrine. A fair use evaluation was completed for using these images as illustrative examples. 97

INSTITUTIONAL REVIEW BOARD STATEMENT
Not applicable.

We thank Juan Quirarte for designing the figures and Shiriki
Kumanyika for comments received on an early draft of this paper. We also thank the Virginia Tech librarians for their assistance to design the scoping review, and the external reviewers for helpful comments received that strengthened this paper. We are grateful for funding provided by Virginia's Academic Library Consortium and Virginia Tech to cover the open access publication costs associated with this paper.
V. I. K. received funding from the Department of Human Nutrition, Foods, and Exercise at Virginia Tech to complete this paper.

CONFLICT OF INTEREST
The authors declare no conflicts of interest related to this paper.