Online RCT of added-sugar warning labels and Spanish-English label education

Ethan C Wolf; Marissa G Hall; Dean Schillinger; Jim Krieger; Jennifer A Woo Baidal; Sarah Solar; Christina Lin; Jennifer Falbe

doi:10.1016/j.amepre.2025.107966

Online RCT of added-sugar warning labels and Spanish-English label education

Am J Prev Med. 2025 Jul 3:107966. doi: 10.1016/j.amepre.2025.107966. Online ahead of print.

Authors

Ethan C Wolf¹, Marissa G Hall², Dean Schillinger³, Jim Krieger⁴, Jennifer A Woo Baidal⁵, Sarah Solar⁶, Christina Lin⁷, Jennifer Falbe⁶

Affiliations

¹ Human Development and Family Studies Program, Department of Human Ecology, University of California, Davis, California, USA; Division of Epidemiology, School of Public Health, University of California, Berkeley, California, USA.
² Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA; Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA.
³ Health Communications Research Program, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.
⁴ Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, Washington, USA.
⁵ Department of Pediatrics, Stanford University, Palo Alto, California, USA. Electronic address: jfalbe@ucdavis.edu.
⁶ Human Development and Family Studies Program, Department of Human Ecology, University of California, Davis, California, USA.
⁷ Human Development and Family Studies Program, Department of Human Ecology, University of California, Davis, California, USA; Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, Washington, USA.

PMID: 40617305
DOI: 10.1016/j.amepre.2025.107966

Abstract

Introduction: A policy requiring front-of-package added-sugar warning labels has the potential to improve dietary patterns in the U.S. However, because such a policy would require English labels, the labels may not be equally effective among individuals with varying English proficiency. One potential way to increase the broad efficacy of warning labels is to use a multilingual campaign to explain the labels. This study's objective was to determine whether combining an added-sugar warning label with a Spanish and English educational message reduces intention to select sugar-sweetened beverages (SSBs) to a greater extent than either the label or educational message alone among Hispanic adults.

Study design: Online RCT.

Setting/participants: 2,000 U.S. Hispanic adults with varying acculturation participated between October-December 2022.

Intervention: Participants were randomized to 1 of 4 conditions: (1) control, (2) language-matched message about added-sugar warning labels (in English or Spanish), (3) warning label (English, yellow, icon) on SSBs, and (4) message-plus-warning.

Main outcome measures: Intention to select an SSB, measured by hypothetical SSB selection in an online shopping task, analyzed May 2023-April 2024.

Results: In the control condition, 58% selected an SSB for themselves. In comparison, a significantly lower percentage of participants selected an SSB in the message (43%), warning label (38%), and message-plus-warning (27%) conditions (p-values<0.001). The message-plus-warning condition had a lower risk of SSB selection than both the message and warning conditions (p-values<0.001). Efficacy was larger for the message among those with lower acculturation and for the warning among those navigating the study in Spanish and certain income categories. Results were similar for the secondary outcome of selecting an SSB for one's child.

Conclusions: Using educational messages in more than one language to accompany rollout of a new warning label may further improve outcomes in populations with varying levels of acculturation.

Trial registration: Trial registered on Clinicaltrials.gov (NCT: NCT05563181).

Keywords: Health equity; hispanic; nutrition policy; sugar-sweetened beverages; warning labels.

Associated data

ClinicalTrials.gov/NCT05563181