Appendix 2 [PDF]

Alcohol marketing and young people – a literature review and mapping exercise Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2)

UK Health Forum

Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2)

Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England Tim Lobstein1, Jane Landon2, Nicole Thornton3 and David Jernigan3 1

Adjunct Professor, Public Health Advocacy Institute of Western Australia, Curtin University, Perth, WA. 2 UK Health Forum, London, UK. 3 Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.

Abstract Background The rising use of digital media in the last decade, including social networking media and downloadable apps, has created new opportunities for marketing a wide range of goods and services, including alcohol products. Policy makers working in public health have recognised that this is an area of concern, especially if commercial interests are using digital media to promote their products in ways that encourage excessive consumption or that undermine prevailing codes of marketing of alcohol products. Objective In this paper we review the available evidence for answers to a series of questions: Is there evidence that alcohol marketing through digital media influences drinking behaviour or increases consumption? What methods of promotional marketing are used, and to what extent? Is there evidence that specific population groups are targeted or attracted? And is there quantitative evidence of their exposure levels? Is there evidence of marketing code violations and especially of exposure of children and young people to alcohol marketing promoted through digital media? Method and findings We conducted a search of scientific, medical and social journals and authoritative grey literature and identified 46 relevant papers (including 14 grey literature documents) providing relevant evidence. Although the evidence is not robust in nature, virtually all studies indicate that marketing through digital media is likely to be having an impact on drinking behaviour, that the marketing activities make use of materials and approaches that are attractive to young people, and that current marketing codes are likely to be undermined by digital media. Conclusion The available evidence indicates that marketing in digital media should be a concern for policy makers. While digital marketing messages are only one contributing factor to the sum of influences on consumption behaviour, a precautionary approach would argue for policy interventions in this area, primarily aiming to ensure greater protection for children and young people. A range of policy options may be considered.

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Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) Introduction Before the last decade, studies of alcohol advertising focused primarily on exposure to marketing through traditional media such as television, radio and magazines (1, 2). As potential consumers are increasingly using digital media for their everyday communications and entertainments (3), alcohol marketers have increased their attention to the opportunities these media provide. Brand owners and their agents have developed brand-promoting websites, they have placed brand-promoting pages on social media platforms such as Facebook, opened Twitter accounts, and developed smartphone apps, screensavers, video games, downloadable ringtones and events listings. They have increased their use of ‘programmatic’ data-driven buying, which offers new efficiencies in reaching target audiences and works best on digital platforms (4). Moreover, unlike traditional marketing, digital marketing provides marketers with opportunities to encourage continuing engagement and individualised interaction with potential customers – such as having message boards and photo galleries where users can post comments or pictures – and also promote the redistribution of the company’s web page material by potential customers, for instance through ‘liking’ or ‘sharing’, to their friends and through their own social networks. Data from trade articles show that the Facebook platform alone can attract millions of users’ ‘likes’ of popular brands (see Table 1 and Annex 1), with one brand alone, Heineken, expected to have amassed 20 million ‘likes’ globally as of early 2015 (5). Five brands (Heineken, Johnny Walker, Miller, Absolut and Birell Turbo) gained over 260,000 new Facebook ‘likes’ in the week that included the New Year partying period, 2014–15 (5). Other digital media are used by the same brands. Company-led Twitter accounts can attract large numbers of followers, with Jack Daniel’s in the UK registering over 100,000 followers for a single account (see Table 1). Dedicated brand channels on YouTube can attract high numbers of viewings, with Budweiser’s dedicated channel attracting over 100 million viewings globally, followed by Bud Light and Heineken with more than 50 million viewings each (5). (Further figures for the UK and worldwide are given in Annex 1.) Note that viewing by brand channel is the exception in how advertising is viewed on YouTube and the figures will underestimate the extent of exposure to YouTube-based advertising (6).

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Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) Table 1: Top 10 alcohol brands ‘liked’ on Facebook and followed on Twitter, United Kingdom (21 January 2015) Champions Drink Responsibly (Bacardi) Smirnoff Eristoff Jack Daniel's Dewar's Somersby Stella Artois Sourz Budweiser Bushmills Irish Whiskey

Facebook fans 1,123,144 779,456 718,859 699,417 666,053 614,415 592,885 551,302 502,086 476,513

Jack Daniel's Bacardi BrewDog Newcastle Brown Ale Rekorderlig Cider Bulmers Cider Hendrick's Gin Adnams Southwold Kopparberg UK The Macallan

Twitter followers* 104,703 75,479 64,226 56,079 36,998 33,480 33,239 31,159 27,353 26,423

* Some brands have several Twitter accounts. Data shown here are for the most popular one. Source: http://www.socialbakers.com/statistics/ (5) Public health concerns about the effects of these new media on alcohol consumption, especially among youth, have been expressed by many advocacy organisations and health researchers (11-13, 16, 36, 63, 64). There is increasing evidence to show that exposure to alcohol advertising in general influences behaviour and is associated with increased consumption. Published reviews of at least 13 longitudinal studies have found exposure to alcohol marketing linked to earlier initiation of drinking and increased consumption (1, 2). Cross-sectional studies have shown an association between a lack of alcohol advertising restrictions and increased prevalence of problem drinking, in populations in general and among youth (2) and elderly people specifically (7). The issue was explored in further detail in a review undertaken for the European Commission in 2009 (8) that considered a wide range of commercial influences on alcohol consumption, but not the influence of digital media. Previous reviews of the literature have recognised a particular difficulty in defining alcohol marketing in digital media. In traditional marketing, the definition of advertising is usually limited to ‘paid-for’ promotional messages, disseminated through third party media such as TV channels or billboards. Non-paid-for, or ‘below-the-line’ forms of promotional activities include product design and labelling, price discounts and, more recently, producer-owned websites and social media pages or feeds. Digital media offer opportunities for interactive engagement with media users, and social networking platforms in particular, including Facebook, Myspace and Bebo; in addition, social messaging and image dissemination through Twitter, Flickr, Instagram and other services create opportunities for branded messages to be rapidly and widely re-distributed by the media users to their friends and through their networks. This media user-generated re-dissemination of branded messages and images not only provides unpaid-for publicity for the original message, but is embedded in a user-endorsed medium, greatly increasing the likelihood that the message will attract the recipient’s attention. Furthermore, brand-promoting websites and Facebook pages may be created entirely by media users without the brand owner’s formal approval. YouTube videos promoting brands may be uploaded and made widely available, again without the brand owner’s formal consent. While the uploaded material often includes brand images and text that contain trademarked and copyrighted 4

Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) material, we are not aware of any actions taken by companies owning the rights to have the material removed. Indeed, there is evidence that some companies have encouraged their website page visitors to upload home-made advertisements featuring the companies’ own products (44). Such informal, user-generated brand promotion is part of a broader discourse around alcohol and drinking behaviour found widely on social networking sites. A 2010 study by Moreno and colleagues (9) assessed 400 randomly selected public MySpace profiles of 17–20-year-olds in Washington State, USA. Of these profiles, 225 (56%) contained 341 references to alcohol. Profile owners who displayed alcohol references were mostly male (54%) and white (71%). Griffiths and Casswell (10) found similar content posted on Bebo in the form of personal information, forum comments, digital photographs and answering quizzes about the individual’s engagement with alcohol. The authors suggested that, through this sharing, “young people are creating ‘intoxigenic social identities’ as well as ‘intoxigenic digital spaces’ that further contribute towards the normalisation of youth consumption of alcohol” (page 525). In the UK, recent reports from the University of Stirling (18) and Liverpool John Moores University (19) have further emphasised the role of digital media exposure and digital social networking in the construction of young people’s identities in relation to alcohol consumption. While it may be the case that the alcohol producers encourage this discourse in social media, it is beyond the remit of the present paper to consider the wider discourse. Here we focus on digital communications that originate primarily from the marketers themselves. We focus on a set of questions relating specifically to the use of digital media by producers for the marketing of alcohol products, as follows: 1. Is there evidence that alcohol marketing through digital media influences drinking behaviour or increases consumption? 2. What methods of promotional marketing are used, and to what extent? 3. Is there evidence that specific population groups are targeted or attracted? And is there quantitative evidence of their exposure levels? 4. Is there evidence of marketing code violations and especially of exposure of children and young people to alcohol marketing promoted through digital media?

Search methods Although the intention of this paper is to provide a narrative review, we approached the search for material as if it were a full systematic review, and included both peer-reviewed and grey literature. The main search terms used were alcohol+ AND (advertis+ OR marketing) AND (Internet OR (digital AND media)). Additional search terms explored included smartphone, apps, video games, social networking. We limited our search to the English language literature, from January 2000 to late January 2015. The year 2000 was taken as a practical cut-off, although we are aware of grey literature studies prior to this period, such as the series of reports by the Washington DC-based Center for Media Education in the late 1990s which sought to identify the ‘new threats’ posed to youth by access to alcohol marketing through digital media (11, 12, 13). Articles retrieved included peer-reviewed papers with primary data (PPD), peer-reviewed systematic reviews and summaries of evidence (PRS), authoritative grey literature reports with primary data (GPD) and authoritative grey literature reports with extensive evidence review (GRS). ‘Authoritative 5

Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) grey literature’ refers to fully-referenced documents published by government agencies and government-funded organisations, independent non-governmental specialist organisations, professional associations and universities. Excluded from the search were books and chapters in books. Information from trade and general press is referred to in the narrative but was not included in the formal search for evidence. Searches were conducted through MEDLINE (PubMed), Proquest, Web of Science, the Cochrane Database, Embase/Ovid, Google Scholar and Google general index. For both Google Scholar and Google general index, the first 500 references sorted by relevance were examined. After sorting and eliminating duplicates, we took all the documents identified in the last three years and conducted a ‘snowball’ review by examining their reference lists for any further potentially relevant papers.

Search results The number of papers initially identified were as follows: MEDLINE (PubMed) = 56 titles, of which 51 abstracts referred for review. Proquest = 762 titles, of which scholarly journals (744), trade journals (8), magazines (6) and newspapers (4) were hand-filtered resulting in 108 abstracts referred for review. Web of Science = 28 titles, of which 20 abstracts referred for review. Cochrane Database = 1 selected. Embase/Ovid = 7,560 titles, of which 21 had four or five star relevance, and 19 abstracts were selected for review. Google and Google Scholar = Over 30,000 ‘hits’. The first 500 (25 pages) were inspected, and 20 documents selected by title for downloading and review. ‘Snowball’ review of references and author contacts = 36 additional abstracts referred for review. Following elimination of duplicates, a total of 192 abstracts were inspected, of which 98 failed to meet the inclusion criteria. The remaining 94 documents were obtained for detailed examination. Of these, 64 were peer-reviewed studies and 30 were grey literature documents. Inspection of the detailed text led to a further 48 documents being removed for failing to meet the inclusion criteria, leaving 46 papers (including 14 grey literature documents) included in the current review. In the Findings section below we identify the different types of paper as: PPD = Peer-reviewed papers with primary data PRS = Peer-reviewed systematic reviews and summaries of evidence GPD = Authoritative grey literature reports with primary data 6

Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) GRS = Authoritative grey literature reports with extensive evidence reviews Findings The findings presented here are described in the context of the specific questions we sought to examine. 1. Is there evidence that alcohol marketing through digital media influences drinking behaviour or increases consumption? As noted in the Introduction, there are a number of studies showing associations between drinking behaviour and exposure to digital media generally or social media discourses on alcohol use in particular. We have excluded these studies in the present paper in order to focus on evidence that might specifically link alcohol marketing activities in digital media to measured aspects of alcohol consumption. Five documents were identified (see Table 2). All of them reported primary data, and in each case the evidence supported the hypothesis that exposure to alcohol marketing in digital media is associated with alcohol purchase intentions, drinking patterns or higher levels of alcohol consumption. Four of the studies (14, 15, 16, 20) showed an association between digital marketing and some aspect of drinking behaviour in young people, using individual interviews which involved recall or recognition of digital marketing exposure and self-reported alcohol consumption patterns. Three of the four studies were limited to children aged under 21 years, and of these, two were restricted to children aged under 17 years. Drinking behaviour associated with exposure to internet marketing included increased consumption, regular consumption, risky behaviour and binge drinking, but was not clearly linked to initiation of drinking. One of the studies was conducted in the UK (20), and involved over 900 schoolchildren in Scotland aged 12–14 years. Of these children, those who reported that they had consumed alcohol at some time (ever drinkers) were more likely to be familiar with a wide range of digital marketing of alcohol products than were those who had not consumed alcohol (never drinkers). None of the four studies used longitudinal designs or controlled interventions, and therefore could not determine the direction of causality. It is plausible that those engaging in alcohol consumption were led to do so by other factors (such as home environments or peer group pressures) and subsequently became interested in branded alcohol messaging, and that a higher level of consumption or a greater propensity to binge drink is not a consequence of digital marketing exposure but rather a cause of it. The fifth study (17) compared the effect of internet marketing in states where regular marketing was restricted and where it was not, and found that exposure to internet marketing increased the proportion of residents (adults) in the restricted states who said they would purchase alcohol, indicating that digital marketing exposure undermines traditional marketing restrictions. This study used a form of controlled intervention that strengthens the evidence for a causal effect.

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Table 2: Association between digital marketing and alcohol behaviour Classification, source, country and reference PPD Hoffman et al 2014, USA (14)

PPD McClure et al 2013, USA (15)

PPD Goldfarb and Tucker 2011, USA (17)

PPD Gordon et al 2011, Scotland, UK (20)

PPD Jones and Magee 2011, Australia (16)

Summary points

In this study, 637 college students completed online surveys to measure their exposure to social and online media generally, as well as their alcohol-related digital media use and engagement with social media-based alcohol marketing activities. The survey found that their participation in social media-based alcohol marketing was associated with greater alcohol consumption and engagement in risky drinking behaviours, whereas the use of social media more generally was not associated with consumption or risky behaviour. The authors report a survey of 2,012 participants younger than 21 who described their alcohol advertising exposure on TV and on the internet (scores for seeing alcohol advertising on the internet; visiting alcohol websites; recognising any of five specific alcohol home pages; and being an online ‘fan’ of an alcohol brand). They found that TV alcohol advertising exposure was associated with initiation of alcohol use whereas internet alcohol marketing exposure is associated with binge drinking among drinkers. The authors explored whether online advertising can undermine regulations by replacing offline (e.g. TV) advertising rather than only reinforcing it. The paper notes that people are 8% less likely to say that they will purchase an alcoholic beverage in states that have bans on alcohol advertising (traditional offline media) compared with states that do not. Following randomised exposure to online advertising for 275 different advertising campaigns to 61,580 people, the gap narrowed to 3%. The effect of online advertising is disproportionately high for new products and for products with low awareness in places that have bans. This suggests that online advertising could reduce the effectiveness of attempts to regulate offline advertising channels because online advertising can replace (rather than simply complement) offline advertising. The authors assessed awareness of, and participation in, offline and online promotional marketing in a group of 920 school students aged 12–14 years, who were categorised as either non-drinkers or drinkers (ever having had one or more drinks). Drinkers were more likely to be aware of alcohol marketing in a range of media, including digital media, and to have participated interactively with alcohol-related websites, mobile phone or computer screen savers, and social networking sites. In this study, 1,113 adolescents aged 12–17 years were surveyed on their exposure to different types of alcohol advertising and their self-reported alcohol consumption. The majority indicated that they had been exposed to alcohol advertisements on television, in newspapers and magazines, on the internet, on billboards/posters and promotional materials, and in retailers, bars and pubs. Exposure to some of these media was associated with increased alcohol consumption, with differences by age and gender. Overall, exposure to alcohol advertising in magazines, retailers, pubs/bars and via promotional materials was associated with alcohol initiation. Alcohol advertising in pubs/bars was associated with regular consumption in the previous 12 months; and magazine, internet and pub/bar advertising was associated with consumption in the previous four weeks. Among young males, exposure to advertising through the internet and magazines was associated with recent alcohol consumption, with internet advertising also associated with regular consumption.

All five documents identified in the search reported primary data, and in each case the evidence supported the hypothesis that exposure to alcohol marketing in digital media is associated with drinking behaviour or higher levels of alcohol consumption. The size of the effect was not estimated, 8

Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) although the Goldfarb and Tucker paper (17) found that advertising on the internet reduced the effect of a ban on advertising in traditional media by some 62%. 2. What methods of promotional marketing are used, and to what extent? Few studies are able to assess the extent of users’ interactions with branded websites and branded social networking pages. Trade monitoring bodies and trade magazines provide some insights into the nature of company-owned web pages but do not quantify their use. These sources do, however, provide some measures of engagement in social networking media, including brand-owned social media pages. For example, the number of overall ‘likes’ for Facebook pages is reported, and can be a guide to users’ engagement. Note that these ‘likes’ are sometimes required to gain access to further pages or products offered, and thus they may not genuinely reflect the users’ positive approval of the site, but only their interaction with the content. The number of brand name Twitter account followers may also represent some measure of interest or engagement with the branded messages. Recent figures provided by market analysts for leading social media alcohol-branded pages and Twitter accounts are given in Table 1 above and Annex 1. The literature search identified 20 studies (reported in 26 publications) that described the nature and magnitude of promotional alcohol marketing on digital media. All studies found extensive evidence of alcohol promotion by many leading brands (see Table 3 below). The studies show the extraordinary range and variety of approaches being used to attract potential consumers and encourage engagement with the brand, and the potential for the re-distribution of both branded and general pro-consumption messages, including:           

notices of events (sports, music) free downloads of music, pictures and messaging accessories notices of parties, and competitions for tickets to enter party events interviews with celebrities free downloadable apps for entertainments, games, hangover advice, alcohol intake monitoring and local retailer location free downloadable widgets to aid invitations to parties via smartphones opportunities to upload messages and photos to the brand website or Facebook page opportunities to purchase branded merchandise and collectables opportunities to purchase alcohol for direct delivery competitions for user-generated videos, cocktail recipes, apps and games tacit approval for unofficial Facebook pages (some brands have over 50 of these).

A study by Uzunoglu (24) noted that the strategy for successful alcohol marketers uses digital media to exploit interactivity, both ‘business-to-consumer’ and ‘consumer-to-consumer’. As Carah (21) comments: “These interactions make brands a part of everyday conversations on Facebook and allow [the brands] to become part of the continuous ‘flow’ of content in the news feeds of their followers. With each interaction, brand content appears in the news feeds of their followers’ friends” (page 5). Of the 21 studies, seven (in 10 papers: 18, 19, 26, 27, 28, 33, 34, 35, 37, 38) reported on the nature of digital marketing for alcohol in the UK. These seven studies found similar marketing strategies and 9

Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) digital media activities being used on branded websites and social media as those found in other countries. One UK study conducted in 2009 (34) found that most, but not all, company-owned digital media pages mentioned responsible drinking, included links to Drinkaware, and did not allow images of what might appear to be underage drinking (see further examination of compliance with marketing codes, below).

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Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) Table 3: Nature and extent of digital alcohol marketing Classification, source, country and reference GPD Purves et al 2015, UK (18)

GPD Atkinson et al 2015, UK (19)

GPD Carah 2014, Australia (21) PPD Carah et al 2014, Australia (22)

PPD Nhean et al 2014, USA (23)

Summary points The researchers conducted a content analysis of alcohol brand activity on five social network sites over a seven-day period, and conducted focus groups with 14–17-year-olds. They found that brands encouraged feedback from users, used the feedback for further brand promotion, and created brand personalities and links to music and sports events. Focus groups confirmed the importance of social networks in building self-identity, allegiance and friendship groups, and the importance of brands – including alcohol brands – in expressing their own identity, and that young people associate the brands with the same values and personality as the brands themselves promote, indicating the success of this type of marketing in this age group. The research involved three stages: a content analysis of social network media, interviews and discussions with friendship groups of young people (16–21 years), and an analysis of young people’s Facebook profiles to examine how alcohol features as part of their online identities and friendship networks. It found a diverse range of distinct and creative marketing strategies were used and were designed to engage and interact with potential consumers, so that SNS users were regularly interacting with and co-creating brand content. Such blurring of the boundaries between official and user-created content and the promotion of brand content may strengthen marketing influence on peer norms around alcohol and peer group drinking cultures. Age verification was in place on both Facebook and Twitter but the age self-verification on Twitter was judged to be easily by-passed. Facebook user comments and tweets did not appear to be created by individuals under the age of 18 and most content was not assessed as targeting underage consumers. Young people were highly knowledgeable about SNS alcohol advertising and chose to engage with marketing content for self-gain (e.g. entering competitions, being informed on local event marketing and promotions). These reports highlight recent information on Australian internet branding by alcohol companies. By the end of 2012, the top 20 alcohol brands in Australia had more than 2.5 million followers on their Facebook pages. During 2012 they posted more than 4,500 items of content. Their followers interacted with that content by liking, sharing or commenting on it more than 2.3 million times. On average over the year, the top 20 alcohol brands posted four items of content per week. The least active brand posted twice a week, the most active posted almost twice a day and the average brand posted every week. Brands continuously seek engagement from fans in the form of likes, comments and shares. They ask questions, host competitions, and post memes and videos to spark engagement and conversation. Brands appropriate content from the internet that they re-post on their own pages to generate interaction with fans. They also produce advertisements, images of promotional activities and Facebook-specific content to engage with fans. The content routinely draws on drinking culture, popular culture and everyday life. Brands arrange the timing and context of their posts to engage with users in real time. The most common day for brands to post is a Friday, and the most popular time of day to post is between 3pm and 5pm. These posts often reference drinking rituals that accompany the end of the day or the week. Brands routinely post content on sporting and music events, cultural pastimes and national holidays. They also post content that fans will interact with via their smartphones. These posts encourage them to ‘check in’ at events, take, upload and tag photos, and comment on time-specific posts. In 2012, the authors conducted a search on Facebook for sites specifically related to 898 alcohol brands across 16 different alcoholic beverage types. They identified 1,017 company-sponsored alcohol brand-related sites on Facebook. The highest scoring product was Diageo’s Smirnoff vodka, with 58 company Facebook sites.

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Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) PPD Uzunoglu and Oksuz 2014, Turkey (24)

PPD Williams and Schmidt 2014, USA (53)

PPD Winpenny et al 2012 (26) and 2014, UK (27) GPD Winpenny et al 2012a, UK (28) PPD Burton et al 2013, international (29) PPD Dadich et al 2013, international (30)

PPD Jones et al 2013, Australia (31) PPD Weaver et al 2013, Australia (32) PPD Nicholls 2012, UK (33)

This paper shows how social media can be used to interact with consumers in the case of ad-restricted alcohol products, providing a case study from Turkey. Alcohol products provide an interesting case study, as they face many restrictions, thus calling for a more creative and efficient approach to the design and implementation of social media practices, and their integration into integrated marketing communication campaigns. The case study shows a well planned, creative campaign that successfully exploits the opportunities provided by interactivity. It indicates the best ways to shape both business-to-consumer and consumer-to-consumer dialogues. In this study, a total of 105 internet alcohol vendor websites were examined for six key features: products offered, average prices and proportions of vendors using different promotions, policy statements and methods for age verification, payment and delivery. The websites sold and promoted a variety of alcohol products, offered as cheaply as US$1.93 for a 750ml bottle. Vendors rely heavily on age verification methods that are unlikely to prevent underage sales. Many vendors advertise shipping of products via methods through which it is illegal or against delivery company policies to transport alcohol, and 99% of vendors accept credit cards. For five alcohol brands most widely advertised on UK television, the researchers analysed their internet-based marketing activities. All five of the alcohol brands maintained a brand website, a Facebook page and a Twitter page, while three of the five also hosted a YouTube channel. Facebook features included profile pages for comments by the marketers and by users, and additional content such as competitions, videos, recipes or applications such as games, inviting users to engage with marketer content. Similarly, marketer-generated YouTube sites contained a variety of videos related to the product, including adverts, and in one case comedy videos. Twitter accounts contained tweets by the marketer and others, relating to the product, but also tweets on a variety of other subjects including comedy, fashion and recipes. Features such as the 'like' button on Facebook and the use of competitions and games enable the spread of brand engagement through social networks. In this study, six Twitter accounts maintained by advocates of safe drinking and/or abstinence were compared with six accounts maintained by alcohol companies. The Twitter accounts of alcohol companies were followed by more people, and their tweets were more likely to use interactive features such as hashtags, to be forwarded to others, and to be associated with positive stimuli, suggesting greater interactivity and influence than the pro-health Twitter messages. The authors surveyed the Twitter use by seven global alcohol brands, including Corona, Heineken, Smirnoff and Jack Daniel’s, over six months, and found they associated their brands with positive and popular themes. They encouraged ‘retweets’ and used searchable hashtags for popular sports and social events. Promotions were often retweeted to a much larger secondary audience, increasing the risk of underage engagement. The study noted that the beer company Budweiser sent 286 tweets to its 15,043 followers, which were then retweeted 13,523 times to other people. The authors examined the official Facebook pages of 12 alcohol brands during May–June 2012. Alcohol brands had an average of 75,000 fans across the 11 Australian-based pages. The two-way nature of communication was evident with Facebook posts by fans exceeding posts by brands by more than 28 to 1 (4,796 compared to 170). All pages appeared to breach one or more clauses of the Alcohol Beverages Advertising Code. The widespread presence of ‘unofficial’ pages is also problematic: six brands had 50 or more such unofficial pages. The authors reviewed the content of 384 alcohol-related downloadable apps for smartphones, and found 50% (192) were entertainment apps, 39% (148) were blood alcohol calculator apps, and 11% (44) were health promotion and/or stop drinking-related apps. Of the entertainment apps, all were pro-consumption, although fewer than one-fifth were brand-promotional, with the remainder offering games, recipes, retail locations and hangover advice. Using screengrab technology, the authors captured the complete Facebook walls and Twitter timelines for 12 leading UK alcohol brands in November 2011. A total of 701 brand-authored posts were identified and categorised. Key strategic trends were identified including the use of

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PPD Gordon 2011, UK (35)

GPD Chester et al 2010, USA (36)

PPD, GPD Hastings et al 2010, UK (37) Hastings 2010, UK (38)

PPD Kim and McClung 2010, USA (39)

real-world tie-ins, interactive games, competitions and time-specific suggestions to drink. These methods reflect a strategy of branded conversation stimulus that is favoured by social media marketing agencies, reinforcing the normalisation of daily consumption. The authors examined a total of 8,476 social networking pages that referred to leading alcohol brands. Alcohol brands were represented both officially (e.g. alcohol advertisements) and unofficially (e.g. user-generated content). Many leading brands also had official Facebook pages, which they were able to create free of charge to promote and advertise their products. Third parties, including young people, had created unofficial advertisements depicting product images, logos and links to official brand websites. Official pages differed slightly in that most, but not all, made reference to responsible drinking, included links to Drinkaware, and did not allow images of what might appear to be underage drinking. Unofficial pages omitted references to responsible drinking and presented alcohol brands and drunkenness in a celebratory manner. The author conducted an audit of the websites of the 10 leading alcohol brands by sales, for each of four categories: lager, spirits, flavoured alcoholic beverages and cider/perry. Each of the 40 sites was visited twice over a one-month period, and the content reviewed. It was found that 27 of 40 leading alcohol brands had a dedicated website. Sites featured sophisticated content, including sports and music sections, games, downloads and competitions. Case studies of two brand websites demonstrate the range of content featured on such sites. This report provides examples of the ‘360 degree’ marketing approach used by alcohol companies to promote their brands ”to reach viewers and users repeatedly, wherever they are across the media landscape, both online and off.” For example, in The Smirnoff Secret Experience Party 2008, admission to what was billed as “the biggest free party” in the country depended on finding tickets that had been placed “in the real world across Australia.” Clues were placed on an ‘underground blog’, on mobile sites, Facebook, YouTube and other online locations. The report gives examples of online games sponsored by beer companies, with promotional advertising in the games. It describes widgets and apps for mobile phones which offer coupons when print ads are scanned by the phone, recipes for cocktails, location finders for the nearest outlet for the user’s favourite drink, and interactive branded games: “Malibu rum’s free iPhone game ‘Get Your Island On’ …The controls are simple. Enter your age (tell the truth!), decide where you want to play, if you want to play alone or with a friend, just grab yourself a ball….” The author shows digital media targeting of Latino- and African-Americans with alcohol promotions. These documents report an analysis of papers obtained by the UK Parliamentary Health Select Committee’s investigation into alcohol marketing self-regulation. They note that digital media – including social networking sites, email, viral marketing and texts – are a fast growing channel for alcohol advertising and are less regulated than traditional media. Viral marketing campaigns are designed to encourage young people to pass on messages to their friends, with no means of controlling who receives them. The aim is to gain credibility by making it seem as if the message is from a trustworthy friend, despite the branded messaging. Similarly, campaigns promoting girls dancing the ‘Lambrini’ have resulted in many self-filmed imitations – often featuring girls who appear to be under the legal drinking age – being posted on the company’s site and various social networking sites. This study examines the views of 253 sport video game users concerning the acceptability of product placement in sport video games. The results indicate that while sport video gamers generally have favourable attitudes toward product placement in sport video games, ethicallycharged products such as alcohol, cigarettes and guns are perceived as less acceptable than other products. Also, sport video gamers who have favourable attitudes toward product placement, in general, are more likely to intend to purchase a product or brand which may be placed in sport video games.

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Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) GPD Mart 2010, USA (40) PPD Mart et al 2009, USA (41) GPD European Centre for Monitoring Alcohol Marketing 2009, Europe (42) GPD Center on Alcohol Marketing and Youth 2004, USA (43) PPD Carroll and Donovan 2002, Australia (44)

The authors examined Facebook ads, pages, apps, events and groups using fabricated users. Ads: After users became fans of several alcoholrelated pages and ‘alcohol’ and ‘bars’ were listed in their interests, they received one alcohol-related advertisement out of every eight received. Pages: 93 pages had over 1.1 million fans listed for the top-selling beer brands, and 334 pages had over 3.2 million fans listed for the 10 topselling spirits brands. Apps: More than 500 apps were associated with eight general alcohol terms. Examples are ‘Bacardi Mojito Party’ (users offer recipes) and ‘Send Your Friends a Shot of Jose Cuervo’ (users upload photos of products). Events: Alcohol-related Facebook events were common, with over 2,200 events associated with the five best-selling beer and spirits brands. Groups: When the term ‘alcohol’ was entered into the Facebook search engine, more than 58,000 groups were found, of which 342 groups were for ‘binge drinkers’. This report provides examples of alcohol marketing practices in the European region. For example “the Dutch website of Heineken gives information on concerts, sports and events, as well as tickets to parties and special events” and an example of a widget is “the Bacardi Banner Widget with which people could invite friends to their party or be invited for another party in a digital setting that was filled with Bacardibranding.” The Absolut Vodka site offered a themed online music radio station while Captain Morgan rum held a ‘pose off’ competition “in which consumers of Diageo’s Captain Morgan Rum were asked to upload pictures of themselves in the same pose as the brand’s mascot Captain Morgan.” The campaign included a gallery of all the uploaded pictures and offered instruction videos by Playboy’s ‘girls next door’. Over a three-week period in October and November 2003, the authors reviewed 74 websites operated by alcohol companies and found widespread use of the kinds of features catalogued by the authors as potentially attractive to underage youth. Branded sites offered video games, downloadable pictures of young women, and a variety of interactive toys such as instant messaging accessories and customised music downloads. Thirty of the sites featured cartoons and animated graphics. This report reviews previous literature and provides examples of the content of six Australian branded websites. For example the Strongbow cider site “features clear links to its current advertising campaign, …[and] includes the current television commercial, a spoof television commercial in which a mother finds and modifies her son’s pornographic magazine collection, and a list of ‘one-liners, quotes and witty content’. Visitors are also invited to produce and send their own spoof Strongbow television commercial.”

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Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) The search for papers demonstrating the nature and extent of digital marketing identified 21 studies, of which 17 reported primary data on marketing using digital media, and two reported reviews and secondary evidence. All papers noted the rising use of a wide range of digital platforms, with some brands having multiple representations on each one, including up to 50 Facebook pages for a brand and several Twitter accounts for a brand. Digital media specifically aim to encourage interaction with the media user, with galleries where users can upload photos and messages. Brands also offer services such as listings of social, sports and music events, and issue messages that they design to be re-issued by users. Retail marketing is also available online, offering home delivery services. Data on the extent of digital media alcohol marketing are indicative of a rapidly increasing use of these forms of media, in many potential markets around the world.

3. Is there evidence that specific population groups are targeted or attracted? And is there quantitative evidence of their exposure levels? Nine studies were found which gave evidence of exposure to digital alcohol marketing in certain groups, from which the authors conclude that these groups are likely to be specifically targeted or may be specifically vulnerable to marketing messages (see Table 4). In several papers the concern was to identify underage exposure or youth exposure, and in these cases the authors conclude that such exposure was demonstrated. In one paper (36) there was evidence that ethnic groups (Latinoand African-Americans) were targeted by alcohol promotions. The review by De Bruijn et al (49) stated that advertisers use child-attractive content, such as animations and animals, but the authors do not demonstrate this with evidence from internet sites of social media content. De Bruijn’s study of young people’s digital media usage in four European countries (46) found that, among children aged 13–14 years, 33% had received promotional mail, emails, or joke, chain or wind up emails mentioning alcohol brands; 18% had downloaded a mobile phone or computer screensaver containing an alcohol brand name or logo; and 66% had noticed an internet page that contained an alcohol advertisement. Only one study compared exposure in different age groups (50) based on interviews with Brazilian children aged 14–17 years and young adults aged 18–25 years, in 2005–06. The study found that 61% of the younger sample and 60% of the older sample reported exposure to alcohol advertising in a range of media 'almost every day' or 'more than once a day' in the previous month although fewer than 10% in both age groups reported seeing alcohol advertising on the internet. Of the nine studies, one (27) was conducted in the UK. The authors estimated exposure of children (6–14 years) and young people (15–24 years) to alcohol marketing on social media, based on artificially-created subscriptions to social networking sites. They found Facebook pages could not be accessed by subscribers who had registered as being under 18 years, but YouTube and Twitter content could usually be accessed by users of all ages.

15

Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) While these papers provide evidence of potential or actual youth exposure, and while the previous section identified that producers’ digital marketing activities were likely to attract youth, there is a shortage of direct evidence showing that youth, particularly those under the legal drinking age, are specifically targeted. The study by Lyons et al (45) indicates that the age group 18–25 years engages heavily with digital alcohol marketing. Brand owners state that they target young adults, that the material they provide is designed to appeal to that age group, and that they restrict access to their marketing by using age barriers.

Table 4: Targeting and exposure of demographic groups Classification, source, country and reference PPD Jernigan and Rushman 2014, USA (6) PPD Winpenny et al 2014, UK (27)

GPD Lyons et al, 2014, New Zealand (45)

GPD De Bruijn 2013, Europe (46)

PRS McCreanor et al 2013, New Zealand (47)

Summary points

This paper looked at brand and user activity on Facebook for the 15 alcohol brands most popular among US youth. It found that Facebook marketing activity has grown dramatically in the previous three years, and underage users may be accounting for some of this activity. This study describes the exposure of children and young adults to alcohol marketing on social media websites in the UK, estimating the reach (proportion of internet users who used the site in each month) and impressions (number of individual pages viewed on the site in each month) for Facebook, YouTube and Twitter, analysed by age (6–14 years and 15–24 years) and gender. Facebook had the highest reach, with an average monthly reach of 89% of males and 91% of females aged 15–24. YouTube had a similar average monthly reach while Twitter had a considerably lower usage in the age groups studied. Of five highly advertised alcohol brands, all maintained a Facebook page, Twitter page and YouTube channel, with varying levels of user engagement. Facebook pages could not be accessed by an under-18 user, but in most cases YouTube content and Twitter content could be accessed by users of all ages. The authors report the findings of a series of group and individual interviews with 141 youth aged 18–25 years. They found that young people appear particularly attuned to the opportunities social networks offer for publicising their tastes and interests, and engage with heavily branded forms of consumption and marketing online. Consuming alcohol to a point of intoxication was common for most of the participants, and social network technologies were fully integrated into their drinking cultures. Facebook was employed by all participants and was used before, during and following drinking episodes. The interviewees said that uploading and sharing photos on Facebook was important to their drinking cultures and their own identities. The AMPHORA study surveyed 2,938 students and found that in the four selected countries one-third of the youngsters aged 13–14 years received promotional mail, emails, or joke, chain or wind up emails mentioning alcohol brands, more than 20% looked at a website for alcohol brands or about drinking, nearly 20% downloaded a mobile phone or computer screensaver containing an alcohol brand name or logo, and over 30% used a Facebook or similar profile page containing an alcohol brand or logo. Nearly two-thirds of the youngsters had noticed an internet page that contained an alcohol advertisement, and 20% reported that they noticed this often or very often. The authors critically review the research literature on (a) social networking technologies and alcohol marketing and (b) online alcohol content on social networks, and then consider implications for public health knowledge and research. They conclude that social networking systems are positive and pleasurable for young people, but are likely to contribute to pro-alcohol environments and encourage drinking. However, research is currently preliminary and descriptive, and innovative methods and detailed in-depth studies are needed to gain greater understanding of young people's mediated drinking cultures and commercial alcohol promotion.

16

Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) PPD Scharf et al 2013, USA (48)

GRS De Bruijn et al 2012, Europe (49) PPD Pinsky et al 2010, Brazil (50)

PPD Chester et al 2010, USA (36)

In this study, a sample of 20 middle and high school students undertook two weeks of monitoring their exposure to alcohol marketing in a range of media. The students recorded 170 exposures to alcohol marketing, representing 8.5 alcohol-related media exposures per participant in the two-week period. Exposures tended to occur in the afternoon (52%), at point of sale (44%) and on days leading up to the weekend (57%). The authors conducted a literature review that concluded, among other things, that advertisements using humour, celebrities and animals make the product attractive to youth. However, in their review of examples of digital marketing of alcohol the authors did not show examples of these characteristics. In this Brazilian study, 661 adolescents and 430 young adults were selected from households in 143 municipalities. Results showed that 61% of the 14–17-year-olds and 60% of the 18–25-year-olds reported exposure to alcohol advertising in different media 'almost every day' or 'more than once a day' in the previous month; however, in this study conducted in Brazil in 2005–06, fewer than 10% in both age groups reported seeing alcohol advertising on the internet. This report examines a wide range of digital marketing techniques and approaches. Among other results, it finds evidence of digital media targeting Latino- and African-Americans with alcohol promotions.

The search found nine studies which indicated that digital media can be identified as targeting certain demographic groups: one paper found evidence of digital alcohol marketing targeting Latinoand African-Americans and eight papers found evidence that digital alcohol marketing was targeting youth. One study indicated that exposure to marketing once a day or more was just as common among children aged 14–17 years as it was among older young people aged 18–25 years. Four of the papers found evidence of exposure of children to such marketing, with either absent age controls (e.g. on YouTube and Twitter) or weak controls (e.g. Facebook).

4. Is there evidence of marketing code violations and especially of exposure of children and young people to alcohol marketing promoted through digital media? As suggested earlier, brand owners state that their marketing is designed to target young adults. This section describes evidence that marketers are creating material that is attractive to younger age groups, and by design or by neglect allowing younger age groups to gain access to their marketing. The literature search identified 12 papers that provide evidence of various forms of code violation (see Table 5). All of these papers give evidence that underage users are gaining access to alcohol marketing through digital media. Other transgressions depend on the code in place in a given region or country: the paper by Brodmerkel and Carah (51) gives evidence that Facebook pages owned by brands encourage viewers to interact with the page and make statements that the company itself cannot make under the prevailing Australian code of marketing. The pages also display users’ photos that encourage excessive consumption and indicate sexual advantages through alcohol consumption (both prohibited under the Australian code). The photos appear to show people aged under 25 consuming alcohol, which is also in breach of the code. Following complaints from the authors of that paper, in September 2012 the Australian Advertising Standards Bureau determined that (a) a brand's Facebook page is a marketing communication tool; and (b) all contents on the page fall under the industry's self-regulatory code of ethics, including consumer-created content such as user-

17

Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) generated comments and photos. The Alcohol and Tobacco Tax and Trade Bureau in the United States has made a similar finding (52). Two papers (25, 53) show that alcohol retailing through digital media allowed underage purchases to be delivered directly to users. Many of these retailer sites required only a confirmation that the purchaser was of the required age. Several sites claimed and utilised delivery services that were supposed to examine age verification at the time of delivery, but 40% of actual deliveries failed to ask for such verification. Furthermore, some sites claimed to use the United States Postal Service (USPS) to verify age at delivery, but USPS did not offer such a service at the time of the research study; furthermore, it was (and remains) illegal to ship alcohol via the USPS. Four of the 12 studies were conducted in the UK (19, 26, 27, 28, 34, 35). In the study by Winpenny and colleagues (26, 27, 28), the authors estimated exposure of children (6–14 years) and young people (15–24 years) to marketing on social media. They found Facebook pages were subject to agegating under-18 users (self-declared), but that in most cases YouTube content and Twitter content could be accessed by users of all ages. According to the authors, at that time: “Twitter does not register the age of those signing up for a Twitter account and does not operate a mechanism for age restriction unless the brand marketers require users to verify their age through an external mechanism. Three of the five Twitter accounts could be accessed by …14-year-old fictitious users; however, both Stella Artois and Carling required an age approval process before users could ‘follow’ the Twitter account and see the tweets. In the case of Carling this involved accessing the Carling website and entering personal information, including confirmation that the user was over the legal drinking age” (page 156). As of July 2012, Twitter has offered age screening to alcohol brands on a voluntary basis. A study by Atkinson et al (34) in 2009–10 looked at brand-owned websites and brand-owned Facebook pages, accessed from the UK. Atkinson found over 8,000 Facebook pages which referred to alcohol brands, but that only 40 of these (0.5%) were clearly identified as officially supported by the brand owner. Third parties, including young people, had created unofficial pages showing product images, logos and links to official pages and brand websites. Official pages differed slightly in that most, but not all, made reference to responsible drinking, included links to Drinkaware, and did not allow images of what might appear to be underage drinking. Unofficial pages omitted reference to responsible drinking and openly presented alcohol brands and drunkenness in a positive and celebratory manner.

The Atkinson et al study (34) also looked at brand-owned websites. The study found that age verification was required on all 14 brand owners’ home web pages examined, and if access was denied then some of these websites (five of them) automatically diverted the underage website user to the Drinkaware site. Of the 14 brand home sites studied, 11 were abiding by Advertising Standards Authority regulations stating that reference to responsible drinking should be made on the home pages of official alcohol brand websites. The prominence of these references varied, with some websites providing the Drinkaware logo and additional information, while others depicted the Drinkaware web link in small text at the foot of the home page.

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Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) A later study by Atkinson et al (19) examined the content of brand-related social networking messaging on Facebook and Twitter and concluded that age verification was in place on both Facebook and Twitter but that the age self-verification on Twitter could be easily by-passed. They also examined the content of the messaging and concluded that Facebook user comments and tweets did not appear to be created by individuals under the age of 18 and most content was not assessed as targeting underage consumers. A study by Gordon (35) in Scotland looked at 40 leading brands and found they had 17 promotional websites, all of which had age restriction messages or controls. Many had content that the author believed would appeal to minors (several audited sites contained material that would be likely to appeal to underage consumers, including arcade games, pinball, Ninja games or Killer Pool, along with colour graphics and music downloads). There were examples of implied sexual success (guides to flirting, or for a girls’ night out, and a game in which players can create the perfect man or woman). The author notes that in 2003, the alcohol brand WKD was judged to have broken the Portman Group code of conduct, because of the inclusion of pole dancers and other features associating the product with sexual success on the website, which was subsequently redesigned. This study also found evidence of linking the brand to driving cars, with Formula 1 coverage (Budweiser), the World Rally Championship (VK Vodka) and an interactive game in which players can ‘Max’ a motor by modifying it (WKD). Lastly, the study reported websites which linked the product to aggressive or anti-social behaviour, such as an interactive game on the Foster’s website ‘We Want You’ which related to shutting down illegal parties by beating up someone, surveillance and a bust mission; on the WKD site a Ninja arcade game featured characters that fight each other; and the Strongbow site contained an interactive game in which the object was to fire a strong-bow at various targets in a bar or club, such as a beer glass, light fitting and DJ box, in a context where people sitting on stools could be hit by the arrow. In this game, a high scorer could register with the company and win festival tickets.

Table 5: Evidence of marketing code violations Classification, source, country and reference GPD Atkinson et al 2015, UK (19)

Summary points

The research involved a content analysis of social network media, interviews and discussions with friendship groups of young people (16–21 years). Age verification was in place on both Facebook and Twitter but the age self-verification on Twitter was judged to be easily by-passed. However, Facebook user comments and tweets did not appear to be created by individuals under the age of 18 and most content was not assessed as targeting underage consumers. Young people were highly knowledgeable about SNS alcohol advertising and chose to engage with marketing content for self-gain (e.g. entering competitions, being informed on local event marketing and promotions).

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Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) PPD Barry et al 2015, USA (54)

PPD Williams and Schmidt 2014, USA (53)

PPD Jernigan and Rushman 2014, USA (6) PRS Jones et al 2014, Australia (55) PPD Jones et al 2012, Australia (56) PPD Winpenny et al 2012 (26) and 2014, UK (27) GPD Winpenny et al 2012a, UK (28) PPD Brodmerkel and Carah 2013, Australia (51)

PPD Jones et al 2013, Australia (31)

The authors assessed 16 alcohol brands (beer and liquor) associated with the highest prevalence of previous 30-day underage alcohol consumption in the USA. Fictitious YouTube user profiles were created and assigned the ages of 14, 17 and 19. These profiles then attempted to access and view the brewer-sponsored YouTube channels for each of the 16 selected brands. Every underage profile, regardless of age, was able to subscribe successfully to each of the 16 (100%) official YouTube channels. On average, two-thirds of the brands' channels were successfully viewed (67%). This paper reports a study of 105 internet alcohol vendor websites that sell and promote a variety of alcohol products, offered as cheaply as US$1.93 for a 750ml bottle. It found that 99% of vendors accept credit cards and that vendors rely heavily on age verification methods – such as possession of a credit card – that are unlikely to prevent underage sales. It also found that many vendors advertise shipping of products using methods which may be illegal, or against delivery company policies to transport alcohol. The authors critically reviewed the existing policies of Facebook, Twitter and YouTube and found weaknesses in measures designed to keep branded alcohol content away from underage youth. Looking at brand and user activity on Facebook for the 15 alcohol brands most popular among US youth, they found activity had grown dramatically in the previous three years, and underage users may be accounting for some of this activity. The authors conducted two studies to examine the existence, and effectiveness, of tools to prevent children from accessing alcohol marketing online. Study 1 examined the strategies used by alcohol marketers to prevent those under the legal drinking age from accessing their product websites, using a sample of 25 alcohol brand websites. Study 2 examined the effectiveness of commercial filters in restricting access to online alcohol marketing, utilising young adult testers and commonly-used internet filters. These studies found that only half of the alcohol websites had a process in place to ‘block’ entry to users aged under 18 years, and in no cases were users prevented from trying again with a different date of birth. Even the most effective commercial filters allowed access to one-third of the sites examined in the study, and most to many more. Using data from the top 10 TV channels in the UK, the authors identified five drinks brands that had the highest TV advertising exposure to children (4–15 years). During February and March 2012, they examined each of these brands across the three social media sites. Facebook was the most used social media site, with an average reach across the observation period ranging from 39% in males aged 6–14 to 91% among females aged 15–24. Age restrictions to alcohol brand content varied across the sites: Facebook users under the age of 18 years were not able to access 'official' alcohol brand pages, although most user-generated content and some brand-generated applications were still accessible. By contrast, YouTube and Twitter did not maintain age restriction, and in most cases users of all ages were able to view and interact with brand content. The authors examined 14 alcohol brands’ official Facebook pages. They found evidence that the brand owners use the Facebook pages (a) to link the brand to cultural practices and values – e.g. national sporting prowess and idealised leisure activities – and to promote popular music and inner-city nightlife; and (b) to mediate drinking culture in a way that challenges regulatory codes by prompting consumers to say things that brands are prohibited from saying. Activities appeared to be in breach of the regulatory codes by promoting the excessive consumption of alcohol, e.g. showing several hundred photos of fans consuming the brand’s products in social settings such as music festivals and clubs, with large boxes of empty vodka bottles and young men surrounded by attractive female Smirnoff promoters wearing tight fitting branded dresses. Many of Smirnoff’s images were taken of young people at music festivals or nightclubs who appeared to be under the age of 25, in contravention of the advertising code. The authors examined the official Facebook pages of 12 alcohol brands during May–June 2012. Alcohol brands had an average of 75,000 fans across the 11 Australian-based pages. The two-way nature of communication was evident with posts by fans exceeding posts by brands by more than 28 to 1 (4,796 compared to 170). All Facebook pages appeared to breach one or more clauses of the Alcohol Beverages Advertising Code, most commonly: 1(a) mature, balanced and responsible approach to consumption of alcohol; 1(b) appeal to children or adolescents; and 1(c) suggest consumption or presence of alcohol beverages as a cause of or contributing to a significant change in mood or environment. The widespread presence of ‘unofficial’ pages is potentially even more problematic, with six of 12 brands having 50 or more.

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Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) PPD Williams and Ribisl 2012, USA (25)


PPD Gordon 2011, UK (35)

GPD Mart 2010, USA (40) PPD Mart et al 2009, USA (41)

In this study, eight individuals aged 18–20 years (underage in North Carolina) participated in attempting to purchase alcohol from online vendors. Of 100 orders placed by the underage buyers, 45% were successfully received, and only 28% were rejected as the result of age verification. Most vendors (59%) used weak, if any, age verification at the point of order and, of 45 successful orders, 23 (51%) used none. Age verification at delivery was inconsistently conducted and, when it was attempted, it failed about half the time. A total of 8,476 social networking pages, which referred to a number of leading alcohol brands, were retrieved. After registering with Facebook using a fictitious age of 14, the researchers found that official alcohol brand pages were not accessible. However, only 40 (0.5%) of the social networking pages devoted to specific alcohol brands were clearly identified as official. Third parties, including young people, had created unofficial advertisements depicting product images, logos and links to official brand websites. Official pages differed slightly in that most, but not all, made reference to responsible drinking, included links to Drinkaware, and did not allow images of what might appear to be underage drinking. Unofficial pages omitted reference to responsible drinking and openly presented alcohol brands and drunkenness in a positive and celebratory manner. This study of 40 leading alcohol brand producers found that 27 had a dedicated brand website, and these featured sophisticated content, including sports and music, games, downloads and competitions. When applying regulatory codes covering traditional alcohol marketing it was found that some alcohol brand websites showed content which may breach the codes in respect of (a) appealing to under-18s; (b) implying sexual success; (c) links to driving cars; and (d) links to risk taking and anti-social behaviour. The authors examined Facebook ads, pages, applications, events and groups, using a fictitious person aged over 21 years (the legal drinking age) and a second aged under 21 years. Ads: After ‘alcohol’ and ‘bars’ were listed in the users' interests, and the users became fans of several alcohol-related pages, one alcohol-related ad appeared out of every eight ads, for both users. Pages: Of the Facebook pages for 12 popular brands, six were accessed by the under-21 user: Captain Morgan, Jack Daniel’s, Bacardi, Bacardi Breezer, Heineken and Mike's Hard Lemonade. Applications: More than 500 separate applications are currently associated with alcohol. Some allowed under-21s to access the applicationsrelated page but not the application itself. Events: Most events pages could be accessed by the under21 user. Groups: When the term ‘alcohol’ was entered into the Facebook search engine, more than 58,000 groups were displayed. The majority of the alcohol-related groups reviewed were accessible to the under-21 user.

The search for evidence of breaches of marketing controls found 12 studies indicating potential code breaches. Four of the studies examined potential weaknesses or code breaches within the UK, and all found evidence for potential violations. There was evidence that the official pages sponsored by alcohol brands on Facebook blocked access to Facebook users who declared themselves to be under 18 years, and the messages posted on these pages do not appear to come from underage users (presumably such messages are edited by the page sponsors). Some of the Facebook pages, but not all, referred to responsible drinking, including links to the Drinkaware site. Access to branded marketing sponsored by alcohol companies on other media platforms, including popular media such as YouTube and Twitter, appeared to have no age restrictions in place or the age restrictions could easily be by-passed.

Discussion Alcohol consumption is driven by a wide range of factors – including familial, cultural and social norms, price and availability – and is stimulated by drinking behaviours represented in mainstream media from TV soap opera to film and music and, as we have noted, representations in social networking media. Alcohol producers have an interest in all these drivers of consumption, including representation in digital media. While it may be the case that the alcohol producers encourage an 21

Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) ‘intoxigenic’ discourse in social media, it is beyond the remit of the present paper to consider the wider discourse. Here we have focused on digital communications that originate primarily from the marketers themselves. This paper has found evidence relating to all four of the questions posed in the Introduction: 1. Is there evidence that alcohol marketing through digital media influences drinking behaviour or increases consumption? 2. What methods of promotional marketing are used, and to what extent? 3. Is there evidence that specific population groups are targeted or attracted? And is there quantitative evidence of their exposure levels? 4. Is there evidence of marketing code violations and especially of exposure of children and young people to alcohol marketing promoted through digital media? Five papers provided some evidence that branded alcohol promotion in digital media is associated with increased alcohol consumption, or increased likelihood of binge drinking behaviour, based on six cross-sectional studies and one controlled intervention. The cross-sectional studies cannot show the direction of causality (e.g. drinkers may be more interested in alcohol advertising) or fully eliminate other factors that could simultaneously influence both digital marketing engagement and alcohol consumption (e.g. personality type). However, the controlled intervention study indicated causality, and the authors of the study concluded that digital media marketing acted to increase consumption directly, rather than as a complementary activity to marketing through other media. They found that digital media marketing was especially effective for products that were newly launched or little-recognised in a particular region. While they could not quantify the direct effects of internet marketing, they noted that such marketing reduced the effect of a ban on advertising in traditional media by some 62%. Twenty-one studies, reported in 26 papers, provided evidence of the nature and methods of promotional marketing in digital media, indicating the wide range of approaches used by product owners and marketing agencies to attract and engage the media users, through both commerciallyowned media and through social networking media. Alcohol brands have multiple websites, as many as 50 different Facebook pages, YouTube clips and dedicated YouTube channels, and multiple Twitter feeds. Their sites encourage interaction and engagement with opportunities to upload users’ photographs of drinking behaviour, post messages and share a general discourse on drinking behaviours. While many of the studies suggested that the messages and methods of marketing in digital media are likely to appeal to children and young people, nine studies gave specific but limited evidence of the extent to which identifiable population groups are attracted to digital alcohol marketing. No paper gave clear breakdowns of differential engagement by sub-group, apart from one conducted in Brazil which indicated that younger adolescents were just as likely as older adolescents/young adults to be aware of digital and non-digital alcohol marketing. No study provided evidence of engagement with alcohol marketing across the full adult range; nearly all papers focused on young adults and/or adolescents. No study gave information on differential access or engagement according to social class or household income, or educational level or other indicator of socio-economic status. One 22

Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) paper indicated that some digital marketing appears to be directed specifically to Latino- and African-Americans in the USA. Lastly, 12 studies, reported in 16 papers, gave evidence for apparent violations of marketing codes in digital media, primarily showing underage access to advertising and marketing messages on digital media, and to retail deliveries purchased through website promotions. Examples are given of online brand websites using material attractive to minors, linking the brand to sexual success, to car driving, and to using violence and anti-social behaviour. A study in the UK showed that while Facebook brand pages had age restrictions, unofficial pages did not, and there were few or no age restrictions to brand-owned Twitter or YouTube media, or the restrictions could be by-passed. As we have noted, the primary concern in most of the papers examined was exposure of children and young people to alcohol-promoting messages. Policies to deal with this problem have ranged widely, and below we note some of the proposals contained in the papers examined for this review. One of the first recommendations is to extend current codes of marketing to online media. In September 2012, the Australian Advertising Standards Bureau declared that brand-owned websites and social networking pages are marketing communications, and that “all content falls within the industry marketing codes,” including “consumer-created content such as user-generated messages and uploaded photographs.” It remains to be seen how this adjudication will affect the content of brand-owned sites in Australia, and whether it might be extended to unofficial, user-generated marketing that includes trademarked or copyrighted material.

A mechanism which has been advanced for restricting minors’ access to adult content has been the use of parental control software. A paper from the Center on Alcohol Marketing and Youth in 2004 (43), which investigated available software for parental controls on digital media platforms for alcohol products, showed that most software products were not adequate for protecting children from accessing alcohol-related websites: 76% of alcohol brands eluded parental controls half the time or more. However, the survey found that software controls offered by MSN were 99% effective, indicating that it is feasible (or was feasible around 2004) to control access to certain online content through parental oversight. In the process of researching this paper we were aware that many authors were keen to support the development of policies that control and restrict alcohol promotion and especially that protect underage youth from any commercial incentives to engage in drinking behaviour. Policy development is not keeping up with the rapid development of digital media, in terms of finding methods for controlling the content of the media or restricting the exposure of underage youth to its content. Table 6 below shows some examples of policy proposals made in the papers we have reviewed. This should not be taken as a comprehensive list, and we recommend that a more detailed examination of policy options be undertaken. Table 6: Examples of policy recommendations from reviewed literature Source

Recommendation

23

Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) Australian National Preventive Health Agency , 2014 (57) Australian Medical Association, 2012 (60) Chester et al, 2010 (36)

University of Stirling, 2013 (59) Australian Medical Association, 2012 (60) Brodmerkel and Carah, 2013 (51)

Carah, 2014 (21)

Chester et al, 2010 (36)

De Bruijn et al, 2012 (49) Eurocare, 2014 (58) University of Stirling, 2013 (59)

Monitoring Monitor, research and regularly review Australian children’s and adolescents’ continued exposure to alcohol advertising, particularly on digital media and the effectiveness of selfregulatory, co-regulatory and legislative measures to limit this exposure, and report on this research every two years to the relevant Ministerial Council. The amount spent annually on marketing by leading alcohol companies should be publicly disclosed, including expenditure on social media, online video, mobile campaigns, events sponsorship and product placement. US alcohol companies and trade associations should be required to publish annual ‘transparency reports’ of what they are doing in digital and virtual marketing, including search engine marketing… what data they are collecting about internet users, and how they are using those data. If these cannot be placed in the public domain for competitive reasons, they should be required to be filed annually with the Federal Trade Commission, which should then summarise them and release the summary results to the public. Alcohol producers should be required to declare their expenditure on marketing and the level of exposure of young people to their campaigns. Regulatory approaches The regulation of alcohol marketing should be expanded to incorporate point-of-sale promotions, branded merchandise, and new media and digital marketing, including marketing through social media, viral campaigns, mobile phones, and the use of data collection and behavioural profiling. Regulations should be sufficiently flexible to incorporate new and evolving digital marketing activities. Regulators need to acknowledge that modern forms of branding bring together popular culture, material spaces, social media, mobile devices and surveillance capacities that allow for location-based targeting in a way that engages young drinkers in a continuous incorporation of the brand into their everyday life, peer networks, identity and cultural experiences. These practices require new regulatory responses that] go beyond examining only the specific content of promotional texts, and require a regulatory approach that recognises that an alcohol brand is not contained within advertisements but is mediated out of the interaction between brands, cultural intermediaries and consumers. If an individual user checks into Facebook and receives vouchers to spend which are also sent to his ‘friends’ group, it shows] how marketing interactions and messages ‘disappear’ into niche social networks where they cannot be observed and accounted for as part of a public process of debate and scrutiny. …Social media pose the important question of the extent to which brands should be publicly observable and accountable….Policy makers need to explicitly address in regulatory approaches the role that marketers get consumers to play in their alcohol marketing activities… Policy makers need to develop regulatory approaches that encompass all forms of alcohol marketing activity in one framework. The US Federal Trade Commission and state attorneys general should investigate the techniques being used to create ads that are designed to foster ‘immersive’ and subconscious messages, including the use of neuromarketing-related techniques designed to influence or measure subconscious responses. Alcohol marketing regulations are recommended to focus on restricting the volume of alcohol marketing rather than the content. Content restrictions that are in place in selfregulation codes are ambiguous and open to interpretation. Recommendations are (a) no alcohol advertising on television or in cinemas; (b) no alcohol advertising on the internet except at points of sale; (c) no alcohol sponsorship of cultural or sports events; and (d) no alcohol advertising should be targeted at young people. In the short term, alcohol advertising should only be permitted in newspapers and other adult press. Its content should be limited to factual information about brand, provenance and product strength. In the longer term, all alcohol advertising and sponsorship should be prohibited. Specific rules on content

24

Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) Australian National Preventive Health Agency, 2014 (57) Eurocare, 2014 (58)

Australian National Preventive Health Agency, 2014 (57) University of Stirling, 2013 (59)

Burton et al, 2013 (29)

Chester et al, 2010 (36) Chester et al, 2010 (36)

Add new provisions to strengthen and improve clarity about appeal to children. Ensure, at minimum, specific prohibitions in the areas of (a) identifiable heroes or heroines of the young; (b) cartoon characters and animations appealing to children; and (c) use of childhood motifs or themes. Alcohol advertising should only be permitted under precise conditions defined by statutory regulation. When alcohol advertising is permitted, its content should be controlled. (a) Messages and images should refer only to information about the products such as degree, origin, composition and means of production. (b) A health message must be included on all alcohol advertisements, drawing attention to specific risks associated with the alcohol product. (c) Messages should neither mention nor link to sexual, social and sports-related images, nor imply benefits related to these areas that accrue from consumption of alcoholic products. Enforcement Examine alternatives for an effective range and hierarchy of sanctions for enforcement of the Australian marketing code decisions including the options of public lists of firms breaching the code and the nature of the breach, adverse publicity orders, required published corrections, and financial penalties. An independent body should be established to regulate alcohol promotion, including product and packaging design, in the interests of public health and community safety.

Non-regulatory actions Alcohol companies are using interaction and personalisation on Twitter far more effectively than organisations promoting safe drinking. To be more effective in their social marketing practices, non-profit organisations may benefit from studying, and learning from, the practices of for-profit organisations. Alcohol industry self-regulatory codes should be strengthened to explicitly ban the collection of psychographic information on underage users of any website, whether controlled by alcohol marketers or not. Alcohol companies should observe a 15% maximum youth audience standard, based on users aged 12–20 (the group most at risk of underage drinking), for placing advertising in digital media. The January 2008 agreement between MySpace and 49 state attorneys general to protect children online, including limitations on tobacco and alcohol advertisements to those aged under 18 and 21, respectively, might serve as a model in this regard.

Lastly, it may be helpful to comment on research priorities. Meier (62) has noted that research has tended to rely on simplified models of marketing and has focused disproportionately on youth populations. The effects of cumulative exposure across multiple marketing channels, targeting of messages at certain population groups and indirect effects of advertising on consumption remain unclear. Meier highlighted specific evidence needs for policy makers:   

the size of marketing effects for the whole population and for policy-relevant population subgroups the balance between immediate and long-term effects and the time lag, duration and cumulative build-up of effects the comparative effects of partial versus comprehensive marketing restrictions on consumption and harm.

Conclusion 25

Appendix 2 – Commercial use of digital media, including social media platforms to market alcohol products: a narrative review of the literature for Public Health England (Review 2) This paper has sought to summarise the research literature available since 2000 on alcohol marketing in digital and social media, viewed from a public health perspective and with a particular focus on the protection of vulnerable populations such as youth. There is evidence to help answer all four of the questions posed, and although this evidence is not robust in nature, virtually all studies indicated that marketing through digital media is likely to be having an impact on drinking behaviour, that the marketing activities make use of materials and approaches that are attractive to young people, and that current marketing codes are likely to be undermined by digital media.

The rapid development of immersive technologies that promote brands as personalities rather than products, and that encourage user engagement and participation in the marketing itself, raises important and challenging regulatory questions. Theoretical models have been developed to show the coincident progression of youth drinking behaviour towards problem drinking; however, as engagement with marketing grows (61), there is a lack of longitudinal studies focused on identifying youth exposure to marketing by brand, and exploring youth alcohol consumption by brand, to demonstrate causal links from the marketing activities to the drinking behaviour. The danger is that by the time such studies are funded and completed, it may be too late to prevent the influence of such marketing on an entire generation of young people. In the meantime a precautionary approach appears justified.

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