Research on Marketing and the Code
These studies explore issues around the marketing of infant formula which come under the umbrella of the International Code of Marketing of Breastmilk Substitutes (the Code). See our dedicated resource page for more information on the Code and further reading.
Prioritising Profits Over Public Health? Why UK Commercial Milk Formula Marketing Regulations Need to be Strengthened and Enforced, Not Weakened
Ahead of the final Competition and Marketing Authority infant formula and follow on formula market study, authors of this article make the following calls to action to the UK Government to better safeguard the health of all UK infants:
- Actively place public health imperatives at the heart of the actions it intends to take following the CMA’s final report.
- Strengthen commercial milk formula marketing regulations and more closely align national rules with the international minimum standards on marketing of breastmilk substitutes outlined in ‘the Code’.
- Improve the provision of sufficient, clear, authoritative and impartial advice on commercial milk formulas to counteract company advertising and better enable parents to make informed decisions on how they feed their babies and young children.
- Impose price controls on necessary commercial milk formulas.
- Ensure the effective enforcement of regulations.
UK government’s nutrition advisers are paid by world’s largest food companies, BMJ analysis reveals
More than half of the experts on the UK government’s advisory panel on nutrition have links to the food industry, a BMJ analysis has found. At least 11 of the 17 members of the Scientific Advisory Committee on Nutrition (SACN) have conflicts of interest with the likes of Nestlé, sugar manufacturer Tate and Lyle, and the world’s largest ice cream producer, Unilever.
Infant formula donations and code violations during earthquake relief efforts in Türkiye in 2023: an observational study
This study aims to document violations of the Code and the OG-IFE during the earthquake relief efforts to help strengthen infant and young child feeding emergency responses and inform future disaster relief policies. These incidents reflected a systematic violation of the Code and non-compliance with the OG-IFE. Globally accepted IYCF standards and recommendations were not consistently followed due to fragmented early responses. There is a critical need to step up efforts to ensure appropriate and safe IYCF practice protecting and supporting breastfed and non-breastfed infants in emergencies.
Violations of Vietnamese laws related to the online marketing of breastmilk substitutes: Detections using a virtual violations detector
This study aimed to quantify the extent and nature of online violations and contradictions in various Vietnamese laws related CMF marketing over 12 months in 2022. Using a cross-sectional study design, the study used an artificial intelligence-enabled virtual violations detector (VIVID) to monitor official websites and social media pages of 25 breastmilk substitute (BMS) merchandise and distributors, every day for 12 months in 2022. Data were summarised descriptively. Findings detected more than 3000 online advertisements that violated or contradicted the intent of Vietnamese laws, involving almost 7000 violations of various articles within these laws (average 9.5 violations per day).
Understanding the Politics of Food Regulation and Public Health: An Analysis of Codex Standard-Setting Processes on Food Labelling
The study involved: (i) collecting Codex Committee on Food Labelling (CCFL) documents (2016-2023); (ii) identification, categorization, and enumeration of actors involved in the development of the Guidelines; and (iii) guided by a constructivist framework, analysis of how actors framed and contested key provisions of the Guidelines. Participation in the Guidelines development process suggests stronger preferences for trade facilitation and commerce over public health. Ambitions to reform the international food regulatory system may require an examination of who participates and how to address this asymmetrical representation of interests. These results suggest the need to greatly strengthen public health representation at Codex.
Outcomes of implementing the International Code of Marketing of Breast-milk Substitutes as national laws: a systematic review
This study systematically searched five academic databases in September 2022 for articles published in English from 1982 to 2022. It used the Mixed Methods Appraisal Tool for quality assessment and synthesized data thematically before applying the Proctor et al. framework to guide synthesis of implementation outcomes and organizing findings according to its taxonomy. Findings indicate that to enhance legal compliance, robust monitoring and reporting systems are necessary. Utilizing technology-assisted solutions for monitoring compliance can be an option for countries with limited human resources. Adequate training for health workers and communication strategies targeting shop managers about national law are also essential in enhancing their acceptability and compliance.
Commercial milk formula marketing entry points: setting the course of infant and young child feeding trajectories
This study highlights how, together with a weak breastfeeding counseling system, and health professionals who lack training in breastfeeding and normal infant behavior, lead to the opportunity for CMF marketing to shape infant feeding, and ultimately to the decision to feed formulas that some mothers were not planning to use and cannot afford.
Guidance on regulatory measures aimed at restricting digital marketing of breast-milk substitutes
Digital environments are fast becoming the predominant source of exposure to promotion of breast-milk substitutes globally. Digital marketing amplifies the reach and power of advertising and other forms of promotion in digital environments, and exposure to digital marketing increases the purchase and use of breast-milk substitutes. In light of this evidence, the Seventy-fifth World Health Assembly requested that WHO develop guidance for Member States on regulatory measures aimed at restricting the digital marketing of breast-milk substitutes. This guidance applies to marketing of products within the scope of the Code as well as foods for infants and young children that are not breast-milk substitutes.
Babies before business: protecting the integrity of health professionals from institutional conflict of interest
This paper outlines how the commercial milk formula industry’s duty to maximise profits conflicts with the health system’s duty to protect health and to support breastfeeding. The marketing tactics and relationships with the commercial milk formula industry including financial or material support, sponsorship of training or research and advertising in journals or at events contribute to conflicts of interest within the health system. It urges national regulatory measures to implement and ensure monitoring of compliance with the International Code of Marketing of Breast-milk Substitutes protect health workers in addition to children and their families.
Health and nutrition claims for infant formula: international cross sectional survey
This international cross sectional survey review analysed available health and nutrition claims for infant formula products to evaluate the validity of the evidence used for substantiation of claims in 15 countries in 2020-22. The main outcome measured included number and type of claims made for each product and ingredient. Results found that most infant formula products had at least one health and nutrition claim. Multiple ingredients were claimed to achieve similar health or nutrition effects, multiple claims were made for the same ingredient type, most products did not provide scientific references to support claims, and referenced claims were not supported by robust clinical trial evidence.
Legislation on marketing of breast-milk substitutes in digital and social media: a scoping review
The aim of this scoping review was to systematically identify and summarise worldwide legislation implemented to regulate breast-milk substitutes (BMS) marketing on digital and social media, as well as identifying areas of opportunity to strengthen and improve it. Documents published from January 2012 to April 2022 were examined using search strategies including multiple databases and citation tracking. A total of 127 sources were evaluated, and only 28 documents from 24 countries meeting the inclusion criteria were retained. The results highlight the urgent call for the explicit regulation of BMS marketing in digital and social media worldwide, as well as the public documentation of such legal measures. Likewise, it is important that there are effective, transparent and free of commercial influence national monitoring systems used to ensure compliance with legal measures.
Content analysis of on-package formula labelling in Great Britain: use of marketing messages on infant, follow-on, growing-up and specialist formula
This study explored on-package formula messaging with reference to legislation and government-issued guidance in Great Britain. Formula products were identified, pictures of all sides of packs collated and on-package text and images were coded. Compliance with both GB legislation and guidance issued by the Department of Health and Social Care (DHSC) was assessed. Findings showed that text and images considered non-permitted according to DHSC guidance for implementing BMS legislation were widespread on formula products available in GB. As terms such as ‘similarity’ are not defined in BMS legislation, it was unclear if breaches had occurred. Findings support the WHO call for loopholes in domestic legislation to be closed as a matter of urgency.
Who benefits from undermining breastfeeding? Exploring the global commercial milk formula industry’s generation and distribution of wealth and income
This report sets out to provide an alternative picture of the global CMF industry’s contribution to economic development and prosperity for national economies by critically examining the industry’s generation and distribution of wealth and income. To achieve this aim, the report seeks to address three interconnected objectives: i) trends in the size and concentration of national CMF markets around the world; ii) the contribution that CMF sales make to the profitability of the global CMF market’s most dominant corporations; and iii) how the global CMF industry distributes its wealth and income, focusing on distribution of corporate wealth and income to governments (i.e., taxation) and among market stakeholders. The paper adopts a novel approach using multiple methods to address these three objectives, sourcing a diverse range of data from various market research and business databases.
Global evidence of persistent violations of the International Code of Marketing of Breastmilk Substitutes: A systematic scoping review
This scoping review systematically examined the published research evidence on the nature and extent of exposure to The International Code of Marketing of Breastmilk Substitutes violations from 1981 to August 2021. Of a total of 657 items, 153 studies were retained in the review from at least 95 countries. Studies reported a broad range of marketing violations, including increased use of marketing via digital platforms, which targeted mothers and families, health workers, and the general public. The evidence showed the use of misleading and inaccurate labeling and health and nutrition claims in breach of the Code. Findings confirm that violations of the Code have not ceased, and calls for renewed attention from the World Health Assembly and national governments are urgently needed in order to protect the health of children and their mothers.
National implementation of the International Code: Status Report 202
This report provides updated information on the status of implementation of the International Code of Marketing of Breastmilk Substitutes (BMS) and subsequent relevant World Health
Assembly (WHA) resolutions and presents the legal status of the Code, including the extent to which the provisions have been incorporated in national legal measures. The report examines how legal measures enacted in the past five years differ from earlier measures. It also identifies provisions specifically pertaining to the digital marketing of breastmilk substitutes (BMS).
View the report by the World Health Organization and UNICEF here.
Conflicts of interest are harming maternal and child health: time for scientific journals to end relationships with manufacturers of breastmilk substitutes
Forty years after the World Health Assembly adopted the International Code of Marketing of Breastmilk Substitutes (the Code), inappropriate marketing of breastmilk substitutes persists and puts infants and young children at risk of malnutrition, illness and death. This report explores how the formula industry uses ‘medical marketing’ strategies to influence scientists and health professionals as to the purported benefit of breastmilk substitutes and calls for all scientific journals and publishers to stop accepting funding from manufacturers and distributors.
Effective regulatory frameworks for ending inappropriate marketing of breast-milk substitutes and foods for infants and young children in the WHO European Region (2022)
This policy brief shares step-by-step guidance on strengthening implementation of the Code and provides a regulatory framework to put an end to unethical marketing practices. It is intended to guide WHO European Region Member States in safeguarding parents and caregivers from promotion of breastmilk substitutes by reviewing current implementation of The International Code of Marketing of Breastmilk Substitutes (the Code) and subsequent resolutions by the World Health Assembly, as well as the 2016 WHO Guidance on ending the inappropriate promotion of foods for infants and young children. Read more and download the brief on our website.
Globalization, first-foods systems transformations and corporate power: a synthesis of literature and data on the market and political practices of the transnational baby food industry
This paper uses a theoretically guided synthesis review method, which integrated diverse qualitative and quantitative data sources, to understand the strategies used by the baby food industry to shape ‘first-foods systems’ across its diverse markets, and in doing so, drive milk formula consumption on a global scale. Findings indicated that the baby food industry uses integrated market and political strategies to shape first-foods systems in ways that drive and sustain milk formula market expansion, on a global scale. Such practices are a major impediment to global implementation of the International Code of Marketing of Breastmilk Substitutes, and other policy actions to protect, promote and support breastfeeding. New modalities of public health action are needed to negate the political practices of the industry in particular, and ultimately to constrain corporate power over the mother-child breastfeeding dyad.
Breastfeeding, first-food systems and corporate power: a case study on the market and political practices of the transnational baby food industry and public health resistance in the Philippines
This paper examines the Philippines as a case study to understand the battle for national Code implementation, with particular attention on political strategies used by the baby food industry to shape the country’s ‘first-food system’. Findings indicate a decline in breastfeeding in the Philippines in the mid-twentieth century associated with intensive breastmilk substitutes (BMS) marketing via health systems and consumer advertising. The Philippines illustrates the continuing battle for worldwide Code implementation, and in particular, how the baby food industry uses and adapts its market and political practices to promote and sustain breastmilk substitutes.
Allergy societies and the formula industry
From the early years, the formula industry aligned itself with allergists and other trusted sources of infant feeding information, leading to widespread inappropriate guidance for infant feeding and false promotion of special health-promoting properties of formula. Hydrolysed formula has been inappropriately recommended for allergy prevention for over 30 years and there is excessive consumption of specialised formula in some regions due to milk allergy overdiagnosis. Formal analysis of allergy societies’ relationships with formula companies has not yet been undertaken, but it is likely that most societies and many conferences and educational activities are sponsored by formula companies. This article discusses the World Allergy Organization’s alignment with the formula industry and calls on them to follow WHO guidance, protect the patients that their members serve and stop accepting funding from formula companies.
Costs of infant formula, follow-on formula and milks marketed as foods for special medical purposes available over the counter in the UK
This report by First Steps Nutrition Trust summarises current data available on the costs of infant formula, follow-on formula and infant milks marketed as foods for special medical purposes marketed over the counter in the UK. The costs of products are given at purchase and have been calculated per 100ml, and per week for a 2-3 month old baby, so that costs can be compared.
Advocacy brief: nutrition for growth year of action: nine SMART breastfeeding pledges
This advocacy brief is organized into two separate papers. The first half acts as a standalone briefing that highlights the importance of the Nutrition for Growth (N4G) Year of Action, positions breastfeeding within its universal health coverage pillar and organizes the SMART breastfeeding recommendations into their corresponding N4G commitment types. The latter half provides the rationale for each of the pledges and signposts towards helpful resources, including official guidance notes and case studies, to support country implementation.
World Health Organization 2021 – License: CC BY-NC-SA 3.0 IGO. ISBN: 9789240030947
Rates and time trends in the consumption of breastmilk, formula, and animal milk by children younger than 2 years from 2000 to 2019: analysis of 113 countries
This time-series analysis combines cross-sectional data from low-, middle- and high-income countries to assess consumption trends in breastmilk, formula, and animal milk by children younger than two years from 2000 to 2019. Increases in breastfeeding rates at six months were found in various regions and income groups, whilst formula consumption increased in upper-middle-income countries. In order to achieve the global target of 70% exclusive breastfeeding by 2030, breastfeeding rates must increase and renewed efforts are needed to counteract declining trends in low-income societies, including strict enforcement of the International Code of Marketing of Breastmilk Substitutes and to halt the marketing and sale of infant formula.
The history and the future of the Code: A four-part series by David Clark
In a four-part series for Alive and Thrive, UNICEF’s former legal specialist for 25 years, David Clark, discusses the history and future of the International Code of Marketing of Breast-milk Substitutes. During his tenure at UNICEF, David was instrumental in assisting more than 60 countries to draft legislation to implement the Code and subsequent resolutions of the World Health Assembly.
Read more on the Baby Friendly blog and visit Alive and Thrive’s website.
Marketing of infant milk in the UK: what do parents see and believe?
Findings from an online survey of 1307 UK mothers with a baby 0 – 12 months revealed that nearly 100% of mothers reported seeing a wide range of adverts for infant milks, with 75% of respondents describing them as ’emotive’ and younger mothers more likely to view them favourably. Mothers who already used infant milks were more inclined to perceive the adverts as clear, scientific and helpful, whilst mothers who did not use infant milks expressed anger at the misleading messaging.
Globalization, first-foods systems transformations and corporate power: a synthesis of literature and data on the market and political practices of the transnational baby food industry
Global milk formula sales grew from ~US$1.5 billion in 1978 to US$55.6 billion in 2019, raising concerns for breastfeeding, child and maternal health and the implementation of the Code. This paper uses a theoretically guided synthesis review method to understand the integrated market and political strategies used by the baby food industry to shape ‘first-foods systems’ and thereby drive global infant formula consumption.
Spotlight on lobbying: Baseline benchmark of major breastmilk substitute manufacturers’ lobbying policies, management systems and disclosure
Lobbying by breastmilk substitute manufacturers is a driving force behind why many countries have not yet adopted the entirety of the Code. This report puts a spotlight on lobbying by evaluating the policies and practices of the nine largest breastmilk substitute manufacturers, which account for 54% of a global market, and highlighting how companies can commit to responsible lobbying.
Access to Nutrition Initiative. Spotlight on Lobbying. May 2021.
Advertising of Human Milk Substitutes in United Kingdom Healthcare Professional Publications: An Observational Study
This cross-observational study calls into question widespread advertising of human milk substitutes which are targeted at UK healthcare professionals. A total of 32 such advertisements were identified, none of which were deemed to be compliant with the International Code of Marketing of Breastmilk Substitutes (the Code) or the UK Formula and Follow-on Formula Regulations. Authors call for urgent adherence to international and local regulations in order to reduce efforts which undermine the protection of breastfeeding.
First‐food systems transformations and the ultra‐processing of infant and young child diets: The determinants, dynamics and consequences of the global rise in commercial milk formula consumption
This study describes trends in global formula sales volumes in 77 countries from 2005 to 2019 in order to understand how first‐food systems (those that provision foods for children aged 0–36 months) explain the global transition to higher formula diets. Results highlight how the marketing and promotion of breastmilk substitutes undermines breastfeeding and harms child and maternal health in all country contexts.
Selling second best: how infant formula marketing works
The study was comprised of a mix of secondary analysis of business databases and qualitative interviews with marketing practitioners, including some of whom had previously worked in formula marketing, to address and attempt to explain the widespread marketing of formula milk. Conclusions found that powerful emotional techniques are used to sell parents a product that is inferior to breast milk and there is urgent need to strengthen regulation.
Danone Nutricia: Why do they want to be your partner?
This evidence-based report published in January 2020 helps NGOs, charities, health professionals and advocacy groups to better understand why breastmilk substitute companies attempt to partner with organisations working with pregnant women, infants and children and how these partnerships can negatively affect care for mothers and babies
Baby Feeding Law Group UK. Danone Nutricia: Why do they want to be your partner? (2020)
Based on science? Revisiting Nestlé’s infant milk products and claims, 2019
This report investigates Nestlé, as the world market leader for infant milk products for babies under 12 months old. It revisits findings from previous reports (Busting the myth of science-based formula, 2018 & Milking it: How Milk Formula Companies are Putting Profits Before Science, 2017 – see write up below). The current report finds that, despite Nestlé committing to making three changes to its global infant formula ranges (removing sucrose and vanilla compounds from all its products for babies aged under 12 months, and removing contradictory nutritional advice on sucrose and vanilla flavourings), it has so far failed to fulfil two out of these three commitments, with only the promise to remove sucrose being fulfilled at the time of publication of the report.
Researchers also found that Nestlé continues to draw comparisons between its products and human milk (a practice coming under the scope of the Code); and practises price premiumisation between different countries and markets. For more detail, see our news post on the report.
Older research
- Morgan, S, Waterston, T, and Kerac, M (2018). Infant formula advertising in medical journals: a cross-sectional study (and struggle to publish). Field Exchange. https://www.ennonline.net/fex/58/infantformulaadvertising
- Don’t push it: Why the formula industry must clean up its act – https://resourcecentre.savethechildren.net/library/dont-push-it-why-formula-milk-industry-must-clean-its-act (March 2018)
- Breaking the rules, Stretching the rules 2017 – https://www.ibfan-icdc.org/ibfan-icdc-launches-its-11th-global-monitoring-report-breaking-the-rules-stretching-the-rules-2017/
- Milking it: How Milk Formula Companies are Putting Profits Before Science – https://changingmarkets.org/portfolio/milking-it
- Jasani, B, et al (2017). Long chain polyunsaturated fatty acid supplementation in infants born at term, Cochrane Database of Systematic Reviews, DOI: 10.1002/14651858.CD000376.pub4