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Online RCT of Added-Sugar Warning Labels and Spanish-English Label Education

Ethan C Wolf¹, Marissa G Hall², Dean Schillinger³

¹Human Development and Family Studies Program, Department of Human Ecology, University of California, Davis, Davis, California; Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California.

American Journal of Preventive Medicine

|July 5, 2025

Abstract

Introduction:

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

Study Design:

This is an online RCT.

Setting/Participants:

A total of 2,000 U.S. Hispanic adults with varying acculturation participated between October and December 2022.

Intervention:

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

Main Outcome Measures:

The main outcome measure is an intention to select a sugar-sweetened beverage, measured by hypothetical sugar-sweetened beverage selection in an online shopping task, analyzed in May 2023-April 2024.

Results:

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

Conclusions:

Using educational messages in more than 1 language to accompany rollout of a new warning label may further improve outcomes in populations with varying levels of acculturation.

Trial Registration:

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

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