Calling time on formula milk advertsBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l1200 (Published 18 March 2019) Cite this as: BMJ 2019;364:l1200
- Fiona Godlee, editor in chief1,
- Sophie Cook, head of scholarly comment1,
- Rebecca Coombes, head of news and views1,
- Emad El-Omar, editor in chief2,
- Nick Brown, editor in chief3
- Correspondence to: S Cook
Nearly 40 years since the introduction of an international code to regulate the marketing of breastmilk substitutes, concerns have resurfaced over the aggressive promotion of these products, and the harmful effect on global rates of breastfeeding. After decades of advertising breastmilk substitutes to readers of The BMJ, we have decided it is time to stop.
In 1981, the World Health Organization and Unicef launched the International Code of Marketing of Breastmilk Substitutes, which explicitly bans advertising and other form of promotion of these products to the general public. The code aimed to rein in unethical behaviour by industry that had coincided with a general decline in breastfeeding rates.12
According to the code, breastmilk substitutes include all milks that may replace breastmilk in the first three years of life, including infant formula, follow-on formula, specialist products, and milks marketed for toddlers, as well as foods marketed for children under 6 months old. We use the term “formula milk” here as a shorthand for all these products.
Countries were expected to adopt the code into national law, although these hopes were never fully realised. The UK, for example, restricts marketing of infant formula to the general public but allows advertising of follow-on milks. All formula milk products can be marketed to health professionals providing the information is “scientific and factual” in the view of the advertiser.
Concern is growing that industry continues to stretch and violate the rules.3 However, the monitoring of legislation is weak, and companies are rarely prosecuted for breaches.4 This allows the $50bn (£38bn; €44bn) a year industry to pursue customers without fear of sanction.5 There is no official mechanism to ratify whether code standards are truly being met. Instead, monitoring is largely done by the International Baby Food Action Network (IBFAN), a self funded international network of nearly 300 public interest groups that refuses any kind of commercial support.6
Industry practices have created confusion about which part of the code, or even which code, companies adhere to. For example, the industry body representing formula milk companies in the UK, the British Specialist Nutrition Association, recently launched its own code of practice, which claims to reflect legislation and show commitment to the international code and uses similar blue branding.7 But Unicef says it contains loopholes to allow increased promotion of products to parents.8
The many benefits of breastfeeding to mother and baby are well established,9 yet internationally breastfeeding rates remain low.10 The reasons behind these low rates are multifactorial, such as limited breastfeeding support, staff training, and a lack of support for nursing mothers returning to work, but ineffective monitoring of promotion by industry also undermines efforts to increase breastfeeding.
The code says that breastmilk substitutes cannot be advertised to parents or the wider public. But few manufacturers abide by this, despite claims of compliance on the websites of many leading brands. Crucially, formula companies interpret the code to apply only to infant formula, a product that is suitable for infants throughout the first year of life but which companies commonly describe as suitable for “the first six months” so they can legally promote a wholly unnecessary alternative product called follow-on formula. This is direct-to- consumer advertising of infant formula in all but name, since these products are closely cross-branded and almost indistinguishable. WHO recommends that mothers breastfeed exclusively for the first six months, continue breastfeeding alongside the addition of complementary foods in the first year, and continue breastfeeding up to age 2 years or beyond.
The code allows the provision of “scientific and factual” information to health professionals but is very clear that this must not be promotional. Advertisements are by their nature promotional, with a high prevalence of unjustified claims of benefit and without full disclosure of the risks. Many claims made by manufacturers are not accepted by scientific bodies, the evidence may be weak or absent, or it may relate to a product other than that being advertised.11 IBFAN takes a hard line: that no advertisement could ever be “code compliant.” For many decades this understanding has languished in a grey area while companies have promoted products to health professionals through magazines, conferences, professional journals such as The BMJ, and bodies such as the Royal College of Paediatrics and Child Health (RCPCH).
BMJ has recently been reminded of the substantial harms caused by promotion of breastmilk substitutes and the biases introduced into research and clinical practice by industry influence.312 We have also gained a greater understanding of the WHO code that seeks to reduce these harms and have reviewed our policy, consulting advertisers and canvassing readers.
As a result, we have decided to stop carrying these advertisements in The BMJ and other BMJ journals, including Gut, Frontline Gastroenterology, and Archives of Diseases in Childhood, as soon as possible. We have chosen a complete ban because previous attempts to implement a due diligence approach have failed. This will have a substantial effect on our revenues—a loss of an estimated £300 000 (€350 000; $400 000) in 2020. The ban on product advertising is not a boycott of the companies themselves. We will honour existing contracts for formula milk advertising, but the final advert will appear later this year. We are not alone in doing this: in February the RCPCH announced it would no longer accept funding from formula milk companies at a loss of £40 000 a year through event sponsorship and advertising.13
Our objective is not to drive an anti-formula campaign, as we recognise that formula milks are essential products for children with complex medical or nutritional needs and for those women for whom breastfeeding is not possible. But decisions on when and how to use infant formula are best informed by sources of unbiased evidence rather than commercial advertisements.
We believe this is the right thing to do based on our desire to support the WHO code, actively promote breastfeeding, and campaign against industry influence in this area. Instead of being part of the problem, we want to be part of the solution.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.