Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution- NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). https://doi.org/10.1177/22799036231168207 Journal of Public Health Research 2023, Vol. 12(2), 1 –13 © The Author(s) 2023 DOI: 10.1177/22799036231168207 journals.sagepub.com/home/phj Journal of Public Health ResearchOriginal Article Introduction The burden of non-communicable diseases (NCDs) is ris- ing globally.1 Consumption of sugar-sweetened beverages (SSBs) and ultra-processed foods are major contributors through their influence on weight gain and their direct link to diseases such as type 2 diabetes, cancers, and dental car- ies.2–4 Reducing adolescent and adult obesity rates and the growing incidence of diet-related NCDs requires changes in social eating norms as early as possible in the lifecycle, especially among children, teens, and young adults. Evidence from the Birth to Twenty (BT20+) cohort study in South Africa shows that poor eating habits such as SSB consumption influenced weight gain5 and prevalence of other chronic diseases, which imposes significant costs on the country’s health system.6–8 1168207 PHJXXX10.1177/22799036231168207Journal of Public Health ResearchBoachie et al. research-article20232023 1SAMRC/Wits Centre for Health Economics and Decision Science – PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 2Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA Corresponding author: Micheal Kofi Boachie, SAMRC/Wits Centre for Health Economics and Decision Science – PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa. Email: micheal.boachie@wits.ac.za Beverage industry’s advertising expenditures and airtimes in South Africa from 2013 to 2019 target children and families Micheal Kofi Boachie1 , Susan Goldstein1, Petronell Kruger1, Shu Wen Ng2, Karen J Hofman1 and Evelyn Thsehla1 Abstract With the growing burden of non-communicable diseases (NCDs), countries across the globe are finding ways to reduce the consumption of ultra-processed food and drinks including sugar-sweetened beverages (SSBs). South Africa implemented a health promotion levy (HPL) in April 2018 as one strategy to reduce sugar intake. Such efforts are frequently countered or mitigated by industry action in various ways, including through marketing and advertising strategies. To better understand trends in the extent of advertising, this paper analyses advertising expenditures and exposure of children to SSB advertisements in South Africa. Using Nielsen’s monthly data on advertising expenditure before and after the introduction of the HPL, for the period January 2013 to April 2019, the results show that manufacturers spent ZAR 3683 million to advertise their products. Advertising expenditure on carbonated drinks accounted for over 60% (ZAR 2220 million) of the total expenditure on SSBs. The results also show that companies spend less in advertising powdered SSBs (an average of ZAR 0.05 million per month). Based on expenditure patterns, television (TV) was the preferred medium of advertisements, with companies prioritizing what is often considered children’s and family viewing time. Urgent mandatory regulations are needed to prevent child-directed marketing. Keywords Advertising expenditure, sugar-sweetened beverages, health promotion levy, non-communicable diseases, child- directed marketing, commercial determinants of health Date received: 28 October 2022; accepted: 20 March 2023 https://journals.sagepub.com/home/phj mailto:micheal.boachie@wits.ac.za 2 Journal of Public Health Research Macro-level factors such as the food environment where people live, work, learn, and play, affordability of unhealthy foods relative to healthier foods, make it difficult for South Africans to attain health-promoting diets.9–11 Indeed, many South Africans across all income groups have high levels of fast food, and SSB consumption and low levels of fruit, vegetable, and whole grain intake. A key factor influencing the consumption of SSBsa and other ultra-processed prod- ucts is marketing and advertising.12–14 Although they affect the preferences of both children and adults, manufacturers target children more often because they are more likely to choose foods and drinks they have seen advertised on tele- vision due to their limited understanding of the persuasive intent of such adverts.15–17 Further, children are seen as future “market of consumers” for companies to develop brand loyalty with many years of purchasing ahead of them. This early exposure affects their short- and long-term dietary preferences and habits18,19; increase snacking fre- quency, with low-nutrient and high-calorie foods. For these reasons, food and beverage companies across the globe fre- quently advertise their products, targeting children as young as 2 years.20,21 In the US, for example, child-directed advertising expenditure has grown significantly, from US$100 million in 1983 to US$17,000 million in 2007.20 In Australia and Canada, companies have been found to spend more resources to advertise unhealthy foods and beverages compared to healthier alternatives.21–23 In fact, 90% of food and beverage advertising expenditure in Canada is for unhealthy foods, with a significant portion of these adver- tisements targeting children.21,23 In South Africa, the consumption of ultra-processed products including SSBs increased by about 40% between 2005 and 2010.24 As part of the measures to control SSB consumption, South Africa declared an intention to tax sugar in June 2016, and in December 2017 the draft legis- lation on a health promotion levy (HPL) (also known as sugar tax) was signed into law.25 In April 2018, the HPL was implemented with the aim of reducing sugar intake in the long-term. An observational study of South African household purchase data showed that the implementation of the HPL has been associated with reduction in purchases of taxed beverages, from 519 mL/person per day to 443.39 mL/person per day compared to pre-HPL trends.26 Findings from before- and-after study in Langa, Cape Town also showed that low-income young adults reduced their self-reported taxed beverage intake from 315 to 198 mL/person per day.27 Since the levy was implemented, government only increased the initial rate in February 2022, but was later post- poned indefinitely. In real terms, the tax rate declined during the period of April 2018 and April 2022.28 Thus, it is not sur- prising that while the HPL helped slowdown the upward trend in SSB intake in the first year of the tax, SSB sales trend continues move upward. The increase in SSB con- sumption, led by young adults and children, can be partly attributed to the beverage industry’s advertising and market- ing strategies,14 and these marketing strategies may have changed since the introduction of the HPL. Manufacturers market or advertise their products using media outlets such as television, radio, print, and internet.14,29,30 Because of the impact of advertising on people’s prefer- ences and consumption patterns, particularly children, the South African government proposed restrictions on food advertising to children through the Foodstuffs, Cosmetics and Disinfectants Act in 2007. The aim of the proposed regulation was to prohibit the advertising or promotion of foods “non-essential to a healthy lifestyle” (e.g., SSBs, ultra-processed products, and certain fast foods) to chil- dren.24,31 However, these regulations were never adopted. A food consortium subsequently developed an advertising code with the input of the South African National Department of Health (NDoH).29 The advertising code stip- ulates that “food and beverage advertising, including pro- motions, should not encourage poor nutritional habits or an unhealthy lifestyle in children, or encourage or condone excess consumption.”32 A voluntary pledge (the South Africa Pledge on Marketing to Children) to adhere to the code was later signed, in 2009, by the major food corpora- tions, requiring manufacturers to use their advertisements to promote healthy dietary choices and healthy lifestyles among children.33,b Similar unsuccessful pledges have been made by major food and beverage corporations such as Coca-Cola South Africa in 2017 in an attempt to self-regu- late.34 Aside from preventing unhealthy eating norms, min- imizing child-directed marketing is justified from a human rights perspective.35 Children have the right to protection from harmful information through the media such as SSB advertising messages. Because online advertising collect, store, and track information of children who visit such online platforms, companies violate the rights of children through advertising.36 While various international treaties and local laws restrict child-directed marketing, food and beverage companies are able to disregard these child rights in their marketing activities due to a lack of enforcement. Overview of media access in South Africa South Africa has a vibrant print (newspapers and maga- zines) and electronic media (i.e., television, radio, and internet) which provides enormous opportunities for advertisers to reach large sections of the population. Statistics from the General Household Survey37 which tracks progress of development and service delivery gaps in South Africa, using participants from 19,649 house- holds, show that many South Africans have access to elec- tronic media (i.e., television and radio). Overall, 82% of households reported owning television (TV) sets in 2019 (ranging from about 70% in the poorest group to over 90% in the richest group (Figure 1)).37 While 51% of South Boachie et al. 3 Africans subscribe to paid TV channels obtained under Digital Satellite Televisionc (DSTV)38 and StarSatd (previ- ously Top TV),39 subscription ranges from 40% in the low- income group to about 75% in the high-income group. South Africa has an estimated 20 million children (i.e., persons of below 18 years), about a third of the popula- tion.37 In every income quintile of the population, children constitute about 35%. Based on household asset ownership (Figure 1), on average, 82% of South African children have access to television. Given the high number of households with access to TV,37 adults and children are spending more hours viewing TV screens which encourages sedentary lifestyle while also increasing exposure to advertising. Figure 2 presents the time used to view TV screens between 2018 and 2020 (for all ages). In 3 years, the daily average time spent view- ing TV screens (including non-broadcasting activities) increased from 3.06 h in 2018 to 3.35 h in 2020.40 Even in the absence of COVID-19 alert levels 5 (26 March to 30 April 2020) and level 4 (01 to 31 May 2020) and resultant COVID-lockdown implementation, the average time spent viewing TV in 2019 was higher than that of 2018. As the number of viewers rise, manufacturers may find it prudent to place more advertisements to attract potential con- sumers. Statistics show that South African Broadcasting Corporation (SABC) 1 and e-TV are the most popular TV channels based on the average number of viewers for their programs, with over 2 million viewers per program (Table 1). Aside from TV, about 63% of South African households have at least one member using the internet,37 which also Figure 1. Household ownership of media channels and share of children in population by income group. Source: Computed from Statistics South Africa.37 Note that income quintiles were created based on the total monthly household income. Stata xtile routine command was used to create the groups. Figure 2. Average daily time in hours for TV screen viewing from 2018 to 2020 (for all ages). Source: Nielsen.40 4 Journal of Public Health Research exposes users to online advertisements. As more house- holds have access to paid and unpaid TV channels coupled with the increased viewing time, opportunities abound for beverage manufacturers to advertise their products using media outlets such as TV, radio, internet, newspapers, and magazines to increase sales. The implication is that an unregulated advertising space will expose children to advertisements that encourage unhealthy eating behaviors such as advertisements promoting SSBs, ultra-processed products and fast foods which are “non-essential to a healthy lifestyle,” and thus increase the consumption of these unhealthy products. An unregulated advertising space will not adequately protect the rights of children as guaranteed in the South African Constitution and South Africa's international law obligations, as it will expose children to messaging harmful to their health and development. While some studies have examined availability and advertising of SSBs to children,29,30,34 none has looked at the trends in advertising expenditures on various SSBs over time; this study seeks to analyze the trends in adver- tising expenditure on SSBs (such as fruit juices, carbon- ated drinks, energy drinks, and powdered drinks). The study also analyses exposure of children to SSBs based on the number of SSB advertisements aired on TV during child and family viewing time. Methods Sources of data For this study, data were extracted from the Nielsen data- base for the period January 2013 to April 2019.42 The Nielsen database provides multiple consumer and media datasets to academic researchers around the world. NielsenIQ produces consumer panel, retail scanner, and advertising intelligence data. The dataset provides infor- mation on advertising expenditures for SSBs in the print and electronic media. There was no primary data collec- tion hence this study is an analysis of secondary dataset with no individual or household identifiers. Although the dataset provides only month and year, we assume that coverage begins from the first day of the month and ends on the last day of the month for the expenditure analysis. The expenditures provided are associated with type of media, broadcast time, and the company paying for the advertisement. In the case of children’s exposure to SSB advertise- ments, the analysis covers only the hours 15:00:01 to 19:00:01. For the purposes of this study, print media refers to printed newspapers and magazines, while electronic media refers to television, radio, and the internet as medium of information. Measures SSB advertising expenditure in South African Rand (ZAR) is the estimated amount spent by beverage companies to purchase broadcasting time for advertisements in both print and electronic media. The beverages were grouped into carbonated drinks, fruit juices, energy drink, squashes and cordials, and powdered concentrates. These beverage categories are provided in the dataset. The Nielsen data contained 112 (108 subscription and 4 non-subscription) TV channels. The subscription channels are accessed under DSTV and StarSat. The non-subscription channels included viewership of South African Broadcasting Corporation (SABC) (1, 2, 3) and e-TV, with an average of 1.6 million viewers per channel (Table 1). All other TV channels are designated in the “other” cate- gory as they have far lower viewership. To determine whether these advertisements are directed at children, we calculated the average number of TV advertisements per hour aired during what is traditionally considered “children viewing time” of 15:00 to 17:00 he from the Nielsen data. The rational is that the more adver- tisement aired during children viewing time, the more exposed children will be. The Nielsen data contains infor- mation on broadcasting time, but no information on the precise date of the advertisement. For this reason, for the purposes of this study in applying children’s viewing time, we assume that all advertisements were aired during the weekday. In line with previous studies,29,30 we know that most children attend school prior to 3 pm (during pre- COVID pandemic times during the school year) and often watch TV from this time onward when the majority of children’s programs begin.29,30,f Further, because parents are at work during 9:00 to 17:00 h and watch TV from 17:00 h onward, many TV channels broadcast talk shows and soap operas during 17:00 to 19:00 h, a period consid- ered “family viewing time” where both children and par- ents watch TV.30 Co-TV viewing has been found to increase children’s screen time.43 The analysis on chil- dren’s exposure (which is based on the number of adverts) excludes both advertisements on radio and the internet since there is no prescribed listening time for children on radio or internet coupled with the fact that radio Table 1. Viewership of top 20 programs by TV channel in South Africa, October 2021. TV channel Viewers (million)a SABC 1 2.72 SABC 2 0.81 SABC 3 0.41 e-TV 2.48 Source: Broadcast Research Council of South Africa.41 aAverage number of viewers per program (see the Broadcast Research Council of South Africa for full details on vierwship of all programs and channels in South Africa). Boachie et al. 5 advertising has minimal impact on consumer behavior, at least in South Africa and India.44,45 Statistical analyses We analyzed monthly advertising expenditures by media type, drink category, and the top 10 manufacturers in South Africa. A top manufacturer was classified as one with an annual advertising spend of at least ZAR 5 million (inflation- adjusted), on average. Media was grouped into television, print, and radio, with all other media outlets such as internet and outdoor designated as “other.” The expenditure analysis covers all types of media, both print and electronic. Analysis of child exposure to adverts is based TV view- ing. Child exposure was calculated based on the number of advertisements (i.e., number of observations in the dataset) in any given month aired on TV during the designated viewing time. The number of advertisements were aggre- gated by year since the number of monthly advertisements did not vary during any specific year. Afterwards, the aver- age number of SSB advertisements per hour was calcu- lated for “child viewing time” and “family viewing time.” Based on the already stated assumptions, advertisements were aired for 1703 days (obtained as (365 days × 6.33 years) minus (8 days × 12 months × 6.33 years)). This results in 6812 h (4 h daily) for both view times. The total number of adverts aired during each viewing time was divided by the estimated total hours for that viewing time. Expenditures were reported in April 2019 prices using the monthly Consumer Price Index.46 The South African rand (ZAR14.14) which was equivalent to US$1 in April 2019 was used for reporting. Stata (version 15) and MS Excel (version 2111, 2021) were used for reporting totals, mean, percentages and producing graphs. In all figures, the X-axis denote time (year/month) while the Y-axis denotes expenditure (the number of adverts in the case of child exposure). Results Monthly advertising expenditures Advertising expenditure on SSBs fluctuated during the study period. In 2013, total advertising expenditure for SSBs (all drink categories) was ZAR 378 million, with car- bonated drinks accounting for over 57% of these advertis- ing expenditures. Advertising expenditure on carbonated drinks was ZAR 89 million in the first half of 2013. By the end of 2017, this expenditure had reached ZAR 583 mil- lion, but later declined to ZAR 398 million by the end of 2018 (Figure 3). In the first 4 months of 2019 alone, bever- age companies spent ZAR 91 million in advertising car- bonated drinks. Between January 2013 and April 2019, manufacturers spent a total of ZAR 3683 million to advertise their prod- ucts. During this period, expenditure on carbonated drinks totaled ZAR 2220 million, with an average of ZAR 29 mil- lion per month. Powdered concentrates recorded the low- est expenditure (ZAR 3.3 million) for the period with a monthly average of ZAR 0.05 million (Figure 3). Between 2016 and 2019, carbonated beverages advertisement expenditures peaked during Christmas holiday season. Based on media type, expenditures were highest for TV-based advertisements (Figure 4). The average monthly TV advertising expenditure increased from ZAR 19.5 mil- lion in 2013 to ZAR 42 million in 2017, and later declined Figure 3. Monthly advertising expenditure in million ZAR (2019 prices) by drink type, January 2013 to April 2019. Dash vertical lines represent the announcement of HPL in June 2016 and HPL implementation in April 2018. 6 Journal of Public Health Research by 17% to ZAR 35 million in 2018. TV expenditures accounted for about 66% of total SSBs advertising expen- diture during the study period. Monthly TV advertising expenditure averaged ZAR 32 million between January 2013 and April 2019. Print media expenditure averaged ZAR 1 million per month during the period. The advertising expenditure across all media by the top 10 companies in South Africa (Figure 5) shows that the highest advertising expenditure was by Coca-Cola South Africa Ltd. The company spent a total of ZAR 2284 mil- lion over 76 months with a monthly average of ZAR 30 million, with a peak in the fourth quarter of 2017. The Figure 4. Advertising expenditure by media type in million ZAR (2019 prices), January 2013 to April 2019. Dash vertical lines represent the announcement of HPL in June 2016 and HPL implementation in April 2018. Figure 5. Advertising expenditure by manufacturer in million ZAR (2019 prices), January 2013 to April 2019. Dash vertical line represent the announcement of HPL in June 2016 and HPL implementation in April 2018. Boachie et al. 7 second and the third highest expenditures were by Pioneer Foods and Red Bull Holdings, with a spent of ZAR 309 and ZAR 232 million, respectively. Children’s exposure to advertisements The analysis of children’s exposure to advertisement is premised on the assumption that TV is available for view- ing during 15:00:01 to 19:00:01 h. This translate into a total of 4 h/day (for weekdays only) for both children’s and family viewing time. Over the 76 months period, children had a total maximum of 6812 h to watch TV during 15:00:01 to 19:00:00. Thus, a child had a maximum of approximately 538 h for each viewing time annually for January 2013 to December 2018 and 179 h for January to April 2019 Figure 6 presents the average number of advertisements per hour per drink category and year for the period January 2013 to April 2019 across all TV channels. Overall, 218,976 SSB advertisements were aired on all TV chan- nels during the hours of 15:00 to 17:00 h, designated chil- dren’s time by the public broadcaster. About 80% of these advertisements were for carbonated and energy drinks. On average, 64 SSB advertisements were aired per hour dur- ing children’s viewing time during the study period across all television channels. The total number of advertisements per hour for carbonated drinks increased from 20 in 2013 to 59 in 2017, but later declined by 48% in 2018. During 2013 and 2017, the average number of advertisements on energy drinks declined by 40%, from 15.9 to 9.6 advertise- ments per hour. This, however, increased to 24 advertise- ments per hour in 2018. Trends in the hourly average of advertisements for other beverage categories are shown in Figure 6. Overall, there were more advertisements during “fam- ily viewing time” (17:00:01 to 19:00:00 hours) (Figure 7). Total advertisements during these hours were 43% higher than during children’s time (15:00:00 to 17:00:00), with carbonated and energy drinks featuring prominently. A significant portion of the advertisements (78%) was aired on channels other than SABC 1, 2, 3, and e-TV (Tables A1 and A2 in Appendix). These channels included, for example, M-NET and 1 MAGIC, accessed through DSTV (these are pay for view channels) which target a higher income group. The average number of advertise- ments for all SSB types per hour across all channels increased from 64 during “child viewing time” to 92 dur- ing “family viewing time.” The average hourly SSB adver- tisements was approximately 78 for the two viewing periods combined. Given that it is unlikely that viewers watching multiple channels at the same time, Table 1 shows that among the non-paying national broadcast channels of South African Broadcasting Corporation (SABC) 1 and 2 and e-TV, viewers are likely to see 3–4 carbonated drink ads per hour during the 15:00 to 17:00 child viewing time, and 3.5–4.5 carbonated drink advertisements per hour during the 17:00 to 19:00 family viewing time. When considering all types of SSBs, viewers are likely to see around six and seven advertisements per hour in each of these two time slots on national broadcast channels. Discussion Consumption of SSBs is a contributory factor to the high level of obesity in South Africa. Obesity, which is a major risk factor for diabetes and other weight-related non- communicable diseases is costing South Africa’s public health sector about ZAR 33.2 billion annually.6,7 By 2030, treatment and management of diabetes alone is expected to cost the South African government and the public ZAR 35 billion.8 Meanwhile, private for-profit companies are increasingly advertising SSBs, which fuels overweight and obesity and the NCD crisis in South Africa. During January 2013 to April 2019, South African SSB manufacturers spent ZAR 3683 million to advertise their drinks. From ZAR 89 million on carbonated drinks in the Figure 6. Average number of SSB advertisements per hour aired during “child viewing time” (15:00:01 to 17:00:00 h), January 2013 to April 2019. 15:00:00 to 17:00:00 h broadcast time is designated for children; powdered concentrates were excluded due to low number. Figure 7. Average number of SSB advertisements per hour aired during “family viewing time” (17:00:01 to 19:00:00 h), January 2013 to April 2019. 17:00:01 to 19:00:00 h broadcast time is designated as family (parents and children) time by public broadcaster; powdered concentrates were excluded due to low number. 8 Journal of Public Health Research first half of 2013, beverage companies increased their advertising spending by nearly 600%. Similar to previous findings,14 SSB advertising expenditure was driven by television advertisements on carbonated drinks. Spending was lower on squashes and powdered concentrates. Carbonated SSBs were the main product of overall adver- tising expenditure, with the majority of these advertise- ments being broadcast on television. This is consistent with findings from recent studies in Australia and Canada which show that TV advertisements account for largest share of total advertisements.22,23 The trends also show that manufacturers increased their advertising expenditures following the announcement of government’s intention to tax SSBs in June 2016. This strategy was, perhaps, so beverage companies could expand their consumer base and generate stronger SSB brand and product loyalty before the HPL implementation so as to maintain existing sales volume after implementa- tion of the HPL. Total advertising expenditures peaked in December 2017 just before the legislation on the HPL was passed and declined afterwards. Nonetheless, the HPL led to a significant decline in taxed beverage purchases,26,27 indicating that consumers are changing their consumption behavior following the HPL. SSB taxes in Mexico47 and Philadelphia, US48 have been associated with lower SSB purchases. This shows that while industry use advertising and marketing strategies to increase SSB consumption, effective implementation of policies like the HPL can neu- tralize the consumption effect of advertising and market- ing strategies of the beverage industry. The top advertiser was Coca-Cola South Africa Limited, spending approximately ZAR 2284 million during the period. Available data show that, in 2020, Coca-Cola accounted for 45% of all off-trade sales in South Africa.49,g The quest to maintain or increase market share may explain their high advertising expenditure during the period. Pepsi, a key competitor of Coca-Cola recorded ZAR 19 million in advertising expenditure. In the same period (2013/14 to 2018/19), the NDoH spent the equivalent of 7.1% of Coca- Cola’s advertising expenditure on NCD prevention strategies.h This shows that beverage companies advertis- ing spending far exceeded government expenditure (or budget) on NCD prevention. Given that the purpose of advertising is to increase SSB consumption particularly among young people,14 they ultimately undermine the pre- vention of NCDs which in the longer term imposes huge cost on the South Africa’s healthcare system and productivity.6–8 While the Consumer Goods Council of South Africa pledged in 2009 to reduce the exposure of children to sug- ary drink advertisements,33 this did not happen. There were numerous advertisements during both the child and family viewing hours, which is consistent with the find- ings from previous studies in South Africa.29,30,34. A sig- nificant number of these advertisements (78%) were aired on channels other than SABC and e-TV. Unpaid channels such as SABC 1 accounted for only 35% of all advertise- ments for energy drinks in 2013.14 The findings illustrate that pledges and self-regulation do not work as is the case of advertising in schools in South Africa.34 Several years later, in 2017, Coca-Cola pledged to remove all SSBs from primary schools in South Africa. However, it appears the company raised its advertising expenditure immediately after the announcement (see Figure 5). Self-regulation by the industry aim to prevent government regulations, influ- ence the policy environment and ultimately public health outcomes in low- and middle-income countries.50 According to the Advertising Regulatory Board of South Africa, food and beverage products that do not rep- resent healthy dietary choices and a healthy lifestyle (based on established scientific standards) should not be adver- tised to children.32 However, this is not enforced, and our study indicates poor compliance of the voluntary South Africa’s Food and Beverage Code and the Pledge on Marketing to Children.33 The voluntary nature of these pledges mean that no consequences will follow. During COVID-19 lockdown levels 5 and 4, people spent more hours viewing TV. At this time, we expect more hours for Co-TV viewing for most parts of the day since both chil- dren and parents were at home. This means that children were exposed to SSB advertisements. Among preschool children in South Africa, it has been shown that such chil- dren spend an average of 3.38 h/week (i.e., approximately 41 min/day) during the weekday on TV,51 and 3.3 h/day among 9–11 years olds.52 This implies that, on a daily basis (i.e., the 4-h window), a preschool child might be exposed to 6 to as many as approximately 53 SSB advertisements in any given channel or across all TV channels. For chil- dren in the 9–11 years age group, the results imply that they might be exposed to 25 to as many as 257 SSB adver- tisements daily. To minimize exposure of children to advertisements of products shown to be harmful to health, urgent mandatory regulation, and cross-sectoral coordination from various government departments and organizations such as the NDoH, Department of Communications and Digital Technologies (DCDT) and Advertising Regulatory Board of South Africa is essential. It is important for all advertis- ing messages to promote trust and security among the people and to protect children from exploitation.53 In this regard, the DCDT will need to implement stricter control on what is advertised in the media. Experience from the tobacco sector may help government to regulate the advertising space of SSBs. Since exposure to advertise- ments influences children and caregivers’ preferences and leads them to choose nutrient-poor foods and drinks,18,19 bans on advertising, promotions, and sponsorships will help reduce children’s exposure to obesogenic foods. This will have long-term effects of reducing obesity rates and NCDs. Boachie et al. 9 Strengths and limitations Using monthly data, this study contributes to the under- standing of the SSBs advertising landscape in South Africa. By this, we show that companies are infringing on children’s rights and violating advertising codes in South Africa. A limitation of the study is its inability to monitor social media advertising. Social media plat- forms such as Twitter, Facebook, Instagram, and Pinterest among others have become important medi- ums of advertising for companies, often using influenc- ers to disguise advertising. The advertising spend on such platforms was not available in the Nielsen data- base but are likely growing.42 Furthermore, there was no information on the day (exact date) these advertise- ments were aired. Therefore, the assumption that all advertisements were aired during the weekday and none for weekends may not reflect the actual exposure during weekdays or weekends. We were also only able to look specifically at SSB advertisements and are unable to account for advertisements of products that also con- tribute to increased risks of NCDs, such as unhealthy foods and alcohol. For this reason, this study only describes SSB advertisements as categorized in the Nielsen database and focuses on the designated period children are most likely (but not exclusively) being exposed to. Finally, this work is also limited in its period of analy- ses to the pre-COVID years. Thus, we are unable to show whether and to what extent the airing of SSB advertise- ments and children’s exposure to them changed given lockdowns resulting in children spending more time at home and thus greater screen time (see Figure 2).40 Future work needs to continue tracking these trends over time to document these economic and commercial determinants of ill health. Future studies should also consider the cost per minute for broadcasting time. Conclusion This study demonstrates that companies are spending sig- nificant funds to market their SSB products, with televi- sion being their preferred medium. The advertising expenditure increased significantly between 2016 and 2017 following government’s announcement of the inten- tion to implement HPL. Companies have failed to adhere to their own voluntary code and their pledges to protect children from advertising of SSBs. The advertising and marketing space in South Africa needs mandatory regulation because the rights of children are being violated. The NDoH, the Advertising Regulatory Board of South Africa, and the Department of Communications and Digital Technologies should monitor both free and paid TV programming, radio, print and digi- tal media, and sanction companies who advertise SSBs to children. Author contributions Conceived the research: MKB, ET, PK. Data analysis: MKB. Contributed analysis/materials: MKB, ET, SG, PK, SWN, KJH. Wrote the first draft: MKB. Provided critical review and edited drafts: MKB, ET, SG, PK, SWN, KJH. All authors approved the final version submitted. Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study received funding from Bloomberg Philanthropies through the University of North Carolina at Chapel Hill, USA [grant number 5106249] and the South African Medical Research Council [grant number 23108]. ORCID iD Micheal Kofi Boachie https://orcid.org/0000-0003-1062-889X Notes a. In this study, sugar-sweetened beverages (SSBs) refer to drinks that are sweetened with various forms of added sugars like brown sugar, corn sweetener, corn syrup, dextrose, fructose, glu- cose, high-fructose corn syrup, honey, lactose, malt syrup, malt- ose, molasses, raw sugar, and sucrose. The Nielsen data classifies drinks into carbonated, energy drink, powdered concentrates, squashes, and so on without any indication of the ingredients. b. The manufacturers who signed the pledge include Cadbury, Coca-Cola, Danone, Entyce/Snackworks (AVI), Epic, Foodcorp, General Mills, Kellogg, Kraft, Mars, Nestle, Oceana brands, Parmalat, Pepsico/Simba, Pioneer Foods, Rainbow Chicken, Tigerbrands, and Unilever. Coca-Cola alone controls 45% of the SSB market in South Africa. The pledge focuses on marketing to children who are 12 years or younger. c. As of 01 March 2023, DSTV has seven market segments. Premium (135+ channels), Compact Plus (115+ channels), Compact (100+ channels), Family (75+ channels), Access (66+ channels), EasyView (25+ channels). d. As of 01 March 2023, StarSat has five market segments. Special (60+ channels), Super (70+ channels), Max (140+ channels), Indian (6 channels), Shembe (60+ channels plus dedicated Shembe channel). e. 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Department of Communication and Digital Technologies, Pretoria, 2016. https://documents-dds-ny.un.org/doc/UNDOC/GEN/G21/015/65/PDF/G2101565.pdf?OpenElement https://documents-dds-ny.un.org/doc/UNDOC/GEN/G21/015/65/PDF/G2101565.pdf?OpenElement https://documents-dds-ny.un.org/doc/UNDOC/GEN/G21/015/65/PDF/G2101565.pdf?OpenElement https://www.dstv.co.za/get-dstv-packages/dstv-decoder-packages/?gclid=Cj0KCQiA6fafBhC1ARIsAIJjL8kSWINN_zlTPjeiIdppC2TNbBeHg1bBX8YQw6YqD4bazDudMqSUvqsaAtmOEALw_wcBgclsrc=aw.ds https://www.dstv.co.za/get-dstv-packages/dstv-decoder-packages/?gclid=Cj0KCQiA6fafBhC1ARIsAIJjL8kSWINN_zlTPjeiIdppC2TNbBeHg1bBX8YQw6YqD4bazDudMqSUvqsaAtmOEALw_wcBgclsrc=aw.ds https://www.dstv.co.za/get-dstv-packages/dstv-decoder-packages/?gclid=Cj0KCQiA6fafBhC1ARIsAIJjL8kSWINN_zlTPjeiIdppC2TNbBeHg1bBX8YQw6YqD4bazDudMqSUvqsaAtmOEALw_wcBgclsrc=aw.ds https://www.dstv.co.za/get-dstv-packages/dstv-decoder-packages/?gclid=Cj0KCQiA6fafBhC1ARIsAIJjL8kSWINN_zlTPjeiIdppC2TNbBeHg1bBX8YQw6YqD4bazDudMqSUvqsaAtmOEALw_wcBgclsrc=aw.ds https://www.dstv.co.za/get-dstv-packages/dstv-decoder-packages/?gclid=Cj0KCQiA6fafBhC1ARIsAIJjL8kSWINN_zlTPjeiIdppC2TNbBeHg1bBX8YQw6YqD4bazDudMqSUvqsaAtmOEALw_wcBgclsrc=aw.ds https://starsat.co.za/packages/special-package/ https://starsat.co.za/packages/special-package/ https://brcsa.org.za/october-2021-top-tv-programs/ https://brcsa.org.za/october-2021-top-tv-programs/ 12 Journal of Public Health Research Table A1. Number of SSB advertisements by drink type and TV channel, January 2013 to April 2019. 15:00:01 to 17:00:00 h 17:00:01 to 19:00:00 h Carbonated ETV Other Total Carbonated ETV Other Total SABC1 SABC2 SABC1 SABC2 2013 1932 1356 1152 6300 10,740 2028 1380 1620 8028 13,056 2014 1296 2664 1488 6036 11,484 3180 1632 2232 10,500 17,544 2015 588 4200 2700 5472 12,960 1824 1812 1476 10,104 15,216 2016 2292 3456 2364 14,868 22,980 1500 2268 2868 24,432 31,068 2017 3564 2148 2904 23,040 31,656 3192 3636 5328 32,352 44,508 2018 1140 864 1128 13,464 16,596 1668 1188 1776 18,468 23,100 2019** 220 104 260 540 1124 220 68 248 1020 1556 Total 11,032 14,792 11,996 69,720 107,540 13,612 11,984 15,548 104,904 14,6048 Hourly average# 3.24 4.34 3.52 20.48 31.58 4.00 3.52 4.57 30.81 42.89 Energy drink ETV Other Total Energy drink ETV Other Total SABC1 SABC2 SABC1 SABC2 2013 168 612 96 7680 8556 192 240 144 8652 9228 2014 252 768 276 12,228 13,524 624 432 288 20,172 21,516 2015 1536 1692 372 9360 12,960 588 600 240 13,428 14,856 2016 420 900 324 9576 11,220 420 576 552 13,488 15,036 2017 432 204 324 4200 5160 240 60 564 6096 6960 2018 156 48 276 12,276 12,756 156 96 420 21,108 21,780 2019** 12 8 1556 1576 16 28 2944 2988 Total 2976 4224 1676 56,876 65,752 2236 2032 2208 85,888 92,364 Hourly average# 0.87 1.24 0.49 16.70 19.31 0.66 0.60 0.65 25.22 27.13 Fruit juice ETV Other Total Fruit juice ETV Other Total SABC1 SABC2 SABC1 SABC2 2013 36 144 480 1920 2580 276 216 300 2712 3504 2014 240 444 72 1908 2664 432 492 168 2712 3804 2015 636 528 2544 3708 888 1272 5556 7716 2016 372 660 24 6492 7548 948 1632 9312 11,892 2017 300 240 60 3696 4296 624 324 192 8352 9492 2018 264 192 612 7656 8724 564 660 1320 17,316 19,860 2019** 96 100 68 1044 1308 136 376 76 2596 3184 Total 1944 2308 1316 25,260 30,828 3868 4972 2056 48,556 59,452 Hourly average# 0.57 0.68 0.39 7.42 9.05 1.14 1.46 0.60 14.26 17.46 Squashes ETV Other Total Squashes ETV Other Total SABC1 SABC2 SABC1 SABC2 2013 84 180 144 576 984 156 168 48 1140 1512 2014 72 264 348 1788 2472 24 348 24 3084 3480 2015 384 468 384 1932 3168 324 684 48 2088 3144 2016 300 876 264 1920 3360 72 708 204 1572 2556 2017 372 456 216 1512 2556 108 324 360 1836 2628 2018 564 516 744 288 2112 264 84 600 312 1260 2019** 92 48 36 28 204 24 92 40 156 Total 1868 2808 2136 8044 14,856 972 2316 1376 10,072 14,736 Hourly average# 0.55 0.82 0.63 2.36 4.36 0.29 0.68 0.40 2.96 4.33 **January to April 2019. #Hourly averages are for January 2013 to April 2019 and calculated using a total of 3405 h for each viewing time. Appendix Boachie et al. 13 Table A2. Number of adverts aired across all TV channels by drink type and year. Children viewing time (15:00:01 to 17:00:00) Family viewing time (17:00:01 to 19:00:00) Year Carbonated Energy drink Fruit Juice Squashes Total CarbonatedEnergy drink Fruit Juice Squashes Total 2013 10,740 8556 2580 984 22,860 13,056 9228 3504 1512 27,300 2014 11,484 13,524 2664 2472 30,144 17,544 21,516 3804 3480 46,344 2015 12,960 129,60 3708 3168 32,796 15,216 14,856 7716 3144 40,932 2016 22,980 11,220 7548 3360 45,108 31,068 15,036 11,892 2556 60,552 2017 31,656 5160 4296 2556 43,668 44,508 6960 9492 2628 63,588 2018 16,596 12,756 8724 2112 40,188 23,100 21,780 19,860 1260 66,000 2019** 1124 1576 1308 204 4212 1556 2988 3184 156 7884 Total 107,540 65,752 30,828 14,856 218,976 146,048 92,364 59,452 14,736 312,600 Hourly average# 31.58 19.31 9.05 4.36 64.31 42.89 27.13 17.46 4.33 91.81 **January to April 2019. #Hourly averages are for January 2013 to April 2019 and calculated using a total of 3405 h for each viewing time.