Advertising to children and teenagers is a multibillion-dollar industry. This policy statement reviews the forms of advertising that children and teenagers encounter, including newer forms of digital marketing, such as sponsored content, influencers, data collection, persuasive design, and personalized behavioral marketing driven by machine learning. Parents and pediatric health care providers need to be aware of the ways different marketing messages reach children and teenagers, including Internet sites, social media, and mobile apps. Evidence suggests that exposure to advertising is associated with unhealthy behaviors, such as intake of high-calorie, low-nutrient food and beverages; use of tobacco products and electronic cigarettes; use of alcohol and marijuana; and indoor tanning. Children are uniquely vulnerable to the persuasive effects of advertising because of immature critical thinking skills and impulse inhibition. School-aged children and teenagers may be able to recognize advertising but often are not able to resist it when it is embedded within trusted social networks, encouraged by celebrity influencers, or delivered next to personalized content. This policy statement expresses concern about the practice of tracking and using children’s digital behavior to inform targeted marketing campaigns, which may contribute to health disparities among vulnerable children or populations. Pediatricians should guide parents and children to develop digital literacy skills to prevent or mitigate negative outcomes, but it is equally important that policy makers and technology companies embrace digital design, data collection, and marketing practices within today’s broad digital environment that support healthier decision-making and outcomes.
The Changing Landscape of Marketing to Children
Advertising to children and teenagers via various forms of media has occurred for decades, with expenditures of $3.2 billion for nondigital and $900 million for digital advertising in the United States in 2018.1 Children and teenagers encounter advertising through television, radio, print media, the Internet, and their mobile phones. Advertising can take many forms, including images, videos, and games that advertise specific brands. However, since the introduction of mobile media and Internet-connected devices (eg, virtual assistants, Internet-connected toys), advertising now comprises a wider range of marketing approaches for which influences on child behavior have not been well described. The purpose of this policy statement is to review the developmental science explaining how children and teenagers are vulnerable to advertising, review the emerging research on novel marketing approaches and evidence regarding advertising and child health, and offer guidance to parents, pediatric health care providers, industry, and policy makers about the needs and rights of children in the modern digital media environment.
Children’s Unique Vulnerability to Advertising
Research on children’s understanding of television advertising2 demonstrates that children 7 years and younger have limited ability to understand the persuasive intent (ie, that someone else is trying to change their thoughts and behavior) of the advertiser. From ages 7 to 11 years, children can start to recognize television advertising and persuasive intent with their parents’ assistance but lack the abstract thinking skills that help individuals recognize advertising as a larger commercial concept. At ∼12 years of age and older, teenagers were able to identify television advertisements (ads) and advertisers’ intention to change behavior (which is why some countries, such as Sweden and Brazil, have laws banning advertising to children younger than 12 years).
However, recognition of persuasive intent does not necessarily lead to the ability to resist marketing, especially with highly appealing products. Marketers use emotional or subconscious approaches3 to engage children, such as using trusted characters4 or celebrities. At as young as age 2, a child can easily identify a familiar character as well as correctly connect them with an endorsed product.5
Most importantly, most research on children’s understanding of advertising involves television and print ads only, but newer forms of advertising found in mobile and interactive media and smart technologies, often powered by personal data, are more difficult to identify. They do not necessarily occur in a predictable manner and are often integrated into the content.6 Advertising may also be linked to rewards or be embedded in trusted social networks or personalized digital platforms, which may undermine children’s abilities to identify or critically think about advertising messages. Regulations on television advertising7 have not yet been updated for the modern digital environment.
New Marketing Approaches
The nature of media used by children and teenagers has changed dramatically in the past decade, and children now spend more time on the Internet, social media, user-created content, video games, mobile applications (apps), virtual or augmented reality, virtual assistants, and Internet-connected toys. The Internet allows advertisers to contact, track, and influence users, as guided by behavioral data collection; a user’s digital trail of location, activities, in-app behavior, likes, and dislikes contributes to a digital profile shared among many companies that can be used to make advertising messages more effective.
Sponsored Content and Influencers
User-created content on social media platforms and video-streaming services (eg, TikTok, YouTube) frequently involves commercial content and marketing messages. Examples include the highly popular unboxing and toy-play videos as well as influencers reviewing or using products with sponsorship from companies. Child advocacy groups have highlighted the large amount of child-directed influencer marketing, often undisclosed, which is not allowed on children’s television (ie, “host selling,” using stars of a television program in commercials airing during that program) because it is harder for children to identify or resist.8
Data and Privacy
Beyond advertising, it is also important for families to understand how data collection influences the information that reaches them through the Internet. Previous online behaviors shape what is delivered to users via news, notifications, and social media feeds, creating a filter bubble in which all input, unbeknownst to users, is tailored to their interests and creates false norms that can undermine healthy behaviors.
In the United States, COPPA is meant to “place parents in control over what information is collected from their young children online” and limit the data that child-directed Web sites, apps, or other online services collect, use, or disclose to third parties in the absence of parental consent.16 However, COPPA leaves open many gaps in its protection. It generally does not protect children when they are using Web sites or apps that are considered targeted to a general audience, nor does it apply after a child is 13 years of age. In addition, the law has not being enforced reliably.11 The European Union’s General Data Protection Regulation (2018) is more ambitious in protecting user privacy, and the UK Information Commissioner’s Office has recently introduced an age-appropriate design code to address children’s vulnerabilities regarding data collection and persuasive design.17
Persuasive Design and Behavioral Marketing
Design elements intended to nudge users into specific behaviors (by constraining choices, highlighting preferred buttons to click, or providing rewards for preferred behavior) are now a common part of digital design.18 These design elements extend digital engagement in ways that increase exposure to advertising, which children and teenagers may not be able to identify or resist. This targeted marketing also results in different products being advertised to different populations, which may accentuate existing disparities.12
Gamified Ads and In-App Purchases
Newer Internet marketing practices in the 2000s included gamified advertising (“advergames”), which rewards users for watching ads or buying products,19 but have evolved to include advertising that is less evident to the child. For example, an analysis of the most-downloaded free apps for children younger than 5 years on Google Play revealed that 96% contained commercial content, including hidden ads, interstitial ads that pop up automatically, and ads that, when viewed, provided incentives, such as more game tokens or making gameplay easier.6 App characters were noted to encourage in-app purchases in some games.6
Artificial Intelligence and Machine Learning
Artificial intelligence and machine learning form the core of many technologies accessed by children and teenagers, including virtual assistants. It is unclear how much data are being collected, how data are being processed or used to shape query responses for the purposes of marketing to children, or how parents can access the information. Young children attribute more animism to and place more trust in these artificial intelligence agents and are more likely to share information with them.20
Specific Health-Related Concerns
Food Advertising and Childhood Obesity
Food marketing funding today is less dependent on television and is instead concentrated on integrated marketing campaigns and cross-platform promotion to spur children’s requests and demands for products,21 as highlighted in the recent comprehensive report by the University of Connecticut Rudd Center for Food Policy and Obesity.22 Food advertising has been linked to higher obesity risk via ads for high-calorie, low-nutrient food and beverages (which influence diet and purchases).23 Screen media consumption is inversely correlated with fruit and vegetable intake and directly correlated with energy-dense, nutrient-poor snacks, drinks, and food.24 Ads also promote intake of foods that contribute to dental caries.25 More fast food and sugar beverages are advertised in African American, Hispanic, and low-income communities, according to the Rudd report,26 as are candy and cereals. Nearly 40% of ads on television targeted to African American and Hispanic populations are for fast food and other restaurants. Unhealthy food advertising in 13- to 17-year-olds is also correlated with development of media-driven norms that supersede healthier family norms.27 Influencers can sway teenagers toward unhealthy choices; Bragg et al28 identified popular music stars endorsing 18% of surveyed ads; 49 (71%) promoted sugar-sweetened beverages, and 21 (80.8%) endorsed foods were energy dense and nutrient poor. In an experimental study, Coates et al,29 found that school-aged children who viewed mock profiles of influencers promoting unhealthy snacks showed a significant increase in intake of unhealthy snacks and total calories compared with children who viewed influencers promoting nonfood items. Folkvord et al30 observed increased caloric intake in 7- to 10-year-olds playing advergames as well, which children with high impulsivity had an especially hard time inhibiting.
Tobacco and Electronic Cigarette Advertising
Multiple studies have revealed that in teenagers, attention and receptivity to cigarette advertising is correlated with both current and future use.31 Cigarette ads on television and radio were banned in 1971 for this reason. This correlation has been found with emerging tobacco products, such electronic cigarettes (e-cigarettes),32,33 to which the majority of middle and high school students have been exposed.34 E-cigarette companies have used social media influencers, hashtags, music videos, and other informal social media presence to advertise their products,35 although companies have deleted their own official social media accounts.
Studies have revealed increased exposure to alcohol content for middle and high school youth via social media,36 banner ads, and video ads, with disparate exposure for African American,37 Hispanic, and American Indian youth.38 A review by Jernigan et al39 of 12 longitudinal studies published from 2009 to 2015 demonstrated a positive correlation between marketing exposure and receptivity and alcohol consumption in youth, and the authors concluded that “existing self-regulatory systems do not meet their intended goal of protecting vulnerable populations from alcohol marketing.”
The legalization of marijuana in many states has led to media and point-of-sale advertising seen by people younger than 21 years40 or increased exposure through social media mentions, sometimes accompanied by cartoon characters or other design elements attracting to children.41 Point-of-service advertising has been found to be more common in areas of lower socioeconomic status and minority populations.42 Marijuana advertising exposure is associated with heavier use, use of marijuana concentrates and edibles in young adults,43 and higher probability of marijuana use and intentions in middle schoolers.44
Cultural Biases, Body Appearance, and Teenager Self-image
By presenting ideals of body appearance, ads can convey cultural biases, such as skin color (eg, skin-lightening products), hair traits (eg, hair-straightening products), or unhealthy body weight ideals (eg, diet products or muscle-building supplements). In addition, ads for indoor tanning salons often target teenagers. Because indoor tanning is considered a class 2 carcinogen, such advertising is restricted over traditional media. For this reason, tanning salons actively use social media as a strategy for attracting and retaining customers,45 encouraging high-frequency tanning,46 and lowering the perception of the risks of tanning.47
Digital literacy requires that children, teenagers, and parents understand that technology is created by other humans with their own agendas and that they can accept or reject its messages, identify advertising and persuasive intent, reflect on their own reactions to media, and engage with media on the basis of their own intentions (rather than reacting to engagement-promoting design). However, Livingstone et al12 identified disparities in knowledge about technology and privacy among parents of different socioeconomic status or digital skills. For example, parents from lower-income backgrounds were more likely to place credence in the learning value of apps marketed as educational for their young children,48 despite a lack of evidence-based data for most such products.49 Thus, differences in digital literacy skills and knowledge by socioeconomic status may contribute to digital disparities.
Digital literacy programs have been developed to teach children how to think about technology, not just how to use it. For example, Zarouali et al10 showed that teenagers responded more favorably to specifically targeted rather than nontargeted ads, but teenagers who understood the privacy intrusions that led to such targeted advertising were more skeptical and less likely to purchase the product. Educational programs and campaigns are recommended, in combination with the design changes discussed below, to mitigate this influence and persuasion.
Many digital media resources, including apps, programs, games, and educational materials, are subsidized and supported by advertising dollars. Children’s and teenagers’ unique developmental needs make them more vulnerable to negative physical, mental, and financial health effects of digital marketing. Although parents play a large role in helping their children be critical of media messages, identify surreptitious advertising approaches, and resist their influence, it is also crucial that there are measures in place in children’s digital media environments to protect their needs.
Excessive media use has been linked with negative health outcomes in children and teenagers. American Academy of Pediatrics (AAP) policies regarding media50,51 provide guidance for parents and families regarding limiting media use and engaging in healthy conversation about media messages. However, parents should not be the only ones held responsible for child privacy in a digital environment that is predicated on a business model of advertising and data collection in which the default settings serve to compromise user privacy or potentiate disparities. Parents can be effective in teaching children and teenagers to think critically about digital media, but this AAP policy statement places the primary duty to protect children on technology developers and policy makers, who should create a digital environment in which families can access content that provides opportunities rather than delivers profits.
To empower parents to help their children, the following steps and resources are recommended:
1. Build digital, privacy, and design savviness. Know what your children are downloading and accessing so that you can help them be an informed consumer, and demand better-designed digital products for children (helpful resources: https://www.childrenscommissioner.gov.uk/wp-content/uploads/2018/11/who-knows-what-about-me-infographic.pdf and https://www.consumerreports.org/digital-security/online-security-and-privacy-guide/).
2. Enhance and monitor privacy settings on personal devices, apps, social media, virtual assistants, and wireless networks. Understand the differences between privacy settings that determine what other users can see about you and the platform collecting data about you (helpful resource: https://www.commonsensemedia.org/privacy-and-internet-safety).
3. Create a family media use plan that intentionally uses high-quality media content that has as few ads as possible, limits data collection, and encourages discussion about privacy (helpful resource: https://www.healthychildren.org/English/media/Pages/default.aspx).
4. Teach children to analyze the ads they see, identify algorithms that affect their streaming content, understand what personal data are collected, and be savvy about the persuasive intent behind the design of the technologies they use (helpful resource: Digital literacy toolkit from Sonia Livingstone: www.myprivacy.uk).
5. Talk to school administrators and teachers about the digital privacy of the technology tools they use (helpful resources: Campaign for a Commercial-Free Childhood parent toolkit for student privacy [https://commercialfreechildhood.org/pf/parent-toolkit-student-privacy/] and Common Sense Media privacy evaluations of educational technology products https://privacy.commonsense.org/evaluations/1]).
The best thing parents can do to encourage digital literacy in their children is to talk openly and critically about media from the time children are young. For example, when watching a television show or using mobile technology, parents can express their skepticism or ask children their opinions. Alternatively, when children ask to buy a specific product, parents can ask questions to explore how advertising might have contributed to that desire. Parents can speak with younger children about what ads are trying to sell or why their favorite app has design features, such as autoplay, that keep them watching longer. For older children, discussions can revolve around influencers, unpacking messages about consumerism, or whether they understand all of their privacy settings. These are just a few examples of how such discussions allow parents to understand the extent of their children’s literacy (or lack thereof), help to align children’s media use with their family values, and help children to feel comfortable reaching out to their parents when they have concerns about online content or privacy.
The AAP recommends the following:
1. Understand how children and teenagers are targeted by advertisers, and help parents understand children’s specific vulnerability to persuasive design and targeted ads. Encourage parents to be discerning consumers of their child’s media and demand better design and data collection practices.
2. Ask patients and families about any media use concerns as a part of routine health maintenance. Encourage families to use the AAP family media use plan to set media use limits, adopt privacy-preserving behaviors, and engage in parent-child communication regarding digital media.
3. Provide educational materials and references (listed above) to help parents and patients build digital literacy, as developmentally appropriate. Consider using a parent or child’s use of a mobile device during visits as a teachable moment to identify ads or persuasive design (helpful resource: AAP News article on building digital literacy: https://www.aappublications.org/news/2019/04/24/masteringmedia042419).
4. Recommend parents to think of themselves as role models for digital media use, digital citizenship, and digital literacy. Encourage discussions about Internet privacy and persuasive design, and recommend settings or filters to reduce ads and improve privacy.
5. Advocate for policies and regulations that limit advertising and data collection from children and teenagers. Pediatricians can advocate with local schools to avoid educational technology that is commercial and does not protect children’s privacy. Pediatricians and parents can also ask for the establishment of digital literacy curricula in public schools so that children from all socioeconomic backgrounds can build equitable understanding of digital marketing and persuasive design.
For Industry and Policy Makers
The AAP recommends the following:
1. Policy makers and technology companies should adopt stricter privacy regulations for all users (including children and teenagers), which include data collection from home technologies, mobile devices, and other Internet-connected devices or toys. Disclosure of such collection should be prominently provided at appropriate literacy and developmental levels, and technology companies should report what data will be collected, how the data will be used, with whom data might be shared, and the risks and benefits to the consumer. Information about blocking this data collection and deleting personal information permanently should be provided. Default settings for platforms, programs, apps, and Internet-connected toys should be set at the highest level of privacy.
2. Strengthen COPPA enforcement to prohibit personal and location data collection from apps and Web sites clearly used by children younger than 13 years without parental consent and by anyone 13 to 17 years of age without the user’s consent. For Web sites and apps used by multiple age groups, such as search engines and YouTube, provide alternative services that do not collect or aggregate data and that limit advertising. Ban targeted (ie, data-driven behavioral) advertising to individuals younger than 18 years.
3. Ban all commercial advertising to children younger than 7 years, and limit advertising to older children and teenagers. All advertising should be clearly labeled as such (eg, as sponsored content).
4. Prohibit in-app host selling and purchases, including loot boxes that pressure gamers to spend money during game play. Require clear separation of content and advertising in media designed for children, including product placement in child-directed videos.
5. Reduce advertising of unhealthy foods and beverages to children and teenagers, particularly targeted advertising that exacerbates disparities when combined with structural sources of inequality (eg, healthy food scarcity, public underinvestment in opportunities for exercise or play).
6. In accordance with the AAP policy statement on tobacco,52 depictions of tobacco products (including e-cigarettes), tobacco product use, and images associated with tobacco product brands in movies and video games should be restricted. Internet sales of tobacco products should be banned because they are easily accessed by minors.
7. In accordance with previous AAP policy statements on marijuana53 and alcohol,54 limit access and marketing of these substances to youth (eg, by using mascots, cartoon characters, or influencers popular with children and teenagers).
8. Require and fund digital literacy curricula in schools. Prohibit use of digital media that contain advertising in the classroom.
9. Fund and promote research on the effects of advertising in digital media in children and teenagers to further identify risks inherent in data collection, digital profiling, and selective targeting of disadvantaged communities and to inform age-appropriate design guidance.
10. Increase efforts to promote digital equity by improving access to quality commercial-free content.
Council on Communications and Media Executive Committee, 2019–2020
Nusheen Ameenuddin, MD, MPH, MPA, FAAP, Chairperson
Rhea Boyd, MD, MPH, FAAP
Ellen Selkie, MD, MPH, FAAP
Jenny Radesky, MD, FAAP
Michael Patrick, Jr., MD, FAAP
Jaime Friedman, MD, FAAP
Yolanda Evans, MD, MPH, FAAP
Suzy Tomopoulos, MD, FAAP
Hansa Bhargava, MD, MBE, FAAP
Jeffrey Hutchinson, MD, FAAP
Edith Bracho-Sanchez, MD, FAAP
Kristopher Kaliebe, MD - American Academy of Child and Adolescent Psychiatry
Dr Radesky drafted the initial policy statement, wrote sections of the manuscript, and critically revised the manuscript on the basis of reviewer feedback; Drs Chassiakos, Ameenuddin, and Navsaria wrote sections of the manuscript and revised the manuscript on the basis of reviewer feedback; and all authors approved the final manuscript as submitted.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
FUNDING: No external funding.
American Academy of Pediatrics
Children’s Online Privacy and Protection Act
POTENTIAL CONFLICT OF INTEREST: Jenny Radesky is a paid consultant and board member for Melissa & Doug. The other authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
RE: Internet should not be a place where advertising for unhealthy products can reach children
E-cigarette companies are using social media influencers, hashtags, music videos, and other informal social media presence to advertise their products to our vulnerable children(1) in order to promote e-cigarette as a healthier and a therapeutic tools for quitting combustible tobacco. However recent evidence clearly show that adverse effects of e cigarette use (moreover, evidence does not support their use as part of population-based cessation strategies (1). The position paper of Royal College of Physicians of Edinburgh highlighted that the physicians need to be cautious about the effects of vaping on the young brain and the potential for addicting a new generation (2).
A new AAP policy statement Digital Advertising to Children helps clinicians and families build awareness of the rapidly evolving - and sometimes exploitative - digital marketing strategies (1). Meanwhile, adolescents are overwhelmingly exposed to social media messages that favor e-cigarettes as smoking cessation aids. Misinformation could danger adolescents overall health and wellbeing. This underlines the need for effective public health engagement with social media and physicians can support policies targeting adolescent e-cigarette use and the dissemination of evidence-based information on social media (3). The most direct entry point for physicians into social media to discuss adolescent e-cigarette use is Twitter given that there is already an abundance of activity on Twitter (3), however Instagram may also be an appropriate social media platform given the visual nature of e-cigarettes (3).
It is essential that physicians explain to adolescents the risks and health concerns e-cigarettes present, and implement measures to prevent or cease e-cigarette use (4). To help protect children from the harmful effects of digital advertising and data collection, the AAP is urging lawmakers, parents and pediatricians to take bold action. And it's advocating for the end of online tobacco sales because the products can easily be purchased by children (1).
In addition, teachable moments have been advocated for promoting health behavior change in a variety of health care settings. Health care providers could use every adolescent patient encounter as a opportunity for a teachable moment (5). We certainly appreciate AAPs timely statement on behalf of our vulnerable children healthy and tobacco free life styles “the internet should not be a place where advertising for unhealthy products can reach children (1)”
(1). Winnicka L, Shenoy MA. EVALI and the Pulmonary Toxicity of Electronic Cigarettes: A Review. J Gen Intern Med. 2020;35(7):2130-2135. doi:10.1007/s11606-020-05813-2
(2). Mathur A, Dempsey OJ. Electronic cigarettes: a brief update. J R Coll Physicians Edinb. 2018;48(4):346-351.
(3). Rubin, R. Getting Social: Physicians Can Counteract Misinformation With an Online Presence. JAMA. doi: 10.1001/jama.2019.10779.
(4). Arane K, Goldman RD. Electronic cigarettes and adolescents. Can Fam Physician. 2016 ;62(11):897-898.
(5). Parker S, Zuckerman BS, Augustyn M. Developmental and behavioral pediatrics: a handbook for primary care. Lippincott Williams & Wilkins, Philadelphia (PA); 2005.