This feature article is a part of Celebrating 40 years of the Code. Visit the Code landing page for more articles, information, resources and timeline of the Code's history.

As the International Code of the Marketing of Breast-milk Substitutes marks its 40^th year, it’s inescapable that the marketing of these products remains pervasive and the companies are raking in profits. What’s going on? How is a public health crisis going on right in front of us, eluding resolution?

The answer is ingenious and powerful marketing, asserts Prof. Gerard Hastings, lead author of Selling Second Best: How Infant Formula Marketing Works, published in the journal Globalization and Health last year. Prof. Hastings, whose background in the commercial determinants of ill-health informed an approach that involved interviewing marketers from the food and infant formula industries, discussed the research with Alive & Thrive.

Alive & Thrive: How did you come to settle on interviewing the former executives as a way to examine what’s happening with BMS?

Hastings: I'm relatively new to the baby milk controversy. I've spent my career in the industrial epidemics area – where commerce abuts with life. The obvious examples are tobacco, alcohol and ultra-processed foods. What's always interested me is the commercial side of the equation - how do these companies work? What is their long-term aim? And how do they cope with the dissonance that must be there at some level? Anybody working in a marketing department of a tobacco company, for instance, must be balancing some really big internal conflicts.

I thought the issue of BMS marketing was all sorted out, I thought it had been dealt with in the 1980s. I was surprised to see how prevalent the marketing is when it's not supposed to occur at all. It is hidden in plain sight.

Alive & Thrive: What surprised you about what you found?

Hastings: One of the immediate points that struck me was what is going on here and what is going on in tobacco, alcohol, fast food, and you can add in gambling and guns: It's how consumer culture works - you get people to consume whatever it is you want them to consume by using very clever persuasive techniques. They end up doing what they are told, while thinking they are exercising their free choice. It's so subtle you don't know you're being seduced. The similarities between selling formula and selling Marlboro were immediately obvious.

Alive & Thrive: So, what BMS companies are doing with their marketing is not unusual.

Hastings: No. We're all being coaxed by oceans of such seduction to consume way beyond our own and the planet's means. We buy it without realizing we're being sold. It’s become culturally imbedded: if you want to improve your lot, you go and buy something, whether it’s masculinity, beauty, or our child’s health.

"We're all being coaxed by oceans of such seduction to consume way beyond our own and the planet's means."

Alive & Thrive: Tell us a bit about the research effort. 

Hastings: We decided the way to do this was to talk to the people doing the marketing. We didn't speak to customers or parents. We talked to a selection of people, all of whom had experience in food marketing and some of whom had worked in formula marketing. The latter group were quite difficult to find, but we succeeded.

Alive & Thrive: I imagine they were not excited to talk to you.

Hastings: There is a certain amount of dissonance. One of the respondents – a former formula marketer – used the expression, “We all drank the Kool-Aid on that,” which is to say they swallowed the line that there's an equivalence between breastmilk and formula. And as with all great lies there is a kernel of truth there – there are women who cannot breastfeed for various reasons. Formula can be a life saver.  But it is nowhere near as good as breast milk.  As the paper explains, if instead of using formula, all babies were breastfed as the World Health Organization (WHO) recommends, over 800,000 infant deaths would be avoided each year.  That's an astonishing statistic. It is on a par with tobacco in fact. The respondent went on to say that she wouldn't do it again.

Certainly, approaching this through the formula industry, is a non-starter. You won't get anywhere doing that – we know because we tried.

Alive & Thrive: What would you say are the key takeaways for nutrition practitioners?

Hastings: The most interesting, almost revelatory, point is that this marketing is built on charm. (BMS companies) do lovely, helpful, supportive things. For example, their way into this market is through Helplines and Baby Clubs. These don’t look like marketing at all – more like a social service. If you waved a magic wand and got rid of this marketing, someone would have to move in and replace those services.   

But it is marketing and builds into powerful emotional connections and brand values. For example, one of the respondents described the use of the tune “Baby Love” by The Supremes and mentioned how that has been used for two generations of mothers. That's massive cultural capital. So, in the 1980s a woman who heard that, now shares it with her daughter and granddaughter. That's what we in public health need to understand: this isn’t obvious, brazen trickery - it is subtle seduction. It is lovely. Every now and again in the United Kingdom, some doctor will be unmasked as having no qualifications, being an imposter. And after that, two things will happen: first, he'll lose his license and be punished severely by the authorities. Second his former patients will protest, saying what a wonderful doctor the imposter had been. It is easy to confuse customer care with real care. 

Alive & Thrive: What else would you say is happening with BMS marketing?

Hastings: The real need for any parent is the welfare of their baby. There's no one saying, “Give me what's second best for my baby.” But that's what they're being offered. The marketing hides the flaws and accentuates the positives. That's no different from any other product – that’s what marketers do. None of this takes away from the enormous crime being committed here. In fact, if anything, I think it makes it worse.

If, as a public health professional, you recommended to ban Coca Cola, which is probably a good thing to do, you'd have a revolution on your hands. A lot of people would say, "You're not going to take away my Coca Cola." What marketers do is they pull you into not only the consumption process, but the marketing process, too. Brands are not owned by the company alone; they're owned by the consumer as well. That's why brands are so powerful, they partly exist in our brains and our hearts.

Alive & Thrive: So, what are some specific instances of BMS marketers developing effective messaging?

Hastings: How marketers use the “Breast is best” line is a good example. That phrase comes directly from public health messaging. And the BMS marketers use it to good marketing effect – and by doing so, it brings them in line with public health. It allows them to say, "Of course it is best" and then say "but...". They've managed to promote their product with the seeming blessing of the public health community.

The phrase that sort of makes me shudder is, "It's informed by 40 years of breastmilk research." That's a beautiful illustration of how marketers talk. It has a lovely ring to it but when you examine it, it’s impossible to pin down what is being said beyond a vague feeling that it must be a good thing. It's very, very clever. You could, for instance, interpret it as suggesting they've replicated breastmilk, which of course is not true. But it doesn’t actually say this, so you can't call them out on it.

One particular campaign that stood out is "Sisterhood of motherhood.” It's brilliant. It also demonstrates that marketing doesn't just boost a particular brand, it can have an impact on the generic market. The ad shows a group of parents who are in a park (pre-COVID). They are chatting and it is clear they all hold various different beliefs and ideas about how to raise their children, and begin to bicker about them. Then one of the buggies goes out of control down a hill and they rush to save the baby. And the message is that, although we may have our disagreements, at the end of the day we're all parents. It reframes the use of formula around personal choice rather than science. It's a chilling illustration of how marketing has an impact on society as a whole – on how we think, feel and act.

"The phrase that sort of makes me shudder is, "It's informed by 40 years of breastmilk research." That's a beautiful illustration of how marketers talk. It has a lovely ring to it but when you examine it, it’s impossible to pin down what is being said beyond a vague feeling that it must be a good thing."

Alive & Thrive: In addition to this very clever marketing you also looked at the BMS companies themselves. What did you find?

Hastings: It is very clear that the soft power of marketing is backed by the brute force of the BMS companies’ fiscal strength. These are multinational companies with massive budgets. It's not just that they are very clever – they are also very, very independently powerful. Governments will listen to them, they have very powerful friends.  That is a very difficult problem.

The companies are making a great deal of money and they can buy expertise, the best people, who can create these ads. There's any number of marketing people who are giants in literature and film, and other creative fields. They have their fingers on the pulse of popular culture. The reality is, if the baby milk industry has a scientific argument, it will lose. They go for the heart because that's where they win.

Alive & Thrive: It sounds hopeless!

Hastings: It's not at all hopeless. Yes, these companies are very big and powerful. But at the end of the day they are utterly dependent on us – to buy their products. In reality these companies are very vulnerable. They're not nearly as powerful as they'd like us to think.

Alive & Thrive: So what’s to be done?

Hastings: We need to do what we set out to do in 1981 and ban formula marketing. This marketing is promoting a second-rate product which is causing massive public health and environmental harm. Paradoxically, we can also learn a great deal from what the companies do. If marketing were driven by good science and ethics rather than profit, if it operated in the baby’s rather than the shareholder’s interest, it could do real good. Baby Clubs and Helplines, for example, could be used to great effect supporting women to breastfeed. If the money and creative genius that went into the Sisterhood of Motherhood were put behind mother’s milk the impact would be enormously beneficial. 

"This marketing is promoting a second rate product which is causing massive public health and environmental harm."

Alive & Thrive: We have supported exclusive breastmilk campaigns with partners in many countries where we work. What would be your advice to public health people designing such campaigns?

Hastings: Formula marketers understand a great deal about infant feeding. I would start by talking to the target audience and what are their concerns and needs, which I’m sure you already do. The starting point has to be where the women are. What is driving them to decide? What would encourage them to make the public health decision? It starts with that kind of intimate insight. Beyond that, I would look at emotional and cognitive resonance. It is also vital to look at the wider environment and make this as supportive as possible. Getting rid of the marketing is part of this, as is support for nursing mothers, proper maternity and paternity leave and a baby-friendly workplace. 

Alive & Thrive: The BMS Code has turned 40 this year. But this marketing is everywhere. Is the BMS Code a failure?

Hastings: No, it's not a failure. 40 years ago we were ahead of the game in realizing that something needed to be done to protect parents from manipulative commercial marketing. But industry is cunning and will resist or subvert controls, as they did in the 1980s with follow-on milks. Consider tobacco. All forms of marketing are now banned in the United Kingdom, but this took time and persistence -- 20 years to pass the law banning all advertising, then another 20 years getting rid of point of sale displays, introducing plain packaging and prohibiting price promotions. We have to realize that whatever we do now, industry will move to minimize it or undermine it, and we have to be ready to respond. So there is no magic spell: we need a coherent, well-resourced ongoing strategy. This way we can and will put an end to the disgrace of formula marketing.

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