Policy on Paper compared with Policy in Practice: A Study of Healthy Default Beverage Implementation and Enforcement in the United States.

Background: Healthy default beverage (HDB) policies, which require restaurants to offer healthier drinks with children's meals, may reduce child sugar-sweetened beverage consumption. Although they are gaining popularity across the United States, restaurant awareness and compliance remains low, warranting deeper investigation into policy guidance and implementer knowledge. Objective: To examine implementing agencies' awareness of HDB policies, the prevalence of implementation and enforcement practices and their alignment with policy documents, and challenges to implementation and enforcement. Methods: We used a mixed-methods approach combining an analysis of HDB policy documents and an online survey of implementers across jurisdictions with state or local policies. A codebook was developed to assess implementation and enforcement provisions in policy documents. Descriptive statistics were used to summarize survey-reported practices, and we examined alignment between these practices and the corresponding policy language. Nineteen policy documents (4 state, 15 local) and 64 survey responses from unique jurisdictions were analyzed. Results: Among jurisdictions, 46 (72%) were knowledgeable about their policy. Most state jurisdictions (86%) and all local jurisdictions reported using a communication strategy regardless of inclusion in policy documents. Restaurant compliance was typically assessed through in-person restaurant visits (state: 78%; local: 42%). Equity-related implementation considerations included additional time for policy implementation (state: 43%; local: 60%) and technical support (state: 72%; local: 60%). Most state (67%) and local (73%) jurisdictions reported issuing warnings and fines for enforcement. Equity considerations for enforcement were reported for some state jurisdictions (27%) and included additional time to become compliant (75%) and issuing warnings without escalating to fines (25%). Implementation misalignment between practices and documents often reflected jurisdictions exceeding policy documents, whereas enforcement misalignment between practices and documents often involved inconsistent or incorrect use of the enforcement strategy in the policy document and misalignment of reported funding allocation. Conclusions: Although jurisdictions frequently expanded beyond written implementation requirements, enforcement knowledge and practices inconsistent with policy documents highlight potential gaps in resources, training, and infrastructure. Efforts to bolster implementer capacity and promote equitable approaches may increase the ability of localities to implement and enforce HDB policies.