Almost all parents and pregnant women in China, Vietnam and the UK are exposed to “aggressive” formula milk marketing campaigns that breach global rules set up after scandals more than 40 years ago, according to a new report.

The marketing techniques can push women away from breastfeeding and include everything from giving free samples, to executives setting up or joining "mums' groups" on popular messaging apps, the report from the World Health Organization (WHO), UNICEF and M&C Saatchi said.

Health workers are also targeted, with gifts, funding for research and even commission from sales, all practices that are banned under international guidelines for the marketing of formula milk.

The WHO recommends exclusive breastfeeding for newborns, where possible, as the healthier option.

The report's authors and several external experts said it was time to reform the International Code of Marketing of Breast-milk Substitutes. The code was set up by WHO in 1981 in a bid to regulate the industry after scandals in the 1970s when Nestle was accused of discouraging mothers, particularly in developing countries, from breastfeeding.

Nigel Rollins, lead author of the report and a WHO scientist, told Reuters in an interview: "Are there areas for strengthening the code? Unquestionably."

Formula milk and tobacco are the only two products for which there are international guidelines to prevent marketing.

Despite this, only 25 countries have fully implemented the code into legislation, and over the last four decades, sales of formula milk have more than doubled, while breastfeeding rates have only slightly increased, the WHO said. The formula milk industry is now worth $55 billion annually.

The report found that more than half of the 8,500 parents across the eight countries surveyed - Bangladesh, China, Mexico, Morocco, Nigeria, South Africa, the United Kingdom and Vietnam – reported exposure to marketing, much of which was in breach of the code.

Titled "How marketing of formula milk influences our decisions on infant feeding", the report also included interviews with marketing executives and 300 health workers, and is the largest of its kind.

In China, 97% of women surveyed had been exposed to formula milk marketing; in the UK it was 84% and in Vietnam, 92%. More than a third of women across all of the countries said that health workers had recommended a specific brand of formula to them.

While the code allows factual informational about formula to be provided, and the authors acknowledged the importance of formula milk for women who cannot or do not want to breastfeed, they said the marketing practices were a key reason for low breastfeeding rates worldwide.

The WHO recommends exclusive breastfeeding for at least the first six months of life, but at the moment, only 44% of babies this age are fed this way.

A major study in 2016 suggested more than 800,000 babies’ lives could be saved annually if breastfeeding rates improved to reach this milestone.

"False and misleading messages about formula feeding are a substantial barrier to breastfeeding, which we know is best for babies and mothers," said UNICEF executive director Catherine Russell in a statement.

Rollins said digital marketing in particular needs work, because of the potential for personalised targeted messaging and because it is now a major area of expansion for formula milk companies, alongside milks for older children and milks for allergies.

In a statement on behalf of the companies, the International Special Dietary Foods Industries (ISDI) said its members complied with all laws and regulations in the countries in which they operate.

"Our members support efforts by national governments to ensure compliance with all national laws and regulations. Our members are ready to work together with all stakeholders to support optimal infant health and well-being," it added.

The WHO declined to comment on individual companies, and does not name them in the report, but said that there were no substantial differences between their practices.

However, an index compiled by the Access to Nutrition Initiative in 2021 found that some companies were more compliant with the code than others: for example, Danone's marketing is 68% in line with the rules, and Nestle, 57%. However, three of the leading companies operating in China – Feihe, Mengniu and Yili – all scored zero.

External experts said that wider reform was needed to bring all companies, and countries, into line, as well as tougher punishments for those who break or skirt the rules.

Gerard Hastings, emeritus professor of marketing at the University of Stirling, Scotland, said regulators like the Food and Drug Administration (FDA) should be more involved.

"We need to rethink how to actually make it (the code) work, so that it can be enforced much more strongly," he told Reuters.

"These agencies really need to go back to the drawing board and think of infant formula products in the same way as you would think of drugs."