Sugar-Sweetened Beverage Fee: A Model to Address Health Disparities in Hawai'i

Sugar-sweetened beverage (SSB) consumption is associated with increased risk of obesity, diabetes, and other chronic diseases. SSB consumption is also a health equity issue, as rates of consumption and related chronic diseases vary by race, ethnicity, and income in Hawai'i. The COVID-19 pandemic has highlighted the need for greater investment in public health and the well-being of communities experiencing health disparities because individuals with chronic diseases are more likely to develop complications from the virus. It has also created economic hardships for the people of Hawai'i, especially the state's most vulnerable populations. Amid this health and economic crisis, an opportunity exists to implement an SSB fee in Hawai'i. An SSB fee would impose a fee on SSB distributors that would be passed on to consumers in the form of price increases that influence purchasing behavior. Jurisdictions with SSB taxes or fees have seen reductions in SSB purchases and consumption and have generated millions of dollars in revenues to support health initiatives and reduce socioeconomic disparities. Models predict that a $0.02 SSB fee in Hawai'i could generate $60.5 million and significantly reduce healthcare costs and chronic diseases. This commentary will present an SSB fee policy as a viable model for Hawai'i to reduce SSB consumption, lower chronic disease risks, and generate needed revenues to support health, reduce inequities, and rebuild the state's economy.

Social determinants of dietary patterns, food basket costs and expenditure on alcohol and tobacco amongst Greenland Inuit

OBJECTIVE

Dietary transition, obesity and risky use of alcohol and tobacco are challenges to public health among indigenous peoples. The aim of the article was to explore the role of social position in dietary patterns and expenditures on food and other commodities.

DESIGN

Countrywide population health survey.

SETTING

Greenland.

PARTICIPANTS

2436 Inuit aged 15+ years.

RESULTS

Less than half of the expenditures on commodities (43 %) were used to buy nutritious food, and the remaining to buy non-nutritious food (21 %), alcoholic beverages (18 %) and tobacco (18 %). Participants were classified according to five dietary patterns. The cost of a balanced diet and an unhealthy diet was similar, but the cost per 1000 kJ was higher and the energy consumption was lower for the balanced diet. Participants with low social position chose the unhealthy pattern more often than those with high social position (40 % v. 24 %; P < 0·0001), whereas those with high social position more often chose the balanced alternative. Participants with low social position spent less money on the total food basket than those with high social position but more on non-nutritious food, alcohol and tobacco.

CONCLUSIONS

Cost seems to be less important than other mechanisms in the shaping of social dietary patterns and the use of alcohol and tobacco among the Inuit in Greenland. Rather than increasing the price of non-nutritious food or subsidising nutritious food, socially targeted interventions and public health promotion regarding food choice and prevention of excessive alcohol use and smoking are needed to change the purchase patterns.

Effectiveness of food environment policies in improving population diets: a review of systematic reviews

Unhealthy population diets contribute to the burden of non-communicable diseases. Policies targeting food environments (FE policies) may improve population diets. This review of systematic reviews aims to summarise recent evidence of the effectiveness of FE policies in improving diets. We searched PubMed for systematic reviews published from January 2010 onwards. Eligible FE policies included: nutrition and food labelling, provision of foods in public institutions or specific settings, price, marketing, nutrition quality and portion size, and availability of foods in retail and food service establishments. A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2) instrument was used to assess review quality. Reviews of critically low quality were excluded. Results were narratively reported in text and tables. The search identified 1102 records after removing duplicates. Following screening and quality assessment we included 12 systematic reviews. Two reviews focused on nutrition and food labelling, two on provision of foods in school settings, four on price, none on marketing policies, three on nutrition quality and portion size and one on the availability of foods in retail and food service establishments. Pricing policies (tax/subsidy) appear effective in altering intake and purchase of targeted foods and beverages. FE policies targeting the availability of foods in retail and food establishments, food provision in school settings, product reformulation and the size of portions/packages or items of tableware also appear effective. Overall, policies targeting food environments appear effective in improving population diets. However, there is a need for further high-quality evidence.

Tobacco control policies and smoking cessation treatment utilization: A moderated mediation analysis

BACKGROUND

Tobacco policies, including clean indoor air laws and cigarette taxes, increase smoking cessation in part by stimulating the use of cessation treatments. We explored whether the associations between tobacco policies and treatment use varies across sociodemographic groups.

METHODS

We used data from 62,165 U.S. adult participants in the 2003 and 2010/11 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) who reported smoking cigarettes during the past-year. We built on prior structural equation models used to quantify the degree to which smoking cessation treatment use (prescription medications, nicotine replacement therapy, counseling/support groups, quitlines, and internet resources) mediated the association between clean indoor air laws, cigarette excise taxes, and recent smoking cessation. In the current study, we added selected moderators to each model to investigate whether associations between tobacco polices and smoking cessation treatment use varied by sex, race/ethnicity, education, income, and health insurance status.

RESULTS

Associations between clean indoor air laws and the use of prescription medication and nicotine replacement therapies varied significantly between racial/ethnic, age, and education groups in 2003. However, none of these moderation effects remained significant in 2010/11. Higher cigarette excise taxes in 2010/2011 were associated with higher odds of using counseling among older adults and higher odds of using prescription medications among younger adults. No other moderator reached statistical significance. Smoking cessation treatments did not mediate the effect of taxes on smoking cessation in 2003 and were not included in these analyses.

CONCLUSIONS

Sociodemographic differences in associations between clean indoor air laws and smoking cessation treatment use have decreased from 2003 to 2010/11. In most cases, policies appear to stimulate smoking cessation treatment use similarly across varied sociodemographic groups.

A qualitative study on retailer experiences with Philadelphia's sweetened beverage tax

The Philadelphia Beverage Tax was implemented on January 1, 2017 for some sugar- and artificially-sweetened beverages. Few qualitative studies have assessed retailers' reactions to beverage taxes. We aimed to understand food retailers' knowledge and attitudes about the Philadelphia beverage tax and how they responded to it with the goal of informing the framing and implementation of beverage taxes in other interested jurisdictions. Researchers conducted semi-structured interviews with retailers within Philadelphia before (n = 15) and after (n = 11) the Philadelphia Beverage Tax was implemented. Purposeful sampling was used to recruit participants with different store locations and customer base characteristics. A priori codes based on the interview guide were used to organize data, and analytic memos were developed and reviewed to identify themes that emerged within the data using a grounded theory approach. Five themes emerged: (a) concerns about the tax purpose, amount, and use of revenue; (b) concerns about the tax's impact on finances and business operations; (c) business strategies implemented to lessen financial burden of the tax; (d) perceptions of customer responses to the tax based on income; and (e) confusion around tax implementation. Results highlighted ways to improve implementation. Retailers in Philadelphia implemented various strategies to offset negative effects on taxed beverage sales. Cities implementing a beverage tax would benefit from investment in educational outreach and support to business owners prior to tax implementation and ensure transparency in how tax revenue will be spent.

Estimating the impact of state cigarette tax rates on smoking behavior: Addressing endogeneity using a natural experiment

INTRODUCTION

Cigarette excise taxes are a well-established policy lever for reducing tobacco use. However, estimating the effect of taxes on smoking behavior can be confounded by endogeneity concerns such as selection. This study leverages a unique natural experiment -compulsory relocation of U.S. military service members to installations - to estimate the relationship between state cigarette taxes and smoking behavior without concerns about selection into environments.

METHODS

The current study uses data from the Department of Defense's 2011 Health-Related Behaviors Survey and 2011 state cigarette excise taxes from the CDC STATE System. Logistic and Poisson regression analyses estimate the cross-sectional associations between state cigarette excise taxes and the following smoking behaviors: current cigarette smoking, frequency of smoking, heaviness of consumption, and cigarette cessation among individuals who smoked while at the current installation.

RESULTS

Higher taxes are associated with lower odds of current cigarette smoking (AOR = 0.94; 95 % CI: 0.89-0.98), fewer smoking days per month among current cigarette smokers (IRR = 0.98, 95 % CI 0.97-0.996), and higher likelihood of quitting smoking among individuals who had smoked at their current installation (AOR = 1.14, 95 % CI 1.05-1.25). Taxes are not associated with the number of cigarettes smoked per day among current smokers.

CONCLUSIONS

Exogenous assignment to installations in states with higher cigarette taxes is associated with lower likelihood of smoking and greater likelihood of quitting. Findings provide novel evidence in support of a causal impact of cigarette taxes on lower smoking levels among adults.

Optimal design of sin taxes in the presence of nontaxable sin goods

Sin good consumption entails health damage, which is in general not fully perceived by individuals, what results in its overconsumption. One way to tackle this problem is to tax these unhealthy goods. However, not all the individual choices that affect health status can be easily observed and effectively taxed by the government. This paper considers a setting where individuals can consume two types of sin goods that differ in their observability (taxability) by the government. As a benchmark, the first-best taxes for the observable and non-observable sin good are derived, considering homogeneous individuals. In the second-best setting, where observability on sin good consumption is limited, the rule for the taxable sin good is shown to depend on the degree of complementarity or substitutability with the unobservable sin good. Finally, redistributional considerations are incorporated by extending the analysis to a setting where individuals differ in their wealth and in their degree of misperception of the health damage caused by sin good consumption. Policy implications are illustrated considering physical inactivity and illicit drugs as examples of non-taxable sin goods, while alcohol, tobacco, fat and sugar account for the taxable sin goods.

Towards unified and impactful policies to reduce ultra-processed food consumption and promote healthier eating

The global surges in obesity and nutrition-related non-communicable diseases (NCDs) have created a need for decisive new food policy initiatives. A major concern has been the impact of ultra-processed foods (UPFs) and ultra-processed drinks on weight gain and on the risk of several NCDs. These foods, generally high in calories, added sugar, sodium, and unhealthy fats, and poor in fibre, protein, and micronutrients, have extensive negative effects on human health and on the environment (due to their associated carbon emission and water use). There is a growing tendency worldwide, and especially in South America, for food companies to add micronutrients to UPFs to make health claims regarding these products, to which food-regulating authorities refer to fake foods. Although more than 45 countries and smaller subregional or urban entities have created taxes on ultra-processed drinks, such as sugar-sweetened beverages, only a few have adopted taxes on snacks and other UPFs, and none have added major subsidies for truly healthy, fresh or minimally processed food for people from lower socioeconomic backgrounds. Another major focus has been on developing effective package labelling. A smaller number of countries have selected the most impactful warning labels and linked them with other measures to create a mutually reinforcing set of policies; a few other countries have developed effective school food policies. We herein present in-depth results from key countries involved in all these actions and in comprehensive marketing controls, and conclude with our recommendations for the future. This field is quite new; progress to date is substantial, but much more is left to learn.

Employment impacts of the San Francisco sugar-sweetened beverage tax 2 years after implementation

Introduction

Sugar-sweetened beverage (SSB) taxes have been implemented worldwide to raise revenue and reduce consumption of SSBs, which is associated with health harms. Empirical evaluations have found that these taxes are successful at reducing demand for SSBs; however, SSB taxes face opposition, in part because of claims that they will lead to substantial job losses. The purpose of this study is to examine the impact of the San Francisco SSB tax, implemented on January 1st, 2018, on employment.

Methods

Monthly employment counts were obtained from the Bureau of Labor Statistics from January 2013 (5-years pre-tax) through December 2019 (2-years post-tax) for the overall economy, private sector, supermarkets and other grocery stores, convenience stores, limited-service restaurants, and beverage manufacturing. A synthetic control analysis was conducted for each employment outcome. The synthetic controls (i.e., estimated counterfactuals) were generated from a pool of urban control counties using pre-tax labor market-related characteristics.

Results

The synthetic controls had similar labor market-related characteristics and employment outcomes to those in San Francisco in the pre-tax period. Up to 2 years post-tax, differences in employment between San Francisco and the synthetic controls were small and not “statistically significant” based on placebo tests for all employment outcomes.

Conclusions

Up to two years post-tax, we do not find evidence that the San Francisco SSB tax negatively impacted net employment, employment in the private sector, or employment in specific SSB-related industries.

Assessing Intertemporal Socioeconomic Inequalities in Alcohol Consumption in South Africa

Background: This paper assesses changes in the socioeconomic inequality in alcohol consumption by exploring whether alcohol consumption (current and binge drinkers) is more prevalent among the wealthier (pro-rich) or poorer (pro-poor) group over time.

Methods: Data come from the 2008, 2010/11, 2012, and 2014/15 waves of the National Income Dynamics Study (NIDS). Various equity stratifiers (sex, age, race, and rural/urban) are used to analyze the prevalence of alcohol consumption and to investigate differences in socioeconomic inequalities. Changes in socioeconomic inequality in alcohol consumption between 2008 and 2014/15 were also assessed using the concentration index.

Results: Current drinkers were more concentrated among richer South Africans, while binge drinkers were concentrated among the poorer population. For current drinkers, irrespective of sex, race, age, and urban, socioeconomic inequality in alcohol consumption had become less pro-rich between 2008 and 2014/15; while inequality in binge drinking, outside of the Asian/Indian and rural categories, had become less pro-poor between 2008 and 2014/15.

Conclusion: The results show evidence that binge drinking is a bigger problem among those of low-SES, young individuals, male and African populations. This paper concludes that the SA government should continue to push forward policies aiming to reduce the prevalence of binge drinking.

SF-6D utility scores for alcohol use disorder status and alcohol consumption risk levels in the US population

AIMS

To estimate US population health utilities for subgroups defined by alcohol use disorder (AUD) status and consumption level.

DESIGN

Cross-sectional survey.

SETTING

Community settings in the United States (i.e. excluding institutional settings).

PARTICIPANTS

A total of 36,042 adults (age 18+) in non-institutional settings in the United States.

MEASUREMENTS

We used 12-item Short Form Survey (SF-12) data from the National Epidemiologic Survey on Alcohol and Related Conditions-III to calculate mean Short Form-6 dimension (SF-6D) utility scores across World Health Organization alcohol consumption risk levels-very high risk, high risk, medium risk, low risk and an additional abstinent level-for three groups: (1) the general population (n = 36,042), (2) individuals with life-time AUD (n = 9925) and (3) individuals with current AUD (n = 5083), and assessed minimally important differences (MIDs) between consumption levels. Each group is a subset of the previous group.

FINDINGS

The general population's mean SF-6D utility was higher than that of individuals with life-time or current AUD across all consumption risk levels (0.79 versus 0.76 for both AUD groups). For all groups, SF-6D utilities increased as consumption risk level decreased to non-abstinent levels, and reducing consumption from very high risk to any lower level was associated with a statistically significant and meaningful improvement in utility. For individuals with life-time or current AUD, becoming abstinent from high-, medium- and low-risk levels was associated with significantly and meaningfully worse utilities.

CONCLUSIONS

Higher alcohol consumption risk levels appear to be associated with lower health index scores for the general population and individuals with a history of alcohol use disorder, meaning that higher alcohol consumption is associated with worse health-related quality of life.

The impact of taxing sugar-sweetened beverages on cola purchasing in Catalonia: an approach to causal inference with time series cross-sectional data

Sugar-sweetened beverage (SSB) taxes related to the quantity of sugar have appeared as a popular regulatory tool around the world during the last decade showing important variations in their implementation and impact. We evaluated the impact of a new SSB tax implemented in Catalonia since May 1, 2017 on the purchased quantities and penetration rates of taxed and untaxed cola beverages. We use aggregate time series of cola beverages purchases in all 17 Spanish Autonomous Communities before and after the implementation of the SBB tax in Catalonia, from January 2013 to June 2019. A comparison between two different types of causal inference methods was conducted: a two-way fixed effects difference in differences model and a modified synthetic control model. Regular cola purchases decreased 12.1% and their penetration rate decreased by 1.27 points during the two post-intervention years using the preferred model. Diet cola purchases increased 17.0% and their penetration rate also increased by 1.65 points. Only regular cola results were robust to all placebo test checks. The SSB tax implemented in Catalonia in 2017 significantly reduced the volume and penetration rates of regular colas with no robust evidence for the substitution effect on diet colas.

An Analysis of the Adoption and Implementation of A Sugar-Sweetened Beverage Tax in South Africa: A Multiple Streams Approach

This paper describes a case study of the adoption and implementation of the sugar-sweetened beverage tax in South Africa, termed the Health Promotion Levy. Qualitative data extraction and analysis of institutional documents, such as policy proposals and parliamentary debate records, stakeholder submissions to Parliament and media reports, were guided by the Kingdon Multiple Streams Theory as adapted to study agenda setting, policy adoption, and implementation. We present the following key findings: First, consistent messaging from policy entrepreneurs, consisting of advocacy groups, health organizations, and research entities, was key to ensuring that a tax policy solution was proposed and passed. Second, the continuity of certain key policymakers contributed to the relatively expedient passage of the tax policy. Third, the use of an excise tax was, amongst others, an appealing policy solution because of its revenue-raising potential; however, uncertainty regarding the purpose of the tax negatively impacted public attitudes toward it. Fourth, industry arguments, relating to unemployment, were effective in restructuring the tax in favor of industry actors. Finally, regulatory action by sectors outside of finance and health impacted stakeholder perceptions of the tax and possibly obstructed regular annual adjustments for inflation.

The impact of the Philadelphia beverage tax on employment: A synthetic control analysis

Prevalence of obesity and other diet-related non-communicable diseases (NCDs) have continued to rise for decades in the United States. In addition to adverse health consequences, these diseases have led to substantial economic costs in the form of medical expenses and productivity losses. To address the rise in NCDs, excise taxes on sugar-sweetened beverages (SSBs) are increasingly proposed and implemented as a policy tool for improving dietary intake and population health. To date, few empirical studies have evaluated the potential unintended economic effects of these taxes. In this paper, we examine the impact of the Philadelphia, PA, sweetened beverage tax (applied to both SSBs and artificially sweetened beverages) on employment in key industries that sell sweetened beverages as well as on net total employment. Drawing on monthly employment count data from the Bureau of Labor Statistics from January 2012 through June 2019, we conducted a synthetic control analysis of total, private sector, limited-service restaurant, and convenience store employment. The synthetic controls reproduced nearly identical pre-tax employment trends to Philadelphia and had similar values of important predictors. In the post-tax period, Philadelphia employment was not lower, on average, than the synthetic control employment for each outcome. Placebo tests suggested a null effect of the tax, and the results were robust to changes in predictors and control site criteria. Overall, we did not find that the sweetened beverage tax resulted in job losses up to two and a half years after the tax was implemented. These findings are consistent with other peer-reviewed modeling and empirical papers on the employment and unemployment effects of sweetened beverage taxes.

Implementation of the WHO Framework Convention on Tobacco Control in Tunisia: Progress and challenges

INTRODUCTION

The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) was the first health treaty that requires state parties to adopt and implement the MPOWER package. The aim of this study is to review the current status of tobacco control policies in Tunisia according to the WHO FCTC recommendations.

METHODS

This paper is a critical narrative literature review in which information was obtained from peer-reviewed articles, official government documents, reports, decrees and grey literature in French, Arabic and English.

RESULTS

Modest progress in FCTC implementation in Tunisia was noted. The smoking ban in public places is not regularly or largely enforced. The advertising and promotion for tobacco and its products is prohibited by law, but, the ban does not cover the display and visibility of tobacco products at points-of-sale, through the internet, and the depiction of tobacco or tobacco use in entertainment media products. Health warnings on tobacco products consist only of text and do not exceed 30% of the main display areas but are expected to increase to 70% with graphics and text when the new law is passed.

CONCLUSIONS

Effective intervention efforts are urgently required. These actions should include accelerating the adoption of a new law, enforcing the present law and the new one once adopted, developing an advocacy and argument about the positive impact on state budget balance, increasing taxes, combating smuggling and illicit manufacturing and counterfeiting, increased education, increased smoking cessation support and implementing periodic surveillance.

Evaluation of Changes in Beverage Prices and Volume Sold Following the Implementation and Repeal of a Sweetened Beverage Tax in Cook County, Illinois

IMPORTANCE

Health taxes are policy tools used to reduce harmful consumption of products and raise tax revenue, and they may also be associated with signaling (ie, informational and educational) factors that enhance their impact.

OBJECTIVES

To examine changes in prices and volume sold of sweetened beverages following the implementation and repeal of the Cook County, Illinois, Sweetened Beverage Tax (SBT) compared with the comparison site of St Louis County and city, Missouri, which did not impose a tax.

DESIGN, SETTING, AND PARTICIPANTS

This study used interrupted time series analyses to assess changes in price and volume sold of taxed (based on beverage type and sweetener status) and untaxed beverages in Cook County compared with St Louis following the implementation of the SBT on August 2, 2017, and its repeal effective December 1, 2017. Statistical analysis was performed from January to June 2020.

EXPOSURES

Implementation and repeal of the Cook County SBT.

MAIN OUTCOMES AND MEASURES

Changes in taxed and untaxed beverage prices and volume sold. Nielsen food store scanner data were obtained for weekly volume and dollar amount sold of nonalcoholic beverage universal product codes (UPCs) for each site in supermarkets and mass merchandise, grocery, drug, convenience, and dollar stores.

RESULTS

The analytic samples included 16 510 UPCs for volume and 2141 UPCs (balanced sample) for prices for 122 pretax weeks, 16 tax weeks, and 35 postrepeal weeks. Compared with St Louis, posttax implementation in Cook County resulted in a level increase in taxed beverage prices of 1.13 cents per fluid ounce (95% CI, 1.01 to 1.25 cents per fluid ounce), representing a slight overshifting, followed by a posttax repeal level decrease of -1.19 cents per fluid ounce (95% CI, -1.33 to -1.04 cents per fluid ounce), with no resulting change pretax to posttax repeal. Volume sold of taxed beverages in Cook County compared with St Louis exhibited a posttax implementation level decrease of 25.7% (β = -0.297; 95% CI, -0.415 to -0.179) and a posttax repeal level increase of 30.5% (β = 0.266, 95% CI, 0.124 to 0.408), with no net change in volume sold from pretax to 8 months after repeal.

CONCLUSIONS AND RELEVANCE

This study using interrupted time series analysis found no net change in volume sold of taxed beverages following the implementation and repeal of the Cook County SBT, suggesting the tax had no signaling association. Repeals of such taxes may fully reverse their associations with reduced demand and harms associated with sweetened beverage intake.

Epidemiological Realities of Alcoholic Liver Disease: Global Burden, Research Trends, and Therapeutic Promise

Globally, alcohol consumption contributes to more than 3 million deaths each year. While much of its ramifications is preventable, a coherent public health discourse on how to limit alcohol-related harm has been overdue. By synthesizing information from national and global databases, we show in this analysis that alcohol consumption level and alcohol-attributable burden of diseases, particularly alcoholic liver disease (ALD), are intimately linked to national income distribution, cultural norms, religion, sex, age, and health status. Prevalence and burden of ALD are positively associated with economic standing in most countries, which necessitate active governmental control via cost-effective policies, such as the best buys proposed by the World Health Organization. To date, a number of critical questions remain unanswered over the molecular mechanisms underlying ALD pathophysiology; the insights gained thereof should provide new opportunities for the advancement of novel diagnostic and management strategies. In comparison with other prevailing liver diseases (e.g., viral hepatitis and nonalcoholic fatty liver disease), governmental support to ALD investigation has been sluggish in most Western countries and China, resulting in a dearth of breakthroughs on both the basic and clinical research fronts in the past decades. Emerging foci of clinical trials for ALD therapy include empirical use of probiotics, antioxidants, growth factors, monoclonal antibodies against key inflammatory mediators, and technology-enhanced behavioral interventions. In this article, we seek to provide a comprehensive analysis on the progress and challenges in tackling ALD as a global health problem, with particular emphasis on global disease burden, socioeconomic influences, research trends, government roles, and future therapies.

The drivers, trends and dietary impacts of non-nutritive sweeteners in the food supply: a narrative review

Poor diets, including excess added sugar consumption, contribute to the global burden of disease. Subsequently, many nutrition policies have been implemented to reduce added sugar intake and improve population health, including taxes, education, labelling and environmental interventions. A potential consequence of these policy actions is the substitution of added sugars with non-nutritive sweeteners (NNS) in a variety of foods and beverages. NNS are used to reduce the energy and sugar content of foods and beverages while maintaining their palatability. Evidence of the toxicological risks of NNS is inconsistent, though concerns have been raised over the potential substitution effects of ultra-processed foods containing NNS for whole foods. This review aimed to provide an overview of current NNS food supply and consumption patterns, assess added sugar-reduction policies and their impact on NNS, and determine the impact of NNS on food choice, energy intake and diet quality. NNS are widely available in a variety of products, though most commonly in carbonated beverages, dairy products, confectionery, table-top sweeteners and fruit drinks. However, the longitudinal trends of different product categories, and differences between geographies and economy-income levels, require further study. Few studies have examined NNS consumption trends globally, though an increase in NNS consumption in beverages has been observed in some regions. Research examining how the increased availability of low-sugar, NNS-containing products affects global dietary patterns is limited, particularly in terms of their potential substitution effects.

Trends in Store-Level Sales of Sugary Beverages and Water in the U.S., 2006-2015

INTRODUCTION

Previous research on sugar-sweetened beverage trends has focused on self-reported consumption from surveys. Few studies used objective store sales or explored differences by area-level demographics and store type.

METHODS

The average volume of beverages sold per store per 3-digit zoning improvement plan code from 2006 to 2015 was calculated using national Nielsen Retail Scanner point-of-sale data from 24,240 stores. A multilevel regression model analyzed annual trends, with random intercepts for state and separate models for beverage type (regular soda, no/low-calorie soda, other sugary drinks, 100% fruit juice, bottled water). Differences by store type (convenience, supermarkets, drug stores, mass merchandisers) and area-level demographics (categorized as tertiles) were examined. Data were analyzed in 2019.

RESULTS

The model-based estimates indicated that sales of regular soda (-11.8%), no/low-calorie soda (-19.8%), and 100% fruit juice (-31.9%) decreased over time, whereas sales of bottled water (+34.4%) increased and sales of other sugary drinks remained stable (+2.4%). Decreases in sugar-sweetened beverage sales were largely concentrated in supermarkets and larger in areas with high income and education levels and a high percentage of black and Hispanic people. There were also relatively larger increases in bottled water sales in states located in the South and Midwest.

CONCLUSIONS

The finding that sales of sugar-sweetened beverages decreased over time, whereas sales of bottled water increased is encouraging because sugar-sweetened beverage consumption is linked to obesity and other chronic conditions. This study provides a novel, rigorous assessment of U.S. beverage sales trends and differences by community and store characteristics.

Using nutritional survey data to inform the design of sugar-sweetened beverage taxes in low-resource contexts: a cross-sectional analysis based on data from an adult Caribbean population

OBJECTIVE

Sugar-sweetened beverage (SSB) taxes have been implemented widely. We aimed to use a pre-existing nutritional survey data to inform SSB tax design by assessing: (1) baseline consumption of SSBs and SSB-derived free sugars, (2) the percentage of SSB-derived free sugars that would be covered by a tax and (3) the extent to which a tax would differentiate between high-sugar SSBs and low-sugar SSBs. We evaluated these three considerations using pre-existing nutritional survey data in a developing economy setting.

METHODS

We used data from a nationally representative cross-sectional survey in Barbados (2012-2013, prior to SSB tax implementation). Data were available on 334 adults (25-64 years) who completed two non-consecutive 24-hour dietary recalls. We estimated the prevalence of SSB consumption and its contribution to total energy intake, overall and stratified by taxable status. We assessed the percentage of SSB-derived free sugars subject to the tax and identified the consumption-weighted sugar concentration of SSBs, stratified by taxable status.

FINDINGS

Accounting for sampling probability, 88.8% of adults (95% CI 85.1 to 92.5) reported SSB consumption, with a geometric mean of 2.4 servings/day (±2 SD, 0.6, 9.2) among SSB consumers. Sixty percent (95% CI 54.6 to 65.4) of SSB-derived free sugars would be subject to the tax. The tax did not clearly differentiate between high-sugar beverages and low-sugar beverages.

CONCLUSION

Given high SSB consumption, targeting SSBs was a sensible strategy in this setting. A substantial percentage of free sugars from SSBs were not covered by the tax, reducing possible health benefits. The considerations proposed here may help policymakers to design more effective SSB taxes.

Alcohol consumption and attributable harm in middle-income South-East Asian countries: Epidemiology and policy options

Background Factors and policies which potentially explain the changes in alcohol consumption and related harms from 2010 to 2017 in 11 middle-income countries in the South-East Asian region (Cambodia, Lao PDR, Indonesia, the Philippines, Malaysia, Maldives, Myanmar, Sri Lanka, Thailand, Timor-Leste, and Vietnam) were examined. Methods Using secondary data from UN agencies, we analyzed trends in alcohol consumption, alcohol-attributable deaths and the burden of disease. Results Starting from a level of consumption significantly below the global average-especially among the Muslim-majority countries (Maldives, Indonesia, and Malaysia)-the majority of the countries in this region had markedly increased their alcohol consumption along with the economic development they experienced between 2010 and 2017. In fact, five middle-income countries in this region (Vietnam, Lao PDR, Cambodia, Myanmar, and Timor-Leste) were in the top 12 countries globally based on absolute increases in adult alcohol per capita consumption (APC). The Philippines and Malaysia were the exceptions, as they had reduced their APC over this period. The majority of South-East Asian countries had parallel increasing trends in the age-standardized alcohol-attributable deaths and DALYs since 2010, in contrast to global trends. While all countries put some alcohol control policies in place, there were differences in the number and strength of the policies applied, commensurate with trends in consumption. In particular, three of the countries which were most successful in reducing consumption and harm (Malaysia, Philippines, and Sri Lanka) applied more effective tax methods based on specific taxation alone or in combination with another taxation method, applying higher taxation rates and regularly increasing them over time. Conclusion To achieve the global target and the Sustainable Development Goal in reducing alcohol consumption worldwide, middle-income countries, especially lower-middle-income countries, should employ stricter alcohol control policies, and apply an appropriate excise tax on alcohol products with regular increases to reflect inflation.

American Cancer Society guideline for diet and physical activity for cancer prevention

The American Cancer Society (ACS) publishes the Diet and Physical Activity Guideline to serve as a foundation for its communication, policy, and community strategies and, ultimately, to affect dietary and physical activity patterns among Americans. This guideline is developed by a national panel of experts in cancer research, prevention, epidemiology, public health, and policy, and reflects the most current scientific evidence related to dietary and activity patterns and cancer risk. The ACS guideline focuses on recommendations for individual choices regarding diet and physical activity patterns, but those choices occur within a community context that either facilitates or creates barriers to healthy behaviors. Therefore, this committee presents recommendations for community action to accompany the 4 recommendations for individual choices to reduce cancer risk. These recommendations for community action recognize that a supportive social and physical environment is indispensable if individuals at all levels of society are to have genuine opportunities to choose healthy behaviors. This 2020 ACS guideline is consistent with guidelines from the American Heart Association and the American Diabetes Association for the prevention of coronary heart disease and diabetes as well as for general health promotion, as defined by the 2015 to 2020 Dietary Guidelines for Americans and the 2018 Physical Activity Guidelines for Americans.

Cigarette excise taxes, clean indoor air laws, and use of smoking cessation treatments: A mediation analysis

The role of smoking cessation treatments in the link between clean indoor air laws and cigarette taxes with smoking cessation is not known. This study examined whether the use of smoking cessation treatments mediates the association between clean indoor air laws and cigarette excise taxes, on the one hand, and recent smoking cessation, on the other hand. Using data on 62,165 adult participants in the 2003 and 2010-2011 Current Population Survey-Tobacco Use Supplement who reported smoking cigarettes in the past year, we employed structural equation models to quantify the degree to which smoking cessation treatments (prescription medications, nicotine replacement therapy, counseling/support groups, quitlines, and internet-based resources) mediate the association between clean indoor air laws, cigarette excise taxes and recent smoking cessation. Recent smoking cessation was associated with clean indoor air laws in 2003 and with both clean indoor air laws and excise taxes in 2010-2011. Smoking cessation treatments explained between 29% to 39% of the effect of clean indoor air laws and taxes on recent smoking cessation. While clean indoor air laws remained significantly associated with the recent smoking cessation over the first decade of the 2000s, excise taxes gained a more prominent role in later years of that decade. The influence of these policies was partly mediated through the use of smoking cessation treatments, underscoring the importance of policies that make these treatments more widely available.

Perspective: Chaos in a Bottle-A Critical Evaluation of Beverage Categorization in Nutrition Research

Beverage consumption is an important contributor to total daily calorie intake among children and adolescents. While associations between excess calories from beverages and development of obesity are well established, a standardized approach for beverage categorization does not exist. As a result, there is marked heterogeneity in assessment and categorization of beverage intake across studies. The purpose of this article is to critically review beverage categorization in recent (published since 2010) observational studies that evaluated beverage intake in relation to weight/adiposity in US youth, and to put forth an initial proposal for a standardized beverage classification system. Standardized beverage classification is critical to ensure transparency in nutrition science research and facilitate comparison of findings across studies. A systematic literature search identified 37 eligible studies, across which beverage categorization varied considerably. The most heterogeneity was observed for categorization of "sugar-sweetened beverages" and the greatest consistency was observed for categorization of 100% juices. This review provides an evidence-based starting point for urgently needed, collaborative work to determine priorities for beverage categorization and leverage existing standards of identity in order to create and disseminate a standardized beverage classification system. A standardized approach will inform meaningful assessment of beverage consumption in research studies and facilitate impactful translation of research findings into public health nutrition policy.

Perceived Importance of Factors in Cannabis Purchase Decisions: A Best-worst Scaling Experiment

BACKGROUND

Consumers' access to cannabis has been considerably expanded in US states where recreational cannabis was legalized and commercialized. However, little is known about the important factors influencing consumers' purchase decisions in cannabis retail dispensaries. This study examined cannabis users' perceptions of the relative importance of policy-relevant factors when they made cannabis purchase decisions.

METHODS

An online survey was administered to 817 adult cannabis users in seven states in the US (California, Colorado, Maine, Massachusetts, Nevada, Oregon, and Washington) that had approved cannabis commercialization by the time of interview in January 2018. Twenty policy-relevant cannabis attributes were evaluated, including those pertaining to product characteristics, quality, package characteristics, price and free sample, store characteristics, and restrictions on use. A best-worst scaling experiment was employed, which asked respondents to select the most and the least important attributes in a choice scenario. Each respondent answered 10 choice scenarios, each including a random combination of four attributes out of the 20. The relative importance of each attribute was evaluated using hierarchical Bayesian estimation of mixed logit models.

RESULTS

Overall, 'quality', 'strain type', 'price', 'THC' (tetrahydrocannabinol) and 'pesticide' were the top five important attributes affecting cannabis users' willingness to buy cannabis in a dispensary. These five attributes jointly accounted for approximately half of the total importance. In subsample analysis, both recreational and dual-purpose users attached higher importance to 'quality', 'THC', and 'price', whereas medical users tended to think 'CBD' (cannabidiol) and 'pesticide' were more important. All cannabis users perceived 'package' to be the least important attribute. Gender had no major differences in perceptions.

CONCLUSIONS

Cannabis users in general perceived product characteristics, quality, and price to be important factors in their willingness to buy cannabis in dispensaries. There were heterogeneities in the perceptions by cannabis use purposes. The findings might deserve consideration in cannabis policy design.

CIGARETTE TAXES AND TEEN MARIJUANA USE

The spillover effect of cigarette taxes on youth marijuana use has been the subject of intense public debate. Opponents of cigarette taxes warn that tax hikes will cause youths to substitute toward marijuana. On the other hand, public health experts often claim that because tobacco is a "gateway" drug, higher cigarette taxes will deter youth marijuana use. Using data from the National and State Youth Risk Behavior Surveys (YRBS) for the period 1991-2017, we explore the relationship between state excise taxes on cigarettes and teen marijuana use. In general, our results fail to support either of the above hypotheses. Rather, we find little evidence to suggest that teen marijuana use is sensitive to changes in the state cigarette tax. This null result holds for the sample period where cigarette taxes are observed to have the largest effect on teen cigarette use and across a number of demographic groups in the data. Finally, we find preliminary evidence that the recent adoption of state e-cigarette taxes is associated with a reduction in youth marijuana use.

Retailer perspectives on sugar-sweetened beverage taxes in the California Bay Area

The sugar-sweetened beverage (SSB) industry has claimed that food and beverage retailers are opposed to SSB taxes. In 2018 and 2019, we formally evaluated retailers’ perceptions of SSB taxes using semi-structured interviews (including open- and closed-ended questions) with 103 randomly selected retailers (50 corner and liquor stores; 28 chain convenience, drug, and mass-merchandise stores; 18 chain supermarkets and discount supermarkets; and 7 independent supermarkets) across 3 cities with SSB taxes (Berkeley, Oakland, and San Francisco); interviews occurred in 2018 and 2019 (approximately 3 years, 1 year and 6 months post tax-implementation, respectively). A majority of both small and large retailers reported the tax had only a minimal effect on their business (70%). About half of retailers believed that other cities should adopt SSB taxes (53%), and were supportive of a statewide SSB tax (53%), noting it would level the playing field and better support health in their communities. Retailers’ responses did not differ based on neighborhood income, and only 2 responses differed significantly between large and small retailers. Only 2 of 103 retailers reported raising the price of a non-beverage product in response to the tax, specifically raising the price of snack foods of low nutritional quality and alcoholic beverages. A majority of retailers in 3 California cities with SSB taxes have no concerns regarding the tax, endorse the health goals of SSB taxes and support statewide expansion of SSB tax policies.

Changes in Beverage Marketing at Stores Following the Oakland Sugar-Sweetened Beverage Tax

INTRODUCTION

In July 2017, Oakland, California implemented a 1 cent/ounce sugar-sweetened beverage tax. This study examined changes in store marketing practices-advertising and price promotions-for sugar-sweetened beverages, artificially sweetened beverages, and unsweetened beverages following the introduction of the tax.

METHODS

The study employed a quasi-experimental research design and included Oakland as the intervention site and Sacramento, California as a comparison site. Based on data collected pretax (May-June 2017), 6 months post-tax (January 2018), and 12 months post-tax (June 2018) at 249 stores across the 2 sites, exterior and interior advertising for 4 taxed sugar-sweetened beverage subtypes and 6 untaxed artificially sweetened and unsweetened beverage subtypes, as well as price promotions for 59 specific taxed products and 69 untaxed products were examined. In 2019, difference-in-differences logistic regressions estimated pre-post changes in Oakland relative to Sacramento.

RESULTS

At 6 months post-tax, the odds of sugar-sweetened beverage price promotions fell 50% in Oakland but only 22% in Sacramento. Price promotions for regular soda in particular declined in Oakland post-tax, by 47% at 6 months and 39% at 12 months (versus no change in Sacramento). Moreover, the odds of artificially sweetened beverage price promotions fell by a similar magnitude as sugar-sweetened beverages in Oakland, 55% at 6 months and 53% at 12 months, which differed significantly from Sacramento. No significant post-tax changes were found in sugar-sweetened or artificially sweetened beverage exterior or interior advertising.

CONCLUSIONS

Rather than increasing marketing, retailers and manufacturers may have tried to offset revenue losses by reducing price promotions for sugar-sweetened beverages, particularly regular soda, and artificially sweetened beverages.

The macroeconomic impacts of diet-related fiscal policy for NCD prevention: A systematic review

BACKGROUND

Diet-related fiscal policies are effective interventions to address non-communicable disease. However, despite these being economic policy instruments, there is little public health attention given to the evidence of macroeconomic impacts. This review aims to assess the global evidence for the macroeconomic impact of diet-related fiscal policies for non-communicable disease prevention on industry revenue, government revenue and employment.

METHODS

For this systematic review we comprehensively searched the bibliographic databases MEDLINE, OvidSP, EMBASE, Global Health, SCOPUS, CINAHL and ECONLIT, and Google Scholar for English peer-reviewed studies or grey literature, with no date cut-off. Global interventions with a focus on diet-related fiscal strategies were assessed for the outcomes of industry revenue, gross domestic product, government revenue and employment. We excluded non-English papers.

FINDINGS

Eleven studies met the inclusion criteria. All studies were on sugar sweetened beverage taxation and one also included an energy-dense food tax. Nine were modelling studies and two used interrupted time series analysis based on empirical evidence. One study found potential employment increases because of taxation; two found no significant job losses and eight found reduced employment. Taxes reduced sales volume and revenue within the sugar/beverage industry. Government revenue generation was positive in all studies. One study considered redistribution of consumer and government spending to other goods and services; INTERPRETATION: We found no robust evidence for negative macroeconomic impacts of diet-related fiscal policies, likely a reflection of the limited methodology used in the analyses. This review suggests that there is a need for more high-quality research into the macroeconomic impacts of diet related fiscal measures and similar to tobacco taxation, government should consider directing revenue generated towards complementary measures to generate employment and/or provide livelihood training for those affected.

Sacco S, L. Pomeranz J. Marketing to Children in Supermarkets: An Opportunity for Public Policy to Improve Children's Diets

Public health experts worldwide are calling for a reduction of the marketing of nutrient-poor food and beverages to children. However, industry self-regulation and most government policies do not address in-store marketing, including shelf placement and retail promotions. This paper reports two U.S.-based studies examining the prevalence and potential impact of in-store marketing for nutrient-poor child-targeted products. Study 1 compares the in-store marketing of children's breakfast cereals with the marketing of other (family/adult) cereals, including shelf space allocation and placement, special displays and promotions, using a national audit of U.S. supermarkets. Child-targeted cereals received more shelf space, middle- and lower-shelf placements, special displays, and promotions compared with other cereals. Study 2 compares the proportion of product sales associated with in-store displays and promotions for child-targeted versus other fruit drinks/juices, using syndicated sales data. A higher proportion of child-targeted drink sales were associated with displays and promotions than sales of other drinks. In both categories, the results were due primarily to major company products. Although in-store marketing of child-targeted products likely appeals to both children and parents, these practices encourage children's consumption of nutrient-poor food and drinks. If companies will not voluntarily address in-store marketing to children, government policy options are available to limit the marketing of unhealthy foods in the supermarket.

Impact of Taxation Policy on Household Spirit Consumption and Public-Finance Sustainability

The objective of this study was to estimate the sensitivity of spirit quantity demanded for price and income changes in Montenegro and to show the effectiveness of taxation-policy changes in the reduction of spirit consumption. It is the first study on this topic in Montenegro, where adverse effects of alcohol are recognized as an important obstacle in achieving Sustainable Development Goals (SDGs). The price elasticity of spirits was estimated using Deaton’s methodology on the Household Budget Survey (HBS) data in the period of 2006–2017. Cigarettes were included as a control variable as, along with spirits, they are one of the most harmful substances used in Montenegro. Using these results, we simulated the effects of spirit use on public revenue. The results show that the spirits’ own price elasticity equaled −0.45, while the cross-price elasticity equaled −0.17, showing that spirits and cigarettes are complementary goods. These results, along with elasticities calculated by sex (male, −0.55; female, −0.5), income groups (low income, −1.16; middle-income, −0.46; high-income, −0.26), and for the working-age group (−0.74), demonstrate that an increase in excise taxes could be a very efficient tool in decreasing the adverse effect of spirits and cigarettes on household member’s productivity, health, and budget, which is in line with SDGs. An efficient road map for sustainable development for Montenegro must include the reduction of health-harmful substance use through excise tax increase.

[Food policies to prevent obesity and the main non-transmissible diseases in Spain: where there's a will there's a way]

INTRODUCTION

In Spain, one third of all children and two-thirds of adults suffer from excess weight, a condition that generates a direct excess medical cost of 2000 million Euros. Obesogenic food environments cause obesity by promoting the consumption of sugar-sweetened beverages and ultra-processed foods. Accordingly, we propose five priority policies capable of reversing the epidemic of obesity and related non-communicable diseases through the creation of healthy food environments.

THE POWER (PODER IN SPANISH) OF FOOD POLICIES

Advertising (Publicidad): regulation of unhealthy food and drink advertisements carried by all media and targeted at children, and prohibition of sponsorships of congresses, conferences or sports events and endorsements by scientific associations or health professionals. Supply (Oferta): promotion of a 100% healthy supply of goods on sale in vending machines sited at educational, health and sports centres. Demand (Demanda): levying a tax of at least 20% on sugar-sweetened beverages, accompanied by subsidies or reduced taxes on healthy foods and availability of drinking water free of charge at all public venues and areas. Labelling (Etiquetado): effective application of the Nutri-Score through the use of incentives, regulation and public-tender mechanisms. Reformulation (Reformulación): revising and redrawing reformulation agreements with the industry, setting more ambitious goals and mandatory compliance.

A FINAL THOUGHT

These five proposed interventions, all of which have been successfully applied in other countries, will serve to raise population awareness and have a positive impact on health and the economy, through reducing the health care costs of obesity and enhancing work productivity. These measures should form part of a wide-ranging transformation of the food system, with agri-food policies that foster the sustainable production of healthy foods.

Drink Choice is Important: Beverages Make a Substantial Contribution to Energy, Sugar, Calcium and Vitamin C Intake among Australians

It is important to understand the role of beverages in population dietary intake in order to give relevant advice. Population estimates were derived from one-day food recall dietary data from 12,153 participants in the 2011–2012 Australian National Nutrition and Physical Activity Survey. Almost all Australians (99.9%) consumed at least one beverage on the day of the survey, accounting for 16.6% of the total energy intake for adults (aged 19 years and over) and 13.0% for children (aged 2–18 years). Similarly, beverages contributed 26–29% to calcium intake, 22–28% to vitamin C intake, and 35–36% to sugar intake. Water was consumed on the day of the survey by 84.1% of Australian adults and 90.5% of children. For adults, the greatest beverage contributors to total energy intake were alcoholic drinks (5.6%), coffee (3.1%), and soft drinks (1.9%), and for children, plain milk (3.1%), flavoured milk (2.8%), and fruit juice (2.6%). Coffee (10.6%) made the greatest contribution to calcium intake for adults; and plain milk (9.9%) and flavoured milk (7.6%) for children. The greatest contributors to vitamin C intake were fruit juice (13.4%) and alcoholic drinks (6.1%) for adults; and fruit juice (23.4%) for children. For total sugar intake, soft drinks (8.0%), coffee (8.4%), and fruit juice (5.9%) made the highest contribution for adults; and fruit juice (9.8%) and soft drinks (8.7%) for children. The type and amount of beverage consumption has considerable relevance to dietary quality for Australians.