Higher Retail Prices of Sugar-Sweetened Beverages 3 Months After Implementation of an Excise Tax in Berkeley, California

The impact of the Oakland sugar-sweetened beverage tax on bottled soda and fountain drink prices in fast-food restaurants

Beverage taxes are increasingly being implemented as an intervention aimed at reducing the consumption of sugar-sweetened beverages (SSBs) and their associated adverse health outcomes. Whether these taxes achieve public health objectives depends, in part, on the extent to which beverage prices increase, known as tax pass-through. Fast-food restaurants are a significant source of SSBs and an environment where the effect of beverage taxes is less understood. This study evaluates the impact of an SSB tax on prices of beverage products sold in fast-food restaurants in Oakland, CA, which implemented a 1-cent per ounce excise tax on SSBs containing 25 or more calories per 12 fluid ounces in 2017. A pre-post intervention difference-in-differences (DID) research design with Sacramento, CA, serving as a comparison site was used to estimate the effect of the tax on fast-food restaurant beverage prices. A panel of fast-food restaurants were audited 1-month pre-tax and 6- and 12-months post-tax. DID regression models with restaurant and product fixed effects were used to estimate tax pass-through to prices of bottled regular (N = 150 observations from 39 restaurants) and diet (N = 106 observations from 32 restaurants) soda and fountain drinks (N = 501 observations from 73 restaurants). Statistically significant (p < 0.05) pass-through of 82% was found for bottled regular soda one year after the tax was implemented. This effect represents an 8% increase in prices from baseline. No statistically significant changes in prices were found in either time period for taxed and untaxed fountain drinks and untaxed bottled diet soda.

Impact of SSB taxes on sales

In this paper, we analyze a tax on sugar-sweetened beverages (SSB) that was introduced in Catalonia on May 1, 2017. The Bill established the requirement of a 100% pass-through of the tax to the final consumer and two levels of the tax: 0.08 euro/liter for products with 5-less than 8 g of sugar and 0.12 euro/liter for products with 8 g of sugar or more. Previous literature focusing on the impact of SSB taxes finds that pass-though is only complete in the long-term. Our paper provides new evidence that, when the tax increases prices substantially and immediately, the sales response is also significant. In particular, we estimate that the new SSB tax in Catalonia reduced SSB purchases by 7.7%. We document that part of this reduction is substituted by an increase in sales of zero/light drinks (substitution effect). Importantly, the reduction in purchases is stronger in areas with a higher incidence of obesity, in areas with higher household incomes and for products with higher sugar content.

Effects of a sugar-sweetened beverage tax on prices and affordability of soft drinks in Chile: A time series analysis

Chile is one of several countries that recently implemented a fiscal policy to reduce soft drink (SD) intake and obesity. In 2014 the government increased the existing ad-valorem tax on high-sugar SD by 5% and decreased by 3% the tax on low-sugar SD, based on a 6.25gr/100 ml sugar threshold. This study aims to evaluate the tax modification passed-on to consumers through prices, and to calculate changes in affordability of SDs. We analysed nationally representative consumer price index data of 41 soft drinks within 6 beverage categories between 2009 and 2016. Price change post-tax implementation was estimated for different categories (carbonates, juices, concentrates, waters and energy-sport drinks), using time-series analyses. In addition, changes in affordability were evaluated by estimating the changes in prices relative to wages. The price of carbonates increased by 5.60% (CI 95% 3.18–8.03%) immediately after the tax was implemented. A sustained increase in the prices of concentrates was observed after the implementation. Unexpectedly, a smaller increase was also seen for the price of bottled water – a category that saw no tax change. There were no effects for juices and energy-sports drinks. There was a reduction in affordability for carbonates, concentrates and waters. Overall, the fiscal policy was effective in increasing prices and there are some signs of reduced affordability. Results varied substantially among categories directly affected by the tax policy. While for carbonates the price increase exceeded the tax change (‘over-shifting’), in other categories subject to a tax cut, a price reduction was expected but the opposite occurred. As the effect of the tax on prices differed between categories, the effects of the tax policy on consumption patterns are likely to be mixed. Our findings underline the need to better understand and anticipate price setting behaviour of firms in response to a tax.

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Chile implemented a tax policy on soft drinks (SD) to promote healthier diets in 2014.

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It consists in a 5% tax increase on high-sugar SD and 3% reduction on low-sugar SD.

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Using consumer price index data we estimate policy impact on SD price/affordability.

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Overall, the policy was effective to increase prices and reduce affordability.

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Results varied substantially among SD categories, with some counterintuitive effects.

Exploring the Social Determinants of Drinking Sugary Beverages Leading to Chronic Illness Among Latina/o Populations

INTRODUCTION

The aim of this qualitative study was to assess Latina/o students' sugary drink consumption patterns and understand the social determinants leading to this consumption behavior in order to design more effective health communication-based campaigns. This study examined the perceived reasons behind high levels of sugar-sweetened beverages (SSBs) consumption among college students of Hispanic origin in the Texas Panhandle region.

METHOD

Fifteen Latina/o students were interviewed via an innovative social media-based online interviewing protocol.

RESULTS

Subsequent analyses revealed that peer pressure, socializing, unavailability of packaged drinking water during social events, targeted advertisements, and poor lifestyle choices were perceived reasons for high intake of SSB in the focal population.

CONCLUSION

This study recommends designing public service announcements geared to Latino/a youth that increase awareness about the long-term health risks that can result from high consumption of SSBs. Moreover, the positive health benefits of drinking water should be highlighted and Latina/o parents should avoid glorifying SSBs and restrict their SSB consumption in front of their children. Further research should aim at designing educational messages, using theoretical backing, to test how Latina/o youth respond to them.

Cost Effectiveness of Nutrition Policies on Processed Meat: Implications for Cancer Burden in the U.S

INTRODUCTION

Processed meats are associated with increased risk of colorectal and stomach cancers, but health and economic impacts of policies to discourage processed meats are not well established. This paper aims to evaluate the cost effectiveness of implementing tax and warning labels on processed meats.

METHODS

A probabilistic cohort-state transition model was developed in 2018, including lifetime and short-term horizons, healthcare, and societal perspectives, and 3% discount rates for costs and health outcomes. The model simulated 32 subgroups by age, gender, and race/ethnicity from the U.S. adult population and integrated nationally representative 2011-2014 data on processed meat consumption, with etiologic effects of processed meat consumption on cancer incidence, medical and indirect societal costs, and policy costs.

RESULTS

Over a lifetime, the 10% excise tax would prevent 77,000 cases of colorectal cancer (95% uncertainty interval=56,800, 107,000) and 12,500 cases of stomach cancer (95% uncertainty interval=6,880, 23,900), add 593,000 quality-adjusted life years (95% uncertainty interval=419,000, 827,000), and generate net savings of $2.7 billion from a societal perspective, including $1.1 billion healthcare costs saved. The warning label policy would avert 85,400 cases of colorectal cancer (95% uncertainty interval=56,600, 141,000) and 15,000 cases of stomach cancer (95% uncertainty interval=6,860, 34,500), and add 660,000 quality-adjusted life years (95% uncertainty interval=418,000, 1,070,000), with net savings of $4.5 billion from a societal perspective, including $1.3 billion healthcare costs saved. In subgroup analyses, greater health and economic benefits accrued to (1) younger subpopulations, (2) subpopulations with greater cancer risk, and (3) those with higher baseline processed meat consumption.

CONCLUSIONS

The model shows that implementing tax or warning labels on processed meats would be a cost-saving strategy with substantial health and economic benefits. The findings should encourage policy makers to consider nutrition-related policies to reduce cancer burden.

Potential impact on prevalence of obesity in the UK of a 20% price increase in high sugar snacks: modelling study

OBJECTIVE

To estimate the potential impact on body mass index (BMI) and prevalence of obesity of a 20% price increase in high sugar snacks.

DESIGN

Modelling study.

SETTING

General adult population of the United Kingdom.

PARTICIPANTS

36 324 households with data on product level household expenditure from UK Kantar FMCG (fast moving consumer goods) panel for January 2012 to December 2013. Data were used to estimate changes in energy (kcal, 1 kcal=4.18 kJ=0.00418 MJ) purchase associated with a 20% price increase in high sugar snacks. Data for 2544 adults from waves 5 to 8 of the National Diet and Nutrition Survey (2012-16) were used to estimate resulting changes in BMI and prevalence of obesity.

MAIN OUTCOME MEASURES

The effect on per person take home energy purchases of a 20% price increase for three categories of high sugar snacks: confectionery (including chocolate), biscuits, and cakes. Health outcomes resulting from the price increase were measured as changes in weight, BMI (not overweight (BMI <25), overweight (BMI ≥25 and <30), and obese (BMI ≥30)), and prevalence of obesity. Results were stratified by household income and BMI.

RESULTS

For income groups combined, the average reduction in energy consumption for a 20% price increase in high sugar snacks was estimated to be 8.9×10³ kcal (95% confidence interval -13.1×10³ to -4.2×10³ kcal). Using a static weight loss model, BMI was estimated to decrease by 0.53 (95% confidence interval -1.01 to -0.06) on average across all categories and income groups. This change could reduce the UK prevalence of obesity by 2.7 percentage points (95% confidence interval -3.7 to -1.7 percentage points) after one year. The impact of a 20% price increase in high sugar snacks on energy purchase was largest in low income households classified as obese and smallest in high income households classified as not overweight.

CONCLUSIONS

Increasing the price of high sugar snacks by 20% could reduce energy intake, BMI, and prevalence of obesity. This finding was in a UK context and was double that modelled for a similar price increase in sugar sweetened beverages.

Sugar-sweetened beverage prices: Variations by beverage, food store, and neighborhood characteristics, 2017

Sugar-sweetened beverage (SSB) consumption is associated with obesity, type 2 diabetes, and cardiovascular disease. A number of U.S. jurisdictions have levied volume-based specific SSB taxes. This study estimated baseline mean SSB prices across categories and sizes as this will help to determine the percentage increase in price resulting from the imposition of specific taxes. Data on food store SSB prices were collected in 2017 in Cook County, IL, St. Louis City/County, MO, Oakland, CA, and Sacramento, CA (N = 11,767 product-level observations from 581 stores). Data were weighted to represent volume sold by category and size. Mean prices per ounce were computed across categories and sizes. Linear regression models, clustered on store, were run to estimate associations between price per ounce and product characteristics, neighborhood (linked by census tract) characteristics, store type, and site. Weighted summary statistics show that the mean price of SSBs was 4.8 cents/oz. Soda was least expensive (3.4 cents/oz), followed by sports drinks (4.8 cents/oz), juice drinks (5.2 cents/oz), ready-to-drink tea/coffee (7.8 cents/oz), and energy drinks (19.9 cents/oz). Prices were higher for individual-sized (9.6 cents/oz) compared to family-sized drinks (>1 L/multi-pack; 3.5 cents/oz). Regression results revealed that prices were lower in stores in majority non-Hispanic black tracts and varied by beverage characteristics and store type but not tract-level socioeconomic status. Given substantial variation in prices by SSB category, a penny-per-ounce SSB tax, if fully passed through, would increase soda prices by 29% versus 5% for energy drinks, highlighting the potential importance of different specific tax rates across beverage categories.

The Economics of Taxes on Sugar-Sweetened Beverages: A Review of the Effects on Prices, Sales, Cross-Border Shopping, and Consumption

During the past decade, dozens of countries, regions, and cities have enacted taxes on sugar-sweetened beverages (SSBs). They have been primarily motivated by a desire to raise prices, reduce sales and consumption, improve population health, and raise revenue. This review outlines the economic rationale for SSB taxes and illustrates their predicted effects. It reviews the research on the effects of these taxes on retail prices, sales, cross-border shopping, consumption, and product availability. The evidence indicates that the amount by which taxes increase retail prices (also called the pass-through of the tax) varies by jurisdiction, ranging from less than 50% to 100% of the tax. Sales tend to decrease significantly in the taxing jurisdiction, although this seems to be partly offset by residents increasingly shopping outside of the taxing jurisdiction (i.e., engaging in cross-border shopping).Overall, taxes lower consumption of the taxed beverages by adults, although not for all types of beverages or all groups of consumers. We conclude with suggestions for improving the design of such taxes and directions for future research.

The distributional impact of taxing sugar-sweetened beverages: findings from an extended cost-effectiveness analysis in South Africa

BACKGROUND

Facing increasing obesity prevalence and obesity-related disease burden, South Africa has devised an obesity prevention strategy that includes a recently implemented tax on the sugar content of sugar-sweetened beverages (SSB). We assess the potential distributional impact (across socioeconomic groups) of this tax on type 2 diabetes mellitus (T2DM) incidence and associated mortality and its financial burden on households.

METHODS

We conducted an extended cost-effectiveness analysis of the new 10% tax on SSBs in South Africa, and estimated: the averted premature deaths related to T2DM, the financial benefits to households (out-of-pocket (OOP) medical costs and indirect costs due to productivity losses averted), the increased government tax revenues and healthcare savings for the government, all across income quintiles.

FINDINGS

A 10% SSB tax increase would avert an estimated 8000 T2DM-related premature deaths over 20 years, with most deaths averted among the third and fourth income quintiles. The government would save about South African rand (ZAR) 2 billion (US$140 million) in subsidised healthcare over 20 years; and would raise ZAR6 billion (US$450 million) in tax revenues per annum. The bottom two quintiles would bear the smallest tax burden increase (36% of the additional taxes). The bottom two income quintiles would also have the lowest savings in OOP payments due to significant subsidisation provided by government healthcare. Lastly, an estimated 32 000 T2DM-related cases of catastrophic expenditures and 12 000 cases of poverty would be averted.

CONCLUSIONS

SSB taxation would have a substantial distributional impact on obesity-related premature deaths, cost savings to the government and the financial outcomes of South Africa's population.

Sugar-based beverage taxes and beverage prices: Evidence from South Africa's Health Promotion Levy

A growing number of jurisdictions are introducing taxes on sugar-sweetened beverages (SSBs) in efforts to reduce sugar intake, obesity, and associated metabolic conditions. A key dimension of the impact of such taxes is how they induce changes in the prices of the taxed beverages and their un-taxed substitutes. At present these taxes have typically been based solely on volume. More recently, however, due to the potential to target the source of SSBs' health harms and to incentivize product reformulation, SSB taxes are being levied based on sugar content. In April of 2018 South Africa implemented such a tax, the Health Promotion Levy (HPL), at a rate of 0.021 ZAR (approximately 0.15 US cents) for each gram of sugar over an initial threshold of 4 g/100 ml. Drawing on a dataset of price observations (N = 71, 677) collected in South Africa between January 2013 and March 2019, we study changes in beverage prices following the introduction of the HPL. We find null price increases among un-taxed beverages and find significant price increases for carbonates, the largest taxed product category. However, within carbonates we find similar increases in price for low- and high-sugar brands, despite the underlying difference in tax liability. In addition, while we find evidence of product reformulation, we find significant price increases among the brands that reduced their sugar content. While the findings are broadly consistent with the price changes of volume-based SSB taxes, future considerations of price effects of sugar-based SSB taxes need to account for the opportunity for intra-firm heterogeneity in price response among large multi-product firms.

Association of a Beverage Tax on Sugar-Sweetened and Artificially Sweetened Beverages With Changes in Beverage Prices and Sales at Chain Retailers in a Large Urban Setting

IMPORTANCE

Policy makers have implemented beverage taxes to generate revenue and reduce consumption of sweetened drinks. In January 2017, Philadelphia, Pennsylvania, became the second US city to implement a beverage excise tax (1.5 cents per ounce).

OBJECTIVES

To compare changes in beverage prices and sales following the implementation of the tax in Philadelphia compared with Baltimore, Maryland (a control city without a tax) and to assess potential cross-border shopping to avoid the tax in neighboring zip codes.

DESIGN, SETTING, AND PARTICIPANTS

This study used a difference-in-differences approach and analyzed sales data to compare changes between January 1, 2016, before the tax, and December 31, 2017, after the tax. Differences by store type, beverage sweetener status, and beverage size were examined. The commercial retailer sales data included large chain store sales in Philadelphia, Baltimore, and the Pennsylvania zip codes bordering Philadelphia. These data reflect approximately 25% of the ounces of taxed beverages sold in Philadelphia.

EXPOSURES

Philadelphia's tax on sugar-sweetened and artificially sweetened beverages.

MAIN OUTCOMES AND MEASURES

Change in taxed beverage prices and volume sales.

RESULTS

A total of 291 stores (54 supermarkets, 20 mass merchandise stores, 217 pharmacies) were analyzed. The mean price per ounce of taxed beverages in Philadelphia increased from 5.43 cents in 2016 to 6.24 cents in 2017 at supermarkets; from 5.28 cents to 6.24 cents at mass merchandise stores, and from 6.60 cents to 8.28 cents at pharmacies. The mean price per ounce in Baltimore increased from 5.33 cents in 2016 to 5.50 cents in 2017 at supermarkets, from 6.34 cents to 6.52 cents at mass merchandise stores, and from 6.76 cents to 6.93 cents at pharmacies. The mean per-ounce difference in price between the 2 cities was 0.65 cents (95% CI, 0.60 cents-0.69 cents; P<.001) at supermarkets; 0.87 cents (95 % CI, 0.72 cents-1.02 cents; P<.001) at mass merchandise stores, and 1.56 cents (95% CI, 1.50 cents-1.62 cents; P<.001) at pharmacies. Total volume sales of taxed beverages in Philadelphia decreased by 1.3 billion ounces (from 2.475 billion to 1.214 billion) or by 51.0% after tax implementation. Volume sales in the Pennsylvania border zip codes, however, increased by 308.2 million ounces (from 713.1 million to 1.021 billion), offsetting the decrease in Philadelphia's volume sales by 24.4%. In Philadelphia, beverage volume sales in ounces per 4-week period between before and after tax periods decreased from 4.85 million to 1.99 million at supermarkets, from 2.98 million to 1.72 million at mass merchandise stores, and from 0.16 million to 0.13 million at pharmacies. In Baltimore, the beverage volume sales in ounces decreased from 2.83 million to 2.81 million at supermarkets, from 1.05 million to 1.00 million at mass merchandise stores, and from 0.14 million to 0.13 million at pharmacies. This was a 58.7% reduction at supermarkets (difference-in-differences, -2.85 million ounces; 95% CI, -4.10 million to -1.60 million ounces; P < .001), 40.4% reduction at mass merchandise stores (difference-in-differences, -1.20 million ounces; 95% CI, -2.04 million to -0.36 million ounces; P = .001), and 12.6% reduction in pharmacies (difference-in-differences, -0.02 million ounces; 95% CI, -0.03 million to -0.01 million ounces; P < .001).

CONCLUSIONS AND RELEVANCE

In Philadelphia in 2017, the implementation of a beverage excise tax on sugar-sweetened and artificially sweetened beverages was associated with significantly higher beverage prices and a significant and substantial decline in volume of taxed beverages sold. This decrease in taxed beverage sales volume was partially offset by increases in volume of sales in bordering areas.

Public Policies to Reduce Sugary Drink Consumption in Children and Adolescents

Excess consumption of added sugars, especially from sugary drinks, poses a grave health threat to children and adolescents, disproportionately affecting children of minority and low-income communities. Public policies, such as those detailed in this statement, are needed to decrease child and adolescent consumption of added sugars and improve health.

Society of Behavioral Medicine (SBM) position statement: Enact taxes on sugar sweetened beverages to prevent chronic disease

The Society of Behavioral Medicine (SBM) encourages stakeholders to implement a sugar sweetened beverage excise tax. Sugar sweetened beverages are the largest source of added sugars in the USA and have detrimental effects on population health by increasing risks for chronic diseases. Based on existing research evidence, SBM supports an excise tax equivalent to at least 20% to meaningfully affect consumption patterns. As evidenced by research studies in Mexico and the USA, sugar sweetened beverage taxes can have positive impacts on population health and can raise significant tax revenue. To avoid potential unintended consequences that may arise from taxes to improve diet-related behaviors, it is important to monitor industry and consumer behavior in response to the tax.

Sugar-Sweetened Beverage Consumption 3 Years After the Berkeley, California, Sugar-Sweetened Beverage Tax

OBJECTIVES

To estimate changes in sugar-sweetened beverage (SSB) and water consumption 3 years after an SSB tax in Berkeley, California, relative to unexposed comparison neighborhoods.

METHODS

Data came from repeated annual cross-sectional beverage frequency questionnaires from 2014 to 2017 in demographically diverse Berkeley (n = 1513) and comparison (San Francisco and Oakland; n = 3712) neighborhoods. Pretax consumption (2014) was compared with a weighted average of 3 years of posttax consumption.

RESULTS

At baseline, SSBs were consumed 1.25 times per day (95% confidence interval [CI] = 1.00, 1.50) in Berkeley and 1.27 times per day (95% CI = 1.13, 1.42) in comparison city neighborhoods. When we adjusted for covariates, consumption in Berkeley declined by 0.55 times per day (95% CI = -0.75, -0.35) for SSBs and increased by 1.02 times per day (95% CI = 0.54, 1.50) for water. Changes in consumption in Berkeley were significantly different from those in the comparison group, which saw no significant changes.

CONCLUSIONS

Reductions in SSB consumption were sustained in demographically diverse Berkeley neighborhoods over the first 3 years of an SSB tax, relative to comparison cities. These persistent, longer-term reductions in SSB consumption suggest that SSB taxes are an effective policy option for jurisdictions focused on improving public health.

Assessing the impact of the Barbados sugar-sweetened beverage tax on beverage sales: an observational study

Background

The World Health Organization has advocated for sugar-sweetened beverage (SSB) taxes as part of a broader non-communicable disease prevention strategy, and these taxes have been recently introduced in a wide range of settings. However, much is still unknown about how SSB taxes operate in various contexts and as a result of different tax designs. In 2015, the Government of Barbados implemented a 10% ad valorem (value-based) tax on SSBs. It has been hypothesized that this tax structure may inadvertently encourage consumers to switch to cheaper sugary drinks. We aimed to assess whether and to what extent there has been a change in sales of SSBs following implementation of the SSB tax.

Methods

We used electronic point of sale data from a major grocery store chain and applied an interrupted time series (ITS) design to assess grocery store SSB and non-SSB sales from January 2013 to October 2016. We controlled for the underlying time trend, seasonality, inflation, tourism and holidays. We conducted sensitivity analyses using a cross-country control (Trinidad and Tobago) and a within-country control (vinegar). We included a post-hoc stratification by price tertile to assess the extent to which consumers may switch to cheaper sugary drinks.

Results

We found that average weekly sales of SSBs decreased by 4.3% (95%CI 3.6 to 4.9%) compared to expected sales without a tax, primarily driven by a decrease in carbonated SSBs sales of 3.6% (95%CI 2.9 to 4.4%). Sales of non-SSBs increased by 5.2% (95%CI 4.5 to 5.9%), with bottled water sales increasing by an average of 7.5% (95%CI 6.5 to 8.3%). The sensitivity analyses were consistent with the uncontrolled results. After stratifying by price, we found evidence of substitution to cheaper SSBs.

Conclusions

This study suggests that the Barbados SSB tax was associated with decreased sales of SSBs in a major grocery store chain after controlling for underlying trends. This finding was robust to sensitivity analyses. We found evidence to suggest that consumers may have changed their behaviour in response to the tax by purchasing cheaper sugary drinks, in addition to substituting to untaxed products. This has important implications for the design of future SSB taxes.

Electronic supplementary material

The online version of this article (10.1186/s12966-019-0776-7) contains supplementary material, which is available to authorized users.

Could a tax on unhealthy products sold for weight loss reduce consumer use? A novel estimation of potential taxation effects

Abuse of widely available, over-the-counter (OTC) drugs and supplements such as diet pills, laxatives, and diuretics by adolescents for weight control is well-documented, yet manufacturers and retailers can sell them to minors without restriction. The aim of our study was to estimate the effect of added taxation of OTC drugs and dietary supplements sold for weight loss on household purchases of these products. With data from 60,538 U.S. households in the 2012 waves of the Nielsen/IRi National Consumer Panel (NCP) and the Nielsen/IRi Retail Scanner (NRS) datasets, we conducted analyses in 2017 to tally annual quantities and expenditures on OTC drugs or dietary supplements making weight-loss, cleanse/detox, or diuretic claims. We estimated the percent reduction in household purchases due to a simulated 20% added tax on each category. Among the 14,151 households reporting at least one purchase in the three claims categories, a 20% higher average price of weight-loss products was associated with a 5.2% lower purchases of those products. Among households with children ages 12 to 17 years old present, purchases were 17.5% lower, and among households with a daughter present, purchases were 10.3% lower. Taxation may be an effective public health strategy to reduce purchasing of potentially dangerous OTC drugs and supplements sold for weight loss, especially for households that include children ages 12-17 years old or a daughter.

Different scientific approaches are needed to generate stronger evidence for population health improvement

In a Perspective, Martin White and Jean Adams discuss challenges in the evaluation of interventions intended to benefit population health.

The Short-Term Impacts of the Philadelphia Beverage Tax on Beverage Consumption

INTRODUCTION

On January 1, 2017, Philadelphia implemented a beverage tax of $0.015/ounce on sugar ("regular") and sugar-substitute ("diet") beverages. The purpose of this study was to evaluate the immediate impact of the tax on residents' consumption of soda, fruit drinks, energy drinks, and bottled water.

METHODS

A repeat cross-sectional study design used data from a random-digit-dialing phone survey during a no-tax period (December 6-31, 2016) and a tax period (January 15-February 31, 2017) among 899 respondents in Philadelphia, Pennsylvania, and 878 respondents in three nearby comparison cities. Survey questions included frequency and volume of bottled water and beverages. Outcomes were daily consumption, and 30-day consumption frequency and volume. Propensity score-weighted difference-in-differences regression was used to control for secular time trend and confounding. Covariates were sociodemographics, BMI, health status, smoking, and alcohol use. Analyses were conducted in 2017.

RESULTS

Within the first 2 months of tax implementation, relative to the comparison cities, in Philadelphia the odds of daily consumption of regular soda was 40% lower (OR=0.6, 95% CI=0.37, 0.97); energy drink was 64% lower (OR=0.36, 95% CI=0.17, 0.76); bottled water was 58% higher (OR=1.58, 95% CI=1.13, 2.20); and the 30-day regular soda consumption frequency was 38% lower (ratio of consumption frequency=0.62, 95% CI=0.40, 0.98).

CONCLUSIONS

Early results suggest that the tax influenced daily consumption of regular soda, energy drinks, and bottled water. Future studies are needed to evaluate longer-term impact of the tax on sugared beverage consumption and substitutions.

Change in non-alcoholic beverage sales following a 10-pence levy on sugar-sweetened beverages within a national chain of restaurants in the UK: interrupted time series analysis of a natural experiment

Background

This study evaluates changes in sales of non-alcoholic beverages in Jamie’s Italian, a national chain of commercial restaurants in the UK, following the introduction of a £0.10 per-beverage levy on sugar-sweetened beverages (SSBs) and supporting activity including beverage menu redesign, new products and establishment of a children’s health fund from levy proceeds.

Methods

We used an interrupted time series design to quantify changes in sales of non-alcoholic beverages 12 weeks and 6 months after implementation of the levy, using itemised electronic point of sale data. Main outcomes were number of SSBs and other non-alcoholic beverages sold per customer. Linear regression and multilevel random effects models, adjusting for seasonality and clustering, were used to investigate changes in SSB sales across all restaurants (n=37) and by tertiles of baseline restaurant SSB sales per customer.

Results

Compared with the prelevy period, the number of SSBs sold per customer declined by 11.0% (−17.3% to −4.3%) at 12 weeks and 9.3% (−15.2% to −3.2%) at 6 months. For non-levied beverages, sales per customer of children’s fruit juice declined by 34.7% (−55.3% to −4.3%) at 12 weeks and 9.9% (−16.8% to −2.4%) at 6 months. At 6 months, sales per customer of fruit juice increased by 21.8% (14.0% to 30.2%) but sales of diet cola (−7.3%; −11.7% to −2.8%) and bottled waters (−6.5%; −11.0% to −1.7%) declined. Changes in sales were only observed in restaurants in the medium and high tertiles of baseline SSB sales per customer.

Conclusions

Introduction of a £0.10 levy on SSBs alongside complementary activities is associated with declines in SSB sales per customer in the short and medium term, particularly in restaurants with higher baseline sales of SSBs.

The association of flavored milk consumption with milk and energy intake, and obesity: A systematic review

Taxes on sugary drinks are being implemented to prevent chronic diseases. Sugar-sweetened milk has been exempt from such policies because of its nutritional value. This systematic review sought to examine whether flavored milk consumption was associated with milk and energy intake, and obesity among children. A search of PubMed, EMBASE, Cochrane, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials and the grey literature was conducted for peer-reviewed publications published before June 6, 2016 that met the following criteria: 1) English-language publications 2) studies of children ages 1 to 18 years, 3) controlled experimental, cohort, case-control, systematic reviews, or meta-analysis studies 4) dependent variable: flavored milk consumption 5) independent variable: weight, weight gain, weight change, body mass index, metabolic syndrome, waist circumference, cholesterol, triglycerides, blood pressure, serum glucose, calories, sugar, or milk consumed. Of 3978 studies identified, 13 met inclusion criteria. Ten studies were experimental and three were longitudinal cohort studies. Eleven studies found that flavored milk increased overall milk intake, five of seven studies that examined energy intake showed that flavored milk increased energy intake, and one of three studies that assessed obesity outcomes demonstrated an increase in weight gain with flavored milk consumption. Only one study was a randomized controlled trial, most studies had high bias, and over half were industry-funded or did not disclose funding. Although flavoring milk may increase milk intake, added sugars may promote increased energy intake. More data regarding flavored milk's impact on health is needed to inform its role in sugary drink policies.

A Review of the Impacts of Different Approaches for Diabetes Prevention and a Framework for Making Investment Decisions

This paper selectively reviews the economic research on individual (i.e., diabetes prevention programs and financial rewards for weight loss) and population-wide based diabetes prevention interventions (such as food taxes, nutritional labeling, and worksite wellness programs) that demonstrate a direct reduction in diabetes incidence or improvements in diabetes risk factors such as weight, glucose or glycated hemoglobin. The paper suggests a framework to guide decision makers on how to use the available evidence to determine the optimal allocation of resources across population-wide and individual-based interventions. This framework should also assist in the discussion of what parameters are needed from research to inform decision-making on what might be the optimal mix of strategies to reduce diabetes prevalence.

Pass-Through of a Tax on Sugar-Sweetened Beverages at the Philadelphia International Airport

This study estimates how much the 1.5¢-per-ounce tax on sugar-sweetened beverages in Philadelphia raised retail prices of soft drinks at the Philadelphia International Airport 1 month after implementation.

Best practices for using natural experiments to evaluate retail food and beverage policies and interventions

Policy and programmatic change in the food retail setting, including excise taxes on beverages with added-caloric sweeteners, new supermarkets in food deserts, and voluntary corporate pledges, often require the use of natural experimental evaluation for impact evaluation when randomized controlled trials are not possible. Although natural experimental studies in the food retail setting provide important opportunities to test how nonrandomized interventions affect behavioral and health outcomes, researchers face several key challenges to maintaining strong internal and external validity when conducting these studies. Broadly, these challenges include 1) study design and analysis; 2) selection of participants, selection of measures, and obtainment of data; and 3) real-world considerations. This article addresses these challenges and different approaches to meeting them. Case studies are used to illustrate these approaches and to highlight advantages and disadvantages of each approach. If the trade-offs required to address these challenges are carefully considered, thoughtful natural experimental evaluations can minimize bias and provide critical information about the impacts of food retail interventions to a variety of stakeholders, including the affected population, policymakers, and food retailers.

The potential impact of food taxes and subsidies on cardiovascular disease and diabetes burden and disparities in the United States

BACKGROUND

Fiscal interventions are promising strategies to improve diets, reduce cardiovascular disease and diabetes (cardiometabolic diseases; CMD), and address health disparities. The aim of this study is to estimate the impact of specific dietary taxes and subsidies on CMD deaths and disparities in the US.

METHODS

Using nationally representative data, we used a comparative risk assessment to model the potential effects on total CMD deaths and disparities of price subsidies (10%, 30%) on fruits, vegetables, whole grains, and nuts/seeds and taxes (10%, 30%) on processed meat, unprocessed red meats, and sugar-sweetened beverages. We modeled two gradients of price-responsiveness by education, an indicator of socioeconomic status (SES), based on global price elasticities (18% greater price-responsiveness in low vs. high SES) and recent national experiences with taxes on sugar-sweetened beverages (65% greater price-responsiveness in low vs. high SES).

RESULTS

Each price intervention would reduce CMD deaths. Overall, the largest proportional reductions were seen in stroke, followed by diabetes and coronary heart disease. Jointly altering prices of all seven dietary factors (10% each, with 18% greater price-responsiveness by SES) would prevent 23,174 (95% UI 22,024-24,595) CMD deaths/year, corresponding to 3.1% (95% UI 2.9-3.4) of CMD deaths among Americans with a lower than high school education, 3.6% (95% UI 3.3-3.8) among high school graduates/some college, and 2.9% (95% UI 2.7-3.5) among college graduates. Applying a 30% price change and larger price-responsiveness (65%) in low SES, the corresponding reductions were 10.9% (95% UI 9.2-10.8), 9.8% (95% UI 9.1-10.4), and 6.7% (95% UI 6.2-7.6). The latter scenario would reduce disparities in CMD between Americans with lower than high school versus a college education by 3.5 (95% UI 2.3-4.5) percentage points.

CONCLUSIONS

Modest taxes and subsidies for key dietary factors could meaningfully reduce CMD and improve US disparities.

Pricing Strategies to Encourage Availability, Purchase, and Consumption of Healthy Foods and Beverages: A Systematic Review

Introduction

Food pricing policies to promote healthy diets, such as taxes, price manipulations, and food subsidies, have been tested in different settings. However, little consensus exists about the effect of these policies on the availability of healthy and unhealthy foods, on what foods consumers buy, or on the impact of food purchases on consumer health outcomes. We conducted a systematic review of studies of the effect of food-pricing interventions on retail sales and on consumer purchasing and consumption of healthy foods and beverages.

Methods

We used MEDLINE, Embase, PsycINFO, Web of Science, ClinicalTrials.gov, and the Cochrane Library to conduct a systematic search for peer-reviewed articles related to studies of food pricing policies. We selected articles that were published in English from January 2000 through December 2016 on the following types of studies: 1) real-world experimental studies (randomized controlled trials, quasi-experimental studies, and natural experiments); 2) population studies of people or retail stores in middle-income and high-income countries; 3) pricing interventions alone or in combination with other strategies (price promotions, coupons, taxes, or cash-back rebates), excluding studies of vending-machine or online sales; and 4) outcomes studies at the retail (stocking, sales) and consumer (purchasing, consumption) levels. We selected 65 articles representing 30 studies for review.

Results

Sixteen pricing intervention studies that sought to improve access to healthy food and beverage options reported increased stocking and sales of promoted food items. Most studies (n = 23) reported improvement in the purchasing and consumption of healthy foods or beverages or decreased purchasing and consumption of unhealthy foods or beverages. Most studies assessed promotions of fresh fruits and vegetables (n = 20); however, these foods may be hard to source, have high perishability, and raise concerns about safety and handling. Few of the pricing studies we reviewed discouraged purchasing and consumption of unhealthy foods (n = 6). Many studies we reviewed had limitations, including lack of formative research, process evaluation, or psychosocial and health assessments of the intervention’s impact; short intervention duration; or no assessment of food substitutions or the effects of pricing interventions on food purchasing and diets.

Conclusion

Pricing interventions generally increased stocking, sales, purchasing, and consumption of promoted foods and beverages. Additional studies are needed to differentiate the potential impact of selected pricing strategies and policies over others.

Declines in the Incidence of Diabetes in the U.S.-Real Progress or Artifact?

National surveillance data show a sustained decline in the incidence rate of diagnosed diabetes, which has been heralded as a success in the battle against diabetes in the U.S. In this Perspective, we take a closer look at these data and provide additional insights to help interpret these trends. We examine multiple sources of data on the prevalence and incidence of diabetes in the U.S. as well as data on trends in diabetes risk factors to provide context for these national surveillance findings. Although some of the incidence decline may represent real progress against diabetes, it is likely that there are also nonbiological factors at play, especially changes in diagnostic criteria for diabetes. We present and discuss data that suggest improved detection and changes in screening and diagnostic practices may have resulted in the depletion of the "susceptible population." Providing this context for the recent declines in new diabetes diagnoses observed in national data is critical to help avoid misinterpretation. We argue that it is premature to declare victory against the epidemic of diabetes in the U.S. and discuss how we might better focus current public health efforts, including a specific emphasis to address prediabetes.

Maternal and child health services and an integrated, life-cycle approach to the prevention of non-communicable diseases

Described as the ‘invisible epidemic’, non-communicable diseases (NCDs) are the world’s leading cause of death. Most are caused by preventable factors, including poor diet, tobacco use, harmful use of alcohol and physical inactivity. Diabetes, cancer and cardiovascular and chronic lung diseases were responsible for 38 million (68%) of global deaths in 2012. Since 1990, proportionate NCD mortality has increased substantially as populations have aged and communicable diseases decline. The majority of NCD deaths, especially premature NCD deaths (<70 years, 82%), occur in low-income and middle-income countries, and among poor communities within them. Addressing NCDs is recognised as central to the post-2015 agenda; accordingly, NCDs have a specific objective and target in the Sustainable Development Goals. While deaths from NCDs occur mainly in adulthood, many have their origins in early life, including through epigenetic mechanisms operating before conception. Good nutrition before conception and interventions aimed at preventing NCDs during the first 1000 days (from conception to age 2 years), childhood and adolescence may be more cost-effective than managing established NCDs in later life with costly tests and drugs. Following a life-course approach, maternal and child health interventions, before delivery and during childhood and adolescence, can prevent NCDs and should influence global health and socioeconomic development. This paper describes how such an approach may be pursued, including through the engagement of non-health sectors. It also emphasises evaluating and documenting related initiatives to underwrite systematic and evidence-based cross-sectoral engagement on NCD prevention in the future.

Funding quality pre-kindergarten slots with Philadelphia's new 'sugary drink tax': simulating effects of using an excise tax to address a social determinant of health

OBJECTIVE

Philadelphia passed a 1·5-cent-per-ounce sweetened beverage tax (SBT). Revenue will fund 10 000 quality pre-kindergarten slots for poor children. It is imperative to understand how revenue from SBT can be used to fund programmes to address education and other social determinants of health. The objective of the present study was to simulate quality pre-kindergarten attendance, educational achievement and sugar-sweetened beverage (SSB) consumption among Philadelphia children and adolescents under six intervention scenarios: (i) no intervention; (ii) 10 000 additional quality pre-kindergarten slots; (iii) a 1·5-cent-per-ounce SBT; (iv) expanded pre-kindergarten and 1·5-cent-per-ounce SBT; (v) a 3-cent-per-ounce SBT; and (vi) expanded pre-kindergarten and 3-cent-per-ounce SBT.

DESIGN

We used an agent-based model to estimate pre-kindergarten enrolment, educational achievement and SSB consumption under the six policy scenarios. We identified key parameters in the model from the published literature and secondary analyses of the Panel Study of Income Dynamics - Child Development Supplement.

SETTING

Philadelphia, Pennsylvania, USA.

SUBJECTS

Philadelphia children and adolescents aged 4-18 years.

RESULTS

A 1·5-cents-per-ounce tax would reduce SSB consumption by 1·3 drinks/week among Philadelphia children and adolescents relative to no intervention, with larger effects among children below the poverty level. Quality pre-kindergarten expansion magnifies the effect of the SBT by 8 %, but has the largest effect on moderate-income children just above the poverty level. The SBT and quality pre-kindergarten programme each reduce SSB consumption, but primarily benefit different children and adolescents.

CONCLUSIONS

Pairing an excise tax with a complementary programme to improve a social determinant of health represents a progressive strategy to combat obesity, a disease regressive in its social patterning.

Improving food environments and tackling obesity: A realist systematic review of the policy success of regulatory interventions targeting population nutrition

Background

This systematic review (PROSPERO: CRD42015025276) employs a realist approach to investigate the effect of “real-world” policies targeting different aspects of the food environment that shape individual and collective nutrition.

Objectives

We were interested in assessing intermediate outcomes along the assumed causal pathway to “policy success”, in addition to the final outcome of changed consumption patterns.

Data sources

We performed a search of 16 databases through October 2015, with no initial restriction by language.

Study eligibility criteria

We included all publications that reported the effect of statutory provisions aimed at reducing the consumption of energy-dense foods and beverages in the general population. We allowed all methodological approaches that contained some measure of comparison, including studies of implementation progress.

Study appraisal and synthesis methods

We reviewed included studies using the appraisal tools for pre-post and observational studies developed by the National Heart, Lung, and Blood Institute. Given the considerable heterogeneity in interventions assessed, study designs employed, and outcome measures reported, we opted for a narrative synthesis of results.

Results and implications

Results drawn from 36 peer-reviewed articles and grey literature reports demonstrated that isolated regulatory interventions can improve intermediate outcomes, but fail to affect consumption at clinically significant levels. The included literature covered six different types of interventions, with 19 studies reporting on calorie posting on chain restaurant menus. The large majority of the identified interventions were conducted in the US. Early results from recent taxation measures were published after the review cut-off date but these suggested more favorable effects on consumption levels. Nevertheless, the evidence assessed in this review suggests that current policies are generally falling short of anticipated health impacts.

The taxation of unhealthy energy-dense foods (EDFs) and sugar-sweetened beverages (SSBs): An overview of patterns observed in the policy content and policy context of 13 case studies

Taxation of energy-dense foods (EDFs) and sugar-sweetened beverages (SSBs) is increasingly of interest as a novel public health and fiscal policy instrument. However academic interest in policy determinants has remained limited. We address this paucity by comparing the policy content and policy context of EDF/SSB taxes witnessed in 13 case studies, of which we assume the tax is sufficiently high to induce behavioural change. The observational and non-randomized studies published on our case studies seem to indicate that the EDF/SSB taxes under investigation generally had the desired effects on prices and consumption of targeted products. The revenue collection of EDF/SSB taxes is minimal yet significant. Administrative practicalities in tax levying are important, possibly explaining why a drift towards solely taxing SSBs can be noted, as these can be demarcated more easily, with levies seemingly increasing in more recent case studies. Despite the growing body of evidence suggesting that EDF/SSB taxes have the potential to improve health, fiscal needs more often seem to lay their policy foundation rather than public health advocacy. A remarkable amount of conservative/liberal governments have adopted these taxes, although in many cases revenues are earmarked for benefits compensating regressive income effects. Governments voice diverse policy rationales, ranging from explicitly describing the tax as a public health instrument, to solely explicating revenue raising.

Prevention of childhood obesity and food policies in Latin America: from research to practice

BACKGROUND

Addressing childhood obesity in Latin America requires a package of multisectoral, evidence-based policies that enable environments conducive to healthy lifestyles.

OBJECTIVE

Identify and examine key elements to translating research into effective obesity policies in Latin America.

METHODS

We examined obesity prevention policies through case studies developed with an expert in the specific policy. Policies were selected based on their level of implementation, visibility and potential impact to reduce childhood obesity. They include: (i) excise taxes on sugar sweetened beverages and energy-dense foods; (ii) front-of-package food label legislation; (iii) trans fatty acids removal from processed foods; and (iv) Ciclovías recreativas or 'open streets'. Case studies were coded to identify components that explained successful implementation and sustainability using the Complex Adaptive Health Systems framework.

RESULTS

The analysis identified key elements for effective and sustainable policy, including evidence justifying policy; evidence-based advocacy by civil society; political will; and legislation and skillful negotiations across government, academia, the private sector and civil society. Scientific evidence and evaluation played an important role in achieving tipping points for policies' launch and sustain effective implementation.

CONCLUSIONS

Well-coordinated, intersectoral partnerships are needed to successfully implement evidence-based anti-obesity policies. Prospective policy research may be useful for advancing knowledge translation.

Ethical imperatives against item restriction in the Supplemental Nutrition Assistance Program

The Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps) is the federal government's largest form of food assistance, and a frequent focus of political and scholarly debate. Previous discourse in the public health community and recent proposals in state legislatures have suggested limiting the use of SNAP benefits on unhealthy food items, such as sugar-sweetened beverages (SSBs). This paper identifies two possible underlying motivations for item restriction, health and morals, and analyzes the level of empirical support for claims about the current state of the program, as well as expectations about how item restriction would change participant outcomes. It also assesses how item restriction would reduce individual agency of low-income individuals, and identifies mechanisms by which this may adversely affect program participants. Finally, this paper offers alternative policies to promote healthier purchasing and eating among SNAP participants that can be pursued without reducing individual agency. Health advocates and officials must more fully weigh the attendant risks of implementing SNAP item restrictions, including the reduction of individual agency of a vulnerable population.

Effectiveness and equity of sugar-sweetened beverage taxation

Sanjay Basu and Kristine Madsen discuss the effects of taxes on sugar-sweetened beverages in both Australia and Berkeley, USA.

Motivating systems-oriented research on environmental and policy changes for obesity prevention

BACKGROUND

Research on the types of interventions needed for population-level prevention of childhood obesity in complex societal systems can benefit from greater use of systems-science concepts and tools.

OBJECTIVES

We report outcomes of a funding programme promoting incorporation of systems-science approaches into studies of imminent policy or environmental changes potentially impacting childhood obesity.

METHODS

Seven funding cycles over 3 years yielded 172 initial submissions from 29 US states and 25 other countries were analyzed.

RESULTS

Submissions focused primarily on aspects of school or child-care settings, parks and recreational settings, or access to healthy food; about half reflected attention to systems perspectives.

CONCLUSIONS

Analysis of initial submissions as well as the 15 funded projects showed some success in motivating use of systems concepts and tools but suggested the need for a more focused effort to educate and prepare the childhood obesity prevention research community for this potentially crucial type of research.

Taxing Sugary Beverages Reduces Their Purchase, Especially Among Poor Households

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. Colchera MA, Popkin BM, Rivera JA, Ng SW. Br Med J 2016;352:h6704.

SOURCE OF FUNDING

Bloomberg Philanthropies, Robert Wood Johnson Foundation, Instituto Nacional de Salud Pública and Carolina Population Center.

TYPE OF STUDY/DESIGN

Observational study.

Sugar Price Supports and Taxation: A Public Health Policy Paradox

Domestic US sugar production has been protected by government policy for the past 82 years, resulting in elevated domestic prices and an estimated annual (2013) $1.4 billion dollar “tax” on consumers. These elevated prices and the simultaneous federal support for domestic corn production have ensured a strong market for high-fructose corn syrup. Americans have dramatically increased their consumption of caloric sweeteners during the same period. Consumption of “empty” calories (ie, foods with low-nutrient/high-caloric density)—sugar and high-fructose corn syrup being the primary sources—is considered by most public health experts to be a key contributing factor to the rise in obesity. There have been substantial efforts to tax sugar-sweetened beverages (SSBs) to both reduce consumption and provide a source of funds for nutrition education, thereby emulating the tobacco tax model. Volume-based SSB taxes levy the tax rate per ounce of liquid, where some are only imposed on beverages with added sugar content exceeding a set threshold. Nonetheless, volume-based taxes have significant limitations in encouraging consumers to reduce their caloric intake due to a lack of transparency at the point of purchase. Thus, it is hypothesized that point-of-purchase, nutrient-specific excise taxes on SSBs would be more effective at reducing sugar consumption. However, all SSB taxes are limited by the possibility that consumers may compensate their decreased intake from SSBs with other high-calorie junk foods. Furthermore, there are no existing studies to provide evidence on how SSB taxes will impact obesity rates in the long term. The paradox of sugar prices is that Americans have paid higher prices for sugar to protect domestic production for more than 80 years, and now, Americans are being asked to pay even more to promote public health. The effective use of sugar taxes should be considered based on their merits in reducing sugar consumption and making available a new source of funds to support nutrition education, not on lobbying efforts by the food industry or sugar and corn producers.

Changes in prices, sales, consumer spending, and beverage consumption one year after a tax on sugar-sweetened beverages in Berkeley, California, US: A before-and-after study

BACKGROUND

Taxes on sugar-sweetened beverages (SSBs) meant to improve health and raise revenue are being adopted, yet evaluation is scarce. This study examines the association of the first penny per ounce SSB excise tax in the United States, in Berkeley, California, with beverage prices, sales, store revenue/consumer spending, and usual beverage intake.

METHODS AND FINDINGS

Methods included comparison of pre-taxation (before 1 January 2015) and first-year post-taxation (1 March 2015-29 February 2016) measures of (1) beverage prices at 26 Berkeley stores; (2) point-of-sale scanner data on 15.5 million checkouts for beverage prices, sales, and store revenue for two supermarket chains covering three Berkeley and six control non-Berkeley large supermarkets in adjacent cities; and (3) a representative telephone survey (17.4% cooperation rate) of 957 adult Berkeley residents. Key hypotheses were that (1) the tax would be passed through to the prices of taxed beverages among the chain stores in which Berkeley implemented the tax in 2015; (2) sales of taxed beverages would decline, and sales of untaxed beverages would rise, in Berkeley stores more than in comparison non-Berkeley stores; (3) consumer spending per transaction (checkout episode) would not increase in Berkeley stores; and (4) self-reported consumption of taxed beverages would decline. Main outcomes and measures included changes in inflation-adjusted prices (cents/ounce), beverage sales (ounces), consumers' spending measured as store revenue (inflation-adjusted dollars per transaction) in two large chains, and usual beverage intake (grams/day and kilocalories/day). Tax pass-through (changes in the price after imposition of the tax) for SSBs varied in degree and timing by store type and beverage type. Pass-through was complete in large chain supermarkets (+1.07¢/oz, p = 0.001) and small chain supermarkets and chain gas stations (1.31¢/oz, p = 0.004), partial in pharmacies (+0.45¢/oz, p = 0.03), and negative in independent corner stores and independent gas stations (-0.64¢/oz, p = 0.004). Sales-unweighted mean price change from scanner data was +0.67¢/oz (p = 0.00) (sales-weighted, +0.65¢/oz, p = 0.003), with +1.09¢/oz (p < 0.001) for sodas and energy drinks, but a lower change in other categories. Post-tax year 1 scanner data SSB sales (ounces/transaction) in Berkeley stores declined 9.6% (p < 0.001) compared to estimates if the tax were not in place, but rose 6.9% (p < 0.001) for non-Berkeley stores. Sales of untaxed beverages in Berkeley stores rose by 3.5% versus 0.5% (both p < 0.001) for non-Berkeley stores. Overall beverage sales also rose across stores. In Berkeley, sales of water rose by 15.6% (p < 0.001) (exceeding the decline in SSB sales in ounces); untaxed fruit, vegetable, and tea drinks, by 4.37% (p < 0.001); and plain milk, by 0.63% (p = 0.01). Scanner data mean store revenue/consumer spending (dollars per transaction) fell 18¢ less in Berkeley (-$0.36, p < 0.001) than in comparison stores (-$0.54, p < 0.001). Baseline and post-tax Berkeley SSB sales and usual dietary intake were markedly low compared to national levels (at baseline, National Health and Nutrition Examination Survey SSB intake nationally was 131 kcal/d and in Berkeley was 45 kcal/d). Reductions in self-reported mean daily SSB intake in grams (-19.8%, p = 0.49) and in mean per capita SSB caloric intake (-13.3%, p = 0.56) from baseline to post-tax were not statistically significant. Limitations of the study include inability to establish causal links due to observational design, and the absence of health outcomes. Analysis of consumption was limited by the small effect size in relation to high standard error and Berkeley's low baseline consumption.

CONCLUSIONS

One year following implementation of the nation's first large SSB tax, prices of SSBs increased in many, but not all, settings, SSB sales declined, and sales of untaxed beverages (especially water) and overall study beverages rose in Berkeley; overall consumer spending per transaction in the stores studied did not rise. Price increases for SSBs in two distinct data sources, their timing, and the patterns of change in taxed and untaxed beverage sales suggest that the observed changes may be attributable to the tax. Post-tax self-reported SSB intake did not change significantly compared to baseline. Significant declines in SSB sales, even in this relatively affluent community, accompanied by revenue used for prevention suggest promise for this policy. Evaluation of taxation in jurisdictions with more typical SSB consumption, with controls, is needed to assess broader dietary and potential health impacts.

Appetite self-regulation: Environmental and policy influences on eating behaviors

OBJECTIVE

Appetite regulation is influenced by the environment, and the environment is shaped by food-related policies. This review summarizes the environment and policy research portion of an NIH Workshop (Bethesda, MD, 2015) titled "Self-Regulation of Appetite-It's Complicated."

METHODS

In this paper, we begin by making the case for why policy is an important tool in efforts to improve nutrition, and we introduce an ecological framework that illustrates the multiple layers that influence what people eat. We describe the state of the science on how policies influence behavior in several key areas: the federal food programs, schools, child care, food and beverage pricing, marketing to youth, behavioral economics, and changing defaults. Next, we propose novel approaches for multidisciplinary prevention and intervention strategies to promote breastfeeding, and examine interactions between psychology and the environment.

RESULTS

Policy and environmental change are the most distal influences on individual-level appetite regulation, yet these strategies can reach many people at once by changing the environment in which food choices are made. We note the need for more research to understand compensatory behavior, reactance, and how to effectively change social norms.

CONCLUSIONS

To move forward, we need a more sophisticated understanding of how individual psychological and biological factors interact with the environment and policy influences.

Going flat: examining heterogeneity in the soda-obesity relationship by subgroup and place of birth among Asian Americans

OBJECTIVE

To determine if the association between soda consumption and obesity is uniform among Asian-American population subgroups.

DESIGN

We conducted multivariate logistic regression analyses on odds of being obese among seven Asian subgroups and by place of birth using data from the 2009 California Health Interview Survey.

SETTING

An omnibus population-based health survey.

SUBJECTS

Non-institutionalized adults, aged 18 years or over, residing in California (n 36 271).

RESULTS

Despite low levels of soda consumption in several Asian-American ethnic groups, soda consumption increased the odds of being obese among Chinese, Koreans and Other Asians but not for Whites. Obesity risk varied across Asian subgroups and by place of birth within these subgroups.

CONCLUSIONS

More public health efforts addressing soda consumption in Asian-American communities are needed as a strategy for not only preventing chronic diseases but also disparities, considering the varying levels of soda intake across subgroups. Results support the growing body of literature critiquing acculturation theory in immigrant health research by documenting inconsistent findings by place of birth. Future research should take into account the heterogeneity among Asian Americans to advance our understanding of health outcomes and disparities.

Taxing sugar-sweetened beverages: impact on overweight and obesity in Germany

BACKGROUND

Consumption of sugar-sweetened beverages (SSBs) increases the risk of overweight and obesity. Taxing SSBs could decrease daily energy consumption and body weight. This model-based study evaluated the impact of a 20% SSB-sales tax on overweight and obesity in the context of Germany.

METHODS

The population aged 15-79 years was modelled. Taxation was assumed to affect energy consumption via demand elasticities, which affected weight and BMI. Model-based analysis was performed to estimate the tax impact on BMI in different age, gender and income groups.

RESULTS

Implementing a 20% SSB tax reduced energy consumption mainly in younger age groups, males, and those with low income. Taxation decreased the mean BMI in younger groups, with the largest decrease in those aged 20-29 years, while effects in groups 60 years or above were minimal. In absolute terms, taxation was estimated to avoid 1,028,000 (-3% relative reduction) overweight individuals and 479,000 obese individuals (-4%). Overweight decreased the most in males aged 20-29 years (408,000 fewer cases /-22%), the same applied for obesity (204,000/-22%).

CONCLUSIONS

An SSB tax could have significant impact on overweight and obesity, which could translate into substantial reductions of morbidity and mortality.

Health impact assessment of the UK soft drinks industry levy: a comparative risk assessment modelling study

BACKGROUND

In March, 2016, the UK Government proposed a tiered levy on sugar-sweetened beverages (SSBs; high tax for drinks with >8 g of sugar per 100 mL, moderate tax for 5-8 g, and no tax for <5 g). We estimate the effect of possible industry responses to the levy on obesity, diabetes, and dental caries.

METHODS

We modelled three possible industry responses: reformulation to reduce sugar concentration, an increase of product price, and a change of the market share of high-sugar, mid-sugar, and low-sugar drinks. For each response, we defined a better-case and worse-case health scenario. We developed a comparative risk assessment model to estimate the UK health impact of each scenario on prevalence of obesity and incidence of dental caries and type 2 diabetes. The model combined data for sales and consumption of SSBs, disease incidence and prevalence, price elasticity estimates, and estimates of the association between SSB consumption and disease outcomes. We drew the disease association parameters from a meta-analysis of experimental studies (SSBs and weight change), a meta-analysis of prospective cohort studies (type 2 diabetes), and a prospective cohort study (dental caries).

FINDINGS

The best modelled scenario for health is SSB reformulation, resulting in a reduction of 144 383 (95% uncertainty interval 5102-306 743; 0·9%) of 15 470 813 adults and children with obesity in the UK, 19 094 (6920-32 678; incidence reduction of 31·1 per 100 000 person-years) fewer incident cases of type 2 diabetes per year, and 269 375 (82 211-470 928; incidence reduction of 4·4 per 1000 person-years) fewer decayed, missing, or filled teeth annually. An increase in the price of SSBs in the better-case scenario would result in 81 594 (3588-182 669; 0·5%) fewer adults and children with obesity, 10 861 (3899-18 964; 17·7) fewer incident cases of diabetes per year, and 149 378 (45 231-262 013; 2·4) fewer decayed, missing, or filled teeth annually. Changes to market share to increase the proportion of low-sugar drinks sold in the better-case scenario would result in 91 042 (4289-204 903; 0·6%) fewer adults and children with diabetes, 1528 (4414-21 785; 19·7) fewer incident cases of diabetes per year, and 172 718 (47 919-294 499; 2·8) fewer decayed, missing, or filled teeth annually. The greatest benefit for obesity and oral health would be among individuals aged younger than 18 years, with people aged older than 65 years having the largest absolute decreases in diabetes incidence.

INTERPRETATION

The health impact of the soft drinks levy is dependent on its implementation by industry. Uncertainty exists as to how industry will react and about estimation of health outcomes. Health gains could be maximised by substantial product reformulation, with additional benefits possible if the levy is passed on to purchasers through raising of the price of high-sugar and mid-sugar drinks and activities to increase the market share of low-sugar products.

FUNDING

None.

Impact of the Berkeley Excise Tax on Sugar-Sweetened Beverage Consumption

OBJECTIVES

To evaluate the impact of the excise tax on sugar-sweetened beverage (SSB) consumption in Berkeley, California, which became the first US jurisdiction to implement such a tax ($0.01/oz) in March 2015.

METHODS

We used a repeated cross-sectional design to examine changes in pre- to posttax beverage consumption in low-income neighborhoods in Berkeley versus in the comparison cities of Oakland and San Francisco, California. A beverage frequency questionnaire was interviewer administered to 990 participants before the tax and 1689 after the tax (approximately 8 months after the vote and 4 months after implementation) to examine relative changes in consumption.

RESULTS

Consumption of SSBs decreased 21% in Berkeley and increased 4% in comparison cities (P = .046). Water consumption increased more in Berkeley (+63%) than in comparison cities (+19%; P < .01).

CONCLUSIONS

Berkeley's excise tax reduced SSB consumption in low-income neighborhoods. Evaluating SSB taxes in other cities will improve understanding of their public health benefit and their generalizability.