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

Associations Between Sugar-Sweetened Beverage Taxes and Weight Outcomes Among US Adolescents

Given the recent implementation and preemption of sugar-sweetened beverage taxes across the United States, we aimed to evaluate the associations between sugar-sweetened beverage (SSB) taxes and adolescent weight-related outcomes using data on 364,540 adolescents drawn from 1999 to 2021 district Youth Risk Behavior Surveys. We used difference-in-differences models to assess the associations and the potential mediating roles of SSBs, milk, and 100% fruit juice consumption. We found that a one cent per ounce increase in SSB taxes was associated with a 0.26 lower body mass index (P < .01), and a 2.19 (P < .01) and 1.68 (P < .01) percentage point decrease in the probability of being affected by overweight and obesity, respectively. SSB consumption had a mediating role, as tax increases were associated with a 2.45 (P < .01) percentage point decrease in adolescents' probability of drinking any SSB. Milk and 100% fruit juices likely also played a role, as we found changes in their consumption in response to tax increases.

Evaluation of the Soda Tax on Obesity and Diabetes in California: A Cost-Effectiveness Analysis

Introduction. Consumption of sugar-sweetened beverages (SSBs) contributes to weight gain, obesity, and diabetes. Soda tax has been proposed to reduce consumption of SSBs. What remains unclear is whether the soda tax has an effect on health and health care costs. We evaluated the cost-effectiveness of a 1-cent-per-ounce soda tax on obesity and diabetes in California. Methods. A microsimulation state-transition model was used to evaluate the cost-effectiveness of the soda tax. Health outcomes were measured in quality-adjusted life-years (QALYs). Health care costs were projected from 2015 to 2035. Results. In a simulated cohort of Californian adults, the soda tax policy prevented 2.28 million cases of overweight (95% confidence interval [CI] -0.06 to 6.63) and 0.49 million cases of obesity (95% CI -0.19 to 1.18). From the health care perspective, the incremental cost-effectiveness ratio of the soda tax was $124,839 dollars per QALY (95% CI -1,151,983 to 557,660). From the health care perspective, the soda tax policy was cost-effective 80% of the time in the probabilistic sensitivity analysis using a willingness-to-pay threshold of $100,000 per QALY. Conclusions. The 1-cent-per-ounce soda tax reduced the number of obesity cases, diabetes cases, and related complications. In addition, the soda tax policy implemented in California was cost-effective most of the time.

Highlights

Question: What remains unclear is whether the soda tax has an effect on health and health care costs.Findings: The 1-cent-per-ounce soda tax reduced the number of obesity cases, diabetes, and related complications. In addition, the soda tax policy brought large amounts of revenue.Meaning: This study provides additional evidence regarding the health care costs and cost-effectiveness related to the implementation of a soda tax.

Impacts of sugar and sweetener warning labels on substitution between sugar- and non-sugar-sweetened beverages in a non-hypothetical selection task

BACKGROUND

Front-of-pack (FOP) warning labels have demonstrated effectiveness for reducing sugar-sweetened beverage (SSB) consumption and switching to water. However, an unintended consequence is that they may also increase switching to non-sugar-sweetened beverages (NSSBs). A non-hypothetical experimental study examined the effectiveness of combining sugar and sweetener FOP warning labels to reduce sugary drink consumption and prevent NSSB substitution. The study also examined potential integration with Australia and New Zealand's existing Health Star Rating (HSR) system to determine suitability for local context and other jurisdictions with interpretive labelling schemes already in place.

METHODS

Participants (N = 414) accessed an online convenience store app via an on-campus laptop to select one drink from an array of 10 beverages, on three occasions. Drink options included a variety of SSBs, 100% fruit juice, NSSBs, and water. Following an escalating exposure procedure, drinks were presented (1) without any additional labelling, (2) with warning labels added to sugary drinks or to both sugary drinks and NSSBs (according to allocated condition), then (3) with HSR icons added to all drinks. Participants were informed they would receive a complementary drink, based on their selections, following the completion of a brief questionnaire.

RESULTS

Baseline results indicated that SSBs and water were the most and least popular drink choices, respectively. Placing FOP warning labels on sugary drinks decreased selection of SSBs and increased NSSB and water choices. Water became the most popular individual drink choice in response to warnings on sugary drinks. Placing FOP warning labels on both sugary drinks and NSSBs successfully avoided an increase in NSSB choices, whilst also increasing water selections, but did not significantly decrease selection of SSBs until HSR ratings were added. The incorporation of HSR icons consolidated warning label effects on NSSB and water selection across both conditions.

CONCLUSIONS

Results demonstrate the potential of FOP sugar warning labels for addressing beverage consumption behaviours. The incorporation of sweetener warning labels may successfully avoid substitution towards NSSBs, whilst still promoting water choices, but may also dilute the impact of the sugary drinks warning labels. Warning labels were complementary to existing interpretive FOP labels.

Associations of the Philadelphia sweetened beverage tax with changes in adult body weight: an interrupted time series analysis

Background

Sweetened beverage taxes are associated with large decreases in sugar-sweetened beverage sales, but their effects on weight outcomes are unclear. We examined associations of the 2017 Philadelphia beverage tax with changes in adult weight outcomes.

Methods

We obtained electronic health record data on adults 18-65 years old in Philadelphia (intervention) and other areas of Pennsylvania and New Jersey (control) from 2014 to 2019. Controlled interrupted time series models compared post-tax changes in trends of body mass index (BMI, primary outcome) and obesity prevalence (secondary outcome). A panel sample comprised 175,675 adults with at least one BMI measure in both the pre-tax (2014-2016) and post-tax (2017-2019) periods. A cross-sectional sample comprised 587,121 adults with at least one BMI measure from 2014 to 2019.

Findings

Before tax implementation, Philadelphia panel patients had a mean BMI of 30.4 kg/m2 and an obesity prevalence of 44.5%. After implementation, in the panel sample, there was a -0.03 kg/m2 (95% CI: -0.07, 0.02) per quarter decrease in BMI vs. control, implying a -0.32 kg/m2 (-0.85, 0.20) change at the end of the 3-year study period. In the cross-sectional sample, there was a -0.05 kg/m2 (95% CI: -0.09, -0.01) per quarter decrease in BMI vs. control, implying a -0.60 kg/m2 (-1.04, -0.16) change at the end of the study period. Results for obesity prevalence were consistent with the BMI results.

Interpretation

There was some limited evidence of a decrease in BMI and obesity prevalence in Philadelphia 3 years after beverage tax implementation. Replication of these results is needed.

Funding

National Institutes of Health.

Effectiveness of implemented global dietary interventions: a scoping review of fiscal policies

BACKGROUND

Although the World Health Organisation (WHO) has proposed the use of fiscal policies to mitigate consumption externalities such as overweight and obesity-related diseases, very little is known about the impacts of the different types and framing of national and/or regional fiscal policies that have been implemented over the years. There is the need to provide up-to-date evidence on the impact of fiscal policies that have been enacted and implemented across the globe.

METHODS

We conducted a scoping review of all implemented government fiscal policies in the food and drinks sector to identify the different types of fiscal policies that exist and the scope of their impact on consumers as well as the food environment. Electronic databases such as the Web of Science and Google Scholar were used to search for appropriate literature on the topic. A total of 4,191 articles were retrieved and 127 were synthesized and charted for emerging themes.

RESULTS

The results from this review were synthesized in MS Excel following Arksey & O'Malley (2005). Emerging themes were identified across different countries/settings for synthesis. The results confirms that fiscal policies improve consumers' health; increase the prices of foods that are high in fats, sugar, and salt; increase government revenue; and shift consumption and purchases towards healthier and untaxed foods.

CONCLUSION

Governments already have the optimum tool required to effect changes in consumer behaviour and the food environment.

Exploring the sugar-sweetened beverage tax (SSBT) pass-through rate in the Irish hospitality sector

BACKGROUND

The World Health Organization (WHO) supports the use of Sugar-Sweetened Beverage Taxes (SSBTs) as a fiscal lever to help reduce sugar consumption and tackle obesity. Obesity is associated with a range of adverse health outcomes. In response to increasing levels of obesity in Ireland, an SSBT was introduced in 2018. Previous research in Ireland has noted that the pass-through rate of the SSBT in retail (off-site consumption) settings was poor. However, to date, no research has examined the SSBT pass-through rate in hospitality (on-site consumption) venues in Ireland.

METHODS

This research examines the SSBT pass-through rate on Coca-Cola versus diet versions of Coca-Cola in a convenience sample of 100 hospitality venues in two provincial Irish cities.

RESULTS

Wilcoxon signed rank test analysis revealed that regular Coca-Cola was significantly more expensive compared to the price charged for diet versions of Coca-Cola. However, in 85.6% of cases the same price was charged for both full-sugar and sugar-free drinks. The mean pass-through rate of the SSBT was 33.8%.

CONCLUSION

The effective functioning of the SSBT is premised on persistent price differences between soft drink prices based on sugar content. However, this is barely evident in the hospitality sector in Ireland. A number of recommendations are suggested, including both increasing the SSBT, and increasing it annually in line with inflation.

A scoping review of policies related to reducing energy drink consumption in children

BACKGROUND

Frequent consumption of Energy Drinks (EDs) is associated with numerous health problems, including overweight and obesity, particularly among children and adolescents. The extensive promotion, wide accessibility, and relatively low cost of EDs have significantly increased their popularity among this age group. This paper examines policies/programs that, directly and indirectly, contribute to reducing ED consumption in children and adolescents and shares global experiences to help policymakers adopt evidence-based policies.

METHODS

A systematic search was performed using PubMed, Scopus, and Web of Science databases from January 2000 to June 2024, along with reputable international organization websites, to find literature on policies aimed at reducing ED consumption among children and adolescents. All sources meeting the inclusion criteria were included without restrictions. Titles and abstracts were initially screened, followed by a full-text review. After evaluating the quality of the selected studies, data were extracted and, along with information from the selected documents, compiled into a table, detailing the country, policy type, and the effectiveness and weaknesses of each policy.

RESULTS

Out of 12166 reviewed studies and documents, 84 studies and 70 documents met the inclusion criteria. 73 countries and territories have implemented policies like taxation, sales bans, school bans, labeling, and marketing restrictions on EDs. Most employ fiscal measures, reducing consumption despite enforcement challenges. Labeling, access restrictions, and marketing bans are common but face issues like black markets.

CONCLUSION

This scoping review outlines diverse strategies adopted by countries to reduce ED consumption among children and teenagers, such as taxation, school bans, sales restrictions, and labeling requirements. While heightened awareness of ED harms has reinforced policy efforts, many Asian and African nations lack such measures, some policies remain outdated for over a decade, and existing policies face several challenges. These challenges encompass industry resistance, governmental disagreements, public opposition, economic considerations, and the intricacies of policy design. Considering this, countries should tailor policies to their cultural and social contexts, taking into account each policy's strengths and weaknesses to avoid loopholes. Inter-sectoral cooperation, ongoing policy monitoring, updates, and public education campaigns are essential to raise awareness and ensure effective implementation.

Temporal trends of carbonated soft-drink consumption among adolescents aged 12-15 years from eighteen countries in Africa, Asia and the Americas

Carbonated soft-drink consumption is detrimental to multiple facets of adolescent health. However, little is known about temporal trends in carbonated soft-drink consumption among adolescents, particularly in non-Western countries. Therefore, we aimed to examine this trend in representative samples of school-going adolescents from eighteen countries in Africa, Asia and the Americas. Cross-sectional data from the Global School-based Student Health Survey 2009-2017 were analysed. Carbonated soft-drink consumption referred to drinking carbonated soft-drinks at least once per day in the past 30 d. The prevalence of carbonated soft-drink consumption was calculated for each survey, and crude linear trends were assessed by linear regression models. Data on 74 055 students aged 12-15 years were analysed (mean age 13·9 (sd 1·0) years; 49·2 % boys). The overall mean prevalence of carbonated soft-drink consumption was 42·1 %. Of the eighteen countries included in the study, significant decreasing, increasing and stable trends of carbonated soft-drink consumption were observed in seven, two and nine countries, respectively. The most drastic decrease was observed in Kuwait between 2011 (74·4 %) and 2015 (51·7 %). Even in countries with significant decreasing trends, the decrease was rather modest, while some countries with stable trends had very high prevalence across time (e.g. Suriname 80·5 % in 2009 and 79·4 % in 2016). The prevalence of carbonated soft-drink consumption was high in all countries included in the present analysis, despite decreasing trends being observed in some. Public health initiatives to reduce the consumption of carbonated soft-drink consumption among adolescents are urgently required.

A Narrative Review of Public Health Interventions for Childhood Obesity

PURPOSE OF REVIEW

Public health interventions that intervene on macrolevel systems hold the promise of reducing childhood obesity at the population level through prevention. The purpose of this review is to highlight some of the recent and best scientific evidence related to public health interventions for the prevention of childhood obesity. We provide a narrative review of scientific evidence for six categories of public health interventions and their impact on childhood obesity: federal nutrition assistance programs, programs implemented in early care and education centers, interventions to support healthy nutrition and physical activity in schools, community-based programs and policies, labeling policies and marketing to children, and taxes on sugar sweetened beverages (SSB).

RECENT FINDINGS

Federal nutrition assistance programs have the strongest evidence to support reduction in childhood obesity and serve populations with the highest prevalence of childhood obesity. Other interventions including SSB taxes, community-wide interventions, and interventions at schools and early care and education centers also show significant improvements in child weight status. Overall public health interventions have strong evidence to support widespread implementation in service of reducing childhood obesity rates at the population level. To effectively address the recalcitrant childhood obesity epidemic, multi-pronged solutions are needed. The current evidence for public health obesity interventions is consistent with the paradigm that recognizes the importance of macrolevel systems influences on childhood obesity: interventions that are most effective intervene at macrolevels.

Leveraging Multiyear, Geospatial Social Media Data for Health Policy Evaluations: Lessons From the Philadelphia Beverage Tax

CONTEXT

Public reactions to health policies are vital to understand policy sustainability and impact but have been elusively difficult to dynamically measure. The 2021 launch of the Twitter Academic Application Programming Interface (API), allowing for historical tweet analyses, represents a potentially powerful tool for complex, comprehensive policy analyses.

OBJECTIVE

Using the Philadelphia Beverage Tax (implemented January 2017) as a case study, this research extracted longitudinal and geographic changes in sentiments, and key influencers in policy-related conversations.

DESIGN

The Twitter API was used to retrieve all publicly available tweets related to the Tax between 2016 and 2019.

SETTING

Twitter.

PARTICIPANTS

Users who posted publicly available tweets related to the Philadelphia Beverage Tax (PBT).

MAIN OUTCOME

Tweet content, frequency, sentiment, and user-related information.

MEASURES

Tweet content, authors, engagement, and location were analyzed in parallel to key PBT events. Published emotional lexicons were used for sentiment analyses.

RESULTS

A total of 45 891 tweets were retrieved (1311 with geolocation data). Changes in the tweet volume and sentiment were strongly driven by Tax-related litigation. While anger and fear increased in the months prior to the policy's implementation, they progressively decreased after its implementation; trust displayed an inverse trend. The 50 tweeters with the highest positive engagement included media outlets (n = 24), displaying particularly high tweet volume/engagement, and public personalities (n = 10), displaying the greatest polarization in tweet sentiment. Most geo-located tweets, reflecting 321 unique locations, were from the Philadelphia region (55.2%). Sentiment and positive engagement varied, although concentrations of negative sentiments were observed in some Philadelphia suburbs.

CONCLUSIONS

Findings highlighted how longitudinal Twitter data can be leveraged to deconstruct specific, dynamic insights on public policy reactions and information dissemination to inform better policy implementation and evaluation (eg, anticipating catalysts for both heightened public interest and geographic, sentiment changes in policy conversations). This study provides policymakers a blueprint to conduct similar cost and time efficient yet dynamic and multifaceted health policy evaluations.

Impact of soda tax on beverage price, sale, purchase, and consumption in the US: a systematic review and meta-analysis of natural experiments

Background

As a primary source of added sugars in the US diet, sugar-sweetened beverage (SSB) consumption is presumed to contribute to obesity prevalence and poor oral health. We systematically synthesized and quantified evidence from US-based natural experiments concerning the impact of SSB taxes on beverage prices, sales, purchases, and consumption.

Methods

A keyword and reference search was performed in PubMed, Web of Science, Cochrane Library, Scopus, and EconLit from the inception of an electronic bibliographic database to Oct 31, 2022. Meta-analysis was conducted to estimate the pooled effect of soda taxes on SSB consumption, prices, passthrough rate, and purchases.

Results

Twenty-six natural experiments, all adopting a difference-in-differences approach, were included. Studies assessed soda taxes in Berkeley, Oakland, and San Francisco in California, Philadelphia in Pennsylvania, Boulder in Colorado, Seattle in Washington, and Cook County in Illinois. Tax rates ranged from 1 to 2 ¢/oz. The imposition of the soda tax was associated with a 1.06 ¢/oz. (95% confidence interval [CI] = 0.90, 1.22) increase in SSB prices and a 27.3% (95% CI = 19.3, 35.4%) decrease in SSB purchases. The soda tax passthrough rate was 79.7% (95% CI = 65.8, 93.6%). A 1 ¢/oz. increase in soda tax rate was associated with increased prices of SSBs by 0.84 ¢/oz (95% CI = 0.33, 1.35).

Conclusion

Soda taxes could be effective policy leverage to nudge people toward purchasing and consuming fewer SSBs. Future research should examine evidence-based classifications of SSBs, targeted use of revenues generated by taxes to reduce health and income disparities, and the feasibility of redesigning the soda tax to improve efficiency.

Evaluating the relative impact of multiple healthy food choice interventions on choice process variables and choices

Fiscal tools-taxes and/or subsidies-are increasingly used to address diet-related health problems. However, some studies have found that these tools are markedly more effective if attention is drawn to the tax or subsidy, suggesting that the price change alone may go unnoticed in the complex food environments that consumers face. Interventions that prompt individuals to consider health during choice show promise for promoting healthy food choices in both simple laboratory settings and complex, real-world markets. In this pre-registered study, I examine the impact of dietary fiber health prompts and/or dietary fiber subsidies on the per-serving fiber content of foods chosen, the documented set of products considered, and (self-reported) nutrition information use by participants in an online supermarket setting. Participants were randomized to one of four conditions: 1) control, 2) subsidy, 3) fiber prompt, and 4) fiber prompt + subsidy. Results show that both the prompt and prompt + subsidy conditions significantly increase fiber content of foods chosen (with the latter having a larger effect). While all three interventions influence the probability of using nutrition information during food choice and affect the set of products that respondents consider relative to the control condition, the effects were larger for the prompt and prompt + subsidy conditions. A multiple mediation analysis illustrates that both direct and indirect (through the set of products considered and the use of fiber information during choice) pathways lead to the significant overall increase in fiber content of selected foods.

Effect of sugar-sweetened beverage taxation on sugars intake and dental caries: an umbrella review of a global perspective

BACKGROUND

As part of the Global Strategy on Oral health, the World Health Organization (WHO) is exploring cost-effective interventions for oral health, including taxation on sugar-sweetened beverages (SSBs). To inform this process, this umbrella review aimed to identify the best available estimates pertaining to the impact of SSB taxation on the reduction of sugars intake, and the sugars-caries dose-response, such that estimates of the impact of SSB taxation on averting dental caries in both high (HIC) and low and middle (LMIC) countries be available.

METHODS

The questions addressed were: (1) what are the effects of SSB taxation on consumption of SSBs and (2) sugars? (3) What is the effect on caries of decreasing sugars? and (4) what is the likely impact of a 20% volumetric SSB tax on the number of active caries prevented over 10 years? Data sources included PubMed, Embase, Web of Science, Scopus, CINAHL, Dentistry and Oral Sciences Source, Cochrane Library, Joanna Briggs Institute (JBI) Systematic Review Register, and PROSPERO. The review was conducted with reference to JBI guidelines. The quality of included systematic reviews was assessed using AMSTAR to identify best evidence.

RESULTS

From 419 systematic reviews identified for questions 1 & 2, and 103 for question 3, 48 (Questions 1 & 2) and 21 (Question 3) underwent full text screening, yielding 14 and five included reviews respectively. Best available data indicated a 10% tax would reduce SSB intake by 10.0% (95% CI: -5.0, 14.7%) in HIC and by 9% (range -6.0 to 12.0%) in LMIC, and that a 20% tax would reduce free sugars intake on average by 4.0 g/d in LMIC and 4.4 g/d in HIC. Based on best available dose response data, this could reduce the number of teeth with caries per adults (HIC and LMIC) by 0.03 and caries occurrence in children by 2.7% (LMIC) and 2.9% (HIC), over a 10-year period.

CONCLUSION

Best available data suggest a 20% volumetric SSB tax would have a modest impact on prevalence and severity of dental caries in both HIC and LMIC.

Sixteen-year trends in adolescent consumption of sugar-sweetened soda in six European countries with a soda tax and comparison countries: a repeated cross-sectional survey analysis

OBJECTIVE

To examine changes in the proportions of daily, weekly and occasional consumers of sugar-sweetened soda in six European countries that introduced/updated a tax between 2001-2002 and 2017-2018 and in neighbouring comparison countries (without a tax).

DESIGN

Repeated cross-sectional surveys.

SETTING

Health Behaviour in School-aged Children study, spanning five survey years (school years 2001-2002 to 2017-2018).

PARTICIPANTS

Nationally representative samples of 13-year- and 15-year-old adolescents (n 236 623, 51·0 % girls).

RESULTS

Tax sizes (€0·02/l to €0·22/l) and pre-tax soda consumption were heterogeneous across countries. Prevalence of daily soda consumption reduced in the survey year following tax implementation in Latvia (from 17·9 to 11·9 %, P = 0·01), Finland (4·2 to 2·5 %, P = 0·001), Belgium (35·1 to 27·8 %, P < 0·001) and Portugal (17·4 to 14·9 %, P = 0·02), but not in Hungary (29·8 to 31·3 %, P = 0·47) or France (29·4 to 28·2 %, P = 0·27). However, reductions were similar (Finland) or smaller (Belgium, Portugal) than those in the comparison countries, except in Latvia where the reduction was larger (Pinteraction < 0·001). Prevalence of weekly soda consumption remained stable (Finland, Hungary and France) or increased (Latvia, Belgium); only Portugal experienced a decline (P < 0·001), which was larger than in the comparison country (Pinteraction < 0·001). Prevalence of occasional soda consumption (<1x/week) did not rise after implementation of the tax in Latvia, Finland, Hungary, France or Belgium, or the rise was similar to the comparison country in Portugal (Pinteraction = 0·15).

CONCLUSIONS

Countries with a soda tax did not experience larger beneficial changes in post-tax adolescent consumption frequency of soda than comparison countries. Further studies, with different taxation types, are needed in the adolescent population.

Do sugar-sweetened beverage taxes improve public health for high school aged adolescents?

Sugar-sweetened beverage taxes have become an increasingly popular policy to combat the worldwide obesity epidemic, but relatively little is known about their impact on health outcomes, particularly among high school aged students. In this paper, I use public-use data from the Youth Risk Behavioral Surveillance System to determine whether high school students living in three of the American cities which have implemented Sugar-sweetened beverage taxes have experienced public health improvements. Using an event-study design that compares outcomes in treated districts to a group of similar control districts, I find reductions in soda consumption in Philadelphia and average body mass index in Philadelphia, San Francisco and Oakland, with suggestive evidence that the improvements are concentrated among female and non-white respondents in both cases.

The role of taxation measures in the management of harmful products, services, and practices in Iran: a qualitative study

BACKGROUND AND AIM

Levying a tax on harmful products, services, and practices can affect consumer choices, effectively preventing diseases and reducing health care costs. The goal of this study was to investigate the role of taxation as a powerful financial tool in the management of harmful products, services, and practices to maintain and improve public health and preserve the financial sustainability of the health care system.

MATERIALS AND METHODS

This qualitative study was conducted in 2020-2021. In order to collect information for this study, semi-structured interviews were conducted. Using purposive and snowball sampling methods, 38 managers, policymakers, economists, and key experts were interviewed. Data were analyzed using the content analysis method. The transcribed interviews were further imported into MAXQDA for classification, and relevant codes were extracted.

FINDINGS

In this study, 6 main themes and 19 subthemes were labeled. The main themes included 1) objectives, effects, and requirements of the taxation of harmful products, services, and practices, 2) definition, instances, elasticity, and grading of harmful products, services, and practices, 3) Problems in controlling harmful products, services, and practices, 4) controlling harmful products, services, and practices, 5) traffic violations and accidents, and social harms, and 6) tax revenue use and the share of health care. The effects of taxing harmful products include reduced access to these products, reduced demand for harmful products, and the promotion of public health.

CONCLUSION

Harmful products, services, and practices have major health and financial implications for individuals, families, and society. To improve public health, the demand for these products and services can be controlled through taxation measures to push consumers toward less harmful alternatives.

The effect of soda taxes beyond beverages in Philadelphia

Soda taxes are implemented in several cities across the United States (US) with the aim of reducing sugar intake from sugar sweetened beverages (SSBs). Sugar is linked to obesity and to higher risk of diabetes and cardiovascular conditions. Sodas are targeted with these taxes since they are the main source of sugar for consumers in the US. In presence of potential substitutes, the policy can be undermined by consumers changing their sources of sugar. We examine the heterogeneous effects of the 2017 Philadelphia soda tax on purchases of other items containing sugar. We present an empirical evaluation focusing on the potential substitution toward additional sugary foods in Philadelphia and counties bordering Philadelphia. We find an increase in sugar from purchases of sweetened foods of about 4.3% following the introduction of the tax in Philadelphia and of 3.7% in the neighboring localities. The substitution to sugary foods in Philadelphia offsets 19% of the decrease of sugar from SSBs. Additionally, we find that the substitution offsets 37% of the decrease of sugar from SSBs when including counties bordering Philadelphia. These results suggest that while SSB taxes might be effective at lowering consumption of SSBs, substitution patterns may limit the effectiveness of the tax to reduce overall sugar intake.

Sweetened beverage taxes: Economic benefits and costs according to household income

Taxing sweetened beverages has emerged as an important and effective policy for addressing their overconsumption. However, taxes may place a greater economic burden on people with lower incomes. We assess the degree to which sweetened beverage taxes in three large US cities placed an inequitable burden on populations with lower incomes by assessing spending on beverage taxes by income after taxes have been implemented, as well as any net transfer of funds towards lower income populations once allocation of tax revenue is considered. We find that while lower income populations pay a higher percentage of their income in beverage taxes, there is no difference in absolute spending on beverage taxes per capita, and that there is a sizable net transfer of funds towards programs targeting lower income populations. Thus, when considering both population-level taxes paid and sufficiently targeted allocations of tax revenues, a sweetened beverage tax may have characteristics of an equitable public policy.

Outcomes Following Taxation of Sugar-Sweetened Beverages: A Systematic Review and Meta-analysis

Importance

More than 45 countries and several local jurisdictions have implemented sugar-sweetened beverage (SSB) taxes to improve nutrition and population health, and evidence on their outcomes to date is essential to inform policy discussions. Responding to this need, the World Health Organization commissioned a systematic literature review on the outcomes of fiscal policies, including SSB taxes.

Objective

To assess the associations of implemented SSB taxes with prices, sales, consumption, diet, body weight, product changes, unintended consequences, health, and pregnancy outcomes.

Data Sources

Searches of 8 bibliographic databases (Business Source Complete, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL, EconLit, PsycINFO, PubMed, and Scopus) were performed from database inception through June 1, 2020, with no language or setting restrictions. Grey literature was assessed using 14 sources and government websites.

Study Selection

The review included primary studies of implemented SSB taxes.

Data Extraction and Synthesis

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. For prices, sales and consumption, results were meta-analyzed using a 3-level random-effects model. Study quality was assessed at the outcome level.

Main Outcomes and Measures

Tax pass-through rate for prices, percentage reduction in SSB demand, and price elasticity of demand for sales and consumption. Heterogeneity was assessed using τ2 and the I2 statistic.

Results

A total of 86 articles were eligible, with 62 studies contributing to the meta-analysis. The overall tax pass-through rate was 82% (95% CI, 66% to 98%; P < .001, I2 = 99%), suggesting tax undershifting. The demand for SSBs was highly sensitive to tax-induced price increases, with the price elasticity of demand of -1.59 (95% CI, -2.11 to -1.08; P < .001; I2 = 100%) and a mean reduction in SSB sales of 15% (95% CI, -20% to -9%; P < .001; I2 = 100%). There was no evidence of substitution to untaxed beverages, and changes in SSB consumption were not significant. The narrative synthesis found reformulation and reduced sugar content of taxed beverages for tiered taxes, cross-border shopping in most studies of local-level taxes, and no negative changes in employment. Data on the heterogeneity of SSB tax outcomes across subpopulations were limited.

Conclusions and Relevance

In this systematic review and meta-analysis of implemented SSB taxes worldwide, SSB taxes were associated with higher prices and lower sales of taxed beverages.

The effect of beverage taxes on youth consumption and body mass index: Evidence from Mauritius

Taxes on sugar-sweetened beverages (SSBs) are relatively new and there is limited evidence about their impact on SSB consumption or body mass index (BMI) (as opposed to prices, purchases, or sales), their impact on youth (as opposed to adults), or their impact in non-Western nations. This paper adds to the evidence across all these dimensions by estimating the effect of an SSB tax on SSB consumption and the BMI of youth in Mauritius, an island nation in the Indian Ocean, which we compare to Maldives, another island nation which did not implement an SSB tax during the time of our data. Results of difference-in-differences models indicate that the tax in Mauritius had no detectable impact on the consumption of SSBs or the BMI of the pooled sample of boys and girls. However, models estimated separately by sex indicate that the probability that boys consumed SSBs fell by 9.4 percentage points (11%). These are among the first estimates of the effect of SSB taxes on youth consumption and contribute to the limited evidence on the impact of SSB taxes on weight, and in non-Western countries.

Evaluation of Seattle's sweetened beverage tax on tax support and perceived economic and health impacts

It is important to understand whether the publics' attitudes towards sugary beverage taxes (SBT) change after tax implementation to ensure the long-term success of tax policies. Seattle's SBT went into effect on January 1, 2018. We administered a mixed-mode survey to adults in Seattle and comparison areas, pre- and 2-years post-tax, to evaluate the impact of the SBT on 1) tax support and 2) perceived tax impacts (N = 2,933). Using a difference-in-differences approach, we employed adjusted income-stratified modified Poisson models to test the impacts of the tax on net changes in attitudes in Seattle versus the comparison areas, pre- to post-tax. Among lower-income individuals in Seattle, support for the tax increased by 14% (PRDD: 1.14; 95% CI: 1.08, 1.21) and there was a 20% net-increase in the perception that the SBT would positively affect the economy (PRDD: 1.20; 95% CI: 1.05, 1.39), compared to changes in the comparison areas. Among higher-income individuals in Seattle, support for the tax was not different (PRDD: 0.93; 95% CI: 0.70, 1.22) pre- to post-tax, but there was a net-increase in the perception that the tax would have negative effects on small businesses (PRDD: 1.44; 95% CI: 1.03, 2.00) and family finances (PRDD: 1.86; 95% CI: 1.09, 3.19). After living with the tax for 2-years, support for the tax increased among lower-income individuals in Seattle. Tax support was high and unchanged among higher-income individuals, but overall attitudes became more negative. Policy makers should consider investing in ongoing campaigns that explain the benefits of SSB taxes and revenues.

Beverage Availability and Price: Variations by Neighborhood Poverty Level in New York City

Objective

To describe the variability in the availability and price of sugary drinks, low-calorie drinks, and water/seltzer across high- and low-poverty census tracts in the five boroughs of New York City (NYC).

Design

Cross-sectional study. Our primary analysis compared the overall sample of beverages. Secondary analyses included tests for differences in the availability of beverage categories by neighborhood poverty level.

Setting

We collected data from 106 stores (31 supermarkets, 29 convenience stores, 29 pharmacies, 9 Targets, and 8 Dollar Trees) in NYC. Fifty-four stores were located in high-poverty census tracts and 52 were located in low-poverty census tracts.

Results

The mean Price per 0.03-liter of sugary drinks across the sample was $0.08, which was significantly higher than the price of low-calorie drinks ($0.07, p=0.01) but not different from water/seltzer ($0.08, p=0.65). Sugary drinks and water/seltzer were available in 91% of retailers, and low-calorie drinks were available in 87% of retailers. There was no statistical difference in availability of sugary drinks compared with low-calorie drinks or water/seltzer overall or within high- or low-poverty census tracts. Analyzed by store type, the mean price per ounce of sugary drinks differed significantly from water/seltzer at convenience stores, pharmacies, and Target stores (bodegas: $0.08 vs. $0.09, p=0.03; pharmacies: $0.11 vs. $0.08, p=0.02; Target stores: $0.07 vs. $0.09, p=0.01).

Conclusions

Sugary drinks were available in most food retail settings in NYC, with little variation by census tract poverty level. Interventions that raise the price of sugary drinks to make healthier alternatives, such as water, the more affordable option should be considered.

Purchases of Nontaxed Foods, Beverages, and Alcohol in a Longitudinal Cohort After Implementation of the Philadelphia Beverage Tax

BACKGROUND

Evidence suggests that sweetened beverage taxes reduce taxed beverage purchases, but few studies have used individual-level data to assess whether these taxes affect purchases of nontaxed foods, beverages, and alcohol. Additionally, research has not examined whether sweetened beverage taxes influence restaurant purchases.

OBJECTIVES

We assessed changes in individuals' purchases of taxed beverage types; low-calorie/low-added-sugar nontaxed beverages; high-calorie/high-added-sugar nontaxed beverages, foods, and alcohol; and beverages from restaurants following implementation of the 1.5 cent-per-ounce Philadelphia sweetened beverage tax.

METHODS

A longitudinal cohort of adult sugar-sweetened beverage consumers in Philadelphia (n = 306; 67% female; mean age: 43.9 years) and Baltimore (n = 297; comparison city without a beverage tax; 58% female; mean age: 41.7 years) submitted all food and beverage receipts during 2-week periods at baseline and at 3, 6, and 12 months posttax. Difference-in-differences analyses compared changes in purchases from pre- to posttax in Philadelphia to changes in Baltimore.

RESULTS

Purchases of taxed juice drinks [ratio of incidence rate ratios (RIRR) = 0.62; 95% CI, 0.42-0.91], but not other taxed beverage types, decreased in Philadelphia compared to Baltimore following the tax. Analyses did not find changes in purchases of low-calorie/low-added-sugar nontaxed beverages, such as water or milk. Additionally, analyses did not find increases in purchases of most high-calorie/high-added-sugar nontaxed products, including alcohol, juice, candy, sweet snacks, salty snacks, and desserts. Purchases of beverage concentrates increased in Philadelphia (RIRR = 2.22; 95% CI, 1.39-3.54).

CONCLUSIONS

In this difference-in-differences analysis, the Philadelphia beverage tax was associated with reduced purchases of taxed juice drinks. Purchases of beverage concentrates increased after the tax, but no increases were observed for other high-calorie/high-added-sugar nontaxed foods, beverages, or alcohol.

Analysis of Public Testimony About Philadelphia's Sweetened Beverage Tax

INTRODUCTION

Although interest in beverage taxes has increased in recent years, industry opposition and other challenges have limited their spread in the U.S. Because beverage tax proposals are often unsuccessful, there is limited empirical evidence to inform advocacy efforts. Philadelphia's 1.5 cent-per-ounce tax on sweetened beverages provides an opportunity to understand how public testimony for and against the tax was framed in a city that ultimately passed the policy.

METHODS

A content analysis of all public testimony about the beverage tax presented to the Philadelphia City Council in 2016 was conducted. Testimonies were coded for policy stance (protax or antitax), speaker type, and specific protax or antitax arguments. Quantitative data were analyzed in 2018-2019 using chi-square tests.

RESULTS

A total of 177 unique testimonies were identified, which included 40 protax arguments (grouped into 11 themes) and 31 antitax arguments (grouped into 10 themes). Most testimonies were delivered orally, and most speakers argued in favor of the tax (58%). Among tax supporters, funding early childhood education was the most common argument (71%), whereas tax opponents most frequently argued that sugar-sweetened beverages were the wrong target for the tax (50%).

CONCLUSIONS

This analysis of public testimony revealed that protax advocacy efforts highlighted the revenue benefits for early childhood education and community infrastructure rather than the tax's potential to reduce sweetened beverage consumption and improve health. By contrast, antitax arguments centered on the unfairness of targeting a single industry, potential negative economic impacts, and the perceived lack of evidence that the tax would influence consumer behavior.

Sugar-Sweetened Beverage Pricing Policies: Simulation of Minimum Price Laws and Taxes in New York City

INTRODUCTION

Minimum price laws, which set a price below which a product cannot be sold, are a promising but understudied strategy for reducing the consumption of sugar-sweetened beverages. New York City has implemented a minimum price law for tobacco products and could consider this policy for sugar-sweetened beverages. This study projects the impacts of a sugar-sweetened beverage minimum price law among New York City adults, with effects of a sugar-sweetened beverage excise tax examined for comparison.

METHODS

In 2020-2021, a microsimulation model of dietary behaviors and body weight was developed using population-based survey data, research on responsiveness to and avoidance of price increases, and a validated weight change model. Analyses applied the model to simulate the impacts of implementing a minimum price law (8 or 10 cents/ounce price floors) or an excise tax (1 or 2 cents/ounce tax rates) on diet and body weight among New York City adults for more than 5 years. Sensitivity analyses varied assumptions about price responsiveness, caloric compensation, and avoidance.

RESULTS

A sugar-sweetened beverage minimum price law with an 8 cents/ounce floor would reduce average sugar-sweetened beverage intake by 16.5 calories/day (95% uncertainty interval= -17.2, -15.8) and obesity prevalence by 0.86 percentage points (95% uncertainty interval= -1.03, -0.69). Benefits were similar for a minimum price law with a 10 cents/ounce floor and for 1 and 2 cents/ounce taxes (range of obesity reductions: -0.84 to -1.24 percentage points). Benefits persisted in sensitivity analyses and were larger for Black and Hispanic than for White and Asian adults and for adults with lower than for those with higher income.

CONCLUSIONS

Excise taxes and minimum price laws for sugar-sweetened beverages could both reduce New York City adults' sugar-sweetened beverage consumption and obesity prevalence and narrow sociodemographic disparities in obesity.

Alcohol outlets and alcohol consumption in changing environments: prevalence and changes over time

BACKGROUND

To examine whether changes in density of neighborhood alcohol outlets affected changes in alcohol consumption 1-year after regulatory changes increased alcohol availability.

METHODS

Person-level data came from a population-based cohort (aged 21-64) residing in/around the Philadelphia, Pennsylvania metropolitan area (2016-2018, N = 772). Fifty-eight percent lived in a state that began implementing new regulations (Pennsylvania) and the remainder lived in states without major regulatory changes (Delaware and New Jersey). Alcohol consumption was assessed as days per week (pw), drinks pw, high consumption (≥8 drinks pw), and binge drinking. Availability of off-premise alcohol outlets was assessed using 1-mile density and distance. Regression models adjusted for age, gender, race/ethnicity, income, education, health status, state and population density.

RESULTS

Cross-sectional analyses found that higher outlet density was associated with more alcohol consumption (days, drinks, high consumption; all p < 0.03) and residing farther from an outlet was associated with less alcohol consumption (days and drinks; all p < 0.04). In longitudinal analyses, relative to no change in outlets, exposure to more outlets was associated with 64% higher odds of drinking on more days pw (p < 0.049) and 55% higher odds of consuming more drinks pw (p < 0.081). However, the longitudinal association between changes in outlets and changes in consumption did not differ for residents in Pennsylvania vs. nearby states. In cross-sectional and longitudinal analyses, outlets were not related to binge drinking.

CONCLUSION

Off-premise outlets were associated with alcohol consumption consistently in cross-sectional analysis and in some longitudinal analyses. Results can inform future studies that wish to evaluate longer-term changes in increased alcohol availability and effects on consumption.

Impact of the Seattle Sweetened Beverage Tax on substitution to alcoholic beverages

INTRODUCTION

Taxes are increasingly used as a policy tool aimed at reducing consumption of sugar-sweetened beverages (SSBs), given their association with adverse health outcomes including type 2 diabetes, obesity and cardiovascular disease. However, a potential unintended consequence of such a policy could be that the tax induces substitution to alcoholic beverages. The purpose of this study is to examine the impact of the $0.0175 per ounce Seattle, Washington, Sweetened Beverage Tax (SBT) on volume sold of alcoholic beverages.

METHODS

A difference-in-differences estimation approach was used drawing on universal product code-level food store scanner data on beer (N = 1059) and wine (N = 2655) products one-year pre-tax (February-November, 2017) and one and two-years post-tax (February-November, 2018 and 2019) with Portland, Oregon, as the comparison site.

RESULTS

At two-years post-tax implementation, volume sold of beer in Seattle relative to Portland increased by 7% (ratio of incidence rate ratios [RIRR] = 1.07, 95% CI:1.00,1.15), whereas volume sold of wine decreased by 3% (RIRR = 0.97, 95% CI:0.95,1.00). Overall alcohol (both beer and wine) volume sold increased in Seattle compared to Portland by 4% (RIRR = 1.04, 95% CI:1.01,1.07) at one-year post-tax and by 5% (RIRR = 1.05, 95% CI:1.00,1.10) at two-years post-tax. The implied SSB cross-price elasticities of demand for beer and wine, respectively, were calculated to be 0.35 and -0.15.

CONCLUSIONS

There was evidence of substitution to beer following the implementation of the Seattle SSB tax. Continued monitoring of potential unintended outcomes related to the implementation of SSB taxes is needed in future tax evaluations.

Bittersweet: How prices of sugar-rich foods contribute to the diet-related disease epidemic in Mexico

I provide new evidence on how price changes of nutritionally similar foods, such as those rich in sugar or fats, change obesity and diet-related diseases in the context of Mexico between 1996-2010. I merge a bar-code level price dataset with product-specific nutritional composition to two datasets with health outcomes: state-level administrative and nationally representative individual-level panel data. Exploiting within-city variation in prices using fixed effects models, I show that decreased prices of sugar-rich foods increase obesity, type 2 diabetes, and hypertension prevalence; yet the prices of foods rich in other nutrients do not. Health responses to price changes are the largest for those abdominally obese or at the highest risk for chronic disease. The association between prices of sugary foods and chronic disease is meaningful: I estimate that in Mexico, price reductions of sugary foods explain roughly 15 percent of the rise in obesity and diabetes during the 15-year study period.

Association of a Sweetened Beverage Tax With Soda Consumption in High School Students

Importance

Sweetened beverage taxes are one policy approach to reduce intake of added sugars. Soda is the leading source of added sugars in the US diet, but few studies have examined how such taxes influence sweetened beverage intake in youth.

Objective

To estimate the association between the Philadelphia, Pennsylvania, beverage tax and adolescent soda intake.

Design, Setting, and Participants

This economic evaluation of school district-level Youth Risk Behavior Surveillance System data from September 2013 to December 2019 compared weekly soda intake in high school students in Philadelphia, a city with a sweetened beverage tax, with that in 7 comparison cities without beverage taxes. Difference-in-differences regression modeling was used to estimate change in soda intake in Philadelphia compared with control cities. Secondary analyses compared 100% juice and milk intake to explore potential substitution associations. Subgroup analyses evaluated differences by race and ethnicity and weight status (obesity and overweight or obesity). Analyses were performed between August 20 and October 20, 2020. School districts that had weighted data and a survey question on weekly soda intake from 2013 to 2019 were included. The study included high school students, grades 9 to 12, in school districts participating in the Youth Risk Behavior Surveillance System from 2013 to 2019.

Exposures

Implementation of a sweetened beverage tax in Philadelphia, Pennsylvania, in January 2017.

Main Outcomes and Measures

Reported weekly servings of soda, 100% juice, and milk.

Results

A total of 86 928 participants (weighted mean [SD] age, 15.8 [1.3] years; 49% female) from 8 US cities (including Philadelphia) were included. Before the tax, adolescents in the 7 comparison cities had a mean intake of 4 servings of soda per week compared with 5.4 servings per week in Philadelphia. Philadelphia's tax was associated with a reduction of 0.81 servings of soda per week (95% CI, -1.48 to -0.14 servings; P = .02) 2 years after tax implementation. There was no significant difference in 100% juice or milk intake, although Philadelphia adolescents consumed more juice than those in nontaxed cities. In subgroup analyses, the tax was associated with a reduction of 1.13 servings per week in Hispanic/Latinx adolescents (95% CI, -2.04 to -0.23 servings; P = .01) and 1.2 servings per week in adolescents with obesity (95% CI, -2.33 to -0.13 servings; P = .03).

Conclusions and Relevance

This economic evaluation found that a sweetened beverage tax was associated with a reduction in soda intake among adolescents, providing evidence that such taxes can improve dietary behaviors.

Longer-term impacts of the Oakland, California, sugar-sweetened beverage tax on prices and volume sold at two-years post-tax

Sugar-sweetened beverage (SSB) consumption is associated with obesity and independently associated with type 2 diabetes and cardiovascular disease. Not only is obesity a growing public health problem, but it is also most recently associated with increased risk of severe illness from COVID-19. Taxes on SSBs are a policy tool used to help curb SSB consumption and are currently implemented in 7 U.S. cities and more than 40 countries. On July 1, 2017, Oakland, California, implemented a 1-cent/ounce tax on SSBs with ≥25 kilocalories/12 ounces. This study estimated the impact of the Oakland tax on prices, volume sold, and cross-border shopping two-years post-tax relative to one-year pre-tax. Universal product code-level Nielsen retail scanner data on non-alcoholic beverage sales were analyzed using a difference-in-differences design with Sacramento, California, as the comparison site. Taxed beverage prices increased by 0.67 cents/ounce, on average, in Oakland relative to Sacramento, corresponding to 67% pass-through. Taxed beverage volume sold decreased by 18% in Oakland relative to Sacramento, with a larger decrease for family-size beverages (23%) relative to individual-size beverages (8%). There was a 9% increase in volume sold of taxed beverages in the two-mile border area surrounding Oakland relative to the Sacramento border area, driven by a 12% increase for family-size taxed beverages. After accounting for this cross-border shopping, there was a net decrease of 6% in taxed beverage volume sold in Oakland. There was no significant change in untaxed beverage volume sold in either Oakland or its border area relative to their respective comparison sites, suggesting there was no substitution to untaxed beverages and cross-border shopping may have been limited to taxed beverages. This two-year post-tax study of the Oakland SSB tax adds to the limited number of longer-term evaluations of local U.S. SSB taxes.

Study protocol for iSIPsmarter: A randomized-controlled trial to evaluate the efficacy, reach, and engagement of a technology-based behavioral intervention to reduce sugary beverages among rural Appalachian adults

Sugar-sweetened beverage (SSB) consumption is disproportionately high among rural Appalachian adults, with intakes double the national average and nearly four times the recommended amount. This trial targets this major dietary risk factor and addresses notable gaps in the rural digital health intervention literature. iSIPsmarter is a technology-based behavior and health literacy intervention aimed at improving SSB behaviors. It is comprised of six Internet-delivered, interactive Cores delivered weekly, an integrated short message service (SMS) strategy to engage users in tracking and reporting SSB behaviors, and a cellular-enabled scale for in-home weighing. iSIPsmarter is adapted from an evidence-based intervention and is grounded by the Theory of Planned Behavior and health literacy, numeracy, and media literacy concepts. The RCT is guided by the RE-AIM framework and targets 244 rural Appalachian adults. The goal is to examine the efficacy of iSIPsmarter to reduce SSB in a two-group design [iSIPsmarter vs. static Participant Education website] with four assessment points. Changes in secondary outcomes (e.g., diet quality, weight, quality of life) and maintenance of outcomes will also be evaluated. Additional secondary aims are to examine reach and representativeness, patterns of user engagement, and cost. Two tertiary aims are exploratory mediation analyses and a systems-level, participatory evaluation to understand context for future organizational-level adoption of iSIPsmarter. The long-term goal is to sustain an effective, scalable, and high reach behavioral intervention to reduce SSB-related health inequities and related chronic conditions (i.e., obesity, diabetes, some obesity-related cancers, heart disease, hypertension, dental decay) in rural Appalachia and beyond. ClinicalTrial registry: NCT05030753.

A Salient Sugar Tax Decreases Sugary-Drink Buying

Many governments have introduced sugary-drink excise taxes to reduce purchasing and consumption of such drinks; however, they do not typically stipulate how such taxes should be communicated at the point of purchase. Historical, field, and experimental data consisting of more than 225,000 purchase decisions indicated that introducing a $0.01-per-ounce sugar-sweetened beverage (SSB) tax-without making it salient on price tags-had no significant effect on purchasing (-1.26%, p = .28). However, when the phrase "includes sugary drink tax" was added to tax-inclusive price tags, SSB purchasing was lower than (a) in the pretax period (-9.78%, p < .001), (b) in a posttax period when drinks did not bear price tags (-5.04%, p < .001), and (c) in a posttax period when drinks bore tax-inclusive price tags that did not mention the tax (-3.83%, p = .002). Making the tax's beneficiary (student programs) salient on price tags had no added effect. Two follow-up studies suggested that tax salience was effective partly because consumers overestimated the tax amount, leading to reduced purchase intentions.

How should we evaluate sweetened beverage tax policies? A review of worldwide experience

Over 45 jurisdictions globally have implemented sweetened beverage taxes. Researchers and policymakers need to assess whether and how these taxes change beverage demand and supply, their intended and unanticipated health, economic and equity impacts. Lessons from such evaluations can maximise the policies' success and impact on non-communicable disease prevention globally. We discuss key theoretical, design and methodological considerations to help policymakers, funders and researchers commission and conduct rigorous evaluations of these policies and related disease prevention efforts. We encourage involving the perspectives of various stakeholders on what evaluations are needed given the specific context, what data and methods are appropriate, readily available or can be collected within time and budget constraints. A logic model /conceptual system map of anticipated implications across sectors and scales should help identify optimal study design, analytical techniques and measures. These models should be updated when synthesising findings across diverse methods and integrating findings across subpopulations using similar methods.

Reply to Vale et al. Comment on "Zhong et al. Sugar-Sweetened and Diet Beverage Consumption in Philadelphia One Year after the Beverage Tax. Int. J. Environ. Res. Public Health 2020, 17, 1336"

Thank you for the opportunity to respond to the recent letter to the editor regarding our paper "Sugar-Sweetened and Diet Beverage Consumption in Philadelphia One Year after the Beverage Tax" [...].

The Impact of Seattle's Sugar-Sweetened Beverage Tax on Substitution to Sweets and Salty Snacks

BACKGROUND

Sugar-sweetened beverage (SSB) taxes may have broad effects on purchases of untaxed foods, and substitution of SSBs with untaxed sweets and/or salty snacks could offset the intended dietary and health effects of these policies.

OBJECTIVES

To test whether there were changes in sales and calories sold for untaxed foods in response to the SSB tax in Seattle, Washington, at 12 and 24 months post-tax implementation.

METHODS

On 1 January 2018, the City of Seattle levied a 1.75 cents per ounce excise tax on distributors selling targeted SSBs. We utilized universal product code-level store scanner data and employed a difference-in-differences approach to assess the impacts of the tax on the changes in 1) sales of sweets and salty snacks; and 2) total calories sold for sweets in Seattle relative to changes in its comparison site of Portland, Oregon, at 12 and 24 months post-tax.

RESULTS

In the 12 months post-tax, sales of sweets increased by 4% [ratio of incidence rate ratios (RIRR), 1.04; 95% CI, 1.03-1.05] in Seattle relative to the changes in Portland; at 24 months post-tax, sweet sales increased by 6% (RIRR, 1.06; 95% CI, 1.05-1.07) relative to the pretax period. There was no significant change in sales of salty snacks at 12 months (RIRR, 1.00; 95% CI, 0.99-1.01) or 24 months (RIRR, 1.00; 95% CI, 0.98-1.02) post-tax. Total calories sold for sweets increased by 3% (RIRR, 1.03; 95% CI, 1.02-1.05) in Seattle compared with Portland at 12 months post-tax and by 4% (RIRR, 1.04; 95% CI, 1.02-1.05) at 24 months after implementation.

CONCLUSIONS

There was modest substitution of SSBs for sweets in Seattle following tax implementation. However, this increase in sales and calories sold is not likely to offset previously identified tax-related reductions in the demand for taxed beverages in Seattle. Thus, SSB taxes are a promising policy tool to reduce caloric intake in the United States.

Population-Level Approaches to Preventing Type 2 Diabetes Globally

Type 2 diabetes (T2DM) is increasingly considered an epidemic rooted in modern society as much as in individual behavior. Addressing the T2DM burden thus involves a dual approach, simultaneously addressing high-risk individuals and whole populations. Within this context, this article summarizes the evidence base, in terms of effectiveness and cost-effectiveness, for population-level approaches to prevent T2DM: (1) modifications to the food environment; (2) modifications to the built environment and physical activity; and (3) programs and policies to address social and economic factors. Existing knowledge gaps are also discussed.

The impact of the Oakland SSB tax on prices and volume sold: A study of intended and unintended consequences

We examine the effects of a sugar-sweetened beverage (SSB) tax that took effect in Oakland, California in 2017. Using rich customized universal product code -level data, we estimate the effect of the SSB tax on prices and volume in the short to medium term in a difference-in-differences framework. We pay particular attention to tax-avoidance strategies that may minimize the policy's intended effect including: (i) transfers to SSBs to the nontaxed border area (i.e., cross-border shopping), (ii) a move from high-priced per ounce single serve to their cheaper multipacks or larger format counterparts (i.e., format switching), and (iii) a move from high-priced beverages to less expensive ones within a category and format (i.e., brand switching). We find that the year-over-year tax pass-through is 49%. We find that volume sold of taxed beverages fell by 14%, but 46% of this decrease is offset with an increase in the border area. We also find evidence of substitution to lower-priced taxed beverages but no evidence of switching to cheaper formats. Finally, we find important dynamic effects with respect to tax pass-through, volume sold and cross-border shopping.

Taxing sugar-sweetened beverages as a policy to reduce overweight and obesity in countries of different income classifications: a systematic review

OBJECTIVE

To evaluate the potential impact of sugar-sweetened beverage (SSB) taxes on overweight and obesity prevalence in countries of different income classifications.

DESIGN

Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO number CRD42020161612). Five databases (Cochrane Library, Embase, LILACS (via Virtual Health Library) and MEDLINE (via PubMed), and Web of Science were searched, from January 2009 to December 2019. Articles that reported changes in purchases, sales, intake, body weight, BMI, overweight and/or obesity prevalence due to a tax on or price change in SSB were included.

SETTING

Studies conducted in countries of different income classifications.

PARTICIPANTS

The search yielded 8349 articles of which 21 met inclusion criteria.

RESULTS

Among the sixteen studies selected, only two did not show that consumption, sales and purchase decreased as the price of SSB increased. In eight of the thirteen studies selected, a positive effect of an SSB tax on decreasing overweight and obesity prevalence was expected. It is estimated that a 20 % taxation on SSB would result in a greater decrease in the prevalence of overweight and obesity compared to a 10 % rate. Studies with no significant effect of taxing on sales, purchases, consumption and prevalence of obesity were from high-income countries, while significant effects of taxing on reducing purchase, consumption and/or obesity prevalence were found in studies from upper-middle- and middle-income countries.

CONCLUSION

A high SSB tax might be an effective fiscal policy to decrease purchase and consumption of SSB and reduce overweight/obesity prevalence, especially if the tax were specific for beverage volume.

Assessing sugar-sweetened beverage intakes, added sugar intakes and BMI before and after the implementation of a sugar-sweetened beverage tax in South Africa

OBJECTIVE

To provide insight into the context and public health implications of the South African sugar-sweetened beverage (SSB) tax (Health Promotion Levy; HPL) by describing SSB and added sugar intakes, as well as BMI, 1 year prior to, at the time of and 1 year after implementation of the HPL.

DESIGN

Longitudinal dietary intake was assessed using a quantitative food frequency questionnaire (QFFQ) and BMI was measured via anthropometry.

SETTING

Soweto, Johannesburg, South Africa.

PARTICIPANTS

Adolescents, young adults and middle-aged adults (n 617).

RESULTS

At baseline, median SSB intakes were 36 ml/d, 214 ml/d and 750 ml/d for those in low, medium and high consumption tertiles, respectively. SSB intake decreased by two times/week in medium consumers and seven times/week in high consumers between baseline and 12 months, equivalent to 107 ml/d and 536 ml/d reductions, respectively. These reduced levels were maintained in the following year (i.e. to 24 months). There was an overall decrease in the amount of energy consumed as added sugar in the low (-48 kJ/d), medium (-153 kJ/d) and high (-106 kJ/d) SSB consumption groups between baseline and 24 months; however, the percentage of total energy consumed as added sugar remained relatively consistent (between 10 and 11 %). There were small overall increases in BMI across low (0·6 kg/m2), medium (0·9 kg/m2) and high (1·0 kg/m2) SSB tertiles between baseline and 24 months.

CONCLUSIONS

These findings suggest reductions in SSB and added sugar consumption contemporaneous to the introduction of the HPL - particularly for those with higher baseline intakes.

Association of a Sweetened Beverage Tax With Purchases of Beverages and High-Sugar Foods at Independent Stores in Philadelphia

Importance

The relationship between a sweetened beverage tax and changes in the prices and purchases of beverages and high-sugar food is understudied in the long term and in small independent food retail stores where sugar-sweetened beverages are among the most commonly purchased items.

Objective

To examine whether a 1.5 cent-per-fluid-ounce excise tax on sugar- and artificially sweetened beverages Philadelphia, Pennsylvania, was associated with sustained changes in beverage prices and purchases, as well as calories purchased from beverages and high-sugar foods, over 2 years at small independent stores.

Design, Setting, and Participants

This cross-sectional study used a difference-in-differences approach to compare changes in beverage prices and purchases of beverages and high-sugar foods (candy, sweet snacks) at independent stores in Philadelphia and Baltimore, Maryland (a nontaxed control) before and 2 years after tax implementation, which occurred on January 1, 2017. Price comparisons were also made to independent stores in Philadelphia's neighboring counties.

Main Outcomes and Measures

Changes in mean price (measured in cents per fluid ounce) of taxed and nontaxed beverages, mean fluid ounces purchased of taxed and nontaxed beverages, and mean total calories purchased from beverages and high-sugar foods.

Results

Compared with Baltimore independent stores, taxed beverage prices in Philadelphia increased 2.06 cents per fluid ounce (95% CI, 1.75 to 2.38 cents per fluid ounce; P < .001), with 137% of the tax passed through to prices 2 years after tax implementation, while nontaxed beverage prices had no statistically significant change. A total of 116 independent stores and 4738 customer purchases (1950 [41.2%] women; 4351 [91.8%] age 18 years or older; 1006 [21.2%] White customers, 3185 [67.2%] Black customers) at independent stores were assessed for price and purchase comparisons. Purchases of taxed beverages declined by 6.1 fl oz (95% CI, -9.9 to -2.4 fl oz; P < .001), corresponding to a 42% decline in Philadelphia compared with Baltimore; there were no significant changes in purchases of nontaxed beverages. Although there was no significant moderation by neighborhood income or customer education level, exploratory stratified analyses revealed that declines in taxed beverage purchases were larger among customers shopping in low-income neighborhoods (-7.1 fl oz; 95% CI, -13.0 to -1.1 fl oz; P = .001) and individuals with lower education levels (-6.9 fl oz; 95% CI, -12.5 to -1.3 fl oz; P = .001).

Conclusions and Relevance

This cross-sectional study found that a tax on sweetened beverages was associated with increases in price and decreases in purchasing. Beverage excise taxes may be an effective policy to sustainably decrease purchases of sweetened drinks and calories from sugar in independent stores, with large reductions in lower-income areas and among customers with lower levels of education.

The Association Of A Sweetened Beverage Tax With Changes In Beverage Prices And Purchases At Independent Stores

In January 2017 Philadelphia, Pennsylvania, implemented an excise tax of 1.5 cents per ounce on beverages sweetened with sugar or artificial sweeteners. Small independent stores are an important yet understudied setting. They are visited frequently in urban and low-income areas, and sugary beverages are among the most commonly purchased items in them. We compared changes in beverage prices and purchases before and twelve months after tax implementation at small independent stores in Philadelphia and an untaxed control city, Baltimore, Maryland. Our sample included 134 stores with price data and 4,584 customer purchases. Compared with Baltimore, Philadelphia experienced significantly greater increases in the price of taxed beverages (1.81 cents per ounce, or 120.4 percent of the tax) and significantly larger declines in the volume of taxed beverages sold (5.76 ounces, or 38.9 percent) after tax implementation. Beverage excise taxes may be an effective policy tool for decreasing the purchase of sweetened drinks in small independent stores, particularly among populations at higher risk for sugar-sweetened beverage consumption.

Taxed and untaxed beverage intake by South African young adults after a national sugar-sweetened beverage tax: A before-and-after study

BACKGROUND

In an effort to prevent and reduce the prevalence rate of people with obesity and diabetes, South Africa implemented a sugar-content-based tax called the Health Promotion Levy in April 2018, one of the first sugar-sweetened beverage (SSB) taxes to be based on each gram of sugar (beyond 4 g/100 ml). This before-and-after study estimated changes in taxed and untaxed beverage intake 1 year after the tax, examining separately, to our knowledge for the first time, the role of reformulation distinct from behavioral changes in SSB intake.

METHODS AND FINDINGS

We collected single-day 24-hour dietary recalls from repeat cross-sectional surveys of adults aged 18-39 years in Langa, South Africa. Participants were recruited in February-March 2018 (pre-tax, n = 2,459) and February-March 2019 (post-tax, n = 2,489) using door-to-door sampling. We developed time-specific food composition tables (FCTs) for South African beverages before and after the tax, linked with the diet recalls. By linking pre-tax FCTs only to dietary intake data collected in the pre-tax and post-tax periods, we calculated changes in beverage intake due to behavioral change, assuming no reformulation. Next, we repeated the analysis using an updated FCT in the post-tax period to capture the marginal effect of reformulation. We estimated beverage intake using a 2-part model that takes into consideration the biases in using ordinary least squares or other continuous variable approaches with many individuals with zero intake. First, a probit model was used to estimate the probability of consuming the specific beverage category. Then, conditional on a positive outcome, a generalized linear model with a log-link was used to estimate the continuous amount of beverage consumed. Among taxed beverages, sugar intake decreased significantly (p < 0.0001) from 28.8 g/capita/day (95% CI 27.3-30.4) pre-tax to 19.8 (95% CI 18.5-21.1) post-tax. Energy intake decreased (p < 0.0001) from 121 kcal/capita/day (95% CI 114-127) pre-tax to 82 (95% CI 76-87) post-tax. Volume intake decreased (p < 0.0001) from 315 ml/capita/day (95% CI 297-332) pre-tax to 198 (95% CI 185-211) post-tax. Among untaxed beverages, sugar intake increased (p < 0.0001) by 5.3 g/capita/day (95% CI 3.7 to 6.9), and energy intake increased (p < 0.0001) by 29 kcal/capita/day (95% CI 19 to 39). Among total beverages, sugar intake decreased significantly (p = 0.004) by 3.7 (95% CI -6.2 to -1.2) g/capita/day. Behavioral change accounted for reductions of 24% in energy, 22% in sugar, and 23% in volume, while reformulation accounted for additional reductions of 8% in energy, 9% in sugar, and 14% in volume from taxed beverages. The key limitations of this study are an inability to make causal claims due to repeat cross-sectional data collection, and that the magnitude of reduction in taxed beverage intake may not be generalizable to higher income populations.

CONCLUSIONS

Using a large sample of a high-consuming, low-income population, we found large reductions in taxed beverage intake, separating the components of behavioral change from reformulation. This reduction was partially compensated by an increase in sugar and energy from untaxed beverages. Because policies such as taxes can incentivize reformulation, our use of an up-to-date FCT that reflects a rapidly changing food supply is novel and important for evaluating policy effects on intake.

Taxation of Sugar-Sweetened Beverages and its Impact on Dental Caries: A Narrative Review

Dental caries is one of the largest health concerns worldwide, and a key causative factor is excess sugar intake. Sugar-sweetened beverages (SSBs) are one of the largest sources of added sugars, which significantly contribute to adverse oral and general health. To reduce SSB consumption and its consequent impact on health, including dental caries, several interventional measures have been implemented; sugar taxation is one such measure. This review aimed at understanding the current knowledge available regarding the effect of sugar taxation on dental caries. Accordingly, PubMed, the Cochrane Library, Web of Science, and Scopus were searched with relevant keywords and findings from the identified studies are discussed in this review article.

Changes in beverage purchases following the announcement and implementation of South Africa's Health Promotion Levy: an observational study

BACKGROUND

In 2016, South Africa announced an intention to levy a tax on sugar-sweetened beverages (SSBs). In 2018, the country implemented an SSB tax of approximately 10%, known as the Health Promotion Levy (HPL). We aimed to assess changes in the purchases of beverages before and after the HPL announcement and implementation.

METHODS

We used Kantar Europanel data on monthly household purchases between January, 2014, and March, 2019, among a sample of South African households (n=113 653 household-month observations) from all nine provinces to obtain per-capita sugar, calories, and volume from taxable and non-taxable beverages purchased before and after the HPL announcement and implementation. We describe survey-weighted means for each period, and regression-controlled predictions of outcomes and counterfactuals based on pre-HPL announcement trends, with bootstrapped 95% CIs, and stratify results by socioeconomic status.

FINDINGS

Mean sugar from taxable beverage purchases fell from 16·25 g/capita per day (95% CI 15·80-16·70) to 14·26 (13·85-14·67) from the pre-HPL announcement to post-announcement period, and then to 10·63 g/capita per day (10·22-11·04) in the year after implementation. Mean volumes of taxable beverage purchases fell from 518·99 mL/capita per day (506·90-531·08) to 492·16 (481·28-503·04) from pre-announcement to post announcement, and then to 443·39 mL/capita per day (430·10-456·56) after implementation. Across these time periods, there was a small increase in the purchases of non-taxable beverages, from 283·45 mL/capita per day (273·34-293·56) pre-announcement to 312·94 (296·29-329·29) post implementation. When compared with pre-announcement counterfactual trends, reductions in taxable beverage purchase outcomes were significantly larger than the unadjusted survey-weighted observed reductions. Households with lower socioeconomic status purchased larger amounts of taxable beverages in the pre-announcement period than did households with higher socioeconomic status, but demonstrated bigger reductions after the tax was implemented.

INTERPRETATION

The announcement and introduction of South Africa's HPL were followed by reductions in the sugar, calories, and volume of beverage purchases.

FUNDING

Bloomberg Philanthropies, International Development Research Centre, South African Medical Research Council, and the US National Institutes of Health.

How do consumers respond to "sin taxes"? New evidence from a tax on sugary drinks

It is unclear what the effects of taxes on sugar sweetened beverages (SSBs) are on consumer behaviour and which consumers may be affected the most. We evaluate the effect of the SSB tax introduced in Catalonia (but not in the rest of Spain) in May 2017 using loyalty card data of monthly purchases by 884,843 households from May 2016 to April 2018. Using a Difference-in-Differences approach, we study the SSB tax effect on the purchased quantity of beverages and sugar. Our results suggest a reduction in purchases of taxed beverages and a small increase in purchases of untaxed beverages. Households have substituted taxed beverages with their lower sugar (untaxed) counterparts. This has led to a 2.2% overall reduction in sugar purchases from beverages. Our study implies that although sin taxes moderately change consumer behaviour, a combination of different policies would be required to tackle obesity.

Unpalatable food for thought: Let marketing research guide effective public obesity interventions

The prevalence of obesity is growing unabatedly despite the considerable efforts directed at the problem. Although abundant research has contributed to our understanding of the multifactorial causes of obesity, there is less attention to research that is relevant for guiding social marketers, public health professionals and policymakers in delivering public health interventions for countering and/or preventing the problem of obesity. This review offers six points for identifying and developing research relevant for guiding community-wide obesity interventions based on the idea that an applied marketing research perspective offers a better model for identifying effective interventions than more theoretical academic research. Specifically, the research guiding public health and social marketing interventions needs to (1) provide information on ultimate outcomes (weight, health and unintended consequences) more than intermediate outcomes (beliefs, attitudes and behaviour), (2) report on observations collected over the longer term, (3) use natural settings (even at a cost of internal validity), (4) endeavour to overcome observer-effects, (5) report effect sizes (rather than statistical significance) and (6) use moderator analyses to capture variation in how a population responds to interventions.

No Evidence of Food or Alcohol Substitution in Response to a Sweetened Beverage Tax

INTRODUCTION

Evidence suggests real-world beverage taxes reduce sweetened beverage purchases, but it is unknown if consumers consequently increase food or alcohol purchases. This study examines whether Philadelphia's 1.5 cents/ounce beverage tax was associated with substitution to 3 kinds of hypothesized substitutes: snacks, nontaxed beverage concentrates, and alcohol.

METHODS

Using commercial retail sales data and a difference-in-differences approach, analyses compared logged volume and dollar sales of snacks and beverage concentrates between 2016 (pretax) and 2017 (post-tax) at chain food retail stores in Philadelphia (n=180) and Baltimore (nontaxed control city; n=60), and logged volume and dollar sales of wine and spirits at liquor stores in Philadelphia (n=44) and nearby Pennsylvania counties (alternate control; n=66). Additional food analyses examined change in logged volume sales of hypothesized products compared to control products (other foods). Analyses were conducted in 2020.

RESULTS

Across store types, analyses showed no statistically significant increases in logged volume or dollar sales of snacks or spirits in Philadelphia stores compared to control sites (decreased, ranging from -10% to 0%). Supermarket analyses showed substitution to nontaxed beverage concentrates (27% increase in volume, 36% increase relative to other food) but remained a relatively small percentage of overall beverage dollar sales (12% at baseline, 15% at post).

CONCLUSIONS

At the population level, there is no evidence that Philadelphia's decline in taxed beverage purchases is offset by increases in snacks or spirits purchasing, but there is evidence of substitution to beverage concentrates in supermarkets. Future studies should explore individual-level purchasing changes.

Warning Labels Reduce Sugar-Sweetened Beverage Intake among College Students

BACKGROUND

Health-related warning labels may reduce the intake of sugar-sweetened beverages (SSBs), but the effectiveness of such labels in real-world settings is not well established.

OBJECTIVES

We investigated the influence of warning labels on SSB intake among college students at a large public Midwestern university.

METHODS

We conducted a quasi-experimental intervention study among 840 undergraduate students recruited from 3 dining halls on 1 university campus. One dining hall was selected as the intervention (I) site, whereas the other dining halls served as control (C) sites. In January 2019, warning labels were posted on SSB dispensers at the I site. All students reported their beverage intake using a modified beverage frequency questionnaire 2 mo before and 2 mo after the warning label implementation. Generalized linear models examined the influence of the warning labels on SSB consumption at the I site compared with the C sites, adjusting for students' sociodemographic characteristics.

RESULTS

In the sample, 68% were aged 17-18 y old at baseline, and 51% identified as female. From baseline to follow-up, there was a 19% decrease in SSB intake at the I site, compared with a 5% decrease at the C sites (P = 0.049 comparing I with C). This difference was driven by significant decreases in the intakes of fruit-flavored drinks, sweetened teas, and flavored milk at the I site compared with the C sites. Although not an SSB, 100% fruit juce consumption decreased 21% at the I site, compared with a 1% increase at the C sites (P = 0.01 comparing I with C). No significant differences were observed in the intakes of soda, energy drinks, sweetened coffees, and nonsugary drinks at the I site compared with the C sites.

CONCLUSIONS

Warning labels were effective in reducing SSB intake among college students, particularly for fruit-flavored drinks, sweetened teas, and flavored milk.This trial was registered at clinicaltrials.gov as NCT04435145.

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.