Distributional equity as a consideration in economic and modelling evaluations of health taxes: A systematic review

Long-term impact of unhealthy food tax on consumption and the drivers behind: A longitudinal study in Hungary

Several countries have introduced public health product taxes with the objective of reducing the absolute amount of consumption of unhealthy food and tackling obesity. This study aims to estimate the long-term impact of the Hungarian public health product tax introduced in 2011. To achieve this, a unique consumer purchase dataset was analysed to examine daily fast-moving consumer goods purchases from a representative sample of 2,000 households from 2010 to 2018. The results indicate that the tax has been fully reflected in consumer prices. A decline in consumption was observed initially, consistent with previous experiences in Hungary and other countries. However, over time, the data suggests a recovery and even an increase in line with the growth of disposable income. The proportion of taxed products in total fast-moving consumer goods purchases increased from 5.9 % (95 % CI: 5.7 % to 6.0 %) in 2010 to 7.4 % (95 % CI: 7.3 % to 7.6 %) in 2018. Furthermore, the tax has contributed to increased inequality as low-income households spend a higher proportion of their total expenditure on it. Although taxes on unhealthy foods have proven effective in the short-term, they may not be adequate for reducing overall consumption in the long-term, particularly as disposable income increases. In conclusion, implementing complex interventions is necessary to achieve sustainable positive changes in dietary habits.

Economic Evaluations of Obesity-Targeted Sugar-Sweetened Beverage (SSB) Taxes-A Review to Identify Methodological Issues

INTRODUCTION

Economic evaluations of public health interventions like sugar-sweetened beverage (SSB) taxes face difficulties similar to those previously identified in other public health areas. This stems from challenges in accurately attributing effects, capturing outcomes and costs beyond health, and integrating equity effects. This review examines how these challenges were addressed in economic evaluations of SSB taxes.

METHODS

A systematic review was conducted to identify economic evaluations of SSB taxes focused on addressing obesity in adults, published up to February 2021. The methodological challenges examined include measuring effects, valuing outcomes, assessing costs, and incorporating equity.

RESULTS

Fourteen economic evaluations of SSB taxes were identified. Across these evaluations, estimating SSB tax effects was uncertain due to a reliance on indirect evidence that was less robust than evidence from randomised controlled trials. Health outcomes, like quality-adjusted life years, along with a healthcare system perspective for costs, dominated the evaluations of SSB taxes, with a limited focus on broader non-health consequences. Equity analyses were common but employed significantly different approaches and exhibited varying degrees of quality.

CONCLUSION

Addressing the methodological challenges remains an issue for economic evaluations of public health interventions like SSB taxes, suggesting the need for increased attention on those issues in future studies. Dedicated methodological guidelines, in particular addressing the measurement of effect and incorporation of equity impacts, are warranted.

Association of cigarette excise taxes and clean indoor air laws with change in smoking behavior in the United States: a Markov modeling analysis

The rates of cigarette smoking in the United States have declined over the past few decades in parallel with increases in cigarette taxes and introduction of more stringent clean indoor air laws. Few longitudinal studies have examined association of taxes and clean indoor air policies with change in smoking nationally. This study examined the association of state and local cigarette taxes and clean indoor laws with change in smoking status of 18,499 adult participants of the longitudinal 2010-2011 Tobacco Use Supplement of the Current Population Survey over a period of 1 year. Every $1 increase in cigarette excise taxes was associated with 36% higher likelihood of stopping smoking among regular smokers. We found no association between clean indoor air laws and smoking cessation nor between taxes and clean indoor air laws with lower risk of smoking initiation. Cigarette taxes appear to be effective anti-smoking policies. Some state and local governments do not take full advantage of this effective policy measure.

An umbrella review of the acceptability of fiscal and pricing policies to reduce diet-related noncommunicable disease

CONTEXT

Poor diet has been implicated in a range of noncommunicable diseases. Fiscal and pricing policies (FPs) may offer a means by which consumption of food and non-alcoholic beverages with links to such diseases can be influenced to improve public health.

OBJECTIVE

To examine the acceptability of FPs to reduce diet-related noncommunicable disease, based on systematic review evidence.

DATA SOURCES

MEDLINE, EMBASE, PsychInfo, SCI, SSCI, Web of Science, Scopus, EconLit, the Cochrane Library, Epistemonikos, and the Campbell Collaboration Library were searched for relevant studies published between January 1, 1990 and June 2021.

DATA EXTRACTION

The studies included systematic reviews of diet-related FPs and: used real-world evidence; examined real or perceived barriers/facilitators; targeted the price of food or non-alcoholic beverages; and applied to entire populations within a jurisdiction. A total of 9996 unique relevant records were identified, which were augmented by a search of bibliographies and recommendations from an external expert advisory panel. Following screening, 4 systematic reviews remained.

DATA ANALYSIS

Quality appraisal was conducted using the AMSTAR 2 tool. A narrative synthesis was undertaken, with outcomes grouped according to the WHO-INTEGRATE criteria. The findings indicated a paucity of high-quality systematic review evidence and limited public support for the use of FPs to change dietary habits. This lack of support was related to a number of factors that included: their perceived potential to be regressive; a lack of transparency, ie, there was mistrust around the use of revenues raised; a paucity of evidence around health benefits; the deliberate choice of rates that were lower than those considered necessary to affect diet; and concerns about the potential of such FPs to harm economic outcomes such as employment.

CONCLUSION

The findings underscore the need for high-quality systematic review evidence on this topic, and the importance of responding to public concerns and putting in place mechanisms to address these when implementing FPs. This study was funded by Safefood [02A-2020].

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021274454.

An umbrella review of the effectiveness of fiscal and pricing policies on food and non-alcoholic beverages to improve health

Poor quality diets represent major risk factors for the global burden of disease. Modeling studies indicate a potential for diet-related fiscal and pricing policies (FPs) to improve health. There is real-world evidence (RWE) that such policies can change behavior; however, the evidence regarding health is less clear. We conducted an umbrella review of the effectiveness of FPs on food and non-alcoholic beverages in influencing health or intermediate outcomes like consumption. We considered FPs applied to an entire population within a jurisdiction and included four systematic reviews in our final sample. Quality appraisal, an examination of excluded reviews, and a literature review of recent primary studies assessed the robustness of our results. Taxes and, to some extent, subsidies are effective in changing consumption of taxed/subsidized items; however, substitution is likely to occur. There is a lack of RWE supporting the effectiveness of FPs in improving health but this does not mean that they are ineffective. FPs may be important for improving health but their design is critical. Poorly designed FPs may fail to improve health and could reduce support for such policies or be used to support their repeal. More high-quality RWE on the impact of FPs on health is needed.

Using GRADE Evidence to Decision frameworks to support the process of health policy-making: an example application regarding taxation of sugar-sweetened beverages

BACKGROUND

Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) frameworks are well-known tools that enable guideline panels to structure the process of developing recommendations and making decisions in healthcare and public health. To date, they have not regularly been used for health policy-making. This article aims to illustrate the application of the GRADE EtD frameworks in the process of nutrition-related policy-making for a European country.

METHODS

Based on methodological guidance by the GRADE Working Group and the findings of our recently published scoping review, we illustrate the process of moving from evidence to recommendations, by applying the EtD frameworks to a fictitious example. Sugar-sweetened beverage (SSB) taxation based on energy density was chosen as an example application.

RESULTS

A fictitious guideline panel was convened by a national nutrition association to develop a population-level recommendation on SSB taxation aiming to reduce the burden of overweight and obesity. Exemplary evidence was summarized for each EtD criterion and conclusions were drawn based on all judgements made in relation to each criterion. As a result of the high priority to reduce the burden of obesity and because of the moderate desirable effects on health outcomes, but considering scarce or varying research evidence for other EtD criteria, the panel made a conditional recommendation for SSB taxation. Decision-makers may opt for conducting a pilot study prior to implementing the policy on a national level.

CONCLUSIONS

GRADE EtD frameworks can be used by guideline panels to make the process of developing recommendations in the field of health policy more systematic, transparent and comprehensible.

Combined carbon and health taxes outperform single-purpose information or fiscal measures in designing sustainable food policies

The food system is a major source of both environmental and health challenges. Yet, the extent to which policy-induced changes in the patterns of food demand address these challenges remains poorly understood. Using a survey-based, randomized controlled experiment with 5,912 respondents from the United Kingdom, we evaluate the potential effect of carbon and/or health taxes, information and combined tax and information strategies on food purchase patterns and the resulting impact on greenhouse gas emissions and dietary health. Our results show that while information on the carbon and/or health characteristics of food is relevant, the imposition of taxes exerts the most substantial effects on food purchasing decisions. Furthermore, while carbon or health taxes are best at separately targeting emissions or dietary health challenges, respectively, a combined carbon and health tax policy maximizes benefits in terms of both environmental and health outcomes. We show that such a combined policy could contribute to around one third of the reductions in residual emissions required to achieve the United Kingdom's 2050 net-zero commitments, while discouraging the purchase of especially unhealthy snacks, sugary drinks and alcohol and increasing the purchase of fruit and vegetables.

Associations Among Select State Policies and the Nutritional Quality of Household Packaged Food Purchases in the United States from 2008 Through 2017

BACKGROUND

Policy interventions are important public health tools because they can reach large numbers of people. State context has been associated with health outcomes, yet few studies have examined the extent to which state-level policies are associated with dietary quality.

OBJECTIVES

The objective of this study was to evaluate whether state policies are associated with the nutritional quality of household packaged food purchases.

DESIGN

This observational study used data from Nielsen Homescan, an open-cohort household panel where participants track purchases, and a combination of state-level food and social safety net policy variables from 2008 through 2017.

PARTICIPANTS AND SETTING

This study included 615,634 household-year observations in the United States from 2008 through 2017. Household-year observations were excluded in the case that a household did not make a minimum number of purchases and in the case that they had incorrect geographic information. The final analytic sample was 611,719 household-years.

MAIN OUTCOME MEASURES

Study outcomes included a set of nutrition-related measures of public health interest, including nutrients of concern (eg, sugar, saturated fat, and sodium) and calories from specific food groups (eg, fruits, nonstarchy vegetables, processed meats, mixed dishes, sugar-sweetened beverages, and desserts and snacks).

STATISTICAL ANALYSIS

This study used multilevel generalized linear models with state fixed effects on three samples: all households, only households with low income, and only households with low educational attainment.

RESULTS

Few significant associations were found between healthy food retail policies and the nutritional quality of purchases, and mixed associations were found between social safety net policies and lower or higher quality packaged food purchases.

CONCLUSIONS

Little evidence was found that state policy context in 2008 through 2017 was associated with the quality of packaged food purchases. However, variation in state policies is increasing over time, warranting future research into the relationship between these policies, the quality of packaged food purchases, and the rest of the diet.

A Study on China's Tobacco Taxation and Its Influencing Factor on Economic Growth

Tobacco is a significant product providing considerable economic benefits to countries worldwide, while its increased consumption causes health and socio-economic losses for smokers and non-smokers. This paper constructs a decomposition system of tobacco taxation: the population aging factor is included in the influencing factors of personal tax, and personal tax revenue is regarded as the product of tax structure, macro tax burden, regional economy, reciprocal aging, and the elderly population. This article conducts an empirical study on the relationship between taxation and economic growth. The estimated coefficients of business tax and corporate income tax are significant at the significance level of 0.1, with a consumption tax and time-variable coefficients reporting a 0.02 level of significance. The T statistic value and the explanatory degree of the variables involved in the model to the explained variables are also very high, reaching more than 95%. We find that increasing the macro tax burden negatively impacts economic growth. Therefore, the study suggests that for fostering the industry’s economic growth, the country needs to ensure the optimal macro tax burden of 17.5%, with different types of taxes influencing economic growth. Personal tax reform should pay attention to the phenomenon of aging, adjust the tax structure to increase personal tax income, provide policy support and guarantee for the elderly labor force, and encourage the re-employment of silver-haired people to alleviate the adverse impact of aging on taxation.

The Impact of Sugar-Sweetened Beverage Taxes by Household Income: A Multi-City Comparison of Nielsen Purchasing Data

Due to the role that sugar-sweetened beverages (SSBs) play in the obesity epidemic, SSB taxes have been enacted in the United States in the California cities of Albany, Berkeley, Oakland, and San Francisco, as well as in Boulder, Philadelphia, and Seattle. We pooled five years of Nielsen Consumer Panel and Retail Scanner Data (2014-18) to examine purchasing behaviors in and around these cities that have instituted SSB taxes. We included households that were either subject to the tax during the study period or were in surrounding areas within the same state. The goal was to test for the differential impact of SSB taxes by income level and type of tax. Multivariate analyses of beverage purchases found that (1) there is a dose-response relationship with the size of the SSB tax; (2) the Philadelphia tax, which is the only one that includes low-calorie beverages, is associated with greater reductions in SSB purchases and an increase in bottled water purchase; and (3) approximately 72% of the tax is passed through to consumers, but this does not vary by income level of the household. Few income-related effects were detected. Overall, our findings suggest that the Philadelphia model may be the most effective at encouraging healthy habits in beverage choice.

Policy and behavioral response to shock events: An agent-based model of the effectiveness and equity of policy design features

In the aftermath of shock events, policy responses tend to be crafted under significant time constraints and high levels of uncertainty. The extent to which individuals comply with different policy designs can further influence how effective the policy responses are and how equitably their impacts are distributed in the population. Tools which allow policymakers to model different crisis trajectories, policy responses, and behavioral scenarios ex ante can provide crucial timely support in the decision-making process. Set in the context of COVID-19 shelter in place policies, in this paper we present the COVID-19 Policy Evaluation (CoPE) tool, which is an agent-based modeling framework that enables researchers and policymakers to anticipate the relative impacts of policy decisions. Specifically, this framework illuminates the extent to which policy design features and behavioral responsiveness influence the efficacy and equity of policy responses to shock events. We show that while an early policy response can be highly effective, the impact of the timing is moderated by other aspects of policy design such as duration and targeting of the policy, as well as societal aspects such as trust and compliance among the population. More importantly, we show that even policies that are more effective overall can have disproportionate impacts on vulnerable populations. By disaggregating the impact of different policy design elements on different population groups, we provide an additional tool for policymakers to use in the design of targeted strategies for disproportionately affected populations.

Effects of minimum unit pricing for alcohol in South Africa across different drinker groups and wealth quintiles: a modelling study

OBJECTIVES

To quantify the potential impact of minimum unit pricing (MUP) for alcohol on alcohol consumption, spending and health in South Africa. We provide these estimates disaggregated by different drinker groups and wealth quintiles.

DESIGN

We developed an epidemiological policy appraisal model to estimate the effects of MUP across sex, drinker groups (moderate, occasional binge, heavy) and wealth quintiles. Stakeholder interviews and workshops informed model development and ensured policy relevance.

SETTING

South African drinking population aged 15+.

PARTICIPANTS

The population (aged 15+) of South Africa in 2018 stratified by drinking group and wealth quintiles, with a model time horizon of 20 years.

MAIN OUTCOME MEASURES

Change in standard drinks (SDs) (12 g of ethanol) consumed, weekly spend on alcohol, annual number of cases and deaths for five alcohol-related health conditions (HIV, intentional injury, road injury, liver cirrhosis and breast cancer), reported by drinker groups and wealth quintile.

RESULTS

We estimate an MUP of R10 per SD would lead to an immediate reduction in consumption of 4.40% (-0.93 SD/week) and an increase in spend of 18.09%. The absolute reduction is greatest for heavy drinkers (-1.48 SD/week), followed by occasional binge drinkers (-0.41 SD/week) and moderate drinkers (-0.40 SD/week). Over 20 years, we estimate 20 585 fewer deaths and 9 00 332 cases averted across the five health-modelled harms.Poorer drinkers would see greater impacts from the policy (consumption: -7.75% in the poorest quintile, -3.19% in richest quintile). Among the heavy drinkers, 85% of the cases averted and 86% of the lives saved accrue to the bottom three wealth quintiles.

CONCLUSIONS

We estimate that MUP would reduce alcohol consumption in South Africa, improving health outcomes while raising retail and tax revenue. Consumption and harm reductions would be greater in poorer groups.

Socio-economic and racial/ethnic disparities in the nutritional quality of packaged food purchases in the USA, 2008-2018

OBJECTIVE

To determine whether disparities exist in the nutritional quality of packaged foods and beverage purchases by household income, education and race/ethnicity and if they changed over time.

DESIGN

We used Nielsen Homescan, a nationally representative household panel, from 2008 to 2018 (n = 672 821 household-year observations). Multivariate, multilevel regressions were used to model the association between sociodemographic groups and a set of nutritional outcomes of public health interest, including nutrients of concern (sugar, saturated fat and Na) and calories from specific food groups (fruits, non-starchy vegetables, processed meats, sugar-sweetened beverages and junk foods).

SETTING

Household panel survey.

PARTICIPANTS

Approximately 60 000 households each year from the USA.

RESULTS

Disparities were found by income and education for most outcomes and widened for purchases of fruits, vegetables and the percentage of calories from sugar between 2008 and 2018. The magnitude of disparities was largest by education. Disparities between Black and White households include the consumption of processed meats and the percentage of calories from sugar, while no disparities were found between White and Hispanic households. Disparities have been largely persistent, as any significant changes over time have been substantively small.

CONCLUSIONS

Policies to improve the healthfulness of packaged foods must be expanded beyond SSB taxes, and future research should focus on what mediates the relationship between education and diet so as not to exacerbate disparities.