Public acceptability of a sugar-sweetened beverage tax and its associated factors in the Netherlands

An unequal health policy landscape? Examining socioeconomic differences in acceptability and preferences for policies that aim to reduce socioeconomic inequalities in health

BACKGROUND

This study explores socioeconomic differences in acceptability and preferences for policies that aim to reduce socioeconomic health inequalities. The investigated policies range from structural policies, requiring no individual agency, to agentic policies, which depend on the individual agency for behaviour change.

METHODS

An online, cross-sectional survey was conducted among 1182 participants, stratified by education and representative of Dutch adults (aged 25-65) for age and gender. Across 31 policies, including structural socioeconomic policies, structural housing and neighbourhood policies, structural and agento-structural behavioural policies (facilitating behaviour) and agentic policies (focusing on information provision for behaviour change), acceptability was measured on a 7-point scale, preferences were measured using participants' top-5 policy choices. Regression analyses examined socioeconomic differences in acceptability and preferences based on education and income, controlling for age, gender, receiving welfare, and employment.

RESULTS

People in lower socioeconomic positions were more likely to accept and favour structural socioeconomic policies, whereas those in higher socioeconomic positions were more likely to accept and favour structural housing and neighbourhood, structural and agento-structural behavioural, and agentic policies. Socioeconomic differences were the largest for agentic policies. Overall, 83.3% preferred at least one structural socioeconomic policy, while only 32% preferred an agentic policy. Most preferred was eliminating taxes on fruits and vegetables, (preferred by 41.4%), and least preferred was a campaign promoting healthy nutrition (preferred by 3.9%).

CONCLUSIONS

These socioeconomic differences in policy support underscore the need for inclusive policymaking processes. Including the perspectives of people in lower socioeconomic positions helps to ensure that their needs are met.

Attitudes of Chinese residents toward sugar-sweetened beverage tax and their willingness to pay: a cross-sectional survey

Background

Excessive consumption of sugar-sweetened beverages (SSBs) is associated with increased risks of obesity and chronic diseases. To effectively control SSB consumption, several countries including Mexico, France, and the United Kingdom have implemented SSB taxes. However, research on SSB taxes in China is limited.

Objective

To assess the attitudes of Chinese residents toward the SSB tax and their willingness to pay the tax. Methods: Data were collected through a questionnaire survey among 881 respondents. The generalized ordered logit regression model and marginal effect analysis were used to analyze Chinese participants' attitudes toward SSB tax and their willingness to pay it.

Results

The average monthly expenditure on SSBs was 44.8 ± 45.3 Yuan (RMB) (6.95 ± 7.02$), and 54.6% of residents supported the SSB tax; they were willing to pay, on average, 1.19 times the original price after additional tax. Age, physical exercise, self-rated health status, weight control plan, awareness of SSBs, children's consumption of SSBs, and proximity to the nearest SSB outlet significantly influenced attitudes toward tax. Notably, SSB awareness had the greatest effect on tax attitudes, with a 17% increase in the probability of supporting SSB tax for every one-level increase in SSB awareness among residents.

Conclusion

Residents in China have attained a certain level of awareness of, support for, and willingness to pay SSB tax. However, promoting knowledge about the health effects of SSBs and conducting further research to evaluate the effect of SSB tax on obesity prevention in China is still essential.

An examination of public support for 35 nutrition interventions across seven countries

BACKGROUND

Public support for evidence-based nutrition interventions can be an important determinant of government willingness to develop and implement such interventions. The aim of this study was to assess support for a broad range of nutrition interventions across seven countries: Australia, Canada, China, India, New Zealand, the United Kingdom, and the United States. Assessed interventions included those relating to food availability, affordability, reformulation, labelling, and promotion.

METHODS

Approximately 1000 adults per country (total n = 7559) completed an online survey assessing support for 35 nutrition interventions/policies. ANOVA analyses were used to identify differences between countries on overall levels of support and by intervention category. Multiple regression analyses assessed demographic and diet-related factors associated with higher levels of support across the total sample and by country.

RESULTS

Substantial levels of public support were found for the assessed interventions across the seven countries and five intervention categories. The highest levels were found in India (Mean across all interventions of 4.16 (standard deviation (SD) 0.65) on a 5-point scale) and the lowest in the United States (Mean = 3.48, SD = 0.83). Support was strongest for interventions involving food labelling (Mean = 4.20, SD = 0.79) and food reformulation (Mean = 4.17, SD = 0.87), and weakest for fiscal interventions (Mean = 3.52, SD = 1.06). Consumer characteristics associated with stronger support were higher self-rated health, higher educational attainment, female sex, older age, and perceptions of consuming a healthy diet.

CONCLUSION

The results indicate substantial support for a large range of nutrition interventions across the assessed countries, and hence governments could potentially be more proactive in developing and implementing such initiatives.

Risk Factors Associated with the Consumption of Sugar-Sweetened Beverages among Czech Adults: The Kardiovize Study

High consumption of sugar-sweetened beverages (SSBs) is associated with a higher risk of cardiovascular disease (CVD). The last report on the prevalence of SSBs consumption in Czechia was 17 years ago, an updated analysis will enable the design of appropriate public health policies. This study aimed to determine the prevalence of SSBs consumption in a Czech city during 2020 and 2022, and its association with cardiometabolic biomarkers, behavioral risk factors, and socioeconomic determinants. A total of 730 participants (33 to 73 years) were assessed from a random population-based survey. SSBs consumption was evaluated using two methods: by calorie amount, with a 24 h dietary recall, and by frequency, with a food frequency questionnaire. By calorie amount, the prevalence of SSBs consumption was none: 52.5%, low: 30.0%, and moderate−high: 17.5%; by frequency was never: 16.0%, occasionally: 64.1%, and daily: 19.9%. SSBs intake was higher in men (p < 0.001) and younger participants (p = 0.001). Men consuming daily had higher waist circumference and visceral fat area compared to both occasional and never consumers. Higher SSBs consumption was associated with low household income, middle education level, and high total energy intake. In total, 20% drank SSBs daily and 17.5% of participants consumed moderate−high calorie amounts of SSBs. These results represent an increase in the prevalence of SSBs consumption in the last two decades. Public health policies should target men of younger age and people with low education and income.

Dietary behaviour and physical activity policies in Europe: learnings from the Policy Evaluation Network (PEN)

The European Policy Evaluation Network (PEN), initiated in autumn 2018, aimed at advancing the evidence base for public policies impacting dietary behaviour, physical activity and sedentary behaviours in Europe. This is needed because non-communicable diseases-the leading cause of global mortality-are substantially caused by physical inactivity and unhealthy dietary behaviours, which in turn are driven by upstream factors that have not yet been addressed effectively by prevention approaches. Thus, successful policy interventions are required that target entire populations and tackle the 'causes of the causes'. To advance our knowledge on the effective implementation of policies and their impact in terms of improving health behaviours, PEN focused on five research tasks: (i) Adaptation and implementation of a Food Environment Policy Index (Food-EPI) and development of a Physical Activity Environment Policy Index (PA-EPI); (ii) Mapping of health-related indicators needed for policy evaluation and facilitating a harmonized pan-European approach for surveillance to assess the impact of policy interventions; (iii) Refining quantitative methods to evaluate the impact of public policies; (iv) Identifying key barriers and facilitators of implementation of policies; and (v) Advance understanding the equity impact of the development, implementation and evaluation of policies aimed at promoting physical activity and a healthy diet. Finally, and in order to provide concrete evidence for policymaking, existing exemplary policies, namely sugar-sweetened beverages taxation, active transport policies and school policies on nutrition and physical activity were assessed in consideration of these five tasks. At the end of the PEN project's formal runtime, considerable advancements have been made. Here, we present an overview of the most important learnings and outputs.

Public perception of the tax on sweetened beverages in France

OBJECTIVE

To assess in 2021 the acceptance and perception of the French tax on sweetened beverages, following its revision in 2018, and factors associated with a higher level of acceptance.

DESIGN

A cross-sectional survey within the NutriNet-Santé cohort study. Participants were invited to complete a self-reported questionnaire in March 2021. Weighting was applied to the sample to allow inferences on the French population. Individual characteristics associated with support for the tax were investigated using logistic regression modelling.

SETTINGS

NutriNet-Santé prospective cohort study.

PARTICIPANTS

Adults engaged in the NutriNet-Santé cohort, aged 18 years or older (n 28 344), living in mainland France.

RESULTS

Almost two-thirds (63·4 %) of the participants were aware of the existence of a tax on sweetened beverages, although less than a quarter had specific knowledge regarding its design and the 2018 revision. In turn, 64·7 % of participants expressed a favourable opinion towards the taxation scheme. This proportion was higher if tax revenues were used to finance health-related measures (respectively 68·8 % of favourable opinion if used to finance a reduction in prices of healthy products and 76·4 % if used to finance the healthcare system). Multivariable analyses showed that support towards the tax varied among subgroups of the population. Groups who tended to be less financially affected by the measure and those who perceived sugar-sweetened beverages as having detrimental effects were more likely to support the tax.

CONCLUSION

The revised French sugar-sweetened beverage tax appeared to be favourably received and perceived by the public.

The 'sugar tax' in Bermuda: a mixed methods study of general population and key stakeholder perceptions

Background

Taxes on discretionary foods and sugar-sweetened beverages have emerged as a strategy for health promotion. Between 2018–2019, the Bermuda government introduced a phased tax on imported sugar-sweetened beverages, confectionery, products containing cocoa and pure sugar, and eliminated import duties on select healthy food items. The aim of this study was to conduct an mixed methods evaluation of perceptions of the tax among the general population and key stakeholders.

Methods

We conducted a survey of the general population (N = 400), and semi-structured interviews with key informants (N = 14) from the government, food and beverage, and health sectors to understand awareness, acceptability, and perceived impact of the tax after implementation. Survey data was analysed using thematic analysis, summary statistics, and Chi-squared tests. Key informant interviews were analysed using the framework method.

Results

General population respondents had high awareness of the sugar tax (94%) but low awareness of the healthy food subsidy (32%). Most respondents (67%) felt the tax was not an appropriate way to motivate healthier consumption due to beliefs the tax would not be effective (44%), and because of the high price of healthy food (20%). However, nearly half (48%) reported consuming fewer taxed products, primarily for health reasons but also motivated by price increases. Key informants indicated there was high awareness but limited understanding of the tax policy. Informants expressed support for taxation as a health promotion strategy, conditional on policy implementation. The lack of clear price differentiation between taxed and un-taxed products and the absence of accompanying health education were key factors believed to affect the impact of the tax. No informants were aware of use of tax revenues for health purposes and tax revenue was reportedly re-directed to other priorities after implementation.

Conclusions

There was high awareness, but limited acceptability of the Bermuda sugar tax as implemented. Clarity in the tax policy, appropriateness of the tax mechanism, and use of revenue in alignment with the tax aim are critical components for acceptance. The absence of complementary education and health promotion affected acceptance and may limit potential health impacts. The lessons learned in Bermuda can inform similar policies in other settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13945-9.

The effects of a sugar-sweetened beverage tax and a nutrient profiling tax based on Nutri-Score on consumer food purchases in a virtual supermarket: a randomised controlled trial

OBJECTIVE

To investigate the effects of a sugar-sweetened beverage (SSB) tax and a nutrient profiling tax on consumer food purchases in a virtual supermarket.

DESIGN

A randomised controlled trial was conducted with a control condition with regular food prices (n 152), an SSB tax condition (n 130) and a nutrient profiling tax condition based on Nutri-Score (n 112). Participants completed a weekly grocery shop for their household. Primary outcome measures were SSB purchases (ordinal variable) and the overall healthiness of the total shopping basket (proportion of total unit food items classified as healthy). The secondary outcome measure was the energy (kcal) content of the total shopping basket. Data were analysed using regression analyses.

SETTING

Three-dimensional virtual supermarket.

PARTICIPANTS

Dutch adults aged ≥18 years are being responsible for grocery shopping in their household (n 394).

RESULTS

The SSB tax (OR = 1·62, (95 % CI 1·03, 2·54)) and the nutrient profiling tax (OR = 1·88, (95 %CI 1·17, 3·02)) increased the likelihood of being in a lower-level category of SSB purchases. The overall healthiness of the total shopping basket was higher (+2·7 percent point, (95 % CI 0·1, 5·3)), and the energy content was lower (-3301 kcal, (95 % CI -6425, -177)) for participants in the nutrient profiling tax condition than for those in the control condition. The SSB tax did not affect the overall healthiness and energy content of the total shopping basket (P > 0·05).

CONCLUSIONS

A nutrient profiling tax targeting a wide range of foods and beverages with a low nutritional quality seems to have larger beneficial effects on consumer food purchases than taxation of SSB alone.

Stakeholder views on taxation of sugar-sweetened beverages and its adoption in the Netherlands

An increasing number of governments worldwide have introduced a tax on sugar-sweetened beverages (SSB) for public health. However, the adoption of such a policy is still debated in many other countries, such as in the Netherlands. We investigated Dutch stakeholder views on taxation of SSB and perceived barriers and facilitators to its adoption in the Netherlands. Semi-structured interviews were conducted in 2019 with 27 stakeholders from health and consumer organizations, health professional associations, trade associations, academia, advisory bodies, ministries and parliamentary parties. Data were analysed using a thematic content approach. The findings reveal that, between and within sectors, stakeholders expressed contradictory views on the effectiveness, appropriateness and (socio)economic effects of an SSB tax. Perceived barriers to the adoption of an SSB tax in the Netherlands included an unfavourable political context, limited advocacy for an SSB tax, a strong lobby against an SSB tax, perceived public opposition, administrative load and difficulties in defining SSB. Perceived facilitators to its adoption included an increasing prevalence of overweight, disappointing results from voluntary industry actions, a change of government, state budget deficits, a shift in public opinion, international recommendations and a solid legal basis. In conclusion, this study shows that several challenges remain to be overcome for the adoption of an SSB tax in the Netherlands. Similar research on stakeholder views in other countries may further inform SSB tax policy processes.

Effectiveness and Policy Determinants of Sugar-Sweetened Beverage Taxes

Sugar consumption is on the rise globally with detrimental (oral) health effects. There is ample evidence that sugar-sweetened beverage (SSB) taxes can efficiently reduce sugar consumption. However, evidence alone is seldom enough to implement a policy. In this article, we present a narrative synthesis of evidence, based on real-world SSB tax evaluations, and we combine this with lessons from policy development case studies. This article is structured according to the Health Policy Analysis Triangle, which identifies a policy's content and process and important contextual factors. SSB tax policy content needs to be coupled to existing problems and public sentiment, which depend on more aspects than aspects related to (oral) health alone. Whether or not to include artificially sweetened beverages, therefore, is not solely a matter of showing the evidence of their oral health impact but also dependent on the stated aim of a tax and public sentiment toward tax policies in general. SSB taxes also need to be in line with existing tax and decision-making rules. Earmarking revenue for specific (health promotion) purposes may therefore be less straightforward as it might appear. The policy process of creating context-sensitive SSB tax policy content is not easy either. Advocacy coalitions need to be formed early in the process, and stamina, expertise, and flexibility are required to get a SSB tax adopted in a specific community. This requires a meticulously considered SSB tax structure implementation process. Oral health professionals who want to lead the way in advocating for SSB taxes should realize that evidence-based arguments on potential effectiveness alone will not be enough to realize change. The oral health community can learn important lessons from other "doctor-activists" such as pulmonologists, who have successfully advocated for higher tobacco taxes by being visible in the public debate with clear messaging and robust policy proposals.

Stakeholder views on the potential impact of a sugar-sweetened beverages tax on the budgets, dietary intake, and health of lower and higher socioeconomic groups in the Netherlands

BACKGROUND

Socioeconomic inequalities in overweight and obesity exist in many European countries. A sugar-sweetened beverages (SSB) tax may contribute to a reduction of these inequalities. However, in the Netherlands, the government decided to not (yet) introduce an SSB tax, although the government has acknowledged its potential to be pro-equity. Understanding how various stakeholder groups perceive the potential effects of an SSB tax on different socioeconomic groups may provide useful insights into equity-related considerations in the debate whether or not to implement an SSB tax. This study aims to gain insight into the perceptions of stakeholder groups in the Netherlands on (1) the effects of an SSB tax on the budgets of lower and higher socioeconomic groups and (2) the impact of an SSB tax on socioeconomic inequalities in dietary intake and health.

METHODS

Semi-structured interviews were conducted in 2019 with 27 participants from various stakeholder groups in the Netherlands (i.e. health and consumer organizations, health professional associations, trade associations, academia, advisory bodies, ministries and parliamentary parties). Data were analyzed using a thematic content approach.

RESULTS

Participants from all stakeholder groups indicated that an SSB tax would have a larger impact on the budgets of lower socioeconomic groups. Participants from nearly all stakeholder groups (except trade associations) mentioned that an SSB tax could have greater health benefits among lower socioeconomic groups as these often have a higher SSB consumption and are more likely to be overweight or obese. Some participants mentioned that an SSB tax may have no or adverse health effects among lower socioeconomic groups (e.g. compensation of lower SSB consumption with other unhealthy behaviours). Some participants emphasised that an SSB tax should only be introduced when accompanied by other interventions (e.g. offering healthy alternatives), to make it easier for lower socioeconomic groups to lower their SSB consumption in response to an SSB tax, and to prevent adverse health effects.

CONCLUSIONS

Participants believed an SSB tax could contribute to a reduction in socioeconomic inequalities in dietary intake and health. However, additional interventions facilitating the reduction of SSB consumption in lower socioeconomic groups were recommended.

The Acceptance of Key Public Health Interventions by the Polish Population Is Related to Health Literacy, But Not eHealth Literacy

Background: Public health and health promotion rely on many different interventions, which range from health education and communication, through community mobilisation and changes to environmental conditions, to legal and fiscal actions. The introduction of the increased tax on sugar-sweetened beverages (SSB), popularly called sugar tax (ST), and a mandatory programme of vaccinations are the strategies inciting the most vivid discussions in Polish society. The study was intended to assess the determinants of the attitudes of Polish society regarding the ST and to vaccinations. Methods: For the analysis, the data originating from the survey of a representative adult sample of Polish society (n = 1000) was used. The survey was based on computer-assisted telephone interviewing (CATI). The assessment of the relationships between the selected variables and the opinions about the introduction of the ST and the safety and effectiveness of vaccinations were carried out using the chi² test and univariate logistic regression models. Results: The acceptance of the ST and vaccination showed a significant relationship to the level of health literacy (HL) but not to eHealth literacy (eHL). Respondents having a higher rather than lower HL; older rather than younger; married rather than singles; retired, or on a disability pension, rather than vocationally active and nonusers of the Internet rather than users were more likely to show an acceptance for both interventions. Those more frequently using health care services and those with chronic diseases showed a greater belief in the safety and effectiveness of vaccinations. Conclusions: The relationship between the opinions of the two public health interventions analysed and the sociodemographic variables demonstrated similar patterns. Interestingly, the opinions were associated only with HL and not with eHL and users of the Internet were more sceptical about the interventions.