Sugary beverage tax policy: lessons learned from tobacco

Policy Opportunities and Legal Considerations to Reform SNAP-Authorized Food Retail Environments

CONTEXT

There is an invigorated national interest in nutrition security, with emphasis on the Supplemental Nutrition Assistance Program (SNAP) playing a key role.

OBJECTIVE

To support healthy food purchasing, several strategies have emerged to modify the food retail environment. However, the legal feasibility of several such policy options has not been established.

DESIGN

Research was conducted using Lexis+ to evaluate statutes, regulations, and case law to determine the legal feasibility of requiring retail-based SNAP signage and nutrition disclosures, healthy endcaps and checkout aisles, and tying advertising restrictions to the licensing of SNAP retailers.

SETTING

US in-store and online food retail retailers.

MAIN OUTCOME MEASURE

Legal feasibility.

RESULTS

Requiring retailers that designate certain foods or locations as SNAP-eligible to consistently do so in all SNAP-eligible pages/locations is likely feasible. If properly drafted to focus on the nutritional quality of food, healthy checkout and endcap restrictions are legally feasible. It is of unclear legal feasibility to require retailers (especially in-store) to disclose nutrition-related labeling, shelf tags, or nonfactual symbols indicating the relative healthfulness of products. Restricting or banning advertising is not legally feasible even if the government ties the restrictions to retail licensing requirements.

CONCLUSIONS

Entities seeking to support healthy food retail should not seek to restrict advertising or compel retailers to convey messages against their interests. The government can license retailers and require them to abide by laws and other requirements that do not violate their constitutional rights. The government can also use its own speech through public service announcements, billboards, and transit advertising to encourage healthy food consumption for all shoppers including those who use SNAP. Additional research is warranted into online retail practices to evaluate variations in online checkout pages and to determine whether online retailers treat SNAP participants differently from non-SNAP participants.

Effects of Sugary Drink Countermarketing Videos on Caregivers' Attitudes and Intentions to Serve Fruit Drinks and Toddler Milks to Young Children

Objectives. To test the effects of countermarketing videos addressing common misperceptions about ingredients and claims on children's sugary drinks. Methods. We conducted an online randomized controlled experiment in January 2021 with US caregivers (n = 600) of young children (aged 8‒37 months) to assess the effects of watching countermarketing versus control videos on intentions to serve sugary and healthy drinks (6-point scales) and attitudes (10-point scales) about fruit drinks and toddler milks. Results. The countermarketing videos significantly reduced positive attitudes about fruit drinks (mean difference = 0.92) and toddler milks (mean difference = 2.10), reduced intentions to serve both (mean difference = 0.50 and 0.92, respectively), and increased intentions to serve plain milk (mean difference = 0.52) versus control videos (all Ps < .001). Intentions differed by individual characteristics, but the videos remained effective after we controlled for these characteristics. Moreover, the videos were more effective for toddler milks versus fruit drinks, and effects on fruit drink intentions were greater for Black versus White caregivers and caregivers of children aged 24 months or younger. Conclusions. A countermarketing campaign aimed at diverse caregivers of young children designed to correct misleading children's drink marketing presents a promising public health approach for reducing sugary drink consumption in the first 1000 days. (Am J Public Health. 2022;112(S8):S807-S816. https://doi.org/10.2105/AJPH.2022.307024).

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.

Infant formula and toddler milk marketing: opportunities to address harmful practices and improve young children's diets

Children's diets in their first 1000 days influence dietary preferences, eating habits, and long-term health. Yet the diets of most infants and toddlers in the United States do not conform to recommendations for optimal child nutrition. This narrative review examines whether marketing for infant formula and other commercial baby/toddler foods plays a role. The World Health Organization's International Code of Marketing Breast-milk Substitutes strongly encourages countries and manufacturers to prohibit marketing practices that discourage initiation of, and continued, breastfeeding. However, in the United States, widespread infant formula marketing negatively impacts breastfeeding. Research has also identified questionable marketing of toddler milks (formula/milk-based drinks for children aged 12-36 mo). The United States has relied exclusively on industry self-regulation, but US federal agencies and state and local governments could regulate problematic marketing of infant formula and toddler milks. Health providers and public health organizations should also provide guidance. However, further research is needed to better understand how marketing influences what and how caregivers feed their young children and inform potential interventions and regulatory solutions.

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

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

Taxation of sugar sweetened beverages and unhealthy foods: a qualitative study of key opinion leaders' views

Background

Fiscal policies to fight obesity such as taxation of unhealthy foods or sugar-sweetened beverages (SSBs) have gained considerable attention in recent years. Many studies modelling the impact of various magnitudes of taxes on SSB purchasing and their potential effects on various health outcomes have been published; however, legislation and implementation of such taxes have encountered many obstacles in the countries that have implemented them to date. We investigated the perceptions and views of key opinion leaders, policy makers and various other Israeli stakeholders on taxation of SSBs and unhealthy snacks. We also evaluated the challenges and barriers that may be expected for initiating such a policy.

Methods

A qualitative study based on 39 in-depth interviews with Israeli stakeholders in the fields of health, nutrition, economics, public advocacy and policymaking.

Results

All stakeholders viewed obesity as a combined societal and personal issue that should be under government responsibility. Only stakeholders from economic sectors thought that taxation of SSBs and unhealthy snacks would reduce their consumption, while the prevailing notion among non-economists was that such a tax would not be acceptable because the higher price would not decrease consumption. Concerns were raised that the tax would mostly affect individuals from low socioeconomic backgrounds. Some of the stakeholders indicated that they would support such a tax only if its revenue would be directed to specific causes such as health-promoting plans. Potential barriers to taxation include: opposition of various sectors, technical and bureaucratic obstacles impeding tax implementation, difficulties in defining which products to tax, and opposition of the treasury to earmark tax revenue for health education.

Conclusions

Taxation should be a part of a multipronged strategy rather than a sole measure for fighting obesity. Dedicating tax revenues to specific predefined causes should be considered, particularly towards health promotion activities, obesity treatment and prevention, education, and subsidies of healthy food.

Lobbying against sugar taxation in the European Union: Analysing the lobbying arguments and tactics of stakeholders in the food and drink industries

Aims: This study investigates the lobbying actors of the food and drink industry (FDI), their web lobbying arguments used in the sugar taxation debate and the tactics deployed when facing legislative restrictions on their products to curb the burden of non-communicable diseases in Europe. Methods: A stakeholder analysis was performed to identify the FDI's actors lobbying against sugar taxation within the EU Platform for Action on Diet, Physical Activity and Health during December 2015. Qualitative content analysis was applied to assess the FDI's web lobbying claims related to three main concepts (sugar as a product, sugar's association with non-communicable diseases and sugar taxation), guided by a framework for corporate political activity. Results: The web site content of a front organization and six FDI lobbyists was analysed. Some new strategies emerged alongside known corporate strategies ('questioning the effectiveness of regulation and promoting benefits of a withdrawal', 'promoting sugar's good traits and shift the blame away from it' and 'establishing relationships with trade unions'). The lobby tactics were similar to those previously applied by the tobacco industry in Europe, although the argument that sugar is a natural ingredient in many foods was unique to the FDI. Conclusions: The observed tactics and arguments presented by the FDI in opposition to sugar taxation have striking similarities with those previously used by the tobacco industry. An improved understanding of the stakeholders' mandate and resources and their most important tactics will strengthen the position of public health experts when debating sugar taxation with the FDI, which may contribute to improving population health.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Taxing Sugary Beverages Reduces Their Purchase, Especially Among Poor Households

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

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

SOURCE OF FUNDING

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

TYPE OF STUDY/DESIGN

Observational study.

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

OBJECTIVES

We assessed the short-term ability to increase retail prices of the first US 1-cent-per-ounce excise tax on the distribution of sugar-sweetened beverages (SSBs), which was implemented in March 2015 by Berkeley, California.

METHODS

In 2014 and 2015, we examined pre- to posttax price changes of SSBs and non-SSBs in a variety of retailers in Berkeley and in the comparison cities Oakland and San Francisco, California. We examined price changes by beverage, brand, size, and retailer type.

RESULTS

For smaller beverages (≤ 33.8 oz), price increases (cents/oz) in Berkeley relative to those in comparison cities were 0.69 (95% confidence interval [CI] = 0.36, 1.03) for soda, 0.47 (95% CI = 0.08, 0.87) for fruit-flavored beverages, and 0.47 (95% CI = 0.25, 0.69) for SSBs overall. For 2-liter bottles and multipacks of soda, relative price increases were 0.46 (95% CI = 0.03, 0.89) and 0.49 (95% CI = 0.21, 0.77). We observed no relative price increases for nontaxed beverages overall.

CONCLUSIONS

Approximately 3 months after the tax was implemented, SSB retail prices increased more in Berkeley than in nearby cities, marking a step in the causal pathway between the tax and reduced SSB consumption.

The Relationship between Parental Behaviors and Children's Sugary Drink Consumption Is Moderated by a Television in the Child's Bedroom

BACKGROUND

The aim of this longitudinal study was to examine the link between perceived authoritative parenting behaviors and sugary drink consumption among children from low-income families who do or do not have televisions (TVs) in their bedrooms.

METHODS

Middle school students (N = 480) completed a baseline survey in sixth grade and a follow-up survey in seventh grade. The students were recruited from 12 schools in a low-income, predominantly black (33%) and Latino (48%), urban school district. The survey assessed the children's perception of their parents' controlling and nurturing behaviors, the presence of a TV in their bedrooms, and their level of sugary drink consumption on the previous school day. Children's report of specific controlling and nurturing parental behaviors were used to create an "authoritative parenting" score. Regression analyses were used to test the main and interactive effects of authoritative parenting behaviors and having a TV in the bedroom with sugary drink consumption in seventh grade, controlling for age, race/ethnicity, gender, BMI, and sugary drink consumption in sixth grade.

RESULTS

A significant interaction emerged: The authoritative parenting score predicted lower levels of sugary drink consumption in seventh grade, but this relationship was moderated by whether or not there was a TV in the child's bedroom.

CONCLUSION

A TV in the child's bedroom may weaken the positive influence of authoritative parenting behaviors on limiting sugary drink consumption among middle school children from low-income families. Stronger initiatives are recommended to educate parents and help them refrain from placing TVs in their children's bedrooms.

Diffusion of Impaired Driving Laws Among US States

OBJECTIVES

We examined internal and external determinants of state's adoption of impaired driving laws.

METHODS

Data included 7 state-level, evidence-based public health laws collected from 1980 to 2010. We used event history analyses to identify predictors of first-time law adoption and subsequent adoption between state pairs. The independent variables were internal state factors, including the political environment, legislative professionalism, government capacity, state resources, legislative history, and policy-specific risk factors. The external factors were neighboring states' history of law adoption and changes in federal law.

RESULTS

We found a strong secular trend toward an increased number of laws over time. The proportion of younger drivers and the presence of a neighboring state with similar laws were the strongest predictors of first-time law adoption. The predictors of subsequent law adoption included neighbor state adoption and previous legislative action. Alcohol laws were negatively associated with first-time adoption of impaired driving laws, suggesting substitution effects among policy choices.

CONCLUSIONS

Organizations seeking to stimulate state policy changes may need to craft strategies that engage external actors, such as neighboring states, in addition to mobilizing within-state constituencies.

Is Sugar the new Tobacco? Insights from Laboratory Studies, Consumer Surveys and Public Health

In the Americas, mean energy intake from added sugar exceeds recent World Health Organization recommendations for free sugars in the diet. As a leading contributor to this excess, sugar-sweetened beverage (SSB) overconsumption represents a risk for the population's health. This article provides an overview of clinical and epidemiological evidence, marketing practices, corporate influence and prevention strategies related to added sugar and SSB. For each aspect of this multidimensional profile, we briefly compare SSB to the case of tobacco pointing to similarities but also major differences. Tobacco control has demonstrated the effectiveness of long term multifaceted prevention strategies in multiple settings supported by strong public policies which may be applied to the consumption of SSB. However, translating these policies to the specific case of SSB is urgently needed, to inform preventive actions, decide which intervention mix will be used, and evaluate the process and impact of the chosen strategy.

Defining commercial speech in the context of food marketing

Obesity is a public health problem in the United States. Experts have identified the regulation of food marketing as a policy strategy to address obesity and poor nutrition. However, the First Amendment can be a barrier to reducing exposure to problematic food marketing. In recent years, courts have become increasingly protective of speech, and particularly of “commercial speech,” or advertising, which can make it more difficult to regulate certain marketing practices.

Effect of national recommendation on sweet selling as an intervention for a healthier school environment

Aims: In 2007, the Finnish National Board of Education (FNBE) and the National Institute for Health and Welfare (THL) gave a national recommendation that Finnish upper comprehensive schools should not sell sweet products. The aim was to find out how the national recommendation changed the schools’ selling of sweet products. Methods: This longitudinal survey was conducted in Finnish upper comprehensive school classes 7–9 (13–15-year-old pupils) in 2007 and 2010. All the schools ( N=970) were invited to answer the questionnaire and 237 schools answered in both years (response rate 24%). The questionnaires contained questions concerning the selling of sweet and healthy products and school policy on sweet selling guidelines. Of the nine items in the questionnaire, three weighted sum scores were formed for oral health promotion: Exposure, enabling and policy (higher score indicating better actions). These sum scores were also trichotomized. Statistical significances of the changes were analyzed using nonparametric Wilcoxon’s test, McNemar’s test, and McNemar-Bowker’s test. Results: Schools had decreased exposure of pupils to sweet products ( p<0.001), more often provided oral health protecting items ( p=0.047) and had improved their oral health-promoting policy ( p<0.001). The selling of some sweet products, candies and soft drinks had decreased ( p<0.001) whereas the selling of other sweet products had not changed ( p=0.665). Schools tended to improve their exposure and policy status ( p<0.001). Conclusion: It is possible to improve school environments by means of a national recommendation. Other actions are needed both inside and outside schools in order to decrease the total consumption of sweet products among adolescents.