Tax awareness and perceived cost of sugar-sweetened beverages in four countries between 2017 and 2019: findings from the international food policy study.

BACKGROUND: The public health benefits of sugar-sweetened beverage (SSB) taxes often rely on, among other things, changes to consumer purchases. Thus, perceived cost of SSBs and signalling effects-via awareness of the tax-may impact the effectiveness of SSB taxes on consumer purchases. OBJECTIVE: The study sought to examine perceived cost of SSBs, tax awareness, and changes in beverage purchasing over time and across four countries with and without SSB taxes. METHODS: The study used data from the 2017, 2018 and 2019 waves of the International Food Policy Study. Annual cross-sectional online surveys were conducted in Australia, Mexico, UK and US, which captured perceived cost of SSBs relative to non-SSBs in all countries (with Australia as a no-tax comparator), and measures of tax awareness and participants' reported changes in beverage purchasing in response to SSB taxes in Mexico (tax implemented in 2014), UK (tax implemented in 2018) and US (subnational taxes since 2015). Logistic regression models evaluated the measures across years and socio-demographic groups. RESULTS: Perceived cost of SSBs relative to non-SSBs was higher in Mexico (all three years) and the UK (2018 and 2019 following tax implementation) than Australia and the US. Tax awareness was higher in UK than Mexico, and decreased over time among Mexican respondents. Patterns of reported beverage purchasing changes in response to the tax were similar across Mexico, UK and US, with the largest changes reported by Mexican respondents. Respondents with characteristics corresponding to lower socioeconomic status were less likely to be aware of an SSB tax, but more likely to perceive SSBs to cost more than non-SSBs and report changes in purchasing in response to the tax, where there was one. CONCLUSIONS: This study suggests that in countries where a national SSB tax was present (Mexico, UK), perceived cost of SSBs and tax awareness were higher compared to countries with no SSB tax (Australia) or subnational SSB taxes (US), respectively, and suggests that perceived cost and tax awareness represent distinct constructs. Improving the 'signalling effect' of existing SSB taxes may be warranted, particularly in tax settings where consumer behaviour change is a policy objective.

Exploring the main and moderating effects of individual-level characteristics on consumer responses to sugar taxes and front-of-pack nutrition labels in an experimental marketplace.

INTERVENTION: This study examined whether the impacts of sugar taxes and front-of-pack (FOP) nutrition labels differ across socio-demographic subgroups. RESEARCH QUESTION: What are the main and moderating effects of individual-level characteristics on the nutrient content of participants' purchases in response to varying taxation levels and FOP labels? METHODS: Data from an experimental marketplace were analyzed. A sample of 3584 Canadians aged 13 years and older received $5 to purchase an item from a selection of 20 beverages and 20 snack foods. Participants were shown products with one of five FOP labels and completed eight within-subject purchasing tasks with different tax conditions. Linear mixed models were used to estimate the main and moderating effects of 11 individual-level variables on the sugars, sodium, saturated fats, and calorie content of participants' purchases. RESULTS: Participants who were younger, male, and more frequent consumers of sugary drinks purchased products containing more sugars, sodium, saturated fats, and calories. Sex and age moderated the relationship between tax condition and sugars or calories purchased: female participants were more responsive than males to a tax that included fruit juice, and younger participants were more responsive to all sugar tax conditions than older participants. Reported thirst and education level also moderated the relationship between tax condition and calories purchased. No individual-level characteristics moderated the effects of FOP labels. CONCLUSION: A small proportion (7 of 176) of the moderating effects tested in this study were significant. Sugar taxes and FOP labelling policies may therefore produce similar effects across key socio-demographic groups.

RéSUMé: INTERVENTION: Dans cette étude, nous avons cherché à déterminer si les effets des taxes sur le sucre et de l'étiquetage nutritionnel sur le devant des emballages sont les mêmes dans différents sous-groupes sociodémographiques. QUESTION DE RECHERCHE: Quels sont les principaux effets et les effets modérateurs des caractéristiques individuelles sur le contenu nutritionnel des achats des participants quand le niveau des taxes et l'étiquetage sur le devant des emballages varient? MéTHODE: Nous avons analysé les données d'un marché expérimental. Nous avons offert à un échantillon de 3 584 Canadiens de 13 ans et plus 5 $ pour acheter un article parmi 20 boissons et 20 grignotines. Les participants se sont fait présenter des produits portant l'une de cinq étiquettes sur le devant de l'emballage et ont effectué huit tâches d'achat intra-sujet avec différentes modalités de taxation. Des modèles linéaires mixtes ont servi à estimer les principaux effets et les effets modérateurs de 11 variables individuelles sur la teneur en sucres, en sodium, en graisses saturées et en calories des achats des participants. RéSULTATS: Les jeunes, les participants de sexe masculin et les consommateurs fréquents de boissons sucrées ont acheté des produits contenant plus de sucres, de sodium, de graisses saturées et de calories. Le sexe et l'âge ont modéré la relation entre la modalité de taxation et les sucres ou les calories achetés : les filles et les femmes étaient plus sensibles que les garçons et les hommes à une taxe incluant les jus de fruits, et les jeunes étaient plus sensibles à toutes les modalités de taxation du sucre que les participants plus âgés. La soif et le niveau d'instruction autodéclarés ont aussi modéré la relation entre la modalité de taxation et les calories achetées. Aucune caractéristique individuelle n'a modéré les effets des étiquettes sur le devant des emballages. CONCLUSION: Seule une petite proportion (7 sur 176) des effets modérateurs testés dans l'étude était significative. Les politiques de taxation du sucre et d'étiquetage sur le devant des emballages pourraient donc produire des effets semblables dans plusieurs groupes sociodémographiques clés.

How Does the Probability of Purchasing Moderately Sugary Beverages and 100% Fruit Juice Vary Across Sugar Tax Structures?

OBJECTIVE: Sugar-sweetened beverage taxes are increasingly used to discourage sugar intake; however, the impact on consumer preferences for particular products is largely unknown. This study explored the impact of two tax structures (tiered vs. nontiered and inclusive vs. exclusive of 100% fruit juice) on participants' probability of purchasing moderately sugary beverages and 100% fruit juice. METHODS: A sample of 3,584 Canadians aged 13 years and older completed a series of beverage purchasing tasks, each corresponding to a different tax condition, within an experimental marketplace. Tax conditions included a no-tax control, plus four taxes varying by structure (tiered vs. nontiered) and whether or not 100% fruit juice was included. RESULTS: The odds of purchasing a moderately sugary beverage were higher under tiered versus nontiered taxes. Purchases of higher sugar beverages differed little across tiered versus nontiered structures. Odds of purchasing 100% fruit juice were lower when these products were taxed versus not taxed. CONCLUSIONS: Results suggest that two key tax structures are likely to function as expected; taxes including 100% fruit juice products may lead to lower probability of purchasing fruit juice, and taxes incorporating multiple tiers may be more likely to encourage purchases of moderately sugary products than nontiered formats.

Impact of sugar taxes and front-of-package nutrition labels on purchases of protein, calcium and fibre.

Taxes and front-of-package (FOP) labels can be effective interventions for reducing consumption of sugar, saturated fat, and sodium; however, few studies have examined their impact on intake of 'positive' nutrients. The current study explored the impact of sugar taxes and FOP labels on the protein, calcium and fibre density of snack food purchases. A total of 3584 Canadians aged 13 years and older participated in an experimental marketplace using a 3 × 8 between-within group experiment. Participants received $5 and viewed images of 20 snack food products available for purchase. Participants were randomized to one of five FOP label conditions (no label, high in, multiple traffic light, health star rating, or nutrition grade) and completed three within-subject purchasing tasks with different sugar tax conditions (no tax, 20%, tiered). Upon conclusion, participants received the product and any change from one of the purchasing tasks. The results indicate that participants purchased snack foods with higher fibre density when either sugar tax was applied (+0.1 g/100 kcal) compared to no tax, and when they were assigned to see the multiple traffic light (+0.4 g/100 kcal) or health star rating (+0.3 g/100 kcal) FOP labels, compared to no FOP label. There were no significant differences in the protein or calcium density of snack foods purchased across the tax or FOP labelling conditions. Overall, the findings suggest that as consumers respond to tax or labelling policies by moving away from sugars, sodium, and saturated fat, there may be no downside-or even an increase-in 'positive' nutrient density.

Taxes and front-of-package labels improve the healthiness of beverage and snack purchases: a randomized experimental marketplace.

BACKGROUND: Sugar taxes and front-of-package (FOP) nutrition labelling systems are strategies to address diet-related non-communicable diseases. However, there is relatively little experimental data on how these strategies influence consumer behavior and how they may interact. This study examined the relative impact of different sugar taxes and FOP labelling systems on beverage and snack food purchases. METHODS: A total of 3584 Canadians 13 years and older participated in an experimental marketplace study using a 5 (FOP label condition) × 8 (tax condition) between-within group experiment. Participants received $5 and were presented with images of 20 beverages and 20 snack foods available for purchase. Participants were randomized to one of five FOP label conditions (no label; 'high in' warning; multiple traffic light; health star rating; nutrition grade) and completed eight within-subject purchasing tasks with different taxation conditions (beverages: no tax, 20% tax on sugar-sweetened beverages (SSBs), 20% tax on sugary drinks, tiered tax on SSBs, tiered tax on sugary drinks; snack foods: no tax, 20% tax on high-sugar foods, tiered tax on high-sugar foods). Upon conclusion, one of eight selections was randomly chosen for purchase, and participants received the product and any change. RESULTS: Compared to those who saw no FOP label, participants who viewed the 'high in' symbol purchased less sugar (- 2.5 g), saturated fat (- 0.09 g), and calories (- 12.6 kcal) in the beverage purchasing tasks, and less sodium (- 13.5 mg) and calories (- 8.9 kcal) in the food tasks. All taxes resulted in substantial reductions in mean sugars (- 1.4 to - 4.7 g) and calories (- 5.3 to - 19.8 kcal) purchased, and in some cases, reductions in sodium (- 2.5 to - 6.6 mg) and saturated fat (- 0.03 to - 0.08 g). Taxes that included 100% fruit juice ('sugary drink' taxes) produced greater reductions in sugars and calories than those that did not. CONCLUSIONS: This study expands the evidence indicating the effectiveness of sugar taxation and FOP labelling strategies in promoting healthy food and beverage choices. The results emphasize the importance of applying taxes to 100% fruit juice to maximize policy impact, and suggest that nutrient-specific FOP 'high in' labels may be more effective than other common labelling systems at reducing consumption of targeted nutrients.

Evaluation of a 24-Hour Caffeine Intake Assessment Compared with Urinary Biomarkers of Caffeine Intake among Young Adults in Canada.

BACKGROUND: Caffeine is a widely consumed stimulant, and caffeine-containing products are increasingly available on the market. Few tools are available to capture caffeine intake, particularly among young adults. To estimate caffeine consumption in the previous 24 hours, the 24-Hour Caffeine Intake Recall (CIR-24) was modeled after the Automated Self-Administered 24-Hour Dietary Assessment Tool, using a brand-specific database of caffeine-containing foods, beverages, and supplements. OBJECTIVE: To evaluate the accuracy of the CIR-24 compared with caffeine concentration biomarkers in urine and a caffeinated beverage intake frequency screener (CBQ) designed to assess usual intake among a young adult population in Canada. DESIGN/PARTICIPANTS: In all, 79 young adults, aged 18 to 29 years, provided 24-hour urine samples and completed the CIR-24 and CBQ. MAIN OUTCOME MEASURES: Excretion for caffeine and eight caffeine metabolites were quantified from urine samples using high-performance liquid chromatography-polarity switching electrospray ionization-tandem quadrupole mass spectrometry with stable isotope-labeled internal standards. STATISTICAL ANALYSES PERFORMED: Pearson correlations and weighted κ coefficients were calculated for the self-report tools and caffeine biomarkers. RESULTS: The CIR-24 was significantly positively associated with all caffeine biomarkers (rp=0.28 to 0.52, κ=0.39 to 0.59), and the CBQ was significantly positively associated with all but one biomarker (rp=0.21 to 0.40, κ=0.32 to 0.45). The CIR-24 yielded a higher mean intake of caffeine than the CBQ. There was strong linear correlation between the CIR-24 and CBQ (rp=0.60, P<0.001), but poor agreement in absolute caffeine consumed (t=2.83, P=0.006); quartile ranking concordance was 0.44 (P<0.001). The CIR-24 performed better than the CBQ across all biomarkers in both linear correlation and quartile ranking. CONCLUSIONS: Although both the CIR-24 and CBQ performed reasonably well in capturing caffeine intake compared with urinary biomarkers of caffeine consumption, the CIR-24 had stronger agreement than the CBQ. The results suggest that the CIR-24 is a promising tool for evaluating caffeine intake among this population.

School Food Policies and Student Eating Behaviors in Canada: Examination of the 2015 Cancer Risk Assessment in Youth Survey.

BACKGROUND: Limited evidence exists on effects of school-based nutrition policies. This study explored the influence of mandatory versus voluntary provincial school nutrition policies on student eating behaviors. METHODS: A cross-sectional, school-based survey assessed student eating behaviors using self-report survey measures in a representative sample of Canadian high school students from 7 provinces (N = 12,110). Provincial school nutrition policies were characterized as mandatory or voluntary. Healthful and nonhealthful eating behaviors were analyzed across sociodemographic characteristics. Regression models were used to assess the association between policy type and eating behaviors, and to explore potential moderating variables. RESULTS: Healthful and nonhealthful eating behaviors differed significantly across several sociodemographic characteristics. Overall, neither healthful nor nonhealthful eating behaviors differed significantly between schools with voluntary and mandatory nutrition policies (odds ratio [OR] = 0.83, 95% confidence interval [CI] 0.64-1.08; OR = 1.16, 95% CI 0.83-1.64). Frequency of buying lunch at school and buying lunch out moderated the association between policy enforcement level and healthful eating behaviors (p = .0472, p = .0119). Frequency of buying lunch out moderated the association between policy enforcement levels and nonhealthful eating behaviors (p = .0009). CONCLUSIONS: This study documents nonhealthful components of Canadian adolescents' diets, and the results highlight important areas for future research in assessing the effectiveness of school nutrition policies.

The impact of price and nutrition labelling on sugary drink purchases: Results from an experimental marketplace study.

OBJECTIVE: To examine the effect of front-of-package (FOP) nutrition labelling and sugary drink taxation on consumer beverage purchases. METHODS: A total of 675 respondents aged 16 years and older participated in an experimental marketplace study using a 4 × 5 within-between group design. Participants were randomised to one of four labelling conditions (no label; star rating; high sugar symbol; health warning) and completed five within-subject purchase tasks. Beverage prices in each task corresponded to 'tax' conditions: 0%, 10%, 20%, 30% and a variable tax proportional to free sugar level. In each task, participants selected from 20 commercially available beverages; upon conclusion, one of five selections was randomly chosen for purchase. RESULTS: As price increased, participants were significantly less likely to select a sugary drink, and selected drinks with fewer calories and less free sugar (p < 0.001 for all). The overall effect of labelling was not statistically significant, although there was a trend for the 'high sugar' label to reduce the likelihood of selecting a sugary drink (p = 0.11) and encouraging participants to select drinks with less free sugar (p = 0.11). CONCLUSIONS: Increasing price was associated with reduced sugary drink purchases. Enhanced FOP labelling results highlight the need for further research to investigate their potential impact. The study adds empirical support for taxation to reduce sugary drink consumption.