Cost-Effectiveness of a US National Sugar-Sweetened Beverage Tax With a Multistakeholder Approach: Who Pays and Who Benefits.

OBJECTIVES: To estimate the health impact and cost-effectiveness of a national penny-per-ounce sugar-sweetened beverage (SSB) tax, overall and with stratified costs and benefits for 9 distinct stakeholder groups. METHODS: We used a validated microsimulation model (CVD PREDICT) to estimate cardiovascular disease reductions, quality-adjusted life years gained, and cost-effectiveness for US adults aged 35 to 85 years, evaluating full and partial consumer price pass-through. RESULTS: From health care and societal perspectives, the SSB tax was highly cost-saving. When we evaluated health gains, taxes paid, and out-of-pocket health care savings for 6 distinct consumer categories, incremental cost-effectiveness ratios ranged from $20 247 to $42 662 per quality-adjusted life year for 100% price pass-through (incremental cost-effectiveness ratios similar with 50% pass-through). For the beverage industry, net costs were $0.92 billion with 100% pass-through (largely tax-implementation costs) and $49.75 billion with 50% pass-through (largely because of partial industry coverage of the tax). For government, the SSB tax positively affected both tax revenues and health care cost savings. CONCLUSIONS: This stratified analysis improves on unitary approaches, illuminating distinct costs and benefits for stakeholders with political influence over SSB tax decisions.

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.

Regulatory initiatives to reduce sugar-sweetened beverages (SSBs) in Latin America.

BACKGROUND AND OBJECTIVES: Latin American (LA) countries have begun to adopt a variety of regulations targeting sugar-sweetened beverages (SSBs) for public health reasons. Our objective was to characterize the regulatory strategies designed to reduce SSB consumption over the last decade, and assess the available evidence on their enforcement and impact. METHODS: We searched legal and public health databases for public and private SSBs regulations in 14 LA countries and then conducted a systematic review of the available literature. We tracked comparative variations in the type of body issuing the regulations, their scope, and binding status. We present data following a 5-category framework we named NUTRE that classifies SSBs regulations as: (1) restrictions to SSB availability in schools (N), (2) taxes and other economic incentives to discourage consumption (U), (3) restrictions on advertising and marketing (T), (4) regulations on government procurement and subsidies (R), and (5) product labeling rules (E). RESULTS: Since 2006, 14 LA countries have adopted at least 39 public and private SSB regulatory initiatives across the NUTRE framework. Comprehensive efforts have only been approved by Chile, México and Ecuador, while the rest have comparatively few initiatives. 28 out of the 39 regulatory initiatives were passed by legislative and executive bodies; 11 initiatives represent self-regulatory undertakings by the beverage industries. An 86% (24/28) of public sector regulations are binding; 56% (22/39) contain explicit monitoring or evaluation methods; and 62% (24/39) provide for sanctions. Moreover, 23 regulations specify the body in charge of monitoring the new rules and standards. CONCLUSIONS: LA countries are targeting SSB consumption through a variety of mechanisms, particularly via restrictions to availability in schools and through taxes. Interdisciplinary evidence comparing alternative regulatory strategies is scarce, and few studies offer data on impact and implementation challenges. More evidence and further comparative assessments are needed to support future decision-making.

Implications of Brexit on the effectiveness of the UK soft drinks industry levy upon CHD in England: a modelling study.

OBJECTIVE: An industry levy on sugar-sweetened beverages (SSB) was implemented in the UK in 2018. One year later, Brexit is likely to change the UK trade regime with potential implications for sugar price. We modelled the effect of potential changes in sugar price due to Brexit on SSB levy impacts upon CHD mortality and inequalities. DESIGN: We modelled a baseline SSB levy scenario; an SSB levy under 'soft' Brexit, where the UK establishes a free trading agreement with the EU; and an SSB levy under 'hard' Brexit, in which World Trade Organization tariffs are applied. We used the previously validated IMPACT Food Policy model and probabilistic sensitivity analysis to estimate the effect of each scenario on CHD deaths prevented or postponed and life-years gained, stratified by age, sex and socio-economic circumstance, in 2021. SETTING: England. SUBJECTS: Adults aged 25 years or older. RESULTS: The SSB levy was associated with approximately 370 (95 % uncertainty interval 220, 560) fewer CHD deaths and 4490 (2690, 6710) life-years gained in 2021. Associated reductions in CHD mortality were 4 and 8 % greater under 'soft' and 'hard' Brexit scenarios, respectively. The SSB levy was associated with approximately 110 (50, 190) fewer CHD deaths in the most deprived quintile compared with 60 (20, 100) in the most affluent, under 'hard' Brexit. CONCLUSIONS: Our study found the SSB levy resilient to potential effects of Brexit upon sugar price. Even under 'hard' Brexit, the SSB levy would yield benefits for CHD mortality and inequalities. Brexit negotiations should deliver a fiscal and regulatory environment which promotes population health.

Does the Mexican sugar-sweetened beverage tax have a signaling effect? ENSANUT 2016.

OBJECTIVE: To evaluate the potential signaling effect of the Mexican tax on sugar-sweetened beverages (SSBs) by analyzing the association between awareness of and opinions about its effectiveness with current consumption of taxed SSBs and with a self-reported change in consumption of SSBs since the implementation of the tax. We also examined the association between psychosocial and environmental determinants of SSB consumption with current consumption of taxed SSBs and with a reported change in consumption of SSBs. METHODS: Cross-sectional analyses of survey and food-frequency questionnaire data from the Mexican National Health and Nutrition Survey 2016. Participants were Mexican adults (20-59 years, N = 6,650). Logistic regression was used to evaluate the probability of a person reporting a decrease in SSB consumption, given their awareness of the tax, opinion about its effectiveness, psychosocial (SSB health-related beliefs, self-efficacy, and liking of SSBs) and environmental (availability of potable water) determinants. Multiple linear regression analysis was utilized to examine the association between the aforementioned factors and current consumption of taxed SSBs. RESULTS: Compared with adults not aware, adults who were aware of the SSB tax were more likely (OR = 1.30) to report a decrease in SSB consumption (p = .012). In urban areas, adults aware of the tax drank a significantly lower amount of taxed SSBs (-15.7%; p = .023) than those not aware. Self-efficacy and liking of SSBs were significantly associated with a reported decrease in consumption and with current consumption (p < .001), while health beliefs and availability of potable water were not significantly associated with either reported change in SSB consumption or current consumption of taxed SSBs. CONCLUSIONS: Implementation of an SSB tax accompanied by highly visible campaigns may further influence the impact of taxes on SSBs consumption. Future public health and nutrition education campaigns designed to increase knowledge and enhance motivation should be complemented by programs to assist individuals develop self-efficacy and self-regulation skills.

Identifying Financially Sustainable Pricing Interventions to Promote Healthier Beverage Purchases in Small Neighborhood Stores.

INTRODUCTION: Residents of low-income communities often purchase sugar-sweetened beverages (SSBs) at small, neighborhood "corner" stores. Lowering water prices and increasing SSB prices are potentially complementary public health strategies to promote more healthful beverage purchasing patterns in these stores. Sustainability, however, depends on financial feasibility. Because in-store pricing experiments are complex and require retailers to take business risks, we used a simulation approach to identify profitable pricing combinations for corner stores. METHODS: The analytic approach was based on inventory models, which are suitable for modeling business operations. We used discrete-event simulation to build inventory models that use data representing beverage inventory, wholesale costs, changes in retail prices, and consumer demand for 2 corner stores in Baltimore, Maryland. Model outputs yielded ranges for water and SSB prices that increased water demand without loss of profit from combined water and SSB sales. RESULTS: A 20% SSB price increase allowed lowering water prices by up to 20% while maintaining profit and increased water demand by 9% and 14%, for stores selling SSBs in 12-oz cans and 16- to 20-oz bottles, respectively. Without changing water prices, profits could increase by 4% and 6%, respectively. Sensitivity analysis showed that stores with a higher volume of SSB sales could reduce water prices the most without loss of profit. CONCLUSION: Various combinations of SSB and water prices could encourage water consumption while maintaining or increasing store owners' profits. This model is a first step in designing and implementing profitable pricing strategies in collaboration with store owners.

The effect of prices on nutrition: Comparing the impact of product- and nutrient-specific taxes.

This paper provides an analysis of the role of prices in determining food purchases and nutrition using very detailed transaction-level observations for a large, nationally-representative sample of US consumers over the period 2002-2007. Using product-specific nutritional information, we develop a new method of partitioning the product space into relevant nutritional clusters that define a set of nutritionally-bundled goods, which parsimoniously characterize consumer choice sets. We then estimate a large utility-derived demand system over this joint product-nutrient space that allows us to calculate price and expenditure elasticities. Using our structural demand estimates, we simulate the role of product taxes on soda, sugar-sweetened beverages, packaged meals, and snacks, and nutrient taxes on fat, salt, and sugar. We find that a 20% nutrient tax has a significantly larger impact on nutrition than an equivalent product tax, due to the fact that these are broader-based taxes. However, the costs of these taxes in terms of consumer utility are only about 70 cents per household per day. A sugar tax in particular is a powerful tool to induce healthier nutritive bundles among consumers.

Sugar and health in South Africa: Potential challenges to leveraging policy change.

A growing body of evidence indicates that excessive sugar consumption is driving epidemics of obesity and related non-communicable diseases (NCDs) around the world. South Africa (SA), a major consumer of sugar, is also the third most obese country in Africa, and 40% of all deaths in the country result from NCDs. A number of fiscal, regulatory, and legislative levers could reduce sugar consumption in SA. This paper focuses on a sugar-sweetened beverage (SSB) tax. The purpose of the paper is to highlight the challenges that government might anticipate. Policies cannot be enacted in a vacuum and discussion is focused on the industrial, economic, and societal context. The affected industry actors have been part of the SA economy for over a century and remain influential. To deflect attention, the sugar industry can be expected either to advocate for self-regulation or to promote public-private partnerships. This paper cautions against both approaches as evidence suggests that they will be ineffective in curbing the negative health impacts caused by excessive sugar consumption. In summary, policy needs to be introduced with a political strategy sensitive to the various interests at stake. In particular, the sugar industry can be expected to be resistant to the introduction of any type of tax on SSBs.

Projected Impact of Mexico's Sugar-Sweetened Beverage Tax Policy on Diabetes and Cardiovascular Disease: A Modeling Study.

BACKGROUND: Rates of diabetes in Mexico are among the highest worldwide. In 2014, Mexico instituted a nationwide tax on sugar-sweetened beverages (SSBs) in order to reduce the high level of SSB consumption, a preventable cause of diabetes and cardiovascular disease (CVD). We used an established computer simulation model of CVD and country-specific data on demographics, epidemiology, SSB consumption, and short-term changes in consumption following the SSB tax in order to project potential long-range health and economic impacts of SSB taxation in Mexico. METHODS AND FINDINGS: We used the Cardiovascular Disease Policy Model-Mexico, a state transition model of Mexican adults aged 35-94 y, to project the potential future effects of reduced SSB intake on diabetes incidence, CVD events, direct diabetes healthcare costs, and mortality over 10 y. Model inputs included short-term changes in SSB consumption in response to taxation (price elasticity) and data from government and market research surveys and public healthcare institutions. Two main scenarios were modeled: a 10% reduction in SSB consumption (corresponding to the reduction observed after tax implementation) and a 20% reduction in SSB consumption (possible with increases in taxation levels and/or additional measures to curb consumption). Given uncertainty about the degree to which Mexicans will replace calories from SSBs with calories from other sources, we evaluated a range of values for calorie compensation. We projected that a 10% reduction in SSB consumption with 39% calorie compensation among Mexican adults would result in about 189,300 (95% uncertainty interval [UI] 155,400-218,100) fewer incident type 2 diabetes cases, 20,400 fewer incident strokes and myocardial infarctions, and 18,900 fewer deaths occurring from 2013 to 2022. This scenario predicts that the SSB tax could save Mexico 983 million international dollars (95% UI $769 million-$1,173 million). The largest relative and absolute reductions in diabetes and CVD events occurred in the youngest age group modeled (35-44 y). This study's strengths include the use of an established mathematical model of CVD and use of contemporary Mexican vital statistics, data from health surveys, healthcare costs, and SSB price elasticity estimates as well as probabilistic and deterministic sensitivity analyses to account for uncertainty. The limitations of the study include reliance on US-based studies for certain inputs where Mexico-specific data were lacking (specifically the associations between risk factors and CVD outcomes [from the Framingham Heart Study] and SSB calorie compensation assumptions), limited data on healthcare costs other than those related to diabetes, and lack of information on long-term SSB price elasticity that is specific to geographic and economic subgroups. CONCLUSIONS: Mexico's high diabetes prevalence represents a public health crisis. While the long-term impact of Mexico's SSB tax is not yet known, these projections, based on observed consumption reductions, suggest that Mexico's SSB tax may substantially decrease morbidity and mortality from diabetes and CVD while reducing healthcare costs.

Effects of plain packaging, warning labels, and taxes on young people's predicted sugar-sweetened beverage preferences: an experimental study.

BACKGROUND: Consumption of sugar-sweetened beverages (SSBs) is associated with increased risk of obesity, diabetes, heart disease and dental caries. Our aim was to assess the effects of plain packaging, warning labels, and a 20 % tax on predicted SSB preferences, beliefs and purchase probabilities amongst young people. METHODS: A 2 × 3 × 2 between-group experimental study was conducted over a one-week period in August 2014. Intervention scenarios were delivered, and outcome data collected, via an anonymous online survey. Participants were 604 New Zealand young people aged 13-24 years who consumed soft drinks regularly. Participants were randomly allocated using a computer-generated algorithm to view one of 12 experimental conditions, specifically images of branded versus plain packaged SSBs, with either no warning, a text warning, or a graphic warning, and with or without a 20 % tax. Participant perceptions of the allocated SSB product and of those who might consume the product were measured using seven-point Likert scales. Purchase probabilities were measured using 11-point Juster scales. RESULTS: Six hundred and four young people completed the survey (51 % female, mean age 18 (SD 3.4) years). All three intervention scenarios had a significant negative effect on preferences for SSBs (plain packaging: F (6, 587) = 54.4, p <0.001; warning label: F (6, 588) = 19.8, p <0.001; 20 % tax: F (6, 587) = 11.3, p <0.001). Plain packaging and warning labels also had a significant negative impact on reported likelihood of purchasing SSB's (p = <0.001). A 20 % tax reduced participants' purchase probability but the difference was not statistically significant (p = 0.2). CONCLUSIONS: Plain packaging and warning labels significantly reduce young people's predicted preferences for, and reported probability of purchasing, SSBs.

Modelling the potential impact of a sugar-sweetened beverage tax on stroke mortality, costs and health-adjusted life years in South Africa.

BACKGROUND: Stroke poses a growing human and economic burden in South Africa. Excess sugar consumption, especially from sugar-sweetened beverages (SSBs), has been associated with increased obesity and stroke risk. Research shows that price increases for SSBs can influence consumption and modelling evidence suggests that taxing SSBs has the potential to reduce obesity and related diseases. This study estimates the potential impact of an SSB tax on stroke-related mortality, costs and health-adjusted life years in South Africa. METHODS: A proportional multi-state life table-based model was constructed in Microsoft Excel (2010). We used consumption data from the 2012 South African National Health and Nutrition Examination Survey, previously published own and cross price elasticities of SSBs and energy balance equations to estimate changes in daily energy intake and BMI arising from increased SSB prices. Stroke relative risk, and prevalent years lived with disability estimates from the Global Burden of Disease Study and modelled disease epidemiology estimates from a previous study, were used to estimate the effect of the BMI changes on the burden of stroke. RESULTS: Our model predicts that an SSB tax may avert approximately 72 000 deaths, 550 000 stroke-related health-adjusted life years and over ZAR5 billion, (USD400 million) in health care costs over 20 years (USD296-576 million). Over 20 years, the number of incident stroke cases may be reduced by approximately 85 000 and prevalent cases by about 13 000. CONCLUSIONS: Fiscal policy has the potential, as part of a multi-faceted approach, to mitigate the growing burden of stroke in South Africa and contribute to the achievement of the target set by the Department of Health to reduce relative premature mortality (less than 60 years) from non-communicable diseases by the year 2020.

Impact of sugars and sugar taxation on body weight control: A comprehensive literature review.

OBJECTIVE: To conduct a comprehensive literature review in the field of added-sugar consumption on weight gain including the effect of fructose-containing caloric sweeteners and sugar taxation. METHODS: A search of three databases was conducted in the time period from the inception of the databases to August 2015. Sensitive search strategies were used in order to retrieve systematic reviews (SR) of fructose, sucrose, or sugar-sweetened beverages (SSBs) on weight gain and metabolic adverse effects, conducted on humans and written in English, Spanish, or French. In addition, a review about SSB taxation and weight outcomes was conducted. RESULTS: The search yielded 24 SRs about SSBs and obesity, 23 SRs on fructose or SSBs and metabolic adverse effects, and 24 studies about SSB taxation and weight control. CONCLUSIONS: The majority of SRs, especially the most recent ones, with the highest quality and without any disclosed conflict of interest, suggested that the consumption of SSBs is a risk factor for obesity. The effect of fructose-containing caloric sweeteners, on weight gain is mediated by overconsumption of beverages with these sweeteners, leading to an extra provision of energy intake. The tax tool alone on added sugars appears insufficient to curb the obesity epidemic, but it needs to be included in a multicomponent structural strategy.

The impact of a tax on sugar-sweetened beverages according to socio-economic position: a systematic review of the evidence.

OBJECTIVE: A tax on sugar-sweetened beverages (SSB) has been proposed to address population weight gain but the effect across socio-economic position (SEP) is unclear. The current study aimed to clarify the differential impact(s) of SSB taxes on beverage purchases and consumption, weight outcomes and the amount paid in SSB taxes according to SEP. DESIGN: Databases (OVID and EMBASE) and grey literature were systematically searched in June 2015 to identify studies that examined effects of an SSB price increase on beverage purchases or consumption, weight outcomes or the amount paid in tax across SEP, within high-income countries. RESULTS: Of the eleven included articles, three study types were identified: (i) those that examined the association between variation in SSB taxes and SSB consumption and/or body weight (n 3); (ii) price elasticity estimation of SSB demand (n 1); and (iii) modelling of hypothetical SSB taxes by combining price elasticity estimates with population SEP-specific beverage consumption, energy intake or body weight (n 7). Few studies statistically tested differences in outcomes between SEP groups. Nevertheless, of the seven studies that reported on changes in weight outcomes for the total population following an increase in SSB price, all reported either similar reductions in weight across SEP groups or greater reductions for lower compared with higher SEP groups. All studies that examined the average household amount paid in tax (n 5) reported that an SSB tax would be regressive, but with small differences between higher- and lower-income households (0·10-1·0 % and 0·03 %-0·60 % of annual household income paid in SSB tax for low- and high-income households, respectively). CONCLUSIONS: Based on the available evidence, a tax on SSB will deliver similar population weight benefits across socio-economic strata or greater benefits for lower SEP groups. An SSB tax is shown to be consistently financially regressive, but to a small degree.