An examination of sugar-sweetened beverage tax regulations in six jurisdictions: Applying a social justice perspective to beverage taxation and exemptions.

Taxes, legislation and politics are social determinants of health, which can impact health through multiple pathways. The purpose of this study was to review regulations regarding sugar-sweetened beverage (SSB) taxation and describe taxation/exemption of various beverage categories. We reviewed SSB taxation regulations from Mexico, the United Kingdom, Berkeley, Philadelphia, San Francisco and South Africa. Supplementary government documents and academic publications were also reviewed to further discern beverage taxation/exemption and zero-rating. There were a number of beverage types that fell clearly into typically taxed or exempt/zero-rated categories across all six jurisdictions (e.g. pop/soda as taxed and water as zero-rated). Exemptions and ambiguities within the six regulations can generally be grouped as a lack of clarity regarding the meaning and use of milk; the meaning of 'medical purposes' and 'supplemental'; the point at which a beverage is prepared; the form of concentrate (i.e. liquid/frozen/powder) or medium used (e.g. water, coffee); and location of preparation or business size of retailer. SSB tax regulations are complex, unclear, vary across jurisdiction and leave several beverage types with added sugar exempt from taxation or at risk of a legal challenge. Lastly, tax exemptions generally reflect and perpetuate existing sociopolitical dynamics within the food system.

An Evaluation of Healthy Hydration Recommendations for 93 Countries with Sugary Beverage Tax Legislation Globally, 2000-2023.

Adequate water intake is essential for human health. Sugary beverage taxes are a best buy policy to reduce obesity and diet-related non-communicable diseases. Food-based dietary guidelines (FBDGs) promote healthy dietary patterns. The study purpose was to evaluate national FBDGs for countries with sugary beverage tax legislation (2000-2023) to promote water and discourage sugary beverage consumption. We developed a coding framework to conduct a content analysis of FBDG documents, and used six indicators to identify messages and images to assign healthy hydration recommendation (HHR) scores from 0-12 to compare FBDGs across countries and six regions. Results showed 93 countries with sugary beverage tax legislation of which 58 countries (62%) had published FBDGs (1998-2023). Of 58 FBDGs reviewed, 48 (83%) had complementary recommendations that encouraged water and discouraged sugary beverages. Of 93 countries, 13 (14%) had the highest HHR scores (11-12); 22, (24%) had high HHR scores (9-10); 20 (21%) had medium HHR scores (4-8); 3 (3%) had low HHR scores (0-3); and 35 (38%) countries had no FBDGs. To reduce health risks for populations, governments must ensure policy coherence to optimize sugary beverage tax impacts by developing FBDGs that encourage water and discourage sugary beverages complementary to national policies.

Childhood obesity and sugar-sweetened beverages in Río Negro: Burden of disease and expected impact of Law no. 27642 on the Promotion of Healthy Eating. / Obesidad infantil y bebidas azucaradas en Río Negro: carga de enfermedad e impacto esperado de la Ley 27642 de Promoción de la Alimentación Saludable.

Introduction. The highest levels of childhood overweight and obesity in Latin America correspond to Argentina; this condition increases the risk of obesity, type 2 diabetes, cardiovascular and cerebrovascular diseases, and other conditions in adulthood. More than 25% of childhood and adolescent obesity are attributable to the consumption of sugar-sweetened beverages (SSBs). Our objective was to assess the disease and financial burden of SSB consumption among children and adolescents in Río Negro, the morbidity and mortality in adulthood, and the impact of reducing sugar consumption via the implementation of Law no. 27642 on the Promotion of Healthy Eating. Population and methods. We used a mathematical simulation model with a comparative risk assessment approach in the Río Negro population aged 0 to 17 years. The burden of obesity attributable to SSB consumption in the short and long term and direct medical costs were assessed. Results. The average consumption of SSBs was 348 mL/day; the prevalence of overweight and obesity was 16.6% and 11.6%, respectively. There were over 6600 cases of overweight in children and adolescents; while in adulthood, there were over 17 500 cases of overweight, 34 deaths attributable to SSBs, 3200 cases of diabetes, and over 4230 other health events. Direct medical costs were estimated at ARS 250 000 000 attributable to SSB consumption. Conclusion. The implementation of a comprehensive policy as established by Law no. 27642 on the Promotion of Healthy Eating in Río Negro would decrease 24% of overweight cases, morbidity, mortality, and associated medical costs.

Introducción. Los mayores valores de sobrepeso y obesidad infantil de Latinoamérica corresponden a Argentina, condición que incrementa el riesgo de obesidad en la adultez, diabetes tipo 2, enfermedades cardiovasculares, cerebrovasculares y otras. Más del 25 % de los casos de obesidad infantojuvenil pueden atribuirse al consumo de bebidas azucaradas (BA). El objetivo fue evaluar la carga de enfermedad y la económica del consumo de BA en niños y adolescentes rionegrinos; morbimortalidad en la adultez e impacto de lograr una reducción del consumo de azúcares con la implementación de la Ley 27642 de Promoción de la Alimentación Saludable. Población y métodos. Se utilizó un modelo de simulación matemática con enfoque de evaluación de riesgo comparativo en la población rionegrina de 0 a 17 años. Se evaluó la carga de obesidad atribuible al consumo de BA a corto y largo plazo, y los costos médicos directos. Resultados. El consumo promedio de BA fue de 348 ml/día y la prevalencia de sobrepeso y obesidad fueron del 16,6 % y el 11,6 %, respectivamente. Se estimaron más de 6600 casos de exceso de peso en niños y adolescentes; y, en la adultez, más de 17 500 casos de exceso de peso, 34 muertes atribuibles a BA, 3200 casos de diabetes y más de 4230 en otros eventos de salud. Se calcularon costos médicos directos por $ 250 000 000 atribuibles al consumo de BA. Conclusión. La implementación de una política integral como establece la Ley 27642 de Promoción de la Alimentación Saludable en Río Negro disminuiría el 24 % de los casos de exceso de peso, la morbimortalidad y los costos médicos asociados.

Are Supplemental Nutrition Assistance Program Restrictions on Sugar-Sweetened Beverages Effective in Reducing Purchase or Consumption? A Systematic Review.

The participants in the Supplemental Nutrition Assistance Program (SNAP) consume greater amounts of sugar and sweetened beverages (SSBs) compared to non-eligible individuals, which could result in potential negative health outcomes. This can be attributed to the lack of restrictions on SSB purchases with SNAP benefits. In view of the increasing calls from advocates and policymakers to restrict the purchase of SSBs with SNAP benefits, we performed a systematic review to assess its impact towards SSB purchases and consumption. We searched articles from five databases-Cochrane, EBSCO, SCOPUS, Web of Science, and PubMed-and selected seven studies, four of which were randomized controlled trials (RCTs) and three were simulation modeling studies. All three simulation studies and one RCT reported outcomes in terms of consumption, while the other three RCTs reported outcomes in terms of purchases. All seven studies found that an SSB restriction led to a decrease in SSB consumption or purchases, with six studies reporting significant results. Nonetheless, limitations exist. These include limited studies on this subject, potential workarounds circumventing SSB restrictions, like making purchases using personal cash, potentially differed estimated effects when combined with incentives or other initiatives, and the limited geographical scope among the selected RCTs.

Understanding Whether Price Tag Messaging Can Amplify the Benefits of Taxes: An Online Experiment.

INTRODUCTION: Excise taxes on unhealthy products like sugary drinks and tobacco can reduce purchases of these products. However, little research has investigated whether messages at the point of purchase, such as enhanced price tags, can increase the effects of taxes by heightening psychological reactions. This study aimed to examine whether including messages about taxes on price tags could amplify the benefits of excise taxes on unhealthy products. METHODS: In 2022, an online study recruited 1,013 U.S. parents to view seven price tag messages (e.g., "includes a 19% sugary drink tax") and a control (i.e., standard price tag with the tax included in the price) displayed in random order alongside sugary drinks. Participants were randomly assigned to view a caution-symbol icon or no icon on price tags. Analyses were conducted in 2023. RESULTS: All seven messages discouraged parents from buying sugary drinks for their children compared to control (average differential effects [ADEs] ranged from 0.28 to 0.48, all p<0.001). All messages led to greater attention to the price tag (ADEs ranged from 0.24 to 0.41, all p<0.001) and greater consideration of the cost of sugary drinks (ADEs ranged from 0.31 to 0.50, all p<0.001). Icons elicited higher cost consideration than text-only price tags (ADE=0.15, p<0.010), but not discouragement (p=0.061) or attention (p=0.079). CONCLUSIONS: Messaging on price tags could make excise taxes more effective. Policymakers should consider requiring messaging on price tags when implementing taxes.

Health taxes in Indonesia: a review of policy debates on the tobacco, alcoholic beverages and sugar-sweetened beverage taxes in the media.

INTRODUCTION: One of the WHO's 'best buys' in controlling non-communicable diseases and their risk factors is to impose health taxes. While the Indonesian political process inhibits the implementation of health tax policy, studies to discuss the issue remain limited. METHODS: We employed media analysis to document health tax policy dynamics, for example, the changes in policy timeline and key actors' statements. We conducted an article search in the Open-Source Intelligence database using appropriate terminology on three commodities, for example, tobacco, alcoholic beverages and sugar-sweetened beverages (SSB). RESULTS: Throughout the 15 years of implementation (2007-2022), tobacco has received the most policy attention compared with the other two commodities. This is mainly related to the increasing tariff and reforming the tax structure. As Indonesia is a Muslim-majority country, alcohol consumption is low, and a tax on alcoholic beverages was nearly unchanging and lacked media coverage. Ministry of Finance (MoF) officials are key opinion leaders often cited in the media for health taxes. MoF's support for health taxes is important to pass and implement health taxes. While SSB taxation is emerging, key opinion leaders' media statements imply policy contestation, leading to delayed implementation. The policy debates on tobacco taxation implied election years as a major challenge for health tax passages. During the political years, anti-health tax arguments emerged from politicians. While the political contestation on SSB concluded that accentuating the health tax arguments in favour of public health generates the strongest opposition against taxation from the industry. CONCLUSIONS: Politics of tobacco tax implementation are complex-compared with the other two commodities. The political context drives the divided views among policy-makers. Policy recommendations include generating public allies with key religious opinion leaders, continuing capacity building for politicians and Ministry of Health, and generating evidence-based arguments in favour of public health for MoF.

Impact of the Seattle Sweetened Beverage Tax on substitution to alcoholic beverages.

INTRODUCTION: Taxes are increasingly used as a policy tool aimed at reducing consumption of sugar-sweetened beverages (SSBs), given their association with adverse health outcomes including type 2 diabetes, obesity and cardiovascular disease. However, a potential unintended consequence of such a policy could be that the tax induces substitution to alcoholic beverages. The purpose of this study is to examine the impact of the $0.0175 per ounce Seattle, Washington, Sweetened Beverage Tax (SBT) on volume sold of alcoholic beverages. METHODS: A difference-in-differences estimation approach was used drawing on universal product code-level food store scanner data on beer (N = 1059) and wine (N = 2655) products one-year pre-tax (February-November, 2017) and one and two-years post-tax (February-November, 2018 and 2019) with Portland, Oregon, as the comparison site. RESULTS: At two-years post-tax implementation, volume sold of beer in Seattle relative to Portland increased by 7% (ratio of incidence rate ratios [RIRR] = 1.07, 95% CI:1.00,1.15), whereas volume sold of wine decreased by 3% (RIRR = 0.97, 95% CI:0.95,1.00). Overall alcohol (both beer and wine) volume sold increased in Seattle compared to Portland by 4% (RIRR = 1.04, 95% CI:1.01,1.07) at one-year post-tax and by 5% (RIRR = 1.05, 95% CI:1.00,1.10) at two-years post-tax. The implied SSB cross-price elasticities of demand for beer and wine, respectively, were calculated to be 0.35 and -0.15. CONCLUSIONS: There was evidence of substitution to beer following the implementation of the Seattle SSB tax. Continued monitoring of potential unintended outcomes related to the implementation of SSB taxes is needed in future tax evaluations.

Influence of the San Francisco, CA, Sugar-Sweetened Beverage Health Warning on Consumer Reactions: Implications for Equity from a Randomized Experiment.

BACKGROUND: In 2020, San Francisco, CA, amended an ordinance requiring warning labels on advertisements for sugary drinks to update the warning message. No studies have evaluated consumer responses to the revised message. OBJECTIVES: To evaluate responses to the 2020 San Francisco sugary drink warning label and to assess whether these responses differ by demographic characteristics. DESIGN: Randomized experiment. PARTICIPANTS AND SETTING: During 2020, a convenience sample of US parents of children aged 6 months to 5 years (N = 2,160 included in primary analyses) was recruited via an online panel to complete a survey. Oversampling was used to achieve a diverse sample (49% Hispanic/Latino[a], 34% non-Hispanic Black, and 9% non-Hispanic White). METHODS: Participants were randomly assigned to view a control label ("Always read the Nutrition Facts Panel") or the 2020 San Francisco sugary drink warning label ("SAN FRANCISCO GOVERNMENT WARNING: Drinking beverages with added sugar(s) can cause weight gain, which increases the risk of obesity and type 2 diabetes."). Messages were shown in white text on black rectangular labels. MAIN OUTCOME MEASURES: Participants rated the labels on thinking about health harms of sugary drink consumption (primary outcome) and perceived discouragement from wanting to consume sugary drinks. The survey was available in English and Spanish. STATISTICAL ANALYSES PERFORMED: Ordinary least squares regression. RESULTS: The San Francisco warning label elicited more thinking about health harms (Cohen's d = 0.24; P < 0.001) than the control label. The San Francisco warning label also led to more discouragement from wanting to consume sugary drinks than the control label (d = 0.31; P < 0.001). The warning label's influence on thinking about harms did not differ by any participant characteristics, including age, gender, race/ethnicity, education, income, or language of survey administration (all P values for interactions > 0.12). CONCLUSIONS: San Francisco's 2020 sugary drink warning label may be a promising policy for informing consumers and encouraging healthier beverage choices across groups with diverse demographic characteristics.

Projecting the Influence of Sugar-Sweetened Beverage Warning Labels and Restaurant Menu Labeling Regulations on Energy Intake, Weight Status, and Health Care Expenditures in US Adults: A Microsimulation.

BACKGROUND: Accurate, readily accessible, and easy-to-understand nutrition labeling is a promising policy strategy to address poor diet quality and prevent obesity. OBJECTIVE: This study projected the influence of nationwide implementation of sugar-sweetened beverage (SSB) warning labels and restaurant menu labeling regulations. DESIGN: A stochastic microsimulation model was built to estimate the influences of SSB warning labels and menu labeling regulations on daily energy intake, body weight, body mass index, and health care expenditures among US adults. PARTICIPANTS/SETTING: The model used individual-level data from the National Health and Nutrition Examination Survey, Medical Expenditure Panel Survey, and other validated sources. STATISTICAL ANALYSES PERFORMED: The model was simulated using the bootstrapped samples, and the means and associated 95% CIs of the policy effects were estimated. RESULTS: SSB warning labels and restaurant menu labeling regulations were estimated to reduce daily energy intake by 19.13 kcal (95% CI 18.83 to 19.43 kcal) and 33.09 kcal (95% CI 32.39 to 33.80 kcal), body weight by 0.92 kg (95% CI 0.90 to 0.93 kg) and 1.57 kg (95% CI 1.54 to 1.60 kg), body mass index by 0.32 (95% CI 0.31 to 0.33) and 0.55 (95% CI =0.54 to 0.56), and per-capita health care expenditures by $26.97 (95% CI $26.56 to $27.38) and $45.47 (95% CI $44.54 to $46.40) over 10 years, respectively. The reduced per-capita health care expenditures translated into an annual total medical cost saving of $0.69 billion for SSB warning labels and $1.16 billion for menu labeling regulations. No discernable policy effect on all-cause mortality was identified. The policy effects could be heterogeneous across population subgroups, with larger effects in men, non-Hispanic Black adults, and younger adults. CONCLUSIONS: SSB warning labels and menu labeling regulations could be effective policy leverage to prevent weight gains and reduce medical expenses attributable to adiposity.

Perspectives of Adult Singaporeans toward Potential Policies to Reduce the Consumption of Sugar Sweetened Beverages-A Cross-Sectional Study.

Excessive consumption of sugar sweetened beverages (SSB) is of growing concern, and several countries are implementing measures to reduce SSB consumption. Understanding perceptions towards SSB policies is crucial to prioritize policy actions and to effectively frame public communication. We conducted a cross-sectional study in a sample of 754 adult Singaporeans to examine support towards 10 hypothetical policies to reduce SSB consumption. Policy scenarios were presented to participants and support was assessed using a 5-point Likert scale. Opinions about policies were elicited by asking participants "What other thoughts do you have about this policy?". We used logistic regression to examine determinants of policy support, and thematic analyses to understand opinions about policies. We observed good public support for a variety of SSB policies. In general, less restrictive policies such as traffic light labels (85.0% agreed/strongly agreed) and free access to water at eateries (77.1%) were better supported as compared to restrictive policies such as portion-size restrictions (64.5%) and taxation (55.0%). There was limited variation by age, ethnicity, income, physical activity and body mass index. Concerns about policies largely centered on loss of personal autonomy and economic implications for businesses. Nevertheless, participants also recognized that policies could support healthier beverage consumption by increasing awareness and enabling informed decision making. Findings from this study provide insights into consumer's perceptions of SSB policies, and can inform public health advocacy and government action in this area.