• Policies & Taxes on Sugary Drinks

    The case studies below present three different perspectives on the successes and challenges involved in adopting a policy and tax-based approach to reducing sugar-sweetened beverage consumption.

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    • Berkeley, California - The city of Berkeley, California instated a $0.01 per fluid ounce tax on sugar-sweetened beverages in 2014, which includes soda, energy drinks, heavily pre-sweetened tea, and added caloric sweeteners used to produce these sugar-sweetened beverages (i.e. pre-made syrup used to make fountain drinks), with the exception of infant formula, milk products, and natural fruit and vegetable juice. Berkeley was the first city in the United States to enact a tax on sugary drinks. The Berkeley Healthy Child Coalition formed in 2013 as a collaboration between public health and healthcare professionals, community organizations, and local parents, teachers, among other diverse stakeholders. Their organization garnered enough signatures from Berkeley residents to put a tax measure on the upcoming November 2014 ballot. However, after becoming aware of the measure, the American Beverage Association poured over $2.4 million into an effort to ensure the measure’s failure. This immense amount of money was spent on creating highly funded counter organizations which claimed that the additional tax on sugary drinks would hurt those of lower income. The beverage association also claimed that the tax was using illegal language and filed a lawsuit. The Healthy Child Coalition worked tirelessly to combat this pressure by organizing hundreds of community volunteers and hosting numerous press events, public and community-based events, and writing op-eds to local newspapers. Through the steadfast work of the Coalition and community members, the measure was ultimately successful, passing with 75% approval from Berkeley residents. Given that this was the first tax on sugary drinks, Berkeley’s tax has been highly studied and published. One of the first studies published examined sales costs and found that after 3 months of tax implementation, SSB prices had increased in Berkeley more than compared to other areas without the tax. Another study showed that within the first year of initiation, SSB consumption in Berkeley reduced by 21%, also resulting in water consumption increasing by 63%. Reductions in SSB consumption were sustained over the first 3 years of the SSB tax, amounting to Berkeley residents cutting their consumption by 52% by 2017. After Berkeley's accomplishment with establishing a SSB tax and many California cities moving in the same direction, the American Beverage Association adapted a novel technique at ensuring the failure of new SSB taxes. It spent $7 million on a statewide ballot initiative that would have made it more difficult for cities to raise taxes in general (not just on SSBs). Faced with the prospect of being unable to raise any kind of tax, California lawmakers were forced into accepting a 12-year moratorium that bans local sugar taxes through 2030.
    • Philadelphia, Pennsylvania - On January 1, 2017, Philadelphia instated a $.015 per fluid ounce tax on all sugar-sweetened and artificially sweetened/ diet beverages, with the exclusion of fruit juices. Money gathered from the tax has been earmarked to go toward universal pre-K, community schools, and playgrounds/ recreation areas. Before the tax was instated, researchers estimated that Philadelphia's soda tax would prevent 14,000 cases of obesity and save $77 million in health care costs over 10 years. Since the tax was initiated, opponents - principally the Ax the Philly Bev Tax Coalition - have argued that the tax has simply prompted families to shift their purchasing to the suburbs to avoid Philadelphia’s tax, therefore hurting small businesses. The opposition to Philadelphia’s tax are incredibly well funded: in one year alone, tax opponents spent almost $11 million dollars to fight the tax. Results from Philadelphia’s tax are just starting to be published, with mixed results. Within the first few months of implementation, surveys with a control showed a 40% decrease in consumption of regular soda, a 64% decrease in consumption of energy drinks, and a 58% increase in consumption of water. However, another study examined beverage purchase data from areas both inside and outside the taxable area and did not find a significant caloric reduction based on purchasing patterns, but instead found an increase in sales of sugary beverages in the areas just outside the city. The upcoming years will be important ones in the future of Philadelphia’s sugar tax, particularly given the well-funded opposition
    • Cook County, Illinois - In 2016, the Cook County Board of Commissioners voted to pass a $0.01 per ounce tax on soda and sugary drinks. The measure was billed both as a way to fill an almost $2 billion budget gap as well as a way to reduce obesity and promote the health of Cook County residents. From the outset before it was even instated, the tax was plagued with trouble. Almost immediately upon its implementation, opponents – predominantly with connections to the Can the Tax Coalition, a group funded by the American Beverage Association - were quick to release well designed materials to rebut and counter points made by Cook County. The opposition coalition has spent more than $3 million on advertisements across radio and TV. Additionally, the language of the measure was changed several times because the ways that it was initially conceived attempted to place illegal taxes. In the meantime, the opposition to the tax grew at the grassroots community level. Community members began to follow the Coalition by organizing boycotts, public events in opposition, and engaging in an overwhelming letter-writing campaign to the commissioners. The timing of the measure also introduced challenges – both the beverage industry as well as the public health (in particular Michael Bloomberg) pledged to donate enough money to impact an upcoming election. This battle between opposition and support for the tax resulted in an overwhelmingly negative reaction toward the tax. In 2017, the same board that voted to instate the tax then voted to repeal it. For additional information that summarizes popular beverage industry efforts to repeal taxes, see the following link:
      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6020730/

  • Behavior Change and Media Campaigns

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    • Live Sugarfreed - In 2017, The Public Good Projects (PGP) published the evaluation of Live Sugarfreed, a mass media SSB reduction campaign that ran for 15 weeks in rural northeast Tennessee (Farley et al, 2017). The evaluation relied on analyzing data from SSB sales - a never-before used evaluation metric - which showed a 4.1% decrease of soda sales in intervention areas. The Live Sugarfreed evaluation suggested that counteradvertising campaigns can be an effective way of reducing SSB consumption
    • NJ Sugarfreed - The Public Good Projects is collaborating with the Nicholson Foundation to follow up on the successes create and implement a digital media campaign focused on reducing consumption of SSBs and increasing water consumption among those at highest risk for negative health consequences. An extensive literature review revealed a need to pay particular attention to low-income, Hispanic/Latino and African American New Jersey residents, as well as the importance of leveraging the role of mothers in decreasing SSB consumption for themselves and their family. With both types of insights in mind, PGP designed campaign content separately and specifically for three distinct audience segments: African American moms (through the Natural Beauty Sugarfreed campaign), Hispanic moms (through the Sugarfreed Belleza campaign) and general audience, including partners and individuals interested in the topic (through the NJ Sugarfreed campaign). All three campaigns used tailored content to empower communities with engaging health communication messages disseminated through social media and partner organizations. A community campaign manager (CCM) was utilized and represented all campaigns across the entire state, but with particular emphasis on Passaic County, which served as the campaign hub and received a higher dose of intervention. Results from an evaluation showed that pairing highly tailored and targeted digital content within grassroots community-building model holds promise in reducing SSB consumption at a large scale.
    • Kick the Can - Kick the Can is a project of Public Health Advocates (PHAdvocates), formerly CA Center for Public Health Advocacy. PHAdvocates is at the forefront of solving the obesity and diabetes epidemics by advocating for groundbreaking policies that build healthier communities. While some of the information is updated as of 2016, the website still provides a helpful repository for examples of policy, legislative and advocacy-related materials. The website provides resources on the negative health effects of soda and other sugary drinks, advocacy tools, language and sample policies to model, summaries of current legislative and educational campaigns, as well as outlets to get involved.
    • Rethink Your Drink - Rethink Your Drink is a public health initiative by the California Department of Health. With the help of local health departments, the program aims to educate Californians about healthy drink options, health identify drinks with added sugar, and make the link between SSB consumption and health risks. This program was integrated into the SNAP-Ed (Supplemental Nutrition Assistance Program-Education) Strategies and Interventions Toolkit, an evidence-based program intended to help people live healthier lives. A statewide evaluation of the SNAP-Ed Program showed that mothers who received higher levels of intervention reported consuming more fruits, vegetables, and fewer calories from high-food fats, and fewer SSBs than mother with lower levels of the intervention.

  • Environmental Changes

    Environmental changes are one potential way to promote positive behavior changes. In particular, two key environments have been highlighted as specific systems that are most relevant for changes - school environments and workplaces.

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    • School Environment Changes - Avenues to effectively reduce SSB consumption and other unhealthy dietary behaviors in children within schools include educational policies, access limitations, and price changes. Educational policies focuses on changing the knowledge, attitude, and behaviors of children towards SSBs. These interventions are either conducted through a school-based lessons and interactive classroom activities or through home and community-based strategies. A study published about one program that discouraged students from drinking SSBs showed significant reductions in consumption levels and subsequent reductions in BMI levels. Another educational program promoting water as healthier alternative reduced the risk of being overweight by 31%. Other school-based interventions involve school-level policies that limit the availability of and access to SSBs. This strategy in a middle school setting has been shown to reduce SSB consumption by 25% and total caloric energy by 30%. Similarly, in-school price policies that either increase SSB prices or reduce prices of lower fat snacks, fruits, and vegetables in school suggest that students may also be sensitive to price differentials for SSB. For more information on other studies, see the following links:
      https://jamanetwork.com/journals/jamapediatrics/article-abstract/1815479
      https://www.fasebj.org/doi/abs/10.1096/fasebj.26.1_supplement.629.9
    • Workplace Environment Changes - Strategically designing the workplace environment to influence and promote the intake of healthful foods and amount of energy consumed has been shown to effectively reduce obesity in adults. Many interventions utilize multiple strategies to increase healthy behaviors, including materials, classes, changes to food supplies, changes in social norms, incentive programs, and physical activity programs. However, because interventions usually include combined strategies, it can be difficult to credit one strategy to behavioral change. Overall, studies have shown that changes to the workplace environment can lead to decreases of up to 9% in total dietary fat and increase up to 16% in daily fruit and vegetable intake. Reducing the costs of healthier alternative by 10% and increasing availability by 50% has also been shown to be an effective strategy in reducing consumption.

  • Industry Efforts

    There are notable approaches that the beverage industry can adopt to reduce sugar-sweetened beverage consumption through marketing, strategic partnerships, and product reformulation.

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    • Marketing Approach - In 2007, the voluntary Children’s Food and Beverage Initiative (CFBAI) established nutritional standards for products advertised directly to children under the age of 12. Companies who participate have policies in place that inhibit direct advertising to children, which can include changing attractive packaging, online games, brand and licenses characters and other marketing approaches that appeal to young children. CFBAI participants include leaders in the beverage and food industry, including Coca-Cola, Pepsico, and Nestle. Core principles of this group include avoiding advertising in elementary school environments, adhering to restrictions on child-centric advertising, and issuing public reports on activities.
    • Voluntary and Regulatory Industry Approach - In a partnership with the Clinton Foundation, the beverage industry agreed to voluntarily eliminate full-calorie beverages from schools and follow guidelines for elementary, middle, and high school. This led to a 90% decrease in calories shipped to U.S. schools. Similarly, in a collaboration with the Healthy Weight Commitment Foundation, the beverage industry was able to remove more than 6 trillion calories per year from the marketplace. Other voluntary initiatives from the beverage industry include placing calorie information on the front of packages, and formulating and developing produce to be lower in calories. While many cities have used taxes based on volume of product for sugar-sweetened beverages, taxing grams of sugar could be a better and more effective strategy to incentive companies to lower sugar content of the taxed products.
    • Partnerships with Industry - In an partnership between Alliance for a Healthier Generation and the American Beverage Association, the Coca-Cola Company, PepsiCO, and Cadbury-Schweppes (now Dr. Pepper-Snapple), the 2016 Alliance School Beverage Guidelines was established. This outlined an agreement to several changes including discontinued sales of full-calorie carbonated soft drinks, shifting production to low and no-calorie beverages, and reducing portion sizes of products sold in school. An evaluation to assess the effect of the agreement between 2004 and the 2009-2010 school year showed promising results: beverage calories shipped to schools decreased by 90%; volume of beverages shipped to schools decreased by 77%; volume of full-calorie, carbonated soft drinks shipped to schools decreased by 97%; and volume of restricted beverages (such as juice drinks, flavored waters, and teas) shipped to schools decreased by 94%. A second agreement between Alliance for a Healthier Generation and the beverage industry shifted to more of a long-term goal of reducing beverage calories consumed per person per day in the United States by 20% by 2025 (from 199 calories per day in 2014 to 159 calories per day by 2015). Through this agreement, partners will continue to promote calorie and sugar awareness on all company-owned equipment (i.e. vending machines, retail coolers, etc), reformulate, distribute, and market no- and low-calorie beverages, and engage in consumer education and outreach at the community level.