Sugar-sweetened Beverage Policy Research Articles

An Inventory of Proposed and Enacted Sugar-Sweetened Beverage Policies at the State, Local, and Tribal Levels in the United States, 2014‒2023.

Objectives. To inventory and describe trends in proposal and enactment of US sugar-sweetened beverage (SSB) policies at state, local, and Tribal levels, 2014-2023. Methods. We systematically searched 6 policy databases in 2021 (updated May 2023) using SSB-related search terms, identifying additional policies through snowball and online searches and a survey of food-policy experts. We reviewed 10 821 policies for inclusion and quantitatively coded included policies. Results. The inventory included 400 (321 unique [i.e., excluding companion]) policies meeting criteria: 335 (256 unique) state-, 63 local-, and 2 Tribal-level policies. From 2014 to 2023, 11% of unique state-, 92% of local-, and 100% of Tribal-level proposed policies were enacted. Across jurisdictions, the most frequently proposed policies related to excise taxes, restaurant children's meals, nutrition standards, and the Supplemental Nutrition Assistance Program, while the largest proportions of enacted policies related to restaurant children's meals, nutrition standards, education, and procurement. More policies were proposed and enacted in California and New York than other states, and in 2017 (proposed) and 2016 (enacted). Conclusions. This comprehensive inventory of US SSB policies provides information to inform future SSB policy development and diffusion. (Am J Public Health. 2024;114(12):1344-1353. https://doi.org/10.2105/AJPH.2024.307855).

Implementation costs of sugary drink policies in the United States.

To support implementation of important public health policies, policymakers need information about implementation costs over time and across stakeholder groups. We assessed implementation costs of two federal sugar-sweetened beverage (SSB) policies of current policy interest and with evidence to support their effects: excise taxes and health warning labels. Our analysis encompassed the entire policy life cycle using the Exploration, Preparation, Implementation, and Sustainment framework. We identified implementation actions using key informant interviews and developed quantitative estimates of implementation costs using published literature and government documents. Results show that implementation costs vary over time and among stakeholders. Explicitly integrating implementation science theory and using mixed methods improved the comprehensiveness of our results. Although this work is specific to federal SSB policies, the process can inform how we understand the costs of many public health policies, providing crucial information for public health policy making.

Framing and Themes of the City of Boulder's Sugar-Sweetened Beverage Tax Coverage in the Local News From 2016 to 2018

The objective of this paper was to analyze the contents of opinion and news articles related to the city of Boulder's sugar-sweetened beverage excise tax campaigns in Boulder's only local newspaper. We searched for articles in The Daily Camera related to the sugar-sweetened beverage tax, published from January 2016 to December 2018. We conducted a content analysis, categorizing 152 relevant articles by type, authors, and frames (pro, anti, neutral) on the basis of the preponderance of arguments, themes, and use of evidence. The majority of articles were opinion (n=92) versus news (n=60). Most articles were pro-frame (n=78) versus anti-frame (n=37) and neutral frame (n=37). Pro-frame articles were more likely to cite evidence in support of arguments or the professional credentials/experience of the authors. The most frequent pro-frame themes were health, benefits of the revenues, equity, and unethical tactics of the industry. The most frequent anti-frame themes were economic consequences, claims that the measure was confusing, government overreach, and purported ineffectiveness of taxes. The leveraging of local issues by the beverage industry was observed. Themes identified in the news regarding Boulder's successful sugar-sweetened beverage tax may appear in future sugar-sweetened beverage policy campaigns and should be anticipated.

Simulation models of sugary drink policies: A scoping review.

Simulation modeling methods are an increasingly common tool for projecting the potential health effects of policies to decrease sugar-sweetened beverage (SSB) intake. However, it remains unknown which SSB policies are understudied and how simulation modeling methods could be improved. To inform next steps, we conducted a scoping review to characterize the (1) policies considered and (2) major characteristics of SSB simulation models. We systematically searched 7 electronic databases in 2020, updated in 2021. Two investigators independently screened articles to identify peer-reviewed research using simulation modeling to project the impact of SSB policies on health outcomes. One investigator extracted information about policies considered and key characteristics of models from the full text of included articles. Data were analyzed in 2021-22. Sixty-one articles were included. Of these, 50 simulated at least one tax policy, most often an ad valorem tax (e.g., 20% tax, n = 25) or volumetric tax (e.g., 1 cent-per-fluid-ounce tax, n = 23). Non-tax policies examined included bans on SSB purchases (n = 5), mandatory reformulation (n = 3), warning labels (n = 2), and portion size policies (n = 2). Policies were typically modeled in populations accounting for age and gender or sex attributes. Most studies focused on weight-related outcomes (n = 54), used cohort, lifetable, or microsimulation modeling methods (n = 34), conducted sensitivity or uncertainty analyses (n = 56), and included supplementary materials (n = 54). Few studies included stakeholders at any point in their process (n = 9) or provided replication code/data (n = 8). Most simulation modeling of SSB policies has focused on tax policies and has been limited in its exploration of heterogenous impacts across population groups. Future research would benefit from refined policy and implementation scenario specifications, thorough assessments of the equity impacts of policies using established methods, and standardized reporting to improve transparency and consistency.

State Preemption of Consumer Merchandise and Beverage Containers: New Strategy to Preempt Sugar-Sweetened Beverage Policies?

State legislators passed laws preempting, or prohibiting, local governments from regulating beverage containers. Although the primary purpose of these laws may be to ban local environmental regulations addressing single-use plastics, it is unknown the extent they also preempt public health policies aimed at reducing sugar-sweetened beverage consumption. In 2021, using LexisNexis, we assessed state legislation preempting local control over consumer merchandise and containers. We identified 8 laws (and 16 failed bills) with broad language preempting local regulation of the sale, use, or marketing of multiple container types, including beverage containers. Most legislative activity occurred during 2016-2021, with legislative intent to avoid a "patchwork" of local laws, avoid burdening retailers, and have a "refreshing drink." Local policy control was characterized as "personal choice." Broad preemption language may stifle local policy making aimed at reducing sugar-sweetened beverage consumption and preempt public health policies such as restricting portion size, in-store promotion and display, and labeling measures.

Community Perceptions in New York City: Sugar-Sweetened Beverage Policies and Programs in the First 1000 Days

ObjectivesTo examine perceptions of Sugar-sweetened beverage (SSB) policies and programs focused on the first 1000 days—gestation through age 2 years—among community stakeholders in Washington Heights and the South Bronx, two neighborhoods in New York City with disproportionately high prevalence of childhood obesity.MethodsA multilevel framework informed interview guide development. Using purposeful sampling, we recruited study participants who were (1) able to speak English or Spanish and (2) resided or employed in Washington Heights or the South Bronx. Participants included community leaders (local government officials, community board members, and employees from community- and faith-based organizations) as well as community members. Trained research staff conducted semi-structured in-depth interviews. Using immersion/crystallization and template style coding, the study team performed thematic analysis until no new relevant themes emerged.ResultsAmong the 19 female study participants, perceived facilitators to SSB policy and program implementation included sustained partnerships with broad coalitions; continual education and clear messaging; and increased accessibility to healthier beverages. Perceived barriers included systems-level challenges accessing programs that support healthy beverage options, and individual-level lack of access to affordable healthy beverages. Acceptable potential intervention strategies included messaging that emphasizes health in pregnancy and infancy; policies that require healthy beverages as the default option in restaurants; and policies that remove SSBs from childcare settings. Some strongly favored SSB excise taxes while others opposed them, but all participants supported reinvestment of SSB tax revenue into health resources among marginalized communities.ConclusionsA multi-pronged approach that incorporates engagement, access, equitable reinvestment of revenue, and continual clear messaging may facilitate implementation of policies and programs to reduce SSB consumption in the first 1000 days.

Nutrition related non-communicable diseases and sugar sweetened beverage policies: a landscape analysis in Zambia

ABSTRACT Background: Taxation on unhealthy products is recommended as a cost-effective intervention to address the global burden of non-communicable diseases. Taxation of sugar-sweetened beverages dis-incentivize consumption of unhealthy products. Implementation of such policies is difficult in Sub-Saharan African countries, which are targets for global corporate expansion by the sugar-sweetened beverages industry. Objective: To identify opportunities to strengthen policies relating to sugar-sweetened beverage taxation in Zambia, through: (1) understanding the policy landscape and political context in which policies for nutrition-related non-communicable diseases are being developed, particularly sugar-sweetened beverage taxation, and exploring the potential use of revenue arising from sugar-sweetened beverage taxation to support improved nutrition. Methods: We conducted a retrospective qualitative policy analysis with a review of nutrition-related non-communicable diseases policies and key informant interviews (n = 10) with policy actors. Data were coded and analyzed data using pre-constructed matrices based on the Kingdon’s Policy Agenda Framework. Results: Government responses to nutrition-related non-communicable diseases were developed in an incoherent policy environment. The health sector’s commitment to regulate sugar-sweetened beverages conflicted with the manufacturing sector’s priorities for economic growth. Increased regulation of sugar-sweetened beverages was a priority for the health sector. Economic interests sought to grow the manufacturing sector, including the food and beverage industries. Consequently, incoherent policy objectives might have contributed to the adoption of a weakened excise tax. The general public were poorly informed about nutrition-related non-communicable diseases. Conclusions: The tension between the Government’s economic and public health priorities is a barrier for strengthening fiscal measures to address nutrition-related non-communicable diseases. However, this did not prevent the introduction of a differential sugar tax on sugar-sweetened beverages. Opportunities exist to strengthen the existing taxation of sugar-sweetened beverages in Zambia. These include a more inclusive consultation process for policy formulation and comprehensive monitoring of risk factors.

Nutrition-related non-communicable disease and sugar-sweetened beverage policies: a landscape analysis in Kenya

ABSTRACT Background: The burden of undernutrition is significant in Kenya. Obesity and related non-communicable diseases are also on the increase. Government action to prevent non-communicable diseases is critical. Taxation of sugar-sweetened beverages has been identified as an effective mechanism to address nutrition-related non-communicable diseases, although Kenya is not yet committed to this. Objective: To assess the policy and stakeholder landscape relevant to nutrition related non -communicable diseases and sugar-sweetened beverage taxation in Kenya. Methods: A desk review of evidence and policies related to nutrition related non-communicable diseases and sugar-sweetened beverages was conducted. Data extraction matrices were used for analysis. Key informant interviews were conducted with 10 policy actors. Interviews were thematically analysed to identify enablers of, and barriers to, policy change towards nutrition-sweetened beverage taxation. Results: Although nutrition related non-communicable diseases are recognised as a growing problem in Kenya most food-related policies focus on undernutrition and food security, while underplaying the role of nutrition related non-communicable diseases. Policy development on communicable diseases is multi-sectoral, but implementation is biased towards curative rather than preventive services. An excise tax is charged on soft drinks, but is not specific to sugar-sweetened beverages. Government has competing roles: advocating for industrial growth, such as sugar and food processing industries to foster economic development, yet wanting to control nutrition related non-communicable diseases. There is no national consensus about the dangers posed by sugar-sweetened beverages. Conclusion: Nutrition related non-communicable diseases policies should reflect a continuum of issues, from undernutrition to food security, nutrition transition, and the escalation of nutrition related non-communicable diseases. A local advocacy case for sugar-sweetened beverage taxation has not been made. Public and policy maker education is critical to challenge the prevailing attitudes towards sugar-sweetened beverages and the western diet.

Strengthening prevention of nutrition-related non-communicable diseases through sugar-sweetened beverages tax in Rwanda: a policy landscape analysis

ABSTRACT Background: Food and beverages high in sugar are recognized to be among the major risk factors for nutrition-related non-communicable diseases. The growing presence of ultra-processed food producers has resulted in shifts to diets that are associated with non-communicable diseases and which include sugar-sweetened beverages. Sugar-sweetened beverage taxation presents an opportunity to prevent non-communicable diseases but it comes with challenges. Objectives: To describe the policy landscape, identify and analyse the facilitators of and barriers to strengthening taxation on sugar-sweetened beverages in Rwanda. Methods: We conducted a desk-based policy analysis to assess the facilitators of and barriers to strengthening sugary beverage taxation policy. We consulted eight stakeholders to validate the findings of the desk review. Results: Non-communicable diseases are recognized as a public health challenge in Government health and non-health policy documents. However, sugar intake is not explicitly identified as a risk factor for non-communicable diseases and existing policies do not clearly aim to reduce sugar consumption. The Rwandan Government's commitment to growing the local sugar industry and the substantial economic contribution of Rwandan beverage producers are potential barriers to fiscal policies aimed at reducing sugar consumption. However, the current 39% excise tax levied on all soft drinks could support the adoption of future sugar-sweetened beverage policies. Conclusions: The landscape for strengthening a sugar-sweetened beverage tax in Rwanda is complex. The policy environment provides both facilitators of and impediments to strengthening the existing tax. A differential tax could be introduced by leveraging on the existing excise tax and linking it to the sugar content of beverages.

Qualitative insights into Australian consumers' views for and against government action on sugary drinks.

Despite significant evidence of harms associated with high levels of sugar-sweetened beverage (SSB) consumption, and international moves towards regulation to curb overconsumption of such drinks, Australia has been slow to take policy action. This study provides in-depth insights into consumers' reactions to different SSB policy options. Eight focus groups were undertaken with 59 regular SSB consumers and/or household purchasers, stratified by: young adults aged 21-29 years (no children), parents aged 35-50 (with children at home); gender; and socio-economic status. Consumer responses to potential government intervention and policy options were explored using thematic analysis. Three main themes were identified. Theme 1 describes participants' changing views on regulation of SSBs throughout the focus groups, expressed through shifts in understandings of personal responsibility and the role of government. It was noted that the term 'regulation' should be used judiciously, as it was widely misunderstood to infer bans. Theme 2 articulates the participants' preference for child-focused measures and educative measures such as clearer front-of-pack labelling. Taxation on SSBs was viewed more favourably if paired with investment into education. Theme 3 describes the parallels that participants drew between SSBs and other substances. A comprehensive approach that includes education, child-focused interventions and regulatory approaches may increase acceptability of policy measures to curb overconsumption of SSBs.

Sugar-Sweetened Beverage Warning Policies in the Broader Legal Context: Health and Safety Warning Laws and the First Amendment

Health and safety warnings are a regular part of the consumer protection landscape. However, the only sugar-sweetened beverage policy passed to date was found unconstitutional under the First Amendment. This paper evaluates sugar-sweetened beverage warning policies in light of existing health and safety warnings on consumer products and the First Amendment. In 2019, using LexisNexis, existing federal, state, and local health and safety warning laws for consumer products were identified. Then, bills proposed and laws passed through July 2019 that required sugar-sweetened beverage warnings were examined. Finally, First Amendment case law related to warning and disclosure requirements was analyzed to identify outstanding questions about the constitutionality of sugar-sweetened beverage warning policies. Warnings on consumer products provide key examples of long-established health and safety warning language, rationales for passage, and formatting requirements. Between 2011 and 2019, a total of 9 jurisdictions proposed 28 bills (including 1 law by San Francisco) requiring sugar-sweetened beverage warnings on labels, advertisements, and at point of sale. This analysis highlighted outstanding First Amendment questions on permissible wording and formatting requirements and the need for evidence and rationales that focus on specific health harms of sugar-sweetened beverages. Warnings on labels and at point of sale may pose fewer First Amendment concerns than on advertisements. Sugar-sweetened beverage warning policies that mirror health and safety warnings long established as permissible on other consumer products should be considered constitutional; however, evolving First Amendment jurisprudence leaves outstanding questions, especially on the interpretation of controversy, formatting requirements, and levels of required specificity for warning language.

How to be SSB-free: Assessing the attitudes and readiness for a sugar sweetened beverage-free healthcare center in the Bronx, NY.

In recent years, communities and institutions have sought new interventions intended to reduce sugar sweetened beverage (SSB) consumption among children. Among these interventions are “SSB-free zones,” where such beverages are not permitted to be consumed on the premises. Insufficient knowledge still exists, however, about the readiness for such restrictive SSB policies within health care institutions. Understanding attitudes toward SSB consumption among adults is necessary to guide an institution-wide policy, where staff and patients serve as role models for parents and their children. We conducted focus groups with health center patients and staff to determine perceptions surrounding health and SSB consumption and to better understand the support and readiness (or lack thereof) for an SSB-free zone intervention prior to its implementation. We found that contextual practices present challenges to breaking personal consumption habits, even if beverages are banned from the worksite. Nevertheless, participants expressed support for SSB-free zones, and recommended more education about the harmful effects of soda and energy drink consumption to help improve acceptability for the policy. We conclude that policies restricting onsite SSB consumption may be more effective when combined with educational information and expressions of understanding that this specific behavior change can be difficult.

A Case Study of the Philadelphia Sugar-Sweetened Beverage Tax Policymaking Process: Implications for Policy Development and Advocacy.

Policymakers are increasingly proposing sugar-sweetened beverage (SSB) taxes as an evidence-based strategy to reduce chronic disease risk; and local health departments (LHDs) are well-positioned to play a role in SSB policy development and advocacy. However, most SSB tax proposals fail to become law and limited empiric guidance exists to inform advocacy efforts. In June 2016, Philadelphia, Pennsylvania, passed an SSB tax. To identify features of the Philadelphia SSB tax policymaking process that contributed to the proposal's passage. Qualitative case study. Semistructured interviews were conducted with key informants closely involved with the policymaking process. Interviews were audio-recorded and transcribed. Local news media about the SSB tax proposal were analyzed to triangulate interview findings. Analysis was conducted in NVivo 10 using inductive qualitative content analysis. Philadelphia, Pennsylvania, during the SSB tax policymaking in process. Nine key informants (2 city councilpersons, 4 city agency officials, 1 community-based advocate, 1 news reporter, and 1 researcher). The Philadelphia SSB tax proposal was introduced with the explicit goal of financing universal prekindergarten and deliberately not framed as a health intervention. This framing shifted contentious debates about government involvement in individual behavior toward discussions about how to finance universal prekindergarten, a goal for which broad support existed. The LHD played an important role in communicating research evidence about potential health benefits of the SSB tax proposal at the end of the policymaking process. During local SSB tax policy development processes, LHD officials and other advocates should encourage policymakers to design SSB tax policies so that revenue is directed toward community investments for which broad public support exists. When communicating with policymakers and the public, LHDs should consider emphasizing how SSB tax revenue will be used in addition to presenting evidence about the potential health benefits of the SSB tax at the local level.

Development of the policy indicator checklist: a tool to identify and measure policies for calorie-dense foods and sugar-sweetened beverages across multiple settings.

We developed the policy indicator checklist (PIC) to identify and measure policies for calorie-dense foods and sugar-sweetened beverages to determine how policies are clustered across multiple settings. In 2012 and 2013 we used existing literature, policy documents, government recommendations, and instruments to identify key policies. We then developed the PIC to examine the policy environments across 3 settings (communities, schools, and early care and education centers) in 8 communities participating in the Childhood Obesity Research Demonstration Project. Principal components analysis revealed 5 components related to calorie-dense food policies and 4 components related to sugar-sweetened beverage policies. Communities with higher youth and racial/ethnic minority populations tended to have fewer and weaker policy environments concerning calorie-dense foods and healthy foods and beverages. The PIC was a helpful tool to identify policies that promote healthy food environments across multiple settings and to measure and compare the overall policy environments across communities. There is need for improved coordination across settings, particularly in areas with greater concentration of youths and racial/ethnic minority populations. Policies to support healthy eating are not equally distributed across communities, and disparities continue to exist in nutrition policies.

Striving for meaningful policies to reduce sugar-sweetened beverage intake among young children.

* Abbreviations: CACFP — : Child and Adult Care Food Program SSB — : sugar-sweetened beverage A strong evidence base links sugar-sweetened beverage (SSB) intake to obesity in older children and adults.1–8 In this issue of Pediatrics , DeBoer et al add to the evidence using data from a nationally representative US cohort study to show a relationship between SSB intake and obesity among preschool-age children.9 The authors conclude that “strong consideration should be made toward policy changes leading to decreases in SSB consumption among children.”9 The questions we are now hoping to answer are the following: what policy solutions can curb SSB consumption among our youngest children? Equally important, how can these policies be meaningfully implemented in real-world settings? DeBoer et al’s study draws attention to a population of preschool-aged children who are often neglected by current SSB policies. Instituting soda taxes and limiting SSB serving sizes in restaurants have been proposed and attempted.10 Healthy beverage policies have been instituted in workplaces,11,12 and >80% of US school districts have policies prohibiting or restricting student access to SSBs.13 However, policies targeting preschool-aged children remain largely absent. There are clear federal policymaking opportunities to reduce SSB consumption among young children. The Child and Adult Food … Address correspondence to Anisha I. Patel, MD, MSPH, MSHS, Department of Pediatrics, and Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, 3333 California St, Suite 245, Mailbox 0503, San Francisco, CA 94118. E-mail: patela{at}peds.ucsf.edu

Impact of School District Sugar-Sweetened Beverage Policies on Student Beverage Exposure and Consumption in Middle Schools

To determine the associations between 1) exposure to sugar-sweetened beverages (SSB) in middle schools and student consumption of SSB during the school day; and 2) school district policies about SSB and exposure to SSB in schools. The strength of school district SSB policies was scored on three SSB policy indicators. Student SSB consumption at school was assessed by a self-administered Beverage and Snack Questionnaire. Exposure to SSB at school was defined as the number of vending slots and SSB venues as determined on-site at each school. Multivariate analysis considered the multilevel nature of the data. Data from 9151 students in 64 middle schools in 28 districts were used in the analysis. With schools as the unit of analysis, the proportion of students who consumed any SSB at school ranged from 19.2% to 79.8%. SSB exposure was a significant predictor of SSB consumption (beta=.157, p < .001). SSB consumption was not significantly associated with the size of the school, the racial or ethnic composition of the school's students, or the proportion of students eligible for free and reduced price meals. District SSB policy scores ranged from 0 to 6 with a mean score of 3.25 (+/-2.15). District SSB policy was a significant predictor of SSB exposure (beta=-9.50, p < .0002). School district SSB policies and exposure to SSB in middle schools are associated with student SSB consumption. Interventions to improve policies and their implementation may offer opportunities to improve the diets of adolescents.