Table 3.

Acceptability of intervention strategies synthesized by included systematic reviews

Reference	Intervention	Subtheme	Narrative synthesis results	Meta-analysis results	Distributional results
Financial and economic considerations
Eykelenboom et al 201933	FP (taxes) on SSBs	Macroeconomic impacts	Beliefs that an SSB tax may have negative macroeconomic impacts – “Concerns about the negative impact of an SSBs tax on the economy were reported in 4 studies on political [n = 2] and public acceptability [n = 3], such as concerns about a reduction in jobs and closing of SSB companies as a result of the tax.”	–	–
		Revenue generation	Beliefs that SSB taxes would be effective in raising revenue for social, health, and general budgets – “the potential to raise revenue for societal health programs (eg, for prevention funds, sport fields and recreational activities) was perceived as a positive consequence of implementation” AND “The potential of an SSBs tax to raise revenue for health care (eg, for the National Health Service) was identified in three studies on political and public acceptability.” AND “Four studies on political acceptability reported that an SSBs tax was viewed as a potential to raise revenue for the general budget”	“Pooled proportions indicated that of the public … 39% (0.36–0.41) believed that an SSBs tax has the potential to raise revenue for societal health programs”	–
Mounsey et al 202049	FP (taxes) on SSBs and energy-dense foods	Employment	Lack of evidence (except from modeling studies) that diet-related taxes result in net unemployment – “the three non-industry supported peer-reviewed academic studies found none of the significant job losses industry reports suggested, but found instead, no significant net decline in employment and job creation.”	–	–
		Gross domestic product	Evidence (from modeling studies) that SSB taxation would reduce GDP contributions; however, these were industry-funded and dependent on modeling assumptions – “the projections for reductions of approximately US$173 million and US $1 billion to GDP contributions from UK and South Africa analyses, respectively, were likely overestimated because of failure to incorporate milk and other substitutions across sectors, and for South Africa, the overshifting of the pass-through rate. It was also clear from the studies reviewed that the PE selected for modeling had a significant impact on the potential GDP effects of a tax.”	–	–
		Industry sales	Evidence (from modeling studies) that SSB taxation would reduce sales revenue generation; however, these were industry-funded and dependent on modeling assumptions – “Three reported the dollar value of sales revenue reductions (between $US13.3 and $US779 million), but not the total revenue prior to the tax, and one reported the percentage reduction in total revenue (23.5 %)” BUT “assumptions regarding the products taxed, wage fixing, the pass-through rate and substitution availability varied between papers, which have significant implications for the outcome of the models.”	–
		Revenue generation	Evidence (including modeling studies) that SSB taxation would increase government revenue – “Estimates ranged from between US$31 million to US$940 million, translating to per capita values of between US$1.05 to US$43.39. The most significant impacts on the magnitude of revenue were the tax levels imposed and onto what products, price-elasticity and substitution estimates.”	–	“One study reported the cross-border shopping impact of the Philadelphia SSB tax on both beverages and non-beverage items and showed a gross loss from the local sales tax revenue that should have been collected”
Niebylski et al 201548	FP (taxes and subsidies) to promote healthy diet	Revenue generation	Evidence (from modeling studies) that SSB taxation would increase government revenue and support for the allocation of revenue towards health initiatives – “In 2008, the CBO estimated that a federal excise tax of $0.03 per 12 ounces of SSB would generate an estimated $24 billion over 2009–2013 and $50 billion over 2009–2018.” AND “Using tax revenue to fund NCD prevention programs and/or subsidize healthy foods was further recommended”	–
Human rights and sociocultural acceptability
Dodd et al, 202047	FP (taxes) on salt and foods high in salt	Taxation as an intervention strategy	Lack of support for the introduction of tax to reduce salt consumption – “In Tonga, focus group discussions revealed food taxes to be unpopular with consumers, due to the cost for consumers” AND “In Ireland, salt tax was the least popular of proposed salt reduction initiatives” BUT “Support for salt taxation was highest amongst those who saw food manufacturers as responsible for reducing salt consumption, suggesting knowledge of the food production process could be key to winning public support”	–	–
Eykelenboom et al 201933	FP (taxes) on SSBs	Mistrust	Beliefs that some stakeholders cannot be trusted as part of SSB tax policy process – “Mistrust of the industry was identified in five studies on public acceptability of an SSBs tax [n = 5]” AND “Public doubts were reported about [government’s] use of raised revenue in four studies on public acceptability of an SSBs tax [n = 4]” AND “Mistrust of public health experts was expressed in one study on public acceptability”	“Pooled proportions indicated that of the public … 49% (0.32–0.66) mistrusted the industry, and 61% (0.56–0.67) mistrusted the government”	–
		Public support for SSB taxation	–	Quantitative estimates on public support for SSB taxation were pooled using a random-effects meta-analysis finding that – “42% of the public (95% CI = 0.38–0.47) supports an SSBs tax, 39% of the public (0.29–0.50) supports an SSBs tax as a strategy to reduce obesity, and 66% of the public (0.60– 0.72) supports an SSBs tax if revenue is appropriately used.”	–
		SSBs as an intervention target	Mixed beliefs as to whether SSBs are a good target for taxation as they provide pleasure but may also contribute to obesity – “Those supportive of an SSB tax believed that SSBs are a major contributor to obesity [n = 6], while opponents indicated a lack of personal evidence that SSBs can cause obesity and referred to the many other determinants of obesity [n = 4].”	“Pooled proportions indicated that of the public … 68% (0.48–0.85) believed that SSBs are an appropriate intervention target”	–
		Taxation as an intervention strategy	Mixed beliefs about whether taxation is an appropriate intervention strategy to reduce SSB consumption – “Taxation was viewed as an appropriate intervention strategy in the majority of studies on political acceptability. Taxation was also considered necessary in two studies on public acceptability. However, in other studies on political and public acceptability taxation was viewed as government intrusion.”		–
Niebylski et al 201548	FP (taxes and subsidies) to promote healthy diet	Taxation as an intervention strategy	Lack of support for taxation as a mean to improve diet – “A public opinion survey to examine attitudes on pro- and anti-food & SSB tax arguments … determined that more people agreed with antitax vs. pro-tax arguments.” AND “Policy support was highest for healthy lifestyle campaigns and food labelling but lowest for taxing unhealthy foods.”	–	–
Balance of health benefits and harms
Eykelenboom et al 201933	FP (taxes) on SSBs	Cost-effectiveness	Beliefs that an SSB tax would be cost-effective – “An SSB tax was seen as a cost-effective intervention for improving public health nutrition and obesity prevention across six studies on political [n = 3] and public acceptability [n = 3]”	–	–
		Effectiveness	Beliefs that taxes would be effective in reducing SSB consumption – “The belief that an SSBs tax would be effective in reducing purchases and consumption of SSBs was reported in studies on political … and public acceptability.”	“Pooled proportions indicated that of the public 39% (95% CI = 0.26–0.54) believed that an SSBs tax has impact on SSB purchases and consumption”	Belief that taxes would be ineffective in reducing SSB consumption among certain groups – “an SSBs tax was perceived to be ineffective in those addicted to SSBs, in those who lacked awareness of SSB prices, in those with obesity, and in rich and stubborn people.”
		Health-related outcomes	Mixed beliefs that an SSB tax would be effective in improving health – “While some studies among the public reported the belief that an SSB tax could improve population health [n = 5], others indicated that such a policy does not cure anything [n = 3].”	“Pooled proportions indicated that of the public … 40% (0.29–0.54) believed that an SSBs tax has impact on health-related outcomes”, WHILE “92% (0.91–0.93) believed that obesity is a problem”	Beliefs that taxes would be unfair for certain groups – “SSB tax [perceived] as unfair to “healthy” individuals who consume SSBs responsibly”
Niebylski et al 201548	FP (taxes and subsidies) to promote healthy diet	Health-related outcomes	Support for policy action to reduce obesity prevalence – “Improving awareness of the multiple causes of obesity could facilitate acceptance of policy action to reduce obesity prevalence.”	–	–
Health equity, equality, and nondiscrimination
Eykelenboom et al 201933	FP (taxes) on SSBs	Socioeconomic inequality	–	“Pooled proportions indicated that of the public … 50% (0.48–0.52) believed that an SSBs tax has a negative impact on socioeconomic equality”	Mixed beliefs on the effect of SSB taxation on inequality – “In three studies on political acceptability, an SSBs tax was believed to have a positive impact on equality in health”; HOWEVER, “concerns primarily arose from the belief that an SSB tax is regressive [n = 7]; low-income individuals have to spend relatively more of their income and consume greater quantities of SSBs [n = 2].”
Niebylski et al 201548	FP (taxes and subsidies) to promote healthy diet	Helping key groups	–	–	Support for policies to help children – “small taxes with the clear purpose of promoting the health of key groups, eg, children, are more likely to receive public support.”
		Tax regressivity	–	–	Beliefs that taxes to reduce SSB consumption would be regressive – “that low SES [groups] may carry more of the fiscal burden … may limit feasibility of SSB fiscal policy implementation”
Societal implications
Eykelenboom et al 201933	FP (taxes) on SSBs	Healthy substitutes	Beliefs that a lack of healthy alternatives would lead consumers to consume unhealthy alternatives – “Three studies on public acceptability reported concerns about an increase in the consumption of artificial sweeteners as a result of an SSB tax”	–	–
		Reformulation	Beliefs that an SSB tax would encourage manufacturers to reformulate SSB contents – “UK news website commentators indicated that manufacturers would reduce the amount of sugar as a consequence of the tax, which was viewed as a potential facilitator in the effectiveness of an SSBs tax.”	–	–
		SSB prices	Beliefs that tax may not be passed through to consumers – “Studies among Australian citizen jurors and students from Michigan, UK, indicated that a tax rate of 50 to 100% may be large enough to change consumer behaviour.”	–	–
Feasibility and health system considerations
Eykelenboom et al 201933	FP (taxes) on SSBs	Feasibility	Beliefs that SSB taxes could be feasible but many barriers exist – “Examples of barriers are a long law-making process in Mexico and the UK, competing national agendas in Mexico, the difficulty of defining products that should be taxed in Israel and the UK, the difficulty of regulating “home-made, unlabelled products” in Mexico, the development of a black market in Israel, a high administrative load in New Zealand, and political costs of taxation in European countries.” AND “resistance from the SSB industry was described to complicate policy adoption and implementation”	–	–

Abbreviations: FPs, fiscal and pricing policies; GDP, gross domestic product; SES, socioeconomic status; SSB, sugar-sweetened beverage.