Abstract
Background
Frequent consumption of Energy Drinks (EDs) is associated with numerous health problems, including overweight and obesity, particularly among children and adolescents. The extensive promotion, wide accessibility, and relatively low cost of EDs have significantly increased their popularity among this age group. This paper examines policies/programs that, directly and indirectly, contribute to reducing ED consumption in children and adolescents and shares global experiences to help policymakers adopt evidence-based policies.
Methods
A systematic search was performed using PubMed, Scopus, and Web of Science databases from January 2000 to June 2024, along with reputable international organization websites, to find literature on policies aimed at reducing ED consumption among children and adolescents. All sources meeting the inclusion criteria were included without restrictions. Titles and abstracts were initially screened, followed by a full-text review. After evaluating the quality of the selected studies, data were extracted and, along with information from the selected documents, compiled into a table, detailing the country, policy type, and the effectiveness and weaknesses of each policy.
Results
Out of 12166 reviewed studies and documents, 84 studies and 70 documents met the inclusion criteria. 73 countries and territories have implemented policies like taxation, sales bans, school bans, labeling, and marketing restrictions on EDs. Most employ fiscal measures, reducing consumption despite enforcement challenges. Labeling, access restrictions, and marketing bans are common but face issues like black markets.
Conclusion
This scoping review outlines diverse strategies adopted by countries to reduce ED consumption among children and teenagers, such as taxation, school bans, sales restrictions, and labeling requirements. While heightened awareness of ED harms has reinforced policy efforts, many Asian and African nations lack such measures, some policies remain outdated for over a decade, and existing policies face several challenges. These challenges encompass industry resistance, governmental disagreements, public opposition, economic considerations, and the intricacies of policy design. Considering this, countries should tailor policies to their cultural and social contexts, taking into account each policy's strengths and weaknesses to avoid loopholes. Inter-sectoral cooperation, ongoing policy monitoring, updates, and public education campaigns are essential to raise awareness and ensure effective implementation.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12889-024-19724-y.
Keywords: Adolescent, Ban, Children, Energy drink, Food environment, Label, Policy, School, Tax
Introduction
Energy drinks (EDs) are non-alcoholic caffeinated beverages containing carbohydrates, amino acids, vitamins, sweeteners, caffeine, and other stimulants like guarana, taurine, and ginseng [1–3]. Both EDs and sugar-sweetened beverages (SSBs) contain high levels of sugar, but they have distinct differences. EDs include stimulants such as caffeine and taurine, which are designed to boost energy and alertness, and SSBs like sodas and fruit drinks primarily contain sugars and sometimes artificial flavors without these additional stimulants [1, 4–6].
EDs, first introduced in the 1960s, have experienced a worldwide surge in consumption, fueled by aggressive marketing campaigns [7]. Currently, EDs have become a rapidly expanding segment of the beverage industry, with around 200 brands available in over 140 countries, and 31% of adolescents aged 12 to 17 consume them regularly [8]. Moderate consumption of EDs is generally not a risk for healthy individuals. However, excessive intake, particularly when combined with alcohol or illegal drugs, poses significant health risks for children, adolescents, and individuals with heart, neurological, or kidney conditions [4]. Previous studies show that frequent ED consumption is associated with poorer mental, physical, behavioral, and educational outcomes [9–12]. Furthermore, the use of ED is tied to side effects such as headaches, insomnia, and increased consumption of alcohol and tobacco [9–12]. These effects are particularly heightened in children and adolescents, a demographic that is especially susceptible [9, 11, 12].
Smart advertising of EDs with catchy advertising slogans has been a key strategy by manufacturers to appeal to children and adolescents [8]. Additionally, the relatively low cost and widespread availability of these drinks further contribute to their increased consumption among young people [13].
Implementing policies to tax EDs seems to influence their consumption, as higher taxes can reduce daily intake [14]. Several countries, including Sweden, Denmark, and Argentina are contemplating initiatives to restrict the accessibility of EDs and prohibit their sale to minors, akin to regulations governing alcohol, which might lead to a decrease in ED consumption [15–17]. The brand and packaging play a significant role in the consumption of these beverages [18]. Consequently, altering the packaging emerges as another essential strategy. These modifications might involve adopting neutral colors, reducing the use of images and eye-catching designs, and enlarging the size of the recommendations on the packaging [19–21].
Numerous policy solutions exist to create a more health-conscious food environment that encourages healthier choices and reduces diets related to non-communicable diseases. So far, governments worldwide have undertaken initiatives to enable consumers to make healthier decisions. They have enacted various policies to reduce the global consumption of SSBs, including EDs [22].
This paper aims to investigate policies and programs that directly and indirectly help reduce ED consumption among children and adolescents. It also seeks to share the experiences of various countries to aid policymakers and decision-makers in adopting evidence-based policies in this field.
Methods
The approach of the scoping review
Given that the studies alone offered a limited perspective for identifying and evaluating existing policies, it was necessary to assess documents of different countries through additional sources, including international organizations' documents. Therefore, a scoping review was selected as the best approach to provide a comprehensive overview of existing policies aimed at reducing children's consumption of EDs. The scope and approach of this scoping review involve synthesizing insights from various countries' policies to assist policymakers and decision-makers in adopting evidence-based strategies in this field.
Protocol
This scoping review adheres to the guidelines provided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [23].
Conceptual framework
In this scoping review, we applied Brennan et al.'s conceptual framework for food environments to define and establish criteria for our research [24]. This model categorizes the food environment into four micro-environments: physical (for instance, food availability), economic (for example, food pricing), social (for instance, influence of parents or peers), and communication (for example, advertising and marketing). It evaluates how these micro-environments simultaneously impact eating behaviors. As a result, modifications in any of these environments can influence children's food choices (Fig. 1) [24].
Fig.1.
Conceptual Framework
Information sources and search
A comprehensive search for studies was conducted across three databases: PubMed, Scopus, and Web of Science (ISI). The search encompassed the timeframe from January 2000 to June 2024. The search was based on the following index terms and titles or abstracts: (“energy drink*” OR beverage* OR “energy shot*” OR “energy tonic*” OR “caffeinated sport drink*” OR “caffeinated drink*” OR “Sugar-Sweetened Beverage*” OR SSB) AND (law OR Guideline OR program* OR evaluate* OR polic* OR govern* OR regula* OR evidence* OR strategy* OR plan OR rule OR tax* OR levy OR advertis* OR market* OR label* OR packag* OR reformulati* OR bann*). Also, the websites of organizations involved in health or food and nutrition research were searched to find evidence and policies related to reducing the consumption of EDs. These organizations include the World Health Organization (WHO) (https://www.who.int), the Food and Drug Administration (FDA) (https://www.fda.gov), the Center for Disease Control and Prevention (CDC) (https://www.cdc.gov), the American Academy of Pediatrics (AAP) (https://www.aap.org), the International Food Policy Research Institute (IFPRI) (https://www.ifpri.org), and the International Network for Food and Obesity / Non-communicable Diseases (NCDs) Research, Monitoring and Action Support (INFORMAS) (https://www.informas.org). We also searched the Global database on the Implementation of Food and Nutrition Action (GIFNA) database to locate relevant papers on reducing the consumption of EDs (https://gifna.who.int). It is a WHO-supported initiative that serves as a resource for tracking and monitoring the implementation of nutrition-related policies and actions at the global level. It provides information on various initiatives, programs, and policies aimed at improving nutrition outcomes worldwide. Additionally, a manual search was conducted in Google Scholar and within the references of the studies to uncover new studies or documents.
No restrictions were made regarding the language, and we reviewed the studies reference section of all available studies and reviews to avoid missing any publications. Furthermore, there were no limits on the design of the study, and we included preprints, conference abstracts, commentaries, etc.
Eligibility criteria
Inclusion criteria included all studies or reports related to policies to decrease ED consumption in children and adolescents (under 18 years old) involved in this study.
In addition, we investigated other reviews that had information about countries' policies to reduce EDs.
Exclusion criteria included studies on beverages other than EDs, studies on other populations or groups (above 18 years), and failure to report policies or laws related to the subject.
Selection of sources of evidence
Initially, the duplicate studies were detected and eliminated using EndNote™ software (version 20). The screening process involved examining the titles and abstracts of the studies. We considered all studies and documents pertaining to EDs, as well as the corresponding regulations, to determine their approach towards children. In cases where the title and abstract did not provide enough information, the complete text of the studies was examined. The purpose was to assess their relevance. Two researchers (MHR and SR) conducted the selection process independently. Any differences or conflicts between them were addressed through discussion until a consensus was reached. If a resolution couldn't be reached, a third opinion (MB) was sought.
Quality assessment
Two reviewers (MHR and SR) independently assessed the quality of the studies. Considering that different types of studies were included in this study, various tools were used to investigate the risk of bias (RoB). These tools included: 1) AMSTAR2 for systematic reviews [25], 2) EPOK for interrupted time series studies [26], 3) PROBAST for modeling studies [27], 4) JBI for nonrandomized experimental studies [28], commentaries, editorials [29] and qualitative studies [30], 5) Newcastle–Ottawa scale (NOS) for observational studies [31], 6) PRISMA-ScR Checklist for the scoping review [23], 7) Mixed Methods Appraisal Tool (MMAT) checklist for the Mixed Method studies [32].
If there were any disagreements, the two researchers would engage in discussions with the third researcher (MB) to address any uncertainties. The assessment was conducted at both the study and outcome levels. Since all primary studies, regardless of their nature, were included, we employed a suitable checklist for each study to assess its quality.
Data extraction
Data extraction was performed by two members of the review team (MRH and SR). The following characteristics of the eligible studies were recorded: year of policy or law adoption, year of implementation, country, actor, content, implementation process, type of policy, strengths, effectiveness, and limitations. If there were no details available for extraction for the above characteristics, 'not reported' was entered.
Data synthesis
The information extracted from the studies and documents is summarized in a table that includes the country, the relevant policy, the actor, the date of introduction, the date of implementation, details of the policy, strengths, and weaknesses. The set of these policies was organized and categorized based on WHO regions. In addition, these policy types were categorized based on WHO regions in the form of a map. Two reviewers (MHR and SR) synthesized the data and the third researcher (MB) checked each synthesis.
Results
The PRISMA diagram (Fig. 2) illustrates the process: the initial search identified 17447 studies/documents. After removing 5281 duplicates, the number was reduced to 12166. Screening titles and abstracts led to the exclusion of 10491 studies/documents, leaving 1,675 for full-text screening. Of these, 78 studies and 70 documents met the inclusion criteria. Additionally, 6 more studies were found through manual searching, bringing the total to 84 studies and 70 documents included. The PICO components for this study are outlined in Table 1 (Supplemental file). The data extraction from 84 studies can be found in Table 2 (Supplemental file), while data extraction from 70 documents is detailed in Table 3 (Supplemental file).
Fig. 2.
PRISMA diagram
Risk of bias findings
The bias risk assessment was conducted for only 84 studies included in the study. The AMSTAR 2 tool was used to assess the RoB in 24 systematic reviews and meta-analyses studies. Of these, 13 studies had a high risk, six had a moderate risk, and five had a low risk of bias. Additionally, an interrupted time series was evaluated separately using the EPOK tool, which demonstrated good quality. Furthermore, five modeling studies were assessed using PROBAST, and only one was found to have a high risk of bias. 12 nonrandomized experimental studies were evaluated using the JBI tool and found to be of good quality. In addition, 17 cross-sectional studies and two cohort studies were also examined with reference from NOS. six of the cross-sectional studies were of low quality and three of them were of medium quality. However, the remaining eight studies demonstrated exceptional quality and exhibited a minimal RoB. Among the two cohort studies, they were of moderate quality. The five qualitative studies included in the study using JBI toll, were in good condition in terms of RoB. They were of acceptable quality. The remaining 14 studies that were used by JBI for the texts, comments, and expert opinions were of good quality. Two scoping reviews were also assessed for quality by the PRISMA-ScR checklist and demonstrated good quality. In addition, two Mix-Method studies were also assessed by the Mixed Methods Appraisal Tool (MMAT) checklist and demonstrated good quality (Supplemental file- Risk of bias assessment).
Summary of policies extracted from studies and documents
The WHO document recommends that countries worldwide implement policies to reduce the consumption of EDs. The organization aims to share successful policy experiences from various countries to facilitate similar implementations elsewhere. The WHO examines how Chile, Hungary, Oman, and Saudi Arabia implemented taxes on EDs and SSBs. These taxes are cost-effective in preventing diseases and can lead companies to reduce sugar content. Additionally, the AAP document provides recommendations specifically aimed at reducing ED intake among children and adolescents. The AAP recommends policies at all levels to reduce added sugar consumption, such as excise taxes on sugary drinks (SDs), with revenue addressing health and socioeconomic disparities. Governments should curb marketing SDs to children, and nutrition programs should promote healthy options. Furthermore, families need easy access to reliable nutrition information, and healthy beverages should be the default. Additionally, hospitals should lead by limiting SD purchases [22, 33]. Despite thorough searching, no relevant documents were found in the INFORMAS, IFPRI, or CDC databases.
The FDA documents have not precisely defined the term EDs, and there are no specific laws regarding them. The industries that produce these products can market ED products as regular food or drink or as dietary supplements. Each of these categories has its own regulations, for example, in the dietary supplement category, all adverse reactions must be reported to the FDA, and in addition, the label must only include ingredients that are presented in more than the usual amount in this composition or claimed to exist. However, in the category of general foods, the reporting of side effects is voluntary, and the labeling must include all information, including calories, carbohydrates, proteins, etc. Regardless of the category, this organization is responsible for ensuring that the manufacturers of these drinks have complied with the rules for that category [34]. In addition, the FDA has announced rules in the field of labeling. Beverages such as EDs with added sugars must declare the added sugar on the label [35, 36].
Based on the gathered information, 73 countries and territories, including Canada, the United Kingdom, Australia, the Philippines, New Zealand, and Saudi Arabia, have implemented various policies such as taxation, sales bans, school bans, labeling, and marketing bans on EDs. Some countries, like Canada, England, and Australia, employ multiple policies simultaneously to regulate children's ED consumption, while others, such as Armenia, Morocco, Bolivia, and Mali, use only one policy.
Additionally, 12 cities and counties in the United States have individually enacted policies to control ED consumption among children [37, 38]. The European Union has also enforced labeling regulations across its member states, mandating that beverages with caffeine content exceeding 150 mg/L must display "high caffeine" along with the specific amount [39].
Most countries with ED consumption control policies for children use fiscal measures. For example, Argentina, Dominica, Albania, and most of the Gulf Cooperation Council (GCC) members have imposed various tax rates and forms on EDs. Studies indicate that these tax policies can effectively reduce children's purchase and consumption of EDs, though challenges such as lack of cooperation from legal authorities, food manufacturers and retailers persist [40, 41].
Some countries, like Jamaica, Armenia, Estonia, and Iran, have restricted ED access in schools to limit children's exposure. Others, like Sweden, Denmark, and Lithuania, have implemented broader restrictions. In Sweden, for instance, selling EDs to children under 15 is prohibited, and in Norway, EDs can only be purchased through pharmacies. Countries like Qatar, New Zealand, and Germany enforce dual access denial policies. However, these policies may also lead to challenges, such as the emergence of black markets within schools. Additionally, schools often struggle to prevent students from purchasing these drinks from nearby stores [42].
Another strategy adopted by countries such as Latvia, Malta, and Costa Rica involves banning the advertising and marketing of EDs. Although few studies have evaluated these policies' effectiveness, successful implementation requires cooperation across various sectors, including ED manufacturers.
Australia and Canada have enacted regulations concerning the formulation of EDs. In Australia, policies concerning the formulation of EDs are primarily centered on voluntary reductions in sugar content, while in Canada, regulations focus on setting the maximum allowable caffeine levels. However, there is a lack of research investigating the effectiveness and constraints of these policies, highlighting the necessity for further studies in this field [43, 44].
Regarding labeling policies, countries like the United States, Italy, Australia, and South Africa have implemented ED labeling, but studies suggest that labeling alone is not significantly effective due to the lack of clear, standardized labeling guidelines across countries [45, 46]. The compiled policy information from studies and documents, along with the synthesized outcomes, are displayed in Table 1.
Table 1.
EDs policies around the world
| WHO region | Country | Policy | Actor/city | Formulation year | Implementation year | Process implementation | Effectiveness | Weak points | Ref |
|---|---|---|---|---|---|---|---|---|---|
|
Region of America (AMR) |
Argentina | ED sales ban | Government | ED ban in nightclubs | [17, 47] | ||||
| ED taxation | Government | Ad valorem excise tax structure | shown promise in reducing SSB (including EDs) consumption and improving public health |
1) Heterogeneity in Tax Design 2) Political and Industry Resistance 3) Coverage of Products 4) Need for Improved Guidance 5) Adjustments for Inflation |
|||||
| USA | ED labeling | Government | Caffeine, along with any other added ingredient, must be disclosed on the product label. The specific quantity of caffeine or other ingredients, however, does not need to be listed | [39, 45, 48–50] | |||||
| American Beverage Association | 2014 | developed guidelines for their members on caffeine labeling of EDs | |||||||
| ED marketing | US Senate Commerce Committee | 2013 | requested 16 ED manufacturers to voluntarily agree not to market to individuals under 18 years old | ||||||
| ED marketing | American Beverage Association | 2014 | published the "Guidance for the Responsible Labeling and Marketing of EDs," which encouraged ED companies to voluntarily report the total caffeine content from all sources, limit marketing to children, and report adverse events to the FDA | several ED companies continued to promote these drinks, and only a few of them reported side effects from ED consumption. In general, the level of adherence of ED manufacturing companies to these policies was generally low, and these policies could not achieve their intended goals | |||||
| ED sales ban | American Beverage Association | 2017 | This policy, restrict EDs for children under 12 years old and for students from kindergarten through 12th grade in schools | ||||||
| ED sales ban | New York County legislator | 2010 | This policy prohibits the sale of EDs to individuals under 19 years old | [50, 51] | |||||
| ED school ban | Virginia High School League | 2010 | [52] | ||||||
| ED taxation | Washington DC | May 2010 | a 6% sales tax | [53] | |||||
| ED taxation | Boulder City Council | 2017 | 2 cents/ounce | [54] | |||||
| ED taxation | Seattle City Council | Jan 2018 | 1.75 cent/ounce |
1)) The implementation of the tax on beverages resulted in a decrease of 53.0 oz or 12.2% in the average monthly household purchases of taxed beverages. This reduction in consumption corresponds to a decrease of 21 cal per day per household, which amounts to a reduction of 5 cal per day per household member. Over a period of approximately 3 years, this reduction in consumption contributed to a weight loss of 0.5 pounds per household member 2) The average price of taxed beverages increased by 90% of the tax amount. Increasing prices is considered a necessary measure for the tax to effectively reduce consumption |
[37, 55, 56] | ||||
| ED labeling | San Francisco | 2020 |
EDs are required to include warning labels with specific messages A strength of the policy is its use of causal language, employing terms like "can cause" and "increases the risk of" rather than "contributes to". The policy emphasizes weight gain as a potential consequence of consuming EDs while excluding references to dental caries |
The warning labels in San Francisco had modest impacts in this study | [37, 38, 57, 58] | ||||
| ED taxation | City and County of San Francisco | Jan 2018 | 1 cent/ounce | The beverage tax led to a significant decrease in household purchases, reducing daily calorie intake per household member and contributing to weight loss over three years | The lack of cooperation from industries in implementing the plan has led the industries to misrepresent retailers' views on the tax. This misrepresentation could be used to counter future disinformation campaigns by the industry, especially in regions considering the adoption of taxes | ||||
| ED taxation | Philadelphia City Council | Jan 2017 |
1.5 cents/ounce Its strength was that the policy applied exclusively to calorie-sweetened beverages (such as regular soda) and calorie-free sweetened beverages (such as diet soda) |
1.Lower the intake of EDs among children 2.Cut the consumption of added sugar in children by 22% 3.The probability of daily ED consumption. decreased significantly by 64% |
[37, 59, 60] | ||||
| ED taxation | Berkeley | NOV 2014 | March 2015 |
$0.01-per-ounce tax First city in the US that implement the tax on SSB and EDs |
Reduction in consumption of EDs, 1 year after tax implementation | These industries have skewed retailers' view of the tax. Paying attention to such problems and limitations can help to better implement these policies | [38, 61–63] | ||
| ED taxation | Cook County Board of Commissioners | 2016 | $0.01-per-ounce tax | [64] | |||||
| ED sales ban | Healthy Beverage Executive Order (HBEO) of Boston City | April2011 | Oct 2011 | [65] | |||||
| ED labeling | Healthy Beverage Executive Order (HBEO) of Boston city | The labels were designed to resemble traffic lights. For instance the red color signified that the drink contained more than 12 g of sugar per 12 oz. Yellow if it contains between 6–12 g sugar per 12 oz or it contains artificial sweeteners |
1) Following the issuance of the executive order, city agencies were significantly more inclined to sell only healthier beverages 2) There were reductions in the sugar content and calories of beverages sold at city properties, along with a 28% average decrease in the availability of high-sugar (red) beverages at these locations in Boston, without any change in price |
1) Not all agencies followed the executive order's labeling standards for ED 2) The implementation of the policy was different in different parts of the city |
|||||
| ED taxation | Chicago city |
A type of Retailers’ occupation tax $0.03 of gross receipts |
[66] | ||||||
| ED taxation | Director of Finance for the City of Oakland | July 2017 | one cent per ounce |
1) As a result of this policy, the availability of EDs decreased due to their notably higher cost per ounce in comparison to other beverages 2) The implementation of the tax led to a significant decrease in the average monthly household purchases of taxed beverages, resulting in a reduction in calorie intake. This reduction in consumption equated to a weight loss of approximately 0.5 pounds per household member over a span of about three years |
The SSB industry has mischaracterized retailer attitudes towards SSB taxation, which can be used to counter future industry-sponsored anti-SSB misinformation campaigns in localities where SSB taxes are being considered | [37, 38, 67, 68] | |||
| Dominica | ED taxation | Government | 2015 | 10% Ad valorem excise taxa |
1) such policies led to reduced consumption of SSBs including EDs 2) shown promise in reducing SSB (including EDs) consumption and improving public health |
1) legal challenges 2) concerns about potential economic impacts 3) Political and industry resistance 4) Inadequate evidence of effectiveness 5) Heterogeneity in Tax Design 6) Coverage of Products 7) Need for Improved Guidance 8) Adjustments for Inflation |
[41, 69–74] | ||
| Barbados | ED taxation | Government | June 2015 | SEP 2015 | 10%VAT | such policies led to reduced consumption of SSBs including EDs |
1) legal challenges 2) concerns about potential economic impacts 3) Political and industry resistance 4) Inadequate evidence of effectiveness 5) Heterogeneity in Tax Design 6) Coverage of Products 7) Need for Improved Guidance 8) Adjustments for Inflation |
[41, 69] | |
| Mexico | ED taxation | 2013 |
Mixed excise tax $1/liter fixed excise taxb |
such policies led to reduced consumption of SSBs including EDs |
1) legal challenges 2) concerns about potential economic impacts 3) Political and industry resistance 4) Inadequate evidence of effectiveness 5) Heterogeneity in Tax Design 6) Coverage of Products 7) Need for Improved Guidance 8) Adjustments for Inflation |
[49, 69, 75, 76] | |||
| Ecuador | ED taxation | National Congress the Legislation and codification commission | 2016 |
Combined excise tax 10% excise tax for beverages that contain more than 25 g sugar/L |
1) such policies led to reduced consumption of SSBs including EDs 2) Improve cardiovascular health outcomes 3) effectively raise prices and reduce consumption |
1) legal challenges 2) concerns about potential economic impacts 3) Political and industry resistance 4) Inadequate evidence of effectiveness 5) Heterogeneity in Tax Design 6) Coverage of Products 7) Need for Improved Guidance 8) Adjustments for Inflation 9) concerns about regressive taxation impacting low-income populations |
[40, 41, 69, 70, 74, 77, 78] | ||
| ED school ban | 2012 | prohibiting the sale of EDs in school bars within educational institutions | [79] | ||||||
| ED marketing |
- restrictions on advertising - Labels have this warning “Product not recommended for diabetics, minors, pregnant women, individuals sensitive to caffeine, elderly individuals, and those with cardiovascular and gastrointestinal diseases."” |
[80] | |||||||
| ED labeling | |||||||||
| Chile | ED taxation |
VAT -For beverages below 6.25 g sugar content 10% net increase in the tax rate -For beverages above 6.25 g sugar content 18% net increase in the tax rate The strength of this policy lies in Chile's unique ad valorem tax approach, which involved a combined tax reform. This reform included both tax increases and decreases based on sugar thresholds, implemented simultaneously |
such policies led to reduced consumption of SSBs including EDs |
1) legal challenges 2) concerns about potential economic impacts 3) Political and industry resistance 4) Inadequate evidence of effectiveness 5) Heterogeneity in Tax Design 6) Coverage of Products 7) Need for Improved Guidance 8) Adjustments for Inflation |
[41, 69, 70, 81, 82] | ||||
| ED marketing | Ministry of Health | -Restrictions on advertising EDs to children under 14 | [83] | ||||||
| ED labeling | Ministry of Health | - EDs are labeled as "HIGH IN CALORIES" | |||||||
| Canada | ED formulation |
Health Canada’s Natural Health Product Regulation and policies |
2011 | 2012 |
1) They must adhere to Consumer Advertising Guidelines for Marketed Health Products 2) marketing to children under 12 years old is prohibited 3) Labels are required to disclose caffeine content per serving and include warnings for children, certain sensitive adults, and advises against mixing EDs with alcohol 4) Canada determined the maximum amount of caffeine permitted per single-serve container to be 180 mg 5) Mandatory cautionary labeling and restrictions on health claims are enforced 6) Caffeine levels in EDs are capped at 100 mg per 250 ml, and manufacturers must add a warning against combining EDs with alcohol to their labels 7) broadcast advertising restrictions are in place 8) Prohibits the promotion of EDs to children in any advertising medium, including promotional samples/giveaways |
[44, 51, 52, 84–87] | |||
| ED labeling | 2011 | 2012 | |||||||
| ED marketing | Canada health | Individuals might be swayed by advertisements from international media channels | |||||||
| Jamaica | ED school ban | Ministry of Health / Ministry of Education Youth & Information | 2018 | [88] | |||||
| El Salvador | ED taxation | 2010 | VAT | shown promise in reducing SSB (including EDs) consumption and improving public health |
1) Heterogeneity in Tax Design 2) Political and Industry Resistance 3) Coverage of Products 4) Need for Improved Guidance 5) Adjustments for Inflation |
[41] | |||
| Brazil | ED taxation | VAT | |||||||
| Nicaragua | ED taxation | 2020 | 15% VAT | [41, 74] | |||||
| Panama | ED taxation | VAT | [41] | ||||||
| Paraguay | ED taxation | VAT | |||||||
| Peru | ED taxation | VAT | |||||||
| Saint Kitts and Nevis | ED taxation | VAT | |||||||
|
Saint Vincent and the Grenadines |
ED taxation | VAT | |||||||
| Belize | ED taxation | Amount-specific excise tax | |||||||
| Bolivia | ED taxation | 5.10 Bolivianos/L, Amount-specific (volumetric) | [41, 74] | ||||||
| Costa Rica | ED taxation | Amount-specific excise tax | [41]90 | ||||||
| ED marketing | Ministry of Public Education and Ministry of Health | Nov2011 | Feb 2012 | ||||||
| ED school ban | Ministry of Public Education and Ministry of Health | 2012 | EDs sale in the school environment is prohibited by the Ministry of Public Education | [89, 90] | |||||
| Guatemala | ED taxation | Amount-specific excise tax | [41] | ||||||
| Honduras | ED taxation | Amount-specific excise tax | |||||||
| Suriname | ED taxation | Amount-specific excise tax | |||||||
| Uruguay | ED taxation | Amount-specific excise tax | |||||||
| ED sales ban | Prohibits EDs entirely | [86] | |||||||
| Colombia | ED marketing | EDs cannot be sold or advertised in a healthy school store | [91] | ||||||
| ED sales ban | [91] | ||||||||
| ED taxation | 2018 | 18% VAT | [92, 93] | ||||||
| European region (EUR) | Denmark | ED sales ban | Fears regarding the adverse effects of excessive caffeine intake prompted Denmark to implement a complete prohibition on EDs | [17, 85, 86, 94] | |||||
| Romania | ED school ban | Ministry of Health | 2008 | prohibits the sale of EDs within school premises in Romania | [95] | ||||
| Spain | ED sales ban | Prohibiting the sale or provision of EDs within the facilities of non-university educational centers | [96] | ||||||
| Albania | ED taxation | [97, 98] | |||||||
| ED school ban |
-Restricts the advertisement of EDs in educational institutions and during and around programs aimed at minors - prohibitions on the use of EDs in specific settings such as cinemas and restaurants - prohibitions on advertising EDs in visual media aimed at minors |
||||||||
| ED marketing | |||||||||
| Latvia | ED marketing | 2016 |
(1) The advertisement of EDs must include a warning about the risks of excessive consumption, occupying at least 10% of the ad space. This warning should be displayed at the bottom of the advertisement in black letters on a white background, maximizing visibility (2) ED advertising and related audiovisual commercials are prohibited from targeting individuals under 18 years old or featuring them in the ads. Similarly, audiovisual commercials for EDs are banned on media channels catering to minors, and print ads targeting individuals under 18 are prohibited (3) Advertisements for EDs must not imply their usage, and they are prohibited in educational institutions and on their premises |
[99] | |||||
| ED sales ban | banned the sale of EDs to minors | [100, 101] | |||||||
| Armenia | ED school ban | According to this policy, the distribution, purchase and consumption of ED in educational centers is prohibited | [102] | ||||||
| Estonia | ED school ban | Ministry of Social Affairs | Sep 2008 | [103] | |||||
| Italy | ED labeling | Ministry of Health | 2015 | Highlight on the label the suggestion "Not recommended for children, during pregnancy and breastfeeding" for the so-called beverages | [104, 105] | ||||
| Turkey | ED sales ban | Turkey Has banned all high-caffeine EDs | [86] | ||||||
| ED school ban | Ministry of Health | 2015 | EDs are not recommended for consumption in schools | [106] | |||||
| Georgia | ED school ban | Government | Oct 2017 | According to this policy, early childhood and preschool institutions are not allowed to include sugary and carbonated beverages, including fruit drinks, carbonated/non-alcoholic beverages, restorative drinks, and EDs, in their standard menu | [107] | ||||
| Finland | ED labeling | Requires labeling drinks with high caffeine content as not recommended for children, pregnant women, or those sensitive to caffeine | [86] | ||||||
| Sweden | ED sales ban | Sales ban to children under 15 | [17, 51] [86, 94, 108] | ||||||
| ED labeling | Labels include warning against consuming EDs after exercise or mixing them with alcohol | ||||||||
| ED Marketing | broadcast advertising restrictions are in place | Individuals might be swayed by advertisements from international media channels | |||||||
| Norway | ED sales ban |
Sales of EDs are restricted to pharmacies only - implement a law requiring age restrictions (16 years) for buying EDs |
|||||||
| ED school ban | Norwegian Directorate of Health | 2015 | [109] | ||||||
| ED Marketing | broadcast advertising restrictions are in place | Individuals might be swayed by advertisements from international media channels | [51] | ||||||
| UK | ED labeling | Labels on EDs must indicate that they are not suitable for individuals under 16 years of age, pregnant or lactating women, and individuals sensitive to caffeine. This warning should be present on every ED can sold in the UK containing 150 mg or more of caffeine per liter | [17, 42, 48, 86, 101, 110–115] | ||||||
| ED sales ban | Voluntary supermarkets | Aug 2018 | Prohibiting the sale of EDs to individuals under the age of 16 (making it unlawful for retailers to sell beverages with elevated levels of sugar and caffeine to minors) | Underground food markets may have been present in certain schools for some time. Additionally, the proximity of supermarkets to certain schools seemed to contribute to the prevalence of clandestine food trade | |||||
| ED school ban | 2007 | Beverages with added sugar including EDs are not permitted. Also, some schools have banned their students from bringing them to school from outside | |||||||
| ED sales ban | 2018 |
Advises against high caffeine consumption for children under 16 years old The UK Government proposed legislation to ban the sale of EDs to minors to ensure consistency across retailers. The Committee concluded that there was insufficient evidence to justify a ban on selling EDs to children. Despite the Committee's motion, the UK Government announced in 2019 its intention to proceed with a ban on the sale of EDs to individuals under 16 years old |
Supporters and opponents of the policy expressed differing views, highlighting a debate over the adequacy of evidence supporting the ban prohibiting ED sales to those under the age of 16 years would miss the opportunity to reduce consumption among the highest consumers, those aged 16–18 years from disadvantaged backgrounds -such restrictions may be maximally effective if coupled with minimum-pricing strategies, placement restrictions and a communications campaign detailing their harmful effects |
||||||
| Hungary | ED sales ban | Minister of Human Resources | 2014 | EDs are not permitted for the age group under 18 years | [116] | ||||
| ED taxation | Sep 2011 | 2012 |
1)250 HUF/L or Kg for ED that contains > 1 mg methylxanthines/100 mL or > 100 mg taurine/100 mL 2) 250 HUF/L or Kg for ED that contains > 8 g sugar/100 mL or caffeine > 10 mg/100 mL Applies to the sugar, caffeine, and salt content of various categories of ready-to-eat foods and drinks, including EDs |
1) Improve cardiovascular health outcomes 2) there was some reported reduction in the consumption but the evidence was insufficient to confirm |
1) Retailers raised prices uniformly for both taxed and untaxed products 2) concerns about regressive taxation impacting low-income populations 3) Industry Opposition 4) Concerns about the potential economic impact on businesses and consumers 5) Difficulties in designing effective tax policies that accurately target unhealthy products without unintended consequences 6) Varying levels of political support and prioritization |
[40, 66, 70, 75, 117–120] | |||
| Germany | ED sales ban | Some states banned specific products due to trace amounts of certain substances | [121] [86] | ||||||
| ED school ban | The German Society for Nutrition (DGE) | 2014 | EDs are not offered in schools | [122] | |||||
| Lithuania | ED sales ban | government | 2014 | Prohibit the sale of EDs to individuals under 18 years old, accompanied by a ban on advertising and promotion of these drinks to minors in educational institutions, sports venues, media channels, and events | [100, 101, 121, 123] | ||||
| ED school ban | prohibited EDs for all school stages | [124] | |||||||
| ED marketing | 2011 | Distributing EDs for promotional purposes is forbidden. Additionally, advertising or sponsorship of EDs in educational institutions attended by individuals under 18 and at venues hosting events for minors is strictly prohibited | [125, 126] | ||||||
| Croatia | ED taxation | Croatian Parliament | 2020 | [127] | |||||
| Poland | ED taxation | Government | 2019 | July 2020 |
1) It was officially announced as a part of the National Cancer Strategy 2) It was postponed to 1 January 2021 due to the Covid-19 pandemics outbreak A fee of PLN 0.10 (0.022 EUR) per 1 L is charged on drinks with the addition of taurine or caffeine (for instance, EDs) the strength of this policy was that the project proposed that the revenues would be allocated to the National Health Fund (NFZ) and local governments to promote health education and address overweight and obesity. In addition the most crucial factor for the political viability of the new law is having a sufficient and stable parliamentary majority. Furthermore, Public authorities need to create and mobilize a strong support coalition for the project and actively involve stakeholders in public debate. Failing to do so may lead to perceptions of political disinterest and result in significant challenges during the implementation of the new law, especially given stakeholders' concerns that the health objectives are secondary to fiscal ones |
1) This policy Decreases the healthcare spending in Poland |
1) Polish stakeholders raised several criticisms of this approach, questioning why sweetened beverages were targeted first, whether the tax was sufficient to discourage consumers, and the legislative process, citing the lack of a grace period and the rushed nature of the legislation 2) Another factor complicating the smooth preparation and implementation of the project is the high level of political conflict, even if the primary dispute is unrelated to the sugar tax |
[128] | |
| Portugal | ED taxation | 28 Dec 2017 | 1 Feb 2018 |
Taxation on manufacturers and industries: 1) Drinks containing less than 80 g of sugar per liter: €8.22 per hectoliter 2) Drinks containing 80 g or more of sugar per liter: €16.46 per hectoliter |
1) Consumption Reduction: Consumption of sugary drinks decreased 2) Product Reformulation: Reformulating EDs reduced sugar content, reclassifying some to lower sugar categories 3) Revenue Generation: The tax generated significant revenue for public health initiatives 4) Public Health Awareness: Increased awareness of health risks from sugary drinks |
[129] | |||
| ED school ban | Office of the Assistant Secretary of State and Health | 2016 | prohibits the sale of EDs in vending machines located within Ministry of Health institutions | [130] | |||||
| Malta | ED school ban | Superintendent of Public Health (MOH) | 2012 | [131] | |||||
| ED marketing | Ministry for Health | 2018 | [132] | ||||||
| France | ED taxation | Jan 2012 | 0.0158 AUD (€0.01)/L on EDs | reducing sugar consumption, obesity rates, and related health outcomes |
1) Industry opposition 2) concerns about economic impacts 3) legal considerations 4)potential public resistance |
[133] | |||
| ED sales ban | EDs with high levels of caffeine and taurine have been banned | [94] | |||||||
| Spain | ED taxation | Catalonia | March 2017 | prevalence of regular consumers of taxed beverages fell by 39% in Barcelona | [134] | ||||
| Western Pacific Region (WPR) | Australia | ED school ban | Government | 2014 | [135] | ||||
| ED marketing | ED industries |
industries pledges to not direct any ED ‘marketing and advertising activities at children |
-The commitment was voluntary and self-regulated with no monitoring, enforcement or penalty mechanisms -failing to reduce children's overall exposure |
[87, 101] | |||||
| ED sales ban | Banned several EDs based on their high caffeine content | difficulties in effectively monitoring and enforcing bans, especially when products are marketed online or imported from other regions with different regulations | [86] | ||||||
| ED taxation | 0.47$/liter | [39, 43, 136–138] | |||||||
| ED labeling | The Department of Health and aged care, The Australia New Zealand Food Authority (ANZFA) |
The Australia New Zealand Food Authority (ANZFA) established a distinct category called "formulated caffeinated beverages," which must contain between 145 mg/L and 320 mg/L of caffeine from any source 1) If caffeine is added, the label must indicate the caffeine concentration in mg/100 mL and mg/serving size. It must also include a non-standardized statement that the ED contains caffeine and “is not suitable for children, pregnant and lactating women, or caffeine-sensitive individuals,” and must provide a recommended maximum daily intake, typically presented in fine print 2) For drinks where the caffeine is solely from natural sources like guarana, the actual amount of caffeine need not be declared. However, maximum daily intake advisory labeling is still required on the can 3) an advisory statement on the package indicating that the recommended daily intake limit (500 ml), and EDs are not recommended for children, pregnant or lactating women, or caffeine-sensitive persons |
1) Does not take the alcohol content into account in labeling 2) In common with other alcoholic beverages, no nutritional information is required on the packaging and consumers do not have access to important information to help in making an informed choice |
||||||
| ED formulation |
Australian Beverages Council (ABC) |
2018 |
1) Voluntary industry commitment to lowering sugar content 2) This policy included various measures, such as reformulating current products, launching low or sugar-free options, increasing sales of these varieties, and offering smaller packages |
For EDs, it seems there is no decrease in sugar content of ED from 2018 to 2019 | |||||
| New Zealand | ED labeling | The Australia New Zealand Food Authority (ANZFA) | established a specific category for beverages known as “formulated caffeinated beverages,” which must contain between 145 mg/L and 320 mg/L of caffeine, inclusive of caffeine from all sources | [39, 139] | |||||
| ED sales ban | 2006 | 2009 | Coca-Cola Amatil NZ and Frucor Suntory signed a Memorandum of Understanding (MOU) with the Ministries of Education and Health to eliminate full-sugar carbonated beverages and EDs from secondary schools | This policy led the industry to recognize that sugary drinks contribute to health issues in New Zealand children, including obesity and dental caries. As a result, the beverage industry aims to mitigate the harm caused by sugary drinks by ceasing direct sales to schools | Sugary drinks are still common in NZ schools for two key reasons: private operators often buy directly from supermarkets, bypassing industry policies, and restrictions on selling to schools don't cover all types of sugary drinks, like juice or flavored milk, contributing to high consumption levels | ||||
| ED sales ban | 2017 | Bottled water is the only beverage available for sale at primary and intermediate schools in New Zealand, while sugar-sweetened carbonated soft drinks or EDs are not sold at secondary schools | |||||||
| ED school ban | Ministry of Health | 2020 | Efforts are made to reduce the availability of EDs | Over time, as per the implementation plan, the distribution of these beverages in schools was phased out | [140] | ||||
| Philippines | ED taxation | Department of Finance -Tax Reform | 2016 |
6 pesos/l (sugar-sweetened and other sweeteners); 12 pesos/l (high-fructose corn syrup) |
1) Decreased Consumption: The taxes resulted in reduced sugary drink consumption in most of the 16 countries analyzed 2) Revenue Generation: Significant revenue was generated, often directed towards public health initiatives 3) Public Health Benefits: There was increased public awareness and positive changes in consumer behavior, contributing to better public health outcomes 4) Reduce the purchase of EDs in stores |
[141–143] | |||
| Mongolia | ED school ban |
- Prohibited from selling EDs within school premises - The placement and use of vending machines that contain the EDs are prohibited within 150 m of primary and secondary educational institutions |
[144] | ||||||
| Malaysia | ED school ban | Ministry of Health | 2011 | EDs are not allowed to be sold in vending machines, food dispensers, refrigerators, trolleys, or any sales corners within health facilities under the Malaysian Ministry of Health | [145] | ||||
| Vanuatu | ED school ban | Ministry of Education and Ministry of Health | prohibited EDs for schools | [146] | |||||
| Brunei | ED school ban | EDs are not allowed to be sold in school canteens | [147] | ||||||
| Pacific Island nation of Tonga | ED taxation | 2017 | EDs and concentrated fruit juices with more than 20 g of sugar per 100 ml are taxed at a higher rate of $4 per liter |
1) Rising prices lead to decreased demand, consequently reducing the importation of goods that heavily rely on imports 2) Taxes implemented in Tonga led to higher prices, lower imports of taxed beverages, increased production of locally bottled water, and a slight rise in the local manufacturing of soft drinks |
[148] | ||||
| Eastern Mediterranean Region (EMRO) | Bahrain | ED taxation | Ministry of Finance and National Economy | 2017 | 100% Ad valorem excise tax |
1) Decreased Consumption: The taxes resulted in reduced sugary drink consumption in most of the 16 countries analyzed 2) Revenue Generation: Significant revenue was generated, often directed towards public health initiatives 3) Public Health Benefits: There was increased public awareness and positive changes in consumer behavior, contributing to better public health outcomes 4) Improve cardiovascular health outcomes 5) A decrease in the annual growth rate of sales volume |
1) There's not enough evidence to determine if taxing effectively reduces their consumption, demand, or expenditure, improves health outcomes, or induces dietary changes regarding substitution and total energy intake 2) concerns about regressive taxation impacting low-income populations 3) Taxation is highly heterogeneous in terms of products and design, which might influence its effectiveness |
[40, 70, 71, 74, 141, 149–153] | |
| ED school ban | MINISTRY Of HEALTH | 2016 | [152] | ||||||
| Saudi Arabia | ED taxation | General Authority of Zakat and Tax | May 2017 | Jun 2017 | A 100% Ad valorem excise tax on EDs was adopted for Gulf Cooperation Council (GCC) countries in 2016 and Saudi Arabia was the first to implement the measure in June 2017. In addition, a 5% value-added tax was added to the beverage tax in 2018 |
1) Reduction in ED consumption of 8%, 1 year after the implementation 2) Participants understood the beneficial effect of the removal of EDs from their diet, which may represent an appropriate public health message to support those interested in preventing weight gain as well as diseases 3) Decreased Consumption: The taxes resulted in reduced sugary drink consumption in most of the 16 countries analyzed 4) Revenue Generation: Significant revenue was generated, often directed towards public health initiatives 5) Public Health Benefits: There was increased public awareness and positive changes in consumer behavior, contributing to better public health outcomes 6) Improve cardiovascular health outcomes 7) A decrease in the annual growth rate of sales volume |
1) The current tax design lacks robust scientific justification 2)ED companies decreased their retail prices 3) There isn't enough evidence to determine if taxing effectively reduces their consumption, demand, spending, improves health outcomes, or induces dietary shifts in substitution and total energy intake 4) concerns about regressive taxation impacting low-income populations 5) potential public resistance |
[40, 70, 71, 74, 141, 149, 150, 153–160] | |
| ED school ban | Ministry of education | 2013 |
1) The "Regulations of Health Conditions for School Canteens" enforces a ban on eight items: confectioneries, chocolates, chips, soft drinks, EDs, sweetened drinks, meat products, and fried foods 2) Advertising and sales of EDs are prohibited in government institutions, educational establishments, health facilities, and athletic clubs in Saudi Arabia. Additionally, the sponsorship of cultural, social, or athletic events by ED companies is restricted, and EDs must be separated from other items in designated refrigerators |
Collaboration with the Saudi Ministry of Education proved successful in Riyadh, leading to the prohibition of soft drinks and sports drinks, as none of the public schools were serving them | |||||
| ED labeling | Ministry of Health | May 2014 | EDs must display a warning label prominently in both English and Arabic, using vivid colors. The label includes a clear statement: "This product provides no health benefits, and consuming more than two cans daily may harm health. It is not suitable for pregnant or breastfeeding women, individuals under 16 years old, those with heart disease, high blood pressure, diabetes, caffeine allergies, or athletes during exercise." | ||||||
| ED marketing | Issued a law to prohibit the marketing of EDs | effective in decreasing their consumption | |||||||
| United Arab Emirate | ED taxation | Ministry of Finance Notification on Excise Tariff | Oct 2017 | 100% Ad valorem excise tax |
1) Decreased Consumption: The taxes resulted in reduced sugary drink consumption in most of the 16 countries analyzed 2) Revenue Generation: Significant revenue was generated, often directed towards public health initiatives 3) Public Health Benefits: There was increased public awareness and positive changes in consumer behavior, contributing to better public health outcomes 4) Improve cardiovascular health outcomes 5) A decrease in the annual growth rate of sales volume |
1) The current tax design lacks robust scientific justification 2)ED companies decreased their retail prices 3) There isn't enough evidence to determine if taxing effectively reduces their consumption, demand, spending, improves health outcomes, or induces dietary shifts in substitution and total energy intake 4) The implementation of excise taxes has a limited impact on the consumption of taxable goods 5) concerns about regressive taxation impacting low-income populations 6) potential public resistance |
[40, 55, 70, 71, 74, 118, 133, 141, 149, 150, 153, 156, 159, 161] | ||
| ED school ban |
Dubai Municipality—Dubai Health Authority Abu Dhabi Education Council, Abu Dhabi Food Control Authority and Health Authority—Abu Dhabi |
2011 | prohibits the sale of caffeine-containing beverages, which includes EDs, in school canteens | [162, 163] | |||||
| ED sales ban |
legal prohibition of selling ED for those who are younger than 16 years old |
relatively lower prevalence of ED consumption among school children |
[164] | ||||||
| Qatar | ED taxation | General Tax Authority | Jan 2019 | 100% Excise tax: ad valorem |
1) Decreased Consumption: The taxes resulted in reduced sugary drink consumption in most of the 16 countries analyzed 2) Revenue Generation: Significant revenue was generated, often directed towards public health initiatives 3) Public Health Benefits: There was increased public awareness and positive changes in consumer behavior, contributing to better public health outcomes 4) A decrease in the annual growth rate of sales volume |
[70, 74, 141, 149, 150, 153, 165] | |||
| ED school ban | Government | 2016 |
prohibited EDs for all school stages - They are prohibited from being provided or consumed to students in schools |
[166–168] | |||||
| ED sales ban | The Ministry of Public Health | 2021 | Prohibition of selling EDs in cafeterias and vending machines | [169] | |||||
| Morocco | ED taxation | The House of Representatives and the House of Councilors | Jan 2019 | MAD 6.00/L (about USD 0.62) on EDs containing m 2 stimulant ingredients for instance caffeine, taurine, glucuronolactone | There isn't enough evidence to determine if taxation leads to decreased consumption, demand, spending, improved health outcomes, or dietary changes regarding substitution and overall energy intake | [70, 170] | |||
| Oman | ED taxation | Sultanate of Oman Tax Authority | 2019 | 100% on EDs | A decrease in the annual growth rate of sales volume | Taxation is highly heterogeneous in terms of products and design, which might influence its effectiveness | [74, 149, 150, 153] | ||
| Kuwait | ED taxation | 2020 | 100% on EDs | A decrease in the annual growth rate of sales volume | [153] | ||||
| Israel | ED school ban | EDs are prohibited from being provided to students in schools | [171] | ||||||
| Iran | ED labeling | Iran Food and Drug Organization | 2014 | The product should carry a warning stating "Not recommended for individuals with diabetes, kidney issues, cardiovascular conditions, pregnant or breastfeeding women, children, individuals sensitive to caffeine, and those with high blood pressure." If the formula contains ginseng, additional cautionary statements should include "Not recommended for cardiovascular patients, pregnant or breastfeeding women, and individuals with high blood pressure," along with information on ginseng interactions with antidiabetic drugs, warfarin, phenazine, NSAIDs, and aspirin | [172] | ||||
| ED marketing | This standard outlines 19 unhealthy food items, including EDs, which are prohibited from marketing due to their high levels of sugar, salt, saturated fat, and trans-fatty acids | [173, 174] | |||||||
| ED school ban | National Standard | ||||||||
| ED taxation | Iran Parliament | 2021 |
16% on domestically produced SSBs 36% on imported SSBs |
||||||
|
Southeast Asian region (SEAR) |
Thailand | ED taxation | Excise Department, Ministry of Finance | Sep 2017 |
1) Taxing beverages at different amounts, depending on their sugar content 2) Products that contain less than 6 g sugar per 100 mL are exempt from the tax, while those products containing 6 g or higher sugar per 100 mL are taxed at a higher rate |
The comparison between the ratio of the taxed to the non-taxed SSBs consumed over time shows significant reductions in the consumption of the taxed group of SSB | [175] | ||
| Indonesia | ED school ban | Directorate of Food Product Standardization | 2013 | Consumption of sports drinks (sports drinks/isotonic drinks/ EDs) is only for school children who exercise for more than 1 h | [176] | ||||
| Bangladesh | ED taxation | National Board of Revenue | 2014 | 35% supplementary duty for EDs | Reduce the consumption and ensure public health through taxation | [177, 178] | |||
| ED Marketing | 2014 | ||||||||
| Sri Lanka | ED taxation | Government | 2017 | Rs. 12 per liter or 50 Cts per gram of sugar contained in the product | [179] | ||||
| ED school ban | Government | 2018 | EDs are prohibited in schools (unless in a special event) | [180] | |||||
| African Region (AFR) | South Africa | ED labeling | government | Manufacturers must label EDs containing over 150 mg per liter of caffeine with a clear message on the front of the nutritional label stating "high caffeine content" and advising against consumption for children under 12 years, pregnant women, or caffeine-sensitive individuals |
1) There are no color-label or type-setting restrictions, allowing producers to obscure this warning from potential buyers through careful package design 2) There is currently no legislation in place that requires the declaration of high sugar content |
[46] | |||
| ED taxation | government | Producers use advertising to prevent tax-induced revenue losses | |||||||
| ED school ban | Department of Basic Education | restricts the sale of beverages in schools | [181] | ||||||
| Côte d'Ivoire | ED taxation | 2017 | [182] | ||||||
| Cape Verde | ED school ban | Education, Health, Cape Verdean School Social Action Foundation (FICASE) | 2016 | EDs are prohibited within and around educational establishments | [183] | ||||
| Mali | ED taxation | The Ministry of Economy and Finance | 2015 | 12% Ad valorem excise tax | [184] |
aFor VAT or ad valorem tax, the tax base is defined as the value of the taxable product, which may be assessed at different stages of the value chain. When the tax base for locally produced beverages is fixed early in the value chain, such as producer price, ad valorem tax rates apply to a commodity. A smaller value reduces the impact of taxes on final retail prices. For imported beverages, countries that impose excise duty use the cost, insurance, and carriage (CIF) value and import and customs duties, if applicable, as the tax base
bFor excise taxes of a specified amount, the tax base may be defined based on the volume of the beverage or the sugar content. Almost all countries that have a specific component use beverage volume as the tax base
In summary, 55 countries have tax policies, 33 have school access bans, 23 have sales bans, 15 have labeling policies, 14 have advertising and marketing bans, and 2 have formulation policies related to controlling ED consumption among children and adolescents. Some countries utilize multiple policies simultaneously (Fig. 3).
Fig. 3.
EDs policies around the world. The map guide is explained at the bottom of the image. The coloring of the countries is based on the classification of the World Health Organization
Discussion
This paper aims to explore policies and programs that, both directly and indirectly, reduce ED consumption among children and adolescents. It also shares the experiences of various countries to help policymakers and decision-makers adopt evidence-based policies in this area. The review found that several countries employ various strategies, including taxation, marketing bans, school bans, labeling policies, sales bans, and reformulation to alter the food environment.
It is promising that policymakers appear to recognize the harmful effects of EDs more than those of other beverages, leading to a stronger push to implement measures aimed at reducing their consumption [154]. As a result, over the past two decades, many countries worldwide have introduced measures to reduce ED consumption among children and teenagers. North American, European, Persian Gulf, Caribbean, and South American countries are at the forefront of implementing effective policies to curb ED intake. However, some of these measures have not been updated for over a decade. In contrast, most Asian and African countries lack similar policies, and some cities and countries have reversed their ED regulations after implementing them. For instance, New York City's 2012 ban on EDs over 16 oz was overturned in 2014 by the state court due to inconsistencies and perceived ineffectiveness. Similarly, France lifted its ban following a recent evaluation by the European Food Safety Authority, which found no safety concerns [17, 185].
Tax policies are frequently implemented globally, with Value Added Tax (VAT) being the most prevalent form, alongside excise tax. VAT is widely used and is essentially a tax on consumption, commonly applied to various goods and services. It is often synonymous with goods and services tax. Unlike targeted food taxes, VAT is more commonly applied across different food categories. VAT is calculated as a percentage of the price of goods and services, irrespective of their volume [186, 187]. On the other hand, excise tax primarily targets goods produced for sale and is often employed to achieve health-related objectives [188].
In the literature we reviewed, only a limited number of studies have explored the efficacy of these policies. Drawing from insights gleaned from the impact of tax policies in Seattle, Philadelphia, and Catalonia, it seems that these measures can reduce the average purchase of EDs and lower overall consumption of these beverages. This could potentially improve health outcomes by decreasing calorie and added sugar intake. Moreover, as a general trend, these policies seem to correlate with a reduction in the number of habitual consumers of such beverages [37, 59, 134].
Drawing from Portugal's experience with tax policies and the WHO's opinion, it appears that taxing the sugar content in EDs is quite effective [129, 189]. This approach reduces the consumption of sugary foods and encourages industries to lower the sugar content in their products. Currently, companies achieve this by reformulating their drinks, often by using sweeteners [129]. While reducing sugar in beverages is beneficial, it can lead to the inclusion of artificial sweeteners like aspartame, which the WHO has recently classified as "probably carcinogenic to humans," potentially causing other health issues such as cancer [190].
Moreover, there are more constraints and challenges associated with tax policies. A primary issue is the opposition from manufacturing industries concerning the implementation methods and effects of these policies [40, 69, 70, 133]. Industries frequently attempt to mitigate the impacts of tax policies by influencing food retailers and increasing advertising for these drinks [38, 61].
In addition, there are disparities among governments in how they execute and approach these tax policies [128]. For example, in the GCC, EDs are taxed more heavily than in other countries due to their higher significance, leading to opposition from some member states. Politicians questioned the distinction between these drinks and others and the rationale behind the specific tax level [154]. Furthermore, some beneficiaries, particularly the manufacturers of these drinks, protested to the World Trade Organization, arguing that the tax was unscientific and illogical. In response, they began reducing prices at distribution points to counteract the tax effects [154].
Among the other limitations of tax policies are their effects on the public. Excise duties can create a significant price gap between cheaper and more expensive products, leading consumers to opt for cheaper, potentially less healthy options, which can result in more severe health problems [191, 192]. These taxes can also face public resistance, with many consumers opposing additional costs on popular products. Concerns exist about the economic impact on both businesses and consumers, including reduced sales for companies and higher prices for buyers. Moreover, designing effective tax policies that accurately target unhealthy products without unintended consequences, such as negatively affecting healthier alternatives, is challenging. Additionally, varying levels of political support and prioritization can hinder the implementation of these taxes, as policymakers may have differing views on their importance and effectiveness [41, 70].
In conclusion, fiscal policies can reduce the consumption of taxable beverages like EDs, potentially improving health outcomes by lowering calorie and added sugar intake. These measures also tend to decrease the number of habitual consumers. However, challenges remain. Industries often resist these policies and counteract their effects. Inconsistent implementation across governments, public resistance, and economic concerns, such as higher prices and reduced sales, complicate the design and effectiveness of these policies.
Another policy implemented by some countries is banning EDs in and around schools to limit children's access. However, research on the effectiveness and limitations of these policies is limited. It appears that such bans often lead to unintended consequences, such as the emergence of black markets in schools or students purchasing these beverages from outside sources. Simply banning the sale and distribution of EDs in schools may not be effective, as children continue to obtain them off school premises. Additionally, due to the lack of clarity regarding the types of prohibited drinks, manufacturers can easily bypass these policies [42, 139].
In the area of marketing policies, more effort and a better understanding of the effectiveness of policies are needed. Current data suggest that banning advertising can reduce ED consumption, but successful implementation requires collaboration from various stakeholders, especially policymakers to define policy limits and engagement from manufacturers [155]. Experiences from Canada, Norway, and Sweden highlight the importance of clear boundaries and frameworks for these policies. In today's digital age, where information is readily available online, simply banning advertisements on traditional media like television and billboards is insufficient. With easy internet access, exposure to diverse advertisements continues, emphasizing the need for comprehensive strategies and support from all stakeholders to ensure policy effectiveness [51].
Regarding labeling policies, there was limited evidence supporting their effectiveness. Data from this study indicated that labeling had no impact on the purchase and consumption of these beverages. Additionally, there is a general lack of specific frameworks and guidelines, such as those for declaring high sugar content. Companies often exploit these regulatory gaps, leading to inadequate labeling practices. This highlights the need for more robust and standardized labeling regulations to enhance their impact on consumer behavior [37, 136].
Various countries are endeavoring to diminish the consumption of EDs by employing a variety of initiatives. However, it's evident that solely relying on one measure isn't enough for optimal effectiveness. Given that the current food environment significantly provides quick and easy access to EDs for children and teenagers, it emphasizes considering all dimensions of the food environment, such as availability, distribution, and affordability, in policy-making and intervention strategies [69, 193]. In developed societies, various policy options are employed to create a healthier food environment. These measures include providing information through labeling, restricting unhealthy food advertisements, implementing financial policies, and interventions at the retail level. However, implementing these policies has consistently been challenging [194].
One of the main obstacles to these policies is opposition from the industry. Industries frequently hinder these efforts, advocating for more research and evidence before adoption and arguing that such policies will negatively impact the economy and the public. They also contend that the government should not interfere in market governance. Additionally, countries like the United Kingdom, the United States, and Australia attempt to implement policy regulations, such as labeling and marketing, on a voluntary basis. The standards in these voluntary policies are often confusing and difficult to interpret [42, 110, 136, 194].
Also, it is evident that there is a lack of adequate involvement from organizations in tackling the issue of ED consumption. This underscores the pressing need for a more comprehensive approach towards investigating and monitoring the effects of EDs. For instance, regulatory bodies like the FDA have yet to establish specific classifications for these beverages, instead opting for a uniform application of regulations across various product categories.
Despite the adoption of various policies such as taxes and access restrictions by numerous countries worldwide, implementing these measures remains challenging and fraught with obstacles. Key challenges include resistance from industries, governmental disagreements on policy-making, public opposition, concerns about economic impacts, and the inherent complexity of designing effective policies. Given these challenges, it is crucial for countries with existing policies to regularly review and update them to ensure continued effectiveness.
Countries that have yet to adopt such policies, particularly in Asia and Africa, should consider their unique cultural and social contexts while learning from the strengths and weaknesses of existing policies. Tailored laws and policies should be developed to suit each country's specific needs. Improving policy design is essential to prevent loopholes and ensure compliance through clear and well-defined frameworks.
Continuous evaluation and monitoring are necessary to identify gaps and issues in policy implementation and to assess their effectiveness. Public education and information campaigns are vital to foster understanding and support for these policies, highlighting their positive impact on public health.
Intersectoral cooperation among governments, manufacturing industries, the private sector, and health organizations is essential for effectively reducing ED consumption among children and teenagers. Collaborative efforts ensure that policies are not only more effective but also enjoy broader support and sustainability. By working together, these diverse sectors can create comprehensive strategies that address various aspects of the issue, from regulatory frameworks and market dynamics to public health education and enforcement. This holistic approach enhances the likelihood of successful implementation and long-term impact, ultimately fostering a healthier environment for children and teenagers.
Additionally, more research should be conducted on the limitations, effectiveness, and strengths of ED-related policies. The findings from these studies can then be used to refine and enhance policies, maximizing their impact on reducing ED consumption and improving public health outcomes.
Strengths and limitations
This study offers a comprehensive review of national and sub-national policies on ED consumption, using multiple reputable databases and international organization websites to ensure reliable and thorough data collection. It provides valuable cross-national comparisons, identifying best practices and innovative strategies adaptable to other contexts. The study evaluates the effectiveness of various policies, highlighting their strengths, weaknesses, and impacts, which aids policymakers in making informed decisions. The study addresses gaps in policy implementation, particularly in many Asian and African countries, and examines the resistance from the manufacturing industry, especially regarding taxation. This focus on the challenges in policy enforcement is crucial for developing strategies to overcome such barriers. By concentrating on children and adolescents, the study ensures that recommendations are tailored to those most at risk from ED consumption. Emphasizing the need for cooperation between governments, institutions, industries, and retailers, the study advocates for a holistic approach to policy implementation. This comprehensive collaboration is essential for the success of public health initiatives. Overall, the study provides a robust framework for understanding and improving global ED consumption policies, particularly to protect children and adolescents from potential health risks.
However, Despite its strengths, this study has several limitations. First, it relies heavily on available literature and documents, which may not fully capture all existing policies or their nuances, particularly in regions with less accessible or undocumented policy measures. The quality and bias assessments of the included studies and documents reveal variability, with some sources showing a high risk of bias or poor quality. This variability could affect the overall reliability of the synthesized conclusions. The study's focus on broader policy impacts might overlook local contextual factors that influence the effectiveness of these policies. The diverse socio-economic and cultural contexts of different countries make it challenging to generalize findings universally. Additionally, the study primarily addresses policies related to ED consumption without delving deeply into the behavioral or psychological aspects of consumption among children and adolescents, which could provide a more comprehensive understanding of the issue. Another limitation of this study was the incomplete information provided in the reviewed studies. Some studies lacked detailed information about the policies, such as the year of implementation and their strengths and weaknesses. Additionally, many countries have policies that apply to other SSBs alongside EDs, which complicates isolating ED-specific regulations. This overlap with broader SSB policies limits the study, as these policies are sometimes combined. Overall, while the study offers valuable insights into national and sub-national policies on ED consumption, these limitations should be considered when interpreting the findings and recommendations.
Conclusion
This review highlights that various countries use diverse strategies, such as altering affordability, promotion, and advertisement regulations, to change the food environment and reduce ED consumption among children and teenagers. Common policies include taxation, school bans, sales restrictions, and labeling requirements. Policymakers increasingly recognize the greater harm posed by EDs compared to other beverages, prompting stronger efforts to curb their consumption. Over the past two decades, numerous countries, particularly in North America, Europe, the Southern Persian Gulf, the Caribbean, and South America, have enacted effective policies. However, many Asian and African countries still lack similar measures, and some existing policies have not been updated in over a decade.
Despite the adoption of these policies, implementation remains challenging. Major obstacles include industry resistance, governmental disagreements, public opposition, economic concerns, and the complexity of designing effective measures. Taxation, while common, faces resistance from manufacturers and can lead to unintended consequences like the use of artificial sweeteners. School bans can reduce access but may inadvertently create black markets, and marketing restrictions often face low compliance from ED companies.
Given these challenges, it is crucial for countries with existing policies to regularly review and update them. Countries yet to adopt such measures should consider their unique cultural and social contexts, developing tailored laws to meet their specific needs. Enhancing policy design is essential to prevent loopholes and ensure clear compliance frameworks. Continuous evaluation and monitoring are necessary to identify gaps and assess policy effectiveness.
Intersectoral cooperation among governments, manufacturing industries, the private sector, and health organizations is essential. Collaborative efforts ensure broader support and sustainability, creating comprehensive strategies that address various aspects of the issue, and ultimately fostering a healthier food environment for children and teenagers.
Supplementary Information
Acknowledgements
Many thanks to the student research committee at Shiraz University of Medical Sciences for reviewing and approving this research project.
Abbreviations
- AAP
American Academy of Pediatrics
- CDC
Centers for Disease Control and Prevention
- ED
Energy drink
- FDA
Food and Drug Administration
- GIFNA
Global database on the Implementation of Food and Nutrition Action
- IFPRI
International Food Policy Research Institute
- INFORMAS
International Network for Food and Obesity / Non-communicable Diseases (NCDs) Research, Monitoring and Action Support
- RoB
Risk of Bias
- SD
Sugary drink
- SSB
Sugar-sweetened beverage
- WHO
World Health Organization
Authors’ contributions
MHR: Negotiated the research questions with MB, conducted the database searches, assessed the literature against the review criteria, undertook data extraction, synthesis, and analysis of the literature, conducted the risk of bias (RoB) assessment MB: Negotiated the research questions with MHR, provided input into the search strategies, supervised the work process at all stages, provided input into findings and conclusions, Edited drafts of the article, read and approved the final manuscript SR: Conducted the database searches, assessed the literature against the review criteria, undertook data extraction, synthesis, and analysis of the literature, conducted the risk of bias (RoB) assessment, provided input into findings and conclusions, edited drafts of the article, read and approved the final manuscript HD: Provided input into findings and conclusions, edited drafts of the article, read and approved the final manuscript.
Funding
This study lacks the financial resources to support it.
Availability of data and materials
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
The student research committee at Shiraz University of Medical Sciences granted approval to this study, and it was assigned the ethics code IR.SUMS.SCHEANUT.REC.1402.082.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
No datasets were generated or analysed during the current study.