Mounting evidence demonstrates that sugar-sweetened beverages (SSBs) contribute to obesity, diabetes, and heart disease while also driving health disparities by ethnicity and income. Reducing the nation’s SSB consumption by just one fifth is projected to avert $24 billion in health care costs over a decade.1 Because of the human and financial toll of obesity, the National Academy of Medicine and others have called for urgent and broad action to reduce SSB consumption. Momentum behind such action has steadily been building as dozens of communities have launched media campaigns and policy initiatives to reduce sugary drink intake.
LIVE SUGARFREED
This issue of AJPH highlights a novel, multiplatform media campaign for discouraging SSB consumption called “Live Sugarfreed.”2 The 15-week campaign featured a bold message comparing the health effects of soda to those of cigarettes. It resulted in a 3.4% decline in SSB sales and a 4.1% decline in soda sales. Live Sugarfreed was unique in its setting—a rural, low-income region of the southeastern United States—and employed a strong evaluation design, using a comparison group and objective SSB sales data. Campaign ads included traditional channels such as TV commercials and leveraged digital platforms including YouTube, Hulu, Pandora, and Facebook. Through a recognition program, local employers and nonprofits were incentivized to support healthy beverage consumption.
A three-year healthy beverage campaign in Howard County, Maryland, also employed sales data and a comparison region in its evaluation.3 The “Howard County Unsweetened” campaign was multifaceted, engaging all levels of the social-ecological model, from the interpersonal to the policy level, and multiple community organizations. After the three-year campaign, soda sales in Howard County stores declined by 19.7%, while sales in comparison stores remained stable.
ADVERTISING WORKS
These evaluations demonstrate what the beverage industry believes to be true based on the billions of dollars it spends annually on marketing—that advertising works. Importantly, this research shows that public health counter-advertising can help consumers make healthier choices even amid highly sophisticated and alluring ads for sugary drinks. This is a significant contribution given that few wide-reaching interventions for reducing SSB consumption have rigorous evidence of effectiveness. Both of these communications campaigns were modestly resourced relative to beverage industry marketing but still required substantial funding. Live Sugarfreed cost $206 950 in placements to make 27 million impressions. (Impressions refer to ad exposures [e.g., number of times a campaign ad was displayed on a Web page or viewed on TV].) Howard County Unsweetened required approximately $800 000 per year, accomplishing 17 million impressions and funding other campaign components. Cost is an important consideration given that only three percent of the US government’s health budget goes toward public health activities.
A question unanswered by these campaign evaluations is how sustainable are effects of communications campaigns after they end? Presumably they dwindle with time, or beverage companies would not spend billions of dollars on advertising year after year. Given the David-to-Goliath ratio of resources that public health programs have compared with beverage companies, how can communities identify funds to pay for and sustain healthy beverage campaigns? And how should they weigh this approach against low-cost, self-sustaining policies such as SSB taxes and warning labels? Warning labels on cigarette packs effectively reduced smoking, and evidence from online experiments suggests that warning labels may work for SSB consumption as well.4 Mandating SSB warning labels can ensure the indefinite and widespread dissemination of information on health risks of SSBs. Once implemented, costs of warning labels are expected to be modest, entailing those related to enforcement and incorporation of labels into packaging and advertisements.
SYNERGISTIC APPROACHES
Deciding among public health approaches for reducing SSB consumption does not have to be an either-or proposition. Strategically planned media campaigns can work in synergy with other approaches. In particular, SSB taxes may provide a logical and sustainable source of funding for campaigns. Successful passage in Berkeley, California, of an excise tax on SSBs made it possible for the city to designate $5 million toward public health activities linked to healthy beverage promotion through fiscal year 2019, including a media campaign.
In addition to generating revenue, evidence increasingly shows that SSB taxes can reduce consumption of sugary drinks. After two years, Mexico’s country-wide SSB tax reduced purchasing of taxed beverages by 12% overall, with the biggest impact observed among low-income households.5 Our evaluation of the Berkeley SSB tax in low-income and racially diverse neighborhoods detected a 21% reduction in self-reported consumption of SSBs just four months after the tax was implemented.6 Our finding were corroborated by another evaluation that used sales data from two large supermarket chains to study changes in SSB sales in the first year after tax implementation in Berkeley.7
Despite the tremendous revenue-raising potential of SSB taxes, projected at $12.5 billion annually if a penny-per-ounce tax were implemented nationwide,1 SSB taxes are not yet politically feasible for many jurisdictions. For some, that may be because of incomplete public knowledge of the health risks and staggering health care costs attributed to SSB consumption and of how influential and ubiquitous SSB marketing can be. In these communities, media campaigns may not only improve health behaviors but, by raising awareness of the rationale for reducing SSB consumption, may also open the door for policies such as SSB warning labels or taxes.
A WAVE OF SODA TAX PASSAGES
The recent wave of SSB tax passages in six jurisdictions in 2016, followed by additional SSB tax and other policy proposals slated for upcoming elections (Table 1), already suggest growing public consciousness in some localities around the health harms of SSBs. Rigorous evaluations of these policies and programs, with a key focus on cost-effectiveness, will continue to provide valuable data to inform our evolving understanding of how to reduce SSB consumption and its associated cardiometabolic risks.
TABLE 1—
Selected List of Major Sugar-Sweetened Beverage Policy Proposals in the United States Since 2014
| Location | Policy | Brief Description | Status |
| Albany, CA | SSB excise tax (2016 ballot measure O1) | 1 cent/oz tax on distribution of SSBs | Passed November 2016; effective April 2017 |
| General taxa | |||
| Baltimore, MD | SSB warning label (Council Bill 16–0617) | Requires a warning label on SSB advertisements, restaurant menus, and at the point of purchase in stores selling SSBs | Proposed |
| Berkeley, CA | SSB excise tax (2014 ballot measure D) | 1 cent/oz tax on distribution of SSBs | Passed November 2014; effective January 2015 (actual: March 2015) |
| General taxa | |||
| Boulder, CO | SSB excise tax (2016 ballot measure 2H) | 2 cent/oz tax on distribution of SSBs | Passed 2016; effective July 2017 |
| Revenues designated for health promotion and chronic disease prevention that improve health equity, such as access to healthy beverages and foods, and physical activity | |||
| California | SSB warning label (2017 SB300) | Requires a health warning label be placed on SSBs sold in California | Proposed |
| Cook County, IL | SSB tax (Board of Commissioners Ordinance 16–5931) | 1 cent/oz tax on distribution of SSBs and artificially sweetened beverages | Passed November 2016; effective July 2017 |
| Requires that the tax be passed on to consumers in the sales price | |||
| Revenues for projected shortfall in county budget | |||
| Davis, CA | Default beverages for children’s meals (City Council Ordinance 2451) | Any default beverage in restaurant children’s meals must be water or milk (or nondairy alternative) | Passed June 2015; effective September 2015 |
| Hawaii | SSB warning label (2017 HB1209 and SB307) | Requires a warning label on SSB containers, vending machines and dispensers, or where SSBs are requested or ordered | Proposed |
| Illinois | SSB excise tax (2017 HB2914 and sections 1–97, SB0009) | 1 cent/oz tax on distribution of SSBs | Proposed |
| HB2914: revenues designated for public health and chronic disease prevention, especially in high-need communities, and obesity prevention and treatment of Medicaid beneficiaries | |||
| SB0009: general tax | |||
| Massachusetts | SSB excise tax, limits on advertising SSBs in schools, default beverages in children’s meals, and SSB warning label (2017 HB3329 and SB1562) | Tax on distribution of SSBs: 1 cent/oz if 5–19 g of added sugar per 12 oz and 2 cents/oz if ≥ 20 g per 12 oz | Proposed |
| Requires that the tax be passed on to consumers in the sales price | |||
| Revenues dedicated to Children’s Health Promotion Fund | |||
| Prohibits advertising of certain beverages and their brands at school | |||
| Any default beverage in chain restaurant children’s meals must be water, milk (≤1% or nondairy), or 100% juice (≤ 8 oz) | |||
| Requires a warning label on SSB advertisements | |||
| Navajo Nation | Sales tax (The Healthy Diné Nation Act of 2014) | 2% sales tax to foods of minimal to no nutritional value, including SSBs | Passed November 2014; effective April 2015 |
| Revenue designated for Chapters for community wellness projects, such as increasing access to healthy food and promoting physical activity | |||
| New York State | SSB warning label (2017 Assembly Bill 5239 and SB162) | Requires a warning label on SSB containers, vending machines and dispensers, or where SSBs are requested or ordered | Proposed |
| Oakland, CA | SSB excise tax (2016 ballot measure HH) | 1 cent/oz tax on distribution of SSBs | Passed November 2016; effective July 2017 |
| General taxa | |||
| Philadelphia, PA | SSB excise tax (City Council vote) | 1.5 cents/oz tax on distribution of SSBs and artificially sweetened beverages | Passed June 2016; effective January 2017 |
| Revenues designated for pre-K programs and other educational and city programs and facilities | |||
| San Francisco, CA | SSB excise tax (2016 ballot measure V) | 1 cent/oz tax on distribution of SSBs | Passed November 2016; effective January 2018 |
| General taxa | |||
| San Francisco, CA | SSB warning label (Board of Supervisors Ordinance 100–15 to amend the Health Code) | Requires a warning label on posted SSB advertisements | Passed June 2015; in 9th Circuit Court of Appeals |
| Santa Fe, NM | SSB excise tax (Bill no. 2017-3: ordinance creating new sections 18–20, Santa Fe City Code 1987) | 2 cents/oz tax on distribution of SSBs | Proposed |
| Revenues designated for early childhood education programs | |||
| Seattle, WA | SSB excise tax (2017 ordinance) | 2 cents/oz tax on distribution of SSBs | Proposed |
| Revenues designated for eliminating racial/ethnic disparities, funding early childhood programs, and increasing access to healthy food | |||
| Stockton, CA | Default beverages for children’s meals (City Council Ordinance 2016-06-07-1502) | Any default beverage in restaurant children’s meals must be water or milk | Passed June 2016; effective July 2016 |
| Washington State | SSB excise tax (2017 new chapter to Title 82, HB1975) | 2 cents/oz tax on distribution of SSBs and artificially sweetened beverages | Proposed |
| Revenues designated for public health account and educational fund | |||
| Washington State | SSB warning label (2016 HB2798) | Requires a warning label on SSB containers, vending machines and dispensers, or where SSBs are requested or ordered | Proposed |
| West Virginia | SSB excise tax (2017 HB3044, HB3045, HB3046, HB3085, SB335, and SB385) | Excise tax on sale, use, handling or distribution of SSBs (HB3045: 2 cents/oz) or bottled soft drinks (HB3085 and SB385: 1 cent/oz; HB3046 and SB335: variable by bottle size) | Proposed |
| Revenues designated for medical, dental, and nursing schools and, depending on bill, teacher pay, medical services, or general fund |
Notes. HB = House Bill; SB = Senate Bill; SSB = sugar-sweetened beverage. Does not include a complete list of all SSB-related policies proposed. For instance, in early 2017 alone, other states with SSB tax proposals include Arkansas, Connecticut, Hawaii, New York, Rhode Island, Texas, and Vermont. Some SSB tax proposals additionally specify designating revenues for administering the tax and evaluating its impact. Some SSB tax and warning label proposals apply only to SSBs containing a minimum amount of sugar.
Requires a process for soliciting advisory recommendations (e.g., through a panel of experts) for expenditure of the tax revenue, including for health or SSB-related purposes.
Footnotes
See also Farley et al., p. 989.
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