Implementation Science Is Important for Understanding and Advancing Beverage Taxes

Results from rigorous evaluations of beverage taxes in seven localities in the United States and in more than 40 countries are mounting rapidly. These studies provide evidence to policymakers looking to take action on reducing consumption of sugary beverages, which are linked to several adverse health outcomes such as obesity and type 2 diabetes and are disproportionately consumed by low-income and racial/ethnic minority populations. Together, these studies point to consistent increases in price (with variation by store type and geographic location) and reductions in sales of taxed beverages (with variation in the magnitude of the decline). Results from Philadelphia, Pennsylvania,¹ and Mexico² further suggest that beverage taxes may help people with lower income or education levels more than those with higher levels. Some evidence also points to reduced consumption of sugary beverages following implementation of beverage taxes, although this literature is mixed. With respect to health outcomes, microsimulation studies predict significant reductions in obesity and cardiovascular disease as a result of beverage taxes.

We know much less about the implementation process for beverage taxes—essentially, how well beverage tax policies are put into effect and the challenges faced by governments. In this issue of AJPH, Falbe et al. (p. 1429) advance the field meaningfully by adding qualitative insights into the implementation of the Berkeley, California, beverage tax, the first US locality to implement a sugar-sweetened beverage tax. Their qualitative approach—including interviews with city staff, its tax administrator, distributors, retailers, and a Sugar-Sweetened Beverage Product Panel of Experts (established by the tax ordinance)—allows them to provide a nuanced assessment of how implementation works in practice (beyond its effect on outcomes) than is typically possible in a quantitative study. In this way, their article adds important insights, including three key lessons that are instructive to other jurisdictions considering sweetened beverage taxes.

KEY LESSONS FROM BEVERAGE TAX IMPLEMENTATION

One key lesson is the importance of the policy package itself. The results by Falbe et al. combined with evidence from the policy adoption literature in political science³ suggest that simpler is better for uptake and implementation of local beverage taxes. This is an important takeaway as core aspects of the beverage tax structure are actively debated by policymakers such as the design (e.g., volume, absolute, tiered), size (e.g., one cent per ounce vs two cents per ounce), and included beverages (e.g., sugar-sweetened drinks only or combination of sugar- and artificially sweetened drinks), as well as the revenue allocation (e.g., appropriation to the general fund or for specific programs). The lesson from Falbe et al. about the importance of the simplicity of the tax design ($0.01/oz) in facilitating implementation is also critical to consider in beverage tax advocacy efforts and for researchers aiming to inform beverage tax debates.

Another key lesson is the importance of context. Both the Falbe et al. study and a recent implementation study out of Cook County, Illinois,⁴ point to the need to understand the local context. Falbe et al. find that local leadership supported by a history of pro-equity policies, supportive institutions, and positive public opinion matter considerably for successful implementation. For example, their interviews suggest that early public outreach about the tax⁴ and programs resulting from tax revenue allocation helped promote and sustain public support. Sustaining buy-in is important because beverage taxes may face postenactment litigation (such as occurred in Philadelphia and in Cook County where the beverage tax law was repealed).⁴ The uniqueness of each beverage tax jurisdiction suggests that parallel studies should be conducted in each to fully understand implementation. These important details are generally outside the scope of quantitative studies assessing the effect of beverage taxes on prices, sales, or consumption.

A third lesson from Falbe et al. is the importance of the implementation process itself, particularly having administrative infrastructure in place with clear lines of communication among stakeholders. Previous qualitative research examining the policymaking process for the Philadelphia beverage tax (where a tax was successfully passed after two failed attempts)⁵ and the Cook County beverage tax (where a tax was successfully passed and then repealed after four months)⁴ similarly points to the need for such processes. In Berkeley, the decision to engage a third-party tax administrator at the outset (in recognition of the city’s need for help with this process) and to hire key city personnel to oversee implementation before the tax took effect was critical and helped the city to engage with, educate, and ultimately obtain buy-in from a range of stakeholders responsible for on-the-ground implementation, including retailers and distributors. Effective implementation also may help fend off likely industry challenges that have defeated many beverage tax attempts and have helped some states enact preemption laws that outlaw beverage taxes. Like the policy process, the policy implementation process is context specific and nonlinear, involving many actors and different factors.

PUBLIC HEALTH EFFECT OF BEVERAGE TAX REVENUE

After ensuring that a beverage tax is put in place as intended (e.g., how much of the tax is passed on to the consumer; whether the tax is applied to the correct beverages), the next most critical piece of the implementation process is the use of collected revenue. Beverage taxes generate a lot of money for local governments, ranging from approximately $1.5 million in Berkeley to more than $75 million in Philadelphia during the first full year of implementation.⁶ Across jurisdictions, this has accounted for approximately 1% to 2% of general revenue funds⁶ and makes beverage taxes very attractive to policymakers for their ability to fill revenue gaps. Revenue in Berkeley has been used toward public health, nutrition, and health equity (e.g., nutrition education in public schools, a healthy beverage media campaign, community grants for health promotion in communities of color) and may become more critical under the coronavirus disease 2019 pandemic. Given that many jurisdictions’ beverage tax revenues are deposited into the cities’ general revenue fund, reallocation of those funds to non–public health-related needs is a constant challenge.

The Falbe et al. study points to the importance of an advisory committee composed of a range of stakeholders to guide or make recommendations to city officials around the use of the revenue focused on equitable allocations for communities and programs in need. Directing revenue toward community investments for which broad public support exists can help to sustain support⁵ and challenge repeal efforts. Furthermore, clearly communicating the downstream positive economic effects of beverage taxes (above and beyond the public health benefits) may help to sustain public support because income earned from the jobs created by revenue is spent on other goods and services and may help to support the local economy.

LEVERAGING THE SCIENCE OF IMPLEMENTATION

To fully understand the story of beverage taxes, knowledge about the nuances of implementation is critical. One of the novel contributions made by Falbe et al. is framing their study in the context of broader implementation science theory—particularly through the use of the Consolidated Framework for Advancing Implementation Science. Their study contributes to the evolving evidence base that provides unique insights as to how beverage tax implementation is operating on the ground. Future studies should similarly incorporate broader implementation science theories to guide this work because it will help to capture common implementation-related constructs across studies moving forward. Ultimately, advancing implementation science about beverage taxes should help to promote more successful and effective beverage taxes in the future.