Revenue allocation from SSB taxes: making the case for oral health promotion

INTRODUCTION TO SUGAR-SWEETENED BEVERAGE TAXES

Non-communicable diseases (NCDs) have reached epidemic proportions globally¹. High consumption of sugar is a key driver of NCDs such as obesity, diabetes and dental carries². Sugar-sweetened beverage (SSBs) are one of the largest sources of free sugars in the diet³, with excess consumption linked with NCDs³. Health impacts are greatest in disadvantaged groups⁴. NCDs pose substantial health and economic burdens³. For instance, obesity incurs care costs in excess of US$2 trillion annually⁵, whilst treatment costs of oral diseases are in excess of US$298 billion⁶. NCDs also incur indirect costs (e.g. as a result of absenteeism)⁷. As a result of the combined burden of NCDs, and the association between sugar and NCD development, policies that can reduce sugar consumption are warranted.

The World Health Organization (WHO) recommended that governments adopt SSB taxes to reduce sugar consumption⁸. Such taxes have since been implemented in over 40 locations globally9, 10. Arguments against SSB taxes exist (e.g. the potential negative impact on local businesses¹¹ and unfair impacts on low-income communities¹²). However, arguments lack research support¹³, with far more research supporting the potential for SSB taxes to reduce purchase and consumption14, 15, and also encourage reformulation of SSBs16, 17. Therefore, SSB taxes could thus reduce NCDs¹⁸ and related economic burdens19, 20. In support, in Mexico, there was a 7.6% decline in SSB consumption over a 2-year period²¹. Similar impacts have been seen in Berkeley, California where consumption of SSBs in low-income neighbourhoods fell by 21%22, 23.

Revenues from SSB taxes are another reason to support their implementation. Revenues can be earmarked to improve health. However, despite the economic and health burdens of oral disease, and the ‘common sense’ argument for reducing SSB consumption to improve oral health, SSB tax revenues are not being used to reduce the incidence of oral disease. Based on expert opinion, and a review of the literature, we present potential oral health interventions that could be funded by SSB tax revenues.

REVENUE FROM SSB TAXES

Sugar-sweetened beverage taxes generate revenue¹⁰ that can be reinvested to further improve health, as occurs with revenues from tobacco taxation⁹. At the implementation of SSB taxes, some governments posited that revenues from SSB taxes would be earmarked for public health activities²⁴. For example, the UK government stated that revenues from the Soft Drink Industry Levy would fund physical education activities in primary schools and provide a funding boost for breakfast clubs25, 26. However, globally the actual use of revenues is not transparent. For instance, the Mexican government stated that part of the proceeds from their SSB tax would be used to increase access to clean water in schools. However, it is unclear if this has been conducted or indeed how the revenues have been spent²⁷. Moreover, not all governments are keen to earmark revenues. This is in part because the revenue from such taxes can be hard to predict in the longer term, thus putting the government in a volatile financial position. This issue has been clearly evidenced in the UK. Following extensive reformulation of SSBs²⁸, there was a reduction in estimated revenues by more than half²⁹. This resulted in a lack of funds for proposed health campaigns.

REVENUE IS NOT BEING USED FOR ORAL HEALTH

There are currently few examples of revenue use from SSB taxes for oral health. This is despite the implementation of a number of SSB taxes to reduce the incidence of oral health issues, including the UK and the Philippines30, 31, 32. It is also despite the prevalence of oral diseases globally, affecting overall wellbeing and economic development (due to lost productivity and absenteeism)33, 34. San Francisco policymakers did state that revenue from their SSB tax would be used to address health inequalities in low-income groups; for example, stating that there would be increased access to dental care³⁵. However, no evaluation schemes were developed to assess the impact and so whether this is happening is uncertain. Therefore, despite the challenges, we, like the WHO and the British Dental Journal³⁶, argue for transparency on the use of revenues⁸. We also advocate for a percentage of revenues to be directed towards oral health promotion. A similar call has been made by other key opinion leaders³⁷, including The British Society of Paediatric Dentistry, the British Association for the Study of Community Dentistry, and local councils in the UK³⁸.

POTENTIAL EXAMPLES OF REVENUE USED FOR ORAL HEALTH PROMOTION AND CARE

To improve overall wellbeing, a common risk factor approach that focusses on tackling the mutual risk factors shared by oral diseases and other NCDs (like SSB consumption) should be considered39, 40. Based on expert opinion and a review of the literature, here we provide examples of how revenue could be used to promote oral health to aid policymakers globally (see Figure 1 for a summary of these examples). We urge dentists and other public health professionals to advocate for such interventions, highlighting their potential impact, feasibility and affordability to policymakers.

Figure 1.

Recommendations for the use of sugar-sweetened beverage (SSB) tax revenues for oral health promotion.

Oral health education in schools

Oral health education is any combination of learning experiences designed to facilitate voluntary actions conducive to health. Although not all educational interventions are effective (in part due to who is leading the sessions⁴¹), some can be a cost-effective method to promote oral health care42, 43, 44, especially if delivered so that children trust the individual delivering the information⁴⁵. Sessions could be delivered by voluntary dentists or trained community members whilst SSB revenues could cover the costs of educational resources such as leaflets. In addition to providing information for children, sessions could also encourage parents to seek dental treatment at an earlier stage than they may otherwise have⁴⁶. Schools are an ideal location for oral health education delivery as all children, regardless of socioeconomic status, receive the same information. Despite this, many countries are overlooking school-based oral health education schemes. The UK is one of the worst countries at educating children about oral health⁴⁷ due to limited funding and a historical lack of political commitment⁴⁸.

Community dental health screening

Sugar-sweetened beverage revenues could also be used to fund community dental screening to identify oral health problems early and act as a vehicle to bring these individuals into contact with oral health services⁴⁹. Such screening could be conducted by dentists or dental nurses who could employ principles similar to a basic periodontal examination⁵⁰. Research suggests that screening could increase the likelihood that individuals visit a dentist and receive dental care⁵¹, especially if personalised referral letters or additional motivation elements are also included⁴⁶.

Tooth-brushing promotion

Globally, tooth-brushing behaviours are varied43, 52, 53, 54, with the lowest practice occurring in socially disadvantaged groups55, 56 and in younger children⁵⁴. Tooth-brushing can reduce tooth decay, with knock-on effects on physical health and quality of life⁵⁷. Thus, the promotion of regular tooth-brushing with fluoridated toothpaste using the correct brushing technique could be a cost-effective intervention to promote oral health58, 59, 60. SSB revenues could fund such programmes, with support from The National Institute for Health and Care Excellence (NICE)⁶¹. Feasibility of such interventions has been supported. In Sheffield, UK tooth-brushing clubs provided children with free toothbrushes, and toothpaste, as well as information and skills related to tooth-brushing. The programme was funded using £1,000 raised from an independent sugar tax run by Sheffield International Venues⁶². Additional support comes from the evaluation of the 21-day Brush Day and Night programme⁶³.

Community water fluoridation

Fluoride is a naturally occurring mineral found in water. It can improve dental health; however, it is often at levels too low to do so. Adding fluoride to water can help to reduce dental decay⁶⁴. Water fluoridation schemes have been employed globally⁶⁵. Although the benefits of fluoridation have been debated due to potential negative health impacts including fluorosis of teeth, the positive outcomes far outweigh the risks⁶⁴. Research suggests that fluoridation can also narrow dental health differences between socioeconomic groups⁶⁶. Fluoridation across a whole country can be expensive. However, SSB tax revenues could be used to fund, at least in part, the fluoridation of water in small areas such as villages in areas of lower socioeconomic status, to reduce oral health and limit inequalities.

ADVOCATING FOR SSB TAX REVENUE TO BE USED FOR ORAL HEALTH PROMOTION AND CARE

The above shows examples of how SSB tax revenue could be used to fund oral health promotion. However, as obesity has a large global prevalence and economic burden, it is important health professionals advocate for the use of SSB tax revenues for both obesity prevention and oral health promotion. Reframing oral health as an important consideration for policymakers and the public is an essential part of that advocacy. Focussing on the economic costs and impacts of both obesity and oral disease on wellbeing (e.g. worsened child development and psychological distress) may help. Advocates should use evidence as a foundation whilst highlighting how revenues could be used for both NCDs to alleviate inequalities and promote social good7, 67.

TO CONCLUDE: OUR CALL

Sugar-sweetened beverages are contributing to the burden of NCDs, including oral health and obesity. SSB taxes can generate revenue that we argue can be used to alleviate both obesity and poor oral health. To do this, we argue that oral health must be framed so that it is viewed as an important part of overall wellbeing globally. Dental interventions can improve oral health. Therefore, we argue that Governments should use a percentage of revenues generated from SSB taxes for oral health promotion. Interventions could include oral health education in schools, community dental screening, tooth-brushing promotion and fluoridation of water sources. We urge dentists and other public health professionals to advocate for the use of SSB tax revenues for oral health promotion, in addition to obesity prevention. Doing so could make a difference to the overall wellbeing of children and adults globally, reducing the burden of oral diseases and closing inequalities in health. The recommendations presented are topical and should spark debate amongst public health professionals, oral health professionals and policymakers.

ACKNOWLEDGEMENTS

The authors are grateful for the help and comments by the members of the World Federation of Public Health Associations oral health group.

Conflict of interests

The authors have no competing interests to declare.

Funding

This research received no specific financial support.