Thursday, December 23, 2010

Taxing Sugar Sweetened Beverages: A Way To Address Obesity In The US.: Why voters in New York said “No” in the just concluded elections. - Zainab Shua


That obesity is on the increase and has reached epidemic proportions globally is no longer news. More than one billion adults are overweight with 300 million being clinically obese.(1) In the past 20 years, dramatic increases in obesity in the United States have been observed. (2) In New York, Sixty percent of the adult population is overweight or obese while 1/3rd of their children are overweight or obese.(3)

The imbalance in our body’s use of energy (input and output) results in obesity and one of the ways this occurs is from the increased consumption of sugar sweetened beverages (SSBs). (4-6) Presently, we consume about 300 more calories a day than we did 30 years ago; this is majorly gotten from added sugar (found in sugar-sweetened sodas, energy drinks or fruit-flavored drinks). (3) According to government surveys, the number one source of calories in the American diet is SSBs, representing 7 percent of the average person’s caloric intake and up to 10 percent for children and teenagers. These calories are worse than useless because they are empty, and contribute to a daily total that is already too high. (3,7)

Studies have shown that individual-level intervention (those targeting one individual or smaller group of individuals) at a time, can lead to a reduction in sugary beverage consumption. A study among adolescents reduced the consumption of sugary beverages and achieved modest weight loss goals among these adolescents. They were randomized to either receive home deliveries of non caloric beverages and counseling on healthy beverage consumption. (8) One school based nutrition education program for children aged 7 through 11 years achieved a modest reduction in carbonated beverage consumption and decreased the incidence of obesity and overweight. (9) Taxing SSBs is a population-level point-of-purchase strategy and it has the potential for larger effects at lower cost. These kinds of interventions have successfully increased sales of fruits and vegetables in a cafeteria (10) and low-fat snack foods in vending machines(11) through the posting of educational messages and a reduction in the price of those items. Additionally, levying taxes has been associated with reduced cigarette smoking rates in several areas, including New York City (12) and the state of California.(13) There is a call by Public health leaders for the taxation of sugary beverages to discourage its consumption and to raise public health funding for obesity prevention programs.(14,15) Alternatively, salient information about the health effects of regular soft drinks may affect consumption.

Significant health implications have been related to increased intake of regular soft drinks and other sugary beverages as studies have shown. These health implications include weight gain and increased risk of developing diabetes.(16,17) Government-supported subsidies on corn syrup and sugar have made soft drinks cheap and readily available. Over the past 30 years, the cost of soft drinks has risen very slowly at only three-quarters of the rate of inflation, while the cost of fresh fruits and vegetables has risen at more than 1.5 times that of the Consumer Price Index pointing towards a failing market. It is therefore not surprising that healthy choices of food are rising in price while the cost of bad choices falls. For example, low-fat milk costs more than soda.(3) Obesity has become really expensive; we're already paying a high price because of overconsumption of SSBs. With the suffering state of our health and Americans consuming 46 gallons/person of SSBs a year the equivalent of 40 pounds of sugar yearly,(3,18) it’s either you pay now or pay you latter. Obesity is no longer just a personal issue but is now a public problem as health care cost is shooting up and taxes are being sapped.(3) It is ironic that the advertisements for these SSBs show happy families having fun but the truth is that the consequences of ingesting SSBs is far from a happy family. It’s been found that youngsters who are heaviest are twice as likely to die before they are 55 years of age compared to their thinner counterparts. (3)

Some critics have compared soda to cigarette; the SSBs producers claim their product is not harmful but healthy, they market to children (increasing childhood obesity and thus increasing childhood diabetes) and they lobby for it to remain as is. They also claim that their products are not addictive.(7) Some public health advocates are pushing for even more aggressive actions, urging that soda be treated just like tobacco: with taxes, warning labels and a massive public health marketing campaign, all to discourage consumption. (7)But, in the case of tobacco, the health risks of smoking were clear, this is not so for SSBs. The beverage industry claims that there is no clear link between soda and obesity. (7)

How do we expect people to lose weight when the usual trend seen now is healthy food being expensive and unhealthy food inexpensive, the goal is to reverse this trend and this tax move is a step in the right direction.

The arguments for the soda tax include the fact that high consumption of SSBs contributes to obesity, appropriate taxation would decrease consumption by raising the price, and taxation would also generate revenue that can be used for additional interventions. (7)

If the US has been able to implement this for gasoline, alcoholic beverages and tobacco (NY is known to have added additional state tax to tobacco),(19) why then did voters in New York say no to taxing SSBs in the just concluded elections?


In preparation for the November 2010 elections in New York, two advertisements were rolled out to the media- the 2010 Pro soda Tax in New York Commercial (20) and the 2010 Anti Soda Tax in New York Commercial (21).My arguments are drawn from these two advertisements.

Below is a table summarizing how these two advertisements compare on some grounds:

2010 Anti Soda Tax in New York Commercial (21)

2010 Pro soda Tax in New York Commercial (20)

Sold core values to the people such as control, freedom, support etc.

Health was being sold as a core value whereas people do not value health as core.

The store manager who is similar to the population being reached out to was used; he is just like one of them and therefore feels their pain and knows exactly where this tax would hurt.

Professionals (people high up) were used in this ad, these ‘rich’ people are not like the common man, they can afford to buy other healthy drinks and food, and they do not know where it pinches in the pocket.

Urged the people to hold on to their freedom and not allow someone dictate to them what to eat/drink.

The freedom of the people was being threatened, it was clear someone was trying to tell them what to/not to drink.

Until the end of this ad, it was not clear who this message was coming from. We only know because at the end, it was written- sponsored by the American beverage association. It might as well have been any other association such as concerned US citizens, association of store owners etc.

It was very clear from the first speaker where this message was coming from; they even had a Doctor putting on his white coat.


The 2010 pro tax ad20 was based on the Health belief model (HBM) (22-25) The HBM was developed to explain health related behavior at the individual level. It assumes that human behavior is rational, planned and within an individual’s control. (26,27) This model is a balancing act that involves perceived susceptibility, perceived severity, perceived benefit, intention, behavior and perceived barriers such as cost, convenience, pain, etc. (27)

The 2010 pro tax ad (20) was selling health as a core value. The message was- vote for taxation of SSBs in order to improve health. They were being told the statistics of obesity, declaring the health effects of being obese such as diabetes, heart disease, cancer etc. Talking about knowing what their future holds and how adding tax to SSBs would help reduce obesity and use the money to help stop devastating health care cuts, and helping New Yorkers lose weight is a matter of life and death… they kept mentioning the word ‘health’, thinking that perceived susceptibility and severity would lead to perceived benefits which would then lead to intention and then behavior. Well, they were wrong. Obesity rates are not skyrocketing because people do not know its health implications, people already know the health implications but perceived susceptibility/severity and benefits doesn’t always lead to intention and if at all it does, intention does not always lead to behavior. For some people, perceived severity leads to negative effects on behavior. (28)

Other core values (which people would lose if they do not have health) such as control, freedom, rebellion, ownership etc. should have been sold through this advertisement.


Unlike the 2010 Anti Soda Tax in New York Commercial (21) that used a face that is similar and familiar to the targeted population (the store owner), the 2010 pro tax advertisement (20) did not use the proper principles of advertising theory (29,30) to reach the people; they used professionals such as Doctors, Nutritionist and Psychologist for this advertisement to try to reach the common man. The people used in this advertisement are people the common man cannot relate to. The common man will see them as seemingly rich people who do not care about them and would probably not be affected by the additional tax after all they can afford healthy drinks. It is known that messages from people who are similar make it less likely to induce reactance/rebellion(31) therefore, it shouldn’t be surprising that the people of New York voted against this tax.


The 2010 pro tax advertisement (20) threatened the freedom of the people by telling them what to do and this is very likely to induce psychological reactance.(32,33) People become motivationally aroused by a threat to or elimination of a behavioral freedom, they do not like to be told what to do (they do not like to lose their freedom), as a matter of fact people would do what you said not to do in order to restore their threatened freedom (this is called reactance). (33) People seek censored activities when their freedom is threatened; they thus choose forbidden decision alternatives. (33,34)

The source of this ad was made very clear right from the beginning and it seemed government is trying to interfere in the food/drink people ingest. Seems like a manipulation from the government trying to get in their food, taking away the freedom to eat what they want. Already Americans feel like the US Government is so much in their personal business as was seen with the protest in the passage of the health care bill, now, they do not need the government telling them what to eat/not eat.

Judging from my arguments above, the 2010 pro tax advertisement (20) was profoundly flawed; most of the psychological theories were not used appropriately, it is therefore not surprising that the people voted ‘no’ to this item in the last elections.


Seeing that taxation worked for tobacco etc, I dare say it is possible that in the past elections, voters would have voted “Yes” to taxation on SSBs if things were done differently. I propose that if the advocates of this tax had used the approach listed below to address this problem, the results would have been positive.

1. Public health needs to be rebranded, we ought to change the message from selling health to selling other more important core values such as control, freedom, rebellion, ownership etc. that are gained by having health. (30) People do not see health as a core value but would rather lean towards something that would lead to health. Immediate incentives in the lives of people are more acute therefore they do not value health as a core value.

2. People are less likely to resist when a message is coming from someone who is similar to them. Interpersonal similarity reduces resistance; it increases the positive force towards compliance by increasing liking. When an audience is attracted to the person passing the message compliance is more likely to occur. Similarity has also been said to increase the communicator’s credibility. (35) Studies have found that similarity and liking makes people overlook the flaws of the people they like and are similar with. (36,37) Similarity has multiple effects that are relevant to deflecting reactance; it increases liking for the communicator, it also fosters positive interpretations of the communicators’ actions. (35) Let the message be that even though it seems ‘bad’ drinks would become more expensive with the increase in tax, this amount is very small in comparison to it the skyrocketing health care cost for obesity in the long run. Everyone (obese or not) pays one way or the other through taxes.

3. Change message to promote life style rather than making it seem like their freedom is being threatened. Provide alternatives and give people freedom to choose.

According to Brehm, two forces come to play in order for compliance to be reached; forces to comply and forces to react. (38) Since Reactance and compliance are conflicting forces, acting on either force independently will affect compliance. A way to increase compliance would also be to increase the positive force and decrease the negative force of the message. (35)The threat to freedom should be countered by increasing the positive force in this case by having the message come from similar people, people they like etc.

4. Educate public to see how soda producing companies are just like the tobacco companies. We should aim towards changing social norms and perception about drinks and foods that cause obesity. After this education phase, we should allow for time for normative change where people can really see SSBs as they saw tobacco years ago. If we do not allow time for people’s perception to change, they are less likely to agree with the intervention.

5. Government should encourage the production of healthier foods by subsidizing the production of healthy foods such as fruits and vegetables, and healthier drinks such as milk, juice etc because people will drink anyway, they would not just be stuck with water alone.

I think that it isn’t fair that government has subsidized corn production (which is now the major culprit ingredient used to sweeten these SSBs) and then wants to tax people on SSBs in order to generate revenue for obesity interventions. It seems to me that people will be paying double tax: one to subsidize the production of corn and the other to generate revenue for interventions. This is an unfair vicious cycle.

Some people suggest that obese soda drinkers be taxed (39) but I do not think this is right because we are not just looking at the obese people in the population now; we are also looking to save the people who will get obese as a result of this drink in the future.


This kind of public health intervention has happened in the past, taxes have been levied on tobacco for instance thus increasing the price of tobacco. This increase in price due to the additional tax was able to reduce the demand for cigarettes (the price elasticity of demand was- for every 10% increase in price, demand decreased by 4% to 8%) (40). It is possible for this kind of change to be seen when it comes to SSBs.

Public health should work closely with psychologist when designing a public health intervention; they should make proper use of the psychological theories out there such as advertizing theory, theory of psychological reactance etc. I would suggest public health seek to educate themselves just as the other side (“anti-public health”) does.

Government should provide healthy alternatives before asking people to give up what they are familiar with (in this case- soda), they should encourage these beverage companies to become more health conscious in their production of drinks for human consumption.

I’d like to reiterate that obesity is very expensive, it’s either we pay now or we pay later.


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