Table 2 Synthesis of qualitative studies on political and public acceptability of a sugar-sweetened beverages (SSBs) tax
Theme | Subtheme | Studies on political acceptability | Studies on public acceptability | Illustrative quotes |
|---|---|---|---|---|
Beliefs about effectiveness and cost-effectiveness | Impact on SSB purchases and consumption | ‘Informants from academia and MOH [Ministry of Health] indicated that taxation may limit SSB consumption’ (Mexico) [29] ‘Many students stated that a positive of SSB taxes was decreased consumption (“I think it would stop so many people from buying sugary drinks.”)’ (US) [39] ‘One female participant said that people had already made up their minds about soft drinks. Those who really love soft drinks would save money from other sources to buy them anyway’ (China) [36] ‘Another student concluded, “I think that the only people that will actually do that [continue to buy SSBs] are people that are really rich and can afford anything or people that just don’t know how to handle an addiction of theirs.”’ (US) [39] ‘A lack of awareness of the price of beverages was reported as a reason for dismissing taxation, as one participant explained: It won’t affect me [tax] because, like me, other people don’t remember the juice prices of last year’ (Mexico) [40] | ||
Impact on health-related outcomes | ‘The Minister for Health proposed the tax due to concerns over diabetes and other chronic diseases’ (Pacific countries) [35] ‘Research evidence about the health effects of SSBs and potential health benefits of SSB taxes was influential toward the end of the policymaking process’ (US) [34] ‘A number of stakeholders were awaiting outcomes from the Mexican SSBs tax, which were not published at the time.’ (New Zealand) [31] ‘Tax is a cure for obesity’ (US) [38] ‘Many commenters thought it would not be not effective in reducing obesity’ (UK) [42] | |||
Impact on SSB prices | [31] | ‘There were concerns that the full tax may not be passed on to consumers by companies as they may spread the load across all types of sweetened and non-sweetened drinks’ (Australia) [44] ‘According to several participants, the tax would only affect them if it were higher: ‘If the price was much higher than it was before, I think yes, I would consider it, but the 10% increase is not that much’ (Mexico) [40] | ||
Availability of healthy alternatives | ‘All informants emphasized the structural barriers to implementation, including an inadequate investment in drinking water infrastructure and lack of healthy alternatives to SSB’ (Mexico) [29] ‘I would much prefer to feed my children a sugary drink then take them out to play in the park and burn it off then so-called diet drinks filled with neurotoxins like Aspartame that does Lord-knows-what to their developing brains’ (UK) [42] ‘I’d rather sugar than artificial sweeteners …’ (UK) [41] | |||
Encourage industry to reformulate content | [42] | ‘It would encourage the drink producers to reduce the sugar’ (UK) [42] | ||
Cost-effectiveness | ‘Participants across all 14 European countries also perceived regulatory measures to be more cost-effective than voluntary measures’ (European countries) [33] ‘If a tax helps that then so be it, it’s worth the extra cost (and will save us loads in the future)’ (UK) [42] | |||
Beliefs about appropriateness | Taxation as an intervention strategy | ‘To counter marketing practices and SSB consumption, almost all insisted that ‘government intervention is crucial to protect children’ (Mexico) [29] ‘Analogies were made to the successes of tobacco taxes and the transfats restriction in improving health’ (US) [28] ‘But I’m an adult and I’m sick to death of being treated like a 5 year old by this nanny-state we’re now living in’ (UK) [42] ‘There should be a limit to government intervention, even if the cause is just and for good values. I think there should be limits to what the government is allowed to intervene in’ (Israel) [32] ‘Bring down the price of healthy foods and then see if there is a decline in obesity’ (UK) [42] | ||
SSBs as an intervention target | ‘Four noted that soft drinks are cheaper than healthy alternatives, suggesting that a tax would assist in adjusting this anomaly, including one consumer, one politician, and one food industry leader’ (New Zealand) [31] ‘The jurors agreed that sugar-sweetened drinks were (…) a major contributor to childhood obesity’ (Australia) [44] ‘I’ve drank soda all my life and I’ve never been overweight’ (UK) [42] | |||
Beliefs about overweight and obesity | [32] | ‘One long-term resident observed, ‘[I’ve] looked at children in the schoolyard and on the streets of Telluride and, for the life of me, I don’t see obesity as a local problem’ (US) [30] ‘If youre fat, its your own fault and its YOUR responsibility to do something about it. Not the NHS Not the Govt Not the tax payer ... Take some responsibility and put down the fork!’ (UK) [42] ‘All of the interviewees, regardless of sector, regarded obesity as a combined public and personal problem’ (Israel) [32] | ||
Beliefs about economic and socioeconomic benefit | Raise revenue for societal health programs | ‘In 2002 the French Polynesian government introduced a range of taxes, including taxes on soft drinks, in order to fund the establishment of the Etablissement pour la prevention (EPAP), a prevention fund’ (Pacific countries) [35] ‘One local mother described in glowing terms her daughter’s experience, concluding, ‘I am prepared to pay an extra 12 cents for my occasional soda … if it means the continuation of these programs for the children of Telluride’ (US) [30] | ||
Raise revenue for health care | [42] | ‘The government at the time proposed the tax because they wanted to enact preventive health interventions as well as fund hospitals’ (Pacific countries) [35] | ||
‘A number of suggestions were made for how tax revenues could be spent to benefit society as a whole–particularly via additional financial support for the NHS’ (UK) [42] | ||||
Raise revenue for the general budget | ‘Mayor Andre Quintero said, ‘[T] here are significant financial hurdles that we need to start dealing with now, so having this type of tax as an option brings in revenue’ (US) [30] | |||
Negative economic impact | ‘One bureaucrat noted the value of evidence of the impact on the economy and productivity’ (New Zealand) [31] ‘The corporations absorb the hit and reduce jobs to offset the increased cost of doing business’ (US) [38] | |||
Impact on socioeconomic equality | ‘Pro-SSB tax advocates, including the LHD, countered this argument with data about the disproportionally high prevalence of obesity and diabetes among low-income Philadelphians and claims that these disparities were regressive’ (US) [34] ‘The main arguments were the regressive nature of the tax - not only would low-income families be spending more of their income on the tax, but these communities also consume greater quantities of soda than higher-income populations’ (US) [28] | |||
Beliefs about policy adoption and implementation | Feasibility | ‘There was general agreement that a soft drink tax would be the easiest intervention to implement of the ones examined. It was agreed that it would be possible to impose an excise tax, such as that on alcohol, as occurs in New Zealand’ (New Zealand) [31] ‘The jurors agreed that sugar-sweetened drinks were easily defined’ (Australia) [44] ‘When asked about the legal framework, informants described a convoluted policymaking system, a prolonged policy adoption process, competing agendas, and opposition (mostly from industry)’ (Mexico) [29] ‘Five people commented on the administrative load of such a tax. A bureaucrat and food industry leader were concerned the load would be high’ (New Zealand) [31] ‘Policymakers are fighting ‘an invisible enemy’ in home-made, unlabeled products, including home-made sugary beverages, that will be difficult to regulate’ (Mexico) [29] | ||
Support of stakeholders | ‘There was agreement from all stakeholder groups on the need to increase public support for such a tax’ (New Zealand) [31] ‘Regarding people such as doctors, whom students believed would be against adolescents’ drinking SSBs, they stated, “They would think that it [a SSB tax] is a good idea.”’ (US) [39] ‘Other potential objectors identified by interviewees were members of the tax system: the Ministry of Finance and the Israeli Tax Authority, as well as Members of Parliament and liberal organizations’ (Israel) [32] | |||
‘However, a consumer representative warned about the power of industry, ‘the hugely influential weight of the industry, you know, they’re in there lobbying the government all the time’ (New Zealand) [31] | ||||
Mistrust | Mistrust of industry | ‘Soda companies ‘want to avoid paying their fair share and don’t care about the safety and health of El Monte’s neighborhoods’ (US) [30] | ||
Mistrust of government | [32] | ‘Some consumers (…) have doubts about the use of proceeds (e.g., “revenue to fund other projects or even their own generous pay raises”)’ (US) [38] ‘… as others have said a tax on sugary drinks is just a government money generating scheme and not addressing the real issues …’ (UK) [41] ‘We know that the Ministry of Finance does not like the use of tax money for a specific cause. The Ministry of Finance wants every penny they collect to be free for use towards the purposes that they choose’ (Israel) [32] | ||
Mistrust of public health experts | [42] | ‘How many of these “experts” struggle with their grocery bill? I‘m sick and tired of hearing “experts” calling for a rise in the cost of living’ (UK) [42] |