Read the article:

"Sugar-sweetened beverage reduction policies: Progress and promise." (Krieger, et al. 2021)

Write a brief reflection of how the content relates to the exploration of the role and function of health policy from this week's materials. Be sure to include references to this week's course material and at least one outside, peer-reviewed source. Include your personal insight, opinions, or relevant experiences as appropriate. word limit is 300.

ANNUAL INTRODUCTION Sugar-sweetened beverages (SSBs) are one of the largest sources of added sugars in the American REVIEWS SSB: sugar-sweetened diet (147) and include sodas; fruit, sports, and energy drinks; and sweetened coffees and teas. beverage Consumption of these drinks is strongly associated with excess mortality (90), obesity (88), and Annual Review of Public Health multiple chronic diseases (27, 91). In 2012, approximately 50,000 heart disease and type 2 diabetes deaths among US adults were associated with the consumption of sugary drinks (96); these diseases Sugar-Sweetened Beverage are more likely to cluster among racial/ethnic minorities and low-income populations (10, 79). Reduction Policies: Progress One study found that adults who drank two or more servings of sugary drinks per day had a 31% higher risk of death from heart disease, compared with people who drank less than one serving of sugary drinks per month (90). A second study found that increasing total sugary beverage intake and Promise (including both SSBs and 100% fruit juices) by >0.50 serving per day over a 4-year period was associated with a 16% higher type 2 diabetes risk among adults (43). Consumption of 1 sugary drink per day increases the risk of developing type 2 diabetes by 26% among adults (92). Soda James Krieger,12 Sara N. Bleich,' Stephanie Scarmo,+ consumption is associated with nearly twice the risk of dental caries in children (131). and Shu Wen Ng5 Intake of SSBs increased dramatically during the last half of the twentieth century (46) and 'Healthy Food America, Seattle, Washington 98122, USA remains at historically high levels despite recent decreases. In 2014, SSBs were consumed at least Department of Health Services, School of Public Health, University of Washington, Seattle, once per day by 61% of children and 50% of adults, down from 80% and 62% in 2003, respectively Washington 98195, USA; email: jukrieg@uw.edu (14). Although soda consumption has declined, consumption of other SSBs such as energy drinks ANNUAL Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, has increased (148). SSB consumption is highest among racial and ethnic minorities such as Blacks REVIEWS CONNECT Harvard University, Boston, Massa etts 02115, USA; email: sbleich@hsph.harvard.edu and Hispanics (14, 65) and among people with low incomes and less wealth (65, 156). American Heart Association, National Center, Dallas, Texas 75231, USA; Recent data suggest a possible plateauing of consumption. According to unpublished author www.annualreviews.org email: stephanie.scarmo@heart.org . Download figures analyses of national survey data from 2015 to 2016, the proportion of SSB drinkers has remained Department of Nutrition, Gillings School of Global Public Health and Carolina Population . Navigate cited references Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27516, USA; relatively constant since the prior wave of data collection in 2013-2014. This trend is consistent Keyword search email: shuwenOunc.edu Annu. Rev. Public Health 2021.42:439-461. Downloaded from www annualreviews.org with evidence from industry analyses, which show modest, consistent declines in beverage calories Access provided by 2600:8803:7481: 10:896b:46f4x683:1d49 on 03/18/23. See copyright for approved use Explore related articles per person per day from 2000 to 2013, a leveling off through 2017, and a small decline from 2017 . Share via email or social media to 2019 (78). Policy makers, public health officials, and advocates have developed a variety of approaches to Annu. Rev. Public Health 2021. 42:439-61 Keywords reduce exposure to and consumption of SSBs. This review provides a framework for the types of First published as a Review in Advance on policies that have been used for SSB reduction (Figure 1) and organizes policies into four cat- November 30, 2020 sugar-sweetened beverages, SSB, sugary drinks, policies, health equity, egories: financial, information, defaults, and availability. Financial policies increase the price of impact, feasibility The Annual Review of Public Health is online at SSBs relative to healthier options and include taxes, restrictions on price or volume promotions publhealth.annualreviews.org Abstract e-g., buy-one-get-one-free offers for soda), and incentives for purchase of unsweetened beverages https://doi.org/10.1146/annurev-publhealth- eg., lowering the price of unsweetened beverages relative to sweetened ones). Information poli- 090419-103005 Evidence showing the effectiveness of policies to reduce the consumption cies seek to reduce the public's exposure to marketing of SSBs or increase awareness of the health of sugar-sweetened beverages (SSBs) is growing. SSBs are one of the largest Copyright @ 2021 by Annual Reviews. This work is risks that SSBs pose. These policies include front-of-package and advertising warning labels and licensed under a Creative Commons Attribution 4.0 sources of added sugar in the diet and are linked to multiple adverse health marketing restrictions (e.g., no advertising during children's television programming). Default International License, which permits unrestricted conditions. This review presents a framework illustrating the various types policies, such as requiring a healthy drink in kids' restaurant meals, make the choice of a healthy use, distribution, and reproduction in any medium of policies that have been used to reduce SSB exposure and consumption; beverage automatic. Availability policies decrease access to SSBs or reduce portion sizes. They provided the original author and source are credited. See credit lines of images or other third-party policies are organized into four categories (financial, information, defaults, include beverage procurement (c.g., purchase or placement of beverages within various settings) material in this article for license information. and availability) and take into consideration crosscutting policy considera- and healthy checkout aisle (c.g., lanes at the grocery store that display healthier options) policies. tions (feasibility, impact, and equity). Next, for each category, we describe a The policy examples provided in each category are illustrative; a wide variety of approaches within specific example and provide evidence of impact. Finally, we discuss cross- each could be used for SSB reduction. OPEN ACCESS cutting policy considerations, the challenge of choosing among the various For each policy category, we provide a specific example and evidence of impact. We then discuss policy options, and important areas for future research. Notably, no single three key crosscutting policy considerations-feasibility, impact, and equity-and the challenge policy will reduce SSB consumption to healthy levels, so an integrated policy of choosing among the various policy options. We conclude with consideration of important approach that adapts to changing market and consumption trends; evolving topics for future research. Evidence for this review was obtained from peer-reviewed scientific social, political, and public health needs; and emerging science is critical. research, gray literature, white papers, websites of government agencies and nongovernmental 439 440 Krieger et al.Financial Advertising consumption, store type, type of beverage taxed, and population demographics (20, 32, 50, 93, Population impact 130, 132). In Philadelphia, a 1.5-cent-per-ounce tax on beverages sweetened with sugar or NNS was associated with a 38% decline in the volume of taxed beverages sold by large retailers one year after implementation, after accounting for tax avoidance (121). Analyses of sales data in Berkeley, Seattle, and Cook County have also shown decreases, although of lesser magnitude (115, 116, 130). However, purchases in Oakland, as measured by an intercept survey among a Taxes Warning labels on front smaller convenience sample, did not change significantly (18). In contrast with these consistent . Restrictions on price/ of package volume promotions Warning labels on findings from studies using objective measures of SSB sales, studies examining the influence of Healthy incentives on advertising SSB taxes on consumption are mixed (17, 18, 51, 83, 122, 130, 158). This variation may be due unsweetened beverages Marketing restrictions to the use of self-reported and imprecise consumption measures and insufficient sample sizes. Defaults Availability Some of the variation in impact may also be due to differences in tax implementation across jurisdictions-some governments have provided minimal guidance to retailers (e.g., press releases from city offices), whereas others have provided more intensive assistance (c.g., on-site visits, well-developed websites, and communications campaigns) (28). SSB taxes in the United States have raised substantial revenues: $135 million per year across the Feasibility Equity seven US cities (70). Each city has allocated revenues to meet its specific needs and has focused in- Healthy kids' beverages . Beverage procurement vestments on low-income communities. Many tax-funded activities are health focused, such as in- . Healthy re creasing access to healthy food and water, educating about nutrition and healthy beverage choices, - Restrictions to federal nutrition assistance providing health services, and expanding opportunities for physical activity. Others address social programs determinants of health such as early childhood education or maintenance of libraries, parks, and Figure 1 recreation centers. The extent of community influence on tax revenue allocation decisions is lim- Policies to reduce sugar-sweetened beverage purchases and consumption. ited in some jurisdictions, whereas community advisory boards have a primary role in awarding funds through grant making in others. organizations, and media coverage. Whenever possible, we used peer-reviewed, empirical studies. Outside of the United States, evaluation of the UK tiered sugar-density volume tax suggests Annu. Rev. Public Health 2021 42:439-461. Downloaded from www.annualreviews.org Access provided by 2600:8803:7481:1c0:896b:46f4:cb83:1d49 on 03/18/23. See copyright for approved use. In the absence of real-world data, we included results from simulation studies. that it has led to reformulation of beverages with lower sugar content (6, 124). It is likely that Volume-based excise sugars are being replaced with NNS. Early evaluations of the South African tax found reductions taxt an excise tax in in the amount of sugar from beverages purchased, likely due to reductions in the volume of taxed POLICY AREAS which the tax rate is beverages purchased and sugar-reduction reformulations by industry (S.W. Ng, personal commu- based solely on the nication) (136; N. Stacey, I. Edoka, K. Hofman, R. Swart, B. Popkin, S.W. Ng, manuscript under Financial: Sugar-Sweetened Beverage Taxes volume of a product review). SSB taxes are viewed as one of the most effective policies for SSB reduction (3, 100). They are Excise taxes: taxes Assessing the health impact of beverage taxes will be difficult. The long lag between tax imple- attractive to policy makers because they both reduce sales of SSBs and raise revenue, although collected directly from mentation and potential health effects and the multiple factors that contribute to health conditions they face strong opposition from the beverage industry. As of August 2020, seven US cities and manufacturers or associated with SSBs make attribution of observed changes in health outcomes to taxes problem- more than 40 nations across the globe have adopted SSB taxes (58). The design of SSB taxes distributors; may or atic. Microsimulation models predict significant reductions in obesity and cardiometabolic dis- varies by jurisdiction with respect to the tax basis (taxing sugar content versus volume), tax rate may not be passed through to prices paid eases (85, 106, 123) (as percentage of price), included beverages [e-g., whether beverages with nonnutritive sweeteners by retailers and/or Opponents have argued that SSB taxes result in job losses, but the evidence to date does not (NNS) are included], and whether the rate is indexed to inflation (25). In the United States, all consumers support this claim (64, 82, 92a, 104). Opponents also argue that they impose a unfair tax burden seven of the taxes are volume-based excise taxes ranging from one to two cents per ounce. Globally, Tiered sugar-density on people with low incomes. While people with lower incomes likely do pay more taxes than tax designs include tiered sugar-density volume taxes, which can include multiple tiers (e-g., the volume tax: a people of greater economic means, emerging evidence suggests that beverage taxes may actually be United Kingdom taxes beverages with 5-8 g of sugar per 100 ml at 18 pence per liter and those volume-based excise progressive and advance health equity. Emerging empirical data and economic simulation models with a higher sugar content at 24 pence per liter) or linear rate beyond a first tier (c.g., South tax in which the tax suggest that beverage taxes reduce SSB purchases more among people with lower incomes or lower Africa taxes beverages at 0.021 rand for every 1 g sugar per 100 mL above 4 g). rate varies based on Available evidence suggests that SSB taxes increase the price and reduce the sales of taxed sugar content educational attainment than among those with higher levels (2, 12). People with low incomes have (g/volume) of the higher SSB consumption rates (65) and a greater likelihood of being affected by adverse health beverages. In the United States, the proportion of the tax that is passed on to consumers in the taxed beverage conditions associated with SSB consumption (79). Consistent with this evidence, health outcome form of increased prices ranges from 43% to 120% (19, 115, 117, 121, 130). The decrease in sales microsimulation models (84, 85, 106, 123) show greater tax-related health benefits among people volume varies from 21% to 39% after accounting, when feasible, for tax avoidance from shopping with lower incomes. Finally, in the United States, nearly all cities with SSB taxes have invested in neighboring areas (20, 115, 116, 121). These ranges mask important differences across and within jurisdictions, suggesting that tax effects depend on factors such as tax rate, baseline SSBunconstitutional by the US Court of Appeals in 2019 and the city council passed a revised bill in 2020, which is now the subject of litigation; the trial is not expected until 2021 (S. Adler, per- GDA: Guideline Daily sonal communication). Laws requiring health warnings on SSB advertising, containers, packaging, ALTO EN ALTO EN GRASAS ALTO EN ALTO EN Amounts menus, or vending machines or at the point of sale of unsealed drinks have been proposed, but not AZUCARES SATURDAS SODIO CALORIAS adopted, in seven states and one additional city. Ministeria Mirinteria Ministerio Simulation and empirical studies suggest that warning labels, compared with numeric nutrient information, are more likely to be noticed, cause stronger emotional reactions, elicit more think- ing about the health effects of SSBs, and lead consumers to choose healthier products (76) while avoiding unhealthy ones (35, 61, 137). A simulation study of a US national mandatory SSB health warning policy found that it would reduce average SSB intake by 25.3 calories per day and total STATE OF CALIFORNIA SAFETY WARNING: energy intake by 31.2 calories per day, reducing obesity prevalence by 3.1 percentage points over Drinking beverages with added sugar(s) may 5 years. The study found larger benefits for racial/ethnic minority and lower-income adults (62). contribute to obesity, type 2 diabetes, and tooth decay. Warning labels also encourage manufacturers to improve the nutritional quality of their products to avoid negative labels (128, 150). Chile's adoption of its Food Labeling and Marketing law in 2012 presented the opportunity to evaluate a real-world warning label policy. The law mandates warnings for products high in sugar, saturated fats, sodium, or energy based on nutrient threshold values (35). Purchases of beverages PER SERVING with "high-in" labels fell by 23.7% after implementation, with similar reductions across all income groups (138). Subsequently, Peru, Mexico (in 2019), and Israel (in 2020) passed or implemented 450 similar legislation, and other countries, such as Brazil and Uruguay, are actively considering fol- 5g 360mg 14g lowing suit. CALORIES SAT FA SODIUM SUGARS The food and beverage industry has aggressively opposed warning labels. It has often promoted 25% DV 15% DV voluntary Guideline Daily Amounts (GDA) labels (Figure 2) as an alternative. However, numer- ous independent studies have demonstrated poor GDA performance on a number of dimensions, Annu. Rev. Public Health 2021.42:439-461. Downloaded from www.annualreviews.org Access provided by 2600:8803:7481:10:896b:46f4x683:1d49 on 03/18/23. See copyright for approved use. including degree of consumer attention (24, 114), case of understanding (39, 133), time needed to Figure 2 assess (11, 129), and intentions to consume unhealthy products (15, 44, 45, 74, 129, 139). More- Examples of front-of-package labels. (@) Nutrient warning implemented in Chile calling out "high-in" over, the GDAs are often combined with positive health or nutrient claims on the package, which nutrients of concern (sugar, saturated fats, sodium, and calories). (#) Health warning proposed (but not adopted) in California in 2019. (c) Industry-developed Guideline Daily Amounts (GDA, also referred to as further confuses consumers (1, 135, 140). In the United States, industry opposition to warning Daily Intake Guide) in Australia, Clear on Calories in Canada, Facts Up Front in the United States, and labels has focused on First Amendment challenges (1 10), claiming that warning labels infringe on "Checa y Elige" in Mexico. commercial free speech. Legal experts suggest that it is possible "to enact food labeling laws within First Amendment parameters" (109, p. 1986), but "future case law is needed to answer outstanding tax revenues in programs that explicitly benefit low-income and other marginalized populations. legal questions, and future research is needed to ensure warnings are effective and not burden- Taking all these factors into account, the net effects of taxes appear to be progressive (2). some" (11 1, p- 5). Warnings on packages and at the point of sale may pose fewer First Amendment concerns than warnings on advertisements (111). Information: Warning Labels Defaults: Healthy Beverage Defaults in Restaurant Meals SSB warning labels on beverage containers or outdoor advertising provide consumers with easy- to-understand nutrition information to support healthy beverage choices and industry with an SSBs are widely available in restaurant meals marketed to children. In 2019, 61% of the top 50 incentive to reformulate products. Two main types of warning labels are used: nutrient warnings restaurant chains (ranked by revenue data) had SSBs on their children's menus (1 19). These menus (indicating a high amount of sugar) and health warnings (describing health harms of SSBs). See bundle SSBs with meals or make them the default option, which normalizes and increases the Figure 2 for examples. The expectation is that warning labels (especially those implemented na- likelihood of consuming SSBs when cating out (1 19). Defaults strongly motivate behaviors in tionally) may have a larger impact on consumer purchasing behavior than the numeric nutrient many contexts (e.g., retirement plans, organ donation, as well as food choice) (154). In restaurants, information found in the Nutrition Facts Panel on the back or side of packages (37, 151). They customers are likely to select the default (41). An analysis of the nutritional quality of children's may also counteract misleading nutrition claims on beverages (1, 135). combination meals at large US chain restaurants found that substituting a lower-calorie beverage More than 40 countries have implemented voluntary or mandatory warning labels, which vary (e-g., water) for a sugary drink would reduce calories in a default meal by 100 calories and 20 g of in appearance and application (155). In the United States, San Francisco passed an ordinance in sugar (47). Improving beverage offerings in children's restaurant meals may have larger impacts 2015 requiring a health warning on outdoor SSB advertisements (11 1). The ordinance was ruled among children from lower-income households and children of color as compared with children from higher-income households or white children. On a typical day, just over one-third (36.3%) of children and adolescents cat in a fast-food restaurant (56). While higher-income families eatout more often at fast-food restaurants, children from lower- and middle-income families con- Table 1 Summary of reimbursement and availability of sugary drinks in major federal nutrition assistance programs sume more calories (118). Additionally, fast-food restaurants are more prevalent in lower-income Beverage type communities (53). USDA: United States Other sugar-sweetened Some restaurants have made voluntary pledges to offer healthier beverages (c.g., water, milk, Department of Program Flavored milk 100% juice drinks Notes 100% juice) as the default option in children's meals. While these voluntary efforts have yielded Agriculture SNAP Must be nonalcoholic some improvements, they are inconsistently implemented. For example, restaurant personnel of- WIC fered at least one healthier drink option with more than 80% of children's meal orders at McDon- SNAP: Supplemental Milk fat level depends on age Nutrition Assistance NSLP/SBP Flavored milk can be 0% or 1% far; ald's, Burger King, and Subway restaurants, but with only 56% of orders at Wendy's and KFC and Program sugary and caffeinated drinks cannot 33% at Dairy Queen (67). Another evaluation found that 32% of parents who ordered a chil- be sold during school day WIC: Special dren's meal from large fast-food restaurant chains continued to receive a sugary drink, despite the CACFP Supplemental SSBs can be served but not restaurants' commitment to offer healthier beverages (68). The beverage calories available with Nutrition Program for reimbursed; no juice for infants children's meals at 45 chain restaurants did not differ between restaurants participating in the Women, Infants, and industry's voluntary Kids LiveWell Initiative (https://restaurant.org/kidslivewell) and nonpar- Children Symbols and abbreviations: X, not allowed; ,/, reimbursable; A, available (but not reimbursable); CACFP, Child and Adult Care Food Program; NSLP, ticipating restaurants. Sugary beverages accounted for 80% of children's beverages served in these National School Lunch Program; SBP, School Breakfast Program; SNAP, Supplemental Nutrition Assistance Program; WIC, Special Supplemental NSLP: National Nutrition Program for Women, Infants, and Children. restaurants, with flavored milks replacing regular soda (97). School Lunch Last updated September 4, 2013 (143). State (c.g., California, Hawaii, and Delaware) and local (c.g., eight California jurisdictions, Bal- Program w.annualreview's.org "Last updated November 27, 2013 (144). timore, New York City, Philadelphia, and others) governments have passed laws to improve the SBP: School Breakfast Last updated September 23, 2019 (146). healthfulness of beverages in children's meals (23). The impact of these children's meal policies is Program dLast updated July 16, 2013 (142). emerging. An early evaluation of California's policy found that more restaurants included a com- CACFP: Child and pliant beverage on menu boards, and fewer restaurants listed sweetened beverages after the policy Adult Care Food saving (7, 8, 99). The reach of the five largest federal nutrition assistance programs suggests that was implemented (74a). However, the same study found no change in Wilmington, Delaware, Program expanded restrictions on SSBs would have a meaningful impact on population health, although it suggesting additional efforts may be needed to support the implementation of policies after they DGA: Dietary FSG: Food Service will be important to consider the potential impact of such a change on participation. are passed. Guidelines for Guidelines Federal policies establish the "floor" for SSB policy, as states and localities can make addi- Americans tional rules. For example, local educational agencies implementing wellness policies can include Access provided by 2600:8803:7481:1c0:896b:46f4:cb83:1d49 on 03/18/23. See copyright for approved use. Availability: Healthy Beverage Policies and Guidelines HHFKA: Healthy additional provisions regarding the availability of SSBs beyond federal policy mandates (40). Hunger-Free Kids Act A second approach for reducing SSB availability is implementation of food service guidelines The policies that determine the availability of sugary drinks through federal nutrition programs of 2010 (FSGs). FSGs, both voluntary and mandatemer son dascases the nibling aur " to CCR. while affect millions of Americans. The United States Department of Agriculture (USDA) administers Annu. Rev. Public Health 2021.42:439-461. Downloaded from w making healthier beverages more a a suite of 15 nutrition assistance programs that together have a budget of nearly $100 billion dards for allowable foods and be (105). The vast majority of these funds is spent on five programs (described in the Supplemental promotion (22). These guidelines Appendix): the Supplemental Nutrition Assistance Program (SNAP), which alone accounts for Supplemental Material > hospitals, parks) and locations with 68% of expenditures (105, 145); the Special Supplemental Nutrition Program for Women, Infants, stands, and meetings) (22). Comp and Children (WIC); the National School Lunch Program (NSLP); the School Breakfast Program within a jurisdiction have been en FER BEAMING (SBP); and the Child and Adult Care Food Program (CACFP). (103) and Philadelphia (108), the 450 14 Recent policy actions have limited access to SSBs (broadly defined to include flavored milk) of Massachusetts (94) and Washin in most of these programs by aligning them with the Dietary Guidelines for Americans (DGAs) Research examining the impact (Table 1). For example, the Healthy Hunger-Free Kids Act (HHFKA) of 2010 required the USDA but early evaluations are promising to align NSLP, SBP, and CACFP with the DGAs (40). SNAP was not affected, although house- the sale of SSBs on city property an holds receiving benefits spend about 9% of food dollars on SSBs (compared with 7% among non- managed food or beverage service SNAP households) (57) and about half of SNAP households support restricting SSB purchases implementation, a single-arm eval with SNAP benefits (55). by 48.6 calories and average suga Data on the effectiveness of SNAP restrictions is limited. Evidence from the only randomized SSB ban at a California hospital controlled trial (conducted among individuals eligible or nearly eligible for SNAP but not partic- their daily intake by about half an ipating) found that pairing incentives for purchasing more fruits and vegetables with restrictions evaluations have been mixed. For Do Snipping Tool on the purchase of less nutritious foods (e.g., SSBs, candies) reduced daily energy intake and im- FSG policy for its government age proved diet quality compared with no incentives or restrictions (66). Evidence from simulation healthier beverages increased 33% studies indicates that restricting SSB purchases in SNAP could reduce consumption by an aver- sales experienced a nonsignificant age of 24 calories per person per day, reduce the prevalence of obesity and diabetes, and be cost 21% (107). Screenshot copied to clipboard and sa Select here to mark up and share the in www annualreviews.org . Sugar-Sweetened Beverage Reduction Policies 445 446 Krieger et al.CHOOSING A POLICY OPTION Impact There are many proven and promising policy approaches for reducing purchases or consumption The impact of a policy is a function of both the number of people it reaches and its effect size of SSBs. Next, we discuss three key considerations-equity, impact, and feasibility-for determin- Dose of a policy: the (157). With respect to reach, some policies touch large numbers of people (c.g., taxes, warning ing which approach or combination of approaches to use. amount and duration labels, nutrition assistance programs) while others affect a smaller proportion of a population (and hence intensity) (e.g., healthy kids' meals and food service guidelines, given the smaller share of total SSB intake or of a policy's Equity implementation purchases from these sources). Notably, the geographical boundaries of a policy can affect reach. For example, shoppers in some, but not all, jurisdictions may avoid a beverage tax by making pur- Health equity means that "everyone has a fair and just opportunity to be as healthy as possible" Preemption: legislative or chases in a neighboring nontaxed jurisdiction, thus reducing reach (20). A tax policy implemented (16, p. 2). Health inequities are differences in health that are not only avoidable but also unfair and nationally will have the greatest reach but may not be as feasible politically as a local tax. unjust. They are rooted in the social conditions that increase the risk of poor health in marginalized regulatory action by a higher level of With respect to effect size, there is also considerable variation. For example, effect sizes on communities. government that reducing sales volume of targeted beverages are large for warning labels (20-35%) implemented Equity considerations are important throughout the policy process, including issue identifica- eliminates or reduces nationwide (61, 138) and for local SSB taxes (21-39%) in the United States (121, 136, 141). Effect tion, policy design, agenda setting, adoption, implementation, and evaluation (80). Equity is more the authority of a sizes are unknown for children's meal defaults, FSGs, and healthy checkout aisles. likely to be considered if policy makers and advocates share power with the community, beginning lower level of government over a The "dose" of a policy also affects impact. For SSB taxes, an example of a higher-dose approach carly in the policy process during the problem definition phase (101). Rigorous evaluation methods specific issue would be one that uses a higher tax rate (e.g., 2 cents per ounce rather than 1 cent) and/or includes a that draw on community-based participatory research approaches are important for understand- wider range of taxed beverages (e.g., beverages sweetened with NNS). For front-of-package labels, ing policy equity impacts (81, 101). These equity considerations are key for crafting just policies; a higher-dose policy would use larger or more graphic warning labels. Therefore, assuring that a those that are poorly designed and insufficiently evaluated can have the unintended consequence policy has an adequate dose should be an important consideration in the policy selection process. of exacerbating health inequities. SSB reduction policies with broad reach among populations most affected by predatory indus- try marketing and the diseases associated with SSBs have the greatest potential to increase equity Feasibility (81). For example, federal nutrition assistance programs reach about one in four Americans each Even the highest-impact policy will not reduce SSB consumption unless it is feasible to imple- year and help primarily lower-income individuals (105). Therefore, reducing availability of SSBs ment. Feasibility has several dimensions. Political feasibility includes the acceptability of a policy in these programs may help to reduce disparities in SSB consumption among a large population. Annu. Rev. Public Health 2021.42:439-461. Downloaded from www.annualreviews.org to decision makers and the public (i.e., political will) as well as the strength of the opposition. If Access provided by 2600:8803:7481:160:896b:46f4x683:1d49 on 03/18/23. See copyright for approved use SSB taxes, which affect everyone living in a jurisdiction, also reach large numbers of people. By the public and policy makers view SSBs and their marketing as unhealthy, unjust, and irrespon increasing prices, taxes may counter industry marketing and pricing strategies that target peo- sible, political will increases and policy change becomes more feasible (59, 73). Legal feasibility ple of color and lower-income communities (60, 87). Other fiscal policies with the potential for refers to whether a policy conforms to existing law. Most relevant to SSB policy is whether a ju- broad reach, such as restricting price promotions on SSBs, could also yield greater benefits for risdiction has the authority to adopt the policy. Preemption of local authority by a higher level of lower-income populations, who are often the targets of such promotions (60). government denies this authority (112). Feasibility of policy implementation refers to barriers to Policy impacts may differ across subpopulations in ways that promote equity. SSB taxes are a putting the policy into effect, such as implementation costs, burden to affected parties, challenges good example of a proequity policy (29). Evidence points to larger declines in sales among people to enforcement, political opposition, and risk of repeal. with lower incomes and people of color, who are at higher risk for SSB consumption and associ- Taxing SSBs is an example of a high-impact policy that may not be feasible in all jurisdictions. ated health issues (26, 102). For example, in Philadelphia, the absolute declines in the volume of Opposition from the public, elected officials, and the beverage industry or competition from poli- taxed beverage purchases among customers shopping in lower-income neighborhoods and among cies higher on decision makers' and advocates' agendas may reduce political feasibility. Legal fea- people with lower education levels were slightly larger (-6.78 ounces and -6.41 ounces, respec- sibility may be jeopardized by state preemption of local taxation (112) or industry lawsuits. In tively) compared with the overall decline (-5.76 ounces), and consumers with lower education Philadelphia, a beverage industry suit that attempted to block tax implementation, on the grounds purchased significantly more untaxed beverages (e-g., water) (12). In Mexico, SSB purchases dur- that it was an unconstitutional local tax duplicating a state tax, was unsuccessful (153). ing the second year of tax implementation fell 14.3% among people of lower socioeconomic status Warning-label policies may have high impact but face legal challenges. The First Amendment's while decreasing 5.6% among those of higher socioeconomic status (30, 31). In the United States, protection of commercial speech, and against compelled speech, has hindered adoption of warn- cities have invested tax revenues primarily in programs that serve these populations, adding to the ing labels on outdoor advertising (111). While certain high-impact front-of-package warnings proequity nature of SSB taxes. Investing revenues in lower-income communities also redistributes may suffer from similar legal feasibility issues, factually accurate warnings may be feasible at the resources from wealthy to poor people (9, 127), thus mitigating concerns about fiscal regressivity federal level (111). State- and local-level labeling policies are limited by the Nutrition Labeling (i.e., that the tax is a larger percentage of income for lower-income households). and Education Act of 1990, which preempts states from requiring nutrient content labels that are Some policies may inadvertently exacerbate inequities. For example, text-based health warn- not identical to federal requirements (109). However, safety warnings are not similarly preempted. ings or front-of-package labels written in English may exclude non-English readers. Icon- In countries that have adopted front-of-package labels, implementation challenges have included based labels may be equally accessible regardless of language and offer a more proequity policy identification of covered products, trade considerations, and the time needed by industry to update approach. packaging and reformulate products (35).Excluding SSBs from SNAP purchases is another example of a potentially high-impact policy. less opportunity for cross-border shopping. Therefore, determining the best policy options for However, this topic is hotly debated with regard to concerns about stigma, fairness, feasibility, and SSB reduction requires sophisticated consideration of a jurisdiction's specific social and political effectiveness of restricting benefits (125). The USDA requires a state wavier to implement this context; a one-size-fits-all approach will not suffice. policy as a pilot project; to date, all state waiver requests (e-g., Minnesota, New York, Maine) have Rigorous policy evaluation can support the passage of effective policies, discourage adoption been denied and, in some cases, multiple times (13). of ineffective policies, and point out policies with unintended consequences (e-g., increasing In contrast, FSGs, which are often adopted by administrative orders, tend to face fewer feasi- inequities). In some cases, the latter may be mitigated through thoughtful policy design and bility barriers, but their impact is uncertain. They can be politically more feasible because they do implementation. In other cases, trade-offs between unavoidable negative outcomes need to be not require a vote by a legislative body and are not usually opposed by industry. Special interests balanced with likely benefits. and customers of vending machines and cafeterias affected by the guidelines may oppose them, No single policy will reduce SSB consumption to healthy levels. Therefore, multiple policies but these parties have less influence than a well-funded industry campaign. However, implement at different levels (organizational, local, state, or national), along with communications campaigns tation may present challenges because enforcement can be difficult, customers may resist changes and other types of interventions, should be integrated to leverage synergies, reinforce healthy to menu and vending offerings, and vendors may not offer desired healthy products (72). norms, and maximize impact (134). Carefully crafted countermarketing campaigns, which have Requiring healthy default beverages in children's meals is another example of a feasible yet po- reduced SSB sales in the United States and Australia (52, 98), could complement any SSB policy. tentially lower-impact policy, given the relatively small proportion of children's SSB consumption Together, these interventions would send a clear and coherent message to the public and industry that occurs in restaurants. Together, quick service restaurants and full-service restaurants account and address SSB exposure in the many places people live, work, learn, and play. or 25% of SSBs consumed by children; most (60%) of the SSBs consumed by children are pur- Emerging evidence suggests adopting a suite of policies rather than relying on any single pol- chased from stores (42). Moreover, fruit drinks are the primary type of SSBs consumed by young icy. Chile's Food Labeling and Marketing Law provides an excellent example of policy integration children (5), and these are not usually included in kids' meals (soda is the typical SSB included (35). The law is the first national policy to jointly mandate front-of-package warning labels, restrict with a kids' meal). child-directed marketing, and ban sales in schools of foods and beverages high in added sugars, Industry efforts to shape public policy can reduce the feasibility of adoption. Evidence is emerg- sodium, or saturated fats. Implementation of these policies was accompanied by guidance to indus- ing of the sugar and beverage industries' attempts to influence policies they consider harmful try, schools, and early-childhood centers, as well as mass media campaigns on using the warning to their interests through mischaracterizing scientific evidence, launching public relations cam- labels (35). In the United States, the Howard County Unsweetened campaign, which combined paigns, operating through front organizations, lobbying, shifting the blame away from their prod- a public awareness campaign with organizational and public policy changes, was associated with acts, and highlighting corporate positive actions (33, 54, 75). significant decreases in sales of soda and fruit drinks (126). Annu. Rev. Public Health 2021 42:439-461. Downloaded from www.annualreviews.org Feasibility can be increased. As the number of SSB reduction policy efforts has grown, lessons Access provided by 2600:8803:7481:10:896:46f4:cb83:1d49 on 03/18/23. See copyright for approved use. We note variation in the level of government adopting SSB policies. The United States is dis- about factors associated with success have emerged. Successful campaigns have increased public tinct from most other countries in that it currently has only local and state SSB policies. It is not awareness of the health and equity issues associated with SSBs, built strong multisector coalitions, uncommon for innovative food policies to be incubated at the state or local level first before being included leaders from communities of color and economically marginalized communities in lead- implemented nationally. Political feasibility is often greater at the local or state level, where agree- ership roles, fielded effective grassroots organizing efforts, launched effective communications ment on policy adoption may be more attainable and political will is greater. While implementing strategies to control the framing of the policy debate early on, articulated clearly the purpose of national SSB policies may be possible in the United States, checks and balances (c.g., bicameral the policy and who will benefit, secured the support of elected officials, and arranged adequate legislature, presidential veto power) and powerful interest groups present significant obstacles. funding. They have allowed sufficient time to develop the groundwork for the campaign, begin- Ideally, policies to reduce SSB consumption should be dynamic, adapting to changing market ning many months or years prior to launching it (28). Resources that describe considerations for and consumption trends as well as emerging science. For example, industry is increasingly adding fielding successful SSB reduction policy campaigns are available (69, 71, 149). NNS to packaged beverages (113). The impact of such potential reformulation on health is cur- Another approach that can increase legal feasibility is opposing or repealing state preemption rently unknown (see the sidebar titled Nonnutritive Sweeteners and Health; 43, 89). If negative of local policies because policy innovation is often easier at the local level. Engaging stakeholders health consequences were to occur, they might blunt the positive effects of taxes or warning la- affected by policy implementation in the policy design and administration can reduce barriers to bels, and policies that discourage reformulation might be needed. Evidence continues to emerge implementation (49)- about the health effects of beverages other than SSBs. Some studies have raised concerns about an association between 100% fruit juice and type 2 diabetes, although findings are currently mixed DISCUSSION and inconclusive (4, 34, 63). Should evidence of harm from 100% juice become more compelling, Many proven and promising policy options for reducing SSB consumption are available to policy allowing juice to count as a fruit serving in US food assistance programs or excluding it from SSB makers and advocates. The decision regarding which approach or combination of approaches taxes may merit reconsideration. to use should consider equity, impact, and feasibility. Will the policy advance equity? Is there Policies must also respond to broader public health trends. The coronavirus disease 2019 sufficient evidence for impact? Is the policy politically feasible, legal, and practical to implement? Is (COVID-19) pandemic has changed the context for SSB policies. Local and state governments it best to implement the policy at the local, state, or national level? The answers to these questions facing serious budget shortfalls are seeking revenues. This need for revenue may create an oppor will differ across policies and contexts. Beverage taxes may be feasible in one jurisdiction but not tunity for accelerating adoption of SSB taxes, perhaps even a national beverage tax, but it could another, may advance equity more in a jurisdiction with a larger lower-income population, and also lead these governments to deposit revenues into general funds rather than dedicating their use to addressing SSB-related health issues and health inequities. If school closures persist, food from may produce greater declines in beverage sales in places with higher baseline consumption andbut coordinated efforts by policy makers, advocates, communities, and independent evaluators to NONNUTRITIVE SWEETENERS AND HEALTH advance policy action, design, and science will allow SSB policies to realize their full potential for The number and types of nonnutritive sweeteners (NNS) used in packaged beverages and foods are increasing, improving health and health equity. in part as a response to sugar reduction initiatives. NNS are also referred to as low-calorie or nonsugar sweeten- ers. They provide sweetness to products while adding few if any calories. Examples include aspartame, saccharin, rebaudioside-A (found predominantly in Stevia), and sucralose. Current evidence regarding the associations of long- SUMMARY POINTS term exposure to NNS with health outcomes such as obesity, diabetes, and cardiovascular disease is inconclusive 1. The rates of sales and consumption of sugar-sweetened beverages (SSBs), which are as- (43, 89). Whether the mixed findings are due to problems with reverse causality, inadequate assessment of exposure, sociated with poor health outcomes, have declined since 2000. However, they remain or failure to distinguish potential varying effects across types of NNS is unclear. For example, the health effects of unacceptable high and may have leveled off more recently. each type of NNS could differ because each has its own unique chemical structure and therefore sensory properties (e-g., sweetener intensities, mouth feel) and physiological effects. More studies assessing the health effects of each 2. Evidence for the effectiveness of four categories of policies to reduce exposure to and consumption of SSBs is growing: financial, information, defaults, and availability. Within type of NNS and their interactions with each other, as well as with the rest of our diets, are needed. Exposure to these categories, some evidence is strong (c.g., beverage excise taxes) and some evidence NNS varies across demographic groups, and further research is needed to quantify this variation and its impacts on population health. is emerging (e-g., healthy beverage defaults). 3. As policy makers choose among approaches for reducing SSB consumption, policy eq- uity, impact, and feasibility should be critical considerations. 4. Because policies to reduce SSB consumption often face strong opposition, ground- schools will comprise a smaller portion of children's diet, suggesting the need for more emphasis softening activities (e.g., grassroots organizing and SSB public awareness campaigns) on policies in other settings. Thus, school closures may increase obesity risk. A recent study sug- can help to increase political feasibility. gests that, for children living in poverty, obesity risk would have been 47% higher in 2018 had not the HHFKA been implemented (77), which established policies to improve the nutritional quality 5. No single policy will reduce SSB consumption to healthy levels. Current and future of foods and beverages served to US children (c.g., more whole grains, fruits, and vegetables). policies should be dynamic, adapting to changing market and consumption trends as Evaluation of proven (c.g., beverage taxes, front-of-package warning labels) and promising well as to emerging science. (e.g., healthy beverage defaults in kids' meals, healthy retail, FSGs, and outdoor advertising warn- 6. Scaling SSB policies with demonstrated effectiveness, testing innovative approaches, and ing labels) SSB reduction policies, individually and in combination, is essential. Policy design varies Access provided by 2600:8803:7481:160:896b:46f4x:683:1d49 on 03/18/23. See copyright for approved use. Annu. Rev. Public Health 2021.42:439-461. Downloaded from www.annualreviews.org implementing multiple policies concurrently will help to maximize impact. substantially across jurisdictions, which supports the value of context-specific evaluation data in- formed by community perspectives to deepen understanding of equity, feasibility, and impact. Future evaluation (see also the Future Issues box below) should address known issues in evalu- ating SSB policies (c-g., collecting baseline data in the limited time between policy adoption and FUTURE ISSUES implementation, securing a valid comparison site, fully accounting for temporal trends and con- 1. More information is needed to inform an evidence-based approach for the adoption founding factors, and reducing bias from self-reported beverage consumption). Although an end goal for SSB reduction policies is the prevention of adverse health outcomes, it may be difficult of SSB reduction policies, including evidence on impact (e-g., differential effects by race/ethnicity or income, comparative cost-effectiveness of policy alternatives, the com- to demonstrate this effect, given the long lag between change in exposure to SSBs and disease incidence as well as the influence of many other discase risk factors in addition to SSBs. Evalua bined impact of multiple SSB reduction policies), unintended consequences (e.g., pos- sible substitution by NNS or other sweetened products), shifting norms (e.g., changes tions should therefore focus on intermediate outcomes such as changes in consumer and industry behavior, particularly for short-term studies. in population norms about SSB consumption), industry opposition (e-g., tactics to de- SSB policy adoption faces considerable opposition, and advocates typically have fewer financial, feat taxes, influence on the policy-making process), other benefits beyond reducing SSB lobbying, and other resources that they can bring to bear. However, partnerships among advocates, consumption (c-g., improved education outcomes attributable to revenue investments), communities, and policy makers can help to counterbalance the financial weight of industry op- and health effects of beverages not currently considered SSBs (c.g., association of 100% fruit juice intake with potential adverse health outcomes). position during policy adoption campaigns (21, 120). Evaluators can contribute to policy adoption by disseminating findings about policy impacts and lessons learned regarding policy design. They 2. Future research should be informed by community perspectives to deepen understand- can also codesign evaluations with policy makers and advocates. Advocates and policy makers, in ing of policy equity, feasibility, and impact. turn, can keep evaluators informed about emerging opportunities for evaluation as policies are 3. For SSB reduction policies that raise revenue (i.e., SSB taxes), it will be important to doc- considered for adoption. ument any additional economic (e-g., job creation from revenue investments) or health In conclusion, existing SSB policies are a proven policy approach for reducing the sales (and, in impacts. This is especially important in light of COVID-19, as resource gaps may raise some subpopulations, consumption) of SSBs, and many promising policies are emerging. Contin- policy makers' interest in SSB taxes. ued progress in this area will require scaling and integrating effective policies and testing innova- tive ones with the goal of maximizing equity, impact, and feasibility. Opposition may slow progress