Could a sugar tax help combat obesity?BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4047 (Published 29 July 2015) Cite this as: BMJ 2015;351:h4047
All rapid responses
Legal Departments of Companies which manufacture and distribute drinks containing sugar will easily oppose any discriminatory tax in Court.
They have valid arguments in their favor: wheat, bread, pasta, dairy products release the same amount of glucose in the bloodstream, contain more calories, and yet they are all excluded from taxation.
Even some brands of wine and whiskey contain more sugar, but are also excluded.
Alcohol is much more calorigenic and cytotoxic, yet wine and beer producers still receive financial incentives.
Competing interests: No competing interests
It was obvious to most readers that I actually support food taxes -- in principle . Specialists have finally realised that price instruments can be useful tools in pursuit of nutritional goals. Excellent.
And the authors come from the Oxford group that is the UK's leading research centre on nutrition and price. They are more knowledgeable than most who hop on the bandwagon of proposing food/calorie/fat/salt/sugar/soft drinks taxes. But they are as selective as any in straining to find support for the cause, ignoring all negative experience from the real world.
More importantly, they have low standards for what they will accept as "evidence" -- consumer surveys, modelling studies and even press releases.
For example, they cite an IPSOS-Mori survey that Britons support a soft drinks tax. This mistakes what people say for what they do. The authors seem to have forgotten the three fuel duty protests and the pasty tax revolt (2012). Politicians have not. That is why in the recent General Election they promised there would be no new food taxes. That is why they slapped down the BMA proposal instantly.
The Oxford group have form in such good-hearted credulousness. In their most important modelling study , they used data from the National Diet and Nutrition Survey (NDNS) to estimate soft drink consumption. This is based on food diaries, that is, on people telling researchers honestly what they eat. But they do not. We know from other government research, based on bio-chemical measures ("doubly-labelled water"), that people "under-report" their true intakes. In plain English, they lie. And they tell whoppers.
In the obligatory short confession of the "limitations" of their research, that journals now insist on at the end of articles, the Oxford group admit that "our estimates of sugar-sweetened drinks consumption seem to underestimate consumption in comparison with sales data". Indeed they do. Subjects in the NDNS report drinking barely a quarter of the soft drinks that the industry is selling. On food, as on much else in life, what people say and what they do is often different.
Now the hopes of advocates are pinned on Mexico and its new food taxes. Here again, the Oxford group show their generous spirit. They accept as a "high quality evaluation", the preliminary results of a study announced at a press conference by a campaigning group (Alianza por la Salud Alimentaria), which claimed to show the "success" of the taxes. When explicitly asked for the data on which the claim was based, the researchers declined, saying their evidence had been submitted to a journal and therefore could not be revealed.
The usual procedure in science is to publish the evidence so colleagues can assess whether it is credible and accurate. The usual procedure in science is to publish first and hold the press conference afterwards. This Mexican "success" story did it the other way around -- and the Oxford group accepted it as "high quality".
In fact, the three other studies on the effects of the Mexican taxes all proceeded in the same way. They also announced the results of their research in press releases, claiming "failure", without disclosing the data on which they were based.
The sad fact is that none of the four studies on Mexican taxes are credible. It is premature to reach any conclusions. Meanwhile, we need to remember the traditional, higher standards about what counts as "evidence".
The Oxford group are on firmer ground when they state that "Health advocates appear to have good reason to suggest that soft drinks companies are resisting the introduction of an SSB tax". They certainly do -- the evidence was plastered on billboards all over California. What unworldly expectations to they have of companies -- support, approval, passivity?
Do they think that any interest group -- industry, company, trade union, professional association, NGO, charity or regional authority -- would not resist a tax imposed on them from the outside? Do they think that American voters were clamouring to be taxed more, only to have their will over-ridden by industry lobbying? If the Oxford group believe either of those propositions, then they live in a more hermetically-sealed ivory tower than anyone suspected.
On what is happening in Europe, I must make a confession myself. On re-reading the WHO Europe report, I found that it states explicitly that three countries introduced food primarily for revenue raising reasons, not four as I suggested. The fourth had mixed motives, revenue and health. Apologies. The important point, however, is that the other 49 countries in the European Region did not introduce any food taxes for any reason. Taxes on food are definitely a minority taste.
What the complainants failed to mention is as important as what they challenged. None of the many US referenda that rejected soft drinks taxes. None of the other six price instruments I described in the article. Like most, they are obsessively focussed on punitive taxes.
Most importantly, they did not consider agricultural policy. (Yes, I know, the CAP is hideously, dauntingly complex, but serious scholars should be able to stomach that). A 20% soft drinks tax will not compensate for a 75% reduction in the price of sugar.
Finally, after the list of sins I am alleged to have committed, it was gratifying to see that they did not challenge one of the central pieces of evidence on ineffectiveness of taxes -- that a 20% soft drinks tax would only reduce average consumption by 4kcal per person per day. It came from their own research.
 That was not just presentational packaging for the BMJ debate. For an explicit endorsement of soft drinks taxes -- when properly presented as part of a package of price instruments -- see Sweanor D, Welch V, Hogg S, Winkler J, Soft Drinks: Making the Healthy Choice the Cheaper Choice, The Grocer, 20 Dec 2013.
 Briggs A, Mytton O, Kehlbach A, Tiffin R, Rayner M, Scarborough P. Overall and income specific effect on prevalence of overweight and obesity of a 20% sugar-sweetened drink tax in UK. BMJ 2013;347:f6189.
Competing interests: No competing interests
We welcome this BMJ debate. We note the focus of the debate was on a “sugar tax”, however medical bodies are specifically calling for a tax on sugar sweetened beverages (SSBs).[2–7] In his piece, Jack Winkler makes a number of assertions about why a sugar tax might not work. We wanted to respond to some of these, considering an SSB tax.
1) Winkler contends that a sugar tax would be “politically unacceptable”. In the UK, more adults support a 20% tax on SSBs than oppose it (41% support vs 35% oppose). Experience from France, Ireland, Australia and Berkeley in the USA suggests the public can support SSB taxes.[9–12]
2) “[Excise] taxes are regressive”. Recent findings from Mexico (SSB tax introduced in January 2014) observed larger declines in the purchases of SSBs amongst those on a lower income, which suggests that the ‘health gains’ may be progressive. At the levels proposed, the burden of a taxation would be slight, an extra 9p per person per week based on 2010 data. We also note that taxes on cigarettes and alcohol are also regressive, but are widely supported and used.
3) “Health advocates attribute defeats to campaigns by big food companies protecting their interests.” Health advocates appear to have good reason to suggest that soft drinks companies are resisting the introduction of an SSB tax. In the USA, the soda industry spent over $10 million trying to defeat legislation to introduce SSB taxes in California alone (compared to less than $0.5 million by supporters).[11,15]
4) ”Only four…states in Europe have adopted food taxes, all with the stated aim of raising revenue, not improving health.” This statement is not accurate. According to the document cited, the four European countries were Denmark (which had the dual aim of raising revenue and reducing consumption of saturated fat), Finland (primary purpose to raise revenue), Hungary (promote healthier eating, encourage product reformulation and raise revenue) and France (primarily to raise revenue, but with recognition that tax aligned with aim of reducing obesity).
5) “Denmark…imposed fat taxes and then repealed them…after near universal opposition”. Some accounts suggest that the repeal of the tax was driven, not by ‘near universal opposition’, but by a well organised industry campaign and the threat of legal action. Active support from the health community only came late. Winkler also reports that there has been “widespread evasion”. However others have questioned whether appreciable numbers of people really did travel across the border explicitly to avoid produce taxed in Denmark, and official data do not support claims from the food industry of a 10% increases in cross-border trade. Nonetheless Denmark may serve as an example of how not to implement such a tax.
6) “Food taxes are economically ineffective”. We disagree. Obesity is common, so small relative changes across the population can have large public health impacts. A 20% tax has been estimated to reduce the number of obese adults by 1.3% (180,000 people). Furthermore, a 20% sugary drinks tax in the UK could raise between £250million and £1billion (the difference largely explained by different estimates of sugary drinks purchases in the UK).[6,14] We would not describe either of these outcomes as “ineffective”.
7) “Evaluation of the Mexico SSB tax are incomplete and by interested parties, have produced different results (one claiming large reductions, three showing small falls)”. Of the three reports that Winkler cites that report small falls, one is a brief analysis of various taxation changes in Mexico, which does not quantify the effect of the tax on purchases, and the other two report aggregate data for soft drinks and carbonated drinks respectively,[22,23] failing to separate out sugar sweetened drinks from diet drinks. None of these reports have been peer reviewed. As Winkler states some of these reports are by interested parties, for example the New Zealand Tax Payers Union (campaigning against an SSB tax in New Zealand) and from a spokesman for soft drinks manufacturers.
We are only aware of one high-quality evaluation. Preliminary data from the first 12 months found that the 1 peso per litre (approximately 10%) tax on SSBs resulted in a 6% reduction in purchases, 9% among low income groups. It also showed a shift away from SSBs to water and diet drinks. The shift towards other drinks not only provides evidence that the decreased consumption is associated with the tax’s introduction, but it also highlights the problem of assessing the effectiveness of a tax simply by measuring changes in all soft or carbonated drinks. This work is currently undergoing peer review, was undertaken by the National Institute for Public Health in Mexico and North Carolina University, and is being funded by the Bloomberg Philanthropies and the Robert Wood Johnson Foundation.
8) “Companies absorb part of all cost increases”. Thus far, empirical data from France, Denmark and the US seems to suggest that the tax would be passed on fully or near fully.[18,24,25] Indeed in some circumstances the pass on-rate may exceed 100%. Of course in the scenario of the tax not being passed on – the tax will still raise revenue (which may be used to fund health initiatives) and may still encourage industry to reformulate.
We should remember that no one solution is going to solve the obesity epidemic. Nonetheless, emerging evidence from Mexico and France suggests that such a tax is likely to reduce consumption of SSBs. Reducing consumption of SSBs is important, not only because SSBs are linked to obesity, but also because they are linked to diabetes, cardiovascular disease and dental caries.[14,28]
SSBs are predominantly consumed by children and young adults. If the government is serious about improving children’s health, it should consider introducing and rigorously evaluating an SSB tax.
Add conflicts of interest
Action on Sugar, the UK Health Forum, Sustain, and the Faculty of Public Health have all advocated for a tax on sugar sweetened drinks. OM is a member of the Faculty of Public Health and UK Health Forum. AB is a member of the Faculty of Public Health. MR is chair of Sustain and a trustee of the UK Health Forum. SC is an adviser to Action on Sugar, vice-chair of the Faculty of Public Health and a trustee of the UK Health Forum.
1 Sarlio-Lähteenkorva S, Winkler JT. Could a sugar tax help combat obesity? BMJ 2015;351:h4047.http://www.ncbi.nlm.nih.gov/pubmed/26223432 (accessed 7 Aug2015).
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3 Faculty of Public Health. A duty on sugar sweetened beverages. London: 2013. http://www.fph.org.uk/uploads/Position statement - SSBs.pdf (accessed 20 Mar2014).
4 Academy of Medical Royal Colleges. Measuring up: the medical professions’s prescription for the nation's obesity crisis. London: 2013.
5 Landon J, Graff H. What is the role of health-related food duties? London: 2012. http://nhfshare.heartforum.org.uk/RMAssets/NHFreports/Health-related food duties meeting report FINAL.pdf
6 Sustain. A Children ’ s Future Fund. London: 2012.
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9 Moretto N, Kendall E, Whitty J, et al. Yes, the government should tax soft drinks: findings from a citizens’ jury in australia. Int J Environ Res Public Health 2014;11:2456–71. doi:10.3390/ijerph110302456
10 Julia C, Méjean C, Vicari F, et al. Public perception and characteristics related to acceptance of the sugar-sweetened beverage taxation launched in France in 2012. Public Health Nutr 2015;:1–10. doi:10.1017/S1368980014003231
11 Gumbel A. How Berkeley took on the might of Big Soda and won. Guardian.com. 2014.http://www.theguardian.com/us-news/2014/nov/15/berkeley-victory-soft-dri...
12 Hosford P. Irish public supports a sugar tax on soft drinks. Thejournal.ie. 2014.http://www.thejournal.ie/irish-public-supports-sugar-tax-on-sugary-drink...
13 Colchero M, Rivera J, Popkin B, et al. Reduction in consumption of taxed beverages after implementation of the tax in Mexico. 2015.http://www.insp.mx/epppo/blog/3666-reduccion-consumo-bebidas.html (accessed 10 Aug2015).
14 Briggs ADM, Mytton OT, Tiffin R, et al. Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK: econometric and comparative risk assessment modelling study. BMJ 2013;347:1–17. doi:10.1136/bmj.f6189
15 Carroll R. California takes fight to soft drinks industry with plan for warning labels. Guardian.com. 2015.http://www.theguardian.com/us-news/2015/feb/19/california-soft-drinks-wa...
16 World Health Organisation Regional Office for Europe. Using price policies to promote healthier diets. Copenhagen: 2015.
17 Vallgårda S, Holm L, Jensen JD. The Danish tax on saturated fat: why it did not survive. Eur J Clin Nutr 2014;:1–4. doi:10.1038/ejcn.2014.224
18 Jensen JD, Smed S. The Danish tax on saturated fat – Short run effects on consumption, substitution patterns and consumer prices of fats. Food Policy 2013;42:18–31. doi:10.1016/j.foodpol.2013.06.004
19 Bødker M, Pisinger C, Toft U, et al. The rise and fall of the world’s first fat tax. Health Policy 2015;119:737–42. doi:10.1016/j.healthpol.2015.03.003
20 Rose G. Sick individuals and sick populations. Int J Epidemiol 1985;14:32–8.http://www.ncbi.nlm.nih.gov/pubmed/3872850
21 Ghirardelly F. Efecto de los impuestos a alimentos y bebidas saborizadas. Kantar Worldpanel. 2015.http://www.kantarworldpanel.com/mx/Noticias-/Efecto-de-los-impuestos-a-a... (accessed 10 Aug2015).
22 Riddiford J. Fizzed out: why a sugar tax won’t curb obesity? Wellington: 2015. http://www.taxpayers.org.nz/fizzed_out
23 Refresqueras eliminan 1,700 empleos por impuestos. CNNExpansion. 2015.http://www.cnnexpansion.com/negocios/2015/07/07/refresqueras-eliminan-17...
24 Berardi N, Sevestere P, Tepaut M, et al. The impact of a ‘soda tax’ on prices: evidence from French micro data. Paris: 2012.
25 Briggs AD, Mytton OT, Madden D, et al. The potential impact on obesity of a 10% tax on sugar-sweetened beverages in Ireland, an effect assessment modelling study. BMC Public Health 2013;13:860. doi:10.1186/1471-2458-13-860
26 Rutter H. The single most important intervention to tackle obesity…. Int J Public Health 2012;57:657–8. doi:10.1007/s00038-012-0385-6
27 Wareham N, Jebb S. What is the evidence base for various fiscal measures? Cambridge: 2015. http://www.cedar.iph.cam.ac.uk/wp-content/uploads/2014/04/HoC-Health-fol...
28 Imamura F, O’Connor L, Ye Z, et al. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ 2015;351:h3576.http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4510779&tool=p... (accessed 23 Jul2015).
Competing interests: Action on Sugar, the UK Health Forum, Sustain, and the Faculty of Public Health have all advocated for a tax on sugar sweetened drinks. OM is a member of the Faculty of Public Health and UK Health Forum. AB is a member of the Faculty of Public Health. MR is chair of Sustain and a trustee of the UK Health Forum. SC is an adviser to Action on Sugar, vice-chair of the Faculty of Public Health and a trustee of the UK Health Forum.
After two decades of fighting obesity, policymakers are still guessing about what will work. The polarized debate about taxing sugar provides a vivid example. The debate continues because definitive evidence about the real world effects of such a tax is inadequate.
But for people with obesity, such debates are, at best, a distraction from urgent needs for evidence-based options to reduce the considerable impact of obesity on health and quality of life. These debates serve as a reminder of how the lives of people with obesity are often given little consideration.
Taxes to increase the cost of foods and beverages that are deemed to be problematic might arguably steer families unaffected by obesity away from such foods. However, there is little evidence to support a claim that taxes would have a therapeutic effect for families already living with obesity.¹ Obesity disproportionately affects people with limited financial resources. So the potentially regressive effect of taxing disfavored foods and beverages is an important concern.²
Enormous energy goes into the formulation of obesity prevention strategies that effectively discount the lives of people with obesity. Sugar taxes are a case in point. Relatively little effort goes toward strategies to actually improve the health and quality of life of people with obesity. They find themselves routinely encountering healthcare providers who dismiss their condition as a self-inflicted injury that should be cured through self-discipline.3,4 Meanwhile, access to more aggressive, evidence-based treatment is often severely limited.5
So, from the perspective of people with obesity, the debate about taxing sugar is somewhat moot. Evidence to settle the question is lacking and no one is suggesting that these taxes will benefit people who are already living with the disease. More heat than light emanates from this debate. The energy consumed by the debate should go into collecting evidence to answer the question. It should not be tolerated as a distraction from improving health and quality of life for people who are living with obesity.
Obesity is a disease that is at least partly transmitted through families and social networks. Preventing obesity in the next generation will not happen without addressing it in the current generation. Thus, taxing sugar -- even if good evidence for a prevention effect emerges -- will be no more than a small part of what is needed to reverse the impact of obesity.
Theodore K. Kyle, RPh, MBA
Obesity Action Coalition Chairman
1. Finkelstein, Eric A., et al. "Food prices and obesity: a review." Advances in Nutrition: An International Review Journal 5.6 (2014): 818-821.
2. Sharma, Anurag, et al. "The Effects of Taxing Sugar‐Sweetened Beverages Across Different Income Groups." Health economics 23.9 (2014): 1159-1184.
3. Doroghazi, Robert M. "A Candid Discussion of Obesity." The American journal of medicine 3.128 (2015): 213-214.
4. Kirk, Sara FL, et al. "Blame, shame, and lack of support a multilevel study on obesity management." Qualitative health research (2014): 1049732314529667.
5. Weiner, Janet and Colameco, Christopher. "Essential health benefits: 50-state variations on a theme." Leonard Davis Institute of Health Economics, October 2014.
Competing interests: No competing interests
Prof. Winkler states that "for decades those concerned about diet and health problems never mentioned the price of food". This may be so but when Derek Heathcote-Amory was Chancellor of the Exchequer (1958--1960) he addressed the Exeter Medico Chirurgical Society and a member of the Society suggested a tax on sugar in the interests of health. Viscount Amory`s reply was that it was the first time that any member of the public had suggested a new tax to him.
More than half a century later it appears an unpromising way of achieving rapid change in taxation policy.
Competing interests: No competing interests
A response to a Daniel come to (mis-) judgement.
I am unable to agree with Dr Daniel that sugar is not a food. Unless I have forgotten biochemistry (sixty-five years is a long time), sugar is a disaccharide which is split into monos. The monos are burnt to produce energy plus CO2 and H2O.
I guess Dr Daniel wants to keep all Kendal cakes for himself. Just not fair. Selfish if you ask me.
But, seriously, why not chew sugar cane as you jog along the Cumbrian hills and dales? Water, sugar and minerals, all in one.
Come home. Chew the cud of contentment. Then back to the surgery.
Competing interests: I like an occasional Kendal Cake
NO. I agree with other responders in that the real debate is about lifestyle change.
The body is very good at handling all types of fuel as it is all essentially interchangeable as far as the body is concerned, as of course the ultimate energy source is ATP. People who are fasting can quite easily maintain a glucose level by producing it from fat in the liver or gut. After all there is only 5 grams of glucose circulating in the whole blood stream at any one time. We can quite happily produce enough glucose for essential functions and burn ketones and recycle lactic acid for further energy. The problem for the body starts with oversupply of nutrients. 30g (a drinks can) of sucrose (glucose and fructose) leads to 15 g of glucose loading up the bloodstream. As it is unlikely to be utilised as glucose, it is converted to glycogen and then fat. The 15 g of fructose in sugar goes straight to fat in most cases. And that fat (and OMG it is saturated!!) is packaged up and sent round the body for storage in the form of LDL complete with cholesterol.
So don't just blame dietary fat. Blame excess carbs as well. A wholesale lifestyle change is needed. And whilst targeting soft drinks might be a feelgood bit of macho posturing, it is clear we need to target all sources of sugar excess. Pizza bases, burger buns, popcorn, the whole lot. Basically ban Saturday nights out. We just need a government with the guts to legislate. Fat chance.
Competing interests: No competing interests
Food should be zero VAT. Sugar is not food, neither is the production cost of a ready meal or a cake. If a product costs £1 but the food ingredients only 20p, then 80p should be taxed. This would have a greater effect than taxing sugar alone and deal with the dangerous triad of pleasant sweet taste / high energy / low preparation effort. In this way, zero added sugar soft drinks would pay the price for their role in making mediocre burgers and fries taste nice.
Competing interests: I enjoy sweet, high-energy foods and eat too much of them.
Could a sugar tax help combat obesity? (1) Why would you worry about poor diets and excess sugar in soft drinks and in food?
The BoehrInger Ingelheim/Lilly advert (prominently displayed on the BMJ website) states:
MEET JANE A BUSY MUM WITH TYPE 2 DIABETES
Jane tries to make healthy choices but life gets in the way......
JARDIANCE IS AN SGLT2 INHIBITOR DESIGNED WITH TYPE 2 DIABETES PATIENTS IN MIND.....
Presumably if you are too busy to organise a healthy diet (combined with regular exercise) this new drug will forgive all transgressions, wellness will be regained from the effects of type 2 diabetes (T2DM)? So why make healthy choices? As the marketing advert states ‘Jane a busy mum with type 2 diabetes’ - being a mum should present an excellent opportunity to prevent another generation of T2DM diagnoses. Healthy eating must be a priority, is she too busy to feed the kids?
We know type 2 diabetes cannot be managed by diet and lifestyle measures, because the drug industry has spent the last few decades telling us so! Are they starting to believe their own marketing?
Jardiance (Empagliflozin) (2) is the latest in a long line of barely tested drugs for T2DM with the added potential of anti-obesity properties.
(1) Sarlio-Lähteenkorva Sirpa, Winkler J T. Could a sugar tax help combat obesity? 2015; 351 :h4047
(2) National Institute for Health and Care Excellence. Empagliflozin in combination therapy for treating type 2 diabetes. NICE technology appraisal guidance 336. March 2015. Available at: www.nice.org.uk/guidance/TA336 (last accessed Juneil 2015).
Competing interests: No competing interests
Now, this may be my blind spot - I do drink tea, coffee, hot chocolate WITH sugar, have always done so and will do so. I do not want to be taxed.
Just let me enjoy my sugared tea.
Now a question: Have the Indian villagers producing sugar cane, Pakistani villagers producing sugar cane, Jamaican villagers producing sugar cane ALWAYS had obesity in children, as compared with their counterparts in the villages not producing sugar cane?
In these wonderful times with instant armchair epidemiology with the lap top, a professor in public health in every medical school, a medical school in every city, this question should be easy to answer.
And now a question to the leaders in preventive medicine, plus the World Bank plus, the WHO, plus our (British Government): why do you not demand the destruction of all breweries, whiskey distillers, whisky distillers and their copy cats in, India, China, etc? After all everyone is agreed that alcohol kills?
And why do you not destroy ALL tobacco crops everywhere? (After all, our Jack Straw justified the Afghan War on the grounds of opium production.)
Competing interests: Not obese.