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Journal of the HEIA Vol. 26, No. 1, 2020 A critical review exploring taxation on sugar-sweetened beverages as a strategy to address in Canada

Alyssa Ramuscak This is the joint winning paper in the graduate category of the Dr Elisabeth Feniak Award for Excellence in Technical Writing 2019 presented by the Canadian Home Economics Foundation.

Abstract such as cardiovascular disease, and Canada’s growing obesity epidemic has the certain , and places individuals at a potential to threaten the sustainability of our greater risk of premature death (Niebylski et al., economy and healthcare system (Niebylski et al., 2015; PHAC & CIHI, 2011). In 2008, obesity 2015). Currently, one in four Canadian adults are cost the Canadian economy $4.6 billion and this obese, placing them at a higher risk of chronic cost is projected to continue to grow (PHAC & diseases and premature death (Navaneelan & CIHI, 2011). If no proactive measures are taken Janz, 2014). To address this growing issue, to address the obesity epidemic, obesity has the the World Health Organization (WHO) potential to threaten global economies and the recommends using national-level strategies to sustainability of healthcare systems (Niebylski et combat obesity. Specifically, WHO has outlined al., 2015). that these strategies should include economic tools such as to promote the consumption Taxation of unhealthy foods—for example, of healthier foods and beverages (Veerman et sugar-sweetened beverages (SSBs)—has been al., 2016). Currently, 40 countries and several recommended by several health organisations as jurisdictions in the United States (US) have a viable national-level strategy to address obesity (Veerman et al., 2016). Price greatly influences implemented taxes on sugar-sweetened beverages consumers’ food choices and, in turn, their (SSBs) (Falbe, 2019). Despite the growing interest overall diet. Implementing an SSBs aims in an SSBs tax to address obesity, there is no to change consumers’ purchasing habits and to Canadian policy related to such a tax. This encourage healthier choices (Mytton et al., 2012). critical review will further examine the benefits Currently, 40 countries and several jurisdictions and drawbacks of taxing SSBs and will draw on of the US have proposed and implemented the evidence to propose policy recommendations SSBs tax policies. These policies have met with that may help to overcome Canada’s obesity success in areas like Berkeley, California, and problem. (Falbe, 2019) (see Table 1 on pages 22–23 for examples of SSBs tax policies). Despite Keywords: obesity, sugar-sweetened beverages, growing interest and recommendations by health taxation, tax organisations, Canada has no federal SSBs . Due to the lack of federal leadership, several Introduction regions have considered using economic tools to Obesity is a growing public health problem combat obesity. Most recently, the Government that affects over 300 million people worldwide of the Northwest Territories announced their (Buhler et al., 2013; Cabrera Escobar et al., 2013; commitment to exploring an SSBs tax policy in Contact details: Public Health Agency of Canada, & Canadian their 2017/18 budget (Government of Northwest Alyssa Ramuscak Institute for Health Information [PHAC & Territories, 2019). T: (647) 381-0611 CIHI], 2011). Within Canada, it is estimated E: [email protected] that one in four adults or about 6.3 million In this critical review, the link between SSBs and individuals (as of 2011–2012) are obese, a statistic poor health outcomes will be addressed as well that has nearly tripled over the past three decades as the current consumption patterns of sugary (Navaneelan & Janz, 2014). Obesity is also a drinks in Canada, and the benefits and potential major risk factor for non-communicable diseases challenges of taxing SSBs. From the review of

18 A critical review exploring taxation on sugar-sweetened beverages as a strategy to address obesity in Canada

the literature, several policy recommendations Consumption of sugar-sweetened within a Canadian context will be proposed. For beverages in Canada the purpose of this paper, SSBs will be defined Global consumption of SSBs has increased as any ‘soda sweetened with sugar, corn syrup or over recent decades (Brownell et al., 2009). other caloric sweeteners and other [sweetened] In Canada, the ready availability of SSBs has carbonated and uncarbonated drinks such as resulted in increased consumption by all age sports drinks and energy drinks’ (Buhler et al., groups, with an estimated 13.1 billion litres 2013). being sold in 2010 (Buhler et al., 2013). In a calculation performed by Buhler and colleagues Literature review (2013) using industry data, it was found that Sugar-sweetened beverages and Canadians are purchasing an equivalent of more connection to health outcomes than one litre a day, per person, per year. The association between regular consumption of SSBs have also become one of the major sources SSBs and weight gain has been well documented of sugar in the Canadian diet. In fact, as (Backholer et al., 2016; Basu et al., 2014; purported by Langlois et al. (2019), if sugary Brownell et al., 2009, Cabrera Escobar et al., beverages—regular soft drinks, milk (containing 2013; Langlois et al., 2019). In fact, it has free sugars), , fruit drinks, energy drinks, been estimated that worldwide over 180 000 plant-based beverages (containing free sugars), deaths per year can be directly associated with and tea and coffee (containing free sugars)— the consumption of SSBs (Backholer et al., were combined together into one category, they 2016). SSBs have also been indirectly linked would be the top source of sugars for all age to obesity-related problems, such as high blood groups of the Canadian population. pressure, elevated cholesterol and triglyceride levels, coronary heart disease, diabetes, Price disparities among healthier beverage joint problems, and several cancers, such as options may also explain these high consumption oesophageal, pancreatic, colorectal, breast, patterns. In a price analysis that compared milk endometrial, prostate and kidney (Basu to soft drinks over 17 years, it was found that et al., 2014; Brownell et al., 2009; Buhler et The World Health the average price of one litre of 2% (reduced-fat) al., 2013). Even more concerning is the strong milk had increased by 75%, whereas the price of Organization association between the consumption of SSBs 2 litres of had only increased by 26% and non-alcoholic fatty-liver disease. In fact, (Buhler et al., 2013). recommends that high consumption of SSBs is considered to be countries take one of the predictors of the disease (Buhler et Given the increased consumption of SSBs and its al., 2013). connection to poorer health outcomes, imposing national-level an SSBs tax policy may be a plausible action to SSBs lack nutritional value and do not support address Canada’s growing obesity problem. approaches to healthy diets (Backholer et al., 2016). A possible address obesity, explanation for the relationship between SSBs, Sugar-sweetened beverages taxation and obesity and obesity-related conditions may potential positive effects such as taxation to be that these liquid calories (kilojoules) are Imposing taxes on food and beverages like SSBs exclusively derived from refined carbohydrates encourage healthier has been identified as a powerful economic tool like simple sugars (Brownell et al., 2009; Buhler to improve the diets of individuals. The World choices et al., 2013). Evidence suggests that individuals Health Organization recommends that countries do not compensate for the energy they consume take national-level approaches to address obesity, in liquid form, in part due to the poor satiating such as taxation to encourage healthier choices properties of sugary drinks (Brownell et al., (Veerman et al., 2016). Evidence suggests 2009; Buhler et al., 2013). For example, in one that an SSBs tax is an effective means of study that observed the SSBs consumption of changing purchasing habits, improving health school-aged children, it was found that children outcomes, and has added benefits like funding who drank nine ounces (~266 mL) or more of complementary health-promotion programs sugary beverages per day (equivalent to ¾ can (Niebylski et al., 2015). of a regular soft drink or more) consumed 200 kcal (836.8 kJ) more than children who did not In a study by Jones et al. (2017) that examined drink SSBs (Brownell et al., 2009). Despite the the health and economic impact of implementing growing evidence linking SSBs to poor health a 20% SSBs excise tax, it was found that over 25 outcomes, Canadians continue to consume an years close to half a million cases of obesity unhealthy amount of SSBs each year. could be prevented in Canada, resulting in an

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estimated $7.4 billion savings in direct healthcare excise tax in 2014 (Backholer et al., 2016; Colchero costs. Similarly, other modelling studies have et al., 2017). Most notably, two years after the projected reduced obesity rates for countries policy was implemented, it was found that SSBs like the US and the , where purchases were down by 9.7%, compared with imposition of a 20% excise tax could result the 5.5% decrease observed after the first year in 3.5% and 1.3% reductions in obesity rates, (Colchero et al., 2017). Findings from Colchero respectively (Mytton et al., 2012; Veerman et and colleagues’ (2017) study also discovered that al., 2016). In addition to reduced obesity rates, households at all three socioeconomic levels had countries may also experience a reduction in reduced their purchases of taxed beverages in chronic diseases. For example, in Canada, it 2015, with the greatest reduction being observed has been projected that taxation on SSBs could among households with the lowest socioeconomic also prevent 12 053 cancer cases, 36 996 cases of status. Similar to the situation for Berkeley, the ischemic heart disease, 4833 strokes and 138 635 revenues generated from Mexico’s SSBs tax were cases of (Jones et al., 2017). not initially earmarked for particular purposes. However, Mexico has stipulated that they will Despite a prominent focus of SSBs tax on use the funds to provide potable water to public consumers’ health and the financial advantages schools in low-income areas (Hagenaars et al., for governments, Falbe (2019) has noted that 2017). employers also stand to benefit from taxation of SSBs through reduced absenteeism, increased Challenges and limitations to a sugar- productivity and savings in employer-paid health sweetened beverages tax insurance. Specifically, within the US, where Despite the predicted benefits and real-life more than half of the population relies on successes of SSBs tax policies, such a tax also employer-paid health-insurance premiums, it was presents challenges and several limitations, estimated that employers could save up to $15.86 including industry resistance, wavering consumer billion in healthcare costs if an SSBs tax were support, a potential substitution effect, and the implemented (Falbe, 2019). argument that SSBs tax policies are regressive.

Although many modelling studies have predicted Industry resistance the potential benefits of taxation of SSBs, several Taxation on SSBs has often been stated by the jurisdictions and countries, like Berkeley, beverage industry to be ineffective, unfair and California and Mexico, have also found notable [damaging to] the industry (Mytton et al., 2012). success in implementing such tax policies. Indeed, these policies are often at odds with the agendas of the individuals who work within the In March 2015, Berkeley, California became the beverage industry, who impose strong first city in the US to successfully implement forces and argue frequently that obesity is a a penny-per-ounce excise tax on SSBs. Despite matter of personal responsibility (Hagenaars et heavy funding (approximately US$2 million) al., 2017). by the American Beverage Association to fight the tax, a majority of Berkeley residents had The primary argument that the beverage industry uses against the taxation of SSBs is that it would supported the proposed policy. This tax policy lead to substantial job losses. This argument was met with success through reports of reduced often resonates with citizens and acts as a barrier SSBs consumption. In fact, in an evaluation of to implementation for lawmakers (Powell et al., the policy using self-reported data, it was found 2014). Oftentimes, research used to support this that low-income neighbourhoods had decreased Such a tax also claim has been industry sponsored, and is the their consumption of SSBs by 21% in the subject of several methodological limitations and presents challenges first four months of the tax’s implementation. questionable assumptions. Specifically, industry- Conversely, it was found that residents’ water sponsored research often focuses on reporting and several (bottle or tap) consumption had increased by gross rather than net job losses, and fails to limitations, including 63%. Although the revenue collected from the account for consumers reallocating spending SSBs tax was placed into a general revenue fund, it on other untaxed products (Powell et al., 2014). industry resistance was reported that one year after implementation, Conversely, in a study conducted by Powell and $US1.5 million of the revenue from the tax had colleagues (2014), it was found that a 20% tax been used to fund community nutrition and on SSBs would actually result in increased net health-promotion programs, like school gardens employment in states like Illinois and California. (Backholer et al., 2016). Although the beverage industry would bear the cost of an SSBs tax, this projected cost would Mexico has also observed sustained positive be minimal in comparison to the total societal outcomes since implementing a one peso per litre benefits of the tax (Falbe, 2019).

20 A critical review exploring taxation on sugar-sweetened beverages as a strategy to address obesity in Canada

Wavering consumer support 2014), the Government of Canada should In addition to industry resistance, support from consider further exploring the option of using consumers for an SSBs tax has often been varied, an SSBs tax. with a 2010 survey revealing that only 44% of Canadian respondents supported such a tax Upon review of the current evidence and (Buhler et al., 2013). Consumers have often consideration of the Canadian environment, the criticised economic policies like SSBs taxes as an following policy actions are recommended: infringement on their right to choose (Buhler • In support of an SSBs tax, a comprehensive The revenue et al., 2013). Despite wavering support, studies obesity strategy, with other policies and generated from have found that when SSBs tax revenues are earmarked to support public-health programs interventions (e.g., subsidising healthy foods), an SSBs tax could and framed as a way to improve health, increased should be created to improve the diet quality support for SSBs taxation has been observed of all Canadians. be allocated to (Brownell et al., 2009). • Current evidence suggests that the best programs to help health outcomes are observed when an excise Potential substitution effect tax of at least 10% is applied (Backholer et individuals who Another concern with the implementation of al., 2016). Therefore, a federal excise tax an SSBs tax is the substitution effect, whereby of 20% should applied to all SSBs. Prior struggle to afford consumers may increase their consumption of to imposing a federal excise tax of 20%, healthier diets other high-calorie (high-kilojoule) drinks to consultation with provincial and territorial offset their decreased consumption of SSBs, governments is highly recommended, resulting in lowered potential of SSBs taxation and careful deliberations should be made to reduce obesity (Jou & Techakehakij, 2012). Some studies have speculated that taxing SSBs concerning the Canadian territories given the may lead to increased consumption of fruit current prices of food and beverages. or high-fat milk (Jou & Techakehakij, 2012). • To support the administrative capacity of To overcome this potential issue, Chaloupka et the taxation of SSBs, Health Canada should al. (2011) have suggested using a targeted SSBs create an office under its Health Products tax that excludes diet drinks but includes high- and Food Branch. This office should work calorie (high-kilojoule) beverages. Despite these collaboratively with multiple stakeholders, observations, more research is needed to explore including the Department of Finance effective strategies and potential consequences, Canada, provincial/territorial leaders, non- and to address a possible substitution effect (Jou profit health organisations (e.g., the Heart & Techakehakij, 2012). and Stroke Foundation of Canada) and beverage-industry representatives. Perception of being regressive • To garner more support from Canadians, Lastly, food taxes are held to be regressive, meaning individuals of lower socioeconomic strategies should be developed for earmarking status often pay a greater proportion of their the revenue from SSBs tax for other income in the taxes than those with higher preventative-health programs. Specifically, socioeconomic status (Brownell et al., 2009; revenue should be earmarked to support the Mytton et al. 2012). However, the health gains health of population subgroups that suffer the of an SSBs tax may be of greater benefit to greatest burden of diet-related poor health. individuals of lower socioeconomic status, as they • Lastly, continued evaluation of the SSBs tax often consume less-healthy diets and experience a should be conducted to assess effectiveness. higher rate of diet-related diseases (Mytton et al., 2012). Additionally, the revenue generated from Conclusion an SSBs tax could be allocated to programs to help Although there is no single solution to solve the individuals who struggle to afford healthier diets, through food subsidies or community nutrition growing obesity problem in Canada, the federal programs (Brownell et al., 2009). government must take action. Multisectoral and comprehensive approaches are urgently needed Policy recommendations to address the complexity of the obesity problem and to ensure the sustainability of our healthcare SSBs taxation has been observed as a successful approach in many countries across the globe (see system. Imposing an SSBs tax presents as one Table 1 for examples). Given that data collected complementary strategy to encourage dietary in 2011–2012 showed that 6.3 million Canadian change. In order to beat the sugary rush, multi- adults were obese and that the prevalence of stakeholder initiatives are needed to tackle obesity continues to rise (Navaneelan & Janz, Canada’s obesity problem.

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Table 1: Examples of taxation of SSBs across the world

Year of Country and currency Implementation Type of Taxation Source/s Canada Proposed in Proposed of 5 cents/100 mL AND Government of Northwest Territories (NWT) 2017/18 budget For sugar-sweetened fountain beverages: Northwest Territories CAD (Canadian dollar) • <250 mL = 10 cents (2019) • 250–500 mL = 20 cents • 500–750 mL = 30 cents • >750 mL = 40 cents

United States Berkeley, March 2015 1 penny/ounce excise tax Backholer et al. (2016); USD California Equivalent to 1 cent/ounce, or 12 cents on a Basu and Madsen (2017) (US dollar) regular can of soft drink (Wang et al., 2012)

Philadelphia, January, 2017 0.015 cents/ounce excise tax, applied to both Backholer et al. (2018); Pennsylvania sugar- and artificially sweetened beverages Hagenaars et al. (2017)

Mexico 1 January 2014 MXN1/L Backholer et al. (2016) MXN ()

Bermuda 2018 50% tax* on candies, sugary drinks and Backholer et al. (2018) syrups *Planned to increase to 75% in April 2019

Barbados 2015 10% excise tax applied to carbonated Backholer et al. (2016); beverages and drinks with high added caloric Foster et al. (2018) sweeteners

Dominica 2015 10% excise tax on high-sugar foods and Backholer et al. (2016) beverages

Chile October 2014 3% on beverages with <6.25 g Nakamura et al. (2018) sugar/100 mL 5% ad valorem tax on beverages with >6.25 g sugar/100 mL

Saint Helena May 2014 Excise tax of SHP0.75/L for carbonated Backholer et al. (2016) SHP ( pound) beverages with >15 g sugar/L

Peru 2018 Two-tier system: Backholer et al. (2018) • 17% for SSBs with <6 g sugar/100 mL • 35% for SSBs with >6 g sugar/100 mL

French Polynesia 2002 USD0.44/L domestic tax (45.1 CFP/L) Backholer and Baker CFP (Pacific Franc) USD0.68/L imported goods (60.7 CFP/L) (2018)

2013 TOP$1/L on beverages containing sugar or Foster et al. (2018) Tonga sweeteners* TOP (Tonga Pa’anga) (TOP1~USD0.50, 2018)

Cook Islands 2014 NZD9.80/kg of sugar Backholer and Baker NZD (New Zealand dollar) (2018)

2006 15% import duty on soft drinks Foster et al. (2018) Fiji FJD0.35/L excise tax on locally manufactured Pacific Islands FJD (Fijian dollar) SSBs

Nauru 2007 30% import tax on SSBs Foster et al. (2018)

2013 0.40 T/L (USD 0.25/L) excise tax and import Backholer and Baker Samoa (2018) WST (Samoan tala)

United Kingdom April 2018 Two-tier system: Backholer et al. (2018); GBP (British Pound) • 18 pence/L for SSBs with 5–8 g added Hagenaars et al. (2017) sugar/100 mL • 24 pence/L for SSBs with >8 g /100 mL

22 A critical review exploring taxation on sugar-sweetened beverages as a strategy to address obesity in Canada

Year of Country and currency Implementation Type of Taxation Source/s Ireland 1916–1992 Excise tax based on price and volume Jou and Techakehakij EUR () (2012)

May 2018 Two-tier system: Backholer et al. (2018) • 20 cents/L for SSBs with 5–8 g sugar/100 mL • 30 cents/L for SSBs with >8 g added sugar/100 mL

Hungary 2011 Excise tax of HUF0.03/L on soft drinks and Backholer et al. (2016); HUF (Hungarian forint) HUF1.25/L on energy drinks Jou and Techakehakij (2012)

France 2017 EUR0.11/1.51 L* Backholer and Baker EUR (Euro) *Artificial sweeteners are also subject to the (2018); Hagenaars et al. same SSBs tax (2017)

Portugal 2017 EUR16.46/100 L for SSBs with >80 g sugar/L Backholer et al. (2016) EUR (Euro) EUR8.22/100 L for SSBs with <80 g sugar/L

Estonia 2018 Three-tier system: Backholer et al. (2018) EUR (Euro) • 10 cents/L for SSBs with <5 g sugar/100 mL • 20 cents/L for SSBs with 5–8 g sugar/100 mL • 30 cents/L for SSBs with >8 g sugar/100 mL

South Africa 2017 2.1 cents per gram of sugar per 100 mL for Backholer et al. (2018); ZAR (South African rand) SSBs above 4 g/100 mL Hagenaars et al. (2017) Note: The reference does not indicate the country to which ‘cents’ refers.

Mauritius January 2013 Excise tax of 1 cent /gram of sugar Backholer et al. (2016) MUR (Mauritian rupee) Note: The reference does not indicate the country to which ‘cents’ refers.

United Arab Emirates (UAE), 2017 50% tax on carbonated beverages and Backholer and Baker Saudi Arabia and Bahrain 100% tax on energy drinks (2018)

Sri Lanka 2017 Excise tax of 50 cents/gram of sugar Backholer and Baker LKR (Sri Lankan rupee) Note: The reference does not indicate the (2018) country to which ‘cents’ refers.

India 2017 Combined goods and services tax (GST) Backholer and Baker and excise tax, equalling 40% on sweetened (2018) carbonated drinks

Thailand 1984 Either THB 0.37/440 mL or 20% of the Jou and Techakehakij THB (Thai bhat) ex-factory price, whichever is higher. (2012); Osornprasop et al., 2018

2019–2023 Plans to incrementally increase the tax rate Backholer and Baker between 2019 and 2023: (2018) • THB1/L (USD0.031/L) for SSBs 6–8 g sugar/100 mL • THB3/L (USD0.094/L) for SSBs 8–10 g sugar/100 mL • THB5/L (USD0.16/L) for SSBs >10 g sugar/100 mL

Philippines 2018 Excise tax for naturally and artificially Backholer et al. (2018) PHP (Philippine peso) sweetened beverages: PHP6/L Excise tax for beverages with high-fructose corn syrup: PHP12/L

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