Can Sugary Beverage Taxes Improve Public Health?

This episode of The Princeton Pulse explores the effectiveness of levies on sugar-sweetened beverages, comparing experiences from South Africa and Philadelphia. Sometimes called soda or sugar taxes, they are used as a policy tool to address rising rates of obesity and other non-communicable diseases, and the related social and economic costs.

Studies show that drinking too much sugar contributes to obesity and increases risk of diabetes, heart disease, and other serious illnesses. With that evidence in mind, more than 45 countries have implemented sugary beverage taxes on a national or subnational level. The taxes are designed to reduce demand for the beverages, promoting healthier choices and ultimately better health. At the same time, the levies can generate revenue to support other aspects of community health and wellbeing. 

Do these taxes actually make people healthier? Can a regressive tax be progressive in its design and impact?  Host Heather Howard, a Princeton University professor and former NJ Commissioner of Health and Senior Services, addresses these issues with Dr. Karen Hofman, a pediatrician and research professor at the University of Witwatersrand, who helped South Africa become the first Sub-Saharan African country to implement this kind of tax; and Dwayne Wharton, a health equity advocate behind Philadelphia’s beverage tax.

They explore lessons learned from public health interventions in multiple jurisdictions, including policy design questions, equity considerations, and the role of research in policy development.

Learn more about Dr. Hofman’s work:
Evidence That a Tax on Sugar Sweetened Beverages Reduces the Obesity Rate: A Meta-Analysis
Daily Maverick: Karen Hofman, the Professor Leading the Fight for Healthy Eating Choices

Read an article by Dwayne Wharton:
The Philadelphia Inquirer: Opinion | Tax on Sugary Beverages is a Good Thing
-------

The Princeton Pulse Podcast is a production of Princeton University's Center for Health and Wellbeing (CHW). The show is hosted by Heather Howard, a professor at Princeton University and former New Jersey Commissioner of Health and Senior Services, produced by Aimee Bronfeld, and edited by Alex Brownstein. You can subscribe to The Princeton Pulse Podcast on Apple Podcasts, Spotify, or wherever you enjoy your favorite podcasts.

Transcript

Episode #2: Do Sugary Drink Taxes Improve Public Health?

Heather Howard  00:00

On today's episode, we're talking taxes. Specifically, we're delving into the issue of levies on sugar sweetened beverages. They're sometimes called soda or sugar taxes, and they're used as a policy tool to address rising obesity rates, and the related economic and social costs. 

Studies show clearly that drinking too much sugar contributes to obesity and increases the risk of diabetes, heart disease and other serious illnesses. With that evidence in mind, more than 45 countries around the world have implemented sugary beverage taxes on either a national or a sub-national level. The theory is to reduce demand for these beverages, promoting healthier choices and ultimately better health. At the same time, the levies can generate revenue to support other aspects of community health and wellbeing. The big question is, do these taxes actually work in terms of making people healthier?  

Here with me to explore these issues are two guests who were instrumental in the adoption of sugary drink taxes. Dr. Karen Hofman is a pediatrician, as well as a research professor and founding director of the South African Medical Research Council at WITS University. Dr. Hofman helped South Africa become the first Sub-Saharan African country to implement this kind of tax in 2018. Also joining us is Dwayne Wharton, a health equity advocate behind Philadelphia's 2017 beverage tax, the first in a major U.S. city. Among many leadership roles, he formerly worked at The Food Trust, and is now a founding principal at Just Strategies, an organization dedicated to equitable public policy. 

Together, we have a unique opportunity today to examine lessons learned from two soda tax initiatives, comparing the challenges and successes of a similar policy tool in two very different contexts. So Karen, and Dwayne, welcome to the show.  

Heather Howard  

Let's start by establishing the problem. Karen, especially as a pediatrician, can you talk about the growing burden of non-communicable diseases in South Africa and globally? 

Dr. Karen Hofman  02:41

Non-communicable diseases, which include heart disease, diabetes, and cancer, are growing considerably in South Africa and indeed in Sub-Saharan Africa and across the world in other low and middle income countries. This trend is driven by obesity and the drivers of obesity, which include the foods and beverages that we eat and drink. So while South Africa is still what we call the epicenter of the HIV epidemic, it is now overtaken by diabetes and heart disease and, in fact, many of the people with HIV are getting these diseases themselves. So wards of the South African hospitals are filled with patients with diabetes who are getting their legs chopped off or amputated before they die, many times. 

Heather Howard  03:46

And tragically, during the pandemic, people with these disease burdens have higher rates of mortality for COVID, don't they? 

Dr. Karen Hofman    04:44

Yes, the hospitals were filled with patients with COVID and the vast majority, 70% in certain age groups, youngish age groups, were filled with people who had underlying co-morbid conditions, such as diabetes, heart disease and high blood pressure. With many of these patients, those conditions could have been prevented well ahead of time if we had paid attention to this.

Heather Howard  05:15

Dwayne, let's bring this back to the States. You worked at The Food Trust, which focuses on expanding access to nutritious foods. Can you talk about what you saw in Philadelphia and what sort of policy interventions you worked on?  

Dwayne Wharton  05:30

The Food Trust is a Philadelphia-based organization that works around the country to bring healthy food access to communities that need it the most. In Philadelphia, it operates a bunch of farmers markets.  The city has a corner store initiative. There is nutrition education in schools. And a big part of what I worked on as Director of External Affairs, along with the national team, was trying to bring supermarkets to under-resourced areas -- thinking about the historical perspective around policies like redlining, and how there's been such underinvestment in these communities, which has shown up in health outcomes. Philadelphia is the largest, poorest city. It has no shortage of disparate outcomes related to health. We saw the soda tax as an opportunity to really think about how to alleviate poverty as a public health intervention, as well as advance the mission of providing healthy access to folks. That also has to mean limiting access to some things that are unhealthy. 

Heather Howard  06:38

That's a great segue. It's important to note that when you're talking about the soda tax, you're seeing it as a tool in the toolbelt to address these growing disease burdens, right?  Do you agree, Karen?

Dr. Karen Hofman  06:52

I do. It's not a silver bullet. We learned from the tobacco issues that the taxes were critically important. But in this situation, which is related to food, we really do need to focus on front of package labeling, so that it's easy, especially for low literacy individuals, to see sugar content. More importantly, we have to limit marketing to children, because the rates of obesity in children are going through the roof, across the world, in high, low and middle income countries. That is the one tool that we really must use because people are, from the very start of their lives, encouraged to eat and drink these sugary foods and drinks. And what is happening now is very difficult because it's all under the radar, on social media. People are getting this information on their phones. And so the drivers are huge. 

Dwayne Wharton  07:52

Target marketing is certainly something of great concern. And I would add that it's a very intentional kind of marketing that is directed toward lower income and communities of color. That notion can't be ignored. Certainly race and income play a factor. In addition to that is water access, particularly in cities like Philadelphia where there are questions that lots of people have around the quality of the water, particularly low income, people of color, and soda is a sort of default. 

Karen, what you don't know about me is that I served in the Peace Corps and lived in Mozambique for a number of years. One of the signs that really stood out to me was part of a marketing campaign. It read, "Avoid the cholera, drink Coca Cola." So when we talk about a soda tax, who it impacts and who it's targeting, we also have to think about who is carrying the greatest burden around it as well.

Dr. Hofman  08:57

That marketing campaign is horrifying to me. I didn't know that. There is an issue around the multinationals who market these sugary drinks, as you say very deliberately and relentlessly. They have said publicly that they are targeting the growth market in Sub-Saharan Africa. And the growth market is the "poor." So it's exactly what you're saying.

Heather Howard  09:27

Those are pretty sobering points. And I guess that brings us to thinking about these soda taxes and how you designed them and advocated for them. Public health professionals usually think about having a spectrum of public health interventions. A tax is on the muscular end of that spectrum. But it sounds like you’re painting such a dire picture about the health challenges here and the inequitable burdens of those, that it brought you to thinking about soda taxes. So let's explore. 

It's so interesting to think about the two contexts of Philadelphia and South Africa... what's similar and what's different. Let's start with what's different, which is how the taxes are designed. Dwayne, can you talk about how the tax is designed in Philadelphia, what kind of a tax it is and how it's implemented? 

Dwayne Wharton  10:17

In Philadelphia, it's an excise tax based on the volume of production. The tax itself is at the distributor level, so it isn't supposed to be passed on to the consumer. It's supposed to be absorbed by these billion dollar corporations. I will add, though, prior to the tax that we all know about, there were two other attempts in Philadelphia to pass taxes that weren't necessarily designed in that way. Mayor Nutter, in 2010, really looked at it as a luxury tax. It was meant to bring in revenue for the city as well as address some of these preventable diseases. That failed miserably. There was another attempt that was brought on by a member of council, which also failed. There was lots of money being put forth by the beverage industry to stop this effort. The biggest champion of the soda tax in Philadelphia is Mayor Kinney. As a councilman, Mayor Kenny was on record as saying that he is not in favor, nor will he ever be in favor, of a soda tax. But when it came to the early days of his administration and thinking about his policy agenda around poverty alleviation, he was quoted as saying that the soda tax is the only way that we can fund these efforts. 

Heather Howard  11:43

What you're saying is that policy change may seem daunting at first, and that policy progress is sometimes slow, but we can get there. 

The Philadelphia tax is an excise tax, so a two liter soda has a higher tax than a can of soda. Right? You said that it's not supposed to be passed on to the consumer, but isn't that sort of the goal? Don't you want people to see that the products are more expensive to be dissuaded from buying them? 

Dwayne Wharton  12:06

Well, I think that was the unspoken goal and understanding that we had from the public health community. In terms of advocacy strategy, that wasn't necessarily something that was talked about. The passing of the tax in Philadelphia is uniquely structured. In some places a tax is passed by a popular vote or a ballot initiative. But in Philadelphia we have a 17 member council, and we just needed it to pass in council - I would say a very friendly Council when it comes to progressive legislation. That made it easier. There was a new mayor who had a lot of political capital and was a former member of council as well. Those are some of the things that contributed to the way it was approached. There was also something about a bottle tax that was introduced by one of the legislators, as an alternative, which was rejected as well. So people were thinking uniquely about how to get this done.

Heather Howard  13:06

You were navigating quite a complex political landscape. And so were you, Karen, in South Africa. Can you talk about how the soda tax was designed differently and how it actually works in South Africa?  

Dr. Karen Hofman

In South Africa, the tax is actually passed on to the consumer. The research that we did was based on other countries a little bit, using specific data from South Africa, but also based on what WHO had recommended at the time, which was a 20% general tax, excise tax. But when it was first announced in 2016, the industry was up in arms. And as they do with many of these substances, they pushed back. The Treasury then re-looked at things and decided they would do what's called a tiered tax. So the first teaspoon of sugar, which is equivalent to four grams of sugar, is excluded from the tax. And after that, it rises. Eventually it got to a point where they agreed to do this, but it was effectively only a 10% tax.  

Heather Howard 

So you ended up getting half of the levy. 

Dr. Karen Hofman  14:27

We got half of the levy, but it was a very useful way of getting the industry to reformulate and to decrease the volumes of sugar. 

Heather Howard  14:36

What's super interesting to me is that, in Philadelphia, the larger the product, the higher the tax. But in South Africa, you're focused on sugar density. You're penalizing by the amount of sugar, or sugar density -- the theory being that perhaps you would influence manufacturers to reduce sugar density. Have you seen that?

Dr. Karen Hofman  15:01

We have seen that; the volumes have definitely come down. Also the volumes consumed by consumers have gone down. We did a study in an area near Johannesburg, called Soweto. And in that setting, the individuals who were drinking approximately 10 cans a week -- mainly younger people, teenagers -- decreased to four cans a week. So consumption really did come down, and the amount of sugar by volume came down as well as the amount of volume of the actual product.

Heather Howard  15:02

That's really interesting. In Philadelphia, it was originally proposed as a 3 cent per ounce tax, and finally passed as 1.5 cent per ounce tax. It certainly was passed on to the consumer. There were lots of arguments around the impact that it would have on small businesses, etc., whether or not the revenue would be continuous, once there was a reduction in the consumption and purchases of beverages. But I really like this notion around the reformulation and pushing the industry. I think the UK did something very similar as well. 

Karen Hofman  16:22

They did. The UK is the only other country that's done that, although it is true that Botswana has now adopted the same tax as South Africa. So it's increasingly being used, this tiered approach. 

Dwayne Wharton  16:33

There is this notion of "better for you" products because all things aren't equal. In Philadelphia, things like water, milk, and anything above 50% fruit juice wasn't taxed. But there's a large spectrum of other beverages that have some added sugar. We actually taxed diet soda as well, which was seen as an equity issue. There were perceptions about who was drinking diet soda, such as more affluent people and race was probably underlying as well, though it wasn't overtly talked about. Therefore, it needed to be added into the tax, from a fairness perspective. 

Heather Howard  17:13

I definitely want to get to equity, but before that, it is interesting to think about how, in South Africa, they can literally move the market by how they designed this tax. In Philly, is it frustrating that you can't do that? As big a city as Philly is, you can't do that. In fact, not only can you not do that, you have to worry about being preempted, right? Can you talk to that? Across the country, we're seeing cities trying to do things and sometimes their states step in and say, "No, you can't do this." Was that a concern in Philly? 

Dwayne Wharton  17:46

Yeah. I served as an advocate for the tax itself, which included lots of visits to city council and op-eds, radio appearances, etc. But the beverage industry was doing the same thing. And I think they were probably able to support campaigns of elected officials in ways that we couldn't and wouldn't. However, because The Food Trust work was based on supporting fresh food retail, we had great relationships with store owners. The soda tax did become a bit of a divisive issue. The food and beverage industry looked at the tax as being harmful, whereas we saw it as a tool to improve public health. And how do you reconcile the two? We had to agree to disagree in that regard. We would be supportive of trying to help finance new grocery store development and supported their efforts to sell healthier products. At the same time, we were encouraging the tax because we knew the benefit that it would have to the community. A lot of businesses couldn't really hold that dichotomy, the multiple truths that exist in this way. 

Heather Howard  19:01

These are both great examples of the policy feedback loop, where you learn from other jurisdictions. For example, Berkeley preceded Philadelphia with a soda tax, right? Did you think about the issue of substitution, where people are going to cross to the next town and to the next county? That's something you didn't have to worry about in South Africa, but something to consider in Philly. 

Dwayne Wharton  19:29

That was part of the conversation. We thought about the leakage of consumers into the border communities. I'm not sure how much evidence exists around that. We saw that there has been, of course, fewer purchases of sugar sweetened beverages and more purchases of water, which we're happy about.  In terms of revenue in stores, there are conflicting studies. Some show that stores had no impact or broke even, and others have said that their revenue decreased. There was one grocery chain that said about 28% of their sales went down after the soda tax. That's just ridiculous; that wasn't what happened. They closed the store in order to send this political message as well. What they didn't say is that a new store opened half a mile up the street, which was brand new and more energy efficient, etc. 

You mentioned this notion of preemption. Yes, I think even today there are efforts from the state legislature to limit Philadelphia's ability to govern itself and to try to advance public health with such a policy. The soda tax went all the way up to the state Supreme Court, and the tax was upheld. But the attempts just haven't ceased since 2017. 

Heather Howard  20:41

It has not been smooth sailing, but you mentioned equity considerations. And I want to dig into those. It would seem, on its face, that the tax itself is regressive -- that if you're low income, you're going to be spending a higher percentage of your income paying this tax, if you're drinking soda. The impact of the tax is felt more significantly by somebody who's low income than somebody who's higher income. Can a tax that's regressive also be equitable in its impact? How did that play out in your both of your jurisdictions?

Dr. Karen Hofman 21:16

It is true that the tax is regressive, 100%. But it is what we call progressive for health. That's the bottom line. It is also true that individuals who can't afford the sugary beverage tax are the most vulnerable in terms of their capacity to obtain good health care. In South Africa, the quality of the public health system can be improved. So it was really good for progressivity, in terms of their health outcomes. 

Heather Howard  21:58

That's right, because aren't those very communities the ones that have faced greater disease burdens? 

Dr. Karen Hofman  22:04

Correct. They have much more of these conditions, diabetes, and high blood pressure. Sixty percent of some communities in South Africa have high blood pressure. These are silent conditions. Diabetes is often not picked up until the end, when somebody has had diabetes for years and the disease is out of control. So they are much sicker and are likely to die quite prematurely. It also affects the workforce. The real issue in South Africa is unemployment, which is through the roof. Since COVID, it's even higher. The official numbers are somewhere around 35 to 40%, but in some places it's close to 70%. So when one introduces something that's going to impact sugar cane workers and others, this is raised again and again. But of course, at the end of the day, we really do need to think about people's health. And it was very interesting for me to see how COVID was privileged of almost everything. And really, it was a very good example of how we ought to be thinking about health in the future.

Heather Howard  23:19

So Dwayne, you mentioned earlier that diet drinks were also taxed with an eye towards equity. How else did this equity question play out?

Dwayne Wharton  23:27

I have to say that, in Philadelphia, health was not the leading driver for this tax. It was more about poverty alleviation. So we talked about the number of early Pre-K slots that would be created through the tax. There was a program called "Rebuild," which was all about improvement to Parks and Recs and communities that need it the most. And even within "Rebuild," we're talking about the building trade in Philadelphia, which has been historically segregated by race. There are 12,000 construction firms in the city and less than 7% are minority owned. And with this initiative tied to the tax, there was a mandate, that council needed to see if it was going to support the tax, that at least 25 to 30% of all contracts went to women- and people of color-owned firms. So yes, in nature, the tax is regressive. It affects people who were targeted with marketing and also bear the greatest burden around illness as it relates to soda consumption. But the benefits are largely to people who also need it the most, and that's the equitable approach. And I think that's one of the reasons why it was successful.

Heather Howard  24:53

So I want to circle back. Earlier you mentioned something about access to water, right? One argument you're making is that it’s more expensive to buy these products, but are you also helping people have access to healthy drinks?  What is the status of access to water in Philly now? 

Dwayne Wharton  25:10

In terms of the advocacy for the soda tax, there was a cross-sector coalition of people in early childhood education, Parks and Rec, public health, and parents who all got together and advocated strongly for the tax itself. While that was happening, an interesting study came out from Children's Hospital that looked at kidney stones and the rising prevalence in young people. And it looked at the overconsumption of sugar sweetened beverages, and having this health impact, particularly on young people of color. As we're talking through the study, and where there could be some interventions, of course, school comes to mind. And when we began working with student leaders, they told us that the quality of the school water is really questionable. Therefore, they weren't in support of the soda tax, because there wasn't a real alternative for them. So there was testing done in all of the schools in Philadelphia, which confirmed the students’ concerns -- not only in terms of taste, color, quality, appearance, etc. Dangerous levels of lead were found throughout many of the schools in Philadelphia. The school district committed one million dollars to add new bottle filling stations in all of the schools, which largely resulted from a conversation started by the soda tax. 

Heather Howard

Another distinction between these two taxes is that, in Philadelphia, the revenue is dedicated to early childhood education, right?  

Dwayne Wharton

Yes, and also Parks and Rec. And then they snuck in some stuff around the pension fund as well. 

Heather Howard  27:06

Karen, where's the revenue going in South Africa?

Dr. Karen Hofman  27:11

In South Africa, there's no ring-fencing of the money. And the Treasury is not concerned about that. They never ring-fence anything in South Africa. Some of the funds have gone to the Department of Health, for health promotion. But in general and in principle, South Africa does not ring-fence taxes, whether they come from alcohol, tobacco or anything else.

Heather Howard  27:47

You've written that you'd like to see the tax increase to what was initially proposed and to see some sort of dedication of those funds, right?

Dr. Karen Hofman  27:53

There should be some dedication of the funds. And the 20% tax in the initial proposal, which became 10%, should go back to 20%. The other thing that was done, which I didn't mention, was that fruit juices were taken out of the proposal. The fact is, in many cases, fruit juices are even more unhealthy than sodas. The fruit juices are largely, though not exclusively, bought by upper income individuals. But everybody thinks that fruit juices are much more healthy. Freshly squeezed orange juice, for example, has got about 10 teaspoons of sugar. And the lesson from that is to eat one's fruit, don't drink it.  

Heather Howard

So if you had a magic wand, you'd add the fruit juice back in? 

Dr. Karen Hofman

We'd add in the fruit juice. We also need to raise the taxes. An increase was announced in the parliament. Then a month later there was industry interference, and it was taken out, again. So there's been no increase with inflation over five years. As we go along, it's certainly true that more and more people understand a little bit more about liquid sugar. But the fact is that the taxes have not kept pace with inflation.

Heather Howard  29:27

So let's dig into the impact. Karen, as a researcher, how do you measure the effectiveness of South Africa's tax, and what have you found so far in your research? 

Dr. Karen Hofman  29:38

Well, our research shows that the tax definitely is working. Fewer people are buying sugary sodas. And there's been an increase in the consumption and buying of bottled water, for better or for worse, because we certainly don't like the plastic issues. For every liter of Coke, 35 liters of water are used in a country that is very water scarce. So we have found that the consumption has decreased, the volumes of the containers have decreased, and the tax has been passed on. And this is consistent with what has been found in other many other countries... Mexico, Brazil, UK, et cetera. So there's no question that this works. Unfortunately, as we said before, it's not the only thing that needs to happen.

Heather Howard  30:42

Dwayne, Karen is saying that it's unquestionable the tax works. Is that what you're seeing in Philadelphia? What does the research show? 

Dwayne Wharton  30:48

There are so many studies that have come out. And again, I think you have some competing outcomes, particularly around the business impact. Some studies say that businesses have been impacted, and some say that they have not. But certainly the sale of sugar sweetened beverages has been reduced. The most recent study that came out of University of Penn shows an almost 40% drop in the volume of taxed beverages purchased at small stores in Philadelphia. We know that there has been reduced consumption among high school students as well. 

And I would say, going back to the goals of the program that were stated, we have 10,000 kids who have received quality Pre-K education. Again, we talked about this as a poverty alleviation program. We think of education as a tool to bring folks out of poverty, but the quality of the education has been limited. Now we have more quality providers. This year, I think there's going to be an increase from 2,000 Pre-K seats a year up to 4,000. I'll also add that there have been nine sites that have been renovated across the city, for Rec centers. There are another nine that are currently in construction. And I think there are probably about three dozen that are in the queue, getting community input around what they want those centers to be and the qualities that they'd like to see.

Heather Howard  32:31

In Philly, because of the dedication of the revenue, you're able to look at the impact more broadly and to take into account the investment in early childhood education and community programs. In South Africa, are you able yet to show health outcomes improving? Or is there a longer tail on that?

Dr. Karen Hofman  32:49

There's a longer tail, no question about it, Heather. It reminds me of the way the Finns dealt with myocardial infarctions, heart attacks. It took them 20 years of decreasing fat and other products. So I think it is going to take a long time. I think people are gradually getting the message. I think we can do more to educate people about sugar, and liquid sugar in particular. So we haven't been able to demonstrate exactly that obesity rates have dropped. Our mathematical modeling showed, originally, that the 20% tax would decrease obesity rates by about a quarter of a million people a year. That is pretty significant. We also did some modeling work showing what the cost of inaction would be, and how the obesity rates would significantly go up. And, in fact, they are going up in South Africa even as we speak, because the tax hasn't kept pace with inflation. But the tax is definitely working. 

Heather Howard  34:00

Finally, I want to explore the policy and political lessons you learned. And that's a great segue, Karen, because policymakers want to see results and they want to see results quickly. Do you find that frustrating as a researcher, the long tail there? How do you deal with that?

Dr. Karen Hofman  34:19

In South Africa, people are very hungry for political change; as politicians, they want it yesterday. But I don't really find it frustrating. I think the biggest frustration that I have, in general, is the industry interference. And the issue of what we call voluntary pledges. By industry, we've done some research on voluntary pledges in general, and found that it doesn't really work. We had a paper published recently, and we actually did some work in the schools of Soweto and schools of Harting, which is a province that we live in. These products are still being sold in school tech shops in a big way, even though the company said they would never sell those products in elementary schools to children.

Heather Howard  35:09

Dwayne, do you want to weigh in on this question of industry involvement and the political considerations that that necessitates? 

Dwayne Wharton  35:18

The industry is throwing a ton of money behind stopping the growing interest in SSB taxes. And there has been preemptive legislation introduced in two dozen states that is aimed at preventing mostly local municipalities from being able to govern themselves as it relates to levying these taxes. The example I would like to talk about is in California, where there was a ban placed on all food and beverage taxes up to the year 2031, that the industry led. And the way they did it is probably the most insidious part of this. They really held the legislature hostage, in that they threatened to negate any local taxes passed that didn't have a two-thirds majority. Folks who were interested in moving forward with the tax had to back away because it really did limit them, not being able to raise any funds for their communities. So it's a fight that continues. Even in Philadelphia, five years later, there was more legislation that was introduced to repeal the tax. It doesn't go away. There are no permanent victories here. 

Heather Howard  36:40

I think that's right. For those who may not know, SSB taxes is just the shorthand for sugar sweetened beverages. Is that the terminology used in South Africa?

Dr. Karen Hofman 37:01

We use a term that the Treasury called Health Promotion Levy. And I think that's exactly what it is. I do want to just endorse what Dwayne has said. It's never over. I was mistaken when I thought we had done our bit. The industry continues to fight back on a daily basis. They have deep, deep pockets. It's David and Goliath all over again. 

Heather Howard  37:43

I'm struck by your message that it's never over, that you've got industry pushback. In the U.S., you have the challenge of preemption -- our style of government. Sometimes good ideas bubble up from the local level and get adopted at higher levels, but sometimes those ideas get squashed, as the California example you mentioned. Can you just speak a little bit to Chicago, where there was an effort that was not successful?

Dwayne Wharton  38:11

Chicago actually passed its own version of a beverage tax in 2017. And I believe the following year, it was repealed. I'm not going to be critical, because I wasn't involved in that policy, but my understanding is that it didn't necessarily have a lot of community buy-in. I find that really challenging for me, because in Philadelphia, at the time of the vote, 60% of Philadelphians didn't support the tax. And that's because the beverage industry had poured $10 million into changing the narrative -- about this tax being regressive. For us, that was a reminder that you really do need legitimate representation of community, who are leading this work. The industry tried to position itself as the victims, despite all the harm that they've done, and all the profits that they've made off of the backs of Black and brown communities. You need someone that's able to push back on that very authentically, to be able to tell stories about the impact that this industry has had on their family members. You also need to have empathy around stores that may have more of a burden, such as shrinking revenue, and jobs that might be impacted. But that doesn't mean that it's not the right thing to do.

Heather Howard  39:48

I want to wrap up by asking you to reflect on what you've learned as researchers and advocates, and what the future is for soda taxes. Dwayne, it sounds like you're saying that it's important to involve the community and how that will be key to sustaining these efforts. Any other reflections?

Dwayne Wharton  40:10

I'd go back to reinforcing that the community needs to decide where that revenue goes, particularly those who are going to be most impacted by the increased price that's being passed along. They should also get to decide how to use that money. If it's the kind of cash cow that some legislators try to introduce it as, I don't think it's going anywhere. If you let the community decide how we can best benefit from it, then you're better off.

Heather Howard  40:38

Thank you. And Karen, you mentioned the clear evidence on reduced consumption in South Africa and reducing the volume of what was sold... not just from South Africa, but also from Mexico, Brazil, and UK. What do you think is the future?

Dr. Karen Hofman  40:52

I think this is going to continue. I think we're going to have more sugary beverages taxes. I'm hoping that this will be sooner rather than later. I think there is significant, growing advocacy in South Africa. South Africa has a long tradition of civil society action, dating back long before we had democracy. And this is continuing in the form of healthy living alliances and other groups that are working on this. I think the issue of free speech in South Africa allows people to really speak their minds. There's a lot of consultation generally. And I think that the Department of Health has certainly put all of this into its strategic plans for the future. There is continuing malnutrition in terms of under-nutrition as well as over-nutrition in South Africa. So we do have a real double burden when it comes to that. And a lot of this is tied up with climate change. I'm hoping that people see that connection more and more so that they can see how important it is that we address this.

Heather Howard  42:08

Well, thank you both for helping us make these connections. Thank you. Thank you.