Emer Scott asks how effective a levy on soft drinks is likely to be in tackling obesity. Emer is a student on the UCD Master of Public Policy programme.
Waistlines in Britain and Ireland have thickened in the last 20 years, and it’s not just our scales that are groaning under the burden of rising obesity. Health services are also under strain from a rising tide of people with weight-related conditions (e.g. Type 2 diabetes) on top of an ageing population and resource constraints. Many of us don’t even realize how much sugar we’re consuming –Table 1 shows that even some popular coffees can contain a lot of hidden sugar.
Table 1: How much sugar are we consuming?
|Tall Starbucks caramel macchiato (semi-skimmed milk)||15.3g added sugar
+ 10.2g natural milk sugars
|Tall Starbucks white chocolate mocha with whipped cream (semi-skimmed milk)||32.1g
+ 12.3g natural milk sugars
|330ml can of Coke (Coca-Cola Classic)||35.0g||139|
|Tesco jam doughnut||6.7g||225|
The ‘on-trend’ policy solution is a sugar tax. Britain and Ireland both intend to impose levies on soft drinks with a sugar content of 5g/100ml or more from April 2018. Mexico introduced a similar scheme in January 2014.
Few would argue that reducing our sugar consumption is good for us, but is there any evidence that soft-drink levies are effective at tackling obesity?
As an organisation that witnesses the impact of obesity-related disease each day and that employs 1.3m people – 700,000 of whom are estimated to be overweight or obese – the NHS might seem a good place to test policies aimed at curbing the tide.
And NHS England is up for that challenge, with plans to tax – or even ban – all sales of sugary hot beverages (e.g. calorific flavoured coffees) as well as soft drinks on premises run by NHS trusts and foundation trusts (FTs) from April 2017. It recently held a process of consultation on the proposals.
Under the levy option, each vendor would pay their dues in arrears to the NHS trust/FT or to their hospital charity in arrears on 1st June each year. Trusts/FTs would have to reinvest it in schemes supporting staff health and wellbeing by 31st March the next year. The other option is a total ban.
Diet versions and those with a milk content of more than 75 per cent and less than 10g/100ml of sugar would not be included in either option. The policy would be enforced by amending the NHS contract to compel trusts/FTs’ compliance, with sanctions for those that failed to reduce sales. The proposals align with NHS England’s 2014 commitment to “set a national example” as an employer providing a healthy workplace.
NHS England’s case for change makes much of the ‘evidence’ from Mexico, where a national sugar levy of one peso per litre was introduced in January 2014. Research published in the BMJ found sales reduced by 6% compared with the previous year. The graphic below summarises the impact of Mexico’s sugar tax:
Source: Colchero, M.A. et. al. ‘Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study’, BMJ 2016 (352).
This has been cited as proof that sugar taxes work, but the researchers themselves noted causality was not proved. They conceded the reduction could have been down to other factors such as messages about the dangers of over-consumption. (Sugar is the new public health ‘evil’.)
Opponents of sugar taxes say they are regressive, hitting poorer people hardest. The evidence from Mexico supports this, with the reduction most pronounced in the least affluent socioeconomic group; interestingly, they bought fewer soft drinks than their richer peers even before the levy. The Food and Drink Federation also claims it reduced intake by just six calories per person per day.
Perhaps most problematic, however, for the case in favour of sugar taxes is the absence of any data on the weights of those who changed their purchasing habits in Mexico. We cannot know whether the 6% reduction was predominantly the already health-conscious or whether key target groups – i.e. overweight/obese people or with high consumption of sugary drinks – changed their behaviour.
And are proposals that only affect NHS premises actually practicable? The NHS England proposals would apply to all vendors, not just in-house teams, and many hospitals are tied into contracts with external retailers (e.g. Costa and WHSmith) and facilities companies. They have no power to compel them to comply.
The NHS England consultation recognises this and says trusts/FTs would include the requirement in new or renegotiated contracts but that could take years. Vendors may be reluctant to change existing contracts in case they lose income to outlets off the hospital premises.
Charities would also be affected. The RVS (Royal Voluntary Society), a charity that supports older people, is the NHS’s biggest retailer. Its 450 hospital cafes and shops raised £6m last year that it gave back to the NHS. Many trusts/FTs also have tea bars run by ‘leagues of friends’, small voluntary groups who raise money for their local hospital.
The RVS already promotes healthy choices in its shops and cafes. And a revealing survey by it indicates the real causes of NHS staff’s unhealthy habits: long hours and pressured environment, with 80% of doctors and nurses saying they regularly skipped meals and 76% confessing they snacked instead.
Professional bodies and health unions have echoed this and also pointed this out that night staff are often reliant on vending machines. NHS organisations know a healthy workforce means better patient care and more resilient services, and 89% of staff say their trusts/FTs “take positive action” around health and wellbeing.
But sugar levies are much easier to implement than addressing the long hours and pressures of working in the NHS, especially when patient numbers and acuity keep rising, and budgets get tighter.
You can see why the policy wonks hope they will have some impact on obesity levels – even when there’s scant evidence that they will.
There are no quick fixes to the obesity epidemic but we need to start somewhere. A vat of cake-flavoured coffee or a sugary soft drink isn’t good for us and contains empty calories.
Increasing the cost – or banning their sale on NHS premises – sends a message and may mean some people stop drinking as much of them. But let’s not kid ourselves that this is the solution to Britain and Ireland’s obesity levels. A few spoonfuls of sugar won’t help the medicine for that particular problem go down.