International Journal of Nutrition

Current Issue Volume No: 6 Issue No: 3

ISSN: 2379-7835
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Research Article Open Access
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  • Provisional

    The Sweet and Sour of the Sugar-Sweetened Beverage Tax

    Al-Alawy Khamis 1    Azaad Moonesar Immanuel 1    Muhsineh Shatha 2   Gaafar Reem 1     Aden Bashir 3  

    1Mohammad Bin Rashid School of Government, Dubai, UAE

    2New York University, Abu Dhabi, UAE

    3Department of Health Abu Dhabi, UAE

    Abstract

    Obesity is a common and preventable Non-Communicable Disease that is of great importance. Population-based interventions are recognised to have a profound effect on improving health outcomes. One of these approaches includes the adoption of the Sugar-Sweetened Beverage (SSB) Tax.

    Objectives

    There were three objectives, 1) explore the associations between age, gender, nationality, and SSB consumption, 2) explore SSB consumption during Covid-19 lockdown and, 3) inform policy decision making.

    Methods

    A cross-sectional survey in the United Arab Emirates. We performed descriptive analysis and chi-square for independence to test the difference between the expected and the observed frequencies in one or more categories.

    Results

    Since the introduction of the SSB tax, we report no change in SSB consumption by age, gender, or nationality. Further analysis of the proportion of sugar intake per day was significant (P-value <0.001) by nationality. There was no significant change in SSB consumption by age, gender, or nationality during the Covid-19 lockdown. Further analysis within the group that reported change in SSB consumption suggests majority (80.5%) reported a reduction in SSB consumption.

    Conclusions

    Age, gender, and nationality do not significantly impact SSB consumption since the introduction of SSB tax, or during Covid-19 lockdown; thus, we accept the Null Hypothesis. Imposing a levy on frequently consumed SSB or revisiting levy by the gram, volume, or type of added sugar (or in combination) may prove more effective in reducing SSB consumption. Further research is needed to determine the extent income and education influence SSB consumption in the UAE and the enablers and barriers associated with SSB consumption.

     

    Author Contributions
    Received 17 Mar 2021; Accepted 28 Mar 2021; Published 15 Apr 2021;

    Academic Editor: Sasho Stoleski, Institute for Occupational Health, Skopje, Republic of Macedonia. WHO Collaborating Centre, Ga2len Collaborating Centre, Skopje, Republic of Macedonia.

    Checked for plagiarism: Yes

    Review by: Single-blind

    Copyright ©  2021 Al-Alawy Khamis, et al.

    License
    Creative Commons License     This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    Competing interests

    The authors have declared that no competing interests exist.

    Citation:

    Al-Alawy Khamis, Azaad Moonesar Immanuel, Muhsineh Shatha, Gaafar Reem,   Aden Bashir (2021) The Sweet and Sour of the Sugar-Sweetened Beverage Tax . International Journal of Nutrition - 6(3):21-35.

    Download as RIS, BibTeX, Text (Include abstract )

    DOI 10.14302/issn.2379-7835.ijn-21-3780

    Introduction

    Obesity is a common and preventable Non-Communicable Disease (NCD) of great clinical importance and public health concern. 1, 2 Obesity raises the risk of developing diseases such as coronary heart disease, diabetes, cancer, self-esteem, and emotional well-being. 3, 4, 5 Obesity also affects the health system and contributes to low productivity and economic loss. 6, 7 In 2019, The United Arab Emirates Ministry of Health and Prevention (MOHAP) reported marked improvements in adult obesity prevalence (37.2% in 2010 to 27.8% in 2019); however, the burden of associated disease and its impact on healthcare services, healthy life expectancy, and economic productivity remains an ongoing concern. 8, 9, 10 To address the health and societal costs associated with obesity, several countries have adopted a Sugar-Sweetened Beverage (SSB) tax; however, policy development and implementation approaches vary, creating complexity in adopting best practice contextually.11 In 2017, the UAE announced an excise sugar tax to reduce unhealthy consumption and harmful commodities to the environment and was fully implemented in 2019.12 The 'Logical Pathway' framework provided insight into the process and expected outcomes from SSB taxation. However, the pathway remains challenging to implement due to the unpredictability of the price pass on rates, price elasticity across different SSB products, substitution effect and lack of evidence on its effectiveness to reduce obesity prevalence (figure 1). 13, 14 The rationale for taxation stems from the evidence that food and drink contribute to child and adult obesity and are price elastic products; thus, taxation can impact unhealthy consumption levels.15, 16 Taxation (pigouvian tax) is also seen as favourable because it is seen as necessary to correct the adverse health effects of unhealthy consumption and is a revenue source for developing and implementing healthier alternatives. 17 Studies have reported associations between different demographic factors and SSB consumption, but little is known about SSB behaviors in the United Arab Emirates (UAE). 18, 19, 20, 21 SSB consumption by age and gender are key factors for research because consumption and calorific needs vary by age and gender. 22 On average, men require 600-800 more calories than women at the age of 18 years, at all activity levels (sedentary, moderately active, and active), and the difference between calorific intake by gender narrows as age increases. 23 Our Null Hypothesis (H0) was a) Gender, Age and Nationalitydo not affect SSB consumption since the introduction of SSB tax and, b) Gender, Age or Nationality does not affect SSB consumption during Covid-19 lockdown. Our objectives were to 1) explore the associations between age, gender, nationality and SSB consumption, 2) explore SSB consumption during Covid-19 lockdown and, 3) inform policy decision making.

     

    Figure 1. The Logical Pathway for Implementing the Sugar-Sweetened Beverage Tax - Modified from the Institute of Economic Affairs. 13
    Figure 1.

     

    Methods

    Development and Distribution of Survey

    A cross-sectional, nationally representative survey was developed following a review of the evidence and research group discussions. 24, 25, 26, 27, 28, 29, 30 Following a pilot phase, the survey was revised and coded using Cronbach Alpha Analysis. The survey included UAE SSB definition (any product with added sugar or other sweeteners, whether in the form of a beverage or a concentrate, powder, gel, extract), or any product that may be converted into a beverage, e.g. energy drinks or carbonated drinks and examples of sugar (white sugar, sucrose, dextrose, fructose, glucose syrup, and lactose, among others). 12 The survey was themed by demographics (age, gender, nationality, residency location) and SSB consumption. Consumption was split into two parts. Part one focused on consumption since the introduction of SSB tax using a five Likert scale (I consume a lot less to I consume a lot more) and percentage of sugar consumed per day from SSB (0%, 20%, 40%, 60%, 80%, 100% and I don't know). Part two included questions on change of SSB consumption during Covid-19 lockdown (yes, no) implemented in 2020. Responses with a yes were then asked to respond to a five Likert scale (I consume a lot less to I consume a lot more). Ethical approval was granted by the Mohammed Bin Rashid School of Government (MBRSG) Ethics Committee (REC-80-2020). The survey was issued electronically in English and Arabic through the Mohammed Bin Rashid School of Government (MBRSG) electronic survey system (Qualtrics). We adopted a random sampling approach and distributed the survey through different government institutions, professionals, and social media channels across the UAE for eight weeks (01/08/20 to 30/09/20). Participants were asked to consent at the start of the survey and were also offered the opportunity to withdraw at any time. Based on the statistical sample size table and reference to a sample size calculator with a 5% margin of error, confidence level as 95% and study population size (adults) as 6 600 000 and the response distribution of 50%, the minimum sample size needed for the study was 385 adults across the UAE. 31, 32, 33, 34

     

    Data Collection and Analysis

    Data were collected in two languages (Arabic and English) through the Qualtrics survey system. Responses in Arabic were translated into English through the Qualtrics system and checked by a native Arabic speaker. All survey data was downloaded onto Microsoft Excel. Data were cleaned and coded on Microsoft Excel as per the survey questions, and responses were transferred into Statistical Package for Social Sciences (SPSS) Subscription version 2021 for analysis.

    Analysis of responses was done for age, gender, and nationality. Age was analysed by the seven categories from the survey (18-25, 26-30, 31-35, 36-40,41-45,46-59 and 60 plus), gender as male and female, and nationality by Emirati and non-Emirati.35, 36 Cross table analysis were performed for each demographic variable against SSB consumption following the introduction of SSB tax, percentage of sugar consumed from SSB per day and SSB consumption during Covid-19 lockdown. Data was presented by demographic variable, number of cases, number of valid cases and percentages and by the number of responses for each category on the Likert scale. Statistical tests to determine the association between the demographic variable and consumption includedPearsons Chi-Square, Likelihood Ratio and Linear-by-linear Association. For the group that reported a change in consumption during Covid-19 lockdown, we provided a breakdown of the responses in a bar chart.

    Results

    Demographic Characteristics of Survey Respondents

    7,500 participants were recruited into the study, and we received 1 290 surveys (participation rate = 17.2%). The distribution of gender was 472 (36.7%) male and 817 (63.3%) female. For Nationality, we report 548 (42.5% Emirati) and 742 (57.5%) Non-Emirati. For age group, we report 276 respondents aged 31-35 years, 274 aged 46-59years, 270 respondents aged 41-45 years, 254 respondents aged 36-40 years, 157 respondents aged 26-30 years, 31 respondents aged 8-25 years, and 26 respondents aged over 60 years. Two missing responses were noted for age, 179 for change in SSB since tax, 179 for the percentage of sugar intake, and 179 for change in SSB consumption since Covid-19 lockdown. Overall, the demographic profile for gender, age, and nationality was consistent with national population data distribution.

     

    Change in SSB Consumption Since the Introduction of SSB Tax

    Change in SSB consumption since the introduction of SSB tax is presented in table 1. We report the highest proportion of responses in the 'no change in consumption’ category for all three demographic variables (522, 521 and 522, respectively). They were 336 respondents that reported consuming a lot less and 218 that reported slightly less. The fewest responses were in the consume more categories (consume slightly more N = 27 and consume a lot more N = 8). There was no statistical significance observed for change in SSB consumption for gender, age, or nationality.

     

    Table 1. SSB Consumption Since Introduction of SSB Tax by Gender, Age and Nationality.
    Demographic Variable Number of Cases Number of Valid Cases I consume a lot less I consume slightly less No Change in Consumption I consume slightly more I consume a lot more
    Male 1290 (100%) 413 143 80 181 8 1
    Female 698 193 138 341 19 7
    Total 1111 (86.1%) 336 218 522 27 8
     
    Chi-Square Tests Value df Asymptotic significance (2-sided)
    Pearsons Chi Square 8.334a 4 0.080
    Likelihood Ratio 8.670 4 0.070
    Linear-by-linear Association 7.423 1 0.006
    No. of Valid Cases 1111      
    a.  1 cell (10%) have expected count less than 5. The minimum expected count is 2.97.
     
    Demographic Variable Number of Cases Number of Valid Cases I consume a lot less I consume slightly less No Change in Consumption   I consume slightly more I consume a lot more
    Age (18-25) 1290 (100%) 27 4 3 18 2 0
    Age (26-30) 129 33 29 64 3 0
    Age (31-35) 244 72 45 121 5 1
    Age (36-40) 214 66 46 94 7 1
    Age (41-45) 235 63 46 115 8 3
    Age (46-59) 236 90 42 99 2 3
    Over 60 24 8 6 10 0 0
    Total 1109 (86%) 336 217 521 27 8
     
    Chi-Square Tests Value df Asymptotic significance (2-sided)
    Pearsons Chi Square 27.869a 24 0.266
    Likelihood Ratio 29.313 24 0.209
    Linear-by-linear Association 5.766 1 0.016
    No. of Valid Cases 1109    
    a. 11 cells (31.4%) have expected count less than 5. The minimum expected count is 0.17.
     
    Demographic Variable Number of Cases Number of Valid Cases I consume a lot less I consume slightly less No Change in Consumption   I consume slightly more I consume a lot more
    Emirati 1290 (100%) 458 139 82 221 13 3
    Non-Emirati 653 197 136 301 14 5
    Total 1111 (86.1%) 336 218 522 27 8
     
    Chi-Square Tests Value df Asymptotic significance (2-sided)
    Pearsons Chi Square 2.022a 4 0.732
    Likelihood Ratio 2.026 4 0.731
    Linear-by-linear Association .282 1 0.595
    No. of Valid Cases 1111    
    2 cells (20.0%) have expected count less than 5. The minimum expected count is 3.30.

     

    Percentage of Daily Sugar Intake from SSB

    The percentage of daily sugar intake from SSB is presented in table 2. For gender, age and nationality, the highest responses were reported in the 20% category (N = 318) followed by 0% (N =181), I don’t know (N =175), 40% (N=169), 60% (N = 135) and 80% (N = 116). The lowest responses were in the 100% category (N=17). Female responses for each percentage were higher. Responses for 18-40 years were higher (N = 619) than those above 40-years (490). For nationality, 457 responses were Emirati and 654 we non-Emiratis. Statistical significance was only observed in the Nationality category (P-value <0.001).

     

    Table 2. Percentage of Sugar Consumed/day from SSB by Gender, Age and Nationality.
    Demographic Variable Number of Cases Number of Valid Cases 0% 20% 40% 60% 80% 100% I don’t know
    Male   1290 (100%)       411 74 124 56 40 40 8 69
    Female 700 107 194 113 95 76 9 106
    Total 1111 (86.1%) 181 318 169 135 116 17 175
     
    Chi-Square Tests Value df Asymptotic significance (2-sided)
    Pearsons Chi Square 7.439a 6 0.282
    Likelihood Ratio 7.518 6 0.276
    Linear-by-linear Association 0.191 1 0.662
    No. of Valid Cases 1111    
    a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 6.29.
     
    Demographic Variable Number of Cases Number of Valid Cases 0% 20% 40% 60% 80% 100% I don’t know
    Age (18-25) 1290 (100%) 27 3 13 2 2 4 0 3
    Age (26-30) 129 14 38 29 15 16 0 17
    Age (31-35) 243 38 63 42 37 26 6 31
    Age (36-40) 220 37 59 33 29 23 3 36
    Age (41-45) 237 38 66 31 28 28 5 41
    Age (46-59) 230 44 71 29 23 19 2 42
    Over 60 23 7 8 2 1 0 1 4
    Total 1109 (86%) 181 318 168 135 116 17 174
     
    Chi-Square Tests Value df Asymptotic significance (2-sided)
    Pearsons Chi Square 40.124a 36 0.292
    Likelihood Ratio 43.797 36 0.174
    Linear-by-linear Association 0.002 1 0.967
    No. of Valid Cases 1109    
    a. 17 cells (34.7%) have expected count less than 5. The minimum expected count is .35.
     
    Demographic Variable Number of Cases Number of Valid Cases 0% 20% 40% 60% 80% 100% I don’t know
    Emirati 1290 (100%) 457 59 115 67 60 62 9 85
    Non-Emirati 654 122 203 102 75 54 8 90
    Total 1111 (86.1%) 181 318 169 135 116 17 175
     
    Chi-Square Tests Value df Asymptotic significance (2-sided)
    Pearsons Chi Square 21.700a 6 0.001
    Likelihood Ratio 21.675 6 0.001
    Linear-by-linear Association 17.729 1 <0.001
    No. of Valid Cases 1111    
    a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 6.99.

     

    Change in SSB Consumption During the Covid-19 Lockdown

    Table 3. presents the findings by age, gender, and nationality. Responses for change in SSB Consumption during Covid-19 Lockdown was grouped into ‘yes’ and ‘no’. We report 574, who reported a change in SSB consumption (exception 572 for age variable), and 537 reported no change in SSB consumption during the covid-19 lockdown. There was no statistical significance observed for change in SSB consumption during Covid-19 lockdown. Of the 574 who reported having had a change in SSB consumption during Covid-19 lockdown, 308 (53.7%) reported to consumer a lot less, 154 (26.8%) reported to consume slightly less, 24 (4.2%) reported no change, 74 (12.9%) reported to consume slightly more, and 13 (2.3%) reported to consume a lot more. In summary, 462 (80.5%) had reported a reduction in their SSB consumption, and 87 (15.2%) reported consuming more (figure 2).

     

    Table 3. Has Your Consumption Changed During the Corona Virus Disease (COVID-19) Lockdown?
    Demographic Variable Number of Cases Number of Valid Cases Yes No
    Male  1290 (100%)  413 210 203
    Female 698 364 334
    Total 1111 (86.1%) 574 537
     
    Chi-Square Tests Value df Asymptotic significance (2-sided) Exact Sig. (2-sided) Exact Sig. (1-sided)
    Pearsons Chi Square .176a 1 .675    
    Likelihood Ratio .128 1 .721    
    Fishers Exact Test .176 1 .675    
    Linear-by-linear Association       .709 .360
    No. of Valid Cases .176 1 .675    
    a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 199.62.b. Computed only for a 2x2 table
     
    Demographic Variable Number of Cases Number of Valid Cases Yes No
    Age (18-25) 1290 (100%)         27 15 12
    Age (26-30) 129 73 56
    Age (31-35) 244 133 111
    Age (36-40) 214 114 100
    Age (41-45) 235 106 129
    Age (46-59) 236 123 113
    Over 60 24 8 16
    Total 1109 (86%) 572 537
     
    Chi-Square Tests Value df Asymptotic significance  
    Pearsons Chi Square 9.720a 6 .137  
    Likelihood Ratio 9.776 6 .134  
    Linear-by-linear Association 4.080 1 .043  
    No. of Valid Cases 1109      
    a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 11.62.
     
    Demographic Variable Number of Cases Number of Valid Cases Yes No
    Emirati 1290 (100%) 458 230 228
    Non-Emirati 653 344 309
    Total 1111 (86.1%) 574 537
     
    Chi-Square Tests Value df Asymptotic significance Exact Sig. (2-sided) Exact Sig. (1-sided)
    Pearsons Chi Square .653a 1 .419    
    Likelihood Ratio .558 1 .455    
    Fishers Exact Test .653 1 .419    
    Linear-by-linear Association       .428 .227
    No. of Valid Cases .653 1 .419    
    a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 221.37.b. Computed only for a 2x2 table

     

    Figure 2. Percent of Effect for Change in SSB Consumption During Covid-19 Lockdown for 'Yes' Responders.
    Figure 2.

    Discussion

    Our study provides new insight into the association between key demographic factors (age, gender, and nationality) and SSB consumption in the UAE.The data analysis suggests that changes in SSB consumption were not statistically significant since the introduction of the SSB tax. The percentage of sugar consumed per day from SSB indicates a statistical significance with nationality (P-value <0.001). Several factors may explain this finding. Approximately 88.53% of the UAE population are non-Emirati derived from over 200 nationalities, and tourism has been steadily rising in the Emirate; for example, Dubai was ranked sixth globally on the tourism index with 16.73 million visitors in 2019 and with this, an increasing need to cater for a variety of dietary needs. 38, 39 Studies have also highlighted higher consumption patterns among high-income countries compared to low-income countries. 40 High-income countries generally consume more sugary drinks due to greater SSB availability, a higher proportion of disposable income and purchasing power. 40 Also, the prevalence of obesity is high in the UAE, particularly among expats. 41

    Several studies have explored the impact of taxation on SSB. Colchero et al. estimated changes in sugar-sweetened beverages (SSB) sales and plain water after a 1 peso per litre excise SSB tax were implemented in Mexico in January 2014. 42 The authors report a 7.3% decrease in SSB sales and a 5.2% increase in water sales but highlighted that change should be evaluated over the longer term. Sliver et al. examined the association of the first penny per ounce SSB excise tax in the United States, in Berkeley, California, with beverage prices, sales, store revenue/consumer spending, and usual beverage intake. 43 The authors report a price increase (but not across all settings), sales declined, and sales in untaxed products (especially water) rose. There was no overall spend per transaction and no significant self-reported SSB change from baseline. The findings from these two studies (Colchero et al. and Sliver et al.) and our findings suggest that SSB tax may promote healthier behaviours, but change may not be statistically significant or long term. The reasons for this might extend to the substitution effect, promotional offers, introduction of new products into the market or effect of technologies such as the growth of online platforms. Thus, decision-makers may need to account for market responses during policymaking because these responses may hinder the desired change or dilute the intended impact of policy. We found no significant change in SSB consumption following the implementation of SSB tax and therefore accept our Null Hypothesis.

    The study explored SSB consumption during Covid-19 lockdown. The number of respondents who reported consuming less SSB during the Covid-19 lockdown was slightly higher than those that reported no change (572 vs 537, respectively). It is plausible that the lockdown may have restricted the temptation for SSB, led to the prioritisation of beverages, or created a false impression of price elasticity among respondents. While research on SSB during Covid-19 lockdown is limited, there is evidence to suggest restricting access and availability of SSB in school and the workplace may lead to substitution or reduction in consumption. 44, 45 We found no significant difference in SSB consumption during Covid-19 lockdown between the ‘yes’ and ‘no’ responses and therefore accept our Null Hypothesis. However, our findings from the group that reported ‘yes’ suggest a positive change within the group.

    The study does not explore the nature of SSB taxation or its impact on obesity and health outcomes, however; the logical pathway remains relevant as a framework for understanding SSB taxation. However, there are challenges in implementing the framework due to a lack of consensus on the policy approach and a lack of standardised tools to quantify consumption. This means consumption may vary considerably among individuals or, indeed, population groups. Consumption may be inappropriately estimated due to insufficient knowledge or recall bias, and respondents may find it difficult to quantify their sugar consumption between food and drink. Thus, there is a need to develop validated research tools to quantify consumption more accurately. This would provide greater insight on the effects of SSB tax within population groups and at scale. Additionally, such tools would make it possible to conduct comparative analysis across different regulatory jurisdictions and maximise opportunities to determine superior SSB policy directives.

     

    Limitations

    The study has limitations. We may have excluded specific groups within the population through random sampling, such as disease-specific groups or groups with limited access to the internet. Despite achieving the minimum study sample for our population, the study would benefit from a higher response rate. They may have been alternative explanations to our results due to several factors that were not accounted for, such as self-reporting and interpretation of questions and responder ability to segregate sugar consumption between ' food and drink. Also, adopting a quantitative approach to measure SSB consumption may limit our understanding of the findings' underlying issues and generalisability.

     

    Policy Implications

    There are several policy implications from the study. Demographic factors should be considered when developing fiscal policy for SSB and different fiscal policy approaches should be pursued. Imposing a levy on frequently consumed SSB or revisiting levy by the gram, volume, or type of added sugar or in combination may prove to be more effective in reducing SSB consumption. Performance measures should be considered at different policy implementation stages to determine the impact and provide the opportunity to mitigate unintended consequences.

    Conclusions

    Age, gender, and nationality do not significantly impact SSB consumption since the introduction of SSB tax, or during Covid-19 lockdown; thus, we accept the Null Hypothesis. Imposing a levy on frequently consumed SSB or revisiting levy by the gram, volume, or type of added sugar (or in combination) may prove more effective in reducing SSB consumption. Further research is needed to determine the extent income and education influence SSB consumption in the UAE and the enablers and barriers associated with SSB consumption.

     

    Ethical Approval

    Ethical approval for the study and survey was granted from the Mohammed Bin Rashid School of Government Ethics Committee (REC-80-2020).

     

    Acknowledgement

    The authors would like to acknowledge Mohammed Bin Rashid School of Government, Dubai, UAE, and the Alliance for Health Policy and Systems Research at the World Health Organization for financial support as part of the Knowledge to Policy (K2P) Center Mentorship Program (BIRD Project).

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