The State of Connecticut is currently considering an excise tax on sugar-sweetened beverages. I have now testified twice before committees of the state legislature in favor of the bill, which would impose a one penny per ounce tax on the miscellaneous beverages that serve as delivery vehicles for added sugar under all of its aliases.
As an equestrian, I have written before that I likely have a more intimate knowledge of the application of carrots and sticks than most-and much prefer carrots (as does my horse). Taxes are the proverbial stick, and none of us ever likes being prodded, even if rather gently and with good intentions. But I favor this tax just the same. There are good arguments for it, weak and predictable arguments against it, and strong arguments against the arguments against it. And lastly we must, and can account for the transformation of what once seemed an innocent pleasure into a public health menace.
• Arguments For
The case for an excise tax on sugar-sweetened beverages (SSBs) is almost entirely concordant with the case for such taxes on tobacco. First, the intent of an excise tax is not to impose a financial burden on the buyer, but rather a financial penalty on the seller for the privilege of peddling wares with serious liabilities. Naturally, the financial burden is passed along from seller to buyer, so this distinction is more one of principle than practical value- but the intent is worth noting just the same.
Poor diet, along with tobacco, has been on the very short list of leading causes of chronic disease and premature death in the United States (and around the world) for decades; excess added sugar is among the salient adulterations of that diet; and SSBs are a particular, if not the principal, source of added sugar in such dietary patterns. Since the leading root causes of premature death were enumerated some 24 years ago, poor diet has surpassed tobacco as number one, due partly to declines in smoking, and partly to the universal and all-too-often pernicious influence of diet.
SSBs are, like tobacco, products no one actually needs; there are many better alternatives to soda than unsatisfied thirst, water noteworthy among them. There is a case to make that both products are addictive as well, although nicotine may satisfy every nuance of that definition a bit more decisively than sugar. The difference, though, is of degree not kind.
Importantly, there is evidence that SSB taxes work as intended to reduce consumption. There is precedent in the U.S., and abroad.
Finally, we might argue in both cases that policy is most warranted when the vulnerable are being exploited. Action against tobacco, including taxation, was much accelerated by the recognition of second-hand smoke as a threat to children. One could readily argue, and indeed I do, that the aggressive marketing of dubious food and drink to children as well as adults has resulted in second-hand obesity, diabetes, and worse. The degradation of our diet quality in the service of corporate profit is prominent among reasons why what was “adult onset” diabetes when I went to medical school in the 1980s is now called “type 2” and diagnosed routinely among children. Big Soda is in the vanguard of the profitably culpable.
• Arguments Against, and the Arguments Against Them
I confess I am impressed by the capacity of legislators to raise hypothetical concerns about solutions to clear, present, and actual threats. My first response to them all is that the law of unintended consequences may well warrant vigilance, and agility- but it is no reason not to fix what is obviously, currently broken.
There is concern among legislators that money raised through an excise tax on soda, and intended for dedicated application to public health causes, might be spent in other ways. My responses to that are that (a) the tax bill should stipulate the intended use of the funds, and the legislature should honor that; and (b) an excise tax intended to dissuade a harmful practice can succeed in doing that no matter how the money is spent. Public health can benefit either way, although far better for it to be the beneficiary of both reduced exposure to a harmful substance, and enhanced funding of genuinely valuable and empowering programming.
There is a bizarre argument that this tax will somehow “kill jobs,” as if it takes fewer teamsters to put bottled water rather than soda into vending machines. I suppose at some point in the future we might need fewer endocrinologists, but they don't seem to be the ones protesting. Let's just file this one under “insultingly ridiculous,” and move on.
To my surprise, the “let's just wait and let the feds do it” argument was also in the mix. This, to me, is right up there with: My house is on fire, but I'm not putting it out until everyone else puts out all the other fires. Logic requires one of two responses: Tell them what they've won, Johnny; and/or Enjoy your soot.
Perhaps the quintessential argument against taxing SSBs is the “nanny state“ objection, the idea that this is government telling responsible adults what to do. This contention is both misguided and naïve. SSBs are marketed aggressively to children, and to select populations the soda companies must deem particularly vulnerable to their messaging. Such marketing, informed by expertise in everything from psychology to the secret life of the hypothalamus (the brain region where the human appetite center resides), and relying on insights from such sources as functional MRI scans, is far more “manipulative” than anything the state might do. Worrying about “big brother” in the halls of government, this preoccupation overlooks a bigger, less compassionate, and utterly unaccountable brother in the marble-lined halls of big business.
And finally, what I consider the best argument against such a tax is that it is regressive, imposing its greatest burden on the socioeconomically disadvantaged. In light of the prevailing trends regarding who gets taxed and at what rate in this country, the idea that legislatures are genuinely concerned about regressivity seems far-fetched, but let's take it at face value. The argument is spurious, for several reasons.
First, the consequences of excess SSB consumption, the very consequences the tax is intended to help redress, are massively regressive. Obesity, diabetes, and every attendant insult and injury fall disproportionately on the socioeconomically disadvantaged. The most important costs of such ill health are measured in years lost from lives, and life lost from years- but medical care comes at a high cost in dollars, too. An excise tax on SSBs, like that on tobacco, is intended to level this playing field, and has meaningful potential to alleviate rather than compound the financial burden on those least able to pay the bills.
Second, as noted, nobody needs to drink SSBs, and unquenched thirst need not be the consequence of just saying “no.” To any for whom an additional penny per ounce is truly an unbearable financial burden, the obvious answer is- as the policy intends- to drink less soda. That expedient choice has the potential to dodge the financial burden, and reap the health benefits of doing so.
• End of the Innocence
I grew up in the generation of “I'd like to by the world a Coke …“ I remember the apparently sweet innocence of it all, the small glass bottles representing an occasional treat. Those days are long gone, replaced with a tsunami of added sugar, rampant obesity, and alarmingly more diabetes.
I personally renounced SSBs long ago, and have had none in roughly 40 years. I have neither missed them, nor suffered from undue thirst since.
The notion that SSBs can't be so bad because they weren't always so bad is nostalgia gone awry. Context is everything. Soda as an occasional treat in a generally wholesome diet would be fine. But if we call that fantasy Kansas- well then, Dorothy, we certainly aren't there anymore. The dose, the context, and the epidemiologic consequences define the poison, and SSBs are indicted accordingly.
In my opinion, arguments for an excise tax on SSBs, here in Connecticut, and everyplace else- are strong. Arguments against such a tax are weak, and submit readily to the arguments against the arguments against. There is much more that could, and should be done, to align food cost better with the goal of actual nourishment, but this is a good place to begin.
As for the reliance on a stick, the science of behavioral economics, and the history of tobacco, both tell us it's what works. Just the same, I side with those who favor discounting carrots, too.
David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.