In general, participants from all stakeholder groups, except from trade associations, thought that an SSB tax would reduce purchases and consumption of SSBs (a description of the views of Dutch stakeholders on the taxation of SSBs in general, and on the factors influencing its potential future introduction in the Netherlands, has been submitted for publication elsewhere ; Eykelenboom M, Djojosoeparto SK, van Stralen MM et al.). Some scientists and participants from trade associations were inconclusive of this reduction. Furthermore, participants shared their views on how an SSB tax would affect the budgets and SSB consumption of different socioeconomic groups and impact on inequalities in dietary intake and health. Below we will elaborate on these different views and Table 2 gives an overview of the perspectives of participants of different stakeholder groups.
Differential effects of an SSB tax on the budgets of lower and higher socioeconomic groups
Participants from all stakeholder groups mentioned that an SSB tax will have a financially regressive effect. Participants (from science and the ministries) reasoned that people with a lower SEP often have a lower income and spend a larger proportion of their income on food purchases. Consequently, an SSB tax will have a larger effect on the budgets of people with a lower SEP. Furthermore, participants (from health professional associations, advisory bodies, science, a ministry, and parliamentary parties) reasoned that people with a lower SEP in general consume more unhealthy foods and drinks like SSBs than people with a higher SEP, which could further increase the effect of an SSB tax on their financial situation if they would stick to their usual levels of SSB consumption. There could be a chance that people with a lower SEP will stick to their usual SSB consumption levels, because they can be less capable of and/or willing to change their routines regarding consuming SSBs than people with a higher SEP, as was mentioned by two scientists. A scientist noted ‘…it is financially unbearable for people when they are not capable to make alternative choices. That is a potential problem.’ Another scientist reasoned that when an SSB tax will disproportionally affect the financial situation of people with a lower SEP, this could thus lead to a widening of budgetary inequalities.
However, a few participants, although acknowledging the regressive effect of an SSB tax, were less concerned about possible adverse financial effects. One policy maker referred to evidence which showed that the regressive effect is likely to be marginal for this specific tax, because the absolute price increase is quite low for these relatively inexpensive drinks. A politician mentioned ‘if the [SSB] tax increases [the price of SSBs], it works regressive. And that is of course…not the intention. On the other hand, there is the discussion about if healthy eating is more expensive…and that is not the case. Thus… if you eat according to the Dutch Wheel of Five [dietary guidelines](26) (and then you do not buy cola and chips because they are not included)….you can eat healthy for 5 a 6 euros per day per person. Yes, that includes less [treats] and less cookies …. but those are also the products you do not need’.
The contribution of an SSB tax to socioeconomic inequalities in dietary intake and health
Participants from all stakeholder groups, except those from trade associations, mentioned the progressive health benefits of an SSB tax. They see it as an advantage rather than a disadvantage that an SSB tax will probably disproportionally affect the budgets and SSB consumption of people with a lower SEP.
Participants (from health professional associations, advisory bodies, science, a ministry, and parliamentary parties) mentioned that people with a lower SEP often have unhealthier dietary behaviour, including a higher consumption of SSBs. According to a few participants (from science) living unhealthier lives among people with a lower SEP may be caused by, for example, less knowledge about healthy behaviour, and by being more vulnerable to and more exposed to an environment that stimulates unhealthy behaviour. Consequently, the prevalence of overweight and obesity is higher among people with a lower SEP and they have a greater risk of experiencing health problems (e.g. type 2 diabetes, cardio vascular disease) than people with a higher SEP according to participants (from health and consumer organizations, a health professional association, science, a ministry, and a parliamentary party). Participants (from health and consumer organizations, science, and a parliamentary party) reasoned that an SSB tax will increase the price of SSBs and will therefore stimulate people, especially people with a lower SEP, to buy and consume fewer SSBs and make more alternative, healthier choices, which will thus positively contribute to their health. A politician noted ‘from a lot of research, it appears that people with a lower socioeconomic position……live unhealthier lives. Thus, if…people with less money to spend choose for more inexpensive drinks which also contain less sugar, that is, I think what we would want.’
Scientists mentioned that an SSB tax could be especially effective for the health of people with a lower SEP, who are more difficult to reach by other interventions. One of these scientists noted ‘The whole environment we are living in invites to unhealthy behaviour….for which [lower socioeconomic] groups are more vulnerable. If they would like to improve the health of all people, and especially of these [lower socioeconomic] groups, this [an SSB tax] is an intervention that could be potentially effective. More than an intervention that depends on individual behavioural change or motivation.”
Thus, according to a number of participants, an SSB tax stimulating people to buy fewer SSBs will contribute positively to the health of people in general, but even more to the health of people with a lower SEP. Consequently, SSB taxation may contribute to a decrease in socioeconomic inequalities in health, like a participant from an advisory body noted ‘prevention aims to decrease socioeconomic health inequalities…this is an advantage [of an SSB tax], as this is just what it does’. A participant from a health professional association mentioned ‘unhealthy [foods] should be made unattractive for everybody. And the rich people will continue buying it, I can believe that. However, especially in the lower socioeconomic groups, that [unhealthy eating] is a big problem in the Netherlands. ….In the lower socioeconomic groups differences will be made and that is I think what is needed.’
In contrast to the arguments above, some participants mentioned an SSB tax could also have no or adverse health effects. As was also noted in the paragraph about the financial effects of an SSB tax, two scientists mentioned that people with a lower SEP can be less capable of and/or willing to change their routines regarding consuming SSBs than those with a higher SEP. One of these scientists argued that ‘if people are stuck in certain behavioural routines, they can’t adjust these very easily’. And then the point is, how strong is the incentive? Is the incentive strong enough to break through a habit?’ These scientists mentioned also that people with a lower SEP can be less willing to change their SSB consumption because they fear that their children will not be happy when they can drink less SSBs, or because they feel that drinking less SSBs would lower their quality of life. As a scientist mentioned: ‘A cola is just one of the last things they [people with a lower SEP] could award themselves with’. Thus, [the implementation of an SSB tax] is not contributing to their quality of life, because it is a larger proportion of their income and it could increase the socioeconomic differences’.
A possible adverse effect of an SSB tax that was raised by a few participants is the possibility that a reduced SSB consumption will be compensated by an increased consumption of other unhealthy products. One participant from a health professional association mentioned: ‘People who cannot afford it [their usual level of SSB consumption] will maybe start doing [other] things which are ‘bad’ [for their health]. One participant from a health and consumer organization mentioned that ‘stop drinking SSBs is, I think, for everybody a very good step for health, but on the other hand, if you compensate that with other unhealthy behaviour, that is of course not desirable’.
When lower socioeconomic groups do not decrease their SSB consumption, or compensate a reduced SSB consumption with eating other unhealthy treats (e.g. more sweets or chocolate bars), and higher socioeconomic groups will reduce their SSB consumption in response to an SSB tax, two participants (a scientist and a professional affiliated with a health professional association) reasoned this could lead to a widening of socioeconomic inequalities in dietary intake and health.
The implementation of an SSB tax should be accompanied by other interventions targeting lower socioeconomic groups
To make it easier for lower socioeconomic groups to lower their SSB consumption in response to an SSB tax, and to prevent adverse effects, some participants emphasized that the implementation of an SSB tax should be accompanied by other interventions. According to a participant from a health and consumer organization, informing people, creating support for an SSB tax, and offering healthier alternatives that are affordable would be essential conditions for its success. One scientist mentioned further: ‘…if you don’t ensure at the same time a decrease in prices of healthy products, then you are disproportionally affecting [lower socioeconomic] group[s], because they cannot even afford themselves….a cola. Thus, you have to make sure there are attractive [healthy] alternatives […] which are festive and cheerful ’. Another scientist mentioned some form of compensation for people with a lower SEP as an additional measure accompanying the implementation of an SSB tax. This could be done by investing the revenues of the SSB tax in a fund from which measures can be paid that benefit the health of people with a lower SEP.