February 14, 2020 On February 14, 2020, Harvard Medical School Center for Bioethics and the Program on Regulation, Therapeutics, and Law (PORTAL) at Brigham and Women's Hospital, in collaboration with the Petrie-Flom Center hosted the monthly health policy consortium on sugar-sweetened beverage excise taxes. In recent years, some cities have tried to impose soda taxes and other new policies to reduce the obesity epidemic in the US—particularly among children—and its critical impact on society and the health care system. How effective are these policies? What is blocking their uptake? What alternatives should we consider? For more information visit our website at: https://petrieflom.law.harvard.edu/events/details/soda-taxes-and-other-policy-responses-to-the-american-obesity-epidemic

1. Sugar Sweetened Beverage
Excise Taxes: Impact on
Health, Health Care Costs,
and Health Disparities
Steven Gortmaker PhD
Harvard Law School
February 14, 2020

2. CHOICES PROJECT
This work was supported in part by grants from The JPB Foundation, the National Institutes of Health
(R01HL146625), the Robert Wood Johnson Foundation(#66284), the Donald and Sue Pritzker
Nutrition and Fitness Initiative and the Centers for Disease Control and Prevention (U48DP001946),
including the Nutrition and Obesity Policy, Research and Evaluation Network. This work is solely the
responsibility of the authors and does not represent official views of the CDC or other funders

3. The Challenge
o Obesity rates are at historically high levels ages 2-
19
o Racial/ethnic & economic disparities persist
Ward et al., N Engl J Med, 2017
Ward ZJ, Bleich SN, Cradock AL, Barrett JL, Giles CM, Flax C, Long MW, Gortmaker SL, N Engl J Med, 2019
Flegal et al., JAMA, 2016
Ogden et al., JAMA, 2016
Research continues to show
that more and more people
have developed obesity in
the U.S.
o About half of the adult U.S.
population will have obesity and
about a quarter will have severe
obesity by 2030

4. Ward ZJ, Long MW, Resch SC, Giles CM, Cradock AL, Gortmaker SL. N Engl J Med, 2017.
Doing nothing to address childhood obesity is not
an option

5. Costs of adults with excess weight
Wang YC, Pamplin J, Long MW, Ward ZJ, Gortmaker SL, Andreyeva T. (2015) Severe Obesity in Adults Cost State Medicaid Programs Nearly
$8 Billion in 2013. Health Aff 34:1923-2931
Obesity health care costs are $116 billion per year
Severe obesity (BMI >35) accounts for $69 billion of this

6. What can we do about this?
o There is strong evidence linking intake sugar
sweetened beverages to excess weight gain
and future chronic disease
o Note that research supporting this work has
occurred just in the past two decades (Our
Lancet study in 2001 was the first longitudinal
study showing the link to obesity in youth)
o Added sugars are mainly found in SSBs in the
US. These are generally nutritionally poor
beverages – sugar and water and some
flavoring.
Malik VS, Pan A, Willett WC, Hu FB. Am J Clin Nutr. 2013 Oct;98(4):1084-102.
Ludwig DS, Peterson KE, Gortmaker SL. Lancet. 2001 Feb 17;357(9255):505-8.

7. Why Reduce Sugar Drink Intake?
U.S. Dietary Guidelines 2015-2020
Figure 2-9. Average Intakes
of Added Sugars as a
Percent of Calories per Day
by Age-Sex Group, in
Comparison to the Dietary
Guidelines Maximum Limit
of Less Than 10 Percent of
Calories

8. Why Reduce Sugar Drink Intake?
U.S. Dietary Guidelines 2015-2020
Figure 2-10. Food Category
Sources of Added Sugars in
the U.S. Population Ages 2
Years and Older

9. CHOICES- Why are we doing this?
Policies and
programs
improving
nutrition and
physical
activity
environments
Best results
for dollars
invested
We want to
improve
population
health via
public policies
and programs
Gortmaker SL, Claire Wang Y, Long MW, Giles CM, Ward ZJ, Barrett JL, Kenney EL, Sonneville KR, Afzal AS, Resch SC, Cradock AL.
Three Interventions That Reduce Childhood Obesity Are Projected to Save More Than They Cost to Implement. Health Affairs, 34, no.
11 (2015):1304-1311.

10. Cost-effectiveness analysis
Cost-Effectiveness Analysis
compares the costs and outcomes of:
One policy or
program intervention
with no intervention
Two or more policy or
program
interventions
OR
vs. vs.

11. More Informed Decision-Making
o Cost-effectiveness framework provides an
opportunity across strategies and health
outcomes for better decision making
• Evidence for impact on health
• Population reach
• Implementation resources, activities &
costs
• Potential impact on disparities

12. Costs & outcomes
Difference in Effectiveness
DifferenceinCost
+
+–
–
Lower costs
Better outcome
Higher costs
Better outcome
Higher costs
Worse outcome
Lower costs
Worse outcome

13. Costs & outcomes
Difference in Effectiveness
DifferenceinCost
+
+–
–
Lower costs
Better outcome
Higher costs
Better outcome
Higher costs
Worse outcome
Lower costs
Worse outcome

14. How the Microsimulation
Model Works

15. Project impact on the
population
The CHOICES microsimulation model projects
the future course of the childhood obesity
epidemic by evaluating how an identified
strategy will impact obesity, healthcare costs
& mortality outcomes over 10 years

16. CHOICES model intervention inputs
Reach
Who will benefit?
Effect
What is effect of
the policy/program
on health?
Cost
Implementation
costs of
program/policy and
healthcare cost
savings
Focus on implementation of interventions to improve nutrition &
physical activity environments
Dietz WH, Gortmaker SL. New Strategies to Prioritize Nutrition, Physical Activity, and Obesity Interventions. Am J Prev Med.
2016 Apr 26. pii: S0749-3797(16)30069-1.

17. How does an SSB Excise Tax work?
o Most current SSB taxes are volume taxes – say
$0.01 per oz (Berkeley CA), or $0.02 per oz
(Boulder CO). ($0.0175 oz on Seattle)
o You can also tax the amount of sugar (e.g. UK).
o Note this is not a sales tax
o The tax raises the price, so people buy less and
then consume less, potentially leading to less
excess weight gain and reduced risk of future
chronic disease
o This approach worked well with tobacco

18. How the CHOICES Model Works
OUTCOMES
Simulate to:
2025
Healthcare
Costs
Mortality
Obesity
HEALTH
STATUS
BMI
INDIVIDUAL
Body Growth
Personal
Characteristics
(e.g. dietary intake)
Smoking
POPULATION
Population
Growth
BMI Trends
Start: 2015
VIRTUAL
POPULATION
From 2010 U.S.
Census Data
BASELINE SCENARIO
Obesity
QALYs

19. OUTCOMES
Simulate to:
2025
Healthcare
Costs
Mortality
Obesity
HEALTH
STATUS
Obesity
How the CHOICES Model Works
INTERVENTION SCENARIO
INTERVENTION
DietaryIntake/PhysicalActivity
INDIVIDUAL
FACTORS
Body Growth
Personal
Characteristics
(e.g. dietary intake)
Smoking
POPULATION
FACTORS
Population
Growth
BMI Trends
Start: 2015
VIRTUAL
POPULATION
From 2010 U.S.
Census Data
INTERVENTION SCENARIO

20. What has CHOICES been finding?
Some strategies are cost-saving
Many strategies reaching only children require
investment
Include adults for immediate large health care
cost savings
Strategies across sectors improve population
health
Some strategies projected to reduce disparities

21. OVERVIEW OF SELECTED
CHOICES NATIONAL MODEL
RESULTS

22. 22
CHOICES Metrics: 3 examples
Metric Definition
Cases of Childhood Obesity
Prevented in 2025
How many cases of childhood obesity will be prevented
in the intervention model compared to no intervention
in 2025?
Net costs The cost of implementing the intervention minus the
health care cost savings; a negative number means
intervention is cost saving
Health Care Cost Saved per $1
Invested
For every $1 invested to implement the intervention,
how much money is saved in health care costs with the
reduction in obesity in the population?

23. NET COST SAVINGS AFTER 10 YEARS CASES OF CHILDHOOD
OBESITY PREVENTED IN 2025
NET COST AFTER 10 YEARS
Example: Interventions to reduce childhood obesity
1The SSB Tax intervention would also produce an estimated $12.5 (2015) billion/year in tax revenue. This is not included
in the cost-effectiveness analysis
2 95% uncertainty interval
576,000SSB Tax1
$-14.2 billion
($-2.65, $-47.1)2
(132,000, 1,890,000)2
Smart
Snacks
$-792 million 344,649
($-251, $-1,340)2
(163,000, 522,000)2
Bariatric
Surgery
$303 million No cases
($209, $401)2

24. No effect on cases
HEALTH CARE COST SAVINGS Per $1 INVESTED1
Bariatric
Surgery
1Gortmaker SL, Claire Wang Y, Long MW, Giles CM, Ward ZJ, Barrett JL, Kenney EL, Sonneville KR, Afzal AS, Resch SC,
Cradock AL. Three Interventions That Reduce Childhood Obesity Are Projected to Save More Than They Cost to
Implement. Health Affairs, 34, no. 11 (2015):1304-1311.
2 95% uncertainty intervals
Example: Interventions to reduce childhood obesity
$30.80
($6.10, $113)2
SSB Tax
$4.60
($2.10, $7)2
Smart
Snacks

25. Impact of SSB Excise Tax on Percentage Reduction (95% UI)
in Childhood Obesity Prevalence, by Race/Ethnicity
0.77%
1.04%
1.02%
0.00% 0.50% 1.00%
White
Black
Hispanic
1.32 times greater,
compared to White
Long MW, Ward ZJ, Barrett JL, Cradock AL, Resch SC, Wang, YC, Giles CM, Gortmaker, SL. Taxing Sugar-sweetened Beverages Estimated to
Reduce Racial/Ethnic Disparities in U.S. Obesity Prevalence. American Public Health Association, Denver CO, 2016.
1.35 times greater,
compared to White

26. 0.91%
0.87%
0.86%
0.80%
0.00% 0.20% 0.40% 0.60% 0.80% 1.00%
≤130% poverty level
131-185% poverty level
186-350% poverty level
>350% poverty level
1.14 times greater, compared
to highest income
1.09 times greater, compared
to highest income
Impact of SSB Excise Tax on Percentage Reduction (95% UI) in
Childhood Obesity Prevalence, by household income
1.07 times greater, compared
to highest income
Long MW, Ward ZJ, Barrett JL, Cradock AL, Resch SC, Wang, YC, Giles CM, Gortmaker, SL. Taxing Sugar-sweetened Beverages Estimated to
Reduce Racial/Ethnic Disparities in U.S. Obesity Prevalence. American Public Health Association, Denver CO, 2016.

27. Summary: Cost-Effectiveness of SSB Excise Tax
o A Sugar Sweetened Beverage excise tax ($0.01 per
ounce) is projected to prevent future obesity and save
more in health care costs than it cost to implement
o This strategy will also likely improve population health
equity while improving population health overall
o In addition, the tax would raise an additional $12.5
billion per year in revenue that could be used for other
preventive programs

28. CHOICES Learning Collaborative Partnership (LCP)

29. Connect with CHOICES
Visit: www.choicesproject.org for more information on publications,
news, and collaborations
Follow us: @CHOICESProject