Evaluation of Fast-Food Restaurant Kids' Meal Beverage Offerings 1 Year After a State-Level Healthy Beverage Default Policy.

Introduction: Ordering from kids' menus and children's restaurant consumption is associated with greater purchasing and intake, respectively, of sugar-sweetened beverages. In response, policymakers have enacted strategies to improve the healthfulness of kids' meal offerings. This study investigated restaurant kids' meal beverage offerings and compliance with an Illinois healthy beverage default act, effective from January 1, 2022. Methods: Using a pre-post intervention (Illinois)-comparison (Wisconsin) site research design, fast-food restaurant audit data were collected before and 1 year after the Illinois Healthy Beverage Default Act from 6 platforms: restaurant interior and drive-thru menu boards and websites/applications and 3 third-party ordering platforms (DoorDash, Uber Eats, and Grubhub). Analyses included 62-110 restaurants across platforms. Difference-in-differences-weighted logistic regression models with robust SEs, clustered on restaurants, were estimated to assess pre to 1-year postpolicy changes in overall compliance for each audit setting in Illinois relative to that in Wisconsin. Results: This study found no statistically significant (p<0.05) changes in the compliance of kids' meal beverage default offerings associated with the enactment of the Illinois Healthy Beverage Default Act in Illinois relative to that in Wisconsin at fast-food restaurants. There were some observed differences in results in the restaurants' physical locations versus online that are worth noting. That is, after the enactment of the Illinois Healthy Beverage Default Act, the results showed greater odds of fast-food restaurants exclusively offering healthy beverage defaults with kids' meals on restaurant interior (OR=1.83, 95% CI=0.93, 3.58) and drive-thru (OR=2.38, 95% CI=0.95, 5.96) menus, with weak statistical significance (p<0.10). However, the policy was not associated with either meaningful or statistically significant changes in healthy beverage default offerings on restaurant websites or third-party online ordering platforms. Conclusions: This study found limited evidence of changes in kids' meal beverage offerings attributable to the Illinois Healthy Beverage Default Act. Future investigations of communication channels that support awareness and implementation and the resources required for implementation and enforcement may provide insight that is key to improving compliance.

Analysis of social media compliance with cannabis advertising regulations: evidence from recreational dispensaries in Illinois 1-year post-legalization.

BACKGROUND: In the USA, an increasing number of states have legalized commercial recreational cannabis markets, allowing a private industry to sell cannabis to those 21 and older at retail locations known as dispensaries. Research on tobacco and alcohol suggests this new industry will use aggressive marketing tactics to attract new users and promote greater intensity of use. Of concern is that cannabis company advertising campaigns may be appealing to youth, promote false or misleading health claims, and disproportionately target low-income and minority communities. In this study, we evaluated recreational cannabis dispensary compliance with advertising regulations on social media in the state of Illinois. METHODS: Primary data were collected from a census of recreational dispensary Facebook and Twitter business pages during the first year of recreational sales in 2020. A quantitative content analysis was conducted to systematically analyze the data; a codebook that detailed a protocol for classifying posts was developed prior to the analysis using advertising regulations outlined in the Illinois Cannabis Regulation and Tax Act. Violations of advertising regulations were organized into three categories: advertisements that may be appealing to youth (< 21 years old), advertisements that make health claims, and other advertising violations. The data were analyzed cross-sectionally and longitudinally. Additionally, differences in compliance were assessed by dispensary and neighborhood characteristics. RESULTS: The results of the analysis revealed substantial and persistent non-compliance throughout the entire study period. Overall, nearly one third of posts had at least one violation and approximately one in ten posts met the criteria for appealing to youth or contained health claims. The majority of posts with health claims included health claims that were not qualifying conditions for medical cannabis access in the state of Illinois. No differences in compliance by neighborhood and dispensary characteristics were found. CONCLUSIONS: The findings from this study suggest that systematic monitoring and enforcement is needed to ensure compliance with advertising regulations.

Neighborhood sociodemographic characteristics and healthfulness of store checkouts in Northern California.

Placement of products at food store checkouts has been shown to trigger impulse purchases and child purchasing requests. Therefore, food companies pay substantial amounts of money to ensure their products are placed at checkout, and these products are mostly unhealthy (e.g., sugar-sweetened beverages [SSBs], candy, chips). To improve the healthfulness of store environments, Berkeley, CA, U.S. became the first jurisdiction globally to implement a healthy checkout policy. This study examined associations between store neighborhood characteristics and healthfulness of foods and beverages offered at checkout to understand the potential for healthy checkout policies, such as Berkeley's healthy checkout ordinance (HCO), to promote equitable food environments. Data on a near census of food and beverage facings (n = 26,758) at sampled checkouts were collected from 102 food stores (supermarkets, grocery stores, drugstores, dollar stores, specialty food stores, and mass merchandisers) across four Northern California cities (Berkeley, Oakland, Davis, and Sacramento) in February 2021. Bivariate regression analyses revealed that neighborhoods with lower socioeconomic status (SES) and higher Black and Hispanic residential composition had a higher prevalence of foods and beverages that did not meet HCO standards, including associations with a higher prevalence of sweets, higher prevalence of SSBs, and/or lower prevalence of healthy foods at checkout. Findings suggest that the checkout environment may be one of many contributors to diet-related health disparities. Additionally, healthy checkout policies may have the potential to increase nutrition equity by improving food environments across neighborhoods and especially in areas with lower SES and higher Black and Hispanic composition.

The impact of the Oakland sugar-sweetened beverage tax on price promotions of sugar-sweetened and alternative beverages.

The goal of sugar-sweetened beverage (SSB) taxes is to raise the prices of SSBs to decrease consumption. Price promotions play an important role in the sales of SSBs and could potentially be used by manufacturers to weaken the impact of such taxes. The purpose of this study is to determine how price promotions changed after the introduction of the 2017 Oakland SSB tax. A difference-in-differences study design was used to compare changes in prices and the prevalence and amount of price promotions for beverages in Oakland, California, relative to Sacramento, California, using two different datasets. Nielsen Retail Scanner data included price promotions for beverages sold and store audit data included price promotions offered by retailers. Changes were analyzed for SSBs, noncalorically sweetened beverages, and unsweetened beverages. After the implementation of the tax, the prevalence of price promotions for SSBs did not change significantly in Oakland relative to the comparison site of Sacramento. However, the depth of price promotions increased by an estimated 0.35 cents per ounce (P<0.001) based on the Nielsen retail scanner data and by 0.39 cents per ounce (P<0.001) based on the store audit data. This increase in the amount by which SSBs were price promoted following the introduction of the Oakland SSB tax may reflect a strategy by manufacturers to weaken the tax and/or retailers to bolster demand.

Evaluation of Short-Term Changes in Fast-Food Restaurant Online Kids' Meal Beverage Offerings Following a State-Level Healthy Beverage Default Policy.

Background: Consumption of food and beverages from restaurants is associated with poorer diet quality and a higher intake of sugar-sweetened beverages (SSBs) among children, and SSBs are commonly offered as part of kids' meals at restaurants. Thus, an increasing number of states and localities have mandated that only healthy beverages be provided by default with kids' meals. Objectives: We examined changes in default beverages offered with kids' meals 4 mo after an IL healthy beverage default (HBD) act took effect. Methods: A pre-post intervention-comparison site study design was used, with WI as the comparison site. Data were collected on default beverages offered on restaurant website or application menus at 64 restaurants in IL and 57 restaurants in WI in November 2021, before the IL HBD Act took effect, and May 2022, 4 mo after the date on which the Act took effect. Difference-in-differences weighted logistic regression models with robust standard errors clustered on restaurants were computed to examine changes over time in beverage offerings in IL relative to those in WI. Results: There was no statistically significant increase in compliance with the IL HBD Act's criteria in restaurants in IL compared with those in WI (OR: 1.40; 95% CI: 0.45, 4.31). Although the compliance by fast-food restaurants increased from 15% to 38% in IL, there was a similar pattern in WI, with an increase from 20% to 39%. There were also no statistically significant changes in specific types of compliant beverages offered by default with kids' meals in IL compared with those in WI. Conclusions: These results highlight the need for communication and enforcement to ensure that restaurants make changes in response to HBD policies broadly, including on their online platforms, and without substantial lags. Future studies should continue to measure the effectiveness of HBD policies alongside implementation strategies to determine how these policies can best achieve improvements in the nutritional quality of kids' meals at restaurants.

Food and Beverage Environments at Store Checkouts in California: Mostly Unhealthy Products.

Background: As the only place in a store where customers must pass through, checkouts may be especially influential over purchases. Research is needed to understand the healthfulness of checkout environments. Objectives: The objective of this study was to classify checkout product facings in California food stores. Methods: In a cross-sectional study, 102 stores, including chains (dollar stores, drugstores, specialty food stores, supermarkets, and mass merchandisers) and independent supermarkets and grocery stores were sampled from 4 northern California cities. Observational assessments of each checkout product facing were conducted in February 2021 using the Store CheckOUt Tool. Facings were classified by category and healthfulness, defined by meeting Berkeley's Healthy Checkout Ordinance's healthy checkout standards: unsweetened beverages and specific foods containing ≤5 g added sugar and ≤200 mg sodium per serving. Log binomial regressions compared healthfulness by store and checkout characteristics. Results: Of 26,758 food and beverage checkout facings, the most common categories were candy (31%), gum (18%), sugar-sweetened beverages (SSBs; 11%), salty snacks (9%), mints (7%), and sweets (6%). Water represented only 3% and fruits and vegetables 1% of these facings. Only 30% of food and beverage facings met Berkeley's healthy checkout standards, with 70% not meeting the standards. The percentage of food and beverage facings not meeting the standards was even higher (89%) among snack-sized packages (≤2 servings/package). Compared with chain supermarkets, mass merchandisers, and specialty food stores (34%-36%), dollar and independent grocery stores had a lower percentage of food and beverage facings that met the healthy checkout standards (18%-20%; P < 0.05). Compared with lane and register areas (35%), endcaps and snaking sections within checkouts had fewer food and beverage facings that met the standards (21%-23%; P < 0.001). Conclusions: Most foods and beverages at checkout consisted of candy, SSBs, salty snacks, and sweets and failed to meet the healthy checkout standards.Curr Dev Nutr 2023;xx:xx.

The impact of recreational cannabis markets on motor vehicle accident, suicide, and opioid overdose fatalities.

In the U.S., an increasing number of states are legalizing regulated commercial markets for recreational cannabis, which allows private industry to produce, distribute, and sell marijuana to those 21 and older. The health impacts of these markets are not fully understood. Preliminary evidence suggests recreational markets may be associated with increased use among adults, which indicates there may be downstream health impacts on outcomes related to cannabis use. Three causes of death that are linked to cannabis use are motor vehicle accidents, suicide, and opioid overdose. Drawing on data from U.S. death certificates from 2009 to 2019, we conducted a difference-in-differences analysis to estimate the impact of recreational markets on fatalities from motor vehicle accidents, suicide, and opioid overdose in seven states: Colorado, Washington, Oregon, Alaska, Nevada, California, and Massachusetts. States with comprehensive medical cannabis programs with similar pre-trends in deaths were used as comparisons. For each outcome, a pooled estimate was generated with a meta-analysis using random effects models. The results revealed substantial increases in crash fatalities in Colorado, Oregon, Alaska, and California of 16%, 22%, 20%, and 14%, respectively. Based on estimates from all seven states, recreational markets were associated with a 10% increase in motor vehicle accident deaths, on average. This study found no evidence that recreational markets impacted suicides. Most states saw a relative reduction in opioid overdose death that ranged between 3 and 28%. On average, recreational markets were associated with an 11% reduction in opioid overdose fatalities.

Outcomes Following Taxation of Sugar-Sweetened Beverages: A Systematic Review and Meta-analysis.

Importance: More than 45 countries and several local jurisdictions have implemented sugar-sweetened beverage (SSB) taxes to improve nutrition and population health, and evidence on their outcomes to date is essential to inform policy discussions. Responding to this need, the World Health Organization commissioned a systematic literature review on the outcomes of fiscal policies, including SSB taxes. Objective: To assess the associations of implemented SSB taxes with prices, sales, consumption, diet, body weight, product changes, unintended consequences, health, and pregnancy outcomes. Data Sources: Searches of 8 bibliographic databases (Business Source Complete, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL, EconLit, PsycINFO, PubMed, and Scopus) were performed from database inception through June 1, 2020, with no language or setting restrictions. Grey literature was assessed using 14 sources and government websites. Study Selection: The review included primary studies of implemented SSB taxes. Data Extraction and Synthesis: The review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. For prices, sales and consumption, results were meta-analyzed using a 3-level random-effects model. Study quality was assessed at the outcome level. Main Outcomes and Measures: Tax pass-through rate for prices, percentage reduction in SSB demand, and price elasticity of demand for sales and consumption. Heterogeneity was assessed using τ2 and the I2 statistic. Results: A total of 86 articles were eligible, with 62 studies contributing to the meta-analysis. The overall tax pass-through rate was 82% (95% CI, 66% to 98%; P < .001, I2 = 99%), suggesting tax undershifting. The demand for SSBs was highly sensitive to tax-induced price increases, with the price elasticity of demand of -1.59 (95% CI, -2.11 to -1.08; P < .001; I2 = 100%) and a mean reduction in SSB sales of 15% (95% CI, -20% to -9%; P < .001; I2 = 100%). There was no evidence of substitution to untaxed beverages, and changes in SSB consumption were not significant. The narrative synthesis found reformulation and reduced sugar content of taxed beverages for tiered taxes, cross-border shopping in most studies of local-level taxes, and no negative changes in employment. Data on the heterogeneity of SSB tax outcomes across subpopulations were limited. Conclusions and Relevance: In this systematic review and meta-analysis of implemented SSB taxes worldwide, SSB taxes were associated with higher prices and lower sales of taxed beverages.

Evaluation of Economic and Health Outcomes Associated With Food Taxes and Subsidies: A Systematic Review and Meta-analysis.

Importance: Fiscal policy is a promising approach to incentivizing better food choices and reducing the burden of chronic disease. To inform guidelines on using fiscal policies, including taxes and subsidies, to promote health, the World Health Organization commissioned a systematic review and meta-analysis of the worldwide literature on the outcomes of such policies for food products. Objective: To assess the outcomes of implemented food taxes and subsidies for prices, sales, consumption, and population-level diet and health. Data Sources: Eight bibliographic databases were searched for peer-reviewed literature and 14 data sources along with governmental websites were searched for grey literature that were published from database inception through June 1, 2020. There were no language and setting restrictions. Study Selection: Only primary studies of implemented food taxes and subsidies were considered for inclusion. Data Extraction and Synthesis: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed. A 3-level random-effects model was used to conduct a meta-analysis of sales and consumption outcomes of fruit and vegetable subsidies. Other outcomes were analyzed in a narrative synthesis. Main Outcomes and Measures: Study estimates in the meta-analysis were combined using a price elasticity measure for sales and consumption outcomes. Heterogeneity was assessed using the I2 statistic and τ2. Studies varied in how diet and health were measured. Results: A total of 54 articles were included in the systematic review, of which 15 studies were included in the meta-analysis. Most food subsidies targeted fruits and vegetables and populations with low income, whereas the evidence on food taxes was primarily from the nonessential energy-dense food tax in Mexico. Sales of subsidized fruits and vegetables increased significantly, with an estimated price elasticity of demand of -0.59 (95% CI, -1.04 to -0.13 [P = .02]; 95% prediction interval, -2.07 to 0.90; I2 = 92.4% [95% CI, 89.0%-94.8%; P < .001]), suggesting inelastic demand. There was no significant change in the consumption of subsidized fruits and vegetables, with an estimated price elasticity of demand of -0.17 (95% CI, -0.49 to 0.15 [P = .26]; 95% prediction interval, -1.01 to 0.67; I2 = 76.2% [95% CI, 54.3%-87.6%; P < .001]). Food excise taxes were associated with higher prices and reduced sales. Evidence was limited on the differential outcomes of food taxes and subsidies across subpopulations. Conclusions and Relevance: Results of this systematic review and meta-analysis indicated that fruit and vegetable subsidies were associated with a moderate increase in fruit and vegetable sales. Further research is warranted to understand the implications of food taxes and subsidies for population-level consumption, diet, and health outcomes.

Impact of the Seattle Sweetened Beverage Tax on substitution to alcoholic beverages.

INTRODUCTION: Taxes are increasingly used as a policy tool aimed at reducing consumption of sugar-sweetened beverages (SSBs), given their association with adverse health outcomes including type 2 diabetes, obesity and cardiovascular disease. However, a potential unintended consequence of such a policy could be that the tax induces substitution to alcoholic beverages. The purpose of this study is to examine the impact of the $0.0175 per ounce Seattle, Washington, Sweetened Beverage Tax (SBT) on volume sold of alcoholic beverages. METHODS: A difference-in-differences estimation approach was used drawing on universal product code-level food store scanner data on beer (N = 1059) and wine (N = 2655) products one-year pre-tax (February-November, 2017) and one and two-years post-tax (February-November, 2018 and 2019) with Portland, Oregon, as the comparison site. RESULTS: At two-years post-tax implementation, volume sold of beer in Seattle relative to Portland increased by 7% (ratio of incidence rate ratios [RIRR] = 1.07, 95% CI:1.00,1.15), whereas volume sold of wine decreased by 3% (RIRR = 0.97, 95% CI:0.95,1.00). Overall alcohol (both beer and wine) volume sold increased in Seattle compared to Portland by 4% (RIRR = 1.04, 95% CI:1.01,1.07) at one-year post-tax and by 5% (RIRR = 1.05, 95% CI:1.00,1.10) at two-years post-tax. The implied SSB cross-price elasticities of demand for beer and wine, respectively, were calculated to be 0.35 and -0.15. CONCLUSIONS: There was evidence of substitution to beer following the implementation of the Seattle SSB tax. Continued monitoring of potential unintended outcomes related to the implementation of SSB taxes is needed in future tax evaluations.

"Holding the City's Feet to the Fire": Lessons Learned From Oakland's Implementation of Measure HH Sugar-Sweetened Beverage Tax.

CONTEXT: Sugar-sweetened beverage (SSB) taxes offer a promising public health strategy to decrease consumption of sugary beverages. To date, 7 US cities have successfully implemented SSB taxes; however, only a few studies have examined adoption and implementation processes. OBJECTIVES: To describe public health and policy lessons learned during the first 2.5 years of implementation of the Oakland, California, penny-per-ounce SSB tax, Measure HH. DESIGN: A mixed-methods, longitudinal, qualitative case study was conducted using a combination of key informant interviews with implementation stakeholders as well as analyses of archival documents and media documents from 2016 to 2019. Interviews were digitally recorded and professionally transcribed. Interview transcripts, archival documents, and media documents were analyzed by 3 coders using Atlas.ti v8. Analyses employed principles of constant comparative analysis to identify themes related to lessons learned. SETTING: Oakland, California. PARTICIPANTS: Key informants (n = 15), archival documents (n = 43), and media documents (n = 90). INTERVENTION: Oakland, California's SSB tax (Measure HH). RESULTS: Implementation lessons included both success stories and challenges. Successes included contracting a third-party tax administrator to support tax collection and education; leveraging a pro-tax coalition to counteract industry attacks and to protect tax revenue; and offering "quick win" funding to support local needs. Challenges were associated with implementing a "general" tax versus a "special" tax; the lack of explicit revenue allocation in the ordinance to support city-level implementation and oversight; and, the original ordinance language for tax application to distributors. CONCLUSIONS: The study offers a range of recommendations-derived from lessons learned over several years of implementation-to policy makers and advocates engaged in SSB tax adoption and implementation efforts in their jurisdictions. SSB tax implementation requires sufficient agency administrative capacity and a strong pro-tax coalition that engages local community organizations to respond to public health needs.

Longer-term impacts of the Oakland, California, sugar-sweetened beverage tax on prices and volume sold at two-years post-tax.

Sugar-sweetened beverage (SSB) consumption is associated with obesity and independently associated with type 2 diabetes and cardiovascular disease. Not only is obesity a growing public health problem, but it is also most recently associated with increased risk of severe illness from COVID-19. Taxes on SSBs are a policy tool used to help curb SSB consumption and are currently implemented in 7 U.S. cities and more than 40 countries. On July 1, 2017, Oakland, California, implemented a 1-cent/ounce tax on SSBs with ≥25 kilocalories/12 ounces. This study estimated the impact of the Oakland tax on prices, volume sold, and cross-border shopping two-years post-tax relative to one-year pre-tax. Universal product code-level Nielsen retail scanner data on non-alcoholic beverage sales were analyzed using a difference-in-differences design with Sacramento, California, as the comparison site. Taxed beverage prices increased by 0.67 cents/ounce, on average, in Oakland relative to Sacramento, corresponding to 67% pass-through. Taxed beverage volume sold decreased by 18% in Oakland relative to Sacramento, with a larger decrease for family-size beverages (23%) relative to individual-size beverages (8%). There was a 9% increase in volume sold of taxed beverages in the two-mile border area surrounding Oakland relative to the Sacramento border area, driven by a 12% increase for family-size taxed beverages. After accounting for this cross-border shopping, there was a net decrease of 6% in taxed beverage volume sold in Oakland. There was no significant change in untaxed beverage volume sold in either Oakland or its border area relative to their respective comparison sites, suggesting there was no substitution to untaxed beverages and cross-border shopping may have been limited to taxed beverages. This two-year post-tax study of the Oakland SSB tax adds to the limited number of longer-term evaluations of local U.S. SSB taxes.

The Potential for Healthy Checkout Policies to Advance Nutrition Equity.

BACKGROUND: As the only place in a store where all customers must pass through and wait, the checkout lane may be particularly influential over consumer purchases. Because most foods and beverages sold at checkout are unhealthy (e.g., candy, sweets, sugar-sweetened beverages, and salty snacks), policymakers and advocates have expressed growing interest in healthy checkout policies. To understand the extent to which such policies could improve nutrition equity, we assessed the prevalence and sociodemographic correlates of purchasing items found at (i.e., from) checkout. METHODS: We assessed self-reported checkout purchasing and sociodemographic characteristics in a national convenience sample of adults (n = 10,348) completing an online survey in 2021. RESULTS: Over one third (36%) of participants reported purchasing foods or drinks from checkout during their last grocery shopping trip. Purchasing items from checkout was more common among men; adults < 55 years of age; low-income consumers; Hispanic, non-Hispanic American Indian or Alaska Native, and non-Hispanic Black consumers; those with a graduate or professional degree; parents; and consumers diagnosed with type 2 diabetes or pre-diabetes (p-values < 0.05). CONCLUSIONS: Purchasing foods or beverages from store checkouts is common and more prevalent among low-income and Hispanic, American Indian or Alaska Native, and Black consumers. These results suggest that healthy checkout policies have the potential to improve nutrition equity.

Evaluation of Changes in Grams of Sugar Sold After the Implementation of the Seattle Sweetened Beverage Tax.

Importance: Adults and children routinely exceed recommended intake amounts of added sugars established by dietary guidelines. Taxes are used as a policy tool to reduce demand for sugar-sweetened beverages (SSBs) given consumption-related adverse health outcomes but may induce substitution to other sources of added sugars. Objective: To examine the extent to which changes in grams of sugar sold from taxed beverages may be offset by changes in grams of sugar sold from untaxed beverages, sweets, and stand-alone sugar after the implementation of the Seattle, Washington, Sweetened Beverage Tax (SBT) on January 1, 2018. Design, Setting, and Participants: This study used difference-in-differences analyses to examine changes in grams of sugar sold from taxed and untaxed products in Seattle compared with Portland, Oregon, at year 1 and year 2 post tax. This study used Nielsen scanner data from supermarkets and mass merchandise as well as grocery, drug, convenience, and dollar stores on unit sales and measurements for beverage and food product universal product codes (UPCs) for each site for the pretax period (January 8-December 30, 2017) and the corresponding weeks in year 1 post tax (2018) and in year 2 post tax (2019). Nutritional analyses assessed grams of sugar for each UPC. The analytical balanced sample included 1326 taxed beverage UPCs, 239 untaxed beverage UPCs, 2054 sweets UPCs, and 81 stand-alone sugar UPCs. Statistical analysis was performed from January to August 2021. Exposures: Implementation of the Seattle SBT. Main Outcomes and Measures: Changes in grams of sugar sold from taxed beverages, untaxed beverages, sweets, and stand-alone sugar. Results: At both year 1 and year 2 post tax in Seattle compared with Portland, grams of sugar sold from taxed beverages decreased 23% (year 2 posttax ratio of incidence rate ratios [RIRR] = 0.77; 95% CI, 0.73-0.80). Sugar sold from untaxed beverages increased at year 1 post tax by 4% (RIRR = 1.04; 95% CI, 1.00-1.07) with no change at year 2 post tax. Sugar sold from sweets increased by 4% at both year 1 and year 2 post tax (year 2 posttax RIRR = 1.04; 95% CI, 1.03-1.06). There were no changes in stand-alone sugar sold. Conclusions and Relevance: This study using difference-in-differences analysis found a net 19% reduction in grams of sugar sold from taxed SSBs at year 2 post tax after accounting for changes in sugar sold from untaxed beverages, sweets, and stand-alone sugar. These results suggest that SSB taxes may effectively yield permanent reductions in added sugars sold from SSBs in food stores.

Impact of a sugar-sweetened beverage tax two-year post-tax implementation in Seattle, Washington, United States.

This study examines longer-run impacts of the Seattle, Washington, Sweetened Beverage Tax (SBT) on beverage prices, volume sold, and cross-border shopping. We use a difference-in-differences estimation approach, drawing on universal product code-level store scanner data on taxed and untaxed beverages one-year pre-tax and two-year post-tax with Portland, Oregon, as the comparison site. Two-year post-tax, prices of taxed beverages increased by 1.04 cents per ounce (59% tax pass-through rate). Volume sold of taxed beverages fell by 22%. Declines were larger for family-size (29%) compared to individual-size (10%) beverages; particularly for soda (36% decrease for family-size compared to no change for individual-size). We found no change in volume sold of taxed beverages in Seattle's 2-mile border area, suggesting no cross-border shopping. Overall, we found a sustained impact of the Seattle SBT two-year post-tax implementation suggesting that sugar-sweetened beverage taxes may yield permanent reductions in demand for sugary beverages and associated health harms.

Examining changes to food and beverage availability and marketing in a low-income community after the opening of a new supermarket.

OBJECTIVE: In 2016, a Whole Foods Market© opened in the Englewood community of Chicago, IL - a predominately low-income African American community. This study aimed to examine changes to food and beverage availability and marketing in Englewood's existing food stores after the opening of this supermarket. DESIGN: Quasi-experimental study. SETTING: Two low-income African American communities in Chicago, IL. PARTICIPANTS: Fieldworkers audited all small grocery and limited service stores (e.g. convenience stores, liquor stores and dollar/discount stores) located within one-square mile of the new supermarket and a one-square mile area of a demographically comparable community that also lacked a supermarket. Stores were audited before (2016) and after (2017 and 2018) the supermarket opened. RESULTS: Of the 78 stores audited at baseline, 71·8 % were limited service stores and 85·9 % accepted Supplemental Nutrition Assistance Program (SNAP) benefits. Overall, the availability of healthy food and beverage options in nearby small stores was low at baseline and both follow-up periods. Difference-in-difference regression models revealed a significant increase in: (1) the percentage of stores in the intervention community (i.e. Englewood) offering regular cheese and promoting salty snacks at check-out from 2016 to 2017; and (2) the percentage of stores in the comparison community with interior store promotions for other sweetened beverages from 2016 to 2018. CONCLUSIONS: Minimal changes in food and beverage availability and marketing occurred 1 and 2 years after the opening of a new supermarket. However, the wide range of staple food items offered by the supermarket expanded healthy food retail in Chicago's Englewood community.

The Impact of Seattle's Sugar-Sweetened Beverage Tax on Substitution to Sweets and Salty Snacks.

BACKGROUND: Sugar-sweetened beverage (SSB) taxes may have broad effects on purchases of untaxed foods, and substitution of SSBs with untaxed sweets and/or salty snacks could offset the intended dietary and health effects of these policies. OBJECTIVES: To test whether there were changes in sales and calories sold for untaxed foods in response to the SSB tax in Seattle, Washington, at 12 and 24 months post-tax implementation. METHODS: On 1 January 2018, the City of Seattle levied a 1.75 cents per ounce excise tax on distributors selling targeted SSBs. We utilized universal product code-level store scanner data and employed a difference-in-differences approach to assess the impacts of the tax on the changes in 1) sales of sweets and salty snacks; and 2) total calories sold for sweets in Seattle relative to changes in its comparison site of Portland, Oregon, at 12 and 24 months post-tax. RESULTS: In the 12 months post-tax, sales of sweets increased by 4% [ratio of incidence rate ratios (RIRR), 1.04; 95% CI, 1.03-1.05] in Seattle relative to the changes in Portland; at 24 months post-tax, sweet sales increased by 6% (RIRR, 1.06; 95% CI, 1.05-1.07) relative to the pretax period. There was no significant change in sales of salty snacks at 12 months (RIRR, 1.00; 95% CI, 0.99-1.01) or 24 months (RIRR, 1.00; 95% CI, 0.98-1.02) post-tax. Total calories sold for sweets increased by 3% (RIRR, 1.03; 95% CI, 1.02-1.05) in Seattle compared with Portland at 12 months post-tax and by 4% (RIRR, 1.04; 95% CI, 1.02-1.05) at 24 months after implementation. CONCLUSIONS: There was modest substitution of SSBs for sweets in Seattle following tax implementation. However, this increase in sales and calories sold is not likely to offset previously identified tax-related reductions in the demand for taxed beverages in Seattle. Thus, SSB taxes are a promising policy tool to reduce caloric intake in the United States.

Employment impacts of the San Francisco sugar-sweetened beverage tax 2 years after implementation.

INTRODUCTION: Sugar-sweetened beverage (SSB) taxes have been implemented worldwide to raise revenue and reduce consumption of SSBs, which is associated with health harms. Empirical evaluations have found that these taxes are successful at reducing demand for SSBs; however, SSB taxes face opposition, in part because of claims that they will lead to substantial job losses. The purpose of this study is to examine the impact of the San Francisco SSB tax, implemented on January 1st, 2018, on employment. METHODS: Monthly employment counts were obtained from the Bureau of Labor Statistics from January 2013 (5-years pre-tax) through December 2019 (2-years post-tax) for the overall economy, private sector, supermarkets and other grocery stores, convenience stores, limited-service restaurants, and beverage manufacturing. A synthetic control analysis was conducted for each employment outcome. The synthetic controls (i.e., estimated counterfactuals) were generated from a pool of urban control counties using pre-tax labor market-related characteristics. RESULTS: The synthetic controls had similar labor market-related characteristics and employment outcomes to those in San Francisco in the pre-tax period. Up to 2 years post-tax, differences in employment between San Francisco and the synthetic controls were small and not "statistically significant" based on placebo tests for all employment outcomes. CONCLUSIONS: Up to two years post-tax, we do not find evidence that the San Francisco SSB tax negatively impacted net employment, employment in the private sector, or employment in specific SSB-related industries.

The impact of the Oakland SSB tax on prices and volume sold: A study of intended and unintended consequences.

We examine the effects of a sugar-sweetened beverage (SSB) tax that took effect in Oakland, California in 2017. Using rich customized universal product code -level data, we estimate the effect of the SSB tax on prices and volume in the short to medium term in a difference-in-differences framework. We pay particular attention to tax-avoidance strategies that may minimize the policy's intended effect including: (i) transfers to SSBs to the nontaxed border area (i.e., cross-border shopping), (ii) a move from high-priced per ounce single serve to their cheaper multipacks or larger format counterparts (i.e., format switching), and (iii) a move from high-priced beverages to less expensive ones within a category and format (i.e., brand switching). We find that the year-over-year tax pass-through is 49%. We find that volume sold of taxed beverages fell by 14%, but 46% of this decrease is offset with an increase in the border area. We also find evidence of substitution to lower-priced taxed beverages but no evidence of switching to cheaper formats. Finally, we find important dynamic effects with respect to tax pass-through, volume sold and cross-border shopping.

Oakland's Sugar-Sweetened Beverage Tax: Honoring the "Spirit" of the Ordinance Toward Equitable Implementation.

Purpose: On November 8, 2016, Oakland, California, voters passed a sugar-sweetened beverage (SSB) tax, which included language to support programs affecting communities and residents most affected by SSB-related health disparities. The purpose of this study was to qualitatively assess the extent to which those communities most affected by SSB-related health disparities were included in implementation decisions and were recipients of funding to support their needs. Methods: A longitudinal case study from 2016 to 2019 in Oakland, CA, explored equity implementation themes through key informant interview transcripts (n=15) triangulated with media (n=90) and archived documents (n=43). Using principals of constant comparative analysis, all documents (n=148) were coded and thematically analyzed in Atlas.ti. Results: SSB taxes-designed to support communities disproportionately impacted by SSB consumption-can be implemented with inclusivity and community representation. The Oakland ordinance established a Community Advisory Board (CAB) that partnered with community organizations throughout implementation to ensure inclusivity and recommend funding for programs to address health inequities, described as the "spirit" of the ordinance. These activities countered the beverage industry's tactics to target lower income communities of color with misinformation campaigns and hinder implementation. Conclusion: A clearly written ordinance provides guidance, which affords an intentional and legal foundation for implementation processes. Establishing a CAB can mitigate inequities as members are invested in the community and initiatives to support residents. Advisory boards are able to liaise between city and local partners, which is a powerful tool for countering opposition campaigns, reaching lower income and communities of color, and ensuring adherence to funding mandates.