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The hazardous and obesogenic food environment are very major contributors to health loss in Aotearoa New Zealand. In this country 32% of adults are obese (Māori: 47%; Pacific: 65%)1 and ischaemic heart disease (for which diet is a key risk factor) is the most common cause of death.2 Indeed, dietary risk factors and high body mass index are both in the top three leading causes of health loss in the country, when considering death and disability combined.2

Nutrition-related diseases such as diabetes, cardiovascular disease and obesity-related cancers are a particular burden for Māori and Pasifika and so are a major driver of ethnic inequalities in health in New Zealand. In particular, obesity appears to increasingly be a key contributor to ethnic inequalities in the cancer burden in this country.3

To give an indication of the huge size of the preventable burden in the nutrition domain, a single intervention to reduce salt (sodium) in the processed food supply in New Zealand could save an estimated 294,000 years of life (more precisely quality-adjusted life-years [QALYs]), over the remaining lifetime of the New Zealand population.4 This salt reduction intervention was also estimated to produce net cost-savings to the health system of NZ$ 1.5 billion. (Examples of other health generating and cost-saving dietary interventions for New Zealand and Australia are detailed in a recently developed online league table5). More specifically, the health risks of some food products are increasingly being clarified eg, consumption of sugar-sweetened beverages (SSBs) is associated with increased mortality primarily through cardiovascular mortality, with a graded association with dose.6 Furthermore, there is evidence that sugary drinks may provide greater health risks relative to sugar-containing foods.7

There are some regulations around food safety in New Zealand, but processed food is largely unregulated for nutritional content, eg, manufacturers have no limits on the amount of potentially hazardous ingredients (ie, sugar, salt and saturated fat) they can add to processed foods (albeit a diverse category that includes ultra-processed foods8). None of the damage to health of New Zealanders and the public health system costs associated with processed food are specifically paid for by the food industry (ie, it is largely paid by the taxpayer-funded health system and also by individuals and their families). This means a major market failure exists9 and negative externalities are imposed on society. Such a market failure provides one rationale for taxes on unhealthy foods and beverages; or at least some type of regulation. But a potentially more important rationale is that taxes can be used as an effective instrument to achieve a societal goal, such as reducing child obesity.

Under Te Tiriti o Waitangi (the Treaty of Waitangi), the New Zealand Government has a duty to protect the health and wellbeing of Māori. In addition to the well-established ethical arguments for reducing health inequities in society, the Treaty provides a strong basis for Government action to reduce the harm imposed on Māori by the processed food industry. The Treaty is also relevant to the protection of land, the environment and the food sources cultivated and harvested by Māori. Treaty settlements also need to address the confiscation of Māori land in the 1800s, with some of this land being a source of food for Māori and part of economic prosperity.10

Given this background, this article briefly considers recent international and New Zealand evidence concerning food/beverages taxes and subsidies. It then identifies those issues of potential relevance to the New Zealand Government around making progress in these domains.

International evidence

Following a literature search, 14 systematic reviews on food or beverage interventions involving taxes or subsidies were identified (search in PubMed from 1 January 2015 to 15 June 2019). The study designs used within these reviews varied and included experimental, cross-sectional, simulations and ‘real world’ quasi-experimental studies. Each systematic review consistently showed changes in food or beverage consumption in directions favouring health (Appendix Table 1). There is some evidence that such interventions can benefit all socio-economic groups (reviews by Olstad et al11 and Backholer et al12 in Appendix Table 1) and may reduce inequities.11 However, one systematic review found unclear income-related impacts (Mizdrak et al13). The evidence around substitution behaviours is somewhat limited. Nevertheless, one meta-analysis reported a suggestive pattern of increased bottled water use with SSB taxes (Teng et al,14 in Appendix Table 1).

Given that most of the evidence in these 14 systematic reviews comes from high-income country studies, it probably has fairly high generalisability to the New Zealand setting. Even the systematic review of sugary drink taxes in middle-income countries15 may have relevance—especially for low-income New Zealand populations who may also be experiencing financial hardship. The overall international evidence is also consistent with the evidence for behaviour changes and health benefits from other health protecting taxes, including tobacco tax for tobacco control16 and alcohol taxes for alcohol control.17–19

Evidence from New Zealand

The recent New Zealand evidence around pricing interventions and food costs is summarised in Appendix Table 2 (covering 12 studies published between 1 January 2010 and 31 March 2019; albeit 13 articles). In general, this evidence is consistent with the international evidence detailed above, by showing that tax and subsidy interventions can potentially improve health. The studies provide some indication that food pricing interventions may have pro-equity impacts (as in Appendix Table 2: Ni Mhurchu et al 201320; Ni Mhurchu et al 201421). In some of this work a modelled 20% tax on all carbonated drinks was estimated to reduce daily energy intakes, avert or postpone 0.2% of all deaths in New Zealand per year, and reduce diabetes and obesity. The impact was estimated to be larger in Māori and Pacific populations compared to non-Māori and non-Pacific populations due to greater responsiveness to food price changes, and among children and young people compared to other ages due to their higher consumption of SSBs.21 A 20% tax on SSBs was estimated to generate NZ$ 40 million in revenue per year (even allowing for reduced consumption), which could be used for health promotion and healthy food subsidies.

The evidence from randomised controlled trials (RCTs) in New Zealand is more limited. One of these was only a pilot study and involved free fruit in schools.22 It indicated an increase in fruit intake, albeit in the short-term. Another RCT indicated some increased purchasing of healthier foods with price discounts in supermarkets.23

More generally in terms of health protecting taxes, New Zealand research provides evidence that tobacco taxes are effective for tobacco control,24,25 and that alcohol taxes contribute to alcohol control.26,27

Issues that the New Zealand Government should consider

The above evidence suggests that the New Zealand Government should give serious consideration to food and beverage pricing interventions. This approach would certainly be favoured by many New Zealand-based experts. For example, expert panels have described this country’s use of “food fiscal policies” as involving “no action” in both 201428 and in 2017.29 Furthermore, this work found that over 50 expert panel members rated the implementation of a tax on SSBs as a high priority for the Government. Below we consider some of the more specific issues that the Government should consider.

A strategic shift towards health protecting taxes

The Tax Working Group recommended in their 2019 Report,30 and the Government accepted, the need to apply “corrective taxes” to reduce externalities and mitigate environmental damage caused by industry. We agree with aspects of this approach, but suggest that the prime reason for such taxes should be to achieve societal goals (ie, reducing child obesity), as opposed to merely “correcting” for negative externalities which are often hard to quantify. In Appendix Table 3 we detail the key issues around adopting a new health protecting tax (ie, a sugary drink industry levy) and make comparisons with an existing health protecting tax: tobacco tax.

Introduction of a sugary drink industry levy

Such a tax is increasingly being adopted in other jurisdictions.31 For New Zealand, it could potentially be modelled on the UK “soft drink industry levy” which triggered substantial reformulation by industry,32 and which modelling studies have suggested there will be significant health benefits.33 Such a levy would be in line with current Government’s priority on improving wellbeing and protecting child health and would be consistent with New Zealand’s approach to taxing tobacco and alcohol. Substitution concerns may be ameliorated by improving access to water (eg, provision of more drinking fountains in public places—which are deficient at present in New Zealand34,35). The literature is also suggestive concerning SSB taxes being associated with increased water consumption (eg, in Berkeley, California36).

In Australia, the discourse around SSB taxes has been informed by using a citizens’ jury,37 and this methodology could be used in New Zealand. However, public support in New Zealand is already relatively high (eg, 67% in one poll in 2017,38 up from 52% in an earlier poll in 201539), if the tax revenue is used to fund childhood obesity prevention programmes. Support might be further enhanced, at least among parents of adolescents, if the SSB tax also encompassed sugary alcohol drinks (ie, ready-to-drink beverages).

A Mexican-style junk food tax

There is real-world evidence for such a tax having an impact from Mexico.40,41 Chile also has such a tax, with modelling work suggesting a likely favourable impact.42 These type of taxes have the particular advantage of covering a wide range of potentially hazardous foods (ie, processed foods high in sodium, sugar and saturated fat, which are also low in dietary fibre). As such, this broad type of tax may lower the risk of adverse substitution effects (eg, people switching from junk food high in sugar to junk food high in sodium). Including targeted food subsidies and tax revenue recycling could be considered as part of the same policy package (as detailed further below).

Tax revenue recycling to the community

To help address concerns around regressivity of food and beverage taxes, it is ideal that the tax revenue is recycled to the community. This could be by funding free (fully-subsidised) healthy breakfasts and lunches in all low-income schools and early childhood education centres, and ensuring adequate drinking water fountains in all public settings. But as per the experience in Philadelphia with a new SSB tax, the community might favour directing the tax revenue to non-health areas such as improved childcare services or parental leave.43 Reductions in GST and income tax are other recycling options. This type of tax revenue recycling can increase community support for raising specific taxes, as seen with British Columbia’s successful carbon tax.44,45

Further research

We consider that there is clearly enough evidence around food/beverage pricing interventions for policy-makers in New Zealand to seriously consider such approaches, eg, adopting a UK-style sugary drinks industry levy. But while doing so, health authorities should also keep systematically evaluating ongoing research (eg, a RCT in New Zealand suggesting benefits of food tax/subsidy interventions that was published just after the review period used in this article46 and as part BODE3 modelling work, as per these publications on dietary interventions47,48). Also further research may help fine-tune any New Zealand-adopted interventions so as to maximise the health gain, the cost-effectiveness of intervention application and the impact on reducing health inequalities in the New Zealand setting (ie, especially for Māori, Pasifika and low-income New Zealanders).

Conclusions

In this article we briefly consider recent literature (14 recent systematic reviews and 12 relevant New Zealand studies) on food/beverage taxes and subsidies. This evidence clearly indicates that tax and subsidy interventions have favourable impacts from a health perspective and would seem likely to work in the New Zealand setting. Given this overall picture, such tax/subsidy interventions would be an important evidence-based policy as part of a wider strategy to improve the nutritional health of New Zealanders. A UK-style sugary drinks industry levy should be considered as an initial step. The findings of this review forms the basis of the position of the Health Coalition Aotearoa, a new non-governmental organisation which includes New Zealand health workers and researchers with expertise in nutrition.

Appendix

Appendix Table 1: Systematic reviews (n=14) published on food and beverage taxes and subsidies (ordered by ascending publication year for the period January 2015 to June 2019).*

Note: *The search was conducted in PubMed for the period 1 January 2015 to 15 June 2019 with a range of search terms: eg, “systematic review” and food/beverage, price/subsidy. But the Teng et al study was identified via co-author involvement in this particular study and the Cochrane review was identified via media reporting. We excluded the systematic review by Sisnowski et al 201558 as it did not cover impacts (but rather the popularity of taxation relative to other interventions).

Appendix Table 2: New Zealand studies (n=12) relating to food pricing and food costs, published in the peer-review literature (for the period January 2010 to March 2019; ordered by publication year).*

Note: * The search was conducted in PubMed for the period 1 January 2010 to 31 March 2019. Search terms included: “Zealand” and food/beverage and price/subsidy/cost.

Appendix Table 3: Primary and supportive issues when considering a new health protecting tax (ie, in this case on sugary drinks) and a comparison with an established tax in New Zealand on tobacco.

Summary

Abstract

The hazardous and obesogenic food environment are major contributors to health loss in Aotearoa New Zealand. Here we consider the potential use of food taxes and subsidies to protect health in this country. We find that each one of the 14 recent systematic reviews on the tax and/or subsidy topic since 2015 in the scientific literature report that such interventions have favourable impacts from a health perspective. The New Zealand evidence we considered (n=12 studies since January 2010) is less definitive, but the pattern of results is consistent with the international evidence. Given this overall picture, the New Zealand Government should seriously consider such tax/subsidy interventions, potentially starting with a UK-style sugary drinks industry levy.

Aim

Method

Results

Conclusion

Author Information

Nick Wilson, Food Policy Group, Health Coalition Aotearoa; BODE3 Programme, University of Otago, Wellington; Lisa Te Morenga, Food Policy Group, Health Coalition Aotearoa; Sally Mackay, Food Policy Group, Health Coalition Aotearoa; School of Population Health, University of Auckland, Auckland; Sarah Gerritsen, Food Policy Group, Health Coalition Aotearoa; School of Population Health, University of Auckland, Auckland; Christine Cleghorn, Food Policy Group, Health Coalition Aotearoa; BODE3 Programme, University of Otago, Wellington; Amanda C Jones, BODE3 Programme, University of Otago, Wellington; Boyd Swinburn, Food Policy Group, Health Coalition Aotearoa; School of Population Health, University of Auckland, Auckland.

Acknowledgements

The authors who work for the BODE3 Programme (NW, CC, AJ) benefited funding support from the Health Research Council of New Zealand (Project number: 16/443).

Correspondence

Professor Nick Wilson; Food Policy Group, Health Coalition Aotearoa; BODE3 Programme, University of Otago, Wellington.

Correspondence Email

nick.wilson@otago.ac.nz

Competing Interests

Nil.

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The hazardous and obesogenic food environment are very major contributors to health loss in Aotearoa New Zealand. In this country 32% of adults are obese (Māori: 47%; Pacific: 65%)1 and ischaemic heart disease (for which diet is a key risk factor) is the most common cause of death.2 Indeed, dietary risk factors and high body mass index are both in the top three leading causes of health loss in the country, when considering death and disability combined.2

Nutrition-related diseases such as diabetes, cardiovascular disease and obesity-related cancers are a particular burden for Māori and Pasifika and so are a major driver of ethnic inequalities in health in New Zealand. In particular, obesity appears to increasingly be a key contributor to ethnic inequalities in the cancer burden in this country.3

To give an indication of the huge size of the preventable burden in the nutrition domain, a single intervention to reduce salt (sodium) in the processed food supply in New Zealand could save an estimated 294,000 years of life (more precisely quality-adjusted life-years [QALYs]), over the remaining lifetime of the New Zealand population.4 This salt reduction intervention was also estimated to produce net cost-savings to the health system of NZ$ 1.5 billion. (Examples of other health generating and cost-saving dietary interventions for New Zealand and Australia are detailed in a recently developed online league table5). More specifically, the health risks of some food products are increasingly being clarified eg, consumption of sugar-sweetened beverages (SSBs) is associated with increased mortality primarily through cardiovascular mortality, with a graded association with dose.6 Furthermore, there is evidence that sugary drinks may provide greater health risks relative to sugar-containing foods.7

There are some regulations around food safety in New Zealand, but processed food is largely unregulated for nutritional content, eg, manufacturers have no limits on the amount of potentially hazardous ingredients (ie, sugar, salt and saturated fat) they can add to processed foods (albeit a diverse category that includes ultra-processed foods8). None of the damage to health of New Zealanders and the public health system costs associated with processed food are specifically paid for by the food industry (ie, it is largely paid by the taxpayer-funded health system and also by individuals and their families). This means a major market failure exists9 and negative externalities are imposed on society. Such a market failure provides one rationale for taxes on unhealthy foods and beverages; or at least some type of regulation. But a potentially more important rationale is that taxes can be used as an effective instrument to achieve a societal goal, such as reducing child obesity.

Under Te Tiriti o Waitangi (the Treaty of Waitangi), the New Zealand Government has a duty to protect the health and wellbeing of Māori. In addition to the well-established ethical arguments for reducing health inequities in society, the Treaty provides a strong basis for Government action to reduce the harm imposed on Māori by the processed food industry. The Treaty is also relevant to the protection of land, the environment and the food sources cultivated and harvested by Māori. Treaty settlements also need to address the confiscation of Māori land in the 1800s, with some of this land being a source of food for Māori and part of economic prosperity.10

Given this background, this article briefly considers recent international and New Zealand evidence concerning food/beverages taxes and subsidies. It then identifies those issues of potential relevance to the New Zealand Government around making progress in these domains.

International evidence

Following a literature search, 14 systematic reviews on food or beverage interventions involving taxes or subsidies were identified (search in PubMed from 1 January 2015 to 15 June 2019). The study designs used within these reviews varied and included experimental, cross-sectional, simulations and ‘real world’ quasi-experimental studies. Each systematic review consistently showed changes in food or beverage consumption in directions favouring health (Appendix Table 1). There is some evidence that such interventions can benefit all socio-economic groups (reviews by Olstad et al11 and Backholer et al12 in Appendix Table 1) and may reduce inequities.11 However, one systematic review found unclear income-related impacts (Mizdrak et al13). The evidence around substitution behaviours is somewhat limited. Nevertheless, one meta-analysis reported a suggestive pattern of increased bottled water use with SSB taxes (Teng et al,14 in Appendix Table 1).

Given that most of the evidence in these 14 systematic reviews comes from high-income country studies, it probably has fairly high generalisability to the New Zealand setting. Even the systematic review of sugary drink taxes in middle-income countries15 may have relevance—especially for low-income New Zealand populations who may also be experiencing financial hardship. The overall international evidence is also consistent with the evidence for behaviour changes and health benefits from other health protecting taxes, including tobacco tax for tobacco control16 and alcohol taxes for alcohol control.17–19

Evidence from New Zealand

The recent New Zealand evidence around pricing interventions and food costs is summarised in Appendix Table 2 (covering 12 studies published between 1 January 2010 and 31 March 2019; albeit 13 articles). In general, this evidence is consistent with the international evidence detailed above, by showing that tax and subsidy interventions can potentially improve health. The studies provide some indication that food pricing interventions may have pro-equity impacts (as in Appendix Table 2: Ni Mhurchu et al 201320; Ni Mhurchu et al 201421). In some of this work a modelled 20% tax on all carbonated drinks was estimated to reduce daily energy intakes, avert or postpone 0.2% of all deaths in New Zealand per year, and reduce diabetes and obesity. The impact was estimated to be larger in Māori and Pacific populations compared to non-Māori and non-Pacific populations due to greater responsiveness to food price changes, and among children and young people compared to other ages due to their higher consumption of SSBs.21 A 20% tax on SSBs was estimated to generate NZ$ 40 million in revenue per year (even allowing for reduced consumption), which could be used for health promotion and healthy food subsidies.

The evidence from randomised controlled trials (RCTs) in New Zealand is more limited. One of these was only a pilot study and involved free fruit in schools.22 It indicated an increase in fruit intake, albeit in the short-term. Another RCT indicated some increased purchasing of healthier foods with price discounts in supermarkets.23

More generally in terms of health protecting taxes, New Zealand research provides evidence that tobacco taxes are effective for tobacco control,24,25 and that alcohol taxes contribute to alcohol control.26,27

Issues that the New Zealand Government should consider

The above evidence suggests that the New Zealand Government should give serious consideration to food and beverage pricing interventions. This approach would certainly be favoured by many New Zealand-based experts. For example, expert panels have described this country’s use of “food fiscal policies” as involving “no action” in both 201428 and in 2017.29 Furthermore, this work found that over 50 expert panel members rated the implementation of a tax on SSBs as a high priority for the Government. Below we consider some of the more specific issues that the Government should consider.

A strategic shift towards health protecting taxes

The Tax Working Group recommended in their 2019 Report,30 and the Government accepted, the need to apply “corrective taxes” to reduce externalities and mitigate environmental damage caused by industry. We agree with aspects of this approach, but suggest that the prime reason for such taxes should be to achieve societal goals (ie, reducing child obesity), as opposed to merely “correcting” for negative externalities which are often hard to quantify. In Appendix Table 3 we detail the key issues around adopting a new health protecting tax (ie, a sugary drink industry levy) and make comparisons with an existing health protecting tax: tobacco tax.

Introduction of a sugary drink industry levy

Such a tax is increasingly being adopted in other jurisdictions.31 For New Zealand, it could potentially be modelled on the UK “soft drink industry levy” which triggered substantial reformulation by industry,32 and which modelling studies have suggested there will be significant health benefits.33 Such a levy would be in line with current Government’s priority on improving wellbeing and protecting child health and would be consistent with New Zealand’s approach to taxing tobacco and alcohol. Substitution concerns may be ameliorated by improving access to water (eg, provision of more drinking fountains in public places—which are deficient at present in New Zealand34,35). The literature is also suggestive concerning SSB taxes being associated with increased water consumption (eg, in Berkeley, California36).

In Australia, the discourse around SSB taxes has been informed by using a citizens’ jury,37 and this methodology could be used in New Zealand. However, public support in New Zealand is already relatively high (eg, 67% in one poll in 2017,38 up from 52% in an earlier poll in 201539), if the tax revenue is used to fund childhood obesity prevention programmes. Support might be further enhanced, at least among parents of adolescents, if the SSB tax also encompassed sugary alcohol drinks (ie, ready-to-drink beverages).

A Mexican-style junk food tax

There is real-world evidence for such a tax having an impact from Mexico.40,41 Chile also has such a tax, with modelling work suggesting a likely favourable impact.42 These type of taxes have the particular advantage of covering a wide range of potentially hazardous foods (ie, processed foods high in sodium, sugar and saturated fat, which are also low in dietary fibre). As such, this broad type of tax may lower the risk of adverse substitution effects (eg, people switching from junk food high in sugar to junk food high in sodium). Including targeted food subsidies and tax revenue recycling could be considered as part of the same policy package (as detailed further below).

Tax revenue recycling to the community

To help address concerns around regressivity of food and beverage taxes, it is ideal that the tax revenue is recycled to the community. This could be by funding free (fully-subsidised) healthy breakfasts and lunches in all low-income schools and early childhood education centres, and ensuring adequate drinking water fountains in all public settings. But as per the experience in Philadelphia with a new SSB tax, the community might favour directing the tax revenue to non-health areas such as improved childcare services or parental leave.43 Reductions in GST and income tax are other recycling options. This type of tax revenue recycling can increase community support for raising specific taxes, as seen with British Columbia’s successful carbon tax.44,45

Further research

We consider that there is clearly enough evidence around food/beverage pricing interventions for policy-makers in New Zealand to seriously consider such approaches, eg, adopting a UK-style sugary drinks industry levy. But while doing so, health authorities should also keep systematically evaluating ongoing research (eg, a RCT in New Zealand suggesting benefits of food tax/subsidy interventions that was published just after the review period used in this article46 and as part BODE3 modelling work, as per these publications on dietary interventions47,48). Also further research may help fine-tune any New Zealand-adopted interventions so as to maximise the health gain, the cost-effectiveness of intervention application and the impact on reducing health inequalities in the New Zealand setting (ie, especially for Māori, Pasifika and low-income New Zealanders).

Conclusions

In this article we briefly consider recent literature (14 recent systematic reviews and 12 relevant New Zealand studies) on food/beverage taxes and subsidies. This evidence clearly indicates that tax and subsidy interventions have favourable impacts from a health perspective and would seem likely to work in the New Zealand setting. Given this overall picture, such tax/subsidy interventions would be an important evidence-based policy as part of a wider strategy to improve the nutritional health of New Zealanders. A UK-style sugary drinks industry levy should be considered as an initial step. The findings of this review forms the basis of the position of the Health Coalition Aotearoa, a new non-governmental organisation which includes New Zealand health workers and researchers with expertise in nutrition.

Appendix

Appendix Table 1: Systematic reviews (n=14) published on food and beverage taxes and subsidies (ordered by ascending publication year for the period January 2015 to June 2019).*

Note: *The search was conducted in PubMed for the period 1 January 2015 to 15 June 2019 with a range of search terms: eg, “systematic review” and food/beverage, price/subsidy. But the Teng et al study was identified via co-author involvement in this particular study and the Cochrane review was identified via media reporting. We excluded the systematic review by Sisnowski et al 201558 as it did not cover impacts (but rather the popularity of taxation relative to other interventions).

Appendix Table 2: New Zealand studies (n=12) relating to food pricing and food costs, published in the peer-review literature (for the period January 2010 to March 2019; ordered by publication year).*

Note: * The search was conducted in PubMed for the period 1 January 2010 to 31 March 2019. Search terms included: “Zealand” and food/beverage and price/subsidy/cost.

Appendix Table 3: Primary and supportive issues when considering a new health protecting tax (ie, in this case on sugary drinks) and a comparison with an established tax in New Zealand on tobacco.

Summary

Abstract

The hazardous and obesogenic food environment are major contributors to health loss in Aotearoa New Zealand. Here we consider the potential use of food taxes and subsidies to protect health in this country. We find that each one of the 14 recent systematic reviews on the tax and/or subsidy topic since 2015 in the scientific literature report that such interventions have favourable impacts from a health perspective. The New Zealand evidence we considered (n=12 studies since January 2010) is less definitive, but the pattern of results is consistent with the international evidence. Given this overall picture, the New Zealand Government should seriously consider such tax/subsidy interventions, potentially starting with a UK-style sugary drinks industry levy.

Aim

Method

Results

Conclusion

Author Information

Nick Wilson, Food Policy Group, Health Coalition Aotearoa; BODE3 Programme, University of Otago, Wellington; Lisa Te Morenga, Food Policy Group, Health Coalition Aotearoa; Sally Mackay, Food Policy Group, Health Coalition Aotearoa; School of Population Health, University of Auckland, Auckland; Sarah Gerritsen, Food Policy Group, Health Coalition Aotearoa; School of Population Health, University of Auckland, Auckland; Christine Cleghorn, Food Policy Group, Health Coalition Aotearoa; BODE3 Programme, University of Otago, Wellington; Amanda C Jones, BODE3 Programme, University of Otago, Wellington; Boyd Swinburn, Food Policy Group, Health Coalition Aotearoa; School of Population Health, University of Auckland, Auckland.

Acknowledgements

The authors who work for the BODE3 Programme (NW, CC, AJ) benefited funding support from the Health Research Council of New Zealand (Project number: 16/443).

Correspondence

Professor Nick Wilson; Food Policy Group, Health Coalition Aotearoa; BODE3 Programme, University of Otago, Wellington.

Correspondence Email

nick.wilson@otago.ac.nz

Competing Interests

Nil.

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The hazardous and obesogenic food environment are very major contributors to health loss in Aotearoa New Zealand. In this country 32% of adults are obese (Māori: 47%; Pacific: 65%)1 and ischaemic heart disease (for which diet is a key risk factor) is the most common cause of death.2 Indeed, dietary risk factors and high body mass index are both in the top three leading causes of health loss in the country, when considering death and disability combined.2

Nutrition-related diseases such as diabetes, cardiovascular disease and obesity-related cancers are a particular burden for Māori and Pasifika and so are a major driver of ethnic inequalities in health in New Zealand. In particular, obesity appears to increasingly be a key contributor to ethnic inequalities in the cancer burden in this country.3

To give an indication of the huge size of the preventable burden in the nutrition domain, a single intervention to reduce salt (sodium) in the processed food supply in New Zealand could save an estimated 294,000 years of life (more precisely quality-adjusted life-years [QALYs]), over the remaining lifetime of the New Zealand population.4 This salt reduction intervention was also estimated to produce net cost-savings to the health system of NZ$ 1.5 billion. (Examples of other health generating and cost-saving dietary interventions for New Zealand and Australia are detailed in a recently developed online league table5). More specifically, the health risks of some food products are increasingly being clarified eg, consumption of sugar-sweetened beverages (SSBs) is associated with increased mortality primarily through cardiovascular mortality, with a graded association with dose.6 Furthermore, there is evidence that sugary drinks may provide greater health risks relative to sugar-containing foods.7

There are some regulations around food safety in New Zealand, but processed food is largely unregulated for nutritional content, eg, manufacturers have no limits on the amount of potentially hazardous ingredients (ie, sugar, salt and saturated fat) they can add to processed foods (albeit a diverse category that includes ultra-processed foods8). None of the damage to health of New Zealanders and the public health system costs associated with processed food are specifically paid for by the food industry (ie, it is largely paid by the taxpayer-funded health system and also by individuals and their families). This means a major market failure exists9 and negative externalities are imposed on society. Such a market failure provides one rationale for taxes on unhealthy foods and beverages; or at least some type of regulation. But a potentially more important rationale is that taxes can be used as an effective instrument to achieve a societal goal, such as reducing child obesity.

Under Te Tiriti o Waitangi (the Treaty of Waitangi), the New Zealand Government has a duty to protect the health and wellbeing of Māori. In addition to the well-established ethical arguments for reducing health inequities in society, the Treaty provides a strong basis for Government action to reduce the harm imposed on Māori by the processed food industry. The Treaty is also relevant to the protection of land, the environment and the food sources cultivated and harvested by Māori. Treaty settlements also need to address the confiscation of Māori land in the 1800s, with some of this land being a source of food for Māori and part of economic prosperity.10

Given this background, this article briefly considers recent international and New Zealand evidence concerning food/beverages taxes and subsidies. It then identifies those issues of potential relevance to the New Zealand Government around making progress in these domains.

International evidence

Following a literature search, 14 systematic reviews on food or beverage interventions involving taxes or subsidies were identified (search in PubMed from 1 January 2015 to 15 June 2019). The study designs used within these reviews varied and included experimental, cross-sectional, simulations and ‘real world’ quasi-experimental studies. Each systematic review consistently showed changes in food or beverage consumption in directions favouring health (Appendix Table 1). There is some evidence that such interventions can benefit all socio-economic groups (reviews by Olstad et al11 and Backholer et al12 in Appendix Table 1) and may reduce inequities.11 However, one systematic review found unclear income-related impacts (Mizdrak et al13). The evidence around substitution behaviours is somewhat limited. Nevertheless, one meta-analysis reported a suggestive pattern of increased bottled water use with SSB taxes (Teng et al,14 in Appendix Table 1).

Given that most of the evidence in these 14 systematic reviews comes from high-income country studies, it probably has fairly high generalisability to the New Zealand setting. Even the systematic review of sugary drink taxes in middle-income countries15 may have relevance—especially for low-income New Zealand populations who may also be experiencing financial hardship. The overall international evidence is also consistent with the evidence for behaviour changes and health benefits from other health protecting taxes, including tobacco tax for tobacco control16 and alcohol taxes for alcohol control.17–19

Evidence from New Zealand

The recent New Zealand evidence around pricing interventions and food costs is summarised in Appendix Table 2 (covering 12 studies published between 1 January 2010 and 31 March 2019; albeit 13 articles). In general, this evidence is consistent with the international evidence detailed above, by showing that tax and subsidy interventions can potentially improve health. The studies provide some indication that food pricing interventions may have pro-equity impacts (as in Appendix Table 2: Ni Mhurchu et al 201320; Ni Mhurchu et al 201421). In some of this work a modelled 20% tax on all carbonated drinks was estimated to reduce daily energy intakes, avert or postpone 0.2% of all deaths in New Zealand per year, and reduce diabetes and obesity. The impact was estimated to be larger in Māori and Pacific populations compared to non-Māori and non-Pacific populations due to greater responsiveness to food price changes, and among children and young people compared to other ages due to their higher consumption of SSBs.21 A 20% tax on SSBs was estimated to generate NZ$ 40 million in revenue per year (even allowing for reduced consumption), which could be used for health promotion and healthy food subsidies.

The evidence from randomised controlled trials (RCTs) in New Zealand is more limited. One of these was only a pilot study and involved free fruit in schools.22 It indicated an increase in fruit intake, albeit in the short-term. Another RCT indicated some increased purchasing of healthier foods with price discounts in supermarkets.23

More generally in terms of health protecting taxes, New Zealand research provides evidence that tobacco taxes are effective for tobacco control,24,25 and that alcohol taxes contribute to alcohol control.26,27

Issues that the New Zealand Government should consider

The above evidence suggests that the New Zealand Government should give serious consideration to food and beverage pricing interventions. This approach would certainly be favoured by many New Zealand-based experts. For example, expert panels have described this country’s use of “food fiscal policies” as involving “no action” in both 201428 and in 2017.29 Furthermore, this work found that over 50 expert panel members rated the implementation of a tax on SSBs as a high priority for the Government. Below we consider some of the more specific issues that the Government should consider.

A strategic shift towards health protecting taxes

The Tax Working Group recommended in their 2019 Report,30 and the Government accepted, the need to apply “corrective taxes” to reduce externalities and mitigate environmental damage caused by industry. We agree with aspects of this approach, but suggest that the prime reason for such taxes should be to achieve societal goals (ie, reducing child obesity), as opposed to merely “correcting” for negative externalities which are often hard to quantify. In Appendix Table 3 we detail the key issues around adopting a new health protecting tax (ie, a sugary drink industry levy) and make comparisons with an existing health protecting tax: tobacco tax.

Introduction of a sugary drink industry levy

Such a tax is increasingly being adopted in other jurisdictions.31 For New Zealand, it could potentially be modelled on the UK “soft drink industry levy” which triggered substantial reformulation by industry,32 and which modelling studies have suggested there will be significant health benefits.33 Such a levy would be in line with current Government’s priority on improving wellbeing and protecting child health and would be consistent with New Zealand’s approach to taxing tobacco and alcohol. Substitution concerns may be ameliorated by improving access to water (eg, provision of more drinking fountains in public places—which are deficient at present in New Zealand34,35). The literature is also suggestive concerning SSB taxes being associated with increased water consumption (eg, in Berkeley, California36).

In Australia, the discourse around SSB taxes has been informed by using a citizens’ jury,37 and this methodology could be used in New Zealand. However, public support in New Zealand is already relatively high (eg, 67% in one poll in 2017,38 up from 52% in an earlier poll in 201539), if the tax revenue is used to fund childhood obesity prevention programmes. Support might be further enhanced, at least among parents of adolescents, if the SSB tax also encompassed sugary alcohol drinks (ie, ready-to-drink beverages).

A Mexican-style junk food tax

There is real-world evidence for such a tax having an impact from Mexico.40,41 Chile also has such a tax, with modelling work suggesting a likely favourable impact.42 These type of taxes have the particular advantage of covering a wide range of potentially hazardous foods (ie, processed foods high in sodium, sugar and saturated fat, which are also low in dietary fibre). As such, this broad type of tax may lower the risk of adverse substitution effects (eg, people switching from junk food high in sugar to junk food high in sodium). Including targeted food subsidies and tax revenue recycling could be considered as part of the same policy package (as detailed further below).

Tax revenue recycling to the community

To help address concerns around regressivity of food and beverage taxes, it is ideal that the tax revenue is recycled to the community. This could be by funding free (fully-subsidised) healthy breakfasts and lunches in all low-income schools and early childhood education centres, and ensuring adequate drinking water fountains in all public settings. But as per the experience in Philadelphia with a new SSB tax, the community might favour directing the tax revenue to non-health areas such as improved childcare services or parental leave.43 Reductions in GST and income tax are other recycling options. This type of tax revenue recycling can increase community support for raising specific taxes, as seen with British Columbia’s successful carbon tax.44,45

Further research

We consider that there is clearly enough evidence around food/beverage pricing interventions for policy-makers in New Zealand to seriously consider such approaches, eg, adopting a UK-style sugary drinks industry levy. But while doing so, health authorities should also keep systematically evaluating ongoing research (eg, a RCT in New Zealand suggesting benefits of food tax/subsidy interventions that was published just after the review period used in this article46 and as part BODE3 modelling work, as per these publications on dietary interventions47,48). Also further research may help fine-tune any New Zealand-adopted interventions so as to maximise the health gain, the cost-effectiveness of intervention application and the impact on reducing health inequalities in the New Zealand setting (ie, especially for Māori, Pasifika and low-income New Zealanders).

Conclusions

In this article we briefly consider recent literature (14 recent systematic reviews and 12 relevant New Zealand studies) on food/beverage taxes and subsidies. This evidence clearly indicates that tax and subsidy interventions have favourable impacts from a health perspective and would seem likely to work in the New Zealand setting. Given this overall picture, such tax/subsidy interventions would be an important evidence-based policy as part of a wider strategy to improve the nutritional health of New Zealanders. A UK-style sugary drinks industry levy should be considered as an initial step. The findings of this review forms the basis of the position of the Health Coalition Aotearoa, a new non-governmental organisation which includes New Zealand health workers and researchers with expertise in nutrition.

Appendix

Appendix Table 1: Systematic reviews (n=14) published on food and beverage taxes and subsidies (ordered by ascending publication year for the period January 2015 to June 2019).*

Note: *The search was conducted in PubMed for the period 1 January 2015 to 15 June 2019 with a range of search terms: eg, “systematic review” and food/beverage, price/subsidy. But the Teng et al study was identified via co-author involvement in this particular study and the Cochrane review was identified via media reporting. We excluded the systematic review by Sisnowski et al 201558 as it did not cover impacts (but rather the popularity of taxation relative to other interventions).

Appendix Table 2: New Zealand studies (n=12) relating to food pricing and food costs, published in the peer-review literature (for the period January 2010 to March 2019; ordered by publication year).*

Note: * The search was conducted in PubMed for the period 1 January 2010 to 31 March 2019. Search terms included: “Zealand” and food/beverage and price/subsidy/cost.

Appendix Table 3: Primary and supportive issues when considering a new health protecting tax (ie, in this case on sugary drinks) and a comparison with an established tax in New Zealand on tobacco.

Summary

Abstract

The hazardous and obesogenic food environment are major contributors to health loss in Aotearoa New Zealand. Here we consider the potential use of food taxes and subsidies to protect health in this country. We find that each one of the 14 recent systematic reviews on the tax and/or subsidy topic since 2015 in the scientific literature report that such interventions have favourable impacts from a health perspective. The New Zealand evidence we considered (n=12 studies since January 2010) is less definitive, but the pattern of results is consistent with the international evidence. Given this overall picture, the New Zealand Government should seriously consider such tax/subsidy interventions, potentially starting with a UK-style sugary drinks industry levy.

Aim

Method

Results

Conclusion

Author Information

Nick Wilson, Food Policy Group, Health Coalition Aotearoa; BODE3 Programme, University of Otago, Wellington; Lisa Te Morenga, Food Policy Group, Health Coalition Aotearoa; Sally Mackay, Food Policy Group, Health Coalition Aotearoa; School of Population Health, University of Auckland, Auckland; Sarah Gerritsen, Food Policy Group, Health Coalition Aotearoa; School of Population Health, University of Auckland, Auckland; Christine Cleghorn, Food Policy Group, Health Coalition Aotearoa; BODE3 Programme, University of Otago, Wellington; Amanda C Jones, BODE3 Programme, University of Otago, Wellington; Boyd Swinburn, Food Policy Group, Health Coalition Aotearoa; School of Population Health, University of Auckland, Auckland.

Acknowledgements

The authors who work for the BODE3 Programme (NW, CC, AJ) benefited funding support from the Health Research Council of New Zealand (Project number: 16/443).

Correspondence

Professor Nick Wilson; Food Policy Group, Health Coalition Aotearoa; BODE3 Programme, University of Otago, Wellington.

Correspondence Email

nick.wilson@otago.ac.nz

Competing Interests

Nil.

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