"Using the Cigarette Tax Playbook Against Big Food"
What we learned from the tobacco experience,
wrote two preeminent public health scholars,
is how powerfully profits can motivate “even at the cost of
millions of lives and unspeakable suffering.”
“Big Tobacco Played Dirty and Millions Died.”
How similar is Big Food?
I’ve talked about how Big Food has used
the same tobacco industry playbook.
What about using the anti-tobacco playbook
to counter the obesity crisis?
Tobacco is one of our great public health victories.
The share of adults who smoke declined from 42 percent in 1965
down to just 15 percent by 2016.
That’s about 5 out of 12 down to less than 2 out of 12.
Thanks to the decline, cigarettes now only kill
about a half million Americans every year,
whereas our diet now kills tens of thousands more.
Currently, the leading cause of death in America is the American diet.
Might we be able to use the same strategies that were so successful
in the battle against Big Tobacco?
It may be no coincidence that three of the most
cost-effective policy interventions against obesity
seem to be taken straight from the tobacco wars:
(1) taxes on unhealthy products;
(2) front-of-pack labeling; and
(3) a restriction of advertising to children.
Excise taxes on cigarettes has been cited
as the single most effective weapon in slashing smoking rates.
A 25 cents per pack tax to help deal with some of the societal costs
of smoking was associated with as much as
a 9 percent decrease in smoking rates.
The World Health Organization has estimated
that a 70 percent global increase in the price could prevent
up to a quarter of all tobacco- related deaths worldwide.
Extending taxes on alcohol and tobacco to foodstuffs
was proposed by none other than Adam Smith
in his 1776 Wealth of Nations:
“Sugar, rum, and tobacco, are commodities
which are nowhere necessities of life,
which have become objects of almost universal consumption,
and which are, therefore, extremely proper subjects of taxation.”
People have the right to smoke and drink and eat fattening foods,
the logic goes, but perhaps they should help defray
some of the publicly-funded medical costs that result.
Well, if that’s the case, why not tax obese people directly?
Taxing people based on their weight was proposed
at least as far back as 1904 in the British Medical Journal,
a kind of pounds- for-pounds strategy
(actually only up to 7 shillings and 6 pence per pound).
This was not only to recompense public coffers,
but nudge behavioral change.
“A tax on fat,” read the proposal, “would also have an excellent effect
on the health of the nation by bringing about a reform
of unwholesome habits of eating and drinking.”
Even a penny-per-ounce tax on sugar-sweetened beverages
could bring in more than a billion dollars a year
in states like Texas and California.
A 10 percent tax on fattening foods on a national level
could yield a half a trillion dollars over ten years.
Even if it was combined with a subsidy that lowered
the cost of fruits and vegetables by 10 percent,
it would be expected to net hundreds of billions of dollars.
But would it actually change people’s habits?
Even a small price differential (about 10 percent)
between leaded and unleaded gas was able to shift
the entire auto industry away from lead.
Could it also shift Americans to apples from apple pie?
A systematic review of the available evidence suggests
that dietary financial incentives and disincentives work.
The cheaper you make fruits and vegetables,
the more people say they’d buy,
and the more you tax unhealthy foods,
the lower consumption drops.
Based on this kind of modeling, a tax on saturated fat—
found mostly in fatty meat, dairy, and junk—
could potentially save thousands of lives a year.
But wouldn’t such a tax disproportionately affect the poor?
Yes, in that we would expect them to benefit the most!
It’s like cigarette taxes.
The classic tobacco industry argument is that cigarette taxes
are “unfair” and “regressive,” burdening the poor the most,
to which the public health community responded “Cancer is unfair;”
cancer disproportionately burdens the poor.
So, taxes would be expected to affect the greatest health gains
for the least well-off.
The fact that the tobacco industry fought tooth and nail
against cigarette taxes— everything from
inventing front groups to overtly buying off politicians—
suggests that taxes can indeed shift consumption patterns,
but much of the evidence on changing food behaviors
has not been based on real-life data.
You can put people through fancy 3D supermarket simulators
and discover that a 25 percent discount on fruits and veggies
appears to boost produce purchasing by the same amount—
up to about two pounds a week.
But virtual vegetables don’t actually do you any good.
Does this work out in the real world?
Apparently so.
South Africa’s largest private health insurer started offering
up to 25 percent cash back on healthy food purchases
to hundreds of thousands of households,
up to the U.S. equivalent of $799 per month.
Why would they give money away?
Because it apparently works— increasing consumption
of fruits and vegetables and whole grains,
while at the same time decreasing the consumption
of foods high in added salt, sugar, and fat,
including processed meats and fast food.
Why not just pay people to lose weight directly?
A systematic review found 11 out of 12 studies
on financial incentives for weight loss described positive results.
The one that failed to find a benefit of direct monetary inducements
was only offering $2.80 a day.
With kids, you can get away with just a nickel or a sticker
to get them to choose dried fruit over a cookie
as an afterschool snack, though as soon as the enticements ended,
so did the change in behavior.
Even if the incentives have to be made permanent,
they might still pay for themselves.
In the U.S., every dollar spent taxing processed foods or milk
might net an estimated $2 in healthcare cost savings.
Every dollar spent making vegetables cheaper could net $3
and subsidizing whole grains might offer more
than a thousand percent return on our investment.
Even a 1 percent decrease in the average price of all fruits and vegetables
might prevent nearly 10,000 heart attacks and strokes every year.
What about taxes, though, which tend to be less popular than subsidies?
In Europe, a number of countries have instituted
taxes on sugary or salty foods,
but Denmark was the first to introduce a tax on saturated fat.
It only took agribusiness about a year to squash it,
demonstrating how weak public health professionals can be
when trying to tackle corporate power.
This was chalked up to the “enormous imbalance”
between the political influence exerted by the public health community
compared to the industry’s lobbying might.