RESEARCH AND PRACTICE
Strategic Messaging to Promote Taxation of Sugar-Sweetened Beverages: Lessons From Recent Political Campaigns Judy Jou, MA, Jeff Niederdeppe, PhD, Colleen L. Barry, PhD, MPP, and Sarah E. Gollust, PhD
The prevalence of obesity in the United States is among the highest worldwide, reaching 35.7% of adults and 16.9% of children from 2009 to 2010.1,2 Cardiovascular disease, type 2 diabetes, and certain cancers are strongly associated with obesity, which accounted for an estimated $147 billion in national medical spending in 2008.3,4 Sugar-sweetened beverages (SSBs) are gaining policy attention as a result of reported links between their consumption and weight gain, metabolic syndrome, and type 2 diabetes.5---8 Evidence also shows an association between decreasing SSB consumption and weight loss among children and adolescents.9---11 One proposed policy solution to reduce the consumption of SSBs is to tax them.12,13 Since 2009, 22 states and 6 cities have introduced SSB tax proposals. Only one state has succeeded in passing a tax sufficiently large to plausibly affect consumption: Washington’s 2010 pennyper-ounce excise tax, which was repealed by popular referendum the following year.14 One reason for this lack of success is limited public support. A 2012 national survey showed that 62% of Americans somewhat or strongly opposed SSB taxes, with 37% strongly opposed.15 However, polls suggest that support increases when tax revenue is earmarked for health-related programs16,17 and that certain protax arguments (e.g., SSBs being the largest contributor to obesity) are more credible than others.18 Strategic messaging (or “framing”) is used to emphasize certain aspects of issues in policy debates, shaping public views and policymaking processes.19,20 The messages used to support or oppose SSB taxation therefore may affect its political viability. Messaging campaigns were particularly salient in 2 California cities during 2012. On their November 2012 ballots, El Monte and Richmond proposed measure H and measure
Objectives. This study explored the use of strategic messaging by proponents of sugar-sweetened beverage (SSB) taxation to influence public opinion and shape the policy process, emphasizing the experiences in El Monte and Richmond, California, with SSB tax proposals in 2012. Methods. We conducted 18 semistructured interviews with key stakeholders about the use and perceived effectiveness of messages supporting and opposing SSB taxation, knowledge sharing among advocates, message dissemination, and lessons learned from their messaging experiences. Results. The protax messages most frequently mentioned by respondents were reinvesting tax revenue into health-related programs and linking SSB consumption to health outcomes such as obesity and diabetes. The most frequently mentioned antitax messages addressed negative economic effects on businesses and government restriction of personal choice. Factors contributing to perceived messaging success included clearly defining “sugar-sweetened beverage” and earmarking funds for obesity prevention, incorporating cultural sensitivity into messaging, and providing education about the health effects of SSB consumption. Conclusions. Sugar-sweetened beverage taxation has faced significant challenges in gaining political and public support. Future campaigns can benefit from insights gained through the experiences of stakeholders involved in previous policy debates. (Am J Public Health. 2014;104:847–853. doi:10.2105/ AJPH.2013.301679)
C, both business license fees of $0.01 per ounce for SSBs sold or provided within city limits. Both were accompanied by complementary resolutions recommending the use of tax revenue for health-related initiatives.21,22 After heated campaigns, both measures were defeated, with 77% of El Monte and 67% of Richmond voters in opposition.23 We explored the use of strategic messaging for SSB taxation with an emphasis on the 2012 experiences of El Monte and Richmond. We interviewed stakeholders in California and across the country to identify commonly used messages and lessons learned about messaging from past advocacy campaigns. With 12 states and 2 cities proposing SSB tax legislation in 2013 or 2014 legislative cycle14 and more likely to follow, analyzing the experiences from previous campaigns can yield lessons for shaping future policy approaches to reducing SSB consumption.
May 2014, Vol 104, No. 5 | American Journal of Public Health
METHODS Between April and December 2012, we conducted semistructured interviews with 18 stakeholders who had extensive experience with SSB taxation. Interviewees were initially identified through a media content analysis of newspapers in jurisdictions that filed SSB tax legislation between 2009 and 2011.24 Advocates, researchers, and policymakers who expressed support for SSB taxation were contacted via e-mail and asked to participate in a telephone interview. We then used snowball sampling to identify additional interviewees. The final sample included individuals from a mix of backgrounds (Table 1). Ten of the interviewees were health or community advocates, 3 were local health officials, 3 were elected officials, and 2 were academic researchers. Fourteen were from California, and 4 were prominent figures from other jurisdictions
Jou et al. | Peer Reviewed | Research and Practice | 847
RESEARCH AND PRACTICE
TABLE 1—Stakeholder Demographics and Jurisdictions: United States, April–December 2012 Stakeholder Category Elected Officials
Local Health Officials
Health and Community Advocates
Researchers and Academics
Total
0
2
1
1
4
1 2
0 0
3 4
0 0
4 6
Non-California
0
1
2
1
4
Total
3
3
10
2
18
Location California El Monte Richmond
that had previously attempted SSB taxation. Within California, 6 of the interviewees were from Richmond, 4 were from El Monte, and 4 were involved with policy at the state level. We developed a semistructured interview protocol to gain participants’ insights regarding 4 main themes: frequently encountered protax and antitax messages and their perceived effectiveness, sources and characteristics of protax messages, sharing of knowledge among stakeholders and message dissemination, and lessons learned and future directions. We assessed respondents’ perceptions of message effectiveness in 2 ways: asking interviewees which messages they found particularly effective and noting any instances when interviewees spontaneously suggested that a message resonated with audiences. Communication research indicates that messages must resonate with audiences to be potentially effective in persuading them.25,26 The interviews, which were 45 to 60 minutes in duration, were audio-recorded and transcribed. We constructed a coding instrument using a combination of deductive and inductive approaches to theme development.27 First, the interview protocol was used to generate an organizing framework for code types. One of the authors (J. J.) then reviewed the transcripts line by line to identify recurring concepts and assign or add codes accordingly. Once an initial coding instrument was completed, 2 coders applied it to a subset of transcripts and resolved disagreements by consensus. Because there were very few disagreements, one of the authors (J. J.) then coded and analyzed all remaining interviews using NVivo 10 (QSR International, Burlington, MA).
RESULTS Table 2 summarizes the messages participants identified as commonly used protax arguments. Two of the most frequently cited messages were using tax revenue to fund health-related initiatives and linking SSB consumption to health outcomes such as obesity and diabetes. Approximately half of the interviewees mentioned messages highlighting the amount of sugar and calories SSBs contain, emphasizing health effects among children, or addressing characteristics of SSBs that justify taxation, such as lack of satiety when liquid calories are consumed. Approximately one third discussed efforts to counterargue concerns over SSB taxation disproportionately affecting the poor (regressivity), messages about reducing consumption through taxation, or the influence of industry marketing on beverage choices. Many of the messages noted as commonly used were also perceived as effective. Most interviewees viewed reinvesting tax revenue into health-related programs as a persuasive argument for SSB taxation, and the opposite was also true: they believed public support was lower when policymakers failed to specify uses for tax funds. As noted by a non-California health advocate, “Folks are going to get upset about taxes, and the only way you’re ever going to get people to vote ‘maybe’. . . is if there’s a connection between what you’re taxing and where the money goes.” In California, because a 1978 constitutional amendment (Proposition 13) requires a supermajority vote for taxes with dedicated revenue, respondents viewed the inability to include language specifying SSB tax revenue for health-related initiatives as a major barrier to both policy-making and effective messaging.28 El
848 | Research and Practice | Peer Reviewed | Jou et al.
Monte was even sued by its planning commissioner for implying that funds from Measure H would be used for child obesity prevention when the proposition included no such language.29 Messages conveying educational content about SSBs were also seen as effective. One strategy thought to resonate with audiences was visually demonstrating the amount of sugar added to SSBs. Another was to link audiences’ personal experiences with obesity and diabetes to SSB consumption. Emphasizing the effects of SSB consumption on children was also viewed as effective, as noted by a non-California health official: “Focusing on the health effects on kids gets a lot more attention than on adults, because of the kids’ vulnerability and their lack of choice.” Interviewees perceived some messages to be ineffective. Although some believed that messages about decreasing consumption through taxation were effective, several suggested that audiences “don’t warm up to” this approach. One California health advocate warned that framing the objective as behavior modification presents SSB taxation as “a punitive tax put forward by wealthy, White, well-educated, rich, nanny-state public health professionals who. . .want to punish us for not doing what they say.” Using SSB taxation as a general revenue source for struggling jurisdictions was also seen as unconvincing, in contrast to linking funds to health initiatives. One prominent messaging theme was social justice. Although all interviewees shared ethical concerns about introducing a regressive tax in low-income jurisdictions, several questioned whether El Monte and Richmond voters were actually persuaded by this argument. One El Monte advocate stated that “the only time [she had] heard anybody ever talk about regressive taxes is among advocates,” and a Richmond advocate noted that voters “weren’t swayed by this idea that it was a regressive tax.” Some interviewees suggested that raising awareness about the health risks of SSB consumption and their disproportionate impact on low-income and minority communities may inoculate residents against antitax messages about regressivity. As one California advocate suggested: A sugar-sweetened beverage tax may be regressive, but. . .what’s really regressive is the health disparities that we document in Richmond and throughout the country that are caused to a considerable extent by sugarsweetened beverages. That’s the real regressive tax: a tax on our health.
American Journal of Public Health | May 2014, Vol 104, No. 5
RESEARCH AND PRACTICE
TABLE 2—Common Messages Supporting Taxation of Sugar-Sweetened Beverages (SSBs): Proponents of SSB Taxation, United States, 2012 No. of Interviewees 14
Message
Illustrative Quotation
SSB tax revenue can be used to fund health- and obesity-related programs
“It’s real important to say ’So you can’t drink as much soda as you want. So you’re going to have to buy it only once a week instead of 7 days a week. . .and your kids might not be able to buy it every day. But your kids will be able to have more soccer fields, they’ll have more dance classes, and there’s going to be nutrition programs in. . .our community centers.’ And people hear that, and they really respond.”
13
SSB consumption is associated with obesity and health conditions such as type 2 diabetes
“We need [to make] the connections between the chronic disease, having to pick their parents up from dialysis and drop them off, to what they’re eating and drinking. And particularly what they’re drinking, which is sodas.”
10
SSBs contain an extremely large amount of sugar and calories
“We started really talking to folks, educating folks about what is in SSBs, why is it making us sick, because a big piece of it is, folks just. . .aren’t aware that there’s so much sugar
9
The effects of SSB consumption on health are particularly harmful to children
in these beverages, and what the consequences of long-term consumption can be.” “Adults generally have a feeling for children, and certainly in Richmond. . .. I’m always reaching out to people in terms of how we want our youth to be healthier, how we want our youth to thrive. I think that resonates with people as well.”
8
SSBs have unique characteristics (liquid calories, empty calories) that justify taxation
“Well, we don’t mean to pick on you, but you’re making an unhealthy product. Liquid calories are different than solid calories, you’re preferentially advertising to our young people, you’re particularly targeting our communities of color, and we wouldn’t mind if the product was healthy, but it’s producing everything from cavities to death, and everything in between.”
7
The health consequences of SSB consumption are even more regressive than SSB taxation
“The frame is, ’We’re going to use this money’—and I think you have to do this, otherwise it’s not ethical—‘we’re going to use this money to benefit those communities that are paying the taxes.’ They’re paying a double tax. They’re paying the taxes, and they’re paying the price in health from the sugar-sweetened beverages. That, I think, has to be the frame, not a punitive frame.”
6
Taxing SSBs can lead to lower consumption
“Some of the messaging that we do about taxes is that if you put a penny-per-ounce tax on SSBs, the anticipated impact will be a 25% or 24% reduction in consumption. That’s a really big impact, and that translates into a lot of calories per year, which
6
Advertising and marketing of foods and beverages affect people’s consumption choices
Development and Dissemination of Protax Messages We asked interviewees about their process for developing messages. Few interviewees’ organizations had sufficient resources to formally test messages via focus groups or polling, but some consulted polling done by others. Several generated messages through conversations with other advocates, including those in jurisdictions with prior experience in SSB taxation, such as Philadelphia; they also drew on research articles and reports published by institutions such as the Rudd Center for Food Policy and Obesity, the Center for Science in the Public Interest, and the California Center for Public Health Advocacy. Many simply adjusted
would have a measurable impact on both calorie intake and obesity.” “Well, none of us have a choice, really, because we’re all being fed all this marketing from day 1 so that we become lifelong consumers.”
their messages on the basis of informal audience feedback, as one California advocate described: When I go around and give these talks over and over again, it becomes obvious what it is that people find most compelling. It’s what they ask questions about, it’s where they gasp. . .you can tell when it is that people are convinced.
Nearly all interviewees tailored messages to some extent, emphasizing different messages for parents, young people, communities of color, and policymakers. According to one non-California researcher: When we talk to conservative legislators, it’s about how much revenue can be generated and how it can help create deficit reduction. When we talk to more liberal legislators. . .we also talk about the human suffering that can be
May 2014, Vol 104, No. 5 | American Journal of Public Health
prevented. When we are addressing people who might be worried about the regressive nature of the tax, we talk about. . .what the industry does to [disadvantaged] communities, how they are disproportionately hit by diabetes.
Another approach was to adjust communication strategies to resonate with different populations. Social media was an important platform for messaging to younger audiences, and several California advocates described a need for translating messages both linguistically and culturally. One El Monte advocate noted that campaign slogans such as “Kick the Can” and “Rethink Your Drink” translated poorly into Spanish and that others such as “Life Is Sweeter with Fewer Sugary Drinks” were more appropriate.
Jou et al. | Peer Reviewed | Research and Practice | 849
RESEARCH AND PRACTICE
The soda industry. . .was very effective with residents in these sorts of scare tactics, that this would be an empty check to the city of Richmond that would go into this big black hole, and we would never see the benefits of it. If the residents that I work with could identify one message that was the most effective, it was that one.
Antitax Messages The 2 most commonly identified antitax messages were local economic burden caused by revenue and job loss and the regressive nature of SSB taxation. Approximately half of the interviewees cited messages about the uncertain use of tax revenue, the government acting as a “nanny state” infringing on personal choice, or the unfairness of targeting SSBs for taxation. A handful mentioned communities’ feelings of goodwill toward beverage companies or general ideological resistance to taxation (Table 3). Many of the antitax messages mentioned by interviewees were also viewed as effective. In El Monte and Richmond, Proposition 13 prevented policymakers from specifying the use of revenue for health-related initiatives, on which opponents were quick to capitalize. As one Richmond advocate explained:
Economic concerns were also strong in El Monte, where “people wonder what our city leaders have done with the money in the first place. The city. . .has one of the highest tax rates; these folks have been taxed to the max. And now you’re trying to propose another tax?” Another strong barrier was the positive corporate image of the beverage companies delivering antitax messaging. One nonCalifornia advocate described soda companies “insinuating themselves into the fabric of civic society” through philanthropic gestures such as sponsoring the Seattle Center. In Richmond, a community advocate noted that Coca-Cola and Pepsi have
been in these communities for a number of years and earned the loyalty of a lot of people. . .. They sponsor sports teams, they sponsor community events, and they’re highly visible as part of the local culture. It’s a really big challenge to try to overcome that kind of presence.
Tax opponents were perceived to have a strong financial advantage. Media reports noted that the beverage industry outspent public health advocates in California by about 35 to 1.30 This allowed the industry not only to conduct more market research in formulating its messages and to disseminate them more widely, but also to target different audiences. One Richmond advocate described billboards with an image of an African American male [indicating the tax was] unfairly targeting. . .lowincome communities. And then you would have an image of a middle-aged White woman, and it would talk about how it. . .was an empty check.
In El Monte, an advocate remarked that “the industry was very savvy in focusing on
TABLE 3—Common Messages Opposing Taxation of Sugar-Sweetened Beverages (SSBs): Proponents of SSB Taxation, United States, 2012 No. of Interviewees 14
Message SSB taxation will harm businesses and workers economically
Illustrative Quotation “So the messaging was ’Measure H for higher taxes,’ and business owners were saying, ’I will go out of business if this tax goes through, and I’ll move to a different city.’ And residents were also saying, ’I’ll just go over to Temple City. . .for my sugarsweetened beverage.’”
11
SSB taxes are regressive (i.e., they have a disproportionate impact on the poor)
“Many people. . .argue against the sugar-sweetened beverage tax because it is a regressive tax, a doubly regressive tax. First, it’s a sales tax, and all sales taxes are regressive. And secondly, it’s a sales tax on things that are disproportionately consumed by low-income and communities of color, and so it’s doubly regressive.”
9
Singling out SSBs for taxation is unfair when other unhealthy
9
The government is acting as a “nanny state” that restricts
9
Governments cannot be trusted to use tax revenue responsibly and transparently
“Why should we have to pay more for soda when it’s just. . .bad management at the city level? The city has plenty of money, and the city just needs to be smarter
8
Taxing an industry that has sponsored local infrastructure and
“A lot of groups were struggling with the money question. Either they had a
foods are not regulated
“Unlike tobacco, ‘people have to eat’ is a common pushback you get from the industry. ’Why pick out sugar-sweetened beverages? All food has calories.’” “Nanny state always comes up as the favorite buzz word.”
individuals’ personal choice
about how it’s spending that money.” scholarships is counterproductive
partnership with a beverage company or vendor, they were getting grants from them, or they had some sort of deal where they advertise for them, and they would build a center there or something. They were in bed with those companies.”
6
Taxes in general are bad policy
“Especially in rural parts, small communities in California, a lot of Tea Party people and conservatives want less government control, less government intrusion, less government overall. So anything that’s about taxes is kind of a third rail, regardless of what it’s for.”
6
SSB taxation will not reduce consumption; individuals can buy their drinks in other places
850 | Research and Practice | Peer Reviewed | Jou et al.
"You often hear ‘People aren’t going to stop drinking soda anyway,’ which is sort of not the point.”
American Journal of Public Health | May 2014, Vol 104, No. 5
RESEARCH AND PRACTICE
the ethnic drinks (horchata, Tampico, boba) [and] in saying, ‘Look, they’re attacking not only your drinks, but your favorite ethnic drinks.’” Many interviewees perceived that limited resources prevented them from targeting messages to a similar extent.
Knowledge Sharing and Message Dissemination In response to our questions on knowledge sharing and message dissemination, interviewees identified policymakers, public officials, public health advocates, and researchers as main message sources. State-level stakeholders mentioned speaking with prominent figures such as Mayor Michael Nutter of Philadelphia, former Governor David Paterson of New York, and Mayor Michael Bloomberg of New York City. City-level stakeholders and community advocates were more likely to rely on local advocacy networks and state-based foundations such as the California Center for Public Health Advocacy. Interviewees also exchanged ideas informally via Facebook, Twitter, and an SSB listserv hosted by the Center for Science in the Public Interest. Interviewees disseminated messages through a combination of traditional and new media. National- and state-level stakeholders reported using national media outlets, whereas county- and city-level advocates favored local media. Although social media were identified as vital for youth outreach, several interviewees warned against relying too heavily on social media given that many connections were among advocates rather than to the general public. Interviewees also described mixed experiences in working with community leaders to disseminate messages. Some had resources to hire community organizers, whereas others worked with existing institutions such as the Seattle Children’s Hospital, First Five Contra Costa and First Five Los Angeles, and local chapters of organizations such as the American Heart Association. Nearly all interviewees stressed the importance of additional grassroots outreach to community groups such as churches, parent-teacher associations, and local nonprofit organizations. As one Richmond advocate noted, “The campaign could have benefited from a more grassroots approach and. . .from an even broader coalition.”
Future Directions We concluded our interviews by asking interviewees about the lessons drawn from their experiences and their outlook on the future of SSB taxation. Two issues related to messaging content were identified as potential concerns. First, several interviewees expressed frustration over legal restrictions that impeded effective messaging. In California, policymakers in El Monte and Richmond anticipated the difficulty of winning a supermajority for a special tax under Proposition 13 and opted instead for a general tax. This decision eliminated advocates’ ability to wield an effective protax message (investing revenue into health initiatives) and bolstered an effective antitax message (gifting city officials with a “blank check”). Second, interviewees found the term sugarsweetened beverages difficult to explain, describing attempts by the beverage industry to spread misinformation about the types of beverages subject to tax, such as “your baby formula and your grandmother’s Ensure.” Another lesson related to paying close attention to the messenger. Many Richmond interviewees found voters reluctant to support a measure seen as proposed and promoted by outsiders (“do-gooders” from “outside the community” telling them they were “obese and needed to get rid of sodas”). Conversely, interviewees reported that messages delivered by community members were better received, especially in jurisdictions with large communities of color. Tax opponents were seen as quick to capitalize on the difficulty of messaging to communities of color. As one Richmond advocate noted, “When [the tax] came out, it got racialized. It got seen through a lens. . .of ‘Oh, you want to tax African Americans and create soccer fields for the growing Latino community.’” In El Monte, where 69% of residents selfidentify as Hispanic or Latino and 25% selfidentify as Asian,31 interviewees worked not only to develop linguistically and culturally appropriate messages but also to select messengers who were known and trusted within these communities, including Spanish-language media personalities and established community workers. Interviewees in all jurisdictions advised policymakers to gauge community readiness for SSB taxation before introducing legislation. Interviewees were optimistic about reducing SSB consumption in the long run. Nearly all
May 2014, Vol 104, No. 5 | American Journal of Public Health
stressed the importance of educating the public about SSBs’ contribution to obesity and diabetes. Many saw education as crucial not only in promoting SSB taxation but also in reducing SSB consumption through other strategies. In fact, several interviewees cautioned against a narrow focus on taxation, including one California advocate: “I think the big issue we’re talking about is soda. . .not soda tax. And when we’re talking as if the soda tax is the answer, we’re forgetting what the problem is.”
DISCUSSION This study adds to the growing literature on the role of messaging in policy debates over SSB taxation. By interviewing advocates “on the ground” in El Monte and Richmond, we built on previous research that explored messaging strategies at a national level,32 allowing for a more nuanced exploration of how messaging is targeted to the specific demographics and circumstances in a given location and how specific aspects of legislative language shape the framing of an issue. Relative to protax messages reported by national media from 2009 to 2011,24 supporters in Richmond and El Monte were equally likely to prioritize protax messages emphasizing the health and financial benefits of SSB taxation, especially regarding obesity reduction and health program funding. Our interviewees were much more likely than national media outlets, however, to cite messages counterarguing regressivity, potentially owing to the large proportions of lower-income residents in El Monte and Richmond. Both national media and our respondents reported antitax messages focusing on economic concerns and the role of government. However, very few of our interviewees reported hearing antitax messages disputing the ability of SSB taxation to decrease obesity prevalence, as compared with 33% of antitax messages in the media nationally.24 Our findings also offer a comparison with messages cited in local news coverage in El Monte and Richmond.23 Our interviewees were less likely than local media to mention protax messages about the soda industry behaving inappropriately and antitax messages refuting SSB taxation’s ability to promote health. However, both our interviewees and
Jou et al. | Peer Reviewed | Research and Practice | 851
RESEARCH AND PRACTICE
the media analysis identified messaging differences between El Monte and Richmond. Messages in El Monte were seen to center more on the city’s impending budget gap, in contrast to the focus of Richmond messages on the health benefits of Measure N. In addition, antitax messaging in Richmond was viewed as exploiting existing tensions between African American and Hispanic/Latino communities owing to competition over sparse resources. In El Monte, concerns over race/ethnicity focused more on how to overcome linguistic barriers.23 On the basis of both existing research and our interviewees’ experiences, we identified several factors that may contribute to messaging success. First, messaging is likely to resonate with audiences when it is supported by clearly written policies that emphasize benefits to voters. Several interviewees noted the difficulty of defining sugar-sweetened beverages for voters and identifying the products subject to tax, creating opportunities for the beverage industry to spread misinformation. In addition, nearly all interviewees believed that specifying the use of tax revenue for health-related initiatives was critical, consistent with polling data.16,18 Second, successful messaging should educate the public about SSBs’ impact on health. Our findings are in line with previous studies suggesting that messages emphasizing SSBs’ contribution to obesity and the effect of industry marketing on children are effective protax messages.18,33 Whereas several common antitax messages appeal to ideological or political beliefs, protax messages draw heavily from scientific evidence about the health effects of SSB consumption. Many interviewees believed that further education about SSBs will, in time, turn the tide of public opinion. Given that a key rationale for supporting SSB taxation is its ability to affect consumption,12,34 an interesting perspective voiced by several interviewees was that emphasizing the message of reducing SSB consumption through taxation can exacerbate the “nanny state” arguments favored by opponents. Several interviewees noted that positive messaging (e.g., emphasizing the benefits of tax revenue and promoting healthier beverages) may be more effective.
Limitations This study involved several limitations. First, although messaging was a vital component of
campaigns, it was only one of several factors that influenced the California elections. We focused on messaging content in this study, and we recommend further research into other factors such as messaging volume and political strategy. Second, our stakeholder sample was small and geographically concentrated, which could limit the generalizability of our findings. In addition, we did not interview stakeholders opposing SSB taxation. Opponents likely have a different set of experiences and tools and different messaging capacities. Finally, although our questions on messaging effectiveness provided insight into stakeholders’ perceptions, other study designs are required to measure the actual effectiveness of the messages in influencing public opinion.
Conclusions Our study contributes to public health practice through its assessment of the role of messaging in a new policy area. In identifying supporting and opposing messages and highlighting the challenges that stakeholders have faced when advocating for SSB taxation, our findings provide legislators, health officials, and advocates with ideas to consider for future policy debates. j
About the Authors Judy Jou and Sarah E. Gollust are with the Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis. Jeff Niederdeppe is with the Department of Communication, Cornell University, Ithaca, NY. Colleen L. Barry is with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Correspondence should be sent to Judy Jou, MA, Division of Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware Street SE, MMC 729, Minneapolis, MN 55455 (e-mail: jouxx008@umn. edu). Reprints can be ordered at http://www.ajph.org by clicking on the “Reprints” link. This article was accepted September 5, 2013.
Contributors J. Jou and S. E. Gollust collected and analyzed the data, with scientific input from J. Niederdeppe and C. L. Barry. J. Jou drafted the article. All authors contributed to the conceptualization and design of the study and reviewed and revised the final version of the article.
Acknowledgments This work was supported by the Robert Wood Johnson Foundation Healthy Eating Research Program (grant 69173). We thank the study participants for generously sharing with us their time and insights.
References 1. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999---2008. JAMA. 2010;303(3):235---241. 2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999---2010. JAMA. 2012;307(5):483---490. 3. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: payerand service-specific estimates. Health Aff (Millwood). 2009;28(5):w822---w831. 4. Ogden CL, Lamb MM, Carroll MD, Flegal KM. Obesity and Socioeconomic Status in Adults: United States, 2005---2008. Hyattsville, MD: US Department of Health and Human Services; 2010. 5. Bleich SN, Wang YC, Wang Y, Gortmaker SL. Increasing consumption of sugar-sweetened beverages among US adults: 1988---1994 to 1999---2004. Am J Clin Nutr. 2009;89(1):372---381. 6. Malik VS, Popkin BM, Bray GA, Després J-P, Willett WC, Hu FB. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care. 2010;33(11):2477---2483. 7. Malik VS, Schulze MB, Hu FB. Intake of sugarsweetened beverages and weight gain: a systematic review. Am J Clin Nutr. 2006;84(2):274---288. 8. Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988---2004. Pediatrics. 2008;121(6):e1604---e1614. 9. de Ruyter JC, Olthof MR, Seidell JC, Katan MB. A trial of sugar-free or sugar-sweetened beverages and body weight in children. N Engl J Med. 2012;367(15):1397-- 1406. 10. Ebbeling CB, Feldman HA, Chomitz VR, et al. A randomized trial of sugar-sweetened beverages and adolescent body weight. N Engl J Med. 2012;367 (15):1407---1416. 11. Ebbeling CB, Feldman HA, Osganian SK, Chomitz VR, Ellenbogen SJ, Ludwig DS. Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study. Pediatrics. 2006;117(3):673---680. 12. Brownell KD, Farley T, Willett WC, et al. The public health and economic benefits of taxing sugar-sweetened beverages. N Engl J Med. 2009;361(16):1599---1605. 13. Brownell KD, Frieden TR. Ounces of prevention— the public policy case for taxes on sugared beverages. N Engl J Med. 2009;360(18):1805---1808. 14. Rudd Center for Food Policy and Obesity. SugarSweetened Beverage Initiatives Since 2009: Legislation, Policies, and Initiatives. New Haven, CT: Yale University; 2013. 15. Rudd Center for Food Policy and Obesity. Many Americans Ambivalent Over Laws Aimed at Healthy Living: Poll. New Haven, CT: Yale University; 2012. 16. Center for Rural Studies. 2011 Vermont SugarSweetened Beverage Tax Study. Burlington, VT: University of Vermont; 2011.
Human Participant Protection
17. DiCamillo M, Field M. Most Californians See a Direct Linkage Between Obesity and Sugary Sodas. San Francisco, CA: Field Research Corp; 2013.
This study was exempted from review by the University of Minnesota institutional review board.
18. Barry CL, Niederdeppe J, Gollust SE. Taxes on sugar-sweetened beverages: results from a 2011 national
852 | Research and Practice | Peer Reviewed | Jou et al.
American Journal of Public Health | May 2014, Vol 104, No. 5
RESEARCH AND PRACTICE
public opinion survey. Am J Prev Med. 2013;44(2): 158---163. 19. Benford RD, Snow DA. Framing processes and social movements: an overview and assessment. Annu Rev Sociol. 2000;26:611---639. 20. Chong D, Druckman JN. Framing theory. Annu Rev Polit Sci. 2007;10:103---126. 21. De Leon R. Election 2012: measure N and measure O. Available at: http://richmondconfidential.org/2012/ 10/31/election-2012-measure-n-and-measure-o. Accessed January 14, 2014. 22. Impartial Analysis of Measure C. El Monte, CA: Office of the City Attorney; 2012. 23. Mejia P, Nixon L, Womack R, Cheyne A, Dorfman L. Soda Tax Debates: News Coverage of Ballot Measures in Richmond and El Monte, California, 2012. Berkeley, CA: Berkeley Media Studies Group; 2013. 24. Niederdeppe J, Gollust SE, Jarlenski MP, Nathanson AM, Barry CL. News coverage of sugar-sweetened beverage taxes: pro- and antitax arguments in public discourse. Am J Public Health. 2013;103(6):e92---e98. 25. Dillard JP, Weber KM, Vail RG. The relationship between the perceived and actual effectiveness of persuasive messages: a meta-analysis with implications for formative campaign research. J Commun. 2007;57 (4):613---631. 26. Zhao X, Strasser A, Cappella JN, Lerman C, Fishbein M. A measure of perceived argument strength: reliability and validity. Commun Methods Meas. 2011;5(1):48---75. 27. Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42 (4):1758---1772. 28. California Constitution, Article 13A (tax limitation). Available at: http://www.leginfo.ca.gov/.const/. article_13A. Accessed January 14, 2014. 29. Velazquez M. El Monte planning commissioner sues over soda tax ballot language. Available at: http:// www.sgvtribune.com/general-news/20120827/elmonte-planning-commissioner-sues-over-soda-tax-ballotlanguage. Accessed January 14, 2014. 30. Oatman M. Will Big Soda Beat the California Soda Taxes? San Francisco, CA: Mother Jones; 2012. 31. US Census Bureau. El Monte, California: state and county quick facts. Available at: http://quickfacts.census. gov/qfd/states/06/0622230.html. Accessed January 14, 2014. 32. Barry CL, Jarlenski M, Grob R, Schlesinger M, Gollust SE. News media framing of childhood obesity in the United States from 2000 to 2009. Pediatrics. 2011;128(1):132---145. 33. Friedman RR, Brownell KD. Sugar-Sweetened Beverage Taxes: An Updated Policy Brief. New Haven, CT: Rudd Center for Food Policy and Obesity; 2012. 34. Chaloupka FJ, Powell LM, Chriqui JF. Sugar-Sweetened Beverage Taxes and Public Health. Princeton, NJ: Robert Wood Johnson Foundation; 2009.
May 2014, Vol 104, No. 5 | American Journal of Public Health
Jou et al. | Peer Reviewed | Research and Practice | 853
Strategic Messaging to Promote Taxation of Sugar-Sweetened Beverages: Lessons From Recent Political Campaigns Judy Jou, MA, Jeff Niederdeppe, PhD, Colleen L. Barry, PhD, MPP, and Sarah E. Gollust, PhD
The prevalence of obesity in the United States is among the highest worldwide, reaching 35.7% of adults and 16.9% of children from 2009 to 2010.1,2 Cardiovascular disease, type 2 diabetes, and certain cancers are strongly associated with obesity, which accounted for an estimated $147 billion in national medical spending in 2008.3,4 Sugar-sweetened beverages (SSBs) are gaining policy attention as a result of reported links between their consumption and weight gain, metabolic syndrome, and type 2 diabetes.5---8 Evidence also shows an association between decreasing SSB consumption and weight loss among children and adolescents.9---11 One proposed policy solution to reduce the consumption of SSBs is to tax them.12,13 Since 2009, 22 states and 6 cities have introduced SSB tax proposals. Only one state has succeeded in passing a tax sufficiently large to plausibly affect consumption: Washington’s 2010 pennyper-ounce excise tax, which was repealed by popular referendum the following year.14 One reason for this lack of success is limited public support. A 2012 national survey showed that 62% of Americans somewhat or strongly opposed SSB taxes, with 37% strongly opposed.15 However, polls suggest that support increases when tax revenue is earmarked for health-related programs16,17 and that certain protax arguments (e.g., SSBs being the largest contributor to obesity) are more credible than others.18 Strategic messaging (or “framing”) is used to emphasize certain aspects of issues in policy debates, shaping public views and policymaking processes.19,20 The messages used to support or oppose SSB taxation therefore may affect its political viability. Messaging campaigns were particularly salient in 2 California cities during 2012. On their November 2012 ballots, El Monte and Richmond proposed measure H and measure
Objectives. This study explored the use of strategic messaging by proponents of sugar-sweetened beverage (SSB) taxation to influence public opinion and shape the policy process, emphasizing the experiences in El Monte and Richmond, California, with SSB tax proposals in 2012. Methods. We conducted 18 semistructured interviews with key stakeholders about the use and perceived effectiveness of messages supporting and opposing SSB taxation, knowledge sharing among advocates, message dissemination, and lessons learned from their messaging experiences. Results. The protax messages most frequently mentioned by respondents were reinvesting tax revenue into health-related programs and linking SSB consumption to health outcomes such as obesity and diabetes. The most frequently mentioned antitax messages addressed negative economic effects on businesses and government restriction of personal choice. Factors contributing to perceived messaging success included clearly defining “sugar-sweetened beverage” and earmarking funds for obesity prevention, incorporating cultural sensitivity into messaging, and providing education about the health effects of SSB consumption. Conclusions. Sugar-sweetened beverage taxation has faced significant challenges in gaining political and public support. Future campaigns can benefit from insights gained through the experiences of stakeholders involved in previous policy debates. (Am J Public Health. 2014;104:847–853. doi:10.2105/ AJPH.2013.301679)
C, both business license fees of $0.01 per ounce for SSBs sold or provided within city limits. Both were accompanied by complementary resolutions recommending the use of tax revenue for health-related initiatives.21,22 After heated campaigns, both measures were defeated, with 77% of El Monte and 67% of Richmond voters in opposition.23 We explored the use of strategic messaging for SSB taxation with an emphasis on the 2012 experiences of El Monte and Richmond. We interviewed stakeholders in California and across the country to identify commonly used messages and lessons learned about messaging from past advocacy campaigns. With 12 states and 2 cities proposing SSB tax legislation in 2013 or 2014 legislative cycle14 and more likely to follow, analyzing the experiences from previous campaigns can yield lessons for shaping future policy approaches to reducing SSB consumption.
May 2014, Vol 104, No. 5 | American Journal of Public Health
METHODS Between April and December 2012, we conducted semistructured interviews with 18 stakeholders who had extensive experience with SSB taxation. Interviewees were initially identified through a media content analysis of newspapers in jurisdictions that filed SSB tax legislation between 2009 and 2011.24 Advocates, researchers, and policymakers who expressed support for SSB taxation were contacted via e-mail and asked to participate in a telephone interview. We then used snowball sampling to identify additional interviewees. The final sample included individuals from a mix of backgrounds (Table 1). Ten of the interviewees were health or community advocates, 3 were local health officials, 3 were elected officials, and 2 were academic researchers. Fourteen were from California, and 4 were prominent figures from other jurisdictions
Jou et al. | Peer Reviewed | Research and Practice | 847
RESEARCH AND PRACTICE
TABLE 1—Stakeholder Demographics and Jurisdictions: United States, April–December 2012 Stakeholder Category Elected Officials
Local Health Officials
Health and Community Advocates
Researchers and Academics
Total
0
2
1
1
4
1 2
0 0
3 4
0 0
4 6
Non-California
0
1
2
1
4
Total
3
3
10
2
18
Location California El Monte Richmond
that had previously attempted SSB taxation. Within California, 6 of the interviewees were from Richmond, 4 were from El Monte, and 4 were involved with policy at the state level. We developed a semistructured interview protocol to gain participants’ insights regarding 4 main themes: frequently encountered protax and antitax messages and their perceived effectiveness, sources and characteristics of protax messages, sharing of knowledge among stakeholders and message dissemination, and lessons learned and future directions. We assessed respondents’ perceptions of message effectiveness in 2 ways: asking interviewees which messages they found particularly effective and noting any instances when interviewees spontaneously suggested that a message resonated with audiences. Communication research indicates that messages must resonate with audiences to be potentially effective in persuading them.25,26 The interviews, which were 45 to 60 minutes in duration, were audio-recorded and transcribed. We constructed a coding instrument using a combination of deductive and inductive approaches to theme development.27 First, the interview protocol was used to generate an organizing framework for code types. One of the authors (J. J.) then reviewed the transcripts line by line to identify recurring concepts and assign or add codes accordingly. Once an initial coding instrument was completed, 2 coders applied it to a subset of transcripts and resolved disagreements by consensus. Because there were very few disagreements, one of the authors (J. J.) then coded and analyzed all remaining interviews using NVivo 10 (QSR International, Burlington, MA).
RESULTS Table 2 summarizes the messages participants identified as commonly used protax arguments. Two of the most frequently cited messages were using tax revenue to fund health-related initiatives and linking SSB consumption to health outcomes such as obesity and diabetes. Approximately half of the interviewees mentioned messages highlighting the amount of sugar and calories SSBs contain, emphasizing health effects among children, or addressing characteristics of SSBs that justify taxation, such as lack of satiety when liquid calories are consumed. Approximately one third discussed efforts to counterargue concerns over SSB taxation disproportionately affecting the poor (regressivity), messages about reducing consumption through taxation, or the influence of industry marketing on beverage choices. Many of the messages noted as commonly used were also perceived as effective. Most interviewees viewed reinvesting tax revenue into health-related programs as a persuasive argument for SSB taxation, and the opposite was also true: they believed public support was lower when policymakers failed to specify uses for tax funds. As noted by a non-California health advocate, “Folks are going to get upset about taxes, and the only way you’re ever going to get people to vote ‘maybe’. . . is if there’s a connection between what you’re taxing and where the money goes.” In California, because a 1978 constitutional amendment (Proposition 13) requires a supermajority vote for taxes with dedicated revenue, respondents viewed the inability to include language specifying SSB tax revenue for health-related initiatives as a major barrier to both policy-making and effective messaging.28 El
848 | Research and Practice | Peer Reviewed | Jou et al.
Monte was even sued by its planning commissioner for implying that funds from Measure H would be used for child obesity prevention when the proposition included no such language.29 Messages conveying educational content about SSBs were also seen as effective. One strategy thought to resonate with audiences was visually demonstrating the amount of sugar added to SSBs. Another was to link audiences’ personal experiences with obesity and diabetes to SSB consumption. Emphasizing the effects of SSB consumption on children was also viewed as effective, as noted by a non-California health official: “Focusing on the health effects on kids gets a lot more attention than on adults, because of the kids’ vulnerability and their lack of choice.” Interviewees perceived some messages to be ineffective. Although some believed that messages about decreasing consumption through taxation were effective, several suggested that audiences “don’t warm up to” this approach. One California health advocate warned that framing the objective as behavior modification presents SSB taxation as “a punitive tax put forward by wealthy, White, well-educated, rich, nanny-state public health professionals who. . .want to punish us for not doing what they say.” Using SSB taxation as a general revenue source for struggling jurisdictions was also seen as unconvincing, in contrast to linking funds to health initiatives. One prominent messaging theme was social justice. Although all interviewees shared ethical concerns about introducing a regressive tax in low-income jurisdictions, several questioned whether El Monte and Richmond voters were actually persuaded by this argument. One El Monte advocate stated that “the only time [she had] heard anybody ever talk about regressive taxes is among advocates,” and a Richmond advocate noted that voters “weren’t swayed by this idea that it was a regressive tax.” Some interviewees suggested that raising awareness about the health risks of SSB consumption and their disproportionate impact on low-income and minority communities may inoculate residents against antitax messages about regressivity. As one California advocate suggested: A sugar-sweetened beverage tax may be regressive, but. . .what’s really regressive is the health disparities that we document in Richmond and throughout the country that are caused to a considerable extent by sugarsweetened beverages. That’s the real regressive tax: a tax on our health.
American Journal of Public Health | May 2014, Vol 104, No. 5
RESEARCH AND PRACTICE
TABLE 2—Common Messages Supporting Taxation of Sugar-Sweetened Beverages (SSBs): Proponents of SSB Taxation, United States, 2012 No. of Interviewees 14
Message
Illustrative Quotation
SSB tax revenue can be used to fund health- and obesity-related programs
“It’s real important to say ’So you can’t drink as much soda as you want. So you’re going to have to buy it only once a week instead of 7 days a week. . .and your kids might not be able to buy it every day. But your kids will be able to have more soccer fields, they’ll have more dance classes, and there’s going to be nutrition programs in. . .our community centers.’ And people hear that, and they really respond.”
13
SSB consumption is associated with obesity and health conditions such as type 2 diabetes
“We need [to make] the connections between the chronic disease, having to pick their parents up from dialysis and drop them off, to what they’re eating and drinking. And particularly what they’re drinking, which is sodas.”
10
SSBs contain an extremely large amount of sugar and calories
“We started really talking to folks, educating folks about what is in SSBs, why is it making us sick, because a big piece of it is, folks just. . .aren’t aware that there’s so much sugar
9
The effects of SSB consumption on health are particularly harmful to children
in these beverages, and what the consequences of long-term consumption can be.” “Adults generally have a feeling for children, and certainly in Richmond. . .. I’m always reaching out to people in terms of how we want our youth to be healthier, how we want our youth to thrive. I think that resonates with people as well.”
8
SSBs have unique characteristics (liquid calories, empty calories) that justify taxation
“Well, we don’t mean to pick on you, but you’re making an unhealthy product. Liquid calories are different than solid calories, you’re preferentially advertising to our young people, you’re particularly targeting our communities of color, and we wouldn’t mind if the product was healthy, but it’s producing everything from cavities to death, and everything in between.”
7
The health consequences of SSB consumption are even more regressive than SSB taxation
“The frame is, ’We’re going to use this money’—and I think you have to do this, otherwise it’s not ethical—‘we’re going to use this money to benefit those communities that are paying the taxes.’ They’re paying a double tax. They’re paying the taxes, and they’re paying the price in health from the sugar-sweetened beverages. That, I think, has to be the frame, not a punitive frame.”
6
Taxing SSBs can lead to lower consumption
“Some of the messaging that we do about taxes is that if you put a penny-per-ounce tax on SSBs, the anticipated impact will be a 25% or 24% reduction in consumption. That’s a really big impact, and that translates into a lot of calories per year, which
6
Advertising and marketing of foods and beverages affect people’s consumption choices
Development and Dissemination of Protax Messages We asked interviewees about their process for developing messages. Few interviewees’ organizations had sufficient resources to formally test messages via focus groups or polling, but some consulted polling done by others. Several generated messages through conversations with other advocates, including those in jurisdictions with prior experience in SSB taxation, such as Philadelphia; they also drew on research articles and reports published by institutions such as the Rudd Center for Food Policy and Obesity, the Center for Science in the Public Interest, and the California Center for Public Health Advocacy. Many simply adjusted
would have a measurable impact on both calorie intake and obesity.” “Well, none of us have a choice, really, because we’re all being fed all this marketing from day 1 so that we become lifelong consumers.”
their messages on the basis of informal audience feedback, as one California advocate described: When I go around and give these talks over and over again, it becomes obvious what it is that people find most compelling. It’s what they ask questions about, it’s where they gasp. . .you can tell when it is that people are convinced.
Nearly all interviewees tailored messages to some extent, emphasizing different messages for parents, young people, communities of color, and policymakers. According to one non-California researcher: When we talk to conservative legislators, it’s about how much revenue can be generated and how it can help create deficit reduction. When we talk to more liberal legislators. . .we also talk about the human suffering that can be
May 2014, Vol 104, No. 5 | American Journal of Public Health
prevented. When we are addressing people who might be worried about the regressive nature of the tax, we talk about. . .what the industry does to [disadvantaged] communities, how they are disproportionately hit by diabetes.
Another approach was to adjust communication strategies to resonate with different populations. Social media was an important platform for messaging to younger audiences, and several California advocates described a need for translating messages both linguistically and culturally. One El Monte advocate noted that campaign slogans such as “Kick the Can” and “Rethink Your Drink” translated poorly into Spanish and that others such as “Life Is Sweeter with Fewer Sugary Drinks” were more appropriate.
Jou et al. | Peer Reviewed | Research and Practice | 849
RESEARCH AND PRACTICE
The soda industry. . .was very effective with residents in these sorts of scare tactics, that this would be an empty check to the city of Richmond that would go into this big black hole, and we would never see the benefits of it. If the residents that I work with could identify one message that was the most effective, it was that one.
Antitax Messages The 2 most commonly identified antitax messages were local economic burden caused by revenue and job loss and the regressive nature of SSB taxation. Approximately half of the interviewees cited messages about the uncertain use of tax revenue, the government acting as a “nanny state” infringing on personal choice, or the unfairness of targeting SSBs for taxation. A handful mentioned communities’ feelings of goodwill toward beverage companies or general ideological resistance to taxation (Table 3). Many of the antitax messages mentioned by interviewees were also viewed as effective. In El Monte and Richmond, Proposition 13 prevented policymakers from specifying the use of revenue for health-related initiatives, on which opponents were quick to capitalize. As one Richmond advocate explained:
Economic concerns were also strong in El Monte, where “people wonder what our city leaders have done with the money in the first place. The city. . .has one of the highest tax rates; these folks have been taxed to the max. And now you’re trying to propose another tax?” Another strong barrier was the positive corporate image of the beverage companies delivering antitax messaging. One nonCalifornia advocate described soda companies “insinuating themselves into the fabric of civic society” through philanthropic gestures such as sponsoring the Seattle Center. In Richmond, a community advocate noted that Coca-Cola and Pepsi have
been in these communities for a number of years and earned the loyalty of a lot of people. . .. They sponsor sports teams, they sponsor community events, and they’re highly visible as part of the local culture. It’s a really big challenge to try to overcome that kind of presence.
Tax opponents were perceived to have a strong financial advantage. Media reports noted that the beverage industry outspent public health advocates in California by about 35 to 1.30 This allowed the industry not only to conduct more market research in formulating its messages and to disseminate them more widely, but also to target different audiences. One Richmond advocate described billboards with an image of an African American male [indicating the tax was] unfairly targeting. . .lowincome communities. And then you would have an image of a middle-aged White woman, and it would talk about how it. . .was an empty check.
In El Monte, an advocate remarked that “the industry was very savvy in focusing on
TABLE 3—Common Messages Opposing Taxation of Sugar-Sweetened Beverages (SSBs): Proponents of SSB Taxation, United States, 2012 No. of Interviewees 14
Message SSB taxation will harm businesses and workers economically
Illustrative Quotation “So the messaging was ’Measure H for higher taxes,’ and business owners were saying, ’I will go out of business if this tax goes through, and I’ll move to a different city.’ And residents were also saying, ’I’ll just go over to Temple City. . .for my sugarsweetened beverage.’”
11
SSB taxes are regressive (i.e., they have a disproportionate impact on the poor)
“Many people. . .argue against the sugar-sweetened beverage tax because it is a regressive tax, a doubly regressive tax. First, it’s a sales tax, and all sales taxes are regressive. And secondly, it’s a sales tax on things that are disproportionately consumed by low-income and communities of color, and so it’s doubly regressive.”
9
Singling out SSBs for taxation is unfair when other unhealthy
9
The government is acting as a “nanny state” that restricts
9
Governments cannot be trusted to use tax revenue responsibly and transparently
“Why should we have to pay more for soda when it’s just. . .bad management at the city level? The city has plenty of money, and the city just needs to be smarter
8
Taxing an industry that has sponsored local infrastructure and
“A lot of groups were struggling with the money question. Either they had a
foods are not regulated
“Unlike tobacco, ‘people have to eat’ is a common pushback you get from the industry. ’Why pick out sugar-sweetened beverages? All food has calories.’” “Nanny state always comes up as the favorite buzz word.”
individuals’ personal choice
about how it’s spending that money.” scholarships is counterproductive
partnership with a beverage company or vendor, they were getting grants from them, or they had some sort of deal where they advertise for them, and they would build a center there or something. They were in bed with those companies.”
6
Taxes in general are bad policy
“Especially in rural parts, small communities in California, a lot of Tea Party people and conservatives want less government control, less government intrusion, less government overall. So anything that’s about taxes is kind of a third rail, regardless of what it’s for.”
6
SSB taxation will not reduce consumption; individuals can buy their drinks in other places
850 | Research and Practice | Peer Reviewed | Jou et al.
"You often hear ‘People aren’t going to stop drinking soda anyway,’ which is sort of not the point.”
American Journal of Public Health | May 2014, Vol 104, No. 5
RESEARCH AND PRACTICE
the ethnic drinks (horchata, Tampico, boba) [and] in saying, ‘Look, they’re attacking not only your drinks, but your favorite ethnic drinks.’” Many interviewees perceived that limited resources prevented them from targeting messages to a similar extent.
Knowledge Sharing and Message Dissemination In response to our questions on knowledge sharing and message dissemination, interviewees identified policymakers, public officials, public health advocates, and researchers as main message sources. State-level stakeholders mentioned speaking with prominent figures such as Mayor Michael Nutter of Philadelphia, former Governor David Paterson of New York, and Mayor Michael Bloomberg of New York City. City-level stakeholders and community advocates were more likely to rely on local advocacy networks and state-based foundations such as the California Center for Public Health Advocacy. Interviewees also exchanged ideas informally via Facebook, Twitter, and an SSB listserv hosted by the Center for Science in the Public Interest. Interviewees disseminated messages through a combination of traditional and new media. National- and state-level stakeholders reported using national media outlets, whereas county- and city-level advocates favored local media. Although social media were identified as vital for youth outreach, several interviewees warned against relying too heavily on social media given that many connections were among advocates rather than to the general public. Interviewees also described mixed experiences in working with community leaders to disseminate messages. Some had resources to hire community organizers, whereas others worked with existing institutions such as the Seattle Children’s Hospital, First Five Contra Costa and First Five Los Angeles, and local chapters of organizations such as the American Heart Association. Nearly all interviewees stressed the importance of additional grassroots outreach to community groups such as churches, parent-teacher associations, and local nonprofit organizations. As one Richmond advocate noted, “The campaign could have benefited from a more grassroots approach and. . .from an even broader coalition.”
Future Directions We concluded our interviews by asking interviewees about the lessons drawn from their experiences and their outlook on the future of SSB taxation. Two issues related to messaging content were identified as potential concerns. First, several interviewees expressed frustration over legal restrictions that impeded effective messaging. In California, policymakers in El Monte and Richmond anticipated the difficulty of winning a supermajority for a special tax under Proposition 13 and opted instead for a general tax. This decision eliminated advocates’ ability to wield an effective protax message (investing revenue into health initiatives) and bolstered an effective antitax message (gifting city officials with a “blank check”). Second, interviewees found the term sugarsweetened beverages difficult to explain, describing attempts by the beverage industry to spread misinformation about the types of beverages subject to tax, such as “your baby formula and your grandmother’s Ensure.” Another lesson related to paying close attention to the messenger. Many Richmond interviewees found voters reluctant to support a measure seen as proposed and promoted by outsiders (“do-gooders” from “outside the community” telling them they were “obese and needed to get rid of sodas”). Conversely, interviewees reported that messages delivered by community members were better received, especially in jurisdictions with large communities of color. Tax opponents were seen as quick to capitalize on the difficulty of messaging to communities of color. As one Richmond advocate noted, “When [the tax] came out, it got racialized. It got seen through a lens. . .of ‘Oh, you want to tax African Americans and create soccer fields for the growing Latino community.’” In El Monte, where 69% of residents selfidentify as Hispanic or Latino and 25% selfidentify as Asian,31 interviewees worked not only to develop linguistically and culturally appropriate messages but also to select messengers who were known and trusted within these communities, including Spanish-language media personalities and established community workers. Interviewees in all jurisdictions advised policymakers to gauge community readiness for SSB taxation before introducing legislation. Interviewees were optimistic about reducing SSB consumption in the long run. Nearly all
May 2014, Vol 104, No. 5 | American Journal of Public Health
stressed the importance of educating the public about SSBs’ contribution to obesity and diabetes. Many saw education as crucial not only in promoting SSB taxation but also in reducing SSB consumption through other strategies. In fact, several interviewees cautioned against a narrow focus on taxation, including one California advocate: “I think the big issue we’re talking about is soda. . .not soda tax. And when we’re talking as if the soda tax is the answer, we’re forgetting what the problem is.”
DISCUSSION This study adds to the growing literature on the role of messaging in policy debates over SSB taxation. By interviewing advocates “on the ground” in El Monte and Richmond, we built on previous research that explored messaging strategies at a national level,32 allowing for a more nuanced exploration of how messaging is targeted to the specific demographics and circumstances in a given location and how specific aspects of legislative language shape the framing of an issue. Relative to protax messages reported by national media from 2009 to 2011,24 supporters in Richmond and El Monte were equally likely to prioritize protax messages emphasizing the health and financial benefits of SSB taxation, especially regarding obesity reduction and health program funding. Our interviewees were much more likely than national media outlets, however, to cite messages counterarguing regressivity, potentially owing to the large proportions of lower-income residents in El Monte and Richmond. Both national media and our respondents reported antitax messages focusing on economic concerns and the role of government. However, very few of our interviewees reported hearing antitax messages disputing the ability of SSB taxation to decrease obesity prevalence, as compared with 33% of antitax messages in the media nationally.24 Our findings also offer a comparison with messages cited in local news coverage in El Monte and Richmond.23 Our interviewees were less likely than local media to mention protax messages about the soda industry behaving inappropriately and antitax messages refuting SSB taxation’s ability to promote health. However, both our interviewees and
Jou et al. | Peer Reviewed | Research and Practice | 851
RESEARCH AND PRACTICE
the media analysis identified messaging differences between El Monte and Richmond. Messages in El Monte were seen to center more on the city’s impending budget gap, in contrast to the focus of Richmond messages on the health benefits of Measure N. In addition, antitax messaging in Richmond was viewed as exploiting existing tensions between African American and Hispanic/Latino communities owing to competition over sparse resources. In El Monte, concerns over race/ethnicity focused more on how to overcome linguistic barriers.23 On the basis of both existing research and our interviewees’ experiences, we identified several factors that may contribute to messaging success. First, messaging is likely to resonate with audiences when it is supported by clearly written policies that emphasize benefits to voters. Several interviewees noted the difficulty of defining sugar-sweetened beverages for voters and identifying the products subject to tax, creating opportunities for the beverage industry to spread misinformation. In addition, nearly all interviewees believed that specifying the use of tax revenue for health-related initiatives was critical, consistent with polling data.16,18 Second, successful messaging should educate the public about SSBs’ impact on health. Our findings are in line with previous studies suggesting that messages emphasizing SSBs’ contribution to obesity and the effect of industry marketing on children are effective protax messages.18,33 Whereas several common antitax messages appeal to ideological or political beliefs, protax messages draw heavily from scientific evidence about the health effects of SSB consumption. Many interviewees believed that further education about SSBs will, in time, turn the tide of public opinion. Given that a key rationale for supporting SSB taxation is its ability to affect consumption,12,34 an interesting perspective voiced by several interviewees was that emphasizing the message of reducing SSB consumption through taxation can exacerbate the “nanny state” arguments favored by opponents. Several interviewees noted that positive messaging (e.g., emphasizing the benefits of tax revenue and promoting healthier beverages) may be more effective.
Limitations This study involved several limitations. First, although messaging was a vital component of
campaigns, it was only one of several factors that influenced the California elections. We focused on messaging content in this study, and we recommend further research into other factors such as messaging volume and political strategy. Second, our stakeholder sample was small and geographically concentrated, which could limit the generalizability of our findings. In addition, we did not interview stakeholders opposing SSB taxation. Opponents likely have a different set of experiences and tools and different messaging capacities. Finally, although our questions on messaging effectiveness provided insight into stakeholders’ perceptions, other study designs are required to measure the actual effectiveness of the messages in influencing public opinion.
Conclusions Our study contributes to public health practice through its assessment of the role of messaging in a new policy area. In identifying supporting and opposing messages and highlighting the challenges that stakeholders have faced when advocating for SSB taxation, our findings provide legislators, health officials, and advocates with ideas to consider for future policy debates. j
About the Authors Judy Jou and Sarah E. Gollust are with the Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis. Jeff Niederdeppe is with the Department of Communication, Cornell University, Ithaca, NY. Colleen L. Barry is with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Correspondence should be sent to Judy Jou, MA, Division of Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware Street SE, MMC 729, Minneapolis, MN 55455 (e-mail: jouxx008@umn. edu). Reprints can be ordered at http://www.ajph.org by clicking on the “Reprints” link. This article was accepted September 5, 2013.
Contributors J. Jou and S. E. Gollust collected and analyzed the data, with scientific input from J. Niederdeppe and C. L. Barry. J. Jou drafted the article. All authors contributed to the conceptualization and design of the study and reviewed and revised the final version of the article.
Acknowledgments This work was supported by the Robert Wood Johnson Foundation Healthy Eating Research Program (grant 69173). We thank the study participants for generously sharing with us their time and insights.
References 1. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999---2008. JAMA. 2010;303(3):235---241. 2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999---2010. JAMA. 2012;307(5):483---490. 3. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: payerand service-specific estimates. Health Aff (Millwood). 2009;28(5):w822---w831. 4. Ogden CL, Lamb MM, Carroll MD, Flegal KM. Obesity and Socioeconomic Status in Adults: United States, 2005---2008. Hyattsville, MD: US Department of Health and Human Services; 2010. 5. Bleich SN, Wang YC, Wang Y, Gortmaker SL. Increasing consumption of sugar-sweetened beverages among US adults: 1988---1994 to 1999---2004. Am J Clin Nutr. 2009;89(1):372---381. 6. Malik VS, Popkin BM, Bray GA, Després J-P, Willett WC, Hu FB. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care. 2010;33(11):2477---2483. 7. Malik VS, Schulze MB, Hu FB. Intake of sugarsweetened beverages and weight gain: a systematic review. Am J Clin Nutr. 2006;84(2):274---288. 8. Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988---2004. Pediatrics. 2008;121(6):e1604---e1614. 9. de Ruyter JC, Olthof MR, Seidell JC, Katan MB. A trial of sugar-free or sugar-sweetened beverages and body weight in children. N Engl J Med. 2012;367(15):1397-- 1406. 10. Ebbeling CB, Feldman HA, Chomitz VR, et al. A randomized trial of sugar-sweetened beverages and adolescent body weight. N Engl J Med. 2012;367 (15):1407---1416. 11. Ebbeling CB, Feldman HA, Osganian SK, Chomitz VR, Ellenbogen SJ, Ludwig DS. Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study. Pediatrics. 2006;117(3):673---680. 12. Brownell KD, Farley T, Willett WC, et al. The public health and economic benefits of taxing sugar-sweetened beverages. N Engl J Med. 2009;361(16):1599---1605. 13. Brownell KD, Frieden TR. Ounces of prevention— the public policy case for taxes on sugared beverages. N Engl J Med. 2009;360(18):1805---1808. 14. Rudd Center for Food Policy and Obesity. SugarSweetened Beverage Initiatives Since 2009: Legislation, Policies, and Initiatives. New Haven, CT: Yale University; 2013. 15. Rudd Center for Food Policy and Obesity. Many Americans Ambivalent Over Laws Aimed at Healthy Living: Poll. New Haven, CT: Yale University; 2012. 16. Center for Rural Studies. 2011 Vermont SugarSweetened Beverage Tax Study. Burlington, VT: University of Vermont; 2011.
Human Participant Protection
17. DiCamillo M, Field M. Most Californians See a Direct Linkage Between Obesity and Sugary Sodas. San Francisco, CA: Field Research Corp; 2013.
This study was exempted from review by the University of Minnesota institutional review board.
18. Barry CL, Niederdeppe J, Gollust SE. Taxes on sugar-sweetened beverages: results from a 2011 national
852 | Research and Practice | Peer Reviewed | Jou et al.
American Journal of Public Health | May 2014, Vol 104, No. 5
RESEARCH AND PRACTICE
public opinion survey. Am J Prev Med. 2013;44(2): 158---163. 19. Benford RD, Snow DA. Framing processes and social movements: an overview and assessment. Annu Rev Sociol. 2000;26:611---639. 20. Chong D, Druckman JN. Framing theory. Annu Rev Polit Sci. 2007;10:103---126. 21. De Leon R. Election 2012: measure N and measure O. Available at: http://richmondconfidential.org/2012/ 10/31/election-2012-measure-n-and-measure-o. Accessed January 14, 2014. 22. Impartial Analysis of Measure C. El Monte, CA: Office of the City Attorney; 2012. 23. Mejia P, Nixon L, Womack R, Cheyne A, Dorfman L. Soda Tax Debates: News Coverage of Ballot Measures in Richmond and El Monte, California, 2012. Berkeley, CA: Berkeley Media Studies Group; 2013. 24. Niederdeppe J, Gollust SE, Jarlenski MP, Nathanson AM, Barry CL. News coverage of sugar-sweetened beverage taxes: pro- and antitax arguments in public discourse. Am J Public Health. 2013;103(6):e92---e98. 25. Dillard JP, Weber KM, Vail RG. The relationship between the perceived and actual effectiveness of persuasive messages: a meta-analysis with implications for formative campaign research. J Commun. 2007;57 (4):613---631. 26. Zhao X, Strasser A, Cappella JN, Lerman C, Fishbein M. A measure of perceived argument strength: reliability and validity. Commun Methods Meas. 2011;5(1):48---75. 27. Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42 (4):1758---1772. 28. California Constitution, Article 13A (tax limitation). Available at: http://www.leginfo.ca.gov/.const/. article_13A. Accessed January 14, 2014. 29. Velazquez M. El Monte planning commissioner sues over soda tax ballot language. Available at: http:// www.sgvtribune.com/general-news/20120827/elmonte-planning-commissioner-sues-over-soda-tax-ballotlanguage. Accessed January 14, 2014. 30. Oatman M. Will Big Soda Beat the California Soda Taxes? San Francisco, CA: Mother Jones; 2012. 31. US Census Bureau. El Monte, California: state and county quick facts. Available at: http://quickfacts.census. gov/qfd/states/06/0622230.html. Accessed January 14, 2014. 32. Barry CL, Jarlenski M, Grob R, Schlesinger M, Gollust SE. News media framing of childhood obesity in the United States from 2000 to 2009. Pediatrics. 2011;128(1):132---145. 33. Friedman RR, Brownell KD. Sugar-Sweetened Beverage Taxes: An Updated Policy Brief. New Haven, CT: Rudd Center for Food Policy and Obesity; 2012. 34. Chaloupka FJ, Powell LM, Chriqui JF. Sugar-Sweetened Beverage Taxes and Public Health. Princeton, NJ: Robert Wood Johnson Foundation; 2009.
May 2014, Vol 104, No. 5 | American Journal of Public Health
Jou et al. | Peer Reviewed | Research and Practice | 853
