The central flaw of Riediger and Bomback’s1 argument is the suggestion that public health solutions are narrow in scope: no single strategy is ever universally effective or equitable. Continuing the connection between tobacco and sugar-sweetened goods, tobacco consumption has been effectively reduced in Canada, as well as internationally, not through the sole agency of taxes, but through a suite of measures (i.e., the World Health Organization MPOWER framework [Monitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion and sponsorship; Raise taxes on tobacco])2 that affect how we interact with tobacco through every stage of the process: manufacturing, regulation, marketing, labels and warnings, retail accessibility and substitution, including cessation aids.
As such, the public health community has equally recognized that taxes are a measure, not the measure, to address obesity or chronic disease caused by poor nutrition. A tax on sugar-sweetened beverages must accompany other policies and programs that form a comprehensive approach to what is debatably a more wicked problem than tobacco. Indeed, through a collective set of measures, an approach may be taken that allows for emphasis of certain approaches for specific populations and locations to maximize effectiveness and minimize any potential inequities produced.
Given that Indigenous people, as pointed out by the authors, do suffer increased barriers to access to fresh drinking water and have higher degrees of food insecurity, efforts to limit intake of unhealthy food and beverages should be at minimum matched by initiatives to increase access to healthier options. In the case of sugar-sweetened beverages, the logistics of delivering water are the same as delivering other bottled beverages, and, as such, shifting consumption habits in Indigenous people will encourage distributors to provide healthier options to that area. Indeed, the experience in Mexico showed that decreases in soda were compensated by increased consumption of water. Similar preliminary results in Seattle, where revenues from sugary drink taxes are used to subsidize fruits and vegetables for low-income earners at farmers’ markets, have shown reduced sugary drink sales, increased produce purchases and more business for local farmers. Clearly, a multifaceted solution allows multiple nutrition and inequity issues to be collectively addressed.
Taxation is an intrinsically blunt instrument that is applied across an entire population. Those in lower income populations are more affected by taxes (though only slightly more than middle- and high-income earners). Given this, taxation is not an effective monotherapy for the obesity and chronic disease crisis, nor should it be. It does, however, allow for often difficult-to-achieve targeting of the commercial determinants of health, as well as provide a rare intervention that can augment rather than attenuate other efforts. Moving forward, it is critical that we consider how best to address the needs of each population through a collective set of measures, including taxes as well as other approaches. We should not let the perfect be the enemy of the good.
Footnotes
Competing interests: None declared.