Article Text
Abstract
Background Obesity implies costs not only for the individual but also for society. The authors explore the opinions of stakeholders on the potential of taxes or subsidies, as measures for tackling obesity in Europe.
Methods Structured interviews were conducted using Multicriteria Mapping, a computer-based, decision-support tool, with 189 interviewees drawn from 21 different stakeholder categories across nine members of the EU interviews, to appraise 20 predefined policy options aimed at reducing obesity, including ‘taxing obesity-promoting foods’ and ‘subsidising healthy foods.’ A four-step approach involved selecting options, defining criteria, scoring options quantitatively and weighting criteria to provide overall rankings of options. Interviews were recorded and transcribed to yield qualitative data.
Results Compared with other policy options appraised, taxation and subsidies were not favourably received, mainly because they were considered difficult to implement. Overall, trade unions rated both options more favourably than all other stakeholder groups. As anticipated, both options received their lowest scores from representatives of the farming, food processing and advertising industries. Nutritional/obesity advisory experts and public sector caterers gave the most positive ratings to subsidies overall. Along with public health professionals, large commercial retailers were most in favour of taxation.
Conclusions Taxation and subsidies were poorly appraised compared with other policy measures, with stakeholders expressing reservations mainly focussed on the practicalities and cost of introducing such measures. Although applying taxes/subsidies could be useful to combat obesity, the study suggests that most stakeholders still need to be convinced of their viability and acceptability when compared with other measures.
- Nutrition policy
- obesity
- tax food
- public health nutrition
- pricing policy
- nutrition
- obesity EPI
- public health policy
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- Nutrition policy
- obesity
- tax food
- public health nutrition
- pricing policy
- nutrition
- obesity EPI
- public health policy
Introduction
It is now apparent that the public health problem of escalating obesity has been brought about by the convergence of economic, environmental and cultural forces1–3 that are capable of destabilising the natural physiological regulation of energy balance. Given its complex aetiology, it is unlikely that the pandemic of obesity can be reversed by strategies based exclusively on educational campaigns aimed at changing individual behaviour, without also creating a supportive environment.
At present, the European Union's (EU) Common Agricultural Policy tends to subsidise surpluses of foods high in calories but low in vitamins, minerals and fibre, rather than foods that could help protect against obesity. Current approaches focus on subsidising production of certain crops in order to stabilise prices, supporting agricultural production and guaranteeing food supply.4 Objections have, however, been raised in terms of the unintentional secondary effects such policies might produce.2 5
Imposing taxes on food could serve several purposes, for example, by raising general revenue in the EU to fund other interventions to promote healthier eating and by influencing purchasing patterns. The price of foods is a major influence on purchasing; consequently, it might be reasonable to expect that a population's dietary habits could be changed through the application of economic measures.6 For example, one study conducted by the UK's Food Standards Agency revealed that of all factors influencing food choice, the most decisive was price.7
Technological developments over recent decades have generally lowered the price of acquiring calories (as food has become cheaper relative to incomes and to non-agricultural commodities) and reduced the likelihood of expending them, hence, reducing economic incentives for maintaining a healthy balance between food intake and physical activity.8 Economic factors, including more sedentary jobs and cheaper cars, have also helped to create an obesogenic environment.9 10 Together, these elements form the base from which it is possible to obtain larger portions of food for a given amount of money, and where sitting in front of a computer at work is associated with maximum productivity. Consequently, there is a growing interest in developing the best strategies possible for achieving healthy dietary habits.11
As a response to this concern, various proposals have been put forward besides food taxation and subsidies, for example, public education campaigns, controls on advertising, promotion of healthy eating in schools and changing the built environment. The World Health Organization maintains that controlling the price of healthy foodstuffs is a key factor in improving diet and preventing disease.12 The European Health Network has called for a broad-based and integrated food policy, which would include policies for price control.13 In addition, in November 2006, European ministers signed a Charter committing them to creating a balance between individual and social responsibility.14
The practice of taxing products as a health policy has a long tradition in public health, and has proved to be effective in controlling consumption and consequently improving health, as can be seen in the cases of alcohol15 and tobacco, for example.16 The theoretical foundation for using economic incentives to regulate dietary habits is the assumption that demand/price curves are downward sloping. However, the use of differentiated food taxes or subsidies to achieve nutritional objectives has not been widely employed in EU public policies, and thus empirical evidence on the effects is scarce, diverse and inconclusive.
The dual aim of this paper, therefore, is first to appraise how taxing obesity-promoting-food and subsidising healthy foods perform compared with other policy options aimed at preventing obesity in the EU, and second to analyse the viewpoints of a wide range of stakeholders on the implementation of subsidies and taxation, to assess whether the debate is as polarised as the literature and traditional stakeholder positions suggest. Evidence for these expected different points of view comes from ongoing debates,17 where public health nutritionists see modifying the obesogenic environment as a priority for obesity prevention,18 19 while those within the large food industry place more importance on the individual's responsibility to effect self-control.20 Industry also places more emphasis on inadequate physical activity as the main contributor to obesity, rather than consumption of energy-dense foods.21 22 This led us to the a priori hypothesis that fiscal interventions are therefore less likely to be favoured by industry because they do not rely on individual self-control or on physical activity. However, there is a lack of published empirical data on these different stakeholder positions.
Methods
Mapping tool
Multicriteria mapping (MCM)23 24 is a novel decision-analysis technique used to provide an integrated, comparative analysis of the different viewpoints of key stakeholders. In this study, it was used to appraise 20 predefined policy options, including one on ‘taxes on obesity-promoting foods’ and a second on ‘subsidies on healthy foods.’
MCM provides information not only on how different options are expected to perform, but also on the reasons for those appraisals, and is described in detail elsewhere.24 25 Quantitative and qualitative data were gathered from a large number of stakeholders to ensure that a comprehensive range of views were mapped. The nine national teams contributing to the Policy Options for Responding to the Growing Challenge of Obesity Research (PorGrow)26 project selected 21 stakeholder categories to be interviewed in each of the countries (Cyprus, Finland, France, Greece, Hungary, Italy, Poland, Spain and the UK), representing actors and institutions which may play an important role in policymaking, either directly or through networks of influence. It is possible to combine these categories into stakeholder affinity groups sharing common commercial, corporate or professional interests. These groups were called ‘Perspectives.’ In order to provide consistency across national contexts, it was agreed at a project meeting held in September 2005 that all national teams would undertake the initial analysis of the interviewees using an agreed list of perspectives. The shared set of perspectives is shown in table 1.
The countries were chosen to encompass Europe's contrasting economies, gastronomies, geographies and cultures. The stakeholders were chosen to encompass those groups likely to be essential in, or important to, an effective policy network.
Selecting stakeholders
To select the individual interviewees, national teams used both an exhaustive web search (using as key words the translation into local languages of the stakeholder categories previously agreed) and a snowball approach using information gathered from key informants and identified stakeholders. The aim was to select stakeholders at the highest national level, who were involved in corporate or public policy-making and could act as spokesperson for their stakeholder category. The project coordinator (EM) ensured that there was sufficient comparability of stakeholder roles between countries by discussing issues surrounding cross-country comparisons of the identified stakeholders' national roles with the participating teams.
Once the candidates for interview had been identified, they were contacted by telephone and sent an invitation letter, along with a leaflet in the local language containing information on the project. When the selected stakeholders agreed to participate, a second package with information on MCM methodology and an example of a previous mapping exercise on energy options was sent by post. The stakeholders were contacted again by telephone to address any remaining questions, giving further information where necessary, and to arrange a time and place to conduct the 2–3 h interview appropriately, that is, without interruption. This process is known as ‘scoping’ in the MCM procedure.24 The interviews were conducted following a common procedure which included tape-recording, the use of special software developed specifically for the project and adhering strictly to the procedures described in the interview manual.
Almost all invited participants agreed to be interviewed (Greece omitted category 6, public sector catering, since catering in all Greek public sector institutions is provided by private contractors), and in a few cases they asked to bring colleagues to join in the procedure. All participants accepted the procedures, and all participants successfully completed the interview, although the time taken for participants to undertake the interview process varied.
Conducting interviews
The MCM interview consists of four steps. First, participants selected and defined a set of policy options that they would evaluate. Prior to the formal start of the project, an attempt was made to identify as wide a range as possible of the policy options under consideration by public policymakers and public health policy analysts for addressing the increasing prevalence of obesity. The scope of this investigation ranged from international organisations such as the World Health Organization and the European Commission, and the governments of EU Member States, to national and EU NGOs representing industrial, commercial, consumer and public health organisations.
Selecting policy options
Thus, before the project's initial launch meeting in September 2004, interpartner exchanges had produced a set of some 28 policy options from which core and discretionary options could be chosen. All partners from the nine participating countries were asked to indicate which of those options could sensibly be considered as relevant to their national contexts. The resulting set of options was then divided into two subsets: namely those that were candidates for the role of ‘core options’ and those that were candidates for the role of ‘discretionary options,’ and these were tabled by the principal investigator (EM) at the first project meeting. Core options were one that all interviewees would be asked to appraise, while discretionary options were suggestions, not requirements. All interviewees were also invited to introduce any further additional options they deemed worth consideration and appraisal.
Debate produced a consensus list of seven core options and 13 discretionary options. For each policy option, three levels of description were developed: a summary phrase, a longer phrase and a full description so that interviewees would have a clear understanding of the options that they were being required and/or invited to appraise. The resulting list is shown in table 2.
For the purpose of this article, we have specifically focused on the valuation of all those interviewed on the choice of two public policies, options 6 and 7 in table 2, defined as:
Taxes on obesity-promoting foods: Change food prices to influence people's dietary choices by increasing the price of obesity-promoting foods, including those high in fat and sugar, as a disincentive for consumers to purchase them. Methods for increasing the price of obesity-promoting foods could include a ‘fat tax,’ or extending value-added tax to cover some dairy foods, fast food and sweet food.
Subsidies on healthy foods: Public subsidies on healthy foods to improve patterns of food consumption. Change food prices to influence people's decision making in favour of healthier foods by introducing subsidies to lower the prices of healthy foods, making them more affordable.
Appraising the performance of policy options
Second, each interviewee provided a set of evaluative criteria to represent their particular viewpoints. The ‘criteria’ are the different factors that the interviewee has in mind when they choose between, or compare, the pros and cons of different options. These may address any issue that has relevance to their assessment of the performance of any of the options, but the criteria must be applicable to assessment of all the options.
Third, options were evaluated according to each criterion and scores on an ordinal numerical scale were given by the interviewees: the higher the score, the more optimistically the interviewee appraised the performance of the option. Here, interviewees were asked to assign numerical scores to characterise their own view of option performance. Usually, interviewees chose to use a 10-point or 100-point range to define these interval scales. Interviewees expressed their judgements of uncertainty as regards the performance of the options by awarding both an optimistic and pessimistic scores to each option.
For the purposes of analysis and comparability in this section, we have focussed on the criteria from which taxes on obesity-promoting foods and subsidies on healthy foods were highlighted when compared with the other options.
Fourth, a quantitative weighting was assigned by interviewees to each criterion, in order to reflect its relative importance according to their viewpoint. Using a simple formula, the scores under each criterion were multiplied by the criteria weightings to produce an overall pessimistic and optimistic relative ranking for each option.
Data analysis and interpretation
Interviews were audio-recorded and transcribed, as the reasons provided by interviewees for their judgements were as important as their quantitative judgements. Once the interviews were completed, several techniques were used to keep in touch with the stakeholders and obtain feedback for incorporation in the results.
In order to facilitate data analysis, a separate specialist software package called MCM Analyst was developed at the University of Sussex, as part of the PorGrow project. This includes a relational database containing both quantitative and qualitative data relating to all participants, interlinked with textual reports for representing relevant sections of the qualitative data in graphics and narrative forms.
Each stage in this analysis was performed primarily by the national teams, although key interpretations were finalised through iterative consultation between national teams and under central coordination to ensure comparability across national analysis.
The findings at each stage were documented separately in the national and international reports (see http://www.sussex.ac.uk/spru/porgrow). Further details of the methodology can be found in the Interview Manual and in the Analysis Manual (see http://www.sussex.ac.uk/spru/1-4-7-1-8-2-1.html).
Finally, and for analytical purposes, in order to facilitate comparisons between the appraisals made by different stakeholders, and for the purposes of this article, the appraisal options tax/subsidies were compared according to stakeholders, the country of origin and the selection criteria considered by those interviewed in their assessment.
Results
Interviews were conducted between November 2004 and May 2005. Twenty-one stakeholder categories were interviewed in each country. The overall aggregated options ranking across all interviewees in all nine participating countries are given in figure 1. The results showed that of the Core options, policies to improve the availability of, and access to, sports facilities, to improve nutritional labelling and to improve food sales in public institutions scored highly overall and in virtually all countries. Of the discretionary options, educational options focussing on both school children and the general adult population were the most popular.
On average, the 189 European stakeholders consulted in the nine participating countries gave low scores and ranks to economic measures involving taxing obesity-promoting food. Subsidising healthy foods received a slightly higher rating than taxes, but implementation of either option was perceived to be limited by unfavourable implications.
Nevertheless, when results for taxes were analysed further by reference to stakeholder profiles, it was seen that three categories of interviewees had given scores slightly over 50, on a normalised 0–100 scale. Those categories were: representatives of large commercial retail chains, public health professionals and trade unions (see figure 2). Although they did not provide many supporting arguments, they based their assessment on the importance of price in determining shopping habits.
As for subsidies, representatives from public sector catering, expert nutrition/obesity advisory committees and trade unions gave that option the highest scores. The reasons given for their optimistic evaluations were that it was technically easy to put in place once the political will was there, that it would benefit some food manufacturers and that subsidies would be widely accepted by citizens, as they would lead to cheaper prices and enable better access to ‘healthier’ subsidised foods for lower socio-economic groups. Some arguments are shown in table 3 (comments 1, 2).
On the other hand, the lowest scores for both taxes and subsidies were given by representatives of the farming industry, town and transport planning, the food processing industry and the advertising industry. Among the reasons they gave for their assessments were the importance of the free market and freedom of choice for the consumer (table 3 (comments 3, 4, 5)).
In addition, some interviewees felt that this classification would imply dividing food into two categories—good and bad—and that it is the overall diet, rather than specific products, that causes obesity. In this case, the principal difficulty would be in identifying which foodstuffs should be taxed or subsidised (table 3 (comments 6, 7)).
Furthermore, the interviewees indicated the implications of taxing obesity-promoting food, pointing out the possible negative impact of this tax on low-income individuals and families, for whom food constitutes their principal outgoings (table 3 (comment 8)).
Moreover, some of those interviewed (usually those who gave this option lower scores) considered these measures to be a target for manipulation by industry, with potential for corrupt practice (table 3 (comment 9, 10)).
Differences between interviewees by country
As can be seen in figure 3, when the quantitative results were analysed by country, differences became apparent. Some representatives of specific areas in each country were in favour of the taxation option as a public policy, with scores close to or over 80 on a scale of 0–100. In Finland, five of the 21 interviewees gave high scores to the taxation option. In the remainder of the countries, two interviewees per country gave high scores, except in Poland, where no high scores were given for this option.
As regards the possibility of subsidising healthy food, six interviewees from Finland gave high scores, followed by Poland and France with three interviewees per country. The stakeholder category which produced high scores with most frequency (3/9 countries) was that of public health professionals, both for taxes (Italy, France and Spain) and for subsidies (Spain, France and Poland).
Appraisal of options according to different criteria
The approach of manipulating food supply through fiscal measures gave a mixed pattern: taxes on obesogenic foods generally scored poorly, especially in terms of cost to individuals especially in poorer communities, but were seen as being favourable to public sector finances, particularly in Greece. Furthermore, those stakeholders who were critical of the measure at the same time accept that there are some positive aspects to the tax option: there were possible gains to be made in terms of social benefits (eg, reduced inequalities, depending on how the measures were applied) and extra health benefits. On these criteria, Finland was the country that gave the highest scores to the tax option. Conversely, subsidies on healthy foods were recognised as being costly to the public sector but not to individuals or for the commercial sector.
Furthermore, as can be seen in figure 4, all bars cramped over to the left by the contribution of the selected criteria to the overall appraisal. As regards the cost to individuals, Finland, Greece and Poland were the countries which gave more positive scores to the subsidy option, while Cyprus, followed much further down the list by Greece and Hungary, gave more favourable scores to costs for the commercial sector (table 3 (comment 11)).
Finally, the participants expressed that, as with many other options, a successful strategy requires consumer education and health promotion for maximum benefit:This strategy could be combined with nutritional labelling or the use of the traffic light system so that those products which are unhealthy could be labelled with a red ‘unhealthy’ sign. Thus, it will be up to the consumers to buy them or not. (Greece, sports providers)
It is preferable to educate the population about the fact that there are some foods that can be consumed generously but others only in moderation, rather than penalizing through taxes according to this classification. (Spain, health ministry representative)
Discussion
The main aim of this analysis is to assess views regarding introducing taxation on obesity-promoting food and subsidises on healthy food compared with other policies aimed at preventing obesity in the EU. Compared with the 18 other core and discretionary options appraised, taxation and subsidies were not favourably received, mainly because they were considered difficult to implement. Imposing food taxes has traditionally been unpopular among the general population, and there was unease from many that taxation, in particular, would be unacceptable. Concerns expressed by some stakeholders in this study that taxation would fall disproportionately on low-income consumers seems to be unfounded2 8 particularly if taxation is not limited to a single nutrient or food, and is balanced by reduced taxes, or subsidies on other foods. The implementation of taxation on a certain category of food, group of foods or method of preparation as a public policy mechanism for controlling calorie consumption is not generally viewed as either a priority or as acceptable and effective for dealing with the obesity epidemic.
Nevertheless, there are significant differences as regards potential implementation by country, Finland being notably more in favour than other countries. Finland, Norway and Sweden constitute the three Scandinavian countries with a tradition of adopting centralised political measures with regard to nutrition and food. Norway enacted its first nutrition plan of action in 1976, and Finland in 1989, where fiscal measures were adopted as a strategy for achieving the nutritional objectives outlined by the plans, using a combination of food subsidies, price manipulation, retail regulations, clear nutritional labelling and public education focused on individuals.27 28
As suggested by the arguments put forward by international organisations (the WHO and IOTF), econometric studies in several countries indicate that prices do have an impact on patterns of food consumption.8 29 Nevertheless, although it is possible to find a wide range of examples of taxes on food products, these have usually been implemented with a view to raising national revenue rather than with the aim of influencing dietary habits and improving health.19 30 Available evidence relating to the use and impact of food taxation on dietary habits is inconclusive, and is limited to retrospective descriptions, or to short periods of time, due to lobbying from the agri-food industry.19 The effects of subsidies differ according to whether they are applied to supply5 or demand.31 Some studies demonstrate the advantages of applying subsidies to demand for specific food products in local action programmes.32 The effect on health, as a public policy measure, has been studied to a lesser degree.31 33
Cost may be considered the main argument in favour of public intervention from a strictly economic perspective, implying that price influences demand in food consumption. Some authors suggest that rather than applying fiscal measures such as food taxes and subsidies in order to combat obesity, subsidies for the production of basic foodstuffs should be withdrawn, as these distort the EU's common agricultural policy (CAP). That is to say that those foodstuffs whose production is currently subsidised are precisely those for which food taxation is being proposed. A step in that direction was the 2003 CAP reform, the main aim of which was to bring supply in line with demand.34 Ironically, the potential cost of introducing subsidies and taxation on the commercial sector and individuals were major concerns to the stakeholders interviewed.
The second purpose of this study was to analyse the different viewpoints of a wide range of stakeholders on the implementation of subsidies and taxation, to assess whether the debate is as polarised as the literature and traditional stakeholder positions suggest. Not all stakeholders were opposed to the implementation of taxes/subsidies. Historically, the debate has been polarised between two positions; those who support the argument based on individual behaviour21 and those who see the solution in more structural terms.18 The latter (structuralists) are more likely to support food taxes, whereas those who see the individual as primarily responsible are more likely to reject taxes.19 This polarisation is reflected in some of the results of this study, where positive scores were recorded by representatives of public-health professionals, trade unions, health NGOs, public sector caterers and expert nutrition/obesity advisory committees (for subsidies). Also, as expected, negative scores were recorded by representatives of the farming, food processing and advertising industries. However, views from different stakeholder groups did not always follow what one might expect. Large commercial caterers, for example, supported taxation more than other stakeholders, which is surprising given that they could incur increased food costs as a result. Since, however, it might affect all equally, it need not change their relative competitiveness. Also unpredictable was the support of large food retailers for taxation; although they remained unfavourable towards subsidies, again one could imagine that taxation would increase prices of some products and therefore be a disadvantage their business, relative to other sectors. On the other hand, we had expected consumer organisations and town and transport policies to be favourable to fiscal intervention, given their role in working for the public; but taxation and subsidies were evaluated poorly by them. However, their reservations were different to stakeholders in the food processing, advertising and farming industries; consumer groups were concerned about putting controls on consumer freedom to choose and disproportionate effects of taxation on lower-income groups, and concerns about feasibility were strong from town planners.
Finally, and taking into account the methodology used in this study, caution should be exercised when interpreting the results; the final map of options corresponds to averages between the ranges of all participants, with variations in scoring under different criteria for each participant and between participants when the categories are combined. A loss of accuracy in the information is therefore unavoidable when aggregating and averaging. Additionally, the position of different stakeholders could have been influenced by their commercial interests and/or their professional expertise. However, a quantitative check indicated that omitting potentially self-serving judgements changed the overall outcomes by no more than ±1%.35
In conclusion, although stakeholders in the political network influencing obesity are not, when viewed collectively, in favour of the application of economic regulation at the present time, compared with other policy measures, neither was there a consensus against implementation of these measures. The standpoints of stakeholders were influenced to some extent by their interests and by their expectations of the costs of regulation, but stakeholders' viewpoints did not always fit into what was expected from conventional positions. In addition, the political culture of each country would seem to have an important influence on the positions of the various stakeholders. Investigation into fiscal measures applied to food as a means of controlling obesity should not be abandoned, as there is some evidence that this can influence food consumption patterns. Our study shows that a decision to apply economic measures such as taxes/subsidies in the EU represents one possible course of action, as part of an integrated and coherent public policy aimed at combating obesity, but only under certain conditions. However, stakeholders will need to be convinced of their viability and acceptability, when compared and integrated with other measures.
What is already known on this subject
The practice of taxing products as a health policy has a long tradition in public health, and has proved to be effective in controlling consumption and consequently improving health, as can be seen in the cases of alcohol15 and tobacco, for example.16 The theoretical foundation for using economic incentives to regulate dietary habits is the assumption that demand/price curves are downward sloping. However, the use of differentiated food taxes or subsidies to achieve nutritional objectives has not been widely employed in EU public policies, and thus empirical evidence on the effects is scarce, diverse and inconclusive.
What this study adds
Price is an important factor for the consumer when choosing food. Consequently, it would be reasonable to assume that the population's dietary habits could be changed through the application of economic measures. The idea behind modified food taxes or subsidies is to provide consumers with economic incentives to change their habits in line with nutritional recommendations, thus reducing the probability of being exposed to obesity and other health risks.
To apply economic measures such as taxes/subsidies in the EU represents one possibly viable course of action, as part of an integrated and coherent public policy aimed at combating obesity, but under certain conditions and with improved stakeholder support.
Acknowledgments
The research team is greatly indebted to all European stakeholders who participated in the project and devoted their precious time to the project. The research team wish to express their sincere thanks to the national PORGROW teams for sharing their cross-national PorGrow database, and our partners P Borg from UKK Institute for health Promotion Research (Finland), SC Savva, from Research and Education Institute of Child Health (Cyprus), and L Szponar, from National Food and Nutrition Institute (Poland).
References
Footnotes
Funding Supported by New and Emerging Science and Technology (NEST) research programme, financed by the 6th Framework Programme for research and technological development of the European Commission (contract no 508913).
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.