Background Fruit and vegetable (F&V) intake is an important modifiable risk factor for cardiovascular disease (CVD). Fiscal policies have been recommended to increase F&V consumption, but their potential impact on health and inequalities are not well described.

We therefore explored the potential benefits of five different fiscal policies on F&V consumption, CVD mortality and associated socio-economic inequalities in Madrid, Spain (total population ~6,700,000 residents).

Methods A modelling study using a comparative risk assessment approach.

We compared five policy options:

Option 1) reducing F&V Value Added Tax (VAT) from 4% to 0%;

Option 2) a F&V price discount of 10%;

Option 3) a targeted F&V subsidy of 50% for low-income families;

Option 4) a mass media campaign promoting F&V consumption, and

Option 5) The combination of Options 3 and 4.

We computed F&V intake, CVD deaths prevented or postponed (DPPs), and CVD mortality inequalities between quintiles of area-level socio-economic status (SES) in 2021–2035, compared to a no-intervention scenario based on observed trends in F&V intake and CVD mortality. We used estimates for price elasticities, pass-through of policies, and F&V effect measures from relevant sources. We conducted sensitivity analyses through 5,000 Monte Carlo iterations with wide margins using the statistical software R.

Results A combined mass media campaign and 50% targeted discount could prevent or postpone approximately 700 CVD deaths (95% UI: 50 – 1000) in 2021–2035, representing a 1% reduction in total CVD mortality. A 50% targeted discount alone might generate some 450 DPPs, (95%UI: 300 – 700), a 10% universal subsidy approximately 300 DPPs, (95%UI: 100 – 450), a mass media campaign some 200 DPPs, (95%UI: 150 – 400), and 0% VAT 100 DPPs, (95%UI: 50 – 200). Every option would modestly reduce socio-economic inequalities in CVD mortality, with the combined policy achieving the greatest reduction, approximately 10 DPPs/100,000 population between highest- and lowest-SES areas.

Conclusion Fiscal policies and mass media campaigns targeting F&V consumption applied singly, or ideally in combination, could reduce CVD mortality and decrease social inequalities in a large southern European urban population.