Oakland's Sugar-Sweetened Beverage Tax: Honoring the "Spirit" of the Ordinance Toward Equitable Implementation

Assessing Policy Impacts on Chronic Disease Risk Reduction: The Science and Art of Policy Measurement and Rating Systems

Public policies have been instrumental in influencing population health, and the desire to study their impact led to the development of the fields of policy surveillance and legal epidemiology. The standardized practice of creating policy measurement systems allows researchers to track and evaluate policy impacts across jurisdictions and over time. Policy measures may take many forms, including dichotomous measures, ordinal ratings, composite measures, or scale measures. The policy measures are determined largely based on the research question but should also consider factors impacting policy implementation and equity. Many sources of evidence, including expert input, national standards, scientific evidence, and existing policies, can be used in the development of policy measurement and rating systems. Any system must be tested, reliable, and clearly documented to create a robust and rigorous dataset. This article reviews key considerations for the development of policy measurement and rating systems for use in public health research.

Design considerations for developing measures of policy implementation in quantitative evaluations of public health policy

Typical quantitative evaluations of public policies treat policies as a binary condition, without further attention to how policies are implemented. However, policy implementation plays an important role in how the policy impacts behavioral and health outcomes. The field of policy-focused implementation science is beginning to consider how policy implementation may be conceptualized in quantitative analyses (e.g., as a mediator or moderator), but less work has considered how to measure policy implementation for inclusion in quantitative work. To help address this gap, we discuss four design considerations for researchers interested in developing or identifying measures of policy implementation using three independent NIH-funded research projects studying e-cigarette, food, and mental health policies. Mini case studies of these considerations were developed via group discussions; we used the implementation research logic model to structure our discussions. Design considerations include (1) clearly specifying the implementation logic of the policy under study, (2) developing an interdisciplinary team consisting of policy practitioners and researchers with expertise in quantitative methods, public policy and law, implementation science, and subject matter knowledge, (3) using mixed methods to identify, measure, and analyze relevant policy implementation determinants and processes, and (4) building flexibility into project timelines to manage delays and challenges due to the real-world nature of policy. By applying these considerations in their own work, researchers can better identify or develop measures of policy implementation that fit their needs. The experiences of the three projects highlighted in this paper reinforce the need for high-quality and transferrable measures of policy implementation, an area where collaboration between implementation scientists and policy experts could be particularly fruitful. These measurement practices provide a foundation for the field to build on as attention to incorporating measures of policy implementation into quantitative evaluations grows and will help ensure that researchers are developing a more complete understanding of how policies impact health outcomes.

A Sugar-Sweetened Beverage Excise Tax in California: Projected Benefits for Population Obesity and Health Equity

INTRODUCTION

Amid the successes of local sugar-sweetened beverage (SSB) taxes, interest in state-wide policies has grown. This study evaluated the cost effectiveness of a hypothetical 2-cent-per-ounce excise tax in California and its implications for population health and health equity.

METHODS

Using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model, tax impacts on health, health equity, and cost effectiveness over 10 years in California were projected, both overall and stratified by race/ethnicity and income. Expanding on previous models, differences in the effect of intake of SSBs on weight by BMI category were incorporated. Costing was performed in 2020, and analyses were conducted in 2021-2022.

RESULTS

The tax is projected to save $4.55 billion in healthcare costs, prevent 266,000 obesity cases in 2032, and gain 114,000 quality-adjusted life years. Cost-effectiveness metrics, including cost/quality-adjusted life year gained, were cost saving. Spending on SSBs was projected to decrease by $33 per adult and $26 per child overall in the first year. Reductions in obesity prevalence for Black and Hispanic Californians were 1.8 times larger than for White Californians, and reductions for adults with lowest incomes (<130% Federal Poverty Level) were 1.4 times the reduction among those with highest incomes (>350% Federal Poverty Level). The tax is projected to save $112 in obesity-related healthcare costs per $1 invested.

CONCLUSIONS

A state-wide SSB tax in California would be cost saving, lead to reductions in obesity and improvement in SSB-related health equity, and lead to overall improvements in population health. The policy would generate more than $1.6 billion in state tax revenue annually that can also be used to improve health equity.

Implementation costs of sugary drink policies in the United States

To support implementation of important public health policies, policymakers need information about implementation costs over time and across stakeholder groups. We assessed implementation costs of two federal sugar-sweetened beverage (SSB) policies of current policy interest and with evidence to support their effects: excise taxes and health warning labels. Our analysis encompassed the entire policy life cycle using the Exploration, Preparation, Implementation, and Sustainment framework. We identified implementation actions using key informant interviews and developed quantitative estimates of implementation costs using published literature and government documents. Results show that implementation costs vary over time and among stakeholders. Explicitly integrating implementation science theory and using mixed methods improved the comprehensiveness of our results. Although this work is specific to federal SSB policies, the process can inform how we understand the costs of many public health policies, providing crucial information for public health policy making.

Framing and Themes of the City of Boulder's Sugar-Sweetened Beverage Tax Coverage in the Local News From 2016 to 2018

The objective of this paper was to analyze the contents of opinion and news articles related to the city of Boulder's sugar-sweetened beverage excise tax campaigns in Boulder's only local newspaper. We searched for articles in The Daily Camera related to the sugar-sweetened beverage tax, published from January 2016 to December 2018. We conducted a content analysis, categorizing 152 relevant articles by type, authors, and frames (pro, anti, neutral) on the basis of the preponderance of arguments, themes, and use of evidence. The majority of articles were opinion (n=92) versus news (n=60). Most articles were pro-frame (n=78) versus anti-frame (n=37) and neutral frame (n=37). Pro-frame articles were more likely to cite evidence in support of arguments or the professional credentials/experience of the authors. The most frequent pro-frame themes were health, benefits of the revenues, equity, and unethical tactics of the industry. The most frequent anti-frame themes were economic consequences, claims that the measure was confusing, government overreach, and purported ineffectiveness of taxes. The leveraging of local issues by the beverage industry was observed. Themes identified in the news regarding Boulder's successful sugar-sweetened beverage tax may appear in future sugar-sweetened beverage policy campaigns and should be anticipated.

Improving "Life Chances": Surveying the Anti-Transgender Backlash, and Offering a Transgender Equity Impact Assessment Tool for Policy Analysis

Transgender inclusion within policy is critical yet often missing. We propose a policy tool to assesses human rights, access to resources and opportunities, language, and implications for transgender and nonbinary individuals. Acknowledging trans communities as standard policy practice can serve as an essential practice to shift dialogue and norms.

Community Perceptions in New York City: Sugar-Sweetened Beverage Policies and Programs in the First 1000 Days

Objectives

To examine perceptions of Sugar-sweetened beverage (SSB) policies and programs focused on the first 1000 days—gestation through age 2 years—among community stakeholders in Washington Heights and the South Bronx, two neighborhoods in New York City with disproportionately high prevalence of childhood obesity.

Methods

A multilevel framework informed interview guide development. Using purposeful sampling, we recruited study participants who were (1) able to speak English or Spanish and (2) resided or employed in Washington Heights or the South Bronx. Participants included community leaders (local government officials, community board members, and employees from community- and faith-based organizations) as well as community members. Trained research staff conducted semi-structured in-depth interviews. Using immersion/crystallization and template style coding, the study team performed thematic analysis until no new relevant themes emerged.

Results

Among the 19 female study participants, perceived facilitators to SSB policy and program implementation included sustained partnerships with broad coalitions; continual education and clear messaging; and increased accessibility to healthier beverages. Perceived barriers included systems-level challenges accessing programs that support healthy beverage options, and individual-level lack of access to affordable healthy beverages. Acceptable potential intervention strategies included messaging that emphasizes health in pregnancy and infancy; policies that require healthy beverages as the default option in restaurants; and policies that remove SSBs from childcare settings. Some strongly favored SSB excise taxes while others opposed them, but all participants supported reinvestment of SSB tax revenue into health resources among marginalized communities.

Conclusions

A multi-pronged approach that incorporates engagement, access, equitable reinvestment of revenue, and continual clear messaging may facilitate implementation of policies and programs to reduce SSB consumption in the first 1000 days.