Soda taxes increase prices but lower consumption, studies find

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Photo by Breakingpic

Local surcharges on sugar-sweetened beverages are becoming the latest “sin tax” designed to reduce our consumption of unhealthy products, like soda, tobacco and alcohol. Driven by the growing health concerns of diabetes, obesity and heart disease, their goal is to improve public health while generating tax revenues.

Commonly called soda taxes, they typically also include sweetened energy, sports and fruity drinks and presweetened tea and coffee — leaving water, milk and natural juices untaxed. If you live in the Bay Area, you’ve probably heard of them since Berkeley, San Francisco, Albany and Oakland imposed soda taxes in the last several years. But do these kinds of surcharges work?

“There’s a lot of debate about whether to pass those kinds of taxes and how to design them,” says Stephan Seiler, PhD, an associate professor of marketing, in a recent Stanford Graduate School of Business news article. “How high should the tax rates be? What type of products should be covered — regular or diet or both? And should the tax be levied at the city or county level?”

Two studies recently investigated the long-term effectiveness of beverage taxes. The first study analyzed sales data from over 1,200 retail stores in Philadelphia, which imposed a 1.5-cent-per-ounce tax on sweetened beverages starting in 2017. As part of the multi-institutional team, Seiler says they wanted to learn how the tax affected things like tax revenue and people’s financial burdens, and use that to contribute to ongoing policy discussions.

As expected, the Philadelphia study found that beverage manufacturers passed on almost all of the tax to consumers by raising prices by 34 percent. As a result, local demand for the taxed drinks dropped by 46 percent. But that didn’t necessarily mean that residents consumed less. Instead, they traveled four or five miles to purchase sweetened beverages outside the taxed area. Taking this into account, the researchers found the demand actually dropped by only 22 percent.

Another recent study analyzed the effectiveness of Berkeley’s 1-cent-per-ounce soda tax using beverage frequency questionnaires from 2014 to 2017 — polling 1,513 people in high-foot-traffic areas in demographically-diverse neighborhoods in Berkeley, as well as  3,712 people in Oakland and San Francisco before their soda taxes were implemented for comparison. This multi-institutional research team included Sanjay Basu, MD, an assistant professor of medicine, health research and policy at Stanford.

After implementation of the Berkeley tax and corresponding increase in prices, the researchers reported a 52 percent decrease in consumption of sweetened drinks and a 29 percent increase in water consumption. The comparison groups in Oakland and San Francisco had similar baseline drink consumptions but saw no significant changes.

One difference between these soda taxes concerns diet soda, which is taxed in Philadelphia but exempt in Berkeley. It may be easier to switch from regular to diet soda, so Seiler suggests that a better design is to tax regular sodas but not their diet counterparts and to levy the tax across a wide geographic area.

In fact, some countries — including Mexico, France, United Kingdom and many others — have implemented a national soda tax. “That type of tax would be harder to avoid,” Seiler says.

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

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Bill for later school start times is defeated, but Stanford sleep specialist isn’t

 

Photo by Santiago Gomez

The medical evidence is clear — teens are suffering physical and mental health problems due to chronic sleep deprivation. That’s why the American Academy of Pediatrics and many other health organizations recommend starting classes at all middle and high schools at 8:30 am or later.

“We’ve known for decades that teenagers are not getting enough sleep,” says Rafael Pelayo, MD, a clinical professor in psychiatry and behavioral sciences with the Stanford Center for Sleep Sciences and Medicine. “Senate Bill 328 came out of presenting the strong evidence-based, peer-reviewed data to elected officials. Even the people opposed to the bill accept the science.”

So if everyone agrees that our teens need more sleep, why didn’t the bill pass? The main objection of teachers, school boards and ultimately Governor Jerry Brown centers on giving the local community control of individual school decisions.

“We’ve stepped into this ongoing battle between state control and local control of schools,” Pelayo says. “But I don’t consider this a political issue. This is a public health issue. Hundreds of schools have already changed and they see the same result — kids are healthier and perform better. This is a matter of honoring kid’s biology. It doesn’t work to just say they should go to bed earlier.”

Pelayo’s push for later school start times is also inspired by his professional experiences. “My career as a sleep doctor began through my knowledge of adolescent sleep. During medical school, my research found a link between suicidal thinking and sleep problems in teenagers. I’ve been learning about poor sleep and mental health issues in teens since the 1980s.”

Despite this recent setback, Pelayo plans to keep volunteering. For years, he’s been giving talks about sleep at many local high schools and middle schools. “Teenagers are interested in sleep apnea, their dreams and all aspects of sleep. I’ve given a bunch of talks on sleep for years,” Pelayo says.

He’s also recently become a director of a national organization called Start School Later. Overall, he hopes to promote more education, research and funding for this issue.

“About 300 school districts have already mandated a later school start time,” Pelayo says, adding that San Diego schools are planning to implement later start times by 2020. “If California had passed SB 328, it would have accelerated this process. Instead, we’ll have to do it piecemeal. And that’s too bad, since kids need sleep now.”

But, Pelayo says, “This issue is not going away, it is actually gaining momentum.”

This is a reposting of my Scop blog story, courtesy of Stanford School of Medicine.

Community cooperation following disasters key to recovery, Stanford study finds

Photo of Norway by Vidar Nordli-Mathisen

Why are some communities resilient in the face of disasters such as epidemics, while others struggle to recover? You might think it is driven by the availability of economic resources, but a new study shows that community cooperation — admittedly challenging in the face of an infectious disease — is the key.

Recently published in Academy of Management Journal, the study led by Hayagreeva Rao, PhD, a Stanford Business professor, found that a community’s resilience primarily depends on two factors:

  • whether the cause of the disaster is attributed to other community members or an act of nature; and
  • whether the community includes diverse organizations that encourage collaboration.

The researchers analyzed and compared two well-documented disasters that occurred in Norway in the early 1900s: an outbreak of the highly-contagious Spanish flu that caused many fatalities, and a severe spring frost that led to economic hardship for the predominantly farming community.

They found that disasters attributed to other community members — like contagious epidemics — weakened cooperation, increased distrust and led to a long-term reduction in organization building. By contrast, disasters attributed to an act of nature evoked a sense of shared fate that fostered cooperation.

Rao and colleague Henrich Greve, PhD, a professor of entrepreneurship at INSEAD, explained in the paper:

“The typical response to pandemics includes isolation and treatment, home quarantines, closure of schools, cancellation of large-scale public meetings, and other steps to reduce social density. While these immediate responses are entirely practical, policy planners should also consider how a pandemic impairs the social infrastructure of a community over the long term, and undertake initiatives to foster the building of community organizations.”

For instance, the Spanish flu impaired the Norwegian communities from building new community organizations for 25 years, they wrote.

In contrast, Norway’s farming families pulled together when faced with natural agricultural disasters — motivating them to form retail cooperatives, mutual insurance organizations and savings banks to help share risk.

The researchers determined that successful disaster recovery also hinged on the existing social infrastructure: a community with diverse and cooperative voluntary organizations more effectively responded.

“The better the infrastructure, the better the recovery,” said Rao in a recent Stanford Business news piece. “A disaster is a shock. Think of those organizations as the shock absorbers.”

In the paper, they offered an example. In the 1995 heat wave in Chicago, which led to far fewer deaths in a Latino neighborhood than in an adjacent African-American neighborhood. This was because the sheer variety of Latino neighborhood organizations created overlapping networks that allowed people to check on the elderly, they wrote.

The authors concluded with a call for more research on the effect of climate-related disasters like floods and droughts. We need to know how these impact the birth and sustainability of community volunteer organizations, they said.

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Using history as a guide to end tobacco addiction

Photo courtesy of Robert Proctor

The public’s opinion of tobacco use has dramatically changed over time. Gone are the days when cigarette companies advertise using slogans like “fresh as mountain air” or “more doctors smoke Camels than any other cigarette.” We now know that cigarettes cause blindness and tuberculosis, among many other conditions, and are highly addictive.

But in the era of nicotine e-cigarettes that are touted as cool and harmless, have we really changed our ways? I spoke with Robert Proctor, PhD, a professor of history at Stanford, to learn about his work.

What inspired you to research the history of cigarette design?

“Cigarettes are the world’s leading preventable cause of death, killing about 6 million people worldwide every year.  A physician might hope to heal a thousand or perhaps ten thousand people over a career, but what if we could save these 6 million people annually?  It was this hope of saving lives that led to my exploring how cigarettes have been designed, and how they might be stopped.”

Where do you find your research materials?

“The Legacy Tobacco Documents Library is a real treasure.  I use it to explore the industry’s myriad secret projects — like Project Subculture Urban Marketing, a secret Reynolds campaign from the 1990s to target gays and the homeless in San Francisco.  I also use it to find out what they’ve been adding to cigarettes—like diammonium phosphate, a free-basing agent used to boost the potency of the nicotine molecule. I also use it to find out who has been working for the industry, as grantees or expert witnesses. Historically that included dozens of Stanford professors, but I don’t know any still working in that capacity today.”

What do you think about the FDA’s plan to reduce nicotine in cigarettes?

“As I explained in a recent op-ed for the New York Times, the Food and Drug Administration will try to mandate the reduction of nicotine in cigarettes to a sub-addictive level. However, they will encounter ferocious resistance from the industry, which sees nicotine as the indispensable ingredient of their business. For beginning smokers, nicotine is actually a negative in the smoking experience. Once addicted, most smokers regret having started. It will be crucial for the FDA to reduce nicotine sufficiently to make sure new users don’t become addicted. De-nicotinization is easy. Multiple techniques are available to achieve this, including genetic technologies and some of the same techniques used to de-caffeinate coffee.”

Have you also studied e-cigarettes?

“I have studied e-cigarettes but not as intensively. Many of the same techniques once used to market traditional cigarettes have been revived for e-cigarettes and other vaping devices, as Robert Jackler, MD, and his colleagues have shown so beautifully. E-cigarettes may help some smokers quit, but they are more likely to renormalize smoking and act as gateways to regular cigarettes. They also serve as bridge products to keep smokers from quitting nicotine entirely, which is why the big cigarette makers have all launched new vaping devices.”

What more can be done?

“Physicians often know the right thing to do, but may not have the power to make that happen — that is medical impotence.  A third of all cancer deaths, for example, are caused by cigarettes. Just knowing that, though, isn’t enough to do any good, since there are powerful forces dedicated to making sure we keep pulling smoke into our lungs. Much more could be done to solve such problems — the new age minima for purchasing cigarettes should help. I also believe we need to explore what I call ‘the causes of causes.’  Cigarette smoking causes disease, but what causes cigarette smoking?  Too often we end with the individual, rather than going upstream to the source of the problem in the first place. Stop the manufacture of cigarettes, for example, and you stop having to yank out tumors from lungs or putting people on oxygen. We need more upstream thinking in the practice of medicine.

We also need to think more about health in our own community. For instance, Stanford got a failing grade from the Santa Clara County Public Health Department in 2011 as the most cigarette-friendly campus in the Bay area — for allowing the sale and use of cigarettes on campus.  We did finally manage get the sale of cigarettes in the student union stopped, after years of painful protest.”

 

Editor’s note: Stanford has a smoke-free environment policy that prohibits smoking in all buildings, facilities, vehicles, covered walkways and during indoor or outdoor athletic events. Smoking has been banned on the School of Medicine campus for a decade. 

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

 

A look at health care reform — in China

Photo courtesy of Karen Eggleston

The struggles with health insurance reform here in the United States piqued my curiosity about what we could learn from other countries. I reached out to Karen Eggleston, PhD, a senior fellow at the Freeman Spogli Institute for International Studies at Stanford, who researches health care systems and health reform in Asia, especially China.

What is health insurance like in China?

“The original system was linked to the centrally planned economy. Communes in rural areas supported the barefoot doctors and state-owned enterprises provided people with health care coverage in the urban areas. But when China converted to a market-based economy, this had to change. So long story short, they’ve put into place a new system of health coverage based on government subsidized insurance for rural and non-employed urban populations, as well as an employee-based medical insurance for the employed urban population. As I like to tell my US colleagues, if you think providing coverage for 40 million uninsured people is a challenge then think about covering over 800 million uninsured — that’s what China was dealing with.

Many westerners would be surprised to know that Chinese have almost complete freedom when choosing their doctor or hospital.”

How has this expanded coverage impacted health and survival?

“There is a lot of evidence that the expanded health insurance improved access to care and helped protect households from high health care expenditures, but it’s actually pretty difficult to pin down the effects on health and survival.

In a recent study in Health Affairs, we looked at the New Cooperative Medical Scheme that provides health insurance to rural areas. We used the fact that it was introduced over time in different counties to look at the effect it had later, correlating this data with cause-specific mortality data from China’s CDC. We didn’t see a significant impact on mortality rate due to expanded medical coverage.

This was and wasn’t surprising. It may take a long time for the results to manifest. But it’s also quite well known in health economic research that health and survival are often shaped by non-medical factors like lifestyle.”

What are some of the biggest health care challenges in China?

“As China urbanizes hundreds of millions of people at a time, they are changing their diet and living a more sedentary lifestyle. As a result, they’re now getting what are sometimes called the diseases of affluence, such as diabetes. Like many developing countries, China’s healthcare system was setup to deal primarily with acute conditions and to control infectious diseases. Now, they need to sustainably finance and manage programs to prevent and care for people with chronic diseases.

A lot of China’s care is also based in hospitals, so they need to strengthen primary care — ironic for a country so famous for barefoot doctors. Physicians’ career trajectories are better in urban hospitals and patients know that’s where the best physicians are. But new policies are trying to lure patients and doctors to primary care.”

What other factors are affecting health in China?

“China has a rapidly aging population — largely due to their triumph in extending lives by controlling infectious diseases and lifting millions out of poverty, and also related to low fertility. This demographic change reinforces the challenge of preventing and controlling chronic disease.

We also know that people with more education tend to have better health and survival than people with lower education. China’s economic growth has brought a rapid increase in living standards but also a rise in inequality, in both rural and urban areas. One of the best ways to address this is to improve opportunities of education for the disadvantaged. This isn’t typically thought of as a health policy, but actually studies have shown education can have long lasting effects on health and survival.”

This is a reposting of my Scope blog post, courtesy of Stanford School of Medicine.

Talk about death — before a health crises, says Stanford’s Philip Pizzo

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Photo by Oldiefan

Most of us have no desire to think, or talk, about death. However, if we never talk about it, we leave our health providers and families guessing about how and where we want to die.

That’s why it’s important to communicate end-of-life preferences early, Philip Pizzo, MD, founder and director of the Stanford Distinguished Careers Institute, argues in a recent perspective in the Proceedings of the National Academy of Sciences.

It’s a topic he’s quite familiar with: Pizzo co-authored the Institute of Medicine’s report “Dying in America,” which addressed how to improve the quality of care for patients with advanced illnesses, without exacerbating the high costs of health care. In the perspective, he summarizes the IOM report’s key recommendations and provides an update.

Pizzo discussed the piece in an email:

“Unless we are facing an illness or event that makes the prospect of death imminent, most of us do not even think about the inevitability of our mortality. These conversations get slotted to times when death is more imminent and when our crisis-oriented decisions may not reflect our true preferences. That is why the IOM report recommended that conversations about death take place with our health care providers and families throughout life. Our thoughts and preferences about dying will vary at different stages of life and wellbeing.”

In the perspective, Pizzo describes the progress that has been made since the report was published. For instance, the Centers for Medicare & Medicaid Services in January 2016 began paying doctors to have end-of-life conversations with patients — a move Pizzo lauds as a major step.

Another important achievement, according to Pizzo, is the national stakeholder conferences that are now bringing constituencies together to implement the report’s recommendations.

He added:

“We witnessed before the IOM Committee began its work how rapidly public opinion can be swayed by political rhetoric. Thankfully since then, the public’s willingness to engage in conversations about death and dying have become better realized and books, like Atul Gawande’s Being Mortal or Paul Kalaniti’s When Breath Becomes Air, have helped to foster more enlightened conversations about dying.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Stanford expert calls for more targeted anti-obesity policies

U. S. Department of Agriculture's helps educate shoppers about the value of food labeling in December 1975. Photo courtesy National Archives and Records Administration.
U. S. Department of Agriculture helps educate shoppers about the value of food labeling in 1975. Photo courtesy National Archives and Records Administration.

Reality TV shows like “The Biggest Loser” are popular in part because the audience can relate to the participants — more than two-thirds of adults and about one-third of children and adolescents are obese or overweight in the US. The Surgeon General and the Centers for Disease Control and Prevent have declared obesity to be a national epidemic and a major contributor to leading causes of death, including heart disease, stroke, diabetes and some types of cancer.

Although our country is committed to finding solutions to the increase in obesity, public policies have fallen short, according to Deborah Rhode, JD, a Stanford law professor and legal ethics scholar. In a recent journal article, she wrote:

Many policy responses have proven controversial, and those most often recommended have frequently faced an uphill battle at the federal, state, and local level. At the same time that obesity rates have been rising sharply, many jurisdictions have resisted, or rolled back, strategies such as soda taxes or regulation of advertising directed at children.

In the journal article, Rhode evaluates anti-obesity policies, including calorie disclosure requirements, taxes or bans on sugar-sweetened beverages, food stamp modifications, zoning regulations, children’s marketing restrictions, physical activities initiatives, food policies and education. She suggests that a more targeted approach is needed to combat obesity. For instance, Rhode recommends creative zoning regulations that restrict the location of fast-food restaurants near schools while encouraging healthy food retailers in underserved neighborhoods.

In a Stanford news release, Rhode noted that the first lady Michelle Obama’s “Let’s Move!” campaign against childhood obesity applies to politics as well as physical activity. Rhode summarized, “Although we need more evaluation of policy strategies, we know enough about what works to chart a course of reform. We should act now on what we know.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.