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Context
A mid-sized city council is considering a tax on sweetened beverages to reduce consumption and raise revenue for community health programs. The DNP-prepared nurse on the city's health advisory board has been asked to analyze the proposal. The city is illustrative. The analysis follows Bardach and Patashnik's (2020) eightfold path.
1. Define the problem
Residents, particularly in low-income neighborhoods, consume large amounts of sugar-sweetened beverages, which contribute to obesity, type 2 diabetes and dental disease. Healthier options are often more expensive or harder to find in these neighborhoods.
2. Assemble some evidence
In January 2017, Philadelphia introduced an excise tax of 1.5 cents per ounce on sugar-sweetened and artificially sweetened beverages. Roberto et al. (2019) compared sales data from large chain stores in Philadelphia with Baltimore, a city without a tax, and with Pennsylvania zip codes bordering Philadelphia. After the tax:
- prices of taxed beverages rose in Philadelphia relative to Baltimore, by 0.65 cents per ounce in supermarkets, 0.87 cents in mass merchandise stores and 1.56 cents in pharmacies;
- volume sales of taxed beverages in Philadelphia fell by 51.0%;
- sales in neighboring zip codes rose by 308.2 million ounces, offsetting 24.4% of the decrease, so the net decrease was about 38%.
The data covered about 25% of taxed beverage volume sold in Philadelphia, mostly from chain stores, and the study measured sales, not consumption or health outcomes.
3. Construct the alternatives
- No change (the status quo)
- An excise tax of 1.5 cents per ounce on sweetened beverages, with revenue dedicated to health programs
- A public education campaign on sugary drinks, without a tax
- Retail and school measures, such as healthier default drinks in children's meals and water access in schools
4. Select the criteria
Effectiveness in reducing purchases; equity (who pays, and who benefits); revenue; cost of administration; and political feasibility.
5. Project the outcomes
| Alternative | Effectiveness | Equity | Revenue | Feasibility |
|---|---|---|---|---|
| No change | None | Existing disparities continue | None | High |
| Excise tax | Large drop in sales, partly offset by cross-border shopping | The tax falls more on lower-income households, but revenue can fund programs in their neighborhoods | Substantial | Moderate; industry opposition expected |
| Education only | Likely small on its own | Neutral | Costs money | High |
| Retail and school measures | Modest, targeted | Benefits children | None | Moderate to high |
6. Confront the trade-offs
The tax is the most effective option for reducing purchases, but it is regressive in who pays. Its equity depends on how revenue is spent. Cross-border shopping reduces its effect, which matters more for a city with easily reached suburbs.
7. Decide
Recommendation: adopt the excise tax combined with retail and school measures, dedicate revenue to programs in the neighborhoods that pay most of the tax, such as pre-kindergarten or community health workers, and commission an independent evaluation of purchases and health outcomes.
8. Tell your story
For council members, the message is that Philadelphia's experience shows a tax can sharply reduce purchases of sweetened drinks, that some buying shifts across city limits, and that the strongest case for fairness is to return the revenue visibly to the communities that pay it.
The nurse's role
Nurses bring credibility and community knowledge to policy debates. The DNP-prepared nurse can present evidence clearly, include residents' voices and push for evaluation built into the policy from the start.
References
Bardach, E., & Patashnik, E. M. (2020). A practical guide for policy analysis: The eightfold path to more effective problem solving (6th ed.). CQ Press.
Roberto, C. A., Lawman, H. G., LeVasseur, M. T., Mitra, N., Peterhans, A., Herring, B., & Bleich, S. N. (2019). Association of a beverage tax on sugar-sweetened and artificially sweetened beverages with changes in beverage prices and sales at chain retailers in a large urban setting. JAMA, 321(18), 1799–1810. https://doi.org/10.1001/jama.2019.4249
