A Sugar-Sweetened-Beverage Tax Campaign: The Key Role of the Dental Community

ABSTRACT

On November 8, 2016, the citizens of Oakland enacted an initiative imposing a tax on sugar-sweetened beverages (SSBs). The passage was the culmination of interdisciplinary efforts, including critical support from the local dental society, as well as individual dentists. Supporters were motivated by the impact of the consumption of soda and other SSBs on children’s health, the long-standing epidemic of dental caries, and the emerging epidemics of obesity and Type 2 diabetes. This article details how the critical support and advocacy of dentistry in collaboration with a wider health professional network and the broader community led to the successful passing of the sugar-sweetened-beverage tax.

KEYWORDS:

• Soda tax campaign
• dentistry
• dental community
• advocacy
• sugar-sweetened beverages

Background

Recent decades have witnessed an alarming rise in the prevalence of Type 1 and Type 2 diabetes in the American pediatric population.¹ By contrast, dental caries, which is far more prevalent and the most common chronic disease afflicting children, was described as a “silent epidemic” by Surgeon General David Satcher² Diabetes prevalence rose 33% in children and adults in the eight years between 1990 and 1998,³ especially distressing because of its association with an increase in the visible problem of obesity and because it leads to serious chronic health problems and premature death (see Figure 1). By 1994, diabetes was labeled “epidemic” by the director of the diabetes program at the U.S. Centers for Disease Control and Prevention,⁴ triggering responses by health agencies, nonprofits and professionals calling for actions primarily focused on personal behavior changes that address the apparent drivers of obesity, physical inactivity and poor dietary choices.

Figure 1. Timeline of events.

Despite other causes of childhood diabetes, obesity, and tooth decay, numerous studies identified SSBs as a common culprit due to their being the largest single source of added sugar in the American diet.^5–7 Recognition of the central role of sugary drink consumption contributing to the onset of diabetes, obesity, and tooth decay led public health agencies and healthcare professions to adopt educational and policy approaches. The American Heart Association and American Academy of Pediatrics together with the California Dental Association (CDA) supported policies and efforts to discourage the consumption of SSBs.

In 2006, the CDA House of Delegates adopted a policy supporting marketplace interventions, such as product-specific taxation, as one of several ways to encourage improved oral and general health.⁸ In 2007, the Alameda County Public Health Department created and launched the “Soda Free Summer” campaign, which was first adopted locally, then regionally, and eventually embraced statewide by CDA. The campaign continued for several years.

Case History: Setting the Stage

In 2012, the Alameda County Public Health Department Office of Dental Health completed a five-year county-wide strategic plan to improve oral health entitled “Healthy Smiles for Healthy Futures: The Alameda County Strategic Plan for Oral Health 2012–2017.”⁹ When the plan was completed, the oral health strategic planning committee, composed of dental, pediatric, nutrition, nursing, and other public health advocates successfully petitioned the Alameda County Public Health Commission for formal status. The Oral Health Committee of the Commission was established with the stated purpose of monitoring, overseeing, and evaluating the adopted five-year plan. One of the five key plan strategies adopted was “education” to improve oral health, specifically naming the development of a broad social marketing campaign using “Soda Free Summer “as a prototype.⁹ The year 2012 also saw the emergence of numerous local, national, and international policy attempts to address the epidemic of obesity and diabetes through measures designed to reduce over-consumption of sugar-sweetened beverages. The city of Richmond, California, for example, placed an excise tax on SSBs on the ballot in 2012, but it failed. In the same year, the Alameda County Oral Health Committee authored a resolution for the Public Health Commission requesting the Alameda County Board of Supervisors study the health and economic impacts of SSBs. Among those providing supportive testimony was Dr. Dave Johnson, Alameda County Dental Society (ACDS) board member, on behalf of the local dental society. The resolution passed unanimously, and the Alameda County Health Care Services Agency proceeded to commission a study entitled “The Health and Economic Impacts of Obesity in Alameda County.” Despite the shift in emphasis to “obesity,” the May 2014 study additionally described the prevalence of diabetes, obesity, and dental caries afflicting the population of Alameda County. It detailed the enormous economic impact of diabetes, exceeding 2 billion dollars in 2006 alone. It emphasized SSBs availability and consumption as a “key contributor to high rates of overweight and obesity and associated with increased risk of dental disease.”¹⁰ The report also elaborated a systematic review of available policy options that might be employed to address excess consumption of SSBs. The Oral Health Committee conducted an impact analysis of these policy options and chose 11 to promote to the Alameda County Public Health Commission and Board of Supervisors, including a “soda tax.”

While the Alameda County study was being conducted, the 2013 Mexican Congress successfully adopted an excise tax on SSBs of 1 peso per liter to tackle the high prevalence of obesity and overweight in the Mexican population, which had risen to 33%.^11,12 In 2013, the New York City Board of Health adopted “a sugary drink portion cap rule“ designed to limit the sale of sweetened drinks in excess of 16 ounces, but the rule was repealed in 2014 by the New York Court of Appeals.¹³ In 2014, San Francisco attempted to enact an SSB tax of 2 cents per ounce tax on SSBs, which gained majority voter support but failed to reach the two-thirds voter threshold needed for passage. Across the bay, however, the City of Berkeley, with seed funding from CDA and other entities, placed an SSB tax of 1 cent per ounce on the ballot, requiring only a simple majority. With 76% voter approval, Berkeley became the first city in the United States to successfully enact a “soda tax” measure. The lessons learned from the success in Berkeley, as well as the dynamics in Richmond and San Francisco, inspired the advocates to take the first steps toward the SSB tax policy in Oakland.

Case History: Tax Policy Adoption

The first real breakthrough in moving the SSB policy agenda occurred when a “soda tax” was casually mentioned to Oakland City Council member Annie Campbell Washington at a local community “meet and greet” on April 20, 2015. According to Oakland North, an online news service, Campbell Washington explained why she “got on board” with the idea of a soda tax.

“If you start to do research on sugar consumption, you’ll start to quickly realize that sugar in liquid form is very toxic,” she said. “A group of doctors and dentists and health experts came to meet with me to talk about sugar and its impact on our community, and more specifically, the diseases related to sugar consumption such as diabetes and tooth decay in children. The statistics they shared showed that one-third of all children and one-half of African American and Latino children are predicted to develop Type 2 diabetes in their lifetimes.”

These numbers amount to what she considered to be a “public health crisis.”¹⁴

Campbell Washington expressed interest in pursuing a “soda tax” initiative, and immediately convened a meeting of several city council members, leadership from the oral health committee, and a local campaign organizer familiar with SSB campaigns, having worked with both the Berkeley and San Francisco campaigns. Despite growing interest among a number of advocates, the campaign organizer expressed serious doubts about the likelihood of success in Oakland. Workgroup meetings were convened over several months, including city council members and representatives from, for example, the American Heart Association, the Public Health Institute, the public health department and dental, nutrition, pediatric, and dietetic professionals. Still, the local campaign organizer dismissed the effort as unachievable unless fundraising were to become a reality. At that time, his fundraising efforts were focused on the San Francisco SSB tax campaign, but ACDS took up the challenge.

Individual and Collective Local Dental Society Participation

Capturing the rationale for the soda tax campaign, ACDS adopted a resolution explaining that:

• Research clearly demonstrates that SSBs are major contributors to the epidemic of dental caries in children in the short-term.

• SSBs are major factors in the epidemic of diabetes and obesity in children and contribute to heart disease and stroke in the long-term.

• Taxes on tobacco products and sugary beverages have demonstrated a significant impact on their consumption.

• The funds derived from such taxes would be used to fund programs that address both the prevention and mitigation of the above health effects.

• ACDS has prioritized support for the SSB initiative in Alameda County as part of its strategic plan for its work in the community.

• CDA has for over a decade endorsed policies to reduce consumption of SSBs.

The ACDS Board of Directors passed the resolution nearly unanimously, thus setting the stage for fundraising and the development of dental society infrastructure to fully participate in the SSB ballot measure campaign in Oakland for the November 8, 2016, election.

Members of the ACDS Board of Directors quickly convened an ad hoc campaign committee. The first step was to develop an educational fact sheet for the membership. The fact sheet cited policy precedents in support of such measures, a description of the causal link of SSB consumption and the prevalence of diabetes, obesity, and tooth decay affecting Oakland, and support of the language of the ballot measure. It explained its intent to 1) raise awareness of the direct correlation between sugar intake, Type 2 diabetes and tooth decay, especially in children, and 2) raise revenue that would be used for nutrition education and school-based programs focused on children’s health and well-being.

Educating and engaging all dental society members was initiated at monthly general membership meetings. Each meeting provided an update on the health effects of SSB consumption and key campaign messages. Campbell Washington attended one such meeting to express her gratitude for and to inspire continued support and to share her motivation for taking on the issue.

In addition to the fact sheet, the dental society members received an invitation to make campaign contributions. Those contributions ultimately totaled nearly $10,000. The funds were donated to the Coalition for Healthy Oakland Children, a newly created body organized to advocate for a soda tax in Oakland. What had been a good idea was now crystallizing into a reality (Figure 2).

Figure 2. Campaign poster in Alameda County Dental Society office window.

While dental society members geared up for campaign activities, Campbell Washington was convening meetings with each city council member and with key coalition spokespersons to educate them and secure council support to place the measure on the ballot. The very last city council member to be engaged was noticeably reluctant. After a bit of hesitation, he poignantly revealed his personal struggle with diabetes. “I’m tired of sticking myself, and honestly, I’m worried about my daughter, too,” he said. On May 4, 2016, the Oakland City Council voted unanimously 8 to 0 to place the “soda tax” measure on the November 2016 ballot.

Once the Oakland ballot measure was official, dental society members participated in every aspect of the campaign. They offered personal measure endorsements, displayed educational and campaign literature (Figure 3) in their offices, posted window and lawn signs, stood shoulder to shoulder with other stakeholders, served as spokespersons at press events, attended campaign headquarters briefings, participated at farmers’ market booths and fundraising events, canvassed neighborhoods, and worked on phone-banking at the campaign headquarters.

Figure 3. Campaign literature.

Dr. Joanne Lagos, CDA trustee and ACDS member, recalled her motivation to work on a campaign that could impact chronic disease. “Participating in the campaign gave me an exciting and tangible opportunity to educate people to both reduce disease and to improve the quality of lives,” she said.

With evidence of local dental society commitment well established, CDA support was immediately forthcoming. With authorization from the CDA executive committee, CDA staff came to Oakland to meet with the Coalition for Healthy Oakland Children steering committee, including several city council members. Engaging in partnership with the local campaign organizer, CDA staff provided technical support for the development of pre-election polling as well as $60,000 seed funding for its implementation.

Following Oakland’s lead, San Francisco and Albany also authorized their ballot measures. As a result, with the Bay Area seen as a single-media market, the pre-election poll was conducted in both San Francisco and Oakland. The pre-election poll revealed strong voter support for the soda tax measures, and these results were pivotal because they catalyzed needed financial support from the Bloomberg Philanthropies to help offset the millions spent by “big soda.” A common affirmation in the Oakland “soda tax” campaign was that “big soda “may have big money, but “we have the ground game.” By reaching beyond their traditional boundaries, dentistry and other coalition members demonstrated the powerful benefit of successful communitywide collaboration.

The Results

The Election – Nov. 8, 2016

On election day, 60.7% of Oakland voters approved the ballot measure to impose a 1 cent per ounce general tax on the distribution of SSBs, including sodas, sports drinks, sweetened teas and energy drinks. Milk products, 100% juice, baby formula, diet drinks and drinks taken for medical reasons were exempted from the tax, as well as small businesses.¹⁴ Despite a barrage of campaign misinformation, legal challenges by the soda industry designed to halt the tax measure and deep-pocket campaign resources, the measure passed not only in Oakland but in San Francisco and Albany as well.

Tax Implementation

Revenue

Within a matter of months, the city of Oakland geared up for tax revenue collection. Revenue collection generated by the Oakland SSB tax was initiated in July 2017. During the first 30 months, between July 2017 and December 2019, $25,272,423 in revenue was raised from the Oakland SSB tax, averaging $842,414 per month.¹⁵

Program Interventions

As required by the measure, the mayor appointed the Sugar Sweetened Beverage Community Advisory Board (CAB) to advise the city council and make recommendations on how and to what extent the council should establish and/or fund programs (Table 1) to prevent or reduce the health consequences of the consumption of SSBs in Oakland communities. Representatives were nominated from each district, including disproportionately affected populations, and specifically included representation from dentistry.

Table 1. Examples of programs funded with Oakland SSB revenue(15).

Funding Area	Types of Agencies Funded	Examples of Projects
Prevention through education and promotion	County public health department, community-based organizations	Rethink Your Drink Oakland Youth Action to Reduce SSB Consumption
Potable water access	Oakland Unified School District (OUSD)/Oakland Parks and Recreation	OUSD FloWater Hydration Stations in every school Head Start FloWater Hydration Stations Oakland Parks and Recreation FloWater hydration stations
Healthy neighborhoods and places	County public health department, community-based organizations	East Oakland Food Matters VeggieRx healthy food and beverages program
Health care prevention and mitigation	Community organizations	Preventive dental services at WIC Oakland Healthy Children
Youth and families	Oakland Fund for Children and Youth	Community grants and other initiatives aimed at reducing or preventing SSB consumption

Collated by Policy, Practice and Prevention Center, University of Illinois, Chicago. March 2020. (15).

One particularly innovative use of the Oakland SSB Tax Community Grant Fund was conceived and successfully implemented by Dr. Huong Le, chief dental officer at Asian Health Services. The Centers for Disease Control and Prevention estimates that 1 in every 5 people in the U.S. doesn’t know they have diabetes. Dentists who see patients as much as three to four times per year are perfectly situated to identify patients who are at risk and do not yet have a diagnosis. Also, there is a high rate (89%) of uncontrolled diabetes among a sample of over 3,000 patients at Oakland’s Asian Health Services clinics Recognizing these and with the SSB Tax Community Grant, Dr. Le provided testing equipment, dental provider training, and testing at multiple sites in Oakland. In one case, a 19-year-old scheduled for oral surgery was found to have uncontrolled diabetes (HbA1C over12) and was referred to the care of an endocrinologist. Once the patient was in the care of a specialist and the diabetes was under control, his dental surgery was safely performed. Labeled as a “best practice” by the Health Resources and Services Administration reviewers, the program has been permanently established in the clinics.

Tax Evaluation: Reduction of SSB Purchases – an Indication of SSB Tax Effectiveness

A 2023 cost-effectiveness study conducted by researchers at UC San Francisco and UC Berkeley revealed that purchases of SSBs in Oakland dropped by 26.8% compared to a similar city, Richmond, not subject to a tax during the interval between July 2017 and December 31, 2019, during which the 1 cent per ounce tax was in effect. Purchases declined in Oakland for all types of SSBs, including by 23.1% for sweetened soda, by 30.4% for fruit drinks, by 42.4% for sports drinks, and by 24.4% for sweetened teas. The authors calculated that consuming 26.8% fewer SSBs over 10 years added 94 quality-adjusted life years (QALYs) per 10,000 residents and saved the city more than $100,000 per 10,000 residents.¹⁶ Dean Schillinger, MD, UCSF professor of medicine and senior author, added that the current estimates may be an underestimate of the health benefits as investigators did not account for the positive impacts of local nutrition and public health programs funded by the tax revenue in Oakland.¹⁷

Discussion and Future Directions

Well-documented reductions in the purchase of SSBs, tax revenue raised, and numerous funded programs and services conducted through grants to the county and community-based organizations and by the city itself stand out as tangible, immediate, and celebration-worthy demonstrations of the SSB tax adopted in Oakland. The strategically chosen formulae for SSB tax measures in Oakland, San Francisco, and previously in Berkeley were designed to require only a simple majority of the voters, i.e., 50% plus 1 for passage. However, while this augers for a greater likelihood of measure passage, California law directs that taxes raised with this formula go directly into the general fund compared to a 66% voter approval that would be required for all such revenues raised to be directed for their particular use.¹⁸ Despite the creation of a community advisory board to “advise” the city council on the use of the revenues to prevent and or to mitigate the negative health effects of SSB consumption, the city council has the legitimate legal authority to allocate SSB tax revenues as it does with any other source of general tax revenue. Reportedly, a portion of spending allocations from the SSB tax in Oakland is being used to fill different voids in the city’s general fund rather than being allocated to support health programming as was the original intent of the tax.¹⁹ These dynamics underscore the importance of ongoing advocacy and monitoring by dentists and community leaders to ensure taxes are implemented as originally intended.

When U.S. Surgeon General Julius Richmond reflected on the struggle to enact a national prevention agenda to address smoking and tobacco, he likened the problem to a three-legged stool requiring all legs to stand. He said that we, as a nation, invest most of our resources into the first leg of scientific knowledge and data. We invest a small amount into the leg of social programs and strategies. But where we repeatedly fail, and the reason the stool topples, is in our inability as a nation to invest in generating the political will.²⁰

The science linking the rise in diabetes, obesity, and the prevalence of dental caries attributable to the consumption of sugar chiefly through SSBs had been well defined. Some well-conceived policies and educational programs had been developed and implemented. Yet what remained was developing the critical mass necessary to mount the necessary political will.

The structure of having a public health commission in Alameda County, under which an oral health committee could be formed, was a unique infrastructure. This can be looked at as an organizational best practice to lay the groundwork to discuss and advance oral health policy on behalf of public health. The professionally diverse Oral Health Committee of the Alameda County Public Health Commission envisioned an opportunity to address a poignant reality of preventable disease afflicting thousands of children, adults, and families. ACDS already had the potential for community engagement on the SSB issue in their strategic plan. CDA was on record with the policy adopted a decade earlier, supporting efforts to curtail products that were detrimental to oral health, including through taxes. The Coalition for Healthy Oakland Children had a committed political champion in Campbell Washington, who embraced the importance of the measure, particularly for children and families disproportionately affected by SSBs. Her passion and leadership were critical to creating a broad-based coalition including political leaders and their key constituents, educators, religious leaders, children’s advocates, community health organizations and health centers, public health organizations, pediatricians, First Five, nutritionists, the medical, nursing and dental associations and nonprofits, which ultimately coalesced around this initiative and offered endorsement and in-kind support.

The challenge to mount a successful campaign, however, was not realized until ACDS advanced the membership initiative that led to financial support, myriad forms of local campaign participation, and the enlistment of technical support and pre-election poll seed funding from CDA. Individual and collective dentist participation, first locally and then with CDA engaging with the broad stakeholder community, catapulted the Coalition for Healthy Oakland Children to electoral success. The collaborative actions with the broader community and the extraordinary effort exhibited by dentistry were nothing short of a classic demonstration of employing the science and art of preventing disease, prolonging life, and promoting health through organized efforts and informed choices of society, organizations, and individuals.

As opportunities for similar measures emerge in localities throughout California and nationwide, the case example in Oakland serves as an encouragement for the work that is yet to be accomplished. Beyond the diagnosis, prevention, and treatment of diseases of the oral cavity and beyond the walls of clinical settings, dentists should be viewed as primary care providers and public health champions. In addition to their demonstrated capacity to identify acute and chronic diseases because of their integral role in the overall fabric of the health care community, they have the potential to contribute to conditions in which the entire community may thrive and enjoy health benefits.

Acknowledgments

Diane Woloshin, Annie Campbell Washington, David Johnson, David Jalen, Joanne Lagos.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Jared I. Fine

Jared I. Fine, is a public health dentist and the former dental health administrator of the Alameda County Public Health Department where he served the Public Health Department for nearly 40 years. After graduation from dental school at Maryland, he served in the US Navy Dental Corps at Treasure Island. He completed his Masters in Public Health at UC Berkeley and dental public health residency at UCSF. He is recognized in California and nationally as a visionary leader in public health policy, program development, advocacy and community organization. He initiated Alameda County’s WIC oral health program. He led Alameda County in the development of it’s first 5 year strategic Plan for Oral Health, which is now being replicated throughout California. He championed the successful 2016 Soda Tax Campaign in Oakland and served on the Oakland Sugar Sweetened Beverage Advisory Commission for 2 years. Dr. Fine chaired the non profit Center for Oral Health. He has served on the Board of the Alameda County Dental Society since 1986 and it was from which he initiated the development of “California Dental Association’s 7 Year Strategic Plan to Overcome Barriers in Access to Care”. Most recently he has served as a consultant to Alameda County’s Healthy Teeth Healthy Communities, Dental Transformation Initiative pilot project serving as the County Dental Health Ambassador.

Darlene G. Fujii

Darlene G. Fujii, has been with the Alameda County Public Health Department (ACPHD) for over 40 years and has been the Director of the Division of Communicable Disease Control and Prevention since 2020. Her career with ACPHD includes more than 20 years in the Office of Dental Health and in Nutrition Services as the assistant director for 10 years. Her work has focused on a range of public health areas including chronic disease prevention with a special focus on sugar sweetened beverage policy, school-based health promotion, oral health and communicable disease. Darlene is a Registered Dietitian and holds a Master’s degree in Education from Tufts University.

Baharak Amanzadeh

Baharak Amanzadeh, is a member of the California Oral Health Technical Assistance Center, and an Assistant Clinical Professor at Univerity of California San Francisco. She has been the Dental Health Administrator at the Alameda County Department of Public Health where she planned, evaluated, and oversaw the dental public health programs. She is an independent consultant in dental public health and works with multiple organizations and local jurisdictions to conduct oral health needs assessments, develop community oral health improvement plans, and guide the implementation and evaluation of such plans. She focuses on school oral health programs and dental care coordination and strives to engage the communities to build the infrastructures to combat oral health disparities. Previously, she directed the Community Based Dental Education program at UCSF School of Dentistry. Dr. Amanzadeh has an extensive background in working with underserved communities, designing educational, preventive programs and integrative systems of care in the areas of children’s oral health and school oral health programs, dental care coordination and community health workers, the oral health of pregnant women, seniors, people with disabilities, and those experiencing homelessness, motivational interviewing, and Trauma-Informed Care.

Larry J. Platt

Larry J. Platt, as a pediatrician and an officer in the US Public Health Service, Dr. Platt has fathered the National Health Service Corps and worked on designing and developing a community health center in Mississippi. He was awarded a Global Community Health Fellowship by the Public Health Service. During that time, he was Chief Resident in Social Pediatrics at Montefiore Hospital in New York City and a Martin Luther King Health Center pediatrician. Throughout his career, Dr. Platt has provided visionary leadership in public health policy and programs at the national, state, and local levels. Some of his work includes: family health studies and program development for children with chronic diseases at NIMH, serving as chief of the Bureau of Maternal and Child Health at the Ohio Department of Health, and conducting child health policy analysis for the Public Health Services Maternal and Child Health Bureau at the Institute for Health Policy Studies, University of California – San Francisco Medical School. Dr. Platt was the Executive Director of the Dental Health Foundation, a non-profit agency trying to improve the oral health status in California through public health efforts. In 2016, he co-chaired the Coalition for Healthy Oakland Children, sponsoring the successful initiative for a soda tax in Oakland. Dr. Platt is a Fellow of the American College of Preventive Medicine.