Am J Community Psychol (2013) 51:299–313
DOI 10.1007/s10464-012-9535-5
ORIGINAL PAPER
Simulation Modeling of Policies Directed at Youth
Sugar-Sweetened Beverage Consumption
David T. Levy • Karen B. Friend
Published online: 19 July 2012
! Society for Community Research and Action 2012
Abstract Childhood obesity is a significant public health
problem requiring innovative solutions. While recent
reviews indicate that some policies show promise, there is
a lack of information regarding which policies, and policy
combinations, work best. Low-nutrition, energy-dense
foods and beverages such as sugar-sweetened beverages
(SSBs) have been identified as a major contributor to the
problem. The purpose of this paper is to use simulation
modeling to show how changes in three categories of SSB
policies—school nutrition, school-based education, and
taxes—impact SSB and other food consumption. The
model shows that policies directed at SSBs, particularly tax
hikes, could lead to substantial reductions in the number of
calories consumed by youth. The estimates, however, are
subject to a high degree of uncertainty. Estimates from
school-based nutrition and school-based education policies,
while also helping to reduce caloric intake, generally show
smaller effects than tax policies and considerable variation
around parameter estimates for individual and combined
policies. We conclude with a discussion of the limits of the
model, and suggest where additional information is needed.
Limitations notwithstanding, simulation modeling is a
promising methodology that can help advance our under-
standing of policy effects, thereby helping policymakers to
better formulate effective policies to reduce obesity prev-
alence and the associated social harms.
D. T. Levy (&)
Cancer Control, Lombardi Comprehensive Cancer Center,
Georgetown University, Washington, DC, USA
e-mail: dl777@georgetown.edu
K. B. Friend
PIRE, Pawtucket, RI, USA
e-mail: kfriend@pire.org
Keywords Simulation modeling ! Obesity ! Policies !
School programs ! Youth ! Sugar-sweetened beverages
Introduction
Obesity and its associated health consequences are widely
recognized as significant public health issues facing
today’s youth. While recent reviews indicate that some
policies directed at the problem show promise (Andreyeva
et al. 2010; Brown and Summerbell 2009; Doak et al. 2006;
Flodmark et al. 2006; Levy et al. 2011; Matson-Koffman
et al. 2005; Seymour et al. 2004), there is a lack of infor-
mation regarding which policies and policy combinations
work best to reduce this major health threat. The difficulty
with policy selections lies in part with the fact that nutrition
involves a complex interaction of individual and genetic
components, coupled with environmental issues related to
food intake and energy output (Gortmaker et al. 2011).
Low-nutrition, energy-dense foods and beverages (LNED)
have been identified as a major contributor. They are broad
in number, however, making it challenging to develop and
implement interventions to target all such offenders. Fur-
ther, the role of specific LNED foods in promoting weight
gain is generally difficult to distinguish.
Despite this difficulty, one specific subset of LNED bev-
erages has been identified as a target for public health inter-
ventions_sugar-sweetened beverages (SSBs). SSBs lack
nutritional value, increase overall appetite, and are not only
associated with weight gain (Malik et al. 2006; Vartanian et al.
2007), but have also been directly linked to diabetes (Malik
et al. 2010), heart disease (Brown et al. 2011) and dental
decay. These effects may be attributed in part to their dis-
placing healthier options such as milk (Malik et al. 2006;
Vartanian et al. 2007). SSB consumption doubled in the US
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between 1977 and 2002 (Duffey and Popkin 2007). Chil-
dren and adolescents now derive 10–15 % of their total
kilocalories per day (kcal/day) from SSBs (Wang et al. 2008).
Three types of policies have received considerable
attention as ways to reduce youth SSB consumption. First are
policies that limit access. One popular option in this category
is limiting the availability of SSBs in schools, where youth
are a ‘‘captive audience.’’ Access in schools, however, only
contributes to a portion of youth SSB consumption, and,
unless schools can educate youth not to drink SSBs at home,
school policies will have limited effects. Second are school
education policies that aim to change consumption habits.
Third are policies that affect all SSB prices inside and outside
of school. Policies in this category can reduce SSB con-
sumption not only among youth, but also adults, which, in
turn, can help promote better role models for youth. Adults
also serve as gatekeepers for youth SSB access, since they
purchase most of the SSBs consumed by youth, including
beverages for lunches brought to school. A compelling body
of evidence shows that cigarette tax hikes are consistently
associated with reduced tobacco use (Chaloupka and Powell
2009; Levy et al. 2000), especially among youth.
While the immediate aim of SSB policies is to reduce
SSB consumption, the ultimate goal from a public health
perspective is to lower the trajectory of the youth body
mass index (BMI) and improve health. Some models and
statistical analyses have examined the impact of policies on
BMI, but they examine a single policy or limited set of
policies. Many studies do not report the effect of policies
on BMI or are inconclusive. In addition, reduced SSB
consumption in schools may be compensated by increased
intake of other LNED or high calorie foods and beverages
inside or outside of schools. In general, past studies do not
yet provide sufficient information to isolate the linkages
from policies to SSB consumption to BMI. This is espe-
cially likely where policies affect only a portion of con-
sumption, such as in schools. The effects may also take
time to develop, and studies often last short periods of time
(Gortmaker et al. 2011; Hall et al. 2011; Levy et al. 2011).
As emphasized in a recently released Institute of Med-
icine report (Institute of Medicine 2010) simulation models
Public policies Consumption
of food
Public policies Physical
activity
Fig. 1 Effects of policies on overweight and obesity
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(SMs) can be especially useful for considering the potential
impact of an array of policies that will be required to tackle
the obesity problem. Simulation models (SMs) are now
widely used to understand and predict behavior in complex
systems. The use of these models in public health is at a
nascent stage, but has tremendous potential to bridge the
gap between research and practice (Homer and Hirsch
2006; Levy et al. 2006; Sterman 2006). SMs combine
information from different sources to provide a useful tool
for examining how the effects of public health policies
unfold over time in complex systems and impact popula-
tion health (Homer and Hirsch 2006; Levy et al. 2006).
SMs can be particularly useful in understanding the
complex interaction of the relationships between public
policy, diet and exercise, measures of overweight and
obesity, and reduced health and other outcomes associated
with overweight and obesity. As shown in Fig. 1, obesity
depends on the energy balance equation, which in turns
depends on caloric intake through food consumption and
calories burnt through physical activity, growth, and other
processes that influence metabolism. Separate public and
private policies may affect nutrition and physical activity.
In this study, we only consider policies affecting nutrition,
focusing on SSB consumption and how SSB policies may
affect the consumption of other foods.
In this paper, we develop a simulation model of the
pathways of policy effects of school-based access to
nutrition, school-based education and SSB tax policies on
the consumption of SSBs by youth, and the resulting
effects on caloric intake. The model will embody a sys-
tematic approach that considers the effect of various school
nutrition policies on the number of SSB calories consumed
inside and outside of school, and how changes in SSB
consumption affect the consumption of other foods (more
specifically, their associated caloric intake). We also con-
sider how a range of price changes through tax increases
influence SSB and non-SSB consumption, so that the dif-
ferent policies can be compared. Because a range of effect
sizes are associated with each of the pathways to final
caloric intake, sensitivity analysis is used to indicate the
uncertainty surrounding the relevant parameters and
Total caloric
intake
Energy BMI
balance distribution
equation
Total caloric
expenditure
Am J Community Psychol (2013) 51:299–313
highlight priority areas for future research. Thereby,
modeling provides an important tool for researchers, as
well as a guide to policymakers.
Methods
In a previous article (Levy et al. 2011), we reviewed the
literature on the direct effects of school nutrition policies
on SSB consumption, the effect of price on SSB con-
sumption (with a focus on youth), the effects of reduced
consumption of SSBs in school on the consumption of
other foods in school (LNEDs or otherwise), the effects of
SSB consumption in school on the consumption of SSBs
and other foods outside of school, and the effects of SSB
consumption on caloric intake (both through direct reduc-
tions in the amount consumed and the effect on the con-
sumption of other foods). We apply those estimates where
feasible in our current modeling approach and incorporate
new studies conducted since that review.
In gauging the effect of caloric intake on BMI, evalua-
tions sometimes apply the equation that a 3,500 yearly
calorie reduction (roughly 10 kcal/day) reduces weight by 1
pound (Hall et al. 2011). However, Butte and Ellis (2003)
argued that the energy gap is higher for children, due to
greater energy expenditures. Studies indicate that the
required calorie reductions to prevent weight gain vary from
as little as 100–140 kcal/day at younger ages (Plachta-
Danielzik et al. 2008; Wang et al. 2006) to 300–500 kcal/day
at slightly higher ages (Butte et al. 2007; Butte and Ellis
2003; Swinburn et al. 2006) and to 600–1,100 kcal/day
(Wang et al. 2006) for those who became overweight ado-
lescents over 10 years. At present, in the absence of a well-
accepted model (Hall et al. 2011), considerable uncertainty
surrounds the changes in caloric intake needed to prevent
abnormal weight gain in youth. For that reason, we stop
short of estimating the effects of SSB policies on BMI and
limit the analysis to the effect of SSB policies on overall
caloric intake.
In-School Nutrition SSB Policy Effect Sizes
As shown in Fig. 2, in-school policies to reduce SSB may
involve (1) limits on access in school, (2) school education
policies, and (3) price policies. Studies that do not include
specific outcome measures useful for modeling, such as
the quantity of SSBs consumed or caloric intake, were
excluded.
School Access Policies
Overall, published research has found that limiting access
to SSBs in school is associated with decreased SSB
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I. Limits on Access to SSBs
a. Vending machines and snack bars
b. Limits on portion size or a la’ carte offerings
c. Cafeterias
i. All meals
ii. Lunch and breakfast programs
d. Open vs. closed campus during lunch
II. Education/Information Policies
a. Education in health classes
b. Parent education programs
c. Ingredient labelling
III. SSB Price Increase
a. Cafeteria
b. Vending machines and snack bars
Fig. 2 School nutrition policies that can be directed at SSBs
consumption. Three studies (Cullen et al. 2008; 2006;
Cullen and Zakeri 2004) examined the effect of a variety of
different school nutrition policies in a Texas middle school
with high Hispanic and lower income populations. Cullen
et al. (2007) and Hartstein et al. (2008) conducted a pilot
study in three states that examined serving size limits.
Johnson et al. (2009) conducted a study in Washington
examined limits in a variety of venues (vending machines,
snack bars and lunch); and Woodward-Lopez et al. 2010)
examined a variety of venues; Shi (2010) focused on
vending machines. A study of Boston schools (Cradock
et al. 2011) examined a general policy of reducing SSB
availability. The most comprehensive study (Briefel et al.
2009) considered a range of access and education policies
across a broad range of schools.
Blum et al. (2008) found no difference in the effect in
the intervention and control groups from reduced á la carte
and vending machines, and Forshee et al. (2004) and?
Fletcher et al. (2010a, b) found little or no effect on weight
of reducing SSB vending machine availability. Because
these studies did not obtain significant effects, they were
excluded from this study. However, they suggest uncer-
tainty regarding the effect of policies, especially on BMI.
School Education Policies
In 2006, 70 % of states required nutrition and dietary
behavior to be taught at the elementary, middle, and high
school levels as part of the health education curriculum but
did not necessarily emphasize SSBs (Kann et al. 2007). For
example, Briefel et al. (2009) found nearly significant
effects of school education policies on SSB consumption in
9–12th grades. Because their study did not distinguish
programs targeting SSB consumption, it may be premature
to draw strict conclusions. Another study of education
programs (Lo et al. 2008) failed to find significant effects,
indicating uncertainty surrounding the effect of education
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policies. In contrast, two randomized control trials of
school education programs targeted at SSB consumption
showed encouraging results: one (James et al. 2004) in
England with elementary school students and another
(Sichieri et al. 2009) in Brazil with students aged 9–12.
School Pricing Policies
No studies were found that directly examined in-school
SSB price policies. However, reducing the price of lower
fat snacks, fruits and vegetables in school has been found to
increase sales (French 2003), suggesting that students may
also be sensitive to SSB prices. We consider the effect of
price assuming that the same elasticities apply inside
school as outside of school, but confining the direct effects
to SSBs purchased in school.
SSB Tax Policy Effect Sizes
A tax on SSBs leads to higher prices, which in turn affects
consumer purchases and SSB consumption. Therefore, the
effects of tax policies occur through differences in the price
paid by the consumer, and statistical studies that consider
prices are likely to provide more direct estimates of their
effect on consumers.
Demand Studies
Demand studies generally estimate the effects of price in
terms of price elasticity, defined as the percentage change in
quantity consumed relative to a specific percentage change
in price. A recent meta-analysis by Andreyeva et al. (2010)
estimated a price elasticity for soft drinks of -0.79, with a
95 % confidence interval of -0.33 to -1.24. However, the
studies varied in their classifications of SSBs, with some
narrowly confining their analyses to sodas and others con-
sidering a broader spectrum of SSBs, such as fruit and
sports drinks. In studies conducted since Andreyeva’s
review, Finkelstein et al. (2010) and Duffey et al. (2010)
obtained elasticities in the range of -0.7 and -0.9. More
extreme elasticities were obtained by Zheng and Kaiser
(2008) of -0.15 and for soft drinks of -1.9 (Dharmasena
and Capps 2011). Smith et al. (2010) obtained a price
elasticity of -1.3 for all SSBs. Using narrowly defined
categories, Zhen et al. (2011) obtained roughly comparable
price elasticities, with less price responsiveness among low-
income than high-income consumers.
For our model, based on the cluster of recent analyses
between -0.3 and -1.4, we use a midpoint of -0.9, with
bounds of -0.4 to -1.4 to estimate the SSB price elas-
ticity. We use a slightly broader estimate of -0.3 to -1.5,
with a best estimate of -0.9, for the narrower category of
carbonated SSBs, i.e., sugar-sweetened sodas, but allow for
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substitution of other SSBs, non-SSBs and other foods, as
described below. Price elasticities are assumed constant
over the range of prices considered.
None of the price studies explicitly examine youth, but
SSBs consumed at home or in restaurants or brought from
home to school are often purchased by adults. Some studies
have found that youth and individuals with high BMIs are
particularly sensitive to food prices (Auld and Powell
2009; Epstein et al. 2006; Powell et al. 2007; Sturm and
Datar 2005, 2008). To be conservative, we apply the esti-
mates developed above for adults to youth, since adults
purchase much of the food for youth.
The Effect of SSB Taxes
Currently, there are differences in the taxes that states
apply and differences in the beverages to which they are
applied, such as carbonated sodas versus sports drinks
(Chriqui et al. 2008; Powell et al. 2009). Possibly because
the form of a sales tax levied at the counter is small, past
studies that consider tax rates (Powell and Chaloupka
2009) have generally found small or weak effects. These
studies are subject to limitations, including that soda taxes
tend to show limited variance and thus are unable to dis-
tinguish effects; are often imposed on a restricted set of
SSBs (e.g., carbonated sodas only); and are taken at the
checkout counter rather than viewed as posted prices.
We assume a common per unit tax across the selected
SSB beverages sold at all locations. While we recognize
that prices and thus the percentage effect of a tax will differ
depending on location (e.g., SSB prices are generally
higher at restaurants than convenience stores), we do not
distinguish the source of purchase due to the lack of suf-
ficiently detailed data.
The tax is assumed to directly affect the price. Besley
and Rosen (1999) found a 129 % pass through of SSB
taxes to price. We consider a range of tax shifting from 80
to 130 %, with our best estimate as 100 % shifting. We
note, however, that while a per unit tax is more likely to be
passed along to consumers than an ad valorem (percentage)
tax (Brownell et al. 2009), a constant per unit tax per ounce
will be applied at different percentages for beverages at
different prices (e.g., SSBs in restaurants are generally
higher priced the same size SSBs bought at supermarkets).
We consider a tax of $0.01/ounce of soda, which translates
to a 20 % increase in price (Andreyeva et al. 2011) with
100 % shifting. We also consider $0.005/ounce and $0.02/
ounce tax increases.
Consumption Parameters
In order to operationalize the above effect sizes, we apply
the effect sizes to measures of average SSB consumption in
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terms of kcals/day (kcal/day). The effect of decreased SSB
consumption on BMI will depend further on how this
reduction is affected by the consumption of other foods and
beverages and their associated calories. We adjust the
estimates of reduced consumption of SSBs to incorporate
the consumption of other beverages and solid foods.
Levels of US SSB Consumption
For the price analysis, the percentage change in price is
multiplied by the average SSB consumption. Using
nationally representative data from the National Health and
Nutrition Examination Survey (NHANES), Wang et al.
(2008) found average daily consumption was 184 kcal/day
(9 % of total caloric intake) for ages 6–11 years and
301 kcal/day (13 % of total intake) for ages 12–19 years.
For policies that target a subset of SSBs, such as carbon-
ated beverages, carbonated drinks contributed 55 % (53 %
for individuals ages 6–11 years and 66 % for those ages
12–19 years) and fruit drinks 33 % of all SSB kcal/day
consumed (Wang et al. 2008).
Policies that apply only to schools, such as school access
policies, require data regarding consumption specifically
while at school. Using the 3rd School Nutrition Dietary
Assessment Study (SNDAS, 2004–2005), Briefel et al.
(2009) found that school children consumed an average of
159 kcal/day on school days (with 209 kcal/day by sec-
ondary school students), of which 93 were at home, 36
were at school and 31 were at other locations. Another
study by Briefel et al. (2009) found that SSBs were con-
sumed by 17 % of students in the elementary school, 32 %
in middle school and 36 % in high school, of which only a
portion were actually purchased at schools (27, 67 and
74 %, respectively). Students purchased and consumed, on
average, 3, 29 and 46 kcal/day in elementary, middle and
high school, respectively.
School studies sometimes report the results in terms of
the absolute change in calories consumed in school and
other times in terms of the percentage change in calories
consumed. We use an estimate of SSBs consumed and
purchased in school to convert the percentage change to
an absolute change. We converted the results to average
daily consumption by multiplying the average reduction
per school day by the percent of school days in the
year (=180/365). The only exception is for Sichieri et al.
(2009), where results were reported in terms of all SSB
consumption.
Substitution to Other Beverages Inside and Outside
of School
The most direct effect of a change in the consumption of
SSBs is to replace other beverages. In the context of
303
demand studies, these effects are measured in terms of
substituting other products in reaction to price changes.
Many of the demand analyses are confined to soda, so that
there may be substitution to other SSBs, such as sport
drinks and fruit drinks.
Examining all SSBs, Smith et al. (2010) estimated that
a 20 % SSB price increase reduced SSB caloric intake by
38.8 % for adults and 48.8 % for youth. They found off-
sets from juices and milk of 1.9 % for adults and 6.1 %
for youth, thus suggesting little offset. Zhen et al. (2011)
also found limited substitution and that, as the price of
sugar-sweetened sodas increased, consumption of other
beverages such as diet soda fell, especially among low-
income consumers. For low-income consumers, Yen et al.
(2004) found a small effect of soda prices on the con-
sumption of other beverages. Finkelstein et al. (2010)
obtained relatively large substitution effects of a tax on all
SSBs, but the overall reduction in calories was still only
about 30 % lower when other non-SSBs were considered.
Calories were, however, reduced another 40 % if the tax
was confined to carbonated sodas. Dharmasena and Capps
(2009, 2011) found substantial substitution, but examined
a limited set of beverages (e.g., milk) Fletcher et al.
(2010a, b) obtained a nearly 100 % offset of SSB con-
sumption through increased milk consumption, but other
studies have found substantially less substitution toward
milk (Vartanian et al. 2007). Brownell et al. (2009) esti-
mated a 25 % offset in calories. Wang (2011) estimated a
39 % offset, assuming that, upon reducing SSB con-
sumption, a third each switched to water, diet soda and
milk or juice.
The studies above demonstrate that substitution effects
are highly dependent on the products considered and
specification of the empirical model. Based on these
results, our best estimate is a 20 % substitution for a tax on
all SSBs, with estimates ranging from 0 to 60 %. substi-
tution of calories from other beverages. If the tax is con-
fined to carbonated SSBs, we estimate an additional 15 %
offset with a range of 5–40 %. The 40 % estimate reflects
the potential that, in reaction to the tax, beverage manu-
facturers may develop new non-carbonated SSBs whose
costs are favorable to consumers.
As shown in Fig. 3, the effect of SSB school policies on
SSB caloric intake involves multiple pathways. When SSB
access is limited in schools, youth may bring SSBs from
home. For non-price policies, we use the estimated sub-
stitution effects from price studies, i.e., an estimated 20 %
reduction per 18 % increase in price, with a range of
0–60 % around that estimate.
The effects of school nutrition access policies on overall
caloric intake also depend on how consumption in school
affects consumption outside of school. Even if SSB pur-
chases are reduced in school, youth may compensate with
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Non-SSB consumption
in school
School SSB
SSB consumption in
policies
school Total caloric
intake
Non-school SSB consumption
SSB policies outside of school
Non- SSB consumption
outside of school
Fig. 3 Effects of youth-oriented SSB policies on caloric intake
increased consumption at home. However, studies that
have considered overall consumption (Briefel et al. 2009;
Cullen et al. 2008; Fernandes 2008; Schwartz et al. 2009;
Woodward-Lopez et al. 2010) have not found increased
SSB consumption at home in response to reduced SSB
consumption in schools. Indeed, youth may further reduce
consumption at home if drinking SSBs becomes less of a
habit. We estimate no effect of reduced in-school SSB
consumption on SSB consumption outside of school, but
increase the variability of our estimates by 25 % to
incorporate the increased uncertainty.
SSB Consumption and Substitution to Solid Foods
Besides substituting for other beverages, reduced con-
sumption of SSBs may be replaced by the consumption of
solid foods. However, it has also been suggested that SSB
consumption may instead increase the appetite for other
foods (Bellisle and Rolland-Cachera 2001; Drewnowski
and Bellisle 2007; Hattersley et al. 2009; Mattes 1996;
Yamada et al. 2008), especially high fat and high salt items
(e.g., French fries). Thus, reduced SSB consumption may
reduce or increase the intake of solid foods.
Some studies have considered how SSB consumption
affects foods consumed and overall caloric intake. Lack of
compensation is supported by a recent meta-analysis by
Vartanian et al. (2007), but an alternative view is presented
in DiMeglio and Mattes (2000). In addition, Wang et al.
(2009) found that each additional 8 oz. serving of SSBs
was associated with a net increased intake of 106 kcal/day
on that day (p \ .001), similar to the 100 kcal/day from an
8-oz serving of sodas, indicating limited substitution to
other foods and beverages.
In general, even while some research reports that SSB
consumption may affect the calories consumed from solid
foods, but the effects appear limited and may be in either
direction. Overall, we estimate no effect of changes in SSB
consumption on caloric intake from solid foods, but
increase the uncertainty of the estimates to allow for an
added 25 % variability in overall caloric intake.
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Results
The parameters used in our analysis are listed in Table 1.
In conducting our analysis, we present best estimates, as
well as upper and lower bounds.
School Access Policies
Table 2 reports the results from studies of school access
studies, followed by the effects calculated in terms of
caloric changes in SSBs. It then incorporates the effect
of reduced caloric intake due to consumption outside
of school, substitution to non-SSBs, and compensation/
reduced consumption of non-liquids, and finally reports the
net effect with bounds after incorporating all substitution
and compensation.
Cullen and Zakeri (2004) found that, when SSBs
became more available to 6th graders, consumption
increased 1.3 ozs/day (from 2.1 to 3.4 ozs), and fell only
slightly in the next year. Upon converting to kcal/day, we
calculate a net increase in SSB consumption averaging
7.1 kcal/day over the entire year, ultimately yielding a net
increase in caloric intake of 5.6 (with bounds of 3.2–8.8)
kcal/day. Allowing for consumption outside of school,
substitution to non-SSBs reduced, and finally compensa-
tion/reduced consumption of non-liquids, the simulation
model estimates a net increase in overall caloric intake of
5.6 (with bounds of 2.4–11.0) kcal/day due to the increased
availability of SSBs.
Upon removing LNEDs from snack bars and in cafeteria
vending machines, Cullen et al. (2006) found that mean
SSB intake declined by 1.9 oz. in lunch and snack bars,
ultimately yielding a 4.9 (2.1–9.5) kcal/day reduction in
overall caloric intake. Of three Texas middle school stud-
ies, the largest effect was in schools limiting portion size
and vending machine availability (Cullen et al. 2008),
whereby overall SSB fell 1.9 oz leading to 7.4 (3.1–14.5)
kcal/day reduced net caloric intake. Results from Hartstein
et al. (2008) indicate that net caloric intake is reduced by
1.3 (0.6–2.5) kcal/day if all 6 schools in their sample are
included and by 2.6 (1.1–5.0) kcal/day if the 2 outlier
North Carolina schools are excluded.
A large scale Washington study (Johnson et al. 2009)
yielded a net decline of 2.9 (1.2–5.6) kcal/day. Two studies
examined California policies, one (Shi 2010) of which
yielded a reduction of 4.9 (2.1–9.6) kcal/day and the other
yielded a reduction of 1.4 (0.6–2.8) kcal/day. (Woodward-
Lopez et al. 2010). Another large scale study for Boston
(Cradock et al. 2011) yielded a net reduction of 9.2
(4.3–18) kcal/day.
Incorporating a vast array of policies, Briefel et al. (2009)
obtained a wide range of effect sizes for the different poli-
cies, many of which were not significant. Estimates for
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Table 1 Estimates and parameters used to determine effects from studies

Parameter Population Best estimate Lower bounda Upper bounda

Consumption
SSBs in kcals Ages 2–19 years 224
Ages 2–5 years 24
Ages 6–11 years 184
Ages 12–19 years 301
Carbonated SSBs Ages 2–19 years 123.2
in kcals Ages 2–5 years 40
Ages 6–11 years 98
Ages 12–19 years 200
SSB consumption Elementary schools 19
in kcals Secondary schools 52
SSB consumption in kcals Elementary school 3
Purchase and consumed Middle school 29
In school High school 46
Tax policy
Size of tax/price increase $0.01/oz tax = 20 % $0.005 = 10 % price $0.02 = 40 % price
price increase increase increase
Shifting of the tax to price 100 % 80 % 130 %
Price elasticity All ages -0.9 -0.3 -1.5
Substitution to other beverages (in terms of the reduction in the effect on kcals)
Soda to other SSBs All ages 20 % 40 % 5%
SSBs to other beverages All ages 20 % 60 % 0%
Compensation Youth 0.0 % 25 % -25 %
(other foods)
In-school policies
Effect size (by individual study—see Table 1)
Substitute SSB consumption outside of school 0 25 % -25 %
Substitution (same as for tax policy)
Soda to other SSBs All ages 20 % 40 % 5%
SSBs to other beverages All ages 20 % 60 % 0%
Compensation Youth 0.0 % 25 % -25 %
(other foods)
a
95 % confidence interval

specific policies ranged from 6.3 kcal/day (lack of pouring
rights in middle school) to 16.2 kcal/day (not offering
French fries in high schools). Some of these reductions,
however, were larger than the average SSB consumption of
students, which may reflect the large differences in con-
sumption between schools with and without restrictive
practices and collinearity between the policy variables. Most
relevant may be the results for their composite measures,
where the model estimated that stricter availability policies
(e.g., limits on vending machines and snack bars) reduces net
caloric intake by 18.9 (8.0–37.0) kcal/day in middle schools
and by 22.1 (9.3–43.2) kcal/day in high schools. Stricter
school lunch policies have the potential to reduce overall
caloric intake by 30.4 (12.8–59.3) kcal/day.
School Education Policies
Briefel et al. (2009) found that having school nutrition
education in all grades had the potential to reduce SSB
consumption by 6.3 (2.7–12.3) kcal/day, although the
effect did not quite reach statistical significance
(p = 0.51). In elementary schools in England, James and
Kerr (2004) reported that carbonated SSB consumption
over 3 days decreased by 0.3 servings (0.4 oz.), implying
the potential to reduce net caloric intake by 0.8 kcal/day
(0.3–1.5) kcal/day. For an education program aimed at
Brazilian students aged 9 to 12, results from Sichieri et al.
(2009) a reduced net caloric intake of 14.5 (6.3–28.4)
kcal/day.

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Table 2 Studies of school nutrition interventions that may affect sugar-sweetened beverages
123
Study Setting year Major findings Reduced kcal With compen With With With With With With com- With com-
location grades consumption/ sation outside compensation compensation compensation compensation compensation pensation of pensation of
(year) day of school outside of of non-SSB of non-SSB of non-SSB of non-liquids non-liquids non-liquids
(lower bound) school (upper drinks (best drinks (lower drinks (upper (best estimate) (lower bound) (upper bound)
bound) estimate) bound) bound)

School nutrition policies

Cullen and TX SSBs increased 2.1–3.4 oz in first 7.1 5.3 8.8 5.6 3.2 8.8 5.6 2.4 11.0
Zakeri 1988–1989 year, decreased from 4.9 to 4.3 oz.
(2004) in second year
ES & early
MS
Cullen TX Mean SSB intake declined from 6.1 4.6 7.6 4.9 2.7 7.6 4.9 2.1 9.5
et al. 2001–2003 5.4 oz to 3.5 oz and sweetened soft
(2006) drink consumption declined from
MS 5.2 oz to 2.6. oz
Cullen TX Year 1–3 from 5.4 to 3.5 to 1.5 ozs 9.3 7.0 11.6 7.4 4.2 11.6 7.4 3.1 14.5
et al. 2001–2003 for all SSBs
(2008)
MS
Hartstein TX, CA, & SSBs reductions across the 6 schools 1.6, 3.2 1.2, 2.4 2, 4 1.28, 6 0.72, 1.4 2, 4 1.28, 2.6 0.54, 1.1 2.5, 5
et al. NC of -1 oz. If the 2 schools with (eliminating (eliminating (eliminating (eliminating (eliminating (eliminating (eliminating (eliminating (eliminating
(2008) 2003 increases are excluded = 0.5 oz. outliers) outliers) outliers) outliers) outliers) outliers) outliers) outliers) outliers)

MS
Johnson WA Net effect of 25 % reduction in SSB 3.6 2.7 4.5 2.9 1.6 4.5 2.9 1.2 5.6
et al. 2007–2008 consumption
(2009)
MS
Shi (2010) CA .181 fewer drinks in schools, and 0.16 6.2 4.6 7.7 4.9 2.8 7.7 4.9 2.1 9.6
2005 fewer drinks using a Kernel-based
propensity score
MS & HS
Woodwad- CA Soda consumption at school fell by 1.8 1.3 2.2 1.4 0.8 2.2 1.4 0.6 2.8
Lopez 2005–2008 7 % & sport drinks fell by about
et al. 5 % (NS) with non-significant
(2010) ES, MS & increases at home

Am J Community Psychol (2013) 51:299–313

HS
Craddock Boston, MA Soda consumption fell 0.16 and other 11.5 8.7 14.4 9.2 5.2 14.4 9.2 3.9 18.0
et al. 2004–2005 SSBs by -0.14 servings/day
(2011) Yielding -0.30 servings/day
HS
Briefel US
et al. 2004–2005
(2009)
MS Attending a school without snack 10.8 8.1 13.6 8.7 4.9 13.6 8.7 3.7 17.0
bars -22 kcal
MS Lack of pouring rights -16 kcal 7.9 5.9 9.9 6.3 3.6 9.9 6.3 2.7 12.3
MS No ala’ carte offerings -52 kcal 25.6 19.2 32.1 20.5 11.5 32.1 20.5 8.7 40.1
HS Attending a school without snack 13.8 10.4 17.3 11.0 6.2 17.3 11.0 4.7 21.6
bars -28 kcal
HS Stricter rules against VMs -40 kcals 19.7 14.8 24.7 15.8 8.9 24.7 15.8 6.7 30.8
HS Not offering french fries -41 kcal 20.2 15.2 25.3 16.2 9.1 25.3 16.2 6.8 31.6
 Am J Community Psychol (2013) 51:299–313
Table 2 continued
Study Setting year Major findings Reduced kcal With compen With With With With With With com- With com-
location grades consumption/ sation outside compensation compensation compensation compensation compensation pensation of pensation of
(year) day of school outside of of non-SSB of non-SSB of non-SSB of non-liquids non-liquids non-liquids
(lower bound) school (upper drinks (best drinks (lower drinks (upper (best estimate) (lower bound) (upper bound)
bound) estimate) bound) bound)

MS, Stricter overall availability practices 23.7 17.8 29.6 18.9 10.7 29.6 18.9 8.0 37.0
composite 48 kcals
HS, Attending a school with stricter 27.6 20.7 34.5 22.1 12.4 34.5 22.1 9.3 43.2
composite overall availability practices -56
kcals
HS, Stricter school lunch policies - 38.0 28.5 47.5 30.4 17.1 47.5 30.4 12.8 59.3
composite 77 kcals
School education policies
Briefel HS School offering nutrition eduction in 7.9 5.9 9.9 6.3 3.6 9.9 6.3 2.7 12.3
et al. every grade-16 kcal, but p = 0.055
(2009)
James England Carbonated SSBs, change for 1.0 0.7 1.2 0.8 0.4 1.2 0.8 0.3 1.5
et al. 2001–2002 controls = 0.0 (95 % CI = -
(2004) 0.3–0.4) and for inter-vention
ES group = - 0.3 (95 % CI = -
0.6–0.1). The difference was 0.3
(95 % CI = -0.4–0.5).
Sichieri Brazil 2005 A decrease in the daily consumption 18.1 13.6 22.7 14.5 8.2 22.7 14.5 6.1 28.4
et al. Ages 9–12 of carbonated SSBs in the
(2009) intervention compared to control
group (mean difference = -56 ml;
95 % CI -119, -7 ml) a 20 %
reduction.
123

307
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Effects of an SSB Tax
Table 3 reports results for the effect of a tax increase using
best estimates of elasticities. We first consider the effects
of the same percentage tax applied to all SSBs. A tax
increase of $0.01 ($0.005, $0.02) per ounce is predicted to
increase price by 20 % (10 %, 40 %) with 100 % tax
shifting. This price increase in turn is predicted to reduce
SSB consumption by 18 % (9 %, 36 %), with lower
bounds of 6 % (3 %, 12 %) and upper bounds of 30 %
(15 %, 60 %). In terms of SSB kcal/day, the $0.01 tax per
ounce is predicted to ultimately reduce SSB consumption
by 40.3 (13.4–67.2) kcal/day. The effects are greater for
those ages 12–19 years, a 54.2 kcal/day reduction, but less
for those ages 6–11 years, a 33.1 kcal/day reduction.
Under the assumption of constant elasticity, the effects
increase directly with the size of the tax; kcal/day reduc-
tions are half as much with a $0.005 tax/oz. and twice as
much with a $0.02 tax/oz. compared to a $0.01 tax/oz.
The effects also depend on tax shifting, where we
assumed 100 % shifting of the tax to price. The effects are
reduced by 20 % (to 32.3 kcal/day) with 80 % tax shifting,
or increased by 30 % (to 52.4 kcal/day) with 130 % tax
shifting. With substitution into other beverages and incor-
porating the consumption of non-liquid food, the kcal/day
reduction falls from 40 to 32.3, with the bounds from 4.0 to
84.0 kcal/day.
If the tax were limited to carbonated soda rather than all
SSBs, the tax would directly affect only the consumption of
carbonated SSBs. With the consumption of carbonated
beverages at 123 kcal/day and the same elasticity, the
consumption of carbonated beverages is reduced to 22.2
(7.4–37.0) kcal/day. Much larger effects are observed for
those ages 12–19 years, with initial consumption of
200 kcal/day, yielding a 36 kcal/day reduction. With a
20 % reduction from substituting toward non-carbonated
SSBs, substitution to other non-SSB drinks and incorpo-
rating the consumption of non-liquid foods, the estimate
declines to 14.2 kcal/day with the bounds expanded by
25 % to 4.0 kcal/day and 84 kcal/day.
We also calculated the effect of higher prices imposed in
all secondary school purchases. With average consumption
of 37.5 kcal/day of SSBs bought and consumed in middle
and high schools, a 3.4 (1.1–5.6) kcal/day reduction in SSB
consumption is estimated with a 10 % price increase, a 4.1
(2.3–11.3) kcal/day reduction is estimated with a 20 %
price increase, and a 8.3 (4.5–22.5) kcal/day reduction is
estimated with a 40 % price increase. Allowing for sub-
stitution to non-SSB beverages and solid foods, a 20 %
price increase yields a 3.3 (0.7–14.1) kcal/day reduction.
Table 4 summarizes other studies simulating the effect
of an SSB tax. These studies, except Smith et al. (2010), do
not specifically consider youth. In addition, none of the
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Am J Community Psychol (2013) 51:299–313
studies consider substitution to non-liquid foods. The
estimates in Table 4 for a 0.01 tax/oz. on all SSBs range
from 6.5 to 56 kcal/day. While we have assumed the same
price elasticities for youth as adults in our analyses, the
results in Table 4 reflect similar ranges to our analysis. The
tax impacts, however, vary according to study methodol-
ogies and subjects investigated (e.g., entire population vs.
subgroups who may be more price sensitive, individuals
with lower vs. higher incomes, etc.).
Discussion
Our models predict that that policies directed at SSBs could
lead to substantial reductions in calories consumed. A tax
of $0.01 per ounce on all SSBs is predicted to reduce
consumption by 32 kcal/day. However, we estimate a
variation of 4–84 kcal/day around that estimate, due to
uncertainty about the effects of SSB prices on SSB con-
sumption and their effect on the consumption of non-SSB
beverages and foods. Estimates from school access and
education policies generally indicate smaller effects than
our estimates of tax policies, again with considerable var-
iation around the effect for each policy and also for the
estimated effects of different policies.
Our estimates are subject to important limitations. More
recent data is needed on SSB consumption. Parameters
estimates will also be improved as more evaluation studies
are conducted. Detailed information is needed on diet at
home as well as in school. For policies in school, it is
important to understand how out-of-school consumption is
related to in-school consumption and how policy-related
changes in SSB consumption affect the consumption of
non-SSBs, especially LNED foods. The mathematical
representation of the effects merits further consideration.
We have used absolute changes or percentage changes in
consumption based on the way that authors reported their
results, but the effect on consumption may depend on the
initial level of consumption (i.e., dependent on relative
effect sizes). In examining the effect of tax increases on
SSB consumption, the reaction of consumers purchasing at
different locations (e.g., restaurants versus school, where
prices and elasticities may differ) merits further study.
The analysis above assumed the same elasticities for
youth as for adults, because adults purchase much of the
SSBs consumed by youth, However, based on the results
for other types of food, especially for low income con-
sumers (Auld and Powell 2009; Epstein et al. 2006; Powell
et al. 2007; Sturm and Datar 2005, 2008), elasticities may
be much higher for SSBs consumed at school and pur-
chased by teens outside of school. In that case, the effects
on SSB consumption will substantially increase, especially
for in-school consumption.
Am J Community Psychol (2013) 51:299–313 309

Table 3 Simulation of the effects of a $0.005, $0.01 and $0.02 per oz. tax increase on caloric intake
0.005 Tax/ounce 0.01 Tax/ounce 0.02 Tax/ounce

Effect of a tax on all SSBs on SSB consumptiona

Price increase assuming 100 % tax shifting 10 % 20 % 40 %
Percent reduction in SSB consumption (best estimate) 9.0 % (3.0 %, 18.0 % (6.0 %, 36.0 % (12.0 %,
15.0 %) 30.0 %) 60.0 %)
Change in SSB kcal/day for those ages 2–19 (best estimate) 20.1 (6.7, 33.6) 40.3 (13.4, 67.2) 80.6 (26.9, 134.4)
Change in SSB kcal/day for those ages 6–11 (best estimate) 16.6 (5.5, 27.6) 33.1 (11.0, 55.2) 66.2 (22.1, 110.4)
Change in SSB kcal/day for those ages 12–19 (best estimate) 27.1 (9.0, 45.15) 54.2 (18.1, 90.3) 108.4 (36.1, 180.6)
Tax shifting of 80 % and 130 %
Change in price with 80 % tax shifting 8% 16 % 32 %
Change in SSB kcals with 80 % tax shifting (best estimate) 16.1 (5.4, 26.9) 32.2 (10.8, 53.8) 64.5 (21.5, 107.5)
Change in price with 130 % tax shifting (best estimate) 13 % 26 % 52 %
Change in SSB kcals with 130 % tax shifting (best estimate) 26.2 (8.7, 43.9) 52.4 (17.5, 87.4) 104.8 (34.9, 174.7)
Effect on overall caloric intake of ages 2–19 with 100 % tax shifting
Best estimate with substitution to other non-SSB beverages, ages 2–19 16.1 (5.4, 67.2) 32.3 (10.8, 134.4) 64.5 (21.5, 107.5)
Best estimate with substitution to liquid and non-liquid consumption 16.1 (2.0, 42.0) 32.3 (4.0, 84.0) 64.5 (8.1, 168.0)
The effect of a tax on carbonated SSBs on carbonated SSB consumption w/100 % tax shifting
Price increase assuming 100 % tax shifting 10 % 20 % 40 %
Percent reduction in carbonated SSB consumption (best estimate) 9.0 % (3.0 %, 18.0 % (6.0 %, 36.0 % (12.0 %,
15.0 %) 30.0 %) 60.0 %)
Change in carbonated SSB kcal/day for those ages 2–19 (best estimate) 11.1 (3.7, 18.5) 22.2 (7.4, 37.0) 44.4. (14.8, 73.9)
Best estimate with substitution to other SSB beverages, ages 2–19 7.1 (1.3, 16.7) 14.2 (2.7, 33.4) 28.4 (5.3, 66.7)
Best estimate with substitution to other non-SSB foods, ages 2–19 7.1 (1.0, 20.8) 14.2 (2.0, 41.7) 28.4 (4.0, 83.4)
Effect on overall caloric intake of high school students of a price increase only in schools
Change in carbonated SSB kcal/day for those ages 12–19 (best 3.4 (1.1, 5.6) 4.1 (2.3,11.3) 8.3 (4.5, 22.5)
estimate)
Overall variation with substitution to home, liquid and non-liquid 2.7 (0.3, 7.0) 3.3 (0.7, 14.1) 6.6 (1.4, 28.1)
consumption
a
95 % confidence intervals shown in parentheses

Table 4 Summary of projected effects from other simulations of the effects of a tax on SSBs
Study Price increase Assumptions Population Kcal reduction

Andreyeva et al. (2010, 2011) 20 % Tax on all SSBs, w/out substitution All 50
Finkelstein et al. (2010) 20 % Tax on carbonated SSBs, w/substitution All 4.2
20 % Tax on all SSBs, w/substitution All 7
40 % Tax on carbonated SSBs, w/substitution All 7.8
40 % Tax on all SSBs, w/substitution All 12.4
Smith et al. 2010 20 % Tax on all SSBs, w/substitution Adults 34.2
20 % Tax on all SSBs, w/substitution Adults, low income 36.8
20 % Tax on all SSBs, w/substitution Adults, high income 33.3
20 % Tax on all SSBs, w/substitution Children 40
20 % Tax on all SSBs, w/substitution Children, low income 33.1
20 % Tax on all SSBs, w/substitution Children, high income 44.7
Sturm et al. (2008, 2010) 20 % tax Tax on all SSBs, w/out substitution 3rd to 5th graders 15.2
Duffey et al. 2010 20 % Tax on all SSBs, w/out substitution 56
Dharmasena and Capps (2009, 2011) 20 % Tax on all SSBs, w/out substitution 19.6, 31.2

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In the above analyses, we used average consumption
data, and conservatively assumed that the impacts were
distributed over the entire population. The effects, how-
ever, would be centered on those who already consume
beverages. Of individuals ages 12–19 years, Wang et al.
(2008) found that males consumed more than females
(357 kcal/day vs. 242 kcal/day), and found little difference
in intake between those overweight or obese and those
normal weight (e.g., for 12–19 year olds, 297 kcal/day for
those less than the 85th percentile, 304 kcal/day by those
between the 85 and 95th percentile, 320 kcal/day by those
above the 95th percentile). Nevertheless, those overweight
may still be disproportionately affected through greater
reductions in consumption. In addition, those at low
income might be expected to be most affected by tax
policies, since they are most likely to be sensitive to price.
For example, Sturm et al. (2010) found limited effects of
taxes on soda consumption by young school children, but
greater effects were observed in schools, and for those who
are lower income, African American and higher BMI.
The effect of school policies at a national level will be
less if other nutrition policies are already in place. Briefel
et al. (2009) and the 2006 SHPPS data (O’Toole et al.
2007) found that SSBs were more accessible in higher
grades. Similarly, the effect of a tax may depend on local
variations in price, and how the industry passes along
the tax changes in different locations. The effects of indi-
vidual policies will also depend on the other nutrition
policies already in effect or those being simultaneously
implemented.
We have not attempted to predict the effect of changes
in total caloric intake on the distribution of BMI. Ludwig
et al. (2001) found that, by replacing SSBs, BMI of those
ages 8–12 years can be reduced by between 0.1 and 0.24
BMIs over 19 months, which translates to between 0.035
and 0.08 kg/year, a substantial portion of the 0.25 kg
reduction needed to maintain appropriate weight (Wang
et al. 2006). Results from Ebbeling et al. (2006) imply a
comparable reduction in BMI of 0.26 kg/m2 for every SSB
serving (12 oz.) per day displaced by adolescents, and
Chen et al. (2009) found about twice that effect for adults.
However, Fletcher et al. (2010a, b) found no effect of SSB
taxes on BMI. Powell et al. (2009) also found no effect of
state-level soda taxes on adolescent BMI, but found a
weak, though insignificant effect of vending machine soda
tax rates on BMI of teens at risk for overweight. Assuming
a linear relationship, Sturm et al. (2010) found that an 18
percent differential soda tax would correspond to 0.23
fewer BMI units, or a 1 % reduction in average BMI. At
12 months, James et al. (2007) found that the percent of
overweight youth showed a net increase of 7.3 % relative
to the control group, but the difference disappeared within
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Am J Community Psychol (2013) 51:299–313
2 years after the program ended, and Sichieri et al. (2009)
found that overweight girls showed a reduction in BMI.
A widely-used metric is that each 3500 calorie reduction
is associated with a one pound weight loss. This relation-
ship was formalized (Hall 2008) to predict an approximate
10 kcal/day reduction in food energy results in one pound
of weight loss at steady state, but the reduction must be
maintained. Larger reductions, as much as three times as
great, would be needed for older youth and as much as six
times as great for youth at higher weight levels (Butte et al.
2007; Jordan and Hall 2008). As indicated above, there is
not yet a well-accepted model for youth to enable us to
make those predictions. Initial weight and food consump-
tion patterns as well changing patterns over time will need
to be considered. Relatively modest behavioral modifica-
tions are required to prevent weight gain at younger ages,
but larger reductions may be required for older youth and
for those at higher weights (Wang et al. 2006).
Generally, simulation models that examine patterns in
consumption and BMI over time as individuals’ age will be
needed to fully understand the effects of the different
obesity policies over time. Information will be needed on
current and past levels of BMI and about how policies
might be anticipated to affect future BMI. Policy effects
may be strengthened over time as attitudes change, or
unanticipated reactions by the individual or industry may
counteract the effects of a policy. The effect of BMI on
disease outcomes is also complex. In addition to their
effect on BMI, SSB consumption may have a direct effect
on diabetes, heart disease and cancers (Jones et al. 2006;
Lightwood et al. 2009; Milstein et al. 2007; Van Meijgaard
et al. 2009). Finally, in making policy choices, the costs
associated with each policy, as well as the feasibility,
sustainability and equity should be considered (Gortmaker
et al. 2011; Swinburn 2008).
The bottom line message of this paper is that the type of
policy analysis needed to tackle the obesity problem
involves dealing with complexity, and admitting the
uncertainty involved in any analysis. Does this mean that
we should throw up our hands and await further study or just
move on to other problems? In our opinion, the answer is
no. The analysis above suggests that, while there is a wide
range of possible outcomes, there is considerable scope for
improving the current consumption habits. We expect that a
multiplicity of policies will be needed, targeting different
populations, such as in tobacco control policy (Levy et al.
2004). As we attempt various policies, outcomes must be
evaluated at the various levels in the chain from the initial
policy impact on behavior to population-level changes in
BMI. Simulation modeling provides a framework for sys-
tematically piecing together that information in order to
summarize the best information and provide direction on
Am J Community Psychol (2013) 51:299–313
the information still needed to better understand the prob-
lem and its solution.
Acknowledgments This study was funded by the Academy for
Educational Development, Project #4245-01 and the Robert Wood
Johnson Foundation Healthy Eating Research Program, Contract
#63048.
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