Exploring the Sugar Sweetened Drinks Tax (Sugar Tax) Pass Through Rate in the Irish Hospitality Sector

Exploring the Sugar Sweetened Drinks Tax (Sugar Tax) Pass Through Rate in the Irish Hospitality Sector | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring the Sugar Sweetened Drinks Tax (Sugar Tax) Pass Through Rate in the Irish Hospitality Sector Frank Houghton, Jennifer Moran Stritch, Jeremy Auerbach, Mia Daly, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4246765/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Aug, 2024 Read the published version in BMC Public Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background The WHO supports the use of Sugar-Sweetened Drinks Taxes (SSDTs) as a fiscal lever to help reduce sugar consumption and tackle obesity. Obesity is associated with a range of adverse health outcomes. In response to increasing levels of obesity in Ireland a SSDT was introduced in 2018. Previous research in Ireland has noted that the pass-through rate of the SSDT in retail (off-site consumption) settings was poor. However, to date no research has examined the SSDT pass-through rate in hospitality (on-site consumption) venues in Ireland. Methods This research examines the SSDT pass through rate on full-sugar versus diet versions of Coca-Cola in a convenience sample of 100 hospitality venues in two provincial Irish cities. Results In 88% of cases the same price was charged for both full-sugar and sugar free drinks. Conclusion It is generally assumed that the SSDT would result in persistent price differences between soft drink prices based on sugar content. However, this is barely evident in the hospitality sector in Ireland. A number of recommendations are suggested, including both increasing the SSDT, and increasing it annually in line with inflation. SSDT SSBT Sugar-Sweetened Beverage Tax Sugar Tax Ireland Pass-Through Rate Figures Figure 1 Introduction Similar to many other areas of the world Ireland is facing unprecedented levels of obesity [1,2]. Recent examinations indicate that between 21-23% of the Irish population are obese, with another 35-37% being overweight [3,4]. Obesity is linked a wide range of non-communicable diseases (NCDs) including cancer and osteoarthritis, as well as diabetes and cardiovascular disease [5]. Sugar intake is linked to obesity [6-8], as well as dental health [9,10]. In response to this growing epidemic of obesity the Irish Government announced the forthcoming introduction of a sugar levy in its 2016 Obesity Policy And Action Plan [11]. A Sugar Sweetened Drinks Tax (SSDT), or Sugar Tax, as it is more commonly termed is a classic example of what is often termed a ‘sin tax’. Such taxes are often charged on commodities deemed harmful to society, such as tobacco, alcohol, gambling and pornography [12]. Ireland introduced its SSDT in May 2018 [13]. This date was delayed somewhat to coincide with a similar tax being introduced in the UK. This was done to ameliorate the concerns of retailers in the border region of Ireland who felt this tax might help drive away potential customers north of the border and into Northern Ireland [14]. The scope of the Irish SSDT was subsequently expanded on 1 January 2019 via the Finance Act 2018 to include certain plant protein drinks and drinks containing milk fats [15]. The SSDT in Ireland is relatively modest. It is a tiered excise duty comprised of three rates based on sugar content [16]. Soft drinks under 5g of sugar per 100ml incur no tax, while those with 5g to under 8g of sugar per 100ml incur a tax which equates to 5 cents on a standard 330ml can. The higher rate of SSDT is for those soft drinks over 8g of sugar or more per 100ml and incurs a SSDT of 8 cents per 330ml can [15]. The WHO recently noted that some form of SSDT, or sugar-sweetened beverage tax (SSBT) as they term it, has been introduced into 108 countries to date [17]. The WHO, and allied groups, are strongly supportive of SSBTs as a cost effective fiscal lever in efforts to control rising levels of obesity globally [18,19]. The WHO state that SSDTs ‘ represent a win-win-win strategy: a win for public health (and averted healthcare costs), a win for government revenue, and a win for health equity’ [17]. From a demand perspective an SSBT may work through three mechanisms. In the first instance an SSBT should make sugar sweetened drinks more expensive, and therefore less appealing and accessible. The second mechanism through which a SSBT may act as a disincentive is informed by rational choice theory and suggests that causing the sugar sweetened drink to be more expensive than its no or low sugar alternative will cause people to opt for the cheaper alternative. Additionally, the higher price may act as a signal to a potential purchaser and remind them of the negatives associated with such a purchase. All three of these mechanisms are reliant on two key factors. In the first instance most or all of the SSDT must be passed on to the customer to pay, rather than this cost being absorbed by the manufacturer or retailer [20,21]. Secondly, zero or low sugar options must remain cheaper than higher sugar drinks that are subject to the SSDT. If for example a retailer opts to increase the price of a 330ml can of Full sugar Coke by 8 cents, as per the SSDT, while at the same time also increasing the price of an equivalent can of Diet Coke by the same amount, then two of these potential dissuasive mechanisms cannot function. Industry is routinely fiercely resistant to the introduction of health oriented taxes, such as SSDTs [22-24], and Ireland is no exception [25-27]. However, a clear understanding of standard industry tactics to delay, deny, and deflect the need for regulation and associated evidence can help overcome such opposition [28, 22]. The SSDT in Ireland has been criticised for a lack of hypothecation, that is a lack of ring fencing of monies raised to support and improve services, in this case such as dental, diabetes, cardiovascular or obesity related health care [29,30]. The Irish SSDT May also be critiqued for its modest tariff, and lack of being annually adjusted for inflation [17,18]. Branded soft drinks sold individually routinely retail for between €1.50 and €2.75 for 330ml - 500ml cans and bottles in supermarkets, garages and corner shops. Prices in hospitality venues may be up to 50% or more dearer. As such an SSDT component in the price structure of five to eight cents per 330ml can is minimal. Finally, the Irish SSDT has been critiqued for the reality that despite the accolades the Irish Government received for this pro-Public Health measure, it was only introduced in Ireland after European Union restructuring effectively closed down the Irish sugar beet industry, thus eradicating potential opposition from Ireland’s powerful farming lobby [31]. There is substantial evidence to suggest that one of the major outcomes of the introduction of an SSDT rather than its direct impact on consumers may instead be seen among manufacturers. Reformulation of the ingredients of many soft drinks by industry to avoid SSDT thresholds is clearly evident in Ireland and elsewhere [32-44]. Many countries, such as Ireland have introduced policies and targets to promote healthier reformulation of food and drink products [32,33]. Globally research has noted considerable variation in the price pass-through rate of SSDTs. Evidence suggests the rates can vary from 40% to well over 100% [45-57]. A recent examination of the SSDT pass-through rate in retail (off-site) premises in Ireland noted that the tax was routinely not passed on to the consumer [30]. In this examination of 14 chain supermarkets it was noted that in instances where the same leading brand and size of container was available in both sugar free and full sugar versions, in approximately 60% of cases the retail price was the same. Even when a price differential was applied it often fell short of the SSDT addition [30]. However, one limitation of this research was its sole focus on the retail, or off-trade, sector to the exclusion of the hospitality sector. This research aimed to remedy this lacuna by examining SSDT pass-through rates in the hospitality (on-site) sector. Methods A convenience sample of 100 hospitality venues were surveyed in two Irish provincial cities. The NielsenIQ report for 2022 identified the top leading carbonated soft drink in Ireland as Coca-Cola followed by 7UP, Pepsi, Club, and Fanta [58]. Of these top five leading brands only Coca-Cola remains above the SSDT threshold of 5g of sugar per 100ml. Coca-Cola contains 10.6g per 100ml. This survey examined the costs of Coca-Cola versus diet versions by the same manufacturer (i.e. Diet Coke or Coke Zero). When originally conceived Club soft drinks were also above the SSDT threshold. However, even though Club drinks had been reformulated to below the SSDT threshold by the time data collection started they were still included to explore the issue of availability. It is important to remember that although reformulation of a drink such as Club Orange is important, every 330ml can of the new recipe still contains over 3 teaspoons of sugar (Club now contains 4.5g of sugar per 100ml). This study was approved by the Institutional Research Ethics Committee at the Technological University of the Shannon- Midwest. Data was collated in MS Excel and analysed using SPSS. Results Data was collected from 99 establishments, with one Café declining to participate. 90.9% (90) of venues sold both full sugar Coca-Cola and diet equivalents (see Table One). Table One: Availability of the Target Soft Drinks in Hospitality Venues Sampled Venue Type Participating Venues Sell Full Sugar Coca-Cola Sell Sugar Free Versions of Coca-Cola Sell Full Sugar Club Orange Sell Sugar Free Version of Club Orange Fast Food 23.2% (23) 91.3% (21) 91.3% (21) 4.3% (1) 4.3% (1) Café 30.3% (30) 76.7% (23) 76.7% (23) 6.7% (2) 0% (0) Restaurant 21.2% (21) 100% (21) 100% (21) 19.0% (4) 0% (0) Pub/Bar 23.2% (23) 100% (23) 100% (23) 21.7 (5) 4.3% (1) Other 2.0% (2) 100% (1) 100% (1) 0% (0) 0% (0) TOTAL 100% (99) 90.9% (90) 90.9% (90) 12.1% (12) 2.0% (2) In contrast just 12.1% (12) establishments sold Club Orange, with just 2.0% (2) selling the no sugar equivalent (Club Orange Zero). Table Two: Prices of the Target Soft Drinks in Hospitality Venues Sampled Venue Type Full Sugar Coca-Cola & Sugar Free Versions the Same Price Full Sugar Coca-Cola More Expensive Than Sugar Free Versions Fast Food 71.4% (15) 28.6% (6) Café 91.3% (21) 8.7% (2) Restaurant 76.2% (16) 23.8% (5) Pub/Bar 100% (23) 0% (0) Other 100% (2) 0% (0) TOTAL 85.6% (77) 14.4% (13) In 85.6% of cases the sugar and sugar free versions of Coca-Cola were for sale at the same price. No venues charged more for the diet version of Coca-Cola. Of the 13 premises which did charge more for the full sugar version the rate charged was less than the tax rate in one venue, and higher in the other 12. Among the 13 venues which did charge a higher price the average higher price was 21.1 cents per 330ml (SD = .15), ranging from 7 cents to 53 cents. Further analysis by hospitality venue type was not possible given the numbers involved. Discussion The results clearly demonstrate that in almost nine out of ten (87.9%) venues the full sugar and sugar free versions of Ireland’s leading soft drink, Coca-Cola, were for sale at the same price. Such equal pricing removes both the rational choice mechanism through which a potential buyer might opt for the cheaper sugar-free instead of the more expensive full sugar version, as well as the warning signalling impact of the differential pricing (See Figure One for an extremely rare example of both differential pricing and explicit signalling). Figure One: Example of Explicit Mention of the SSDT on a Nando’s Menu It is important to acknowledge the complexity of the obesity issue and the diverse range of approaches that are required to respond to this issue. However, obesity remains a major threat to the health and wellbeing of Ireland’s population via a range of non-communicable diseases (NCDs) and the SSDT remains a proven fiscal level to address this threat [ 2 , 5 , 11 ]. Sugar-sweetened drinks are a threat to population health, with little to recommend them given their ‘empty calories’ [ 59 ]. Given the lack of price differentiation evident in Ireland based on this on-site (hospitality venue) study and the prior off-site (retail) study [ 30 ] it is strongly recommended that the current SSDT is increased significantly. The mark-up on soft drinks in the Irish hospitality sector has long been acknowledged as excessive and effectively negates the SSDT [ 60 ]. In their response to the initial consultation process on the SSDT in Ireland the Royal College of Physicians of Ireland [ 61 ] specifically noted that only taxes achieving a 10–20% price increase would reduce consumption of sugar sweetened drinks [ 62 , 63 ]. The WHO have recently stated that ‘ While no empirical best practice for effective SSB tax levels have been set, excise taxes need to be sufficiently high to impact affordability ’ [ 17 ]. Given the minimal SSDT introduced in Ireland initially, and both high levels of inflation since it was introduced [ 64 ] and the lack of annual index-linked increases in the tax, as well as clear evidence of minimal SSDT pass-through or price differentiation in either retail [ 30 ] or hospitality settings, an increase of the SSDT to 50 cents per 330ml can is suggested for the higher tier (8g or more sugar 100ml). The rate for the lower SSDT tier of 5g-7.99g of sugar per 100ml should be 30 cents per standard 330ml can. This SSDT should be inflation linked and adjusted annually. Recent research has noted that demand for sugar-sweetened beverages is sensitive to tax related price increases [ 65 ]. Evidence also suggests that adding the phrase ‘includes sugary drink tax’ onto price tags can act as a disincentive to purchasing [ 66 ]. It is there suggested that additional legislation is introduced in Ireland to require cans, bottles, menus, and price lists to include a phrase specifically mentioning that the price includes the SSDT. This will both act as a signal to consumers, similar to traffic light style warnings on food [ 67 ], and help prevent retailers from simply increasing the prices of both sugar-sweetened and no/low sugar drinks, as the purchasing public will be constantly reminded of the SSDT factor in the pricing structure. Other countries have increased SSDTs dramatically over short time periods and have seen positive results [ 68 ]. Having examined demand led factors, supply side considerations should also be taken into account [ 69 ]. In terms of the availability of sugar free options, it is important to note that although every establishment surveyed which sold full-sugar Coca-Cola also sold diet versions, this was not the same for Club Orange. Although the reformulated lower sugar version was sold in just 12.1% of establishments, only 2% sold the sugar free version. This under-availability of the sugar free versions of popular brands appears to be an under-researched topic in the literature. Potential customers with a favourite low or zero sugar soft drink that is not available in their chosen brand may opt for the sugared version of that product, rather than an alternative sugar free brand. Further research is required on the availability of sugar free versions of popular soft drinks. Reformulation has clearly been an important factor in reducing the impact of sugar Irish consumers may typically encounter from soft drinks. In recent years Pepsi re-formulated its ingredients to fall below the SSDT threshold of 5g of sugar per 100ml [ 39 ]. Many manufacturers have worked to avoid the SSDT by developing recipes below threshold level. For example the sugar version of Pepsi now contains 4.55g of sugar per 100ml, while equivalent Fanta, 7Up and Sprite brands each contain 4.5g, 4.7g and 4.4g respectively. Given the SSDT was only announced by Government in 2016 and introduced in 2018, manufacturers have achieved this transition in a relatively short time frame [ 11 ]. This begs the question of whether a revised lower SSDT sugar threshold rate is appropriate? The 5g of sugar per 100ml SSDT threshold is by no means universal [ 2 ]. It is important to note that differing health targets internationally may have important implications for health [ 70 ]. For example South Africa and Mauritius both have SSDT thresholds of 4g of sugar per 100ml [ 19 , 71 ]. It is suggested that a revised SSDT threshold of 4g of sugar per 100ml be introduced in 2030, with the threshold reducing to 3g in 2035. The standard 330ml can appears to be increasingly replaced in retail premises by larger 500ml cans and bottles. The impact of reformulation may be minimised if those opting to drink sugared soft drinks are consuming cans and bottles that contain approximately 50 percent more volume. In order to maintain public support for this measure the Irish Government also needs to hypothecate SSDT raised to support relevant health and dental services. Although the Irish Government has explicitly argued against this approach [ 72 ], it is a crucial to order to build and maintain public confidence [ 29 ]. Although the SSDT is important it only targets soft drinks. It is strongly suggested that a similar tax is introduced for confectionary and food products [ 73 , 74 ]. A broadening of the sugar tax should also target alcohol. Although in most cases sugar is used up in the fermentation process, in certain drinks, such as coffee liqueurs, a substantial volume of sugar is added back into product after the yeast has died. Finally, given a history of poor quality evidence in this field, it is essential that any changes to the SSDT and associated taxes is accompanied by clear baseline evaluations and a structured and funded review process [ 75 ]. Declarations Funding Declaration/ Declaration of interest : This study was conducted as part of a review of the impact of the implementation of the SSDT in Ireland. This review was funded by Ireland’s Department of Health. However, the opinions offered here are those of the authors and not the official position of either the Department of Health or the Irish Government. Ethics: This study was approved by the Research Ethics Committee of the Technological University of the Shannon: Mid-West. Authors Contributions : FH and JMS conceived and designed the study. FH and MD designed the data collection instrument. MD and DH collected and input the data. FH and JA analysed the data. FH led the writing of the paper. 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British Medical Journal. 2012;344:e2931. Ng SW, Ni Mhurchu C, Jebb SA, Popkin BM. Patterns and trends of beverage consumption among children and adults in Great Britain, 1986-2009. British Journal of Nutrition. 2012;108(3):536-551. Central Statistics Office. Consumer Price Index. https://www.cso.ie/en/statistics/prices/consumerpriceindex/ Andreyeva T, Marple K, Marinello S, Moore TE, Powell LM. Outcomes Following Taxation of Sugar-Sweetened Beverages: A Systematic Review and Meta-analysis. JAMA Netw Open. 2022;5(6):e2215276. doi: 10.1001/jamanetworkopen.2022.15276. Donnelly GE, Guge PM, Howell RT, John LK. A Salient Sugar Tax Decreases Sugary-Drink Buying. Psychological Science. 2021;32(11):1830-1841. Magnusson RS. Obesity prevention and personal responsibility: the case of front-of-pack food labelling in Australia. BMC Public Health 2010;10:662 Teng A, Puloka V, Genç M, Filimoehala O, Latu C, Lolomana'ia M, Osornprasop S, Signal L, Wilson N. Sweetened beverage taxes and changes in beverage price, imports and manufacturing: interrupted time series analysis in a middle-income country. Int J Behav Nutr Phys Act. 2020;17(1):90. doi: 10.1186/s12966-020-00980-1. Claudy M, Doyle G, Marriott L et al. Are sugar-sweetened beverage taxes effective? Reviewing the evidence through a marketing systems lens. J Public Policy Mark 2020;40(3):403–18. Houghton F, Houghton S, O’Doherty D, McInerney D, Duncan B. The tobacco endgame: The importance of targets and geography. Canadian Journal of Public Health. 2018;109(5-6):900-901. https://doi.org/10.17269/s41997-018-0150-6 MRA (2024) Excise Duty on Sugar Content of Sugar Sweetened Products. Mauritius Revenue Authority. https://www.mra.mu/index.php/customs1/more-topics/excise-tax-on-sugar-content-of-sugar-sweetened-non-alcoholic-beverages KildareStreet (2020) Tax Code. https://www.kildarestreet.com/wrans/?id=2020-07-14a.724 Jensen JD, Smed S. State-of-the-art for food taxes to promote public health. Proc Nutr Soc. 2018;77(2):100-105. doi: 10.1017/S0029665117004050. Temple NJ. A Proposed Strategy against Obesity: How Government Policy Can Counter the Obesogenic Environment. Nutrients. 2023;15(13):2910. doi: 10.3390/nu15132910. Pfinder M, Heise TL, Hilton Boon M, Pega F, Fenton C, Griebler U, Gartlehner G, Sommer I, Katikireddi SV, Lhachimi SK. Taxation of unprocessed sugar or sugar-added foods for reducing their consumption and preventing obesity or other adverse health outcomes. Cochrane Database Syst Rev. 2020;4(4):CD012333. doi: 10.1002/14651858.CD012333.pub2. Additional Declarations Competing interest reported. This study was funded by Ireland's Dept. of Health as part of a review of the impact of the SSDT in Ireland. Cite Share Download PDF Status: Published Journal Publication published 30 Aug, 2024 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 17 May, 2024 Reviews received at journal 15 May, 2024 Reviews received at journal 15 May, 2024 Reviewers agreed at journal 15 May, 2024 Reviewers agreed at journal 30 Apr, 2024 Reviewers invited by journal 30 Apr, 2024 Editor invited by journal 17 Apr, 2024 Submission checks completed at journal 16 Apr, 2024 Editor assigned by journal 16 Apr, 2024 First submitted to journal 10 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4246765","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":292160189,"identity":"93ac8a78-97af-41a9-9fbb-c5a28cfc1016","order_by":0,"name":"Frank Houghton","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIie2RsQrCMBCGz8nltKtB8BlSBF1EX6VF8BHETUXo1AdoH0LoJI6RG1yKWQsuujhKXcRB0IQiOkXdBPNByB3k4+4nABbLD9ITAKUJkCpR951xIgUIk8LhqagbBsgz7zuFlPJmMV6nwz4CanA5X+9OS6mVkshNWaqDtpvArcmzoz+N0y1ylWUVmaYgtNgOyE+y1J1VAqUIT61nVMrnV2VTKFejgi2WaEWGWhGFYoyPOGQRpybL0I3joI8s8ier0LzYgoUjalRlyvNT0EXHIcovpjGFqE7Ne3T6fz7CER8+tFgslr/jDixdWQg6GoKVAAAAAElFTkSuQmCC","orcid":"","institution":"Technological University of the Shannon: Midlands Midwest","correspondingAuthor":true,"prefix":"","firstName":"Frank","middleName":"","lastName":"Houghton","suffix":""},{"id":292160190,"identity":"6b7be26a-d03f-49f0-91c0-14a22c98e85e","order_by":1,"name":"Jennifer Moran Stritch","email":"","orcid":"","institution":"Technological University of the Shannon: Midlands Midwest","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"Moran","lastName":"Stritch","suffix":""},{"id":292160191,"identity":"dc5e799b-4759-4968-885b-7a7c3451826a","order_by":2,"name":"Jeremy Auerbach","email":"","orcid":"","institution":"University College Dublin","correspondingAuthor":false,"prefix":"","firstName":"Jeremy","middleName":"","lastName":"Auerbach","suffix":""},{"id":292160192,"identity":"ca9384be-8654-43dc-9158-7fcdd7699ad9","order_by":3,"name":"Mia Daly","email":"","orcid":"","institution":"University of Limerick","correspondingAuthor":false,"prefix":"","firstName":"Mia","middleName":"","lastName":"Daly","suffix":""},{"id":292160193,"identity":"c50471e8-7af9-4e2a-87ea-5945aade0e78","order_by":4,"name":"Daisy Houghton","email":"","orcid":"","institution":"University of Galway","correspondingAuthor":false,"prefix":"","firstName":"Daisy","middleName":"","lastName":"Houghton","suffix":""}],"badges":[],"createdAt":"2024-04-10 10:31:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4246765/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4246765/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-024-19891-y","type":"published","date":"2024-08-30T15:57:54+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":55251741,"identity":"8ec0598d-7c8b-4e89-bc66-43e535d4fe0a","added_by":"auto","created_at":"2024-04-24 17:42:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":832869,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eExample of Explicit Mention of the SSDT on a \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eNando’s \u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003eMenu\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4246765/v1/1137409bbc96c802becb499a.png"},{"id":63821106,"identity":"647bc5bb-d7d1-4093-8f9f-d44fbab13ec2","added_by":"auto","created_at":"2024-09-02 16:11:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1595504,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4246765/v1/1e571628-4dcd-461a-adf1-808d57918d3f.pdf"}],"financialInterests":"Competing interest reported. This study was funded by Ireland's Dept. of Health as part of a review of the impact of the SSDT in Ireland.","formattedTitle":"Exploring the Sugar Sweetened Drinks Tax (Sugar Tax) Pass Through Rate in the Irish Hospitality Sector","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSimilar to many other areas of the world Ireland is facing unprecedented levels of obesity [1,2]. Recent examinations indicate that between 21-23% of the Irish population are obese, with another 35-37% being overweight [3,4]. Obesity is linked a wide range of non-communicable diseases (NCDs) including cancer and osteoarthritis, as well as diabetes and cardiovascular disease [5]. Sugar intake is linked to obesity [6-8], as well as dental health [9,10]. In response to this growing epidemic of obesity the Irish Government announced the forthcoming introduction of a sugar levy in its 2016 Obesity Policy And Action Plan [11].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A Sugar Sweetened Drinks Tax (SSDT), or Sugar Tax, as it is more commonly termed is a classic example of what is often termed a \u0026lsquo;sin tax\u0026rsquo;. Such taxes are often charged on commodities deemed harmful to society, such as tobacco, alcohol, gambling and pornography [12]. Ireland introduced its SSDT in May 2018 [13]. This date was delayed somewhat \u0026nbsp;to coincide with a similar tax being introduced in the UK. This was done to ameliorate the concerns of retailers in the border region of Ireland who felt this tax might help drive away potential customers north of the border and into Northern Ireland [14]. The scope of the Irish SSDT was subsequently expanded on 1 January 2019 via the Finance Act 2018 to include certain plant protein drinks and drinks containing milk fats [15].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The SSDT in Ireland is relatively modest. It is a tiered excise duty comprised of three rates based on sugar content [16]. Soft drinks under 5g of sugar per 100ml incur no tax, while those with 5g to under 8g of sugar per 100ml incur a tax which equates to 5 cents on a standard 330ml can. The higher rate of SSDT is for those soft drinks over 8g of sugar or more per 100ml and incurs a SSDT of 8 cents per 330ml can [15].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The WHO recently noted that some form of SSDT, or sugar-sweetened beverage tax (SSBT) as they term it, has been introduced into 108 countries to date [17]. The WHO, and allied groups, are strongly supportive of SSBTs as a cost effective fiscal lever in efforts to control rising levels of obesity globally [18,19]. The WHO state that SSDTs \u0026lsquo;\u003cem\u003erepresent a win-win-win strategy: a win for public health (and averted healthcare costs), a win for government revenue, and a win for health equity\u0026rsquo;\u0026nbsp;\u003c/em\u003e[17].\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;From a demand perspective an SSBT may work through three mechanisms. In the first instance an SSBT should make sugar sweetened drinks more expensive, and therefore less appealing and accessible. The second mechanism through which a SSBT may act as a disincentive is informed by rational choice theory and suggests that causing the sugar sweetened drink to be more expensive than its no or low sugar alternative will cause people to opt for the cheaper alternative. Additionally, the higher price may act as a signal to a potential purchaser and remind them of the negatives associated with such a purchase.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;All three of these mechanisms are reliant on two key factors. In the first instance most or all of the SSDT must be passed on to the customer to pay, rather than this cost being absorbed by the manufacturer or retailer [20,21]. Secondly, zero or low sugar options must remain cheaper than higher sugar drinks that are subject to the SSDT. If for example a retailer opts to increase the price of a 330ml can of Full sugar Coke by 8 cents, as per the SSDT, while at the same time also increasing the price of an equivalent can of Diet Coke by the same amount, then two of these potential dissuasive mechanisms cannot function.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Industry is routinely fiercely resistant to the introduction of health oriented taxes, such as SSDTs [22-24], and Ireland is no exception [25-27]. However, a clear understanding of standard industry tactics to delay, deny, and deflect the need for regulation and associated evidence can help overcome such opposition [28, 22]. The SSDT in Ireland has been criticised for a lack of hypothecation, that is a lack of ring fencing of monies raised to support and improve services, in this case such as dental, diabetes, cardiovascular or obesity related health care [29,30]. The Irish SSDT May also be critiqued for its modest tariff, and lack of being annually adjusted for inflation [17,18]. Branded soft drinks sold individually routinely retail for between \u0026euro;1.50 and \u0026euro;2.75 for 330ml - 500ml cans and bottles in supermarkets, garages and corner shops. Prices in hospitality venues may be up to 50% or more dearer. As such an SSDT component in the price structure of five to eight cents per 330ml can is minimal. Finally, the Irish SSDT has been critiqued for the reality that despite the accolades the Irish Government received for this pro-Public Health measure, it was only introduced in Ireland after European Union restructuring effectively closed down the Irish sugar beet industry, thus eradicating potential opposition from Ireland\u0026rsquo;s powerful farming lobby [31].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;There is substantial evidence to suggest that one of the major outcomes of the introduction of an SSDT rather than its direct impact on consumers may instead be seen among manufacturers. Reformulation of the ingredients of many soft drinks by industry to avoid SSDT thresholds is clearly evident in Ireland and elsewhere [32-44]. Many countries, such as Ireland have introduced policies and targets to promote healthier reformulation of food and drink products [32,33].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Globally research has noted considerable variation in the price pass-through rate of SSDTs. Evidence suggests the rates can vary from 40% to well over 100% [45-57]. A recent examination of the SSDT pass-through rate in retail (off-site) premises in Ireland noted that the tax was routinely not passed on to the consumer [30]. In this examination of 14 chain supermarkets it was noted that in instances where the same leading brand and size of container was available in both sugar free and full sugar versions, in approximately 60% of cases the retail price was the same. Even when a price differential was applied it often fell short of the SSDT addition [30]. However, one limitation of this research was its sole focus on the retail, or off-trade, sector to the exclusion of the hospitality sector. This research aimed to remedy this lacuna by examining SSDT pass-through rates in the hospitality (on-site) sector.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA convenience sample of 100 hospitality venues were surveyed in two Irish provincial cities. The NielsenIQ report for 2022 identified the top leading carbonated soft drink in Ireland as Coca-Cola followed by 7UP, Pepsi, Club, and Fanta [58]. Of these top five leading brands only Coca-Cola remains above the SSDT threshold of 5g of sugar per 100ml. Coca-Cola contains 10.6g per 100ml. This survey examined the costs of Coca-Cola versus diet versions by the same manufacturer (i.e. Diet Coke or Coke Zero). When originally conceived Club soft drinks were also above the SSDT threshold. However, even though Club drinks had been reformulated to below the SSDT threshold by the time data collection started they were still included to explore the issue of availability. It is important to remember that although reformulation of a drink such as Club Orange is important, every 330ml can of the new recipe still contains over 3 teaspoons of sugar (Club now contains 4.5g of sugar per 100ml).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;This study was approved by the Institutional Research Ethics Committee at the Technological University of the Shannon- Midwest. Data was collated in MS Excel and analysed using SPSS.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eData was collected from 99 establishments, with one Caf\u0026eacute; declining to participate. 90.9% (90) of venues sold both full sugar Coca-Cola and diet equivalents (see Table One).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable One: Availability of the Target Soft Drinks in Hospitality Venues Sampled\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVenue Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipating Venues\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSell Full Sugar Coca-Cola\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSell Sugar Free Versions of Coca-Cola\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSell Full Sugar Club Orange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSell Sugar Free Version of Club Orange\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFast Food\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.2% (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.3% (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.3% (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.3% (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.3% (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCaf\u0026eacute;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.3% (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.7% (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76.7% (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.7% (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0% (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRestaurant\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.2% (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100% (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100% (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.0% (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0% (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePub/Bar\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.2% (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100% (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100% (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.7 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.3% (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0% (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100% (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100% (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0% (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0% (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTOTAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100% (99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.9% (90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.9% (90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.1% (12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.0% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn contrast just 12.1% (12) establishments sold Club Orange, with just 2.0% (2) selling the no sugar equivalent (Club Orange Zero).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable Two: Prices of the Target Soft Drinks in Hospitality Venues Sampled\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVenue Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull Sugar Coca-Cola \u0026amp; Sugar Free Versions the Same Price\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFull Sugar Coca-Cola More Expensive Than Sugar Free Versions\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFast Food\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.4% (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.6% (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCaf\u0026eacute;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91.3% (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.7% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRestaurant\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.2% (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.8% (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePub/Bar\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100% (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0% (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100% (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0% (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTOTAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.6% (77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.4% (13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn 85.6% of cases the sugar and sugar free versions of Coca-Cola were for sale at the same price. No venues charged more for the diet version of Coca-Cola. Of the 13 premises which did charge more for the full sugar version the rate charged was less than the tax rate in one venue, and higher in the other 12. Among the 13 venues which did charge a higher price the average higher price was 21.1 cents per 330ml (SD\u0026thinsp;=\u0026thinsp;.15), ranging from 7 cents to 53 cents. Further analysis by hospitality venue type was not possible given the numbers involved.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results clearly demonstrate that in almost nine out of ten (87.9%) venues the full sugar and sugar free versions of Ireland\u0026rsquo;s leading soft drink, Coca-Cola, were for sale at the same price. Such equal pricing removes both the rational choice mechanism through which a potential buyer might opt for the cheaper sugar-free instead of the more expensive full sugar version, as well as the warning signalling impact of the differential pricing (See Figure One for an extremely rare example of both differential pricing and explicit signalling).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure One: Example of Explicit Mention of the SSDT on a\u003c/b\u003e \u003cb\u003eNando\u0026rsquo;s\u003c/b\u003e \u003cb\u003eMenu\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIt is important to acknowledge the complexity of the obesity issue and the diverse range of approaches that are required to respond to this issue. However, obesity remains a major threat to the health and wellbeing of Ireland\u0026rsquo;s population via a range of non-communicable diseases (NCDs) and the SSDT remains a proven fiscal level to address this threat [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Sugar-sweetened drinks are a threat to population health, with little to recommend them given their \u0026lsquo;empty calories\u0026rsquo; [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Given the lack of price differentiation evident in Ireland based on this on-site (hospitality venue) study and the prior off-site (retail) study [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] it is strongly recommended that the current SSDT is increased significantly. The mark-up on soft drinks in the Irish hospitality sector has long been acknowledged as excessive and effectively negates the SSDT [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn their response to the initial consultation process on the SSDT in Ireland the Royal College of Physicians of Ireland [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] specifically noted that only taxes achieving a 10\u0026ndash;20% price increase would reduce consumption of sugar sweetened drinks [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. The WHO have recently stated that \u0026lsquo;\u003cem\u003eWhile no empirical best practice for effective SSB tax levels have been set, excise taxes need to be sufficiently high to impact affordability\u003c/em\u003e\u0026rsquo; [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Given the minimal SSDT introduced in Ireland initially, and both high levels of inflation since it was introduced [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] and the lack of annual index-linked increases in the tax, as well as clear evidence of minimal SSDT pass-through or price differentiation in either retail [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] or hospitality settings, an increase of the SSDT to 50 cents per 330ml can is suggested for the higher tier (8g or more sugar 100ml). The rate for the lower SSDT tier of 5g-7.99g of sugar per 100ml should be 30 cents per standard 330ml can. This SSDT should be inflation linked and adjusted annually. Recent research has noted that demand for sugar-sweetened beverages is sensitive to tax related price increases [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEvidence also suggests that adding the phrase \u0026lsquo;includes sugary drink tax\u0026rsquo; onto price tags can act as a disincentive to purchasing [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. It is there suggested that additional legislation is introduced in Ireland to require cans, bottles, menus, and price lists to include a phrase specifically mentioning that the price includes the SSDT. This will both act as a signal to consumers, similar to traffic light style warnings on food [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e], and help prevent retailers from simply increasing the prices of both sugar-sweetened and no/low sugar drinks, as the purchasing public will be constantly reminded of the SSDT factor in the pricing structure. Other countries have increased SSDTs dramatically over short time periods and have seen positive results [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHaving examined demand led factors, supply side considerations should also be taken into account [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. In terms of the availability of sugar free options, it is important to note that although every establishment surveyed which sold full-sugar Coca-Cola also sold diet versions, this was not the same for Club Orange. Although the reformulated lower sugar version was sold in just 12.1% of establishments, only 2% sold the sugar free version. This under-availability of the sugar free versions of popular brands appears to be an under-researched topic in the literature. Potential customers with a favourite low or zero sugar soft drink that is not available in their chosen brand may opt for the sugared version of that product, rather than an alternative sugar free brand. Further research is required on the availability of sugar free versions of popular soft drinks.\u003c/p\u003e \u003cp\u003eReformulation has clearly been an important factor in reducing the impact of sugar Irish consumers may typically encounter from soft drinks. In recent years Pepsi re-formulated its ingredients to fall below the SSDT threshold of 5g of sugar per 100ml [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Many manufacturers have worked to avoid the SSDT by developing recipes below threshold level. For example the sugar version of Pepsi now contains 4.55g of sugar per 100ml, while equivalent Fanta, 7Up and Sprite brands each contain 4.5g, 4.7g and 4.4g respectively. Given the SSDT was only announced by Government in 2016 and introduced in 2018, manufacturers have achieved this transition in a relatively short time frame [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This begs the question of whether a revised lower SSDT sugar threshold rate is appropriate? The 5g of sugar per 100ml SSDT threshold is by no means universal [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is important to note that differing health targets internationally may have important implications for health [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]. For example South Africa and Mauritius both have SSDT thresholds of 4g of sugar per 100ml [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. It is suggested that a revised SSDT threshold of 4g of sugar per 100ml be introduced in 2030, with the threshold reducing to 3g in 2035. The standard 330ml can appears to be increasingly replaced in retail premises by larger 500ml cans and bottles. The impact of reformulation may be minimised if those opting to drink sugared soft drinks are consuming cans and bottles that contain approximately 50 percent more volume.\u003c/p\u003e \u003cp\u003eIn order to maintain public support for this measure the Irish Government also needs to hypothecate SSDT raised to support relevant health and dental services. Although the Irish Government has explicitly argued against this approach [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e], it is a crucial to order to build and maintain public confidence [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the SSDT is important it only targets soft drinks. It is strongly suggested that a similar tax is introduced for confectionary and food products [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. A broadening of the sugar tax should also target alcohol. Although in most cases sugar is used up in the fermentation process, in certain drinks, such as coffee liqueurs, a substantial volume of sugar is added back into product after the yeast has died. Finally, given a history of poor quality evidence in this field, it is essential that any changes to the SSDT and associated taxes is accompanied by clear baseline evaluations and a structured and funded review process [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e].\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFunding Declaration/ Declaration of interest\u003c/strong\u003e: This study was conducted as part of a review of the impact of the implementation of the SSDT in Ireland. This review was funded by Ireland\u0026rsquo;s Department of Health. However, the opinions offered here are those of the authors and not the official position of either the Department of Health or the Irish Government.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics:\u003c/strong\u003e This study was approved by the Research Ethics Committee of the Technological University of the Shannon: Mid-West.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthors Contributions\u003c/strong\u003e: FH and JMS conceived and designed the study. FH and MD designed the data collection instrument. MD and DH collected and input the data. FH and JA analysed the data. FH led the writing of the paper. All authors contributed to review \u0026amp; revisions of the paper. All authors approve the final version of the paper.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO. Who European Regional Obesity Report 2022. 2022. https://apps. who.int/iris/bitstream/handle/10665/353747/9789289057738-e ng.pdf \u003c/li\u003e\n\u003cli\u003eForesight. Tackling obesities: future choices\u0026mdash;project report. The Stationery Office, London; 2007. http://www.foresight.gov.uk/Obesity/obesity_final/Index.html\u003c/li\u003e\n\u003cli\u003eDepartment of Health, Ipsos MRBI (2019) Healthy Ireland Survey Report 2019. 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Fi Global Insights; 2022. https://insights.figlobal.com/reduction-reformulation/soft-drink-industry-beats-eu-sugar-reduction-targets-challenges-remain \u003c/li\u003e\n\u003cli\u003ePEPSICO UK (2023) PEPSICO UK \u0026amp; Ireland Reformulates Pepsi, Reducing Sugar by 57%. https://www.pepsico.co.uk/news/stories/reformulates-pepsi-reducing-sugar-by-57\u003c/li\u003e\n\u003cli\u003ePublic Health England. Sugar Reduction: Report on Progress between 2015 and 2018. 2019. https://www.gov.uk/government/publications/sugar-reduction-progress-between-2015-and-2018 \u003c/li\u003e\n\u003cli\u003eScarborough P, Adhikari V, Harrington RA et al. Impact of the announcement and implementation of the UK soft drinks industry levy on sugar content, price, product size and number of available soft drinks in the UK, 2015-19: a controlled interrupted time series analysis. PLoS Med. 2020;17(2):e1003025.\u003c/li\u003e\n\u003cli\u003eStacey N, Mudara C, Ng SW et al. Sugar-based beverage taxes and beverage prices: evidence from South Africa\u0026rsquo;s health promotion levy. Soc Sci Med. 2019;238:112465.\u003c/li\u003e\n\u003cli\u003eHashem KM, He FJ, MacGregor GA. Labelling changes in response to a tax on sugar-sweetened beverages, United Kingdom of Great Britain and Northern Ireland. Bull World Health Organ. 2019;97(12):818\u0026ndash;27 https://doi.org/10.2471/BLT.19.234542\u003c/li\u003e\n\u003cli\u003eChu B, Irigaray CP, Hillier SE et al. The sugar content of children\u0026rsquo;s and lunchbox beverages sold in the UK before and after the soft drink industry levy. Eur J Clin Nutr 2020;74(4):598\u0026ndash;603 https://doi.org/10.1038/s41430-019-0489-7\u003c/li\u003e\n\u003cli\u003eAndreyeva T, Marple K, Marinello S et al. Outcomes following taxation of sugar-sweetened beverages: a systematic review and meta-analysis. JAMA Netw Open 2022;5(6):e2215276.\u003c/li\u003e\n\u003cli\u003eAguilar A, Gutierrez E, Seira E. The effectiveness of sin food taxes. Instituto Tecnol\u0026oacute;gico Aut\u0026oacute;nomo de M\u0026eacute;xico (ITAM) Working Paper. ITAM; 2019. https://ssrn.com/abstract=3510243 or http://dx.doi.org/10.2139/ssrn.3510243\u003c/li\u003e\n\u003cli\u003eAlsukait R, Wilde P, Bleich SN, Singh G, Folta SC. Evaluating Saudi Arabia\u0026rsquo;s 50% carbonated drink excise tax: Changes in prices and volume sales. Economics \u0026amp; Human Biology. 2020;38:100868. DOI: 10.1016/j.ehb.2020.100868\u003c/li\u003e\n\u003cli\u003eBerardi N, Sevestre P, Tepaut M, Vigneron A. The impact of a \u0026ldquo;soda tax\u0026rdquo; on prices: evidence from French micro data. Applied Economics. 2016;48(41):3976-3994.\u003c/li\u003e\n\u003cli\u003eBollinger B, Sexton SE. Local excise taxes, sticky prices. And spillovers: evidence from Berkeley\u0026rsquo;s soda tax. Quantitative Marketing and Economics. 2018;21(2):1-51. DOI: 10.1007/s11129-023-09263-y\u003c/li\u003e\n\u003cli\u003eCapacci S, Allais O, Bonnet C, Mazzocchi M. The impact of the French soda tax on prices and purchases. An Ex Post Evaluation. PLoS One. 2019;14(10):e0223196. https://doi.org/10.1371/journal.pone.0223196\u003c/li\u003e\n\u003cli\u003eCawley J, Frisvold D. The Incidence of Taxes on Sugar-Sweetened Beverages: The Case of Berkeley, California. NBER Working Paper Series No. 21465. NBER; 2015. http://www.nber.org/papers/w21465\u003c/li\u003e\n\u003cli\u003eEtil\u0026eacute; F, Lecocq S, Boizot-Szantai C. The Incidence of Soft-Drink Taxes on Consumer Prices and Welfare: Evidence from the French \u0026ldquo;Soda Tax\u0026rdquo;. Paris: Paris School of Economics. Working Paper No. 2018-24, HAL Id: halshs-01808198; 2018. https://shs.hal.science/halshs-01808198\u003c/li\u003e\n\u003cli\u003eFalbe J, Rojas N, Grummon AH, Madsen KA. Higher retail prices of sugar-sweetened beverages 3 months after implementation of an excise tax in Berkeley, California. American Journal of Public Health. 2015;105(11):2194-2201.\u003c/li\u003e\n\u003cli\u003eGrogger J. Soda taxes and the prices of sodas and other drinks: Evidence from Mexico. American Journal of Agricultural Economics. 2017;99(2):481-498.\u003c/li\u003e\n\u003cli\u003eRojas C, Wag EY. Do taxes for soda and sugary drinks work? Scanner data evidence from Berkeley and Washington. Economic Inquiry. 2017;59(17). DOI: 10.1111/ecin.12957\u003c/li\u003e\n\u003cli\u003eSeiler S, Tuchman A, Yao S. The impact of soda taxes: Pass-through, tax avoidance, and nutritional effects. Journal of Marketing Research. 2021;58(1):22-49. Hrrps://doi.org/10.2139/ssrn.3302335\u003c/li\u003e\n\u003cli\u003eZhong Y, Auchincloss A, Lee B, Kanter G. The short-term impacts of the Philadelphia beverage tax on beverage consumption. American Journal of Preventive Medicine. 2018;55(1):26-34. doi: 10.1016/j.amepre.2018.02.017\u003c/li\u003e\n\u003cli\u003eAhern D. Ireland\u0026rsquo;s Top 5 Soft Drinks Keep Their Fizz On Robust Demand. Checkout.Checjout.ie; 2023. https://www.checkout.ie/retail/irelands-top-5-carbonated-soft-drinks-revealed-198560#:~:text=Coca%2DCola%20topped%20Checkout\u0026apos;s%20Top,breaking%2018%20years%20in%20succession.\u003c/li\u003e\n\u003cli\u003eWhiting SJ, Healey A, Psiuk S, et al. Relationship between carbonated and other low nutrient dense beverages and bone mineral content of adolescents. Nutr Res. 2001;21:1107\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003eColes A. Markup on bottles of Coke in pubs and restaurants slammed as \u0026apos;extortionate\u0026apos;. The Irish Mirror, 13/03/2017. https://www.irishmirror.ie/news/irish-news/markup-bottles-coke-pubs-restaurants-10012788\u003c/li\u003e\n\u003cli\u003eRoyal College of Physicians of Ireland. Sugar Sweetened Drinks Tax Response to Department of Finance Public Consultation. Dublin: RCPI; 2017.\u003c/li\u003e\n\u003cli\u003eMytton OT, Clarke D, Rayner M. Taxing unhealthy food and drinks to improve health. British Medical Journal. 2012;344:e2931.\u003c/li\u003e\n\u003cli\u003eNg SW, Ni Mhurchu C, Jebb SA, Popkin BM. Patterns and trends of beverage consumption among children and adults in Great Britain, 1986-2009. British Journal of Nutrition. 2012;108(3):536-551.\u003c/li\u003e\n\u003cli\u003eCentral Statistics Office. Consumer Price Index. https://www.cso.ie/en/statistics/prices/consumerpriceindex/\u003c/li\u003e\n\u003cli\u003eAndreyeva T, Marple K, Marinello S, Moore TE, Powell LM. Outcomes Following Taxation of Sugar-Sweetened Beverages: A Systematic Review and Meta-analysis. JAMA Netw Open. 2022;5(6):e2215276. doi: 10.1001/jamanetworkopen.2022.15276. \u003c/li\u003e\n\u003cli\u003eDonnelly GE, Guge PM, Howell RT, John LK. A Salient Sugar Tax Decreases Sugary-Drink Buying. Psychological Science. 2021;32(11):1830-1841. \u003c/li\u003e\n\u003cli\u003eMagnusson RS. Obesity prevention and personal responsibility: the case of front-of-pack food labelling in Australia. BMC Public Health 2010;10:662\u003c/li\u003e\n\u003cli\u003eTeng A, Puloka V, Gen\u0026ccedil; M, Filimoehala O, Latu C, Lolomana\u0026apos;ia M, Osornprasop S, Signal L, Wilson N. Sweetened beverage taxes and changes in beverage price, imports and manufacturing: interrupted time series analysis in a middle-income country. Int J Behav Nutr Phys Act. 2020;17(1):90. doi: 10.1186/s12966-020-00980-1.\u003c/li\u003e\n\u003cli\u003eClaudy M, Doyle G, Marriott L et al. Are sugar-sweetened beverage taxes effective? Reviewing the evidence through a marketing systems lens. J Public Policy Mark 2020;40(3):403\u0026ndash;18.\u003c/li\u003e\n\u003cli\u003eHoughton F, Houghton S, O\u0026rsquo;Doherty D, McInerney D, Duncan B. The tobacco endgame: The importance of targets and geography. Canadian Journal of Public Health. 2018;109(5-6):900-901. https://doi.org/10.17269/s41997-018-0150-6\u003c/li\u003e\n\u003cli\u003eMRA (2024) Excise Duty on Sugar Content of Sugar Sweetened Products. Mauritius Revenue Authority. https://www.mra.mu/index.php/customs1/more-topics/excise-tax-on-sugar-content-of-sugar-sweetened-non-alcoholic-beverages\u003c/li\u003e\n\u003cli\u003eKildareStreet (2020) Tax Code. https://www.kildarestreet.com/wrans/?id=2020-07-14a.724\u003c/li\u003e\n\u003cli\u003eJensen JD, Smed S. State-of-the-art for food taxes to promote public health. Proc Nutr Soc. 2018;77(2):100-105. doi: 10.1017/S0029665117004050. \u003c/li\u003e\n\u003cli\u003eTemple NJ. A Proposed Strategy against Obesity: How Government Policy Can Counter the Obesogenic Environment. Nutrients. 2023;15(13):2910. doi: 10.3390/nu15132910. \u003c/li\u003e\n\u003cli\u003ePfinder M, Heise TL, Hilton Boon M, Pega F, Fenton C, Griebler U, Gartlehner G, Sommer I, Katikireddi SV, Lhachimi SK. Taxation of unprocessed sugar or sugar-added foods for reducing their consumption and preventing obesity or other adverse health outcomes. Cochrane Database Syst Rev. 2020;4(4):CD012333. doi: 10.1002/14651858.CD012333.pub2. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"SSDT, SSBT, Sugar-Sweetened Beverage Tax, Sugar Tax, Ireland, Pass-Through Rate","lastPublishedDoi":"10.21203/rs.3.rs-4246765/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4246765/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe WHO supports the use of Sugar-Sweetened Drinks Taxes (SSDTs) as a fiscal lever to help reduce sugar consumption and tackle obesity. Obesity is associated with a range of adverse health outcomes. In response to increasing levels of obesity in Ireland a SSDT was introduced in 2018. Previous research in Ireland has noted that the pass-through rate of the SSDT in retail (off-site consumption) settings was poor. However, to date no research has examined the SSDT pass-through rate in hospitality (on-site consumption) venues in Ireland.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis research examines the SSDT pass through rate on full-sugar versus diet versions of Coca-Cola in a convenience sample of 100 hospitality venues in two provincial Irish cities.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn 88% of cases the same price was charged for both full-sugar and sugar free drinks.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIt is generally assumed that the SSDT would result in persistent price differences between soft drink prices based on sugar content. However, this is barely evident in the hospitality sector in Ireland. A number of recommendations are suggested, including both increasing the SSDT, and increasing it annually in line with inflation.\u003c/p\u003e","manuscriptTitle":"Exploring the Sugar Sweetened Drinks Tax (Sugar Tax) Pass Through Rate in the Irish Hospitality Sector","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-24 17:42:27","doi":"10.21203/rs.3.rs-4246765/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-17T05:25:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-16T02:41:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-15T11:20:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"76461834179682894421310061360094643690","date":"2024-05-15T08:58:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"14090932954805505297391090636623949309","date":"2024-04-30T08:35:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-30T07:57:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-04-17T05:22:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-16T22:31:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-16T22:31:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-04-10T10:29:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c16a4b61-1261-4b53-82ce-f89423767b0c","owner":[],"postedDate":"April 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-02T16:03:47+00:00","versionOfRecord":{"articleIdentity":"rs-4246765","link":"https://doi.org/10.1186/s12889-024-19891-y","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2024-08-30 15:57:54","publishedOnDateReadable":"August 30th, 2024"},"versionCreatedAt":"2024-04-24 17:42:27","video":"","vorDoi":"10.1186/s12889-024-19891-y","vorDoiUrl":"https://doi.org/10.1186/s12889-024-19891-y","workflowStages":[]},"version":"v1","identity":"rs-4246765","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4246765","identity":"rs-4246765","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}