5

Innovations and Challenges of Emerging Strategies

The fourth session of the workshop sought to explore novel policies, programs, and approaches to limiting sugar-sweetened beverages that have the potential to be implemented in other locations and scaled up. Henrietta Sandoval-Soland, food access director for the Community Outreach and Patient Empowerment (COPE) Program, described her organization’s participation in the Notah Begay III (NB3) Water First! Learning Community and presented preliminary findings from a needs assessment conducted in the Navajo Nation. Marlene Schwartz, director of the Rudd Center for Food Policy and Obesity, then provided an overview of the policy, outreach, and media approach taken in the Howard County Unsweetened campaign. Following her presentation, she and Sandoval-Soland took part in a facilitated discussion with the audience, moderated by Tracy Fox, president of Food, Nutrition and Policy Consultants, LLC.

Next, a panel of speakers discussed the feasibility, challenges, and effects of local ordinances and regulations related to sugar-sweetened beverages. Each panelist gave a brief presentation to open the panel. Margo Wootan, director of nutrition policy at the Center for Science in the Public Interest, described the advocacy and policy approaches that have been used to make healthier items the default with restaurant children’s meals. Lynn Silver, senior advisor at the Public Health Institute, discussed sugar-sweetened beverage excise taxes and presented key findings from an analysis of Berkeley, California. She also discussed the use of warning labels. Michelle Mello, professor of law at Stanford Law School and professor of health research and policy at Stanford University School of Medicine, highlighted select ordinances that have been subject to litigation. Following their pre-

pared remarks, Wootan, Silver, and Mello took part in a panel discussion, moderated by Anna Maria Siega-Riz, which toward the end of the session expanded to a facilitated discussion with the audience.

COPE WATER FIRST INITIATIVE WITH THE NOTAH BEGAY III FOUNDATION¹

The Navajo Nation is the largest tribe in the United States, with more than 170,000 members living in areas of Arizona, New Mexico, and Utah. Its residents, noted Sandoval-Soland, are disproportionately affected by poverty and unemployment as compared to national averages. To help create health equity and improve the well-being of Navajo Nation residents, the COPE Program, a nonprofit organization, focuses on issues related to access to healthy foods, chronic diseases (e.g., diabetes, cancer care), and educational outreach.

The COPE Program is currently undertaking a project as part of the NB3 Foundation’s Water First! Learning Community. The Water First! Learning Community “seeks ways to increase consumption of safe drinking water or promote breastfeeding, as well as create healthy habits for children in their earliest years of life,” Sandoval-Soland explained. The nine Water First! awardees will work during a grant period of 2.5 years to assess these issues to inform policy and system changes in their respective communities. Although each of the awardees has a different focus area,² opportunities exist throughout the award period for the grantees to convene and discuss progress, share ideas, and discuss strategies. One gathering hosted by the NB3 Foundation was the February 2017 Healthy Beverage Summit. The summit brought together not only the awardees, but also community members, organizations, and agencies to discuss reducing sugar-sweetened beverage consumption among Native American children in New Mexico and Arizona (Baca, 2017).

The Water First! Learning Community is aligned with the 2014 Dine Nation Act, which places a 2 percent tax on unhealthy foods in the Navajo

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¹ This section summarizes information presented by Henrietta Sandoval-Soland.

² Sandoval-Soland briefly described the focus areas of the eight other awardees, as follows: (1) Five Sandoval Indian Pueblos are working with the Special Supplemental Nutrition Program for Women, Infants, and Children to promote breastfeeding; (2) Jemez Pueblo is focusing on policies and practices; (3) Mescalero Apache are focusing on youth-directed health education and activities; (4) Ramah Navajo School Board is focusing on policies and curriculum; (5) Santa Domingo Pueblo is using a community-based approach to promote drinking water and breastfeeding; (6) STAR School is focusing on clean water access and school-based education programs; (7) Tamaya Wellness Center is using education, marketing, and policy work to promote community attitudes and social norms; and (8) Zuni Pueblo Youth Enrichment Program is focused on hydration.

Nation, including sugar-sweetened beverages, Sandoval-Soland explained. The revenue from the tax is being invested back into the community to help support health and wellness projects such as vegetable gardens, greenhouses, farmer’s markets, clean water, exercise equipment, and health classes, she stated.

Sandoval-Soland next discussed the design and progress of the COPE Program’s Water First! project. She explained that the project’s mission is to “increase access to safe drinking water among families with preschool children.” Between October 2016 and June 2017, COPE conducted a needs assessment within the Navajo Nation. From July 2017 through September 2018, COPE will move on to what Sandoval-Soland described as the “implementation phase.”

As part of their work during the first phase of the project, the COPE Program made a video that captures insight from a community elder regarding water and food (COPE Program, 2017). Sandoval-Soland emphasized the importance of this perspective, stating “We want to make sure that we are listening to the traditional knowledge of our elders.”

To guide its needs assessment, the COPE Program developed a strategy map that contains four action areas (see Figure 5-1). Information was then

gathered through a variety of ways, including surveys, interviews, focus groups, and community meetings. Sandoval-Soland noted that a central theme that emerged was that water is sacred and has importance beyond consumption, including being a part of ceremonial practices.

Sandoval-Soland shared some preliminary findings from the COPE Program’s needs assessment, which consisted of 59 surveys collected across five Navajo Nation chapters. She highlighted a number of comments survey respondents provided regarding the influence of Navajo tradition involving food and beverages. Some of the respondents indicated that Navajo tradition affects how they regard or purchase foods and beverages (e.g., “It is a huge influence.”) or that they would like to move more toward Navajo tradition (e.g., “I personally was not raised traditionally, but I’m in the process of learning traditional teachings.”). Others indicated less of an influence (e.g., “I don’t consciously think of my cultural values when buying and purchasing food or beverages; I usually buy what I know my family will consume”). Elements of tradition and belief emerged in feedback from respondents on the relationship between health and water (e.g., “Water is so important to Mother Earth.” “I was told that water was always considered life.” “Water is my clan.”). Respondent comments revealed that family and kinship also influence food and beverage selections (e.g., “When food is prepared at home by the hands of my mother/sister/family members I know that it was made with love and reassurance. I feel safe eating it.”).

The needs assessment provided insight into issues around drinking tap water, which included taste, perceived safety, and the color of the water. Sandoval-Soland explained that the findings from the needs assessment will inform the next phase of the project, helping to ensure that what is developed is traditionally and culturally relevant.

To conclude her presentation, Sandoval-Soland touched on the concept of incentives to promote change. Drawing on another COPE Program initiative as an example, she explained that her organization runs a food voucher program that promotes affordable access to fruits and vegetables and healthy eating in underserved communities. Sandoval-Soland thought a similar concept could be applied to improving water access.

HOWARD COUNTY UNSWEETENED: POLICY + OUTREACH + MEDIA = CHANGE³

To provide context for the Howard County Unsweetened campaign, Schwartz described the demographics of Howard County, Maryland. The county has a population of approximately 317,000 residents. The majority identify as non-Hispanic white (54 percent), with 18 percent of

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³ This section summarizes information presented by Marlene Schwartz.

residents identifying as black/African American, 18 percent identifying as non-Hispanic Asian, 7 percent identifying as Hispanic, and 4 percent identifying as other. More than one-quarter of county residents hold a professional degree. In 2015, Howard County had the fourth highest median household income in the United States. The proportion of students receiving free and reduced price lunch, which ranges from 4 to 40 percent in Howard County schools, suggests variability in income levels, noted Schwartz. She also added that the prevalence of overweight and obesity in the county (25 percent) is slightly below that of the state of Maryland (27 percent).

Howard County Unsweetened is a multidimensional, community-based initiative that seeks to improve the county’s beverage landscape and reduce the consumption of sugar-sweetened beverages in particular. The campaign was led by the Horizon Foundation, which has a mission to improve the health of the county. “This was very much a community campaign that started in that community,” noted Schwartz. Showing an image developed by the Horizon Foundation (see Figure 5-2), Schwartz called Howard County Unsweetened the “social ecological model in practice.” Employing a multiyear, multicomponent strategy allowed the campaign to address different levels in various ways. During her presentation, Schwartz highlighted a handful of the project’s components.

Schwartz described two of the individual- and family-level interventions of the campaign. She began with the Better Beverage Finder, which is a website that offers users alternatives to sugar-sweetened beverages as well as maps of where such products could be purchased in Howard County (Horizon Foundation, 2014). Those involved in conceptualizing the website thought it was necessary to not only focus on beverages to limit but also provide options for what could be consumed instead, noted Schwartz. Another component was a media campaign that included advertisements on local cable television, social and digital media buys, and direct mailings to county households. The advertisements primarily targeted mothers (e.g., “Want to make mornings easier? Try them unsweetened.”) and specifically identified the beverages (e.g., “Sugary sports drinks can put children at risk.”).

Howard County Unsweetened has several broader organizational- and community-level components. The Healthy Howard program, for example, was a project in which existing policies and practices within child care centers were evaluated. Providers were then helped to set goals to improve beverages, screen time, and breastfeeding support. Schwartz also described the update to the Howard County Public School System’s wellness policy, a process that included an evaluation of the established and revised policies, along with public feedback. The Better Choices Coalition component of the campaign has community organizations, faith groups, and businesses agree to improve the vending and food options served at meetings and to educate visitors, members, and clients of the negative health effects of sugar-sweetened beverages. The Maryland chapter of the American Academy of Pediatrics formed a learning collaborative and developed a pamphlet physicians could use to educate their patients about sugar-sweetened beverages.

Schwartz explained that the changes that occurred in Howard County existed in the context of changes that were taking place within the state. The Sugar Free Kids Maryland Coalition, which has more than 250 members, generated media attention during this time as it advocated for state-level changes. One policy change that occurred was the Maryland Healthy Eating and Physical Activity in Childcare Act, which passed in 2014, and, among other things, limited sugar-sweetened beverages in child care settings.

Evaluation has played an important role in the Howard County Unsweetened campaign, shared Schwartz. She explained that initially, the messaging focused on “soda” and “sugary drinks.” Evaluation data on beverage consumption by children led to the expansion of the messaging to include “fruit drinks” and “sports drinks,” as these are more commonly consumed by children. She said that there is also messaging about limiting portion sizes of 100 percent juice, but to a lesser extent. Schwartz explained that the evaluation plan was developed before the campaign was implemented and consists of the following four components: assessing

retail sales, conducting an annual survey of sixth grade students, coding child care and school policies, and performing health professional surveys.

In detailing the retail sales portion of the evaluation plan, Schwartz explained that 15 supermarkets in Howard County were matched with 17 supermarkets in a nearby state (“control state”). The stores were matched based on sales of soda, diet soda, sports drinks, fruit drinks, and 100 percent juice at baseline. The evaluation assessed changes in volume sales per product per week in Howard County as compared to changes in the control state. Schwartz reported that between 2012 and 2015, Howard County experienced a 20 percent decrease in volume of sugar-sweetened soda sold, while the sales in the control state remained unchanged. Sales of fruit-flavored beverages and 100 percent juice decreased more in Howard County than in the control state, while sports drinks remained unchanged in both locations. Diet soda sales did not differ between Howard County and the control state but decreased in both locations.

Schwartz also described findings from the annual survey of sixth grade students. She noted that the vast majority of students, approximately 97 percent, reported consuming water every day. “It is really not so much the regular soda as much as the fruit drinks that seem to be the most popular, followed by the sports drinks,” Schwartz commented. Decreases in daily consumption of fruit drinks, flavored milk, sports drinks, flavored water and teas, regular sodas, energy drinks, and 100 percent juice were noted between the 2012 and 2016 surveys. When daily sugar-sweetened beverage consumption was assessed by racial and ethnic groups, some differences emerged. Black and Hispanic students reported higher average daily consumption rates than white and Asian students. Notably, all four groups of students reported lower rates of daily consumption in 2016 compared to 2012; the drops were significant for white, black, and Hispanic students. Despite these declines, black and Hispanic students continue to report higher rates of daily sugar-sweetened beverage consumption. Students were also asked about sugar-sweetened beverage availability in the home. Schwartz noted slight declines in fruit drinks and regular soda availability, but pointed out that these products are still in the majority of households.

To conclude her presentation, Schwartz highlighted key features of Howard County Unsweetened and discussed what she saw as future directions. She thought that one aspect that bolstered the success of the campaign was its origin within the community. She also emphasized the role of having an evaluation plan in place prior to implementation that is then used to guide the intervention. Schwartz acknowledged that while inroads are being made, sugar-sweetened beverages are still prevalent in the county and disparities exist. On the topic of disparities, she mentioned that the messages are beginning to be adapted to different population groups, such as including messages in Spanish.

FACILITATED DISCUSSION WITH THE AUDIENCE

After Schwartz’s presentation, she and Sandoval-Soland took part in a facilitated discussion with the audience, moderated by Fox. Several of the audience questions posed by Fox asked the speakers to provide insight into how to implement an initiative, including considerations related to finding funding and persuading policy makers. Sandoval-Soland responded that community engagement and collaboration with local partners have been important. She said that one approach that has been helpful has been to use local champions to promote the cause and having the Navajo Nation tribal leadership onboard. Schwartz answered that in Howard County, there was the county government, a single school district for the county, and the Horizon Foundation, which had established connections and initiatives that could be leveraged. Schwartz emphasized that a focus on children also helps. “I think that politically, that was an easier sell. There is still quite a bit of work to do, and we see this as using all the tools in the toolbox to move forward,” Schwartz commented. She added that funding was another important element, but thought funding should not be what dissuades a community from trying something. When questioned as to whether the Howard County Unsweetened campaign could be implemented in a less prosperous community, Schwartz countered by stating that children’s health is a concern for any community.

Posing another audience member question, Fox asked the speakers to discuss possible opportunities to reduce children’s sugar-sweetened beverage intake in the home environment. Schwartz stated that retail environments are affecting what people are bringing into their homes and it is for this reason that taxes, which affect people at the point of purchase, are so powerful. Schwartz also said that there are retail-based strategies, such as in-store placement and messaging, that may have influences on home purchases. Sandoval-Soland suggested that home visitation programs may offer opportunities to provide education about nutrition and health, and, specifically, reducing sugar-sweetened beverages.

LOCAL ORDINANCES AND REGULATIONS: FEASIBILITY, CHALLENGES, AND IMPACT

Healthy Defaults in Restaurant Meals for Children⁴

Wootan observed that parents often feel as though they are in control of their children’s food choices, despite children frequently being in non-parental care (e.g., child care settings, school, after-school programs). Even

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⁴ This section summarizes information presented by Margo Wootan.

when parents are with their children, the food environment plays an important role in what foods children desire and are offered, she continued. Characterizing restaurants as “one particular place where children’s diets get undermined,” Wootan noted that approximately one-quarter of calories children consume are from away-from-home foods. When children eat out, they consume more sugar-sweetened beverages, calories, saturated fat, and sugars, and fewer fruits, vegetables, and whole grains as compared to when they eat at home, she explained.

The top food category marketed to children is restaurant food, stated Wootan. She indicated that the primary message children take away from fast-food advertisements is for them to go to the restaurant. The menu at the restaurant is another form of marketing and children’s meals are marketed for young children. By bundling food items together for a reduced price, children’s meals set defaults, which “set people’s expectations for what they should do,” she noted. Evidence suggests that changing the default options in children’s meals to healthier options is highly accepted, and has an effect on the average calories in the children’s meals ordered. She highlighted a finding from a study of Walt Disney World restaurants that found when the healthy beverage was the default in the children’s menu, it was retained 66 percent of the time, despite soda being available for the same price (Peters et al., 2016).

Wootan discussed two approaches to change the defaults in children’s menus: advocacy and public policy. Through partnerships and advocacy, restaurants have been encouraged to improve the dietary quality of their children’s meals. Wootan described the progress toward making children’s meals healthier as “modest.” She shared, however, that through a variety of efforts (e.g., email, letter writing campaigns, Twitter campaigns, shareholders’ actions) sugar-sweetened beverages have been removed from many children’s menus. Approximately 75 percent of leading restaurant chains offered sugar-sweetened beverages on their children’s menu in 2016 as compared to more than 90 percent offering such beverages in 2008, noted Wootan.

Wootan suggested that the slow pace of progress has led some communities and states to improve the nutritional quality of restaurant children’s meals through public policy. The first two policies, passed in Santa Clara County and San Francisco, set nutritional standards for children’s meals that come with a toy. Other policies have been passed in California (Santa Clara County and the cities of Davis, Perris, and Stockton) that change the default beverage in children’s meals to healthier options. The options and standards for default beverages differ across the jurisdictions, but generally include unsweetened water and milk, with some allowing juice. Wootan suggested that the public policies aiming to improve the nutritional quality

of children’s meals have become less controversial and less contested over time.

Concluding her presentation, Wootan acknowledged that improving children’s meals and removing sugar-sweetened beverages will not be a “magic bullet” and will not be the singular solution to the obesity epidemic. She argued, however, that restaurant food is heavily marketed and is a significant source of calories; making improvements to children’s meals is a way to change social norms for children’s food.

Taxation and Warning Labels on Sugar-Sweetened Beverages⁵

Silver began her remarks by noting that various approaches have been attempted by localities in the United States to limit sugar-sweetened beverages, including fiscal measures (e.g., taxation, Supplemental Nutrition Assistance Program restrictions), place-based regulations (e.g., child care, schools), product modifications (e.g., New York City portion caps, children’s meal ordinances), retail environment changes, and marketing restrictions. In doing so, she highlighted that sugar-sweetened beverage excise taxes and warning labels are two strategies that exist within a broader context of strategies.

A sugar-sweetened beverage excise tax can influence health outcomes through two paths, Silver explained. First, the taxes will increase the price of the products, leading to decreased consumption and perhaps reformulation, which will reduce the risk of obesity and chronic disease and improve health. The second modality is through the revenue generated, which can be used for social investment and change, ultimately improving health and community well-being, Silver added.

In the past decade, approximately 60 sugar-sweetened beverage tax measures proposed in different localities in the United States have failed (Chriqui et al., 2013; Public Health Advocates, 2017; WCRF, 2015). Since 2014, however, such regulations have passed in nine jurisdictions (see Table 5-1). The existing sugar-sweetened beverage taxes vary in terms of the level of taxation, the products that are subject to the tax, and the uses of the revenue generated from the tax.

Evidence from the first year of a penny-per-ounce excise tax on sugar-sweetened beverages in Berkeley, California, has recently become available. Falbe et al. (2016) reported that sugar-sweetened beverage consumption decreased by 21 percent, and water consumption increased by 63 percent, in Berkeley’s low-income neighborhoods 4 months after implementation of the tax relative to pre-tax consumption. Analyses using scanner data on over 15 million customer visits from two supermarket chains in Berkeley

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⁵ This section summarizes information presented by Lynn Silver.

showed a 9.6 percent decline in sugar-sweetened beverage sales and a 3.5 percent increase in untaxed beverage sales during the first year of taxation (Silver and Ng et al., 2017). Silver noted that while sales of plain water and plain milk increased during the first year of taxation (15.6 and 0.6 percent, respectively), sales of diet soft drinks decreased (9 percent), despite being an untaxed beverage category. Scanner data suggest a 0.67 cent per ounce pass-through of the 1 cent per ounce tax on taxed beverages in Berkeley (Silver and Ng et al., 2017). Silver indicated there may have been a spillover effect in nearby stores not in Berkeley, but stated that neighboring areas now have sugar-sweetened beverage taxes of their own.

Silver reported that there was “no increase in average grocery bill in these chains, nor greater decline in store revenue per transaction in Berkeley.” The tax raised approximately $13 per person per year in Berkeley, which was fully used for health promotion activities. Silver acknowledged that there are no data on the effect of Berkeley’s sugar-sweetened beverage

tax on children, or the effect of the uses of the revenue generated. Since enacting the sugar-sweetened beverage tax, employment across the food sector in Berkeley increased by 7.2 percent and food-sector sales tax revenue increased approximately 15 percent (Silver, 2017). Taken together, the findings suggest that “taxes may be effective in shifting consumers to healthier beverages without undue economic hardship and while raising revenue,” stated Silver.

Silver then described two models for warning labels proposed as local laws: labeling on products and labeling on print advertising. On-product labeling has yet to be passed as legislation, being defeated in California and in New York State. Warning labels on print advertisement, in contrast, would primarily affect point-of-sale ads in stores and on coolers. Warning labels on certain sugar-sweetened beverage print advertising has been passed in San Francisco, but it is currently being challenged in the courts. Two experimental studies suggest that adolescents and adults would be less likely to select sugar-sweetened beverages if the product carried a warning label (Roberto et al., 2016; VanEpps and Roberto, 2016). Silver also cited two international examples of warning labels. Chile uses a black octagon as a front-of-package warning on all foods with sugar over a certain level, and Ecuador uses a traffic light indicating the level of sugar, which has led to product reformulation.

“Building understanding, community support, and political feasibility is the greatest obstacle,” said Silver. She believes that local strategies are likely to act synergistically—“it really is looking at how we pull different measures together.” Silver concluded by saying she felt that the strategies to limit sugar-sweetened beverages are similar to how Tarja Halonen, former president of Finland, described smoke-free air—new ideas go from being ridiculous, to being possible, to being normal.

Legal Challenges to Limiting Sugar-Sweetened Beverages⁶

Mello began her remarks by noting that the local level is a source of innovative approaches to limit sugar-sweetened beverages, and that only a subset of these strategies have been legally challenged. While the plaintiffs vary and are typically individuals, she suggested that a variety of industry, restaurant, retail, and advertising groups and organizations are often behind the lawsuits. These lawsuits seek declaratory relief (a declaration that the law is illegal) and injunctive relief (an order to stop the law from taking effect).

Reflecting on lawsuits that have been brought against sugar-sweetened beverage ordinances, Mello noted that regulating commercial speech is

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⁶ This section summarizes information presented by Michelle Mello.

difficult from a legal perspective, technicalities in local and state laws are being leveraged by those challenging the laws, and legal challenges should be expected but can be overcome with careful planning.

Mello suggested that regulations on sugar-sweetened beverage advertisements are more difficult to legally defend than an outright ban on a product. She explained that what makes it so challenging is judicial protection of commercial speech. To highlight this point, Mello described a lawsuit brought against two San Francisco ordinances. One ordinance restricts the advertisement of sugar-sweetened beverages on certain city properties. The other is an ordinance that would require a warning label on sugar-sweetened beverage advertisements. Those in opposition to the two ordinances view them as restricting commercial speech while also forcing companies to express the government’s viewpoint (compelled speech), said Mello. Decisions on such cases tend to come down to the stringency of the standard of judicial review—that is, how closely the court looks at the justification for the law, she stated. In cases of compelled speech, the government can get a quite favorable standard of review if it can demonstrate that it is merely requiring the disclosure of factual and uncontroversial information. In the case of the San Francisco warning label ordinance, the plaintiffs argue that the information is not uncontroversial because questions exist as to whether the health effects of added versus natural sugars are similar, and because there is disagreement about the specific contribution of sugar-sweetened beverages to the obesity epidemic, said Mello. She noted that it is not presently clear if the courts will require the disclosure to be uncontroversial, or merely accurate and factual. While there is precedent for courts to rule that disclosures need only be accurate and factual, but perhaps still scientifically controversial—as was the case for a recent case in Berkeley regarding cell phone radiation—Mello noted that it remains to be seen what standard of review will be applied in San Francisco.

On her second point, Mello provided three examples of how legal technicalities have been used to challenge various strategies to limit purchasing sugar-sweetened beverages. In the first example, she explained that the New York City portion cap was adopted by the Board of Health and was overturned because the City Charter only granted the City Council the authority to impose such a rule. In the case brought against the Philadelphia sugar-sweetened beverage tax, Mello noted that the objectors invoked a state law that restricts what taxes can be imposed at the local level (the Sterling Act), and argued that it was a duplicative tax. The third example she highlighted, also used in the challenge to the Philadelphia sugar-sweetened beverage tax, was the uniformity clause in the Pennsylvania Constitution, which requires taxes to be applied in a uniform way.

Mello concluded her remarks with the observation that many legal challenges to local public policy can be avoided through careful policy de-

sign decisions informed by legal guidance. She emphasized the importance of cities keeping a record of their decision making and documenting the science behind the policy so an adequate evidentiary basis underlies the legal defense.

PANEL DISCUSSION

Following Mello’s presentation, Siega-Riz moderated a panel discussion that incorporated audience questions toward the end of the session. Siega-Riz opened the discussion by asking what partnerships have not yet been considered. Wootan responded by saying that partnerships are quite common in public health, and perhaps to a fault in certain circumstances. She thought that there are points in the process where not every stakeholder needs to be involved. Based on her experience with partnerships and advocacy, Wootan felt that different approaches can be used at different times to bring partners to the table. Mello noted that there are toolkits and guides to help communities navigate the legal defense of local strategies, and local attorneys could be an important resource for understanding the parameters of state laws. Silver noted that there could be two types of partnerships: public–private partnerships, as have been used for salt reduction, for example, and social partnerships (e.g., mobilized community partners), such as those used to pass sugar-sweetened beverage taxes over industry opposition. Which type of partnership is best to use, she noted, can depend on the context of the situation.

Siega-Riz next posed an audience member question that asked about the difference between warning labels for sugar-sweetened beverages and those on tobacco products. Mello replied that tobacco warning labels arose under the fairness doctrine, in which the Federal Communications Commission permits equal time to be allocated to opposing viewpoints on broadcast media. She stated that the tobacco industry did not fight this doctrine. Mello indicated that there is no analog to this doctrine for food. Wootan commented that policies initially perceived as controversial typically become acceptable, necessary, and inevitable over time through educating the public and raising awareness. Silver stated the evidence base of the risk and epidemiological relationship about sugar-sweetened beverages exists and can be part of a sound evidence base used as a legal defense for local ordinances; evidence on how much each intervention affects risk will take time to build.

Siega-Riz also asked the panelists to share what they thought could be learned from the Philadelphia sugar-sweetened beverage tax and what the next steps might be. Mello responded that the purpose of adopting the tax had nothing to do with preventing obesity or obesity-related illness, but instead was positioned to generate revenue. She explained that this posi-

tioning is why artificially sweetened beverages that have zero calories are included in Philadelphia’s definition of sugar-sweetened beverages. Silver added that these measures will be much more successful if they are framed as generating revenue for something people care about. Wootan commented that the message that works is the message that best resonates with consumers. She rationalized that nobody wants increased taxes, but people do want health and child care.

In the final question posed to the panel, Siega-Riz asked the speakers to reflect on possible trickle-down effects of these regulations on children 5 years of age and younger. Silver explained that these policy efforts that are not specifically targeting young children will benefit children by changing the broader social and societal norms. Wootan thought that making low-fat milk or water the default beverage for young children at restaurants would help to create a habit that would follow children as they age.

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