JAMA Forum: Prohibition Won’t Work for Soft Drinks Any More Than It Did for Alcohol

Aaron Carroll, MD, MS

Aaron Carroll, MD, MS

While much of the nation’s attention is focused on the US Supreme Court’s impending ruling on the Affordable Care Act, other health-centered policy efforts emerge (albeit on a smaller scale). One of the latest is the decision by New York City Mayor Michael Bloomberg to ban the sale of large soft drinks in certain settings in his city. It’s not hard to understand why he’s taken this step. You’d have to be living under a rock not to know that there is an epidemic of obesity afflicting the United States. Moreover, there is a growing body of evidence that sugar-sweetened beverages may be in part to blame for this. A 20-ounce soda contains more than 225 calories, more than 10% of a woman’s recommended daily calories. Teenage boys are drinking, on average, almost 275 calories of sugar-sweetened beverages every day.

These calories are “empty.” They provide little nutritional benefit. And the number of calories we’re getting in such drinks has been rising at a surprising rate. A soda sold in the 1950s as part of a restaurant meal was 7 ounces; today that meal contains an average of 42 ounces of soda. That’s an enormous increase, and it’s likely one of the reasons Americans are, on average, more than 25 pounds heavier today than they were back then.

If you want to reduce the number of calories that people are consuming without affecting the rest of their health, there are few things you can eliminate that would be as riskless as sugar-laden beverages. It’s no surprise that’s what Mayor Bloomberg decided to target.

But good intentions aren’t enough. The real question is whether the policy will lead to results. In other words, will it actually result in better health?

Those who support the ban may point to smoking as evidence that such restrictions can change behavior. But there are huge differences between the 2 policies. When cigarettes were banned from restaurants in New York City, they were completely banned. Soft drinks, on the other hand, have only had sizes larger than 16 ounces prohibited. In other words, you can’t buy a 20-ounce soda, but nothing stops you from buying two 12-ounce cans and consuming 24 ounces of the stuff.

To make a comparison with tobacco, this would be akin to saying that “large” cigarettes are not permitted, but “smaller” ones are fine. You’d just need to smoke more of them. Does anyone think that would have worked?

The strangeness of the ban gets worse. Sure, the restrictions apply to movie theaters. But they don’t apply to convenience stores, vending machines, or supermarkets. Nor will they stop those dining at restaurants from refilling their 16-ounce cups as many times as they like.

We also can’t blame obesity on soft drinks alone. It’s not just soda cups that have been increasing in size. Research published in JAMA shows that from 1977 to 1998, salty snacks’ size increased by 93 calories, hamburgers by 97 calories, French fries by 68 calories, and Mexican food by 133 calories. Things have only gotten worse since then.

How does it make sense to ban a 225-calorie soda when a “Gotta Have It”–sized PB&C (peanut butter and chocolate ice cream) shake at Cold Stone Creamery clocks in at 2010 calories alone? That drink got the top prize in the 2011 Xtreme Eating Awards sponsored by the Center for Science in the Public Interest. Or perhaps you could wander over to the Cheesecake Factory and get yourself a Farmhouse Cheeseburger (for 1530 calories) and a nice piece of Ultimate Red Velvet Cake Cheesecake (for an additional 1540 calories). Without even touching a French fry, you’ve consumed more than 3000 calories.

Fancier food isn’t immune either. A Morton’s steakhouse Porterhouse with mashed potatoes and half a side of creamed spinach rates 2570 calories, 85 g of saturated fat, and 2980 mg of sodium. As the CSPI noted, “That’s the calories of eight pieces of Original Recipe chicken plus mashed potatoes and gravy, coleslaw, and four biscuits at KFC [Kentucky Fried Chicken], with an extra 1½ days’ [saturated] fat on the side.”

And all of that is okay as long as you don’t accompany it with a drink larger than 16 ounces.

None of this means I don’t think there are policy options that might make more sense. Some have proposed a tax on high-sugar soft drinks as a means to improve health. The Center on Budget and Policy Priorities has estimated that a 10% increase in the price of such drinks would reduce consumption by almost 8%. Although that might seem like too high a tax, it’s important to remember that cigarettes are taxed at an average rate of 58%. That’s how you get people to stop doing something. It would also have the added benefit of bringing in revenue, something that might help states cover increasing health care costs.

We’d need a pretty high tax to make a difference. A recent study showed that it would take a tax on soda of more than 16% to reduce the caloric intake from them by 100 calories per day. But that same study found that almost all of the calories saved from reduced soda intake would likely be replaced by increased calories from other foods and drinks. That’s borne out in research. Partial fixes don’t work. If you ban sugar-sweetened beverages in school, kids will just drink more when they’re not in school.

Further, we can’t ignore the effect that a ban has on average Americans. More people, regardless of their political affiliation, oppose the proposal than support it. When Prohibition tried to eliminate alcohol completely, the results were disastrous. We still haven’t tried to make cigarettes illegal. We may make it difficult to smoke, and we may make it expensive, but it’s still legal, and you can still do it.

Mayor Bloomberg’s cherry-picking of certain sizes of 1 type of food only in certain environments may bring comfort to those frustrated by the lack of progress in our fight against obesity. But that alone won’t achieve our goals. We can’t ignore the super-sized appetizers, entrees, side dishes, and desserts while attacking the drinks. It’s all got to be on the table. We also can’t expect people to just quit these things cold turkey.

We need a holistic approach to obesity and one that doesn’t offend the inherent values of most Americans. These alternatives won’t be popular or easy either; accomplishing significant change never is.

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About the author: Aaron E. Carroll, MD, MS, is a health services researcher and the Vice Chair for Health Policy and Outcomes Research in the Department of Pediatrics at Indiana University School of Medicine. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll.

About The JAMA Forum: To provide ongoing coverage throughout this election year, JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide insight about the political aspects of health care. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



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