Policy work

Co-authored with Rosa Carolina Sandoval (PAHO) and Maristela G. Monteiro (PAHO).

Background and Aims: Excise taxes represent one of the most cost-effective policies to reduce the harmful use of alcohol. Existing information about their design is limited and no standardized metric has been used to compare tax levels in the Region of the Americas. This study aimed to compare alcohol excise tax policies throughout the Americas, compare tax levels and consider opportunities to improve the impact of excise taxes on alcohol consumption and health.
Design and Setting: Descriptive analysis using a method developed by the Pan American Health Organization and adapted from the World Health Organization's tobacco tax monitoring. Data were collected by surveying ministries of finance and reviewing tax legislation in effect as of November 2020 in the Region of the Americas.
Measurements: Tax policy design indicators, taxes as a percentage of the retail price of the most-sold brand of beer, wine and spirits, including a weighted average indicator across beverage types, and tax levels per standard drink (10 g ethanol) in international dollars at purchasing power parity.
Findings: Thirty-three countries in the Americas (94%) apply excise taxes on alcoholic beverages, with Argentina and Uruguay not applying them to wine. There is significant heterogeneity in excise tax design across countries and beverage types. Only a third of amount-specific excise taxes are regularly adjusted to avoid erosion. Regional median excise taxes represent the highest share of the price for spirits (21.4%) and the lowest for wine (11.0%). The regional median consumption-weighted average excise tax share across all beverage types is 12.0%. Excise tax shares are generally higher in Latin America than in the Caribbean and Canada. Excise tax levels per standard drink are generally lower for spirits than for other beverages.
Conclusions: Alcohol excise tax policies vary significantly across the Americas, often reflecting national consumption patterns. To maximize their public health impact, tax rates could be increased and tax designs improved, particularly to ensure higher tax burdens on high-strength drinks.

Conference presentations: Alcohol Policy 19 (2022)

Co-authored with Rosa Carolina Sandoval (PAHO), Sehr Malik (PAHO), Itziar Belausteguigoitia (WHO), and Gilberto Morales-Zamora (PAHO).

During the past decade progress has been made from a public health perspective in advancing tobacco taxation policies in the World Health Organization’s Region of the Americas, and there are important lessons to be learned from this experience. This report aims to systematize and distill the key lessons learned, both by documenting progress and paving the way toward a comprehensive approach to taxing other health-harming products, particularly those considered to be drivers of the noncommunicable disease epidemic, such as alcohol and sugar-sweetened beverages. A thorough review of publications and institutional documents was undertaken and discussions were held with experts about the experiences of the past decade. Broadly, the lessons can be characterized according to the main mechanisms that have fostered progress. These are the robust, consistent and standardized monitoring of tobacco taxes that has enabled comparisons between countries and across time; the setting of tax policy within a framework of multisectoral policy coherence; and the development of guidelines and the generation of independent evidence to support tobacco taxes and tackle harmful industry interference. Currently, progress in these areas is lagging for taxes on alcohol and sugar-sweetened beverages. Applying the lessons learned from the extensive experience with tobacco taxation can help advance progress in taxes on alcohol and sugar-sweetened beverages and capture the potential synergies to be gained from building a comprehensive approach. Although more work is needed in developing and implementing taxation policies across all three products, the findings from this report can assist in strengthening their public health objectives to tackle noncommunicable diseases and improve population health. 

Co-authored with Rosa Carolina Sandoval (PAHO), Adriana Bacelar Gomes (PAHO), Natalia Parra (Campaign for Tobacco-Free Kids), and Francisco Armada (PAHO).

This report describes the current status of the tobacco control measures contained in the Strategy and Plan of Action to Strengthen Tobacco Control in the Region of the Americas 2018-2022 (Pan American Health Organization) and the advances made in its application, identifying achievements from 2016 to 2020 and challenges that still need to be addressed in order to reach the expected goals. This analysis relied on data from the World Health Organization (WHO) Report on the Global Tobacco Epidemic from 2015, 2017, and 2019, and national regulations were analyzed to determine their consistency with WHO criteria. Significant progress has been made in implementation of the WHO Framework Convention on Tobacco Control in the Americas. By 2020, most countries had regulations on 100% smoke-free environments in indoor public places, workplaces, and public transport, and large graphic health warnings on tobacco packaging. The number of countries that ban tobacco advertising, promotion, and sponsorship and that tax tobacco at the minimum level recommended by WHO has doubled since 2016. However, the 2022 targets have not yet been reached for any of these measures or for ratification of the relevant international agreements. Although progress has been made in the Region, it has not been uniform. Unless the pace of application of the tobacco control measures contained in the Strategy and Plan of Action accelerates, it is unlikely that its targets will be met. Tobacco industry interference remains one of the main challenges. 

Co-authored with Miriam Alvarado (University of Cambridge), Rosa Carolina Sandoval (PAHO), Fabio da Silva Gomes (PAHO), and Guillermo Paraje (Universidad Adolfo Ibanez).

Background: Excise taxes can be used to reduce the consumption of sugar-sweetened beverages (SSBs), an important preventable risk factor for noncommunicable diseases. This study aimed to compare novel standardized indicators of the level of taxes applied on SSBs as a percentage of the price across beverage categories in Latin America and the Caribbean.

Methods: We used a method developed by the Pan American Health Organization and adapted from the World Health Organization's tobacco tax share. The analysis focused on the most sold brand of five categories of non-alcoholic beverages. Data were collected by surveying ministries of finance and reviewing tax legislation in effect as of March 2019.

Findings: Of the 27 countries analyzed, 17 applied excise taxes on SSBs. Of these, median excise taxes represented the highest share of the price for large sugar-sweetened carbonated drinks (6·5%) and the lowest for energy drinks (2·3%). In countries where excise taxes were applied on bottled waters, tax incidence exceeded the one applied on most SSBs. Overall, excise tax shares were higher in Latin America than in the Caribbean. Including all other indirect taxes (e.g., value added tax), median total tax shares were between 12·8% and 17·5%. At least two countries earmarked part of SSB excise tax revenues for health purposes.

Interpretation: Excise tax levels are generally low in the region. From a public health perspective, tax rates could be increased, and tax designs improved (e.g., excluding bottled waters). The method describe here provides a feasible and informative way to monitor SSB taxation and could be replicated in other regions and over time.

Seminar presentations: PAHO (2022, link)

Co-authored with Brian Hutchinson (RTI International), Farisha Brispat (Ministry of Health, Suriname), Lorena Viviana Calderon Pinzon (Ministry of Health, Colombia), Alejandra Sarmiento (FOSALUD, El Salvador), Esteban Solis (Ministry of Health, Costa Rica), Rachel Nugent (RTI International), Nathan Mann (RTI International), Garrison Spencer (RTI International), Carrie Ngongo (RTI International), Andrew Black (WHO FCTC Secretariat), Maria Carmen Audera-Lopez (WHO FCTC Secretariat), Tih Armstrong Ntiabang (WHO FCTC Secretariat), Dudley Tarlton (UNDP), Juana Cooke (UNDP), Roy Small (UNDP), and Rosa Carolina Sandoval (PAHO).

Objective: To synthesize learnings from four national tobacco control investment cases conducted in the Americas (Colombia, Costa Rica, El Salvador, Suriname) under the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) 2030 project, to describe results and how national health authorities have used the cases, and to discuss implications for the role of investment cases in advancing tobacco control.

Methods: We draw on findings from four national investment cases that included 1) a cost-of-illness analysis calculating the health and economic burden of tobacco use, 2) a return-on-investment analysis of implementing key tobacco control demand reduction measures, and 3) a subsidiary analysis of one tobacco control topic of national interest (e.g., equity implications of cigarette taxation). Co-authors reported how cases have been used to advance tobacco control.

Results: In Colombia, Costa Rica, El Salvador, and Suriname, tobacco use causes social and economic losses equivalent to between 1.0 to 1.8 percent of GDP. Across these countries, implementing WHO FCTC demand reduction measures would save an average of 11 400 lives per year over the next 15 years. Benefits of the measures would far outweigh the costs of implementation and enforcement. Governments are using the cases to advance tobacco control, including to improve tobacco control laws and their enforcement, strengthen tobacco taxation, prioritize tobacco control planning, coordinate a multisectoral response, and engage political leaders.

Conclusions: National investment cases can help to strengthen tobacco control in countries, including by increasing public and political support for implementation of the WHO FCTC and by informing effective planning, legislation, coordination and financing.

Co-authored with Rosa Carolina Sandoval (PAHO), Itziar Belausteguigoitia (University of Lancaster), Miriam Alvarado (University of Cambridge), Luis Galicia (Ministry of Health, Uruguay), Fabio da Silva Gomes (PAHO), Guillermo Paraje (Universidad Adolfo Ibanez).

Objective: To characterize the design of excise taxes on sugar-sweetened beverages (SSBs) in Latin America and the Caribbean and assess opportunities to increase their impact on SSB consumption and health.

Methods: A comprehensive search and review of the legislation in effect as of March 2019, collected through existing Pan American Health Organization and World Health Organization monitoring tools, secondary sources, and surveying ministries of finance. The analysis focused on the type of products taxed, and the structure and base of these excise taxes. 

Results: Out of the 33 countries analyzed, 21 apply excise taxes on SSBs. Seven countries also apply excise taxes on bottled water and at least four include sugar-sweetened milk drinks. Ten of these excise taxes are ad valorem with some tax bases set early in the value chain, seven are amount-specific, and four have either a combined or mixed structure. Three countries apply excise taxes based on sugar concentration. 

Conclusions: While the number of countries applying excise taxes on SSBs is promising, there is great heterogeneity in design in terms of structure, tax base, and products taxed. Existing excise taxes could be further leveraged to improve their impact on SSB consumption and health by including all categories of SSBs, excluding bottled water, and relying more on amount-specific taxes regularly adjusted for inflation and possibly based on sugar concentration. All countries would benefit from additional guidance. Future research should aim to address this gap.

Co-authored with Franco Sassi (Imperial College London)

Co-authored with Anne-Marie Thow (University of Sidney), Kate Mandeville (World Bank), and Libby Hattersley (World Bank)

Co-authored with Rosa Carolina Sandoval (PAHO), Anne-Marie Perucic (WHO), Itziar Belausteguigoitia (WHO), Miriam Alvarado (University of Cambridge), Luis Galicia (Ministry of Health, Uruguay), and Guillermo Paraje (Universidad Adolfo Ibanez)

We draw from the well-established global monitoring of tobacco taxes by the World Health Organization and provide a proposed similar approach to develop new – or adapt existing – monitoring tools for taxes on alcoholic beverages and sugar-sweetened beverages (SSBs). Since 2008, the periodical and global monitoring of tobacco tax levels, prices, affordability and additional tax structure and tax administration information has enabled standardised comparisons across countries and over time, informed policymaking and institutional opportunities or barriers to apply tobacco taxes, led to defining best practices in the design of such taxes, and provided powerful tools for advocacy, especially with ministries of finance to promote fiscal and health policy coherence. Monitoring taxes on alcoholic beverages and SSBs in a similar way would require adjusting the methodology used to monitor taxes on tobacco products to the unique characteristics of these beverages – namely the fact that these products are more diverse than tobacco products in terms of product types consumed, and in volume sizes and content. In addition to collecting data on the tax structure, tax rates, tax bases and nominal retail prices on several different beverage types, monitoring taxes on alcoholic beverages and SSBs would require information on beverage volume sizes and sugar content and alcohol concentration. A balance would need to be reached between characterising the diversity of global or regional consumption patterns, ensuring the standardisation and precision of the indicators, and limiting the data requirements from national authorities. While institutional considerations are to be considered in expanding the global routine monitoring systems for taxes on alcoholic beverages and SSBs, there are lessons to be learned and potential synergies from the experience monitoring tobacco taxes. The successful monitoring of taxes applied on these three unhealthy products would play a great role in promoting global action and driving progress to reduce the burden of non-communicable diseases.