Published 11 April 20169 May 2023 · Culture / Debate / Inequality When paternalism works: a response to ‘Sugar taxes and porridge gospels’ Sheila Ngoc Pham Giovanni Tiso’s ‘Sugar taxes and porridge gospels’ is a thought-provoking piece. However, the lack of public health context is what has led him to falsely conclude that the concept of a sugar tax is an unjust burden on ‘the poor’. As someone who has worked on numerous obesity prevention campaigns, it’s just not as simple as that. Tiso equates obesity and eating, and lung cancer and smoking, in this way: ‘[A sugar tax] … will be passed on entirely to the consumer, reinforcing the ideological notion that obesity, like lung cancer before it, represents a failure in the exercise of personal responsibility. A failure that must be priced accordingly.’ But that’s not an accurate characterisation of the tax on cigarettes, which is not merely about punishing individuals for smoking. In fact, its history of taxation as a consumable long predates our collective consciousness about lung cancer risk. Like tobacco, sugar also has a long history of taxation that begins with its colonial history, when the British even referred to it as ‘white gold’. A modern-day sugar tax is not about punishing a particular group and has a far more utilitarian basis. The concept of it is based on its function as a disincentive to change a set of unhealthy behaviours – and here I’d like to make the case for paternalism, which Tiso is so wary of. Paternalism is often widely applauded – like compulsory minimum education, vaccination, drivers wearing seatbelts. These examples of state-enforced behaviours require individuals to act for the good of themselves and society, whether they like it or not. Such laws are not immune to critique, nor should they be, and we should certainly acknowledge the moral costs. But that’s ultimately how societies like ours can move along in roughly the right direction. Added sugar is not fundamental to our diets and has only been introduced to such a great extent in a short period of time. Perhaps sugar has even increasingly filled the void that cigarettes would have once inhabited (cupcakes, macarons, cronuts, doughnuts). Sugar is clearly trickier to regulate than tobacco because you can have a certain amount without adverse health consequences. Ultimately, however, it’s the way the market works which is a fundamental problem in societies such as Australia and New Zealand. Nowhere is this clearer than in developing countries. Soft drinks are ruining the health of people in countries like Mexico, where tap water isn’t safe to drink and sugary fizzy drinks are priced not much more than sterilised water for sale – which is exactly why Mexico finally introduced a ‘soda tax’ in 2014. One key result, by the way, is that ‘the drop [in soda sales] was greatest among the poorest Mexicans’. Soft drink consumption as a habit starts from a young age, which is exactly what the big companies want … which actually sounds an awful lot like the story of smoking in the twentieth century. We would do well to carefully examine the history of tobacco control in relation to sugar. Smoking is a complex social phenomenon which has required a barrage of strategies to control its use, while still allowing some to have the freedom to smoke. Taxation, as it turns out, is one of the only things which consistently works and hitting people in their hip pocket not only helps to overcome a powerful addiction but is also an effective counter to insidious marketing campaigns. The least well-off also benefit the most, as researchers from the University of Illinois at Chicago found in a highly comprehensive review of over 100 studies on tobacco taxes as a tobacco control strategy: Significant increases in tobacco taxes that increase tobacco product prices encourage current tobacco users to stop using, prevent potential users from taking up tobacco use, and reduce consumption among those that continue to use, with the greatest impact on the young and the poor. Is it really such a stretch to think about sugar in the same way? A sugar tax will not cause worse health outcomes among the poorest but it will encourage people to spend money differently, which their children will also benefit from. Behaviour change at a societal level involves both carrots and sticks. Sticks, like taxes, can work well as disincentives in complex, stratified, multicultural societies. Carrots could also work but are not applicable to products like soft drinks. However, they could be applied to increase consumption of fruit and vegetables, for example. Tiso puts forward some alternative ideas, which are actually neither carrots nor sticks: ‘A government could pass laws to restrict or ban marketing, or to limit the sugar content of drinks below a certain level, or to label foods more clearly.’ Yes the government could do all those things, and the way things are going it inevitably will, but in doing so could also be accused of paternalism. So you’re damned if you do and damned if you don’t. In any case, those strategies are not particularly powerful and all involve going up against Big Sugar, which has multimillion-dollar budgets to resist exactly such measures – and always manage to water them down when they do give in. It’s not a fair fight and while it drags on for years and years, millions of people will lose. ‘It is quite possible that a sugar tax would work, by a very limited definition of working,’ concedes Tiso. Given the multidimensional nature of obesity – which involves a set of interrelated behaviours and social determinants, to say nothing of a possible genetic basis – to have the tax work as it’s meant to is a good thing. After all, companies are using price incentives every day to ensure that people consume bigger, and consume more often. Until we can give the companies a knock-out punch, which is what we did with Big Tobacco, a sugar tax will shift things in the right direction. — If you liked this article, please subscribe or donate. Image: Daniel Horacio Agostini/Flickr Sheila Ngoc Pham Sheila Ngoc Pham (@birdpham) has worked in public health settings in Australia and south-east Asia. She has a Master of Bioethics and a Master of Public Health. She's a writer, ABC radio producer and project manager at Sydney Story Factory. 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