Running head: MARYLAND SUGAR-SWEETENED BEVERAGE TAX 1

Recommendation for Maryland to Implement a

Sugar-Sweetened Beverage Excise Tax
Amanda Tome
NTD 625-90 Nutrition Policy & Programs
West Chester University
May 1, 2017
Running head: MARYLAND SUGAR-SWEETENED BEVERAGE TAX 2

Recommendation for Maryland to Implement a Sugar-Sweetened Beverage Excise Tax

Introduction
State Information
Maryland is on the eastern coast of the United States (U.S.), bordering Pennsylvania,
Delaware, Virginia, and West Virginia. The land was granted to George Calvert, the first Baron
of Baltimore, by King James I of England in 1625 (Maryland State Archives, 2010). Also
known as “The Old Line State,” Maryland was named by King Charles I of England to honor his
wife, Henrietta Maria of France (NState, 2016). It ratified the U.S. Constitution on April 28,
1788, becoming the 7th U.S. state (Maryland, n.d.).
Maryland is geographically small, having a total area of 12,407 square miles and ranking
nd
42 in the U.S, and has a diverse topography that includes mountains, valleys, forests, pastures
and farmland, swamps, marshes, and fresh and salt water bodies of water (Maryland, n.d.;
Maryland Office of Tourism, n.d.). Maryland has a diverse and prosperous economy, including
technology, research, trade, manufacturing, agriculture, and commercial fishing (Maryland State
Archives, 2017b). In February, 2017, the unemployment rate in Maryland was 4.2%, lower than
the 4.7% national rate (Maryland State Archives, 2017b). Chemicals, computer and electronic
equipment, food and beverages, tobacco, and plastics and rubber are Maryland’s top
manufactured products and transportation equipment, chemicals, and electronics are its key
exports (Maryland State Archives, 2017b).
Located in the Eastern Uplands, Southern Seaboard, and the Northern Crescent farm
regions, 2.02 million acres – one-third (32%) of Maryland’s total land area – is used for
agriculture by 12,200 farms (Maryland State Archives, 2017a; National Agricultural Statistics
Service, 2016; Wilde, 2013a). Agricultural products include corn, wheat, soybeans, barley,
potatoes, vegetables, fruit, dairy, livestock, poultry and eggs, honey and seafood, especially blue
crabs, oysters, and clams (Maryland State Archives, 2017a; Maryland State Archives, 2017b).
As the second most Democratic U.S. state, Maryland is predominantly governed by
Democratic males (Jones, 2015). Benjamin Cardin and Chris Van Hollen, both Democrats, are
Maryland’s U.S. senators and C.A. “Dutch” Ruppersberger, John P. Sarbanes, Anthony G.
Brown, Steny H. Hoyer, John K. Delaney, Elijah Cummings, Jaime Raskin, and Andy Harris, the
only Republican, are Maryland’s eight U.S. representatives (Vote-USA, n.d.). Republicans
Larry Hogan and Boyd Rutherford are the governor and lieutenant governor, respectively, and
more than two-thirds (70.2%) of the 47 state senators –13 female; 34 male – are Democrats
(Vote-USA, n.d.).
As of 2015, there are 6,006,401 individuals residing in Maryland; 60.8% white, 31.5%
black, 7.1% Asian or Pacific Islander, and 0.7% American Indian (Maryland Dept. of Health and
Mental Hygiene [DHMH], 2015). In 2015, the overall birthrate was 12.2 births per 1,000 people
and the age-adjusted death rate was 705.6 per 100,000 people (DHMH, 2015). Heart disease,
cancer, cerebrovascular disease (CVD), and diabetes mellitus are the first, second, third, and
sixth leading causes of death in Maryland (DHMH, 2015). Life expectancy declined for the first
time from 79.8 years in 2014 to 79.5 years in 2015 with black males comprising the largest
decline and now having a life expectancy of 73.4 years (DHMH, 2015).
Although Maryland had the second lowest poverty rate (9.7%) in the U.S. in 2016, 12.8%
of Maryland children live in poverty, and African Americans (14.5%) and Latinos (14.2%) are
MARYLAND SUGAR-SWEETENED BEVERAGE TAX 3

disproportionately affected by poverty compared to Caucasians (7.1%) and Asian Americans

(7.6%) (Center for American Progress, n.d). The biggest challenge that affects Maryland
residents is the elevated cost of living. According to the Missouri Economic Research and
Information Center (MERIC, n.d.), there are only four states within the contiguous United States
that have a higher cost of living than Maryland. Housing is the most significant factor
responsible for increasing the cost of living. The cost of living index for Maryland is 125.0, and
its cost index for housing, groceries, transportation, utilities, and health are 176.7, 113.3, 106.3,
102.5, and 92.3, respectively (MERIC, n.d.).
Nutrition Policy Problem
Despite Maryland’s affluence and resources, it is still afflicted by the obesity epidemic.
Almost two-thirds (64.9%) of Maryland adults are overweight or obese with 29.6% being obese,
and 25.8% of Maryland adolescents are overweight or obese with 11.0% being obese (Centers
for Disease Control and Prevention [CDC], 2016). Although Maryland’s adult obesity rate is
lower than the national rate, it has dramatically increased over the past several decades. In 1990,
only 10.8% of Maryland adults were obese, which increased to 19.6% in 2000 (State of Obesity,
n.d.). Furthermore, 14% of Marylanders have fair or poor health status and 13% do not have
access to health care coverage (DHMH, 2013). Obesity is a risk factor for several chronic
diseases, including CVD, type 2 diabetes mellitus (T2DM), and some forms of cancer. Chronic
diseases are also prevalent among Maryland residents: 35% have been diagnosed with
hypercholesterolemia, 32% with hypertension, and 10% with T2DM and four of the top 10
leading causes of death associated with obesity (DHMH, 2013).
Currently, obesity-related medical costs for adults are approximately $147 to $190 billion
and account for 20.6% of the U.S. national healthcare expenditure (Cawley & Meyerhoefer,
2012; CDC, 2016). Trogdon, Finkelstein, Feagan, and Cohen (2012) estimated that 38.7% of
obesity-related expenses are borne by the state and federal government through Medicare and
Medicaid.
Causation
Although obesity is a complex disease with multiple and interrelated etiologies, a poor
diet and physical inactivity are contributing factors to developing obesity and chronic diseases.
A substantial proportion of Maryland residents are physically inactive and have a poor diet. One-
quarter (26%) of Maryland adults, 18.5% of adolescents are physically inactive, and only 43% of
adults and 20.8% of adolescents meet their physical activity recommendations (CDC, 2012;
DHMH, 2013). Additionally, 35.9% of adults and 39.6% of adolescents in Maryland consume
less than one serving of fruit per day and 22.0% of adults and 37.8% of adolescents in Maryland
consume less than one serving of vegetables per day (CDC, 2016). The prevalence of
consuming one or more sugar-sweetened beverages (SSBs) per day has increased from 23.4% in
2012 to 28.5% in 2013 among adults in Maryland, and 21.3% of adolescents drink at least one
SSB every day (CDC, 2012; Kumar et al., 2014; Park, Xu, Town, & Blanck, 2016).
It is well-known that excessive caloric intake results in weight gain and is associated with
obesity. Consumption of SSBs, which includes soda, sports drinks, energy drinks, and
sweetened juice, tea, coffee, and water, is a contributing dietary factor. A systematic review by
Schillinger, Tran, Mangurian, and Kearns (2016) found that 34 of the 60 studies examined found
a positive correlation between SSB consumption and obesity and diabetes; however, all but one
of the 26 studies that found a negative correlation were sponsored by the soda industry, whereas
MARYLAND SUGAR-SWEETENED BEVERAGE TAX 4

all but one of the 34 studies that found a positive correlation were independently sponsored.
SSBs are energy dense and do not provide any nutritional value. Furthermore, liquid
carbohydrates, especially in SSBs, are easily digested, less satiating, and tend to increase total
caloric intake (Pan & Hu, 2011). Among adults, SSB consumption is associated with an
increased risk of weight gain, overweight and obesity, CVD, T2DM, and dental erosion
(Friedman & Brownell, 2012). A twenty-year prospective study by Mozaffarian, Hao, Rimm,
Willett, and Hu (2011) found that individual who consumed an additional 12 oz. serving of soda
per day typically experienced a one pound weight gain per year. Malik, and Hu (2012) found
that individuals who consumed one or two SSBs per day had a 26% increased risk of developing
T2DM and a 20% increased risk of developing metabolic syndrome than those who consumed
less than one SSB per month. Among children and adolescents, SSB consumption is also
associated with an increased risk of overweight and obesity during childhood and in adulthood,
CVD during adolescence, hypertension, dental carries, and micronutrient deficiencies (Friedman
& Brownell, 2012). Lastly, consumption of SSBs is often greatest among children and
adolescents and among individuals with the highest obesity and T2DM risk (Friedman &
Brownell, 2012).
Policy Change Goal
A statewide SSB excise tax would help to combat the obesity epidemic in two ways.
First, excise taxes generate revenue that can be used to fund public health programs and
campaigns to treat and prevent obesity. Second, excise taxes on products increase the display
price of that product, which is a purchasing disincentive that will decrease demand in those with
price elasticity (Wilde, 2013b). Implementing an SSB tax can also communicate to the public
that policymakers are concerned about the health and well-being of their constituents. In
October 2016, the World Health Organization (WHO) recommended a 20% SSB tax as a public
health policy to combat obesity and T2DM, and current evidence suggests that a 10 to 20% tax
on unhealthy foods and beverages could produce a meaningful change in consumption patterns
and the prevalence and cost of chronic diseases, with greater impacts being associated with
higher taxes (Thow, Downs, & Jan, 2014; WHO, 2016). A 10% tax is roughly equivalent to a
one cent per ounce excise tax, if the tax is completely passed on to the consumer (Friedman &
Brownell, 2012). Therefore, it is recommended that Maryland implement an inflation-adjusted
two cents per ounce excise tax on all SSBs.
Literature Review
Types of SSB Taxation
There are two main types of taxes that could be imposed on SSBs: a flat sales tax
(valoric) or an excise tax. Valoric taxes increase with inflation, but the tax is not denoted on the
shelf price and consequently might not deter purchase or it might induce consumers to purchase
larger containers to reduce the cost per ounce (Freidman & Brownell, 2012). Excise taxes are
based on quantity, not price, and are imposed on manufacturers, which usually pass the tax onto
consumer, so the tax is reflected on the shelf price; however, excise taxes, unless indexed to
inflation, will not increase with inflation and therefore the economic impact will lessen over time
(Freidman & Brownell, 2012). Because SSB excise taxes are based on volume or sugar content,
they do not tend to encourage consumers to purchase larger containers.
MARYLAND SUGAR-SWEETENED BEVERAGE TAX 5

SSB Taxation History

Although SSB taxation is a relatively recent public health policy idea, there has been
significant prior advocacy work in the U.S. and other countries over the past several years. In
2010, New York City’s mayor made the first attempt in the U.S. – which ultimately failed – to
tax SSBs, followed by the unsuccessful passage by Congress of the SWEET Act of 2014 and
2015 (Institute on Taxation and Economic Policy [ITEP], 2016). In 2014, Berkeley, California,
was the first U.S. city to pass an SSB excise tax of one cent per ounce, and in 2016 Philadelphia
passed a 1.5 cents per ounce excise tax on SSBs and diet soda; three California cities, San
Francisco, Oakland, and Albany, passed a one cent per ounce excise tax on SSBs containing 25
or more calories per 12 ounces; Boulder, Colorado, passed a two cents per ounce excise tax on
SSBs containing five or more grams of sugar per 12 ounces; and Cook County, Illinois, approved
an excise tax on SSBs and diet sodas (ITEP, 2016). SSB excise taxes have also been
implemented in other countries. France implemented an excise tax on artificially sweetened
beverages in 2012 and energy drinks in 2013; Mexico approved a five cent (one peso) per liter
tax on SSB in 2013; and in 2016 the United Kingdom approved a three-tier SSB tax based on the
beverage’s sugar content (ITEP, 2016). A bill for a statewide SSB excise tax is currently
pending before three different state legislatures: Washington (two cents per ounce),
Massachusetts (one cent per ounce for beverages containing 5-20 grams sugar per 12 ounces and
two cents per ounce for SSB containing more than 20 grams sugar), and Illinois (one cent per
ounce on SSBs containing at least five grams of sugar per 12 ounces) (Center for Science in the
Public Interest [CSPI], 2017a).
Short-Term Effects of SSB Tax
Taxation on unhealthy foods and beverages is predicted to have two primary benefits: (1)
decrease consumption of the undesirable food or beverage item based on price elasticity and (2)
generate revenue. Decreasing consumption of energy-dense and nutrient-deficient foods is a
common recommendation for combatting obesity; however, critics of nutrient- and food-specific
taxation as a public health intervention claim that taxation will not produce the desired outcomes.
The first U.S. health-based SSB tax initiative took effect in Berkeley, on March 1, 2015, with
promising results thus far. Falbe et al. (2016) investigated the effect of the one cent per ounce
excise tax on SSB consumption in Berkeley to SSB consumption in comparable, neighboring
cities – Oakland and San Francisco – using a beverage frequency questionnaire. The survey was
orally administered to 990 participants from low-income neighborhoods in the three cities before
the tax was implemented and 1689 participants eight months after the tax was implemented
(Falbe et al., 2016). Four months after the tax was implemented, Falbe et al. (2016) found a 21%
decrease in SSB consumption in Berkeley compared to a 4% increase in SSB consumption in the
comparison cities. However, the differences in consumption patterns were even more
remarkable when individual SSB categories were compared. In Berkeley, consumption of all
SSB categories decreased, whereas consumption patterns differed greatly by category in the
comparison cities. Falbe et al. (2016) found a 26% decrease in regular soda in Berkeley but a
10% increase in comparison cities, a 36% decrease compared to a 21% increase in sports drinks,
and a 13% decrease compared to a 22% increase in sweetened coffee and tea. All three cities
demonstrated a decrease in energy and fruit drinks and an increase in water consumption but
Berkeley’s energy drink consumption was two times lower (-29% vs. -14%) and water
consumption was 3.3 times greater (+63% vs. +19%) in Berkeley than in Oakland and San
Francisco (Falbe et al., 2016). Furthermore, Falbe et al. (2016) found that 22% of Berkeley
MARYLAND SUGAR-SWEETENED BEVERAGE TAX 6

participants altered their drinking habits by consuming SSB less often or by choosing smaller
portions, and only 2% of Berkeley participants purchased SSB in other jurisdictions as a direct
result of the tax.
Slightly longer term results are available by examining the effect of a country-wide SSB
tax in Mexico, which was implemented in January 2014. Colchero, Guerrero-Lopez, Molina,
and Rivera (2016) investigated the effect of a one peso (~ 5.5 U.S. cents) per liter excise tax on
SSB on the sales of SSB and plain water using the Monthly Surveys of the Manufacturing
Industry sales data. Using unadjusted, raw sales data, they found that the sales of SSB and plain
water increased during the two years after the tax was implemented compared to five years of
sales data preceding the implementation of the SSB excise tax (Colchero et al., 2016). However,
after adjusting for the global indicator of economic activity, a short-term measure of economic
trends, Colchero et al. (2016) found a 7.3% decrease in per capita sales of SSBs and a 5.2%
increase in per capita sales of water for two years after the SSB excise tax implementation. This
data is consistent to their prior findings – a 6% decrease in SSB sales and a 4% increase in
untaxed beverages one year post tax –in which they surveyed a panel of urban households about
their beverage purchases (Colchero et al., 2016). The most significant limitation of this study
was the inability to account for potential confounding factors that could influence beverage sales,
such as temperature, increased SSB advertisements and promotions, and increased public health
campaigns and nutrition education to promote awareness about the negative health effects
associated with SSB (Colchero et al., 2016).
Projected Long-Term Effects of SSB Taxation
Since SSB taxation is relatively new, most research has focused on investigating the
effects of the tax on SSB consumption; therefore long-term effects of SSB taxation are merely
projections based on modeling programs. Using data from the 1998-2007 Nielsen Homescan
panels and the 2003-06 National Health and Nutrition Examination Survey (NHANES), Smith,
Lin, and Lee (2010) estimate that a 20% tax-induced price increase on SSBs would result in 37
and 43 fewer calories per day among adults and children, respectively, which would result in a
3.8 pound weight loss among adults and a 4.5 pound weight loss among children the following
year. Smith et al. (2010b) further estimated that a 20% SSB tax could reduce the prevalence of
overweight and obesity by 3.0 to 4.5% among adults and would reduce the prevalence of at-risk
of overweight and overweight children by 2.9 and 5.3%, respectively. However, this study did
not account for food and beverage substitutions, which could offset the estimated daily energy
intake reduction and therefore could have resulted in an overestimated impact on obesity rates.
To account for the effect of dietary substitutions, Finkelstein et al. (2013) used grocery purchase
data from the 2006 Nielsen Homescan panel and two models to predict the effects of a 20% tax
on body weight. Based on 19 potential food and beverage substitution categories, Finkelstein et
al. (2013), estimate that a 20% SSB tax would decrease energy intake by 24.3 calories per day
and would result in an average 1.6 pound weight loss one year post tax and a 2.9 pound weight
loss 10 years post tax.
Veerman, Sacks, Antonopoulos, and Martin (2016) conducted a study to estimate the
effect of a 20% valoric tax on SSB consumption, chronic disease incidence and prevalence,
mortality, and healthcare costs in Australia using lifetable-based epidemiological modeling.
According to the modeling program, a 20% valoric tax would result in a 12.6% decrease in SSB
consumption; a small BMI reduction; a 1.2 and 2.7% decrease in obesity among women and
men, respectively; an annual diabetes incidence decrease of 800; 4,400 fewer heart disease cases,
MARYLAND SUGAR-SWEETENED BEVERAGE TAX 7

1,100 fewer stroke cases, and 1,606 fewer deaths by year 25; AUD400 million annual revenue;
and reduced annual healthcare spending during the first 20 years and then AUD29 million
savings thereafter (Veerman et al., 2016).
Using a country-specific adapted version of the Cardiovascular Disease Policy Model,
post-tax SSB consumption data, and national health and economic statistics, Sanchez-Romero et
al. (2016) investigated the effect of Mexico’s one peso per liter (i.e., 10%) excise tax on
morbidity, mortality, and healthcare costs. Based on a 10% decrease in SSB consumption and an
estimated 39% of calories from SSB being replaced with other foods and beverages, Sanchez-
Romero et al. (2016) projected a 4.9% lower incidence of T2DM and $983 million (-0.8%) in
diabetes-related healthcare savings over 10 years, with the largest reductions occurring among
Mexicans adults aged 35-44 years. Sanchez-Romero et al. (2016) also projected a decreased
CVD incidence (20,400 fewer strokes and myocardial infarctions) and all-cause mortality
(18,900 fewer deaths) within 10 years. The economic advantages are likely to be more
substantial because Sanchez-Romero et al. (2016) did not account for the healthcare savings
associated with reduced CVD and all-cause mortality, nor did they account for generated revenue
or indirect healthcare savings, such as increased labor productivity.
Based on UConn Rudd Center for Food Policy & Obesity’s (n.d.) revenue calculator for
SSB taxation and a price elasticity of -1.2, it is estimated that a two cents per ounce SSB excise
tax in Maryland, could generate $3.62 million and $3.67 million in 2018 and 2019, respectively.
The Veerman et al. (2016) study estimated that the healthcare cost savings by a 20% valoric tax
would be 14 times greater than the cost of implementing and governing the tax.
Target and Allies
Target
Maryland State Senators Joanne Benson and Catherine Pugh and State Representatives
Antonio Hayes and Cheryl Glenn are more likely than the other state senators and representatives
to support a SSB excise tax in Maryland as they have all previously sponsored health and
nutrition-related bills in Maryland. In 2016, Senators Benson and Pugh sponsored Maryland
Senate Bills 333 and 602, which would limit the types of beverages that a restaurant could
include in a child’s meal and that would require that 75% of all packaged food and beverages in
vending machines on state property be healthy, respectively (LegiScan, n.d.-b; LegiScan, n.d.-c).
Unfortunately, both bills died in the Senate Finance Committee, but the act of supporting these
bills implies that both Senators may be receptive to this proposal. Representatives Hayes and
Glenn supported a bill (HB 1498) in 2016 that would require 75% of all packaged food and
beverages in vending machines on state property be healthy, and after that bill was withdrawn
due to an unfavorable report by Economic Matters, they reintroduced a similar bill that lowered
the percentage of required healthy food to 50% (HB 1509) this year (LegiScan, n.d.-a; LegiScan,
n.d.-b).
Allies
Recently, SSB taxation has become a popular national and global topic as a means of
combatting society’s obesity and chronic disease epidemics. As such, SSB taxation has been
proposed by numerous public health-focused organizations, which could provide resources and
support a SSB excise tax in Maryland. Public Health Advocates, a nonpartisan nonprofit
organization whose primary mission is to increase awareness about public health issues and to
MARYLAND SUGAR-SWEETENED BEVERAGE TAX 8

advocate for policy change, created Kick the Can, a website devoted to reducing SSB
consumption (Kick the Can, n.d.). The CSPI and former New York City Mayor Michael
Bloomberg are advocates for SSB taxation. CSPI is a nonprofit consumer advocacy lobbyist
group that advocates for health, nutrition, and food safety (CSPI, n.d.). Mr. Bloomberg, who
unsuccessfully attempted to pass an SSB tax in New York, has helped fund SSB tax campaigns
in Berkeley, Philadelphia, San Francisco, Oakland, and Mexico (CSPI, 2016; Vinton, 2016).
Additionally, the American Heart Association and John and Laura Arnold provided significant
financial support to help pass SSB taxes in 2016 (CSPI, 2016). Other organizations that have
been involved in SSB taxation advocacy include Action for Healthy Food, the American Cancer
Society, the California Center for Public Health Advocacy, Change Lab Solutions, the Public
Health Law Center, and the UConn Rudd Center for Food Policy and Obesity (Action for
Healthy Food, 2015).
Although national organizations can provide valuable support, funding, and other
resources, it is imperative to include state-based organizations and community members. Sugar
Free Kids Maryland (n.d.-a), established in 2014, is a Maryland coalition that is trying to
improve the health of Maryland’s children by preventing the development of T2DM, CVD, and
dental carries. It is comprised of six core organizations – Horizon Foundations, MedChi, the
Maryland State Medical Society, the American Heart Association, National Association for the
Advancement of Colored People, the Maryland Association of Student Councils, and 1199SEIU
United Healthcare Workers East – 75 additional statewide or regional organizations, and 154
local organizations (Sugar Free Kids Maryland, n.d.-a). Horizon Foundations and county
residents created the Howard County Unsweetened (n.d.-a) initiative and Better Choices
Coalition of Howard County (n.d.-a) – which now includes 49 local organizations – with the sole
mission to reduce SSB consumption to improve the health of its children. Other potential allies
include Johns Hopkins University, Maryland Department of Health and Mental Hygiene, and
Maryland Public Health Association, because these organizations are all devoted to improving
public health in Maryland.
Previous Advocacy Work
In October 2016, the WHO proposed a 20% SSB tax as a public health policy to combat
obesity and T2DM (WHO, 2016). Action for Healthy Food (2015) has created a 32 page report,
A Roadmap for Successful Sugary Drink Tax Campaigns, that has reviewed, evaluated, and
compiled prior advocacy work and provides a detailed framework for successfully advocating
this issue. Berkeley, CA successfully passed a SSB excise tax, becoming the first municipality
to do so as a public health intervention, despite the soda industry and other opponents
successfully quashing similar proposals in numerous other jurisdictions. It is suspected that
Berkeley was successful when so many other municipalities were not because of Berkeley’s pro-
tax campaign, “Berkeley vs. Big Soda, that included a diverse coalition, prominently featured
community representatives, widespread messages highlighting the negative health effects
associated with SSB and the soda industry’s negative tactics, and a vast network of allies (Falbe
et al., 2016).
Although there are no organizations in Maryland that have advocated for a state SSB tax,
there are several organizations and coalitions that have advocated for other policies and
programs that would reduce SSB consumption. Sugar Free Kids Maryland (n.d.-b) has actively
supported a bill that would require warning labels on SSBs in Baltimore, MD, a bill that would
require healthier food and beverage options in vending machines located on government
MARYLAND SUGAR-SWEETENED BEVERAGE TAX 9

property, and a bill that would require licensed childcare facilities to serve healthier beverages.
The Howard County Unsweetened initiative created a campaign in 2013 that targeted reducing
SSB consumption via social media, television and physical advertisements, and soda-swapping
events where volunteers would approach individuals in the public venues and engage in an active
conversation trying to get them to drink SSB alternatives (Aubrey, 2017). After three years, soda
and fruit drink sales decreased by 20 and 15%, respectively (Aubrey, 2017). They have also
created “Better Beverage Finder,” a tool that uses input criteria to provide a list of SSB
alternatives, with a short description, health ranking, if and how it is sweetened, and a link to
more detailed information including sugar and calorie content and locations where it can be
purchased (Howard County Unsweetened, n.d.-b). The Better Choices Coalition of Howard
County (n.d.-b) reaches out to local organizations in an effort to get those organizations to
provide better beverage choices at meetings, events, and in vending machines and has developed
a toolkit to assist individuals in advocating for better beverage options in their organizations.
Lastly, Maryland already taxes SSBs through its general sales tax. Although food
purchased for consumption in a substantial grocery store or market business are exempt from
Maryland 6% sales tax, food for immediate consumption, soda, bottled water, confectionary
items, and alcoholic beverages are not exempt (Comptroller of Maryland, n.d.).
Potential Barriers
Based on opposition to SSB taxation proposals in other jurisdictions, it is extremely
likely that this proposed policy will be vehemently opposed by the soda industry, libertarians,
anti-tax coalitions, and individuals or groups who disagree with the policy. There are three main
arguments against SSB taxation: the tax would unfairly target the poor, the government is
limiting personal choice through paternalism, and SSB are being unfairly targeted (Robert Wood
Johnson Foundation, 2012). Since 2009, the soda industry, predominantly comprised of
PepsiCo, Coca Cola, and the American Beverage Association, has spent $67 million fighting
SSB taxes and other public health measures (CSPI, 2016).
Advocacy Plan
Action plan
To lead a successful state advocacy campaign, especially regarding a controversial issue
such as an SSB tax, is to engage state residents and organizations; therefore, the first step in this
advocacy plan is reach out to potential allies by writing and sending a letter. The letter would
explain how obesity and chronic diseases are critical issues in Maryland, how these health issues
are related to SSBs, and how an SSB excise tax would help combat these issues. The letter
would also connect their mission and goals to an SSB excise tax and conclude with a plea for
their support and engagement in the campaign. A week later, I would follow-up the letter with a
phone call to each potential ally to confirm that they received my letter and to ask for their
support or at the very least a scheduled meeting to discuss an alliance.
After alliances have been formed, we would develop a campaign name and work together
to prepare an issue brief about the negative health effects associated with SSB consumption and
how a two cents per ounce SSB excise tax in Maryland could help solve health problems
affecting Maryland residents. After the issue brief has been written, I would schedule a
legislative visit with Maryland State Senators Joanne Benson and Catherine Pugh and State
Representatives Antonio Hayes and Cheryl Glenn in an attempt to gain their support in
MARYLAND SUGAR-SWEETENED BEVERAGE TAX 10

sponsoring an SSB tax bill. I would ask to schedule the legislative visit sometime during this
summer (General Assembly of Maryland 2017 post-session), as that would be several months
before the start of the 2018 session and would allow adequate time to earn their support. At the
legislative visit, I would deliver the issue brief, provide a list of the allies supporting the issue
brief, and discuss its key talking points. Hopefully, the legislative visit would result in the
sponsorship of least one senator and one representative but, if not, I would try to persuade them
by increasing social support.
First, I would create a social media campaign using Facebook and Twitter. The
Facebook page would include a list of members and supporters, our goal, information about the
soda industry and their lobbying and advertising tactics, and information about our actions. I
would also create a Twitter account that would send daily tweets about the negative effects of
SSBs, the benefits of an SSB excise tax, and the reactions and tactics of the soda industry. I
would also create or use existing infographics and posters to increase awareness and generate
support. The infographics and posters would highlight the negative health effects of SSBs, the
benefits of a two cents per ounce SSB excise tax, and facts about the soda industry’s lobbying
and advertising tactics. An example of a poster discussing the negative health effects of SSB
consumption and the benefits of a SSB tax is included in the next section, Messages and Actions.
After contacting local businesses, organizations, schools, churches, and civic groups, I would
display the posters and infographics in permitted locations and public venues and post them on
the Facebook page.
I would schedule a march in Annapolis, outside the State Capitol, for Wednesday,
January 10, 2018, at 11:00 am, which is one hour before the Maryland General Assembly
reconvenes for the first day of the 2018 session (General Assembly of Maryland, n.d.). I would
also contact all of the allies, asking for their attendance and participation in the march and for
their help in advertising it. I would advertise the march on Facebook, Twitter, and posters
displayed throughout the state. I would also contact Maryland news stations, including WBAL-
TV 11, WJZ-13 CBS Baltimore, and ABC2 News; local radio stations, including Today’s 101-9
and 98 Rock Baltimore; and Maryland newspapers, including The Baltimore Sun and The
Capital, to publicize and cover the march. Ideally, with the help of the allied organizations, I
would send or deliver letters requesting support to other potential allies, including local, regional,
and state health, community, educational, and political organizations, school boards, parent
groups, churches, restaurants, and grocers, as all of these groups supported Berkeley’s SSB tax
campaign (Berkeley vs. Big Soda, n.d.).
Lastly, I would create a form action letter that could be emailed to Maryland state
legislators directly from our Facebook page. Since legislation must be introduced within the first
24 days of session, I would schedule an action day for Monday, January 15, 2018, in which
action request alerts and emails would be sent to all Facebook and Twitter followers and allied
organization members.
Messages and Actions
The poster shown below would be posted on the Facebook page, sent to potential allies
along with a letter requesting support, and posted in public venues and on the premises of
business and organizations that grant permission to do so.
MARYLAND SUGAR-SWEETENED BEVERAGE TAX 11
MARYLAND SUGAR-SWEETENED BEVERAGE TAX 12
MARYLAND SUGAR-SWEETENED BEVERAGE TAX 13

Evaluation
The action plan will be evaluated in several ways. First, I would evaluate the efficacy of
network building and outreach by calculating the number of new advocates, partnerships, and
alliances. I would also calculate the percentage of alliances that were contacted and the number
who joined the Maryland SSB tax advocacy campaign. Next, I would evaluate the efficacy of
achieving social support and increased awareness by the number of “likes” the Facebook page
generated, the number of hits the Twitter account received, and the number of demonstrators
who attended the march in front of the General Assembly in Annapolis. Lastly, I would
determine the efficacy of the overall campaign by the percentage of the targets – Maryland State
Senators Joanne Benson and Catherine Pugh and State Representatives Antonio Hayes and
Cheryl Glenn – who agree to sponsor the bill and whether or not the bill is passed.
The ultimate goal of an SSB tax is to decrease consumption of SSBs and improve health
outcomes. The effect of the tax on SSB consumption could be evaluated by comparing the sales
of SSBs in Maryland two years pre- and post-tax. It could also be evaluated by having a
randomized sample of Maryland residents complete a beverage-focused food frequency
questionnaire at the start of the campaign and one year after the tax became effective. The effect
of the tax on health outcomes could be measured by comparing the prevalence and incidence
rates of obesity, T2DM and CVD among Maryland residents before the tax was implemented
and 10 years after implementation, using the annual Vital Statistics Report published by
Maryland Department of Health and Mental Hygiene.
MARYLAND SUGAR-SWEETENED BEVERAGE TAX 14

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