A piece of legislation was proposed in New York City in September of 2012 to ban the sales of sugar-sweetened beverages over 16 ounces in the city (1). The proposed law, deemed the “Soda Ban,” had several key features. Principally, it prohibited sugary beverage sales in establishments such as restaurants, movie theatres, food trucks, pizza shops, deli’s and sports venues (2). It exempted both grocery stores and convenient stores, however. The criteria that dictated which specific beverages fell under the law included all those that were non-alcoholic, greater than 25 calories per 8 ounces, sweetened by sugar or an alternative caloric sweetener, and less than 50 percent milk or milk substitute (1). Drinks most affected included soda, juice, coffee, tea and energy drinks. Any establishment found to be in violation of this law would be subject to a $2,000 fine per violation (1).
The legislation was sponsored by Mayor Michael Bloomberg as a means to combat one of the most serious public health issues we currently face: obesity. Obesity is on the rise, with over 35% of Americans currently classified as obese (3). Sugary drinks are at the forefront of obesity’s causes, as they contain a significant amount of calories and sugar. There are 15 to 18 teaspoons of sugar and 240 calories in a typical 20-ounce soda, and over 700 calories in a 64-ounce soda (4).
These drinks are of even greater importance to the obesity issue due to the trend over the past several decades toward higher portion sizes and increased consumption of soft drinks. From 1977-1996, average soft drink consumption rose from 13.1 ounces to 19.9 ounces (5). In the same time period, consumption of calories from sugar increased by 83 calories per day(5). This trend is seen across all ages, as obesity among children and adolescents has almost tripled since 1980 (6). Of highest concern, consumption of sugary beverages has been associated with increased risk of serious negative health outcomes including obesity, coronary heart disease, diabetes, and insulin resistance (7). This made for a compelling case to intervene to reduce consumption of sugar-sweetened beverages.
Reliance on Health Belief Model to Predict Behavior Changes
The underlying assumption behind the NYC Soda Ban is that limiting the container size in which sugary drinks can be sold will limit consumption of the beverages. This expectation relies heavily, but perhaps mistakenly, on the Health Belief Model. The model explains that behavior begins when a person rationally weighs the benefits and costs of a health action. With these in contrast, a person then forms an intent, which is then carried out in an action (8). The aggregate of these individual actions is a behavior. The logic is that by banning large sugary drinks, a person’s awareness of the health costs associated with consuming these types of drinks will be heightened. This in turn will cause people to form intent to less frequently purchase and consume sugary beverages. The issue with using this model of thought to predict reduced soda consumption is that it assumes that purchasing soda is a calculated decision based on an individual’s perception of their health risk weighed against the benefit of consuming that beverage. It does not take into account any external sources that may provide information or an interpretation of taking part in the behavior (9). Not everyone who walks into a NYC Deli for a drink has equal access to information to make this type of rational calculation.
Humans have extensive external factors to consider when deciding to purchase or consume something such as a soda, one of which is access to alternatives. In the urban landscape that makes up New York City, many neighborhoods simply do not have access to healthy and affordable food and beverage options. Full-service grocery stores, farmers markets and vendors selling fresh items are out of reach for many. What is instead available is an abundance of fast food restaurants and shops that sell processed, high fat and high sugar options (10). In a NYC neighborhood walkability study, almost all participants lived within 0.5 miles of an unhealthy food outlet, with an average of 31 of these types of outlets per square kilometer (11). In comparison, healthy food outlets were only seen in densities of 4 per square kilometer. While healthy food outlets are highly capable of providing tasty and fulfilling soda substitutes, if these healthy alternatives are simply unavailable individuals cannot engage in a cost-benefit analysis of sugary beverages versus healthy alternatives to inform their purchases and consumption. With no alternatives in taste or satisfaction, consumers will simply continue to buy soda.
Another major flaw of using the Health Belief Model to predict behavioral change from the banning of large sugary drinks is that it incorrectly assumes a person’s intent to reduce their consumption actually leads to the behavior of reducing consumption when not everyone makes such rational calculations about their health behaviors. When it comes to decision-making, studies of the brain suggest that emotion rules decisions almost completely (12). Someone may have serious intentions to reduce their soda consumption, to start dieting or to exercise more, but that does not guarantee that they will modify their current actions to carry out these new behaviors. What comes between the intentions and actions are emotions, social influences and other significant external factors.
One such factor is the physical addiction that many people have to sugar and caffeine, both prevalent in soda. Caffeine is highly prevalent in soda, as it is an added ingredient in approximately 70% of soft drinks in the United States (13). Caffeine meets the criteria for an addictive substance, as it has effects of dependence, tolerance and withdrawal for both adults and children (14). Sugar is also an addictive substance, with intermittent access leading to neurochemical changes in the brain as well as behavioral changes that resemble the effects of a substance of abuse (15). For those individuals that are regular consumers of caffeinated and sugar-sweetened beverages, they likely have some form of dependence on these ingredients and will not easily give them up simply due to their availability in large containers being restricted.
Ignoring the Importance of Social Influences
Both consumption and obesity are social in nature. Obesity is considered contagious, as your risk for gaining weight increases if those in your close social circle are overweight (16). Why is this? For one, humans are greatly influenced by others, and our consumption patterns directly reflect this. For example, a light eater eats much more when in a group of heavy eaters, and vise versa (16). Although consumption of food is usually coupled with hunger, sugar-sweetened beverages are often consumed in the absence of hunger, in order to satisfy social reasons (7). This is further supported by the notion of ‘collective conservatism,’ which states that once a pattern has become established (like drinking Big Gulps of Coca-Cola), it is likely to be stuck to, even without any basis for its perpetuation (16). Americans have become normalized to sodas that are upwards of 32 ounces, as well as acclimated to the prevalence of obesity (17). Social norms play a huge role in consumption, however they have not been considered in the NYC soda ban. The emphasis of the ban is solely on regulating the quantity of sugary drinks available for consumption, without any attempt to pair this with interventions to change the social norms around consumption. A policy of this scale has the capacity to affect entire communities, however it lacks a crucial component encapsulated in the Social Expectations theory- that the law be tied to changing social norms (18). On a social and cultural level, modifying the old rules for social interactions or establishing new ones is what brings new guides to behavior for the long-term (18).
A related behavioral paradigm also ignored by the NYC Soda Ban policy is that of the Social Learning theory. It explains that people embrace particular habits when the adoption of that behavior provides a gratifying result, and that people are likely to adopt behaviors that are modeled by important individuals (18). One study that supported this notion looked at soft drink consumption among adolescents. It found that social modeling was a strong determinant of soft drink consumption, along with attitude towards soda and preference for its taste (19). If individuals have family members, close friends or peers that regularly consume large, sugary drinks and exclaim their enjoyment, they notice this pattern of behavior and attach value and norms to it. A policy regulating soda size will not succeed in changing consumption patterns without intervening to remove these social norms and values.
Violation of Psychological Reaction Theory
It is unsurprising how unpopular a restrictive law would be in New York City, where people value freedom, independence and autonomy above all. The name of the grass roots group that has rallied against the soda ban, New Yorkers for Beverage Choice, says it all. People value freedom of choice, and do not want to be told what they can and cannot purchase or consume. When people sense that their freedom or control is threatened it invokes reactance, which is a state of mind motivated to restore the threatened freedom by engaging in the prohibited behavior (20). The NYC soda ban would most certainly induce reactance, as residents would feel as though their power to purchase had been significantly reduced through this prohibition of large sizes of various sugar-sweetened beverages. In fact, soda consumption is actually expected to increase under this ban. Store owners reportedly planned to offer bundles of smaller sized drinks packaged together for lower prices (21), a plan developed in direct reactance to this ban. It is clear that both store owners and consumers feel a sense of rebellion to this ban, which is counterproductive to the goal of reducing sugary drink consumption.
Psychological Reactance Theory explains that humans are inherently interested in subjects and activities that are censored, as they represent things that have been threatened (22). People react to threats to their freedom by ascribing new value to those very things that are censored, and seek to engage in the censored behavior. The sentiment that comes across in the NYC Soda Ban is that of “soda is bad. It causes obesity and serious health issues and you should stop drinking it.” The ban has effectively made soda a censored consumer good, thus leaving the serious potential for individuals to crave it even more than before the restriction.
Framework for a Novel Approach
The “soda ban” law in New York City sought to curtail obesity by limiting access to sugar-sweetened beverages, but failed to address the realistic and complicated underpinnings that drive people’s consumption. People do not drink soda simply because it’s there. Some are addicted to the sugar and caffeine they have regularly consumed from these beverages. Some have insufficient access to healthier and more affordable drink alternatives. Others still simply model their consumption on the observed patterns of others around them. The NYC Soda Ban intends to curb consumption of sugary beverages by making people more attuned to the health risk of their consumption by limiting their available size. With a heightened awareness, people will recognize and assign greater importance to the extensive health risks and weigh them against the ephemeral benefits, rationally deciding to reduce their consumption. However, these are naive assumptions, as people value freedom of choice above health. The social norms around drinking soda, as well as the ad campaigns by the beverage industry that misconstrue the benefits of soda consumption also lead even rational cost-benefit analyses awry. A comprehensive campaign that makes healthier alternatives widely available and emphasizes their desirability is needed. This alternative intervention would include developing advertisements, disseminating written material and creating partnerships among industry members to enhance accessibility to healthy drink alternatives. A comprehensive campaign of this nature would be designed to convince individuals of their own desire to switch to an alternative beverage type, putting them back in the control seat.
Shift In Message Delivery
The NYC Ban on sugary drinks makes the flaw of assuming that by regulating the size of the sugary drink container, this will be enough deterrent to reduce consumption of such beverages by way of a heightened sense of negative cost associated with the consumption behavior (8). However, any campaign aiming to curb consumption also must acknowledge that actions can be spontaneous and contradict any previous intentions an individual may have had (23). Therefore, the proposed intervention would tweak its message in order to invoke feelings instead of rational decision making calculations. The campaign would portray healthy alternative beverages in a provocative and passion-invoking way so that these feelings effectively modify a person’s action when they are making a decision in front of the drink cooler. If the campaign can conjure thoughts of a sexy and daring healthy alternative to a stale soda, the alternative can become the leading choice, even without a rational health calculation.
In order to address external aspects of consumption decision-making such as access and cost, promotions and vouchers for alternative and healthy drink options could also be made readily available. One approach is to utilize promotional drink carts or cars to distribute free drinks and coupons to urban neighborhoods. Since an effective way to change behavior is to have people actually engage in the desired alternative behavior (8), this method would achieve this initial step towards consumption change.
Strategic use of Social Circles to Modify Norms
We know that people do not live in isolated settings, but instead live in interconnected social environments with constant feedback from others. Since behavior is often modeled after the behavior of others in a social circle or after those that are in a revered social position (16), a successful campaign would also address the social norm of soda consumption as a desirable behavior. Instead of ignoring the implications of societal norms like the Soda Ban did, this alternative campaign would utilize Social Network Theory, which describes the social network as the place where flow of information and resources gets transferred (24). Social networks can be reached by targeting people at the center of social circles, who disseminate ideas and norms throughout their networks. Thus, the backbone of this campaign would be to get influential members of social networks to adopt preferences toward healthy drink alternatives. By making alternatives such as green tea or natural iced tea fashionable and the new norm, soda could potentially fall behind as the product that used to be trendy but has been effectively replaced by something new and fresh. Strong and creative ad campaigns could be developed and tweaked using focus groups to ensure that the most convincing message regarding the desirability of soda alternatives comes across. One way to ensure that focus groups are comprised of influential individuals would be to advertise in trendy or expensive stores that draw a particular crowd likely to have sway within their circle.
Advertising Theory to Sell An Alternative
Advertising Theory is a valuable tool that could help make healthy alternatives to sugary beverages seem just as appealing as sodas like Coke, which received the lions share of the $2.9 billion that Coca-Cola spent on advertising in 2010 (25). Advertising Theory is a useful behavioral model in this situation because it frames an intervention around people’s core values in order to convince them that it will provide a desirable benefit (26). In this intervention, the promise offered would be sexiness and desirability, promised to viewers by way of drinking healthy and delicious alternative beverages. Instead of restricting people’s choices of drink options and invoking reactance, the focus would be to convince people that they actually want to take part in this new consumption behavior. If the behavioral change comes from an internal rather than external source, it is likely to be stronger and longer-lasting (27). In this case, convincing people that they can choose the right option for themselves, while simultaneously making the healthy option appealing, will reduce or eliminate any potential reactance (27).
Since similarity to the communicator is an established determinant of compliance (22), a successful ad campaign would feature people from a variety of demographics. Instead of approaching the issue of soda consumption with statistics, which may not invoke a strong reaction or connection from viewers, personal narratives would be used. The narratives would be based on unique and compelling stories of people who kicked soda and chose something else as their ‘new drink of choice’. The positive social and physical consequences that went along with this switch would be emphasized. For example, a young adult campaign would highlight a person’s story of losing weight, becoming more attractive, meeting someone special, and eventually having their dream wedding. This type of story speaks to the deeply ingrained aspirations of that particular age group, and helps create a strong mental association between making the switch to alternative beverages and desirable outcomes. Similar stories tailored for each demographic would be used to capture attention from that audience.
In summary, the approach of the New York City Soda Ban to curbing sugary beverage consumption is ineffective at best. It discounts the complex social and environmental reasons people engage in consumption, incorrectly assumes that people’s best intentions actually lead to the appropriate actions when faced with the choice, and does not provide viable alternatives to the current beverage paradigm. A campaign of intervention is needed that strikes individuals enough to change how they think about sugary beverages, a precursor to long-term behavioral change . A successful campaign needs to get people to associate healthy alternative beverage consumption with desirable outcomes, which will increase adoption of those alternatives and set that consumption behavior on a path toward becoming the new social norm. Once healthy alternatives are adopted as the social norm, the pervasive and harmful over-consumption of soda can be a thing of the past.
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