Impact of sin taxes on consumption volumes of sweetened beverages and soft drinks in Saudi Arabia

Background: The consumption of sweetened drinks plays a major role in increasing the burden of diseases such as obesity and cardiovascular diseases. The prevalence rate of obesity and overweight individuals in Saudi Arabia has increased alarmingly among children over the past decade, revealing a crucial need the initiate and monitor effective prevention measures of obesity. Hence, this paper aims to measure the impact of sin taxes of sugar-sweetened beverages on the consumption level of such beverages in Saudi Arabia. Building enough evidence to guide other countries in the Eastern Mediterranean Region (EMR) on how to reduce the level of sugar intake consumption to reduce obesity and malnutrition has an impact on the economy as a whole. Methods: The excise taxes on sugar-sweetened beverages were applied in 2017. The impact of this was measured using a time series data set that covered sales volumes of soft drinks in Saudi Arabia from 2010 to 2020. Results: Sin taxes had a significant negative impact on the sales volume over the years. A significance level of <1% was found as sales volume of soft drinks decreased by 57.64% from 2010 to 2017 when sin taxes were applied on energy and soft drinks. Conclusions: Sin tax policy is recommended to other countries in the EMR to reduce obesity levels among children. These recommendations advocate the recommended priority actions by the World Health Organization for the strategy on nutrition for the EMR 2020-2030.


Introduction
Sugar-sweetened beverages are well-known to be related to adverse health outcomes as they are considered a significant source of excess caloric intake (Fidler Mis et al., 2017). The consumption of such sweetened drinks, especially those containing fructose, plays a major role not only in increasing the calories, but also in increasing the burden of diseases such as obesity, cardiovascular diseases, fatty liver disease, and increased blood pressure. Multiple problems can occur in obese children, such as the high risk of having sleep disordered breathing (Paglia et al., 2019). Further, consuming large quantities of sugar is associated with adverse health outcomes such as attention deficit disorder and hyperactivity disorder (Del-Ponte et al., 2019;Johnson et al., 2011). Children are categorized as overactive when they cannot sit still, cannot concentrate, cannot keep silent, and leave one unfinished activity and move to the next (Bellisle, 2004).
The impact of sugar-sweetened beverages has been also measured on children's cognitive level using the Kaufman Brief Intelligence Test. The results showed that as the consumption of sugar-sweetened beverages increases, the verbal scores of the mid-childhood Kaufman test decreases. On the contrary, there was a positive association between fruit consumption and higher cognitive scores (Cohen et al., 2018). These facts demonstrate the negative impact of sugar-sweetened beverage consumption on the cognition level of the children, showing that it is directly related to their productivity in schooling performance, which is eventually reflected in their productivity and income level in the future.
The increased risk of gaining weight caused by the sugar contained in many drinks, such as soft drinks and energy-rich drinks, has been proved in many longitudinal studies and clinical trials. It should be noted that there were no significant differences in gaining weight recorded when sucrose was replaced with low-calorie artificial sweeteners. However, some of the artificially sweetened drinks can increase the risk of diabetes and may lead to weight gain and obesity (Al-Jawaldeh et al., 2018).
Eastern Mediterranean Region (EMR) policymakers have been advised to measure the levels of current free-sugar intake in drinks and foods given the emphasized importance of reducing sugar intake in areas where there is malnutrition. Also, the adoption of measures and policies became a necessity given that 60% of our daily energy intake is constituted from carbohydrates, such as refined cereals and sugars (Al-Jawaldeh et al., 2018).
The high prevalence of obesity and overweight adults and children has been observed in the EMR, with the highest prevalence of regional diabetes rates worldwide. These facts spotlight the high rates of overweight children in the region as it has been observed in some countries that more than 15% of children are affected (World Health Statistics, 2016).
Saudi Arabia is among the Gulf Cooperation Council (GCC) countries that has experienced a high prevalence rate of obesity and overweight; reaching 13.4% and 18.2% of overweight and obesity, respectively (Alqarni, 2016). The prevalence rate of obesity and overweight individuals has increased alarmingly among children in Saudi Arabia over the past decade, revealing a crucial need to initiate and monitor effective prevention measures of obesity (Al-Hussaini et al., 2019). Mexico reached the highest consumption level of sugarsweetened beverages worldwide in 2012 (Valadez, 2013), which was linked to the high prevalence rates of obesity and overweight individuals -30% of children and 71% of adults (Barquera et al., 2013;Encuesta Nacional de Salud y Nutrición (2012). Evidence showed that 71% of the consumption of added sugars was derived from sugar-sweetened beverages (Sánchez-Pimienta et al., 2015). The Mexican government reacted by setting sugar-sweetened beverages taxes in order to reduce their consumption, leading to a reduction in the high rate of obesity/overweightness. In addition, studies showed that such taxes decreased the consumption of sugar-sweetened beverages in Mexico (Colchero et al., 2016;Pan American Health Organization, 2015).

World Heahlth Organization recommendations and fiscal policies
Resilient and sustainable food systems for healthy diets are one of the main nutrition strategies of the United Nations Action on Nutrition. The EMR of the World Health Organization (WHO) has developed an action plan and policy statement for sugar reduction based on the guidelines of the WHO, considering the energy intake per person that exceeded 2000 kcals/day in all regional countries (Alwan et al., 2017). Hence, the average intake of sugar should be decreased by more than 50% for adults and children (WHO, 2020).
The WHO recommends the use of well-designed subsidies and taxes in order to incentivize the consumption and production of healthier drinks and foods. One of the vital Eastern Mediterranean regional initiatives that have been developed to support the actions for obesity prevention 2019-2023 is the implementation of fiscal measures. These fiscal measures include the implementation of applying taxes on sugar-sweetened drinks, as well as other subsidies and taxes that promote healthier diets (WHO, 2019).

Objective
The objectives of this study were as follows: 1. Provide an overview of the impact of interventions to discourage sugar intake and reduce the consumption level; 2. Measure the impact of sin taxes on the sales and consumption level of sugar sweetened beverages in Saudi Arabia, one of the countries in the Mediterranean region who applied excise taxes on these products.

Amendments from Version 1
There are no major differences in the new version of the article except of more recommendations added at the end of the article.

Data collection
This paper measured the impact of sin taxes on sugarsweetened beverages using a time series data set that covered sales volumes of soft drinks in Saudi Arabia from 2010 to 2020. The data were secondary data collected by Global Company Intelligence (GCI), which is a company that specializes in collecting data from national governments and international industrial companies.
The authors requested GCI to create a report with the following variables concerning Saudi Arabia for the period 2010 to 2020: value of soft drinks in million dollars and local currency of Saudi Arabia per year, consumption of soft drinks in million liters per year, percentage growth from previous period to current period in million liters, and percentage growth from previous period to current (PP Growth %). The dataset created by GCI can be found in Underlying data. The impact of sin taxes has been tested via the following model: Where SalesVol t refers to the sales volume in million liters and Price t refers to the price of soft drinks in million US dollars.
Data analysis STATA 16.0 was used to conduct descriptive statistics and data anlaysis. Subsequently autocorrelation of the sales volume trends over the years was tested. Finally, the impact of sin taxes on sales volumes was been tested via regression analysis after testing for normal distribution of the time series of both dependent and independent variables using the Shapiro-Wilk test.

Results
In Saudi Arabia, the obesity rate has doubled over the past decade (Al-Hussaini et al., 2019). This lead to vital actions taken by Saudi policymakers, such as imposing 50% excise taxes on sweetened-soft beverages in 2017, as a response to the proposed policy priorities that have been recommended by the EMR-WHO to prevent diabetes and obesity in the region (Alwan et al., 2017).  Figure 1a); however, the percentage change of the sales volume (PP growth) started to decrease sharply in 2017, the year that sin taxes were applied to the prices of soft drinks (Figure 1b).

Testing autocorrelation over time
In Table 2, autocorrelation shows that the time series has been divided into three lags indicating three stages of PP growth. The results show that the impact of sin taxes in reducing sales volume over time and the trend between the three lags is statistically significant (P<0.05).

Testing normal distribution of the variables
The normal distribution of sales volume, the growth rate of sales volume, as well as the value of soft drinks have been tested before estimating a regression model using the Shapiro Wilk test. H 0 assumes a normal distribution of the variables. Table 3 shows that the time series of all variables are normally distributed, which qualifies them to be used in the regression models.
The results show that sin taxes have a significant negative impact on the percentage volume growth over the years with a significance level <1% and high R 2 of around 68%, which reflects that the model estimates the impact of sin taxes at 68% (Table 4).

Discussions
The prevalence rate of obesity and overweightness has increased alarmingly among children in Saudi Arabia over the past decade, leading to a crucial need for intervention (Al-Hussaini et al., 2019). Evidence shows that there is a positive relationship between the consumption of sugar-sweetened beverages and the prevalence rate of obesity and overweightness (Paglia et al., 2019). Hence, EMR of the WHO recommended governments  to introduce a sustainable reduction of sugar intake over the coming 3-4 years. Considerable reductions of sugar intake should be 50% or more to terminate the increase in obesity and diabetes to decrease the burden of premature deaths, as non-communicable diseases are expected to reach 25% by 2025 (WHO, 2020). These facts were alarming enough for the WHO to set their action plans for the nutrition strategy 2020-2030 (WHO, 2019), which recommended the implementation of taxes on sugar-sweetened beverages to reduce obesity rates in various nations.
These facts were inspiring enough to study the impact of sin taxes that have been applied to sugar-sweetened beverages in one EMR country, Saudi Arabia, in 2017. The current study is consistent with the regional WHO recommendations to apply the United Nations Political Declaration on Non-Communicable Diseases, the priority legal interventions that target the prevention of non-communicable diseases in the EMR ( The results showed that the rate of change in the sales volume over the last decade in Saudi Arabia started to decrease sharply in 2017, the year the sin taxes have been applied to the prices of soft drinks. Sales volumes from 2017 were increasing but at decreasing rates, and the sin tax had a significant negative impact on the change of sales volumes over the past 10 years. These results are in line with the nutrition strategies of the United Nations of Action on Nutrition that was based on evidence and experimental studies, which observed effective fiscal measures of taxes and subsidies in shifting habits of purchases and promotion of dietary change (Thow et al., 2014;WHO, 2015a;WHO, 2016). This is expected to decrease the obesity levels among Saudi children over the coming years. Improvements in children's health are expected to be reflected in better cognition, intelligence, and schooling performance of the children. Moreover, this study showed a decrease of around 57% of the percentage change of sales volume, which aligns with previous evidence from countries that applied taxes and reduced the purchases of sugar-sweetened beverages in a range of 20-50% (Colchero et al., 2016;Ells et al., 2015;Mozaffarian et al., 2012;Powell et al., 2013;Thow et al., 2014;WHO, 2015b;WHO, 2016).
Limitations of this research were not knowing the nutrition status of the children after imposing the sin taxes, and limited analysis using simple linear regression that does not consider any confounding factors.

Conclusions and recommendations
Recently, the WHO shed light on the importance of reducing obesity among children in the EMR given the high rate that has been observed lately. One intervention that was suggested is to impose taxes to sugar-sweetened beverages (Lobstein, 2014). The impact of applying such an intervention has been previously shown to have a positive impact in reducing the level of consumption of sugar-sweetened beverages in GCC countries. Hence, such a policy is recommended to extend to cover other countries in the EMR. In addition, public health education should be considered using social marketing campaigns and restriction of media advertisements about sugar-sweetened beverages, and guide the manufacturers to impose compulsory information of health risks on the front of pack labels of SSBs. This should support the imposition of sin taxes, as recommended by Lobstein (2014). In addition, schools and pre-schools should support such policy by encouraging the consumption of water and discouraging the intake of sweetened beverages that should not be available by educational and behaviour changing programs. Such actions should be supported by parents who should abide the availability of SSBs at home and avoid its consumption to please their children. These recommendations advocate the recommended priority actions by the WHO for the strategy on nutrition for the EMR 2020-2030 (WHO, 2019).
Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

Ali Arabi
Faculty of Veterinary Medicine, University of Khartoum, Khartoum, Sudan The introduction: There are many repeated phrases concerning obesity and overweight -the authors need to shorten.
○ An introduction should include other problems like caries and enamel erosion, short sleep duration, hyperactivity, increased blood pressure and non-alcoholic fatty liver disease. High sugar content and low pH render SSB is a real threat to the developing dentition.

○
Methodology and results are okay.
In recommendations the authors should also include: Advertising of SSBs to children should be banned.

○
The introduction of compulsory information on the front of pack labels of SSB on health risks should be considered.

At School:
Educational and behaviour-changing programs on appropriate choices of beverages and encouraging water consumption should be implemented in pre-schools and schools.

○
Pre-schools and schools should offer unlimited access to drinking water, for example, by water fountains, whereas SSBs and other sweet beverages should not be made available.

Parents:
Parents should avoid the use of SSBs to please their children.
○ SSBs should not be easily available at home.

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility? Yes

Are the conclusions drawn adequately supported by the results? Yes
© 2020 Hoteit M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Maha Hoteit
Faculty of Public Health, Nutrition and Dietetics Department, Lebanese University, Hadath, Lebanon Sin tax is a tool that contribute to enhancing consumer behavior and if implemented can have a positive health impact on the population. In general, the decisions taken at the governmental level in terms of the introduction of new taxes, should be supported by reliable analyses and this paper is a good evidence to show the improvement of the countries to reduce the intake of sugar through the decrease in consumption of soft drinks that is responsible of aggravating the prevalence of obesity in EMR. The results of this study highlighted the sharp decrease in 2017, the year when the sin taxes have been applied to the prices of soft drinks and the sin tax had a significant negative impact on the change of sales volumes over the past 10 years. This manuscript is well written that reflect background literature on soft drink consumption in Saudi Arabia and highlight the importance of implementing sin taxes in all GCC.

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility? Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.