Introduction

Obesity is widespread in the Kingdom of Saudi Arabia (KSA). According to the findings from previous studies, there is an increasing trend in the prevalence of obesity and overweight in the KSA ^1,2. The National Nutrition Survey reported that the KSA is the 15th most obese country in the world, with an overall obesity rate of 33.7% ³. Research on the relationship between obesity and health problems has indicated that being overweight or obese might increase the risk of cardiovascular disease (CVD), diabetes mellitus (DM), cancer ², and other diseases ⁴.

There are many factors that may influence the risk of obesity and other health-related problems. Dietary components are one of the most important factors that should be considered in obesity and health-related problem processes ⁵. In recent years, soft drinks and energy drinks have become the common dietary components and have become highly visible and controversial public health and public policy issues worldwide. Both drinks have been shown by many studies as major contributors to an increased risk of obesity and other related health problems and have consequently been targeted as a means to help curtail the increasing prevalence of obesity ^6,7.

One method that has been used widely to decrease SD and ED consumption is a taxation system. The aim of this system is to reduce the consumption of high-calorie beverages and to shift from unhealthy to healthy choices by subsidizing healthier drinks such as fruit and vegetable juices; the system is also implemented for economic reasons ^8,9. In 1930, Denmark was the first country to implement soft drink and juice taxation. After that, other countries used the same method, such as Finland and Hungary in 2011, France in 2012 ¹⁰, Mexico in 2013 ⁶, the United Kingdom in 2016 ¹¹, and Berkeley, California in 2014 ¹².

Trend studies indicate the high consumption of SDs and EDs among Saudis in different age groups in both sexes ^13–16. The General Authority of Zakat and Tax (GAZT) is one of the main sectors responsible for the implementation and management of all taxation affairs in the KSA. In January 2018, the GAZT applied a 100% tax on energy drinks and a 50% tax on carbonated drinks such as soft drinks. In the present study, the main aim was to assess SD and ED consumption patterns and knowledge about the link between health-related problems and SD and ED consumption after taxation. In addition, we assessed the characteristics of those who consume both SDs and EDs and the public level of support for an added 50% tax on SDs and 100% tax on EDs. Finally, we examined the public anticipated reaction to taxes on SD and ED. The aim of this study is to provide new data related to SD and ED consumption after taxation.

Materials and Methods

Study Design

This was a descriptive cross-sectional study that assessed adults’ knowledge, attitudes and practices toward SD and ED taxation. This study was conducted in three different food markets (Carrefour, Hyper Panda, and Mandarin) in Al-Madinah Al-Munawara in Madinah from February to March 2020. The study was approved by the research committee of research ethics at the University of Taibah, KSA (Number SREC/AMS 2019/95/NAMS).

Sampling

A total of 384 adults (192 male and 192 female) aged 18-45 years were randomly selected and recruited to participate in the study. All the participants provided informed consent prior to the study. Only those participants who were willing to participate in the study were included. All underweight, pregnant and lactating subjects were excluded from the study. Participants were interviewed for 20 minutes using a questionnaire by trained students. A structured questionnaire was developed based on its reliability in previous studies ^17,18. The questionnaire consisted of three sections: demographic characteristics, knowledge and attitudes about health-related problems associated with SD and ED consumption, and behaviors related to SD and ED consumption and taxation. Demographic characteristics included questions about sex (male, female), age in years (18-24, 25-39, 40-45), educational level (high school or less, some college, college graduate), physical activity (yes, no) and body mass index (BMI). BMI was computed as weight in kilograms and height in centimeters as weight/height². According to the values provided by World Health Organization classification in 2006, subjects were classified as underweight (BMI≤ 18.0), normal (BMI= 18.5-24.9), overweight (BMI= 25.0-29.9), or obese (BMI≥ 30.0) ¹⁹.

Data Collection

To assess the level of knowledge and attitudes about the effect of SD and ED consumption on health-related problems, participants were asked if they were drinking soft drinks or energy drinks every day. Then, they were asked true or false statements about whether drinking SDs and Eds can cause obesity or diseases such as diabetes, tooth cavities, and if there is a link between obesity and heart problems,  cancer,  blood pressure, and asthma.

To assess attitudes about taxing SDs and EDs, participants were asked, “Do you think taxation at a rate of 100% on energy drinks and 50% on soft drinks impeded you from consuming them?” (yes or no), “Related to the previous question, do you think you lost some weight because you are not consuming these drinks?” (yes or no), ” Do you think that taxation on energy drinks and soft drinks leads you to drink other alternatives?” (yes or no), “If so, which kind of alternative do you drink?” (water, fresh juices, canned juices), “Do you think that it is important for the government to implement taxation on the goods that are harmful to health?” (yes or no), and “Do you support SD and ED taxation?” (yes or no).

Statistical Analysis

The Statistical Package for Social Sciences (SPSS Ins., Chicago, IL, USA) version 25 was used to enter and analyze the data on a personal computer. Descriptive analyses were conducted to examine the association between demographic data and SD and ED consumption by the chi-square test. Logistic regression analyses were used to evaluate the correlates of SD and ED taxation support while controlling for the covariates.

Results and Discussion

A total of 384 participants were included in the present study. The majority of participants (52%) did not consume SD and were male (51%) and aged from 18-24 years old. On the other hand, 65% of participants of both sexes reported not consuming EDs, and their ages were approximately 18-39 years old. Over 75% of SD and ED consumers were either students or recent graduates of college, not physically active and had normal body weight. Although education and BMI were significantly affected by both SD and ED consumption, age was only significant in regard to SD consumption (Table 1 and 2).

Table 1: Characteristics of the Participants Categorized based on SD.

* Significant at the 5% level of significance: p<0.05.

Table 2: Characteristics of the Participants Categorized based on ED Consumption.

* Significant at the 5% level of significance: p<0.05.

The study found that 52% and 65% of the participants did not consume SDs and EDs in the past week after taxation, which is not consistent with previous studies from the KSA before taxation; approximately 60% of participants consumed sweetened soft drinks either daily or usually, which indicated a consumption level far exceeding the amount consumed in Western populations ^20–22. In fact, Benajiba et al ²⁰ reported that consumption has increased over the past decade, with increasing rates leading to various health problems among individuals of different ages in the KSA.

The analysis confirmed that a high percentage of participants reported non-consumption of SDs after taxation, especially among both sexes, those who were 18-24 years old, college students, those who were not physically active, and those with a normal body weight. These results are consistent with the results of different target populations from different countries, such as the United States of America (USA) ^7,17, the United Kingdom (UK) ²³, and Brazil ²⁴. All of these studies focused on testing the association between SD consumption and the risk of obesity and other health-related problems. Other studies focused on testing the association of soft drink taxes with purchases in different countries, such as the USA, the UK, Mexico, Catalonia, Chile, and France ²⁵.

On the other hand, we found that a high percentage of participants reported that after taxation, males, those who were aged 18-24 years old, college students, those who were not physically active, and those who had normal and overweight body weight were not consuming EDs. Previous research is consistent with the results except more males were not consuming EDs than females ²¹ because males usually consume EDs more than females; however, due to the taxation of 100% of the original price, males reduced their intake, or they may have become more knowledgeable about the effects of EDs on health.

The analysis of consumers’ knowledge of health-related problems associated with high consumption of SDs and EDs is shown in Fig 1. Over 90% of the participants believed that high consumption of SDs and EDs increased the risk of chronic disease, high blood sugar, obesity, and tooth cavities. A high percentage of the participants thought there was a link between obesity and heart problems, and over half of the participants thought there was an association between obesity and asthma and between obesity and cancer; the corresponding percentages were 90%, 58% and 50%, respectively.

Figure 1: Participants’ Knowledge about Health Effects of Drinking SDs and EDs (N=384). Click here to view Figure

When participants interviewed, they were asked about their attitude about SD and ED taxation; 69% stated that taxation on these beverages impeded their consumption, but 54% of them reported they did not lose any weight. Sixty percent of the participants reported that they drank other alternatives due to taxation on SDs and EDs, and water was the top alternative (56%), followed by fresh juices (29%) and canned juice 15%. Furthermore, 89% of the participants believed that the government should implement taxation on foods and beverages that are harmful to health (Table 3).

Table 3: Participants’ Attitudes about SD and ED Taxation (N=384).

The analysis of participants’ attitudes toward health-related problems of obesity and SD and ED consumption indicated that most of the participants were aware of the adverse effects of excessive consumption of SDs and EDs. These results may indicate improvements in Saudis’ health knowledge, especially regarding the effects of SDs and EDs on obesity-related health problems. We believe that this improvement in the health knowledge of the participants may have occurred due to the hard work and effort of health education specialists in both government and private sectors ²⁶ over the last decade. These sectors included hospital settings ²⁶ and other agencies such as the Saudi Food and Drug Authority in Saudi Arabia ²⁷, the Saudi Center for Disease Prevention and Control ²⁸, and professional associations in healthcare, which provide health education activities and programs that focus on providing ways to live a healthy lifestyle and improve the quality of life.

Stepwise multiple regression with adjusted odds ratios was performed, and the results are shown in Table 4 and Table 5. Overall, 56% of participants supported the implementation of a tax on SDs, with the greatest support among those aged 40-45, those with a higher level of education, and those who were overweight or obese (P<0.05). In addition, 60% of participants supported the implementation of a tax on EDs, with the greatest support among those aged 25-39 and those who were overweight or obese (P<0.05).

Table 4: The Odds Ratios of Support for Taxation on SDs by Demographic Characteristics.

† Model was adjusted for sex, age, income, education, and BMI.

* Significant at the 5% level of significance: p<0.05. OR: odds ratio; CI: confidence interval.

Table 5: The Odds Ratios of Support for Taxation on EDs by Demographic Characteristics.

† Model was adjusted for sex, age, income, education, and BMI.

* Significant at the 5% level of significance: p<0.05. OR: odds ratio; CI: confidence interval.

The results showed that due to taxation, most of the participants reduced their SD and ED consumption, and they replaced SDs and EDs with water. These results were consistent with the results from different countries, such as Fiji, Samoa, Nauru and French Polynesia ²⁹, the USA ³⁰, and Mexico ³¹. Most of these studies focused on questions regarding cross‐price elasticity, that is, how would an increase in SD and ED prices affect the consumption of non‐SDs and non-EDs? In addition, no studies have determined how consumers choose alternative beverage options to quench their thirst in place of SDs and Eds ³². Only one study in 2007 estimated the net reduction in daily energy intake of not consuming SDs and EDs. They suggest that replacing SD and ED consumption with either water, diet drinks, or other caloric beverages reduced daily energy intake by 9 kcal/day, 6 kcal/day, and 1 kcal/day for each unit of SD and ED consumption, respectively ³³.

The strength of the present study is that the sample size was calculated based on the method described by Krejcie & Morgan ³⁴, which makes the present study population unique and appropriate for investigating the knowledge, attitudes, and behaviors regarding SD and ED taxation in Al Madinah Al-Munawara. This study was the first to estimate the consumption of SDs and EDs after taxation. This study has several limitations. We could not determine a causal link between the impact of SD and ED taxation and other variables due to the cross-sectional study design. The data collection was based on self-reporting, which may increase the concern of underestimating because it has been reported that people underestimate their sugary food and beverage intake ³⁵. Finally, the predict that the actual impact of taxation is clear because it has already been implemented, but we could not compare the consumption before and after taxation because there were no available data to compare among adults in Al Madinah Al-Munawara in Madinah.

Conclusion

In terms of the main outcome, the evidence generally indicated low consumption of SDs and EDs among participants. We detected a substantial shift in the consumption of SDs and EDs reflected by reduced consumption and increased consumption of other alternatives. Additionally, most of the participants understood the beneficial effect of the removal of SDs and EDs from their diet, which may represent an appropriate public health message to support those interested in preventing weight gain as well as diseases. Moreover, a positive association between supporting SD and ED taxation and demographic characteristics of participants indicated higher health literacy, which is important for people because it affects their capacity to make decisions and take action to manage their health. These findings are subject to confirmation by further analysis among different age groups and in both sexes among adolescents and children.

Acknowledgment

The author would like to thank all subjects for their enthusiastic participation in the study.

Funding Sources

The author received no financial support for the research, authorship, and/or publication of this article.

Conflict of Interest

The author has no conflict of interest.

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