Processus politiques et débats associés à la taxation des boissons sucrées en santé publique : du cas français à la situation canadienne

Parmi d’autres interventions visant à promouvoir une saine alimentation et prévenir les maladies chroniques, la taxation des boissons sucrées est recommandée et près de 50 juridictions à travers le monde l’ont adoptée au cours des 15 dernières années. Pourtant, cette mesure reste controversée. Après une introduction sur le concept de taxe nutritionnelle, le 1er chapitre de cette thèse analyse la pertinence d’une taxation des boissons sucrées en santé publique, puis les chapitres 2 et 3 approfondissent les processus politiques et débats associés à cette mesure dans deux pays : la France, où une taxe a été adoptée, et le Canada, où les discussions se poursuivent. Adapté d’un ouvrage publié en 2016, le 1er chapitre est une synthèse de connaissances intégrant des données issues de multiples disciplines dans un cadre d’analyse en 3 volets (bien-fondé, effets potentiels, applicabilité). Tout en pointant les aspects devant être davantage évalués, l’analyse indique qu’une taxation des boissons sucrées pourrait faire partie d’un éventail de politiques nutritionnelles, y compris au Canada. Une consommation excessive de ces boissons est associée à un risque accru de gain de poids, de carie dentaire et de diabète de type 2. Les taxes qui les visent tendent à générer des hausses de prix qui, lorsqu’elles sont significatives (≥ 10%), sont généralement suivies de baisses d’achat. Dans certains cas, cette mesure pourrait aussi encourager les fabricants à réduire la teneur en sucres de leurs produits. La taxation des boissons sucrées est également un moyen de générer des recettes. Son acceptabilité par le public, plutôt faible, tend à augmenter si ces revenus sont réinvestis au bénéfice de la population. Toutefois, taxer les boissons sucrées soulève des préoccupations éthiques, d’équité, de faisabilité juridique et d’acceptabilité politique dépendantes du contexte. Le 2ème chapitre met l’accent sur l’importance d’analyser le processus d’élaboration d’une « taxe soda », puisqu’il sous-tend sa conception, son éventuelle adoption et ses effets potentiels. Il existe peu d’études en la matière. L’étude du cas français (2005-2012) s’appuie sur une recension d’articles de presse et de documents institutionnels ainsi que sur une analyse thématique guidée par la théorie des courants multiples de Kingdon. Elle met en évidence plusieurs conditions ayant contribué à ouvrir une « fenêtre politique » en 2011: l'annonce a été faite par le gouvernement dans un contexte de déficits budgétaires importants ; des scénarios de taxe avaient été élaborés par le passé ; le projet de loi a été appuyé par des politiciens convaincus. Ensuite, diverses conditions (réaction vive mais désorganisée de l'industrie, intérêt des députés pour les recettes générées) ont favorisé l’adoption de la taxe, mais au détriment de sa finalité initiale de santé publique. Tenant compte de la littérature internationale, la discussion identifie divers facteurs pouvant éclairer les acteurs de santé publique souhaitant influencer le processus d’élaboration d’une « taxe soda ». Le 3ème chapitre se penche sur la situation canadienne. Afin d’explorer en quoi le débat public a pu freiner l’élaboration d’une taxation des boissons sucrées ces dernières années, une analyse de cadrage dans la presse écrite (2007-2016) a permis d’apprécier le poids respectif des positions pro- et antitaxation, le type d’acteurs qui en sont à l’origine et leurs argumentaires. Une recherche d’articles de presse a conduit au recensement de 762 positions. Les résultats mettent en évidence un nombre de positions plus important en 2016 (n=234), à l’échelle fédérale (n=267) et au Québec (n=254). Les « pics de positions » mensuels (n ≥ 10) dans ces deux juridictions révèlent un portage politique limité, un contexte politique et économique peu favorable, et des efforts de plaidoyer d’organisations « prosanté » qui n’ont pas semblé réunir le soutien suffisant pour faire basculer le débat en leur faveur. Advenant l’ouverture d’une « fenêtre politique », cette étude apporte un éclairage sur des éléments de cadrage susceptibles de « résonner » dans le débat public tout en étant compatibles avec les données probantes les plus prometteuses quant à la pertinence d’une telle taxe. Finalement, la conclusion intègre les enseignements des trois chapitres en soulignant l’intérêt d’avoir mobilisé différentes perspectives théoriques et disciplinaires, résume les conditions qui influencent l’élaboration d’une « taxe soda », et revient sur les enjeux d’une telle recherche pour soutenir les processus de décision.Among other interventions aimed to promote healthy eating and prevent chronic diseases, sugarsweetened beverage taxation has been recommended and nearly 50 jurisdictions around the world have adopted such a tax over the past 15 years. However, this measure remains controversial. After an introduction on the concept of health-related food taxation, the first chapter of this thesis analyses the relevance of taxing soda for public health, then chapters 2 and 3 focus on the political processes and debates associated with this measure in two countries: France, where a tax has been adopted, and Canada, where discussions are still ongoing. Adapted from a book published in 2016, Chapter 1 is a knowledge synthesis integrating data from multiple disciplines into a three-part analytical framework (rationale, potential effects, applicability). While identifying areas for further evaluation, the analysis indicates that sugar-sweetened beverage taxation could be part of a portfolio of nutrition-enhancing policies, including in Canada. Excessive consumption of these drinks is associated with an increased risk of weight gain, dental caries and type 2 diabetes. Taxing sugar-sweetened beverages tends to generate price increases which, when significant (≥ 10%), are generally followed by purchase reductions. In some cases, this measure could also encourage manufacturers to reduce the sugar content of their products. Soda taxation is also a way to generate revenue. Its acceptability to the public, which is rather low, tends to increase if these revenues are reinvested for the benefit of the population. However, soda taxes raise ethical and equity concerns, legal feasibility challenges and political acceptability issues, depending on the context. Chapter 2 emphasizes the importance of analyzing the policy process of a soda tax, as it underlies its design, possible adoption and potential effects. There are few studies on this subject. The French case study (2005-2012) is based on a review of press articles and institutional documents as well as a thematic analysis guided by Kingdon's multiple streams theory. It highlights several conditions that contributed to opening a "policy window" in 2011: the announcement made by the government occurred in the context of severe budgetary deficits; tax scenarios had been developed in the past; the bill was supported by convinced political leaders. Then, various conditions (strong but disorganized reaction from the industry, interest of Deputies in the revenues generated) favoured the adoption of the tax, but to the detriment of its initial public health purpose. Taking into account the international literature, the discussion identifies various factors that may inform public health actors wishing to influence soda tax policy processes. Chapter 3 focuses on the Canadian situation. In order to explore how the public debate may have hindered the elaboration of a soda tax in recent years, a framing analysis of the topic in the media was conducted (2007-2016) to assess the respective weight of pro- and anti-taxation positions, the type of actors they originate from and their arguments. A total of 762 positions have been identified from the review of press articles. The results show a larger number of positions in 2016 (n=234), at the federal level (n=267) and in Quebec (n=254). The monthly "peaks of positions" (n ≥ 10) in these two jurisdictions reveal limited political support, an unfavourable political and economic context, and advocacy efforts by "pro-health" organizations that did not seem to gather sufficient support to shift the debate in their favour. Should a "policy window" open, this study sheds light on framing elements that may "resonate" in the public debate while being compatible with the most promising evidence regarding the relevance of such a tax. Finally, the conclusion integrates lessons from the three chapters, emphasizes the interest of having mobilized various theoretical and disciplinary perspectives, summarizes key conditions influencing the elaboration of a soda tax, and discusses how such a research may contribute to inform decisionmaking processes

Soda Taxes: The Importance of Analysing Policy Processes Comment on “The Untapped Power of Soda Taxes: Incentivising Consumers, Generating Revenue, and Altering Corporate Behaviours”

Abstract Sarah A. Roache and Lawrence O. Gostin’s recent editorial comprehensively presents soda taxation rationales from a public health perspective. While we essentially agree that soda taxes are gaining momentum, this commentary expands upon the need for a better understanding of the policy processes underlying their development and implementation. Indeed, the umbrella concept of soda taxation actually covers a diversity of objectives and mechanisms, which may not only condition the feasibility and acceptability of a proposal, but also alter its impact. We briefly highlight some conditions that may have influenced soda tax policy processes and why further theory-driven case studies may be instructive

The Science Case for Multi-Object Spectroscopy on the European ELT

This White Paper presents the scientific motivations for a multi-object spectrograph (MOS) on the European Extremely Large Telescope (E-ELT). The MOS case draws on all fields of contemporary astronomy, from extra-solar planets, to the study of the halo of the Milky Way and its satellites, and from resolved stellar populations in nearby galaxies out to observations of the earliest 'first-light' structures in the partially-reionised Universe. The material presented here results from thorough discussions within the community over the past four years, building on the past competitive studies to agree a common strategy toward realising a MOS capability on the E-ELT. The cases have been distilled to a set of common requirements which will be used to define the MOSAIC instrument, entailing two observational modes ('high multiplex' and 'high definition'). When combined with the unprecedented sensitivity of the E-ELT, MOSAIC will be the world's leading MOS facility. In analysing the requirements we also identify a high-multiplex MOS for the longer-term plans for the E-ELT, with an even greater multiplex (>1000 targets) to enable studies of large-scale structures in the high-redshift Universe. Following the green light for the construction of the E-ELT the MOS community, structured through the MOSAIC consortium, is eager to realise a MOS on the E-ELT as soon as possible. We argue that several of the most compelling cases for ELT science, in highly competitive areas of modern astronomy, demand such a capability. For example, MOS observations in the early stages of E-ELT operations will be essential for follow-up of sources identified by the James Webb Space Telescope (JWST). In particular, multi-object adaptive optics and accurate sky subtraction with fibres have both recently been demonstrated on sky, making fast-track development of MOSAIC feasible.Comment: Significantly expanded and updated version of previous ELT-MOS White Paper, so there is some textual overlap with arXiv:1303.002

In Centralized Health Systems, Much Is Left Out When Analyses of Local HiAP Strategies Are Limited to Public Administration; A Commentary on "A Realist Explanatory Case Study Investigating How Common Goals, Leadership, and Committed Staff Facilitate Health in All Policies Implementation in the Municipality of Kuopio, Finland"

International audienceWe argue that the lessons drawn by Guglielmin and colleagues (2022), from the Health in All Policies (HiAP) approach in the municipality of Kuopio, are of limited use to centralised health systems. There is a need for research more attuned to the circumstances of local governments that have little power over the provision of health programmes; yet can address a range of determinants of population health. In these cases, adopting a state-centric perspective may fail to capture the role of other actors such as NGOs and local branches of state agencies. Evidence from France shows that centralised health systems can foster HiAP locally through political commitment and dedicated coordination staff whose role is to mobilise and support NGOs, inhabitants, and other local branches of regional and central governments. We highlight, as three important challenges, the issue of legitimacy, funding and positioning of the HiAP instrument in the local government structure

Collaboration of primary care and public health at the local level: observational descriptive study of French local health contracts

International audienceAim: In this paper, we report on a study investigating the involvement of primary care providers in French local health contracts. Background: Worldwide actions are carried out to improve collaboration between primary care and public health to strengthen primary healthcare and consequently community health. In France, the local health contract is an instrument mobilising local stakeholders from different sectors to join in their actions to improve the health of the population. Methods: We developed an instrument to analyse the frequency and nature of involvement of primary care providers in 428 action plans extracted from a sample of 17 contracts (one per French region). The number of primary care actions were counted, and thematic analyses were conducted to identify the nature and level of involvement of the professionals. Findings: Primary care providers were involved in 20.1% (n = 86) of the action plans and were mostly described as a target of the action rather than leaders or partners. Within those action plans, 76.7% (n = 66) of these action plans aimed to improve access to care for local communities; an issue that appears as the main driver of collaboration between public health and primary care actors

Coordination et mobilisation des acteurs locaux dans les Contrats locaux de santé des régions Bretagne et Pays de la Loire

Within the framework of the inter-regional health research, evaluation and expertise scheme (DIREES), EHESP was awarded a mandate to study Local Health Contracts (CLS) by the ARS Bretagne and Pays-de-la-Loire. The first part of the mandate aimed to improve the understanding of the impact and added value of the CLSs deployed in their territories in terms of health promotion and environmental health.The second part, which is the subject of this report, aimed to understand the issues relating to the management and mobilisation of actors within a CLS in order to improve their actions to tackle social inequalities in health.Dans le cadre du dispositif inter-régional de recherche, d’évaluation et d’expertise en santé (DIREES), un mandat portant sur les Contrats Locaux de Santé (CLS) a été octroyé à l’EHESP par les ARS Bretagne et Pays-de-la-Loire. Son premier volet visait à améliorer la compréhension des impacts et de la plus-value des CLS déployés sur leur territoire en matière de promotion de la santé et de santé environnement.Le second volet, faisant l’objet du présent rapport, visait quant à lui à saisir les enjeux relatifs au pilotage et à la mobilisation des acteurs au sein d'un CLS afin de tendre vers une amélioration de leurs actions visant à lutter contre les inégalités sociales de santé

How primary care and public health interact in local health contracts in France?

International audienceThe demographic and epidemiological changes orient health care services towards communities with a focus on prevention and health promotion. Moreover, in France, the rapid decline of General Practitioners affect access to care in certain areas. Thus, it has made a call for interaction of primary care (PC) services and public health which can be strengthened by the actions at the local level. In 2009, the local health contracts (Contract local de santé; CLS) were developed to foster collaborative actions on the social determinants of health and to improve access to care. Considering the critical contribution of PC in these issues, one may ask how CLS mobilized PC and facilitate linkages between actions oriented toward population and primary care.The objective of this ancillary study (part of the CloterreS project), is to explore how often and how CLS involve PC in access to care and public health related actions.A mixed-method study based on document analysis, with a random sample of 17 CLSs (N = 165) from all French regions, was developed. A quantitative analysis of the 440 forms identified in 17 CLS computed frequency of involvement of PC actors and/or PC organizations and a qualitative analysis defined typology of interactions.All CLS and 20.1% (n = 86) of the forms involved PC actors and 43.2% (n = 185) concerned access to care. Of the access to care forms, 35.7% (n = 66) concerned PC. The most common strategies related to actions on the health workforce and on planning of services. The role of primary care professionals was as the target of the action and rarely as leader and partner.PC, mostly GP’s involvement, had a big place and access to care was at the core of local health contracts. The impact of CLS as an instrument to invite interaction public health and healthcare at the local level should be further assessed

L'effet réseau alimente des actions collectives de prévention en santé très significatives

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Conditions influencing the adoption of a soda tax for public health: Analysis of the French case (2005–2012)

International audienceAlthough over 40 jurisdictions have adopted a tax on sugar-sweetened beverages (SSBs) for public health worldwide, it is still debated in many places. Policy processes can influence the prospect of an SSB tax, its design and its public health benefits. To get an insight into such processes, we undertook a case study of the soda tax enacted in France on the 1st of January 2012. Newspaper articles (2003–2013) and institutional documents (2007–2012) were identified using keywords and search engines. Qualitative data extraction and analyses were performed on a thematic and chronological basis, with guidance from Kingdon’s multiple streams theory (MST). Triangulation was enhanced by using complementary sources. This study shows that in August 2011, the French government surprisingly announced a €3.58 cent/L excise tax on SSBs, excluding juices with no added sugars and non-calorically sweetened beverages (NCSBs). As part of a large budgetary plan, the proposal aimed to reduce SSB consumption and raise revenue that was earmarked for health care. Several conditions contributed to opening a policy window: The announcement occurred in the context of severe budgetary deficits; soda tax scenarios had already been discussed at a high level; and the bill was supported by convinced political leaders. Subsequently, the tax successfully passed through the legislative process due to a series of unexpected events, but its public health rationale and design were weakened. The first event was the disorganised reaction by the food industry, despite their sharp opposition to the tax. The next event was the support of the soda tax that came from a majority of Deputies, provided that the revenues would serve another purpose: relieving wage costs in the farming sector. Finally, policy entrepreneurs favoured a compromise to make the tax politically acceptable and legally viable: The tax rate doubled, the scope was extended to NCSBs and revenues were split between health care and agriculture. This study sheds light on influence factors that could be taken into account by public health actors willing to influence soda tax policy processes