Table 6 Themes, sub-themes, and illustrative quotes from key stakeholder interviews

Awareness

 Knowledge and understanding of the tax

“Doing something as drastic as the sugar tax was, it did generate a lot of conversation in Bermuda.” (P03 Health)

“The aim was to make more money and dress it up as something it is not.” (P13 Food and Beverage)

“One [aim} was to create a dialogue around healthy eating… The second [aim} was to actually raise some money that we were going to use for various health initiatives.” (P14 Government)

“I don't think [the tax] is clear, completely, to me. And I certainly don't think it's clear to the public.” (P02 Health)

Beliefs about appropriateness and acceptability

 Taxation as a strategy for health promotion

“I think in some cases [sugar taxes] are a useful design and they can have a positive impact on our health as a population strategy. Yes, so I am in favour of them, [when rolled] out the right way, and in a way that's meaningful, and a way that gives back into programs that will further improve public health.” (P03 Health)

I'm 100% in favour of health regimes. I'm 100% in favour of control of obesity… By the same token, I also respect people's ability to choose.” (P11 Government)

I think it needs to be very clear where that money is being put afterwards and to what it has been put to use for. Then I think it's very acceptable. But this is not the case.” (P13 Food and Beverage)

 Tax mechanism and level

“We decided quickly that we weren't going to be able to [administer the tax] at point-of-sale because we don't have any tax structure that would allow that. And it would also, if we did put in infrastructure to facilitate that, it would wipe out any benefit of that the tax. It would be very expensive to implement.” (P14 Government)

“So the wholesalers import the goods and pay the 75%. And then they sell it to the grocery stores. And then the grocery stores sell it to [the consumer]. So then you have got all the different mark-ups or markdowns.” (P04 Government)

“There's no point-of-sale effect that you can say, ‘Oh, you know what, that's cheaper’. So I know I should have the diet or the sugar free one, so let me just go buy that because it's cheaper.” (P03 Health)

“The import duty on a sugary drink, I think is more than cigarettes, more than tobacco.” (P06 Food and Beverage)

“I think we're the only country in the world that has a rate this high.” (P04 Government)

 Intervention targets

“So, the question begged as to how carefully the implementation and the determination as to what categories would be covered. I don't believe that was well thought through.” (P11 Government)

“…what was so confusing, or frustrating, was that it didn't matter if it was 50 g of sugar per serving, or 0.5 g of sugar per serving.” (P07 Food and Beverage)

“…we were having items dutied that in our opinion had nothing to do with what the sugar tax should have been focusing on. Things like protein powders and smoothies were being hit with the tax.” (P01 Food and Beverage)

Beliefs about economic and equity impacts

 Impact on prices

“By the time the consumer goes to the shelves…the way that the cost was spread by the wholesalers and the retailers, creates virtually no price differentiation. In some instances, there is zero price differentiation between a diet soda and a regular soda.” (P09 Government)

“… the sugar tax, it just made the price of all foods go up. That's my personal experience and I've heard other people say the same thing.” (P08 Health)

“But that food right beside the one that was taxed when it landed, has gone up to absorb the price of the one that was taxed at 75%. So they have all gone up.” (P03 Health)

“Sugar or no sugar, this seems to be the excuse to be able to increase costs, across the board.” (P11 Government)

 Affordability of healthy food

“If a bag of apples is still going to be $9, then a Snickers bar at $1.85 is still going to be less expensive and may go into a kid’s lunchbox instead.” (P01 Food and Beverage)

“[Drinks that] have less than 1% sugar in them, but they’re still hit with the sugar tax. So at the end of the day if you really look at trying to push somebody from a [high-sugar soda] to a one gram [of sugar flavoured sparkling water], it’s very difficult to do that when they’re both hit with the same tax.” (P13 Food and Beverage)

 Impact on socioeconomic equality

“…all you're going to do by increasing the duty on [sugar-taxed items], is you're going to increase the ultimate price. And that's going to disadvantage the poorer consumer. Because people who only have a certain amount of disposable income, spend a disproportionately large amount on food and beverage.” (P07 Food and Beverage)

 Use of tax revenues

“The $1 million, $3 million that [the government] grossed in the first year [did not come] back directly into any specific new [health education] curriculum.” (P03 Health)

“Well what the government, and the Premier specifically, committed to was that all of [sugar tax revenue] would be used for health initiatives. Or health promoting initiatives. Or initiatives that would advance health… That side of things has not panned out quite as intended.” (P09 Government)

Beliefs about the effectiveness of the tax as a health promotion measure

 Impact on purchasing and consumption of sugar-taxed products

“We did observe through surveys that consumption of sugary items, of sodas in particular for which we had benchmark data, had gone down.” (P09 Government)

“People have just gotten used to paying whatever they’re paying for their sweet drink. Yeah, I’m not sure it has actually caused any lasting behaviour change.” (P14 Government)

“It’s naive to say that the implementation of the sugar tax has had a massive benefit because people buy less sugary sodas. That’s been on the decline for 10 years.” (P01 Food and Beverage)

“Nobody is going to tell me that if you have to pay more for your soda, and you pay more for your candies, that you’re going to forego those choices and buy some carrots.” (P11 Government)

 Impact on health outcomes

“No, I don’t think it will [have an impact on health] …it’s not a sustainable change for changing people’s behaviour around chronic disease risk factors.” (P14 Government)

“If we had specifically designed programmes and further education that were as a result of the revenue from [the tax], then perhaps we'll see an effect of that in improving health. (P03 Health)

“It was not well thought through, not well implemented; and therefore, it's our opinion that it has none of the advertised effect on the public health that it was supposed to.” (P12 Food and Beverage)

 Impact of the healthy food subsidy

“…when [the government says] they have reduced the duties on cauliflower or broccoli… it literally amounts to three or four cents a pound. Half of the products that they talk about are embargoed six to eight months a year. So there is no impact at all.” (P01 Food and Beverage)