Sugar tax and product reformulation proposals reduce the perceived legitimacy of health-promotion institutions: a randomized population-based survey experiment

Background: Structural nutrition interventions like a sugar tax or a product reformulation are strongly supported among the public health community but may cause a considerable backlash (e.g. inspiring aversion to institutions initiating the interventions among citizens). Such a backlash potentially undermines future health-promotion strategies. This study aims to uncover whether such backlash exists. Methods: We fielded a pre-registered randomized, population-based survey experiment among adults from the Longitudinal Internet Studies for the Social Sciences panel (n ¼ 1765; based on a random sampling of the Dutch population register). Participants were randomly allocated to the control condition (brief facts about health-information provision/nudging), or one of two experimental groups (the same facts, expanded with either a proposed sugar tax on or reformulation of sugar-sweetened beverages). Ordinary least squares regression was used to estimate the proposed interventions’ effects on four outcome variables: trust in health-promotion institutions involved; perceptions that these institutions have citizens’ well-being in mind (i.e. benevolence); perceptions that these institutions’ perspectives are similar to those of citizens (i.e. alignment of perspectives); and attitudes toward nutrition information. Results: Trust, perceived benevolence and perceived alignment of perspectives were affected negatively by a proposed sugar tax (−0.24, 95% CI −0.38 to −0.10; −0.15, −0.29 to −0.01; −0.15, −0.30 to 0.00) or product reformulation (−0.32, −0.46 to −0.18; −0.24, −0.37 to −0.11; −0.18, 0.33 to −0.03), particularly among the non-tertiary educated respondents. Conclusions: Sugar taxes or product reformulations may delegitimize health-promotion institutions, potentially causing public distancing from or opposition to these bodies. This may be exploited by political and commercial parties to undermine official institutions.