Potential effects of sugar-sweetened beverage taxation on oral and systemic health outcomes

to reduce sugar, and better access to safe drinking water, to cut SSB intake and reduce the burden of both oral and systemic diseases.The association between SSB consumption and oral disease is well established. SSBs, including sodas, energy drinks, and flavored beverages, are major dietary sources of free sugars and acidity that promote oral microbial dysbiosis, enamel demineralization, and dental caries (4,5). Their sugars are fermented by cariogenic bacteria such as Streptococcus mutans (6), producing organic acids that lower the oral pH and gradually dissolve tooth enamel, while their intrinsic acidity further accelerates enamel erosion and tooth decay. Multiple studies have shown a direct association between high added-sugar intake and the development and progression of periodontal disease, likely through local and systemic inflammation (7). A 2022 systematic review of 13 observational studies found that 11 reported a significant association between the frequent consumption of free-sugar-containing foods or SSBs and a higher incidence of periodontal disease (8). Similarly, an NHANES III analysis of 2,437 young adults aged 18-25 years found that higher added-sugar intake was significantly associated with an increased risk of periodontal disease (9). In addition, a recent systematic review and meta-analysis showed that reducing free-sugar intake significantly improved gingival health and reduced gingival inflammation, further supporting the inflammatory role of excessive sugar consumption in periodontal disease progression (10). Therefore, SSBs contribute to oral disease through both cariogenic and erosive Opinion Article pg. 4 mechanisms: their fermentable sugars, especially sucrose, promote acid production by dental biofilms, while their intrinsic acidity increases the risk of enamel erosion (11).The global economic burden of oral diseases is estimated to exceed US$710 billion annually, including approximately US$387 billion in direct treatment costs and US$323 billion in productivity losses, highlighting their major public health and socioeconomic impact (12). Oral diseases also significantly reduce quality of life and overall well-being. Direct oral healthcare costs vary widely, from about US$0.52 per capita in lower-income countries to roughly US$260 per capita in high-income countries (12). Dental caries is among the most common NCDs worldwide; according to the WHO, more than 530 million children have caries in primary teeth, and untreated caries in permanent teeth affect an estimated 2.4 billion people globally (13). Although highly preventable, dental caries remains a major public health challenge because of its effects on systemic health, its disproportionate burden on disadvantaged groups, and its substantial treatment costs (14). Limited access to oral healthcare also leads to large losses in productivity and human capital, often captured as indirect costs through absenteeism and presenteeism. These effects are reflected in higher DALYs and YLDs, underscoring the broad human and economic costs of oral disease (15).Increasing fiscal taxation on SSBs constitutes an evidence-based public health intervention. The underlying mechanistic rationale is that price increases at the Opinion Article pg. 5 upper end of the price distribution are likely to induce shifts in consumer dietary behavior, reducing the consumption of high-calorie, low-nutrient foods and SSBs.Consequently, this approach reduces the prevalence of lifestyle-and nutritionrelated NCDs, such as obesity and type 2 diabetes mellitus, while simultaneously generating fiscal resources that can be allocated to public health programs.SSBs successfully reduced the consumption of SSBs (16). However, ideological debates and political opposition, particularly strong industry lobbying, concerns about regressive impacts on low-income populations, and voter resistance to new taxes, have created significant challenges for advancing the taxation of SSBs on policy agendas and securing legislative approval worldwide (16). Despite these barriers, several countries have successfully implemented policy strategies to overcome regulatory challenges. For instance, Mexico earmarked tax revenue on SSBs to fund free drinking water in schools and public health programs, while the United Kingdom paired its Soft Drinks Industry Levy with transparency requirements and industry collaboration to encourage reformulation. In Brazil, framing the taxation of SSBs as part of a broader food security and child health agenda helped develop public support and reduce industry pushback. These examples illustrate how strategic framing, revenue earmarking, and multisectoral partnerships can enhance the political feasibility of the taxation of SSBs across diverse contexts. Soft Drinks Industry Levy, introduced in the United Kingdom in 2018, implements a tiered excise tax linked to sugar content. This policy has compelled soft drink manufacturers to reformulate their products by removing added sugar from retail shelves. One year after the implementation of the UK Soft Drinks Industry Levy, free sugar Opinion Article pg. 6 consumption decreased significantly among both children and adults. Daily free sugar intake from soft drinks decreased by approximately 3 g/day in children and 5 g/day in adults, indicating a beneficial effect on dietary sugar intake (17). It has been reported that total sugar sales from drinks decreased by 35.4%, from 135,500 tons in 2015 to 87,600 tons in 2019 (18). During the same period, the sales weighed average total sugar content decreased from 5.7 g per 100 ml in 2015 to 2.2 g per 100 ml in 2019, which is a decrease of 43.7% (Figure 1) (18). It should be noted that the -43.7% figure is Public Health England's Soft Drinks Industry Levy-specific, modelled reduction metric, not the simple percentage change in the sales-weighted average; of relevance, the arithmetic drop from 5.7 g to 2.2 g per 100 mL corresponds to approximately 61%. In Mexi