The Domino Theory, Redux - NYTimes.com Imagine you had a multibillion-dollar industry that was (a) enormously profitable and (b) under frequent attack from public health researchers because (c) it's demonstrably bad for the health of your customers. This was, of course, the story of the tobacco industry, and it is - right now - the story of the sugar-sweetened beverage industry.[1] Like the cigarette makers, the peddlers of soda cannot do much about any of this: they owe it to their shareholders to maintain those profits, and the products they sell evidently cannot, no matter how hard they try, be tinkered with to change factors (b) and (c). Even if the beverage industry were composed of the nicest people in the world, it will not stop marketing to children unless it's made to; indeed, these marketing efforts are within the rules of the game, however deadly they may be. The outcome of those rules and the marketing they allow is pandemic obesity and all the costs associated with it, which have been detailed enough elsewhere to pass over here. The goal of right-thinking people, then, is to change the rules and somehow make it more difficult for the marketers to do their job. This can be done by legislation, executive mandate or - in some places, like California - referendum. Legislation to impose a significant tax on soda - a penny or even two per ounce - has failed everywhere, though it's come close, especially in Philadelphia. After failing to pass legislation for a soda tax, Mayor Michael Bloomberg proposed (and will evidently institute, five months from now) a ban on large sizes of soda in many New York City places. Now the California cities of Richmond and El Monte have put the soda tax - which has been endorsed by the United Nations, the American Heart Association, the American Medical Association, The New England Journal of Medicine, the Institute of Medicine and many others, and which the Centers for Disease Control and Prevention commissioner, Thomas Frieden, has called "the single most effective measure to reverse the obesity epidemic" - on the Nov. 6 ballot. Both of these are working-class, largely nonwhite cities, with populations of about 100,000. Richmond [3] , ranked sixth-most-obese city in the state, is in the East Bay, north of Berkeley; El Monte - which ranks ninth - is just east of Los Angeles, in the I-10 corridor.[4] Were either to institute a soda tax, the prediction here is that some or even many nearby cities would follow suit quickly, for two reasons. The first, almost immediate, is that these nearly broke municipalities would each gain a new source of income that could, according to the soda tax calculator developed by the economist Tatiana Andreyeva of the Rudd Center in New Haven, be about $3 million annually . The cities must decide how to spend these small windfalls. Dr. Jeff Ritterman, a retired cardiologist serving on the Richmond City Council, says that "for $86,000 we can teach every third grader how to swim at one of our municipal pools, and for $800,000 we can put a nutrition-gardening-cooking instructor in each of our 10 elementary schools." The longer-term benefit, which may take a year, or three, or even five to become evident and accepted, is health. Studies have shown that reduced soda consumption results in reduced weight. How quickly and how significantly a soda tax would reduce consumption remains to be seen. But without this kind of intervention, says Ritterman, "Our adult obesity rate will go from 24 percent to 42 percent when the present fifth and seventh graders reach adulthood." There's a third reason other cities will follow suit, and that's reputation. As a local observer said to me, "You don't think San Francisco is going to be out-done by Richmond, do you?" For all of these reasons, the first city to institute a soda tax will gain historic relevance and begin a kind of domino effect that proponents of public health can get behind. But it's not going to happen without a struggle; remember, the beverage industry has no choice. And while the proponents of the tax are largely volunteers, public health proponents and well-intentioned politicians (not an oxymoron!), the beverage industry has the bucks, and is spending them at a rate of about 100 to 1, in Richmond, at least: according to Ritterman, as of last week the industry had spent $2.2 million getting out the "no" vote; supporters had raised $34,000 and spent $29,000. Though Ritterman is optimistic ("We're going to win because truth and science are on our side"), El Monte's mayor, Andre Quintero, is more cautious: "The industry is spending very aggressively here: they have every single possible tool you can imagine having at their disposal." [7] El Monte, also, is a small city of less than 10 square miles, so businessmen argue that it's easy for their customers to leave to buy soda (or to eat, and order soda with a meal) in a neighboring town. "But," says Quintero, "even making that conscious decision - I'm going to step out of the boundary to get my sugary drinks - is going to work on the person and make them think, Is this a choice I really need to make?" That's the spirit: changing the rules to give people a reason to think, to consider, should change their behavior. The New York experiment may be effective, but most experts believe a tax is the way to go. Whether it's Richmond, El Monte, both, or someplace else, the first city to institute a soda tax will be the first domino to fall and eventually gain the gratitude of the rest of the country. I'll just call this "soda" from now on, but equally culpable are sugar-sweetened iced teas, so-called fruit juices, so-called sports drinks, so-called energy drinks, sweetened waters, coffee drinks with a calorie content like that of a banana split and anything else that has more sugar than you could ever imagine pouring into a cup of coffee. Just FYI, a 12-ounce soda contains up to 10 teaspoons of sugar; 12 ounces of Snapple is about the same; in fairness, Gatorade has "only" a little more than half as much sugar as that. A "tall" Frappuccino, by the way, contains 8 teaspoons of sugar. 2.This isn't a matter of building safer cars and putting seat belts in them, or of engineering cell phones so they won't receive texts while you're driving (that'll happen). At some point a wildly popular and safe substitute for sugar may be found, but at some point a safe cigarette might be invented, or indeed a pill that will allow you to eat supersized cheeseburgers, fries and cokes twice a day, and not gain a pound. The winning ticket in those lotteries is worth billions if not trillions of dollars, and "they're" working on it, but "they're" working on energy from fusion, too. Home of Rosie the Riveter National Park! El Monte is one of those rare cities that actually has a municipal health and wellness plan, and it recently banned sodas from its park and recreation facilities. The same calculator tells us that a penny-per-ounce tax in Los Angeles would reap more than $113 million in its first year. A measure to force those working against the tax to disclose their funding sources was passed by the city council and successfully challenged by the industry. 7.This includes referring to the soda tax as if it were a grocery tax, implying that soda = food, which it decidedly does not. See my column, What Is Food?