Trends in childhood hospital admissions for carious tooth extractions in England in relation to the UK soft drink industry levy: an interrupted time series analysis of Hospital Episode Statistics

Background Tooth extraction due to dental caries is associated with socioeconomic-deprivation and is a major reason for elective hospital admissions in England in childhood. Consumption of sugar-sweetened beverages is a risk factor for dental caries. We examined whether the soft drinks industry levy (SDIL), announced in March 2016 and implemented in April 2018, was associated with changes in incidence rates of hospital admissions for carious tooth extraction in children, 22 months post-SDIL implementation. Methods Changes in incidence rates of monthly hospital admissions for carious tooth extractions (January 2012-February 2020) in England were estimated using interrupted time series and compared with a counterfactual scenario (no SDIL announcement or implementation). Periodical changes in admissions, auto-correlation and population structure were accounted for. Estimates were calculated overall, by index of multiple deprivation (IMD) fifths and by age group (0-4, 5-9, 10-14, 15-18 years). Findings Compared to the counterfactual scenario, there was a relative reduction of 12·1% [95%CI 17·0%-7·2%] in hospital admissions for carious tooth extractions in all children (0-18 years). Children aged 0-4 and 5-9 years had relative reductions of 28·6% [95%CI 35·6-21·5] and 5·5% [95%CI 10·5%-0·5%], respectively; no change was observed for older children. Reductions were observed in children living in most IMD areas regardless of deprivation. Interpretation The UK SDIL was associated with reductions in incidence rates of childhood hospital admissions for carious tooth extractions, across most areas regardless of deprivation status and especially in younger children. Funding UK National Institute of Health and Care Research, UK Medical Research Council Evidence before this study We searched PubMed and Google Scholar for articles and reviews on the impact of sugar sweetened beverages and sugar sweetened beverage taxes on dental health, published from inception to October 15, 2022 using search terms (“sugar sweetened beverages” OR “soda” OR “soft drinks”) AND (“sugar tax” OR “sugar sweetened beverage tax” or “sugar levy”) AND (“tooth extractions” OR “tooth caries” OR “oral health” OR “dental caries”) AND (“childhood” OR “children”). Further relevant papers were found by checking reference lists of identified articles. Dental extractions due to caries are one of the most common reasons for children having an elective admission to hospital in many high income countries, including England. Identified studies suggest a strong relationship between consumption of sugar-sweetened beverages (SSBs) and the development of dental caries. The overall prevalence of caries in children has been declining for more than a decade. However, a strong social gradient exists with survey data showing children living in the most deprived areas have twice the number of decayed, missing (due to decay) and filled teeth as those living in the least deprived areas in England. Studies that have previously investigated the potential effect of SSB taxes on dental caries have mostly relied on public health modelling, with only a single empirical study based on observational data. Studies including young children (<5 years old) are particularly scarce. At present there are no studies that have examined associations between SSB taxes and changes in childhood hospital admissions for carious tooth extractions, an indicator of severe dental decay. Added Value of this study We used routinely collected nationally representative hospital episodes statistics (HES), on monthly admissions of children aged 0-18 years in England, to NHS hospitals for tooth extraction due to caries between January 2012 and February 2020. Taking account of historical trends in hospital admissions for carious tooth extraction we examined changes in these admission types in relation to the UK soft drink industry levy (SDIL), a sugar sweetened beverage (SSB) tax announced in March 2016 and implemented in April 2018. Analysis was conducted overall, and by age group and Index of Multiple Deprivation (IMD) of the child’s area of residence After accounting for existing trends, we found that the SDIL was associated with an estimated overall relative reduction of 12.1% (17.0, 7.2), in hospital admissions for carious tooth extractions in children aged 0 to 18 years. Reductions were found in children living in most IMD areas regardless of deprivation and particularly in younger children aged 0-4 and 5-9 years. Implications of all available evidence These findings add to the currently limited evidence base that SSB taxes can improve children’s dental health. These effects were seen across the spectrum of deprivation suggesting widespread population benefits and particularly in pre-school and primary school age children who have limited agency to make their own dietary decisions. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement NTR, OM, MW, and JA were supported by the Medical Research Council (grant Nos MC\_UU\_00006/7). This project was funded by the NIHR Public Health Research programme (grant Nos 16/49/01 and 16/130/01) to MW. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health and Social Care, UK. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data was acquired through a data sharing agreement with NHS digital for which conditions of use apply. Requests for data must be made directly to NHS digital and cannot be granted by the authors