Facing ongoing national fiscal budgetary challenges, policy makers in the USA are debating whether to cut spending on federal nutrition assistance programmes, including the Supplemental Nutrition Assistance Program (SNAP), formerly known as the Food Stamp Program( 1 , 2 ). Simultaneously, the public health community is urgently seeking policy solutions to the obesity epidemic with the potential to both improve population health and reduce future obesity-related medical expenditures( 3 ).
In December 2011, a record 46·5 million people, or approximately one in seven Americans, participated in SNAP( 4 ). With a budget of $US 75 billion in 2011, SNAP is the largest of the fifteen federal nutrition assistance programmes. SNAP aims to alleviate hunger and improve the health of low-income individuals by providing resources to purchase food( 5 ). As one of the major federal anti-poverty programmes, SNAP has provided a critical buffer against poverty for millions of adults and children( Reference Tiehen, Jolliffe and Gundersen 6 ). Despite the programme's success at reducing hunger and poverty, few efforts have been undertaken to leverage spending on SNAP to improve the health of programme participants. Recent evidence-based nutrition updates to the National School Lunch Program and the Special Supplemental Nutrition Program for Women, Infants, and Children demonstrate the potential for aligning SNAP benefits with the Dietary Guidelines for Americans( 3 , 7 , Reference Shenkin and Jacobson 8 ).
A range of policies aimed at improving the nutritional impact of SNAP have been proposed or piloted, including incentivizing SNAP participants to purchase healthful foods such as fruits and vegetables, increasing the amount of SNAP benefits per household, limiting the use of SNAP benefits for unhealthful foods such as sugar-sweetened beverages or sugary drinks, and increasing nutrition education efforts targeting SNAP participants( 3 , Reference Shenkin and Jacobson 8 – 10 ). In 2011, the US Department of Agriculture (USDA) rejected a request from New York City (NYC) to pilot test removing sugar-sweetened beverages from the products SNAP participants could purchase using benefit dollars( Reference Shahn 11 ). The USDA noted potential stigmatization of SNAP participants as one of the reasons why it rejected the proposal. However, support for the proposal among SNAP participants was not assessed as part of the agency's review process in making the decision.
To inform the ongoing SNAP policy debate, we assessed the opinion of a representative sample of US adults, including SNAP participants, regarding federal spending on SNAP and on policy proposals to improve the nutritional impact of SNAP.
Methods
Data are from a four-question survey added to an ongoing weekly Harris Interactive poll by researchers at the Harvard School of Public Health assessing attitudes regarding support for federal spending on nutrition assistance and farming programmes as well as support for policies to improve the nutritional impact of SNAP (Appendix). Harris Interactive conducted the random-digit-dialled telephone survey as part of the weekly Harris Poll National Quorum omnibus survey within the USA between 12 and 22 April 2012, among 3024 adults (aged 18 years and over), including 418 adults who reported that their household had received SNAP benefits in the previous 12 months. That survey was conducted over three waves with ∼1000 respondents each wave on 12–15 April, 13–16 April and 19–22 April. Cooperation and response rates in the Harris Poll National Quorum are not reported for every wave fielded, but the poll had an average cooperation rate of 36 % and an average response rate of 5 % during this period computed according to the American Association for Public Opinion Research standard definitions for cooperation (COOP3) and response (RR3) rates, assuming 31 % of telephone numbers with unknown eligibility would be eligible based on recent research( 12 , Reference Kohut, Keeter and Doherty 13 ). According to the American Association for Public Opinion Research, the cooperation rate is the number of complete interviews divided by all eligible households contacted, whereas the response rate is the number of complete interviews divided by all eligible households in the sample.
Survey responses were weighted for age, sex, race/ethnicity, education, region, number of adults in the household and number of telephone lines in the household where necessary to bring them into line with their actual proportions in the population. Although response rates to telephone surveys have declined in recent years, independent studies have found that weighted results from shorter-duration telephone surveys are similar to results from surveys with longer duration and higher response rates( Reference Kohut, Keeter and Doherty 13 – Reference Blendon, Benson and Desroches 15 ). In addition to possible non-response bias and sampling error, variation in responses may occur due to question wording or order when compared with other surveys.
Demographic variation in support for SNAP spending and support for SNAP nutrition policy proposals is presented based on weighted and unweighted responses, with 95 % confidence intervals based on weighted data. There were no qualitative differences between weighted and unweighted results. Differences in the proportion of respondents supporting SNAP spending and nutrition policy proposals by demographics were tested for significance adjusting for survey weighting using the Rao–Scott χ 2 test. Data were analysed using the PROC SURVEYFREQ statement in the SAS® statistical software package version 9·3.
Results
Seventy-seven per cent of the public believed that federal spending on SNAP should be increased (48 %) or maintained (29 %; Table 1). Only 21 % of the public believed that federal spending on SNAP should be decreased. Among other factors, support varied significantly by political party identification (P < 0·001); 88 % of Democrats believed that federal spending should be increased or maintained compared with 81 % of Independents and 61 % of Republicans. The majority of respondents supported increasing or maintaining spending on SNAP across all sociodemographic subgroups measured.
Public opinion regarding federal spending on SNAP by sociodemographic factors in a survey of 3024 US adults aged 18 years or older selected by random digit dialling conducted in April 2012
SNAP, Supplemental Nutrition Assistance Program; NH, non-Hispanic.
Proportions are presented based on both unweighted and weighted frequencies. Party identification as Democrat or Republican includes those who responded as Independents but reported leaning towards either party. Whites, blacks and other/mixed race are non-Hispanic; Hispanics are of any race. Responses to the SNAP spending question are not reported from respondents answering ‘don't know’ or refusing responses to demographic questions unless the ‘don't know/refused’ category was greater than 10 % of respondents to the demographic question.
*P value based on Rao–Scott χ 2 test of association between demographic categories and attitudes towards spending (increased a lot, increased a little or kept the same v. decreased a little, decreased a lot or don't know) on SNAP adjusting for survey design.
Support for proposed policies to improve the nutritional impact of SNAP was also high across political party identification and SNAP participation status (Table 2). Of the four policies proposed, respondents were most supportive of a proposal to provide ‘…additional money to SNAP (Food Stamp) participants that can only be used on fruits, vegetables or other healthful foods’. Eighty-two per cent of all respondents supported this proposal, including 87 % of Democrats and 76 % of Republicans. SNAP participants also supported this proposal (86 %) more than any of the other three policies proposed. While still supported by the majority of respondents, support was lowest (65 %) for a proposal to provide SNAP participants ‘…more food stamp dollars to guarantee that they can afford a healthy diet’. This proposal to increase SNAP benefit levels had the largest gap in support across political party identification, with only 49 % of Republicans supporting the proposal compared with 77 % of Democrats.
Support for policy proposals to improve nutritional impact of SNAP by political party identification and SNAP status in a survey of 3024 US adults aged 18 years or older selected by random digit dialling conducted in April 2012
SNAP, Supplemental Nutrition Assistance Program
Proportions are presented based on both unweighted and weighted frequencies. Party identification as Democrat or Republican includes those who responded as Independents but reported leaning towards either party. Responses to SNAP policy questions are not reported from the fewer than 10 % of respondents who answered ‘don't know’ or refused to respond to demographic questions.
*P values based on the Rao–Scott χ 2 test of association between political party or SNAP participation and support (strongly support or somewhat support v. somewhat oppose, strongly oppose or don't know) for each policy adjusting for survey design. The frequency of ‘don't know’ responses ranged from 1 % to 3 % of all respondents for each SNAP policy question.
The proposal to remove ‘…sugary drinks (such as soda) from the list of products that can be purchased using SNAP (or Food Stamp) benefits’ was supported by 69 % of all respondents with no gap in support between Republicans (70 %) and Democrats (69 %). A majority of SNAP participants (54 %) supported removing sugary drinks from SNAP benefits. Respondents who did not support removing sugary drinks from SNAP benefits were asked whether they would support removing sugary drinks if the proposal was combined with a policy that would provide additional money to purchase fruits, vegetables and other healthy foods. Of the 46 % of SNAP participants who initially did not support removing sugary drinks (n 181), 45 % (95 % CI 36, 54 %) supported removing sugary drinks if the policy also included additional benefits to purchase healthful foods (data not shown).
Discussion
As Congress debates changes to SNAP and other components of US farm and nutrition policy, the present nationally representative survey found widespread public support for increased or maintained federal spending on SNAP. These results are very consistent with a survey conducted for the Food Research and Action Center in January 2012, which similarly found that 77 % per cent of US adults did not support cutting federal spending on SNAP as a way to reduce government spending( 16 ). A June 2012 survey conducted for the National Journal also found that a majority (62 %) of respondents supported increasing or keeping SNAP spending the same( Reference Cooper 17 ). As research from the USDA has recently shown, SNAP provides a critical buffer against the experience of severe poverty, particularly for children( Reference Tiehen, Jolliffe and Gundersen 6 ).
In addition to confirming public support for maintaining SNAP benefits identified in previous surveys, the broad public support for removing sugary drinks from SNAP benefits identified in the present study highlights the need for a more comprehensive debate about the current ability of SNAP to fulfil its mandate to ‘provide for improved levels of nutrition among low-income households’( 18 ). Although a recent Institute of Medicine report emphasized that improving the nutritional impact of SNAP is an essential component of a national strategy addressing the obesity epidemic due to the programme's scale, reach and level of federal investment in the programme, the Institute of Medicine committee concluded that in addition to practical considerations, ‘…limiting food choices for SNAP recipients may be viewed as patronizing and discriminatory to low-income consumers’( 3 ). Similar concerns regarding potential stigmatization of SNAP participants were raised in the USDA's rejection of the request from NYC to pilot test removing sugary drinks from SNAP benefits( Reference Shahn 11 ). However, a 2011 in-person survey of 498 SNAP participants and applicants in NYC found that 49 % supported NYC's proposal to remove SNAP benefits for purchasing sugary drinks, compared with 16 % who did not care and 35 % who did not support the proposal( Reference Sheehan and Sykes 19 ). The current study is the first national survey of whether SNAP participants would support removing SNAP benefits for the purchase of sugary drinks. In contrast to concerns over patronizing SNAP participants and in line with findings from NYC, over half of SNAP participants surveyed in the present study supported the proposal. The percentage rises to three-quarters of SNAP participants supporting removing sugary drinks from benefits if the policy also included incentives to purchase healthful foods.
While the USDA rejected NYC's request to evaluate the impact of removing sugary drinks from SNAP benefits, it is currently running a small $US 20 million pilot programme testing the impact of incentivizing the purchase of fruits and vegetables in SNAP( 10 ). Consistent public approval for incentivizing SNAP fruit and vegetable purchases across political parties and SNAP participation status supports increased investment in evaluation of this strategy. Additionally, given the demonstrated negative health impact of sugary drinks( Reference Barnhill 20 ) and public support identified in the present study, policy makers should consider a pilot programme that both incentivizes healthful SNAP purchases such as fruits and vegetables and removes sugary drinks from the list of products that can be purchased with SNAP benefits.
The present study provides decision makers with a clear statement of public support for continued federal investment in preventing hunger and severe poverty through the SNAP. As decision makers seek to improve the effectiveness and impact of federal spending, the findings from the study also document widespread support for policy proposals to align investments in SNAP with the broader goal of improving the health of Americans.
Acknowledgements
Sources of funding: This study received funding from the Harvard School of Public Health Department of Nutrition and from a gift from the Cabot Foundation. M.W.L. was supported by the Barry R. and Irene Telenius Bloom Fellowship and the Bernard and Gloria Salick Fellowship. C.W.L. was supported by a National Institutes of Health training grant (5 T32 CA009001-35). The study protocol was reviewed and determined to be Not Human Subjects Research by the Harvard School of Public Health Institutional Review Board. Conflicts of interest: The authors report no conflicts of interest. Authors’ contributions: M.W.L., C.W.L., L.W.Y.C. and W.C.W. designed the study; M.W.L. and C.W.L. analysed the data; M.W.L., C.W.L., L.W.Y.C. and W.C.W. interpreted the data; M.W.L. drafted the manuscript; C.W.L., L.W.Y.C., W.C.W. and S.J.B. contributed to critical revision of the manuscript. All authors contributed significantly to the work, and read and approved the final version of the manuscript. All authors had full access to all data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. Acknowledgements: The authors would like to thank the reviewers for their comments as well as Robert Blendon and Gillian SteelFisher for their advice throughout the project.
Appendix
Survey developed by researchers at the Harvard School of Public Health. Random-digit-dialled landline-only telephone survey of 3024 US adults aged 18 years or older conducted by Harris Interactive in three waves fielded 12–15 April, 13–16 April and 19–22 April 2012.
Base: all respondents
Q1 ‘Congress is currently debating support for farming and nutrition assistance programs included in the federal budget. I'm going to read some nutrition and farm assistance programs and for each one, I'd like you to tell me whether you think spending on that program should be increased a lot, increased a little, kept the same, decreased a little or decreased a lot.’ (READ EACH ITEM – ‘Should spending on this program be increased a lot, increased a little, kept the same, decreased a little or decreased a lot?’)
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1. Increased a lot
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2. Increased a little
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3. Kept the same
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4. Decreased a little
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5. Decreased a lot
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6. Don't know (v)
(1–6 below read in random order)
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1. ‘The Supplemental Nutrition Assistance Program, also known as the SNAP or Food Stamp program, which helps forty-six million people in the US afford food.’
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2. ‘The WIC program, which provides nutritious food to nine million pregnant or breastfeeding women, infants and children under 5 years old.’
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3. ‘The School Lunch and Breakfast Programs which provide low-cost or free meals to thirty-two million school children.’
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4. ‘Crop Insurance Programs, which pay farmers if their crops are lost due to weather or natural disasters.’
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5. ‘Payments to support farmers growing corn, wheat, soybeans, and other crops.’
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6. ‘Conservation programs that protect farmland and other natural resources.’
Base: all respondents
Q2 ‘How much do you agree or disagree that participants in the SNAP or Food Stamp program use their SNAP benefits to purchase healthy foods? Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?’
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1. Strongly agree
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2. Somewhat agree
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3. Somewhat disagree
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4. Strongly disagree
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5. Don't know (v)
Base: all respondents
Q3 ‘Please tell me how much you would support or oppose the following SNAP (or Food Stamp) program policies to improve participants’ diets.’ (READ EACH ITEM – ‘Do you strongly support, somewhat support, somewhat oppose or strongly oppose this policy?’)
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1. Strongly support
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2. Somewhat support
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3. Somewhat oppose
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4. Strongly oppose
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5. Don't know (v)
(1–4 below read in random order)
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1. ‘Removing sugary drinks (such as soda) from the list of products that can be purchased using SNAP (or Food Stamp) benefits.’
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1a. (ASK ONLY OF RESPONDENTS WHO CHOSE ‘SOMEWHAT OPPOSE, STRONGLY OPPOSE OR DON'T KNOW ON Q3.1) ‘Providing additional money to SNAP participants that can only be used on fruits, vegetables or other healthful food in addition to the removal of sugary drinks from the list of products participants can purchase with food stamps.’
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2. ‘Providing additional money to SNAP (or Food Stamp) participants that can only be used on fruits, vegetables, or other healthful foods.’
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3. ‘Providing SNAP (or Food Stamp) participants with more food stamp dollars to guarantee that they can afford a healthy diet.’
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4. ‘Educating SNAP (or Food Stamp) participants by providing nutrition or cooking classes.’
Base: all respondents
Q4 ‘During the past 12 months, have you or a member of your immediate family received benefits from the SNAP (or Food Stamp) program?’
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1. Yes
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2. No
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3. Don't know (v)
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4. Decline to answer (v)
