The case for developing a cohesive systems approach to research across unhealthy commodity industries

Pills and the damage done: the opioid epidemic as man-made crisis

The prescription opioid epidemic has slowly evolved over the past quarter century with increasingly detrimental consequences for public health. Man-made crises are often unforeseen and characterized by a situation without natural causes where - because of human intent, error, negligence, or the failure of manmade systems - the level of needs in the population exceeds available resources to counter the problem. This paper presents the prescription opioid epidemic as a man-made crisis and explores the public health impact of opioid manufacturers and other industries producing commodities with addictive potential as a shared vulnerability among countries. We examine this concept within the framework of the commercial determinants of health. We address three key aspects of the commercial determinants of health: (1) Cross-industry mechanisms, (2) policy inertia, and (3) the role of industry in science. Within cross-industry mechanisms, we explore parallels between prescription opioid epidemic and unhealthy commodity industries in terms of marketing, corporate use of misinformation, and diversionary tactics. Next, we examine how policy inertia has dominated the slow response to this man-made crisis. Lastly, we discuss how results from clinical trials are used as a key marketing strategy for drugs. The origins of the prescription opioid epidemic may be traced to innovations in drug development with the promise of improved pain management. However, through multiple factors, including fraudulent marketing from pharmaceutical industry and policy inertia, the resulting crisis represents a multi-system failure of regulation exploited by corporate greed.

Constructing public-private partnerships to undermine the public interest: critical discourse analysis of Working Together published by the International Alliance for Responsible Drinking

BACKGROUND

The global burden of alcohol harm has increased and is forecast to grow further without effective policy implementation. Public-private partnerships aiming to address global health, and other societal challenges, are a burgeoning feature of neoliberal governance. Rhetorically distancing themselves from tobacco, the major alcohol companies are committed to tackling 'harmful drinking' and have created a distinct type of public relations organization for this purpose. The activities of such organizations are increasingly recognized as an impediment to the implementation of policies to reduce alcohol harm, including in low- and middle-income countries where markets are expanding.

METHODS

The approach of critical discourse analysis is used to examine the discursive tactics and strategies used in Working Together; a 'toolkit' published by the key global level alcohol industry public relations organization, the International Alliance for Responsible Drinking (IARD). This study considers how it works discursively to set the terms of, and overcome skepticism about partnerships, to define aims and position various actors by constructing their roles. The construction of prospective partners provides insights into the alcohol industry itself.

RESULTS

The toolkit operates as an ideological resource for forming public-private partnerships across the world based on the accumulated know-how of the major companies through IARD. This allows the largest alcohol companies to exercise leadership of the industry, while remaining off-stage. The toolkit relies on a form of rhetorical work which creates distance from obvious corporate interests and the harms caused to population health and society. This is accomplished by working against evidence-informed population level approaches, and thus avoiding policies that will make any significant difference to overall alcohol harm. Unspecific "complexity" affords opportunity for preferred types of "actions", and "partnership" provides opportunity to gain credibility by association, further minimizing the likelihood of any material harm being reduced.

CONCLUSIONS

The toolkit is designed to not only legitimate the inclusion of alcohol industry actors as initiating 'partners', but also assigns them roles as managers of a set of carefully constructed relationships. This vision of public-private partnership reproduces the hegemonic narrative that has successfully blocked policy advances for decades and led to growing alcohol harm globally.

Reconceptualising the commercial determinants of health: bringing institutions in

The concept of the 'commercial determinants of health' (CDOH) has been developed by public health researchers as a way to describe the political economy of corporations and the impact of their practices on health, social inequalities and climate change. In this analysis, we assess the conceptual work that has developed this field and the influence of the more established 'social determinants of health' models. We highlight the dominance of epidemiologic and biomedical concepts on understandings of structure and agency in the CDOH literature and argue that the terminology of 'risk factors', 'drivers' and 'pathways' reflects an agent-centred approach. We suggest that, as a result, there is a tendency to overlook the importance of political institutions in shaping the exercise of corporate power. Our analysis seeks to 'bring institutions in' to CDOH research, using the empirical cases of Health in All Policies and Better Regulation in the European Union to highlight how institutional contexts shape political legitimacy and accountability, and in turn the strategies of corporate actors. Institutionalist approaches, we argue, have the potential to develop and expand understandings of CDOH by opening the black box between agency and structure.

Framing health taxes: a scoping review

Health taxes are increasingly positioned as effective policy instruments for curbing non-communicable disease, improving health and raising government revenues. Their allure has caused many health advocates to look beyond tobacco and alcohol to other harmful products such as sugar-sweetened beverages (SSBs), salty foods, fatty foods and fossil fuels. These efforts, however, directly conflict with commercial actors' interests. Both pro-tax health advocates and anti-tax industry representatives seek to frame health tax policy in favourable ways. Yet, little is known about which types of frames resonate in which settings, or how they deploy morals and values in their attempts to persuade. To fill this gap, we conducted a scoping review on framing health taxes using six databases in 2022. A total of 40 peer-reviewed empirical research articles, from 2006 to 2022, were identified from 20 different countries. Most research was conducted in high-income countries, published in the last 4 years and increasingly focused on excise taxes for SSBs. Studies captured multiple actors constructing context-specific frames, often tied to broader economic, health and administrative considerations. Actors also engaged in a range of political activities in addition to framing. We found some evidence that anti-tax framing strategies potentially incorporated a broader array of morals and social values. More in-country comparative research, particularly from low/middle-income countries, is needed to understand the politics of framing health taxes. We argue that these insights can improve efforts to advance health taxes by constraining corporate power, improving population level health and promoting greater social harmony.

Commercial lobbying and political contributions: an Australian scoping review

OBJECTIVE

Many of the most effective and equitable policies to reduce the burden of non-communicable diseases threaten the interests of powerful corporations. A first step for public health advocates seeking to challenge powerful corporate interests is to understand the nature and extent of corporate political practices. This scoping review explored public health research on two political practices in Australia: lobbying and political donations.

METHODS

We searched six databases, two Google Advanced searches and 11 Australian public health websites. We screened 2866 documents in total, and extracted information about political practices, industry actors and datasets.

RESULTS

62 studies published between 1980 and 2021 were identified, analysing public health advocacy, policy submissions, direct engagement with government representatives and political donations. We extracted data from 14 studies that focused on direct engagement and/or political donations. Most focused on 'unhealthy commodity industries.'

CONCLUSIONS

Analysis of lobbying and political contributions in Australia is a nascent but expanding area of public health research. We discuss opportunities for future research to strengthen the evidence base and support public health advocacy to counter harmful corporate practices and promote and protect population health.

IMPLICATIONS FOR PUBLIC HEALTH

Countering powerful commercial interests requires greater investment in understanding corporate political activities.

The use of participatory systems mapping as a research method in the context of non-communicable diseases and risk factors: a scoping review

CONTEXT

Participatory systems mapping is increasingly used to gain insight into the complex systems surrounding non-communicable diseases (NCDs) and their risk factors.

OBJECTIVES

To identify and synthesize studies that used participatory systems mapping in the context of non-communicable diseases.

DESIGN

Scoping review.

ELIGIBILITY CRITERIA

Peer-reviewed studies published between 2000 and 2022.

STUDY SELECTION

Studies that focused on NCDs and/or related risk factors, and included participants at any stage of their system's mapping process, were included.

CATEGORIES FOR ANALYSIS

The main categories for analysis were: (1) problem definition and goal-setting, (2) participant involvement, (3) structure of the mapping process, (4) validation of the systems map, and (5) evaluation of the mapping process.

RESULTS

We identified 57 studies that used participatory systems mapping for a variety of purposes, including to inform or evaluate policies or interventions and to identify potential leverage points within a system. The number of participants ranged from 6 to 590. While policymakers and professionals were the stakeholder groups most often included, some studies described significant added value from including marginalized communities. There was a general lack of formal evaluation in most studies. However, reported benefits related mostly to individual and group learning, whereas limitations described included a lack of concrete actions following from systems mapping exercises.

CONCLUSIONS

Based on the findings of this review, we argue that research using participatory systems mapping would benefit from considering three different but intertwined actions: explicitly considering how different participants and the power imbalances between them may influence the participatory process, considering how the results from a systems mapping exercise may effectively inform policy or translate into action, and including and reporting on evaluation and outcomes of the process, wherever possible.

Corporate Political Activity: Taxonomies and Model of Corporate Influence on Public Policy

BACKGROUND

Non-communicable diseases (NCDs) kill 41 million people a year. The products and services of unhealthy commodity industries (UCIs) such as tobacco, alcohol, ultra-processed foods and beverages and gambling are responsible for much of this health burden. While effective public health policies are available to address this, UCIs have consistently sought to stop governments and global organisations adopting such policies through what is known as corporate political activity (CPA). We aimed to contribute to the study of CPA and development of effective counter-measures by formulating a model and evidence-informed taxonomies of UCI political activity.

METHODS

We used five complementary methods: critical interpretive synthesis of the conceptual CPA literature; brief interviews; expert co-author knowledge; stakeholder workshops; testing against the literature.

RESULTS

We found 11 original conceptualisations of CPA; four had been used by other researchers and reported in 24 additional review papers. Combining an interpretive synthesis of all these papers and feedback from users, we developed two taxonomies - one on framing strategies and one on action strategies. The former identified three frames (policy actors, problem, and solutions) and the latter six strategies (access and influence policy-making, use the law, manufacture support for industry, shape evidence to manufacture doubt, displace, and usurp public health, manage reputations to industry's advantage). We also offer an analysis of the strengths and weaknesses of UCI strategies and a model that situates industry CPA in the wider social, political, and economic context.

CONCLUSION

Our work confirms the similarity of CPA across UCIs and demonstrates its extensive and multi-faceted nature, the disproportionate power of corporations in policy spaces and the unacceptable conflicts of interest that characterise their engagement with policy-making. We suggest that industry CPA is recognised as a corruption of democracy, not an element of participatory democracy. Our taxonomies and model provide a starting point for developing effective solutions.

Power and Other Commercial Determinants of Health: An Empirical Study of the Australian Food, Alcohol, and Gambling Industries

BACKGROUND

Commercial determinants of health (CDoH) represent a critical frame for exploring undue corporate and commercial influence over health. Power lenses are integral to understanding CDoH. Impacts of food, alcohol, and gambling industries are observable CDoH outcomes. This study aims to inform understanding of the systems and institutions of commercial and/or corporate forces working within the Australian food, alcohol, and gambling industries that influence health and well-being, including broader discourses materialised via these systems and institutions.

METHODS

Twenty semi-structured interviews were conducted with key-informants on Australian public policy processes. Interviewees were current and former politicians, political staff members, regulators and other public servants, industry representatives, lobbyists, journalists, and researchers with expertise and experience of the Australian food, alcohol, and/ or gambling industries. Interviews sought participants' perceptions of Australian food, alcohol, and gambling industries' similarities and differences, power and influence, relationships, and intervention opportunities and needs.

RESULTS

Strategies and tactics used by Australian food, alcohol and gambling industries are similar, and similar to those of the tobacco industry. They wield considerable soft (eg, persuasive, preference-shaping) and hard (eg, coercive, political, and legal/economic) power. Perceptions of this power differed considerably according to participants' backgrounds. Participants framed their understanding of necessary interventions using orthodox neoliberal discourses, including limiting the role of government, emphasising education, consumer freedom, and personal choice.

CONCLUSION

Food, alcohol, and gambling industries exercise powerful influences in Australian public policy processes, affecting population health and well-being. Per Wood and colleagues' framework, these manifest corporate, social, and ecological outcomes, and represent considerable instrumental, structural, and discursive power. We identify power as arising from discourse and material resources alike, along with relationships and complex industry networks. Addressing power is essential for reducing CDoH harms. Disrupting orthodox discourses and ideologies underpinning this should be a core focus of public health (PH) advocates and researchers alike.

Conceptualising commercial entities in public health: beyond unhealthy commodities and transnational corporations

Most public health research on the commercial determinants of health (CDOH) to date has focused on a narrow segment of commercial actors. These actors are generally the transnational corporations producing so-called unhealthy commodities such as tobacco, alcohol, and ultra-processed foods. Furthermore, as public health researchers, we often discuss the CDOH using sweeping terms such as private sector, industry, or business that lump together diverse entities whose only shared characteristic is their engagement in commerce. The absence of clear frameworks for differentiating among commercial entities, and for understanding how they might promote or harm health, hinders the governance of commercial interests in public health. Moving forward, it is necessary to develop a nuanced understanding of commercial entities that goes beyond this narrow focus, enabling the consideration of a fuller range of commercial entities and the features that characterise and distinguish them. In this paper, which is the second of three papers in a Series on commercial determinants of health, we develop a framework that enables meaningful distinctions among diverse commercial entities through consideration of their practices, portfolios, resources, organisation, and transparency. The framework that we develop permits fuller consideration of whether, how, and to what extent a commercial actor might influence health outcomes. We discuss possible applications for decision making about engagement; managing and mitigating conflicts of interest; investment and divestment; monitoring; and further research on the CDOH. Improved differentiation among commercial actors strengthens the capacity of practitioners, advocates, academics, regulators, and policy makers to make decisions about, to better understand, and to respond to the CDOH through research, engagement, disengagement, regulation, and strategic opposition.

Protecting children and young people from contemporary marketing for gambling

Around the world, children are being exposed to intensive marketing for gambling products. This normalizes perceptions that gambling is essentially a harmless form of entertainment, despite mounting evidence of the harms it causes. Young people and their parents are supportive of strategies to protect children from being exposed to gambling marketing. Yet existing regulatory efforts are inconsistent and inadequate, and have not protected children from exposure to the many forms of marketing now being developed and exploited by the gambling industry. We outline existing knowledge about strategies used by the gambling industry to market its products, with a specific focus on the potential impact of gambling marketing on young people. We provide a definition of gambling marketing and outline the different forms of promotion that are currently used to market gambling, current regulatory responses, and the impact of marketing on children and young people. We then argue that a comprehensive public health approach to gambling is urgently required, which must include effective action to limit the influence of marketing for gambling products, while recognizing that it is never possible to insulate children entirely from their reach.

National Public Health Surveillance of Corporations in Key Unhealthy Commodity Industries - A Scoping Review and Framework Synthesis

BACKGROUND

Corporations in unhealthy commodity industries (UCIs) have growing influence on the health of national populations through practices that lead to increased consumption of unhealthy products. The use of government-led public health surveillance is best practice to better understand any emerging public health threat. However, there is minimal systematic evidence, generated and monitored by national governments, regarding the scope of UCI corporate practices and their impacts. This study aims to synthesise current frameworks that exist to identify and monitor UCI influence on health to highlight the range of practices deployed by corporations and inform future surveillance efforts in key UCIs.

METHODS

Seven biomedical, business and scientific databases were searched to identify literature focused on corporate practices that impact human health and frameworks for monitoring or assessment of the way UCIs impact health. Content analysis occurred in three phases, involving (1) the identification of framework documents in the literature and extraction of all corporate practices from the frameworks; (2) initial inductive grouping and synthesis followed by deductive synthesis using Lima and Galea's 'vehicles of power' as a heuristic; and (3) scoping for potential indicators linked to each corporate practice and development of an integrated framework.

RESULTS

Fourteen frameworks were identified with 37 individual corporate practices which were coded into five different themes according the Lima and Galea 'Corporate Practices and Health' framework. We proposed a summary framework to inform the public health surveillance of UCIs which outlines key actors, corporate practices and outcomes that should be considered. The proposed framework draws from the health policy triangle framework and synthesises key features of existing frameworks.

CONCLUSION

Systematic monitoring of the practices of UCIs is likely to enable governments to mitigate the negative health impacts of corporate practices. The proposed synthesised framework highlights the range of practices deployed by corporations for public health surveillance at a national government level. We argue there is significant precedent and great need for monitoring of these practices and the operationalisation of a UCI monitoring system should be the object of future research.

Corporate Harm Minimisation: Promises and Perils Comment on "Understanding Marketing Responses to a Tax on Sugary Drinks: A Qualitative Interview Study in the United Kingdom, 2019"

Taxes on sugary drinks are often used to encourage companies to reformulate their products to reduce the sugar content. This comment discusses how product reformulation can strengthen the market and political power of the food industry, and questions whether these political risks outweigh the public health benefits. It proposes the term 'corporate harm minimisation' to describe the strategic adaptation of a public health harm reduction strategy to align with company or industry goals. It concludes by reflecting on the other ways that corporations influence health beyond the production and marketing of 'unhealthy commodities,' and why public health actors must explore other strategies to challenge powerful corporations.

A proposal for systematic monitoring of the commercial determinants of health: a pilot study assessing the feasibility of monitoring lobbying and political donations in Australia

BACKGROUND

The commercial determinants of health include a range of practices to promote business interests, often at the expense of public health. Corporate political practices, such as lobbying and campaign donations, are used to influence policy makers and foster a political and regulatory environment conducive to business interests. Despite recognition of their public health importance, thus far there are relatively few efforts to systematically monitor commercial political practices.

METHODS

A pilot study was conducted to explore the feasibility of systematically monitoring two political practices - lobbying and political contributions - for 'harmful industries' (alcohol, gambling, ultra-processed food and tobacco industries) in Australia. Potential data sources were reviewed to compare data availability and detail. Two publicly available datasets were selected for the pilot: ministerial diaries for New South Wales and annual donor filings from the Australian Electoral Commission. Google Data Studio was used to analyse and visualise findings.  RESULTS: The pilot study resulted in the creation of several interactive charts and dashboards that supported analysis and interrogation of the data. These charts helped to easily convey the volume of lobbying and political donations, as well as changes over time. For example, we found that between July 2014 and December 2020, NSW ministers had 20,607 meetings, of which 634 meetings were with harmful industries. And between 1998 and 2020, a total of $576,519,472 disclosed donations were made to political parties and other entities, of which $35,823,937 were from harmful industries.

CONCLUSIONS

Opportunities to develop a program to monitor commercial political practices face several challenges including access barriers arising from poor availability and detail of data, technical barriers arising from the format of data disclosures and coding challenges arising from the diverse nature of the commercial sector. Despite these challenges, our pilot study demonstrates the potential to implement a monitoring program and to expand its scope to other commercial determinants of health.

Typology of how 'harmful commodity industries' interact with local governments in England: a critical interpretive synthesis

INTRODUCTION

Industries that produce and market potentially harmful commodities or services (eg, tobacco, alcohol, gambling, less healthy foods and beverages) are a major influence on the drivers of behavioural risk factors for non-communicable diseases. The nature and impact of interactions between public bodies and 'harmful commodity industries' (HCIs) has been widely recognised and discussed at national and international levels, but to date little is known about such interactions at local or regional government levels. This study aimed to identify and characterise actual and potential interactions and proposes a typology of interactions between HCIs and English local authorities (LAs).

METHODS

Five electronic databases covering international literature (PubMed, EBSCO, OVID, Scopus and Web of Science) were searched up to June 2021. We also performed online searches for publicly available, web-based grey literature and documented examples of interactions in an English LA context. We conducted a critical interpretive synthesis of the published and grey literature to integrate and conceptualise the data in the context of English LAs.

RESULTS

We included 47 published papers to provide the frame for the typology, which was refined and contextualised for English LAs through the available grey literature. Three categories were developed, describing the medium through which interactions occur: (1) direct involvement with LAs, (2) involvement through intermediaries and (3) involvement through the local knowledge space. Within these, we grouped interactions into 10 themes defining their nature and identified illustrative examples.

CONCLUSION

Our typology identifies complex inter-relationships and characterises interactions between HCIs and LAs, with illustrative examples from English LAs. Drawn from well-established theories and frameworks in combination with contextual information on English LAs, this typology explores the LA perspective and could help local decision-makers to maximise population health while minimising negative impacts of HCIs.

PROSPERO REGISTRATION NUMBER

CRD42021257311.

Politics of hesitance and the formation of ethical subjects through responsible gambling practices

INTRODUCTION

Instead of harm prevention and risk related to gambling products, responsible gambling discourse emphasizes the importance of voluntary measures. From the point of view of governmentality, the responsible gambling practices produce, rely on, and call forth subjectivities. The aim of the study is to find out what kind of subjects are being produced through the responsible gambling practices of four Nordic state-owned gambling companies. As the companies are state-owned and operate on different types of markets, there are reasons to suspect that the companies could endorse different versions of the figure of responsible gambler. Previous research indicates that responsible gambling practices typically presuppose or aim to produce a self-governing subject making informed choices. Less attention has been given to detailed analyses of the heterogeneous factors contributing to the ethical subject formation. Moreover, there is a growing body of literature indicating, that along with the use of detailed behavioral data (big data), new forms of governmentality, that are highly relevant from the point of view of subject formation, are emerging.

METHODS

The responsible gambling practices are analyzed along Michel Foucault's four aspects of ethics. First, there is ethical substance, the problematic aspect of the self that is taken as the target of the ethical work. Second, the subject needs to have a certain relation to social norms and moral codes. Third, ethical work is needed to mold the problematic aspect of the self. Fourth, the aim of the ethical work is a certain mode of being or relationship to oneself. The analyzed material consists of the annual reports of the companies between 2019 and 2021.

RESULTS AND DISCUSSION

The results show that the figure of subject making informed voluntary choices is deeply embedded in the responsible gambling practices of the companies. The companies entice the gamblers to think about themselves and to act upon themselves as subjects capable of self-control. Hesitancy to intervene characterizes the activities of the companies, even if all the companies collect and use detailed behavioral data. The inclusion of the precarious subject of gambling harm would allow the companies to do much more to prevent gambling harm.

Using Regulatory Stances to See All the Commercial Determinants of Health

Policy Points The commercial determinants of health (CDoH) concept, which currently focuses on markets that harm health, should be expanded to refer to the interface between commerce and health, which can sometimes have positive public health consequences. The regulatory stances framework helps us classify public health preferences for regulating specific markets related to CDoH, based on the intended effects of regulations on market size. The regulatory stances a jurisdiction can adopt can be classified as ranging from prohibitionist through contractionist, permissive, and expansionist, to universalist. The regulatory stances framework increases the usefulness of the CDoH concept by expanding the conversation beyond negative determinants of health and providing a fuller view of the tools at the disposal of society to alter markets and improve health.

CONTEXT

The effects of commerce on the public health are omnipresent. The commercial determinants of health (CDoH) represent a burgeoning area of scholarly debate and activist policymaking to redress markets that adversely affect public health. The CDoH debate is a logical extension of the tobacco control movement, but, to its detriment, the CDoH conversation remains primarily focused policies and proposals that are analogous to historical tobacco control strategies.

METHODS

This paper argues that for the CDoH to develop further and broaden its appeal, it should expand to cover markets with conditional and positive impacts on health. To explain and order this conversation, a comparative framework for regulatory policy is introduced: the regulatory stances. The regulatory stances classify a regulatory policy based on the intended effect of policy on the size of a market in the future relative to the present.

FINDINGS

Some markets that interface between commerce and health do not inherently harm health. Regulatory policy toward these markets should be different in intent than regulatory policy for markets with negative health effects.

CONCLUSIONS

By using the regulatory stances framework to encompass markets that have positive or conditional effects on health as well as those that have adverse health effects, the CDoH conversation can shift away from the exclusive focus on strategies to shrink markets with adverse health impacts to consider a wider array of policy options.

A review of front-of-pack nutrition labelling in Southeast Asia: Industry interference, lessons learned, and future directions

Front-of-pack nutrition labelling is an evidence-based nutrition intervention that is recommended by the World Health Organization and other health agencies as an effective non-communicable disease prevention strategy. To date, the types of front-of-pack labels that have been identified as being most effective have yet to be implemented in Southeast Asia. This has been partly attributed to extensive industry interference in nutrition policy development and implementation. This paper outlines the current state of food labelling policy in the region, describes observed industry interference tactics, and provides recommendations for how governments in Southeast Asia can address this interference to deliver best-practice nutrition labelling to improve diets at the population level. The experiences of four focal countries - Malaysia, Thailand, the Philippines, and Viet Nam - are highlighted to provide insights into the range of industry tactics that are serving to prevent optimal food labelling policies from being developed and implemented.

Funding

This research was supported by the United Kingdom Global Better Health Programme, which is managed by the United Kingdom Foreign, Commonwealth and Development Office and supported by PricewaterhouseCoopers in Southeast Asia.

The distribution of harmful product marketing in public outdoor spaces and the effectiveness of marketing bans

Children's exposure to the marketing of harmful products in public outdoor spaces may influence their consumption of those products and affect health into adulthood. This study aimed to: i) examine the spatial distribution of children's exposure to three types of marketing-related 'harms' (alcohol, unhealthy food, and gambling) in outdoor spaces in the Wellington region, New Zealand/Aotearoa; ii) compare differences in the distribution of harms by socioeconomic deprivation; and iii) estimate the effectiveness of different policies that ban such marketing. Data were from 122 children aged 11-13y who wore wearable cameras and GPS devices for four consecutive days from July 2014 to June 2015. Images were analysed to identify harmful product marketing exposures in public outdoor spaces. Eight policy scenarios were examined to identify the effectiveness of marketing bans, for all children and by socioeconomic deprivation. Children's ratio of harmful marketing was higher for children from high deprivation households and was also found to cluster, with hots spots observed around city centers. The effectiveness of marketing bans depended on the target setting and ban area, with banning 400 m around bus stops leading to the largest reduction. Effectiveness varied also by type of harm and socioeconomic deprivation. For example, banning alcohol marketing in residential areas was estimated to have a larger effect on exposure reduction for children from high deprivation households. Our findings suggest that alcohol, unhealthy food and gambling marketing often cluster outdoors and that targeted bans of such marketing would likely improve child health and, for some banning scenarios, promote equity.

Would the Brazilian population support the alcohol policies recommended by the World Health Organization?

OBJECTIVE

To evaluate the support of the Brazilian population to the alcohol-policies proposed by the World Health Organization to decrease alcohol harm (specifically: to decrease alcohol availability and advertising, and to increase pricing). In addition, we evaluated the factors associated with being against those policies.

METHODS

Data from 16,273 Brazilians, aged 12-65 years, interviewed in the 3rd Brazilian Household Survey on Substance Use (BHSU-3) were analyzed. The BHSU-3 is a nationwide, probability survey conducted in 2015. Individuals were asked if they would be against, neutral, or in favor of seven alcohol policies grouped as: 1) Strengthen restrictions on alcohol availability; 2) Enforce bans or restrictions on alcohol advertising, sponsorship, and promotion; and 3) Raise prices on alcohol through excise taxes and pricing. Generalized linear models were fitted to evaluate factors associated with being against each one of those policies and against all of policies.

RESULTS

Overall, 28% of the Brazilians supported all the above mentioned policies, whereas 16% were against them. The highest rate of approval refers to restricting advertising (53%), the lowest refers to increasing prices (40%). Factors associated with being against all policies were: being male (AOR = 1.1; 95%CI: 1.0-1.3), not having a religion (AOR = 1.4; 95%CI: 1.1-1.8), being catholic (AOR = 1.3; 95%CI: 1.1-1.5), and alcohol dependence (AOR = 1.6; 95%CI: 1.1-2.4).

CONCLUSIONS

The Brazilian government could count on the support of most of the population to restrict alcohol advertising. This information is essential to tackle the lobby of the alcohol industry and its clever marketing strategy.

Understanding the long-term policy influence strategies of the tobacco industry: two contemporary case studies

OBJECTIVE

This paper explores transnational tobacco companies' (TTCs) long-term policy influence strategies using two case studies, harm reduction and illicit tobacco, to identify lessons for the tobacco control movement and wider efforts to address the commercial determinants of health.

METHODS

Evidence from a broad combination of sources including leaked documents and findings from over two decades of TTC monitoring were reviewed for each case study and categorised using the Policy Dystopia Model, focusing on the primary discursive strategy and key instrumental (action-based) strategies used.

RESULTS

In both case studies, TTCs seek to advance their interests by engaging primarily in reputation management, coalition management and information management strategies over the long-term to propagate their over-riding discursive strategy-'we've changed, we are part of the solution'-despite clear evidence from both case studies that this is not the case. These strategies are globally coordinated and attempt primarily to reshape norms towards TTC involvement in tobacco control policy and delivery. Findings also suggest that industry denormalisation and the advent of Article 5.3 have led to the TTCs growing use of increasingly complex and opaque 'webs of influence'.

CONCLUSIONS

The tobacco control community must develop its own proactive long-term strategies which should include industry denormalisation, new ways to fund research that reduce industry control, and improved transparency measures for research and policy. These findings, including TTC adaptations to Article 5.3, also indicate the need for more structural solutions, addressing corporate power and the underlying political and economic system. These lessons can be applied to other unhealthy commodity industries.

An objective assessment of children's exposure to brand marketing in New Zealand (Kids'Cam): a cross-sectional study

BACKGROUND

Marketing promotes values of consumerism and overconsumption, and negatively affects children's wellbeing and psychological development. The threat marketing poses to planetary health is just being realised. However, little is known about children's exposure to marketing at an aggregate level. Using an objective method of wearable cameras, we aimed to determine the nature and extent of children's exposure to marketing.

METHODS

Kids'Cam was a cross-sectional study of children aged 11-13 years in New Zealand, from which we randomly selected a sample of 90 children. Children wore cameras from when they woke up until they went to sleep for four consecutive days (Thursday-Sunday) that captured images at an angle of 136° every 7 s for exposure to marketing. Marketing brands were categorised into three groups: core food and social marketing messages, harmful commodities (eg, non-core food, alcohol, and gambling), or other. Exposure rates by marketing medium, setting, and product category were calculated using negative binomial regression models.

FINDINGS

From June 21, 2014, to June 30, 2015, we recruited 168 children, and randomly selected data from 90 children for the present study. Children in this study were exposed to a mean of 554 brands per 10 h day (95% CI 491-625), nearly a brand a minute, through multiple mediums (predominantly brand labels [36% of exposures] and product packaging [22%]) and mostly in schools (43%) and at home (30%). Food and beverages (20% of exposures) were the dominant product category. The most pervasive marketing brands typically sold a range of products across more than one product category (eg, children were exposed to Nike on average 20 exposures per day). Children were exposed to more than twice as many harmful commodities (mean 76 per 10 h day [95% CI 55-105]) as core food and social marketing messages (32 [26-39]) per day.

INTERPRETATION

We found that children are repeatedly exposed to marketing through multiple mediums and across all settings, and our findings suggests that marketing privileges particular messages, for example, marketing of harmful commodities. Given the key role marketing plays in establishing and supporting consumption norms, and perpetuating the normalisation of overconsumption which contributes to environmental degradation, these findings suggest an urgent need to reduce marketing to promote planetary health.

FUNDING

This research was funded by a University of Otago, Dean's Research Grant. The Kids'Cam study was funded by a Health Research Council of New Zealand Programme Grant (13/724).

An evaluation of the evidence submitted to Australian alcohol advertising policy consultations

BACKGROUND

Industry self-regulation is the dominant approach to managing alcohol advertising in Australia and many other countries. There is a need to explore the barriers to government adoption of more effective regulatory approaches. This study examined relevance and quality features of evidence cited by industry and non-industry actors in their submissions to Australian alcohol advertising policy consultations.

METHODS

Submissions to two public consultations with a primary focus on alcohol advertising policy were analysed. Submissions (n = 71) were classified into their actor type (industry or non-industry) and according to their expressed support for, or opposition to, increased regulation of alcohol advertising. Details of cited evidence were extracted and coded against a framework adapted from previous research (primary codes: subject matter relevance, type of publication, time since publication, and independence from industry). Evidence was also classified as featuring indicators of higher quality if it was either published in a peer-reviewed journal or academic source, published within 10 years of the consultation, and/or had no apparent industry connection.

RESULTS

Almost two-thirds of submissions were from industry actors (n = 45 submissions from alcohol, advertising, or sporting industries). With few exceptions, industry actor submissions opposed increased regulation of alcohol advertising and non-industry actor submissions supported increased regulation. Industry actors cited substantially less evidence than non-industry actors, both per submission and in total. Only 27% of evidence cited by industry actors was highly relevant and featured at least two indicators of higher quality compared to 58% of evidence cited by non-industry actors.

CONCLUSIONS

Evaluation of the value of the evidentiary contribution of industry actors to consultations on alcohol advertising policy appears to be limited. Modifications to consultation processes, such as exclusion of industry actors, quality requirements for submitted evidence, minimum standards for referencing evidence, and requirements to declare potential conflicts, may improve the public health outcomes of policy consultations.

Regulatory Resistance? Narratives and Uses of Evidence around "Black Market" Provision of Gambling during the British Gambling Act Review

Commercial gambling is increasingly viewed as being part of the unhealthy commodities industries, in which products contribute to preventable ill-health globally. Britain has one of the world's most liberal gambling markets, meaning that the regulatory changes there have implications for developments elsewhere. A review of the British Gambling Act 2005 is underway. This has generated a range of actions by the industry, including mobilising arguments around the threat of the "black market". We critically explore industry's framing of these issues as part of their strategy to resist regulatory change during the Gambling Act review. We used a predefined review protocol to explore industry narratives about the "black market" in media reports published between 8 December 2020 and 26 May 2021. Fifty-five articles were identified and reviewed, and themes were narratively synthesised to examine industry framing of the "black market". The black market was framed in terms of economic threat and loss, and a direct connection was made between its growth and increased regulation. The articles mainly presented gambling industry perspectives uncritically, citing industry-generated evidence (n = 40). Industry narratives around the "black market" speak to economically and emotionally salient concerns: fear, safety, consumer freedom and economic growth. This dominant framing in political, mainstream and industry media may influence political and public opinion to support the current status quo: "protecting" the existing regulated market rather than "protecting" people. Debates should be reframed to consider all policy options, especially those designed to protect public health.

Trust and responsibility in food systems transformation. Engaging with Big Food: marriage or mirage?

Concentration of power among transnational 'Big Food' companies has contributed to food systems that are unsustainable, unhealthy and inequitable for people and planet. Given these commercial determinants of health, if 'food systems transformation' is to be authentic-more than a passing narrative-then leveraging Big Food is paramount. To this end, researchers, practitioners and policy-makers are increasingly encouraged to engage with these powerful entities. However, given the conflicts of interest at stake, engagement relies on trust and transparency, that all stakeholders take responsibility for their actions and demonstrate commitment to do no harm. Given Big Food's track record in influencing policy, shifting costs and responsibility for their harms-and while profit primarily drives business decision making-we question whether it is logical to expect trust.This analysis explores concepts of responsibility and trust in relation to food systems transformation involving public-private partnerships. Through short cautionary case studies-looking at the United Nations Food Systems Summit, and Big Food's plastic burden-it argues that unless such companies take responsibility for their cross-cutting effects and earn authentic trust through demonstrably doing no harm, their participation in evidence generation and policy processes should be limited to responding to information requests and adhering to regulation. Any involvement in research agenda-setting or formulating policy solutions introduces conflicts of interest, legitimises corporate irresponsibility and jeopardises scientific integrity. Big Food has dynamism and power to address food system problems, but while it contributes to so many of these problems it should follow-not formulate-transformational evidence, policies and regulations.

Corporate political activity in the context of unhealthy food advertising restrictions across Transport for London: A qualitative case study

BACKGROUND

Diets with high proportions of foods high in fat, sugar, and/or salt (HFSS) contribute to malnutrition and rising rates of childhood obesity, with effects throughout the life course. Given compelling evidence on the detrimental impact HFSS advertising has on children's diets, the World Health Organization unequivocally supports the adoption of restrictions on HFSS marketing and advertising. In February 2019, the Greater London Authority introduced novel restrictions on HFSS advertising across Transport for London (TfL), one of the most valuable out-of-home advertising estates. In this study, we examined whether and how commercial actors attempted to influence the development of these advertising restrictions.

METHODS AND FINDINGS

Using requests under the Freedom of Information Act, we obtained industry responses to the London Food Strategy consultation, correspondence between officials and key industry actors, and information on meetings. We used an existing model of corporate political activity, the Policy Dystopia Model, to systematically analyse arguments and activities used to counter the policy. The majority of food and advertising industry consultation respondents opposed the proposed advertising restrictions, many promoting voluntary approaches instead. Industry actors who supported the policy were predominantly smaller businesses. To oppose the policy, industry respondents deployed a range of strategies. They exaggerated potential costs and underplayed potential benefits of the policy, for instance, warning of negative economic consequences and questioning the evidence underlying the proposal. Despite challenging the evidence for the policy, they offered little evidence in support of their own claims. Commercial actors had significant access to the policy process and officials through the consultation and numerous meetings, yet attempted to increase access, for example, in applying to join the London Child Obesity Taskforce and inviting its members to events. They also employed coalition management, engaging directly and through business associations to amplify their arguments. Some advertising industry actors also raised the potential of legal challenges. The key limitation of this study is that our data focused on industry-policymaker interactions; thus, our findings are unable to present a comprehensive picture of political activity.

CONCLUSIONS

In this study, we identified substantial opposition from food and advertising industry actors to the TfL advertising restrictions. We mapped arguments and activities used to oppose the policy, which might help other public authorities anticipate industry efforts to prevent similar restrictions in HFSS advertising. Given the potential consequences of commercial influence in these kinds of policy spaces, public bodies should consider how they engage with industry actors.

Commercial use of evidence in public health policy: a critical assessment of food industry submissions to global-level consultations on non-communicable disease prevention

Background

Ultra-processed food industry (UPFI) actors have consistently opposed statutory regulation in health policy debates, including at the WHO. They do so most commonly with claims that regulatory policies do not work, will have negative consequences or that alternatives such as self-regulation work well or better. Underlying this are often assertions that industry is aligned with principles of evidence-based policymaking. In this study, we interrogate if this holds true by exploring the extent and quality of the evidence UPFI respondents employed to support claims around regulatory policy, and how they did this.

Methods

First, we identified all submissions from organisations who overtly represent UPFI companies to consultations held by the WHO on non-communicable disease policy between 2016 and 2018. Second, we extracted all relevant factual claims made in these submissions and noted if any evidence was referenced in support. Third, we assessed the quality of evidence using independence from UPFI, nature, and publication route as indicators. Lastly, where peer-reviewed research was cited, we examined if the claims made could be justified by the source cited.

Results

Across 26 included consultation responses, factual claims around regulation were made in 18, although only 10 referenced any evidence at all. Of all 114 claims made, 39 pieces of identifiable evidence were cited in support of 56 claims. Of the 39 distinct pieces of evidence, two-thirds were industry-funded or industry-linked, with only 16 externally peer-reviewed. Over half of industry-funded or industry-linked academic articles failed to declare a conflict of interest (COI). Overall, of only six claims which drew on peer-reviewed and independent research, none appropriately represented the source.

Discussion

UPFI respondents made far-reaching claims which were rarely supported by high-quality, independent evidence. This indicates that there may be few, if any, benefits from consulting actors with such a clear COI.

Towards unified and impactful policies to reduce ultra-processed food consumption and promote healthier eating

The global surges in obesity and nutrition-related non-communicable diseases (NCDs) have created a need for decisive new food policy initiatives. A major concern has been the impact of ultra-processed foods (UPFs) and ultra-processed drinks on weight gain and on the risk of several NCDs. These foods, generally high in calories, added sugar, sodium, and unhealthy fats, and poor in fibre, protein, and micronutrients, have extensive negative effects on human health and on the environment (due to their associated carbon emission and water use). There is a growing tendency worldwide, and especially in South America, for food companies to add micronutrients to UPFs to make health claims regarding these products, to which food-regulating authorities refer to fake foods. Although more than 45 countries and smaller subregional or urban entities have created taxes on ultra-processed drinks, such as sugar-sweetened beverages, only a few have adopted taxes on snacks and other UPFs, and none have added major subsidies for truly healthy, fresh or minimally processed food for people from lower socioeconomic backgrounds. Another major focus has been on developing effective package labelling. A smaller number of countries have selected the most impactful warning labels and linked them with other measures to create a mutually reinforcing set of policies; a few other countries have developed effective school food policies. We herein present in-depth results from key countries involved in all these actions and in comprehensive marketing controls, and conclude with our recommendations for the future. This field is quite new; progress to date is substantial, but much more is left to learn.

A public health approach to gambling regulation: countering powerful influences

Often portrayed as a harmless leisure activity in the UK, gambling is being increasingly recognised as a public health concern. However, a gambling policy system that explicitly tackles public health concerns and confronts the dependencies and conflicts of interest that undermine the public good is absent in the UK. Although there is a window of opportunity to change the gambling policy system, with the UK Government's launch of a review of the Gambling Act 2005, the adoption of a comprehensive and meaningful public health approach is not guaranteed. Too often, government policy has employed discourses that align more closely with those of the gambling industry than with those of the individuals, families, and communities affected by the harms of gambling. In view of the well described commercial determinants of health and corporate behaviour, an immense effort will be needed to shift the gambling discourse to protect public health. In this Viewpoint, we seek to advance this agenda by identifying elements that need challenging and stimulating debate.

Big food and the World Health Organization: a qualitative study of industry attempts to influence global-level non-communicable disease policy

INTRODUCTION

There is an urgent need for effective action to address the over 10 million annual deaths attributable to unhealthy diets. Food industry interference with policies aimed at reducing non-communicable diseases (NCDs) is widely documented at the national level but remains under-researched at the global level. Thus, this study explores how ultra-processed food industry actors have attempted to influence NCD policy at WHO.

METHODS

A combination of inductive and deductive thematic coding of internal industry documents, academic literature and interviews with key informants from international organisations and global civil society was used to identify action-based strategies ultra-processed food industry actors employ to influence global-level policy.

RESULTS

Ultra-processed food industry actors have attempted to influence WHO and its policies through three main action-based strategies: coalition management, involvement in policy formulation, and information management. Coalition management includes the creation and use of overt alliances between corporations-business associations-and more covert science-focused and policy-focused intermediaries, the hiring of former WHO staff and attempted co-option of civil society organisations. Industry involvement in policy formulation is operationalised largely through the lobbying of Member States to support industry positions, and business associations gaining access to WHO through formal consultations and hearings. Information management involves funding and disseminating research favourable to commercial interests, and challenging unfavourable evidence.

CONCLUSION

We provide novel insights into how ultra-processed food industry actors shape global-level NCD policy and identify a clear need to guard against commercial interference to advance NCD policy. In their approach, the political behaviour of multinational food corporations bears similarities to that of the tobacco industry. Increased awareness of, and safeguarding against, commercial interference at the national as well as the global level have the potential to strengthen the crucial work of WHO.