Acting on the Commercial Determinants of Health

‘Our world won’t be here if you continue to devastate the lands. There will be no more money to make.’ 19-year-old Australian (Arnot et al., 2023b) In 1986, when Health Promotion International was launched, the founding Chair of the Editorial Board, Professor Ilona Kickbusch, stressed that promoting health is not easy in the face of the well planned strategies of ‘powerful interest groups’ and the ‘wheelings and dealings of power politics’ [(Kickbusch, 1986), p. 3]. Thirty years later, Kickbusch and colleagues called for efforts to unite the critical public health analysis of the corporate sector and its tactics, arguing that the Commercial Determinants of Health (CDoH) enabled researchers to systemize efforts to confront the commercial drivers of disease and inequalities (Kickbusch et al., 2016). A decade on from this call to action, we continue to need urgent coordinated approaches at this critical and precarious time for people and planet (Thomas and Daube, 2023). However, we are also reminded that despite powerful opposition, important advances can be made in exposing and addressing the predatory tactics of health harming industries at global, national and local levels (World Health Organization, 2003). Tobacco control advocates have shown us the art of the possible—that health protecting policies that once seemed unthinkable (such as bans on advertising and plain packaging) could be achieved with robust independent evidence, coordinated advocacy and political will (Daube and Maddox, 2021). Once shown to be possible in one country, these achievements could be replicated elsewhere. However, tobacco control advocates also emphasized that we should never sit back and assume that we have ‘won’ our fight to protect health from the predatory and aggressive tactics of powerful industries and their allies. Rather, we must continue to work together to protect what has been achieved—and go further. We must always be aware that health harming industries will be innovative in maintaining and diversifying their markets and in protecting their profits (Arno et al., 1996; Jernigan and Babor, 2015; Mehrotra et al., 2019; Dewhirst, 2023). New, often unforeseen products, industries or political threats will emerge—exemplified by Big Tech and its role in enabling the creation and rapid spread of mis- and disinformation (Thomas and Daube, 2023; Zenone et al., 2023). Coordinated efforts have also shown the importance of working together across industries. This entails recognizing the similarities in the ‘corporate playbook’ that multiple commercial actors use to promote and market products, influence public and political norms, manipulate and deny science, and delay regulatory reform (Bond et al., 2009; Brownell and Warner, 2009; Moodie et al., 2013; Petticrew et al., 2017). There are also well founded concerns about the impact of corruption (The Lancet, 2024). While scholarship initially focused on the tobacco, alcohol and ultra-processed food industries as core drivers of noncommunicable diseases (Gilmore et al., 2023; Lee, 2023), new areas of focus such as gambling (Thomas et al., 2023) and Big Pharma (Marks, 2020) have demonstrated the broader impacts of powerful industries on health and social harms. We have seen continued warnings about the role of extractive industries on the perilous health of the planet (Ripple et al., 2024)—the pollution of our water, soil and air, the destruction of natural habitats and ecosystems, and the disconnection between communities and their food sources (Sula-Raxhimi et al., 2019; van Schalkwyk et al., 2023). Most recently, researchers have revealed how commercial determinants influenced access to vaccines and other health system responses to COVID-19 (Freeman et al., 2023). Conceptual and theoretical frameworks also show us that we must look beyond specific commercial actors to consider the broader ‘systems, practices, and pathways’ which influence health and social inequities [(Gilmore et al., 2023), p. 1195]. This involves acknowledging the ecosystem that supports and protects the activities of industries and political systems that prioritize private wealth of a few over public health for all, and neoliberal policies that have favoured decreased regulations. This ecosystem includes roles played by sporting organizations (Kickbusch, 2012), mainstream and social media (Even et al., 2024), industry-funded lobbying groups (Aravena-Rivas et al., 2024), management consultancy companies (Even et al., 2024), academics and institutions (Proctor, 2012; McDonald et al., 2023), and the revolving door between harmful industries and government (Watts et al., 2023). However, these frameworks also remind us that while there is an important focus on those that contribute to harm, other commercial actors and investment in health can have a positive impact on population wellbeing and equity. As with the social determinants of health, some population subgroups are more vulnerable to the negative impacts of predatory corporate practices than others. These include children and young people (Soraghan et al., 2023; Pitt et al., 2024), women (McCarthy et al., 2023; Thomas et al., 2024), and First Nations people (Crocetti et al., 2022; Eisenkraft Klein and Shawanda, 2024). Inequitable exposure to harms is created by the broader pathways and systems through which products are promoted to these groups, but also how they are exploited within production processes, and in industry public relations and corporate social responsibility strategies (McCarthy et al., 2023). The growing collaboration, activity and global focus on the CDoH holds great promise. As the contributions in this special issue show, new scholarship is emerging and novel ideas and ways of thinking are being generated—particularly from our graduate students, early career researchers and new interdisciplinary global partnerships. With this growing momentum, it is important to reflect on the values that unify us, the challenges that we face and how we overcome these (Thomas and Daube, 2023). What is the future that we envisage for the CDoH field, and what role does this play in improving health and wellbeing for all? The first challenge is to acknowledge that the multiple theoretical and conceptual frameworks developed to study the CDoH have largely originated from Global North academics and organizations. Frameworks are, of course, important in providing a foundation for action and may be appropriate for local contexts. They have helped to show that health harming industries increasingly target Lower- and Middle-Income Countries (LMICs) and Small Island Developing States (SIDS) which may not yet have the robust policy or regulatory infrastructure needed to respond to powerful vested interests (Dumbili, 2019; Mialon and Gomes, 2019). Decolonizing the CDoH must be an important part of our discussions, ensuring that power, knowledge systems and expectations about ‘action’ are not solely shaped by academics and organizations in the Global North. To move forward at a global level, we must not only acknowledge our privilege but also engage with LMICs and SIDS, and discuss where power is held (and withheld) in the CDoH, as well as seeking to address any power asymmetries more broadly in global health (Abimbola et al., 2021). Second is our responsibility to help create the necessary structures to catalyse work in this area. This includes a commitment to educating and training the public health workforce about the CDoH. We must also protect the wellbeing, safety, and credibility of those who research and challenge powerful vested interests. Many of us will know all too well that a key part of the corporate playbook entails strategies designed to dispute and discredit the work and character of independent researchers and their research (Daube, 2015). While there are an increasing number of global reports drawing attention to and encouraging work in the CDoH, there is still very limited focus on workforce development and providing the structures that are needed to support our colleagues working in this area. This is a significant omission, and we must invest in mechanisms to protect and empower the CDoH workforce as advocates for health and equity. The third challenge is establishing a united approach to engagement with commercial actors, based on a recognition of the cross-industry playbook and a need to scrutinize an industry’s practices and not just the inherent harmfulness of their products. While industries often seek to frame themselves as being an important part of the solution to the very problems that they cause, we must always remember that the fundamental purpose of any big business is to turn maximum profit for investors, regardless of environmental or social impact. Article 5.3 of the WHO Framework Convention on Tobacco Control, which is widely seen as a model for approaches to health harming industries, requires Parties to protect public health policies ‘from the commercial and other vested interests of the tobacco industry’ (World Health Organization, 2003). However, this standard is very poorly applied to other industries. Some researchers and organizations have framed contact with commercial actors such as the gambling, pharma and ultra-processed food industries as inevitable and even inherently beneficial. Others may bolster the legitimacy of involvement with harmful industries by accepting sponsorship or industry participation at scientific or related forums (Dun-Campbell et al., 2022). If we agree that these industries pose a threat to the health and equity of communities, that their primary motive is profit rather than community wellbeing, and that they oppose or undermine measures that will reduce their harms, we must take all forms of engagement with harmful commercial actors seriously. We must be led by the evidence on the risk to public health goals such engagement poses. We also may need to think carefully about how we define and broaden the concept of ‘harm’ and consider the inequity that a range of different actors may cause for different communities (van Schalkwyk et al., 2022). This includes recognizing that some harms are disproportionately concentrated in LMICs and SIDS. Some commercial actors may cause harms that are more overt (e.g. the tobacco or alcohol industries), while others may be more insidious (e.g. pharma or gambling), or play significant roles in developing harmful industry strategies (such as through advertising and public relations agencies and management consultancy companies). These discussions are challenging, but they are important as they will create a foundation of trustworthiness in the CDoH community. Finally, and perhaps most importantly, we should consider how we engage a diverse range of communities and stakeholders in the discussions and decisions that are made about the CDoH. We must recognize the urgent need for an intergenerational lens on the CDoH in order to strengthen the workforce and foster future leaders. This includes developing meaningful strategies to engage young people in discussions about areas of focus that are important to them (Arnot et al., 2023a). Young people face a precarious future. It is understandable that they feel frustrated, powerless, hopeless and angry at the decisions that will affect their futures based on the profit-based motivations and priorities of commercial and political actors. We must also acknowledge that young people may have different priorities about the issues that have an immediate impact on their health and wellbeing. These include access to secure housing, increasingly casualized and unstable workforces, affordable and accessible education, continued global conflicts, the rise of mis- and disinformation, and the need for urgent action on the climate crisis. Young people are innovative, powerful and insightful. We must work with and learn from them in setting agendas and priority areas for the CDoH, be champions for their right to take part in decision-making, and embrace and support new ways of communicating and engaging. As this special edition of the journal shows, there is a strong and growing interest among researchers in both exploring and exposing different aspects of the CDoH and identifying approaches that may assist in countering and reducing their negative impacts. We will continue to highlight this area as a fundamentally important aspect of health promotion at all levels, and to invite and support further discussion so that over time we can focus not only on the challenges we face, but on the progress that has been made, in part as a result of the work of our contributors and colleagues, and those we seek to support. S.T.: Has received funding for gambling research from the Victorian Responsible Gambling Foundation, Healthway, the Australian Research Council, Department of Social Services and the Office of Gaming and Racing NSW. She has received funding for research on the CDoH from VicHealth. She has received funding for alcohol, vaping and tobacco research from Deakin University. She a member of the Board of the International Confederation of Alcohol and other Drug Research Associations. She is currently Editor-in-Chief of Health Promotion International. M.D.: Has received funding for gambling research from the Victorian Responsible Gambling Foundation, Healthway and the Australian Research Council. He has received travel funding from the World Health Organization. He is currently Chair of the Boards of Health Promotion International. M.v.S.: Was funded by the National Institute for Health and Care Research (NIHR) Doctoral Fellowship (NIHR3000156) and her research was also partially supported by the NIHR Applied Research Collaboration North Thames. She has received funding through the SPECTRUM consortium, which is funded by the UK Prevention Research Partnership (UKPRP), a consortium of UK funders [UKRI Research Councils: Medical Research Council (MRC), Engineering and Physical Sciences Research Council (EPSRC), Economic and Social Research Council (ESRC) and Natural Environment Research Council (NERC); Charities: British Heart Foundation, Cancer Research UK, Wellcome and The Health Foundation; Government: Scottish Government Chief Scientist Office, Health and Care Research Wales, National Institute of Health Research (NIHR) and Public Health Agency (NI)]. O.A.-Y.: Has funding from the Africa Capacity Building Foundation for building capacity in tobacco industry monitoring for effective policy advocacy in Africa. He is currently a member of the Editorial Advisory Board of Health Promotion International. B.F.: Has received consultancy funding from the NSW Ministry of Health (2022) and WHO (2024), and travel reimbursement from the PHAA, VinFuture Foundation, Australian Association for Adolescent Health, Health and Wellbeing Queensland and the Department of Health, and Hong Kong SAR to present on e-cigarettes at forums/conferences. She is a named investigator on research projects funded by: NHMRC, MRFF, NSW Health, Cancer Institute NSW, Healthway, Ian Potter Foundation, Heart Foundation, Minderoo Foundation, and the Australian Department of Health and Aged Care. She was a member of the Australian National Health and Medical Research Council [NHMRC] Electronic Cigarettes Working Committee (2020–2023) and an unpaid advisor to the Cancer Council Australia on tobacco control research, Cancer Institute NSW on vaping messaging and the NSW Chief Health Officer e-cigarette expert panel. She is a member of the Editorial Advisory Board for Health Promotion International. T.A.S.: Has received funding from the World Obesity Federation, NCD Child, Healthy Caribbean Coalition, International Development Research Centre, Canada and Caribbean Public Health Agency, Ministry of Health and Wellness, Jamaica. She is currently an editor at BMC Public Health. E.V.: None to declare.

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