Commercial Determinants of Health

Population health is an interdisciplinary construct that encompasses the health outcomes of groups and the distribution of these outcomes within and across populations. This paper provides a comprehensive exploration of the major determinants shaping population health, integrating perspectives from biological sciences, behavioral theory, social epidemiology, and ecological health. Building upon the Healthy People 2030 framework and foundational scholarship from Kindig and Stoddart, the analysis examines how genetic predispositions, individual behaviors, social structures, policy environments, healthcare systems, physical environments, and global ecological dynamics collectively influence population well-being. The paper also critiques the limitations of reductionist biomedical approaches, advocating instead for systems-oriented, preventive strategies that emphasize equity and structural determinants. The concept of social determinants of health (SDOH) is explored in depth, with particular focus on policy interventions, systemic inequities, and the broader forces that shape lived experiences and access to care. Furthermore, ecological determinants and their growing influence in the context of climate change are integrated into the analysis to reflect the evolving complexity of health challenges in the 21st century. The paper concludes by arguing that understanding and addressing the full spectrum of health determinants is essential for clinicians, public health professionals, and policymakers to design equitable and sustainable health systems that respond to the needs of diverse populations.

Research on commercial determinants of health (CDoH) has burgeoned in the Global North. However, despite the heavy presence of harmful commodity industries in Africa, little scholarly attention has been paid to CDoH. Transnational alcohol corporations (TNACs) in Nigeria deploy well-articulated marketing strategies and practices that negatively impact health in their quest for profit maximisation, wealth extraction and influence. Nevertheless, their tactics and practices are largely unregulated and understudied. This commentary demonstrates how TNACs in Nigeria are a key perversive and harmful CDoH, highlighting the policy implications of their strategies and practices. Focusing on changing norms that constrain young people's drinking, TNACs promote hazardous drinking practices by using drinking games as a marketing strategy where the winners receive more alcohol and money as prizes. Alcohol corporations also encourage sexual risk-taking and associated harm by marketing alcoholic bitters as aphrodisiacs and sex enhancers. From 2014-2016, one TNAC organised the annual Nigerian Beer Symposium, spreading misleading information that beer consumption prevents cancer, reduces kidney stones, and improves women's skin beauty. Furthermore, through partnerships with the government, TNACs appear to use industry-led CSR initiatives to lobby officials, enhance corporate reputations, sustain pro-drinking framings, misinformation and selfregulation and silence discussions on alcohol policy implementation. While TNACs' products and practices negatively impact health/equities, decision-makers appear to enable their enormous power. The government should embrace evidence against TNACs as CDoH, implement policies to regulate them and collaborate with CSOs/advocates to hold them to account. Relatedly, the government should hold TNACs to account through international mechanisms because most of their practices violate laws in the Global North countries where they are headquartered.

Alcohol marketing, as a commercial determinant of health, presents an emerging threat to global health and is of particular importance in low-resource settings. This study is composed of data from 'The Onward Project On Wellbeing and Adversity' (TOPOWA) project, a multicomponent prospective cohort study examining the mechanistic pathways of adverse mental health conditions among women aged 18 to 24 years living in the Kampala slums in Uganda. The cohort consists of 300 women recruited in 2023 from three study sites (i.e., Banda, Bwaise, and Makindye). In this study, we deployed an underutilized tool, daily diaries, for assessing the exposure to alcohol marketing and an alcoholpromoting environment among young women living in the urban slums of Kampala, Uganda to spur new research and action. At baseline, participants completed a 5-day daily diary and an interviewer-administered survey. Findings show that alcohol-related neighborhood features were most frequently reported, including bars (Mean = 3.88 days), people drinking alcohol (Mean = 3.75), alcohol selling points (Mean = 3.45) and alcohol ads on TV (Mean = 2.51). Women who were exposed to bars (PR = 1.31) and alcohol ads on billboards (PR = 1.14) in a day were more likely to report alcohol use. Similarly, those exposed to alcohol ads on billboards (PR = 1.76) and bars (PR = 2.02) every day were more likely to report alcohol use. Higher cumulative exposure to different alcohol-related features was associated with a greater likelihood of alcohol use, particularly in the group with the highest exposure level. These findings underscore a need to develop alcohol counter-marketing strategies and harm reduction approaches. Daily diaries proved to be a feasible strategy in capturing real-time exposure data, which could in turn support prevention measures and the evaluation of intervention strategies.

This article examines victimization caused by corporate environmental crime related to per-and polyfluoroalkyl substances (PFAS) pollution. The systematic qualitative literature review and thematic synthesis of 27 studies from the USA, Australia, Italy, Sweden, and the United Kingdom aimed to identify critical areas of concern by analyzing the experiences of fence line communities and workers exposed to PFAS. The analysis revealed five stages of the PFAS adaptation process: pre-discovery, discovery, lifestyle change, change in social networks, and restitution. In each of these five phases, unique lived experiences faced by those exposed to corporate environmental harm are highlighted, and physical, psychological, emotional, and socioeconomic consequences are discussed. Based on the findings, a conceptual framework of corporate harm adaptation consisting of the five phases was developed to enhance understanding of the complexities and broader impacts of PFAS pollution on those exposed to it. This review highlights the importance of recognizing and addressing the multifaceted harms of PFAS pollution and emphasizes the need to expand the knowledge base on corporate crime through an improved understanding of the victim experiences and consequences of PFAS pollution. This study serves as a reminder of the need to consider the multifaceted experiences of affected fence line communities and workers in addressing corporate environmental crimes.

We are a group of researchers and academics with decades of experience in the protection and promotion of public health. We are writing to raise our concerns about how conflicts of interest are reported in public health nutrition research. We highlight examples of why it is important to accurately declare such conflicts, as well as providing examples of situations in which conflicts of interest have been inadequately reported. We call on researchers, and others, to be transparent about conflicts of interest in research. Journal editors in particular have an important responsibility in fully understanding how conflicts of interest can impact on research findings. They need to agree and adopt clear guidelines on conflicts of interest and ensure that authors abide by these to facilitate trust in the scientific process and the credibility of published articles.

Introduction: The narrative of prosperous economic livelihood of tobacco farmers in Kenya as alleged by the tobacco industry deserves challenge as evidence increasingly suggests that smallholder tobacco farmers are making little or no profits. Article 17 of the World Health Organization Framework Convention on Tobacco Control encourages viable alternative livelihoods for tobacco farmers. There is little evidence, however, on how tobacco farmers make livelihood choice decisions. Methods: A total of 527 purposefully selected smallholder tobacco farmers in Kenya from three main tobacco-growing regions participated in a 2017 economic livelihood survey. Geo-economic data were matched to surveyed farmers' Global Positioning System coordinates to estimate each farmer's access to nearby economic centers. Ownership of cell phones or radios was also used to estimate farmers' virtual access to nearby economic activities to understand better the role of information. Multivariate logistic regressions were used to control socioeconomic status and selfreported activity in nearby economic centers. Results: Tobacco farmers rarely live within 10 km of an economic center. Results suggest that the further away farmers live from economic centers, the less likely they are to grow tobacco, but more likely to grow tobacco under contract. Also, farmers owning a cell phone or radio are not only less likely to grow tobacco, but also to not engage in farming under contract if they do grow tobacco. Conclusions: Physical and virtual access to nearby economic activities is significantly associated with tobacco farmers' livelihood choice decision and should be taken into consideration by decision makers while developing interventions for FCTC Article 17. Implications: Smallholder tobacco farmers in lower-income countries are making little or no profits, but few studies have been conducted to illuminate what perpetuates tobacco production, with such studies urgently needed to support governments to develop viable alternative livelihoods for tobacco farmers. This study suggests that geographic and technological factors that shape farmers' economic decisions can help policy makers tailor alternative livelihood policies to different regional contexts and should be a focus of future research in this area.

Unhealthy foods and tobacco remain the leading causes of non-communicable disease (NCDs). These are key agricultural commodities for many countries, and NCD prevention policy needs to consider how to influence production towards healthier options. There has been little scholarship to bridge the agriculture with the public health literature that seeks to address the supply of healthy commodities. This scoping review synthesizes the literature on government agricultural policy and production in order to 1) present a typology of policies used to influence agricultural production, 2) to provide a preliminary overview of the ways that impact is assessed in this literature, and 3) to bring this literature into conversation with the literature on food and tobacco supply. This review analyzes the literature on government agricultural policy and production. Articles written in English and published between January 1997 and April 2018 (20-year range) were included. Only quantitative evaluations were included. Studies that collected qualitative data to supplement the quantitative analysis were also included. One hundred and three articles were included for data extraction. The following information was extracted: article details (e.g., author, title, journal), policy details (e.g., policy tools, goals, context), methods used to evaluate the policy (e.g., outcomes evaluated, sample size, limitations), and study findings. Fifty four studies examined the impact of policy on agricultural production. The remaining articles assessed land allocation (n = 25) (e.g., crop diversification, acreage expansion), efficiency (n = 23), rates of employment including on-and off-farm employment (n = 18), and farm income (n = 17) among others. Input supports, output supports and technical support had an impact on production, income and other outcomes. Although there were important exceptions, largely attributed to farm level allocation of labour or resources. Financial supports were most commonly evaluated including cash subsidies, credit, and tax benefits. This type of support resulted in an equal number of studies reporting increased production as those with no effects. This review provides initial extrapolative insights from the general literature on the impact of government policies on agricultural production. This review can inform dialogue between the health and agricultural sector and evaluative research on policy for alternatives to tobacco production and unhealthy food supply.

Introduction: The narrative of prosperous economic livelihood of tobacco farmers in Kenya as alleged by the tobacco industry deserves challenge as evidence increasingly suggests that smallholder tobacco farmers are making little or no profits. Article 17 of the World Health Organization Framework Convention on Tobacco Control encourages viable alternative livelihoods for tobacco farmers. There is little evidence, however, on how tobacco farmers make livelihood choice decisions. Methods: A total of 527 purposefully selected smallholder tobacco farmers in Kenya from three main tobacco-growing regions participated in a 2017 economic livelihood survey. Geo-economic data were matched to surveyed farmers' Global Positioning System coordinates to estimate each farmer's access to nearby economic centers. Ownership of cell phones or radios was also used to estimate farmers' virtual access to nearby economic activities to understand better the role of information. Multivariate logistic regressions were used to control socioeconomic status and selfreported activity in nearby economic centers. Results: Tobacco farmers rarely live within 10 km of an economic center. Results suggest that the further away farmers live from economic centers, the less likely they are to grow tobacco, but more likely to grow tobacco under contract. Also, farmers owning a cell phone or radio are not only less likely to grow tobacco, but also to not engage in farming under contract if they do grow tobacco. Conclusions: Physical and virtual access to nearby economic activities is significantly associated with tobacco farmers' livelihood choice decision and should be taken into consideration by decision makers while developing interventions for FCTC Article 17. Implications: Smallholder tobacco farmers in lower-income countries are making little or no profits, but few studies have been conducted to illuminate what perpetuates tobacco production, with such studies urgently needed to support governments to develop viable alternative livelihoods for tobacco farmers. This study suggests that geographic and technological factors that shape farmers' economic decisions can help policy makers tailor alternative livelihood policies to different regional contexts and should be a focus of future research in this area.

Background The aggressive marketing of breastmilk substitutes (BMS) reduces breastfeeding, and harms child and maternal health globally. Yet forty years after the World Health Assembly adopted the International Code of Marketing of Breast-milk Substitutes (The Code), many countries are still to fully implement its provisions into national law. Furthermore, despite The Code, commercial milk formula (CMF) markets have markedly expanded. In this paper, we adopt the Philippines as a case study to understand the battle for national Code implementation. In particular, we investigate the market and political strategies used by the baby food industry to shape the country’s ‘first-food system’, and in doing so, promote and sustain CMF consumption. We further investigate how breastfeeding coalitions and advocates have resisted these strategies, and generated political commitment for a world-leading breastfeeding policy framework and protection law (the ‘Milk Code’). We used a case study desig...

This chapter from the book “Sustainable Food System Assessment: Lessons from Global Practice,” addresses missing data that could help inform food systems governance. The ways in which the food security issue has been framed has shaped what data are gathered and how these are disaggregated and interpreted (knowledge effect); the data, in turn, reinforces policy and programmatic focus of the state (governance effect). The chapter highlights challenges, and suggests alternative approaches to data, reflecting on the potential impact of global data reporting processes, such as the UN Sustainable Development Goals (SDGs) and the 100 Resilient Cities programme

The inappropriate marketing and aggressive promotion of breastmilk substitutes (BMS) undermines breastfeeding and harms child and maternal health in all country contexts. Although a global milk formula 'sales boom' is reportedly underway, few studies have investigated its dynamics and determinants. This study takes two steps. First, it describes trends and patterns in global formula sales volumes (apparent consumption), by country income and region. Data are reported for 77 countries, for the years 2005-19, and for the standard (0-6 months), follow-up (7-12 m), toddler (13-36 m), and special (0-6 m) categories. Second, it draws from the literature to understand how transformations underway in first-food systemsthose that provision foods for children aged 0-36 monthsexplain the global transition to higher formula diets. Total world formula sales grew by 121.5% between 2005 and 2019, from 3.5 to 7.4 kg/child, led by highly-populated middle-income countries. Growth was rapid in South East and East Asia, especially in China, which now accounts for one third of world sales. This transition is linked with factors that generate demand for BMS, including rising incomes, urbanisation, the changing nature of woman's work, social norms, media influences and medicalisation. It also reflects the globalization of the baby food industry and its supply chains, including the increasing intensity and sophistication of its marketing practices. Policy and regulatory frameworks designed to protect, promote and support breastfeeding are partially or completely inadequate in the majority of countries, hence supporting industry expansion over child nutrition. The results raise serious concern for global child and maternal health.

Objective:To measure change in price of food groups over time (1995–2030) in Brazil, considering the Brazilian Dietary Guidelines’ recommendations.Design:Data from the Household Budget Survey (2008–2009 HBS) and the National System of Consumer Price Indexes (NSCPI) were used to create a data set containing monthly prices for the foods and beverages most consumed in the country (n 102), from January 1995 to December 2017. Data on price of foods and beverages from 2008–2009 HBS (referring to January 2009) were used to calculate real price over time using the monthly variation in prices from NSCPI. All prices were deflated to December 2017. Foods and beverages were classified following the Brazilian Dietary Guidelines’ recommendations. The monthly price for each food group and subgroup was used to analyse changes in prices from 1995 to 2017 and to forecast prices up to 2030 using fractional polynomial models.Setting:Brazil.Participants:National estimates of foods and beverages purchase...

We are a group of researchers and academics with decades of experience in the protection and promotion of public health. We are writing to raise our concerns about how conflicts of interest are reported in public health nutrition research. We highlight examples of why it is important to accurately declare such conflicts, as well as providing examples of situations in which conflicts of interest have been inadequately reported. We call on researchers, and others, to be transparent about conflicts of interest in research. Journal editors in particular have an important responsibility in fully understanding how conflicts of interest can impact on research findings. They need to agree and adopt clear guidelines on conflicts of interest and ensure that authors abide by these to facilitate trust in the scientific process and the credibility of published articles.

We are a group of researchers and academics with decades of experience in the protection and promotion of public health. We are writing to raise our concerns about how conflicts of interest are reported in public health nutrition research. We highlight examples of why it is important to accurately declare such conflicts, as well as providing examples of situations in which conflicts of interest have been inadequately reported. We call on researchers, and others, to be transparent about conflicts of interest in research. Journal editors in particular have an important responsibility in fully understanding how conflicts of interest can impact on research findings. They need to agree and adopt clear guidelines on conflicts of interest and ensure that authors abide by these to facilitate trust in the scientific process and the credibility of published articles.

Changing global markets have generated a dramatic shift in tobacco consumption from high-income countries (HICs) to low- and middle-income countries (LMICs); by 2030, more than 80% of the disease burden from tobacco use will fall on LMICs. Propelling this shift, opponents of tobacco control have successfully asserted that tobacco is essential to the economic livelihoods of smallholder tobacco farmers and the economy of tobacco-growing countries. This nexus of economic, agricultural and public health policymaking is one of the greatest challenges facing tobacco control efforts, especially in LMICs. To date, there is a lack of comparative, individual level evidence about the actual livelihoods of tobacco-growing farmers and the political economic context driving tobacco production. This comparative evidence is critically important to identify similarities and differences across contexts and to provide local evidence to inform policies and institutional engagement. Our proposed four-ye...

Introduction Tobacco production continues to increase in low- and middle-income countries creating complications for tobacco control efforts. There is the need to understand and address the global tobacco leaf supply as a means of decreasing tobacco consumption and improving farmers livelihoods in line with Article 17 of the WHO Framework Convention on Tobacco Control. This study aims to understand the reasons why farmers grow tobacco and identify factors that influence these reasons. Methods Primary survey data (N=1770) collected in Kenya, Malawi and Zambia in the 2013-2014 farming season. Data analysis uses both descriptive and multinomial logistical regression methods. Results Majority of farmers started and are currently growing tobacco because they believed it was the only economically viable crop. Compared to Malawi, farmers in Kenya and Zambia have a 0.2 and 0.4 lower probability of growing tobacco respectively because they perceive it as the only economically viable crop, bu...

BackgroundIn Tanzania, strong tobacco control measures that would lead to a reduction in prevalence (consumption) have so far not been implemented due to concern about possible economic effects on gross domestic product and employment. The aim of this study is to analyse the economic effects of reducing tobacco consumption in Tanzania.MethodsThe study uses computable general equilibrium (CGE) modelling to arrive at the effects of decreasing tobacco prevalence. A full-fledged global CGE model was developed, including comprehensive details on tobacco and tobacco products/sectors using the Global Trade Analysis Program-Environment model and database.ResultsThe results indicate that a 30% reduction in prevalence could lead to employment losses of about 20.8% in tobacco and 7.8% in the tobacco products sector. However, when compensated by increases in other sectors the overall decline in employment is only 0.5%. The decline in the economy as a whole is negligible at −0.3%.ConclusionIniti...

Tobacco is the primary export commodity in Malawi and an important contributor to foreign earnings. The entrenchment of tobacco interests within government has partly explained why Malawi has lagged in its efforts to address the health consequences of tobacco and has been a vocal opponent of global tobacco control. Despite the extensive historical and entrenched relationship between the economy of Malawi and tobacco production, there have been important shifts at the highest policy levels towards the need to explore diversification in the agricultural sector. There is explicit recognition that alternatives to tobacco production must be pursued. This study provides an analysis of the policies and perspectives that characterize contemporary government approaches to tobacco and alternatives in Malawi by interviewing key government officials working on tobacco policy and reviewing recent policy documents. This research finds that there is openness and movement towards reducing tobacco g...

Background The UN system’s shift towards multistakeholder governance, now embedded in the Sustainable Development Goals (SDGs), invites a broad range of actors, including the private sector, to the policymaking table. Although the tobacco industry is formally excluded from engagement, this approach provides opportunities for other unhealthy commodity industries to influence the World Health Organization’s (WHO’s) non-communicable disease (NCD) agenda. Focusing on the food industry, this research maps which actors engaged with WHO consultations, and critically examines actors’ policy and governance preferences as well as the framing they employ to promote these preferences in the global context. Methods All written responses from food industry actors to publicly available NCD-relevant WHO consultations held between September 2015 and September 2018 were identified, totalling forty-five responses across five consultations. A qualitative frame analysis was conducted to identify policy ...

Objective To estimate the impact on sugar farmers globally of reduced consumption of free sugars, in line with World Health Organization recommendations. Methods Using multiregion input-output analysis, we estimated the proportional impact on production volumes of a 1% reduction in free sugars consumption by the public. We extracted data on sugar production from the Food and Agriculture Organization database for the top 15 sugar cane and beet producing countries globally, and created a custom multiregion input-output database to assess the proportions of production going to human consumption, drawing on household expenditure surveys and national input-output databases (data valid for years 2000-2015). We also considered the impact on production volumes in relation to countries' gross domestic product. Findings A high proportion of current sugar production from these countries goes to human consumption, and would thus be impacted by reduced consumption of sugars. The largest impacts on cane sugar production, and thus on farmers, would likely occur in Brazil, China, India and Thailand and on beet production in Belarus, Germany, Russian Federation and United States of America. Conclusion A global opportunity exists for public health leadership to bring together the health, economic, environmental and agriculture sectors to collaborate and build capacity for promotion of alternate livelihoods for sugar farmers. Lessons regarding strategy and the importance of political economy factors can be learnt from tobacco control measures. Further research to quantify the impact of reductions in sugars consumption would provide useful insights for designing policies to complement and strengthen efforts to improve diets and health.

In principle, pharmaceutical producers lack the incentives to develop orphan drugs, i.e. medicines intended to treat rare diseases. Regulation (EC) n. 141/2000 addresses the issue, providing orphan drug producers with accelerated approval, tax benefits, and a ten-year market exclusivity period. Today, orphan drug prices are extremely high and are set independently of ordinary pharmaceutical pricing criteria. Consequently, some scholars suggest that a competition law action for unfair prices under Art. 102, let. a, TFEU may be warranted. This paper claims that the prohibition of abuse of dominant position could play a role in reducing orphan drugs' prices. First, it is shown that market exclusivity provides orphan drug manufacturers with a dominant position in their reference markets. Then, the paper applies and adapts the excessive price test developed by the ECJ to orphan drugs. Civil liability could also play a role, by compensating the damages suffered by NHSs. Finally, recent enforcement developments in the EU concerning excessive prices of medicines confirm the potential role of competition law in curbing orphan drug prices.

Despite  intergovernmental  calls  for  greater  policy  coherence  to  tackle  rising  non-communicable  diseases  (NCDs),  there  has  been  a  striking  lack  of  coherence  internationally  and  nationally  between  trade  and  health  sectors. In this commentary, I explore the arguments by Lenucha and Thow in relation to barriers for greater coherence for NCDs, apply them to regional trade agreements, and point to next steps in research and advocacy for greater attention to health and NCD prevention in government trade agendas.