Industrial epidemics, public health advocacy and the alcohol industry: lessons from other fields

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.

The influence of share buybacks on ill-health and health inequity: an exploratory analysis using a socio-ecological determinants of health lens

INTRODUCTION

Share buybacks, when a corporation buys back its own shares, are recognised as having potentially harmful impacts on society. This includes by contributing to economic inequalities, and by impeding investments with the potential to protect and promote the welfare of various stakeholders. Share buybacks, however, have received minimal analytical attention in the public health literature. This paper aimed to explore the potential influence of share buybacks on population health and health inequity using a socio-ecological determinants of health lens.

METHODS

We conducted a descriptive analysis of share buybacks made by corporations listed on United States (US) stock exchanges between 1982 and 2021, using quantitative data sourced from Compustat. We examined annual trends in share buyback expenditure, including comparisons to dividend, net income, capital expenditure, and research and development expenditure data. We then purposively sampled a set of corporations to provide illustrative examples of how share buybacks potentially influence key socio-ecological determinants of health. The examples were: i) three COVID-19 vaccine manufacturers; ii) five of the world's largest fossil fuel corporations; and iii) US car manufacturer General Motors. For these, we conducted an analysis of data from Compustat, company reports and grey literature materials, focusing on key sources of profits and their allocation to share buybacks and particular investments.

RESULTS

US-listed corporations spent an estimated US$9.2 trillion in real terms on share buybacks between 2012 and 2021 (nearly 12 times more than from 1982 to 1991). The contribution of share buybacks to total shareholder 'returns' increased from 11% in 1982 to 55% in 2021, with expenditure on shareholder returns increasing considerably relative to capital, research and development expenditure over this period. The three examples illustrated how some corporations have prioritised the short-term financial interests of their shareholders, including via implementing large share buyback programs, over investments with considerable potential to protect and promote the public's health.

CONCLUSION

The potentially substantial impacts of share buybacks on health warrant increased research and policy attention. Arguably, more must be done to regulate share buybacks as part of efforts to address the corporate drivers of ill-health and inequity.

'A priori' external contextual factors and relationships with process indicators: a mixed methods study of the pre-implementation phase of 'Communities in Charge of Alcohol'

BACKGROUND

It is widely recognised that complex public health interventions roll out in distinct phases, within which external contextual factors influence implementation. Less is known about relationships with external contextual factors identified a priori in the pre-implementation phase. We investigated which external contextual factors, prior to the implementation of a community-centred approach to reducing alcohol harm called 'Communities in Charge of Alcohol' (CICA), were related to one of the process indicators: numbers of Alcohol Health Champions (AHCs) trained.

METHODS

A mixed methods design was used in the pre-implementation phase of CICA. We studied ten geographic communities experiencing both high levels of deprivation and alcohol-related harm in the North West of England. Qualitative secondary data were extracted from pre-implementation meeting notes, recorded two to three months before roll-out. Items were coded into 12 content categories using content analysis. To create a baseline 'infrastructure score', the number of external contextual factors documented was counted per area to a maximum score of 12. Descriptive data were collected from training registers detailing training numbers in the first 12 months. The relationship between the baseline infrastructure score, external contextual factors, and the number of AHCs trained was assessed using non-parametric univariable statistics.

RESULTS

There was a positive correlation between baseline infrastructure score and total numbers of AHCs trained (Rs = 0.77, p = 0.01). Four external contextual factors were associated with significantly higher numbers of lay people recruited and trained: having a health care provider to coordinate the intervention (p = 0.02); a pool of other volunteers to recruit from (p = 0.02); a contract in place with a commissioned service (p = 0.02), and; formal volunteer arrangements (p = 0.03).

CONCLUSIONS

Data suggest that there were four key components that significantly influenced establishing an Alcohol Health Champion programme in areas experiencing both high levels of deprivation and alcohol-related harm. There is added value of capturing external contextual factors a priori and then testing relationships with process indicators to inform the effective roll-out of complex interventions. Future research could explore a wider range of process indicators and outcomes, incorporating methods to rate individual factors to derive a mean score.

TRIAL REGISTRATION

ISRCTN81942890, date of registration 12/09/2017.

Mobilizing COVID-19 level public health interventions for climate breakdown is necessary

The COVID-19 pandemic has proven that extraordinary public health measures can pivot every aspect of society. Norms, politics, economics, and business practices rapidly responded to coordinated simultaneous policies worldwide. This begs the question of why such advancements have not yet been similarly executed to reduce the short- and long-term morbidity and mortality due to environmental destruction and climate change. This article reviews various reasons explaining the discrepancy between the policies of these two health threats, using a terror management theory lens. Exploring how anthropogenic climate change potentiated the contagion and outcomes of COVID-19, the environmental determinants of health deserve increased attention in public discourse. The industry-driven response to COVID-19 also has exacerbated preexisting health inequalities and vulnerabilities, suggesting that a just transition for climate change must not repeat some of the same mistakes taken in global pandemic measures. Finally, addressing emergency health harms in ways that create increased environmental health harms is deemed iatrogenic, displacing rather than truly treating disease. Thus, a planetary health model focused on multisolving health issues is recommended for the basis of addressing COVID-19 and other health disasters.

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 realist review of voluntary actions by the food and beverage industry and implications for public health and policy in low- and middle-income countries

The increasing availability of unhealthy processed food products is linked to rising rates of non-communicable diseases and obesity in low- and middle-income countries. Voluntary actions (VAs) are often adopted in lieu of regulating the composition, production, marketing and sale of unhealthy commodities, but their effectiveness is unclear. This realist review examines VAs adopted by the food and beverage industry in low- and middle-income countries. We developed a conceptual framework and followed a three-stage search to identify literature and VAs and, adhering to the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines, we produced a synthesized analysis of VAs. VAs, often initiated in response to governments' efforts to introduce regulations, were difficult to evaluate due to vague language and a lack of enforcement mechanisms. The review found no evidence indicating that VAs are effective in safeguarding public health. Yet their implementation has resulted in weaker responses and policy substitution, and so we suggest that VAs have the potential to negatively influence public health and policy. The United Nations should rescind their endorsement of industry involvement and mandatory measures should be favoured over VAs.

From silos to policy coherence: tobacco control, unhealthy commodity industries and the commercial determinants of health

Tobacco control has achieved remarkable successes, underpinned by the distinctive norms codified in Article 5.3 of the WHO Framework Convention on Tobacco Control. Tobacco control's experience in managing conflicts of interest is increasingly recognised as relevant for addressing other non-communicable disease epidemics. At the same time, the wider environmental and social harms of tobacco-and other unhealthy commodity industries-underline the potential for enhanced strategic collaboration across health, development and environmental agendas. Such collaboration is increasingly necessary to address key challenges shared across tobacco control and related policy spheres, including the extent to which the harms of tobacco (and other unhealthy commodities) are underpinned by economic and social inequities. Here we demonstrate the relevance of a commercial determinants of health perspective, both for advancing tobacco control and for linking it with health and development more broadly. This perspective is already evident in many areas of research, policy and advocacy, where innovative approaches support the development of closer links with actors in related fields. We draw on the concepts of policy coordination, coherence and integration to show how tobacco control can advance key strategic goals via information sharing, complementary approaches to common problems and collective action with other related movements. Embrace of a commercial determinants perspective will help in building on tobacco control's successes and reorienting strategies in other sectors to more effectively manage health risks and promote sustainable development.

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.

Drink, but don't drive? The alcohol industry's involvement in global road safety

Drink-driving is a major cause of global road traffic fatalities, yet few countries have laws that meet international best practices. One possible reason is the alcohol industry’s opposition to meaningful policies that are perceived to directly threaten sales. Our primary objectives are to document alcohol industry involvement in global road safety policies and programmes and to critically evaluate the responses of public health and road safety communities to this involvement. Under the guidance of the Policy Dystopia Model, we used a mixed methods approach in which data were gathered from expert interviews and a mapping review of 11 databases, 5 watchdog websites and 7 alcohol industry-sponsored initiatives. Triangulation was used to identify points of convergence among data sources. A total of 20 expert interviews and 94 documents were analysed. Our study showed that the alcohol industry acknowledges that drink-driving is an issue but argues for solutions that would limit impact on sales, akin to the message ‘drink—but do not drive’. Industry actors have been involved in road safety through: (1) coalition coupling and decoupling, (2) information production and management, (3) direct involvement in policymaking and (4) implementation of interventions. Our study also shed light on the lack of cohesion within and among the public health and road safety communities, particularly with regard to the topics of receiving funding from and partnering with the alcohol industry. These results were subsequently used to adapt the Policy Dystopia Model as a conceptual framework that illustrates the ways in which the alcohol industry has been involved in global road safety. Several implications can be drawn from this study, including the urgent need to increase awareness about the involvement of the alcohol industry in road safety and to build a cohesive transnational alcohol control advocacy alliance to curb injuries and deaths related to drink-driving.

Support for Alcohol Policies in Marginalized Populations

AIM

Kingdon [(2014) Agendas, Alternatives, and Public Policies. Essex. United Kingdom: Pearson Education Limited] argues that windows of opportunity to pass policies emerge when problems, solutions and policy support co-occur. This study aims to identify a set of alcohol policies with the potential to reduce alcohol-related disparities given high levels of support from marginalized groups, such as racial/ethnic minorities and lower-income groups.

METHODS

This study used data from five US National Alcohol Surveys, which were based on household probability samples of adults in 1995 (n = 4243), 2000 (n = 5736), 2005 (n = 1445), 2010 (n = 4164) and 2015 (n = 4041). We used multiple logistic regression to determine the odds of policy support by racial/ethnic group and income level, considering price, place and marketing policies as well as individual-level interventions.

RESULTS

Overall a majority of Americans supported banning alcohol sales in corner stores (59.4%), banning alcohol advertisements on television (55.5%), and establishing universal health coverage for alcohol treatment (80.0%). Support was particularly high among Blacks, Hispanics/Latinos and lower-income persons. Multivariate models showed that compared with White people, foreign-born Hispanics/Latinos had the most robust levels of support, including raising alcohol taxes (aOR = 2.40, 95% CI: 2.00, 2.88, P < 0.0001), banning alcohol sales in corner stores (aOR = 2.85, 95% CI: 2.22, 3.65, P < 0.0001) and reducing retail sales hours (aOR = 2.91, 95% CI: 2.38, 3.55, P < 0.0001).

CONCLUSION

Of the policies examined, banning alcohol sales at corner stores is most likely to be in a "window of opportunity" for reducing alcohol-related disparities. By simultaneously reducing population-level consumption and harms from others' drinking, place-based policies have the potential to reduce harms experienced by marginalized groups.

Co-regulation and alcohol industry political strategy: A case study of the Public Health England-Drinkaware Drink Free Days Campaign

This article examines the Drink Free Days (DFD) campaign run by Public Health England and the industry funded alcohol education charity, Drinkaware, in eight English regions in 2018-2019. More specifically, it examines uses, and usefulness, of the campaign to the alcohol producers which fund Drinkaware. It draws on 36 semi-structured interviews with policy actors and a framing analysis of industry social media accounts and news coverage of the campaign. Industry-associated bodies such as Drinkaware have been identified as key components of alcohol industry strategies to influence policy and shape the regulatory contexts in which they operate in three ways. First, funding such bodies forms part of corporate social responsibility programmes which allow companies to position themselves as legitimate policy actors and 'part of the solution' to alcohol related harms. Second, reliance on industry funding incentivises governments to co-operate with industry actors and provides leverage in policy debates. Third, their programmes absorb policy bandwidth and deflect from more effective, evidence based interventions (e.g. on pricing and advertising) which affect industry sales and profits. This is particularly effective if the perception of independence from the industry is created. The analysis presented below suggests that the DFD was not used explicitly by the industry actors for public relations purposes. However, it was useful to their broader strategic aims. It reinforced the position of Drinkaware as a key policy actor and promoted the particular, industry-favoured understanding of alcohol harms and their solutions which it promotes. This is in keeping with the previous insights from international research literature on corporate political activity in health harming industries which finds that policy influence is often subtle, indirect and designed to embed organisations within the policy architecture. It suggests that government agencies should proceed with great caution in entering into such partnerships with industry associated bodies.

Interested constituents: identifying groups to mobilize in community organizing efforts to strengthen alcohol control policies

Background: Policy support research identifies demographic profiles of those who support policies, but community organizers aim to mobilize groups with an existing structure. Thus, identifying established groups that support alcohol policies may aid organizing efforts.Objective: This paper calculates prevalence and odds of policy support among three potential constituency groups (i.e., religious affiliation, persons harmed by others' drinking, and persons in recovery from alcohol) for three policies: alcohol tax increases, banning alcohol in corner stores, and universal coverage for alcohol treatment.Methods: Using the 2014-15 National Alcohol Survey (n = 3,444; 1,457 male, 1,987 female) and logistic regression, this study explores associations between constituency groups and policy support.Results: Support was higher for the individual-level strategy of alcohol treatment (80.8%) than raising taxes (27.5%) and banning sales in corner stores (52.2%). Support for taxes was higher among persons who valued religion highly (vs not; aOR = 1.46, p < .01), persons harmed by others' drinking (vs not; aOR = 1.71, p < .001), and persons in recovery (vs. not; aOR = 1.76, p = .02); Catholics had lower odds of support for taxes (vs no denomination; aOR = 0.63, p = .01). Persons who valued religion highly (aOR = 1.53, p < .001), Protestants (aOR = 1.63, p < .01), Catholics (aOR = 1.46, p = .03), and persons with other religious denominations (aOR = 2.17, p = .02) had higher odds of supporting bans in corner stores. Only those in recovery showed greater support for treatment (aOR = 3.20, p < .001).Conclusion: Overall, support was lower for population-wide approaches, but results revealed constituency groups that supported these policies. These groups may be allies to organizers who seek to reduce population-level alcohol consumption and harms.

Medidas regulatórias de proteção da alimentação adequada e saudável no Brasil: uma análise de 20 anos

Medidas regulatórias estão entre as estratégias de promoção da alimentação adequada e saudável preconizadas pela Política Nacional de Alimentação e Nutrição (PNAN). Embora outras ações de promoção da alimentação adequada e saudável tenham avançado no Brasil, essas medidas progridem lentamente. O objetivo do trabalho é identificar e descrever fatores relacionados ao desenvolvimento e à implementação das principais medidas regulatórias de proteção da alimentação adequada e saudável no Brasil nos últimos 20 anos. É um estudo qualitativo documental que avaliou algumas medidas regulatórias de proteção à alimentação adequada e saudável federais, propostas ou em discussão, entre 1999 e 2020. São elas: regulação da publicidade de alimentos; regulação da comercialização de alimentos no ambiente escolar; implantação da rotulagem nutricional frontal obrigatória de alimentos; e tributação de bebidas adoçadas. A maioria das barreiras identificadas foram estratégias de atividade política corporativa protagonizadas pelo setor privado, principalmente, pela indústria de alimentos. Dentre as estratégias de atividade política corporativa utilizadas em diversas etapas dos processos políticos destacam-se: ações judiciais contra a ação do Estado; substituição de políticas sugerindo alternativas voluntárias ou inefetivas; oposição, fragmentação e desestabilização, com busca de apoio da comunidade. No período estudado, nenhuma das medidas foi aprovada. Diante desse cenário, os obstáculos para aprovação das medidas regulatórias de proteção a alimentação adequada e saudável necessitam ser superados no Brasil.

Policy congruence and advocacy strategies in the discourse networks of minimum unit pricing for alcohol and the soft drinks industry levy

BACKGROUND AND AIM

Public health policy development is subject to a range of stakeholders presenting their arguments to influence opinion on the best options for policy action. This paper compares stakeholders' positions in the discourse networks of two pricing policy debates in the United Kingdom: minimum unit pricing for alcohol (MUP) and the soft drinks industry levy (SDIL).

DESIGN

Discourse analysis was combined with network visualization to create representations of stakeholders' positions across the two policy debates as they were represented in 11 national UK newspapers.

SETTING

United Kingdom.

OBSERVATIONS

For the MUP debate 1924 statements by 152 people from 87 organizations were coded from 348 articles. For the SDIL debate 3883 statements by 214 people from 175 organizations were coded from 511 articles.

MEASUREMENTS

Network analysis techniques were used to identify robust argumentative similarities and maximize the identification of network structures. Network measures of size, connectedness and cohesion were used to compare discourse networks.

FINDINGS

The networks for both pricing debates involve a similar range of stakeholder types and form clusters representing policy discourse coalitions. The SDIL network is larger than the MUP network, particularly the proponents' cluster, with more than three times as many stakeholders. Both networks have tight clusters of manufacturers, think-tanks and commercial analysts in the opponents' coalition. Public health stakeholders appear in both networks, but no health charity or advocacy group is common to both.

CONCLUSION

A comparison of the discourse in the UK press during the policy development processes for minimum unit pricing for alcohol and the soft drinks industry levy suggests greater cross-sector collaboration among policy opponents than proponents.

Selling second best: how infant formula marketing works

Background

Despite the clear policy intent to contain it, the marketing of formula milk remains widespread, powerful and successful. This paper examines how it works.

Methods

The study comprised a mix of secondary analysis of business databases and qualitative interviews with marketing practitioners, some of whom had previously worked in formula marketing.

Results

The World Health Assembly Code aims to shield parents from unfair commercial pressures by stopping the inappropriate promotion of infant formula. In reality marketing remains widespread because some countries (e.g. the USA) have not adopted the Code, and elsewhere industry has developed follow-on and specialist milks with which they promote formula by proxy. The World Health Assembly has tried to close these loopholes by extending its Code to these products; but the marketing continues. The campaigns use emotional appeals to reach out to and build relationships with parents and especially mothers. Evocative brands give these approaches a human face. The advent of social media has made it easier to pose as the friend and supporter of parents; it is also providing companies with a rich stream of personal data with which they hone and target their campaigns.

The formula industry is dominated by a small number of extremely powerful multinational corporations with the resources to buy the best global marketing expertise. Like all corporations they are governed by the fiduciary imperative which puts the pursuit of profits ahead of all other concerns. This mix of fiscal power, sophisticated marketing, and single-mindedness is causing great harm to public health.

Conclusions

Formula marketing is widespread and using powerful emotional techniques to sell parents a product that is vastly inferior to breast milk. There is an urgent need to update and strengthen regulation.

An overview of the commercial determinants of health

Background

Different terms are described in the literature that refer to commercial determinants as drivers of ill-health. The aim of the present review was to provide an overview of the commercial determinants of health, through a review of the literature on this subject. The review was conducted in December 2019 and updated in February 2020. Searches were conducted from peer-reviewed scientific articles, commentaries, books, and books chapters, with no restriction in their publication dates and languages.

Main body

The commercial determinants of health cover three areas. First, they relate to unhealthy commodities that are contributing to ill-health. Secondly, they include business, market and political practices that are harmful to health and used to sell these commodities and secure a favourable policy environment. Finally, they include the global drivers of ill-health, such as market-driven economies and globalisation, that have facilitated the use of such harmful practices.

Short conclusion

The discussion on the commercial determinants of health offers a unique opportunity to shift the dominant paradigm in public health, where individual behaviours are considered to be driven by inadequate environments. Ill-health, damages to the environment, and health and social inequalities, might be better understood through a commercial determinant lens.

The optics of noncommunicable diseases: from lifestyle to environmental toxicity

Until recently, the noncommunicable disease (NCD) category was composed of four chronic diseases (cancer, cardiovascular disease, diabetes and chronic respiratory disease) and four shared, 'modifiable' behavioural risk factors (smoking, diet, physical activity and alcohol). In late 2018, the NCD category was expanded to include mental health as an additional disease outcome and air pollution as an explicit environmental risk factor. The newly-expanded NCD category connects behavioural and environmental readings of risk and shifts attention from individual acts of consumption to unequal and inescapable conditions of environmental exposure. It thus renders the increasing 'toxicity' of everyday life amid ubiquitous environmental contamination a new conceptual and empirical concern for NCD research. It also, as this paper explores, signals a new 'optics' of a much-maligned disease category. This is particularly significant as chronic disease research has long been siloed between public and environmental health, with each discipline operationalising the notion of the 'environment' as a source of disease causation in contrasting ways. Given this, this paper is positioned as a significant contribution to both research on NCDs and environmental risk, bringing these interdisciplinary domains into a new critical conversation around the concept of toxicity.

Advancing public health policy making through research on the political strategies of alcohol industry actors

Development and implementation of evidence-based policies is needed in order to ameliorate the rising toll of non-communicable diseases (NCDs). Alcohol is a key cause of the mortality burden and alcohol policies are under-developed. This is due in part to the global influence of the alcohol industry. We propose that a better understanding of the methods and the effectiveness of alcohol industry influence on public health policies will support efforts to combat such influence, and advance global health. Many of the issues on the research agenda we propose will inform, and be informed by, research into the political influence of other commercial actors.

Public Health Surveillance Studies of Alcohol Industry Market and Political Strategies: A Systematic Review

OBJECTIVE

This review examines public health surveillance (PHS) studies of alcohol industry actors that explore the implications of the integration of business and political strategies for public health.

METHOD

Eligible for inclusion were studies published in English language peer-reviewed journals since 1980 that sought to investigate both alcohol industry business and political strategies and their implications for public health. Studies were also required to present economic, political, and health data together. Seven databases were searched until May 2018.

RESULTS

Six studies were identified as eligible for inclusion in this review, undertaken in high-, middle-, and low-income countries and published between 2000 and 2015. Political strategies are driven largely by business interests, whether at the company, sectoral, or industry level, and corporate social responsibility activities may be integrated within overall strategies. There is a high degree of collaboration in political strategy development between companies, facilitated by growing concentration among global producers operating in increasingly oligopolistic markets. There are limited insights into the dynamics of market competition and limited methodological data available.

CONCLUSIONS

PHS studies play a valuable role in identifying aspects of alcohol industry strategies that warrant more detailed and carefully designed research, as well as in elucidating global health implications. Further research in PHS and other kinds of studies will assist efforts to reduce the global burden of disease caused by alcohol.

Gambling and public health: we need policy action to prevent harm

Prevention of harms related to gambling requires investment in population based approaches, say Heather Wardle and colleagues

The handling of evidence in national and local policy making: a case study of alcohol industry actor strategies regarding data on on-premise trading hours and violence in Norway

BACKGROUND

Effective alcohol policy measures conflict with the interests of the alcohol industry. In this study we addressed how various alcohol industry actors in Norway have responded to research findings and police data relating to the possible impacts of changes in on-premise trading hours on violent offending.

METHODS

A content analysis of documents was undertaken. The documents comprised i) hearing statements from policy processes on on-premise trading hours at the national level, and in 15 Norwegian cities, and ii) newspaper articles and other media coverage of this topic in Norway.

RESULTS

Alcohol industry actors employed a range of strategies to shape the use of evidence regarding on-premise trading hours and violence. Nationally, the relevance of the international research literature was questioned before the publication of an unfavourable national study which was criticized directly. This led to commissioned attacks on the findings, constructing what were claimed to be disagreements between experts, emphasis on the complexity of violence and the role of confounding variables, and deflecting attention to alternative interventions. The handling of evidence at the local level was importantly different, where different industry actors and forms of evidence, notably police data, were involved in debates.

CONCLUSION

Alcohol industry actors employed various strategies to shape perceptions and use of evidence to advance their interests. The particular strategies and arguments changed over time as new data and research became available, and also varied between the national and the local levels, and by categories of industry actors.

Changing Collective Social Norms in Favour of Reduced Harmful Use of Alcohol: A Review of Reviews

Background

Public sector bodies have called for policies and programmes to shift collective social norms in disfavour of the harmful use of alcohol. This article aims to identify and summarize the evidence and propose how policies and programmes to shift social norms could be implemented and evaluated.

Design

Review of reviews for all years to July 2017.

Data sources

Searches on OVID Medline, Healthstar, Embase, PsycINFO, AMED, Social Work Abstracts, CAB Abstracts, Mental Measurements Yearbook, Joanna Briggs Institute EBP, Health and Psychosocial Instruments, International Pharmaceutical Abstracts, International Political Science Abstracts, NASW Clinical Register and Epub Ahead of Print databases.

Eligibility

All reviews, without language or date restrictions resulting from combining the terms ((review or literature review or review literature or data pooling or comparative study or systematic review or meta-analysis or pooled analysis) and (social norms or culture) and (alcohol drinking)).

Results

Two relevant reviews were identified. One review of community-based interventions found one study that demonstrated small changes in parental disapproval of under-age drinking. One review stressed that collective social norms about drinking are malleable and not uniform in any one country. Three factors are proposed to inform programmes: provide information about the consequences of the harmful use of alcohol, and their causes and distribution; act on groups, not individuals; and strengthen environmental laws, regulations and approaches.

Conclusions

Purposeful policies and programmes could be implemented to change collective social norms in disfavour of the harmful use of alcohol; they should be evidence-based and fully evaluated for their impact.

Unpacking policy formulation and industry influence: the case of the draft control of marketing of alcoholic beverages bill in South Africa

Alcohol is a major contributor to the Non-Communicable Disease burden in South Africa. In 2000, 7.1% of all deaths and 7% of total disability-adjusted life years were ascribed to alcohol-related harm in the country. Regulations proposed to restrict alcohol advertising in South Africa present an evidence-based upstream intervention. Research on policy formulation in low- and middle-income countries is limited. This study aims to describe and explore the policy formulation process of the 2013 draft Control of Marketing of Alcoholic Beverages Bill in South Africa between March 2011 and May 2017. Recognising the centrality of affected actors in policy-making processes, the study focused on the alcohol industry as a central actor affected by the policy, to understand how they-together with other actors-may influence the policy formulation process. A qualitative case study approach was used, involving a stakeholder mapping, 10 in-depth interviews, and review of approximately 240 documents. A policy formulation conceptual framework was successfully applied as a lens to describe a complex policy formulation process. Key factors shaping policy formulation included: (1) competing and shared values-different stakeholders promote conflicting ideals for policymaking; (2) inter-department jostling-different government departments seek to protect their own functions, hindering policy development; (3) stakeholder consultation in democratic policymaking-policy formulation requires consultations even with those opposed to regulation and (4) battle for evidence-evidence is used strategically by all parties to shape perceptions and leverage positions. This research (1) contributes to building an integrated body of knowledge on policy formulation in low- and middle-income countries; (2) shows that achieving policy coherence across government departments poses a major challenge to achieving effective health policy formulation and (3) shows that networks of actors with commercial and financial interests use diverse strategies to influence policy formulation processes to avoid regulation.

Can internal tobacco industry documents be useful for studying the UK alcohol industry?

Background

The release of internal documents now available in the Truth Tobacco Documents Library has offered important insights into the machinations of tobacco companies. These documents potentially offer additional insights into the nature of the alcohol industry, due to co-ownership and collaborative working across industries. This proof of concept study aims to build on the few examples of internal tobacco company documents being used to study alcohol industry activities, to identify the scope of information available on the UK alcohol industry.

Methods

We identified the principal company names of the major national brewers, including predecessor company names, until the late 1990s, contemporaneous to the bulk of the tobacco documents. Using these names as initial search terms, we searched the Library to identify relevant material. Documents returned were then analysed for evidence of alcohol industry connections to the tobacco industry in the UK.

Results

We found evidence of significant relationships between the two industries including previously unidentified data on co-ownership and cross industry shareholding; informal help-seeking between sectors; collaboration on issues of common interest; and cross industry ties via third party service providers, membership of common organisations and participation in shared events and platforms.

Conclusions

These findings call for further research to analyse in greater depth the information identified here, and to explore alcohol industry activities and links with tobacco companies in other national contexts. This preliminary investigation suggests there is much valuable data available in the Truth Tobacco Documents Library that can serve to guide research on the alcohol industry.

Remembering who owns the river

We have discovered the elixir of life. For the first time in human existence we now know how we can avoid disease, make our lives healthier and more fulfilled, and even fend off the grim reaper himself (at least for a while). We may not have joined the immortals - many traps and snares continue to prey on us - but we are beginning to learn some of their secrets. Why then are we failing to grasp these heady opportunities? WHO data show that nine out of ten of we Europeans are dying of lifestyle diseases; that is diseases caused by our own choices - self-inflicted diseases. Despite the all too familiar consequences for our bodies, we continue to smoke the tobacco, swallow the junk food and binge on the alcohol that is killing us. Yes, there are systemic drivers at work - commercial marketing, corporate power, inequalities, addiction - but we don't have to collaborate. No one holds a gun to our heads and commands us to eat burgers or get drunk and incapable. This paper argues that public health progress - and human progress more widely - depends on us solving the conundrum of this self-inflicted harm. The urgency of this task increases when we consider our irresponsible consumption behaviour more widely, and that it is not just harming our own health but everyone else's too. Most egregiously anthropomorphic climate change is being caused by the free choices we in the wealthy global north make to drive SUVs, go on intercontinental holidays and accumulate a foolish excess of stuff. It need not be so. Historical experience and two millennia of thinking show we are capable of better. We have moral agency and we can make the right choice even when it is the difficult one. Indeed, it is this capacity and desire ' to follow after wisdom and virtue', to rebel against injustice and malignancy, that makes us human and cements our collective identity. In the last century this realisation was focused by the terrible events of the Second World War and resulted in the formation of the United Nations and the Universal Declaration of Human Rights. Importantly these rights do not just protect us from oppression but enshrine in international law our entitlement to be an active participant in the process of progressive social change.

Cannabis regulatory science: risk-benefit considerations for mental disorders

The evolving legal cannabis landscape in the US continues to present novel regulatory challenges that necessitate the development of a Cannabis Regulatory Science. Two specific issues of concern within Cannabis Regulatory Science are (1) the impact that cannabis use has on the incidence, prevalence, and severity of mental disorders, and (2) how cannabis laws and regulations modify this impact. This paper first provides several conceptual points that are useful for evaluating the relationship between cannabis use and mental disorders. Second, it selectively reviews and comments on data relevant to the relationship between cannabis use and depression, several forms of anxiety, post-traumatic stress disorder, schizophrenia, and bipolar disorder. Next, regulatory and public health parallels between the nascent cannabis industry and the pharmaceutical, tobacco, and alcohol industries are discussed. The focus is on specific types of industry practices that may harm those with or at risk for mental disorders. Recommendations are then offered for legal cannabis regulations that could mitigate this harm. Last, future research goals are discussed for building the field of Cannabis Regulatory Science and addressing the potential negative impact of cannabis on those with mental disorders.

Impact of Spiritual Behavior on Self-Reported Illness: A Cross-Sectional Study among Women in the Kailali District of Nepal

Background

Different health behaviors influence health and illness. Spiritual well-being is one of the most important aspects of health promotion. The aim of this study was to identify the association between spiritual behavior in relation to meditation, worship, and physical exercise during yoga with self-reported disease/illness among women of the Kailali district of Nepal.

Methods

This was a cross-sectional study with 453 randomly selected women in the Kailali district of Nepal within 1 municipality and 4 village development committees (VDC) using cluster sampling. We used a semi-structured interview to collect the data for selected respondents. Socioeconomics, lifestyle, self-care, and spiritual behavior variables were independent variables, and self-reported illness in the past year was a dependent variable. Descriptive statistics, chi square, hierarchical logistic regression for odds ratio, and 95% CI were used when appropriate.

Results

Study results showed that 89% of participants were from the rural area, 29.3% were housewives, 51.4% had no formal education, 43.2% used tobacco, 42.1% did yoga, and 16.9% engaged in regular worship. Self-reported illness was associated with safe toilet-using behavior, tobacco use, junk food consumption, yoga and regular exercise, worship, and regular sleeping habits. Comparing odds ratios and 95% CIs, the women who had safe toilet behavior and did not use tobacco were 2.48 (1.98-7.98) and 2.86 (1.74-7.34) times less likely to be ill, respectively. Likewise, women who consumed junk food; did not regularly exercise, meditate, or worship; and had irregular sleeping habits were 1.65 (1.32-4.61), 2.81(1.91-5.62), 2.56 (2.01-4.88), 4.56 (3.91-8.26), and 2.45 (2.12-5.03) times more likely to become ill, respectively.

Conclusion

Our study concludes that spiritual behavior is effective for better health and low risk for disease occurrence. A spiritual health policy and separate curriculum for basic education and medical education should be promoted globally, and further research is recommended.

Reassessing policy paradigms: A comparison of the global tobacco and alcohol industries

Tobacco is widely considered to be a uniquely harmful product for human health. Since the mid-1990s, the strategies of transnational tobacco corporations to undermine effective tobacco control policy has been extensively documented through internal industry documents. Consequently, the sale, use and marketing of tobacco products are subject to extensive regulation and formal measures to exclude the industry from policy-making have been adopted in the Framework Convention on Tobacco Control. In contrast to tobacco, alcohol is subject to less stringent forms of regulation, and the alcohol industry continues to play a central role in policy-making in many countries and at the global level. This article examines whether there is a sufficient rationale for such different regulatory approaches, through a comparative analysis of the political economy of the tobacco and alcohol industries including the structure of the industries, and the market and political strategies they pursue. Despite some important differences, the extensive similarities which exist between the tobacco and alcohol industries in terms of market structure and strategy, and political strategy, call into question the rationale for both the relatively weak regulatory approach taken towards alcohol, and the continued participation of alcohol corporations in policy-making processes.

Competing with big business: a randomised experiment testing the effects of messages to promote alcohol and sugary drink control policy

Background

Evidence-based policies encouraging healthy behaviours are often strongly opposed by well-funded industry groups. As public support is crucial for policy change, public health advocates need to be equipped with strategies to offset the impact of anti-policy messages. In this study, we aimed to investigate the effectiveness of theory-based public health advocacy messages in generating public support for sugary drink/alcohol policies (increased taxes; sport sponsorship bans) and improving resistance to subsequent anti-policy messages typical of the sugary drink/alcohol industry.

Methods

We conducted a two-wave randomised online experiment assigning Australian adults to one of four health policies (sugary drink tax; sugary drink industry sports sponsorship ban; alcohol tax; alcohol industry sports sponsorship ban). Within each health policy, we randomised participants to one of five message conditions: (i) non-advocacy based message about the size and seriousness of the relevant health issue (control); (ii) standard pro-policy arguments alone; (iii) standard pro-policy arguments combined with an inoculation message (forewarning and directly refuting anti-policy arguments from the opposition); (iv) standard pro-policy arguments combined with a narrative message (a short, personal story about an individual’s experience of the health issue); or (v) standard pro-policy arguments combined with a composite inoculation and narrative message. At time 1, we exposed participants (n = 6000) to their randomly assigned message. Around two weeks later, we re-contacted participants (n = 3285) and exposed them to an anti-policy message described as being from a representative of the sugary drink/alcohol industry. Generalised linear models tested for differences between conditions in policy support and anti-industry beliefs at both time points.

Results

Only the standard argument plus narrative message increased policy support relative to control at time 1. The standard argument plus narrative and standard argument plus inoculation messages were effective at increasing resistance to the persuasive impact of anti-policy messages relative to control at time 2.

Conclusions

Dissemination of advocacy messages using inoculation or narrative components can help strengthen public resistance to subsequent anti-policy messages from industry groups.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4972-6) contains supplementary material, which is available to authorized users.

A comparative content analysis of media reporting of sports betting in Australia: lessons for public health media advocacy approaches

Background

Harmful gambling is a significant public health issue. There has been widespread discussion in the Australian media about the extent and impact of sports betting on the Australian community, particularly relating to young men and children. Given the role that the media plays in influencing policy change and political agendas, and the acknowledgement that media based advocacy is a fundamental component of successful advocacy campaigns, this research aimed to investigate how different stakeholder groups discuss sports betting within the Australian print media. The study uses this information to provide recommendations to guide public health media advocacy approaches.

Methods

A quantitative content analysis of print media articles was conducted during two significant Parliamentary Inquiries about sports betting - (1) The Joint Select Committee Inquiry into the Advertising and Promotion of Gambling Services in Sport (2012/2013), and (2) 'The Review of Illegal Offshore Wagering (2015/2016). A total of 241 articles from 12 daily Australian newspapers were analysed. Statistical analysis was used to compare frequency of, and changes in, themes, voices and perspectives over time.

Results

Discussions about the marketing and communication of sports betting was a main theme in media reporting (n = 165, 68.5%), while discussions about gambling reform decreased significantly across the two time periods (p < 0.0001). The presence of sports betting industry (p < 0.0001), sporting code (p < 0.0001) and public health expert (p = 0.001) voices all increased significantly across the two time periods. There were very few (n = 11, 4.6%) voices from those who had experienced gambling harm. Finally, while there were significantly fewer articles taking the perspective that regulation changes were needed to protect vulnerable sub-populations (p < 0.0001), articles that had a neutral perspective about the need for regulation change increased significantly across the two time periods (p < 0.0001).

Discussion and conclusions

Mapping the media reporting of sports betting is important in developing effective public health advocacy approaches. This study indicates that discussions about the marketing strategies utilised by the sports betting industry was still a main theme in media articles. However, discussions relating to sports betting reforms, in particular to protect individuals who may be vulnerable to the harm associated with these products and their promotional strategies (for example children and young men) decreased during the time periods. Public health advocates may seek to address the decrease in media reports about reform by developing clear evidence-based messages about why regulatory reform is needed, as well as the potential consequences of not implementing reforms. Working with organisations to build capacity for people who have experienced gambling harm may help ensure that individuals with a lived experience of harm have an increased voice in the media.

Advocacy Coalition for Safer Sex in the Adult Film Industry: The Case of Los Angeles County's Measure B

BACKGROUND

Performers in the adult film industry are routinely exposed to bloodborne pathogens. In 2012, public health advocates in Los Angeles County convinced voters to pass a ballot initiative-Measure B-to mandate condom use on adult film sets. This article presents a case study of the advocacy coalition's strategies used to achieve greater workplace safety using the advocacy coalition framework.

METHOD

The authors were given access to all memoranda, market research, and campaign tools used to promote Measure B. To reconstruct adult film industry counterefforts, the authors reviewed trade publications, social media, and blog posts.

RESULTS

When legislative efforts failed, advocates engaged in a step-by-step strategy built around voters to achieve passage of a ballot initiative mandating condom use for all adult films produced in Los Angeles County. Although the industry immediately filed a lawsuit after passage of Measure B, its constitutionality has been upheld.

CONCLUSIONS

Measure B passed because public health advocates were able to assemble scientific evidence, build public support, counter false claims, and maintain consistent messages throughout the campaign. The adult film industry lacked social capital, cohesion, and nimbleness. To bolster regulatory efforts, appealing to voters to favor safe workplaces may be an effective advocacy strategy for other industries.

Healthy people and healthy profits? Elaborating a conceptual framework for governing the commercial determinants of non-communicable diseases and identifying options for reducing risk exposure

Background

Non-communicable diseases (NCDs) represent a significant threat to human health and well-being, and carry significant implications for economic development and health care and other costs for governments and business, families and individuals. Risks for many of the major NCDs are associated with the production, marketing and consumption of commercially produced food and drink, particularly those containing sugar, salt and transfats (in ultra-processed products), alcohol and tobacco. The problems inherent in primary prevention of NCDs have received relatively little attention from international organizations, national governments and civil society, especially when compared to the attention paid to secondary and tertiary prevention regimes (i.e. those focused on provision of medical treatment and long-term clinical management). This may in part reflect that until recently the NCDs have not been deemed a priority on the overall global health agenda. Low political priority may also be due in part to the complexity inherent in implementing feasible and acceptable interventions, such as increased taxation or regulation of access, particularly given the need to coordinate action beyond the health sector. More fundamentally, governing determinants of risk frequently brings public health into conflict with the interests of profit-driven food, beverage, alcohol and tobacco industries.

Materials

We use a conceptual framework to review three models of governance of NCD risk: self-regulation by industry; hybrid models of public-private engagement; and public sector regulation. We analyse the challenges inherent in each model, and review what is known (or not) about their impact on NCD outcomes.

Conclusion

While piecemeal efforts have been established, we argue that mechanisms to control the commercial determinants of NCDs are inadequate and efforts at remedial action too limited. Our paper sets out an agenda to strengthen each of the three governance models. We identify reforms that will be needed to the global health architecture to govern NCD risks, including to strengthen its ability to consolidate the collective power of diverse stakeholders, its authority to develop and enforce clear measures to address risks, as well as establish monitoring and rights-based accountability systems across all actors to drive measurable, equitable and sustainable progress in reducing the global burden of NCDs.

Alcohol harm reduction advertisements: a content analysis of topic, objective, emotional tone, execution and target audience

BACKGROUND

Public health mass media campaigns may contribute to reducing the health and social burden attributed to alcohol consumption, but little is known about which advertising characteristics have been used, or have been effective, in alcohol harm reduction campaigns to date. As a first step towards encouraging further research to identify the impact of various advertising characteristics, this study aimed to systematically identify and examine the content of alcohol harm reduction advertisements (ads).

METHOD

Ads were identified through an exhaustive internet search of Google, YouTube, Vimeo, and relevant government and health agency websites. Eligible ads were: English language, produced between 2006 and 2014, not primarily focused on drink-driving or alcohol in pregnancy, and not alcohol industry funded. Systematic content analysis of all ads was performed; each ad was double-coded.

RESULTS

In total, 110 individual ads from 72 different alcohol harm reduction campaigns were identified, with the main source countries being Australia (40%) and the United Kingdom (26%). The dominant topic for 52% of ads was short-term harms, while 10% addressed long-term harms, 18% addressed underage drinking, 17% communicated a how-to-change message, and 3% advocated for policy change. The behavioural objective of most ads was to motivate audiences to reduce their alcohol consumption (38%) or to behave responsibly and/or not get drunk when drinking (33%). Only 10% of all ads mentioned low-risk drinking guidelines. Eighty-seven percent of ads used a dramatisation execution style and 74% had a negative emotional tone. Ninety percent of ads contained messages or content that appeared to target adults, and 36% specifically targeted young adults.

CONCLUSIONS

Some message attributes have been employed more frequently than others, suggesting several promising avenues for future audience or population-based research to compare the relative effectiveness of different characteristics of alcohol harm reduction ads. Given most alcohol-attributable harm is due to long-term disease, these findings suggest future campaigns may fill a potentially important gap if they were to focus on long-term harms. There is scope for such long-term harm campaigns to place greater emphasis on encouraging reduced personal consumption of alcohol, potentially through more frequent communication of low-risk drinking guidelines.

Does public health advocacy seek to redress health inequities? A scoping review

The public health (PH) sector is ideally situated to take a lead advocacy role in catalysing and guiding multi-sectoral action to address social determinants of health inequities, but evidence suggests that PH's advocacy role has not been fully realised. The purpose of this review was to determine the extent to which the PH advocacy literature addresses the goal of reducing health and social inequities, and to increase understanding of contextual factors shaping the discourse and practice of PH advocacy. We employed scoping review methods to systematically examine and chart peer-reviewed and grey literature on PH advocacy published from January 1, 2000 to June 30, 2015. Databases and search engines used included: PubMed, CINAHL, PsycINFO, Social Sciences Citation Index, Google Scholar, Google, Google Books, ProQuest Dissertations and Theses, Grey Literature Report. A total of 183 documents were charted, and included in the final analysis. Thematic analysis was both inductive and deductive according to the objectives. Although PH advocacy to address root causes of health inequities is supported theoretically and through professional practice standards, the empirical literature does not reflect that this is occurring widely in PH practice. Tensions within the discourse were noted and multiple barriers to engaging in PH advocacy for health equity were identified, including a preoccupation with individual responsibilities for healthy lifestyles and behaviours, consistent with the emergence of neoliberal governance. If the PH sector is to fulfil its advocacy role in catalysing action to reduce health inequities, it will be necessary to address advocacy barriers at multiple levels, promote multi-sectoral efforts that implicate the state and corporations in the production of health inequities, and rally state involvement to redress these injustices.

Why media representations of corporations matter for public health policy: a scoping review

Background

Media representations play a crucial role in informing public and policy opinions about the causes of, and solutions to, ill-health. This paper reviews studies analysing media coverage of non-communicable disease (NCD) debates, focusing on how the industries marketing commodities that increase NCD risk are represented.

Methods

A scoping review identified 61 studies providing information on media representations of NCD risks, NCD policies and tobacco, alcohol, processed food and soft drinks industries. The data were narratively synthesized to describe the sample, media depictions of industries, and corporate and public health attempts to frame the media debates.

Results

The findings indicate that: (i) the limited research that has been undertaken is dominated by a focus on tobacco; (ii) comparative research across industries/risk-factors is particularly lacking; and (iii) coverage tends to be dominated by two contrasting frames and focuses either on individual responsibilities (‘market justice’ frames, often promoted by commercial stakeholders) or on the need for population-level interventions (‘social justice’ frames, frequently advanced by public health advocates).

Conclusions

Establishing the underlying frameworks is crucial for the analysis of media representation of corporations, as they reflect the strategies that respective actors use to influence public health debates and decision making. The potential utility of media research lies in the insights that it can provide for public health policy advocates about successful framing of public health messages and strategies to counter frames that undermine public health goals. A better understanding of current media debates is of paramount importance to improving global health.

Keeping Public Health Clean: Food Policy Barriers and Opportunities in the Era of the Industrial Epidemics

Poor diet accounts for a larger burden of disability and death than tobacco, alcohol and physical inactivity combined.[1] The World Health Assembly has recognized this as a priority and has challenged member countries to reduce non-communicable disease (NCD) mortality by 25% by 2025 targeting their determinants.[2] Reaching these ambitious targets is possible, but it will require decisive action on diets and tobacco smoking if we want to make a difference.[1] Certainly diet can deliver these reductions rapidly, possibly in less than a decade, and particularly by reducing cardiovascular disease burden, still one of the most important cause of death globally. [3],[4]

But the impact of these diseases can be substantially lowered. Several natural experiments have shown the dramatic changes in mortality can be observed after changes of risk factors at population level, many attributable to changes in food intake [5]

Reducing the Role of the Food, Tobacco, and Alcohol Industries in Noncommunicable Disease Risk in South Africa

Noncommunicable diseases (NCDs) impose a growing burden on the health, economy, and development of South Africa. According to the World Health Organization, four risk factors, tobacco use, alcohol consumption, unhealthy diets, and physical inactivity, account for a significant proportion of major NCDs. We analyze the role of tobacco, alcohol, and food corporations in promoting NCD risk and unhealthy lifestyles in South Africa and in exacerbating inequities in NCD distribution among populations. Through their business practices such as product design, marketing, retail distribution, and pricing and their business practices such as lobbying, public relations, philanthropy, and sponsored research, national and transnational corporations in South Africa shape the social and physical environments that structure opportunities for NCD risk behavior. Since the election of a democratic government in 1994, the South African government and civil society groups have used regulation, public education, health services, and community mobilization to modify corporate practices that increase NCD risk. By expanding the practice of health education to include activities that seek to modify the practices of corporations as well as individuals, South Africa can reduce the growing burden of NCDs.

Hazardous alcohol use and associated factors in a rural Ethiopian district: a cross-sectional community survey

BACKGROUND

Alcohol related health and social problems are on the rise in sub-Saharan Africa. This survey reports the prevalence and associated factors for hazardous drinking in rural Sodo district, southern Ethiopia. The survey was part of a multi-center study, Programme for Improving Mental Health Care (PRIME), which is a consortium of research institutions and ministries of health of five low and middle income countries, namely Ethiopia, India, Nepal, South Africa and Uganda in partnership with UK institutions and World Health Organization (WHO).

METHODS

A cross-sectional community survey was conducted involving 1500 adults, age 18 and above, recruited using multi-stage random sampling. Data on alcohol use was collected using the Fast Alcohol Screening Test (FAST). Standardised instruments were used to measure potential associated factors, including a validated adaptation of the Kessler 10 (psychological distress), the List of Threatening Experiences (number of adverse life events). Exploratory multivariable logistic regression was conducted to examine factors associated with hazardous alcohol use.

RESULTS

The overall prevalence of hazardous alcohol use was found to be 21 %; 31 % in males and 10.4 % in females, P < 0.05. Factors independently associated with hazardous alcohol use were being male (adjusted OR = 4.0, 95 % CI = 2.44, 6.67), increasing age, having experienced one or more stressful life events (adjusted OR = 1.71, 95 % CI = 1.18, 2.48, and adjusted OR = 2.12, 95 % CI = 1.36, 3.32 for 1-2 and 3 or more adverse life events, respectively) and severe psychological distress (adjusted OR = 2.96, 95 % CI = 1.49, 5.89). High social support was found to be protective from hazardous alcohol use (adjusted OR = 0.41, 95 % CI = 0.23, 0.72).

CONCLUSION

High level of hazardous alcohol use was detected in this predominantly rural Ethiopian setting. The finding informed the need to integrate services for hazardous alcohol use such as brief intervention at different levels of primary care services in the district. Public health interventions to reduce hazardous alcohol use also need to be launched.

Comparing global alcohol and tobacco control efforts: network formation and evolution in international health governance

Smoking and drinking constitute two risk factors contributing to the rising burden of non-communicable diseases in low- and middle-income countries. Both issues have gained increased international attention, but tobacco control has made more sustained progress in terms of international and domestic policy commitments, resources dedicated to reducing harm, and reduction of tobacco use in many high-income countries. The research presented here offers insights into why risk factors with comparable levels of harm experience different trajectories of global attention. The analysis focuses particular attention on the role of dedicated global health networks composed of individuals and organizations producing research and engaging in advocacy on a given health problem. Variation in issue characteristics and the policy environment shape the opportunities and challenges of global health networks focused on reducing the burden of disease. What sets the tobacco case apart was the ability of tobacco control advocates to create and maintain a consensus on policy solutions, expand their reach in low- and middle-income countries and combine evidence-based research with advocacy reaching beyond the public health-centered focus of the core network. In contrast, a similar network in the alcohol case struggled with expanding its reach and has yet to overcome divisions based on competing problem definitions and solutions to alcohol harm. The tobacco control network evolved from a group of dedicated individuals to a global coalition of membership-based organizations, whereas the alcohol control network remains at the stage of a collection of dedicated and like-minded individuals.

Clear principles are needed for integrity in gambling research

Commercial gambling is expanding rapidly across the globe. However, the field of gambling research has not kept pace with this expansion, and continues to focus on prevalence studies and individuated treatment regimes, with little attention to the political, economic or technological underpinnings of commercial gambling. The implications of this lack of sophistication in the research agenda are that society is ill-equipped to understand the nature and underlying causes of gambling harms, and how these might best be avoided, minimized or ameliorated. Around the world, various levels of government benefit from gambling revenue, with consequences for the independent regulation of gambling. Further, there is considerable industry influence on the research agenda, often involving similar techniques to those employed previously by the tobacco and alcohol industries to engage researchers. This influence is compounded by a failure of many gambling researchers and journals to adopt traditional academic safeguards, such as the disclosure of conflicts of interest, and by many arguing for a 'partnership model' with industry to advance the research agenda. This paper identifies five basic principles to restore reasonable standards of integrity in gambling studies: (1) research should not be funded by the proceeds of gambling; (2) research priorities should not be influenced by the beneficiaries of gambling; (3) conferences and other research fora should not be influenced by industry; (4) funding sources should be disclosed in journals and at conferences; and (5) meaningful access to gambling products and environments must be part of licensing. We also propose a range of actions to promote greater transparency and independence in the gambling research field.

Multinational Alcohol Market Development and Public Health: Diageo in India

Alcohol is a risk factor for communicable and noncommunicable diseases, and alcohol consumption is rising steadily in India. The growth of multinational alcohol corporations, such as Diageo, contributes to India's changing alcohol environment. We provide a brief history of India's alcohol regulation for context and examine Diageo's strategies for expansion in India in 2013 and 2014. Diageo is attracted to India's younger generation, women, and emerging middle class for growth opportunities. Components of Diageo's responsibility strategy conflict with evidence-based public health recommendations for reducing harmful alcohol consumption. Diageo's strategies for achieving market dominance in India are at odds with public health evidence. We conclude with recommendations for protecting public health in emerging markets.