Brussels Declaration: a vehicle for the advancement of tobacco and alcohol industry interests at the science/policy interface?

Rebalancing commercial and public interests in prioritizing biomedical, social and environmental aspects of health through defining and managing conflicts of interest

Biomedical research is intended to benefit human beings and their health. Toward that end, scientific norms involve examining and criticizing the work of others and prioritizing questions that should be studied. Yet, in areas of health research where industry is active, it has often utilized well-honed strategies aimed at evading scientific standards and at dominating the research agenda, largely through its financial support and lack of transparency of its research practices. These tactics have now been documented to uniformly support industry products. Commercial entities are aided in this pursuit by public policy that has significantly embedded commercial interests and agendas into federal research funding and infrastructure. Therefore, to understand the resulting landscape and its effect on priority in health research agendas, traditional definitions of individual conflicts of interest (COI) and the less well developed institutional COI must be supplemented by a new construct of structural COI, largely operating as intellectual monopolies, in support of industry. These arrangements often result in financial and reputational resources that assure dominance of commercial priorities in research agendas, crowding out any other interests and ignoring justified returns to the public from investment of its tax dollars. There is no sustained attention to mechanisms by which public interests can be heard, normative issues raised, and then balanced with commercial interests which are transparently reported. Focus on research supporting approval of commercial products ignores social and environmental determinants of health. Commercial bias can invalidate regulatory research protections through obscuring valid risk-benefit ratios considered by IRBs.

The Commercial Determinants of Health and Evidence Synthesis (CODES): methodological guidance for systematic reviews and other evidence syntheses

BACKGROUND

The field of the commercial determinants of health (CDOH) refers to the commercial products, pathways and practices that may affect health. The field is growing rapidly, as evidenced by the WHO programme on the economic and commercial determinants of health and a rise in researcher and funder interest. Systematic reviews (SRs) and evidence synthesis more generally will be crucial tools in the evolution of CDOH as a field. Such reviews can draw on existing methodological guidance, though there are areas where existing methods are likely to differ, and there is no overarching guidance on the conduct of CDOH-focussed systematic reviews, or guidance on the specific methodological and conceptual challenges.

METHODS/RESULTS

CODES provides guidance on the conduct of systematic reviews focussed on CDOH, from shaping the review question with input from stakeholders, to disseminating the review. Existing guidance was used to identify key stages and to provide a structure for the guidance. The writing group included experience in systematic reviews and other forms of evidence synthesis, and in equity and CDOH research (both primary research and systematic reviews).

CONCLUSIONS

This guidance highlights the special methodological and other considerations for CDOH reviews, including equity considerations, and pointers to areas for future methodological and guideline development. It should contribute to the reliability and utility of CDOH reviews and help stimulate the production of reviews in this growing field.

"Using information to shape perception": tobacco industry documents study of the evolution of Corporate Affairs in the Miller Brewing Company

BACKGROUND

The Miller Brewing Company (MBC) was wholly owned by Phillip Morris (PM), between 1970 and 2002. Tobacco industry document studies identify alliances between the alcohol and tobacco industries to counter U.S. policies in the 1980s and 1990s. This investigation sought to study in-depth inter-relationships between MBC and PM, with a particular focus on alcohol policy issues. We used the Truth Tobacco Industry Documents library to trace the evolution of corporate affairs and related alcohol policy orientated functions within and between MBC and PM.

RESULTS

MBC was structured and led by PM senior executives from soon after takeover in 1970. Corporate Affairs sought to influence public perceptions of alcohol to align them with business interests. Alcohol education was specifically designed to prevent the adoption of policies inimical to those interests (e.g., raising excise taxes). Strategic consideration of alcohol policy issues was integrated within company-wide thinking, which sought to apply lessons from tobacco to alcohol and vice versa. PM directly led key alcohol industry organisations nationally and globally, which have successfully delayed the adoption and implementation of known effective policy measures in the U.S. and worldwide.

CONCLUSIONS

PM has been a key architect of alcohol industry political strategies. This study builds on earlier work on alcohol companies in the tobacco documents, and offers historical data on how tobacco companies have used commercial involvements in other sectors to influence wider public health policy. We are only beginning to appreciate how multi-sectoral companies internally develop political strategies across product categories. Global health and national governmental policy-making needs to be better protected from business interests that fundamentally conflict with public health goals.

The Views of Researchers on the Alcohol Industry's Involvement in Science: Findings from an Interview Study

INTRODUCTION

Debates in the peer-reviewed literature on alcohol industry involvement in science have been polarized, with the activities of the International Center on Alcohol Policies and industry provision of research funding being particularly contentious. We aimed to explore researchers' views on the nature of the debates and the issues raised.

METHODS

Qualitative interview study with experienced researchers working on alcohol policy-relevant topics across ten countries (n = 37). Thematic analysis of views articulated, supported where appropriate by accounts of how experiences informed particular perspectives.

RESULTS

The main finding is how much common ground there now is among participants, regardless of whether they had previously worked with industry organizations or received alcohol industry funding. Norms have changed and participants agree that the earlier debates were dysfunctional. Participants on all sides of these earlier debates experienced significant psychological burdens as a result of industry-related activity in alcohol research. These include reputational harms from working with industry organizations and/or receiving research funding, and harassment by industry for producing findings contrary to commercial interests. Key ongoing contentious issues include the extent to which conflicts of interest can or should be managed by individual researchers, and how distinct the alcohol industry is from other funders and other industries. Participant views on ways forward include improving the evidence-base underpinning the debates, and having collegiate discussions among researchers, including all strands of opinion and experience.

CONCLUSIONS

This group of alcohol researchers shares more nuanced contemporary positions on issues relating to industry involvement in science than are reflected in the existing material in peer-reviewed journals. Almost all regard the alcohol industry's involvement in research as having been damaging.

Alcohol, cardiovascular disease and industry funding: A co-authorship network analysis of systematic reviews

BACKGROUND

Alcohol's effects on heart health is the site of a major scientific controversy. We conducted a co-authorship network analysis of systematic reviews on the impacts on alcohol on cardiovascular disease (CVD) in order to investigate patterns of co-authorship in the literature, with particular attention given to industry funding.

METHODS

We used Epistemonikos to identify systematic reviews. Review characteristics, influential authors, co-authorship subnetworks, prior histories of alcohol industry funding, study outcomes and citations were investigated.

RESULTS

60 systematic reviews with 231 unique authors met our inclusion criteria. 14 systematic reviews were undertaken by authors with histories of alcohol industry funding, including 5 that were funded directly by the alcohol industry itself. All 14 such reviews identified a cardioprotective effect of alcohol. These formed distinct co-authorship subnetworks within the literature. Of reviews by authors with no prior histories of alcohol industry funding, the findings were mixed, with 54% (25/46) concluding there was evidence of health protective effects. These two groups of reviews differed in other respects. Those with industry funding were more likely to study broader outcomes such as 'cardiovascular disease' or 'coronary heart disease' as opposed to specific CVD issues such as hypertension or stroke (93% [13/14] versus 41% [19/46]) (chi-squared 12.4, p < 0.001) and have more included studies (mean of 29 versus 20). They were also more widely cited by others. Over time the proportions of systematic reviews on CVD and alcohol undertaken by authors with no prior histories of alcohol industry funding has increased.

CONCLUSIONS

Systematic reviews undertaken by authors with histories of alcohol industry funding were more likely to study broader outcomes, and be cited more widely, and exclusively reported favorable conclusions.

Alcohol policy, multi-level governance and corporate political strategy: The campaign for Scotland's minimum unit pricing in Edinburgh, London and Brussels

The Scottish government's plans for a minimum unit price for alcohol were vehemently opposed by the alcohol industry leading to a 6-year delay in implementation after legislation was passed. This article seeks to explain the consequences of devolution and European Union membership for the development of minimum unit price in Scotland through the concepts of multi-level governance, veto points and venue shifting. Systems of multi-level governance create policy interdependencies between settings, an increased number of veto points at which policies can be blocked, and the potential for policy actors to shift decision-making to forums where favourable outcomes are more likely to be attained. In the minimum unit price debates, the alcohol industry engaged in multiple forms of venue shifting and used regulatory compliance procedures and legal challenges at the EU level to try to prevent and delay the policy. This has led to a 'chilling effect' on subsequent alcohol policy developments across the United Kingdom.

Beyond nutrition and physical activity: food industry shaping of the very principles of scientific integrity

BACKGROUND

There is evidence that food industry actors try to shape science on nutrition and physical activity. But they are also involved in influencing the principles of scientific integrity. Our research objective was to study the extent of that involvement, with a case study of ILSI as a key actor in that space. We conducted a qualitative document analysis, triangulating data from an existing scoping review, publicly available information, internal industry documents, and existing freedom of information requests.

RESULTS

Food companies have joined forces through ILSI to shape the development of scientific integrity principles. These activities started in 2007, in direct response to the growing criticism of the food industry's funding of research. ILSI first built a niche literature on COI in food science and nutrition at the individual and study levels. Because the literature was scarce on that topic, these publications were used and cited in ILSI's and others' further work on COI, scientific integrity, and PPP, beyond the fields of nutrition and food science. In the past few years, ILSI started to shape the very principles of scientific integrity then and to propose that government agencies, professional associations, non-for-profits, and others, adopt these principles. In the process, ILSI built a reputation in the scientific integrity space. ILSI's work on scientific integrity ignores the risks of accepting corporate funding and fails to provide guidelines to protect from these risks.

CONCLUSIONS

The activities developed by ILSI on scientific integrity principles are part of a broader set of political practices of industry actors to influence public health policy, research, and practice. It is important to learn about and counter these practices as they risk shaping scientific standards to suit the industry's interests rather than public health ones.

Alcohol marketing versus public health: David and Goliath?

BACKGROUND

Alcohol harms are rising globally, and alcohol policies, where they exist, are weak or under-developed. Limited progress has been made since the formulation of the World Health Organisation (WHO) Global Strategy in 2010. WHO is seeking to accelerate progress in implementing international efforts to reduce the harmful use of alcohol. The threat to global health posed by tobacco is well understood by policy communities and populations globally; by contrast alcohol is much less so, despite available evidence.

THE COMPETITION FOR EPISTEMIC AUTHORITY

Global alcohol corporations have sought to become trusted sources of advice for policy makers and consumers, while continuing to grow their markets. Evidence-informed public health messaging faces formidable competition from transnational corporations as the worlds of corporate and political communications, social and mainstream media become increasingly linked, presenting new opportunities for corporate actors to shape global health governance. Alcohol messaging that uses means of persuasion tied to industry agendas does not tell a clear story about commercial determinants of health, and does not contribute to health improvement. On the contrary, the basic tenets of an evidence-informed population-based approach are denied and the policy measures supported by high quality evidence are being opposed, because they are inimical to commercial interests. A David and Goliath metaphor for this state of affairs, which seems to fit at first glance, may unwittingly reinforce the status quo.

CONCLUSION

Public opinion on alcohol and policy issues varies across time and place and can be influenced by dedicated public health interventions. Alcohol marketing dominates people's thinking about alcohol because we currently allow this to happen. Greater ambition is needed in developing countermarketing and other interventions to promote evidence-informed ideas with the public. Alcohol policies need to be further developed, and implemented more widely, in order to arrest the growing burden of alcohol harms across the world.

The Commercial Determinants of Three Contemporary National Crises: How Corporate Practices Intersect With the COVID-19 Pandemic, Economic Downturn, and Racial Inequity

Policy Points  The United States finds itself in the middle of an unprecedented combination of crises: a global pandemic, economic crisis, and unprecedented civic responses to structural racism.  While public sector responses to these crises have faced much justified criticism, the commercial determinants of these crises have not been sufficiently examined.  In this commentary we examine the nature of the contributions of such actors to the conditions that underpin these crises in the United States through their market and nonmarket activities.  On the basis of this analysis, we make recommendations on the role of governance and civil society in relation to such commercial actors in a post-COVID-19 world.

Mechanisms for addressing and managing the influence of corporations on public health policy, research and practice: a scoping review

OBJECTIVE

We identified mechanisms for addressing and/or managing the influence of corporations on public health policy, research and practice, as well as examples of where these mechanisms have been adopted from across the globe.

DESIGN

We conducted a scoping review. We conducted searches in five databases on 4 June 2019. Twenty-eight relevant institutions and networks were contacted to identify additional mechanisms and examples. In addition, we identified mechanisms and examples from our collective experience working on the influence of corporations on public health policy, research and practice.

SETTING

We identified mechanisms at the national, regional and global levels.

RESULTS

Thirty-one documents were included in our review. Eight were peer-reviewed scientific articles. Nine discussed mechanisms to address and/or manage the influence of different types of industries; while other documents targeted specific industries. In total, we identified 49 mechanisms for addressing and/or managing the influence of corporations on public health policy, research and practice, and 43 of these were adopted at the national, regional or global level. We identified four main types of mechanisms: transparency; management of interactions with industry and of conflicts of interest; identification, monitoring and education about the practices of corporations and associated risks to public health; prohibition of interactions with industry. Mechanisms for governments (n=17) and academia (n=13) were most frequently identified, with fewer for the media and civil society.

CONCLUSIONS

We identified several mechanisms that could help address and/or manage the negative influence of corporations on public health policy, research and practice. If adopted and evaluated more widely, many of the mechanisms described in this manuscript could contribute to efforts to prevent and control non-communicable diseases.

TRIAL REGISTRATION DETAILS

The protocol was registered with the Open Science Framework on 27 May 2019 (https://osf.io/xc2vp).

Reconceptualising the study of alcohol policy decision-making: the contribution of political science

In this article, we demonstrate the applicability of a 3-I (interests, institutions, and ideas) framework to alcohol policy research. The analysis uses literature from political science research to provide a core theoretical framework. To help illustrate the argument, we draw on relevant examples from alcohol policy in the UK as well as initial findings from an ongoing research study on minimum-unit pricing in Wales. The Welsh case study provides an opportunity to examine the value of the framework in generating testable hypotheses in alcohol policy research. We find that several interrelated factors promoted policy change in Wales, including the government's power to legislate on matters of public health (institutionally), a relatively weak alcohol industry (a key interest group), and a public health community with specific policy arguments on why and how to tackle alcohol-related harms (ideas). Our analysis has important implications for public health research and evidence-based policymaking. It suggests that the uptake of new ideas depends on the existing configuration of interests, institutions and ideas. This analysis provides alcohol policy researchers with a portable framework for analysing the policy context.

How can the integrity of occupational and environmental health research be maintained in the presence of conflicting interests?

BACKGROUND

The sciences, and especially the research subspecialties of occupational and environmental health, are being misused. The misuse serves to interfere with the advancement of policies that depend on rational evidence needed for policies to protect public health.

METHODS

We selectively surveyed the independent scientific literature. In addition, the efforts of respected international professional organizations of scientists whose focus is on maintaining and improving public health have been considered. This commentary is unique in assembling not only the factual basis for sounding alarms about significant bias in occupational and environmental health research, but also about the manipulative mechanisms used, and, in turn, the methods needed to keep science honest.

RESULTS

Scientific integrity is based on the principle that research is conducted as objectively as possible; it cannot be compromised by special interests whose primary goals are neither to seek truth nor to protect human health. Evidence demonstrates a significant risk of bias in research reports sponsored by financial interests. Practices of corporate malfeasance include the orchestrated contamination of editorial boards of peer-reviewed scientific journals with industry apologists; interference with activities of national regulatory bodies and international review panels engaged in safeguarding occupational and public health; constructing roadblocks by capitalizing on uncertainty to undermine scientific consensus for much-needed government regulation of carcinogenic, endocrine-disrupting and/or immunotoxic agents; promoting "causation" criteria that lack foundation and effectively block workers' access to legal remedies for harms from occupational exposures resulting in morbidity and premature mortality; and, violating standards of professional conduct by seducing reputable scientists with financial incentives that make them beholden to corporate agendas.

CONCLUSIONS

Well-orchestrated assaults on science continue unabated and must now be met head-on. Success could be achieved by promoting and protecting the integrity of research. Furthermore, avoiding influence by conflicted corporate affiliates in occupational and public health regulations is needed. Identifying, managing and, ideally, eliminating corporate influence on science and science policy are needed to protect research integrity. Protecting the public's health, preventing disease, and promoting well-being must be the unambiguous goals of research in occupational and environmental health.

Bridging the Gap Between Research and Policy and Practice Comment on "CIHR Health System Impact Fellows: Reflections on 'Driving Change' Within the Health System"

Far too often, there is a gap between research and policy and practice. Too much research is undertaken with little relevance to real life problems or its reported in ways that are obscure and impenetrable. At the same time, many policies are developed and implemented but are untouched by, or even contrary to evidence. An accompanying paper describes an innovative programme in Canada to help bridge this gap. This commentary notes the growing acceptance of such initiatives but highlights the challenges of sustaining their benefits.

The intersections of industry with the health research enterprise

There is increased awareness of the negative impact of large multinational corporations – the ‘industry’ – on public health. These corporations have established different types of relationships with a number of actors in the field of health research. This Commentary explores the different types of relationships between the industry and the actors of health research, how they intersect with the different research steps, and how these relationships allow the industry to exert influence. The types of relationships discussed consist of funding of research, direct relationships with the actors of research (namely advocacy groups, funding agencies, experts, professional organisations, regulatory agencies and health practitioners), and the influencing research standards. The potentially influenced research steps either precede the research (i.e. the prioritisation of research question), relate to it directly (i.e. its planning, conduct, reporting, dissemination and evaluation), or build on it (i.e. regulatory approval, integration into guidelines and adoption into practice). In conclusion, the industry has successfully fostered relationships with almost every actor of the health research enterprise and is using these relationships to influence the different steps of health research. The degree of influence the industry is having on health research calls for more work on managing the relationships discussed herein.

Tobacco and electronic nicotine delivery systems regulation

The smoking of tobacco cigarettes by millions of people over the past 100 or more years has had devastating public health consequences around the world. In some countries, this has been mitigated by the introduction of multiple regulatory strategies that have taken decades to implement. But even in the countries with most success at tobacco cigarette regulation, some smokers find it very hard to quit and need better treatment. Electronic cigarettes and other electronic nicotine delivery systems (ENDS) have emerged in the last decade or so. Initially designed to help smokers quit and produced by small independent entities, ENDS have become big business, with major transnational tobacco companies competing hard for market share where, for example, in the United States, a single device came to dominate the market within a couple of years and where soaring uptake by adolescents reached levels high enough to alarm the FDA. No doubts remain about the damaging health consequences of tobacco cigarettes. Controversies persist about e-cigarettes-their efficacy, health impacts, development of addiction and whether or not they provide a "gateway" to tobacco cigarette smoking. The regulation of tobacco cigarettes falls under a global WHO treaty, the Framework Convention on Tobacco Control (FCTC); over 180 countries are party to the FCTC. The regulation of ENDS has no such treaty, varies considerably around the world and in many countries remains completely untrammelled by specific directives. This paper will not discuss the evidence for or against the of e-cigarettes in smoking cessation (effectively discussed in this issue by Dr. Wallace) but aims to review the current state of tobacco regulation around the world, identify key differences in ENDS regulation, examine the impact of industry influence on public health policy and determine how the lessons of tobacco control should apply to ENDS.

Time for complete transparency about conflicts of interest in public health nutrition research

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 and interpretations. 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.

Time for complete transparency about conflicts of interest in public health nutrition research

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.

Gathering momentum for the way ahead: fifth report of the Lancet Standing Commission on Liver Disease in the UK

This report presents further evidence on the escalating alcohol consumption in the UK and the burden of liver disease associated with this major risk factor, as well as the effects on hospital and primary care. We reiterate the need for fiscal regulation by the UK Government if overall alcohol consumption is to be reduced sufficiently to improve health outcomes. We also draw attention to the effects of drastic cuts in public services for alcohol treatment, the repeated failures of voluntary agreements with the drinks industry, and the influence of the industry through its lobbying activities. We continue to press for reintroduction of the alcohol duty escalator, which was highly effective during the 5 years it was in place, and the introduction of minimum unit pricing in England, targeted at the heaviest drinkers. Results from the introduction of minimum unit pricing in Scotland, with results from Wales to follow, are likely to seriously expose the weakness of England's position. The increasing prevalence of obesity-related liver disease, the rising number of people diagnosed with type 2 diabetes and its complications, and increasing number of cases of end-stage liver disease and primary liver cancers from non-alcoholic fatty liver disease make apparent the need for an obesity strategy for adults. We also discuss the important effects of obesity and alcohol on disease progression, and the increased risk of the ten most common cancers (including breast and colon cancers). A new in-depth analysis of the UK National Health Service (NHS) and total societal costs shows the extraordinarily large expenditures that could be saved or redeployed elsewhere in the NHS. Excellent results have been reported for new antiviral drugs for hepatitis C virus infection, making elimination of chronic infection a real possibility ahead of the WHO 2030 target. However, the extent of unidentified cases remains a problem, and will also apply when new curative drugs for hepatitis B virus become available. We also describe efforts to improve standards of hospital care for liver disease with better understanding of current service deficiencies and a new accreditation process for hospitals providing liver services. New commissioning arrangements for primary and community care represent progress, in terms of effective screening of high-risk subjects and the early detection of liver disease.

Philip Morris International-funded 'Foundation for a Smoke-Free World': analysing its claims of independence

The Foundation for a Smoke-Free World was launched in September 2017 with an announced 12-year funding commitment of $1 billion from Philip Morris International (PMI). The Foundation claims that its governing documents (certificate of incorporation, bylaws and a pledge agreement) ensure that it has an independent research agenda and stringent protections from conflicts of interest. We analysed the text of these governing documents. Their provisions have multiple loopholes, particularly regarding conflicts of interest. Further, these documents cannot substitute for other important documentation such as information about PMI's internal business case for investing $1 billion in the Foundation, an unwaivable conflict of interest policy, annual disclosure statements, copies of pre-Foundation establishment correspondence between key individuals, all signed contracts or salary information, none of which, as of July 2018, the Foundation has made publicly available. Even if these were released, however, it is problematic that the Foundation's fundamental purpose was decided on and its leader selected following a tobacco company-paid, privately negotiated arrangement with the Foundation's president. It cannot be regarded as independent.

Revisiting the Corporate and Commercial Determinants of Health

We trace the development of the concept of the corporate determinants of health. We argue that these determinants are predicated on the unchecked power of corporations and that the means by which corporations exert power is increasingly unseen. We identify four of the ways corporations influence health: defining the dominant narrative; setting the rules by which society, especially trade, operates; commodifying knowledge; and undermining political, social, and economic rights. We identify how public health professionals can respond to these manifestations of power.