Protecting whose welfare? A document analysis of competition regulatory decisions in four jurisdictions across three harmful consumer product industries

BACKGROUND AND METHODS

Competition regulation has a strong influence on the relative market power of firms. As such, competition regulation can complement industry-specific measures designed to address harms associated with excessive market power in harmful consumer product industries. This study aimed to examine, through a public health lens, assessments and decisions made by competition authorities in four jurisdictions (Australia, South Africa, the United States (US), and the European Union (EU)) involving three harmful consumer product industries (alcoholic beverages, soft drinks, tobacco). We analysed legal case documents, sourced from online public registers and dating back as far as the online records extended, using a narrative approach. Regulatory decisions and harms described by the authorities were inductively coded, focusing on the affected group(s) (e.g., consumers) and the nature of the harms (e.g., price increases) identified.

RESULTS

We identified 359 cases published by competition authorities in Australia (n = 202), South Africa (n = 44), the US (n = 27), and the EU (n = 86). Most cases (n = 239) related to mergers and acquisitions (M&As). Competition authorities in Australia, the US, and the EU were found to make many decisions oriented towards increasing the affordability and accessibility of alcohol beverages, soft drinks, and tobacco products. Such decisions were very often made despite the presence of consumption-reduction public health policies. In comparison, South Africa's competition authorities routinely considered broader issues, including 'Black Economic Empowerment' and potential harms to workers.

CONCLUSION

Many of the competition regulatory decisions assessed likely facilitated the concentration of market power in the industries we explored. Nevertheless, there appears to be potential for competition regulatory frameworks to play a more prominent role in promoting and protecting the public's health through tighter regulation of excessive market power in harmful consumer product industries.

Unhealthy and health promoting sponsorship of male and female professional sporting teams in Australia

ISSUE ADDRESSED

There are concerns that unhealthy industries may use sponsorships to align their brands with the increased popularity of professional women's sporting events. This study aimed to identify and compare the sponsors of Australian male and female professional sporting teams in relation to unhealthy industries (alcohol, gambling, discretionary food and drink, and venues) and health-promoting companies and organisations (charities, government departments, and educational institutions).

METHODS

A web-based scan was conducted from July to October 2021 to identify team and uniform sponsors, with descriptive statistics used to identify and compare results.

RESULTS

About one tenth of sponsors (team n = 269; 10.9%; uniform n = 62; 10.6%) were for unhealthy industries. Men's teams had a greater number of these sponsors as compared to women's teams. Just under 10% of sponsors were for health-promoting organisations (team n = 210; 8.5%; uniform n = 44; 7.5%), with women's teams more likely to have these sponsors as compared to men's teams.

CONCLUSIONS

Professional sport provides an important opportunity to facilitate health-promoting rather than -harming sponsors. Health-promoting sponsors are more prominent in women's sport, but as women's professional sport continues to grow in popularity, there is a need for policy, funding, and support to prevent engagement with unhealthy industry sponsorship and create a level playing field with men's sport. SO WHAT?: Mechanisms should be developed to help sporting codes, particularly women's sport, to adopt business models that are not reliant on industries that cause harm. Establishing strong relationships with health-promoting organisations may provide alternative sponsorship opportunities for sporting teams.

A landscape analysis of investors in the global breast milk substitute industry to target for advocacy

The International Code of Marketing of Breast-milk Substitutes and subsequent resolutions (the Code) was adopted to address increases in mortality and morbidity resulting from the practices of the breast-milk substitute (BMS) industry. The lack of success in ensuring company compliance with the Code has prompted advocates to consider engaging with investors to shape the governance of BMS companies. To support these efforts, this paper aimed to identify prominent investors in the global BMS industry and explore their Code-related policies and practices. Using multiple methods and data sources, we developed a novel approach to identify and rank investors in the world's leading publicly listed BMS companies. We also examined the policies and voting behaviour of a sample of investors using publicly accessible materials from 2020 to 2022. We found that a small number of large investors, led by BlackRock and Vanguard, hold a substantial share in the global BMS industry. Of the top-10 ranked investors, only Norway's Government Pension Fund (NBIM) reported policy information relating specifically to BMS marketing. Most of these large investors also opposed the sample of public health-related shareholder proposals analysed. In addition, we identified several investors that have reported engaging with BMS companies on Code-related issues, including NBIM, Pictet, and UBS, along with several potential investor targets for future advocacy efforts, including some North American public pension funds. The inclusion of Code-related issues as part of broader policies, disclosures and regulations related to environmental, social and governance oriented investment warrants increased attention.

Ladders and stairs: how the intervention ladder focuses blame on individuals and obscures systemic failings and interventions

Introduced in 2007 by the Nuffield Council on Bioethics, the intervention ladder has become an influential tool in bioethics and public health policy for weighing the justification for interventions and for weighing considerations of intrusiveness and proportionality. However, while such considerations are critical, in its focus on these factors, the ladder overemphasises the role of personal responsibility and the importance of individual behaviour change in public health interventions. Through a study of vaccine hesitancy and vaccine mandates among healthcare workers, this paper investigates how the ladder obscures systemic factors such as the social determinants of health. In overlooking these factors, potentially effective interventions are left off the table and the intervention ladder serves to divert attention away from key issues in public health. This paper, therefore, proposes a replacement for the intervention ladder-the intervention stairway. By broadening the intervention ladder to include systemic factors, the stairway ensures relevant interventions are not neglected merely due to the framing of the issue. Moreover, it more accurately captures factors influencing individual health as well as allocations of responsibility for improving these factors.

Bridging the commercial determinants of Indigenous health and the legacies of colonization: A critical analysis

To date, there has been scarce effort to consider the intertwining of colonization and the commercial determinants of Indigenous health. This is a vital omission, and one that this paper proposes to address. We propose how four losses of tradition borne out of colonialism are intertwined with four respective commercial determinants of Indigenous health: 1) loss of traditional diets and the ultra-processed food industry; 2) loss of traditional ceremony and the tobacco industry; 3) loss of traditional knowledge and the infant formula industry; and 4) loss of traditional support networks and the alcohol industry. Building on Indigenous efforts to decolonize spaces and assert control over their own lives, we argue that analyzing the mechanisms through which industry activities intersect with colonial legacies will improve broader understandings of Indigenous health disparities.

Governmental institutionalization of corporate influence on national nutrition policy and health: a case study of Ecuador

Corporate influence in policy and decision-making is an important public health concern. This Health Policy paper reviews Ecuador's child malnutrition strategy instruments, approved between 2020 and 2023, to identify how private interests are becoming legally integrated into the public sector. Evidence indicates that recent changes are enabling corporations to promote their brands, gain tax deductions, oversee public policy and set priorities, allocate resources, and decide on implementation of the country's child malnutrition strategy. Further, corporate representatives are active members of an advisory council, free from scrutiny or accountability, while being privy to undisclosed government information. Moreover, a UN agency (the World Food Program) engaged in corporate promotion of highly processed foods, illustrating the breadth of Ecuador's corporate influence scheme. Improved regulations should set clear limits to the influence of food and beverage industries in national nutrition policy, while following transparency laws in the composition and operation of Ecuador's child malnutrition strategy and related efforts.

The U.S. hemp-derived cannabinoid industry and the potential of self-regulation: Using social media to assess an evolving health risk

BACKGROUND

Facing statewide bans and increasing oversight in the U.S., representatives from the hemp-derived cannabinoid industry, product advocates, and consumers have been discussing self-policing and self-regulation. Prominent examples of these discussions are found online in Reddit groups.

METHODS

We conducted a qualitative thematic analysis of Reddit posts between September 2020 to August 2022, focusing on the conversations surrounding regulation and consumer safety. Approximately 3800 posts were collected and subject to initial analysis. Thematic analysis was guided by literature on self-regulation and consumer health, from the anthropology of pharmaceuticals and the commercial determinants of health.

RESULTS

The hemp-derived cannabinoid community is discussing self-regulation, shared standards, and transparency. Self-regulation is desired by many, in hopes to stave off prohibition or restrictive government regulation and simultaneously protect consumer health. However, there is little agreement as to what these standards should be, who should oversee them, or how basic concepts should be defined. Subreddit moderators note the ease at which unlicensed or untested products can enter retail store shelves or the informal market, thereby putting health at risk. Given the lack of collective agreement, the absence of state and federal oversight, and the possibilities for consumer deception, consumer frustration and confusion are rampant. With limited access to trustworthy and verifiable information about product safety, purchasers ultimately resort to experimenting on their own bodies to assess risks and benefits.

CONCLUSIONS

Reddit posts reflect the multiple existing tensions in the evolving industry between a genuine appeal among some for workable and consistent industry standards that could protect consumer health, a distrust of regulatory scrutiny from state or federal government, and a desire by others to maintain current profits within the existing unrestrictive free market. Our findings emphasize the urgency of developing coherent, collective, agreed upon policies structured by objective, transparent, scientifically informed regulation in order to develop a safe supply of cannabinoid products and protect consumer health.

The alcohol industry-A commercial determinant of poor health for Rainbow communities

BACKGROUND

Alcohol use is an area of challenge for health promotion internationally. The alcohol industry operates as a key commercial determinant of health in that its actions contribute to alcohol misuse, resulting in a range of health and social harms to individuals, families and communities. Rainbow people (including those who identify as lesbian, gay, bisexual, transgender or gender diverse) are one group experiencing considerable harm from alcohol use.

METHODS

Data from 24 focus groups involving 131 people held in six cities in New Zealand during 2018, were used to explore local understandings of the ways in which the alcohol industry operates as a commercial determinant of health for Rainbow communities. The focus group discussions were analysed thematically.

RESULTS

Three key themes were identified. First, the alcohol industry was identified as present in the 'everyday', through targeted alcohol promotion to Rainbow people, and due to the centrality of bars to their social and cultural landscapes. Second, participants recognised the benefits of alcohol industry support for Rainbow communities. Last, an opposing view was articulated, with the alcohol industry and its commercial activities viewed negatively.

CONCLUSIONS

These findings highlight that alcohol as a commodity and the alcohol industry are successfully and firmly embedded within Rainbow communities. Overall, given alcohol is widely regarded in a positive way, this is likely to create difficulties for health promotion efforts to reduce alcohol related harm in these communities.

Taking on the Corporate Determinants of Ill-health and Health Inequity: A Scoping Review of Actions to Address Excessive Corporate Power to Protect and Promote the Public's Health

BACKGROUND

In many sectors of the economy, for-profit business corporations hold excessive power relative to some governments and civil society. These power imbalances have been recognised as important contributors to many pressing and complex societal challenges, including unhealthy diets, climate change, and widening socio-economic inequalities, and thus pose a major barrier to efforts to improve public health and health equity. In this paper, we reviewed potential actions for addressing excessive corporate power.

METHODS

We conducted a scoping review of diverse literature (using Scopus, Web of Science, HeinOnline, and EBSCO databases), along with expanded searches, to identify state and collective actions with the potential to address excessive corporate power. Actions were thematically classified into overarching strategic objectives, guided by Meagher's '3Ds' heuristic, which classifies actions to curb corporate power into three groups: dispersion, democratisation, and dissolution. Based on the actions identified, we proposed two additional strategic objectives: reform and democratise the global governance of corporations, and strengthen countervailing power structures.

RESULTS

We identified 178 documents that collectively cover a broad range of actions to address excessive corporate power. In total, 18 interrelated strategies were identified, along with several examples in which aspects of these strategies have been implemented.

CONCLUSION

The proposed framework sheds light on how a diverse set of strategies and actions that seek to address excessive corporate power can work synergistically to change the regulatory context in which corporations operate, so that broader societal goals, including health and equity, are given much greater prominence and consideration vis-à-vis powerful corporate interests.

Qualitative study of states' capacity to support alcohol prevention policies during the COVID-19 pandemic in the USA

INTRODUCTION

The onset of the COVID-19 pandemic accelerated rates of alcohol purchasing and related harms in the USA. The increases followed governors' emergency orders that increased alcohol availability, including the allowance of alcohol home delivery, alcohol to-go from restaurants and bars, and curbside pickup from retailers.

METHODS

Semi-structured interviews were conducted with 53 participants involved in state-level alcohol prevention policy across 48 states. Interviewees' perspectives on changes to alcohol prevention policies during the COVID-19 pandemic, including capacity to respond to alcohol-focused executive and legislative changes to alcohol availability, were explored. Initial codes were developed collectively and refined through successive readings of transcripts using a phenomenological, action-oriented research approach. Themes were identified semantically after all transcripts were coded and reviewed.

RESULTS

Four themes were developed including: (i) alcohol prevention policies and capacity during COVID-19; (ii) industry-related challenges during COVID-19; (iii) limited pre-COVID-19 alcohol prevention capacity; and (iv) needs to strengthen alcohol prevention capacity.

DISCUSSION AND CONCLUSIONS

The pandemic exacerbated states' capacity limitations for alcohol prevention efforts and created additional impediments to public health messaging about alcohol health risks related to greater alcohol availability. Participants offered a myriad of strategies to improve alcohol prevention and to reduce alcohol-related harms. Recommendations included dedicated federal and state prioritisation, more funding for community organisations, greater coordination, consistent high-quality trainings, stronger surveillance and widespread prevention messaging. States' alcohol prevention efforts require dedicated leadership, additional funding and support to strengthen population-based strategies to reduce sustained alcohol-related harms associated with increases in alcohol availability.

Illustrating the impact of commercial determinants of health on the global COVID-19 pandemic: Thematic analysis of 16 country case studies

Previous research on commercial determinants of health has primarily focused on their impact on non-communicable diseases. However, they also impact on infectious diseases and on the broader preconditions for health. We describe, through case studies in 16 countries, how commercial determinants of health were visible during the COVID-19 pandemic, and how they may have influenced national responses and health outcomes. We use a comparative qualitative case study design in selected low- middle- and high-income countries that performed differently in COVID-19 health outcomes, and for which we had country experts to lead local analysis. We created a data collection framework and developed detailed case studies, including extensive grey and peer-reviewed literature. Themes were identified and explored using iterative rapid literature reviews. We found evidence of the influence of commercial determinants of health in the spread of COVID-19. This occurred through working conditions that exacerbated spread, including precarious, low-paid employment, use of migrant workers, procurement practices that limited the availability of protective goods and services such as personal protective equipment, and commercial actors lobbying against public health measures. Commercial determinants also influenced health outcomes by influencing vaccine availability and the health system response to COVID-19. Our findings contribute to determining the appropriate role of governments in governing for health, wellbeing, and equity, and regulating and addressing negative commercial determinants of health.

Australian young people's perceptions of the commercial determinants of the climate crisis

There is increasing public health focus on how corporate practices impact population health and well-being. While the commercial determinants of the climate crisis pose serious threats to human and planetary health, governments largely seek to balance climate action with economic imperatives. Global stakeholders recognize that young people have important voices in influencing climate responses. However, few studies have investigated young people's perceptions of the commercial determinants of the climate crisis. A qualitatively led online survey of n = 500 young Australians (15-24 years) investigated their understanding of corporate responses to the climate crisis, factors that influenced these responses and strategies to respond. A reflexive approach to thematic analysis was used. Three themes were constructed from the data. First, young people perceived that corporate responses to the climate crisis focussed on soft options and lacked meaningful action. Second, they stated that these responses were largely influenced by economic imperatives rather than planetary health, with policy levers needed to implement environmentally responsible corporate practices. Third, young people perceived that systems needed change to create demand for a cleaner environment, leading to improved practices. Young people have a clear understanding of the commercial determinants of the climate crisis and associated threats to population health. They recognize that corporate practices (and consumer demand) will not change without significant policy and structural change. Public health and health promotion stakeholders should work alongside young people to influence decision-makers to address harmful corporate behaviours.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Health Promotion in Debate: The Role of Women Leaders in the Favelas of Rio de Janeiro, Brazil

This study aimed to discuss the actions of women leaders in favelas in Rio de Janeiro, Brazil, regarding the health promotion of people residing in territories affected by urban violence and inequalities. The understanding of social determinants of health (SDH) is not unequivocal and challenges us to expand our practices in health promotion and equity. A mixed-methods study was conducted with 200 women living in 169 favelas of Rio de Janeiro between 2018 and 2022. Questionnaires and semi-structured face-to-face interviews followed by thematic analysis were conducted. The analysis focused on the socio-demographic profile, community activism, and health promotion strategies undertaken by these groups, expanding knowledge on the experiences of these leaders in confronting social injustices. Results showed that participants performed health promotion actions in their communities by 1. strengthening popular participation and human rights, 2. creating environments favorable to health, and 3. developing personal skills towards social participation in policy design through mobilizing health services and third-sector organizations. With the limited presence of government public agents in these spaces, participants assumed roles as managers of local demands, and, by means of resistance, intersectionality, and solidarity, they transformed this micro-power into the potential for social transformation.

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.

Contextual Factors That May Impact on the Development and Implementation of the Sugary Drinks Policy Comment on "Understanding Marketing Responses to a Tax on Sugary Drinks: A Qualitative Interview Study in the United Kingdom, 2019"

Forde et al proposed an interesting framework to understand marketing response to a tax in sugary drinks based on stakeholder interviews. Sugary drinks regulation can lead to various strategies in the industry's marketing activity. That is, it can either result in the industry introducing no changes or it can lead to changes, which can conflict or align with public health objectives. The importance of Forde and colleagues' analysis lies in the potential for governments to anticipate the industry's reaction to the legislation and the need of drivers to enable both big and small companies to follow the rules. Governments must not forget the importance of other contextual factors that will have an impact both on the development and implementation of this type of policies and on possible responses that could mitigate their impact such as public acceptance, the influence of mass media and corporate activities aimed at influencing policy.

Drinking and swimming around waterways: The role of alcohol, sensation-seeking, peer influence and risk in young people

The role of individual and sociocultural factors contributing to drowning risk for young adults is complex and poorly understood. This study examined the relationship between behaviour in and around waterways and: 1) alcohol consumption; 2) resistance to peer influence; 3) sensation-seeking; 4) perception of risk among people aged 15–24 in Western Australia. A cross-sectional online survey was conducted at three time-points with a convenience sample. Predictor variables included: Alcohol Use Disorder Identification Test Consumption (AUDIT_C); Resistance to Peer Influence; Brief Sensation Seeking scale; Benthin’s Perception of risk. Pearson chi-squared tests determined the association between demographic and predictor variables. Logistic regression explored influence of potential predictor variables on behaviour in and around water. The final sample (n = 730) participants, consisted of females (n = 537, 74.5%), metropolitan dwelling (n = 616, 84.4%), and attended university (n = 410, 56.9%). Significant associations were found for those who swum after drinking alcohol compared with those that had not by age, gender, education. For every 1-unit increase in AUDIT-C participants were 60% more likely to swim after drinking (OR 95% CI 1.60 1.44–1.78). Participants who considered an adverse event serious were 15% less likely to have swum after drinking alcohol (OR 0.85 95% CI 0.73–0.99). The complex relationship between social participation in activities in and around waterways, higher drowning rates, propensity for risk, and the meaning young adults attach to risk locations and practices present unique challenges for drowning prevention research. Findings should be used to improve the awareness and education components of future youth water safety strategies in high-income settings.

Integrating Social, Political and Commercial Determinants of Health Frameworks to Advance Public Health in the twenty-first Century

Existing frameworks seek to elucidate the social, political, and commercial determinants of health in order to inform practice, policy, and research that can improve health and reduce health inequities. Each approach has widened the scope of public health practice and research and identified new partners and targets for intervention. But as the public health crises of the past decade have shown, these frameworks have not yet yielded insights that have enabled the public health profession and movement to prevent or overcome dominant threats to global health and health equity. This report explores the value of an integrated framework that combines insights from previous scholarship and practice using the social, political, and commercial determinants of health. It proposes the questions such an integration would need to answer and suggests processes and tasks that could lead to the creation of a blended framework.