Strategies to expand corporate autonomy by the tobacco, alcohol and sugar-sweetened beverage industry: a scoping review of reviews

Alcohol, No Ordinary Commodity: policy implications for Canada

Alcohol is a favorite psychoactive substance of Canadians. It is also a leading risk factor for death and disability, playing a causal role in a broad spectrum of health and social issues. Alcohol: No Ordinary Commodity is a collaborative, integrative review of the scientific literature. This paper describes the epidemiology of alcohol use and current state of alcohol policy in Canada, best practices in policy identified by the third edition of Alcohol: No Ordinary Commodity, and the implications for the development of effective alcohol policy in Canada. Best practices - strongly supported by the evidence, highly effective in reducing harm, and relatively low-cost to implement - have been identified. Measures that control affordability, limit availability, and restrict marketing would reduce population levels of alcohol consumption and the burden of disease attributable to it.

Characteristics of commercial determinants of health research on corporate activities: A scoping review

INTRODUCTION

Business practices have influenced human health for centuries, yet an overarching concept to study these activities across nations, time periods, and industries (called 'the commercial determinants of health' (CDH)) has emerged only recently. The purpose of this review was to assess the descriptive characteristics of CDH research and to identify remaining research gaps.

METHODS

We systematically searched four databases (Scopus, OVID Medline, Ovid Embase, and Ovid Global Health) on Sept 13, 2022 for literature using CDH terms that described corporate activities that have the potential to influence population health and/or health equity (n = 116). We evaluated the following characteristics of the literature: methods employed, industries studied, regions investigated, funders, reported conflicts of interest, and publication in open-access formats.

RESULTS

The characteristics of the articles included that many were conceptual (50/116 articles; 43%) or used qualitative methods (37; 32%). Only eight articles (7%) used quantitative or mixed methods. The articles most often discussed corporate activities in relation to the food and beverage (51/116; 44%), tobacco (20; 17%), and alcohol industries (19; 16%), with limited research on activities occurring in other industries. Most articles (42/58 articles reporting a regional focus; 72%) focused on corporate activities occurring in high-income regions of the world.

CONCLUSIONS

Our findings indicate that literature that has used CDH terms and described corporate practices that influence human health has primarily focused on three major industries in higher-income regions of the world. Qualitative methods were the most common empirical method for investigating these activities. CDH-focused investigations of corporate practices conducted by less-studied industries (e.g., social media) and in lower-income regions are recommended. Longitudinal quantitative studies assessing the associations between corporate practices and a range of health outcomes is also a necessary next step for this field.

Towards a conceptual framework for the prevention of gambling-related harms: Findings from a scoping review

The global gambling sector has grown significantly over recent years due to liberal deregulation and digital transformation. Likewise, concerns around gambling-related harms-experienced by individuals, their families, their local communities or societies-have also developed, with growing calls that they should be addressed by a public health approach. A public health approach towards gambling-related harms requires a multifaceted strategy, comprising initiatives promoting health protection, harm minimization and health surveillance across different strata of society. However, there is little research exploring how a public health approach to gambling-related harms can learn from similar approaches to other potentially harmful but legal sectors such as the alcohol sector, the tobacco sector, and the high in fat, salt and sugar product sector. Therefore, this paper presents a conceptual framework that was developed following a scoping review of public health approaches towards the above sectors. Specifically, we synthesize strategies from each sector to develop an overarching set of public health goals and strategies which-when interlinked and incorporated with a socio-ecological model-can be deployed by a range of stakeholders, including academics and treatment providers, to minimise gambling-related harms. We demonstrate the significance of the conceptual framework by highlighting its use in mapping initiatives as well as unifying stakeholders towards the minimization of gambling-related harms, and the protection of communities and societies alike.

Characterizing restrictions on commercial advertising and sponsorship of harmful commodities in local government policies: a nationwide study in England

BACKGROUND

Commercial advertising and sponsorship drive the consumption of harmful commodities. Local authorities (LAs) have considerable powers to reduce such exposures. This study aimed to characterize local commercial policies across all English LAs.

METHODS

We conducted a census of all English LAs (n = 333) to identify local commercial policies concerning advertising and sponsorship of tobacco, alcohol, less healthy foods and gambling, through online searches and Freedom of Information requests. We explored policy presence, commodity frequency and type, and associations with LA characteristics (region, urban/rural and deprivation).

RESULTS

Only a third (106) of LAs in England had a relevant policy (32%). These included restrictions on tobacco (91%), gambling (79%), alcohol (74%) and/or less healthy foods (24%). Policy prevalence was lowest in the East of England (22%), North East (25%) and North West (27%), higher in urban areas (36%) than rural areas (28%) and lower in the least (27%) compared with the most (38%) deprived areas. Definitions in policies varied, particularly for alcohol and less healthy foods.

CONCLUSIONS

English LAs currently underutilize their levers to reduce the negative impacts of harmful commodity industry marketing, particularly concerning less healthy foods. Standardized guidance, including clarity on definitions and application, could inform local policy development.

Framing health taxes: learning from low- and middle-income countries

Health taxes are effective policy instruments to save lives, raise government revenues and improve equity. Health taxes, however, directly conflict with commercial actors' interests. Both pro-tax health advocates and anti-tax industry representatives seek to frame health tax policy. Yet, little is known about which frames resonate in which settings and how framing can most effectively advance or limit policies. To fill this gap, we conducted qualitative research in 2022, including focus group discussions, in-depth interviews, document reviews and media analysis on the political economy of health taxes across eight low-income and middle-income countries. Studies captured multiple actors constructing context-specific frames, often tied to broader economic, health and administrative considerations. Findings suggest that no single frame dominates; in fact, a plurality of different frames exist and shape discourse and policymaking. There was no clear trade-off between health and economic framing of health tax policy proposals, nor a straightforward way to handle concerns around earmarking. Understanding how to best position health taxes can empower health policymakers with more persuasive framings for health taxes and can support them to develop broader coalitions to advance health taxes. These insights can improve efforts to advance health taxes by better appreciating political economy factors and constraining corporate power, ultimately leading to improved population-level health.

Framing health taxes: a scoping review

Health taxes are increasingly positioned as effective policy instruments for curbing non-communicable disease, improving health and raising government revenues. Their allure has caused many health advocates to look beyond tobacco and alcohol to other harmful products such as sugar-sweetened beverages (SSBs), salty foods, fatty foods and fossil fuels. These efforts, however, directly conflict with commercial actors' interests. Both pro-tax health advocates and anti-tax industry representatives seek to frame health tax policy in favourable ways. Yet, little is known about which types of frames resonate in which settings, or how they deploy morals and values in their attempts to persuade. To fill this gap, we conducted a scoping review on framing health taxes using six databases in 2022. A total of 40 peer-reviewed empirical research articles, from 2006 to 2022, were identified from 20 different countries. Most research was conducted in high-income countries, published in the last 4 years and increasingly focused on excise taxes for SSBs. Studies captured multiple actors constructing context-specific frames, often tied to broader economic, health and administrative considerations. Actors also engaged in a range of political activities in addition to framing. We found some evidence that anti-tax framing strategies potentially incorporated a broader array of morals and social values. More in-country comparative research, particularly from low/middle-income countries, is needed to understand the politics of framing health taxes. We argue that these insights can improve efforts to advance health taxes by constraining corporate power, improving population level health and promoting greater social harmony.

A sweet deal for domestic industry: the political economy and framing of Vanuatu's sugar-sweetened beverage tax

INTRODUCTION

The Government of Vanuatu introduced an excise tax on sugar-sweetened beverages (SSBs) in 2015. While lauded for its alignment with the WHO's Best Buys recommendations for addressing non-communicable diseases (NCDs), little is known about the tax's adoption process or whose interests it serves.

METHODS

Using case study methodology, this study examined how and why Vanuatu's SSB tax was introduced. Policy documents, key informant interviews (n=33) and direct observations were analysed using theories of policy analysis, power analysis and postcolonial theory to map the policy's adoption, surrounding political economy and the ideas, interests and institutions that shaped the tax and its framing.

RESULTS

The SSB tax emerged during a politically and economically unstable time in Vanuatu's history. The tax's links to the national health agenda were tenuous despite its ostensible framing as a way to combat NCDs. Rather, the tax was designed to respond to tightening economic and trade conditions. Spearheaded by several finance-focused bureaucrats, and with limited input from health personnel, the tax targeted less frequently consumed carbonated SSBs (which are mostly imported) without any revenue reinvestments into health. Driven by the desire to generate much-needed government revenue and instal domestic protections via selective implementation and carve-outs for local producers, the Vanuatu SSB tax did meet national objectives, just not the dual health and economic 'win-win' projected by the NCD Best Buys.

CONCLUSION

Vanuatu's SSB tax adoption process reveals the limitations of decontextualised policy recommendations, such as the NCD Best Buys, whose framing may be overcome by local political realities. This research highlights the need for further political economy considerations in global health recommendations, since contextual forces and power dynamics are key to shaping both how and why policies are enacted and also whose interest they serve.

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.

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.

The Founder: Dispositional Greed, Showbiz, and the Commercial Determinants of Health

Marketing unhealthy products by multinational corporations has caused considerable harm to individual health, collective wellbeing, and environmental sustainability. This is a growing threat to all societies and a significant contributor to the rising global burden of non-communicable diseases and early mortality. While there is growing consideration of the commercial determinants of health, this is largely focused on the methods by which unhealthy products are marketed and disseminated, including efforts to manipulate policy. Little attention has been paid to the underlying psychological traits and worldviews that are driving corporate greed. Here, we consider the role of "dispositional greed" in the commercial determinants of health with a focus on the historical attitudes and culture in the ultra-processed food industry-exemplified by "The Founder" of the McDonald's franchise. We argue that greed and associated psychological constructs, such as social dominance orientation and collective narcissism, permeate the commercial determinants of health at a collective level. This includes how a culture of greed within organizations, and individual dispositional greed, can magnify and cluster at scale, perpetuated by social dominance orientation. We also consider the ways in which "showbiz" marketing specifically targets marginalized populations and vulnerable groups, including children-in ways that are justified, or even celebrated despite clear links to non-communicable diseases and increased mortality. Finally, we consider how greed and exploitative mindsets mirror cultural values and priorities, with trends for increasing collective narcissism at scale, recognizing that many of these attitudes are cultivated in early life. A healthier future will depend on navigating a path that balances material prosperity with physical and spiritual wellbeing. This will require cultural change that places higher value on kindness, reciprocity, and mutualistic values especially in early life, for more equitable flourishing.

Lessons learned from fostering tobacco taxes in the Americas and implications for other health taxes

During the past decade progress has been made from a public health perspective in advancing tobacco taxation policies in the World Health Organization’s Region of the Americas, and there are important lessons to be learned from this experience. This report aims to systematize and distill the key lessons learned, both by documenting progress and paving the way toward a comprehensive approach to taxing other health-harming products, particularly those considered to be drivers of the noncommunicable disease epidemic, such as alcohol and sugar-sweetened beverages. A thorough review of publications and institutional documents was undertaken and discussions were held with experts about the experiences of the past decade. Broadly, the lessons can be characterized according to the main mechanisms that have fostered progress. These are the robust, consistent and standardized monitoring of tobacco taxes that has enabled comparisons between countries and across time; the setting of tax policy within a framework of multisectoral policy coherence; and the development of guidelines and the generation of independent evidence to support tobacco taxes and tackle harmful industry interference. Currently, progress in these areas is lagging for taxes on alcohol and sugar-sweetened beverages. Applying the lessons learned from the extensive experience with tobacco taxation can help advance progress in taxes on alcohol and sugar-sweetened beverages and capture the potential synergies to be gained from building a comprehensive approach. Although more work is needed in developing and implementing taxation policies across all three products, the findings from this report can assist in strengthening their public health objectives to tackle noncommunicable diseases and improve population health.

Healthy or Not Healthy? A Mixed-Methods Approach to Evaluate Front-of-Pack Nutrition Labels as a Tool to Guide Consumers

This study explored how South African food labels could be improved, to enhance customer evaluation of the overall healthiness of packaged food. Focus was given to the comparison of front-of-pack (FOP) nutrition labels as a quick assessment tool. The exploratory sequential mixed-methods design used qualitative interviews (n = 49) to gain insight into labeling challenges and select FOP nutrition labels for consumer testing. Consumers (n = 1261) randomly assessed two out of six possible FOP nutrition labels relative to a ‘no-label’ control in one of 12 online surveys, applied to a fictitious cereal product. A mixed-model analysis of variance was used to compare the differences in health ratings for the different FOP nutrition labels. The interviews revealed three themes for label improvement, that are presented over three time horizons. In terms of helping consumers identify less healthy products, the effect sizes were most prominent for health warnings (p < 0.01) and low health star ratings (p < 0.01). The findings of this research not only clarify whether FOP nutrition labeling formats used in other regions such as Europe, South America and Australia could be useful in the South African context, but they can assist policymakers and decision-makers in selecting an effective FOP label.