Profit Before People: The commercial determinants of health and lessons from the tobacco epidemic (2023)
Introduction
The World Health Organisation (WHO) defines a commercial determinant of health as 'a key social determinant referring to the conditions, actions and omissions by commercial actors that affect health'. (World Health Organisation (2021) Commercial determinants of health1.
The term 'commercial actors' means private sector businesses, and it is their commercial activities in providing goods or services for payment, and the circumstances in which that commerce takes place, that help shape the social and physical environments in which we live. While some activities may be positive (for example. creating jobs and so improving living standards), there are also negative impacts associated with the unrestricted pursuit of profit generation for shareholders. When it comes to making profits, the various multinational companies that make up the tobacco industry (TI) are past masters.
Such industries are commonly termed as unhealthy commodity industries, and this report will focus for the most part on the TI which is responsible for one of the biggest public health threats the world has ever faced.
All forms of tobacco use are harmful, and there is no safe level of exposure to tobacco. Cigarette smoking is the most common form of tobacco use worldwide, but we shouldn't overlook other tobacco products such as cigars, waterpipe tobacco, roll-your-own tobacco, pipe tobacco, cigarillos, bidis and kreteks, and smokeless tobacco products2.
Tobacco kills over eight million people a year around the world, with more than seven million of those deaths the result of direct tobacco use, while the remainder are the result of non-smokers being exposed to second-hand smoke.
There are 1.3 billion tobacco users worldwide, with around 80% of these living in low- and middle-income countries, where the burden of tobacco-related illness and death is heaviest. This international inequality is also reflected at smaller scale where less affluent communities have higher smoking prevalence and suffer greater harm than more affluent areas. Tobacco contributes to poverty by diverting household spending from basic needs such as food and shelter to maintaining the addiction.
The highest recorded level of smoking among men in Great Britain was 82% in 1948. By contrast, smoking prevalence among women in 1948 was 41% and remained constant until the early 1970s, peaking at 45% in the mid-1960s.
Overall, the proportion of adults (aged 16 and over) smoking in Great Britain has been declining since 1974 and current prevalence for men is 14.6% and for women 11.2%1.
This amazing decline is due to the persistent efforts of public health advocates who, despite the best efforts of tobacco manufacturers, have evolved a model of tobacco control over time which has seen smokers quitting and allowed the growth in the numbers of people who have never smoked. While some progress has been made in some western countries such as the UK, the TI continues to drive up their sales and profits in those countries less able to mount a coordinated response.
This report will examine how tobacco came to be the original commercial determinant of health, demonstrate that profit ultimately outweighs health and wellbeing considerations, how a Tobacco Control approach to reduce the harm caused by tobacco has (with great effort) made progress in the last few decades, and most importantly, what now needs to happen to create a smokefree generation and finally end the tobacco epidemic in our area. We will also consider the lessons learned from the Tobacco Control success story and what that may mean for some other key commercial determinants of health.