Profit Before People: The commercial determinants of health and lessons from the tobacco epidemic (2023)

When asked 'what makes us healthy,' often people think about the absence of a variety of illnesses, and the role that medicine, GPs and hospitals play in treatment. However, our health is not simply the absence of illness - it's so much more than that. Our health is strongly shaped by the conditions in which we are born, grow up, work, live and age. The key 'social, cultural, political, economic, commercial, and environmental factors' which shape our world are commonly known as the social determinants of health³⁷. These issues do not work in isolation but overlap and work together to impact our lives. They also affect people in diverse ways due to factors such as 'age, gender, ethnicity, sexuality, and disability.'

'[Health is] not just the physical wellbeing of an individual but also the social, emotional and cultural wellbeing of the whole community, in which each individual is able to achieve their full potential as a human being, thereby bringing about the total wellbeing of their community.³⁸'

Dahlgren and Whitehead produced a diagram to demonstrate the factors which influence our health and wellbeing and how they are related:

Within this broad range of issues is a key determinant which is generating much interest in recent times - the commercial determinants of health, which can be defined as:

'a key social determinant referring to the conditions, actions and omissions by commercial actors that affect health¹.'

From a positive perspective, some commercial actors work to provide some essential products and resources. The World Health Organisation (WHO) notes that commercial activities are capable of shaping both the physical and social environments in which we are born, grow, work, live and grow old, which can be positive and negative in terms of influence:

'the private sector influences the social, physical and cultural environments through business actions and societal engagements; for example, supply chains, labour conditions, product design and packaging, research funding, lobbying, preference shaping and others¹.

However, a recent paper published by the Lancet³⁹ acknowledges that:

'the products and practices of some commercial actors - notably the largest transnational corporations - are responsible for escalating rates of avoidable levels of ill health, planetary damage and health inequity.'

This paper also highlights that a number of small industries, known as unhealthy commodity industries, are the driving force behind multiple health conditions, the rising burden of non-communicable disease, as well as our climate emergency. Four key industry sectors - alcohol, tobacco, ultra-processed food and fossil fuels, in addition to the climate emergency and non-communicable disease epidemic, are responsible for at least a third of global deaths.

As the influence of these transnational corporations continues to increase, and hence the harms to both individuals and climate health, so does their wealth and power³⁹. However, those trying to counteract these harms become 'impoverished and disempowered or captured by commercial interest', and this 'power imbalance' and associated 'policy inertia,' results in health harms which our systems struggle to cope with.

Like tobacco, other commercial products which have a negative impact and are difficult to address include ultra-processed foods, sugary drinks and alcohol. We could also include problems caused by the gambling industry in this. In the North-East, this was recognised with the formation of Balance, which is a regional response to the health harms caused by alcohol and is based on the Fresh TC programme. Responses to other commercial determinants can also be informed by lessons learned from TC. 

The TI had a playbook, a script, that emphasised personal responsibility for actions and impacts, paid for research and scientists to create doubt about legitimate scientific and public health concerns, carried out lobbying activities, and denied, and continued to deny for decades. These activities have cost millions of lives, and it is important to recognise the similarities with other corporate interests.

If we take the issue of food for instance, it is obviously different from tobacco, and the food industry differs from the TI in important ways, but there are also significant similarities in their responses to concern that their products cause harm. Obesity is now a major global problem, and we can't afford to repeat the mistakes of the tobacco epidemic, in which industry talks about the moral high ground but does not occupy it⁴⁰.

The problem of overweight and obesity provides a useful example of how these factors overlap: 

• Production and marketing of high fat, high salt, high sugar convenience foods
• Promotions such as 'buy one, get one free' in supermarkets and takeaways
• Jobs and workplaces which make it difficult for people to be active
• Workplaces with poor access to healthy food, or indeed supplying unhealthy food  (vending machines)
• Lack of access to parks and green spaces
• Higher prices of unprocessed (healthier) foods 
• Poor walking routes/cycle lanes

This is a small snapshot of the many factors which contribute to obesity, but already we can see how diverse they are and that they result in multiple problems that cannot be resolved easily, much as we found in considering tobacco harm. One common link between different commercial actors whose products cause harm are financial considerations - how much something costs to produce, how much to buy, healthy options (both food related or environment/infrastructure) being more expensive and complicated, and what profits can be made.

References

1. World Health Organisation (2021) Commercial determinants of health.WHO - commercial determinants of health (opens new window)

37. Lovell, N and Bibby, J (2018) The Health Foundation - 'What makes us healthy? An introduction to the social determinants of health' (opens new window)

38.  Aboriginal Health and Medical Research Council of New South Wales. Definition of Aboriginal Health. Cited in: Lovell, N and Bibby, J 'What makes us healthy? An introduction to the social determinants of health' The Health Foundation. (2018)

39. 'Defining and conceptualising the commercial determinants of health'. The Lancet, 2023, Apr 8;401(10383):1194-1213. A (opens new window)

40. Brownell, K and Warner, K. (2009)The Perils of Ignoring History: Big Tobacco Played Dirty and Millions Died. How Similar is Big Food? Millbank Quarterly, Vol 8 (opens new window)