Private companies have a big impact on public health. That's not surprising in a world in which an increasing number of deaths are linked to non-communicable diseases. Four commercial products — tobacco, alcohol, ultra-processed food, and fossil fuels — account for 19 million global deaths annually, according to a 2019 Global Burden of Disease study.

For years, scientists have studied how industry products and practices contribute to ill health and inequity — what’s known as commercial determinants of health. A landmark new series published earlier this year in the medical journal The Lancet proposed that it’s not only the products and practices of industries such as tobacco and fossil fuels that negatively impact our health; it’s also the regulatory systems from government to law that allow companies to market and sell harmful products. The series also included recommendations for strengthening regulation and holding industries accountable for harm.

The Examination discussed the series and its recommendations with Dr. Kelley Lee, a professor and Canada research chair in Global Health Governance at Simon Fraser University and editorial board member for the World Health Organization’s forthcoming Global Report on the Commercial Determinants of Health.

This interview has been edited for clarity and brevity.

The Lancet series describes commercial determinants of health “as the systems, practices, and pathways through which commercial actors drive health and equity.” What do you think about that definition and the idea that commercial actors can impact our health in negative and positive ways? 

This is a real academic discussion that's been going on for a long time, and people come at it from different angles. If you look at The Lancet definition, [commercial determinants of health] are described as not just the commercial actors that are at play, but all the social structures that enable them to do what they do. It's large corporations that are very dominant commercial actors, but the kinds of other actors around them that enable them to behave the way they do or regulate them is also very important to consider, like parts of government that regulate commercial activity, and other actors like legal firms, accounting firms, consultancy firms. A lot of the industries have associations, so you can get quite broad in how you understand what enables the commercial system to tick. 

The other thing you mentioned about positive and negative impact … initially, definitions tend to focus on the negative, like harmful products. But many of these commercial actors also produce things that do promote health like essential medicines or medical supplies. But it’s those activities that are adversely affecting our health that public health researchers are most focused on. 

The term commercial determinants of health is not something I would casually say in conversation to a friend or sibling, but the concept has great bearing on our personal health. What would it mean for people to become more aware of the term and how it impacts them?

Through the concept of social determinants of health, our choices are defined by who we are, where we live, how much money we have, etc. The same with the commercial determinants of health. We'd like to think we have free will, but we're shaped by what we hear, what we are exposed to, and so on. Being aware of that is a really important thing, because we can go through life and think that we're making good choices. But if we're more conscious of what is influencing our choices, I think that would lead us to maybe be more mindful of the choices we make and why we make them. I think it's useful for people to understand the term. It sounds like a mouthful. But I think people get it very quickly. 

Tobacco, alcohol, ultra-processed food and fossil fuels account for 19 million global deaths annually, according to research. Companies say the rise in death and noncommunicable diseases are a result of individual choices. What should people understand about choice?

This narrative is still very dominant, this behavioral change approach where people are always held to account for any sort of ill health because they might have poor nutrition, or they're not active enough, or they smoke or drink. But research has shown that this approach has a limited effect. Our choices aren’t just down to us as individuals, the society around us provides us the options. If you're living in a place where there's a food desert, how is it possible that you can buy fresh fruits and vegetables? Or if you don't earn enough money, how can you afford the organic food you’re supposed to be eating? So we need to kind of recognize that it's a combination of the social context in which we live, as well as the choices we make, and it's still a disproportionate focus on the latter. 

Also, as we see noncommunicable diseases rising up, you can’t keep saying it’s because individuals are making bad choices when in fact, companies are pushing that narrative. We know that ultra-processed foods are cheaper, they’re readily available, and the marketing and advertising is everywhere. All of that is part of the reason why we make the choices we make. We like to think we're making free choices, but actually, we're being shaped by all sorts of things around us.

You mentioned that focusing on behavioral change is not always the most effective way to reduce noncommunicable diseases and address harm caused by commercial actors. What  measures can governments take to address these issues?  

We try to look at what are called market and non-market strategies by the commercial sector. Market strategies are the ways that commercial actors behave to sell their products and make profits. Governments can address that. From regulating product labeling to regulating what products get on the market, to the ingredients in them, and how they are allowed to advertise these products, and to who.

The non-market side are really the political strategies that commercial actors use to influence that regulatory system. This can be lobbying or putting out their own [favorable] research or advertising their corporate social responsibility. And again, you can prevent undue influence by these actors. Lobbying registers make it very transparent who is talking to the government and what they are discussing. For example, the World Health Organization’s Framework Convention on Tobacco Control (FCTC) encourages countries not to allow the tobacco industry to interfere with their health policies. So there are ways we can manage and regulate the way that these commercial actors interact with state actors and government actors. 

The article of the anti-tobacco treaty you mentioned is supposed to curb interference from the tobacco industry, but it doesn’t stop companies like Philip Morris from lobbying countries.  Where are policies falling short and where could they be better? 

Making a commitment to do something and actually doing it is another thing. With the FCTC, most countries have committed to doing X, Y, and Z, but when they go back and report how they’ve done this, it’s [a checkbox] for the FCTC Secretariat. So, the reporting could be improved. And then of course there's the follow up. Who checks, right? The government says, “Yeah, we’re not talking to anybody that we shouldn't be talking to under the FCTC.” But how do you validate that? 

The other thing I want to draw your attention to is the role of consultancy firms and think tanks. We, the public, seem to think that they're independent. They put out a report, and then the media picks it up and reports what the think tank has said, as if it is independent research. Certain think tanks are very well funded by tobacco companies, alcohol companies and whoever is out there who wants to get a certain narrative out. And we don't know that because we can't peek behind the curtain and say, “Oh, but you receive X amount of dollars from this company. And now you put this report out.” 

As an academic, on every paper I write, I have to say where my funding comes from so people can make a judgment, so why is it that think tanks don't have to do that?  Those are the kind of holes in the system, which I think allows opaqueness. And if we want to have an informed society where there's more trust from the public towards government and big companies, and political processes, we need to clean that up because both right and left on the political spectrum have legitimate questions about what the heck is going on, and how individual citizens are being impacted by these really obscured relationships. 

The Lancet series floats the idea of making companies pay for the harms caused by their products. Is that an effective accountability mechanism? 

Yeah, I would say the best way you can get companies to behave differently is through financial incentives or disincentives. Making them incorporate costs into their decision-making as they produce a product is where they're going to change. If you can trace the full life of a product from when it's conceived to after it's consumed, and the impact on the consumer, and on the environment, those are the things that should be costed. Why should we be paying all these things as citizens? And as a government? Why should companies, at the same time, pressure governments not to lower taxes and so on? So absolutely, that is the way forward. And there's a lot of issue areas, not just health, but climate change and other areas where there are externalities that have always been borne by either the planet or by individuals, rather than the companies themselves. So it's a different way of thinking. And it could be a paradigm shift. 

Between 2011-2030, noncommunicable diseases will cost the global economy more than US$ 30 trillion, according to research. How does talking about cost change the conversation? 

That’s the way forward if governments are really going to pay attention. When people start talking about money, they start to sort of pay notice. For example, the tobacco control community worked to shift the narrative and highlighted the cost of tobacco to society to challenge a lot of the industry arguments that the industry contributes to taxes and employment.

Another thing we haven’t touched on is the environmental costs. For example, tobacco is an incredibly greedy plant, it takes a lot of resources to grow. You also cut down a lot of trees to grow tobacco in many countries, and so we have to estimate those things. Commercial determinants of health is not just a health issue. It's almost like the commercial determinants of health and well-being of the whole planet. That really is what we're talking about here.