Understanding the commercial determinants of health

Early one morning in the spring of 1994, in a room deep inside the grandiose marble walls of the Rayburn House Office building in Washington, a group of 7 distinguished, successful, well-educated gentlemen sat before the US House of Representatives subcommittee on Health and the Environment, chaired by Rep. Henry Waxman. 
 
Each of these gentlemen was the CEO of a major US tobacco company and was there, for the first time, as a witness, part of Waxman’s ongoing attempt to deal what he called in his introductory remarks: “the single most dangerous consumer product ever sold”. The appearance of the CEOs from companies such as Phillip Morris and RJ Reynolds, representing ubiquitous cigarette brands such as Marlboro and Camel and many others, in itself was momentous. 
 
It represented a seismic shift from an old way of operating, in which many US representatives and tobacco companies enjoyed close, mutually beneficial relationships. Waxman said as much, as he brought his introduction to a close: 
 
“…This hearing marks the beginning of a new relationship between Congress and the tobacco companies. The old rules are out, the standards that apply to every other company are in. We look forward to hearing the testimony this morning, and to working with these companies to begin to reduce the extraordinary public health threat that tobacco poses. An old proverb says that a journey of a thousand miles must begin with a single step. Today is the first step. Many more are to come as we deal with the most serious health problem facing our Nation.”
 
This statement was carefully worded. In it he not only made it clear that tobacco represents an extraordinary threat to public health, but also that he hoped that in recognition of this great threat, tobacco companies might work with government to reduce it. 
 
Following these remarks, all 7 CEOs raised their right hands and agreed under oath that their testimony would be “…the truth, the whole truth, and nothing but the truth.”. What happened next in that room would become a powerful illustration of how utterly futile any hope of a collaborative effort was. 
 
The first question to the group, from Rep Wyden, was simple: “…Yes or no, do you believe nicotine is not addictive?” Each of the CEOs in turn leant towards their personal silver microphone, and one after the other, answered: “I don’t believe that nicotine or our products are addictive”, “I believe nicotine is not addictive”, “and I too, believe that nicotine is not addictive…”. The CEOs were unanimous in their denial. 
 
Days after this testimony, documents would be leaked to the public that showed these companies had known that the exact opposite was true for decades. A top executive had mulled in an internal memo in 1963, over 30 years earlier: “We are then in the business of selling nicotine, an addictive drug effective in the release of stress mechanisms.” The tobacco executives had listened to Waxman’s concerns for the public interest, sworn an oath to tell the truth, and immediately, unanimously, lied to protect their businesses.
 
In the years that followed, through a combination of leaks and lawsuits, in particular the Master Settlement Agreement (in which 46 US states settled their Medicaid lawsuits against the tobacco industry for recovery of their tobacco-related health-care costs), as many as 14 million internal documents were divulged, detailing a wide range of tactics the industry employed to sow doubt about the links between smoking and disease, and using its economic power and marketing prowess to manipulate the media, the scientific community, the public and governments (World Health Organisation, 2009). This behaviour was reflected in the language of the WHO’s historic Framework Convention on Tobacco Control, as parties to the FCTC agree that there is a “fundamental and irreconcilable conflict” between tobacco and public health policy interests (World Health Organisation, 2005). 
 
However one of the most important lessons from the tobacco documents is one which I believe we have failed to learn. What was exceptional about the tobacco industry? 
Was it that they sold a harmful product? No. Other global industries sell and are largely dependent on products that are also harmful to population health. 
Were their staff motivated by some uniquely evil intent? No. A comprehensive review of findings of the tobacco documents suggested that the main motivation for tobacco industry tactics was profit, and within that, three interlinking goals: Avoiding any new regulation, avoiding negative PR, and avoiding litigation (Bero, 2003). I would argue that this motivation is the opposite of exceptional. These goals are in fact core objectives for any large publicly owned company, core objectives that the CEO is answerable to shareholders for. And for some of these companies, just like for tobacco, these objectives may be at odds with population health. 
 
Getting back to the earlier question: What was exceptional about the tobacco industry? Nothing, other perhaps than the fact they got caught.
 
So, if there are other industries that rely on profits at the expense of population health, and that share these basic objectives, not to mention in many cases sharing the same law firms, PR firms, advertising firms and lobbyists, why would we expect them to act differently from the tobacco industry if their profits are threatened by regulation, litigation or negative PR? This is not to say the private sector in general can’t play a role in improving population health. But we must be clear in recognising that for some industries there is an irreconcilable conflict of interest between population health and profit. This conflict exists from the very top, as such a company’s Board of Directors have a fiduciary duty to protect shareholders investments. 
 
Indeed, the evidence is mounting that where there is a conflict of interest, other industries exhibit similar tactics to those previously observed with tobacco companies. The alcohol industry is largely dependent on drinkers that consume to harmful levels (Casswell et al., 2016; Viet Cuong et al., 2018)and has also lobbied extensively against policy best buys such as restricts on marketing and availability, or tax increases (Hawkins et al., 2018; Martino et al., 2017; McCambridge et al., 2018; Savell et al., 2016), and misleading the public on the risks associated with alcohol consumption (Petticrew, Maani Hessari, et al., 2017; Petticrew et al., 2018). The gambling industry? Much the same (Cowlishaw and Thomas, 2018; Mandel and Glantz, 2004; Petticrew, Katikireddi, et al., 2017; Thomas et al., 2016). Believe it or not, there is still an asbestos industry, with a history of lobbying and fighting lawsuits on liability for asbestos related injuries (Rosner and Markowitz, 2017). Exxon Mobil internal memos long acknowledged the link between fossil fuels and climate change, but the company commissioned advertorials in leading newspapers questioning this same link (Supran, 2017). Coca Cola funded research groups to divert attention away from the links between SSBs and obesity (Barlow et al., 2018). 
 
In spite of such examples, these industries remain close partners with government in many countries, including via self-regulation, or even drafting legislation on the very harms their products are causing, in ways that we would no longer allow the tobacco industry to. We failed to learn the most important lesson of the tobacco industry example: That their motivation was not exceptional at all, but rather based on profit from sales that happened to be at odds with population health. 
 
I would argue that this situation both undermines population health and runs the risk of bringing undeserved negative attention to public private initiatives with industries that don’t share such a conflict of interest.
 
So what can we as public health researchers, practitioners or advocates do to address this? 

• We can conduct research to analyse the extent to which such tactics occur in harmful product industries, and the many ways this may impact on health, but also on public finances
• We can ensure robust conflict of interest guidelines are in place to ensure that such companies are not allowed to influence our priorities or actions
• We can independently evaluate corporate social responsibility initiatives to assess the true impact on health, as opposed to corporate public relations, so that we are clear when these may complement instead of comprising evidence-based policy
• We can help increase the public understanding of how these COIs can harm science and the public; and increase public and policy awareness of such industry strategies
• We can always be mindful of the difference in our fundamental goals and objectives

 
This of course is no small challenge, and may not always be the popular, political or most fundable of directions. However it is clear that if we are to truly improve population health, particularly in an era of increasing focus on the benefits of public private partnership, I would argue that these issues must be wrestled with.

Dr Nason Maani Hessari, BSc MPH PhD FRSA
Research fellow within the Department of Health Services Research and Policy at the London School of Hygiene & Tropical Medicine

Abreviaturas usadas:
CEO - Chief Executive Officer
PR - Public Relations

Referências bibliográficas:

1. Barlow, P., Serodio, P., Ruskin, G., McKee, M., & Stuckler, D. (2018). Science organisations and Coca-Cola's 'war' with the public health community: insights from an internal industry document. J Epidemiol Community Health, 72, 761-763. doi: 10.1136/jech-2017-210375
2. Bero, L. (2003). Implications of the tobacco industry documents for public health and policy. Annu Rev Public Health, 24, 267-288. doi: 10.1146/annurev.publhealth.24.100901.140813
3. Casswell, S., Callinan, S., Chaiyasong, S., Cuong, P. V., Kazantseva, E., Bayandorj, T., . . . Wall, M. (2016). How the alcohol industry relies on harmful use of alcohol and works to protect its profits. Drug Alcohol Rev, 35, 661-664. doi: 10.1111/dar.12460
4. Cowlishaw, S., & Thomas, S. L. (2018). Industry interests in gambling research: Lessons learned from other forms of hazardous consumption. Addict Behav, 78, 101-106. doi: 10.1016/j.addbeh.2017.11.007
5. Hawkins, B., Holden, C., Eckhardt, J., & Lee, K. (2018). Reassessing policy paradigms: A comparison of the global tobacco and alcohol industries. Glob Public Health, 13, 1-19. doi: 10.1080/17441692.2016.1161815
6. Mandel, L. L., & Glantz, S. A. (2004). Hedging their bets: tobacco and gambling industries work against smoke-free policies. Tob Control, 13, 268-276. doi: 10.1136/tc.2004.007484
7. Martino, F. P., Miller, P. G., Coomber, K., Hancock, L., & Kypri, K. (2017). Analysis of Alcohol Industry Submissions against Marketing Regulation. PLoS One, 12, e0170366. doi: 10.1371/journal.pone.0170366
8. McCambridge, J., Mialon, M., & Hawkins, B. (2018). Alcohol industry involvement in policymaking: a systematic review. Addiction. doi: 10.1111/add.14216
9. Petticrew, M., Katikireddi, S. V., Knai, C., Cassidy, R., Maani Hessari, N., Thomas, J., & Weishaar, H. (2017). 'Nothing can be done until everything is done': the use of complexity arguments by food, beverage, alcohol and gambling industries.J Epidemiol Community Health, 71, 1078-1083. doi: 10.1136/jech-2017-209710
10. Petticrew, M., Maani Hessari, N., Knai, C., & Weiderpass, E. (2017). How alcohol industry organisations mislead the public about alcohol and cancer. Drug Alcohol Rev. doi: 10.1111/dar.12596
11. Petticrew, M., Maani Hessari, N., Knai, C., & Weiderpass, E. (2018). The strategies of alcohol industry SAPROs: Inaccurate information, misleading language and the use of confounders to downplay and misrepresent the risk of cancer. Drug Alcohol Rev. doi: 10.1111/dar.12677
12. Rosner, D., & Markowitz, G. (2017). "Ain't Necessarily So!": The Brake Industry's Impact on Asbestos Regulation in the 1970s. Am J Public Health, 107, 1395-1399. doi: 10.2105/ajph.2017.303901
13. Savell, E., Fooks, G., & Gilmore, A. B. (2016). How does the alcohol industry attempt to influence marketing regulations? A systematic review. Addiction, 111, 18-32. doi: 10.1111/add.13048
14. Supran, G. O., N. (2017). Assessing ExxonMobil’s climate change communications (1977–2014). Environmental Research Letters, 12. 
15. Thomas, S. L., David, J., Randle, M., Daube, M., & Senior, K. (2016). Gambling advocacy: lessons from tobacco, alcohol and junk food. Aust N Z J Public Health, 40, 211-217. doi: 10.1111/1753-6405.12410
16. Viet Cuong, P., Casswell, S., Parker, K., Callinan, S., Chaiyasong, S., Kazantseva, E., . . . Parry, C. (2018). Cross-country comparison of proportion of alcohol consumed in harmful drinking occasions using the International Alcohol Control Study. Drug Alcohol Rev. doi: 10.1111/dar.12665
17. World Health Organisation. (2005). Framework Convention on Tobacco Control.
18. World Health Organisation. (2009). Tobacco industry interference with tobacco control.