Series

Commercial Determinants of Health 3

Commercial determinants of health: future directions
Sharon Friel, Jeff Collin, Mike Daube, Anneliese Depoux, Nicholas Freudenberg, Anna B Gilmore, Paula Johns, Amos Laar, Robert Marten,
Martin McKee, Melissa Mialon

This paper is about the future role of the commercial sector in global health and health equity. The discussion is not Lancet 2023; 401: 1229–40
about the overthrow of capitalism nor a full-throated embrace of corporate partnerships. No single solution can Published Online
eradicate the harms from the commercial determinants of health—the business models, practices, and products of March 23, 2023
https://doi.org/10.1016/
market actors that damage health equity and human and planetary health and wellbeing. But evidence shows that
S0140-6736(23)00011-9
progressive economic models, international frameworks, government regulation, compliance mechanisms for
See Editorial page 1131
commercial entities, regenerative business types and models that incorporate health, social, and environmental goals,
See Comment page 1137
and strategic civil society mobilisation together offer possibilities of systemic, transformative change, reduce those
See Perspectives pages 1147
harms arising from commercial forces, and foster human and planetary wellbeing. In our view, the most basic public and 1148
health question is not whether the world has the resources or will to take such actions, but whether humanity can
This is the third in a Series of
survive if society fails to make this effort. three papers about commercial
determinants of health. All
Introduction Offering an alternative papers in the Series are available
at thelancet.com/series/
The COVID-19 pandemic, the climate emergency, the The model in the first paper in this Series1 highlights the
commercial-determinants-
rising burden of non-communicable diseases (NCDs), many ways in which health and health equity harms can health
and growing health inequities within and between arise from commercial forces. Fundamentally, the model Menzies Centre for Health
countries make a business-as-usual approach to public suggests a need to change how societies define and Governance, School of
and planetary health increasingly untenable. As measure progress, and the role of commercial actors in Regulation and Global
Governance, The Australian
described previously in this Series,1,2 powerful achieving that progress. It makes clear that both policies
National University, Acton,
commercial interests and their activities have played key focused on commercial determinants of health (CDOH) ACT, Australia (Prof S Friel PhD);
roles in exacerbating these crises. practices and transformation of the systems that build School of Political and Social
This is the third paper in this Series and looks towards harmful commercial power is key to sustainable social Science, University of
Edinburgh, Edinburgh, UK
the future. As societies strive to build forward fairer, progress.
(Prof J Collin PhD); Faculty of
questions of how to thrive in a world dominated by In a call to rethink social progress, contemporary Health Sciences, Curtin
powerful commercial interests, and what role this sector capitalism, and the role of the commercial sector within University, Perth, WA, Australia
should play in shaping this world, loom large. To improve it, we imagine societies in which public and private (Prof M Daube BA); Virchow-
Villermé Public Health Centre,
health and health equity, current political, economic, and actors prioritise environmental sustainability, human University of Paris, Paris,
social structures and systems need to change. rights, basic needs, health and wellbeing, and a normative France (A Depoux PhD); School
Fundamentally, global society as a whole must ask which shift away from harmful consumptogenic systems. of Public Health and Health
political and economic arrangements will contribute Imagine progressive business models that embed health, Policy, City University of New
York, New York, NY, USA
most to 21st century health and health equity; what the equity, and environmental goals, for which businesses (Prof N Freudenberg DrPH);
role is of markets in a society that privileges public are held accountable: macroeconomic policies designed Tobacco Control Research
interests; which institutional arrangements and to ensure a fair social foundation and economic Group, Department for Health,
enforcement practices can effectively regulate harmful environments operating within the ecological ceiling.3 University of Bath, Bath, UK
(Prof A Gilmore PhD); ACT
business practices, products, and problems that transcend Imagine public policies free from commercial inter­ Health Promotion, Rio de
national boundaries; how progressive and regenerative ference; employment, education, transport, housing, and Janeiro, Brazil (P Johns MS);
business models can be incentivised; and how citizens health care policies and systems that support people to School of Public Health,
and civil society can promote the necessary public policy live with dignity, in good health, and with a full sense of University of Ghana, Legon,
Ghana (A Laar PhD); Alliance for
and business changes and ensure accountability. wellbeing; and a governance model that privileges the Health Policy and Systems
We examine these questions and offer a vision for a public over private interests. Research, World Health
system that advances public interests, where public and Achieving societal progress as suggested here entails Organization, Geneva,
planetary health and health equity are priority goals for multiple actions by diverse actors including Switzerland (R Marten PhD);
London School of Hygiene &
collective actions. We lay out an immediate and long- governments, international organisations, businesses, Tropical Medicine, London, UK
term transformational agenda through the lens of civil society groups, and researchers.4 This will require (Prof M McKee DSc); Trinity
multilevel governance, analysing the potential for change progressive and regenerative commercial entities, and Business School, Trinity College
from global to local policies and regulatory powers and Dublin, Dublin, Ireland
market actors to change their profit at-any-cost models
(M Mialon PhD)
progressive business approaches, and recognising the to embrace more socially and environmentally conscious
agency of local and transnational networks of citizens business models, respect regulations to prevent harmful
and civil society organisations that are independent of practices and products, and end opposition to public
industry interests. health policies that jeopardise their power or profits.

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Correspondence to: national legislation, policies, and legally or morally

Prof Sharon Friel, Menzies Centre Key messages binding international conventions. Accountability will
for Health Governance, School of
Regulation and Global • There is no single solution to eradicate harms from the require the development of intersectoral public policies
Governance, The Australian business models, practices, and products of market actors that privilege equity and sustainability, without being
National University, Acton, that affect patterns of human and planetary health influenced by commercial interference, recognising and
ACT 2601, Australia implementing what can be referred to as policy coherence
[email protected]
• Growing evidence highlights the need for action both on
specific industries and the broader systemic roles of and health equity-in-all policies. Achieving societal
commercial actors progress will also require citizens and civil society
• Fundamentally, addressing the commercial determinants organisations to demand progressive change and action
of health and health inequities requires rebalancing by businesses and governments and to hold these
power asymmetries organisations to account. For health actors specifically, it
• The world needs a multilevel governance system that will require breaking with the hegemony of a biomedical
privileges public interests over profits and challenges model of health5 and addressing the influence of the
contemporary capitalism to increase compatibility with CDOH.
health and health equity
• An action agenda for progressive economic and political Realising the alternative: governing for public
systems, international frameworks, domestic policy and interests
regulations, regenerative business models, and strategic Fundamentally, achieving such social progress requires
civil society mobilisation together offer possibilities for changing the status quo and challenging power
transformative systemic change imbalances. However, commercial actors and some
• This vision requires: public institutions benefit from, and work to maintain,
• States and international organisations to use their the status quo. All actors use diverse strategies to advance
structural power to change policy systems and interests, exercise rights, influence norms and other
incentivise investment in business models that are actors, make decisions, and meet obligations; these are
essential for health, equity, and sustainability expressions of power.
• Commercial actors to end opposition to health Commercial actors exert their structural power and
regulatory policies, respect regulations to reduce influence via practices including investment, production,
harmful practices and products, and implement marketing, and employment. They also exert significant
regenerative business models influence through ideational power that shapes
• Civil society groups to raise their collective voices, narratives, norms, and ideologies.1 By aligning
articulate alternative visions, and hold commercial government norms and decisions with their interests,
actors and governments accountable the ideas they use to frame issues, and the extent to
• Academia and researchers, in collaboration with policy which such portrayals resonate with existing ideologies,
actors, to provide evidence that is fit for purpose and commercial actors create policy and regulatory
presented in the right way, at the right time, to the environments conducive to their interests. Scholars have
right audiences shown how these different forms of power are used
• Health actors to break with the hegemony of a biomedical effectively across industries (including tobacco,6 soft
model of health and engage more broadly, for example, drinks,7 alcohol,8,9 palm oil,10 sugar,11 gambling,12 fossil
with influential trade, finance, and business actors fuels,13,14 and social media15), resulting in restrained public
• This moment of COVID-19 and the growing global climate health action.16–18
emergency provides a context that requires the However, a power lens not only illuminates the ways in
advancement of bold conceptualisations of social progress which commercial actors exert power, it also identifies
to make public interests and human and planetary health public policies and public health advocacy strategies that
and wellbeing higher priorities than profit can counteract these exercises of power.19,20 For example,
analyses of power dynamics across multisectoral policies
revealed the institutional processes and persuasive
Given what is known about the CDOH, this will require frames used by public-interested actors to recalibrate
government actors to harness their structural power, as structural power inequities, including among the CDOH,
some have done during the COVID-19 pandemic, in favour of health and health equity.21 The creation of
through norm setting and regulation of markets, to alternative spaces enables power to be claimed. When
mitigate harms from economic activity and promote people feel that they are not getting their fair share of
human and planetary wellbeing. Central to reimagining economic and social gains, the rise of their political
social progress will be the embrace of new economic consciousness can find expression outside of traditional
ideas such as the degrowth, circular economy, wellbeing arrangements in social movements, subcultures, and
economy, and doughnut economy approaches.3 The role countercultures. Harnessing that political consciousness
of governments in protecting, promoting, and assuring around a shared vision and organised action can lead to
the health of their citizens is operationalised through transformative change, as observed in the Access to

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Medicines Campaign, Via Campesina, and the Harnessing global public policy landscapes
Divestment movement.22,23 In these ways, evidence- The agenda of the Sustainable Development Goals has
informed advocacy by citizens and civil society been critiqued as neglecting commercial determinants,34
organisations plays a key role in challenging commercial yet it provides a pathway forward. Sustainable
power.24 The power of mobilised populations must never Development Goal 17 reflects neoliberal ideology by
be underestimated. making commitments to trade liberalisation and to
The involvement of a diverse array of governments, multistakeholder approaches that privilege the private
international organisations, commercial entities, and sector; however, there are also pledges to ensure policy
civil society actors in shaping health equity, along with coherence and protect public policy space.35 These
these actors’ various power dynamics, points to tensions illustrate a division in global governance for
governance models that privilege public interests over health,36 visible but not limited to NCD policies. On
profits as being key to curtailing the excessive power of one side lies the WHO Framework Convention on Tobacco
commercial actors and to creating health and health Control, a legally binding agreement that requires the
equity.25 What could a suite of approaches by these actors protection of policy making from the tobacco industry.37
look like to rebalance the spectrum of commercial On the other side, the UN Political Declaration on NCDs38
activities (which range from illegal; legal but harmful; suggests tackling obesity and alcohol harms via ineffective
legal and neutral but influential; to legal and healthy) in regulatory approaches including voluntarism, self-
ways that advance human and planetary health and regulation, and corporate social responsibility, and a
health equity? We describe four key areas for action, reliance on discredited partnership approaches.39–42
ranging from economic and political systems; A new opportunity to ensure greater and more cohesive
international frameworks and domestic policy and global attention to the commercial influences on health
regulations; revised business types and models; to social could emerge from WHO’s new focus on the CDOH
and political campaigns, that together offer possibilities within their Department of the Social Determinants of
for systemic transformative change from the status Health. In setting direction for action on the CDOH,
quo.26 WHO should support national governments to implement
effective regulatory approaches across the full range of
Rethinking the political and economic system commercial influences on health beyond the long-
It has long been recognised that a singular focus on gross recognised harmful commodity industries (ie, tobacco,
domestic product growth is inadequate and has enabled alcohol, firearms, and ultra-processed food) to include, for
unsustainable economic growth that does not account example, mining, fossil fuels, gambling, technology and
for environmental or health harms.27 It is promising, social media, and automobile industries, and commercial
therefore, that national governments (eg, in Bhutan, practices that can lead to health inequity. A prerequisite
Ecuador, New Zealand, Scotland, Wales, and Norway) for effective governance for health is the establishment of
and subnational governments (eg, in Brazil) are rules for engagement, or non-engagement, with
challenging this economic growth discourse.28–30 By commercial entities and conflicts of interest.43,44 There are
adopting wellbeing economy principles and frameworks a number of tools to build on what WHO has developed to
and budgets that put the wellbeing of people and the support countries in managing conflicts of interest in the
planet first, some governments are now engaging with food, pharmaceutical, and tobacco industries.36,45–47
new policy norms and directions, with the potential to
reshape the dominant power of capitalism.31,32 The International regulatory frameworks
implementation of doughnut economic models, which The WHO Framework Convention on Tobacco Control48 For more on the
are based on regenerative and distributive principles to is cited as a model for an overarching treaty approach to implementation of doughnut
economics see https://
meet the needs of all people within the means of the both addressing a global pandemic and curbing the
doughnuteconomics.org/
living planet, is gaining momentum worldwide. effects of commercial interests.18 Article 5.3 of the
Similarly, circular economy models, based on the Framework Convention on Tobacco Control states that
reduction, reuse, recycle, and repair of materials and “in setting and implementing their public health policies
products, are also increasing in popularity, reflecting with respect to tobacco control, Parties shall act to protect
sociocultural shifts away from hyper­ consumerism.33 these policies from commercial and other vested interests
Over time, such approaches might incentivise better of the tobacco industry in accordance with national law”.
types of commerce at scale. Amid enthusiasm to replicate the Framework
Convention on Tobacco Control approach in other
Rethinking structural and sectoral policies spheres,49,50 the limitations of that experience must be
Some key multilevel public policy and regulatory acknowledged. These limitations include inequitable
approaches could help to advance public interest and implementation across countries, barriers to effective
incentivise and repurpose commercial practices, participation by low-income and middle-income
including those that are illegal; legal but harmful; legal countries (LMICs), thus further exacerbating global
and neutral but influential; and legal and healthy. inequities, and challenges in generating resources for

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full implementation.51–53 Article 5.3 is far from universally Public health professionals can increase influence on
implemented, whereas the tobacco industry has invested trade and investment policies by building the capacity of
heavily in using reputation management, public relations health actors to understand the implications of these
activities, and front groups as more indirect and difficult policies for health outcomes and promoting transparency
to expose influence strategies.54,55 to enable effective engagement in negotiations.61 Civil
In expanding the scope of actions, some governments society groups, including those with transnational linkages,
have shifted priority from product-specific regulations can play an important role in widening public engagement
to building effective governance that encompasses and demanding govern­ment action for health and health
multisectoral strategies, national coordination mech­ equity within trade and other macroeconomic policies.69
anisms, and international collaboration.56,57 A possible
foundation for a comprehensive suite of policy responses is Taxation
the development of a broader convention to control the Adequate public finance to fund action across all
CDOH, focusing on the practices, political processes, and determinants of health is fundamental to improved health
norms discussed in paper 1 of this Series.1 Such a and health equity.70 Key to domestic revenues are effective
convention would require strong, continuing support from tax systems, which can also help curb commercial harms.
WHO and its member states, and other UN agencies, and Taxation influences health by providing revenues for
would be fiercely opposed by the commercial entities that health care, providing revenues for public health and
benefit from the status quo, the organisations they fund, public interest civil society organisations, discouraging
and from political leaders that align with them, whether for consumption or production of harmful products, and
ideological, financial, or corrupt reasons. It could, however, reducing income and wealth inequality.71–73
provide national governments, especially from LMICs, An essential element of a tax system includes the
with a legal defence and framework for action on the effective taxation of transnational corporations.74 For the
CDOH,58 and would provide civil society organisations with past 50 years at least, reducing taxes and opposing
a platform from which to press for stronger action. corporate and other tax increases has been a top priority
for transnational corporations: they invest in offshore tax
Macro-economic policy havens, evade taxes, and lobby for and use tax exemptions
National governments advance their macroeconomic for core activities. Transnational corporations short-
policy objectives via instruments such as international change countries out of at least US$245 billion in tax
trade and investment agreements. These agreements are every year just through the use of tax havens.75
frequently influenced by commercial actors to promote Successful implementation of national taxation rules
free market ideas and rules to liberalise or deregulate.59 requires improved cooperation at the international level
As a result, such agreements favour private sector and there are signs of a shift in thinking about how to do
interests, often at the expense of health.60–63 this.76 In July, 2021, the G20 finance ministers endorsed
Some successes in trade policy governance provide an attempt brokered by the Organisation for Economic
useful counter examples. For example, Thailand’s Co-operation and Development to make transnational
experience of institutionalising links across ministries of corporations pay more tax. 130 countries have agreed to a
trade and health; building capacity among health officials two-part global tax reform that would require trans­
and advocates; and selecting health issues that resonate national corporations to pay more tax in the countries in
with policy makers and the public provides important which they sell products or services, and establish a
lessons.64 In Ghana, following increasing imports of low global minimum corporate tax rate of 15%.77 However,
quality and high fat meats, the Government implemented the difficulty will be in the details, still under negotiation,
food standards that applied to all domestic and imported including which companies will be covered and what tax
meats, ensuring compliance with World Trade Organi­ changes will result.78 Some LMICs have criticised the
sation commitments to be non-discriminatory and agreement for a narrow focus on sales, ignoring company
evidence based.65 When the Australian parliament intro­ presence in countries for production or extraction
duced laws that required the plain packaging of cigarettes, purposes. These LMICs argue that this model would
it was in the interest of public health.66 Having lost their continue to transfer wealth from LMICs to high-income
case at the Australian High Court, Philip Morris lodged a countries.79
dispute to be determined at international arbitra­ tion, Notably, externalities remain largely absent from
including through the use of an investment dispute clause taxation discussions. If health, social, and environmental
in an investment treaty signed by Australia and Hong Kong. externalities were costed into taxation formulas,
Philip Morris lost; public health won.67 This empowerment commercial actors would have less incentive to manu­
of the public sector snowballed throughout the negotiations facture and sell harmful products and lower profits
of the Trans-Pacific Partner­ship agreement. The tobacco would reduce their structural power. Incorporating a
carve-out in the text of the final agreement is by no means polluter-pays principle and true-cost accounting into
perfect, but it reflects the potential for protections that fiscal policy could both enhance sustainable financing
could be extended to other areas of public health.68 for health and development and help address the CDOH.

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Public procurement responsibility, democracy, equality, equity, and solidarity.

Public procurement involves the purchase by In 2017, almost 10% of the world’s employed population,
governments of goods, services, and works, and provides mainly in agriculture, worked for cooperatives.88 As
a mechanism to control the CDOH across key settings.80,81 member-owned, member-run and member-serving
The Brazilian School Food Program is an example of a businesses, cooperatives offer the potential to empower
public procurement policy that has several benefits: it people to shape decisions that affect their lives.
improves the health of children of school age through the
promotion of adequate diets; it promotes local economy Alternative forms of investment
and livelihoods of local workers, family farmers, One option for investment is public investment.
Indigenous groups, and other disadvantaged groups; and Investment and regulatory mechanisms are needed to
protects environmental services of smaller rural incentivise the growth of alternative types of commerce
settlements and protected areas. Brazilian School Food and business models so that the relative dominance of
Program is the largest school meal programme in the large corporations and their health-harming practices is
world, and it is mandated to purchase 30% of its supply reduced. Internationally, the concept of Global Public
for meals from family farmers. School feeding in Brazil Investment89 was developed in recognition of inter­
is a universal right of students enrolled in public basic national public finance (global aid) needing to evolve a
education and a duty of the state granted by the new framework for fiscal policy that fits with the current
constitution. Brazilian School Food Program regulates and future global challenges. At the domestic level,
and guarantees school feeding as a right for across The Organisation for Economic Co-operation and
schoolchildren. Integrated into Brazilian School Food Development countries, governments are currently
Program is the regulation of the sale and marketing of investing in agrifood technology, with the objectives of
food within and outside school premises.82 creating climate-resilient food systems and increasing
food security. Embedding social equity and health
Rethinking the commercial sector and addressing its considerations into these investment strategies is crucial.
practices With new forms of social financing, a number of social
This Series paper has focused on public sector policy and enterprises are aiming to create social value, including
regulatory tools. In this section, we discuss actions that disease prevention.90 For example, a social procurement
can be taken by commercial actors, including those financing model is used in the Australian Victorian
mandated by regulation. Government’s Partnerships Addressing Disadvantage
where investment is directed towards social enterprises
Alternative types of business and business models in delivery agencies or service providers.91 Other finance
Growing evidence shows that the dominant types of formulations include social impact investment, indirect
businesses and business models impose high costs on equity, debt financing, crowdfunding, credit support,
social progress and human and planetary wellbeing.83 grants, and concessional tax finance. Blended forms of
Alternative business models can make positive social and financing can enable a broader range of investors to
environmental outcomes higher priorities and can shift support locally driven initiatives to complement state
the focus from shareholder to stakeholder needs.84 The investments. For example, Indian municipalities with
sustainable business model,85 for example, identifies social enterprises that received local venture philanthropic
profits as a means rather than an end in itself, and seeks investment had a decrease in income inequality, and the
to create value not only for the business, its customers, effect was stronger in social enterprises with strong
and business partners but also for diverse stakeholders, collectivistic organisational identities.92
including environmental groups and local communities. The other option for investment is private investment.
Benefit Corporations (also known as B Corps) have Fundamentally, 21st century capitalism is no longer
emerged as new types of business that embed social and dominated by businesses making profit from products
environmental issues into their business models, with a and services; key players in the commercial system
dominant objective of creating positive societal effects include financial investors operating in pension funds,
rather than maximising profit.86 Questions remain about hedge funds, and asset management firms.93 Financial
whether only a few, small, privately owned companies will investors, therefore, are key players in the necessary
use this approach or, if it is scalable, how it will avoid reforms related to the type and size of investments.
becoming an updated version of corporate social The development of indicators, including environmental,
responsibility and can be adopted by large, publicly listed social, and governance indicators94 enables investors to
companies to catalyse a shift in the current economic make more informed decisions, and more than a third of
order. large asset owners have signed up to the UN’s Principles
With less focus on the pursuit of profit, commercial for Responsible Investment.95 The inclusion of health
entities such as cooperatives are collectively owned indicators should be encouraged to create environmental,
by members empowered in making decisions.85,87 social, health, and governance company measures (as
Cooperatives are often driven by mutual aid, discussed in the second paper in this Series).2 It will,

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however, be important to ensure that industries do not use Governments can also implement comprehensive
environmental, social, and governance indicators simply policy measures that counter commercial forces. Public
as a form of reputation management, promoting authorities can restrict the ability of businesses to make
misleading perspectives, to gain inappropriate credibility, inappropriate health claims for their products and
and as a means of distracting attention from their harmful market unhealthy products, disincentivise consumption
activities (see the first paper in this Series).1 of unhealthy products (through taxes and tariffs), and
Another potentially useful private sector governance ensure that public procurements favour healthy options.
mechanism that could inform investment decisions is the In this regard, much attention has been given to food
Task Force on Climate Related Financial Disclosures. environment policies in the past 10 years,105,106 although
Established in 2015, the taskforce includes major only a handful of countries are implementing them.
companies and investors, banks, insurers, and credit The 2020 WHO Global NCD Progress Monitor, for
rating agencies. The Task Force on Climate Related example, reported little government effort in
Financial Disclosures uses a mix of reporting metrics, implementing these policies in Africa.107 South Africa
including disclosure of governance, strategy and risk (in 2013) and Morocco (in 2019) adopted mandatory
management, and scenario analyses that can consider the targets for salt reduction in several food categories.
potential effects of a transition to a low carbon economy. Morocco is implementing marketing restrictions and
Although the reporting is currently voluntary, there are saturated fatty acids and trans-fats policies.107 South
precedents for making such approaches mandatory—eg, Africa was the first African country to enact and
the EU Non-Financial Reporting Directive.96 implement a sugar-sweetened beverage tax in 2016.
There are grounds for optimism that ethical Morocco repealed its sugar-sweetened beverage tax
investment can gain momentum. The Initial Public in 2018 before its implementation in 2019—in response
Offering of the company Deliveroo failed on the basis of to pressures from the agrifood industry.108 In this regard,
For more on Tobacco Free concerns about employee working conditions. Tobacco the peculiar heterogeneity of the African food
Portfolios see https:// Free Portfolios has attracted high rates of support and environments and their variegated political economies
tobaccofreeportfolios.org
divestment in the tobacco industry by pension funds should be recognised during promulgation and
and banks. To date, divestment largely reflects the implementation of these policies—a lesson for many
success of tobacco control in increasing the financial regions globally.105
and ethical risks for investors. But closer collaboration
between public health and divestment communities Social mobilisation
could offer further opportunities: investors will better Civil society constitutes a fourth and key element of the
understand emerging risks and the public health CDOH governance system, working on different scales,
community will be better able to access the financial with different strategies, and articulating different
sector. Given the COVID-19 pandemic, prudent visions and values.109 Health organisations and other civil
prospective investors should consider a company’s society organisations independent of vested commercial
resilience to future health threats. interests, grassroots groups, journalists, activist
Whether ethical investment strategies can lead to academics, and citizens play a major role in mobilising
substantive and symbolic improvements in the business action on the CDOH, creating a body of knowledge and
effects on wellbeing will depend on the political power practice that can inform the development of effective
that can be mobilised to require businesses to maintain strategies to address the CDOH.110,111 In the past century,
and expand such changes. social movements of workers, environmentalists, women,
Addressing the diverse commercial practices that Indigenous people, and others have played a crucial role
underpin the sector’s ability to harm health (panel) will in limiting the harmful CDOH.
be key to addressing the CDOH, with interventions that Civil society uses its organisational, structural, and
curb the power of the commercial sector playing an ideological power to influence the CDOH.23 Civil society
important role. A first step is to better understand these exerts power by mobilising evidence; advocating for
practices. Taxonomies of commercial practices have thus conventional policy tools such as legislation; through
far been developed to explain political and scientific electoral campaigning, litigation, public education,
practices97,98 and can and have been used to predict and lobbying and other forms of advocacy; and via political
counter industry interference. strategies intended to disrupt the status quo such as
For example, controlling the worst aspects of the boycotts, strikes, demonstrations, and sit-ins. Proponents
commercial sector’s political and scientific practices can recognise that these strategies, like any advocacy strategies,
reduce the power of commercial actors.104 Examples include should be carefully considered to avoid unintended
excluding conflicted industries from playing a role in policy counterproductive effects.112 Civil society seeks to bring
formulation, improving transparency through obligatory about changes in five domains that influence health and
lobbying registers and commercial sector reporting, health equity. First, with evidence, civil society draws
changing the way science is funded, and regulating to attention to the magnitude of the health and equity harms
reduce monopoly concentration across the economy. caused by the CDOH. Second, civil society increases

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Panel: Commercial sector practices and example solutions

Political44,97 Labour and employment101
• Minimise industry engagement in policy formulation • Enforce rules on decent work conditions and health and
• Create enforceable conflict of interest, lobbying, and safety standards
transparency policies (including funding for think thanks, • Enable and support unionisation
lobby groups, civil society organisations, and lawyer firms) • Protect whistleblowers
• Implement enforceable bribery and corruption legislation • Institute rules on pay gaps within organisations (including
• Protect whistleblowers caps on Chief Executive Officer salaries and bonuses)
• Ensure transparency in policy consultations (eg, public • Hold commercial organisations responsible for supply chain
disclosure and details of funding) labour conditions
Scientific98 Financial102
• Ensure funding systems based on public interest that reduce • Prevent tax deductible expenditures for marketing or
industry ability to shape science promotional practices that are posing as corporate social
• Create a public registry of trials responsibility
• Stop industry-sponsored science education • Effectively address tax avoidance and transfer pricing
• Train users of science, including journalists • Incorporate the polluter pays principle to provide
• Strengthen conflict of interest and transparency governance sustainable finance to address the commercial determinants
in research organisations and scientific journals of health
• Promote scholar activism • Implement anti-monopoly competition policies
• Create registers of beneficial owners to help improve
Marketing99
transparency of international financial flows
• Enforce comprehensive controls on the marketing of
products damaging to health (including via social media, Reputational management44,103
labelling, and predatory marketing methods— • Denormalise harmful commodity industry practices to
eg, automated marketing and robot calls) expose real practices
• Create and enforce regulations on predatory marketing • Expose and denormalise fraudulent corporate social
strategies by industry responsibility and environmental, social, and
governmental efforts and ensure sufficient oversight
Supply chain100
of others. Classify health harming industry corporate
• Include externalities—full cost accounting and tax increases
social responsibility efforts as marketing and restrict
• Improve data on supply chain health and environmental
their use
risks and harms
• Prohibit government or intergovernmental partnerships
• Ensure minimum price rates in supply contracts
with health-harming commercial sector organisations
• Implement excise duties to increase price of and discourage
use of harmful products

transparency and exposes and socialises the extent and role make it more difficult to distort science to advance
of commercial actors in creating health and health equity commercial interests, or improve the transparency of
problems, enabling it to denormalise harmful practices.113 corporate political activity.
Third, civil society seeks to modify government policies In the past two decades, civil society actors have used
that harm health and expose and counter industry these and other strategies to achieve their goals.
interference during policy debates. By advocating for First, civil society actors have built coalitions. To
regulatory, tax, employment, and trade policies that amplify their power, widen their appeal to diverse
encourage businesses to reduce harm to health or the constituencies, and convince policy makers to act, civil
environment and pressing for better (independent of society organisations have created coalitions and
industry) education and information, civil society uses its alliances, sometimes with unusual partners, whose
power to persuade public officials to take action. Fourth, presence together changes public thinking about an
civil society promotes ideational change in contesting the issue and provides an opportunity for action.116 The
commercial status quo; it challenges ideas that constrain Framework Convention on Tobacco Control process
stronger public health protections such as the concept of stimulated civil society groups to create the Framework
the nanny state or corporate emphases on individual Convention Alliance in the early 2000s.117 Now a network
responsibility. By reframing these debates, civil society can of nearly 300 organisations from more than 100 countries,
make it easier to win public policy battles.114,115 Finally, civil the Alliance monitors government adherence to the
society participates in changing governance structures to Framework Convention on Tobacco Control, exchanges
amplify the voices of people harmed by commercial actors, best practices, and strengthens national and international

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Government or international organisations Commercial sector

• Ensure greater and more cohesive global attention to commercial influences • Adhere to strong, well enforced, evidence-based government regulation
on health and health equity • Improve workers’ conditions, healthiness of products, and reduce all negative
• Strengthen multilateral mechanisms and spaces for participation and social externalities
oversight of the CDOH • Accelerate alternative and ethical investment
• Develop and implement a global convention to control CDOH • The activities of the commercial sector should be open and transparent
• Set new policy norms by implementing wellbeing economy frameworks and • People at the highest levels of companies in the commercial sector should be
budgets that put the wellbeing of people and the planet first held accountable for the harms knowingly caused by their activities
• Implement multisectoral policies that will counter commercial practices that • Scale up regenerative business models that privilege stakeholders not
harm health and incentivise regenerative types of business shareholders
• Establish rules for engagement and conflicts of interest • Progressive business should advocate for systemic changes in the current ways
• Build the capacity of health actors to understand the implications of, for of doing business
example, trade, tax, or finance for health outcomes and enable effective
engagement in their development

Researchers and research funders Civil society

• Place high priority on understanding how to effect positive systemic change • Be noisy: publicly support evidence-based health measures; make the case for
and generate better understanding of obstacles to action (including action to the government and the community; expose and oppose the
distractions) harmful influences, policies, practices, and products of commercial entities
• Make power an explicit focus of research in the governance of CDOH • Successful civil society mobilisation will be achieved through strong, united
• Expose the health-harmful policies and practices of different industries coalitions; consensus, evidence-based positions; strategic use of political and
• Defend the use of science to support public health policy and oppose industry policy entrepreneurs; compelling issue framing; exploiting cleavages within
efforts to manipulate or distort science to advance industry interests industry; focused and timely advocacy; and persistence
• Increase public spending on research to reduce the incentives for, and reliance • Doctors and other health professionals must use their legitimacy and
on, researchers to seek industry funding authority to influence action on CDOH and emphasise the importance of
• Ensure that education on CDOH issues becomes part of all health and other prevention
relevant curricula
• Promote advocacy and education on advocacy as a key component of health
curricula; create a global group of academic activists

Figure: Actors and the actions they can take to prevent health harms from commercial actors across the current governance system
CDOH=commercial determinants of health.

implementation of the treaty. However, insufficient settlements against opioid manufacturers, tobacco
funding remains a barrier to effective coalitions.118 companies, pesticide producers, automobile makers, and
Second, civil society actors have used advocacy and other industries have shown that public health litigation
campaigns. Public health campaigns enable opponents can win compensation for victims of corporate harm,
of a particular business practice to target a specific reimburse governments for repairing corporate harms,
corporation, industry, or government agency; mobilise a promote effective regulation, deter future wrong doing,
broad cross-section of partners at multiple levels; and and change social norms towards industry.126,127 Climate
change tactics and messages in response to changing litigation has effectively linked threats to human health to
conditions. The success of this strategy is exemplified by the effect of dangerous climate change. Ground­breaking
South Africa’s Treatment Action Campaign, which forced climate change-related court decisions in Australia and
global pharmaceutical companies to improve access to the Netherlands shed light on the scope for claims based
antiretroviral medications.119 Scholar activism has often on duties to individuals to modify the emissions
been an important force for social change. Morton et al trajectories of fossil fuel companies.128
discuss how radical sociological scholarship affected the A key issue remains that public interest organisations
anti-war and anti-poverty movements and campaigns.120 often struggle for funding compared with industry-
Third, actors have employed an ethical argument established and funded think tanks, front groups, and
strategy. Diverse national and global civil society groups fake grassroots (astroturf) organisations. Requirements
have made strategic use of the ethical argument, for full disclosure of both current and historical funding
employing discursive and network power to persuade as a prerequisite for lobbying through obligatory and
investors to disinvest from companies.121–123 Compelling comprehensive transparency registers for third-party and
issue framing can shame investors, highlight the industry-specific lobbyists can help address this issue.
financial risks of investment in harmful industries, and Allocating public funding to support community
promote alternative socially responsible investments. organisations that monitor corporate compliance with
Such initiatives have led to the disinvestment of hundreds the law is a promising strategy for increasing the power
of billions of dollars from the tobacco, fossil fuel, and and resources of civil society.129
firearms industries.23
Fourth, civil society actors have used strategic litigation. Calling the global health community to action
Law can be a powerful determinant of health.124,125 Laws The global health community concerned with health and
can empower individuals and communities and authorise health equity must move beyond observation to action.
governments to act to advance public interests. Court This requires breaking from the hegemony of a

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biomedical model of health and acting on the influence “The end of growth, does not mean the end of social
of the CDOH. All actors can take meaningful action progress”
(figure). State actors can use their regulatory power to Tim Jackson (2021)27
change policy systems essential for health, equity, and
Contributors
sustainability. Civil society groups and social movements SF, JC, MD, NF, ABG, RM, and MMi contributed to the
can raise collective voices, articulate alternative visions, conceptualisation of the paper and its aims. SF, JC, MD, AD, NF, ABG,
and hold commercial actors and governments to account. PJ, AL, RM, MMc, and MMi contributed to the design of the project. SF,
JC, MD, AD, NF, ABG, PJ, AL, RM, MMc, MMi synthesised literature.
Researchers provide important evidence, which must be
SF was responsible for project administration. All authors contributed to
fit for purpose and be presented in the right way, at the multiple drafts, including substantive commentary and revision.
right time, to the right recipients. Specifically, health Declaration of interests
actors must understand the language of, and engage SF has received research grants from the Australian Research Council
with, influential government and business actors such as and the National Health and Medical Research Council. AL has received
finance and trade ministers and financial investors. grant funding from the International Development Research Centre,
Canada, for research to support the Ghanian Government’s efforts to
The task of tackling the CDOH is daunting but that regulate the marketing of unhealthy foods to children. ABG is European
should not be reason not to proceed. Progress is almost editor of Tobacco Control and a member of the Royal College of
always incremental and sequential, but with persistent Physicians Tobacco Advisory Group, the Council of Action on Smoking
advocacy, transformative change can be achieved in areas and Health, WHO International Expert Groups on Commercial
Determinants of Health and on Smoking and COVID-19, the European
where it would once have been unthinkable. The urgency Respiratory Society Executive Committee, and the Framework
of COVID-19 and the growing global climate emergency Convention Alliance Strategy Development Working Group; she has
provide a context that requires bold conceptualisations of received travel support from WHO, the Prince Mahidol Award, the UK
social progress in ways that privilege public interests and Prevention Partnership, and the European Health Forum Gastein; she
has received research grants from Bloomberg Philanthropies, the UK
human and planetary health and wellbeing. Prevention Research Partnership, WHO Europe, the Dutch Lung Fund,
This Series paper has laid out key components of, and the Heart Foundation, the Dutch Cancer Society, the Thrombosis
steps towards, a future fit-for-purpose governance system Foundation, the Diabetes Fund, The National Institute for Health
that challenges contemporary capitalism to increase the Research, Cancer Research UK, UK Research and Innovation, and the
Global Challenges Research Fund; and she has consulted for the World
compatibility with health and health equity. This paper Bank for a UK case study on illicit tobacco. MD has received travel
shows that there is no easy solution to curb the harms support from WHO and research grants from Heathway, the Victorian
from the CDOH. The growing evidence on the CDOH Responsible Gambling Foundation, the Australian Research Council,
highlights the need for immediate action on both specific and the National Health and Medical Research Council. All other
authors declare no competing interests.
industries and the broader systemic roles of commercial
actors. Organisational policies are needed that require Acknowledgments
We would like to acknowledge Alice Fabbri and Krista Bondy for their
action at all levels and across all sectors, moving beyond contributions to panel 2 and Jenn Lacy-Nichols for review of paper drafts.
silos to build coalitions capable of advancing innovative
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