The Pitfalls of Ascribing Moral Agency to Corporations: Public Obligation and Political and Social Contexts in the Commercial Determinants of Health.

Policy Points Government and civil society should be held more accountable for creating food and beverage regulatory policies rather than assigning moral agency to the food and beverage industry. Nutrition policymaking institutions should ensure civil society's ability to design regulatory policy. Government policymaking institutions should be isolated from industry interference.

Is the commercial determinants conversation confined to the health sciences? Potentially, and that's a problem.

The commercial determinants of health (CDoH) are attracting increased interest and are of great importance when discussing how trade affects health. Through a citation analysis of recent foundational CDoH documents (a Lancet paper series and an Oxford University textbook), we find that fully 71% of all citations reference the health sciences. The health sciences may be well suited to documenting the specific pathways of how commercial (by)products and practices harm human health. However, to operationalize upstream solutions for mitigating these harms, our citation analysis suggests that the field can engage political scientists, economists, sociologists, the trade law and business, as well as advocates in civil society and journalism, more so than it currently does. With CDoH explicitly referring to the interaction between commerce and health, CDoH researchers might be uniquely positioned to get health on the agenda of others, which requires that CDoH methods, datasets, evidence reviews, and proposed interventions are drawn from the widest possible range of sources.

Agnogenic practices and corporate political strategy: the legitimation of UK gambling industry-funded youth education programmes.

Agnogenic practices-designed to create ignorance or doubt-are well-established strategies employed by health-harming industries (HHI). However, little is known about their use by industry-funded organizations delivering youth education programmes. We applied a previously published framework of corporate agnogenic practices to analyse how these organizations used them in three UK gambling industry-funded youth education programmes. Evidential strategies adopted previously by other HHI are prominent in the programmes' practitioner-facing materials, evaluation design and reporting and in public statements about the programmes. We show how agnogenic practices are employed to portray these youth education programmes as 'evidence-based' and 'evaluation-led'. These practices distort the already limited evidence on these educational initiatives while legitimizing industry-favourable policies, which prioritize commercial interests over public health. Given the similarities in political strategies adopted by different industries, these findings are relevant to research and policy on other HHI.

A qualitative framing analysis of how firearm manufacturers and related bodies communicate to the public on gun-related harms and solutions.

There is a growing understanding that the producers and sellers of harmful products directly and indirectly affect population health and policy, including through seeking to influence public understanding about the nature of harms and their solutions. However, the firearm industry and related organisations have not to date been the subject of this type of enquiry. This study sought to address this evidential gap through examining the ways in which the firearm industry and industry-associated organisations frame firearms, firearm-related harms and possible solutions to gun violence. This was a thematic qualitative documentary analysis of materials from 7 of the largest firearm manufacturers and associated organisations. Two authors independently extracted textual material from web articles, press releases, annual reports and shareholder communications between 1st April 2019 to 1st April 2020 (302 documents). A hybrid approach combining both deductive and inductive coding was adopted, guided by the literature on the commercial determinants of health and using NVivo version 12. The firearm industry and firearm industry-funded organisations use framings about the safety and role of guns, evidence on associated harms and solutions that align with the industry's business interests, consistent with evidence on other harmful product manufacturers. This study identified framing strategies employed by the firearm industry and related organisations. These included attempts to undermine evidence, linking regulation to a dystopian future, minimising some of the most common harms, placing the responsibility for harms on individuals, and attempting to foster a heightened sense of risk to personal safety.

Under the influence: system-level effects of alcohol industry-funded health information organizations.

There is now an established body of evidence that the alcohol industry seeks to obstruct public health policies that could affect the availability, affordability or marketing of alcohol. In parallel, the alcohol industry is active in funding corporate social responsibility initiatives, with a particular focus on 'responsible drinking' campaigns, often facilitated by national-level charities established and/or funded by the alcohol industry and associated organizations. While evidence continues to grow regarding biases in the content produced by such health information organizations, they remain active in partnerships with government health departments on national health promotion campaigns and provide a range of health-related information to the public, community organizations and schools. To understand the implications of such access for policymakers, researchers and the public, there is a need to consider the wider, system-level influences of such organizations and their place in wider alcohol industry strategies. In this article, we describe evolving evidence of the direct and indirect strategic effects of such organizations and demonstrate how they serve key roles in the alcohol industry through their existence, content, partnerships and public profiles. We end by considering the implications for how we conceptualize charities established or funded (entirely or partly) by harmful commodity industries, and to what extent current conflicts of interest guidelines are sufficiently effective.

Back to our roots or sowing new seeds: thinking anew on the paradigms of health, harm and disease.

Health, harms and disease are intimately linked, and their promotion and distribution are determined by the social, political and physical worlds in which people live. Yet, the popular narrative on health is still dominated by a biological model that focuses on a disease-causing 'pathogen' or 'agent' that leads to pathology which is diagnosable and amenable to intervention at the individual level via measures delivered through the health care and public health systems. This model generally rests on understanding populations as a collection of individuals, with the pattern of disease seen as the sum of a series of risk factors acting on each of them. Too little attention is paid to the ways in which health, harm, disease, causation and risk are conceptualized and used as guiding concepts in research, policy debates and other fora. We often overlook the distribution of health and the regulatory regimes, norms, values and rights that promote or undermine health. By challenging our ways of thinking about health, harms and disease, we can start to appreciate with greater depth the ways in which health can be threatened and what should be seen as harmful, and conversely, opportunities for moving our systems towards promoting and protecting health.

The Commercial Determinants of Three Contemporary National Crises: How Corporate Practices Intersect With the COVID-19 Pandemic, Economic Downturn, and Racial Inequity.

Policy Points  The United States finds itself in the middle of an unprecedented combination of crises: a global pandemic, economic crisis, and unprecedented civic responses to structural racism.  While public sector responses to these crises have faced much justified criticism, the commercial determinants of these crises have not been sufficiently examined.  In this commentary we examine the nature of the contributions of such actors to the conditions that underpin these crises in the United States through their market and nonmarket activities.  On the basis of this analysis, we make recommendations on the role of governance and civil society in relation to such commercial actors in a post-COVID-19 world.

Our Postpandemic World: What Will It Take to Build a Better Future for People and Planet?

Policy Points Despite the pandemic's ongoing devastating impacts, it also offers the opportunity and lessons for building a better, fairer, and sustainable world. Transformational change will require new ways of working, challenging powerful individuals and industries who worsened the crisis, will act to exploit it for personal gain, and will work to ensure that the future aligns with their interests. A flourishing world needs strong and equitable structures and systems, including strengthened democratic, research, and educational institutions, supported by ideas and discourses that are free of opaque and conflicted influence and that challenge the status quo and inequitable distribution of power.

Energy, Data, and Decision-Making: a Scoping Review-the 3D Commission.

Access to energy is an important social determinant of health, and expanding the availability of affordable, clean energy is one of the Sustainable Development Goals. It has been argued that climate mitigation policies can, if well-designed in response to contextual factors, also achieve environmental, economic, and social progress, but otherwise pose risks to economic inequity generally and health inequity specifically. Decisions around such policies are hampered by data gaps, particularly in low- and middle-income countries (LMICs) and among vulnerable populations in high-income countries (HICs). The rise of "big data" offers the potential to address some of these gaps. This scoping review sought to explore the literature linking energy, big data, health, and decision-making.Literature searches in PubMed, Embase, and Web of Science were conducted. English language articles up to April 1, 2020, were included. Pre-agreed study characteristics including geographic location, data collected, and study design were extracted and presented descriptively, and a qualitative thematic analysis was performed on the articles using NVivo.Thirty-nine articles fulfilled eligibility criteria. These included a combination of review articles and research articles using primary or secondary data sources. The articles described health and economic effects of a wide range of energy types and uses, and attempted to model effects of a range of technological and policy innovations, in a variety of geographic contexts. Key themes identified in our analysis included the link between energy consumption and economic development, the role of inequality in understanding and predicting harms and benefits associated with energy production and use, the lack of available data on LMICs in general, and on the local contexts within them in particular. Examples of using "big data," and areas in which the articles themselves described challenges with data limitations, were identified.The findings of this scoping review demonstrate the challenges decision-makers face in achieving energy efficiency gains and reducing emissions, while avoiding the exacerbation of existing inequities. Understanding how to maximize gains in energy efficiency and uptake of new technologies requires a deeper understanding of how work and life is shaped by socioeconomic inequalities between and within countries. This is particularly the case for LMICs and in local contexts where few data are currently available, and for whom existing evidence may not be directly applicable. Big data approaches may offer some value in tracking the uptake of new approaches, provide greater data granularity, and help compensate for evidence gaps in low resource settings.

Integrating Social Determinants in Decision-Making Processes for Health: Insights from Conceptual Frameworks-the 3-D Commission.

The inclusion of social determinants of health offers a more comprehensive lens to fully appreciate and effectively address health. However, decision-makers across sectors still struggle to appropriately recognise and act upon these determinants, as illustrated by the ongoing COVID-19 pandemic. Consequently, improving the health of populations remains challenging. This paper seeks to draw insights from the literature to better understand decision-making processes affecting health and the potential to integrate data on social determinants. We summarised commonly cited conceptual approaches across all stages of the policy process, from agenda-setting to evaluation. Nine conceptual approaches were identified, including two frameworks, two models and five theories. From across the selected literature, it became clear that the context, the actors and the type of the health issue are critical variables in decision-making for health, a process that by nature is a dynamic and adaptable one. The majority of these conceptual approaches implicitly suggest a possible role for data on social determinants of health in decision-making. We suggest two main avenues to make the link more explicit: the use of data in giving health problems the appropriate visibility and credibility they require and the use of social determinants of health as a broader framing to more effectively attract the attention of a diverse group of decision-makers with the power to allocate resources. Social determinants of health present opportunities for decision-making, which can target modifiable factors influencing health-i.e. interventions to improve or reduce risks to population health. Future work is needed to build on this review and propose an improved, people-centred and evidence-informed decision-making tool that strongly and explicitly integrates data on social determinants of health.

Improving Decision-Making for Population Health in Nonhealth Sectors in Urban Environments: the Example of the Transportation Sector in Three Megacities-the 3-D Commission.

Noncommunicable diseases (NCDs) represent a significant global public health burden. As more countries experience both epidemiologic transition and increasing urbanization, it is clear that we need approaches to mitigate the growing burden of NCDs. Large and growing urban environments play an important role in shaping risk factors that influence NCDs, pointing to the ineluctable need to engage sectors beyond the health sector in these settings if we are to improve health. By way of one example, the transportation sector plays a critical role in building and sustaining health outcomes in urban environments in general and in megacities in particular. We conducted a qualitative comparative case study design. We compared Bus Rapid Transit (BRT) policies in 3 megacities-Lagos (Africa), Bogotá (South America), and Beijing (Asia). We examined the extent to which data on the social determinants of health, equity considerations, and multisectoral approaches were incorporated into local politics and the decision-making processes surrounding BRT. We found that all three megacities paid inadequate attention to health in their agenda-setting, despite having considerable healthy transportation policies in principle. BRT system policies have the opportunity to improve lifestyle choices for NCDs through a focus on safe, affordable, and effective forms of transportation. There are opportunities to improve decision-making for health by involving more available data for health, building on existing infrastructures, building stronger political leadership and commitments, and establishing formal frameworks to improve multisectoral collaborations within megacities. Future research will benefit from addressing the political and bureaucratic processes of using health data when designing public transportation services, the political and social obstacles involved, and the cross-national lessons that can be learned from other megacities.

Analysis of the accuracy and completeness of cardiovascular health information on alcohol industry-funded websites.

BACKGROUND: The Alcohol Industry (AI), and the Social Aspects/Public Relations Organisations (SAPRO) it funds, has been shown to mis-represent the risk of alcohol with respect to cancer and pregnancy. It is theorized that the AI would position alcohol as 'heart healthy' to further undermine public perceptions of risks from drinking. METHODS: A comparative analysis (including content, thematic and context analyses) of cardiovascular health information published on the websites of AI-funded (n = 18, such as 'Drinkaware' and the 'Distilled Spirits Council of the US') and non-AI-funded (n = 18, such as 'NHS.uk') organizations based in multiple high-income jurisdictions. RESULTS: Websites of non-industry-funded health organizations were more likely than AI/SAPRO websites to label alcohol as a risk factor for a range of important cardiovascular diseases (such as myocardial infarction, congestive cardiac failure, hypertension and stroke). Conversely, AI/SAPRO websites were more likely to suggest alcohol was protective in the development of some heart conditions. AI/SAPRO websites frequently referenced the J-shaped curve as proof of benefit from moderate alcohol consumption; suggested a balance between the benefits and harms from drinking; positioned alcohol as consistent with a 'healthy lifestyle'; and framed drinking as a social norm. CONCLUSIONS: AI-funded health organizations mis-represent the evidence on cardiovascular effects of moderate alcohol consumption. Healthcare professionals should appreciate the role of funding source in biasing content, and exercise caution when directing patients to content funded by the AI. Tighter regulation of messaging that AI/SAPRO's provide to the public is required, to avoid the dissemination of harmful misinformation.

Taking the Long View: COVID-19 Priorities for the Biden Administration.

The COVID-19 pandemic transformed the American political landscape, influencing the course of the 2020 election and creating an urgent policy priority for the new administration. The Biden-Harris plan for beating COVID-19 represents a practicable, technically competent plan to contain the pandemic, one that will serve the country well in the months ahead. The authors suggest that the United States would also benefit from an even bolder set of aspirations-reframing the national conversation on COVID-19, embedding equity in all health decision making, strengthening the social safety net, and changing how we talk about health-as part of the national response to COVID-19. This would represent a genuine step forward in the US approach to health, informed by the systemic flaws COVID-19 exposed, and would realize benefits from the pandemic moment that in turn would propel national health forward for the rest of the century.

Dark Nudges and Sludge in Big Alcohol: Behavioral Economics, Cognitive Biases, and Alcohol Industry Corporate Social Responsibility.

Policy Points Nudges steer people toward certain options but also allow them to go their own way. "Dark nudges" aim to change consumer behavior against their best interests. "Sludge" uses cognitive biases to make behavior change more difficult. We have identified dark nudges and sludge in alcohol industry corporate social responsibility (CSR) materials. These undermine the information on alcohol harms that they disseminate, and may normalize or encourage alcohol consumption. Policymakers and practitioners should be aware of how dark nudges and sludge are used by the alcohol industry to promote misinformation about alcohol harms to the public. CONTEXT: "Nudges" and other behavioral economic approaches exploit common cognitive biases (systematic errors in thought processes) in order to influence behavior and decision-making. Nudges that encourage the consumption of harmful products (for example, by exploiting gamblers' cognitive biases) have been termed "dark nudges." The term "sludge" has also been used to describe strategies that utilize cognitive biases to make behavior change harder. This study aimed to identify whether dark nudges and sludge are used by alcohol industry (AI)-funded corporate social responsibility (CSR) organizations, and, if so, to determine how they align with existing nudge conceptual frameworks. This information would aid their identification and mitigation by policymakers, researchers, and civil society. METHODS: We systematically searched websites and materials of AI CSR organizations (e.g., IARD, Drinkaware, Drinkwise, Éduc'alcool); examples were coded by independent raters and categorized for further analysis. FINDINGS: Dark nudges appear to be used in AI communications about "responsible drinking." The approaches include social norming (telling consumers that "most people" are drinking) and priming drinkers by offering verbal and pictorial cues to drink, while simultaneously appearing to warn about alcohol harms. Sludge, such as the use of particular fonts, colors, and design layouts, appears to use cognitive biases to make health-related information about the harms of alcohol difficult to access, and enhances exposure to misinformation. Nudge-type mechanisms also underlie AI mixed messages, in particular alternative causation arguments, which propose nonalcohol causes of alcohol harms. CONCLUSIONS: Alcohol industry CSR bodies use dark nudges and sludge, which utilize consumers' cognitive biases to promote mixed messages about alcohol harms and to undermine scientific evidence. Policymakers, practitioners, and the public need to be aware of how such techniques are used to nudge consumers toward industry misinformation. The revised typology presented in this article may help with the identification and further analysis of dark nudges and sludge.

Bringing the commercial determinants of health out of the shadows: a review of how the commercial determinants are represented in conceptual frameworks.

BACKGROUND: The term 'commercial determinants of health' (CDOH) is increasingly focussing attention upon the role of tobacco, alcohol and food and beverage companies and others-as important drivers of non-communicable diseases (NCDs). However, the CDOH do not seem to be clearly represented in the most common social determinants of health (SDOH) frameworks. We review a wide range of existing frameworks of the determinants of health to determine whether and how commercial determinants are incorporated into current SDOH thinking. METHODS: We searched for papers and non-academic reports published in English since 2000 describing influences on population health outcomes. We included documents with a formal conceptual framework or diagram, showing the integration of the different determinants. RESULTS: Forty-eight framework documents were identified. Only one explicitly included the CDOH in a conceptual diagram. Ten papers discussed the commercial determinants in some form in the text only and fourteen described negative impacts of commercial determinants in the text. Twelve discussed positive roles for the private sector in producing harmful commodities. Overall, descriptions of commercial determinants are frequently understated, not made explicit, or simply missing. The role of commercial actors as vectors of NCDs is largely absent or invisible in many of the most influential conceptual diagrams. CONCLUSIONS: Our current public health models may risk framing public health problems and solutions in ways that obscure the role that the private sector, in particular large transnational companies, play in shaping the broader environment and individual behaviours, and thus population health outcomes.

Claiming Health as a Public Good in the Post-COVID-19 Era.

The global response to COVID-19 has been uneven and disappointing in the vast majority of countries. The United States has borne the largest absolute burden of disease globally, as COVID-19 exploited pre-existing poor population health among Americans to spread rapidly, with devastating consequences. Why does the country that spends the most on healthcare in the world have one of the worst responses to COVID-19? We argue that this is because the United States conception of health is predominantly focused on healthcare, an overwhelming investment in developing drugs and treatments, and an underinvestment in the foundational conditions that keep people healthy. COVID-19 has exposed the limits of this approach to health. In order to prevent COVID-19 and future such pandemics, we must create the conditions that can keep population-level health threats at bay. This means addressing the conditions that shape health, including economics, employment, community networks, racial disparities, how we treat older adults, and the physical layout of our communities. To do so means acknowledging health as a public good, as a transnational project with countries working together to build a healthier world. It also means acknowledging that everyone has a right to health. These aspirations should become core to the global community's health aspirations in the post-COVID-19 era.