More than a Nuisance: Implications of Food Marketing for Public Health Efforts to Curb Childhood Obesity.

Fifteen years ago, public health experts urged industry, governments, and advocates to take action to dramatically improve the unhealthy food-marketing environment surrounding children in order to address the global childhood obesity crisis. Since then, research has confirmed that food marketing to children has far-reaching negative effects on their diets and health, takes advantage of adolescent vulnerabilities, and contributes to health disparities. In addition, digital marketing has profoundly changed young people's engagement with brands. Moreover, reliance on industry self-regulation as a solution has proven ineffective. Government-led policies have been more successful, but they remain limited in scope and challenging to adopt and implement. New approaches are necessary to increase public and policy maker awareness that food marketing is more than a nuisance, that it threatens the long-term health of children and adolescents worldwide, and that meaningful governmental action is urgently required to curtail industry's negative impact on young people's well-being.

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.

Mapping the Lobbying Footprint of Harmful Industries: 23 Years of Data From OpenSecrets.

Policy Points Our research reveals the similarities and differences among the lobbying activities of tobacco, alcohol, gambling, and ultraprocessed food industries, which are often a barrier to the implementation of public health policies. Over 23 years, we found that just six organizations dominated lobbying expenses in the tobacco and alcohol sectors, whereas the gambling sector outsourced most of their lobbying to professional firms. Databases like OpenSecrets are a useful resource to monitor the commercial determinants of health. CONTEXT: Commercial lobbying is often a barrier to the development and implementation of public health policies. Yet, little is known about the similarities and differences in the lobbying practices of different industry sectors or types of commercial actors. This study compares the lobbying practices of four industry sectors that have been the focus of much public health research and advocacy: tobacco, alcohol, gambling, and ultraprocessed foods. METHODS: Data on lobbying expenditures and lobbyist backgrounds were sourced from the OpenSecrets database, which monitors lobbying in the United States. Lobbying expenditure data were analyzed for the 1998-2020 period. We classified commercial actors as companies or trade associations. We used Power BI software to link, analyze, and visualize data sets. FINDINGS: We found that the ultraprocessed food industry spent the most on lobbying ($1.15 billion), followed by gambling ($817 million), tobacco ($755 million), and alcohol ($541 million). Overall, companies were more active than trade associations, with associations being least active in the tobacco industry. Spending was often highly concentrated, with two organizations accounting for almost 60% of tobacco spending and four organizations accounting for more than half of alcohol spending. Lobbyists that had formerly worked in government were mainly employed by third-party lobby firms. CONCLUSIONS: Our study shows how comparing the lobbying practices of different industry sectors offers a deeper appreciation of the diversity and similarities of commercial actors. Understanding these patterns can help public health actors to develop effective counterstrategies.

Making Big Business Everybody's Business: Aboriginal leaders' perspectives on commercial activities influencing aboriginal health in Victoria, Australia.

BACKGROUND: The commercial determinants of health is a rapidly expanding field of research; however Indigenous perspectives remain notably underrepresented. For Indigenous peoples the intersection of globalisation, colonialism and capitalism may amplify commercially-driven health inequities. This study aimed to explore the perspectives of Aboriginal leaders regarding the influence of commercial activities on Aboriginal health and wellbeing in Victoria, Australia. METHODS: Semi-structured interviews with 23 Aboriginal leaders from across five sectors (n = 15 urban, n = 8 rural/regional) were analysed through reflexive thematic analysis. RESULTS: Three overarching themes were identified encompassing (i) harmful commercial practices and processes, (ii) improving corporate engagement and (iii) opportunities for self-determination through business. Participants expressed concern over aggressive marketing by the gambling industry, commercial exploitation of Aboriginal culture, the privatisation of public services, and lack of oversignt of corporate social responsibility strategies. Simultaneously, Aboriginal-led businesses were viewed as opportunities for cultural connection, and financial empowerment and self-determination. CONCLUSION: Numerous commercial entities and activities are perceived to influence Aboriginal health and wellbeing. This study highlights the need for stronger policy and regulation to mitigate harmful industry practices while incentivising the potential positive impacts of the commercial activities on Aboriginal health and wellbeing.

Continuities and change in alcohol policy at the global level: a documentary analysis of the 2010 Global Strategy for Reducing the Harmful Use of Alcohol and the Global Alcohol Action Plan 2022-2030.

BACKGROUND: There are only two major statements which define alcohol policy development at the global level. There has not been any comparative analysis of the details of these key texts, published in 2010 and 2022 respectively, including how far they constitute similar or evolving approaches to alcohol harm. METHODS: Preparatory data collection involved examination of documents associated with the final policy statements. A thematic analysis across the two policy documents was performed to generate understanding of continuity and change based on comparative study. Study findings are interpreted in the contexts of the evolving conceptual and empirical literatures. RESULTS: Both documents exhibit shared guiding principles and identify similar governance challenges, albeit with varying priority levels. There is more emphasis on the high-impact interventions on price, availability and marketing in 2022, and more stringent targets have been set for 2030 in declaring alcohol as a public health priority therein, reflecting the action-oriented nature of the Plan. The identified roles of policy actors have largely remained unchanged, albeit with greater specificity in the more recent statement, appropriately so because it is concerned with implementation. The major exception, and the key difference in the documents, regards the alcohol industry, which is perceived primarily as a threat to public health in 2022 due to commercial activities harmful to health and because policy interference has slowed progress. CONCLUSIONS: The adoption of the Global Alcohol Action Plan 2022-30 potentially marks a pivotal moment in global alcohol policy development, though it is unclear how fully it may be implemented. Perhaps, the key advances lie in advancing the ambitions of alcohol policy and clearly identifying that the alcohol industry should not be seen as any kind of partner in public health policymaking, which will permit progress to the extent that this influences what actually happens in alcohol policy at the national level.

Breastfeeding, first-food systems and corporate power: a case study on the market and political practices of the transnational baby food industry in Brazil.

BACKGROUND: The exploitative marketing of commercial milk formula (CMF) reduces breastfeeding, and harms child and maternal health globally. Yet forty years after the International Code of Marketing of Breast-Milk Substitutes (The Code) was adopted by WHO member states, many countries are still to fully implement its provisions into national law. Furthermore, despite The Code, worldwide CMF markets have markedly expanded. In this paper, we adopt Brazil as a case study to understand the power of the baby food industry's marketing and corporate political activity, and how this influences the country's 'first-food system' in ways that promote and sustain CMF consumption. METHODS: We used a case study design, drawing data from from documents and key informant interviews (N = 10). RESULTS: Breastfeeding rates plummeted in Brazil to a historic low in the 1970s. A resurgence in breastfeeding from the mid-1980s onwards reflected strengthening political commitment for a national policy framework and breastfeeding protection law, resulting in-turn, from collective actions by breastfeeding coalitions, advocates, and mothers. Yet more recently, improvements in breastfeeding have plateaued in Brazil, while the industry grew CMF sales in Brazil by 750% between 2006 and 20. As regulations tightened, the industry has more aggressively promoted CMF for older infants and young children, as well as specialised formulas. The baby food industry is empowered through association with powerful industry groups, and employs lobbyists with good access to policymakers. The industry has captured the pediatric profession in Brazil through its long-standing association with the Brazilian Society of Pediatrics. CONCLUSION: Brazil illustrates how the baby food industry uses marketing and political activity to promote and sustain CMF markets, to the detriment of breastfeeding. Our results demonstrate that this industry requires much greater scrutiny by regulators.

Privatisation of government services in Australia: what is known about health and equity impacts.

BACKGROUND: Historically in Australia, all levels of government created collective wealth by owning and operating infrastructure, and managing natural assets, key public goods and essential services while being answerable to the public. This strong state tradition was challenged in the 1980s when privatisation became a widespread government approach globally. Privatisation involves displacing the public sector through modes of financing, ownership, management and product or service delivery. The Australian literature shows that negative effects from privatisation are not spread equitably, and the health and equity impacts appear to be under-researched. This narrative overview aims to address a gap in the literature by answering research questions on what evidence exists for positive and negative outcomes of privatisation; how well societal impacts are evaluated, and the implications for health and equity. METHODS: Database and grey literature were searched by keywords, with inclusion criteria of items limited to Australia, published between 1990 and 2022, relating to any industry or government sector, including an evaluative aspect, or identifying positive or negative aspects from privatisation, contracting out, or outsourcing. Thematic analysis was aided by NVivo qualitative data software and guided by an a-priori coding frame. RESULTS: No items explicitly reflected on the relationship between privatisation and health. Main themes identified were the public cost of privatisation, loss of government control and expertise, lack of accountability and transparency, constraints to accessing social determinants of health, and benefits accruing to the private sector. DISCUSSION: Our results supported the view that privatisation is more than asset-stripping the public sector. It is a comprehensive strategy for restructuring public services in the interests of capital, with privatisation therefore both a political and commercial determinant of health. There is growing discussion on the need for re-nationalisation of certain public assets, including by the Victorian government. CONCLUSION: Privatisation of public services is likely to have had an adverse impact on population health and contributed to the increase in inequities. This review suggests that there is little evidence for the benefits of privatisation, with a need for greater attention to political and commercial determinants of health in policy formation and in research.

"It's changing our lives, not for the better. It's important that we have a say". The role of young people in informing public health and policy decisions about gambling marketing.

BACKGROUND: Marketing has a significant impact on the normalisation of gambling for youth across the globe. This has included shaping positive attitudes towards gambling, as well as increasing the social and cultural acceptance of gambling - particularly aligned with valued activities such as sport. Because of this, public health experts argue that gambling marketing poses a significant risk to the health and wellbeing of youth. While young people are increasingly exposed to, and impacted by marketing for gambling products, they are rarely consulted about policy issues and options. This study aimed to explore young Australians' perceptions of current policy responses to gambling advertising, whether they thought young people should be involved in discussions and decisions about gambling marketing regulations, and their perceptions of the duty of governments to protect young people from gambling industry marketing strategies. METHODS: Qualitative focus groups (n = 22) were held with n = 64, 12-17 year olds in the Australian states of Victoria and New South Wales. Participants were asked to reflect on current gambling policies, particularly relating to marketing, what they thought should be done about gambling marketing, and if and how young people should be included in public health responses to gambling. An interpretivist 'Big Q' approach to reflexive thematic analysis was used. RESULTS: Young people highlighted the need for more effective regulations around the content and frequency of gambling marketing. They also wanted to see more realistic representations of the negative impacts of gambling to counter persistent positive commercial marketing messages. Most thought that young people should be given an opportunity to have a say about responses to gambling due to their unique experiences. Participants identified mechanisms to increase young people's engagement in decision making, such as direct lines of communication to different levels of government, involvement in research, and diversifying ways of engagement. Specific recommendations included more regulatory action such as bans on gambling advertising. CONCLUSIONS: Creating formal structures that facilitate the inclusion of young people's perspectives in decisions made about gambling can result in more innovative and effective strategies to prevent the harms from gambling industry products, promotions, and practices.

"Older people will die of old age. I'll die of climate change": engaging children and young people in climate decision making for public health.

BACKGROUND: The climate crisis is a significant risk to the health and wellbeing of children, young people, and future generations. While there are calls for children and young people's engagement in climate decision making, current power structures limit their participation. This paper aimed to understand children's perspectives about the impact of the climate crisis on their futures, their ability to influence climate decisions, and strategies and mechanisms to facilitate their greater engagement in decisions made about the climate crisis. METHODS: Online in-depth interviews were conducted with n = 28 children (aged 12-16 years) across Australia. Photo elicitation techniques were used to prompt discussion about how the climate crisis impacted their futures, their ability to influence climate decisions, and strategies and mechanisms to engage them in climate decision making. A reflexive approach to thematic analysis was used to construct three themes from data. Images were analysed for ascribed meanings. RESULTS: First, participants stated that they and future generations will inherit the climate crisis from older generations, specifically decision makers. Second, they described a need to address a range of age-related barriers that limit children and young people's engagement in climate decision making, including perceptions about their capabilities. Finally, they discussed strategies and mechanisms to embed children and young people's perspectives within climate decision making, including at civic and political levels. CONCLUSIONS: Children and young people have the right to be involved in decisions made about the climate crisis which significantly impact their futures, including their health and wellbeing. They argue for structural changes to embed their views in climate decision making, and describe a range of engagement strategies and mechanisms to structure their perspectives and knowledge with decision making processes. Furthermore, genuine involvement of children and young people in climate discussions must avoid youthwashing and tokenistic participation. The public health community can help address barriers to youth participation in climate action and should actively engage and collaborate with children and young people to facilitate their political and democratic influence over the climate crisis. This involves making room and creating an accessible seat at the decision making table to ensure their perspectives are embedded in climate decisions.

Children, young people and the Commercial Determinants of Health.

The commercial determinants of health (CDoH) have a significant impact on the health and well-being of children and young people (subsequently referred to as young people). While most research has focused on the influence of harmful industry marketing on young people, more recent CDoH frameworks have emphasized that a range of commercial systems and practices may influence health and well-being. Focusing on the impact of traditional and digital media, contemporary marketing strategies and corporate production and consumption processes, the following article outlines the impact of the CDoH on the health and wellbeing of young people. The article also provides evidence about how young people conceptualize the impact of corporate actors on health, and their involvement in advocacy strategies to respond. The article recommends that when collaborating with young people to understand the impacts of and responses to the CDoH, we should seek to diversify investigations towards the impact of a range of corporate tactics, systems and structures, rather than simply focusing on the impacts of advertising. This should include considering areas and priorities that young people identify as areas for action and understanding why some young people are more vulnerable to commercial tactics than others. Youth are powerful allies in responding to the CDoH. Public health and health promotion stakeholders could do more to champion the voices of young people and allow them to be active participants in the decisions that are made about harmful commercial practices and health.

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.

Ghosts in the labour market: perceived health implications of informal labour in Australia.

Employment conditions are important social and commercial determinants of health. Informal employment-also known as 'cash-in-hand' and 'undeclared' work-is a discrete employment condition that has salience around the world. Fuelled by neoliberal ideology, informal employment has become increasingly common in high-income countries. Public health research concerning the health of informal workers comes largely from low- and middle-income countries, where the phenomenon is more visible. There has been little research on the health effects of informal employment in high-income countries including Australia. Twenty-nine workers aged 18 years and older, who were undertaking informal work activities, were recruited using social media and an online marketplace in Tarndanya (Adelaide-Kaurna Country), Australia. Qualitative narrative data, demographic profiles, and physical and mental health scores were collected. Most informal workers reported unfair and indecent employment conditions including job insecurity, low income, coercion, and lack of respect and dignity at work, and were often exposed to unsafe and unhealthy work environments. Workplace injuries and exposure to occupational hazards were common; and Physical and Mental Component Scores were poorer among informal workers when compared to the population of South Australia as a whole. With informal employment in Australia described as part of a 'significant, pervasive, damaging and growing' problem, there is a need for a health promotion lens over industrial relations policies in the interest of creating equitable access to fair and decent work.

A Critical Understanding of Inclusion in Oral Microbiome Research through the Lens of Racial Capitalism.

There are important calls for greater inclusion of Indigenous and racialised communities in oral microbiome research. This paper uses the concept of racial capitalism (the extractive continuity of colonialism) to critically examine this inclusion agenda. Racial capitalism explicitly links capitalist exploitations with wider social oppressions e.g., racisms, sexism, ableism. It is not confined to the commercial sector but pervades white institutions, including universities. By using the lens of racial capitalism, we find inclusion agendas allow white institutions to extract social and economic value from relations of race. Racially inclusive research is perceived as a social good, therefore, it attracts funding. Knowledge and treatments developed from research create immense value for universities and pharmaceutical companies with limited benefits for the communities themselves. Moreover, microbiome research tends to drift from conceptualisations that recognise it as something that is shaped by the social, including racisms, to one that is determined genetically and biologically. This location of problems within racialised bodies reinforces racial oppressions and allows companies to further profit from raciality. Inclusion in oral microbiome research must consider ways to mitigate racial capitalism. Researchers can be less extractive by using an anti-racism praxis framework. This includes working with communities to co-design studies, create safer spaces, giving marginalised communities the power to set and frame agendas, sharing research knowledges and treatments through accessible knowledge distributions, open publications, and open health technologies. Most importantly, inclusion agendas must not displace ambitions of the deeper anti-oppression social reforms needed to tackle health inequalities and create meaningful inclusion.

National survey of infant feeding bottles in Germany: Their characteristics and marketing claims.

Bottles and teats are ubiquitously used for feeding infants and young children. Yet there are limited empirical studies on the scope of infant feeding bottles, their attributes, or their marketing claims. We report the first comprehensive survey on infant feeding bottles and teats in Germany. We aimed to explore the extent of bottles and teats available in Germany, describe their physical attributes and analyze their marketing claims. A cross-sectional survey of German bottle and teat manufacturer websites was conducted between June and November 2022. Product attributes are presented with descriptive statistics and photographs. Marketing claims are summarized in a descriptive content analysis. We identified 41 brands encompassing 447 unique products (226 bottles, 221 teats). The majority of bottles were plastic (147, 65%) or glass (64, 28%), and the majority of teats were silicone (188, 85%). Most brands (38, 93%) promoted products using one or more inappropriate marketing claims, including equivalency to breastfeeding (29, 73%), idealization through technical or medical descriptions (23, 58%), claims on disease prevention (31, 78%), references to naturalness (29, 73%), infant autonomy (10, 25%), and endorsements from parents (10, 25%) or health professionals (11, 28%). The majority of bottles and teats available in Germany appear to be marketed inappropriately and hold the potential to undermine public health recommendations on infant and young child feeding. Therefore, we recommend Germany strengthens legislation on the marketing of bottles and teats in accordance with the International Code of Marketing of Breastmilk Substitutes.

Framing Commercial Determinants of Health: An Assessment of Potential for Guiding More Effective Responses to the Public Health Crises of the 21st Century.

Policy Points The commercial determinants of health (CDH) framework can inform public health policy, practice, and research in ways that contribute to overcoming the world's most serious public health challenges. By documenting the pathways by which commercial actors shape health, the CDH framework can provide a unifying focus for collective action to prevent and ameliorate global health crises. To realize these opportunities, CDH proponents need to find synergies in the multiple emerging streams of research, practice, and advocacy and create a body of scientific evidence, methodologies, and ideas that can inform a public health practice for the 21st century.

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.

A proposal for systematic monitoring of the commercial determinants of health: a pilot study assessing the feasibility of monitoring lobbying and political donations in Australia.

BACKGROUND: The commercial determinants of health include a range of practices to promote business interests, often at the expense of public health. Corporate political practices, such as lobbying and campaign donations, are used to influence policy makers and foster a political and regulatory environment conducive to business interests. Despite recognition of their public health importance, thus far there are relatively few efforts to systematically monitor commercial political practices. METHODS: A pilot study was conducted to explore the feasibility of systematically monitoring two political practices - lobbying and political contributions - for 'harmful industries' (alcohol, gambling, ultra-processed food and tobacco industries) in Australia. Potential data sources were reviewed to compare data availability and detail. Two publicly available datasets were selected for the pilot: ministerial diaries for New South Wales and annual donor filings from the Australian Electoral Commission. Google Data Studio was used to analyse and visualise findings.  RESULTS: The pilot study resulted in the creation of several interactive charts and dashboards that supported analysis and interrogation of the data. These charts helped to easily convey the volume of lobbying and political donations, as well as changes over time. For example, we found that between July 2014 and December 2020, NSW ministers had 20,607 meetings, of which 634 meetings were with harmful industries. And between 1998 and 2020, a total of $576,519,472 disclosed donations were made to political parties and other entities, of which $35,823,937 were from harmful industries. CONCLUSIONS: Opportunities to develop a program to monitor commercial political practices face several challenges including access barriers arising from poor availability and detail of data, technical barriers arising from the format of data disclosures and coding challenges arising from the diverse nature of the commercial sector. Despite these challenges, our pilot study demonstrates the potential to implement a monitoring program and to expand its scope to other commercial determinants of health.

The influence of share buybacks on ill-health and health inequity: an exploratory analysis using a socio-ecological determinants of health lens.

INTRODUCTION: Share buybacks, when a corporation buys back its own shares, are recognised as having potentially harmful impacts on society. This includes by contributing to economic inequalities, and by impeding investments with the potential to protect and promote the welfare of various stakeholders. Share buybacks, however, have received minimal analytical attention in the public health literature. This paper aimed to explore the potential influence of share buybacks on population health and health inequity using a socio-ecological determinants of health lens. METHODS: We conducted a descriptive analysis of share buybacks made by corporations listed on United States (US) stock exchanges between 1982 and 2021, using quantitative data sourced from Compustat. We examined annual trends in share buyback expenditure, including comparisons to dividend, net income, capital expenditure, and research and development expenditure data. We then purposively sampled a set of corporations to provide illustrative examples of how share buybacks potentially influence key socio-ecological determinants of health. The examples were: i) three COVID-19 vaccine manufacturers; ii) five of the world's largest fossil fuel corporations; and iii) US car manufacturer General Motors. For these, we conducted an analysis of data from Compustat, company reports and grey literature materials, focusing on key sources of profits and their allocation to share buybacks and particular investments. RESULTS: US-listed corporations spent an estimated US$9.2 trillion in real terms on share buybacks between 2012 and 2021 (nearly 12 times more than from 1982 to 1991). The contribution of share buybacks to total shareholder 'returns' increased from 11% in 1982 to 55% in 2021, with expenditure on shareholder returns increasing considerably relative to capital, research and development expenditure over this period. The three examples illustrated how some corporations have prioritised the short-term financial interests of their shareholders, including via implementing large share buyback programs, over investments with considerable potential to protect and promote the public's health. CONCLUSION: The potentially substantial impacts of share buybacks on health warrant increased research and policy attention. Arguably, more must be done to regulate share buybacks as part of efforts to address the corporate drivers of ill-health and inequity.

Situating commercial determinants of health in their historical context: a qualitative study of sugar-sweetened beverages in Jamaica.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of mortality across the Caribbean and similar regions. Structural determinants include a marked increase in the dependency on food imports, and the proliferation of processed foods, including sugar-sweetened beverages (SSBs). We focused on Jamaica as a case study and the health challenge of SSBs, and situated contemporary actions, experiences and policies within their historical context to investigate underlying drivers of commercial determinants of health and attempts to counter them. We asked: how can a historical perspective of the drivers of high level SSB consumption in Jamaica contribute to an enhanced understanding of the context of public health policies aimed at reducing their intake? METHODS: An ethnographic approach with remote data collection included online semi-structured interviews and workshops with 22 local experts and practitioners of health, agriculture and nutrition in Jamaica and attending relevant regional public webinars on SSBs and NCD action in the Caribbean. Our analysis was situated within a review of historical studies of Caribbean food economies with focus on the twentieth century. Jamaican and UK-based researchers collected and ethnographically analysed the data, and discussed findings with the wider transdisciplinary team. RESULTS: We emphasise three key areas in which historical events have shaped contextual factors of SSB consumption. Trade privileged sugar as a cash crop over food production during Jamaica's long colonial history, and trade deregulation since the 1980s through structural adjustment opened markets to transnational companies. These changes increased Jamaican receptiveness to the mass advertisement and marketing of these companies, whilst long-standing power imbalances hampered taxation and regulation in contemporary public health actions. Civil society efforts were important for promoting structural changes to curb overconsumption of SSBs and decentring such entrenched power relations. CONCLUSION: The contemporary challenge of SSBs in Jamaica is a poignant case study of commercial determinants of health and the important context of global market-driven economies and the involvement of private sector interests in public health policies and governance. Historically contextualising these determinants is paramount to making sense of the sugar ecology in Jamaica today and can help elucidate entrenched power dynamics and their key actors.

A framework of NGO inside and outside strategies in the commercial determinants of health: findings from a narrative review.

BACKGROUND: Public health scholarship has uncovered a wide range of strategies used by industry actors to promote their products and influence government regulation. Less is known about the strategies used by non-government organisations to attempt to influence commercial practices. This narrative review applies a political science typology to identify a suite of 'inside' and 'outside' strategies used by NGOs to attempt to influence the commercial determinants of health. METHODS: We conducted a systematic search in Web of Science, ProQuest and Scopus. Articles were eligible for inclusion if they comprised an empirical study, explicitly sought to examine 'NGOs', were in English, and identified at least one NGO strategy aimed at commercial and/or government policy and practice. RESULTS: One hundred forty-four studies met the inclusion criteria. Eight industry sectors were identified: extractive, tobacco, food, alcohol, pharmaceuticals, weapons, textiles and asbestos, and a small number of general studies. We identified 18 types of NGO strategies, categorised according to the target (i.e. commercial actor or government actor) and type of interaction with the target (i.e. inside or outside). Of these, five NGO 'inside' strategies targeted commercial actors directly: 1) participation in partnerships and multistakeholder initiatives; 2) private meetings and roundtables; 3) engaging with company AGMs and shareholders; 4) collaborations other than partnerships; and 5) litigation. 'Outside' strategies targeting commercial actors through the mobilisation of public opinion included 1) monitoring and reporting; 2) protests at industry sites; 3) boycotts; 4) directly engaging the public; and 5) creative use of alternative spaces. Four NGO 'inside' strategies directly targeting government actors included: 1) lobbying; 2) drafting legislation, policies and standards; 3) providing technical support and training; and 4) litigation. NGO 'outside' strategies targeting government included 1) protests and public campaigns; 2) monitoring and reporting; 3) forum shifting; and 4) proposing and initiating alternative solutions. We identified three types of NGO impact: substantive, procedural, and normative. CONCLUSION: The analysis presents a matrix of NGO strategies used to target commercial and government actors across a range of industry sectors. This framework can be used to guide examination of which NGO strategies are effective and appropriate, and which conditions enable NGO influence.