Brexit, trade and the governance of non-communicable diseases: a research agenda.

BACKGROUND: The UK's post-Brexit trade strategy has potentially important implications for population health and equity. In particular, it will impact on the structural risk factors for non-communicable diseases (NCDs), including the consumption of health-harming commodities such as tobacco, alcohol and ultra-processed food and beverages. This article catalogues recent developments in UK trade policy. It then presents a narrative review of the existing research literature on trade and health and previous, prospective studies on the health impacts of Brexit. In so doing it identifies key questions and foci for a future research agenda on the implications of UK's emerging trade regime for NCD prevention. MAIN TEXT: We identify five key areas for future research. (1) Additional scholarship to document the health effects of key trade agreements negotiated by the UK government; (2) The implications of these agreements for policy-making to address health impacts, including the potential for legal challenges under dispute settlement mechanisms; (3) The strategic objectives being pursued by the UK government and the extent to which they support or undermine public health; (4) The process of trade policy-making, its openness to public health interests and actors and the impact of the political and ideological legacy of Brexit on outcomes; (5) The impact of the UK's post-Brexit trade policy on partner countries and blocs and their cumulative impact on the global trade regime. CONCLUSIONS: Further research is urgently need to understand the ways in which the UK's post-Brexit trade strategy will impact on NCDs and policy responses to address these, including the openness of the trade policy architecture to health issues. The outcomes of this process will have wider systemic effects on the global trade regime with implications for health. Researchers must be cognizant of the ideological components of the policy debate which have been absent from previous analysis of Brexit, trade and health.

A multi-level, multi-jurisdictional strategy: Transnational tobacco companies' attempts to obstruct tobacco packaging restrictions.

Despite the extensive literature on the tobacco industry, there has been little attempt to study how transnational tobacco companies (TTCs) coordinate their political activities globally, or to theorise TTC strategies within the context of global governance structures and policy processes. This article draws on three concepts from political science - policy transfer, multi-level governance and venue shifting - to analyse TTCs' integrated, global strategies to oppose augmented packaging requirements across multiple jurisdictions. Following Uruguay's introduction of extended labelling requirements, Australia became the first country in the world to require tobacco products to be sold in standardised ('plain') packaging in 2012. Governments in the European Union, including in the United Kingdom and Ireland, adopted similar laws, with other member states due to follow. TTCs vehemently opposed these measures and developed coordinated, global strategies to oppose their implementation, exploiting the complexity of contemporary global governance arrangements. These included a series of legal challenges in various jurisdictions, alongside political lobbying and public relations campaigns. This article draws on analysis of public documents and 32 semi-structured interviews with key policy actors. It finds that TTCs developed coordinated and highly integrated strategies to oppose packaging restrictions across multiple jurisdictions and levels of governance.

European Union implementation of Article 5.3 of the Framework Convention on Tobacco Control.

BACKGROUND: Article 5.3 of the World Health Organization's Framework Convention on Tobacco Control (FCTC) requires Parties to the agreement to take proactive measures to protect health policy from the vested interests of the tobacco industry. Parties to the FCTC are required to submit periodic reports to the Convention Secretariat on the efforts undertaken to implement it. Previous analyses of national compliance with the FCTC suggest that Article 5.3 implementation is piecemeal and insufficient in many contexts, with governments relying on general transparency and other existing policies for the purpose of Article 5.3 implementation. No in-depth study of Article 5.3 compliance within the European Union (EU) - a signatory to the Convention - has been undertaken. This study seeks to assess the extent of Article 5.3 compliance in European Union institutions, through an analysis of the mechanisms in place in the European Commission and European Parliament. It analyses EU documents relevant to Article 5.3 compliance, as well as semi-structured interviews with policy actors in the EU institutions and the field of tobacco control. RESULTS: As with many national governments, Article 5.3 compliance within EU institutions is partial and incomplete. Much of the compliance activity cited in EU reports is derived from general codes of conduct for EU staff and the Juncker Commission's transparency agenda. Interview respondents reveal widespread lack of knowledge about the existence of the FCTC and Article 5.3 amongst key policy actors across the institutions. Within the Commission policies vary greatly between Directorates General, and issues surrounding the conceptualisation of the role of Members of the European Parliament affect implementation in that context. While there is growing awareness of the issue in both the Commission and the Parliament, in large part as a result of the experience of lobbying over the Tobacco Products Directive, there remains considerable resistance in both institutions to further substantive action to implement Article 5.3. CONCLUSIONS: We recommend that a binding and comprehensive policy and code of conduct, specifically designed for the implementation of Article 5.3 and based on the World Health Organization's guidelines, be created to cover the activities of all employees of all EU institutions. Crucially, such guidelines would need to deal explicitly with third parties acting for the tobacco industry.

Reassessing policy paradigms: A comparison of the global tobacco and alcohol industries.

Tobacco is widely considered to be a uniquely harmful product for human health. Since the mid-1990s, the strategies of transnational tobacco corporations to undermine effective tobacco control policy has been extensively documented through internal industry documents. Consequently, the sale, use and marketing of tobacco products are subject to extensive regulation and formal measures to exclude the industry from policy-making have been adopted in the Framework Convention on Tobacco Control. In contrast to tobacco, alcohol is subject to less stringent forms of regulation, and the alcohol industry continues to play a central role in policy-making in many countries and at the global level. This article examines whether there is a sufficient rationale for such different regulatory approaches, through a comparative analysis of the political economy of the tobacco and alcohol industries including the structure of the industries, and the market and political strategies they pursue. Despite some important differences, the extensive similarities which exist between the tobacco and alcohol industries in terms of market structure and strategy, and political strategy, call into question the rationale for both the relatively weak regulatory approach taken towards alcohol, and the continued participation of alcohol corporations in policy-making processes.

Graduated Sovereignty and Global Governance Gaps: Special Economic Zones and the Illicit Trade In Tobacco Products.

Illicit trade in tobacco products has been a significant problem globally for many years. It allows cigarettes to be sold far below their legal price and thus contributes to higher consumption, morbidity and mortality, and deprives state treasuries of a substantial amount of revenue. This article identifies special economic zones (SEZs), particularly free trade zones, as a key conduit for this illicit trade. The development of SEZs as weak points in the global governance architecture is explained with reference to the concept of 'graduated sovereignty', whereby the uniform management of territory by modern states has given way to a more spatially selective form of territorial governance, in which some slices of territory are more fully integrated into the world economy than others via various forms of differential regulation. Attempts to comprehensively (re)regulate SEZs, in the face of growing evidence of the dysfunctionalities that they can engender, have so far been unsuccessful. It is concluded that the neo-liberal global economy has facilitated a regulatory 'race to the bottom', a problem that can only ultimately be overcome by international negotiation and agreement.

Controlling corporate influence in health policy making? An assessment of the implementation of article 5.3 of the World Health Organization framework convention on tobacco control.

BACKGROUND: The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) stands to significantly reduce tobacco-related mortality by accelerating the introduction of evidence-based tobacco control measures. However, the extent to which States Parties have implemented the Convention varies considerably. Article 5.3 of the FCTC, is intended to insulate policy-making from the tobacco industry's political influence, and aims to address barriers to strong implementation of the Convention associated with tobacco industry political activity. This paper quantitatively assesses implementation of Article 5.3's Guidelines for Implementation, evaluates the strength of Parties' efforts to implement specific recommendations, and explores how different approaches to implementation expose the policy process to continuing industry influence. METHODS: We cross-referenced a broad range of documentary data (including FCTC Party reports and World Bank data on the governance of conflicts of interest in public administration) against Article 5.3 implementation guidelines (n = 24) for 155 Parties, and performed an in-depth thematic analysis to examine the strength of implementation for specific recommendations. RESULTS: Across all Parties, 16% of guideline recommendations reviewed have been implemented. Eighty-three percent of Parties that have taken some action under Article 5.3 have introduced less than a third of the guidelines. Most compliance with the guidelines is achieved through pre-existing policy instruments introduced independently of the FCTC, which rarely cover all relevant policy actors and fall short of the guideline recommendations. Measures introduced in response to the FCTC are typically restricted to health ministries and not explicit about third parties acting on behalf of the industry. Parties systematically overlook recommendations that facilitate industry monitoring. CONCLUSION: Highly selective and incomplete implementation of specific guideline recommendations facilitates extensive ongoing opportunities for industry policy influence. Stronger commitment to implementation is required to ensure consistently strong compliance with the FCTC internationally.

KT&G: From Korean monopoly to 'a global name in the tobacco industry'.

Until the late 1980s, the former South Korean tobacco monopoly KT&G was focused on the protected domestic market. The opening of the market to foreign competition, under pressure from the U.S. Trade Representative, led to a steady erosion of market share over the next 10 years. Drawing on company documents and industry sources, this paper examines the adaptation of KT&G to the globalization of the South Korean tobacco industry since the 1990s. It is argued that KT&G has shifted from a domestic monopoly to an outward-looking, globally oriented business in response to the influx of transnational tobacco companies. Like other high-income countries, South Korea has also seen a decline in smoking prevalence as stronger tobacco control measures have been adopted. Faced with a shrinking domestic market, KT&G initially focused on exporting Korean-manufactured cigarettes. Since the mid-2000s, a broader global business strategy has been adopted including the building of overseas manufacturing facilities, establishing strategic partnerships and acquiring foreign companies. Trends in KT&G sales suggest an aspiring transnational tobacco company poised to become a major player in the global tobacco market. This article is part of the special issue 'The emergence of Asian tobacco companies: Implications for global health governance'.

A Prospective Randomized Clinical Trial in Total Hip Arthroplasty-Comparing Early Results Between the Direct Anterior Approach and the Posterior Approach.

BACKGROUND: We report a prospective randomized study comparing early clinical results between the direct anterior approach (DAA) and posterior approach (PA) in primary hip arthroplasty. METHODS: Surgeries were performed by 2 senior hip arthroplasty surgeons. Seventy-two patients with complete data were assessed preoperatively 2, 6, and 12 weeks postoperatively. The primary outcomes were the Western Ontario McMasters Arthritis Index and Oxford Hip Scores. Secondary outcome measures included the EuroQoL, 10-meter walk test, and clinical and radiographic parameters. RESULTS: Data analyses showed no difference between DAA (n = 35) and PA (n = 37) groups when comparing total scores for primary outcomes. No significant differences were observed for 10-meter walk test, EuroQoL, and radiographic analyses. Subgroup analysis for surgeon 1 identified that the DAA group had shorter acute hospital stay, less postoperative opiate requirements, and smaller wounds. However, this was offset by increased operative time, higher intraoperative blood loss, and weaker hip flexion at 2 and 6 weeks. Subgroup analysis of items on the Western Ontario McMasters Arthritis Index and Oxford Hip Score identified that hip flexion activity favored the DAA group up to 6 weeks postoperatively. There was an 83% incidence of lateral cutaneous nerve of thigh neuropraxia at the 12-week mark in the DAA group. No neuropraxias occurred in the PA group. One dislocation occurred in each group. A single patient from the DAA group required reoperation for leg-length discrepancy. CONCLUSION: DAA total hip arthroplasty (THA) has comparable results with PA THA. Choice of surgical approach for THA should be based on patient factors, surgeon preference, and experience.

A Corporate Veto on Health Policy? Global Constitutionalism and Investor-State Dispute Settlement.

The importance of trade and investment agreements for health is now widely acknowledged in the literature, with much attention now focused on the impact of investor-state dispute settlement (ISDS) mechanisms. However, much of the analysis of such agreements in the health field remains largely descriptive. We theorize the implications of ISDS mechanisms for health policy by integrating the concept of global constitutionalism with veto point theory. It is argued that attempts to constitutionalize investment law, through a proliferation of International Investment Agreements (IIAs), has created a series of new veto points at which corporations may seek to block new policies aimed at protecting or enhancing public health. The multiplicity of new veto points in this global "spaghetti bowl" of IIAs creates opportunities for corporations to venue shop; that is, to exploit the agreements, and associated veto points, through which they are most likely to succeed in blocking or deterring new regulation. These concepts are illustrated with reference to two case studies of investor-state disputes involving a transnational tobacco company, but the implications of the analysis are of equal relevance for a range of other industries and health issues.

Tobacco control and the World Trade Organization: mapping member states' positions after the framework convention on tobacco control.

OBJECTIVE: To note the frequency of discussions and disputes about tobacco control measures at the World Trade Organization (WTO) before and after the coming into force of the Framework Convention on Tobacco Control (FCTC). To review trends or patterns in the positions taken by members of the WTO with respect to tobacco control measures. To discuss possible explanations for these observed trends/patterns. METHODS: We gathered data on tobacco-related disputes in the WTO since its establishment in 1995 and its forerunner, the General Agreement on Tariffs and Trade (GATT), prior-FCTC and post-FCTC. We also looked at debates on tobacco control measures within the WTO more broadly. To this end, we classified and coded the positions of WTO member states during discussions on tobacco control and the FCTC, from 1995 until 2013, within the Technical Barriers to Trade (TBT) Committee and the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Council. RESULTS: There is a growing interest within the WTO for tobacco-related issues and opposition to tobacco control measures is moving away from high-income countries towards low(er) income countries. CONCLUSIONS: The growing prominence of tobacco issues in the WTO can be attributed at least in part to the fact that during the past decade tobacco firms have been marginalised from the domestic policy-making process in many countries, which has forced them to look for other ways and forums to influence decision-making. Furthermore, the finding that almost all recent opposition within the WTO to stronger tobacco regulations came from developing countries is consistent with a relative shift of transnational tobacco companies' lobbying efforts from developed to developing countries.

Tobacco industry globalization and global health governance: towards an interdisciplinary research agenda.

Shifting patterns of tobacco production and consumption, and the resultant disease burden worldwide since the late twentieth century, prompted efforts to strengthen global health governance through adoption of the Framework Convention on Tobacco Control. While the treaty is rightfully considered an important achievement, to address a neglected public health issue through collective action, evidence suggests that tobacco industry globalization continues apace. In this article, we provide a systematic review of the public health literature and reveal definitional and measurement imprecision, ahistorical timeframes, transnational tobacco companies and the state as the primary units and levels of analysis, and a strong emphasis on agency as opposed to structural power. Drawing on the study of globalization in international political economy and business studies, we identify opportunities to expand analysis along each of these dimensions. We conclude that this expanded and interdisciplinary research agenda provides the potential for fuller understanding of the dual and dynamic relationship between the tobacco industry and globalization. Deeper analysis of how the industry has adapted to globalization over time, as well as how the industry has influenced the nature and trajectory of globalization, is essential for building effective global governance responses. This article is published as part of a thematic collection dedicated to global governance.

Creating demand for foreign brands in a 'home run' market: tobacco company tactics in South Korea following market liberalisation.

OBJECTIVE: To analyse the tactics transnational tobacco companies (TTCs) used to increase market share in South Korea after market liberalisation in 1988, and the subsequent impact of TTCs' activities on the domestic industry and ultimately public health. METHODS: Internal tobacco industry documents were searched iteratively and analysed by keyword related to strategies for increasing market share in Korea since liberalisation. RESULTS: Following market liberalisation, TTCs faced entrenched cultural and institutional barriers in Korea which hindered increased sales of cigarette imports. TTCs identified population groups more favourably inclined towards imported brands, developed new distribution channels and used promotional activities targeting these groups. The growth in market share by TTCs suggests that these activities were successful at challenging the Korea Tobacco & Ginseng Corporation (KTGC) monopoly. In response, KTGC shifted to a proactive marketing approach and adopted strategies similar to TTCs. This, in turn, made the Korean market highly competitive. Findings show that, after market liberalisation, there was an upward trend in cigarette consumption and smoking prevalence among the targeted population groups, notably youth and young women. CONCLUSIONS: Governments engaging in trade negotiations that may lead to the opening of domestic tobacco markets need a fuller understanding of previous industry activities for expanding into emerging markets as well as how the domestic industry can change accordingly. To protect public health, the adoption of comprehensive tobacco control measures, guided by WHO Framework Convention on Tobacco Control, are needed as part of such negotiations.

Vested interests in addiction research and policy. The challenge corporate lobbying poses to reducing society's alcohol problems: insights from UK evidence on minimum unit pricing.

BACKGROUND: There has been insufficient research attention to alcohol industry methods of influencing public policies. With the exception of the tobacco industry, there have been few studies of the impact of corporate lobbying on public health policymaking more broadly. METHODS: We summarize here findings from documentary analyses and interview studies in an integrative review of corporate efforts to influence UK policy on minimum unit pricing (MUP) of alcohol 2007-10. RESULTS: Alcohol producers and retailers adopted a long-term, relationship-building approach to policy influence, in which personal contacts with key policymakers were established and nurtured, including when they were not in government. The alcohol industry was successful in achieving access to UK policymakers at the highest levels of government and at all stages of the policy process. Within the United Kingdom, political devolution and the formation for the first time of a Scottish National Party (SNP) government disrupted the existing long-term strategy of alcohol industry actors and created the conditions for evidence-based policy innovations such as MUP. CONCLUSIONS: Comparisons between policy communities within the United Kingdom and elsewhere are useful to the understanding of how different policy environments are amenable to influence through lobbying. Greater transparency in how policy is made is likely to lead to more effective alcohol and other public policies globally by constraining the influence of vested interests.

The Limits of Corporate Social Responsibility: Techniques of Neutralization, Stakeholder Management and Political CSR.

Since scholarly interest in corporate social responsibility (CSR) has primarily focused on the synergies between social and economic performance, our understanding of how (and the conditions under which) companies use CSR to produce policy outcomes that work against public welfare has remained comparatively under-developed. In particular, little is known about how corporate decision-makers privately reconcile the conflicts between public and private interests, even though this is likely to be relevant to understanding the limitations of CSR as a means of aligning business activity with the broader public interest. This study addresses this issue using internal tobacco industry documents to explore British-American Tobacco's (BAT) thinking on CSR and its effects on the company's CSR Programme. The article presents a three-stage model of CSR development, based on Sykes and Matza's theory of techniques of neutralization, which links together: how BAT managers made sense of the company's declining political authority in the mid-1990s; how they subsequently justified the use of CSR as a tool of stakeholder management aimed at diffusing the political impact of public health advocates by breaking up political constituencies working towards evidence-based tobacco regulation; and how CSR works ideologically to shape stakeholders' perceptions of the relative merits of competing approaches to tobacco control. Our analysis has three implications for research and practice. First, it underlines the importance of approaching corporate managers' public comments on CSR critically and situating them in their economic, political and historical contexts. Second, it illustrates the importance of focusing on the political aims and effects of CSR. Third, by showing how CSR practices are used to stymie evidence-based government regulation, the article underlines the importance of highlighting and developing matrices to assess the negative social impacts of CSR.

Industry use of evidence to influence alcohol policy: a case study of submissions to the 2008 Scottish government consultation.

Jim McCambridge and colleagues analyze industry submissions to a Scottish Government consultation on whole-population approaches to alcohol policy.

Are transnational tobacco companies' market access strategies linked to economic development models? A case study of South Korea.

Transnational tobacco companies (TTCs) have used varied strategies to access previously closed markets. Using TTCs' efforts to enter the South Korean market from the late 1980s as a case study, this article asks whether there are common patterns in these strategies that relate to the broader economic development models adopted by targeted countries. An analytical review of the existing literature on TTCs' efforts to access emerging markets was conducted to develop hypotheses relating TTCs' strategies to countries' economic development models. A case study of Korea was then undertaken based on analysis of internal tobacco industry documents. Findings were consistent with the hypothesis that TTCs' strategies in Korea were linked to Korea's export-oriented economic development model and its hostile attitude towards foreign investment. A fuller understanding of TTCs' strategies for expansion globally can be derived by locating them within the economic development models of specific countries or regions. Of foremost importance is the need for governments to carefully balance economic and public health policies when considering liberalisation.

Alcohol industry influence on UK alcohol policy: A new research agenda for public health.

The British government has been criticised for according industry interests too much weight in alcohol policy-making. Consequently, it has been argued that alcohol strategy in the UK is built around policies for which the evidence base is weak. This has clear implications for public health. The purpose of this commentary is to map recent developments in UK alcohol policy and related debates within the alcohol policy literature, thus laying the foundations for a systematic examination of the influence of the alcohol industry on alcohol policy. It highlights the changing structure of the industry and summarises what is known about the positions and strategies of industry actors towards alcohol policy. In so doing, it aims to contribute not just to debates about alcohol policy, but to a broader understanding of health policy processes and the relationships between government and other stakeholders. It advances a new research agenda focused on the role of corporate actors in the field of alcohol policy and public health more broadly.

Cleavages and co-operation in the UK alcohol industry: a qualitative study.

BACKGROUND: It is widely believed that corporate actors exert substantial influence on the making of public health policy, including in the alcohol field. However, the industry is far from being monolithic, comprising a range of producers and retailers with varying and diverse interests. With a focus on contemporary debates concerning the minimum pricing of alcohol in the UK, this study examined the differing interests of actors within the alcohol industry, the cleavages which emerged between them on this issue and how this impacted on their ability to organise themselves collectively to influence the policy process. We conducted 35 semi-structured interviews between June and November 2010 with respondents from all sectors of the industry as well as a range of non-industry actors who had knowledge of the alcohol policy process, including former Ministers, Members of the UK Parliament and the Scottish Parliament, civil servants, members of civil society organisations and professionals. METHODS: The paper draws on an analysis of publicly available documents and 35 semi-structured interviews with respondents from the alcohol industry (on- and off-trade including retailers, producers of wines, spirits and beers and trade associations) and a range of non-industry actors with knowledge of the alcohol policy process (including former Ministers, Members of Parliament and of the Scottish Parliament, civil servants, members of civil society organisations and professional groups). Interviews were recorded, transcribed and analysed using Nvivo qualitative analysis software. Processes of triangulation between data sources and different types of respondent sought to ensure we gained as accurate a picture as possible of industry participation in the policy process. RESULTS: Divergences of interest were evident between producers and retailers and within the retail sector between the on and off trade. Divisions within the alcohol industry, however, existed not only between these sectors, but within them. Cleavages were evident within the producer sector between different product categories and within the retail sector between different types of off-trade retailers. However, trade associations were particularly important in providing a means by which the entire industry, or broad sectors within it, could speak with a single voice, despite the limitations on this. There was also evidence of ad-hoc cooperation on specific issues, which resulted from both formal and informal contacts between industry actors. CONCLUSIONS: Alcohol industry corporations and trade associations collaborate with one another effectively where there are shared interests, allowing the best placed bodies to lead on a given issue. Thus, whilst industry actors may be deeply divided on certain issues they are able to coordinate their positions on occasions where there are clear advantages in so doing. Health policymakers may benefit from an awareness of the multiplicity of interests within the industry and the ways that these may shape collective lobbying positions.

Resolution of parenteral nutrition-associated jaundice on changing from a soybean oil emulsion to a complex mixed-lipid emulsion.

BACKGROUND AND OBJECTIVE: Resolution of parenteral nutrition (PN)-associated jaundice has been reported in children given a reduced dose of intravenous fat using a fish oil-derived lipid emulsion. The aim of the present study was to examine the effect on PN-associated jaundice of changing from a soybean oil-derived lipid to a mixed lipid emulsion derived from soybean, coconut, olive, and fish oils without reducing the total amount of lipid given. METHODS: Retrospective cohort comparison examining serum bilirubin during 6 months in children with PN-associated jaundice who changed to SMOFlipid (n=8) or remained on Intralipid (n=9). RESULTS: At entry, both groups received most of their energy as PN (SMOFlipid 81.5%, range 65.5-100 vs Intralipid 92.2%, range 60.3-100; P=0.37). After 6 months, both tolerated increased enteral feeding but still received large proportions of their energy as PN (SMOFlipid 68.4%, range 36.6-100 vs Intralipid 50%, range 37.6-76; P=0.15). The median bilirubin at the outset was 143 µmol/L (range 71-275) in the SMOFlipid group and 91 µmol/L (range 78-176) in the Intralipid group. After 6 months, 5 of 8 children in the SMOFlipid and 2 of 9 children in the Intralipid group had total resolution of jaundice. The median bilirubin fell by 99 µmol/L in the SMOFlipid group but increased by 79 µmol/L in the Intralipid group (P=0.02). CONCLUSIONS: SMOFlipid may have important protective properties for the liver and may constitute a significant advance in PN formulation. Randomised trials are needed to study the efficacy of SMOFlipid in preventing PN liver disease.