Commentary on Casswell (2013): The commercial determinants of health

Abstract

Sally Casswell's paper 1 highlights important differences between the ways in which the alcohol industry and tobacco industry are able to operate to promote their products and as a result limit government action aimed at reducing the harm that these products cause. Those of us in the field of tobacco research might wish to draw attention to the fact that in much of the world the tobacco industry still has considerable influence on government policy through either connivance with individuals within government by aggressive lobbying, or by litigation against governments that seek to implement policies which might reduce the industry's prodigious profits 2. Nevertheless, Casswell is correct in asserting that the alcohol industry has an easier time of it; so does the food industry and the gambling industry. So, too, for that matter, does the oil industry, car manufacturers, diamond mining companies—and indeed, all those industries that provide goods or services that many people want, or can be induced to want. Unfortunately, the production and consumption of all these goods comes at a huge cost, including global health and climate change 3. Michael Marmot has drawn attention to the ‘social determinants of health’. He and others have pointed out that a substantial proportion of the variance in life expectancy is attributable to social position 4. This goes beyond poverty and extends across the whole social spectrum although, clearly, poverty plays an important role. Casswell's paper should serve to remind us of what is perhaps even more important globally: the ‘commercial determinants of health’. These can be defined as ‘factors that influence health which stem from the profit motive’. For example, it is estimated that 75% of diabetes and 40% of cancers would be prevented by eliminating four risk factors: smoking, excessive consumption of alcohol and food and increasing physical activity, i.e. reducing consumption of tobacco, alcohol, food and fossil fuels 5. Public companies have a legal duty to maximize the return to their shareholders, and those running the companies are heavily incentivized to achieve this. Many observers are outraged by stories of what some of these companies do to maximize returns, but as people working in the tobacco industry can testify, being the subject of widespread opprobrium is more than offset by the financial rewards; and cognitive dissonance can take care of any residual unease about contributing to the suffering and death of fellow humans whom they do not personally know. In England, the government has set up a ‘Responsibility Deal’ involving some sectors of industry, including the alcohol industry, with a view to working together to mitigate the harm that they cause to health (see http://www.responsibilitydeal.dh.gov.uk). Given the need to reduce consumption to improve health, it is unclear how such deals can maintain profits. To rile against this is like complaining about a dog for barking. It's ‘what they do’. The World Health Organization (WHO) Treaty, the Framework Convention on Tobacco Control, provides a legal barrier to tobacco companies becoming involved directly in this Deal 6. In the case of the tobacco companies, progress has been made in some countries because the harm equation is so obviously tilted in one direction, and because the results of studies have persuaded policy makers that tobacco is bad for their nation's wealth as a well as its health. Perhaps the next step in the case of the other commercial determinants of health is to communicate more effectively to the public that the harm equation is also tilted against their interests. Thus, for example, in England, the recent alcohol strategy framed the benefits of minimum pricing for a unit of alcohol in terms of reduced violent crime and public order offences, a framing that may explain the somewhat muted public opposition. The greatest challenge to improving health may lie in the tension between wealth- and health-creation. Most, if not all, modern economies are built upon excessive consumption, to the detriment of population health and the sustainability of life on the planet. Reducing consumption requires re-thinking macro-economics to achieve prosperity without growth, a brave but vital initiative to curb the commercial determinants of health before the planet becomes too hostile to support human existence 7, 8. Robert West undertakes research and consultancy for companies that develop and manufacture smoking cessation medications. His salary is paid by Cancer Research UK. He is an unpaid co-director of the national Centre for Smoking Cessation and Training and a Trustee of the charity, QUIT.