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From silos to policy coherence: tobacco control, unhealthy commodity industries and the commercial determinants of health
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  1. Sarah E Hill1,2,
  2. Paula Johns3,
  3. Rima T Nakkash4,
  4. Jeff Collin1,2
  1. 1 Global Health Policy Unit, University of Edinburgh, Edinburgh, UK
  2. 2 SPECTRUM Consortium, Edinburgh, UK
  3. 3 ACT Promoção da Saúde (ACT Health Promotion), Rio de Janeiro, Brazil
  4. 4 Health Behaviour and Education Department, American University of Beirut, Beirut, Lebanon
  1. Correspondence to Professor Jeff Collin, Global Health Policy Unit, University of Edinburgh, Edinburgh, UK; jeff.collin{at}ed.ac.uk

Abstract

Tobacco control has achieved remarkable successes, underpinned by the distinctive norms codified in Article 5.3 of the WHO Framework Convention on Tobacco Control. Tobacco control’s experience in managing conflicts of interest is increasingly recognised as relevant for addressing other non-communicable disease epidemics. At the same time, the wider environmental and social harms of tobacco—and other unhealthy commodity industries—underline the potential for enhanced strategic collaboration across health, development and environmental agendas. Such collaboration is increasingly necessary to address key challenges shared across tobacco control and related policy spheres, including the extent to which the harms of tobacco (and other unhealthy commodities) are underpinned by economic and social inequities. Here we demonstrate the relevance of a commercial determinants of health perspective, both for advancing tobacco control and for linking it with health and development more broadly. This perspective is already evident in many areas of research, policy and advocacy, where innovative approaches support the development of closer links with actors in related fields. We draw on the concepts of policy coordination, coherence and integration to show how tobacco control can advance key strategic goals via information sharing, complementary approaches to common problems and collective action with other related movements. Embrace of a commercial determinants perspective will help in building on tobacco control’s successes and reorienting strategies in other sectors to more effectively manage health risks and promote sustainable development.

  • global health
  • environment
  • low/middle income country
  • disparities
  • tobacco industry

https://doi.org/10.1136/tobaccocontrol-2021-057136

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    Introduction

    Tobacco is often positioned as a product like no other: the only legally sold commodity to kill up to half those who use it as intended.1 Correspondingly, tobacco control has been pursued via a distinctive model of governance predicated on minimising industry engagement in policy and research—a norm codified in Article 5.3 of the WHO’s Framework Convention on Tobacco Control (FCTC).2 The distinctive nature of this model, termed ‘tobacco exceptionalism’3 in recognition of its divergence from dominant partnership approaches in other areas of health and social policy, has been a cornerstone of tobacco control’s success in reducing population tobacco exposure via effective regulation of the tobacco industry.4 Yet tobacco is hardly the only health-damaging product to be manufactured and marketed on an industrial scale,5 while other unhealthy commodity industries (including alcohol and ultra-processed foods) similarly employ questionable tactics in resisting regulation and protecting their profits with significant implications for population health.6 7 This suggests that efforts to protect policy and research from industry interference should be seen less as a tobacco-specific ‘exception’ than as a model for tackling the drivers of non-communicable diseases (NCDs).

    Tobacco control's distinctive approach is widely regarded as a public health success. While there is much work still to be done, over half the world’s population is now protected by multiple tobacco control measures8; processes to safeguard health policy from industry interference are widespread4; and tobacco use is declining globally.8 The FCTC remains the only treaty initiated under the auspices of the WHO,9 and in requiring actions to minimise industry interference provides a model envied by colleagues tackling other industrial epidemics.5 6 10

    Here we highlight the potential for strengthening tobacco control’s links with broader health and development agendas in order to support coherent approaches to advancing global health. We argue that such efforts are facilitated by understanding and addressing tobacco from a commercial determinants of health (CDoH) perspective.7 11 12 This means regulating the tobacco industry as part of an intersectoral strategy to mitigate the impacts of corporate actors whose profit-driven policies, practices and products damage health via their influence on wider social, economic and political determinants. Drawing on examples of innovative practice in tobacco control, we suggest that fully engaging with a CDoH perspective can increase tobacco control’s policy salience and reinforce its alignment with sustainability, development and social justice. Importantly, situating tobacco control within a CDoH approach could also help address a key fault-line in contemporary health governance: that is, the divide between an exclusionary approach (in which tobacco control policy is protected from industry interference) and the politically dominant emphasis on partnership and multistakeholder approaches in other spheres of global health.13

    We develop this case in two parts. First, we present inequities as a defining challenge for tobacco control in common with other industrial epidemics.5 We examine the relationship between tobacco and social justice, highlighting how narrow (product/behaviour-focused) approaches to tobacco control marginalise its potential to address global inequities, while its integration with a broader pro-equity agenda can build bridges with other movements seeking to promote health and sustainability. Second, we explore strategies for linking tobacco control with control of other industrial epidemics via strengthening collaboration across research, policy and advocacy. Drawing on the concepts of policy coordination, coherence and integration and examples of innovative practice from diverse geographical settings, we explore how a CDoH perspective strengthens research governance, supports policy collaboration across NCD risk factors and expands the mandate of leading tobacco control coalitions. We conclude that increasing alignment with a CDoH agenda brings shared benefits, enhancing progress elsewhere in health and development while securing core tobacco control objectives.

    Addressing inequities and commercial determinants: a shared policy challenge

    Inequities constitute a defining challenge for tobacco control. Tobacco use now follows a marked social gradient in most parts of the world, with smoking more prevalent among the poor, ethnic minorities and others holding less privileged position in society.14–18 At a global level, the burden of tobacco-related disease falls disproportionately on low-income and middle-income countries (LMICs),19 while coverage of tobacco control interventions is correspondingly inequitable.4 Alongside this unequal health burden, tobacco contributes to economic inequities both within and between countries,20 21 with its recognition as a barrier to sustainable development22–24 reflected in the third Sustainable Development Goal (SDG3)’s emphasis on strengthening FCTC implementation.25

    Tobacco companies play an active role in these inequities. They have targeted marketing at less advantaged groups, including the poor, ethnic minorities and women,18 26 27 and promoted voluntary measures28 such as health information campaigns (less effective for disadvantaged groups29) over stronger forms of tobacco control.26 30 At a macro level, transnational cigarette manufacturers aggressively pursue market access and resist regulation,31–33 thus increasing their structural power12 and exacerbating economic and social inequities.27 34

    While evidence is strongest for tobacco, similar inequities are evident in other industrial epidemics. For example, the health burden of alcohol and ultra-processed food falls disproportionately on less privileged groups,26 while producers seek to expand their markets and increase consumption in LMICs.35–38 These patterns reflect commonalities in the commercial determinants of health, whose activities undermine equity at multiple levels.34 39

    While tobacco control has sought to address such inequities, broader policy efforts are urgently required. Inequities in smoking threaten aspirations of a tobacco endgame,40 whose attainment will not be achieved without dramatic reductions in tobacco exposure among poor and ethnic minority populations41–44 and greater support for FCTC implementation in LMICs.45 At the same time, inequities will increase where tobacco control is pursued via a narrowly defined (product/behaviour-focused)46 agenda, since most interventions have greater success among advantaged smokers.47 48 Moon and colleagues45 warn of potentially uneven impacts by geography, gender, race and other aspects of social location, noting that ‘[s]trategies for achieving the endgame in [high income countries] must mitigate against the consequences for the economies and well-being of nations in LMICs’. Given its growing association with disadvantage, there is a risk tobacco use is seen as a problem of the poor, that is, an ‘unhealthy lifestyle’ rather than a shared social challenge.49 50

    By addressing the tobacco epidemic from a commercial determinants perspective, tobacco control efforts are focused on its structural drivers and relevant macrosocial policy responses. Siloed approaches to NCD prevention invite the kind of ‘lifestyle drift’50 that reduces public health aspirations to a narrow set of behavioural changes. By adopting a commercial determinants perspective, the tobacco control movement pushes back against a neoliberal framing that misrepresents collective action as the antithesis of individual ‘choice’. This creates much needed policy space, aligning tobacco control with efforts to limit corporate power, restore community agency and advance social and environmental justice.51 Such an approach facilitates reductions in tobacco exposure among all population groups,52 while positioning tobacco control as central to broader approaches in NCD prevention, poverty reduction and development.53 This helps address perceived tensions between economic and health goals,54 stimulating engagement and promoting coherence across diverse agendas.55–57

    Tobacco control and the commercial determinants: opportunities for collaboration and innovation

    A commercial determinants lens situates the long-recognised challenges confronting tobacco control among shared strategic priorities requiring synergistic solutions across multiple public policy domains. This reframing highlights the importance of intersectoral collaboration, aligning tobacco control with broader policy agendas. By emphasising shared objectives, a CDoH perspective helps break down silos between tobacco control and other sectors, facilitating joined-up governance.

    In considering how tobacco control might further strengthen its links with related agendas, we draw on the concepts of policy coordination, coherence and integration.58–60 These interlinked concepts point to strategies for addressing fragmented actions across different ministries and levels of government.58 61 62 Here, we draw on these concepts to highlight examples of innovative collaboration and partnership between tobacco control and other related agendas.

    Enhancing coordination across policy, advocacy and research

    On a spectrum of interaction from loose collaboration to full partnership, coordination with other policy domains is most widely evident in established tobacco control practices. The challenge of involving other ministries in tobacco control is reflected in the FCTC’s provision for national coordination mechanisms.55–57 Here we use ‘coordination’ to refer to processes for ‘joint and holistic working, joint information systems, dialogue between agencies, processes of planning, and making decisions’,61 essentially processes for information sharing across organisations to advance their respective goals.58

    The newfound prominence of NCDs in global health and development encourages tobacco control’s increasing engagement with other agendas. Tobacco control advocates have skilfully employed enhanced coordination to centre tobacco control within wider commitments to tackle NCDs. Promotion of policy coherence was a key rationale for using the 2011 United Nations (UN) High-Level Meeting on NCDs as a platform to enhance FCTC implementation63; for the Framework Convention Alliance becoming a global partner of the NCD Alliance steering group64; for supporting advocates and policymakers using the SDG agenda to advance tobacco control at the country level65; for joint civil society statements encouraging states to realise global commitments66; and for positioning tobacco control and NCD prevention as key elements of pandemic recovery strategies.67

    A commercial determinants perspective has similarly created opportunities for tobacco control researchers to engage with colleagues from other fields in addressing shared funding and governance challenges.68 69 For example, researchers from the American University of Beirut (AUB) explored how public health researchers regard funding from a range of industries, given growing pressure for universities to generate commercial sector funding and the increasingly prominent sponsorship of unhealthy commodity industries in university campuses, health research and public health campaigns. The AUB researchers, with backgrounds in tobacco research, were conscious that industry funding creates significant risks, but felt such risks were not widely understood in the academic public health community (whose views had not previously been surveyed70). Their research was supported by the Canadian International Development Research Centre (IDRC), a government agency with a traditionally strong tobacco control focus that was increasingly interested in food systems and nutrition.71

    The AUB researchers surveyed universities across five global regions, asking public health academics about their attitudes concerning industry-supported funding for research, practice and education. The survey had a strikingly low response rate (less than 2.5% overall),72 with wider conversations suggesting many public health academics were reluctant to discuss the issue of commercial funding. There was a sense of resentment at the ‘righteous attitude’ of tobacco researchers, with some (non-tobacco) researchers seeming to question ‘who are you to tell us what to do?’ (a dynamic seemingly exacerbated by the perception that researchers from the Global South were questioning practices in the Global North). It was also evident that, outside of tobacco research, there were very different norms concerning industry support of research and advocacy, which was often regarded as a necessary and accepted practice, particularly in resource-limited settings.

    In contrast, the AUB researchers found space and even enthusiasm for critical discussion if the role of unhealthy commodity industries was considered from a broader ‘determinants of health’ perspective. Most health researchers, advocates and policymakers were conscious that relevant industries exert substantial influence in the wider environment, including via sectors such as education and food systems. By positioning their relationship with industry actors as part of this ‘bigger picture’, discussion seemed to shift from a perceived questioning of researchers’ personal integrity to a broader analysis of industry power. It also moved the debate beyond one of distinction (eg, tobacco vs other ‘less harmful’ products) to a more nuanced appraisal of the potential benefits and harms associated with acceptance of industry funding. This reframing made it more likely that researchers, advocates and policymakers would draw connections between the tactics used by cigarette companies and those employed by other unhealthy commodity producers, thus sharing lessons from tobacco control relevant to those working in related areas.

    Towards coherence: defining shared objectives, developing common policy instruments

    Beyond more extensive information exchange across policy domains, tobacco control policymakers and advocates are exploring ways of developing complementary approaches to shared problems. Efforts to build policy coherence seek to minimise conflicts and maximise synergies across policy agendas,10 73 promoting consistency in policy objectives, target populations and instruments.58 Tobacco control clearly shares objectives with other NCD agendas centred on reducing consumption of harmful commodities, and the evidence base points to similar approaches and target populations in addressing the social gradient of associated harms.74

    Policymakers are seeking instruments capable of delivering public health gains across multiple fields, often looking to build on tobacco control’s successes. The most significant attempts have focused on fiscal policy, such as the Philippines’ 2012 reform of tobacco and alcohol taxes, which linked increased taxes with funding of healthcare.75 76 This is reflected in the UN’s emphasis on tobacco taxation as a source for financing the SDGs77 and Bloomberg Philanthropies’ Task Force on Fiscal Policy for Health,78 which sought to tackle NCDs and boost public revenue by promoting excise taxes on tobacco, alcohol and sugary beverages.

    Initiatives to address commercial determinants can also generate important opportunities for tobacco control. In Scotland, a coalition of non-governmental organizations (NGOs) focused on health - including Action on Smoking and Health (ASH) Scotland, Alcohol Focus Scotland and Obesity Action Scotland - sought to coordinate approaches and build political momentum to tackle unhealthy commodity industries. This led to the establishment of a parliamentary cross-party group comprising members of the Scottish Parliament, public health organisations and researchers.79 Replacing previous issue-specific groups, this collaborative forum promotes coherent action to address the impacts of industrial epidemics. The group’s conflict of interest policy applies the principles underpinning FCTC Article 5.3 to exclude all unhealthy commodity industries from group membership, thus creating a safe space for discussion in the absence of commercial interests.79 Other outputs from the advocacy coalition include a joint manifesto by 10 leading health charities calling for coordinated action to tackle the inequitable burdens of tobacco, alcohol and obesity,80 and a report highlighting six agreed policy recommendations for tackling health-harming products.81

    Innovation via integration

    The development of a joint manifesto and agreed policy priorities (above) reflects a substantive commitment to advancing policy coherence, and arguably a step towards policy integration. Integration implies a more radical shift in existing practices, however, entailing ‘a new mandate by which policies and organization work under a new logic, subordinating their objectives to a new overall goal, and making their decisions based on the needs and priorities derived from the complex problem’.56 In other words, the integration of tobacco control with a broader commercial determinants agenda means that tobacco control goals sit alongside (rather than taking precedence over) those of other health and development agendas, with actors choosing to prioritise actions that advance shared or common objectives.

    An example of such transformation is represented by the changing nature of health advocacy in Brazil. Aliança de Controle do Tabagismo (ACT) was established in 2006 as a civil society coalition to reduce tobacco use and advocate for effective control policies in line with the FCTC. Building on striking successes in this field, the coalition has increasingly engaged with a broader NCD prevention agenda, which by 2013 included the promotion of healthy eating, physical activity and alcohol control. The organisation’s remit was formally expanded, such that ACT became ACT Promoção da Saúde (ACT Health Promotion).82

    The impetus for extending its focus beyond tobacco control had multiple intersecting origins. Within Brazil, concern over the country’s growing NCD burden83 meant health officials at both state and federal levels were keen to draw on lessons from tobacco control in tackling obesity and alcohol. Internationally, this broader remit aligned with increasing interest in NCD prevention across global health and development, and with changes in the funding priorities of donors such as IDRC and Bloomberg Philanthropies, particularly as regards food policy.

    From a ‘health determinants’ perspective, the tobacco control experience has clear relevance for NCD prevention more broadly. In reflecting on the success of tobacco control in Brazil, ACT staff were aware of the need for similar progress to improve nutrition and reduce alcohol-related harms. In other words, it was ‘time to share’ the insights gained from their experience as part of the tobacco control movement with the wider health and development communities. From being the organisation’s primary focus, tobacco control came to be viewed as part of a broader mission to prevent NCDs by tackling their structural drivers. The importance of regulating industry activity stood out as a key lesson from tobacco control, one with parallels for regulating producers of alcohol, ultra-processed foods and other health-damaging industries. This perspective has actively shaped how ACT engages with new agendas, including its strong emphasis on managing conflicts of interest with the commercial sector in food systems contexts84 and its participation in the Brazilian Alliance for Healthy and Adequate Food. Experience in managing tobacco industry interference informed ACT’s work with the Pan American Health Organization in testing and developing tools to manage conflict of interest in nutrition policy.13 85 This highlights the potential for cross-sector learning and collaboration, facilitated by a commercial determinants perspective that positions tobacco control as part of broader health and development agendas.

    Conclusion

    This paper makes the case for embracing an emergent shift from tobacco ‘exceptionalism’ towards understanding and addressing the tobacco industry as a commercial determinant of health. It is important to emphasise that nothing in this analysis questions the ongoing centrality of tobacco control to global health. Rather, a commercial determinants perspective is intended both to buttress that centrality and enable lessons from the tobacco control experience (and the expertise and insights of advocates and researchers) to inform advances in related fields. Similarly, the focus on collaborative innovation across coordination, coherence and integration does not imply that all organisations focused on tobacco control must transform their mandates. In many contexts, tobacco-specific actions generate significant wins in the short term. Explicitly adopting a commercial determinants framing may be difficult for government officials and politicians to engage with, particularly if this is presented in crude ‘anti-business’ terms.

    We do, however, see a compelling strategic case for tobacco control engaging more fully with other agendas. The international success of tobacco control, underpinned by the FCTC, can help inform progress in other spheres. However, our argument rests less on altruism than enlightened self-interest. Tobacco control faces challenges that will be more effectively addressed in concert with other movements; broadening health and development agendas have shifted and complicated policy priorities; and tobacco exceptionalism is rapidly approaching its sell by date. COVID-19 has highlighted the extent to which evidence-based health interventions can be undermined by inequities,86 reinforcing that control of pandemics (both infectious and industrial) requires policy attention to the social and economic conditions with which they interact. Increased global attention to climate change—and calls to follow the example of the FCTC by excluding fossil fuel companies from related policy discussions87—highlights the importance of understanding and addressing commercial actors whose activities have far-reaching88 and unequal89–91 impacts. Tobacco control has much to contribute—and much to gain—from a broader approach to such global challenges.

    Perhaps most fundamentally, engaging more fully with a commercial determinants perspective provides an opportunity to address an Achilles heel in health governance: namely the contemporary dominance of the partnership paradigm in many areas of health policy.13 Here, the very uniqueness of Article 5.3 constitutes a potential vulnerability. The comparatively narrow scope of provisions addressing conflict of interest constitutes a barrier to effective whole-of-government engagement in tobacco control, while the reach of tobacco industry philanthropy in the context of COVID-1992 93 highlights limitations in implementation of Article 5.3.94

    Tobacco control has had remarkable successes in regulating an industrial epidemic across national and international levels. Its distinctive governance model and experience in managing conflict of interest have much to offer the emergent field of the CDoH. At the same time, tobacco control has much to gain from engaging with a commercial determinants perspective. This framing reinforces tobacco control’s alignment with sustainable development and could help reorient the SDG agenda to address wider conflicts of interest, strengthen capacity to manage national and global health risks (SDG3d), and enhance coherence for sustainable development (SDG17.14).95 From a tobacco control perspective, such engagement is commended as an effective way to protect existing gains and tackle key challenges affecting multiple agendas.

    What this paper adds

    • Tobacco control’s successes build on the distinctive norms codified in Article 5.3 of the WHO Framework Convention on Tobacco Control, which prioritises protection from industry interference and highlights the need to manage conflict of interests with commercial actors.

    • While tobacco has often been regarded as an exceptionally harmful product—reflected in a distinctive or ‘exceptional’ policy approach to its control—there is growing awareness of the similarities between tobacco and other unhealthy commodity industries.

    • A commercial determinants of health perspective highlights opportunities for tobacco control to strengthen links with related agendas via coordination, coherence and strategic integration.

    • Such collaboration can help reinforce the centrality of tobacco control for health and sustainable development and facilitate collective action to address shared challenges.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study does not involve human participants.

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    Footnotes

    • Twitter @rimanakkash

    • Contributors The analysis presented in this article was conceptualised by JC and SEH. All authors contributed to drafting of the article and have read and approved the final manuscript.

    • Funding The work of SEH and JC was supported via the SPECTRUM Consortium funded by the UK Prevention Research Partnership (MR/S037519/1), an initiative funded by the UK Research and Innovation Councils, the Department of Health and Social Care (England) and the UK devolved administrations, and leading health research charities: https://mrc.ukri.org/research/initiatives/prevention-research/ukprp/.

    • Competing interests PJ is Director of ACT Health Promotion (ACT Promoção da Saúde), Brazil. JC is a member of the Scottish Parliament’s Cross-Party Group on Improving Scotland’s Health. SEH and JC have previously received funding from Bloomberg Philanthropies to write a background paper for the Task Force on Fiscal Policy for Health. RTN is part of a group of researchers who received funding from the International Development Research Centre, Canada (grant number 106773-001) to explore public health academics’ attitudes towards accepting funding from for-profit organisations.

    • Provenance and peer review Commissioned; externally peer reviewed.