Need2Know - How to address the Commercial Determinants of Health
Spotlight on the role of harmful industries in Addiction, Mental Health and NCDs
The Commercial Determinants of Health (CDoH) refers to strategies and approaches used by the private sector to promote products and choices that influence public health. Understanding the commercial forces influencing health is crucial because corporate practices and market dynamics play a major role in shaping environments and behaviours that contribute to the development and perpetuation of harm and illness. In this brief, we are focusing on addiction and mental health, and, in particular, on the role of the alcohol, tobacco and gambling industries.
Here is what you “need to know” from the current evidence base.
(This brief has been authored by Christina Tsoulfa and Dr Antonis Kousoulis)
The Importance of the Commercial Determinants of Addiction
The Commercial Determinants of Health (CDoH) refer to strategies and approaches used by the private sector to promote products and choices that influence public health. The majority of the discussions about CDoH are centred on conditions like obesity, cardiovascular disease, and certain types of cancers, while the association with mental health, addictions included, is often omitted. However, understanding the commercial forces driving addiction is crucial because corporate practices and market dynamics play a major role in shaping environments and behaviours that contribute to the development and perpetuation of addictive behaviours.
Companies in the harmful products industries, most notably alcohol, tobacco and gambling, use sophisticated marketing, lobbying, and product design strategies to maximise profits and consumption. By promoting conditions that encourage excessive unhealthy consuming behaviours, these practices cause and worsen addiction.
CDOH features include the manufacture, promotion, and sale of goods that have adverse health effects, and the ways companies influence policies and laws that benefit their operations and are detrimental to public health. There is strong evidence of the influence of various commercial factors in encouraging addictive behaviour across a wide range of products and services. For example:
Alcohol companies use promotional strategies, such as appealing to younger and other susceptible consumers, to promote consumption. These tactics lead to higher rates of alcohol addiction and other health risks.
For tobacco, the strategies include political influence, production of appealing-looking products, and misleading advertisement campaigns that create a satiable demand for cigarettes resulting in nicotine dependence and the resultant diseases.
People may spend countless hours gambling due to the availability of new technologies and persuasive tactics that are employed in the online gambling platforms that make more money and entice people into getting addicted to gambling.
The focus of this brief is highly relevant to the upcoming United Nations High-Level Meeting on Non-Communicable Diseases (NCDs) and Mental Health. The comorbidity between NCDs, addiction and mental health conditions is a significant public health concern. These conditions are interrelated in many ways and often share common risk factors influencing each other's progression and outcomes. The direct causative factors for a wide range of physical NCDs and their interaction with mental health conditions include various behavioural, biological and environmental factors. For example, smoking is a major risk factor for many NCDs, including cardiovascular disease, respiratory disease, and cancers, while it is also strongly associated with depression, anxiety and psychosis. In addition, excessive alcohol consumption is a direct cause of liver disease, certain forms of cancer and cardiovascular disease, while it is closely linked to mental health conditions such as depression, anxiety and alcohol dependence. Furthermore, chronic stress and social isolation can lead to hypertension, cardiovascular disease and weakened immune function, while at the same time these factors contribute to the development of addictions, such as gambling.
Based on an umbrella review of the literature (including 17 systematic reviews and/or meta-analyses, covering a variety of age groups and policy interventions from a total of 1,768 individual studies), we are providing in this Brief the key policies and tactics that can be used to address the impacts of the harmful products and industries on substance use and mental health.
Harmful Industries: Products and Tactics
The three major industries directly impact mental health and fuelling addictive behaviours are alcohol, tobacco and gambling. There is extensive work showing that they employ a range of tactics to influence policy and shape addictive behaviours, increase addiction, and use new technologies to remain relevant and appeal to younger consumers. A short overview is provided below.
Alcohol Industry: Most alcohol producers now employ slick marketing techniques to ensure that they capture a wide market including youth. This affects the probability of young people becoming regular alcohol consumers. Youth alcohol consumption and attitudes are more favourable when being exposed to alcohol marketing, which involves sponsorships, promotional activities, and advertisements.
The role of the alcohol industry in policy influencing through lobbying and political contributions is well established. In addition, the alcohol industry is engaging in several strategies in the regulation of marketing as it tries to sway both public sentiment and policymakers. Funding by the industry has been found to increase the risk of biased results in favour of the alcohol industry.
Many alcoholic drinks have been created with an attractive appearance and with the ability to be easily shaped into any vessel for consumption. Some examples include flavoured alcohol products, products specifically targeting young consumers, association with popular celebrities, attractive packaging, and many more.
Gambling Industry: The concepts of virility, seduction, and glamour are the most prominent types of advertising in the gambling business, which aims at enhancing the consumer’s active participation and expenditure. Online gambling websites make use of design, gaming and augmented reality features that enhance the appeal and the addictive nature of their offerings. Internet ads are created by targeting the potential gamblers depending on their tendency. More recently, AI and machine learning algorithms enable marketing to a specific gender, age, or any other group of particular consumers.
A key concept that concerns gambling industry stakeholders is product design for the purpose of constant engagement with the user. In gambling, product characteristics like the illusion of proximity, small but more frequent wins, and excellent video imaging were intentionally made to sustain the player’s interest. Such features may foster a hedonic experience that amplifies excitement and perceived control, thereby influencing the probability of gambling addiction. The industry has implemented various strategies to promote harm reduction, including education and awareness campaigns, which all fall short of addressing the root causes of problem gambling.
Tobacco Industry: There is extensive evidence in how the tobacco industry is engaging in a variety of strategies affecting both consumers and public policy. The industry is using social media in advertising products and manipulating opinions, whilst many government policy documents have been found to cite tobacco-sponsored research evidence. Influencing behaviours, regulations targeting advertising and taxation, and tax avoiding practices have all been well studied as part of the playbook of the tobacco industry, which continues to actively directly reach to youth both with tobacco and e-cigarette products.
Despite regulations for plain packaging in many countries, the tobacco industry has been found to be actively altering consumers’ perceptions through social media accounts and to manipulate public opinion in their favour. Products are often advertised with messages about their relative safety and risks, whereas public health messaging is very clear that all products are harmful.
Overview of Policy and Regulatory Approaches
Product Labelling and Packaging: An essential component of controlling the commercial aspects that contribute to dependency is the rules that govern product labelling and packaging. There is evidence that changes in packaging, especially the use of plain packaging and large and graphic health warnings, help to reduce appeal of tobacco products and enhance understanding of the perils of tobacco consumption. Further, research shows that visual messages, as opposed to text-only ones, improve focus, memory, and risk perceptions, and graphic warnings have a greater impact on reducing smoking intentions and encouraging cessation behaviours through the reduction of brand appeal.
Taxation Policies: Taxation measures are one of the approaches that are commonly used in efforts to decrease the rate of usage of addictive substances. This policy has helped in its implementation by raising taxes on tobacco and alcohol products, effectively reducing their consumption, and helping redirect revenues for funding health activities. Evidence shows that increasing the taxation and minimum pricing of alcohol units was associated with reduced morbidity and mortality due to alcohol use. This increase in prices was particularly associated with the reduced consumption of alcohol, and reductions in many forms of health problems, including liver diseases, traffic fatalities, and violence. Also, the increase in taxes on commodities associated with tobacco leads to overall decrease in smoking rates and quantity of consumption and primarily affects vulnerable consumers including youth and those in lower socioeconomic groups.
Digital Marketing Restrictions: With new advertising methods widespread, evidence shows that a modernisation and updating of regulations, to be more appropriate for modern platforms, is necessary. Advocates have been calling for greater shared responsibility on protection from online harms, including marketing that is direct to children, and promotion on smartphone apps.
Enforcement and Compliance: Despite the efficacy of existing policies, their application and compliance still need to be improved. It has been shown that when international organisations and governments apply strict limits to industry interference, coupled with strong enforcement mechanisms, there is more effective implementation of policies and associated benefits to public health.
Policy Recommendations
1. Implement Comprehensive Advertising Bans
Systematic review-level evidence shows that comprehensive advertising bans are more effective than partial restrictions (e.g. prohibiting gambling, alcohol, and tobacco advertising and promotion and sponsorship across all media). Research shows that such restrictions can be effective in lowering consumption, especially for young people.
2. Increase Taxation
There is a strong need for policy intervention through raising taxes on alcohol and tobacco products and bringing in or raising taxes on gambling revenues. It is well evidenced that such an approach reduces consumption and improves population health.
3. Restrict Availability
Clearer limitations on the selling of harmful products have been shown to work; this includes, for example, limiting the number of outlets, and controlling sales times.
4. Expand Minimum Pricing
Measures setting the minimum price at which alcohol can be sold (increasing with the strength and volume of alcohol) have been implemented in certain settings, with evidence of reducing consumption and inequalities, and should be expanded.
5. Create Smoke-Free Environments
Tobacco-free (including e-cigarette) policies and environments in all workplaces, healthcare facilities and public places are critical to safeguard the health of non-smokers and support smokers’ efforts to quit.
6. Implement Mandatory Graphic Warnings
Graphic health warnings on tobacco packs should be extended to other tobacco and alcohol products to alert people about the health harms of consumption and the lack of safe levels of consumption.
7. Provide Support for Self-Exclusion Programmes
Self-exclusion programmes that enable people to opt out of gambling establishments or online gambling sites have yielded good results. These should be extended to ensure that companies offer such self-ban options for gambling to assist people in regulating their gambling activities.
8. Implement Mandatory Pre-Commitment Systems for Gambling
As a harm-reduction measure, people gambling should be able to lock the amount of money they intend to spend before they start placing bets or using gaming features. This supports preventing adverse effects associated with gambling.
Key Evidence Statements for Advocates
Addictive behaviours to products that are legally widely available (alcohol, tobacco, gambling) are largely driven by for-profit industries, using a playbook that is harming public health.
It is not just the products, but also marketing and advertising strategies that significantly increase the likelihood of consumer addiction to products such as tobacco, alcohol and gambling.
Individuals of lower socioeconomic status are disproportionately targeted and affected by the harmful industries, leading to higher rates of substance misuse and addictive behaviours.
For example, exposure to targeted advertising by the alcohol industry is correlated with increased alcohol consumption and higher rates of alcohol use disorders.
Implementing stricter regulations on the advertising and promotion of harmful products should extend to modern versions of them, such as vaping products, to protect adolescents and young adults.
Enforcing complete bans on advertising and promotion of addictive products, like tobacco, alcohol and gambling, is likely to deter their use and prevalence among the general population and high-risk groups.
Regulatory approaches that include advertising restrictions, product regulations, and strict policy enforcements, are more effective in reducing addiction rates than public awareness campaigns alone.
If you are interested in the umbrella review and the evidence underpinning this Need2Know brief, you can download the list of included papers here.
