Commercial determinants of noncommunicable diseases in the WHO European Region
Executive summary
Advances in public health research and practice have contributed to a growing recognition of the role of commercial actors as powerful determinants of people’s health, safety and well-being the world over. For too long, the ways in which commercial practices and products threaten and undermine public health policymaking and goals have not received the attention they demand. Applying a new commercial determinants lens to the pressing public health issues of our time is urgently needed to prevent unnecessary harm and health inequities. This report aims to catalyse new thinking and action to help ensure health and equity throughout the WHO European Region.
Introduction — the importance of addressing commercial threats to NCD policies in the WHO European Region
The introduction provides an overview of the NCD burden in the Region driven by commercial practices and products. It examines the key challenges in reaching the global NCD targets in the Region and the current concerns with unsatisfactory implementation of NCD “best buy” policies. It sets out the goals of the publication — to explain the common practices used by commercial actors, and to mobilise policy actors to recognise undue commercial influence and take action.
Chapter 1 — Conceptualising commercial determinants of health related to NCDs
Chapter 1 introduces the concept of the commercial determinants of health (CDoH), highlighting how commercial sector actors and their practices impact health, particularly NCDs. It defines what commercial determinants entail, discusses the diversity of commercial actors and their profit-driven motives, and sets out the shared strategies that may harm public health. It calls for urgent recognition and regulation of CDoH to mitigate these health impacts and address growing health inequalities.
Chapter 2 — Marketing strategies increase exposure to NCD risk factors and negatively affect NCD care
Chapter 2 details how industries — including tobacco, alcohol, food, pharmaceuticals and the healthcare industry — use integrated marketing campaigns to glamourise and normalise the use of harmful products, often targeting children and socioeconomically disadvantaged groups. It examines the pervasive role of digital marketing and the challenges in regulating it given advanced technologies and algorithmic targeting. Case studies include industry opposition to the United Kingdom’s food marketing restrictions, the French Loi Évin on alcohol advertising and promotion, and the marketing of surgical robots. The chapter then discusses potential regulatory actions, barriers created by industry opposition, and the importance of strong legal measures to protect public health from harmful marketing practices.
Chapter 3 — Industry structure and market power negatively influence policies
Chapter 3 explores how industry structure and market power are used to shape public policies on NCDs. It examines the ways in which industries — such as meat production, nonalcoholic beverages and pharmaceuticals — use market dominance to maintain monopolistic positions, extend product lines into new sectors and manipulate pricing. Case studies illustrate the high costs of innovative medicines and the battles over access to affordable medicines, highlighting the need for regulatory frameworks to curb industry power and protect health outcomes.
Chapter 4 — Industry lobbying and its impact on NCD policies
Chapter 4 examines the impact of industry lobbying on NCD public policies. It illustrates how commercial industries, including tobacco, food and pharmaceuticals, engage in political practices to prevent, weaken and delay public health regulations. Case studies include industry opposition to the regulation of electronic cigarettes in Georgia, opposition to sugar-sweetened beverage taxes, and pharmaceutical industry lobbying using patient associations and families.
Chapter 5 — The impact of international trade and investment agreements on policy
Chapter 5 addresses the impact of trade and investment agreements (TIAs) on NCDs and related policies. It discusses how these agreements can constrain governments’ ability to implement public health measures by prioritising commercial interests over health. Case studies include tobacco industry challenges to tobacco packaging laws, potential health impacts from changes to trade agreements following the United Kingdom’s withdrawal from the European Union, and pharmaceutical industry influence on trade agreements. The chapter calls for careful consideration of health impacts in trade negotiations and policies that ensure governments can effectively address NCDs.
Chapter 6 — Casting doubt on evidence: manipulating research related to NCD causes, prevention and management
Chapter 6 investigates the use of scientific practices by commercial actors, highlighting the systemic problem of disinformation and misinformation related to NCD prevention and management. It describes five key strategies used by commercial actors — particularly in health-harming industries — to influence scientific research and public understanding, including funding industry-favourable research, spreading misinformation and undermining public health guidelines. It emphasises the need for robust measures to counteract these practices, prevent conflicts of interest and promote independent, evidence-based knowledge.
Chapter 7 — Corporate social responsibility (CSR) and its negative impacts
Chapter 7 focuses on CSR as a strategy for corporate reputation management and discusses how companies — especially in health-harming industries — use CSR initiatives to improve their public image and gain influence, often at the expense of public health. Case studies examine “pinkwashing” by the alcohol industry through associations with breast cancer charities, and “artwashing” by the pharmaceutical and gambling industries through sponsorship of arts and culture. It calls for critical scrutiny of CSR and for true accountability mechanisms and regulation.
Chapter 8 — Employment and health: the role of commercial economic narratives and shifting labour markets
Chapter 8 examines the relationship between employment, health and the role of commercial economic narratives in shaping labour markets. Case studies explore the mental health effects of precarious employment in Sweden and labour-market shocks. The chapter underscores the importance of addressing the economic and employment conditions that contribute to health inequities and NCDs, advocating for policies that promote stable, fair employment and protect workers’ health.
Chapter 9 — Financial practices and the extraction of wealth: increasing inequity and undermining NCD prevention and control
Chapter 9 explores how financial practices and the extraction of wealth by commercial actors increase inequity and undermine NCD prevention and control. It highlights the role of tax avoidance, profit shifting to tax havens and aggressive financial planning strategies that deprive governments of revenues needed to fund public health. Case studies include British American Tobacco’s tax avoidance and COVID-19 vaccine manufacturers’ share buybacks. The chapter emphasises the need for financial reforms and stricter regulation to ensure that commercial entities contribute fairly to public finances.
Chapter 10 — Economic union and European Union single market laws: how health-harming industries undermine policies to reduce NCDs
Chapter 10 examines how economic union and EU single market laws are used by commercial actors to oppose policies aimed at addressing the NCD burden. It highlights how industries can leverage legal frameworks to challenge national public health regulations, arguing that such policies impede free trade and competition. It examines how the tobacco and alcohol industries exploit EU laws to prevent the implementation of health measures, and calls for stronger regulatory mechanisms and a more health-oriented interpretation of these laws.
Chapter 11 — The commercial industry taking advantage of crises and emergencies
Chapter 11 discusses how commercial actors may exploit crises and emergencies to advance their commercial interests, often at the expense of public health. Case studies illustrate how companies such as McDonald’s, Philip Morris International and the commercial milk formula industry have used events including the cost-of-living crisis, the COVID-19 pandemic and the war in Ukraine to promote their products and influence public policies. It calls for vigilance and stronger regulation to prevent industries from leveraging crises for commercial gain.
Chapter 12 — Taking action to address the commercial determinants of NCDs in Europe
Chapter 12 outlines actions to reduce the burden of NCDs by addressing CDoH. It emphasises the need for coordinated efforts involving governments, civil society and international organisations to implement effective policies and regulations. Case studies include Kyrgyzstan’s Joint Annual Review for NCD coordination and Estonia’s success with a sugar-sweetened beverage tax through coalition-building. It advocates for comprehensive approaches — including coalition-building, policy dialogues and regulatory mechanisms — and for addressing the limitations of the political-economic system.
Chapter 13 — The power of people’s voice: actions that citizens and civil society can take to reduce commercial determinants of NCDs
Chapter 13 emphasises the importance of civil society action in addressing the commercial determinants of NCDs and highlights actions civil society can take to advocate for stronger public health policies and regulations. Case studies include the adoption of tobacco legislation amendments in Slovenia and the role of the Women’s Council of the Kyrgyz Republic in supporting tobacco control legislation. It underscores the power of collective action, adequate funding, and strategic alliances.
Conclusion — a stepwise approach to addressing the commercial determinants of NCDs in Europe: an agenda for action
The conclusion emphasises the urgency of acting to mitigate commercial determinants of NCDs to address the rising NCD burden in the Region. It calls on governments, civil society and academia to build coalitions, emphasise well-being and develop a clear NCD policy agenda based on the core values of equity, sustainability and resilience. It calls on public health actors to develop competencies in identifying, preventing and managing CDoH and conflicts of interest; to critically assess industry-funded research and leverage evidence for stronger regulation; to engage more effectively in debates and policy developments on the economy and trade; and to support governments in opposing litigation that blocks or delays effective NCD policies. It calls on governments in Europe to enforce existing regulations and to advocate for stringent and effective measures to curtail the influence of commercial actors.