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A growing evidence base indicates that sugar-sweetened beverage (SSB) taxes are an effective tool to help reduce excess sugar intake. The effects of SSB taxes and the mechanisms which underlie them, however, are dependent on a number of interrelated factors such as policy design and responses of industry and consumers. Forde and colleagues contribute to unpacking these mechanisms by exploring the way in which the UK’s Soft Drinks Industry Levy (SDIL) shaped the four Ps of soft drinks marketing: product, price, placement, and promotion. This commentary builds on the authors’ insights by connecting them to existing knowledge on corporate political activity and the commercial determinants of health (CDOH) more broadly. Specifically, I discuss the risk that an industry framing of regulation-induced marketing changes as a voluntary step towards corporate responsibility undermines the need for government intervention to address obesity in other contexts and countries. I conclude by arguing that the public health community would benefit from considering marketing responses to regulation alongside industry narratives about these changes

Meta-regulation – the rules that govern how individual policies are developed and reviewed – has not received much attention in the study of health policy. We argue that these rules, far from value-free and objective, have significant potential to shape policy outputs and, as such, health outcomes. Channelling and operationalising wider paradigms like neoliberalism, they determine, for instance, what is considered ‘good’ policy, how decisions are made, based on which evidence, and whose voices matter. Exploring an archetypal example of meta-regulation, the European Union’s Better Regulation agenda, we illustrate why meta-regulatory tools such as impact assessment, stakeholder consultation, and evaluation – and the norms that underlie their application – matter for health. In so doing, we concentrate especially on the ways in which Better Regulation may affect interest groups’ ability to exert influence and, conversely, how actors have sought to shape Better Regulation. We argue that attention to meta-regulation contributes to counter-balancing the focus on agency within debates at the intersection of globalisation and health, and notably those on regulatory practices and coordination. Whilst research has noted, for instance, the origins of frameworks like Better Regulation and the increasing inclusion of 'good regulatory practice' provisions within trade and investment agreements, less attention is directed to the role that these frameworks play once institutionalised. Yet, as we illustrate, there is considerable scope for meta-regulation to enhance our understanding of the forces shaping health policy via, for instance, conceptualisations of the (social, economic, political, commercial) determinants of health. As such, we call for increased attention to the role of meta-regulation in research and practice aimed at improving human and planetary health.

Diets with high proportions of foods high in fat, sugar, and/or salt (HFSS) contribute to malnutrition and rising rates of childhood obesity, with effects throughout the life course. Given compelling evidence on the detrimental impact HFSS advertising has on children's diets, the World Health Organization unequivocally supports the adoption of restrictions on HFSS marketing and advertising. In February 2019, the Greater London Authority introduced novel restrictions on HFSS advertising across Transport for London (TfL), one of the most valuable out-of-home advertising estates. In this study, we examined whether and how commercial actors attempted to influence the development of these advertising restrictions. Using requests under the Freedom of Information Act, we obtained industry responses to the London Food Strategy consultation, correspondence between officials and key industry actors, and information on meetings. We used an existing model of corporate political activity, the Policy Dystopia Model, to systematically analyse arguments and activities used to counter the policy. The majority of food and advertising industry consultation respondents opposed the proposed advertising restrictions, many promoting voluntary approaches instead. Industry actors who supported the policy were predominantly smaller businesses. To oppose the policy, industry respondents deployed a range of strategies. They exaggerated potential costs and underplayed potential benefits of the policy, for instance, warning of negative economic consequences and questioning the evidence underlying the proposal. Despite challenging the evidence for the policy, they offered little evidence in support of their own claims. Commercial actors had significant access to the policy process and officials through the consultation and numerous meetings, yet attempted to increase access, for example, in applying to join the London Child Obesity Taskforce and inviting its members to events. They also employed coalition management, engaging directly and through business associations to amplify their arguments. Some advertising industry actors also raised the potential of legal challenges. The key limitation of this study is that our data focused on industry-policymaker interactions; thus, our findings are unable to present a comprehensive picture of political activity. In this study, we identified substantial opposition from food and advertising industry actors to the TfL advertising restrictions. We mapped arguments and activities used to oppose the policy, which might help other public authorities anticipate industry efforts to prevent similar restrictions in HFSS advertising. Given the potential consequences of commercial influence in these kinds of policy spaces, public bodies should consider how they engage with industry actors.

Background: Non-communicable diseases (NCDs) kill 41 million people a year. The products and services of unhealthy commodity industries (UCIs) such as tobacco, alcohol, ultra-processed foods and beverages and gambling are responsible for much of this health burden. While effective public health policies are available to address this, UCIs have consistently sought to stop governments and global organisations adopting such policies through what is known as corporate political activity (CPA). We aimed to contribute to the study of CPA and development of effective counter-measures by formulating a model and evidence-informed taxonomies of UCI political activity. Methods: We used five complementary methods: critical interpretive synthesis of the conceptual CPA literature; brief interviews; expert co-author knowledge; stakeholder workshops; testing against the literature. Results: We found 11 original conceptualisations of CPA; four had been used by other researchers and reported in 24 additional review papers. Combining an interpretive synthesis of all these papers and feedback from users, we developed two taxonomies – one on framing strategies and one on action strategies. The former identified three frames (policy actors, problem, and solutions) and the latter six strategies (access and influence policy-making, use the law, manufacture support for industry, shape evidence to manufacture doubt, displace, and usurp public health, manage reputations to industry’s advantage). We also offer an analysis of the strengths and weaknesses of UCI strategies and a model that situates industry CPA in the wider social, political, and economic context. Conclusion: Our work confirms the similarity of CPA across UCIs and demonstrates its extensive and multi-faceted nature, the disproportionate power of corporations in policy spaces and the unacceptable conflicts of interest that characterise their engagement with policy-making. We suggest that industry CPA is recognised as a corruption of democracy, not an element of participatory democracy. Our taxonomies and model provide a starting point for developing effective solutions.

IntroductionThere is an urgent need for effective action to address the over 10 million annual deaths attributable to unhealthy diets. Food industry interference with policies aimed at reducing non-communicable diseases (NCDs) is widely documented at the national level but remains under-researched at the global level. Thus, this study explores how ultra-processed food industry actors have attempted to influence NCD policy at WHO.MethodsA combination of inductive and deductive thematic coding of internal industry documents, academic literature and interviews with key informants from international organisations and global civil society was used to identify action-based strategies ultra-processed food industry actors employ to influence global-level policy.ResultsUltra-processed food industry actors have attempted to influence WHO and its policies through three main action-based strategies: coalition management, involvement in policy formulation, and information management. Coalition management includes the creation and use of overt alliances between corporations—business associations—and more covert science-focused and policy-focused intermediaries, the hiring of former WHO staff and attempted co-option of civil society organisations. Industry involvement in policy formulation is operationalised largely through the lobbying of Member States to support industry positions, and business associations gaining access to WHO through formal consultations and hearings. Information management involves funding and disseminating research favourable to commercial interests, and challenging unfavourable evidence.ConclusionWe provide novel insights into how ultra-processed food industry actors shape global-level NCD policy and identify a clear need to guard against commercial interference to advance NCD policy. In their approach, the political behaviour of multinational food corporations bears similarities to that of the tobacco industry. Increased awareness of, and safeguarding against, commercial interference at the national as well as the global level have the potential to strengthen the crucial work of WHO.

Background The UN system’s shift towards multistakeholder governance, now embedded in the Sustainable Development Goals (SDGs), invites a broad range of actors, including the private sector, to the policymaking table. Although the tobacco industry is formally excluded from engagement, this approach provides opportunities for other unhealthy commodity industries to influence the World Health Organization’s (WHO’s) non-communicable disease (NCD) agenda. Focusing on the food industry, this research maps which actors engaged with WHO consultations, and critically examines actors’ policy and governance preferences as well as the framing they employ to promote these preferences in the global context. Methods All written responses from food industry actors to publicly available NCD-relevant WHO consultations held between September 2015 and September 2018 were identified, totalling forty-five responses across five consultations. A qualitative frame analysis was conducted to identify policy positions expressed by respondents, as well as arguments and frames used to do so. Results Though no individual companies responded to the consultations, the majority of participating business associations had some of the largest multinational food corporations as members. Respondents overarchingly promoted non-statutory approaches and opposed statutory regulation and conflict of interest safeguards. To this purpose, they framed the food industry as a legitimate and necessary partner in policymaking, differentiating themselves from the tobacco industry and referencing a history of successful collaboration, while also invoking multistakeholder norms and good governance principles to portray collaboration as required. Respondents contrasted this with the limits of WHO’s mandate, portraying it as out of step with the SDGs and framing NCD decision-making as a matter of national sovereignty. Conclusion We observed that the UN’s call for partnerships to support the SDGs is invoked to defend corporate access to NCD policy. This highlights the need for more cautious approaches which are mindful of the commercial determinants of health. Systematic opposition to regulation and to governance approaches which may compromise commercial actors’ insider role in global health by food industry actors shown here, and the strategic use of the Sustainable Development agenda to this purpose, raises questions about the value of collaboration from the perspective of international health agencies such as WHO.

BackgroundUltra-processed food industry (UPFI) actors have consistently opposed statutory regulation in health policy debates, including at the WHO. They do so most commonly with claims that regulatory policies do not work, will have negative consequences or that alternatives such as self-regulation work well or better. Underlying this are often assertions that industry is aligned with principles of evidence-based policymaking. In this study, we interrogate if this holds true by exploring the extent and quality of the evidence UPFI respondents employed to support claims around regulatory policy, and how they did this.MethodsFirst, we identified all submissions from organisations who overtly represent UPFI companies to consultations held by the WHO on non-communicable disease policy between 2016 and 2018. Second, we extracted all relevant factual claims made in these submissions and noted if any evidence was referenced in support. Third, we assessed the quality of evidence using independence from UPFI, nature, and publication route as indicators. Lastly, where peer-reviewed research was cited, we examined if the claims made could be justified by the source cited.ResultsAcross 26 included consultation responses, factual claims around regulation were made in 18, although only 10 referenced any evidence at all. Of all 114 claims made, 39 pieces of identifiable evidence were cited in support of 56 claims. Of the 39 distinct pieces of evidence, two-thirds were industry-funded or industry-linked, with only 16 externally peer-reviewed. Over half of industry-funded or industry-linked academic articles failed to declare a conflict of interest (COI). Overall, of only six claims which drew on peer-reviewed and independent research, none appropriately represented the source.DiscussionUPFI respondents made far-reaching claims which were rarely supported by high-quality, independent evidence. This indicates that there may be few, if any, benefits from consulting actors with such a clear COI.

Background The crucial role of non-governmental organisations (NGOs) in advancing effective regulation of health-harming corporate practices is widely accepted, yet how precisely they shape global health governance is not well-understood. While a vast literature has grappled with corporate power and its political, market, and technological dimensions, less attention has been paid to strategic efforts to counter the influence of corporate actors. Drawing on international relations and political economy scholarship, we seek to understand NGO strategies aimed at achieving greater regulation of the ultra-processed food (UPF) and alcohol industries in global fora, and examine the considerations and constraints which inform NGO strategy choice. Methods We conducted 22 semi-structured interviews with professional advocates active in global debates on UPF and/or alcohol governance, complemented by six interviews with officials from international organisations (IOs). Coding combined inductive and deductive approaches, with the latter informed by existing models of advocacy strategy. Results Participants described ‘inside’ strategies targeting IOs and member states as the primary focus of their organisations’ global advocacy, underpinned by a sense that such approaches are more effective. More confrontational, outside approaches were seen as inappropriate particularly for targeting the World Health Organisation as a key forum. Core advocacy activities thus include participation in consultations and meetings hosted by IOs, although advocates did highlight less radical forms of ‘outside’ strategies, rooted in information provision rather than protest. The direct targeting of corporations was relatively uncommon, with monitoring and exposing of corporate practices primarily aimed at building momentum for governmental regulation. Advocates highlighted the importance of engagement beyond health governance, noting, however, that resource challenges preclude effective entry into new fora for many NGOs. Discussion The challenge of attaining and maintaining insider status in relevant fora introduces constraints which may explain the reliance on quieter, less confrontational strategies. We reflect critically on the potential value of a noisier approach to addressing health-harming corporate practices, and challenge the notion that a primary function of NGOs can and should be to act as a ‘watchdog’ of corporate practices, instead advancing a wider perspective on corporate accountability.

Background A central question in contemporary health governance is how to prevent undue corporate influence. There is limited practical guidance beyond the tobacco control model. Global partnership approaches have continued to promote alcohol and ultra-processed food (UPF) industry engagement, and these industries have influenced policy and governance in ways that benefit their interests, often to the detriment of strong health regulation. In Australia industry influence has delayed the introduction of mandatory alcohol health warning labels and ensured voluntary rather than mandatory front of pack food labelling. This qualitative study is the first to our knowledge to map underlying institutional logics shaping variation in the interactions of NGOs who are not reliant on industry core funding with alcohol, UPF and related industries. Results Drawing on thirty interviews with senior policy and advocacy staff from nongovernment organisations active in alcohol and/or UPF advocacy in Australia, we find shared opposition to partnerships with the alcohol industry and significant variation towards approaches to interactions with the UPF industry. All interviewees spoke of challenges in delineating the interests of other industries that may work with alcohol and UPF, such as supermarkets and retailers, advertising agencies and public relation firms, and banks and investment entities. We identify four institutional logics for disengagement with alcohol and UPF industries: a logic of reputational risk, a logic of delegitimation, an FCTC logic, and a logic of competing interests. In contrast, we find two logics for limited engagement with alcohol and UPF industries: a logic of intelligence gathering, and a logic of ‘acting reasonable’. Finally, we identify two logics for engagement with a wider range of industries: a logic of partnership and a logic of revenue raising. Only a small number of organisations had formal written policies on conflicts of interest. Conclusions We find that many organisations have conflicting internal logics creating challenges for organisational coherence. The development of internal risk assessments by some organisations indicate efforts by staff to prevent undue corporate influence. We recommend greater transparency of policies by NGOs on preventing corporate influence, preventing conflicts of interest, and approaches to engaging a variety of corporate actors, and the establishment of a global community of practice for sharing innovative tools and approaches to preventing undue corporate influence.

Background Multistakeholderism as a norm stating that global public issues should be addressed by all those who affect or are affected by this issue, has become increasingly institutionalised in global governance, including the United Nations (UN) system. Despite an increasing body of evidence showing the risks of corporate capture of multistakeholder governance (MSG) and its related inability to deliver effective public health outcomes, this approach is increasingly common. While research shows that industry actors have pushed for MSG, and others have questioned its legitimacy, how MSG is constructed, legitimised and contested by different actors has not been systematically studied. Analysing responses to World Health Organization (WHO) consultations related to non-communicable diseases (NCDs) and associated risk factors, this study examines how actors construct or contest the legitimacy of MSG to address these public health issues. Results Our analysis of 135 responses to 10 consultations revealed significant differences in how actors justified or contested MSG. Proponents of MSG, primarily industry-affiliated organisations, often cited industry expertise and resources as key justifications for a multistakeholder approach, in which they invariably included industry as a key stakeholder. Conversely, non-profit and academic respondents often argued against industry inclusion in MSG, referring to conflicts of interest, corporate capture of the policy process and the associated risks that MSG with industry actors poses to democratic and effective policymaking. While actors commonly invoked the same values (e.g., participation, effectiveness, fairness), they interpreted these differently, to argue for or against the inclusion of industry in MSG. Conclusion Our findings underscore the contested nature of MSG, with actors calling on similar values and terminology to support fundamentally opposing positions. The ambiguity of concepts like participation, accountability and conflicts of interest may risk creating an opportunity for private sector interests to promote MSG as an ambiguous governance concept to fit their agenda. Given the normative role of WHO and other UN agencies in shaping what is considered ‘good governance’, it is essential for the WHO and other UN agencies to critically examine the evidence on multistakeholder approaches before deciding on its appropriateness and use unambiguous terminology when discussing their interpretation of the approach.