Manufacturing dissent: How unhealthy commodity industries subvert public health action against non-communicable diseases

Non-communicable disease (NCD) is an umbrella term referring to medical conditions not directly transmissible from one person to another. Historically a concern of more economically developed nations, this group of diseases now accounts for 75% of deaths worldwide, with the vast majority occurring in low-and middle-income countries

outlined: 1) Research -Industry sponsors and promotes favourable research in order to undermine and discredit scientific consensus, 2) Law & Lobbying -Lawyers and front-organizations are utilized to influence the policymaking process, and 3) Public relations -The positive role and economic importance of the industry is promoted through direct and indirect misinformation campaigns (WHO FCTC 2019). Drawing inspiration from this report, this essay will generalize its findings to consider each of these three strategies in turn through the lens of three influential industries.

Research: sugar-coating the evidence
The concept of 'nutrition transition' describes the transformation in consumption patterns which coincides with economic development and demographic remodelling (Singh et al. 2020). With expanding globalization, energy-dense, nutrient-poor, processed foods have become increasingly available worldwide. Changes in dietary sugar intake exemplify this shift, with global sugar consumption rising from 130 to 178 million tons between 2000/01 and 2014/15 (WCRF International 2015). Sugar has been associated with a myriad of NCDs and their metabolic precursors, including cardiovascular disease, diabetes, non-alcoholic fatty liver disease, and obesity (Alam, Kim, and Jang 2022). However, conflicting reports of these associations have been presented over the years and legislative action into reducing sugar intake has therefore proven challenging.
As cardiovascular disease rose disproportionately in the United States during the 1950s, a wave of research began to point towards the culpability of dietary sugar. The sugar industry sensed the tides shifting unfavourably and intervened swiftly. Recent revelations of internal corporate correspondence document the role of the Sugar Research Foundation (SRF) in manipulating scientific debate during this critical period, directly funding and setting the research objectives of an influential literature review published by Harvard scientists in the New England Journal of Medicine (Kearns, Schmidt, and Glantz 2016). The review dismissed evidence linking sugar and cardiovascular disease citing methodological flaws, instead concluding there was 'no doubt' that the only solution to the evolving health crisis was the reduction of cholesterol and fat intake (McGandy, Hegsted, and Stare 1967). The result was that the 1980 Dietary Guidelines for Americans emphasized limiting the daily intake of these dietary fats, providing a powerful demonstration of the ability of industry to undermine scientific research.
The SRF industry body exists to this day as the 'Sugar Association', with donors including beverage giants such as Coca-Cola and PepsiCo. The cunning strategy of exploiting the power of systematic reviews to shape scientific discussion persists too. A 'systematic review of systematic reviews' demonstrated that the findings of reviews declaring financial conflicts of interest with the food & beverage industry were in direct contradiction to those which did not (Bes-Rastrollo et al. 2013). Over 80% of industry-funded studies found no evidence of an association between sugar intake and weight gain, compared to over 80% of unbiased studies which reported clear links.
As well as casting doubt over the links between dietary sugar intake and disease, the industry has deftly diverted attention to other behavioural risk factors. Coca-Cola has spent millions of dollars in promoting the predominant role of exercise in health, helping to found the non-profit Global Energy Balance Network (GEBN) and influencing public health conferences run by the International Society for Physical Activity and Public Health (ICPAPH) (Griffin 2020;Serodio et al. 2020). The wicked brilliance of manipulating research in this way is that the industry does not need to win the arguments it fabricates. The act of subverting scientific consensus and creating the pervasive impression of inconclusive evidence is enough to influence public debate and frustrate international efforts for public health action.

Law & lobbying: under the influence
The consumption of alcohol has been strongly linked with the development of various cancers, poor cardiovascular outcomes, as well as liver and pancreatic disease (Parry, Patra, and Rehm 2011). In addition, it has been proposed as both a potential causative and exacerbating factor in mental health conditions such as depression (McHugh and Weiss 2019). Given its wide availability and accessibility, its consumption is therefore associated with enormous costs -both socially and economically -particularly in younger demographics (Burton and Sheron 2018). This significant and growing burden has been met by an increasing impetus from legislators for stricter regulation.
The alcohol industry is made up of factional competitors, but in opposition to the erosion of their market they have often formed powerful political alliances to protect their interests (Room 2006). Their impact can be observed in the United Kingdom, where policy dictates that alcohol duty should increase with Retail Price Index each year. Instead, it has been either frozen or cut every year over the past decade other than 2017/18 (Institute of Alcohol Studies 2022). The role of industry lobby groups in the corridors of power has been cited as a key influence in alcohol regulation policy development (Hawkins, Holden, and McCambridge 2012). These kinds of interventions in the policy process are important, as the affordability of alcohol has been directly linked with levels of consumption, and consumption with the burden of associated health complications (Lila Rabinovich 2009). Freezing alcohol duty has been shown to lead to greater numbers of alcohol-related diseases, hospitalizations, and deaths (Angus and Henney 2019). Producers and retailers have achieved great success in impeding major reform by covertly nurturing long-term personal relationships with policymakers McCambridge, Hawkins and Holden 2014).
The problem of industry influence is not unique to the United Kingdom. The proposition of alcohol labelling policies has been subject to intense international debate where the subtle power of industry to shape dialogue can be seen clearly. Analysis of World Trade Organisation (WTO) committee meetings revealed that over 55% of WTO member statements utilized industry arguments to express their disapproval of regulatory measures (Barlow et al. 2022). These ranged from well-worn industry rhetoric, warning of the economic importance of the industry, to directly confronting the evidence base associating alcohol consumption and disease. Even moderate proposals regarding objective health warning labelling such as 'Drinking during pregnancy can be harmful to your unborn baby' have been met with hostility (The Lancet Gastroenterology & Hepatology 2022). Policy changes to enlarge such labels in South Africa were signed into law in 2017, but revoked within a few years after succumbing to pressure both nationally and internationally.
Open threats of litigation constitute a relatively small proportion of the alcohol industry's overall strategy but they remain a powerful last-resort (Savell, Fooks, and Gilmore 2016). Devolved Scottish power has to a degree liberated its legislators from the grip of behind-the-scenes lobbying efforts; however, it has also revealed the lengths to which the industry is willing to go to preserve its interests. Attempts to introduce minimum unit pricing (MUP) have resulted in the Scottish government becoming embroiled in an ongoing legal struggle with the Scotch Whiskey Association (Hawkins and McCambridge 2020). The details of this case illustrate not only the direct impact of legal proceedings, but how the mere prospect of an expensive and complicated legal battle threatened throughout, remarked to 'cast a shadow over the entire policy process'.

Public relations: smoke and mirrors
The dangers of tobacco smoking are perhaps the most well characterized of the three risk factors addressed in this essay. It is estimated that there are over 1 billion smokers globally, with smoking accounting for almost 8 million deaths per year (Reitsma et al. 2021). The NCDs implicated in this process are numerous, including cardiovascular disease, chronic respiratory disease, and a number of malignancies (Omare et al. 2022). In many respects, tobacco corporations have provided the blueprint for detrimental counterpart industries such as alcohol and sugar. Whilst the tobacco industry continues to invest in research and lobbying, these approaches have become gradually less effective as unfavourable evidence has mounted and legislative cooperation has become less politically expedient for governments. Increasingly, however, they have adapted to promote their wider contributions to society, emphasizing the industry's role in philanthropic programmes and importance to the economy.
Corporate social responsibility (CSR) is a concept which has evolved to describe the humanitarian activities of private enterprises -pursuits which allegedly demonstrate a company's concern for society as a whole rather than merely to its shareholders (Dorfman et al. 2012). The University of Bath's Tobacco Control Research Group comprehensively outlines a great number of these schemes, documenting that in 2018, Marlboro parent company, the Altria Group, donated over 50 million USD to social programmes ('CSR Strategy -TobaccoTactics' n.d.). Recipients included environmental sustainability groups, Gay Pride Virginia, the American Red Cross, and the National Museum of African American History & Culture. Visiting the British-American Tobacco (BAT) website, it is difficult to recognize that it is even a tobacco company. Its involvement in charitable campaigns is at the forefront of its rainbow themed rebrand, boasting £19 million in 'community investment programmes', including 'crop diversification, women's empowerment and rural development to provide access to healthcare, clean water and sanitation' (' BAT -Corporate Social Investment' n. d.). For context, BAT and the Altria Group recorded revenues of over 35 billion and 26 billion USD in 2021, respectively (Macrotrends n.d.).
Tobacco usage has been highlighted as a major contributor to the NCD burden in South-East Asia, with smoking rates as high as 63% amongst men in Indonesia (Thakur et al. 2011). The role of CSR initiatives in establishing this foothold has been pivotal, with tobacco corporations portraying themselves as pillars of economic growth and development, thus developing valuable political relationships and generating an element of reputability amongst the public (Amul, Tan, and Van Der Eijk 2021). The industry-line of economic importance is an enduring one, tracing back to the earliest tobacco public relations campaigns. However, the tobacco industry provides a relatively modest contribution to the economy, and it has been shown that individual spending on cigarettes is simply redirected to other sectors of the economy following smoking cessation (Warner 2000).
A generous reading of these CSR activities would be that tobacco companies are showing genuine recognition for the harmful consequences of their dealings and acting to rectify them. However, the evidence does not support this view. Archived documents shared by American tobacco companies as part of a lawsuit settlement showcase a core intention in the formation of CSR programmes -'a means of enhancing reputations and improving financial success' (Coombs 2017). Seeking to address growing public scrutiny, a former tobacco executive advised colleagues that the industry 'must be seen to be listening, must be seen to be trying to fix things' (Philip Morris Records 2000). Seen to be trying. Taking into account the industry's history, financial incentives, and internal correspondence, a more realistic perspective is that the true motivation for CSR programmes is to associate the industry with the integrity of popular social movements in order to launder its murky reputation, generate positive, tax-free publicity, and protect long-term economic interests.

Discussion & solutions
Big industry strategy to subvert health discourse and policy presents a major barrier to progress, but in truth, these obstacles are symbolic of wider structural challenges. Large, multi-national corporations wield powerful influence in our system of global governance, but are ultimately beholden only to their stakeholders. They are under no obligation of social responsibility, despite their attempts to show otherwise. Further, competing international interests -public and private -can conflict with broader global ambitions. For example, cigarette usage plummeted in the USA during the 1980s due to policy interventions such as taxation and public health messaging (Garfinkel 1997). During the same period, American exports of cigarettes increased by 260%, thus retaining any economic benefits and distributing the harmful health consequences overseas (Saloojee and Dagli 2000). This has become a feature of the modern approach of tobacco corporations which now target more poorly resourced countries, perceiving them to have weaker facilities to resist industry power (Amul, Tan, and Van Der Eijk 2021).
Short of a global systemic overhaul, there are pragmatic options to limit the influence of industry in the policymaking process, responses do not need to be generated from scratch, either. The tobacco industry provided an example that other industries have followed -similarly we can reapply principles in the global battle against tobacco to other sectors. This essay posits that the role of industry in public health policymaking should be zero, and that a starting point would be to reapply WHO FCTC recommendations more widely to any sectors judged to be harmful to health.
Guidelines should be developed from these foundations through inclusive international collaboration, with a clear mission statement to eliminate the influence of industry in population health intervention. Policies to manage the role of industry in research could incorporate expanding research disclosure policies to increase transparency -for example detailing the role of industry in shaping research questions -and increasing available funding for relevant research to reduce necessity to find funding from biased sources. In regulating lobbying, propositions could include mapping institutions linked with harmful industry, screening and if necessary excluding prospective collaborators in the policymaking process, educating government officials on the harmful impact of industry involvement, and ensuring that any agenda for product control includes holding industry accountable and liable for any damaging practices. With regards to public relations, emphasis should be placed on disincentivising CSR activities such as through reviewing tax breaks which are currently widely available and facilitate what is essentially free advertising. Efforts should also be made to publicize the true impact and intention of CSR programmes. Industry influence is certainly not the only obstacle in reducing the global burden of NCDs, but without decisive action to counteract it, it will continue to hinder and reverse progress indefinitely. Only by engaging directly with industry strategy with an equally comprehensive platform of reform produced in the spirit of international solidarity can this challenge be met effectively.

Disclosure statement
No potential conflict of interest was reported by the author(s).