Commercial determinants of health : how do they shape health policy and the consumption of unhealthful commodities?

This thesis is about the role that commercial interests, such as multinational corporations, play in driving the consumption of unhealthful commodities such as tobacco and alcohol. The focus is on the role that health policy, namely tobacco and alcohol control policy, plays in mediating any positive association that may exist between the power of these commercial interests and the prevalence and/or incidence of tobacco and alcohol consumption. To investigate these associations, I built a novel measure of corporate power – the Corporate Permeation Index. I then use it to explain variations in the consumption of tobacco and alcohol as well as variations in the quality and/or comprehensiveness of the regulatory framework for these commodities. I also use it to quantify the interaction between state interventions such as monopolies on alcohol production and/or retail and corporate power and how the former may curb the capacity of the latter to boost alcohol consumption. Finally, I address the question of whether these associations differ by country income level. The rationale is that countries with fewer economic and human resources may be more vulnerable to corporate power and thus to weaker formulation and implementation of evidence-based health policy. I find that that corporate power is associated with higher prevalence of smoking and drinking and with weaker policy packages. I also find that the protective effect of public health policy varies according to income level but not for both substances. My findings suggest that there is a role for evidence-based public health policy in reducing the prevalence and the incidence of risk behaviours and in weakening the associations between corporate power and the adoption of these behaviours. While state interventions such as government monopolies seem to be associated with lower alcohol consumption at all income levels, tobacco control policy seems to be less effective at lower income levels. This finding suggests that more resources could be devoted to assist countries with fewer resources to improve tobacco control policy implementation.