Big Alcohol and the Commercial Determinants of Health: What can public health do?

By Callie Anderson

Callie Anderson is completing her Masters of Public Health at the University of Waterloo. She currently works as a Health Promoter developing programs and advocating for policies to improve public health and health equity at the community level.

What are the Commercial Determinants of Health?

The commercial determinants of health (CDoH) are “the strategies and approaches the private sector uses to promote products and choices that are detrimental to health” ¹. The concept of the CDoH has only relatively recently emerged as an area of inquiry despite its connection to one of the most urgent public health challenges worldwide, the prevention of non-communicable disease (NCD). 

The inquiry into the CDoH over the past decade has led to a focus on the leading risk factors (e.g., tobacco use, alcohol consumption, poor diet, physical inactivity) for NCDs and how the burden of disease can be attributed to the significant influence exerted by Big Tobacco, Big Alcohol, and Big Food ^2,3. While these three industries are most common in CDoH research, discussion of the CDoH can also be extended to include other industry and products of concern including fossil fuels and gambling ⁴.

Earlier this year, the Canadian Centre on Substance Use and Addiction (CCSA) released a revised version of the Low-risk Alcohol Drinking Guidelines with new guidance for alcohol consumption ⁵. To lower one’s risk of alcohol related health harms, it is recommended to limit alcohol intake to two standard drinks per week ⁵. This recent revision has brought a renewed attention to the societal impact of alcohol and has spurred my interest in exploring some of the ways commercial interests of the alcohol industry can shape consumption patterns and even alcohol policy.

Use of the “Corporate Playbook”: A few examples from Big Alcohol

Lacy-Nichols et al. have synthesized and defined the key strategies commonly used by industry to protect business interests, largely at the expense of public health, as the ‘corporate playbook’ ⁶. Here I discuss only a few of these strategies deployed by Big Alcohol specifically. 

Normalization, denial, and the spread of misinformation

The alcohol industry deploys several strategies to normalize alcoholic beverages, effectively framing the public’s understanding and perceptions of alcohol ⁴. We can observe these strategies in plain sight, for example, through marketing and advertising at sporting events, on social media, on bus shelters and billboards, to product placements in our favorite TV shows and movies. 

However, many of these strategies are less visible. For example, youth educational programs have been found to teach students about peer pressure and ‘responsible’ alcohol consumption while largely leaving out discussion of industry marketing and advertising tactics, as well as the health harms associated with alcohol ⁴. These strategies present alcohol as a normal behaviour that one must learn to navigate, thus placing any blame for irresponsible consumption on the individual and away from the industry ⁴.

Beyond strategies to normalize alcohol consumption, the alcohol industry has also played a significant role in shaping the perception of alcohol-related harm through denying and distorting scientific evidence ⁷. Leading alcohol industry bodies have been found to deny, for example, that a relationship between alcohol and cancer exists or have omitted any mention of cancer in messaging ⁷. Further, industry has also been found to distort the facts, implying that the risk depends on consumption patterns (i.e., binge drinking is associated with higher risk) ⁷. Distraction is yet another strategy used to take attention away from health harms and the role alcohol plays, in which industry has been found to focus attention on the various other risk factors for cancer ⁷. Such actions have led to the spread of misinformation that has largely allowed alcohol consumption to remain stigma-free. 

Political and policy influence via problem framing 

While normalization and denialist strategies have been effective in shaping the public’s understanding and perception of harms associated with alcohol, such strategies have also influenced how alcohol is understood among policymakers and framed as a problem requiring policy action. ⁸. By framing problems associated with alcohol consumption as operating only at the individual level, this effectively removes the industry from the discussion and therefore any subsequent policy measures used to address the problem ⁸. The alcohol industry also actively works to situate itself as a key stakeholder in policymaking by participating in public consultations, parliamentary committees, building relationships with government actors and regarding themselves as partners in policy development ⁸. 

We can see examples of this type of industry influence on Canadian policy most recently in alcohol industry’s successful lobbying of the federal government to reduce a scheduled 6.3% excise tax increase on alcohol products, which was pegged to the rate of inflation ⁹. These types of excise taxes are some of the most effective policy tools at the government’s disposal to improve public health and generate revenue to address the health and social costs of health harming products.  The actual impact of this tax increase on both producers and consumers would have been minimal: for example, the price of an imported six-pack of beer would increase by only 5-10 cents. 

However, the industry immediately engaged in government lobbying and used the media to shape the narrative, citing significant impacts on restaurants and bars that are still recovering post-pandemic ¹⁰. As a result of this lobbying, and industry outcry, the government responded by raising the excise tax by only 2% for 2023-2024, after which point it will be re-evaluated. By contrast, the scheduled 6.3% excise tax increase on tobacco products went ahead without opposition.

Corporate social responsibility

A brief search of the provincial liquor control boards demonstrates this industry strategy in action. From the Liquor Control Board of Ontario’s (LCBO) “Shine Sustainability” campaign to British Columbia Liquor's (BCL) fetal-alcohol spectrum disorder (FASD) awareness, safe ride, and Red Cross disaster relief initiatives, such campaigns create an ‘illusion of righteousness’ ¹¹. While the LCBO’s initiative strives to associate the industry with philanthropy, it is also a means of brand marketing and allows the industry to access currently untapped markets ¹¹. In addition to philanthropic initiatives, BCL’s campaigns further contribute to the framing of alcohol as an individual responsibility, thus aiding in framing the public and policymaker understanding of alcohol, shaping the narrative and perpetuating a positive industry reputation ¹¹. 

What can public health do?

With the new Low-Risk Alcohol Drinking Guidelines, it is likely that a large proportion of Canadians are consuming alcohol at hazardous level, as such there is a need for alcohol policy to better align with that applied to other known health-harming substances. Below are a few ideas for how public health can respond to the corporate playbook. I encourage you to read the article by Lacy-Nichols et al. to learn more.

Education and training for public health professionals ⁶: Public health undergraduate and graduate degrees should include a focus on the commercial determinants of health and how to counter industry tactics through advocacy, communications, and community engagement/mobilization, among other strategies⁶.

Increase public sector resources ⁶: To challenge the strategies of multi-billion-dollar industries, the public sector must also be sufficiently resourced. Health taxes, like the excise tax initially scheduled for alcohol products, are evidence-based policy tools that can generate revenues that can be directed towards public health initiatives to improve health outcomes ⁶. Through health policy advocacy efforts, public health should include a focus on exposing industry tactics that are working to influence not only policy, but public perception and understanding as well.
 

Change the narrative ⁶: Industry has great power to shape the narrative of what is considered harmful and who is responsible when harms occur (i.e., individuals as opposed to industry or government). This narrative pervades society and affects the degree to which government actors take action to protect public health. Public health must find new ways to communicate and advocate for evidence-based policy that addresses the root causes of poor health in order to challenge the corporate narratives that protect commercial interests at the expense of public health ⁶. 

Have your say: advocate to your Member of Parliament in support of maintaining the scheduled excise tax increases on alcohol products.

References
1.    Kickbush, I., Allen, L. & Franz, C. (2016). The commercial determinants of health. The Lancet, 4(12). https://doi.org/10.1016/S2214-109X(16)30217-0 
2.    de Lacy Vawdon, C. & Livingstone, C. (2020). Defining the commercial determinants of health: a systematic review. BMC Public Health, 20(1022). https://doi.org/10.1186/s12889-020-09126-1 
3.    Mailon, M. (2020). An overview of the commercial determinants of health. Globalization and Health, 16(74). https://doi.org/10.1186/s12992-020-00607-x
4.    Maani, Nason, Mark Petticrew, and Sandro Galea (eds), The Commercial Determinants of Health (New York, 2022; online edn, Oxford Academic, 20 Oct. 2022), https://doi.org/10.1093/oso/9780197578742.001.0001
5.    Paradis, C., Butt, P., Shield, K., Poole, N., Wells, S., Naimi, T., Sherk, A., & the Low-Risk Alcohol Drinking Guidelines Scientific Expert Panels. (2023). Canada’s Guidance on Alcohol and Health: Final Report. Ottawa, Ont.: Canadian Centre on Substance Use and Addiction
6.    Lacy-Nichols, J., Marten, R., Crosbie, E. & Moodie, R. (2022). The public health playbook: ideas for challenging the corporate playbook. The Lancet, 10(7). https://doi.org/10.1016/S2214-109X(22)00185-1 
7.    Petticrew, M., Hessari, N. M., Knai, C. & Weiderpass, E. (2017). How alcohol industry organisations mislead the public about alcohol and cancer. Drug and Alcohol Review, 37(3). https://doi.org/10.1111/dar.12596 
8.    McCambridge, J. Mialon, M. & Hawkins, B. (2018). Alcohol industry involvement in policymaking: a systematic review. Addiction, 113(9). https://doi.org/10.1111%2Fadd.14216 
9.    Federal government capping excise tax on alcohol after outcry (28 March 2023). CTV News. Retrieved from https://ottawa.ctvnews.ca/federal-government-capping-excise-tax-on-alcohol-after-outcry-1.6332687 
10.    Restaurants and bars brace for biggest alcohol jump in 40 years (24 March 2023). CTV News. Retrieved from https://www.ctvnews.ca/politics/restaurants-and-bars-brace-for-biggest-alcohol-tax-jump-in-40-years-1.6327044?_cldee=KJ8N_g8RmdENuysGHRKg4l7USzzGJmLKY4-CmZKP6ARHer7-1XnFg5SSPtXI7Q3z&recipientid=contact-34d93a183ae6eb11bacb0022486d826f-d48ca09de7504ddc88a0335a46f74788&esid=7744f375-42ca-ed11-b596-000d3a09c3d2 
11.    Yoon, S. (2013). The illusion of righteousness: corporate social responsibility practices of the alcohol industry. BMC Public Health, 13(630). https://doi.org/10.1186/1471-2458-13-630