• public health

The subversive influence of industries peddling tobacco, alcohol, ultraprocessed food and drink, and gambling (known as unhealthy commodity industries) is a recognised threat to public health, including the production of evidence and the implementation of public health policy.1 There has been considerable work in this area trying to expose the influence.1 In this issue of BMJ Global Health, two papers further explore these issues.

In the first paper by Knai et al,2 the authors make a convincing case of using a complex systems approach to conduct research across unhealthy commodity industries; reframing their impact ‘not so much as an aggregation of individual ‘choices’ but more a result of the interactions between diverse actors, factors and their environments’ which ‘are greater than the sum of their parts’, producing change across the system. They argue that such an approach will be more effective in uncovering the diverse and complex ways in which these industries exert influence, resulting in an improved response from the public health community.

The second paper by Lacy-Nichols and Marten,3 argue that ‘power has been overlooked in conceptualisations of the Commercial Determinants of Health’ by presenting coercion and appeasement as two broad ways in which industry uses power to influence public health policy. Coercion can be antagonistic (and so, more visible)—for example, aggressive lobbying and campaigns against policies. However, appeasement takes a more subtle approach to neutralise opposition by establishing partnerships between industry and public health. Such appeasement can undermine the integrity of the researchers, allow for the science to be questioned and can fracture public health groups thus diminishing their collective effectiveness.

In situations of ‘appeasement’ such as partnerships between industry and public health professionals (including researchers), declaration of conflicts of interest have been used, often pre-emptively, as a method to deal with potential concerns. However, such simple disclosure is insufficient (given the complexities involved in relations with industry), and many researchers are uncertain as to when conflicts of interest need to be declared.4 Furthermore, conflicts of interest have focused on individuals and not institutions, as identified in at least one case study of how the opioid epidemic was propagated in the USA.5

In this editorial, we, as members of the International Network for Epidemiology in Policy (https://epidemiologyinpolicy.org/—an organisation which exists to promote integrity, equity, and evidence in policies impacting health) describe our recent experience of a potential ‘appeasement’ strategy to influence public health policy—that is, through debates and discussions in an academic journal. Our experience occurred as part of a new experimental policy forum, by the American Journal of Public Health, in which the journal invited comments on the new (US) national guidance by the Food and Drug Administration on e-cigarettes.6

The forum’s objective was to ‘…facilitate a dialogue among public health practitioners on emerging health issues that might otherwise go unnoticed’6 To date, this is the only experimental forum that the journal has published. The commentaries were reviewed internally, and the editors highlighted four themes from the solicited commentaries. However, the exact process to select the commentators, the questions posed and how the highlighted themes were determined are not presented in the forum. Of the 13 commentaries published in that forum, three declared industry ties,7 in addition to a few other academics who are sympathetic to such views. A recognised strategy used by the tobacco product industry has been to undermine and discredit broadly accepted bodies of evidence.1 One of the conclusions of the forum was highlighting the lack of evidence and suggesting ‘…there may be research bias operating here, whereby industry-sponsored studies are discredited or there is an overwhelming focus on toxicity’.6

Understanding how this conclusion was reached is difficult to ascertain. Current evidence-based guidelines concur that there is insufficient evidence to promote use of e-cigarettes for cessation purposes, or for broad public consumption; including by the US Surgeon General, the US National Academies of Sciences, Engineering and Medicine, The Cochrane Collaboration and WHO.8–11 In fact, with such potential for harm and insufficient evidence, public health practitioners, as a precaution, call for more research, and support harm reduction policies to minimise risks.

Our letter to the editor of that journal detailing these concerns was rejected in contrast to the stated objectives of the forum. In our opinion, this is a risk to the impartiality of the journal and a failure to uphold methodologically sound, scientifically defensible views. Unfortunately, instead, the forum gave industry an unequal, unjustifiable voice to influence the policy discussion while at the same time, claiming bias against the industry. Ultimately, the industry creates doubt by implying that the benefits of e-cigarettes outweigh risks and by exaggerating results from studies that are favourable while undermining and attacking unfavourable results.

Interestingly, the same journal—American Journal of Public Health—published a 2019 systematic review that reported a strong association between industry funded authors and a supportive stance on e-cigarette products.12 The growing use of misinformation in science and marketing to influence policy decisions requires extreme caution to prevent industry-funded research or commentary that promote ‘efficacy’ over cautions about real and potential harms,12 whether it be tobacco products, or any of the other unhealthy commodity industries.

The conclusion of the policy forum is inherently difficult to separate from acknowledged conflicts of interest declared by some of the authors whose comments were selected for inclusion in the policy forum. Although published alongside other comments (ie, with comments by authors who had not declared any such conflicts of interest), the policy forum risks being seen as providing evidence towards supporting electronic nicotine delivery systems as a ‘best solution’ for the tobacco epidemic—which is ultimately the industry’s goal.

The policy forum may, therefore, be seen as a possible manifestation of the type of influence that was described Knai et al2 and by Lacy-Nichols and Marten.3 We are thus very pleased to see these two publications addressing these concerns in ways that go beyond simple disclosure of conflicts of interest—by highlighting the complexity of such influences, the need to make their more subtle forms more visible and opportunities to challenge and diminish such industry influences on public health. Both papers provide a framework for more broadly considering, studying, addressing and avoiding the influence of industry on public health.

Public health professionals and organisations (including academic journals in their role as platforms for debates and discussion), with the interest of the public as the foremost aim, must work together to carefully avoid, scrutinise and qualify any (appearances of) such advances and appeasement, and act as a resource for the public, independent of any (appearances of) financial, ideological or other types of conflicts. We, therefore, agree with and join the call for a unified public health alliance to uncover the influence of industry, as ‘…the absence of a unified public health alliance has important consequences’.3