Introduction

The “commercial determinants of health” have been recently defined as “the systems, practices and pathways through which commercial organisations drive health and equity”¹. Although commercial entities can make positive contributions to health, there is growing evidence that many of the products and practices of the largest transnational corporations are responsible for increasing avoidable ill-health and social and health inequalities. They do this using various tactics including aggressive marketing and promotion, lobbying politicians to influence legislation in their favour, and tax avoidance to prioritise their profits over public health. The scale and enormous cost of the problem is indicated by the evidence that just four industry sectors (tobacco, ultra-processed food, fossil fuels and alcohol) are estimated to account for 19 million global deaths annually².

Unhealthy products and marketing

Marketing practices by large transnational corporations drive increased consumption of unhealthy products such as high fat, sugar and salt foods, alcohol and sugary drinks.

Sponsorships

Corporations such as Budweiser, Coca-Cola and MacDonalds frequently sponsor major international sporting events such as the FIFA World Cup and the Olympic Games, which normalises consumption of their unhealthy products, particularly among children³.

Advertising
Outdoor advertisements for unhealthy foods and drinks are concentrated in deprived areas and in those frequented by young people, which may reinforce social inequalities in health^4,5.

Lobbying
Guidance by the previous Conservative government which prompted food retailers in England to promote minimally processed and nutritious food was abandoned in 2023 after a lobbying campaign by the Food and Drink Federation⁶, which represents corporations including Nestlé, Coca-Cola and Mars, some of the world’s biggest ultra-processed food firms.

A 2025 analysis of food industry lobbying, by the Food Foundation, reported that ministers at DEFRA (Department for Environment, Food and Rural Affairs) met with food businesses and their trade associations 1,408 times during the period January 2020 to June 2024, and that there was a lack of transparency about the content of these meetings⁷. The highest number of ministerial meetings were with the main supermarkets. The government, however, states its intention to continue to include the food industry in the development of its policies to combat obesity⁸.

Location of “health-reducing” amenities
Vital community amenities such as pharmacies, supermarkets and banks are being replaced in high streets by vape shops, bookmakers and takeaway outlets, so called “health-reducing” amenities⁹. This trend is particularly striking in deprived areas, including areas in the North of England where health and economic inequalities are already significant. Furthermore, slot machine companies are targeting Britain’s poorest neighbourhoods. Slot machines are considered among the most addictive gambling products in health surveys. A third of 1,452 adult gaming centres with 24-hour access are located in the poorest 10% of local authorities, with more than half in the most deprived 20%, compared to no gaming centres in 14 local authorities which rank in the top 50% wealthiest council areas¹⁰. 

Housing and health

Housing can also be classed as a commercial determinant of health because houses are built by developers driven by financial gain. Viability testing allows developers to reduce the number of affordable homes they build, if building them risks reducing their profits to below 20%. A 2017 review of 11 local authorities across nine cities in England found that 2,500 planned affordable homes (79%) were not built as a result of viability testing. This practice was most prevalent in Manchester, Birmingham and parts of London resulting in less than 1% affordable homes being built¹¹. However, the government is reluctant to review viability testing in case this negatively impacts its target of 1.5m homes¹².

Pollution

The Volkswagen emissions scandal, which involved the installation of illegal software in their diesel vehicles to manipulate emission tests and exceed allowed nitrogen oxide levels, is another example of a commercial company prioritising profit over health. The company agreed to pay £193m to settle 91,000 legal claims in England and Wales to avoid the legal costs of a trial and possible appeals, without admitting any wrongdoing¹³.

Nitrogen oxides are known to be harmful to health and, because of our over-reliance on fossil fuel-driven cars, people who live close to major roads are exposed to higher levels, particularly in deprived areas¹⁴. In addition, airborne metals and polycyclic aromatic hydrocarbons (PAHs) derived from combustion, industrial and vehicle emissions in urban areas are a major risk to health. PAH levels in Manchester are potentially linked to 1,455 in one million cancer cases¹⁵.

Work
The employment conditions of people working for large corporations can sometimes be detrimental to their health. Around one in ten UK workers are in insecure work, or work longer hours (one in six), night shifts (one in nine) or irregular hours (one in six). In addition, rates of working to tight deadlines (three-fifths) and at high speed (two-fifths) are among the highest in Europe, whilst half of all workers work more hours than expected and only one-third have control over how they work¹⁶. These types of work, often undertaken by those already disadvantaged in the labour market, such as those in low-paid work, black people, young people and the disabled, put the health of UK workers at risk. For example, a significant link between zero-hours contracts (i.e. are on call and only paid for the hours they work) and a mental health issue or low wellbeing was found in eight of 17 studies reviewed by the Mental Health Foundation, whilst only two studies found no association¹⁷.

The Pharmaceutical Industry
The pharmaceutical industry in general has a positive impact on people’s health via its development of drugs and vaccines which improve patient outcomes and life expectancy. However, pharmaceutical companies often prioritise common medical conditions to maximise profits at the expense of rare diseases. In addition, some large pharmaceutical companies use a variety of tactics to prioritise profits over public health, including tax avoidance, charging high prices for their products and paying-off competitors to secure the market.

In 2018, the pharmaceutical companies, Abbott, Johnson & Johnson, Merck, and Pfizer, were reported to be hiding their profits in overseas tax havens and, at the same time, charging high prices for their products, resulting in less money available to governments to invest in healthcare¹⁸.  Recent evidence suggests that this practice is more widespread and that 15 of the world’s biggest pharmaceutical companies have more than 1,300 subsidiaries in tax havens, amassing profits of over 580 billion euros over the last five years¹⁹.

Auden Mckenzie and Actavis UK (now known as Accord-UK) were fined over £260m by the Competition and Marketing Authority for charging the NHS excessively high prices for hydrocortisone tablets over almost 10 years. In addition, they paid off would-be competitors to stay out of the market so as to retain their role as sole provider of the drug²⁰.

Furthermore, the high prices of the weight-loss drugs Ozempic/Wegovy and Mounjaro to the NHS mean that only 220,000 people in England will benefit, out of 3.4 million who are eligible, over the next three years²¹. These drugs, which improve health by reducing the comorbidities associated with obesity, are available privately, but only to those who can afford them.

What the UK Government is doing to tackle commercial determinants of poor health 

Conclusions

Both powerful transnational corporations and UK-based companies are using a variety of tactics to increase their profits at the expense of public health. These actions exacerbate existing health inequalities, particularly in those of lower socio-economic status in deprived areas of the country. The UK government has taken some action to tackle the adverse commercial determinants of health but more is needed²⁴. For example, monitoring and exposing corporate activities, closing legal loopholes, new legislation, and challenging misleading evidence provided by corporations to detract from harmful products. These need government involvement, together with support from the general public and all organisations committed to improving the nation’s health.

Barbara Baker

References

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