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Health and Wellbeing Board |
16 July 2025 |
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Report of Peter Roderick, Director of Public Health, City of York Council |
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The Commercial Determinants of Health – Exploring a York approach
Summary
1. The activity of the private sector shapes the physical and social environments in which people are born, grow, work, live and age – both positively and negatively – and therefore influences the health and wellbeing of York residents.
2. This report introduces to the Board the substantial evidence emerging within health and social policy research on what are termed the ‘Commercial Determinants of Health’ (henceforth CDOH). This concept, applied locally, refers to the way unhealthy commodity industries, for instance those selling tobacco, alcohol, unhealthy food, or gambling products, are undermining our local Health and Wellbeing Strategy objective to ‘become a health-generating city’ and have a negative impact on goals improve healthy life expectancy and reduce the gap between the richest and poorest in the city.
3. In particular the evidence is strongest about our youngest: if York is committed to giving every child the ‘best start in life’, we need to protect our youngest residents from the influence and marketing of harmful products, and give them freedom to live healthier lives.
4. Partners around the Health and Wellbeing Board are asked to note the report, as well as the presentation to be given on the day, which includes a number of recommendations around
· greater awareness of CDOH amongst partner organisations
· suggested policy positions organisations may want to take
· The Board endorsing the Association of Directors of Public Health (APDH) Y+H Consensus Statement on the CDOH.
The link between unhealthy commodities and health in York
5. In York, two thirds of the life expectancy gap in both females and males between our richest and poorest communities comes from three areas: cardiovascular diseases, cancer and respiratory diseases.
6. An estimated 80% of CVDs are considered preventable (World Heart Foundation), 30% of cancers are considered preventable (World Health Organisation) and around 60% of respiratory diseases are considered preventable (Office for National Statistics).
7. Data from the Global Burden of Disease study shows that the trio of three unhealthy commodities leads to more than a third of all deaths in York, tobacco (at 17%), unhealthy food (at 13%) and alcohol (at 4%).
8. The burden of these unhealthy commodities falls particularly hard in terms of early deaths. 594 deaths in York in 2021 were of people under 75 whose death was considered ‘preventable’, 90% of these were from non-infectious causes and an estimated 45% of these were from unhealthy commodities; this means that 240 out of 594 early deaths in York in 2021 were due to unhealthy commodities.
9. Beyond early mortality, unhealthy commodities result in a significant amount of life lived with long terms illness or disease in York – in fact, compared to a decade previously, in 2023 males in our city lived with an additional 27 months of ill health, and females 43 months.
10.Unhealthy commodities cost the York economy dearly, through health and care costs, lost productivity, economic drag through taxation, and wider societal implications such as smoking-related fires or alcohol-related antisocial behaviour. It is estimated by Action on Smoking and Health that smoking costs York £109m per year, and by the Institute of Alcohol Studies that alcohol costs York £91.7m per year.
Commercial determinants of health – the academic evidence
11.The literature on the commercial determinants of health stretches back decades and begun with significant evidence that global and local action to regulate the harmful effects of tobacco was very slow to be implemented due to the actions of the tobacco industry. Whilst conclusive proof of the link between smoking and lung cancer emerged in the early 1950s, the first piece of legislation (ban on TV advertising) did not come in until 1965, and subsequent legislation such as a wider advertising ban and indoor smoking bans were not introduced until the 2000s.
12.Leaked releases from major tobacco companies showed extensive use of a shared ‘playbook’, the aim of which was to dissemble, sow doubt around the evidence, introduce distraction tactics (e.g. cigarette filters and ‘mild’ cigarettes), and aggressively lobby governments to avoid or delay stronger legislation.
13.With the tobacco industry, such tactics and activity still persist, although the signing by 182 countries of the WHO Framework Convention on Tobacco Control has been a highly successful measure to curb its influence. Similar tactics are however now known to be used by other unhealthy commodity industries, such as alcohol, gambling and unhealthy food companies.
14.In 2023, the Lancet Commission on the Commercial Determinants of Health published a definitive series of articles laying out a definition of CDOH as
private sector activities which impact public health, either positively or negatively, directly or indirectly, and their enabling political and economic systems and norms. [1]
15.The authors were clear that ‘Commercial entities can have positive effects on health and society, not least through the creation of products and services that are beneficial, or even essential, to health’. However ‘there is now overwhelming evidence that some, particularly the largest, multinational and transnational corporations … are having increasingly negative effects on human and planetary health and social and health inequities’.
16.Examples of industries where these unhealthy commodity practices occur including gambling, tobacco, fossil fuels, formula milk, alcohol, unhealthy food, the car industry, companies offering loans which could be considered ‘predatory’, sugar sweetened beverage manufacturers, and social media companies.
17.However, it should again be emphasised that CDOH approaches are not designed to focus on any industry specifically, but on the tactics which are found to be common across unhealthy commodity industries and which undermine health, which in summary include:
· Preventing, undermining, or circumventing public policy
· Manufacturing doubt on the science, and shifting blame
· Aggressive marketing and advertising
· Shaping social norms around personal responsibility
· Public-private partnerships (e.g. sponsorship)
· Reputational management
18.The Lancet series identified three issues that lie at the heart of the CDOH: the political and economic system, the commercial sector and key underlying drivers – power, externalities, and norms; and it concluded that
‘Reshaping the model in the public interest will therefore require the political and economic changes that are increasingly being called for. Commercial entities will need to meet the true costs of the harm they cause; governments will need to exercise their power in holding commercial entities to account; and norms need to be reshaped in the public interest, drawing attention to the right to health and governmental obligation to protect health and not just corporate freedoms.’
19.Three examples are now given of how these mechanisms of commercial influence work in practice.
Example #1 – Infant formula
20.The protection, promotion and support for breastfeeding are a vitally important public health priority as breastfeeding promotes health, prevents disease, and provides numerous benefits for both mother and baby. There is overwhelming evidence that breastfeeding saves lives and protects the health of babies and mothers both in the short and long term.
21.UNICEF and the World Health Organisation recommend exclusive breastfeeding for the first six months of an infant’s life, with continued breastfeeding alongside the introduction of appropriate complementary foods up to two years of age; however, breastfeeding is no longer seen as the norm.
22.Research has shown that eight out of ten women stop breastfeeding before they want to. Factors for this include: a lack of support from family or professionals; belief that they have insufficient milk supplies to nourish their baby; employers who have not got adequate provision to support women returning to work and expressing breast milk; or lack of supportive environments in which women feel comfortable feeding their babies when out in the community.
23.Breastfeeding is viewed by many as difficult to achieve and often unnecessary because formula milk is seen as a close second best. This is largely due to the strong commercial influences from formula milk companies, which use marketing strategies to promote formula milk as equal to breast milk.
24.The marketing of commercial milk formula (CMF) has irrevocably altered the infant feeding ecosystem, as more infants are fed formula milks than breastmilk.
25.CMF marketing is a multifaceted, sophisticated, well resourced, and powerful system of influence that generates demand and sales of its products at the expense of the health and rights of families. Digital platforms and use of individual data for personalised and targeted marketing have substantially enhanced the reach and influence of this system.
26.CMF marketing oversimplifies parenting challenges into a series of problems and needs that can be resolved by buying specific products. Marketing of CMF manipulates and exploits emotions, aspirations, and scientific information with the aim of reshaping individual, societal, and medical norms and values.
27.Health professionals and scientific establishments are also targeted through financial support, corporate-backed science, and medicalisation of feeding practices. Conflicts of interest threaten the integrity and impartiality of health professionals.
28.To limit the impact of CMF marketing on breast feeding The International Code of Marketing of Breast Milk Substitutes was developed for regulating inappropriate marketing and promotion of CMF
29.The International Code of Marketing of Breastmilk Substitutes (the Code) is an international health policy framework to regulate the marketing of breastmilk substitutes in order to protect breastfeeding. It was published by the World Health Organisation in 1981 and is an internationally agreed voluntary code of practice.
30.The Code was written in response to the marketing activities of the infant feeding industry which were promoting formula feeding over breastfeeding, in turn leading to dramatic increases in maternal and infant morbidity and mortality.
31.The underlying basis for the Code is the belief that the health of babies is so important that the usual rules governing market competition and advertising should not apply to products intended for feeding babies. Therefore, all Governments should legislate to prevent commercial interests from damaging breastfeeding rates and the health of their population.
32.The Code regulates the marketing of breastmilk substitutes, which includes infant formulas, follow-on formulas and any other food or drink, together with feeding bottles and teats intended for babies and young children.
33.The Code also sets standards for the labelling and quality of products and for how the law should be implemented and monitored within countries.
34.Restricting marketing does not mean that the products cannot be sold, or that factual and scientific information about them cannot be made available. Nor does it restrict parents’ choice. It simply aims to make sure that their choices are made based on full and impartial information rather than misleading, inaccurate or biased marketing claims.
35.Parents make decisions, frequently in vulnerable situations, and often in the absence of timely, clear, accurate and impartial information. Understandably, they want to do the best for their babies, and are highly responsive to brand reputation, which is built in different ways, including through marketing of adjacent products such as follow-on formula, and messaging on packs. Most parents are likely to find it difficult to meaningfully assess information about product quality. Price is often used as a proxy for quality despite NHS advice that ‘It does not matter which brand you choose, they'll all meet your baby's nutritional needs, regardless of price’. Once parents have found a brand that works for their baby, they are unlikely to switch, remaining loyal to their chosen brand.
36.Recommendations for protecting, supporting and promoting breastfeeding nationally and locally:
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National government and policy makers |
Local healthcare systems and education |
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An end to the marketing of formula milk via effective legislation, monitoring and implementation of the Code |
Provision of culturally appropriate breastfeeding care and support |
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Increased regulation and transparency around lobbying to decrease the influence of formula milk companies |
Improvements in breastfeeding education, training and skills of healthcare professionals |
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Investments in maternity protection, supporting breastfeeding in the workplace and enforcing legislation prohibiting discrimination against women during maternity |
Empowering parents and families to breastfeed their children for as long as they wish |
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Health organisations rejecting funding from the Commercial Milk Formula industry |
Education and training so professionals and families understand “normal” baby behaviours to reduced introduction of early infant formula |
Example #2 – Alcohol
37.From headaches and poor-quality sleep to high blood pressure, anxiety and cancers, the wide-ranging impacts of alcohol affect a significant proportion of the population. There are also increasing numbers of people requiring hospital admission and dying before their time because of alcohol-related illnesses. High alcohol-related hospital admissions rates are of particular concern in York and represent the tip of the iceberg of local alcohol-related harms. In addition, it is noted that people in socio-economically disadvantaged groups experience greater levels of harm from alcohol despite lower consumption levels.
38.The key factors influencing alcohol consumption and therefore driving alcohol harms, are:
· price (‘affordability’)
· how we think about alcohol and what’s normal (‘acceptability’ / social norms)
· ease of purchase (‘availability’), recognising that availability may also impact both price and norms / cues around drinking alcohol.
39.The large companies that make, promote and sell alcohol play a major role in influencing these factors through shaping not only our environments and the nature and pricing of products on offer, but also social and political perceptions and responses to alcohol, steering focus away from action on these factors in favour of implementation of less effective measures.
40. Without strong laws to direct their activity, alcohol companies market alcohol intensively and pervasively, not surprisingly looking to target new groups (notably women in the past few decades), increase sales among existing consumers and promote new opportunities for alcohol consumption. Influence begins early; children and young people’s exposure to alcohol marketing paves the way for current and future alcohol harms by encouraging them to develop brand preferences and positive expectations around alcohol, as well as creating and reinforcing social norms around alcohol consumption.[3]
41. Alcohol companies’ marketing and ‘corporate social responsibility’ strategies also, through subtle but powerful means, shape the way people think about alcohol and divert public attention from the influence they have over available options and choices.
42. The ‘drink responsibly’ tagline that often accompanies alcohol adverts is difficult to define and can mean different things to different people. It implies that (1) there is a safe level / way to consume alcohol, which is not the case from a health perspective – the UK Chief Medical Officer’s alcohol guidelines provide a guide on ‘low risk’, not safe, levels of consumption, and (2) those who experience alcohol-related harm do so due to their individual choice without any recognition of the role of the substance itself and its marketing. This emphasis on individual responsibility also increases stigma around those who develop alcohol use disorder and ignores the significant role of the industry in misinforming the public of the true harms of alcohol and lobbying against effective measures to reduce alcohol-related harm.
43. Major alcohol producers and retailers fund alcohol education programmes and Community Alcohol Partnerships Community Interest Company (CAP CiC), which is a national organisation that currently works in various locations to run ‘Community Alcohol Partnerships’ (CAPs).
44. CAP CiC directs dissemination of alcohol industry-backed resources for education settings. Academic analysis of school educational materials and programmes produced by industry funded Drinkaware, Alcohol Education Trust, and Smashed (Diageo’s anti-underage drinking programme) revealed that the programmes:
· promote familiarisation and normalisation of alcohol as a ‘normal adult consumer product’ which children must learn about and master how to use ‘responsibly’ when older
· selectively present harms, including misinformation about cancer
· do not address the role of alcohol price and availability and the impacts of alcohol and the alcohol industry on inequalities.[4]
45. In short, youth education programmes can be used to disseminate alcohol industry-preferred narratives and aren’t only ineffective but can actually cause harm.[5]
46. Alcohol industry action also seeks to steer government policy / regulation away from effective measures that address price, availability and social norms of alcohol through activities such as:
· development of alliances, with trade associations and with non-industry allies such as think tanks
· funding researchers, and summarising and disseminating findings
· direct engagement with policymakers – shaping and responding to consultations, but also through unsolicited lobbying
· influencing trade rules and using these regulations to challenge unfavourable laws.
Example #3 – Ultra-Processed Food
47. Food is a basic necessity, but also a commercial product deeply influenced by market forces. The concept of food as a commercial determinant of health goes beyond what we eat—it encompasses the entire food system, including production, processing, distribution, marketing, and sustainability. It also involves the environments in which we make our food choices[6].
48. Obesity and overweight are complex public health issues influenced by a range of biological, behavioural, environmental, and socio-economic factors. A growing body of evidence highlights the impact of ultra-processed foods and the broader commercial determinants of health—factors shaped by the food industry that influence what people eat, how much they eat, and how they move.
49. These interrelated influences form what is known as an obesogenic environment—an environment that promotes weight gain and discourages physical activity. Key features of such environments include:
· Ready access to high-calorie, nutrient-poor foods
· Increasing portion sizes
· Limited opportunities for physical activity
· Sedentary lifestyles
· Urban design that discourages active travel
· Limited availability of affordable, healthy food
· Aggressive marketing of unhealthy food products
50.The commercial determinants of obesity[7] are particularly concerning. These include:
· Food Marketing: Aggressive promotion of sugary drinks, processed snacks, and fast food contributes to overconsumption.
· Food Pricing: Unhealthy options are often cheaper and more accessible than healthier alternatives.
· Food Availability: In low-income and rural areas, access to fresh, nutritious food is limited, leading to reliance on processed items.
· Food Labelling: Misleading or unclear labels can make it difficult for consumers to make informed dietary choices.
· Portion Sizes: Larger portions encourage overeating.
· Industry Influence: Lobbying by food companies can weaken policies related to marketing, labelling, and pricing of food.
· Physical Inactivity: Urban design and digital lifestyles promote sedentary behaviour, further compounding the problem.
51. Although York is often regarded as a city in good health, recent findings from the Our City Health Narrative[8] 2025 Joint Strategic Needs Assessment (JSNA) paints a more nuanced picture: an increasing number of children are living with unhealthy weight in both reception and Year 6, two-thirds of adults in York are overweight or obese, and 20% of the population leads a sedentary lifestyle.
52.In December 2019, the City of York Council signed the Local Government Declaration on Healthy Weight[9], committing to a place-based approach to health and wellbeing. The declaration includes several commitments, notably:
· Promoting sustainable and active travel, aligning with York’s target to become a carbon-neutral city by 2030.
· Developing a Sport and Physical Activity Strategy for York.
· Supporting the health and wellbeing of council staff.
· Using health evidence in planning decisions
· Mobilising community assets, such as York’s vibrant community food programmes.
Example #4 – Tobacco
53.Tobacco use remains one of the leading causes of preventable illness and death in the UK, with 2 out of 3 long tobacco users ultimately dying from smoking-related causes.
54.While significant Public Health progress has been made in reducing smoking prevalence, the role of the tobacco industry as a key commercial determinant of health continues to undermine these efforts. The industry’s strategic marketing, lobbying, product innovation (e.g., heated tobacco, nicotine pouches), and corporate social responsibility tactics continue to influence policy, shape public perception, and drive consumption—particularly among disadvantaged populations.
55.Tobacco companies have historically used misinformation, lobbying, and opposition to regulation as they seek to delay, weaken, or circumvent public health regulation, including restrictions on marketing, plain packaging, and taxation. There is strong lobbying against the current Tobacco and Vapes Bill that is moving through the Commons and Lords.
56.Despite declining smoking rates nationally and locally, tobacco use remains disproportionately high in areas of deprivation, driven in part by commercial targeting. Local retailers, many of whom are economically dependent on tobacco sales, are caught in the tension between health harm and commercial need. Furthermore, tobacco industry actors continue to exert influence on local policy indirectly, for example, through front groups or so-called "corporate social responsibility" initiatives.
57.There are strict rules on the amount of tax charged to tobacco companies on cigarettes and tobacco products – with an annual price escalator to ensure that the price rises each year. However, the tobacco industry uses many tactics to circumvent these rises.[10] One such tactic is raising the price of premium products more than on budget products, in order to keep prices lower and more accessible to those on lower incomes.
58.More recently, tobacco companies have diversified into alternative nicotine products (e.g. heated tobacco, nicotine pouches), marketing them as harm reduction tools while maintaining dual product use and continuing to recruit new users. The use of flavoured products, sleek designs, and attractive packaging often appeals to non-smokers and children. At present, regulation of these new novel products is far less robust than traditional tobacco products.
59.Effective action on tobacco as a commercial determinant requires robust implementation of the WHO Framework Convention on Tobacco Control (FCTC), particularly Article 5.3, which mandates protection of public health policies from industry interference.
60.Continued system-wide collaboration across public health, education, trading standards, housing, and voluntary sectors is also required, to create environments that discourage tobacco use and reduce exposure. This is alongside sustained investment in targeted support for priority populations, including pregnant smokers, people with mental health conditions, routine and manual workers and those who face inequality in accessing health-based services.
How to respond: the ‘anti-playbook’
61.It may seem that, in the face of the trans-national forces and large-scale issues set out above, members of the York Health and Wellbeing Board have little agency or influence within the sphere of the CDOH.
62.A telling example of how the CDOH can often seem like a ‘David and Goliath’ issue is to compare, for example the marketing budget in 2022 of a global manufacturer of sugar sweetened beverages (£3.1bn) with the entire public health grant in England in the same year (£3.5bn).
63.While acknowledging the scale of this issue, and the necessity of global, national and regional action, there are still significant ways in which local partners in an area can take action to limit the negative effects of CDOH for the benefit of population health.
64.The ‘Local Health Global Profits’ Consortium is a UKRI funded research consortium bringing together leading researchers from the Universities of Bath, Cambridge, Edinburgh, Sheffield, and the London School of Hygiene and Tropical Medicine. LHGP’s work ‘aims to identify, implement and evaluate population-level actions most likely to improve health, wellbeing and equity at local authority level by addressing the commercial determinants of health’. This work offers and emerging and strong evidence platform for local action.
65.
In
terms of what works, there is consensus in the literature on how
CDOH can be tackled, constituting an ‘anti-playbook’
which aims to counter the tactics of unhealthy commodity
industries:
· The key levers of availability, accessibility and pricing, for instance the granting of gambling licenses, a minimum unit price for alcohol, installing ‘healthy vending machines’
· Restrictions on advertising and marketing of health-harming products
· Shaping the local environment through the planning system, for example guidance which aims to reduce the density of Hot Food Takeaways in poorer areas
· Framing health messages away from narratives of ‘personal responsibility’ and ‘choice’ towards a recognition that ubiquitous addictive and cheap consumer products actually reduce choice
· Good governance, including the cessation of public / private partnerships and sponsorship from industry, removal or industry representation on steering / advisory groups, and clear rules on conflicts of interest
· Participation in advocacy work, for instance supporting calls through professional groups (e.g. Royal Colleges) for tighter regulations on health-harming products.
66.Examples of local work in the region which aims to tackle the CDOH include:
· Introducing comprehensive advertising and marketing policies relating to gambling, alcohol, high fat salt sugar food, vaping (see from York and from Sheffield, which also includes fossil fuel industry advertising)
· Responding to planning applications made by companies selling unhealthy commodities, aiming to tackle the targeting of poorer communities with high densities of outlets
· Introducing Supplementary Planning Documents (SPD) which take an evidence-based approach to where unhealthy commodity outlets can be approved, for instance the Newcastle SDP which does not allow new Hot Food Takeaways in areas where childhood obesity levels are higher than 10% of the yr 6 population
· Removing Community Alcohol Partnership / Alcohol Education Trust / Smashed materials from the school curriculum given their clear links to the alcohol industry
· Using a licensing harm matrix to identify geographical areas at higher levels of such alcohol-related harm as done by Leeds
· Values-based public health messaging which aims to undercut the influence of commercial industry such as the Gambling Understood campaign
· Objections to the siting of Adult Gaming Centres, such as in Sheffield
· Development of the Good Governance Toolkit which offers advice and guidance on how to safeguard public bodies from commercial interests and influence.
APDH Yorkshire and the Humber Consensus statement on the CDOH
67.Annex A of this paper contains the Association of Director of Public Health Yorkshire and the Humber Consensus statement on the CDOH
68.This statement offers a broader and more in-depth summary of the contents of this paper, and board members are asked to note the contents and recommendations of this paper.
Recommendations
69.Board members are asked to:
· note the Association of Director of Public Health Yorkshire and the Humber Consensus statement on the CDOH
· consider how they can avoid use of educational or promotion materials produced by organisations established or funded by (whether entirely or in part) unhealthy commodity industry bodies in our educational settings or communities.
· consider ending any partnerships, sponsored or funded work which has links to unhealthy commodity industries, using the Good Governance Toolkit as guidance
· Consider their approach to advertising and marketing, and adopting a policy which matches the City of York Advertising and Marketing Policy
Strategic/Operational Plans
70. The Health and Wellbeing Strategy 2022-2032 contains an aspiration to become a ‘Health Generating City’, and this paper supports this goal.
Implications.
· Financial – There are no direct financial implications of his report. Action on the CDOH is likely to prevent chromic illness and reduce costs on the public sector.
· Human Resources (HR) – There are no direct HR implications of this report
· Equalities – There is a direct link between this report and health inequalities, affecting people based on socioeconomic status as well as other equalities characteristics such as age, gender and ethnicity. Unhealthy commodities adversely affect poorer communities, through for instance the targeting of advertising / marketing.
· Legal – There are no direct legal implications of this report
· Crime and Disorder – There are no Crime and Disorder implications of this paper
· Information Technology (IT) – There are no IT implications of this report
· Property - There are no Property implications of this report
Contact Details
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Authors:
Phil Truby (Public Health Specialist Practitioner)
Philippa Press (Public Health Specialist Practitioner)
Anna Brown (Health Improvement Officer)
Natalie McPhillips (Public Health Specialist Practitioner) |
Chief Officer Responsible for the report: |
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Peter RoderickDirector of Public Health
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Annexes
Annex A: Commercial Determinants of Health Position Statement