Defining and conceptualising the commercial determinants of health.

Although commercial entities can contribute positively to health and society there is growing evidence that the products and practices of some commercial actors-notably the largest transnational corporations-are responsible for escalating rates of avoidable ill health, planetary damage, and social and health inequity; these problems are increasingly referred to as the commercial determinants of health. The climate emergency, the non-communicable disease epidemic, and that just four industry sectors (ie, tobacco, ultra-processed food, fossil fuel, and alcohol) already account for at least a third of global deaths illustrate the scale and huge economic cost of the problem. This paper, the first in a Series on the commercial determinants of health, explains how the shift towards market fundamentalism and increasingly powerful transnational corporations has created a pathological system in which commercial actors are increasingly enabled to cause harm and externalise the costs of doing so. Consequently, as harms to human and planetary health increase, commercial sector wealth and power increase, whereas the countervailing forces having to meet these costs (notably individuals, governments, and civil society organisations) become correspondingly impoverished and disempowered or captured by commercial interests. This power imbalance leads to policy inertia; although many policy solutions are available, they are not being implemented. Health harms are escalating, leaving health-care systems increasingly unable to cope. Governments can and must act to improve, rather than continue to threaten, the wellbeing of future generations, development, and economic growth.

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Declaration of interests ABG reports grants from Bloomberg Philanthropies (Stopping Tobacco Products and Organizations), WHO Europe, UK National Institute for Health and Care Research, Cancer Research UK, UK Research and Innovation, Global Challenges Research Fund, and UK Medical Research Council; consulting fees from World Bank; support for attending meetings or travel from WHO, Prince Mahidol Award Conference, and European Health Forum Gastein; and is European Editor of Tobacco Control and is an unpaid member of the Royal College of Physicians Tobacco Advisory Group, Council of ASH, WHO International Expert Group on the Commercial Determinants of Health, WHO International Expert Group on Smoking and COVID-19, European Respiratory Society's Executive Committee, and Framework Conventional Alliance strategy development working group. FB reports royalties from her books published with Oxford University Press; support for travel from the organisers of the Prince Mahidol Award Conference annual meeting in 2019 and 2020; and is Chair of the Global Steering Council of the People's Health Movement and Board Member of Cancer Council of South Australia. LR reports grants from Bloomberg Philanthropies (Stopping Tobacco Products and Organizations), New Zealand Heart Foundation, Royal Society of New Zealand (Marsden), and Otago Medical Foundation Trust; and support for attending meetings or travel from Bloomberg Philanthropies. MP is a coinvestigator in the SPECTRUM consortium, which is funded by the UK Prevention Research Partnership. All remaining authors declare no competing interests.