Harmful industries still exert their influence over health professionals, academia, and health systems; robust change is required, write Chris van Tulleken, Nigel Rollins, and Rebecca Coombes
In the 1950s, smoking was proven beyond doubt to cause cancer and yet efforts to curb this pandemic were stalled over the next half century by a network of individuals and institutions with competing interests. The industry paid doctors, academics, charities, and policy makers to dilute and distort the science and public health messaging. By the 1980s, the largest tobacco companies bought the largest food companies and used the same methods to create a food environment where poor diet has overtaken tobacco as the leading cause of early death globally.
Food and tobacco are just two of the industries that use their economic power to evade effective regulation; food, alcohol, pharmaceuticals, gambling, and fossil fuels, among others, have the same commercial incentives and obligations as the tobacco industry and directly impact human and planetary health.
The World Health Organization (WHO) has defined these commercial determinants of health as "…private sector activities that affect people’s health, directly or indirectly, positively or negatively”.
To varying degrees, all these industries fund and partner with those that would regulate them. From de facto regulators, including charities, press offices, health professional associations, academic departments, doctors, and influencers, to formal regulators such as the government and guideline committees.
This funding creates competing interests because the interests of these industries conflict with the interests of public health. Many of the corporations in these sectors are “financialised” and have obligations to prioritise profit and growth above other interests and thus they are not suitable partners for change.
Furthermore, in the case of food, alcohol, and tobacco, the economic costs associated with the harms to health significantly exceed the revenue generated from taxation. Despite these issues, influential national and local health advisory committees on food, alcohol, and pharmaceuticals commonly include experts who have important financial conflicts of interest.
Meanwhile, companies in these sectors invite senior clinicians and academics to be on advisory boards to portray impartiality and build credibility. These actions on the part of industry reflect the important and trusted role of health professionals in society and why they are high value targets of industry marketing strategies.
Each sector presents unique challenges and requires specific approaches. The pharmaceutical industry is more regulated than food or alcohol, but it has promoted competing interests with guidelines committees, advocacy groups, clinicians, and academia that work against the interests of patients.
Moves toward more transparency in medicine have failed. The pharmaceutical industry’s disclosure scheme, Disclosure UK, allows doctors to remove their name from companies’ annual declarations of payments and gifts. Unsurprisingly, many of these doctors opt to continue to accept actual or in-kind remunerations (including educational trips to conferences and meetings, speaker fees, hospitality, meals, and gifts) away from the public gaze.
Mandatory disclosure does not reduce or mitigate against competing interests. Last year in the US, where any payments must be declared, US$2.29 bn in non-research payments was made to physicians from pharmaceutical companies.
In the UK, a requirement for comprehensive registers of interest at NHS trusts failed and a high profile call for all UK doctors to submit their declarations of interest to a public register held by the General Medical Council has been ignored.
Journal declarations can detail some competing interests but standards vary, leading to misleading or partial statements, often hidden in footnotes. Similarly, medical royal colleges do not always disclose publicly the millions of pounds they receive from drug and medical device companies. No accurate collection or reporting of pharma payments to NHS trusts is published. We need a reset.
Why this matters
Conflicts of interests create bias, which we might also call co-option or even corruption. They act in several ways to impact public health, health policies, and patient care. They affect the behaviour and beliefs of individuals and institutions. These conflicts shape research agendas and determine which questions are asked and which ones are not. They then affect the outcomes of that research. Conflicts affect what we and our children eat and drink, which drugs and devices are prescribed, and the research that is undertaken, published, and reported.
Even when an institution or individual can remain independent of the interests of their funders, these competing interests silence critique and protect the reputations of corporations that market products known to cause harm. Additionally, these biases erode trust in science, medicine, and public health.
What needs to happen
Change has to be intentional, systematic, evidence based, and robust. The onus for action is not with industry who, because of their responsibilities to shareholders, are unable to prioritise public health.
All institutions and individuals who have the stated aim of improving human health—health authorities, research funders, medical schools, health professional associations, charities and advocacy organisations, and individual practitioners, to name just some—must first recognise the pervasive harm that conflicts of interest cause.
Governments must set the standard and lead by example. Terms of engagement that end actual and perceived competing interests should be established while not precluding the possibility of discussion with these industries. Advisory committees, regulatory bodies and harm reduction strategies must be conflict free.
A change in culture among health professionals and in those making decisions about health policy and investments is needed. It is accepted today that doctors, universities, and health institutions should not accept funding from the tobacco industry. This principle needs to be widened to the other industries whose products or marketing practices also harm or undermine health.
Health professional associations must act to protect their membership and end conflicts of interest. Medical, nursing, midwifery, and pharmacy schools must prepare their trainees to recognise competing interests and respond ethically and effectively.
Medical and science journals can implement stricter competing interest policies to make clear when evidence is industry funded, make competing interest statements more visible but also consider introducing stricter, zero tolerance policies on clinical education articles that are designed to protect patient care.
The financial incentives that drove the tobacco industry to create a pandemic of smoking related disease are common to many other industries that supply potentially harmful goods and services. The first step in limiting the harms caused by commercial determinants is to end their competing interests with those who would regulate them.
