# The commercial determinants of health in Ireland: fueling an industrial epidemic at home and abroad

Mélissa Mialon, James Larkin, Clare Patton, Mimi Tatlow-Golden, Kathryn Reilly, Paula Leonard, Malvina Walsh, Norah Campbell

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Mélissa Mialon, James Larkin, Clare Patton, Mimi Tatlow-Golden, Kathryn Reilly, et al.. The commercial determinants of health in Ireland: fueling an industrial epidemic at home and abroad. BJGP Open, 2024, 10.3399/bjgpo.2024.0029. hal-04576261

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# The commercial determinants of health in Ireland: fueling an industrial epidemic at home and abroad

Mélissa Mialon¹,²*, James Larkin³, Clare Patton⁴, Mimi Tatlow-Golden⁵, Kathryn Reilly⁶, Paula Leonard⁷, Malvina Walsh⁸, Norah Campbell¹

¹Trinity Business School, Trinity College Dublin, Dublin, Ireland; ²Univ Rennes, EHESP, CNRS, Inserm, Arènes—UMR 6051, RSMS (Recherche sur les Services et Management en Santé) - U 1309, Rennes, France; ³Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland; ⁴School of Law, University of Leeds, Leeds, UK; ⁵Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, UK; ⁶Irish Heart Foundation, Dublin, Ireland; ⁷Alcohol Forum Ireland, Letterkenny, Ireland; ⁸Citizen researcher, West Wicklow, Ireland

More than half of deaths in Ireland are caused by four harmful commodities: tobacco, alcohol, fossil fuels, and unhealthy foods (Table 1). Commercial actors, through mechanisms that make these commodities artificially cheap, hyper-convenient, and seductively attractive, are a key driver for ill-health. The cumulative effects of these commercial vectors have been described in a landmark Series on the Commercial Determinants of Health (CDOH) by the eminent medical journal *The Lancet* in 2023.¹ Here, we reflect on the findings and recommendations from the Series in the context of Ireland.

In Ireland, alcohol consumption is responsible for three deaths per day,² yet the alcohol industry lobbies government ministers, senior officials and Oireachtas members against the introduction of regulation on alcohol.³ The alcohol industry met 361 times with the Irish government in 2018 alone, the year the Dáil debated the Public Health Alcohol Act.⁴ The food industry, and its representative trade bodies, have access to officials in the Department of Health, exercising influence on issues such as taxation, marketing, and food labelling.⁵ Despite its conflicting interest with those of public health, the gambling industry, through the Gambling Awareness Trust (GAT),⁶ is fast establishing itself as one of the primary sources of funding for Ireland's response to gambling harms. The pharmaceutical and medical device industries shape integral aspects of our health system to align with commercial interests, including medical education, medical procurement, research and development, open science practices, the patent system, and drug pricing.⁷ In addition, the private healthcare sector in Ireland has used its power to undermine efforts to provide universal access to healthcare.⁸

Ireland, like other countries across the globe, as discussed in the Lancet Series, faces an industrial epidemic, where commercial actors are responsible for the exposure of the Irish population to harmful commodities and commercial practices.⁹ The Lancet Series made it clear that the industrial epidemic is the face of a political economic system which benefits commercial interests at the expense of the human right to health.¹⁰ Towards the end of the last century, the Irish government pursued policies of deregulation and low corporate taxation.¹¹ Though this has increased economic activity in the country, it has had concomitant negative externalities. Ireland's low corporation tax deprives many countries (including low and middle income countries) of revenue that could be used to strengthen health and education systems.¹²

In that context, and given the harms to population health of the CDOH and the recommendations made in the Lancet Series, we call on health professionals and experts in Ireland to take action by:

* getting informed about the CDOH;

* engaging in training and capacity building on the topic;

*For correspondence: melissa.mialon@ehesp.fr

**Competing interest:** The authors declare that no competing interests exist.

**Received:** 29 January 2024

**Accepted:** 09 April 2024

**Published:** 15 May 2024

©This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)

**Author Keywords:** Commercial determinants of health, public policy, public health, general practitioners, primary healthcare, marketing, corporate political activity, corporate social responsibility

Copyright © 2024, The Authors;
DOI:10.3399/BJGPO.2024.0029
<figure><img src="image_2.png" /></figure>

# The commercial determinants of health in Ireland: fueling an industrial epidemic at home and abroad

Mélissa Mialon¹,²*, James Larkin³, Clare Patton⁴, Mimi Tatlow-Golden⁵, Kathryn Reilly⁶, Paula Leonard⁷, Malvina Walsh⁸, Norah Campbell¹

¹Trinity Business School, Trinity College Dublin, Dublin, Ireland; ²Univ Rennes, EHESP, CNRS, Inserm, Arènes—UMR 6051, RSMS (Recherche sur les Services et Management en Santé) - U 1309, Rennes, France; ³Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland; ⁴School of Law, University of Leeds, Leeds, UK; ⁵Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, UK; ⁶Irish Heart Foundation, Dublin, Ireland; ⁷Alcohol Forum Ireland, Letterkenny, Ireland; ⁸Citizen researcher, West Wicklow, Ireland

More than half of deaths in Ireland are caused by four harmful commodities: tobacco, alcohol, fossil fuels, and unhealthy foods (Table 1). Commercial actors, through mechanisms that make these commodities artificially cheap, hyper-convenient, and seductively attractive, are a key driver for ill-health. The cumulative effects of these commercial vectors have been described in a landmark Series on the Commercial Determinants of Health (CDoH) by the eminent medical journal *The Lancet* in 2023.¹ Here, we reflect on the findings and recommendations from the Series in the context of Ireland.

In Ireland, alcohol consumption is responsible for three deaths per day,² yet the alcohol industry lobbies government ministers, senior officials and Oireachtas members against the introduction of regulation on alcohol.³ The alcohol industry met 361 times with the Irish government in 2018 alone, the year the Dáil debated the Public Health Alcohol Act.⁴ The food industry, and its representative trade bodies, have access to officials in the Department of Health, exercising influence on issues such as taxation, marketing, and food labelling.⁵ Despite its conflicting interest with those of public health, the gambling industry, through the Gambling Awareness Trust (GAT),⁶ is fast establishing itself as one of the primary sources of funding for Ireland's response to gambling harms. The pharmaceutical and medical device industries shape integral aspects of our health system to align with commercial interests, including medical education, medical procurement, research and development, open science practices, the patent system, and drug pricing.⁷ In addition, the private healthcare sector in Ireland has used its power to undermine efforts to provide universal access to healthcare.⁸

Ireland, like other countries across the globe, as discussed in the Lancet Series, faces an industrial epidemic, where commercial actors are responsible for the exposure of the Irish population to harmful commodities and commercial practices.⁹ The Lancet Series made it clear that the industrial epidemic is the face of a political economic system which benefits commercial interests at the expense of the human right to health.¹⁰ Towards the end of the last century, the Irish government pursued policies of deregulation and low corporate taxation.¹¹ Though this has increased economic activity in the country, it has had concomitant negative externalities. Ireland's low corporation tax deprives many countries (including low and middle income countries) of revenue that could be used to strengthen health and education systems.¹²

In that context, and given the harms to population health of the CDoH and the recommendations made in the Lancet Series, we call on health professionals and experts in Ireland to take action by:

* getting informed about the CDoH;

* engaging in training and capacity building on the topic;

*For correspondence: melissa.mialon@ehesp.fr

**Competing interest:** The authors declare that no competing interests exist.

**Received:** 29 January 2024

**Accepted:** 09 April 2024

**Published:** 15 May 2024

©This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)

**Author Keywords:** Commercial determinants of health, public policy, public health, general practitioners, primary healthcare, marketing, corporate political activity, corporate social responsibility

Copyright © 2024, The Authors;
DOI:10.3399/BJGPO.2024.0029
<table><caption>**Table 1** Burden of annual deaths attributable to commercial products in Ireland. Our table was adapted from Gilmore et al. Lancet Series on Commercial Determinants of Health 2023.¹⁰ We used data for Ireland from the Global Burden of Disease Collaborative Network - Global Burden of Disease Study 2019 (GBD 2019) Results, Institute for Health Metrics and Evaluation (IHME). Data are available from https://vizhub.healthdata.org/gbd-compare/#. Results are underestimated, as explained in the Lancet Series</caption><thead><tr><th>Risks factors for deaths in Ireland</th><th>Number of annual deaths</th></tr></thead><tbody><tr><td><strong>Air pollution</strong></td><td></td></tr><tr><td>Ambient ozone pollution</td><td>15.72</td></tr><tr><td>Ambient particulate matter pollution</td><td>535.45</td></tr><tr><td><strong>Alcohol</strong></td><td>1,543.08</td></tr><tr><td><strong>Dietary-related risks</strong></td><td></td></tr><tr><td>Diet high in red meat</td><td>1,001.96</td></tr><tr><td>Diet high in processed meat</td><td>373.74</td></tr><tr><td>Diet high in SSB</td><td>169.50</td></tr><tr><td>Diet high in sodium</td><td>336.36</td></tr><tr><td>Sub-optimal breastfeeding</td><td>0.65</td></tr><tr><td><strong>Tobacco</strong></td><td>6,458.64</td></tr><tr><td><strong>All deaths</strong></td><td>18,655.16</td></tr><tr><td><strong>Deaths attributable to those commercial products in Ireland</strong></td><td>10,435.10 (56%)</td></tr></tbody></table>

* avoiding partaking in education sponsored by commercial actors;

* working in coalition to address the CDOH;

* lobbying for the introduction of mechanisms to protect public health policy from undue corporate influence; for example, lobbying organisations that you are a member or employee of to introduce stringent conflict of interest policies;

* avoiding payment for your work from commercial actors, particularly those with an interest conflicting with that of public health.

## Funding

Dr Mélissa Mialon is funded by the Health Research Board Ireland [Grant Number ARPP-2020-002]. Dr James Larkin is funded by the Health Research Board Ireland. In the past three years, Dr Mimi Tatlow-Golden was funded by Safefood, the European Commission, Public Health England, the National Institutes of Health Research UK, UNICEF, and the World Health Organization.

## Ethical approval

N/A

## Data

There is no data or software associated with this article.

## Author Contributions

MM was responsible for the drafting of this manuscript. All authors critically reviewed, commented, and revised the manuscript.

## Acknowledgements

This manuscript is the results of a one-day event entitled "Commercial Determinants of Health: Reliance for research, advocacy and public policy in Ireland" hosted at Trinity College Dublin in May 2023. This event was funded by a Research Fellow Award, from the Faculty of Arts, Humanities and Social Sciences, Trinity College Dublin to Dr Mialon. The Trinity Research in Social Sciences (TRiSS) group shared its seminar room free of charge for the day. Dr Mialon and Dr Campbell would like to acknowledge all participants, including those who contributed to the present publication.
<table><caption>**Table 1** Burden of annual deaths attributable to commercial products in Ireland. Our table was adapted from Gilmore et al. Lancet Series on Commercial Determinants of Health 2023.¹⁰ We used data for Ireland from the Global Burden of Disease Collaborative Network - Global Burden of Disease Study 2019 (GBD 2019) Results, Institute for Health Metrics and Evaluation (IHME). Data are available from https://vizhub.healthdata.org/gbd-compare/#. Results are underestimated, as explained in the Lancet Series</caption><thead><tr><th>Risks factors for deaths in Ireland</th><th>Number of annual deaths</th></tr></thead><tbody><tr><td><strong>Air pollution</strong></td><td></td></tr><tr><td>Ambient ozone pollution</td><td>15.72</td></tr><tr><td>Ambient particulate matter pollution</td><td>535.45</td></tr><tr><td><strong>Alcohol</strong></td><td>1,543.08</td></tr><tr><td><strong>Dietary-related risks</strong></td><td></td></tr><tr><td>Diet high in red meat</td><td>1,001.96</td></tr><tr><td>Diet high in processed meat</td><td>373.74</td></tr><tr><td>Diet high in SSB</td><td>169.50</td></tr><tr><td>Diet high in sodium</td><td>336.36</td></tr><tr><td>Sub-optimal breastfeeding</td><td>0.65</td></tr><tr><td><strong>Tobacco</strong></td><td>6,458.64</td></tr><tr><td><strong>All deaths</strong></td><td>18,655.16</td></tr><tr><td><strong>Deaths attributable to those commercial products in Ireland</strong></td><td>10,435.10 (56%)</td></tr></tbody></table>

* avoiding partaking in education sponsored by commercial actors;

* working in coalition to address the CDoH;

* lobbying for the introduction of mechanisms to protect public health policy from undue corporate influence; for example, lobbying organisations that you are a member or employee of to introduce stringent conflict of interest policies;

* avoiding payment for your work from commercial actors, particularly those with an interest conflicting with that of public health.

## Funding

Dr Mélissa Mialon is funded by the Health Research Board Ireland [Grant Number ARPP-2020-002]. Dr James Larkin is funded by the Health Research Board Ireland. In the past three years, Dr Mimi Tatlow-Golden was funded by Safefood, the European Commission, Public Health England, the National Institutes of Health Research UK, UNICEF, and the World Health Organization.

## Ethical approval

N/A

## Data

There is no data or software associated with this article.

## Author Contributions

MM was responsible for the drafting of this manuscript. All authors critically reviewed, commented, and revised the manuscript.

## Acknowledgements

This manuscript is the results of a one-day event entitled "Commercial Determinants of Health: Reliance for research, advocacy and public policy in Ireland" hosted at Trinity College Dublin in May 2023. This event was funded by a Research Fellow Award, from the Faculty of Arts, Humanities and Social Sciences, Trinity College Dublin to Dr Mialon. The Trinity Research in Social Sciences (TRiSS) group shared its seminar room free of charge for the day. Dr Mialon and Dr Campbell would like to acknowledge all participants, including those who contributed to the present publication.
References

1. The Lancet. Unravelling the commercial determinants of health. *The Lancet* 2023; **401**(10383): 1131. DOI: https://doi.org/10.1016/S0140-6736(23)00590-1

2. Health Research Board. New HRB overview presents latest research on alcohol consumption, harm and policy in Ireland [Online] Health Research Board; 15 Apr 2021. 2021. https://www.hrb.ie/news/press-releases/single-press-release/article/new-hrb-overview-presents-latest-research-on-alcohol-consumption-harm-and-policy-in-ireland/ (accessed 2 May 2024).

3. Lesch M, Cambridge J. Understanding the political organization and tactics of the alcohol industry in Ireland 2009–2018. *J Stud Alcohol Drugs* 2022; **83**(4): 574–581. DOI: https://doi.org/10.15288/jsad.2022.83.574

4. O'Halloran M. Drinks industry lobbyists met Government members and officials 361 times in 2018. The Irish Times [Online] 9 Mar 2020; 2023; https://www.irishtimes.com/news/health/drinks-industry-lobbyists-met-government-members-and-officials-361-times-in-2018-1.4197333 (accessed 2 May 2024).

5. Standards in Public Office Commission, The Register of Lobbying.. Ibec (1 May, 2023 to 31 Aug, 2023), *Public policy or programme - Lobbying* 2023. https://www.lobbying.ie/return/99165/ibec (accessed 2 May 2024).

6. Gambling Addiction, About Gambling Care. Gambling Care. 2023. https://web.archive.org/web/20240420095305/ https://gamblingcare.ie/about-us/ (accessed 20 Apr 2024).

7. Sismondo S. Epistemic corruption, the pharmaceutical industry, and the body of medical science. *Front Res Metr Anal* 2021; **6**: 614013. DOI: https://doi.org/10.3389/frma.2021.614013

8. O'Neill TP. Health, medicine and politics in Ireland, 1900–1970, by Ruth Barrington. Ppxi, 348. Dublin: Institute of public administration. 1987. IR£9.95 paperback, IR£20 Hardback. *Ir Hist Stud* 1900; **27**(105): 83–84. DOI: https://doi.org/10.1017/S0021121400010373

9. Jahiel RI, Babor TF. Industrial epidemics, public health advocacy and the alcohol industry: lessons from other fields. *Addiction* 2007; **102**(9): 1335–1339. DOI: https://doi.org/10.1111/j.1360-0443.2007.01900.x

10. Gilmore AB, Fabbri A, Baum F, et al. Defining and conceptualising the commercial determinants of health. *The Lancet* 2023; **401**(10383): 1194–1213. DOI: https://doi.org/10.1016/S0140-6736(23)00013-2

11. Kitchin R, O'Callaghan C, Boyle M, et al. Placing Neoliberalism: the rise and fall of Ireland's Celtic Tiger. *Environ Plan A* 2012; **44**(6): 1302–1326. DOI: https://doi.org/10.1068/a44349

12. McCarthy Flynn M, Oxfam Ireland. *Hard to Swallow: How Ireland could do more to tackle corporate tax avoidance* 2018. https://www.oxfamireland.org/policy/hard-to-swallow-how-ireland-could-do-more-to-tackle-corporate-tax-avoidance (accessed 2 May 2024).
References

1. The Lancet. Unravelling the commercial determinants of health. *The Lancet* 2023; **401**(10383): 1131. DOI: https://doi.org/10.1016/S0140-6736(23)00590-1

2. Health Research Board. New HRB overview presents latest research on alcohol consumption, harm and policy in Ireland [Online] Health Research Board; 15 Apr 2021. 2021. https://www.hrb.ie/news/press-releases/single-press-release/article/new-hrb-overview-presents-latest-research-on-alcohol-consumption-harm-and-policy-in-ireland/ (accessed 2 May 2024).

3. Lesch M, McCambridge J. Understanding the political organization and tactics of the alcohol industry in Ireland 2009–2018. *J Stud Alcohol Drugs* 2022; **83**(4): 574–581. DOI: https://doi.org/10.15288/jsad.2022.83.574

4. O'Halloran M. Drinks industry lobbyists met Government members and officials 361 times in 2018. The Irish Times [Online] 9 Mar 2020; 2023; https://www.irishtimes.com/news/health/drinks-industry-lobbyists-met-government-members-and-officials-361-times-in-2018-1.4197333 (accessed 2 May 2024).

5. Standards in Public Office Commission, The Register of Lobbying.. Ibec (1 May, 2023 to 31 Aug, 2023), *Public policy or programme - Lobbying* 2023. https://www.lobbying.ie/return/99165/ibec (accessed 2 May 2024).

6. Gambling Addiction, About Gambling Care. Gambling Care. 2023. https://web.archive.org/web/20240420095305/ https://gamblingcare.ie/about-us/ (accessed 20 Apr 2024).

7. Sismondo S. Epistemic corruption, the pharmaceutical industry, and the body of medical science. *Front Res Metr Anal* 2021; **6**: 614013. DOI: https://doi.org/10.3389/frma.2021.614013

8. O'Neill TP. Health, medicine and politics in Ireland, 1900–1970, by Ruth Barrington. Ppxi, 348. Dublin: Institute of public administration. 1987. IR£9.95 paperback, IR£20 Hardback. *Ir Hist Stud* 1900; **27**(105): 83–84. DOI: https://doi.org/10.1017/S0021121400010373

9. Jahiel RI, Babor TF. Industrial epidemics, public health advocacy and the alcohol industry: lessons from other fields. *Addiction* 2007; **102**(9): 1335–1339. DOI: https://doi.org/10.1111/j.1360-0443.2007.01900.x

10. Gilmore AB, Fabbri A, Baum F, et al. Defining and conceptualising the commercial determinants of health. *The Lancet* 2023; **401**(10383): 1194–1213. DOI: https://doi.org/10.1016/S0140-6736(23)00013-2

11. Kitchin R, O'Callaghan C, Boyle M, et al. Placing Neoliberalism: the rise and fall of Ireland's Celtic Tiger. *Environ Plan A* 2012; **44**(6): 1302–1326. DOI: https://doi.org/10.1068/a44349

12. McCarthy Flynn M, Oxfam Ireland. *Hard to Swallow: How Ireland could do more to tackle corporate tax avoidance* 2018. https://www.oxfamireland.org/policy/hard-to-swallow-how-ireland-could-do-more-to-tackle-corporate-tax-avoidance (accessed 2 May 2024).