Manufacturing Doubt: the commercial determinants of health with Dr Nason Maani

Episode Transcript
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(00:05):
[Music] Welcome to Complicating the Narrative, a podcast that takes on the challenging questions
in public health by embracing complexity rather than avoiding it. I'm your host, Salma Abdalla.
Today, we're diving into one of the frameworks that has gained traction in public health
over the past few decades. The commercial determinance of health. We have all heard

(00:25):
about the importance of individual choices for our health: eating right, exercising,
not smoking. But what if the choices we are making are heavily influenced by a much larger,
often invisible force? This framework asks us to look beyond individual choices and even beyond
traditional social determinants of health to examine how industries shape the conditions in

(00:47):
which we live, work, and make decisions about our health. From the marketing strategies that
influence what we eat and drink, to urban planning decisions that determine whether we have access,
to green spaces to the lobbying efforts that shape our healthcare policies.
Commercial interests are deeply embedded in the structural fabric of health. What makes

(01:07):
this framework helpful is that it forces us to confront uncomfortable questions about power,
agency, and responsibility. It's not simply about good or bad companies, but about understanding
how commercial determinants and systems incentivizes and can create health-promoting
or health-harming environments, often regardless of individual intentions.

(01:29):
My guest today is Dr. Nason Maani who has been one of the leading voices in shaping how we think
about the role of commercial actors in shaping health outcomes over the past few decades.
He's a senior lecturer or for those in the US an associate professor in inequities and
global health policy at the University of Edinburgh. He's also the editor of
the Commercial Determinants of Health book, which was published by Oxford University Press in 2022,

(01:53):
and a co-author of the upcoming book, A Healthy Profit, in 2026. Nason is also a
good friend and a collaborator.Nason, welcome to the podcast.
Thank you so much for having me, Salma.
Thank you for being here. Uh so maybe can we can start a bit
uh by introducing yourself to the audience and hopefully people can get to know you as

(02:14):
much as I do or maybe slightly more than they know you right now just through your writing.
Sure. So um hi everyone. It's a pleasure to be part of this conversation. Um my
name is Nason Maani and I, by background, was a biomedical scientist. So I did an undergraduate
in biomedical science and a PhD in um in sort of bench research, biochemistry, and

(02:41):
uh then I worked for three or four years in health communications. So kind of in the private sector
around clinical trial reporting and physician education, that kind of thing. And uh it was
during that time that I kind of became centrally interested in and animated by and concerned with

(03:02):
commercial influence on health because we were dealing a lot with kind of pharmaceutical industry
sponsored trials, clinical trials. And I began to notice as I was writing about these that the
end points at times were being shaped primarily by profit rather than kind of clinical benefit.

(03:23):
I remember participating writing up one large trial that looked at hypoglycemia for example in a
range of countries around the world and it seemed to focus very much on marketing messages regarding
a product rather than really contributing a huge amount that could have been a real gap in what
we knew about hypoglycemia at the time globally particularly in the global south. And it kind

(03:46):
of really animated me, I guess, to think about this connection between profit and health. And
like you said, what what are the misaligned incentives here? And um around that time,
my eldest son Charlie had just been born and that created a second impetus to sort of try to find
work that more aligned with my values. And I was very fortunate to find public health and London

(04:10):
School of Hygiene Tropical Medicine. So I quit my job, with a very supportive spouse supporting me,
and went to London School of Hygiene, did my master's dissertation on the alcohol industry and
responsible drinking campaigns, and really from that point on, and that was about 10 years ago,
have really been centrally interested in the commercial determinants of health more broadly.

(04:35):
So for those who haven't maybe heard the term before, can you explain to us a bit
what is the commercial determinants of health? What is a commercial determinant
of health framework? And really importantly, what is it not? Because some people might be
saying there are other types of framework. So what distinguishes this specific framework?
That's a really good question, Salma. I think broadly speaking, we can, when we think about

(04:59):
what are determinants of health, right? We're talking about those upstream factors,
those kind of environments around us. It could be physical environments, social environments
that shape our health directly and indirectly. And I guess commercial determinants of health,
broadly speaking, are those direct and indirect factors that affect health and health equity

(05:26):
that stem from the profit motive. And what they do include is uh direct effects like the effect
of medicines on health, in a, in a positive sense, or harmful effects, direct effects like
um the effects of cigarette smoking um alcohol consumption. And they also include the indirect

(05:50):
effects. So things like the shifting of social norms through marketing campaigns,
also the shaping of regulatory landscapes through political funding or lobbying, the funding of
certain types of evidence over others, and those kind of wider effects. They differ from other
frameworks that focus on economic determinants for example, or political determinants, in that they

(06:16):
often place companies or sectors or industries as core units of measurement, if that makes sense. So
looking at these entities as worthy of measurement in their own right, and as kind of vectors or
actors in systems rather than sort of seeing economic factors or determinants as a kind of

(06:38):
more nebulous political economy type um concept but seeing individual companies, individual
sectors as worthy units of measurement in their own right. And that also se, separates them
apart from I guess what you might consider more traditional risk factor epidemiology which often
focuses on individual behaviors like consumption patterns or, or that kind of thing. So I hope that

(07:04):
helps in sort of articulating what we mean when we think about commercial determinants of health.
I do think that's very helpful. Um, but I also recognize that for a lot of,
maybe my students in public health, a lot of the things we do when they're in
the school of public health, it's just that we go through a lot of frameworks
and sometimes you might have too many frameworks in your head. So,

(07:26):
uh, one thing I thought might be helpful for us to do today is maybe just really dig deeper into
one of your studies that illustrates the role of corporations as a separate actor within a system.
And one of the studies I think that were always fascinating to me, and you and I have discussed it
uh multiple times, is really the study that also I think has a really awesome name:

(07:46):
Manufacturing Doubts. Um so which you, and, you and your team tried to really u think through
what would be the different types of messaging that corporations actually um put out there for
consumers but also do those affect uh how people then think about the certainty of the evidence.
Um I don't want to describe it all. I thought maybe would be helpful for you actually to first

(08:06):
describe what was that study and what prompted you to actually start thinking about that study.
Yeah, absolutely. Thanks so much for bringing up that study. It's one that I really enjoyed
working on. And I guess what it sought to do is provide empiric evidence for the parallels in
the way commercial messaging can work. And it particularly focused on a subset of commercial

(08:30):
messaging which has been termed as alternative causation arguments. So these are messages about
the links between products and harms that kind of offer an alternative causation story and these
were very common in tobacco industry framing. So in, in seeking to dispute the links between

(08:51):
tobacco smoking and lung cancer, they would use what are known as alternative causation arguments.
So they would say something like tobacco smoking may cause lung cancer but so does age,
socioeconomic status, you know, and they'd list a whole bunch of these other alternative cause,
alternative causes in a kind of a diluting distracting kind of um with a with a dilution

(09:16):
kind of goal. And so what we sought to do in our paper was to examine the effects of these
kind of messages and look at them across a range of products. So we took similar messaging from
uh promotional, or sort of health promotional campaigns, or corporate social responsibility
initiatives, including the sort of funded industry funded charities that communicate

(09:38):
to the public on harms across a range of of of product categories. So we looked at
um smoking and lung cancer. We looked at alcohol and breast cancer. We looked at alcohol and fetal
alcohol syndrome. Uh sugar-sweetened beverages and obesity. You know, like a range of these kind of
product harm relationships. And we randomized people to either, so members of the public

(10:04):
uh through a an online survey, to either read one of these statements or a factual control statement
by a health authority like the WHO or this kind of thing. And then we assessed their certainty
on the links between the product and the harm and we compared it. So it's like a randomized control
trial where people received either the industry sponsored message, alternative causation argument,

(10:29):
or a factual control statement. And what we found is that these, these arguments, these
these industry messages consistently increased the uncertainty in the mind of the public about
these links, And that bearing in mind these are sort of corporate social responsibility messages,
these are supposed to be educating consumers about the links between products and harms.

(10:51):
And what we actually found is they led to about a 60% increase in uncertainty about the links
between products and harms. And I think what was really interesting about the study is that,
first of all it showed a kind of magnitude of effect, right? That you have like kind of this
dose, dose of, of sort of alternative causation argument and it has an impact on the public's

(11:12):
understanding of a particular product's relation to harm. But also that there was
this kind of commonality in strategy across a range of different sectors. And you could see
that in the similarity in language between the different ones. And I think that speaks to an
important element of commercial determinants of health, which is that there is merit in studying

(11:34):
these kind of dynamics across industry sectors, across multiple product types because ultimately,
particularly in the context of harmful products, there are really strong parallels and those occur
for a variety of reasons. Often they're receiving the same legal advice. They're
working with the same third party organizations in terms of consultancy firms or public relations

(11:58):
or advertising. And they're responding to similar concerns, like concerns about liability or change
or declines in consumer support for particular brands. So they're, they're, they're dealing
with similar problems using similar tools. And so it's kind of inevitable that the strategies

(12:19):
echo. And I think the final interesting thing about the study is that it alludes to the idea
of cumulative effects, if that makes sense. So you have for example the notion of fossil fuel
companies seeking to dispute climate change evidence and the notion of tobacco companies

(12:43):
seeking to dispute secondhand smoking evidence and so on and so on. But there is like a behind the
scenes like a cumulative impact of all this which is a a a greater uncertainty around public health
evidence or expertise more generally, right? About like government sponsored scientific
research more generally and that's a separate issue that we should probably think about more.

(13:08):
Oh, so there's a lot there. Um and I actually want to dig deeper into the
methods and results. I have a few questions about those.
Sure.
Um uh but I want to start conceptually first. And I I have to say I reread the paper um this week in
preparation for this u discussion and maybe in the spirit of complicating the narrative
um I started picking up a few things that I actually wanted to talk to you about and maybe

(13:28):
hopefully complicate even that narrative that you just said now more. Um so just
like first question people might ask is, we're talking here about alternate causations and I,
I looked at some of the examples you provided in the introduction so you're saying like green tea,
other examples, pollution I think I, I think they provide a few examples like when they talk about
the specific causation. One could ask a question of, and you use the control group, you use the

(13:53):
term factual. One could argue aren't some of the alternate causations they're using in a way also
have some scientific backing? Like, it might not be as strong as it should be or could be,
um it might be a distraction but it's not like they're saying something that
is completely wrong. And, and correct me if I'm if I misread the introduction part about the paper.
No, I think you're absolutely right. I think that's one of the, the great pars of alternative

(14:20):
causation arguments more broadly, in that part of what they seek to do is to complicate the
narrative. And there is some truth to that. You know that often associations are complicated and
more than one thing causes cancer, for example. In fact, if you look at some of the alternative
causation arguments about tobacco and lung cancer, again, there you could argue that's

(14:46):
entirely correct. It's factually correct to say smoking causes lung cancer alongside a whole range
of other agents. That is true. But I suppose as a health promotion message, that is both unhelpful,
for example, to put that message on a packet of cigarettes to say smoking causes lung cancer

(15:07):
alongside a whole range of things like where you're sitting and how much money you make,
doesn't really help as a health promotion message, and it also is kind of misleading
to the to the reader who is unfamiliar with epidemiological research because it creates a
false equivalence. It says, "Okay, smoking is on par with all these other things." Whereas,

(15:28):
you and I both know that smoking is an incredibly strong independent risk factor for lung cancer and
drives the vast majority of lung cancer cases. And so you're right to say there's a comp,
there is definitely a lot of truth to the idea that these things are more complicated,
but in a health promotion setting, it's questionable, A, how helpful that that is or,

(15:50):
B, how much more misleading it is to to to leave the reader with that sense of equivalence.
No, I definitely agree specifically with the second part in the health promotion setting,
especially I think when, as you said the strength of the association is just so different that maybe
it shouldn't be even something that should be mentioned in the same line. You can't really

(16:12):
talk about green tea and smoking um in the same sentence. I'm not even sure if there is evidence.
Uh I have to look at the literature about green tea. But even if there is like some evidence
somewhere that it's definitely not on the same line, but I do wonder also if that made you,
as you're thinking about the structure of the study, also thinking about the nuances when
thinking about the different industries. Um I, I imagine, I could be wrong, that it was,

(16:38):
it's much harder to make those or draw the lines between what is an alternative causation
or alternate causation when they're talking about smoking, just because we have so much literature
on this that is very clear, compared to let's say some of the evidence that is,
they're try to, or the industry tries to uses, to use when they're talking about climate change.

(16:58):
So I don't know if you also thought about that does the strength of the evidence or the strength
of the alternate causation argument differ even within the industries that you're thinking about.
Just because also I'm thinking more about climate change is way more complex on its own
um and its effect on human beings that corporations might get away with a lot
of more nuance arguments there that they can find some evidence for just because of the complexity

(17:23):
of the pathway compared to what they can, what we can actually prove when they talk about smoking.
Yeah, I think well I think first of all absolutely there are you know really important distinctions
in terms of the range and nature of the complex causal chains, indirect effects, and the kind of
system level effects of these kind of things, definitely, and that's really important. I

(17:45):
would say there is a simplicity in some of the fundamental conflicts of interest, or parallels
in the fundamental conflicts of interest, that we shouldn't confuse with that complexity
um in the sense that, at core I guess, the commercial incentive and the commercial

(18:06):
the alignment or misalignment of commercial interest is really very basic in the sense
that you know a company that faces regulatory pressure or the risk to future revenue is,
is very strongly incentivized to argue against, in a whole range of ways, often

(18:27):
in logically inconsistent ways against those kind of measures. So you will see companies arguing in
part on the complexity of the science, in part on the legality, in part of the culture and history,
in part on the economic sort of cost-benefit analysis. Like in a lot of different ways,

(18:50):
like ceasing to coalesce a lot of different arguments, um, and it's not because those
arguments are necessarily logically grounded or consistent. It's because there's a real
fundamental strategic interest there. But that's not to say that there isn't also a huge amount of
complexity in the research. And I think that's, that is important to say. What I would say in

(19:13):
the in the context of fossil fuels is, it's still probably fundamentally unhelpful for us to rely,
for public understanding or for the communication of these this kind of complexity, on fossil fuel
companies or fossil fuel company-funded education campaigns, corporate social responsibility,

(19:39):
um evidence submissions, because of that basic conflict of interest. Like I think we can find
ways to navigate this complexity without that kind of overriding uh commercial interest.
And I think that was really the helpful part for me in that study. First of all, I just,
I'm a I'm a data nerd, so I love the design of the study. But I think also just like the through line

(20:03):
that you just talked about is the idea is like there seems to be a systematic approach that
different industries take when trying to address the issue of health promotion. We can we can dig
deeper into like is this industry doing it more in a more blatant way? Is this industry like
actually using the more um nuance approach? But still ultimately there seems to be a systematic

(20:24):
approach to how they actually contribute to, or is it helpful to actually for corporations to
contribute to um health promotion activities? And I think, I think we definitely both agree that,
I don't know if I will ever feel comfortable saying this is a health promotion study that
was sponsored by an industry, to say well I take just just because of like the existing
conflict of interest there. It just it seems to me that like that's like a an obvious thing

(20:47):
to think about and I think that's what also what was really helpful about your study to
actually show like once it's sponsored by industry maybe, that a good word to frame
it would be just like it seems to be always like a muddying of the waters effect in those
um conversations and those messages where, yes it could be that they're saying something else that
is true but still that doesn't negate that the first true statement about whether they

(21:10):
cause climate change or whether they actually contribute to a higher prevalence of cancer.
Okay. So, maybe let's dig deeper than it.
Yeah. Go ahead. Yeah.
Oh, sorry. I was just going to say maybe in in I think another really interesting
example of that where actually there's really good scientific evidence, there's, you know,
there's there's good evidence for something but that doesn't mean we shouldn't be really concerned

(21:33):
about conflicts of interest is the example of sugar sweetened beverages and physical activity,
right? So it's unquestionable that physical activity, level of physical activity, you know,
relates to obesity, childhood obesity. It's unquestionable. But when you have
huge globally consolidated manufacturers of sugar sweetened beverages funding a bunch of

(21:58):
physical activity research, then you, you kind of need to maybe question, A, why is it that
sugar sweetened beverage manufacturers are, are spending so much money funding physical activity
research and not research on the independent effects of sugar sweetened beverages on

(22:19):
Their products
On obesity, right?
I think I love that example.
Yeah, there's two there's two reflections there,
right? The first is why is this industry a source of any kind of expertise on this
topic at all, right? Like they are experts in producing and marketing sugar beverages,
not on obesity or on physical activity, right? And second, should we allow the scale of funding,

(22:44):
of one stream of research over another, to dictate how we feel about the kind of wider
evidential complexity? And I think that's an example that, that asks both of those questions.
And I think that's really interesting because like the first thing that you were saying spoke
to the side of me. I come from the other side of structural and social determinants
of health where I do want people to actually do more research about what structures do we

(23:07):
need to increase physical activity. But then I think this is the helpful component of the
commercial determinants of health framework where it says like, but also that should not take away
from the other big component that contributes to all of the chronic diseases that we're seeing,
which is the the really ultraprocessed food that we have throughout our environment.

(23:28):
Um, so then let's talk more about the methods and the results. I have still
have more questions. Some of them I'm really curious. Some of them still in the spirit of
complicating the narrative. So thinking about the methods that we you had um,
I was actually wondering did you ask participants beforehand their level of

(23:49):
certainty about different areas? I couldn't, I couldn't really figure that out from the
methods that you had. And maybe you can talk also about just your population for the study.
Yes. So we use public we use Qualtrics panels. So Qualtrics is like a platform that researchers
can use to kind of set up a study and then send out online surveys and people, survey panelists,

(24:15):
then sort of are exposed to whatever it is that you want them to be exposed to and then they fill
it in. We did, as part of that, ask them questions some questions beforehand. As you know, the more
you complicate a survey, the more you reduce the completion rate and you kind of introduce
these other these other limitations. We did ask them about their level of knowledge beforehand,

(24:37):
broadly speaking. Um, I'd have to remember, I, I can't remember exactly how we phrased it, but we
did ask them their level of knowledge beforehand. And we did do a kind of a stratified analysis
after the fact to see if the effect of these messages varied based on what they self-reported
as their level of knowledge beforehand. And we did find that there was an increasing effect. So in,

(25:02):
in those areas where they reported they had lower baseline knowledge, they then had, that kind of
the misinformation had a bigger effect on their um on, on their level of knowledge. But we didn't
ask in in great detail. We just asked them whether they were sort of not or slightly knowledgeable,
whether moderately knowledgeable, or extremely or very knowledgeable about the particular,

(25:24):
um about the particular topic. So we didn't, we could have probably, I mean there was scope to
do a lot more really interesting research along these lines that looks like educational status,
right? Or that like breaks it down by different geographic regions. But this
was really kind of top level and just basic self-reporting of uh level of knowledge.

(25:47):
So we will link to the study in the notes of the show here. But um you had, just opening up the
study here, you had about 48% uh 48.6% uh among those who were in the treatment group that were,
um that were rated as knowledgeable, very extremely knowledgeable, compared to 47.2

(26:08):
two were those who um in the control group. And I think I'm looking at the other numbers,
it's like yeah they are pretty comparable across groups which probably comes also just like from
the randomization that, that you had. So I, I, I do agree with you and I think also randomization
probably takes care of some of the concerns about maybe one group had more uncertainty

(26:28):
coming in. So randomization takes care of a lot of that. And I, I, I also shared your
um your worry about as soon as your survey becomes very complex you actually lose a lot.
So there's always a fine balance about what you to include to get a concrete answer versus not.
So then thinking more about the results section. I was actually interested in the fact that it

(26:49):
seems like for some industries the effect size was much larger and I wasn't sure also
um how much to read into it compared to just maybe those other industries that we've been there for
a while and they're new industries or maybe you and your team had a more alternative alternate
um or alternative explanation for why we're seeing for some specific

(27:12):
studies we're seeing such a larger effect. I have to say the effect was
uh visible for all um industries but for some specific ones that was much higher.
Yeah, it's a good question and it's, it's, you kind of want to avoid reading into it too much
because for quite a few of them we did see, so the magnitude of effect varied but the 95%

(27:34):
confidence intervals did overlap for, for, for those. Um, I think the one that jumped out to me
as really striking was probably smoking and lung cancer, because one would have assumed that in
general the public would be very, very familiar about the links between smoking and lung cancer,

(27:56):
more so than alcohol and breast cancer or the fossil fuels and climate change or
etc. And what you, what we actually found is that that was the one that introduced the
biggest sort of shift in uncertainty. Those messages really introduced the biggest shift
in uncertainty. And I guess one reflection on that is perhaps the fact that people do have,

(28:19):
people did have very strong views at the outset about smoking and lung cancer.
But then the message is quite a powerful alternative causation one. It almost like sticks
in the mind because it's like, "Oh, actually all these other things also cause lung cancer."
Oh, I didn't know about that.
Yeah. Yeah.
Maybe someone saying that. Yeah.

(28:40):
Yeah. Yeah. I didn't That's really striking. That's sticking with me. Oh, yeah. I guess other
things do cause lung cancer, you know, and sort of like it was almost like ready to be knocked down a
peg or two. Of course, it's more complicated than that. Um, but yeah, you're right that there are
some really interesting differences in effect size. And I think the important thing to note
is that we weren't looking at a massive number of these alternative causation arguments. So it could

(29:01):
be that, in part, if we think about it as like if we think this as an example of, of misinformation
with different uh potencies, it could be that we have a range of potencies, a somewhat arbitrary
range of potencies based on the examples and some just have a, a greater potency at a given

(29:21):
dose than others. Um, so yeah, it's hard. I, I, I'm hesitant to read into them too much other
than the smoking and lung cancer one because it was just so much stronger than the others.
This is helpful for me because I think I went down a rabbit hole trying to think through the smoking
and lung cancer just like you. My, my intuition was that, oh, this one would be the least,

(29:44):
like they would be the least capable of actually shaking. Um, and again, as I said,
maybe we shouldn't read too much into it. But I started thinking maybe it's because actually like,
we got so comfortable with the fact that we know the messaging about smoking that maybe we stopped
more factual promotional messaging about smoking. We see, recently we see younger people using more
vaping because maybe they were not as exposed in the past um as we were about smoking growing up.

(30:07):
So I, I, I went through um a lot of different explanations in my head, but I fully agree with
you. I think the main message here really is that we're seeing a systematic approach in trying to
um maybe seed more uncertainty about certain messages in, instead of thinking about them uh
industry by industry. But smoking is certainly much much higher than I thought it would be.

(30:27):
So then another result that was interesting for me. I don't know if you felt the same,
and maybe because I'm increasingly interested in trust, is the secondary outcome that you
had which did the study um lead to a reduction in trust in scientists and science in general,
in public health, and it seems like you haven't detect you did not really end up
detecting a lot of effects especially yeah from that small exposure. I don't

(30:51):
know if you have thoughts about why did the results shape up to be that way.
Yeah, it's a good it's a good question. I suppose it was a kind of, it was a question of,
it was a final question if that makes sense. And maybe the way we framed the question wasn't that
helpful when I think back. So we asked about their trust in science in general. Did they
trust it a lot? Did they trust it somewhat? Not much, not at all. And already when you ask them

(31:16):
that most people responded that they trusted it a lot or some and very few really didn't have a
a baseline trust in science. So it was kind of quite, the baseline level was quite high,
and maybe it wasn't necessarily that clear to them what they should read from the messages,

(31:40):
like should those affect their their trust in science. So maybe it was partly the fact that we
didn't give sufficient information linking these alternative causation arguments with the broader
science, the impact of commercial, you know, commercial forces on on this on the evidence base
or on how it's presented, and that's probably, that's probably why. I think what's really

(32:03):
fascinating about probing this more is because of what, what we talked about at the outset this
idea of cumulative impact on a range of these messages. I think this is probably the wrong way
to test cumulative impact on trust in science. But when you think about sponsored campaigns,

(32:23):
so WHO, IARC is a really good example, the International Agency for Research on Cancer,
you can find if you go online industry sponsored campaigns specifically to discredit IARC when
they, after they evaluate a carcinogen that has commercial impact, so like glyphosate or others.
And it's hard to imagine that kind of sponsored campaigns that explicitly say IARC is biased,

(32:50):
is based on per quality science, we shouldn't fund IARC. It's hard to imagine those don't impact on
trust in science over the longer term because that seems to be explicitly what the goal is. But
in this particular instance, it's probably not the right way to test that change in trust in science.
So then before moving into the next topic, um I had a few more questions.

(33:11):
Uh the first one really just, what was the most surprising result from this analysis because
you probably set in with the hypothesis that some of this messaging actually leads to uncertainty.
Yeah. You know actually the general effect size was quite surprising, if that makes sense,

(33:31):
because you got to remember that a lot of the control messaging is not set out specifically
to counter misinformation, it's just set out to educate the public, right? Like, so it's not like
the, the government health agency messaging is like tailored in a way to sort of cut through

(33:53):
misinformation or to be super, super clear. It's just intended to be factual. And with that in
mind, it was really striking that there was such a different, a large effect size between the,
the control messages and the corporate social responsibility or industry-funded charity
messaging. Um I think that was really, that was quite a striking finding the, the, the size of

(34:19):
it. But I think the other really interesting finding for me was how many people connected
with and reached out to us after that study came out because you, you were probably looking at it,
Salma, and I have to say based on our conversation you've probably read the study more than almost
anyone else who has engaged with it. This is the longest, most fruitful conversation I've

(34:43):
had about the methods, the results, the kind of rationale which is great. But we did get a lot
of interest and questions and followup from people who were interested in either specific industries,
like sugar sweetened beverages or fossil fuels, or industries that we hadn't considered here,

(35:03):
like meat or other sectors, where they they had sort of an almost like an instinctual sense that
this kind of thing was going on, that there was something about the messaging by sort of
commercially funded entities that was different from their understanding of the evidence,
but they could put couldn't put their finger on why or what that was. Does that make sense? So

(35:29):
um I think this is an example where a commercial determinants of health lens can be really helpful
in that it doesn't require necessarily you to, to bring huge methodological novelty, but it requires
you to maybe cast the lens above the level of the individual consumer or, or, or, or member

(35:51):
of the public to, to that unit of analysis that's concerned with industry, or with industry actors,
and just by moving the level of analysis you can say some interesting and relatively novel things.
So then maybe then two questions here for an early career researcher who thought,
oh this sounds so cool I want to do a similar um study. I had two questions I swear only two

(36:17):
questions more about the methods. The first one really is um why would you advise a researcher,
or maybe you wouldn't, that this is this would be a good choice compared to doing a document
analysis, especially when it comes to cost to actually do a study like this compared to just
going through document analysis and comparing the messages. Where do you think is the benefit here?

(36:39):
So, well I think first of all it, it very much depends on, especially as an early career
researcher, it depends on the, the methodological expertise and support around you. I would say,
that is a really important consideration in doing something like this particularly because if you're
going to be potentially making quite impactful conclusions that relate to industry sectors,

(37:04):
that relate to messaging, then you have maybe a higher than average risk of being critiqued,
of having letters sent to the editor, or you know that kind of thing of these aren't
Not speaking from experience at all
Well, we could get on to that if you like, but I guess having done bench science for a number of

(37:25):
years, I was struck that it's possible, it was possible to write, like the most highly cited
paper I've ever been involved in, has nothing to do with commercial determinants of health,
generated zero uh comments to the editor, zero calls to my university leadership,
anything like that. It was like consequence-free, read only by other, you know, biomedical science

(37:49):
researchers on quadruplex DNA topologies. Yet, that was, you know, it was cited a lot because
there's a lot of funding a lot of interest and that kind of thing. And the flip side is
you can do research on something like this and find that there's a lot of opposition to it,
direct and indirect, and so because of that I think you, as an ECR, you want to make sure you

(38:11):
got the right support networks around you, that you have senior people who can see the value of
what you're doing, that you have people who can help bounce methodological questions that you can
that you can sort of help figure out um, and so that you've sort of framed the the limitations,
the strengths and limitations correctly in anticipation of those kind of things. So I

(38:33):
would almost say that is more important, first, in determining whether you go down the document
analysis route or survey design, that kind of thing. The second thing that I think is
really valuable about this kind of approach is that you are generating primary data. You're
generating kind of empiric evidence that is more easily communicable to a wider group of people,

(38:56):
I feel. I feel like documentary analysis you have kind of often quotes and themes but it
can be harder to convey that, to say, a more medically minded audience or a more, I guess,
a health policy kind of audience, whereas this kind of empiric finding based on sort of opinions

(39:18):
or views of the public and how they've been shaped is a lot closer to what decision makers
and health researchers might be used to seeing and interpreting. And, and that can matter for,
for uses beyond the academic including in legal cases or arguments and that kind of thing.
So then maybe the second part, someone decides, and an ECR is an early career researcher. And an

(39:45):
early career researcher decides this is great, again, I really want to do this where how. How
did you draw the line between I want to make the messages very realistic, but also remain routed
uh or rooted in ethical principles about being ethical enough not to provide messaging that
might shape people's behavior after being exposed to the survey? What were the guard,

(40:09):
guard rails that you actually had to make sure that doesn't happen?
Yeah, that's a really good question, Salma. And I think that is something that is important to
grapple with in any kind of research um like this, that kind of ethical balance. So we,
in order to sort of be as transparent as possible, we made sure that we published in supplementary

(40:33):
material all the different messages that we used and their sources. So they were all real world
examples. And we did our best, there was a team of us involved to collect them together, to sort
of divvy them up accordingly, but then above all to be transparent about which ones we used, what
their, their online source was, to avoid any sense that we were gaming the system somehow or that we,

(40:57):
you know, that we weren't being representative in, in the examples that we chose. And then we
did have a message um at the end of the survey. So regardless of what they were randomized to,
at the end of the survey, all respondents got kind of the accurate, the, the control statement,
the kind of non-industry information and a link to a trusted source, to sort of, so that they don't

(41:23):
go away with that um just having read a kind of, an industry funded piece of misinformation and go
out into the wild. So they were sort of, at the end once we collected the data the final thing
they saw was a clarifying statement about the real nature or the you know the nature of the risk.

(41:43):
So I do think that's a fascinating study. I hope everyone actually gets a chance to
go and read it. I also think it, it is um an innovative study and a creative one.
So Nason, now to the easier part.
Oh my word, Salma.
I want to step back maybe thinking about the commercial determinants of health and,
I'm sorry again today seems like you're the spokesperson of the commercial determinants

(42:06):
of health, and maybe just offer a few push backs, wider push backs that you probably hear,
um and you probably experience on a daily basis, and then maybe hear some of your
responses about those. And again, this is going to be the easier part hopefully.
So the first one is really the individual agency critique um that we hear a lot about. So what do
you say to people who say, well health ultimately is the responsibility of the

(42:31):
individual and actually putting it on industries takes away the agency of someone who could have
just maybe chosen not to smoke that cigarette, or chosen not to eat that ultraprocessed food.
Yeah.
Also, can you tell me how many of those messages do you usually get? That would be fun.
I, yeah, I have gotten that quite a lot in a in a range of different forms. First of all

(42:53):
I would say it's always useful to think about that, because one of the dangers I think is if
we restrict ourselves to kind of our very narrow professional bubbles or networks of individuals,
that we kind of fall into the trap of kind of often assuming that we all share the same

(43:14):
interpretation of the kind of role of individual behaviors, versus structural factors and that
kind of thing. And the truth is we really don't. And we move outside those bubbles,
the public health bubbles, health policy bubbles, global health bubbles. Actually perceptions are
radically different and it's important to remember that. Um so I would say that there is of course

(43:35):
a really important role for individual agency in any kind of health behavior, as an example. But I
think it would be unscientific not to think about the relative effects of the environments in which
a person exists. So in a way to navigate, to, to ignore the effects of the choice environment,

(44:01):
because you you make choices in the context of an environment and, if your environment is shaped in
certain ways, that influences on your choices like whi, literally which options you can you can make.
And, so, I think that's really important and the example we've used in the upcoming book, A Healthy
Profit, is to use the example of a a captain captain navigating a difficult journey by sea.

(44:29):
And you know, the captain, she may be incredibly competent, you know, incredibly well trained, have
a really good sense of direction, but ultimately she can only control what direction she points
the ship in and how the sails are set. She can't control how deep the water is, or what, how strong

(44:53):
the storm is or the currents are like all these wider forces, right? And so inevitably if a 100
people make that journey with the same amount of skill, but with very different weather conditions,
they'll get very different outcomes, right? Like, it's, it, it would be unscientific for us to say
that those don't really matter. And I think the same is true of people navigating the choice

(45:16):
environments in their neighborhoods. You know, if it's simply a less healthy set of choices, then
that will have aggregate effects over time. And I think the other, so there's a scientific argument
for focusing on these kind of wider structures around us. But I think there's also a justice,
a kind of a moral argument, which is that, I find it really annoying whenever people say you should

(45:44):
have just done what I did, you know, you should have you know what I mean like if only they'd done
what I did then they'd be if they'd be healthy like me, or or that kind of thing. And again I
think to go back to that ship metaphor that is like someone who crossed that journey on a sunny
day with relatively low levels of wind, right? Emerges the other side unscathed and then says,

(46:05):
"I don't know what all these shipwreck victims are complaining about." Like, it's easy. You just make
the healthy choice, then you'll be fine. And I think there's a kind of justice argument that if
we don't have sort of fair choice environments, if we don't have sufficient agency and control

(46:26):
over our choice environments, then it's kind of hard, it's hard to expect that we should have the
same health outcomes. It's just kind of unjust. So I think that's the, the second component.
So I think to me this also fits into, the second part, at least the moral argument, fits more into

(46:47):
the discussion around freedom to freedom from. So I if you live in a neighborhood where the stores
only provide ultrarocessed food, it's very hard for you to actually get healthy food regardless
of how much healthy conscious you are and you read all the wellness newsletters that you can possibly
read. I might be more libertarian than you when it comes to this, but I, I do, I do think,

(47:07):
this is at least, this is my framing when it comes to structural um issues and especially when it
comes to commercial issues. Um, and it seems to me it's, it's a no-brainer if we're only seeing, if
we're seeing that outside of schools for children, the only available food is ultraprocessed food.
If kids don't have space uh to go and sit in that doesn't have any smoking because everyone

(47:31):
there is allowed to smoke wherever they are. Seems like it's a no-brainer choice.
So, then another critique you probably hear a lot is saying,
well, this is just anti-capitalism dressed up as public health and public health science.
How do you usually respond to that criticism?
Yeah, I mean, I think I haven't gotten that criticism as explicitly as that,

(47:54):
but I guess my response has always been, look, is it anti- capital, you know, it, saying,
saying it's anti-capitalist to study the health effects, a direct and indirect health effects, of
a set of very powerful actors is a bit like saying it's, it's, it's anti-pump handle to, you know,

(48:21):
to do a basic epi study that links collar cases back to, you know, to a pump. It's not anti-pump
handle. You're just following following evidence to its source kind of thing. And we could we could
talk about the John S, the limitations of the John Snow, right? But it's something everyone's
very familiar with. Like you, you wouldn't say, "Gosh, this guy started out with a real be in his

(48:43):
bonnet about pump handles." You, you would, you know, it's more the fact that you're following
the evidence. So I would say that's the first thing. And the second thing, I would say, is
that actually you know there is no such thing as one simple one single capitalism. If you look at
different countries around the world you see lots of different flavors of a market-based societies,

(49:05):
market-based systems, and a good example of that would be something like pharmaceutical industry.
It's very differently regulated in different countries around the world and that leads to very
different incentive structures, very different pricing and availability of products and in, it's,
it's the same industry but its manifestations and how it influences public life, consumer behaviors,

(49:29):
policy choices, pricing and availability, it differs dramatically. And none of that is sort
of capitalism versus socialism or communism. It's just different regulatory frameworks,
different incentive frameworks. So I would say, a lot of benefit can be achieved, you know,

(49:51):
within the current constraints uh of what we're operating in. And that's not to say that there
isn't as important,, an, an important reason to critique the wider capitalist system to
critique the kind of concentration of power in different segments of it. Um but I think
that it is important to remember there is this great variation. And I think the other thing
that I would say is that particularly in key areas like energy, or ultraprocessed foods, or tobacco,

(50:20):
right? Where, that matter a lot to public health, you see increasingly kind of monopolistic or
oligopolistic kind of dynamics, where, actually, you don't necessarily see a properly functioning
market. You see a few, very large heavily consolidated uh companies that are exerting

(50:41):
kind of an excess influence over their own kind of pond that they're operating in. So that's not
to the benefit of all the other players, the small and medium enterprises that are seeking to to work
in that space. It's not of it's not that helpful to the employees within those companies but also
in the wider markets that they're operating in. So there's a, I would say there's a lot, there's

(51:07):
ways in which profit can be healthier with, while still being a kind of profit-based system overall.
So then on the flip side, yeah, could someone make an argument that we know it's
all about power? We've known this, this is not new. What we're doing right now,

(51:29):
and you and I have written about the commercial determinants of health in different settings,
is we're just dressing up a real urgent problem as an academic exercise that
might not necessarily lead to change. So what would you say that, to that?
I would say it's always important to ask that kind of question. You know, I don't know about you,

(51:49):
but I am kind of an accidental academic. I didn't set out to be in public health.
I think this is probably how we bonded.
Yeah. I didn't settle to be in public health. And if you were to look at my background, like
who my parents are, where I grew up, the schools I went to, the friends I had, you would not be like,
"Oh yeah, this guy's going to be an academic at a Russell Group University." That is not

(52:12):
the way you would have thought that would go at all. Um, and I think it's really important
to actually remind ourselves like why are we doing this actually? Like what value is there
in this kind of inquiry? And I ask myself that all the time. That's part of the reason why my,
my podcast is not called commercial determinants of health, because I, I don't think it's a term
that most of the public really understand. Um but I do think it is really helpful to provide

(52:40):
empiric evidence in this space. I don't think it's nec, I mean, I think if others want to sort of
talk about the need to tear down the system more broadly or the fact that this is all about power,
I think that's a legitimate critique to make. Um and there, there, there are lots of political
scientists, social scientists, e, you know, people with more economics backgrounds who can do that. I

(53:02):
guess where my interest is, is producing evidence that is compelling and sort of generates a,
almost like a human response in, in people. So I think one of the things that I've really
liked about working in commercial determinants of health, and in doing documentary analysis
on leaked documents, or on sort of internal emails, communications, public campaigns,

(53:28):
is there is often a kind of visceral response to examples of that power asymmetry. You know,
like the notion that you know one paper on internal advertising case studies we showed
that alcohol companies were targeting low-income, high consuming individuals. They were you know
act actively targeting them to increase the revenue further from those individuals that

(53:53):
were already drinking at very high levels, in very harmful ways, but they were like the golden goose,
so they kept going back to them. And in a way, I think, that can do a lot for public support for
action, for kind of understanding of how health inequalities are shaped in terms of structural,
structural upstream factors, in a way that just simply saying this is all about power and here

(54:21):
are some frameworks for us to think about that can do, if that makes sense. Like I think there's
value in doing both, but where my interest is is more in in that former kind of style of inquiry.
First of all, very nice plug to your podcast, which I actually think it's
great. Uh we will also link to it in the show notes and it's called um Money, Power,

(54:46):
Health. It's an excellent podcast. I recommend people to listen to it. But
I also wanted to follow up on what you just said and the fact that you did try to take,
and I think you continuously try to do that, where you take your work from just sitting
in an academic setting to work with different policy makers and decision makers and how that
can shape them policy. So, maybe we can talk a bit quickly about some of the efforts that

(55:07):
you've been in trying to change policies based on the sum of research that you did.
Sure. Yes. I mean I would say that um first of all a lot of the academic work that I've
been involved in is really team oriented, you know, and I've had the pleasure of working with
a huge range of academic colleagues. And then, any kind of policy relevant outputs,

(55:29):
uh reports, or public events, that kind of thing, is again often as a result of a large team of, of,
of, of, colleagues from a range of backgrounds, including uh advocacy backgrounds, for example,
right? Where, or practitioner backgrounds. So I would say none of it is stuff that I would

(55:51):
say is an individual, you know, this is, like not, not because I've done it per se,
but I give it an example of a really interesting initiative that happened recently is that,
um in Scotland there was kind of the formation of a coalition of charities called the Scottish
NCD alliance. So there's over 20 charities in Scotland, there were heart disease charities,

(56:15):
um, obesity, smoking, you know, a range of different charities. And,
um, they decided to form an alliance and, as an alliance, publish a 10-year policy document,
an a 10-year policy ask, a kind of manifesto on behalf of all of them on addressing the commercial
determinants of health in Scotland. And I think what was really interesting about that is that it

(56:40):
showed that there is really strong potential when looking at the upstream drivers of some of these
issues. So the upstream drivers of inequalities in heart disease incidents, in obesity incidents,
in um in smoking prevalence, in low-inccome communities, right? Like there are individual

(57:00):
policy asks one can focus on as an advocate but there are upstream common policy asks that a range
of advocacy voices can ask for, like transparency in government decision-making, like managing
conflicts of interest, like better balancing the voices of civil society and business, if that
makes sense. And those really speak to the kind of power dynamics that I think you were referring to,

(57:25):
Salma, right? Which is that, part of the challenge in these settings is that people often talk about
empowering communities or empowering individuals, but really like power is relative. If you're going
to empower them, sometimes you got to disempower something else. You know, you know what I mean?
And so, what I really liked about the, the way that the NCD Alliance approached this issue,

(57:47):
they involved a wide group of experts, they really relied on their advocacy and lobbying expertise,
but sort of sacrificed a little bit of their own individual um entity,
individual identities in pursuit of this common agenda, you know, like to say we all would benefit

(58:08):
uh from this. So I think that's an example of a really interesting development.
We've seen similar developments in, in Brazil and other contexts. And I think what it,
what it shows is that, that, that that, is both magnifying the voice of civil society generally,
but it also seems to be really impactful in the mind of the public. So they commissioned

(58:30):
public panels that were representative of the population of Scotland. And I had the
privilege of speaking at one of these public panels. So you had students, you had retirees,
you had people from high and low-income backgrounds and everything in between.
And actually presenting evidence on commercial determinants of them and, and the range of policy
options to address that, it was really fascinating to see positive responses from public panels,

(58:55):
from a range of backgrounds, about particular approaches, about the value of kind of the
framing of power and power asymmetry. So yeah, I think that kind of thing is really exciting.
So can I ask what keeps you going? And maybe this is the question for us to wrap up the
part about commercial determinants of health. Because, I just, you alluded to this earlier,

(59:15):
but if you're talking to someone who is early career, who's interested in this,
and you did end up dragging me to the field of commercial determinants of health where I've,
I've written a bit about commercial determinants of health in low- and middle-income countries,
but unlike me I think you're someone who receives um I, I write a lot about policies, governments
and structures and how they shape health outcomes and what need to change. But I don't think I've

(59:37):
ever had to go to a lawyer to check whether I should submit something. You've alluded to
this earlier. You almost always have to work with lawyers. You receive letters to the editor. You,
I don't know if you want to tell that story. You also sometimes receive even emails and calls to
your school leadership. So if you can give us just like some examples of the complexities
that someone should have a clear eye coming into this field, working on, but also maybe talk a

(01:00:02):
bit about what keeps you going and why why do you think this is still really important work to do?
Yeah. So I think in terms of the complexities um it it varies massively. Um and I think it doesn't,
it's not about the strength of your evidence or your methods. I think it's important to remember
that the complexity really arises from, I guess, the, the, the, nature of the the discourse around

(01:00:29):
the topic that you're you're doing, the potential vested interests related to the topic that you're
involved in. So you could do, you know, sort of some, some really um stellar research,
but because it doesn't maybe actively harm a particular commercial interest, then you
won't get any of that push back. You could do something else. It's almost like a lot smaller

(01:00:54):
um and a lot more incomplete in some ways, but because it references some specific brands,
or because it speaks to a particular policy that's under active deliberation, and that a particular
set of actors is, is opposing or is promoting, then you get a lot more opposition. So, I think
the first thing to say is it can be hard to know when you will and when you won't get opposition.

(01:01:15):
And it's not necessarily either predictable or linear, based on any particular metric. Um and
the second the second thing I would say is that it's it, it is probably important to think about,
um depending on your career status, on the level of support you have around you.

(01:01:36):
I think one of the things I learned from doing research based at London School of Hygiene and
Tropical Medicine is that it's always useful to communicate the publication of any potentially
contentious studies in advance, so that the communications office is aware of it.
Seeking legal appro, you know, legal review or legal approval within your institution,

(01:01:58):
um just to make sure that any claims you're making are, I guess, covered when it comes to
issues like liable in the, in the, the country context that you're in. So like doing that kind
of thing is really good practice I think. And above all one of the things that I've really
enjoyed about commercial determinants of health research and the kind of research that we've done,

(01:02:21):
which again is one small subset of commercial determinants research, there's a much bigger
body of of research out there of all different types and disciplines, is that it has helped make
us be incredibly precise about the claims that we make and the conclusions that we come to, because
we kind of try and read it and reread it from the perspective of a kind of, the kind of person

(01:02:43):
who would write uh a critique or complain to the editor or otherwise kind of disparage the research
because of potential conflicts of interest. Um so yeah, I wouldn't say that I mean I, I,
I, I can think of researchers who's faced a lot more opposition direct and indirect than I have.

(01:03:05):
And I would say, when you think, when you widen that to advocacy particularly in some contexts,
um I'm thinking of South America in particular, there have been horrendous costs associated with
advocating against certain environmental policy or that kind of thing, where like, you know,
in terms of risk to life and safety. Um, and I think by contrast, getting complaint letters,

(01:03:31):
uh, mildly threatening legal letters, that kind of thing is, is, is, is definitely not on that level.
On your second question about what motivates me, um, I would say I'm
still kind of pinching myself that I'm able to do this kind of work. Um, as I mentioned,

(01:03:56):
I'm kind of an accidental academic. When I finished high school in Greece, um, in Rhodes,
I, I think my grades were enough for me to go to be a mechanic in, in technical college,
and that's what I was going to do. I was going to be a mechanic and I was kind of looking forward to
that. And my parents kind of just insisted that I try to go through the process of clearing. So go,

(01:04:22):
you can sort of once universities have taken up all the candidates they want, sometimes they
have extra spaces and so you can go through this process of clearing in the UK where you can sort
of apply to different programs and, if there's a space that no one else has taken on a particular
program, then you can get in even if you don't have the requirements, academic requirements,
and that's how I got into university, uh on undergraduate, you know, I applied for

(01:04:45):
a whole bunch of different things and it just so happened that I got in at University of Ulster,
which is a former polytechnic college, not a kind of an Ivy League or, you know, a very you know
sort of high-profile university. And so I was an accidental academic I guess from the beginning,
as an undergraduate even, and having worked in the private sector, having worked in a kind of cubicle

(01:05:12):
where you're just told to write certain things as fast as possible, or to pitch for work to clients,
um having had that kind of lack of autonomy and having done things that you didn't really believe
in, that you weren't that interested in, to have the freedom to kind of do research on basically

(01:05:35):
any topic that you can convince people is important, to have that kind of autonomy,
to me I'm still pinching myself. So that's, what motivates me is that I'm kind of living the dream.
Like this is an incredibly privileged position to be in and you know I I just want to take as
much advantage of it as I can and hopefully do that opportunity justice. Do my do my parents

(01:06:02):
justice. You know, my parents listen to the podcast and I, I'm immensely gratified by that
because I feel like they're almost like holding me to account, you know, they know enough about
what I'm doing with my life that they can say, you know, is that right? Do you think that's, and that
kind of thing that kind of thing matters to me. So that's, that's, I suppose, what motivates me.
So then, our last question. Um if you could define or think about what would be something

(01:06:30):
that keeps you up at night, or maybe an issue that you think should be more complicated but
we usually think about it in simple terms in public health, what would be that issue?
Wow. Gosh, there's so many, so many possible issues that keep me up at night. You know,
I think one of the things that I think really keeps me up at night is the extent to which, the,

(01:06:58):
is the extent to which what we often automatically think of as success is largely defined by our
choice environments. You know, we were, talked, in the talk, at the beginning about individual
agency and structure. And I think, often what we think of as success in global health,
or public health, or academia, that itself is shaped by a choice environments. It's bigger

(01:07:18):
grants and more citations, or it's maybe bigger leadership positions in a UN agency,
or what whatever it is that your, your choice environment is. And I think it's important to
remember that those choice environments are very different to what the majority of people on this
Earth are facing. And the thing that keeps me up at night is that fundamental disparity. Is,

(01:07:43):
is the fact that in the UK, you know, maybe 1% of people has been excluded from school,
but in the prison population, it's like closer to half of all the prison population have been
excluded from school. Like that is an example of dramatically different choice environments

(01:08:04):
that we're navigating all the time. And I think those kind of things keep me up
at night because I just don't know that we center them or acknowledge them in
a visceral enough sense. And I think it comes back to what you and I have talked about often,
which is like we are inevitably in a very privileged minority in that sense.

(01:08:27):
Nason Maani, thank you so much for your time.
Thank you, Salma. It's been a pleasure.
This podcast was edited by Zach Linhares and Catalina Melendez
Contreras. It is supported by the School of Public Health and Frick Initiative at
Washington University in St. Louis. You can access this and other episodes wherever you

(01:08:48):
get your podcast or you can watch it on video on YouTube. Thank you for watching.

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