Toward Monitoring and Addressing the Commercial Determinants of Health: Where Can We Go From Here?

Abstract

Policy Points.

• We describe ways to advance two key priorities related to the commercial determinants of health (CDH): the development of systems to monitor commercial practices and the creation of policy recommendations to address the CDH.

• Specifically, we discuss corporate nonfinancial reporting as a potential mechanism to obtain data on commercial practices that influence population health, describe the potential risks and benefits, and propose opportunities to advance high‐quality corporate reporting on health impacts.

• We also review previous global agenda‐setting exercises to suggest five key considerations to inform the World Health Organization's forthcoming policy recommendations for addressing the CDH.

In the last two decades, the concept of the commercial determinants of health (CDH) has become an increasingly common lens for understanding the causes of adverse health outcomes and their distribution across populations. In a recent Lancet series on the CDH, Gilmore and colleagues defined the CDH as “the systems, practices, and pathways through which commercial actors drive health and equity.” ^{1 p1195} The study of these systems, practices, and pathways has been informed by the work of civil society organizations that have tackled these issues for many decades. ² , ³ More recently, the CDH concept has been incorporated into public health practice and policy in some jurisdictions, such as within Australia's National Preventive Health Strategy. ⁴ , ⁵ Efforts to advance the theoretical and practical use of the CDH concept have faced a myriad of challenges that include insufficient funding, a lack of attention to commercial practices within public health education programs, a lack of metrics for measuring commercial activities and assessing impacts, a diverse and complicated commercial sector, and industry opposition and intimidation. ² , ⁶ , ⁷ , ⁸ Despite these challenges, the CDH concept has the potential to be a useful tool to overcome some of the key barriers the field of public health has faced in promoting healthier communities and improving health equity (e.g., advancing policies that challenge entrenched interests). ⁹ , ¹⁰

In this article, we seek to advance discussion on two key priorities related to the CDH: 1) the development of mechanisms to measure and monitor the practices of commercial entities, and 2) the development of effective policy recommendations for addressing the CDH. We begin by summarizing recent research contributions, key areas of tension and disagreement, and current priorities for the CDH field. We then describe a critical challenge associated with monitoring corporate practices (i.e., the lack of accessible, high‐quality data) and discuss how corporate nonfinancial (NF) reporting could be leveraged as a means to obtain data. Finally, we review the strengths and shortcomings of previous agenda‐setting exercises (i.e., the Sustainable Development Goals [SDGs] and global action to address the social determinants of health [SDH]) to suggest five key considerations (i.e., prioritization, multilevel action, collaboration, projection, and effective framing) to inform the development of the World Health Organization (WHO)’s forthcoming policy recommendations for addressing the CDH. ¹¹

The recommendations that we offer in this article were informed by our previous research efforts to advance these two priorities. Specifically, we have systematically reviewed CDH literature to identify and describe the diverse set of commercial activities that influence health, ¹² generated evidence to inform CDH monitoring priorities and pinpoint monitoring gaps for the food and beverage (F&B) industry (forthcoming), and explored corporate NF reporting (NFR) as a means to both monitor and address the CDH (forthcoming). Through the process of conducting this research, we have reviewed a significant amount of relevant literature and have had conversations with individuals working in government, intergovernmental organizations, civil society, academia, and the financial sector. The reflections, recommendations, and illustrative examples that we provide throughout this article resulted from this organic process and not a systematic literature search.

Recent Advances and Current Challenges in CDH Research, Policy, and Practice

In the last 5 years, scholars of the CDH have sought to expand the concept from an initial focus on the food, alcohol, and tobacco industries and their impact on the noncommunicable disease (NCD) crisis to consider other industries (e.g., social media), commercial allies (e.g., consulting firms), health conditions (e.g., mental health), behaviors (e.g., gambling and physical [in]activity), mechanisms (e.g., climate change), and populations (e.g., adolescents). ² , ⁶ , ⁸ , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ Alongside increased knowledge of the practices through which commercial entities can influence health, the concept has been advanced by placing a stronger focus on the underlying norms (e.g., maximizing shareholder value), legal structures (e.g., corporate rights to unlimited political spending in the United States), policies (e.g., deregulation), and forms of power (e.g., excessive access to and control of economic resources) that may allow for and/or incentivize these practices. ¹ , ² , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ Recently, CDH scholars have also sought to refine the definition of the CDH to recognize the diversity of commercial actors, incorporate more neutrality in the framing of the influence of commercial actors on health, and place a stronger focus on health equity alongside the acknowledgment of the influence of structure as well as agency. ¹ , ² , ⁸ , ³⁰

Though these efforts have helped to generate a more comprehensive, rigorous, and refined body of academic work, there are several challenges and points of disagreement that still exist within the field. These include unresolved debates about the extent to which CDH research should consider the positive influences of commercial entities on health and ways that the public sector should engage (or not engage) with commercial actors on health issues. ⁹ , ³¹ , ³² , ³³ The CDH concept has features that may enable its wide‐scale adoption by policymakers, politicians, and the public (e.g., an increasing body of scientific literature, uptake by prominent global organizations such as the WHO, and emergence from grassroots social movements). ² , ⁶ , ³⁴ , ³⁵ , ³⁶ However, it is not yet clear whether the concept can gain enough support to overcome the procorporate neoliberal ideology that is embedded in many societies. ² , ³⁷ Moreover, addressing the CDH often requires policies that may transcend the traditional purview of health policymakers (e.g., policy related to trade agreements, tax, and lobbying activities); achieving meaningful progress is likely to require strategic collaboration with nonhealth actors. ²⁹ , ³⁸

In addition to these challenges, the CDH field also faces uncertainty with respect to how to advance several important priorities for action and research. ² , ⁶ , ⁹ , ¹⁰ , ³⁹ , ⁴⁰ In the following sections, we aim to advance discussion on two critical priorities. The first priority is to develop systems that can be used to measure and track the practices of commercial entities that affect health outcomes. The second is the imperative to develop effective policy recommendations for addressing the CDH. These priorities have been identified by numerous CDH scholars as important to advancing progress on the CDH, yet both objectives also face significant challenges to being achieved (e.g., a lack of available data and unclear policy traction). ² , ³ , ⁸ , ⁹ , ¹⁰ , ²⁹ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ As such, they represent important opportunities for further discussion and analysis.

Overcoming Data Unavailability: A Key Challenge to Measuring and Monitoring Commercial Practices

Systematic monitoring of the practices of commercial entities that influence population health has been consistently identified as a key priority for the CDH field. ⁸ , ⁹ , ¹² , ³⁹ , ⁴¹ , ⁴² , ⁴³ Measurement and monitoring (i.e., surveillance) is a cornerstone of public health practice, and projects such as the Global Burden of Diseases, Injuries, and Risk Factors Study demonstrate the utility of tracking risk factors as a mechanism for identifying priorities for action and assessing progress. ⁴⁵ , ⁴⁶ Measurement and monitoring of commercial practices would allow CDH scholars and public health decision makers to make comparisons of commercial practices over time and within and across industries and regions, assess the impacts of commercial practices on specific health outcomes, and identify practices that require attention within research and policy. ² , ⁴¹ , ⁴² Corporate monitoring initiatives such as the Access to Nutrition Index (ATNI) and the International Network for Food and Obesity/Noncommunicable Diseases Research, Monitoring and Action Support (INFORMAS) private sector module have demonstrated that corporate benchmarking can increase engagement with the private sector, activate investors, and promote corporate action. ⁴⁷ , ⁴⁸ , ⁴⁹

One of the key challenges in monitoring commercial activities that influence health, however, is the lack of publicly accessible, high‐quality data. ⁹ , ⁵⁰ , ⁵¹ Existing monitoring efforts have implemented different strategies to address this challenge. ATNI, for example, engages with F&B companies to obtain nonpublic data using nondisclosure agreements. ⁵² The INFORMAS private sector module recommends that countries monitor the practices of F&B companies by starting with the collection of publicly available data on corporate policies and commitments, as these data points are easier and less expensive to collect than data on performance and corporate political activities. ⁵³ In their Corporate Health Impact Assessment approach, Baum and colleagues ⁵⁴ propose using interviews with stakeholders, document analyses, and database searches to investigate the impacts of transnational corporations in specific regions. Though interviews with representatives of corporations are recommended as part of this approach, corporate nonengagement was found to be a limitation in practice. ⁵⁵ , ⁵⁶ The authors also described challenges in obtaining information on equity impacts (e.g., location of fast‐food outlets in comparison with socioeconomic status). ⁵⁶ Others have proposed ways to overcome challenges with patchy, inconsistent, or complex data on corporate activities. ⁵⁷ , ⁵⁸ Based on their efforts to extract and analyze data on political contributions and lobbying in Australia, Lacy‐Nichols and Cullerton ⁵⁷ suggested that governments should provide data in structured, machine‐readable formats to facilitate large analyses. Though these initiatives have greatly advanced our ability to monitor corporate practices, their potential has been constrained by the poor availability and inadequacy of publicly accessible data and the significant time and resources required to collect the data so that they can be used. ⁴⁸ , ⁴⁹ , ⁵⁴ , ⁵⁵ , ⁵⁷ These constraints likely also stymy efforts to integrate monitoring of commercial practices into governmental surveillance programs; surveillance of commercial practices at the national governmental level is largely absent at this time. ⁸ , ⁴¹ Table 1 provides a list of existing monitoring efforts and information about their methodological approaches.

Table 1.

Examples of Existing Initiatives to Monitor Commercial Practices, Their Data Collection Procedures, and Example Data Points ^a

Existing Monitoring Initiatives	Description	Data Collection Procedures b	Example Data Point Used to Monitor Commercial Practices
The Global ATNI	The Access to Nutrition Initiative's Global Index is an assessment of 25 of the largest food and beverage manufacturers in terms of how they contribute to addressing all forms of malnutrition. 52	Companies are invited to provide information on a voluntary basis, with the option to do so using a nondisclosure agreement. The ATNI also extracts information from corporate websites and other publicly available sources. Information about products is obtained from various industry and public health databases (e.g., FoodSwitch). 52	In the last 3 years, has the company undertaken research to demonstrate the efficacy of its portion control efforts on consumer behavior?
BIA‐Obesity	BIA‐Obesity is a tool for benchmarking the nutrition‐related policies, commitments, and practices of food and beverage companies at the country level. 59 It was developed as part of the private module of the INFORMAS. 60	Countries implementing the BIA‐Obesity tool are encouraged to select companies of interest and collect data on corporate policies, commitments, practices, and performance from publicly available company websites or other sources (e.g., media releases, sustainability reports). After the information is collected, companies can be invited to verify the publicly available information and/or provide additional confidential information. 60	Does the company publish a comprehensive set of commitments or objectives related to new product development and reformulating its existing products with respect to reducing the nutrients of concern and energy (salt, saturated fats, trans fats, free sugar, and kilojoules)?
The CHIA	The CHIA was developed as a structured assessment tool for investigating the health and equity impacts of individual transnational corporations in specific regions, with a focus on the food and beverage and extractive industry sectors. 54 , 55 , 56	Baum and colleagues 54 recommended conducting document analyses of corporate policies and governmental reports, conducting interviews with key stakeholders (e.g., company representatives, affected communities), and searching relevant databases (e.g., news databases).	Corporate affiliations with trade groups
Lobbying and political donations in Australia	Lacy‐Nichols and Cullerton 57 conducted a pilot study of the feasibility of monitoring lobbying and political donations by “harmful industries” (i.e., alcohol, gambling, ultraprocessed food, and tobacco) in Australia.	The authors extracted and cleaned data from two sources: New South Wales ministerial diaries and federal records of political donation returns. They developed fact and dimension tables to organize, code, and analyze the data. 57	Number of meetings between ministers of New South Wales and representatives of harmful industries
Tobacco Tactics	Tobacco Tactics provides research and data on the activities of the tobacco industry, including information about key tactics (e.g., litigation), actors in the supply chain (e.g., manufacturers), and associated organizations (e.g., think tanks). 61	The information is compiled by an editorial and investigatory team. 61 Information sources include industry documents (publicly available, obtained during litigation, or leaked), market data, public registers (e.g., lobbying registers), media articles, resources shared by local advocacy organizations, and research conducted by the Tobacco Control Research Group (University of Bath), among other sources (Karin Silver, email correspondence, August 5, 2024).	Cases of litigation used by the tobacco industry to challenge regulations
OpenSecrets	OpenSecrets tracks campaign contributions, lobbying activities, revolving doors, and other information related to the influence of individuals and corporations on politics in the United States. 62	OpenSecrets extracts, transforms, and links publicly available data from the United States government (e.g., the Federal Election Commission, Internal Revenue Service, Senate Office of Public Records). 62	Total annual lobbying expenditures made by a corporation
World Benchmarking Alliance	The World Benchmarking Alliance engages in benchmarking of company performance on issues such as human rights, decent work, ethical conduct, gender equality, human health, and biodiversity. 63	Indicators are developed through research and consultation with stakeholders (including representatives from companies). Data are initially populated via publicly available information (e.g., corporate reports). Assessed companies are then invited to provide additional information. 64	[Does] the company provide quantitative evidence of minimizing the use of pesticides in its production and/or sourcing practices?
IDL	The IDL houses industry documents related to the opioid, drug, food, fossil fuels, and tobacco industries and their impact on public health. 65	The IDL collects industry documents that were publicly released as the result of litigation. 65	Not applicable. The IDL provides a resource for research and monitoring of corporate practices but does not conduct monitoring or benchmarking itself.

ATNI, Access to Nutrition Index; BIA‐Obesity, Business Impact Assessment – Obesity and population‐level nutrition; CHIA, Corporate Health Impact Assessment; IDL, Industry Documents Library; INFORMAS, International Network for Food and Obesity/Non‐Communicable Diseases.

^a The examples in this table are presented for illustrative purposes and are not meant to be an exhaustive list of all existing monitoring initiatives.

^b Data collection procedures are summarized in this table. For more detailed and complete information, please see the respective articles/reports.

One way to improve data availability and reduce some of the monitoring burden on governments and civil society may be by leveraging corporate NFR. NFR refers to the issuance of reports by commercial entities that provide information about the company's impacts on society and the environment (e.g., greenhouse gas emissions, operations at risk for use of child labor) and how the company manages these impacts. ⁶⁶ Other terms used to describe this activity are “corporate sustainability reporting” and “Environmental, Social, and Governance (ESG) reporting.” These terms fall under the umbrella of NFR and are often used interchangeably, though they can be used to delineate slightly different reporting foci. ⁶⁶ For illustrative purposes, Appendix 1 provides links to examples of NF reports.

Companies voluntarily engage in NFR to gain access to capital, respond to stakeholder requests, facilitate organizational learning, and/or because of pressure to conform to reporting norms, among other reasons. ⁶⁷ , ⁶⁸ , ⁶⁹ , ⁷⁰ According to a 2022 survey conducted by KPMG, 96% of the world's largest corporations (by revenue) currently engage in some form of NFR. The implementation of regulation that mandates NFR in major jurisdictions (e.g., the European Union [EU]) means that corporate reporting of information about social and environmental impacts is likely to be even more common in the future. ⁷¹ Reporting standards, such as the Global Reporting Initiative (GRI) Standards, are used to guide the types of data points that companies provide in NF reports (see Table 2 for examples of disclosures required by major reporting standards). An entire industry of ESG rating providers and data aggregators generate ESG ratings, rankings, and data sets (using corporate disclosures, information scraped from the internet, or other data) to inform the investment decisions of money managers (e.g., pension fund managers). ⁷² , ⁷³ Bloomberg Intelligence estimates that ∼29% of assets under management (40 trillion USD) will be managed using ESG/NF factors by 2030. ⁷⁴

Table 2.

Prominent NF Reporting Standards and Their Characteristics

NF Reporting Standard	Description	Audience	Mandatory or Voluntary Reporting	Number of Companies Using Standards to Report NF Information	Examples of CDH‐Relevant Information That Companies Are Asked to Report
GRI Standards	The GRI Standards are designed to assist organizations in reporting information about their impacts on the economy, environment, and people. They consist of a series of interconnected standards composed of universal standards (e.g., human rights), sector standards (e.g., coal), and topic standards (e.g., biodiversity). 75	Businesses, investors, policymakers, civil society, and other stakeholders	Voluntary	∼10,000 organizations in over 100 countries 75	Total monetary value of financial and in‐kind political contributions made directly and indirectly by the organization by country and recipient/beneficiary Industry associations, other membership associations, and national or international advocacy organizations in which [the company] participates in a significant role
SASB Standards	The SASB Standards are industry‐specific standards designed to provide investors with sustainability‐related information deemed relevant to the financial performance of a company. 76	Primarily investors	Voluntary	3,551 unique reporting companies from 170 countries since 2022 77	Total recordable incident rate and fatality rate [for employees] Revenue from products labeled and/or marketed to promote health and nutrition attributes
IFRS Sustainability Disclosure Standards	The IFRS produces globally accepted Accounting Standards. In 2021, they formed the ISSB to develop a set of standards to guide the reporting of sustainability information for investors (released in June 2023). The standards are currently focused on climate‐related activities. 78	Primarily investors	Voluntary, though individual jurisdictions may choose to make reporting mandatory in the future	In December 2023, hundreds of companies and corporate membership groups demonstrated support for the standards. 79	Absolute gross greenhouse gas emissions during the reporting period The quantitative and qualitative climate‐related targets [the company] has set to monitor progress toward achieving its strategic goals
ESRS	The ESRS Standards are standards that companies subject to the EU's CSRD must use to report information about their social and environmental impacts. The first reports based on the ESRS standards will be published in 2025. 80	Investors, civil society organizations, consumers, and other stakeholders	Mandatory for companies subject to the CSRD (i.e., EU companies meeting certain criteria such as employing more than 250 people)	The CSRD and associated ESRS Standards apply to approximately 50,000 EU businesses. 81	Total water consumption in cubic meters in areas at water risk, including areas of high‐water stress Whether all [of the company's] employees are paid an adequate wage, in line with applicable benchmarks

CDH, commercial determinant of health; CSRD, Corporate Sustainability Reporting Directive; ESRS, European Sustainability Reporting Standards; EU, European Union; GRI, Global Reporting Initiative; IFRS, International Financial Reporting Standards; ISSB, International Sustainability Standards Board; NF, nonfinancial; SASB, Sustainability Accounting Standards Board.

^a This table describes some of the most prominent reporting standards, identified based on our prior knowledge and a review of the literature. This is not an exhaustive list of all reporting standards currently in use.

Despite their increasing popularity, the practices of reporting NF information and using the information to inform investment decisions face many conceptual challenges. ⁸² Attention to corporate reporting of NF information began in the 1960s/1970s in response to preexisting socially responsible investment strategies and burgeoning research and discussion in the field of accounting on corporate externalities (i.e., costs or benefits incurred by a third party ¹ ). ⁶⁷ , ⁸³ , ⁸⁴ , ⁸⁵ , ⁸⁶ NFR and associated investment strategies emerged from a complex interplay between societal concerns (e.g., civil rights, climate change) and the development of a financial rationale for incorporating ESG factors into investment decision making that was initially proposed in a report published by the UN Global Compact (an initiative to encourage corporations to contribute to a sustainable global economy ⁸⁷ ) and several major financial institutions. ⁶⁷ , ⁸³ , ⁸⁴ , ⁸⁵ , ⁸⁶ , ⁸⁸ Currently, investors use ESG information for different purposes: some use NF data to align their investments with their values (referred to as values‐driven investing), whereas others engage in ESG screening because they believe that companies that manage ESG issues effectively will financially outperform those that do not (i.e., value‐driven investing). ⁸⁶ , ⁸⁹ , ⁹⁰ Likewise, some ESG reporting standards focus only on ESG information that is deemed financially relevant (e.g., the Sustainability Account Standards Board [SASB] Standards ⁷⁶ ), whereas others encourage companies to report information about their impacts that is important from a societal perspective (e.g., the GRI Standards ⁷⁵ ; Table 2). Given the relevance of corporate NF information to many different stakeholders, the GRI has argued that NFR should be a valued activity regardless of the financial relevance of the information. ⁹¹ Critics, on the other hand, argue that NFR is a waste of company resources and that the costs of complying with mandatory reporting rules would trickle down to workers and consumers. ⁹² , ⁹³ They contest the proposed relationship between ESG performance and financial outcomes and suggest that asset managers’ use of ESG information to make investment decisions violates their fiduciary duty to maximize returns for shareholders. ⁹⁴ The various uses of NF information and associated critiques have led to significant confusion about its nature, purpose, and value. ⁸⁶ , ⁹⁵ , ⁹⁶

In addition to these conceptual challenges, NF disclosures are also widely critiqued for their highly variable quality and the inadequate levels of independent assurance in place to verify the information. ⁶⁹ , ⁹⁶ , ⁹⁷ , ⁹⁸ , ⁹⁹ This has led to concerns about “greenwashing” (i.e., portraying data about environmental performance in a way that is favorable to the company's reputation) and “cherry‐picking” (i.e., selectively reporting data points) in NF reports. ⁶⁹ , ¹⁰⁰ Moreover, companies disclose NF information in various ways, meaning that the data have low levels of comparability within and across industries. ⁶⁹ , ⁹⁹ , ¹⁰¹ , ¹⁰² These issues have hindered the ability of ESG data to identify which companies manage ESG issues well and which do not. ⁶⁹ , ⁹⁰ , ⁹⁶ , ⁹⁸ Ultimately, ESG data have suffered from a crisis of credibility that has limited its broader uptake. ⁹⁶ , ¹⁰³ There have been several recent efforts by prominent organizations (e.g., the European Commission and International Sustainability Standards Board) to improve the quality, comparability, accuracy, and accessibility of corporate NF information. ⁷⁹ , ¹⁰⁴ , ¹⁰⁵

Importantly, another critical challenge faced by NF reports and associated NFR standards is that they traditionally focus on social (usually referring to employment) and environmental issues and relatively little is known about how companies report information about their health impacts or the accuracy of health disclosures within these reports. ¹⁰ , ¹⁰⁶ Recent research on nutrition‐related disclosures required by existing reporting standards for the F&B industry suggests that the quality of information that F&B companies are encouraged to report regarding the nutritional composition of their products is inadequate (e.g., focused on single nutrients as opposed to using an externally validated nutrient profiling system). ¹⁰⁷ , ¹⁰⁸ The authors conducting this work also reported a lack of attention to product distribution and equity. ¹⁰⁷ , ¹⁰⁸ The Robert Wood Johnson Foundation and GRI, ¹⁰⁹ and our author team have sought to characterize further the types of health‐related data that are available in NF reports (e.g., occupational injury rates, noncompliance with marketing codes). Others have documented how the NFR of the F&B industry aligns with the SDGs (including SDG 3). ¹¹⁰ , ¹¹¹ , ¹¹² Industry watchdogs have called out tobacco companies for portraying themselves as “sustainable” and “socially responsible” within NF reports while failing to acknowledge their significant health impacts. ¹¹³ , ¹¹⁴ Importantly, these analyses have illuminated critical gaps in NFR, including a lack of attention to reporting about tax, lobbying, and litigation practices; employee working time (i.e., work–life balance); and product characteristics (e.g., extent of food processing). ¹⁰⁹ , ¹¹⁰ , ¹¹¹ , ¹¹² Yet, despite these efforts, much more work remains to investigate the content of NF reports across multiple industries and identify the types of data they may provide for CDH‐related monitoring initiatives.

Once the CDH field gets a better picture of what and how corporations are reporting about their health impact, CDH scholars and civil society actors could identify and advocate for novel or higher‐quality disclosures that address specific data gaps within existing initiatives to monitor commercial practices that affect health. There are important upcoming opportunities to do this. For example, over 10,000 organizations in more than 100 countries report social and environmental information based on the GRI Standards, including large companies in harmful commodity industries. ⁷³ The GRI has plans to launch a “sector standard” for the F&B industry (date to be determined) and will recruit a multistakeholder working group to inform its development. ¹¹⁵ Other sector standards are continuously being launched, and contributing to these (via membership in a working group or during the public comment period) may provide an opportunity to integrate important CDH‐related disclosures into NFR (e.g., amount spent on lobbying, number of senior management employees with previous positions in the government). Another strategy to promote the uptake of CDH‐related disclosures may be to generate legislative support for mandatory corporate disclosures of health impacts. Organizations such as ShareAction are already engaged in policy advocacy work to promote the adoption of mandatory corporate health disclosures in the United Kingdom, and these efforts could be replicated in other jurisdictions. ¹¹⁶ In the United States, the Surgeon General recently called on social media companies to release data on the health impacts of their products. ¹¹⁷ These calls could be replicated in other jurisdictions to amplify support for mandatory corporate health reporting.

Efforts to generate political and normative support for corporate health disclosures will likely be most effective if informed by the successes and challenges of previous efforts to encourage high‐quality environmental and social reporting. As described earlier, support for corporate sustainability reporting was galvanized by a combination of societal concerns (e.g., climate change, racial inequities) and related events (e.g., the Black Lives Matter protests in 2020) as well as a corresponding financial rationale. ⁶⁷ , ⁸³ , ⁸⁴ , ⁸⁵ , ⁸⁶ Larrinaga and Bebbington ⁶⁷ further describe how sustainability reporting was normalized based on prior societal acceptance of corporate financial reporting. The authors also propose that the endorsement of corporate sustainability reporting by multiple “epistemic communities” (e.g., academics, accountants, consultants) and “norm carriers” (e.g., the Dow Jones Sustainability Index) helped propel it to the position of a de facto (and increasingly regulated) law of business. ¹¹⁸ This suggests that the existing precedent of corporate sustainability reporting may facilitate the adoption of more rigorous corporate health disclosures and that key events (e.g., the COVID‐19 pandemic and concerns about the NCD crisis) may catalyze attention to corporate health impacts. Finally, utilizing strategic narratives to successfully convince multiple stakeholders of the importance of rigorous corporate health disclosures may be an important mechanism to generate support. For example, Robinson and colleagues have conducted research that suggests that profit‐driven investors may be convinced about the need for high‐quality corporate health disclosures by the financial risks (e.g., regulation, litigation) associated with investing in a company that fails to address its health impacts. ¹⁰ , ¹¹⁹ , ¹²⁰ , ¹²¹ Likewise, the Tobacco Free Portfolios initiative has successfully convinced organizations managing more than 18 trillion USD in assets to pledge engagement in tobacco‐free finance (e.g., divesting and refusing to lend money to tobacco companies). ¹²² They did this by employing both value‐based (e.g., describing the financial risks of tobacco investment) and values‐based arguments (e.g., drawing attention to the health harms of the tobacco industry). ¹²³ Both types of rhetorical strategies may be useful in promoting the uptake of evidence‐based corporate health disclosures.

In addition to lending insight into how we may encourage corporate health reporting, the environmental and social reporting movements also provide insight into how we can improve the quality and accessibility of corporate health disclosures. Data on corporate health impacts, for instance, likely share similar technical and conceptual challenges with corporate environmental and social data. For example, reporting useful data on the nutritional quality of products shares commonalities with measuring emissions across the supply chain. That is, both issues require accepted definitions and feasible, standardized measurement methodologies that facilitate comparability across firms. ¹²⁴ , ¹²⁵ Both types of disclosures may also benefit from the recent creation of digital taxonomies for reporting (e.g., the GRI's “Sustainability Taxonomy”) that promise to enhance the comparability and accessibility of NF information by requiring standardized inputs and delivering machine‐readable data. ¹⁰⁵ Other corporate activities, such as the propagation of rhetoric that emphasizes individual responsibility for health (e.g., the “problem gambler” ¹²⁶ ), share similarities to social reporting indicators such as employment discrimination in that they are challenging to operationalize and may or may not be amenable to self‐report. ¹²⁷

Another important similarity among health, environmental, and social corporate disclosures concerns the risk of bias associated with self‐report measures in which the reporting agent is incentivized to portray a positive image. “Greenwashing” and “social washing” (i.e., publishing misleading corporate disclosures), for instance, have been key concerns for environmental and social reporting, respectively. ¹⁰⁰ Though these concerns have not yet been addressed (and may never be fully addressed), mechanisms such as independent audits and triangulating data with other sources (e.g., anonymous tips, crowdsourcing) may be means to assess and prevent bias. The NFR legislation in the EU (i.e., the Corporate Sustainability Reporting Directive) requires that companies provide “limited” assurance of the accuracy of their NF reports (i.e., the opinion of an auditor on compliance of the report with relevant EU legislation), with a gradual shift to “reasonable” assurance (definition to be determined) by 2028. ¹²⁸ Esty ⁹⁸ has argued that NF reports should be verified in the same way as financial reports: by a certified accountant with the threat of legal action for inaccurate reports. Similar accountability mechanisms could be adopted for corporate health disclosures to prevent “health washing.” ¹⁰

In addition to these technical challenges, there are also existential risks associated with corporate health reporting. That is, there is the potential that corporate health reporting reinforces “business‐as‐usual” approaches in which corporate health impacts are deemed manageable within current corporate models of profit maximization. This risk has also been discussed in the context of corporate sustainability reporting; some believe that so‐called “sustainability” reports fail to address major societal issues that result (in part) from corporate activities, such as hyperconsumption, violations of planetary boundaries, and inequitable wealth distribution. ¹²⁹ These omissions may lead to the understanding that sustainability is achievable without substantive changes to the nature and structure of business. ¹²⁹ Importantly, arguments that corporate health reporting should be undertaken because it is valuable to investing, and profit maximization could impede more transformational approaches that realize the value of health (and health reporting) as an end in itself, not solely a means to facilitate shareholder returns and create economic growth. ¹³⁰ It is not yet clear how solutions and argumentative strategies that are more practicable in the current economic environment (e.g., financial rationales for corporate health disclosures) can be effectively aligned with more transformative approaches (e.g., advancement of well‐being economy principles). ⁹ , ¹³⁰

Considering these risks and limitations, corporate health disclosures may provide a useful source of data but are not likely to be a panacea for data availability challenges faced in monitoring corporate practices. To improve data availability, we suggest that the CDH field should first seek to identify the data points that would be most useful in advancing the measurement and monitoring of key corporate practices that affect population health. Based on their 2021 synthesis of frameworks describing the practices of the tobacco, alcohol, and ultraprocessed food industries, Bennett and colleagues concluded that “many corporate practices were named in multiple frameworks… However, since no explicit or relative justification for inclusion of certain corporate practices was made in any framework, it is currently unclear why some corporate practices should be prioritized for monitoring over others.” ^{41 p 11} Approaches such as Delphi studies and concept mapping could be used to determine priority indicators using criteria such as the health impact of the measured corporate activity (e.g., magnitude and extent, equity implications) and the extent to which the activity can be addressed by regulations or incentives. ⁴¹ , ¹³¹ , ¹³² Our author team recently recruited experts to identify the types of corporate practices and activities that are priorities for measurement and monitoring of the F&B industry (forthcoming). Others have conducted work to identify priority indicators to monitor the practices of the tobacco industry in Southeast Asia and the United States (e.g., the use of certain marketing imagery). ¹³¹ , ¹³³ Though this work provides a useful starting point, much more work remains to be done to identify a limited number of key corporate practices and associated data points to prioritize for monitoring within or across industries and regions. Once these priorities are ascertained, the most effective and efficient path forward to improving data quality and availability will be more easily identifiable.

In summary, a key barrier to the development of systems to measure and monitor commercial practices that affect population health and health equity is the lack of high‐quality, publicly accessible data. Corporate NFR may provide an opportunity to improve data availability. CDH scholars and civil society actors could support the development and uptake of high‐quality corporate health reporting by contributing expertise to existing standard‐setting initiatives and learning from policy advocacy efforts undertaken in other jurisdictions. Efforts to advance corporate health reporting may also benefit from examining the successes and challenges of analogous initiatives to encourage social and environmental reporting and improve the quality and accessibility of reported data. However, an effective plan for addressing issues of data availability may be best facilitated by first identifying CDH measurement priorities for major industries of interest. From there, the most effective and efficient approach for obtaining the necessary data can be determined with greater clarity.

Moving Toward Solutions: Developing Effective Policy Recommendations to Address the CDH

Monitoring commercial practices may facilitate government action and promote private sector change. ⁴⁷ , ¹³⁴ However, it is unlikely to be a sufficient driver of change in itself. Achieving effective progress on the CDH will require the implementation of evidence‐based mechanisms for action.

The WHO's recently established Economic and Commercial Determinants of Health (ECDH) unit provides a significant opportunity to achieve progress on the CDH. ³⁴ , ⁴⁴ The ECDH unit was launched following the identification of the CDH as an important priority area at the WHO Strategic Meeting on the Social Determinants of Health in September 2019. ¹³⁵ As the UN agency dedicated to international health, the WHO plays an important role in setting the international agenda for action on health issues, providing technical assistance, and facilitating collaboration among member states. ¹³⁶ , ¹³⁷ The WHO has announced plans to publish a Global Report on the Commercial Determinants of Health in 2025 (hereafter referred to as “the Global Report”). ¹¹ This report has the potential to drive action on CDH across member states. Evidence has been commissioned (e.g., a scoping review, technical papers, regional and topic‐specific consultations) and an editorial board comprised of scientific and policy experts has been established to guide the development of the report. ¹¹ , ¹³⁸ Importantly, one of the aims of the Global Report is to “support countries with evidence‐based policy recommendations” for addressing the CDH. ¹¹

The Global Report will follow other recently published WHO reports that describe the influence of the CDH in specific regions. In June 2024, the WHO Regional Office for Europe published a report with the goal of raising awareness among EU policymakers of the influence of commercial actors on the development of policies designed to address the NCD burden. ³⁸ The report provides an overview of key practices used by commercial actors to influence the policymaking process (e.g., lobbying), case studies describing these practices in action (e.g., the tobacco industry's lobbying against proposed regulations for heated tobacco products in Georgia), and resulting policy considerations (e.g., implementation of a framework convention on public health to manage interactions with harmful industries). ³⁸ Other notable WHO publications include a draft report on the impact of the economic and CDH on NCDs, mental health conditions, and violence in Small Island Developing States (SIDS). ⁴³ This report identifies the unique vulnerabilities (e.g., lack of economic diversification) and opportunities (e.g., whole‐of‐society approaches) that SIDS face in addressing the CDH and proposes policy interventions to facilitate action (e.g., access to information legislation to facilitate monitoring). ⁴³ Though the impact of these recently published reports on governmental policy priorities is not yet known, they have the potential to drive the CDH agenda in these respective regions.

Research on actions to address the CDH has progressed rapidly in the last few years. ³ , ¹⁰ , ²⁹ , ³³ , ³⁹ , ⁴⁰ , ⁴⁴ , ¹³⁴ , ¹³⁹ , ¹⁴⁰ , ¹⁴¹ , ¹⁴² , ¹⁴³ , ¹⁴⁴ , ¹⁴⁵ However, determining the best path forward for achieving meaningful progress on the CDH is still an ongoing topic of research and discussion. In the next section, we briefly review some of the strengths and limitations of two relevant, global agenda‐setting initiatives: the SDGs and global efforts to address the SDH. In reviewing these approaches, we extract insights that can inform policy recommendations designed to address the CDH. We conducted this exercise with the specific goal of informing the WHO's forthcoming policy recommendations expected in the Global Report. However, our reflections may also be useful to others (e.g., CDH researchers and regional policymakers) who are interested in driving action on the CDH.

Strengths and Challenges of Existing Global Agendas

The United Nations’ SDGs consist of 17 goals and 169 targets designed to advance global progress on economic, social, and environmental objectives during the period of 2015–2030. ¹⁴⁶ Following the Millennium Development Goals, they reflect one of the most prominent global agenda‐setting exercises in history and have received widespread acceptance across nations, in part because of an extensive consultation process undertaken during their development. ¹⁴⁷ The SDGs have been lauded for their focus on vulnerable populations and the flexibility they give nations to implement the goals based on their specific political and economic contexts. ¹⁴⁷ , ¹⁴⁸ However, critiques of the SDGs suggest they are overly ambitious (both in breadth and depth), especially for countries with limited resources. ¹⁴⁹ , ¹⁵⁰ The SDGs also require some trade‐offs among economic, social, and environmental priorities, and the processes to make these difficult decisions are not obvious. ¹⁵¹ , ¹⁵² For example, the pursuit of economic growth may not be compatible with the need to respect planetary limits. ¹⁵³ Finally, the achievement of the SDGs necessitates collaboration among multiple actors with different interests, yet the roles of different stakeholders have not always been made clear. ¹⁴⁹ , ¹⁵⁴ Relatedly, some have described the risks associated with the involvement of the private sector in developing and implementing the SDGs and the failure of the SDGs to address the commercial interests that benefit from “dirty development.” ¹⁴⁹ , ¹⁵⁵ Overall, progress on the SDGs has been mixed across both targets and countries. For example, although Norway has achieved significant progress on SDG 3 (“Good Health and Well‐Being”), many other countries are facing significant challenges in making progress on health targets. ¹⁵⁶ , ¹⁵⁷

There has also been a significant global effort to promote action on the SDH: prominent global reports and declarations include the 2008 report of the WHO's Global Commission on Social Determinants of Health, the 2011 Rio Political Declaration on Social Determinants of Health, and the 2010 and 2019 Adelaide Statements on Health in All Policies, among others. ¹⁵⁸ , ¹⁵⁹ , ¹⁶⁰ , ¹⁶¹ , ¹⁶² Despite significant and sustained global attention, the actual impact of the SDH framework on policy and resulting reductions in inequalities has been disappointing. ¹³² , ¹⁵⁸ , ¹⁶³ , ¹⁶⁴ A variety of reasons have been proposed to explain why this is the case. First, the SDH are complex and difficult to communicate to different stakeholders. ¹⁶⁴ Second, the existence of inequalities for centuries has made it challenging to create a sense of urgency about the SDH. ¹⁶⁵ Third, research to identify interventions to tackle the SDH has tended to focus on generating evidence and, to a lesser extent, translating evidence into policy. ¹⁶⁶ , ¹⁶⁷ Policymakers embedded in specific roles and departments have felt overwhelmed by the sheer scope and complexity of the problem and the lack of manageable policy actions. ¹⁶⁶ , ¹⁶⁷ Finally, some suggest that existing economic structures, powerful actors, international trade regimes, and neoliberal ideology have impeded progress on the SDH, thereby emphasizing the need to tackle the CDH. ¹⁶³ , ¹⁶⁷ , ¹⁶⁸

Key Considerations in Developing Effective Policy Recommendations for Addressing the CDH

Drawing on these insights, we propose five key considerations to inform the development of the WHO's policy recommendations for addressing the CDH in the forthcoming Global Report.

First, we suggest that the recommendations should seek to define a limited number of manageable, specific, and high‐priority policy actions. The policy recommendations should seek to strike a balance between providing enough options and flexibility such that the recommendations could be adapted to widely differing national and local regulatory environments while avoiding overwhelming policymakers with an abundance of potential interventions and a lack of guidance regarding which actions are most important. ¹⁴⁷ , ¹⁶⁶ A set of policy priorities could be identified by asking experts to evaluate proposed policies based on criteria such as the probability the policy will avert harm or increase benefit, the magnitude and distribution of harm and benefit, the extent of political will required to implement the proposed policy, and the potential for unintended negative side effects. Locating policy actions on a spectrum of “feasible” (e.g., regulating product packaging) to “aspirational” (e.g., winding down harmful industries) may also allow countries to implement the proposed policies using a phased approach, depending on local contextual barriers and resources. ¹³²

Second, we believe that the WHO's recommendations will be most effective if they aim to target the CDH at multiple levels. ¹⁰ , ³⁸ , ⁴⁴ Lacy‐Nichols and colleagues ⁴⁴ suggest taking action on the CDH at the level of actors, practices, and systems. We add to their framework by suggesting two additional areas of action: action at the level of industries and action that is designed to protect specific population groups. The former can inform approaches that target harmful industries and commodities (e.g., restrictions on the sale of harmful commodities, such as New Zealand's now‐repealed smoking ban ¹⁶⁹ ). The latter can help center health equity within CDH policymaking and protect groups that may be disproportionately affected by the CDH (e.g., Indigenous populations in Western countries ¹⁷⁰ ). Considering interventions based on these levels may allow for a balance between the implementation of longer‐term systems‐level interventions (e.g., remodeling corporate structures) and interventions that prevent specific harms from occurring (e.g., regulating marketing to reduce consumption). This may lead to more effective, equitable, and sustainable change than efforts that focus on only one of these levels (e.g., practices). ¹⁰ Table 3 presents a list of mechanisms (aggregated from previous literature) that can be leveraged to address the CDH at each of these levels. Appendix 2 provides descriptions and examples of each of the mechanisms.

Table 3.

Mechanisms That Can Be Used to Address the CDH (Aggregated From Previous Literature ^a ), Categorized by the Level at Which They Seek to Create Change (Levels Adapted From Lacy‐Nichols and Colleagues) ^{44 , b}

		Group(s) Involved in the Implementation of the Mechanism c
Level of the Mechanism	Mechanism	Local and/or National Governments	Intergovernmental Organizations	Civil Society	Research and Academic Organizations	Media	Commercial Actors	Consumers	Employees	Shareholders and Investment Managers
Commercial actors c	Organize and support boycotts			X				X
	Organize and support protests			X				X
	Engage in strategic litigation against commercial actors	X		X				X	X
	Hold private meetings with commercial actors or leverage surrogate actors (e.g., banks) to influence decision making			X
	Engage in shareholder activism			X						X
	Dissolve harmful corporations	X
	Participate in worker strikes								X
	Support and participate in whistleblowing	X	X	X		X	X	X	X
Practices d	Implement lobbying regulation	X	X
	Mandate employee benefits	X
	Regulate tax avoidance	X	X
	Monitor and report on commercial practices	X	X	X	X	X	X
Population groups e	Regulate marketing of harmful goods to vulnerable groups	X	X
	Strengthen worker unions	X
	Regulate profiteering, especially in times of emergency (e.g., COVID‐19)	X
	Strengthen requirements of consent to undertake projects in local communities	X	X				X
	Regulate corporate influence in schools	X
	Regulate exposure to environmental and smoke pollution	X	X
Industries f	Establish international public health treaties	X	X
	Regulate product packaging and labeling	X
	Place availability restrictions on harmful products	X
	Regulate product contents (e.g., nutritional contents, flavoring agents, toxins)	X
	Divest from harmful industries	X		X	X					X
	Wind down harmful industries (e.g., reducing, substituting, or prohibiting their operations)	X	X
Systems g	Develop guidelines for managing conflicts of interest	X	X	X	X	X
	Establish public conflicts of interest databases	X	X	X	X	X
	Protect public health actors from industry intimidation, litigation, and threats	X	X	X	X
	Teach public health students and others about the CDH and provide training on relevant competencies		X	X	X
	Regulate interactions and industry contributions (i.e., financial and nonfinancial) to the public sector	X	X	X	X	X
	Implement policies to limit revolving doors between the public and private sectors	X
	Strengthen antitrust regulation	X
	Implement progressive tax policies and tax floors	X	X
	Return privatized services to public ownership and control	X						X
	Support and organize alternative modes of business	X	X	X			X
	Integrate a health lens into investment strategies	X	X	X	X					X
	Develop, adopt, and support alternative economic paradigms	X	X	X	X		X
	Establish new international organizations and institutional arrangements to govern transnational corporations	X	X
	Remodel corporate structure and law (e.g., limited liability provisions)	X
	Measure and limit cost externalization (e.g., excise taxes)	X	X	X	X

CDH, commercial determinant of health.

^a The list of mechanisms presented in the table was aggregated from previous literature or added by the authors. For sources, detailed descriptions, and examples of each of the listed mechanisms, please see Appendix 2. The table is intended to be illustrative and is not comprehensive of all of the available mechanisms.

^b The levels are not mutually exclusive. Some mechanisms (e.g., mandating employee benefits) address more than one level (i.e., practices, population groups).

^c The involved groups were identified from the same literature used to develop the list of mechanisms (see Appendix 2). In some cases, the authors reviewed additional literature to identify involved groups or proposed additional groups that could be involved in developing or implementing the respective mechanism.

^c A commercial actor refers to an entity engaged in the buying, selling, or producing of goods and services primarily for profit. These may vary in form and size, including transnational corporations, trusts, sole proprietorships, partnerships, cooperatives, and state‐owned enterprises. ¹ , ⁸

^d Practices refer to the specific activities through which commercial actors exert their influence on health and may include political, economic, and preference‐ and perception‐shaping practices. ¹ , ¹² , ¹⁷¹

^e Population groups refer to groups of people with similar characteristics that are affected by corporate practices (e.g., workers, consumers, local communities, disadvantaged groups, vulnerable groups).¹² Mechanisms that address this level are designed to protect these groups from harmful impacts of the CDH (or maximize the benefits of salutary impacts).

^f An industry refers to a collective of commercial actors that produce or sell similar products or services (e.g., tobacco, alcohol, ultraprocessed food). ¹

^g Systems refer to the political, economic, regulatory, and institutional frameworks that shape, enable, and drive the actions of commercial actors. ²² , ⁴⁴

Third, the WHO could provide guidance and infrastructure to facilitate collaboration among different actors and different countries in implementing the recommendations. ³⁸ , ¹⁴⁵ Table 3 draws attention to the fact that the development and implementation of each mechanism often involve contributions from multiple actors. ¹⁴⁰ Cohesive action across these actors may be supported by mapping out the work that is already occurring in different sectors and providing clear guidance on the specific roles each actor can play to advance the WHO's recommendations and support other actors in the CDH community. ¹⁷² To facilitate coordination across countries, the WHO could also consider providing infrastructure for policymakers to connect, share challenges, and learn from other countries’ experiences (e.g., a global CDH conference, a system for recording and tracking policy responses, challenges, and outcomes). ¹³² , ¹⁷³

Importantly, however, the spirit of collaboration should not necessarily extend to commercial actors. Table 3 includes commercial actors to acknowledge that they may be involved in implementing some of these mechanisms (e.g., creating a corporate culture that supports employee whistleblowing). However, there is significant evidence that harmful commodity industries (e.g., tobacco, alcohol, gambling, and others) engage in concerted attempts to influence and circumvent public health policies that do not serve their interests. ¹ , ¹² , ⁴¹ , ¹⁷¹ , ¹⁷⁴ , ¹⁷⁵ , ¹⁷⁶ For this reason, collaboration with these actors on CDH initiatives should be avoided. The WHO could establish this norm by leading by example—that is, by extending their nonengagement policy with the tobacco industry to other harmful actors such as the alcohol industry—and recommending strict boundaries of engagement between policymakers and harmful commodity industries within the Global Report. ³³ , ¹⁷⁷ , ¹⁷⁸ , ¹⁷⁹

The fourth policy principle we recommend is that the potential undesired side effects of the proposed recommendations should be thoroughly assessed. ¹⁸⁰ Though there is a need to take action on the CDH quickly, it will be important not to prioritize quick action over effective action. Implementing mechanisms with unclear effectiveness or unidentified side effects could lead to unintended harm, especially for already marginalized populations (e.g., job loss, reduced access or higher costs of essential goods, industry alliances with affected groups, withdrawal of foreign direct investment). ¹⁸¹ , ¹⁸² , ¹⁸³ Engaging in scenario planning (i.e., “anticipating possible alterative futures” ^{184 p69}) with an interdisciplinary team (i.e., those with expertise in public health, economics, business, trade, and other relevant fields) may help identify contexts in which the proposed recommendations could fail to elicit the intended outcome and/or may lead to undesired side effects. ¹⁸⁰ , ¹⁸⁴ The process of scenario planning may also allow for the abandonment of policy options that are deemed too risky, the identification of ways that corporations may be able to circumvent proposed policies, and the recognition of key assumptions that may not hold in the future. ¹⁸⁴ Proactively identifying potential negative consequences may also assist in confronting companies’ strategic use of potential negative impacts as a means to garner opposition to policies that reduce their profits. ¹⁸¹ The WHO could consider issuing guidance to countries that are interested in implementing certain policies on how they might prevent, navigate, manage, and recover from potential undesirable side effects. Regional reports on the CDH such as the aforementioned WHO Europe and SIDS reports will be useful in identifying and addressing vulnerabilities in specific contexts (e.g., small local economies). ³⁸ , ⁴³

Finally, the importance of effectively framing the CDH and associated actions should not be underestimated. ¹⁸⁰ , ¹⁸⁵ , ¹⁸⁶ Like the SDH, the CDH are difficult to define and communicate, and efforts to address the CDH are likely to face significant opposition from actors with conflicting interests (e.g., harmful commodity producers). To facilitate acceptance by national governments and other sectors, the CDH field needs to find ways to communicate about the CDH that are both straightforward and compelling. ¹⁷² It is not yet clear which aspects of the CDH concept are most persuasive to government policymakers in different contexts and why. This may be a fruitful area of future investigation. However, generating public support and describing the benefits (e.g., higher public revenue) that certain mechanisms (e.g., excise taxes) deliver for governments may facilitate stronger endorsement. ¹⁴⁰ , ¹⁶⁶ It may also be beneficial to identify synergies between action on the CDH and the achievement of other goals, such as developing sustainable economies and addressing the SDH. ³⁸ , ¹³²

We hope that these reflections are useful in both informing the WHO's forthcoming policy recommendations and contributing to the ongoing discussion on ways to drive action on the CDH.

Conclusion

In this article, we have sought to advance discussion on two key priorities related to the CDH: 1) the development of mechanisms to measure and monitor the practices of commercial entities, and 2) the development of effective policy recommendations for addressing the CDH. Specifically, we discussed how corporate NFR could provide a means to obtain data on commercial practices, described the potential risks and benefits, and identified opportunities for CDH scholars and civil society actors to support the adoption of high‐quality corporate health reporting. We also extracted insights from previous global agenda‐setting exercises to propose five key considerations (i.e., prioritization, multilevel action, collaboration, projection, and effective framing) to inform the WHO's forthcoming policy recommendations to address the CDH. Cross‐cutting themes from both discussions include the value of learning from analogous efforts, the need to develop strategic narratives to build support, and the importance of priority‐setting.

Funding/Support

The authors did not receive any direct funding to write this article. However, a version of this article forms part of R.B.’s doctoral dissertation, which has been supported by the Canadian Institutes of Health Research (CIHR) (Doctoral Foreign Study Award) and the International Chapter of the Philanthropic Educational Organization (PEO; Scholar Award). The CIHR and PEO did not play any role in the study design, data collection and analysis, decision to publish, or preparation of the paper.

Conflict of Interest Disclosures

The authors have no conflicts of interest to declare.

Appendix 1.

Links to Examples of Corporate Nonfinancial Reports

PepsiCo:

ESG performance metrics report (2023): https://www.pepsico.com/docs/default‐source/sustainability‐and‐esg‐topics/2023‐esg‐summary/2023‐esg‐performance‐metrics.pdf?sfvrsn=a2c3df64_1 ¹⁸⁷

Reporting as requested by the SASB standard (2023): https://www.pepsico.com/docs/default‐source/sustainability‐and‐esg‐topics/2023‐sasb‐index.pdf?sfvrsn=ae358335_5 ¹⁸⁸

Chevron:

Sustainability Report (2023): https://www.chevron.com/newsroom/media/publications/corporate‐sustainability‐report ¹⁸⁹

Note: Pages 55–72 provides performance metrics mapped to the SASB standards.

Johnson & Johnson:

‘Health for Humanity’ Report (2023): https://healthforhumanityreport.jnj.com/2023/_assets/downloads/johnson‐johnson‐2023‐health‐for‐humanity‐report.pdf?h=Ka9OvM1t ¹⁹⁰

Note: Pages 49–61 provides ESG performance metrics.

Appendix 2.

Descriptions and Examples of the Mechanisms That Can Be Used to Address the Commercial Determinants of Health (Aggregated From Previous Literature ^a ), Categorized by the Level at Which They Seek to Create Change (Levels Adapted From Lacy‐Nichols and Colleagues ⁴⁴ ) ^b

Level of the Mechanism	Mechanisms	Description	Example
Commercial Actors c	Organize and Support Boycotts	Consumers may take part in consumer boycotts targeting commercial actors, thus pressuring them to shift or discontinue certain practices that are harmful to health. Civil society groups may help to organize or promote these boycotts. 3	In late 2023, a consumer started a Reddit thread to voice her frustration about the price of food at Loblaws, a dominant food retailer in Canada. The thread grew as more consumers expressed their concerns and posted pictures highlighting the prices of their grocery items. Following this thread, consumers worked together to launch a nation‐wide consumer boycott against Loblaws, encouraging people around the country to source their food from local, independent grocers. 191
	Organize and Support Protests	Protest and public campaigns may be directed toward government to call for greater regulations and interventions against the CDH, or to shame commercial actors for their harmful practices, and to demand change. 44	In 2014, the American Legislative Exchange Council (ALEC), a non‐profit and corporate lobbying group that seeks to advance corporate interests by drafting model legislation, came under fire by environmental activists that accused the group of denying climate change. Following this, many companies (e.g., Google, British Petroleum) ended their partnerships with ALEC, thus weakening the group's power. 44 , 192 , 193
	Engage in Strategic Litigation Against Commercial Actors	Private or qui tam lawsuits (those in which individuals or organizations assist in prosecution on behalf of a government) can be used to curb harmful practices and support the legal remediation of groups harmed. 3	In South Africa, lawsuits filed against pharmaceutical firms over the high prices of HIV/AIDS treatment resulted in some companies being found guilty of abusing antitrust law. These lawsuits also led to the allowance of generic medications that helped reduce drug prices for HIV. 3 , 194
	Hold Private Meetings with Commercial Actors to Influence Decision‐Making	NGOs may hold private meetings and roundtables with commercial actors as a way of finding commercial allies. They may also target commercial actors (e.g. banks and investors) that are able to influence other actors (e.g., extractive companies). 3	Central and East European Bankwatch is a non‐profit organization that monitors publicly‐financed projects in Africa and Central Asia. Through their monitoring and advocacy efforts, they place pressure on banks that are loaning funds to projects with environmental, social, or political implications. 195 , 196
	Engage in Shareholder Activism	Shareholders may participate in voting on corporate policies, filing shareholder resolutions, and engaging in other strategies to influence corporate decision‐making in the public interest. 29	The Interfaith Center on Corporate Responsibility (ICCR) is a coalition of investors that uses shareholder engagement strategies to advocate for corporate change. One way ICCR engages with corporations is by filing shareholder resolutions: proposals outlining a specific request (e.g., to report on the impacts of their operations, or to change their policies and practices) to the company that are put forward by a group of shareholders. 197 , 198
	Dissolve Harmful Corporations	Privileges granted to corporations via incorporation may be revoked for companies that consistently engage in fraudulent activity and breach the public interest. 29	A bankruptcy settlement in 2021 would have dissolved Purdue Pharma, a company involved in the manufacturing of opioids. In 2007, the company and three Purdue executives pleaded guilty to federal criminal charges for minimizing the risk of addiction associated with OxyContin, a practice that fueled the US opioid epidemic. By 2019, Purdue was facing 2,900 lawsuits and eventually filed for bankruptcy restructuring. The bankruptcy settlement allowed for $6 billion to reimburse victims of the opioid epidemic, an amount that was estimated to be significantly less than the costs of the epidemic. As a result of the settlement, Purdue would be restructured into a public benefit corporation that would manufacture addiction treatment medications. However, the settlement would also provide liability protection for the owners (the Sackler family). Because of the protections the settlement provided to the Sacklers, the settlement was overturned in June 2024 by the Supreme Court; negotiations have resumed. 29 , 199 , 200
	Participate in Worker Strikes	Workers may join unions and take part in strikes and sit‐ins. Governments and civil society organizations can offer legal protection and support for workers engaging in strikes. 29	The US National Labor Relations Act (NRLA) includes a section outlining worker strikes as a concerted activity protected for employees regardless of union membership status. 201
	Support and Participate in Whistleblowing	Workers, consumers and investigative reporters may participate in whistleblowing, which is the act of exposing illegal, fraudulent, immoral, illicit or unsafe activity within a corporation. 202 Governments and civil society organizations may offer legal protection and support for whistleblowers. Corporations may implement internal whistleblowing policies and mechanisms. 40	National governments can provide protection for whistleblowers with guarantee of confidentiality, secure communication, legal assistance, and civil and criminal sanctions against the perpetrators of retaliation against them. Canada's Competition Act and Criminal Code includes a section that outlines such mechanisms. NGOs also provide support, such as the Platform to Protect Whistleblowers in Africa, which provides legal and media assistance to whistleblowers, among other services. 40 , 203 , 204
Practices d	Implement Lobbying Regulation	Lobbying regulation may involve setting standards for expected behavior, implementing bans on lobbying for former ministerial staffers and senior public servants, and implementing measures to secure compliance. Governments may also establish public databases of lobbyists that provide information to the public on lobbying activities, objectives, beneficiaries, funding sources, and targets. 40	Canada has extensive lobbying regulation including a 5‐year lobbying restriction on parliamentarians, ministerial staff, and senior executives after stepping away from their designated position in government. Other mechanisms include a Lobbyists' Code of Conduct, a national Registry of Lobbyists, and non‐compliance measures (e.g., fines, imprisonment, lobbying bans). 205
	Mandate Employee Benefits	Governments may implement laws to mandate employer provision of employee benefits (e.g. paid parental leave, unemployment benefits, and sick leave) for permanent, casual, and contract workers. 44	Paid maternity leave is mandated in most OECD countries, with the average being just under 19 weeks. Payment rates vary between countries, with most countries providing between one third and two thirds of previous earnings. 206
	Regulate Tax Avoidance	Commercial entities can engage in tax avoidance by various means such as exploiting tax loopholes or engaging in profit‐shifting (i.e., avoiding taxes by leveraging tax havens and low‐tax jurisdictions). The Organization for Economic Co‐operation and Development (OECD) estimates that ‘tax base erosion and profit‐shifting’ cost countries $100‐240 billion USD every year in lost revenue. Countries and jurisdictions may collaborate to develop international tax instruments to that prevent tax avoidance. 10 , 44 , 207	The OECD/G20 Inclusive Framework on base erosion and profit shifting (BEPS) involves 145 countries and jurisdictions collaborating on 15 actions (e.g. promoting country‐by‐country reporting of income, profit, and taxes paid by multinational enterprises) to improve coherence of international tax regulation and tackle tax evasion internationally. 10 , 207
	Monitor and Report on Commercial Practices	Monitoring and reporting of corporate activities (e.g., by civil society organizations, researchers) may draw attention toward the harmful impacts of commercial practices and promote awareness among the public and policymakers. It may also help identify priorities for regulatory or other action. 44	Several institutions have been established to monitor the influence of corporations on public health policy, research, and practice, such as Corporate Europe Observatory in Europe, that has been investigating and reporting on the influence of large corporations and corporate lobby groups on European Union policymaking. 44 , 208
Population Groups e	Regulate Marketing to Vulnerable Groups	Restricting certain marketing techniques (e.g., use of cartoon characters, disproportionate marketing of harmful products in disadvantaged neighborhoods) that target vulnerable or disadvantaged groups (e.g., youth, low‐income adults) may help reduce these practices and ultimately, address health inequities. 33	In July 2023, the WHO released an updated guideline on policies to protect children from the marketing of food and beverages that are high in saturated fatty acids, trans fatty acids, free sugars, and/or salt. Recommendations to Member States include implementing mandatory regulations that protect children of all ages, using a government‐led nutrient profile model to identify foods subject to the restrictions, and implementing regulations that are comprehensive enough to prevent the risk of migration of marketing to other mediums or age groups. 210
	Strengthen Worker Unions	Strong labor laws and strict enforcement may support worker unionization within corporations, which may result in increased employee bargaining power. 29 , 210	Several states in the U.S. have moved to strengthen collective bargaining protections, and expand bargaining rights to additional employees (e.g., public employees). The states of Minnesota and Maryland have passed laws to make it easier for public employee unions to organize, and the state of Washington expanded collective bargaining rights for academic student employees and for management service employees. 211
	Regulate Profiteering, Especially in Times of Emergency (e.g., COVID‐19)	Profiteering refers to seeking an unreasonable profit, which may include selling goods or services at excessive or inflationary prices, especially during times of emergency or high demand. 212 Government actions to limit profiteering and protect consumers include legislation and taxation. 213	At the beginning of the COVID‐19 pandemic, India invoked its ‘Essential Commodities Act’ and ‘Disaster Management Act’ in an attempt to increase the supply of face masks and hand sanitizers and ensure their affordability. This allowed the government and states to regulate the production, quality, distribution, and price of these items (including taking action against suspected price gouging). 214 , 215
	Strengthen Requirements of Consent to Undertake Projects in Local Communities	Strengthening consent processes involves establishing formal processes for gaining and maintaining community consent, and thus the corporation's license, to engage in industry and/or infrastructure projects in host communities. This may be particularly relevant to extractive projects and projects with impacts on Indigenous communities and other marginalized groups. 216 , 217	In the last decade, there have been concerns among Indigenous Peoples in Canada regarding the lack of steps taken to gain consent to expand the Trans Mountain pipeline, which carries crude oil and refined petroleum products through parts of Canada. Indigenous Peoples that protested the expansion have argued that affected Indigenous communities have not provided their consent to the expansion. The United Nation's Declaration on the Rights of Indigenous Peoples (UNDRIP) outlines the principles of Free, Prior and Informed Consent (FPIC) as a right granted to Indigenous Peoples, which is closely related to their right to self‐determination. Although the UNDRIP provides a framework in which courts may use to interpret law, the declaration itself is not legally binding. In 2022, the UN issued a third letter to Canada's representative to the UN expressing grace concern about the expansion and subsequent treatment (i.e., land evictions) of non‐consenting Indigenous Peoples. 218 , 219 , 220
	Remove Corporate Influence in Schools	Public School Boards, Universities, Colleges and other education institutions sometimes accept sponsorships, in‐kind donations, training and other forms of contributions from corporations. Notably, a number of exclusivity contracts have formed, in the 2000s, between corporations (i.e., Coca‐Cola, Pepsi, Nike) and school districts in the western and southwestern U.S. states. Exclusivity contracts involve exclusive, multi‐year distribution and advertising deals in schools, in exchange for cash payments. To address the potential health harms, especially on young students, school districts and their governing jurisdictions can create policies to regulate or prohibit such agreements. 221	In 2014, the Vancouver School Board (British Columbia, Canada) refused a partnership with Chevron's “Fuel Your School Program” based on concerns about the company being involved in education. Chevron proposed to donate one dollar to purchase school supplies when a customer buys 30 liters of gas or more from Chevron. The deal had been accepted by five other school boards in the province. The Province of British Columbia gives individual school boards the autonomy to make decisions regarding corporate contributions. 222 , 223
	Regulate Exposure to Environmental and Smoke Pollution	Regulating exposure to pollution may include limiting or taxing emissions and obliging the reporting of spills and other forms of pollution. Additionally, processes and technologies may be developed to support cleanup and environmental remediation by removing or reducing pollutants in the natural environment. The implementation of smoke‐free policies can also protect workers and the public from exposure to environmental tobacco smoke pollution in workplaces and public places. 224 , 225	As of 2023, over 70 countries worldwide have policies against smoking in indoor places. Mexico has strict anti‐smoking laws that ban smoking in all public places, including beaches and parks. 226
Industries f	Establish International Public Health Treaties	International public health treaties offer the advantage of establishing binding obligations in international law and ensuring policy coherence across member states. Treaties may be targeted toward regulating and limiting the harms of specific industries. 10 , 33	The WHO Framework Convention on Tobacco Control (FCTC) was the world's first global public health treaty, which was developed in response to the global tobacco epidemic. There are currently 182 parties, who are obliged to implement provisions related to the governance, supply, and demand of products and activities in the tobacco industry. The WHO collaborates with the Bloomberg Initiative to Reduce Tobacco Use to track the country‐level implementation of the FCTC demand reduction measures and publishes a progress report every two years in the WHO Global Report on the Tobacco Epidemic. 33 , 227
	Regulate Product Packaging and Labeling	Regulating the packaging and labeling of harmful commodity industry (HCI) products (e.g. alcohol, tobacco, gambling, foods and drinks high in salt, sugar and fat), such as mandating clear information about the risks posed by certain products, may address misinformation and overconsumption of such products, especially among vulnerable groups. 33	In 2019, Mexico enforced a front of packaging nutrition labeling (FOPNL) system to place warning labels on foods high in sugar, saturated fats, trans fats, calories, and salt and captions on foods with caffeine and non‐caloric sweeteners. This system has seen high compliance by food & beverage companies, despite some attempts to circumvent the policy (e.g., ‘double fronts’ on products in which only one side contains the warning label). 228
	Place Availability Restrictions on Harmful Products	Placing restrictions on the hours of sale, product density, and minimum age of purchase of products harmful to human health (e.g., alcohol, tobacco, gambling) can limit their availability to consumers. 33	Nordic countries (excluding Denmark), and some provinces in Canada (e.g., Ontario) have created retail monopoly systems for the sale of alcohol. These government‐owned and controlled monopolies limit the number of outlets where alcohol is sold, and place tight regulations on when, where and at what price alcohol is sold. However, some jurisdictions are moving toward privatization. For example, the Canadian province of Ontario recently announced that sales of certain types of alcohol will be allowed at convenience, grocery, and big box stores (up to 8,500 new locations). 229 , 230
	Regulate Product Contents (e.g., nutritional contents, flavoring agents, toxins)	Regulating the content of products may include restricting or prohibiting certain ingredients (e.g., flavoring agents, sweeteners) in harmful products that can enhance attractiveness, addictiveness, or pose an increased risk to the health of consumers, particularly for vulnerable groups such as children. 33	Many countries (e.g., Philippines, Colombia, Brazil, Slovenia) have implemented regulations on the sale of electronic nicotine products, including bans on the use of flavors and other features (e.g., flavor descriptions, cartoons) that may be particularly appealing to youth. 231
	Divest from Harmful Industries	Civil society groups may support shareholders to divest from harmful industries. Governments and universities may also benefit from the support of civil society groups in developing their investment portfolios. 29	Tobacco Free Portfolios is an organization that collaborates with financial institutions to inform, prioritize, and advance tobacco‐free finance (e.g., investments, loans, insurance). As of June 2024, they have convinced institutions managing 18 trillion USD of assets to sign their Tobacco‐Free Finance Pledge. 29 , 44 , 122 , 232
	Wind Down Harmful Industries (e.g., reducing, substituting, or prohibiting their operations)	Winding down harmful industries involves employing strategies to reduce, substitute, phase out or prohibit the operations of corporations, and sale of products or services that are in direct conflict with planetary and public health. 29	New Zealand introduced a rising smoking age in 2022 to ban those born after January 2009 from ever buying cigarettes. Much to the disappointment of public health advocates, this legislation was repealed the following year by the new government. 233
Systems g	Develop Guidelines for Managing Conflicts of Interest	Conflict of interest (COI) standards for engagement with commercial actors may be adopted by various groups. Intergovernmental organizations may play a role in the development of such standards and provide technical guidance on their adoption. Guidelines may include how COIs will be reported, reviewed, monitored, and managed, with sanctions in the case of non‐compliance with policies. 40 , 44	The Organization for Economic Co‐operation and Development (OECD)’s ‘Guidelines for Managing Conflict of Interest in the Public Service’ outlines their recommendations to Member Countries regarding the development of COI policies. All Member countries are encouraged to take the OECD guidelines into account when establishing, amending, or reviewing their COI policies. 234
	Establish Public Conflicts of Interest Databases	Databases that report ties between individuals and institutions in public health (e.g., scientists, universities, research trials, or journalists) and industry can be developed and made publicly available to increase transparency related to COIs. 10 , 40	Transparencé Santé is France's publicly accessible database containing information on interactions between corporations and actors in the health sector. Corporations producing or marketing products for human use and/or health purposes are obliged to declare partnerships, remuneration, and benefits linking them to actors in the health sector. 40 , 235
	Protect Public Health Actors from Industry Intimidation, Litigation, and Threats	Informational and financial resources, as well as legal support, can be developed to protect public health actors from industry intimidation (including litigation, surveillance, defamation, and personal threats). 39	The McCabe Center for Law and Cancer in Australia provides legal training to lawyers, policymakers, and leaders from low‐ and middle‐income countries to develop, implement, and defend laws designed to address non‐communicable diseases. Similar legal training could be provided to teach public health advocates how to defend themselves against legal threats from industry actors. 39 , 236
	Teach Public Health Students and Others about the CDH and Provide Training on Relevant Competencies	Teaching competencies related to the CDH to public health students and others (e.g., business students) can be used to improve awareness and galvanize support for action on the CDH. 10 , 38	The book titled ‘The Commercial Determinants of Health’ contains a chapter that describes the key competencies (e.g., policy evaluation), concepts (e.g., externalities), and pedagogical strategies (e.g., community‐engaged pedagogy) that inform teaching on the CDH. 7
	Regulate Interactions and Industry Contributions (i.e., financial and non‐financial) to the Public Sector	Various groups (e.g., universities, academic journals, civil society organizations, governments) may develop mechanisms and policies to regulate their interactions with industries (e.g., donations, gifts, hospitality and meetings). Relevant mechanisms and policies may include prohibitions, limits, and disclosures of contributions from corporations, especially those are received from health‐harming commodity industries 40	The Australian Public Service Commission's Guidance for Agency Heads on gifts and benefits requires that all agency heads, and immediate family and dependants of agency heads publicly disclose all gifts and benefits received during official duties that are valued over $A100. 40 , 237
	Implement Policies to Limit Revolving Doors Between the Public and Private Sectors (e.g., ‘cooling‐off’ period)	The term ‘revolving door’ refers to the movement of individuals between positions as public officials and as private‐sector employees or lobbyists. 238 To limit revolving doors, policies such as ‘cooling off’ periods (i.e., a period of time in which prior public sector employees are not permitted to accept positions in the private sector) may be introduced to prohibit such movement between positions. 40 , 238	As of the time this article was written, US legislation restricts former Senators and Members of the House of Representatives from lobbying current employees of Congress and other legislative offices for a period of two years and one year, respectively, after leaving office. The “Close the Revolving Door Act” was proposed in the US Senate in 2023. This Act would impose a lifetime ban on lobbying for Senators and Members of the House of Representatives. 40 , 239
	Strengthen Anti‐Trust Regulation	Antitrust laws may be established to break up monopoly industries and promote fair competition within a marketplace. 29	The first antitrust laws in the United States were passed in 1890 and 1914 and continue to be in effect in August 2024. The laws have three main objectives: to preserve competition, provide incentives for the efficient operation of businesses, and keep prices low and quality high for the benefit of consumers. In 2023, industries such as the technology, pharmaceutical, and alcohol industries were subject to antitrust litigation in the United States, including challenges to proposed mergers. 29 , 240 , 241
	Implement Progressive Tax Policies and Tax Floors	Tax policies may be implemented to curb excessive corporate power and equitably redistribute wealth. Tax floors may address the “race to the bottom”, in which countries competitively lower their corporate tax rates to attract multinational corporations. 10 , 44	Solidarity taxes are temporary taxes levied on a group of taxpayers for the purposes of achieving a specific societal goal. For example, Argentina issued a one‐time levy on wealthy individuals in December 2020 to fund medical supplies, business relief packages, scholarships, social developments, and natural gas ventures. 242 As part of the OECD's BEPS project (see ‘Regulate Tax Avoidance’) a two‐pillar agreement has been reached by 142 members (as of May 28, 2023) that includes a global minimum corporate tax rate of 15%. So far, over 50 jurisdictions have taken steps to implement the minimum tax rate. 10 , 243
	Return Privatized Services to Public Ownership and Control	Public goods' or public services such as water, energy, housing, transport, security, finance and school canteens, may be controlled and operated by private industries. Public takeover involves the transfer ownership and control back to communities and/or to the relevant level of government. 29	In 2017, Valladolid, a populous municipality in Spain, decided to shift from private to public water provision following the termination of a 20‐year concession with a private supplier. As a result, the city established AquaVall, a public water company, to supply water to the city and five other municipalities within its metropolitan area. An analysis conducted in 2022 found the re‐municipalization of Valladolid's water to be “largely successful”, in part due to the ability to keep domestic water tariffs relatively low, provide discounts for low‐income households, and invest additional funds to improve water services. 244
	Support and Organize Alternative Modes of Business	Establishing alternative modes of business, promoted through policy, public investment initiatives, and supportive legal frameworks, may allow communities to bypass systems of production and distribution that create health‐related harms. 10	Cooperatives are enterprises that are owned by their members (e.g., workers, customers), are democratically‐controlled, and are designed to meet members' economic, social, or cultural needs. Cooperatives often prioritize values such as equality, sustainability, and concern for community. In Spain, cooperatives enjoy tax benefits that capitalist firms do not have access to, including lower tax rates, tax exemptions, and reduced payables for social security. 245 , 246
	Integrate a Health Lens into Investment Strategies	Investors can use a health lens to make investment decisions, thereby diverting capital away from corporations that perpetuate health harms. 10	ShareAction is a registered charity that engages with investors, policymakers, and companies to advance responsible investment in the United Kingdom. Their ‘Long‐term Investor's in People's Health’ program seeks to prioritize health within investment decisions and improve the health data landscape by supporting investors and engaging with policymakers. 247
	Develop, Adopt, and Support Alternative Economic Paradigms	Governments can adopt new economic concepts and models, such as the wellbeing economy or doughnut economics. 10	‘Doughnut economics’ is an economic model that proposes that societies should seek to live between a social ‘foundation’ and an ‘ecological ceiling’; it is an alternative to models that promote poorly‐constrained economic growth. Doughnut economics has been embraced by cities such as Amsterdam (Netherlands), Nanaimo (Canada), and Dunedin (New Zealand) as a way to guide policies that address social needs while remaining ecologically sustainable. 248 , 249
	Establish New International Organizations and Institutional Arrangements to Govern Transnational Corporations	International institutions, involving multiple member states, may be established to govern transnational corporations. 29	The United Nations Centre on Transnational Corporations (UNCTC) was established in 1974. During its operation, the Centre was a platform for all matters related to transnational corporations, with the aim to “enhance the contribution of transnational corporations to national development goals and world economic growth, while controlling and eliminating their negative effects; strengthen the negotiating capacity of host countries, in particular the developing countries, in their dealings with transnational corporations.” 251 However, due to opposition from the US and corporations, the UNCTC failed to gain consensus on its legally binding Code of Conduct for Transnational Corporations. It was abolished in 1992. 29 , 250 , 251
	Remodel Corporate Structure and Law (e.g., limited liability provisions)	Remodeling corporate structure and laws to better support health may involve stricter control and, in some cases, systemic revocation of some of the legal, political, and economic privileges of corporations. 29	As a result of the protections afforded to the Sackler family during the 2021 Purdue Pharma bankruptcy settlement (see ‘Dissolve Harmful Corporations’), some members of Congress introduced a bill (called the ‘Sackler Act’) that would prohibit a bankruptcy court from releasing claims brought by states, tribes, municipalities, or the federal government against non‐debtors in the future. 199 , 252
	Measure and Limit Cost Externalization (e.g., sin taxes)	Cost externalization refers to corporations transferring their costs to a third party, thus avoiding financial accountability for the harms they cause. Approaches targeting this practice include the development of tools to measure the cost externalities of corporate actions, and the implementation of fiscal policies to target and redistribute externalized costs. 29	An excise tax describes a tax on specific activities or products (e.g., alcohol, tobacco, gambling), to reduce their consumption and generate public revenues. The WHO reports that Colombia implemented a fiscal reform in 2016 that included increases to its tax rate for cigarettes. As a result, cigarette consumption fell by 34% by 2018 and the revenues from excise taxes doubled; these revenues were earmarked to fund universal health coverage in the country. 253

^a The list of mechanisms presented in this table were aggregated from previous literature or added by the authors.^{3,10,29,39,40,44} Many of the presented mechanisms were identified in multiple sources, though our citation strategy does not attempt to capture all of the instances in which the mechanism was mentioned. Some of the examples described in this table were also originally identified in these sources. The table is intended to be illustrative and is not comprehensive of all of the mechanisms or examples that are available or that were identified in the respective literature sources.

^b The levels are not mutually‐exclusive. Some mechanisms (e.g., mandating employee benefits) address more than one level (i.e., practices, population groups).

^c A commercial actor refers to an entity engaged in the buying, selling, or producing of goods and services primarily for profit. These may vary in form and size, including transnational corporations (TNCs), trusts, sole proprietorships, partnerships, cooperatives, and state‐owned enterprises. ¹

^d Practices refer to the specific activities through which commercial actors exert their influence on health and may include political, economic, and preference and perception shaping practices. ¹ , ¹²

^e Population groups refer to groups of people with similar characteristics that are affected by corporate practices (e.g., workers, consumers, local communities, disadvantaged groups, vulnerable groups).¹² Mechanisms that address this level are designed to protect these groups from harmful impacts of the CDH (or maximize the benefits of salutary impacts).

^f An industry refers to a collective of commercial actors that produce or sell similar products or services (e.g., tobacco, alcohol, ultra‐processed food). ¹

^g Systems refer to the political, economic, and regulatory frameworks that enable and drive the actions of commercial actors. ⁴⁴