The Commercial Determinants of Health: How Clinicians Can Make a Difference

ABSTRACT

Commercial determinants of health (CDoH) describe the health‐harming products and practices from corporate activities. The rise of global mega‐corporations means these entities have unprecedented power and impact over the public's health and environments, mediated by multi‐pronged influence over individual behaviours, the scientific evidence base, policymakers and regulatory bodies. Clinicians are not immune to corporate reach. Having an umbrella term and dedicated academic focus for CDoH helps us to understand shared industry tactics and develop safeguards to mitigate harms. We encourage clinicians to combine forces with academics and other professionals to counteract the health harms. There are things we can all do.

1. Introduction

Corporations that manufacture and market health‐harming products or practices are leading vectors for disease, with a causal role in the international increase in non‐communicable disease‐related mortality [1, 2]. The rise of global mega‐corporations means these entities have unprecedented power and impact over the public's health and environments, mediated by multi‐pronged influence over the scientific evidence base, policymakers, regulatory bodies and individual behaviours, including clinicians. Rising awareness of this problem among academics and policymakers has led to the increasingly cited term ‘commercial determinants of health’ (CDoH) [2], which extends and expands on ‘social determinants of health’ to describe products and practices of industries that harm the public's health and health equity [3]. Health practitioners' understanding of CDoH terminology and key concepts is not yet well established [4]. It seems timely, therefore, to provide a brief introduction, with a particular focus on Australian issues and leadership in this field, and discussion about future actions. Our aim is to build awareness to help health practitioners better understand how they can act to counter these harms on the public's health.

2. CDoH: Why It Matters and How It Happens

A recent report from the Australian Institute of Health and Welfare (AIHW) showed that chronic disease accounts for most of the burden of disease in Australia, with over 60% of the population living with at least one chronic illness [5]. Collectively, the tobacco, alcohol, ultra‐processed foods and fossil fuels industries are responsible for about one‐third of preventable deaths globally [1]. Other industries (e.g., gambling and plastics) contribute to more deaths and further harms [2]. The pharmaceutical industry is also implicated in CDoH. Although pharmaceutical products can deliver great health benefits, there is a long history of practices from the pharmaceutical industry that lead to harm, including heavy marketing of opioids [6], under‐reporting of known side effects [7], promoting over‐diagnosis and over‐treatment [8] and artificially raising drug costs (e.g., by prolonging patents [9] or manipulating prescribers and patients to prefer products that are more expensive but lack added health benefits).

The concept of CDoH also recognises that corporate harms to the public's health can be mediated indirectly by intermediary strategies that heighten demand and use of health‐harming products. Such strategies include industry influence over the scientific evidence base, political processes, health policy, regulatory bodies, community norms and individual behaviour [2, 10]. Sociopolitical changes have facilitated this. These include, for example, shifts away from state funding of scientific research towards industry‐funded research—with the inherent biases that entails—delivering an additional ‘megaphone effect’ for industry‐friendly messaging [11]. Targeting clinicians is another strategy, via tactics such as industry sponsorship of professional bodies and their conferences, clinician research funding, offers of gifts, consultancies and professional opportunities.

3. CDoH in Australia

Recent local conferences on CDoH [12, 13, 14] have highlighted some of the current concerns about harms to particular populations within Australia. Some examples of topics from those conferences are provided in Box 1.

BOX 1. Some recent examples of Australian commercial determinants of health topics of concern.

• Australia relies on industry self‐regulation via Medicines Australia to govern disclosure of pharmaceutical industry payments to clinicians. This is less robust than using legislative processes as per other countries (such as the United States and France) because it is vulnerable to change and fails to provide governance over companies such as Purdue Pharma that are not members of Medicines Australia [15].

• There is insufficient regulatory protection for Australians, including children, with regard to gambling advertising [16], meaning that children perceive betting to be a normal and fun part of being a sports fan. This is despite awareness that many Australians experience significant problems from this activity.

• There is government failure to adequately recognise or reduce health harms from per‐ and polyfluoroalkyl (PFAS; ‘forever’) chemicals, including for our First Nations populations [17, 18].

• Australian and New Zealand commercial determinants of health academics are targets of intimidation tactics from industry and industry‐funded groups but experience inadequate legal protection [19].

• Australian patient groups have no independent policy support for navigating industry sponsorship arrangements [20, 21], instead relying heavily on industry co‐branded governance policies.

Australia's history of awareness and action to mitigate health harms from commercial products and practices includes some key clinicians and academics: Dr. Nigel Gray was instrumental in the banning of tobacco advertising in Australia [22] and the later introduction of plain packaging was a world‐leading policy change for tobacco control [23]. Australian academics have been prominent in raising awareness about the role of the pharmaceutical industry in delivering harm through over‐medicalisation and over‐diagnosis, via books aimed at the public [8] and organisational leadership of international biennial Preventing Overdiagnosis conferences [24]. The Australian National Health and Medical Research Council (NHMRC) has developed a gold‐standard policy for managing or avoiding conflicts of interest in government‐funded clinical guidelines committees [25].

There are many more strategies that can be used for change (Appendix S1). In this perspective article, we focus particularly on what clinical readers might consider doing here and now.

4. How Clinicians Can Make a Difference

4.1. Professional Practice

Like everyone, clinicians are susceptible to influence via an individual or company deliberately engendering feelings of reciprocity. To avoid this, practitioners can consider alternatives to placing themselves in a situation of debt to corporate entities. Situations that induce feelings of reciprocity might include receiving honoraria for speaking engagements, advisory board memberships, costs for attending conferences and accepting meals and entertainment [26, 27]. Clinicians can also work with their Royal Colleges and professional societies to discuss ways to disengage from industry funding of conferences and other educational activities [28]. Similarly, they can talk with hospital and clinic management teams to review policies around sales representative visits and industry‐sponsored grand rounds meetings, rejecting direct industry contact in favour of independent, in‐house educational services with indirect use of industry educational materials where required [29].

Health practitioners are role models for the public and can take care to act responsibly in their professional and public lives around health‐harming products and activities. They can review their behaviour around junior clinicians with regard to industry interactions, including with pharmaceutical and medical device representatives; for example, declining industry offers of meals and entertainment and setting up third‐party platforms to negotiate compassionate access to efficacious drugs not yet on the Pharmaceutical Benefits Scheme [30].

Clinicians engaging with or recommending consumer organisations to patients can review groups' policies and practices around industry funding [20]. They may consider limiting or rejecting interactions and endorsements for groups that allow funding from health‐harming industries or fail to disclose funding information, instead seeking out member‐funded groups and groups with strong, independently written and publicly available conflict‐of‐interest policies [21].

The NHMRC conflict‐of‐interest policies focus on clinical guideline development but can be adapted for other settings. For example, clinicians affiliated with non‐government organisations could share core principles and assist with development of conflict‐of‐interest policies that restrict involvement of those with financial conflicts of interest [25, 31, 32].

4.2. Reading the Scientific Literature

Clinicians can remind and educate themselves and their peers that industry funding and financial ties of researchers create a risk of bias and approach such research with scepticism. These biases are often hidden or hard to detect: industry‐funded drug and device studies are more likely to deliver outcomes in favour of the sponsor's products when compared with non‐industry‐funded research, even when the methodology appears sound [11]. Clinicians can seek out high‐quality independently funded research, such as Cochrane reviews, instead of, or to supplement reading of, industry‐funded articles. More generally, readers can take care to remember that corporations have a long history of strategies to influence evidence, such as suppressing results about product harms [33], using spin to highlight non‐significant but seemingly favourable results [34], flooding the literature with opinion pieces by industry‐funded practitioners [35] and distracting readers with studies on tangential topics (such as second‐hand smoke) [2, 36].

4.3. Clinician Advocacy

Clinicians are trusted voices for the public and policymakers. Those inclined towards advocacy could consider using their personal experience and professional standing to effect change. This could mean engaging directly with the media and politicians or working through professional organisations such as the Australian Medical Association, the Royal Colleges and/or advocacy organisations, including the Public Health Association of Australia and the Australian Council on Smoking and Health. Clinicians may wish to upskill for more effective advocacy through training courses in media, advocacy and/or policy development.

4.4. Research

Clinician researchers should be cautious about engaging with would‐be sponsors implicated in CDoH industries. Commercial funders may demand control over data, meaning that publication of unfavourable results might be delayed or refused [37]. Some pharmaceutical industry‐funded research may be primarily a marketing exercise, with so‐called ‘seeding trials’ aimed at building awareness and familiarity around a new product, rather than answering a legitimate health question [38]. If clinicians decide to engage in industry‐sponsored research, research contracts can include firewalls to maintain independence and control over the design, conduct, analysis and reporting of study results [39].

Clinicians interested in engaging directly with research on CDoH research have a lot to offer. It is no coincidence that seemingly disparate corporations use similar tactics to extend their influence [35, 40]. The so‐called ‘corporate playbook’ arises from sharing of strategies and personnel between different corporate entities [41, 42]. In the same way, clinicians sharing expertise with academics and policymakers can help identify commonalities in the industry playbook, facilitating the development of mitigation strategies [43].

5. Conclusion

There have always been businesses that seek commercial profits with scant regard for the health of consumers. The difference now is the extent of the problem: the size and reach of global corporations means that influence is multifactorial, extending through a range of actors to deliver systems‐level influence and drowning out opposition [1]. As per the AIHW report, Australians are experiencing more chronic disease and related quality of life concerns [5], and there are associated healthcare expenses. There is a close link between social determinants of health and CDoH: people at lowest socio‐economic levels are often at highest risk of harm from commercial health‐harming practices. The obesity epidemic and the lack of access to affordable healthier foods for the same price as heavily marketed ultraprocessed foods is a case in point. These are not two separate paradigms; they are strongly intertwined, and to address social determinants of health adequately, commercial determinants cannot be ignored.

We invite readers to learn more about CDoH (see Appendix S1 for additional resources). Clinicians can have a role in addressing root causes as much as they focus on treatment: naming the CDoH, changing their personal and professional engagement with health‐harming global corporations and encouraging change at the institutional level. We encourage clinicians to share their stories and ideas with colleagues in business, law and politics and to engage with local experts who are working towards increasing awareness and advocating for policy change. Clinicians are well placed to participate in advocacy for more systemic change, a key professional competency and complementing their direct care of patients. Advocacy may not be for everyone: it can be time‐consuming, results may be slow and advocates themselves may at times be subject to personal criticisms. As a minimum, however, health professionals have a responsibility to be aware of industry strategies aimed at manipulating their own clinical behaviour, be alert to the risk of bias from industry‐funded research and educate their patients, counteracting misinformation driven by commercial agendas.

Author Contributions

Lisa Parker was responsible for conceptualisation, writing the original and final draft and the revision. Nicholas Chartres contributed to writing the original draft and revising the final draft and revision. Kellia Chiu, Barbara Mintzes and Lisa Bero contributed to reviewing and revising the drafts and revision.

Funding

No funding was received for this work. This article drew on experiences and learnings of authors, including from two Commercial Determinants of Health symposia in Sydney, Australia, in 2023 and 2025. Both conferences received funding support from the Charles Perkins Centre, University of Sydney. Neither conference received industry funding.

Disclosure

Not commissioned; externally peer reviewed.

Artificial Intelligence (AI) Statement: AI tools were not used for this submission.

Conflicts of Interest

Lisa Parker, Nicholas Chartres, Kellia Chiu and Lisa Bero report no relevant disclosures. Barbara Mintzes acted as an expert witness for Australia's Therapeutic Goods Administration and Health Canada on two legal challenges to regulatory decisions. She has no other conflicts to declare.

Supporting information

Appendix S1: Additional resources.

Data Availability Statement

The authors have nothing to report.