Addiction Industry Studies: Understanding How Proconsumption Influences Block Effective Interventions

Abstract

The legalized consumption of products with addiction potential, such as tobacco and alcohol, contributes in myriad ways to poor physical and mental health and to deterioration in social well- being. These impacts are well documented, as are a range of public health interventions that are demonstrably effective in reducing harm.

I have discussed the capacity for the profits from these substances to be deployed in ways that block or divert resources from interventions known to be effective.

Addiction industry studies constitute a new and previously neglected area of research focusing specifically on understanding the salient relationships that determine policy and regulation. This understanding will increase the odds of adopting effective interventions.

Legalized products, such as tobacco, alcohol, and gambling, with a high potential for dependence (referred to here as “addictive products”) contribute globally in a multitude of ways to the social determinants of health (e.g., poverty, inequalities), to common risks to health (e.g., injury, disease), to mental health concerns (e.g., suicide, addictions), and to crime (e.g., violence, drunk driving).^1–4 Considerable research has focused on improving the understanding of how addictive products generate harm and on developing effective public health and treatment interventions to reduce such harm.

This effort has assumed that when the evidence for a particular approach is sufficiently persuasive, government sector agencies, as a matter of course, will be persuaded to invest. However, despite the emergence of solid evidence and the combined energy of concerned citizens, researchers, and community agencies, the outcomes in terms of policy and regulation are by and large disappointing.^5,6 For example, counter to the mounting evidence of the effectiveness of changes in the promotion, pricing, and availability of alcohol products, recent reforms of alcohol legislation in countries such as the United Kingdom, New Zealand, and Canada have been weak from a public health perspective.^7–10 These experiences, plus many similar histories of disappointing policy reform for tobacco and gambling, speak loudly of the power of other influences.

A key aspect to the commercialization of high-volume addictive products is the ability to generate profits beyond those that ordinary, nonaddictive products, such as gasoline, pizza, and televisions, generate. For example, a pivotal feature of addictive drinking is consumption that goes well beyond what is acceptable and sensible. Addicted consumers, by the very nature of addictive behavior, will consume to excess. Although there are fewer of them than nonaddicted consumers, they invest more heavily and, accordingly, contribute far more to profits. For example, Australian studies indicate that although the prevalence of problem gamblers is 1% to 2% of most adult populations, problem gamblers contribute 40% to 50% to expenditure (loss) on electronic gambling machines.^11,12 In addition, although a sizeable group of frequent and heavy consumers do not yet display signs of addiction, they can consume in ways that have a negative impact. For example, because nonaddicted heavy drinkers are more numerous than are addicted drinkers, they contribute significantly to harms such as road fatalities, unsafe sex, and impairment in the workplace.^13–15 This further reinforces the link between profits and harm.

The profit surplus that addicted consumers generate—the addiction surplus—underpins not only the motive force for expansion but also the resource base for a range of proproduct initiatives that seek to guard against potential threats, particularly those associated with policy and regulation.^16–18 These initiatives bring together a wide range of key players to collaborate in protecting the profit yield. Such networks typically include the product industries themselves (e.g., tobacco corporations, breweries, casinos), industry services (e.g., advertisers, lobbyists, public relations companies, and law firms), government agencies (at local, state, and national levels), and community beneficiaries (through, e.g., grants, sponsorship, gifts).

Moreover, ways of gaining favor and influence are not limited to paying for a service, such as advertising,^19,20 or paying political lobbyists.^21,22 Benefits can include appointments (e.g., nominating retired politicians for boards), cross-board memberships (e.g., putting company executives on government advisory committees), exchanges in kind (e.g., contributing to a hospital with the understanding that there will be looser regulations), and currying public favor (e.g., funding local sporting or cultural events). We know little about the specific details of these relationships and the overall processes by which such influence is exerted.

Accordingly, something appears to be missing; some other area of inquiry is required in the mix to work out more effective ways of translating strong evidence into policy. This calls for the development of what might be called “addiction industry studies”: an area of inquiry in which the key questions are where are the proproduct influences occurring, on what scale, and how might they be moderated? Attempts at making sense of these proproduct influences call on the combined efforts of investigators from varying disciplinary backgrounds.

UNDERSTANDING INFLUENCE PATHWAYS

How are addiction surpluses deployed to influence both public and government views on such products? Although the answers are at an early stage, some promising lines of inquiry are emerging. One approach involves delving deeper into the way key players engage in and form ongoing relationships. Investigations typically bring public health academics together with social scientists (e.g., sociologists, political economists) in coming up with an account of how these relationships form. For example, Gundle et al. examined documents that identified how tobacco industries used research into genetics to deflect attention away from wider public health approaches.²³

Similarly, Smith and Rubenstein looked at how Canadian government agencies provided poor accountability processes for monitoring their gambling industries,²⁴ and Miller et al. explored how alcohol industry public relations organizations work at undermining harm prevention initiatives.²⁵ Taking a more systematic approach, Jahiel has developed an analytic framework that examines an “epidemiological cascade” from the higher level of government-sanctioned corporate profits to the lower levels of societal harms. By carefully tracking the chain of influences, a complex picture emerges of how profit-based societal power translates to individual harms.²⁶

Another approach draws on business studies (e.g., accounting, marketing) to sketch a more detailed picture of how influence operates. For example, MacKenzie and Collin examined how Philip Morris promoted its tobacco interests in Thailand by sponsoring art events.²⁷ Babor et al. outlined in their book how beer and spirits production has been consolidated into a few powerful global corporations focused on expanding their operations in Eastern Europe, Asia, Africa, and Latin America.²⁸ Bond et al. examined the strong similarities in the way the tobacco and alcohol industries foster influence and the extent to which they work together.²⁹ A variant of this approach involves detailed case studies of a particular organization or an influential individual. For example, Jernigan explored how the International Centre for Alcohol Policy pursues alcohol industry interests by distorting the underlying science,³⁰ and Bakke and Endal tracked how an Australian health expert assisted African governments in adopting industry-friendly alcohol policies.³¹

One final approach draws on backgrounds in psychology and philosophy in seeking to understand the ethical reasoning involved for those who choose to benefit from these profits. For example, Adams examined the self-talk addiction researchers use to justify accepting funding from industry sources,³² and Striley reviewed the ethical dilemmas associated with addiction research.³³

MAKING INFLUENCES VISIBLE

How much is spent by addictive product industries to influence the views of government agencies and the public? Currently, little information is available at local and international levels on the scope and volume of such financial exchanges. Occasionally information does surface; for example, in 2011 operators of electronic gambling machines in New South Wales claimed to have put aside 40 million dollars (Australian) for a campaign opposed to the Australian government’s gambling reforms—a campaign rewarded at the end of the year by the government stepping away from strong measures.³⁴ But such disclosures are unusual. The amounts invested in activities such as government lobbying, sports sponsorship, and informal gifting are usually well concealed.

At least part of what makes these investments effective is the general unawareness of how much money is involved and how it is being deployed. For example, a young male drinker may have no idea about the extent to which alcohol advertising is reinforcing links to his sense of manhood, just as a woman regularly gambling in a casino may fail to appreciate that charitable donations are primarily aimed at boosting the casino’s public profile. Ready access to such information could lead many to reappraise their involvement. The power of increased transparency was highlighted when a class action suit against Philip Morris led to revelations of how tobacco companies garner influence through political, community, and academic relationships.^35,36 Public Internet access to industry-internal correspondence facilitated a significant shift in public attitudes toward the tobacco industry—enough of a shift to enable major changes in regulations.

One way to facilitate these shifts in awareness is by increasing access to information. I am part of a team (with colleagues from backgrounds in computer science and accounting) working to construct a database designed to allow users easy access to tracking financial relationships between profits from product and profit beneficiaries. Users will eventually be able to access an Internet site where they can either browse financial links associated with a particular organization (e.g., a brewery or a university) or request summaries of financial information across a class or a cluster of organizations. By increasing access to such information, the lines of influence become more visible and then form the focus for future research on whether this could contribute to shifts in both public awareness and beneficiary behavior.

INTERVENING WITH INFLUENCES

How might proproduct influences be moderated or disrupted? This is the newest and, as yet, least researched area of addiction industry studies. Most efforts have focused on activities aimed at raising people’s ethical consciousness and promoting a critical stance on industry influences. For example, Fisher found in her interviews with street drug users strong interest in the ethical issues associated with addiction research.³⁷ This suggests that people, when provided with an opportunity, are capable and willing to question unethical practices. Building on this idea, I developed an assessment procedure to assist organizations and their boards in assessing the level of risk they are taking when accepting such profits.³⁸ A variety of organizations have used the procedures both as a means to openly discuss difficult ethical issues and to form judgments on where to draw the line.³⁹

An important consideration when looking at intervening in industry influence is that should the interventions appear to be having some effect, industry organizations are unlikely to be accepted passively without some form of counterresponse. The substantial profits from addictive products could be deployed—or could be seen as capable of being deployed—in ways that discourage intervention. For example, in Australia in 2009 Miller et al. published a letter in the Medical Journal of Australia challenging the funding of alcohol research that DrinkWise, an organization established by Australia’s alcohol industry, provided. The board of DrinkWise then responded, indicating that some of their members had felt “defamed” by the letter, which, by implication, Miller et al. interpreted as a warning that they could become the subject of legal action.^40,41

This encounter raises questions regarding the appropriate role of addictive industry corporations. Some involved in public health would argue that industry capacity to deploy profits and acquire influence makes them unsuitable to participate in public health policymaking: they lack relevant expertise and they have a clear vested interest.^42–44 This opens up a role for public health practitioners and their organizations to educate professionals and the public about these conflicts and to support them in constraining corporations to appropriate involvement.

Another, higher-level approach involves developing ethical guidelines for managing vested interests. For example, a group of journal editors have devised a common standard for authors in declaring conflicts of interest⁴⁵; some universities and research institutions have formulated policies that set limits on receiving industry funding—but to date very few have active policies⁴⁶; and international health agencies such as the World Health Organization have explored policies that minimize industry influence.⁴⁷ These efforts could be extended to government agencies and political organizations.

CONCLUSIONS

I have presented addiction industry studies as a necessary partner to addiction research in general because without the capacity to manage industry influences, addiction research will continue to have minimal effects on policy. This emerging area of research is beginning to draw a picture of the range of ways and the dynamics of industry influences. Health research funders need to look carefully at how supporting this research will maximize progress made in other areas.