Using Regulatory Stances to See All the Commercial Determinants of Health

Abstract

Policy Points

• The commercial determinants of health (CDoH) concept, which currently focuses on markets that harm health, should be expanded to refer to the interface between commerce and health, which can sometimes have positive public health consequences.

• The regulatory stances framework helps us classify public health preferences for regulating specific markets related to CDoH, based on the intended effects of regulations on market size. The regulatory stances a jurisdiction can adopt can be classified as ranging from prohibitionist through contractionist, permissive, and expansionist, to universalist.

• The regulatory stances framework increases the usefulness of the CDoH concept by expanding the conversation beyond negative determinants of health and providing a fuller view of the tools at the disposal of society to alter markets and improve health.

Context

The effects of commerce on the public health are omnipresent. The commercial determinants of health (CDoH) represent a burgeoning area of scholarly debate and activist policymaking to redress markets that adversely affect public health. The CDoH debate is a logical extension of the tobacco control movement, but, to its detriment, the CDoH conversation remains primarily focused policies and proposals that are analogous to historical tobacco control strategies.

Methods

This paper argues that for the CDoH to develop further and broaden its appeal, it should expand to cover markets with conditional and positive impacts on health. To explain and order this conversation, a comparative framework for regulatory policy is introduced: the regulatory stances. The regulatory stances classify a regulatory policy based on the intended effect of policy on the size of a market in the future relative to the present.

Findings

Some markets that interface between commerce and health do not inherently harm health. Regulatory policy toward these markets should be different in intent than regulatory policy for markets with negative health effects.

Conclusions

By using the regulatory stances framework to encompass markets that have positive or conditional effects on health as well as those that have adverse health effects, the CDoH conversation can shift away from the exclusive focus on strategies to shrink markets with adverse health impacts to consider a wider array of policy options.

Taken together, tobacco smoking and alcohol use account for one in five deaths in high‐income countries. ¹ In addition to tobacco and alcohol, many other products raise public health concerns due to their association with high rates of morbidity and mortality. Examples include asbestos, prescription drugs, firearms, automobiles, and processed foods of low nutritional value. Put simply, many markets and industries harm the public health. Concern over these issues has motivated a wide range of social movements and has produced vast policy outcomes. In recent decades, scholars have begun to coalesce on a broad terminology for these markets that harm health, the concept of “commercial determinants of health” (CDoH). ² CDoH scholars study markets, policies, and corporate actors that form the direct interface between health and commerce. These scholars point out that the toll from the use of these products is not an inevitable consequence of the human condition. They argue that markets and political forces produce and enable widespread consumption of dangerous goods and the resultant morbidity and mortality that follow. ³

In a 2012 editorial that helped introduce the CDoH concept, ² Ilona Kickbusch, the director of Health Promotion at the World Health Organization (WHO) from 1994 to 1998, claims she would rewrite one of global health's foundational documents, the Ottawa Charter for Health Promotion of 1986. ⁴ Whereas the Ottawa Charter classified factors that determine global health in seven categories (political, economic, social, cultural, environmental, behavioral, and biological), Kickbusch argued that five determinants of health (political, commercial, social, environmental, and behavioral) should be emphasized. ² By fusing the social and economic (along with a dose of the political) determinants of health, Kickbusch kickstarted a campaign to place the CDoH alongside these other factors as the modifiable targets for public health improvement. Hundreds of peer‐reviewed research articles have since used Kickbusch's framework to useful ends and have focused attention on the role that commerce plays in contributing to morbidity and mortality around the world. However, these scholars have focused nearly exclusively on markets with a negative impact on health and have not sufficiently considered the multifaceted relationship between commerce and health.

In this paper, I offer a novel theoretical concept—regulatory stances—as a useful lens through which to view the CDoH literature, and I suggest a constructive path forward to a world that could better address the health harms inflicted by markets. By foregrounding regulation's goal to affect the size of a market, policymakers can better focus on the purpose of addressing the CDoH, discover powerful new policy tools, and constructively reframe the CDoH discussion. Using tobacco control to frame and guide the construction of the CDoH is a limiting choice. It blinds well‐intentioned advocates from seeing the full range of effects that commerce can have on health. The paper establishes that the CDoH exist in three varieties: negative, conditional, and positive. Each category begs a particular regulatory stance, an intended market size in the future compared to the present, as its public health remedy. This innovative regulatory‐stances perspective expands the scope of the CDoH beyond those markets with purely negative effects on health.

In recent years, much of the attention of scholars and policymakers concerned with noncommunicable diseases has been explicitly focused on the social determinants of health (SDoH). ⁵ By focusing attention on the issues that drive systemic health inequities across and within borders, SDoH scholars have risen to become a powerful cultural and political force. ⁶ , ⁷ They have focused their studies on the harms and benefits of structural societal conditions on populations and try to tease apart how these conditions cause preventable health inequities. They document gradients in health outcomes across gender, race, socioeconomic status, educational attainment, religion, social class, sexual orientation, geography, and access to the essentials of life such as food, housing, and health care. ⁸ Further, they study whether specific interventions decrease these gaps in outcomes across groups, and they have worked to integrate their rhetoric and narrative into the political battles to implement their favored policy solutions. ⁹ Most importantly, SDoH scholars have successfully introduced the idea that social policy is health policy and that such policies should be advanced to remedy health inequities. ¹⁰ , ¹¹

The CDoH literature starts from a similar rhetorical point as the SDoH literature. It points out that the health inequities it seeks to redress are preventable. ¹² The very existence of people living longer and healthier lives when they are at the lower end of exposure to toxic forces and products implies that morbidity and mortality in populations that are currently at the higher end of exposure to those forces and products can be reduced by decreasing their exposure. ¹³ The CDoH literature then goes on to propose, in large part via analogy to the tobacco control movement, that unhealthy markets can be corralled and health inequities caused by said markets may be resolved. The CDoH discussion has certainly evolved to produce a rich literature that approaches the problems of commerce through vast numbers of disciplinary, methodological, and theoretical lenses. ¹⁴ , ¹⁵ CDoH foci have expanded beyond addressing noncommunicable diseases, and beyond offering more superficial‐level policy fixes and toward diagnosing the role of larger forces such as corporate power and global trade governance. ¹⁶ , ¹⁷ But the nearly exclusive emphasis on unhealthy markets holds the CDoH concept back from reaching its full scholastic and political potential. The regulatory stances concept proposed in this paper reframes the debate around CDoH in a constructive and politically potent manner.

The Influence of the Tobacco Control Movement on Subsequent CDoH Policy

The push to elevate CDoH as a target for concerted public policy intervention stemmed from an implied consensus among the global public health community that lessons from tobacco control needed to be scaled up and applied to other industries. As a scholar and member of the tobacco control movement, I understand the attraction of emulating tobacco control tactics. However, my experience in tobacco control leaves me wary of telling other public health scholars and advocates that following tobacco control's example will yield the desired outcomes for their CDoH of concern.

At the start of the 21st century, during the development of the WHO's Framework Convention on Tobacco Control, a prominent justification for writing a global health treaty that aimed to confront the harms of a single unhealthy commodity industry began to circulate. ¹⁸ This justification, termed “tobacco exceptionalism,” contended that the tobacco industry was so inherently harmful and its influence was so insidious that countries should sign a treaty to bar tobacco companies from influencing regulatory policy over their businesses. ¹⁹ Memorably, a panel of WHO‐convened experts concluded in a 2000 report, “Tobacco use is unlike other threats to global health […] There are no front groups to promote the spread of cholera. Mosquitoes have no lobbyists.” ^{20 (p244)} Although this observation is true in the specific case of mosquitoes and cholera, it does not hold up to scrutiny if it is extended to other (unhealthy) commodity industries. ²¹

CDoH scholars have moved forward since the early 2000s to correctly diagnose a series of issues that sorely lacked attention from policymakers, scholars, and the public; namely, why has the world not faced down other unhealthy commodity industries as it has done with tobacco? ²² CDoH scholars rightly seek to rebuke tobacco exceptionalism by applying regulatory policies that are viewed as having successfully controlled tobacco markets to other unhealthy commodity industries. Although this method and its goals are admirable, after close examination of the CDoH track record and toolkits, I argue this analogy and its consequences are under‐developed, to the detriment of the CDoH conversation. Starting from the assumption that the tobacco control movement has been a stunning success, CDoH scholars and public health advocates look for ways to import policies and lessons from tobacco control to their policy areas to solve analogous problems in their areas of interest. (See, for example, Buse 2017. ²³ ) If we are measuring the tobacco control movement's progress exclusively from a morbidity and mortality reduction perspective, ²⁴ the movement has achieved enormous successes. For example, in the 50 years after the publication of the landmark 1964 Surgeon General's Report, tobacco control efforts in the United States are projected to have averted 8 million premature deaths. ²⁵ This pattern has been repeated around the world; although it should be noted that most declines in tobacco use and death are concentrated in high‐income countries. ²⁶ Furthermore, if we measure tobacco control's progress from the perspective of having made tobacco companies economically unviable, an ambitious position taken by advocates like former WHO director‐general Margaret Chan, ²⁷ the movement has unquestionably failed. Table 1 demonstrates that in 2019, global tobacco companies were still highly profitable, even when compared to peers selling consumer staples that are not subject to comparable regulatory policies. ²⁸

Table 1.

Earnings‐to‐Revenue Proportions by Large Consumer Staples Companies ^a in 2019

Primary Industry	Company	Earnings (Millions of US$) b	Revenue (Millions of US$)	Proportion (%)
Tobacco	British American	13,443	33,042	40.7
Alcohol	Anheuser‐Busch	20,828	52,329	39.8
Tobacco	Philip Morris	11,495	29,805	38.6
Tobacco	Japan Tobacco	6,267	20,016	31.3
Soft drinks	Coca‐Cola	11,451	37,266	30.7
Food	Nestle	22,957	93,469	24.6
Alcohol	Heineken	6,236	26,845	23.2
Cleaning	Unilever	11,973	58,218	20.6
Food	Mondelez	4,934	25,868	19.1
Soft drinks	PepsiCo	12,723	67,161	18.9
Food	Danone	5,129	29,113	17.6
Food	Kraft Heinz	3,758	24,977	15.0
Cleaning	Procter & Gamble	8,311	67,384	12.3

Data derived from Macrotrends.^29‐41 All figures are for 2019 (prepandemic) EBITDA margins.

^a Large companies are defined as companies with annual revenues over US$20 billion.

^b Earnings are defined as earnings before interest, taxes, depreciation and amortization (EBITDA).

Even in countries that are tobacco‐control success stories, where tobacco control policy has produced public health improvements, such as the United States, the tobacco control story is not one of pure success in terms of tearing down the tobacco market. Cigarette use prevalence among US adults peaked in 1965, cigarette sales per capita peaked in 1981, and cigarette sales by inflation‐adjusted value did not peak until 2006. ⁴² , ⁴³ But viewed through the lens of market size, inflation‐adjusted cigarette sales in 2018 were equivalent to sales in the late 1990s, ⁴³ an era hardly defined as a nadir of tobacco industry power and influence. In terms of producing returns to employees and shareholders, tobacco companies have thrived in what is perceived to be a declining market of customers in a wealthy country. Although these material resources do not directly translate to political power and influence, such resources help (from the perspective of a corporation) defend a profitable status quo. ⁴⁴

The reasons why tobacco companies have been able to stay profitable are multifaceted: Their products are addictive, contributing to an inelastic demand curve. ⁴⁵ Tobacco companies have overshifted excise tax increases onto consumers, blunting the revenue sting from tax increases. ⁴⁶ , ⁴⁷ Tobacco companies have shifted their marketing into targeted channels to replenish their consumer base via the delivery of direct contacts, discounts, and coupons. ⁴⁸ , ⁴⁹ The economically rational responses on the part of tobacco companies to market regulations illustrate the difficulty of the task of successfully controlling any other CDoH.

Given this sobering information about the impact that the tobacco control movement has had on the industry it sought to regulate, why would the CDoH movement consider the tobacco control movement and its policy toolkit as the model for success in their burgeoning movement? One reason may be the widespread perception that the tobacco control movement has been successful in its initial primary goals of decreasing the prevalence and acceptability of smoking, although the data in Table 1 indicate that tobacco companies have paid only a small monetary price for becoming a pariah industry relative to peers that have not been subject to a comparable regulatory policy campaign. I would argue that another key reason is that the tobacco control movement has proposed solutions that seem reasonable on their face to redress the harms caused by other unhealthy commodity industries. ⁵⁰

Many policymakers and policy advocates seeking to address CDoH seem intent on transplanting tobacco control policy solutions to other types of CDoH (see Table 2), and they often cite evidence of the impact of tobacco control on tobacco use as a justification for their policy proposals. These policy solutions from tobacco control, with the help of keen policy entrepreneurs “found” additional problems to solve and were then transplanted into the CDoH debate. ⁵¹ For example, focusing policy attention on transplanting health warning labels from cigarettes to beer ⁵² may hamper the development of solutions that may more directly address the unique challenges of regulating each market, such as the implementation of minimum unit pricing to raise the cost of alcohol in a targeted fashion to the heaviest drinkers who suffer the greatest chronic health toll from alcohol use. ⁵³

Table 2.

Examples of Policy Ideas to Address Commercial Determinants of Health (CDoH) That Are Transplanted From the Tobacco Control Movement Versus Original Ideas

Policy Proposal	References	Transplanted or Original Idea?
Raise excise taxes on negative CDoH	Millar 2013 54 ; Buse, Tanaka, Hawkes 2017 23	Transplanted
Restrict advertising for negative CDoH to children	Millar 2013 54 ; Buse, Tanaka, Hawkes 2017 23	Transplanted
Add warning labels to negative CDoH packaging	Buse, Tanaka, Hawkes 2017 23	Transplanted
Adopt plain packaging of negative CDoH	Bollard et al. 2016 55	Transplanted
Remove negative CDoH from view at point of sale	Millar 2013 54	Transplanted
Limit negative CDoH industry influence in policymaking	Buse, Tanaka, Hawkes 2017 23	Transplanted
Pass a global health treaty to address threat for negative CDoH	Buse, Tanaka, Hawkes 2017 23	Transplanted
Removing sales tax from positive CDoH	Millar 2013 54	Original
Reformulating products to remove negative CDoH	Millar 2013 54	Original

Attempts to apply policies initially created for tobacco control to other unhealthy commodity industries are understandable because these policies have been tried and tested and arrive with a ready‐made body of evidence behind them. ²³ It is entirely reasonable that CDoH scholars wish to repeat in other markets what are correctly perceived as public health victories for tobacco control . But, I argue, these scholars may be thinking too small. Tobacco control has not wholly succeeded in stopping tobacco companies from trying to circumvent contractionist regulatory policies. The continuing profitability of the tobacco business (Table 1) indicates that the tobacco control movement has fallen short of its most ambitious goals. Most importantly, the very fact that this goal has not been achieved signals that more efficacious policies are (theoretically) possible. Hypothetically, an alternate regulatory framework could dramatically drive down the size of the cigarette market over years instead of decades. To better explore and explain the importance of this hypothetical regulatory framework, it needs a name, and a theoretical underpinning, to situate it.

What Is a Regulatory Stance?

Economists argue the reason that markets need to be regulated is that market failures must be remedied through collective action. ⁵⁶ Since John Stuart Mill and Henry Sidgwick began in the 19th century a formalized rejection of Adam Smith's presumption that private enterprise usually maximizes welfare, scholars have identified numerous kinds of market failures that lead to some form of suboptimal welfare maximization. ⁵⁷ When left to their own devices, markets and the actors within them will behave in ways that empower concentrated or already‐powerful interests. ⁵⁸ These actors will maximize short‐run returns at the expense of long‐run sustainability, fail to solve collective‐action problems, and underprovide to vulnerable consumers. This is not to say that markets cannot be beneficent forces that stimulate innovation or solve pressing problems. But market failures occur so often that society has developed governance systems to try to fix or prevent these failures. Collectively, policies that intend to redress market failures are called regulation. ⁵⁹ To better understand such a sprawling notion as regulation, I propose a parsimonious organizing concept to help us draw lessons from comparative exercises.

I argue that each form of market failure can be resolved by adopting policies intended to change the size of a market in the future relative to the present. I use the term “regulatory stance” to refer to the intended effect of the collected regulatory policies for a given market. The regulatory stances concept describes the choices policymakers make to grow or strangle markets and provides a richer understanding of the way governments manage markets through regulation. It accomplishes this by placing focus on the intent of policy to shape markets. The regulatory stances a jurisdiction can adopt can be classified as ranging from prohibitionist through contractionist, permissive, and expansionist, to universalist (see Figure 1). I posit that the collected regulatory policies of an entire government, or regulatory framework, for any market in any jurisdiction at any time can be placed at some point along the range of regulatory stances, as is illustrated in the simplified example of the beverage market in Figure 2. A parsimonious metric such as the regulatory stance can be used to make comparison across time, markets, and jurisdictions. A regulatory stance can be identified for as broad or fine of a division in a market as a user wishes (Figure 2). By specifying finer divisions, users can more precisely identify which market segments a policy will target for contraction or subsequent substitution‐driven growth. For example, a policy that contracts the spirits market through a targeted excise tax hike should cause the beer and wine markets to expand because those beverages would gain a competitive advantage via their relatively lower purchase costs. Whether this fairly represents the intentions of the adopters of a spirits tax policy or not, such substitution can occur.

Figure 1.

The Range of Regulatory Stances

Figure 2.

Hypothetical Example of Market Division and Regulatory Stances^a [Colour figure can be viewed at wileyonlinelibrary.com]

^aSee Figure 1 for regulatory stance legend.

In Table 3, the left column (adapted from Baldwin et al. ^{60 (p24)}) lists some of the most common rationales for market regulation. The right column identifies the corresponding regulatory stance to address each market issue to be resolved. For example, if a market is causing negative externalities, that is, the market imposes indirect costs that are not priced into a market, leading to overconsumption. Depending on the severity of the negative externality, a regulatory stance that would remedy this overconsumption would either reduce the size of the market (contractionist stance) or reduce the market size to zero (prohibitionist stance).

Table 3.

Regulatory Stances Applied to the Common Rationales for Regulating Markets

Rationale for Regulation a	Example Problem/Example Policy for Regulatory Stance	Regulatory Stance to Remedy
Negative externalities	Air pollution from coal power plant is high. Levy an excise tax on coal‐sourced electricity	Prohibitionist or Contractionist
Information inadequacies led to overprovision	Consumers are not aware that unhealthy trans‐fats are in their food. Mandate inclusion of trans‐fat content on package labels	Contractionist
Planning for the future to fix overprovision	Too many flood‐prone homes are being built near rising seas. Prohibit issuing government‐backed flood insurance to danger‐zone homes	Contractionist
Rationalization and coordination	Too many soybeans are being grown threatening sale prices. Assign production quotas to farmers to stabilize the market	Contractionist
Windfall profits	Gasoline prices rise more than production costs after a pipeline shuts down. Institute price controls to preserve gasoline affordability	Expansionist
Information inadequacies led to underprovision	Consumers are not aware of high costs of long‐term care. Create central marketplace for subsidized long‐term care insurance	Expansionist
Planning for the future to fix underprovision	Not enough nurses are being trained to treat an aging population. Introduce tuition‐free education for potential new nurses	Expansionist
Monopoly	Monopoly's telephone service is too expensive and low quality. Break up monopoly to create competition and expand access	Expansionist or Universalist
Positive externalities	Vaccine uptake to prevent transmission of an infectious disease is too low. Distribute free vaccines	Expansionist or Universalist
Availability of service	Rural areas lack high‐speed internet access. Subsidize construction of private internet cables with public funds	Universalist or Expansionist
Public goods	Scientific research is expensive to conduct and read. Provide government‐backed research grants conditioned on open access results	Universalist

^a Rationales are adapted from Baldwin et al.^60(p24)

The conditions that are required to reach the neoclassical economists’ model of a perfectly competitive free market (fully rational actors, full information, costless transactions, etc.) are rarely achieved in practice, and failures to satisfy the conditions of such a functioning market can cause either over‐ or underprovision of goods in a market. If we accept that a perfectly competitive market is seldom achievable, then we should also accept that the regulatory stances that jurisdictions adopt when regulating markets intend to produce a market closer to the size that a perfectly competitive market would achieve. This is not to say that government interference can achieve perfect market conditions, as government failures are a near‐certainty in questions of regulation (especially when regulation is sought by industry). ⁶¹ , ⁶² This more perfectly sized market would be affected by all manner of policies causing distortions in prices, information, transaction costs, entry and exit, market power, and demand, but if it is regulated in good faith, it should inflict less of the harm caused by inadequate or excessive market size.

Alternative Comparative Regulation Frameworks

In years of searching the literature for a framework to enable comparative studies of market regulation, this author was left mostly unsatisfied with available options. The proposed regulatory stances framework is derived from Paarlberg's continuum of policy options. ⁶³ The primary difference between Paarlberg's concept, which was developed for the nascent market of the 2000s in genetically modified foods, and the regulatory stances concept is that the former classifies regulatory policies based on their intended effect on market growth, whereas the regulatory stances concept classifies policy based on its intended effect on market size in the future compared to the present. The refined regulatory stances concept can be applied to established markets instead of only applying to nascent or novel markets.

Other scholars have proposed similar typologies of regulatory policy options in a comparative perspective. Van de Graaf et al. classify European nations’ regulatory “attitudes” toward shale gas extraction along within a range from opposition to precaution to tolerance to support. ⁶⁴ MacCoun and coauthors classify drug control regimes on a range from pure prohibition to regulatory prescription to a free market. ⁶⁵ Rogeberg classifies regulatory policy options as ranging from prohibition to regulation to laissez‐faire. ⁶⁶ These frameworks sort regulation into a typology from restrictive to open. While these sorts of typologies seem like a straightforward way to evaluate a regulatory framework based on its empirical content, they forego the important wrinkle provided by Paarlberg: a theory that speaks to the intent of regulation, especially concerning the important outcome of growth. Paarlberg's concept stands apart from other proposed frameworks because it does not make distinctions between regimes based on field‐specific terms that are difficult to define and apply across different markets or over time. Paarlberg also mostly avoided most terms loaded with a prior meaning in the regulatory policy literature such as deregulated, free market, or command‐and‐control. The regulatory stances framework attempts to accomplish the same objectives as Paarlberg's model, with the important exception that my concept includes the term “prohibition,” which I have defined in a way that can be operationalized, observed, and defended.

The regulatory stances concept can also attach established ideas in regulatory theory, like performance‐based regulation, to a functional descriptive framework. ⁶⁷ , ⁶⁸ While performance‐based regulation proposes setting targets for regulated entities to meet (greenhouse gas emission levels, limits on automobile accident casualties, etc.) and allows those entities to figure out how to meet those standards, a regulatory stance describes these goals as the intent of the regulation, especially as they link to the size of a market. That is, greenhouse gas emissions are correlated with the level of fossil fuel consumption, so efforts to reduce those emissions should be considered a contractionist regulatory stance toward the fossil fuel market.

The regulatory stances concept allows participants in debates about markets to clearly state their preferences and accurately describe both status quo and proposed policies. When regulatory policy is succinctly described according to its placement on a single, meaningful dimension, comparative opportunities and lessons spill forth. By focusing on a common point of reference between regulatory issues, the regulatory stances concept clarifies the content of the market‐regulating policy and can help extend discussion and lesson‐sharing across subject area divides.

The utility of the regulatory stances concept is further enhanced by the fact that any market in any place at any time was, is, and will be subject to a regulatory stance. We can describe the US regulatory stance toward trans fats as shifting from permissive in the 1990s to contractionist in the 2000s (with the advent of ingredient labeling) to prohibitionist in the 2010s (as the products were reclassified as unsafe for consumption). ⁶⁹ We can ask why Japan shifted toward nuclear power prohibition in the aftermath of the Fukushima Daiichi disaster in 2011, but the United States only slightly shifted toward a contractionist stance regarding nuclear energy in the aftermath of the 1979 Three Mile Island meltdown. ⁷⁰ Thus, we can recognize the common strategies employed to corral or grow markets, and we can gather more cases for consideration than were once apparent. By determining the current regulatory stance that is applied to a market, as well as the preferred regulatory stances of each stakeholder in regulatory policy battles, we gain an entirely new perspective on regulatory policy debates. We can recognize the goals of stakeholders on all sides of a regulatory debate, and we can judge the relative merit of each preference set. This new perspective informed by the regulatory stances concept points to the possible benefits of rethinking and expanding the scope of the CDoH.

The Regulatory Stances Concept Expands the Commercial Determinants of Health

The CDoH, as currently conceived, has almost entirely concerned itself with consideration of markets that it posits should normatively be subject to contractionist or prohibitionist regulatory stances. As a result, application of the CDoH concept has been limited almost exclusively to unhealthy commodity industries selling products that are inherently harmful to health such as alcohol, soda, and junk food. Recent additions to the CDoH literature have moved beyond the realm of markets that affect risks for noncommunicable diseases such as cancer and diabetes to address markets that harm mental health or spread health‐harming misinformation (e.g., social media), and to consider markets that harm environmental health (e.g., fossil fuels); however, the markets of focus are still overwhelmingly harmful to human health. ⁷¹ , ⁷² When we adopt the regulatory stances lens, a missing portion of the CDoH comes immediately into view: markets that ought to be subject to expansionist or universalist regulatory stances. This omission is glaring when considering the expanse of SDoH.

The SDoH literature points to the importance of conditions that reduce health inequities as well as those that exacerbate health inequities. The provision of quality education, social support, and health care, as well as political and social rights, heals divides in health outcomes. ⁷³ , ⁷⁴ , ⁷⁵ In other words, there are positive and negative SDoH, and advocates pushing public policy solutions for each issue can adopt substantively different approaches to achieve their ends. In contrast, the CDoH literature rarely mentions a positive role for corporate influence with regard to public health.

I propose classifying markets as having a positive, conditional, or negative effect on health. The CDoH literature, as currently situated, points almost exclusively to markets such as alcohol and ultra‐processed foods as examples of negative CDoH. Lencucha and Thow briefly recognize the role of “healthy commodity industries” in their response to a wide‐ranging critique of their investigation into the relationship of neoliberalism to CDoH. ⁵⁸ , ⁷⁶ , ⁷⁷ Buse and coauthors suggest developing a formula to determine the harm caused by individual corporate actors to determine which entities should be excluded from political participation, ⁷⁸ in the fashion of Article 5.3 of the Framework Convention on Tobacco Control which requires governments to protect policymaking activities from tobacco industry influence. Some CDoH scholars come close to recognizing a difference between different kinds of corporate entities or market activity, ⁷⁹ but few have formalized this boundary and explained why an expansion of the CDoH to cover these other types of markets is necessary.

As I formalize a distinction between commercial activities, I choose to do so at the market level. Figure 2 demonstrates that we can divide a broadly defined market (e.g., beverages) into subcategories to help us determine whether we believe that a given market subcategory has a negative or positive impact on health. For example, in 2010, the US Food and Drug Administration (FDA) determined that caffeinated malt liquors were causing more harm to health than was tolerable and declared in four letters to manufacturers that caffeine is an “unsafe food additive” in their malt liquor beverages. ⁸⁰ This shift in the FDA's regulatory stance placed the caffeinated malt liquor market at a competitive disadvantage to its competitors. Total alcohol sales as a share of the US economy, and even malt liquor sales, have grown since the FDA issued its letters to manufacturers, but sales of caffeinated malt liquor products have ended. ⁸¹ Granting the entire US alcohol market this permissive‐to‐expansionist regulatory stance was likely poor public health policy. However, being able to identify that such market expansion is taking place eases the identification of alternative policy preferences (e.g., contracting the alcohol market) that align with the interests of the public health.

We can also use the regulatory stances framework to identify markets that should be identified as positive CDoH; examples include vaccines ⁸² and vegetables. ⁸³ Some markets, like e‐cigarettes ⁸⁴ and opioids, ⁸⁵ , ⁸⁶ should be defined as conditional markets because they can either improve or harm public health. Markets with conditional health outcomes likely require context‐specific regulations to improve public health and avoid harms.

Even in cases where specific CDoH are recognized as having a potential positive effect on public health, as with the provision of COVID‐19 vaccines by pharmaceutical companies, CDoH scholars have seemed reticent to encourage a fuller range of corporate political activity that would grow positive CDoH markets. These scholars cite concerns around power and resource imbalances between public health and corporate interests as the root of this nervousness to engage with corporate actors in the policymaking process, ⁸⁷ and their concern is proper. However, some of the suggested solutions such as delegitimizing corporate power, an option scholars like Lacy‐Nichols and Marten ⁸⁸ credit to the tobacco control case, may not translate well outside of the context of negative CDoH. We ought to consider what it means if negative, positive, or even conditional CDoH all exist, and we should then adapt the rules of engagement with corporate entities to specific situations.

The underconsumption of beneficial goods causes great harm to societal welfare and public health. As currently conceived, the CDoH concept has little to offer discussions around how the growth of positive CDoH markets might be accelerated. To advance CDoH‐related policymaking, it may prove to be useful rhetorically and strategically to understand what policies best control markets to obtain optimal health outcomes, instead of aiming to eliminate all sources of health harm that stem from commerce.

In what is certainly an oversimplification, I argue it is reasonable to assume that corporate actors will set a rank‐ordered preference of health‐related regulatory stances for markets in which they operate, and this ordering will proceed sequentially from universalist to expansionist to permissive to contractionist and finally to prohibitionist. For markets with positive health outcomes, public health advocates might have the same rank‐order preference of regulatory stances. This agreement might extend as far as general market‐size goals, but will certainly differ in the details. But, for markets with negative health outcomes, the rank‐order preferences of public health advocates are likely inverse to those of the corporate actors—starting from prohibitionist and moving to contractionist to permissive to expansionist to universalist. Public health advocates may wish to avoid the term “prohibitionist” and its requisite policies and may instead prefer a contractionist stance above all else. However, when the divisions within a market are drawn finely enough (e.g., caffeinated malt liquor, as shown in Figure 2), we might observe a preference among public health advocates for a prohibitionist stance. Even in cases where a prohibitionist stance may be preferred for a finely drawn category, the stance for a broader category (e.g., alcoholic beverages in the case of a caffeinated malt liquor ban) may still be most accurately described as contractionist. For markets with conditional health outcomes, the rank‐ordered preference for regulatory stances among public health advocates should favor permissive over contractionist or expansionist stances, which are in turn favored over prohibitionist or universalist stances. Conditional markets require more precise policies that prefer contraction under certain conditions and expansion under others, with preferences on average drifting toward the middle range of the regulatory stances but expansionist or contractionist preferences determined on a case‐by‐case basis.

By viewing debates over the regulation of CDoH through this lens, we realize that there are policy debates where public health and corporate actors will find themselves in agreement (positive health outcome markets), direct opposition (negative health outcome markets), and protracted negotiation (conditional health outcome markets). Resolving these disputes, negotiations, and areas of compromise is performed through the practice of politics. Recognition of harms, benefits, and relative costs of each regulatory stance can focus policy debates on these matters and lay out a path forward. The regulatory stances concept highlights what necessary corrective action is needed in different markets rather than a blanket solution across markets.

Seeking policy progress in areas of potential agreement might be easier than areas where disagreement reigns. But, simply because progress may be easier in one domain, does not mean that seeking resolution over the regulatory policy in areas of disagreement is no less important. Recognizing the existence of areas where public health and corporate interests may be congruent may open the possibility that advocates of corporate and public health positions can reach compromises using issue linkage strategies, ⁸⁹ wherein corporate interests agree to contractionist policies to regulate negative health outcome markets when those policies are linked to expansionist policies for conditional or positive health outcome markets. For example, a policy that shifts an alcoholic drinks manufacturer's profits from high‐alcohol drinks toward low or no‐alcohol versions of the same beverages is likely more acceptable to more parties than a policy seeking to decrease alcohol manufacturer profits writ large. Shrewd public health actors could decide whether such compromises are preferable to the status quo. The construction of policies that can pass through legislatures depends on whether coalitions of advocates can persuade a majority of the lawmakers to vote for their side of an issue, and gaining the support of one's adversary can increase the odds of successfully achieving regulatory policy change. Focusing on the intended size of a market opens possibilities to advance policy in a manner that might have a broader appeal than the current rhetoric undergirding the CDoH literature.

Illustrative Cases

The concept of CDoH can be sharpened, expanded, and made more effective by viewing the challenge posed by the literature to determine how to decrease the harm caused by commerce through the regulatory stances lens. Markets with positive health effects might represent legitimate areas of cooperation with corporate entities. Markets with conditional health effects represent real opportunities to study regulatory policy divergence and to identify which stances and undergirding policies yield the best results for health, equity, or other relevant outcomes. Recognizing the inherent negative health effects of other markets and grappling with the actions and conditions necessary to adopt contractionist stances might yield new insight that leads to the pursuit of more efficacious policies. Examining cases where cooperation, compromise, and conflict are necessary illustrates why the CDoH conversation needs to be vastly enlarged to incorporate corporate activity in markets that harm or help the public health.

Vaccines

Vaccines against communicable diseases are one of the most powerful public health tools at the disposal of societies. ⁹⁰ , ⁹¹ Vaccines are a classic public good that provides positive externalities to everyone around a person who receives the treatment. ⁹² In recent decades, contemporary vaccine development and production have become increasingly reliant on private‐sector actors. ⁹³ The COVID‐19 pandemic has brought the value of vaccines to operating a safe and healthy society into stark relief. ⁹⁴

COVID‐19 vaccine manufacturers are engaged in one of the most socially productive business practices in memory. Moderna, Pfizer/BioNTech, and their peers are reaping billions of dollars of profits from the sale of their COVID‐19 vaccines and giving the world trillions of dollars in benefits in return. ⁹⁵ , ⁹⁶ Compared to commercial entities performing services or selling goods that have a comparatively negligible effect on health (e.g., a manufacturer of children's toys), the profits being accrued to COVID‐19 vaccine manufacturers are positively preferable from a societal perspective.

Doctors Without Borders and other advocates for wider and faster distribution of COVID‐19 vaccines and vaccine technology at lower costs have criticized COVID vaccine manufacturers for pursuing untoward strategies to increase profits from their vaccines. ⁹⁷ , ⁹⁸ Their points about vaccine manufacturers profiting from taxpayer‐funded research and the hoarding of intellectual property rights have the ring of truth in them, and it is understandable why health advocates are angry. These advocates may prefer to prevent COVID‐19 vaccine manufacturers from capturing the positive externalities of their products in the form of wide profit margins, and instead prefer to make the shots as affordable as possible.

However, stripping profits from the beneficiaries of public research is precisely the opposite of what should be done to address the issue of the profiting from selling COVID vaccines. While this is an admirable impulse, it is difficult to think of an alternative commercial activity that these manufacturers should be engaging in to pursue windfall profits, at least from a perspective that weighs public health gains against profits. When we arrive at a place where public expenditure on vaccines begins crowding out other equally valuable necessities for life like food or clean water, we might need to discuss whether prices for these shots are above what is socially optimal.

What other activity would we prefer that these companies engage in? The pharmaceutical sector is replete with markets that produce low value to the patients much less to society at large. ⁹⁹ Instead of focusing on COVID‐19 vaccine profits, a regulatory stances perspective should be applied. Using the regulatory stances framework, we ask how large the market for COVID‐19 vaccines should be and then act accordingly. COVID‐19 vaccine manufacturing likely stands apart as a uniquely valuable opportunity to adopt a universalist regulatory stance and expand this market to the largest extent possible as fast as possible. The benefit from reaching global herd immunity to an ongoing and evolving pandemic is mammoth. Very little good comes from being penny‐wise and negotiating discounts and pro bono supplies from manufacturers, especially compared to adopting a universalist regulatory stance that would ask us to consider how to achieve maximum market expansion. Would wealthy countries band together to purchase enough doses for the rest of the world and distribute those for free? Could intellectual property transfer schema be set up to allow technology transfer to low‐income countries with subsidies from wealthy donor states? Putting this solution together in the most expedient fashion is in the global common good. ¹⁰⁰ Fussing about who might profit and by how much entirely misses the boat.

Electric Vehicles

Reducing the burden of climate change by cutting carbon emissions is one of the great challenges of the 21st century, and transitioning from transportation powered by internal combustion to electric vehicles has been recommended as a strategy to improve climate sustainability and public health. ¹⁰¹ , ¹⁰² Automotive manufacturers have historically resisted regulations that raised vehicle production costs in the name of safety and environmental concerns. ¹⁰³ However, growing concerns about climate change and energy consumption have led governments to adopt stringent fuel economy standards and even schedule moratoriums on the sale of internal combustion engine vehicles. ¹⁰⁴ These policies have rapidly increased pressures for automakers to sell more fuel‐efficient and electric vehicles. ¹⁰⁵ , ¹⁰⁶ Electric vehicles, in particular, should be viewed as a positive CDoH given their environmental benefits relative to vehicles fueled by oil and gas. This implies that expansionist regulatory stances are preferable from a public health perspective.

The contractionist and prohibitionist stances being adopted by governments toward internal combustion vehicles might provide adequate competitive advantages to the electric vehicle sector to achieve the preferred growth of that sector. But we should keep in mind that the political battles that concluded with governments issuing such stringent rules were not always pursued for altruistic or even environmental reasons. Often, these governments were motivated by national self‐interest as they sought to invigorate automotive manufacturing employment and profits. ¹⁰⁷ Viewing these decisions through the regulatory stances lens leads us to notice that adopting a prohibitionist stance on internal combustion engine cars was politically feasible when incumbent internal combustion legacy automobile manufacturers were encouraged to build electric vehicles.

While electric vehicles are not a complete solution to climate change, they represent a vast reduction in the carbon footprint of the transportation sector. ¹⁰⁸ Although the same companies who profited off dirtying the air with leaded gasoline, particulate matter, ground‐level ozone, and carbon dioxide now stand to profit from the sale of electric vehicles and the maintenance of infrastructure that make us dependent on automobiles, the shift in sales away from internal combustion engine vehicles is still an important improvement for the health of humanity. Recognizing that our regulatory policy goal is to encourage the expansion of electric vehicle sales at the expense of internal combustion‐powered vehicles allows us to learn more about ending harmful corporate practices at scale and pace.

Alternative Proteins

Our modern food production and manufacturing systems are deservedly identified as essential CDoH, with some aspects of these systems associated with widely recognized negative outcomes on health. Ultra‐processed foods increase rates of obesity, cancer, heart disease, and diabetes. ¹⁰⁹ Meat production is a catastrophically large contributor to greenhouse gas emissions, and it is frequently associated with worker abuse and poor animal welfare. ¹¹⁰ However, humans need food to survive, and many foods are beneficial to the human body, the public health, and the planet; therefore, it does not make sense to regard all food industry businesses as purely negative CDoH. Instead, we should note that food corporations can participate in some negative CDoH markets such as factory‐farmed meat and sugar‐sweetened beverages while also maintaining large interests in positive or conditional CDoH markets such as alternative proteins (nuts, mushrooms, plant‐based meat alternatives, and laboratory‐grown meats) or vegetables.

While consumption of alternative proteins does not necessarily have positive health effects (relative to eating conventionally farmed meat), these products reduce animal cruelty, resource use in production, and greenhouse gas emissions. ¹¹⁰ Furthermore, these products are gaining economies of scale that make them economically viable and consumer‐acceptable products, and meat‐producing corporations have begun aggressively moving into the alternative protein market. ¹¹¹ Under current regulatory policy regimes, stakeholders most closely involved with expanding the market for alternative proteins do not envision a world where such foods displace conventionally farmed products. ¹¹² Accordingly, public health advocates should examine the utility of giving alternative proteins effective competitive advantages over their more harmful incumbent competitors to aggressively shift the priorities of meat‐producing corporations toward fulfilling the protein needs of our world without conventionally farmed meat. It is not yet clear what combinations of expansionist policies toward alternative proteins and contractionist policies toward conventional meat would work best to shift the market. Will strict animal welfare standards increase the market for mushrooms and legumes? Will dropping bans on the sale of genetically modified foods be necessary to contract factory‐farmed meat in a world where lab‐grown meat is an economical protein option? A diverse research agenda that studies expansionist and contractionist food policy options can uncover these answers. Nonetheless, gaining the cooperation of the food companies that have experience feeding the world to help radically shrink the conventionally farmed meat market may help ensure the goal is accomplished with the urgency it merits.

Housing

The interface between the production of housing and government regulation is extensive, multifaceted, and highly consequential for the fortunes of all involved. Safe and reliable housing is an essential component of the SDoH, and a great deal of progress toward recognizing and promoting improved housing has been made in global health policy circles. ¹¹³ , ¹¹⁴ However, the creation and administration of housing involve a great deal of commercial enterprise, and thus it is useful to consider if housing is a positive CDoH. Housing affordability is an ongoing global crisis. ¹¹⁵ Recently, the consequences of unaffordable housing have included increased health inequities during the COVID‐19 pandemic, exacerbated homelessness crises, particularly among individuals with mental health challenges; as well as disparate physical morbidity and mortality outcomes. ¹¹⁶ , ¹¹⁷ These outcomes are ameliorable to policy intervention, particularly through the encouragement of producing more high‐quality housing, an expansionist regulatory stance.

The usefulness of the regulatory stances to the CDoH is clearly illustrated by considering the case of factory‐built versus stick‐built housing in the United States. In the 19th and 20th centuries, to lower production costs and increase quality, assembly‐line production methods proliferated across most commercial sectors, including the production of manufactured homes. From 1960 to 1972, factory‐built housing production exploded in the United States, rising from 10% to 60% of total housing production. ¹¹⁸ Through Section 235 of the Housing and Urban Development Act of 1968, the federal government began subsidizing the mortgages of stick‐built homes for low‐income Americans, while excluding factory‐built homes built homes from the program. ¹¹⁸ This stick‐built housing advantage was extended further in 1974 when a national building code was adopted for factory‐built housing, while a similar national code for stick‐built housing was never adopted.^119,120The national building code for factory‐built housing often exceeded requirements in local building codes in ways that increased the costs for factory‐built homes; for example, the national code required that factory homes be equipped with an inert and nonfunctional chassis. Buyers of manufactured homes were forced to pay the higher interest rates of automobile and property loans, which are not backed by federal insurance plans, in addition to the higher building costs to meet code requirements. ¹²¹ As a result, the share of factory‐built houses among new homes plummeted to below 25‐% by 1980 and never rebounded. ¹¹⁸

Regulatory policy choices can be made to put factory‐ and stick‐built housing on level competitive footings and provide a lower‐cost housing alternative for low‐income families. That is, a permissive regulatory stance can be adopted where local and customer‐specific requirements could dictate which housing type gains more market share. By allowing both types of housing to access mortgage subsidies, or subjecting each type of housing to similar national building codes, we might allow consumers to have new and better choices in safe and affordable housing.

E‐Cigarettes

Circling back to the origin of the CDoH in the tobacco control movement, the introduction of electronic cigarettes (e‐cigarettes) tests the claim that all corporate activity to sell nicotine products has inherently negative effects on public health. Depending on the size and shape of the e‐cigarette market, e‐cigarettes can have both positive and negative public health effects. ¹²² E‐cigarettes have thus far been shown to be less harmful to health than the tobacco cigarettes they were invented to replace, but they are not entirely safe. ¹²³ Young people can be harmed by deeply inhaling the compounds in e‐cigarettes. ¹²⁴ However, current cigarette smokers will likely benefit if they switch completely to using e‐cigarettes. While the e‐cigarette market undoubtedly affects health, it does so in a manner that does not immediately lead health advocates to prefer wholesale growth or decline of the market, absent other information. The CDoH regulatory stance toward e‐cigarettes is are therefore conditional. Crafting a regulatory framework for e‐cigarettes can balance concerns about decreasing the size of the market for e‐cigarettes among young nonsmokers while increasing the size of the market among current smokers. ¹²⁵

While the modern tobacco control originated in the mid‐20th century as a movement that was largely unified in its pursuit of contractionist policies toward the combusted tobacco market, ¹²⁶ it has now splintered into factions that are favor adopting expansionist policies towards e‐cigarettes and those that prefer contractionist policies toward that market. ¹²⁷ The very presence of e‐cigarettes moved the largely unified‐in‐purpose tobacco control policy movement to begin to disagree on tactics and policy goals. As they came to dominate the upstart e‐cigarette market (at least in the United States), ⁶⁶ the actions of incumbent cigarette manufacturers to successfully sell their e‐cigarette brands (primarily JUUL, blu, VUSE, and Vype) to young people ¹²⁸ made these disagreements within the tobacco control community even tougher to resolve.

However, by not viewing tobacco as an exceptional CDoH case, we can draw parallels between regulatory approaches that can be used in the e‐cigarette case and the regulatory approaches relevant to electric vehicles or alternative proteins. By establishing strong contractionist or even prohibitionist policies for internal combustion engine automobiles or factory‐farmed meat, policymakers can push corporate actors to shift (potentially with urgency) away from negative CDoH and toward alternative products with conditional or positive health effects. Because we can make a plausible public health argument to allow for the growth of a conditional CDoH market, we should consider potential regulations that promote cautious expansion of the e‐cigarette market. For example, a country could mandate that nicotine levels in tobacco cigarettes be reduced to nonaddictive levels while allowing e‐cigarettes to contain addiction‐sustaining levels of nicotine. Such a cigarette “de‐nicotinization” policy would dramatically contract the cigarette market and expand e‐cigarette sales, and in the process avert millions of tobacco‐caused deaths. ¹²⁹ A policy that preserves some form of business for incumbent cigarette companies is likely to meet less political resistance than a policy that removes all business opportunities from incumbent negative CDoH firms. Designing a regulatory framework that is not strongly opposed by corporate interests may yield improved odds of obtaining large‐scale public health improvement.

Conclusion

Corporate commercial activities are an immense drag on public health, contributing to problems such as pollution, smoking, opioid addiction, alcoholism, gun violence, and high rates of diabetes and obesity. Those of us in public health who seek to fix the problems caused by excessive actions of markets have begun to coalesce on the CDoH verbiage to describe a collection of disease vectors that, theoretically, if properly controlled would immensely improve human health and well‐being. ² , ¹⁵ The CDoH are distinct from other disease vectors or even the SDoH in that the CDoH involve formal entities (corporations) and the people who operate and support them, whose livelihood is derived from participating in the continued commerce in these lines of business. ³ This means that, unlike in other health policy areas, the parties responsible for propagating harm from CDoH often have a seat at the negotiating table when policy solutions are being discussed.

Prior CDoH literature largely fails to point to examples where regulatory stances that could increase corporate profits served to improve public health. Some definitions of the CDoH, such as those offered by Kickbusch, ¹² are structural impediments to this discussion, as they limit CDoH discussions to cases where only markets with negative health effects are considered. However, there is no structural reason why the CDoH cannot be expanded to consider markets with conditional or positive health effects. As I have argued in this paper, this wider view of the CDoH encourages advocates to consider additional approaches to solving the problems where health and commerce collide.

Current debates around how best to redress the CDoH often offer only a constrained set of policy solutions: voluntary corporate self‐regulation, public‐private partnerships, or government regulation. ²³ Each of these solutions is pursued in service of contractionist regulatory stances of markets with negative health effects, typically without considering whether markets with positive or conditional health effects could replace markets with negative health effects. As so many have pointed out, government regulation is necessary to decrease the size of markets because corporations have every incentive to grow their profits. ¹³⁰ , ¹³¹ However, if our goal is to increase the size of a market, that does not mean the government must abdicate its role as regulator. Governments possess a great deal of power to alter the relative profitability of markets and to drive corporate behavior in the desired direction. Markets are not born free, rather they are crafted through institutions and policy and path dependence. ¹³² Regulation makes markets: pointing out this fact must be added to the public health policy advocates’ repertoire.

Although the CDoH literature offers useful core concepts, it can come across as an anticorporate screed to those with politically centrist or right‐of‐center perspectives. On occasion, the CDoH literature questions the orientation of public policy, capitalism, and politics in a manner that could become antithetical to achieving a healthier society when operating in a political context that accepts the roles of capitalist enterprises as legitimate. This perspective is further impoverished by the narrow view the CDoH literature takes toward the role of corporate influence on health: that where corporate influence is involved, profits will rise while the public health will suffer. Questioning the orientation of public policies that inflict disparate societal harm is the proper role for public health advocates, but I argue that it may be practical to expand the appeal of the CDoH concept by focusing on achieving more narrowly drawn policy goals with broader political appeal.

Because the CDoH concept has been previously limited to markets with negative health effects, the CDoH literature often concludes that the solution to many of the world's health issues is to diminish corporate power. ⁵⁰ , ¹³³ This might be the correct conclusion, or it might be an unnecessary step if there are other ways to shape markets in the interest of health. For example, our focus is climate change, a policy to contract the operation of fossil fuel power plants will likely gain a broader coalition of support if it does not also aim to dismantle the primacy of shareholder capitalism in an economy. This advice to fight to directly diminish corporate power could be unhelpful to practitioners of politics as it concludes with recommendations that public health advocates essentially participate in the political process by “demanding a seat at the table” or learning how to “mobilize for political action” or asking politicians to “stand up to industry.” ⁵⁰ , ¹³¹ , ¹³⁴ While some scholars may suggest their own preferred routes to accomplishing these goals, they are inviting a pure power struggle. A pure power struggle between public health and corporate interests, where resources are measured in financial terms, is not one that will often be settled in the favor of public health. McKee and Stuckler starkly set out the terms of this struggle: corporations will use their power to frame debates, set entry barriers, engage in protracted litigation, and produce evidence that favors the conclusions of corporate actors. ¹⁶ Public health advocates cannot counter that power, imbalanced or not, by simply being present in policy debates.

The regulatory stances lens encourages public health advocates to focus on their ultimate goals more closely. Trying to push corporations toward markets with positive or conditional impacts on health and away from those with negative effects may prove to be an effective strategy in which common ground can be found between corporate and public health interests. Convincing corporations and their investors to put aside profit motives and persuading politicians to give up a pro‐growth mindset may prove impossible. And yet, it is a terrible idea to simply capitulate to corporate demands for a light government touch to allow them to pursue their business interests by expanding markets that harm health. The regulatory stances framework give public health advocates the power to name the policy preferences of corporations, present how corporate preferences can serve private interests while harming the public, and demand that alternative regulatory stances be adopted that serve the public interest. The regulatory stance concept is a simplifying theoretical construction of regulatory policy that organizes vast bodies of law and policy onto a single dimension. It cannot contain all the fine nuances of policy debates, but it can be used to impose a sense of order over debates of huge consequence to economic, political, and health outcomes. I caution against caving to those who claim that regulatory policy cannot confront the “complexity” of the world's problems; ¹³⁵ that argument only serves to advantage our flawed status quo. Instead, scholars and advocates should use good theoretical constructs to push through the morass of difficult problems to establish the direction they believe that regulatory policy should head. With a clarity of purpose, public health advocates can offer to create competitive advantages for corporations to move their profit centers into conditional or positive CDoH markets. Alternatively, public health advocates can pursue the contraction of harmful markets without offering a substitute line of business and without concessions to corporate actors or their political allies. From a public health perspective, we can argue whether the tradeoffs from each approach are worth exchanging for the benefits. Naming these policy preferences is a powerful exercise that can aid the brokering of solutions.

Aneurin Bevan, who was charged with establishing the United Kingdom's National Health Service, noted that, to clinch a deal convincing private‐sector physicians to effectively become nationalized, he had to “stuff their mouths with gold.” ¹³⁶ Bevan persuaded physicians that any loss of autonomy they would suffer from nationalizing the medical system would be compensated by enhancing their pocketbooks. ¹³⁷ Bevan removed British doctors’ incentive to dissent, thereby removing one of the largest political impediments to establishing universal health care. Emulating this strategy is likely not possible in every CDoH area, but it is possible to envision a food industry that is less abusive toward human health and the planet, an automotive industry that stops polluting at the tailpipe, or a pharmaceutical industry that prioritizes pursuing public health gains. Imagining a world with these reformed industries is less difficult than and likely preferable to imagining a world without them.

Seeking to dismantle the influence of corporate power on politics may be a noble goal and one that could pay dividends: if were it to succeed. However, focusing on the intent of the regulation might help policymakers, advocates, and citizens better recognize why we should care about regulatory policy. We should care because it alters the composition of our economy. What may be more consequential than curtailing corporate power writ large is determining how to adopt regulatory stances that serve the interest of public health, even when that redounds to private profit. Therefore, focusing on the purpose of regulation might enable us to move faster toward a healthier society.

Funding/Support: None.

Conflict of Interest Disclosures: The author completed the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Liber received grants from the Norwegian Cancer Society, the US Food and Drug Administration, and the US National Cancer Institute; consulting fees from Johns Hopkins University and the Brazilian Health Regulatory Agency; and speaker's fees from the World Health Organization.

Acknowledgments: I want to thank Jeffrey Drope, Scott Greer, Holly Jarman, Daniel Beland, Paula Lantz, Kenneth E. Warner, and Luz Maria Sanchez‐Romero for their helpful feedback during the long development period for this article. My thanks also go to the two anonymous reviewers for their constructive input and to Elizabeth Nishiura for her astute and thorough copyediting.