Corporate practices, such as advertising, public relations, lobbying, litigation, and sponsoring scientific research, have a significant impact on the health of the people in the United States. Recently, health professionals and advocates have created a newscope of practice that aims to modify corporate practices that harm health. This article describes how corporate policies influence health and reviews recent health campaigns aimed at changing corporate behavior in six industries selected for their central role in the U.S. economy and their influence on major causes of mortality and morbidity. These are the alcohol, automobile, food, gun, pharmaceutical, and tobacco industries. The article defines corporate disease promotion and illustrates the range of public health activities that have emerged to counter such corporate behaviors. It analyzes the role of health professionals, government, and advocacy groups in these campaigns and assesses the implications of this domain for health education practice and research.
In recent years, citizens, consumer and health activists, state and local government officials, and health professionals have created a new arena of public health advocacy designed to change corporate policies that damage health. Tobacco control activists have been at the forefront, winning new legislation to restrict advertising, limit public smoking, and raise excise taxes and forcing the tobacco industry to contribute billions of dollars to pay for tobacco-related illnesses and support efforts to reduce smoking (Glantz & Balbach, 2002; Kluger, 1997; Schroeder, 2004). More recently, however, consumer and environmental activists have also targeted the automobile industry for its production and advertising of unsafe and polluting sports utility vehicles (SUVs; Bradsher, 2002; Gladwell, 2004). Health, food, and nutrition groups have challenged the food industry for its contributions to obesity and diabetes (Nestle, 2002, 2003), and antiviolence, public safety, and health organizations have opposed the marketing and production practices of the gun industry (P. H. Brown & Abel, 2003; Diaz, 1999). Mothers Against Drunk Driving and its allies have criticized the alcohol industry for its youth-oriented advertising (Hamilton, 2000); health professionals, senior citizens, and health care reformers have taken on the pharmaceutical industry for making windfall profits based on publicly funded research, covering up harmful side effects of their products, and disease mongering, creating, or exaggerating new diagnoses to promote sales of their products (Angell, 2004; Moyniham, Heath, & Henry, 2002; Topol, 2004).
This special section of Health Education & Behavior examines this new public health advocacy to change health-damaging corporate behavior and analyzes its implication for health education practice and research. In this article, I define the concept of disease promotion, review the scientific and political rationale for efforts to change corporate behavior, and provide an overviewof the scope of this emerging arena of health advocacy. I also explore its implications for health education practice and research.
In the next article, Dorfman,Wallack, andWoodruff (2005) use the concept of framing to assess commonalities among recent public health campaigns to control, for example, the tobacco, food, and gun industries, and to analyze the underlying philosophical and moral frameworks for these debates. They suggest that health educators can use new insights on framing from research in communications, political science, sociology, and media studies to win broader public support for health objectives. In the third article, Nathanson (2005) compares the achievements of tobacco control movements in the United States, Canada, France, and Great Britain. She argues that political systems, historical traditions, and government structures in each nation create unique opportunities
and constraints for tobacco control and suggests that this cross-national perspective can help health educators and other health professionals plan more effective strategies. Finally, Kreuter (2005) examines the relevance of this new public health practice and locates it within the context of health promotion both in the United States and around the world.
THE SCIENCE AND POLITICS OF DISEASE PROMOTION
Disease promotion describes organizational practices or policies that encourage unhealthy behaviors, lifestyles, or environments. The concept is based on the social determinants of health literature, which identifies social, political, and structural factors and processes that contribute to patterns of health and disease. Recently, researchers have called for greater attention to these determinants and have advocated increased scientific and professional efforts to develop interventions that address this level of causation (Marmot, 2002; Tarlov & St. Peter, 2000; Wilkinson, 1996). In addition, disease promotion borrows from the concept of health promotion and its emphasis on agency—the ability to act to improve health—but reverses the focus to spotlight actors and actions that harm health.
No level of social organization has a monopoly on disease promotion: cells, organs, individuals, groups, organizations, government, and ecosystems can each act to advance disease. Our focus here, however, is on population health and therefore on organizational agents of disease promotion. The goal of studying the process of disease promotion is to identify opportunities for prevention.
Corporations have long been an essential component of American society. In the late 19th century, they emerged as central agents of the American economy, and today, most observers agree that they dominate the global economy (Bakan, 2004; Berle & Means, 1968; Friedman, 1982; Galbraith, 1952). Their actions shape every aspect of our health and lives, from the food we eat and the air we breathe to our concepts of democracy, sexuality, intimacy, and self-worth. Obviously, corporations play a vital role in our economy: They provide millions of jobs, produce many of the goods and services that distinguish the American lifestyle, pay taxes, and contribute to charity.
But it is equally evident that corporate practices play a central role inAmerica’s health problems. According to a recent Centers for Disease Control and Prevention (CDC) report (Mokdad, Marks, Stroup, & Gerberding, 2004, 2005), in 2000, products of the tobacco industry were estimated to kill 435,000 Americans a year; diet and physical inactivity, in part because of food industry advertising and the easy availability of high-fat, high-calorie foods, were implicated in at least 365,000 deaths; alcohol was associated with 85,000 deaths, including homicides, automobile accidents, and alcohol-related diseases, such as cirrhosis and liver cancer; 43,000 Americans died in automobile accidents, and several thousand additional deaths were associated with automobile pollution; and 29,000 Americans died in gun-related homicides, suicides, or accidents, and many more were injured. Finally, by pricing its drugs out of reach of people who need them, opposing policies that would lower prices, covering up life-threatening side effects, and focusing on the most profitable drugs rather than those that best protect public health, the drug industry contributes to many excess deaths (Angell, 2004; Topol, 2004). In addition to the lost lives, the products of these industries cost consumers, taxpayers, and the larger society billions of dollars of costs in health care and lost productivity (CDC, 2002; Finkelstein, Fiebelkorn, & Wang, 2003). Sturm (2002) has estimated that the annual U.S.
health care costs associated with obesity are $395 per person, with current or former tobacco use $230 per year and with problem drinking $150 per year, costs that can be seen in part as industry taxes on society and individuals.
Obviously, not every death or illness related to a particular product can be blamed on corporate practices. No complex health problem has a single cause, and undoubtedly, biological, behavioral, cultural, and environmental factors contribute to morbidity and mortality from tobacco, food, automobile, guns, alcohol, and pharmaceuticals. Here, the epidemiological concept of attributable risk is helpful. Attributable risk indicates the absolute incidence of a condition that can be attributed to a causal factor; it is a function of both relative risk (the ratio of incidence in those exposed versus those not exposed) and the prevalence of the causal factor (Susser, 1973). Precisely because corporate practices, such as advertising and political interference with regulation, are so ubiquitous, their influence is significant. To give a hypothetical example, even if exposure to fast food advertising contributed much less to obesity than an obesity gene at the individual level, the fact that so many more people are exposed to advertising than carry the obesity gene would mean that advertising caused more cases of obesity than genetic factors.
Clearly, the number of tobacco and gun deaths would decline precipitously if these industries did not produce, promote, and distribute their products; their efforts to resist public control have contributed substantially to mortality. On the other hand, the food, automobile, and pharmaceutical industries produce goods that can both enhance and damage health. However, the fact that an industry may contribute to health problems should not discourage investigation of policies aimed at limiting its harmful consequences.
Future research is needed to quantify the attributable risk related to specific industry practices. But the pervasive exposure to disease-promoting practices and the very substantial health burden the products of these industries impose require public health professionals to examine whether changing the behavior of corporations is a promising strategy for improving public health and achieving national health goals, such as those articulated in Healthy People 2010 (U.S. Department of Health and Human Services, 1999).
Some evidence supports the value of policy change to modify corporate behavior. In 1998, the Congressional Prevention Coalition, a bipartisan group of more than 60 lawmakers dedicated to prevention, asked the Partnership for Prevention (2000), a nonprofit nonpartisan group, to assess opportunities for prevention. Based on interviews with more than 80 public health researchers, the group identified several policies with the greatest potential for reducing mortality and morbidity. Six strategies with potential for saving almost 250,000 lives a year require changing corporate practices or overcoming corporate opposition. Table 1 shows these six policies and the expert panel’s estimate of the number of lives each change would save annually.
[Table 1: Priorities for Policy Change – see PDF]
In this article, I have chosen to focus on six industries (tobacco, food, automobile, gun, alcohol, and pharmaceutical) because of their central role in health and disease, their importance to the U.S. and global economies, and their economic and political influence and because public health advocates have already acted to modify their practices (Advocates for Highway and Auto Safety, 2001; Angell, 2004; Center on Alcohol Marketing and Youth, 2002; Diaz, 1999; Glantz & Balbach, 2002; Nestle, 2002).
A FRAMEWORK FOR THE STUDY OF HEALTH ADVOCACY TO CHANGE CORPORATE PRACTICES
A systematic study of health advocacy to change corporate practices would benefit from a framework that focuses on variables of interest and allows comparisons across industries, cases, and levels of social organization (e.g., local, state, or national). Figure 1 shows such a conceptual model for the study of campaigns to change corporate behaviors that harm health. I propose it as a heuristic to guide future research, subject to modification based on empirical findings. These campaigns are shaped by the broader social and political context (Box 1 in Figure 1), which includes political structures (Nathanson, 2005), economic conditions, cultural beliefs, and historical influences
(Cohen, 2003; Hertz, 2001). The second row shows each of the three principal actors: corporations and their allies (Box 2); the government, including the federal, state, and local levels and the executive, legislative, and judicial branches (Box 3); and public health and advocacy organizations (Box 4), which includes health departments (which thus may appear in both Boxes 3 and 4; see Wolfson, 2001, for a discussion), health care providers, professional organizations, advocacy groups, and others. Each of these actors has organizational structures, histories, cultures, and connections with various networks and faces external pressures that influence their behaviors. In the third row, the focus is on this behavior itself, the actions that corporations (Box 5) and health professionals and
advocates (Box 6) take in their efforts to change or defend corporate practices and policies
deemed to harm health. As shown in the fourth row, these interactions shape health outcomes (Box 7), which are also influenced by other biological, environmental, behavioral, social, and political factors. The vertical and horizontal arrows in Figure 1 show the dynamic character of these public health campaigns and also the multiple opportunities for intervention.
[Figure 1 – Conceptual model for the study of campaigns to change corporate practices that harm
health – see PDF]
For public health advocates, the central question is the following: What actions can best ensure that their activities lead to improved health outcomes? For health researchers, the key questions are the following: What is the relative efficacy of these interventions compared to others, what factors influence the process and outcome of these interactions, and to what extent can findings derived from one campaign or one industry be generalized to another? In the next section, I examine some of the actors and actions engaged in campaigns to change corporate practices.
CORPORATE ACTORS AND ACTIONS
Corporate practices and policies that damage health are carried out by a variety of actors. Although corporations, such as Philip Morris (Kessler, 2001), Colt Industries (P. H. Brown & Abel, 2003), and Merck (Hawthorne, 2003), have played central roles in defending their own practices against public health critics, other players are also important. Advertisers, for example, design and carry out campaigns to increase sales of harmful products. Trade associations, such as the Pharmaceutical Research and Manufacturers Association (Angell, 2004) and the National Shooting Sports Foundation (P. H. Brown & Abel, 2003), often serve as the public voice of industries. Lobbying and lawfirms, such as Hill and Knowlton (Kluger, 1997) and Verner, Liipfert, Bernard, McPherson, and Hand (Pertschuk, 2001), often act to advance the legislative and legal agendas of several of the industries reviewed here. Retail associations also contribute to lobbying and legislation at the state and local levels. Citizen organizations also act to defend corporations. The National Rifle Association (NRA), for example, is one of the most influential organizations inWashington, D.C., and often acts to defend the gun industry (P.H. Brown & Abel, 2003).
A few analysts have assessed the respective roles of these actors in specific circumstances (Bradsher, 2002; P. H. Brown & Abel, 2003; Nestle, 2002; Pertschuk, 2001), but more research is needed to identify the particular and generalizable contributions of each and the implications for advocacy campaigns.
Corporate Behaviors That Promote Diseases
Corporations and their allies engage in a variety of actions to advance their agendas.
Advertising. Advertising seeks to create new customers and encourage existing ones to purchase more. When the product being advertised is lethal (as in the case of tobacco or guns) or can easily be used in ways that harm health (e.g., alcohol, SUVs, and some pharmaceuticals), advertising falls squarely within the rubric of disease promotion. The six target industries spend vast amounts on advertising, as shown in Table 2. In 2003, the domestic advertising spending for these six industries alone ($38.7 billion) was 7 times greater than the combined total budgets of the U.S. CDC and Prevention ($3.84 billion), the Food and Drug Administration (FDA; $1.45 billion), the Federal Trade Commission ($176.5 million), and the Consumer Safety Product Commission ($57 million; U.S. Department of Health and Human Services, 2003).
As manufacturers saturate their potential customers in one population, advertising seeks new markets, thus creating the potential to spread risks to health. For example, the tobacco industry targets African Americans and smokers in the developing world (Balbach, Gasior, & Barbeau, 2003), the gun industry persuadeswomen to buy handguns to feel safer (Brady, n.d.), and the alcohol industry markets sweet wine coolers to young drinkers (Garfield, Chung, & Rathouz, 2003). In recent years, drug companies have advertised prescription drugs directly to consumers. “Feeling sad? Anxious? Tired?” asks a Pfizer ad for the antidepressant drug Zoloft (Ives, 2003). Although drug and media companies claim that these ads empower consumers to make informed choices and communicate better with their doctors, consumer advocates claim they downplay side effects
or adverse reactions and may lead some patients to pressure doctors to prescribe medicines they do not need (Ives, 2003).
[Table 2 – Annual Spending on Advertising, Political Contributions, and Number of Lobbyists by
Industry – see PDF]
Public Relations. Public relations fosters a positive public image for corporate America and blocks proposals that harm its perceived interests (Marchand, 1998). When critics challenge the safety of a product, corporations and their trade associations often respond forcefully, seeking to influence the debate in such a way as to preclude action to limit profits, restrict advertising, or regulate manufacturing or distribution. For example, when the FDA proposed new regulations for vitamins, industry groups sponsored television ads showing soldiers storming suburban homes to seize vitamin C bottles (Kessler, 2001, p. 335).
To make their public messages more credible, industries may create front groups to act as their public voice. Philip Morris formed the National Smokers Alliance to contest tobacco regulation (Kessler, 2001, p. 170); the tobacco, food, and restaurant industries funded the Center for Consumer Freedom to oppose smoking bans in public places and lower legal limits on blood alcohol levels (Brownell, 2003, p. 269); and the auto industry hired aWashington lobbying firm to create Nevadans for Fair Fuel Economy Standards, a paper organization that opposed higher mileage standards that would reduce pollution (Bradsher, 2002, p. 64). To improve its public image, the food industry has supported the American Dietetic Association (Nestle, 2002), and the tobacco industry has contributed to arts, sports, and African American groups (Kluger, 1997).
As Dorfman et al. (2005) explain, public relations seeks to frame the public dialogue on issues relevant to the industry. Across the six industries reviewed here, corporations articulate strikingly similar messages: Market mechanisms provide the best remedies for dangers to consumers, it is wrong to restrict advertising of legal products, individuals are responsible for their own behavior, and having choices is the American way (Brownell, 2003 pp. 258-268; Diaz, 1999; Menashe & Siegel, 1998). In many cases, corporate publicrelations expenses are tax deductible, creating a public subsidy for messages intended to thwart policy changes to protect health.
Industries also use more subtle forms of public relations to quell unfavorable portrayals. In a stark display of the power of the tobacco industry, in the 1980s, nowomen’s magazine that accepted tobacco advertising published a single article, editorial, or column on the harmful effects of tobacco, despite the fact that it was then that lung cancer surpassed breast cancer as the leading cause of cancer deaths among women (Anderson, 1995; Hertz, 2001, p. 137). As U.S. and global media ownership becomes more concentrated among a handful of large multinational corporations (Bagdikian, 2004), often with links to the six industries described here, the willingness of major media outlets to investigate corporate malfeasance or disease promotion may further diminish.
Lobbying and Other Legislative Activities. Lobbying and other legislative activities are a central tool for advancing corporate objectives. In 2000, the Center for Responsive Politics (n.d.) estimated that there were more than 20,000 registered lobbyists in Washington, D.C. About 1,000 lobbyists work in the nation’s capital for the food industry (Nestle, 2002, p. 99) and 675 for the pharmaceutical industry (S. Brown & Doyle, 2004; see Table 2). More lobbyists work in state capitals. In the mid-1990s, for example, the tobacco industry had 25 lobbyists in Minnesota alone (Wolfson, 2001, p. 153) working to defeat or water down that state’s tobacco regulations.
Lobbyists work both to pass legislation that benefits their employers and to defeat laws deemed to be harmful. In 2003, the pharmaceutical industry poured millions of dollars into a concerted, and successful, lobbying effort to convince Congress to pass legislation that would increase coverage of senior citizens for some prescription drugs and defeat provisions that would have allowed the federal government to negotiate lower prices on behalf of Medicare patients or import lower cost medicines from Europe or Canada. Analysts estimated the law would increase drug company profits by $13 billion a year. Pharmaceutical companies acted despite overwhelming public support for the restrictions they opposed and expert opinion that the measure would leave major gaps in coverage
and fail to contain costs (Connolly, 2003). In 1994, lobbyists for the dietary supplement industry succeeded in persuading Congress and the president to agree to label dietary supplements as foods rather than drugs, thus escaping FDA requirements for safety and effectiveness. A few years later, after aggressive advertising of the benefits of these products, deaths from supplements, such as ephedra, illustrated the public health costs of this deregulation and led to calls for renewed public oversight (Fontarosa, Drummond, & DeAngelis, 2003).
Corporate success at lobbying is increased by the revolving door between industry and the government. For example, presidential adviser Karl Rove had been chief political strategist for Philip Morris before working for Bush, and the president’s chief of staff, Andrew Card, had been General Motors’ top lobbyist in Washington, D.C. (Bradsher, 2002). Dan Glickman, secretary of agriculture in the Clinton administration, left office to join a law firm that lobbies for agriculture and food companies (Nestle, 2002, p. 100). In 1994, when Philip Morris needed someone to testify against FDA regulation of tobacco before Congress, it hired former FDA Commissioner Charles Edwards, paying him $120,000 for the consultancy (Kessler, 2001, p. 315). In 1998, 128 former members of Congress were listed as lobbyists, 12% of all senators and representatives who had left office since 1970 (Abramson, 1998; Nestle, 2002, p. 100). Compared to the handful of lobbyists who advocate for public health, these personal and professional associations between elected and appointed officials and corporate lobbyists provide industry with a competitive advantage in influencing legislation and regulation.
Campaign Contributions and Electoral Activities. Campaign contributions and electoral activities help cement this advantage by increasing the chances that the legislators or executive branch officials that lobbyists meet will be grateful or indebted to them. The six industries reviewed here each make substantial campaign contributions, as shown in Table 2. Many industry political action committees contribute to both parties, ensuring influence no matter what the outcome of an election. In 2002, for example, the drug industry contributed about $22 million to the Republicans and almost $8 million to Democrats (S. Brown & Doyle, 2004). The NRA and its gun industry allies offer not only financial support to sympathetic candidates but also assistance in voter mobilization and campaigning (Diaz, 1999), helping to explain why the gun industry and the NRA consistently win legislative victories even though public opinion polls show high levels of public support for restrictions on assault rifles and opposition to exempting gun manufacturers from liability suits.
Litigation. Litigation allows industry to delay, weaken, or overturn laws and regulations they dislike. The six industries have gone to court to seek action against individuals, organizations, and government agencies that they perceived as threats to their business goals. For example, in 1996, the Texas Cattle Ranchers Association filed a $10 million suit against OprahWinfrey for violating that state’s food disparagement lawby saying the threat of mad cow disease made her stop eating hamburgers. Although Winfrey ultimately won, she spent more than $1 million defending herself, a cost that might deter less wealthy critics (Nestle, 2002, pp. 162-165). In 1994, Philip Morris filed a $10 billion libel lawsuit against ABC television for reporting that cigarettes were “artificially spiked”
with nicotine (Kessler, 2001, p. 156). A tobacco industry executive later commented that “with one legal action—the filing of the ABC suit—the word ‘spiking’ has been dropped from the lexicon of the anti-tobacco crowd. Frankly, if that is all the suit ever does, it will have beenworth it” (Kessler, 2001, p. 169). In 2000, seven gun makers filed a suit against Housing and Urban Development Secretary Andrew Cuomo, New York State Attorney General (AG) Elliott Spitzer, and other state and local officials, claiming they were violating the gun makers’right to sell legal firearms by seeking to force them to accept a code of conduct on the sale and design of handguns. The manufacturers did not seek monetary damages but instead asked the court to bar the officials from seeking to convince local
police departments to buy weapons only from companies that had signed the agreement (P. H. Brown & Abel, 2003).
Scientific Research. Scientific research often influences the public debates about whether specific products harm health. Many industries seek to influence this debate by funding scientific research that will support their case and by hiring scientists to contest damaging information. Until the Tobacco Master Settlement Agreement eliminated it, the Tobacco Institute funded scientists to refute links between smoking and health and to bring this so-called evidence to the public. The food industry supports nutrition researchers who emphasize exercise rather than diet as the cause of obesity, and the New York State AG recently brought the drug maker GlaxoSmithKline to court for failing to publish or disclose studies that showed no benefit from its popular antidepressant Paxil (Harris,
2004). Krimsky (2003), who has studied corporate behavior related to scientific research, uses the term manufactured doubt to describe the practice of sowing confusion to avoid or delay regulatory action.
Illegal Activities. Illegal activities are another strategy some corporations have used to advance their objectives. In the early 1970s, Ford Motor Company fabricated auto safety test data, leading to a $7 million fine (Yates, 1983, p. 261). In 1994, tobacco industry executives lied under oath to Congress about their prior knowledge on nicotine’s addictiveness (Kessler, 2001), and in 1999, the U.S. Justice Department reached a $255 million settlement with the vitamin industry for price fixing, a practice that made its products more expensive for consumers (Nestle, 2002, p. 168). Given spotty enforcement of regulations on corporate behavior, data are not available to ascertain whether illegal activities constitute the renegade actions of a few bad apples or a common business practice.
In summary, a variety of corporate behaviors, including advertising, public relations, lobbying, litigation, campaign contributions, and sponsored research, advance industry objectives of increasing profits and defeating stricter regulations. Although in most cases their activities comply with current laws, these actions nevertheless contribute to preventable illnesses and deaths. In most cases, there is no evidence that corporate managers who engage in these behaviors intend to harm health; although, the evidence of the harmful impact is usually widely known. Many of these corporate behaviors also appear to contradict free-market principles. Free markets depend on equal access to information and on competition. When corporate interests suppress information, obfuscate public debate, or stifle competition, they interfere with the market forces that proponents of free markets cite as the best protection for consumers.
Has the adverse impact of corporate influence on health worsened in recent years? Although data are not available to answer this question definitively, several trends provide cause for concern. First, advertising has increased significantly in the past 2 decades, and corporate influence now penetrates every sphere of public and private life, from the classrooms and malls to movies and music (Cohen, 2003). Second, corporate involvement in political life has grown significantly, with increases in the number of lobbyists, the amount of campaign contributions, and the influence of big business interests in Washington, D.C., and state capitals (Drew, 2000). Third, since 1980, many U.S. industries have been deregulated or allowed to monitor themselves, and the remaining regulatory agencies are often underfunded, understaffed, and frequently criticized by corporate and political leaders, making them less able and willing to carry out their missions (Hilts, 2003; Kessler, 2001). Finally, for a variety of reasons, a number of potentially countervailing powers, such as an informed and mobilized electorate, active consumer and environmental movements, forceful local and state officials, and a crusading media, have declined, leaving fewer voices to challenge corporate influence (Bagdikian, 2004; Cohen, 2003; Patterson, 2003). Whether the new public health activism described here can become such a counterweight remains to be seen.
HEALTH AND ADVOCACY RESPONSES TO
CORPORATE DISEASE PROMOTION
A variety of constituencies have mobilized to take action to protect public health against these corporate practices. A review of campaigns against the six target industries reveals common actors, strategies, and outcomes.
Who are the individuals and organizations involved in advocating for changes in corporate
practices? Several key stakeholder groups have played roles in many campaigns to modify corporate practices.
National Organizations. National organizations serve as conveners, clearinghouses, catalysts, and advocates in government arenas. Larger organizations often have full-time staffs of scientists, lawyers, educators, lobbyists, and organizers. Examples of such groups include the Center for Science in the Public Interest, Union of Concerned Scientists, Public Citizen, Brady Campaign to Prevent Gun Violence, Sierra Club, American Legacy Foundation (which also funds advocacy groups), American Lung Association, and Mothers Against Drunk Driving. These organizations often have a detailed understanding of the policy process and the resources to compete with industry groups in legislative
and legal bodies. In some cases, the national groups can provide grassroots groups with credibility and clout; although, they may also seek to compromise grassroots militancy to achieve political compromises (Wolfson, 2001).
Coalitions. Coalitions bring together like-minded organizations to amplify their political power, share resources, or coordinate strategies. Coalitions organize political strategies, mobilize their constituencies, and educate the public. Most coalitions confine their attention to a single industry (e.g., tobacco, guns, or food), but some work across local, state, and national levels. Examples include the Coalition for a Healthy California, which led the effort to support tobacco control propositions (Glantz & Balbach, 2002, p. 382); the Coalition on Smoking or Health, which included several large national voluntary health organizations (Wolfson, 2001, p. 84); the Louisiana Alliance to Prevent Underage Drinking; and The Infant Feeding Action Coalition, which coordinated the boycott of
Nestle (2002, p. 149). Although coalitions play integral roles in campaigns to modify corporate
behavior, maintaining the coalition and keeping it focused on external goals can often be demanding (Pertschuk, 2001; Wolfson, 2001).
Health Professionals and Researchers. Health professionals and researchers provide scientific and technical expertise to efforts to modify health-damaging policies. They conduct original research, summarize available evidence, testify at public hearings or in court cases, and educate advocates and organizers. Organizations, such as the Center on Alcohol Marketing and Youth at Georgetown University in Washington, D.C., and the Center for Gun Policy and Research at Johns Hopkins University, and individuals, such as Marion Nestle, a nutritionist at New York University; Stanton Glantz, a tobacco researcher at the University of California San Francisco; and GarenWintimute, director of the Violence Prevention Research Program at the University of California Davis, have
provided epidemiological and policy evidence that advocates have taken to the political arena. Some researchers are advocates themselves, whereas others prefer to let theirwork speak for itself. Of course, other scientists also work for the corporations that are the targets of advocacy campaigns; contesting industry-supported research is often a key task for the researchers allied with advocacy efforts.
Public Health Agencies. Public health agencies, such as local and state health departments, have often become key players in campaigns against tobacco, alcohol, guns, and other harmful products. Local health departments are often active members of tobacco control coalitions, often funding community organizations to carry out education and advocacy (Wolfson, 2001). In Marin County, California, the county Department of Health and Human Services joined a coalition that successfully supplanted Miller Brewing Company as a sponsor for the county fair, using its booth at the fair to educate about alcohol rather than give out beer (Marin Institute, 2004). Some local health departments have also supported efforts to end the sales of high sugar soda in schools (Fried & Nestle, 2002).At the federal level, a fewadministrators have taken stands against health-damaging industries. As head of the FDA, for example, Kessler (2001) led the fight against the tobacco industry, and Dr. Jeffrey Runge, of the National Highway Traffic Safety Administration, has been an outspoken critic of the automobile industry’s failure to make safer cars (Skrzycki, 2003).
Legal Groups. Legal groups are at the front line of the litigation against the tobacco, automobile, food, and gun industries. Using class action lawsuits, they have sought damages, injunctions, and changes in advertising or manufacturing. Players include lawyers at universities and nonprofit groups, such as John Banzaf at GeorgeWashington University, the Northeastern University School of Law’s Tobacco Products Liability Project, and the Legal Action Project of the Brady Campaign to Prevent Gun Violence, and at law firms, such the Castano Group in New Orleans, a network of lawyers active in tobacco and gun litigation (P. H. Brown & Abel, pp. 301-303).
In the public sector, state AGs have played increasingly prominent roles in using litigation to protect consumers against corporate excesses. The best known example is the Master Tobacco Settlement negotiated by state AGs to end some forms of advertising and to fund antitobacco activities (Schroeder, 2004). New York AG Elliot Spitzer has also challenged the drug company GlaxoSmithKline for its failure to disclose negative information about a popular antidepressant, Paxil (Harris, 2004).
Local Organizations. Local organizations bring debates about corporate practices directly to their communities and often provoke a dialogue that sparks media coverage, popular mobilization, and a response from the government or industry. In many communities, for example, anti-SUV activists ticketed SUVs, charging them with pollution and defective safety designs (Earth on Empty, n.d.). In Philadelphia, a coalition of church and community groups forced Philip Morris to abandon its plan to introduce a new cigarette, Uptown, targeted at urban African Americans (Sutton, 1993).
Other Participants. Other participants in campaigns to change corporate practices include reporters and other media representatives, elected officials, and other business groups; for example, the insurance industry has often joined advocacy efforts to improve car safety. Often, these parties have helped mobilize public opinion, represent a group’s interest in the political arena, or add political heft to a campaign.
The actors involved in campaigns to change corporate practices have used a variety of strategies to realize their objectives. Creating a typology of actions can help provide a framework for comparative assessment of the process and outcome of these strategies.
Getting Information. Getting information is often the first step in acting to change health-damaging corporate behavior. Advocates for tobacco and gun control have used the discovery process in court cases to uncover damaging information and industry efforts to hide such data (P. H. Brown & Abel, 2003; Kessler, 2001). National advocacy groups, such as Public Citizen and Center for Science in the Public Interest, have used the Freedom of Information Act to extract information about business activities from reluctant regulators (Hilts, 2003, p. 197). In some cases, industry insiders with troubled consciences have turned to the mass media to tell their stories, alleging, for example, that the tobacco industry covered up harmful data and that the gun industry knew its products were going to illegal dealers (Butterfield, 2003; Kessler, 2001).
Legislative Action. Legislative action provides public health advocates with the opportunity to suggest laws and regulations they believe will better protect public health. Health organizations and their allies haveworked to persuade lawmakers to raise taxes or end tax breaks on tobacco, alcohol, junk food, and fuel-inefficient cars to discourage their use (Hakim, 2004; Nicholl, 1998; Stivers, 1994); to set standards for production and advertising of health-damaging products (P. H. Brown & Abel, 2003); to modify zoning or land use laws to reduce access to tobacco, alcohol, or fast food (Ashe, Jernigan, Kline, & Galaz, 2003); to restrict use of tobacco, guns, or alcohol by certain populations or in certain places (Hemenway, 2004; Rabin & Sugarman, 2001); to mandate disclosure of product dangers (Kessler, 2001); and to fund health education to alert the public to hazards (Glantz & Balbach, 2002). To achieve these legislative objectives, advocacy groups have educated citizens and policy makers, lobbied, used the media, organized demonstrations and rallies, and formed coalitions.
Electoral Activities. Electoral activities take the action to the voting booth. In several recent local, state, and national elections, supporters and opponents of tobacco and gun control endorsed candidates, contributed money, and campaigned for politicians who supported their cause (DeMarco & Schneider, 2000; Zakocs, Earp, & Runyan, 2001). In some states, ballot initiatives and referenda provide another opportunity to take health issues to the voters. In California, for example, statewide or local tobacco control advocates used ballot initiatives or propositions to bring tobacco policy to the voters throughout the 1980s and 1990s (Glantz & Balbach, 2002).
Litigation. Litigation enables advocates to bring to court corporations alleged to have harmed health. Judges can order an end to dangerous practices, award compensatory or punitive damages, and set a precedent that will apply in other jurisdictions. In recent years, activists have taken each of the six industries reviewed here to court based on the health consequences of their actions. Several recent review articles have summarized the accomplishments and limitations of litigation as a public health strategy (Jacobson & Soliman, 2002; Parmet & Daynard, 2000; Pearson, 1997).
Actions Aimed at Corporations. Actions aimed at corporations provide advocates the opportunity to bring their messages directly to corporate directors or shareholders. In their campaigns to change howthe multinational Nestle Corporation marketed infant formula in developing nations, activists organized aworldwide boycott that has been periodically reinstated during the past 3 decades (Nestle, 2002, pp. 145-158). In the state of Washington, some activists have proposed revoking the corporate charters issued by the state for companies that repeatedly violate the law (Parrish, 1999). Investors have also become more active. By 2000, more than a trillion dollars was invested in U.S.-managed portfolios that used some social investment strategy, a thirtyfold increase from 1984 (Hertz, 2001, p. 122). Shareholder activism has, for example, forced 3M,America’s third largest billboard company, to end tobacco advertising on its billboards, and Kimberly Clark to sell its holdings in tobacco companies (Hertz, 2001, p. 124).
Education, Information, and Mobilization Campaigns. Education, information, and mobilization campaigns often constitute the foundation for other strategies and also serve to put an issue on the public agenda. Health advocates seeking to change corporate behavior have used counteradvertising campaigns against SUVs, tobacco, and alcohol (Agostinelli & Grube, 2002; Glantz & Balbach, 2002; Hakim, 2003); media advocacy to influence public opinion on alcohol, guns, and food advertising aimed at children (Holder &Treno, 1997;Wallack, Dorfman, Jernigan,&Themba, 1993); and community organizing to mobilize constituencies to support access to lower priced pharmaceutical products in other countries (American Association of Retired Persons, 2004). As Dorfman et al.
(2005) note, these strategies play an important role in framing conflicts between public health advocates and corporations and thus influence the outcome of these interactions.
In the past few decades, health professionals, advocates, and their supporters have accumulated an impressive body of experience using these strategies to influence corporate practices and policies. Each strategy has elicited counteractions by the corporate targets, and thus, strategies and tactics on both sides of these conflicts have changed continually. Systematic research is needed to identify the relative benefits and costs of these strategies and the circumstances that contribute to successful efforts to reduce the promotion of diseases.
Although a comprehensive assessment of the efficacy of these strategies is beyond the scope of this report and perhaps premature, available evidence suggests that public health advocacy to change corporate practices has the potential to contribute to improved health. A few examples illustrate the range of achievements.
In some cases, environmental regulations can be remarkably effective in reducing threats to health. Between 1968 and 1983, for example, primarily as a result of new clean air standards advocated by the environmental movement, American automobile air pollution, which contributes to lung and heart disease, was reduced by 90% (Yates, 1983). Similarly, federal mandates for automobile seatbelts and air bags, long opposed by the auto industry (Doyle, 2000), are now credited with saving thousands of lives because consumer advocates persuaded Congress to require these devices (Martin, Crandall, & Pilkey, 2000).
In California, an aggressive tobacco control program that targeted both industry practices and individuals is estimated to have reduced tobacco consumption by 75% in 10 years, a much larger reduction than in states without such programs (Glantz & Balbach, 2002, p. 5). A recent study found that following a local law banning smoking in public places and in the workplace in Helena, Montana, the number of monthly admissions for acute myocardial infarction from the city but not from areas where the ban was not in effect dropped significantly (Sargent, Shepard,&Glantz, 2004), suggesting that changes in the law may be able to produce even short-term benefits.
In Washington, D.C., a lawbanning the purchase, sale, transfer, or possession of handguns by civilians was associated with a prompt decline in homicides and suicides in the city but not in adjoining areas without such bans (Loftin, McDowall, Wiersema, & Cottey, 1991). More recently, the threat of ongoing litigation led Colt Industries to decide to abandon much of its retail gun business and focus instead on producing for the military and police (P. H. Brown & Abel, 2003, p. 141), a clear example of pressure leading to changes in corporate practices.
IMPLICATIONS FOR HEALTH EDUCATION RESEARCH AND PRACTICE
To evaluate the overall health impact of campaigns to change corporate behavior and to develop guidelines for effective practice will require a more systematic approach to this phenomena and a more standardized body of literature. Some of the research questions that emerged from this review include the following:
1. What is the impact of corporate characteristics, such as the position of a company within its industry, the unique corporate culture, current profit levels, competitiveness within the industry, and its influence within the political arena, on a corporation’s policies and practices related to health? Under what circumstances do market forces lead to reductions in health-damaging practices?
2. What are the potentials and limitations of health advocacy campaigns at different levels and within different branches of the government? What shapes a particular government agency’s responsiveness to corporate versus health advocacy demands? Under what political and economic conditions are governments likely to support or oppose public health campaigns to change corporate behavior? What are the unique opportunities and constraints for change in different phases of economic, budget, and electoral cycles?
3. What frames best enable public health advocates to win public support for their goals? What are the relative advantages, disadvantages, and efficacy of the various strategies for changing corporate behavior? What is the relative efficacy of different types of advocacy coalitions or networks in changing corporate practices?
4. What are the specific social and behavioral processes by which corporate practices and policies damage health? What are the specific social and behavioral processes by which public health advocacy campaigns can mitigate or reverse these adverse health outcomes?
5. To what extent does corporate disease promotion contribute to or exacerbate disparities in health among different socioeconomic, racial, and ethnic groups? Do campaigns to change corporate behavior offer a way to reduce these inequities?
Designing studies to answer these questions constitutes a research agenda on disease promotion
and advocacy to change corporate practices that can guide future intervention.
A focus on corporate practices also challenges health educators to reconsider the theoretical paradigms that have guided our work. For many years, the dominant paradigm in health education has been that individual behavior and lifestyle are the primary determinants of population health in the United States (Fuchs, 1998; Knowles, 1977; McGinnis &Foege, 1993). Critics have long challenged this perspective (Freudenberg, 1978; Israel et al., 1995; Minkler, 1989), and a more recent synthesis is that policy also has an important influence on health and that public health interventions should seek to change individuals, organizations, and policies (Caraher & Coveney, 2004; Committee on Assuring the Health of the Public in the 21st Century, 2003; Green & Kreuter, 2005; Melkote, Muppidi, & Goswami, 2000). Despite this emerging scientific consensus, the vast majority of public health interventions still target only individual behavior, and few organized interventions have made meaningful and sustained efforts to change policy at a level that could influence population health (Bowen&Beresford, 2002; Freudenberg et al., 2000).
This focus on public health advocacy to change corporate practices also offers an opportunity to revise the dominant paradigm. If etiologic research confirms that corporate policies have a substantial impact on morbidity and mortality here in the United States and globally, modifying these behaviors takes on a new imperative. If evaluation research demonstrates that the intervention strategies described here successfully modify corporate behavior enough to reduce adverse health consequences, then public health professionals need to master the competencies needed to develop and sustain such interventions.
What does all this have to with health education? In 1986, the Ottawa Charter for Health Promotion (First International Conference on Health Promotion, 1986) defined health promotion as “the process of enabling people to increase control over, and to improve their health” (p. 1). More than any other single profession, health educators have as their central task educating and mobilizing individuals, organizations, and communities to promote health. Public health advocacy to change health-damaging corporate practices has emerged as a promising strategy for health promotion.Areviewof accounts of these advocacy campaigns shows that many of the core tasks in these efforts closely
parallel professional descriptions of health education competencies: framing public health issues, mobilizing community and institutional resources, educating the public, identifying political opportunities for action, building coalitions, and evaluating success. Similarly, the implicit or explicit rationales for these campaigns often rely on the same theoretical literatures that health educators use: theories on social movements, organizational and behavioral change, communications, ecological models, and empowerment (Glanz, Rimer, & Lewis, 2003; Green & Kreuter, 2005). These parallels between health education and health advocacy suggest that health educators already have some of the competencies needed to play leadership and supporting roles in these campaigns.
At the same time, advocacy to change corporate practices will require new competencies and perspectives. First, transferring the focus from changing the behavior of individuals to one that includes modifying corporate or government action will necessitate ideological as well as skills transformation. A starting point is to examine to what extent existing theories, such as the health belief model or social learning theories (Glanz et al., 2003), can also help predict and then change institutional behavior. Second, current health education practice relies heavily on cooperative and consensus-building strategies, based on the liberal assumption that people of goodwill can come together and agree on compromises. Recent advocacy campaigns to change corporate practices, however, have often used adversarial strategies, borrowing more from social movements and contentious politics (Tarrow et al., 1998) than from small group or social marketing theories. As Kreuter (2005) notes, power is the language that corporations speak and understand best. To prepare health educators with the skills to analyze power dynamics and the stomach and backbone for political conflict that advocacy campaigns against multinational corporations may require, training programs will need to modify their curricula.
Some health educators will raise understandable objections to an expansion of our practice to include advocacy to change corporate behavior. Some will contest the epidemiological evidence, asserting that the proximate role of individual behavior in current patterns of morbidity and mortality makes it the logical focus of health education efforts, not the more distant corporate policies. Others may agree that corporate practices play an important role but argue that changing such behaviors is too difficult or too risky, jeopardizing funding from government or corporate sources. Another point of view is that health educators should remain neutral rather than participate in social conflicts (e.g., debates on the appropriate roles for the government and markets in our society), maintaining
an objective, fair, and balanced stance. These concerns get to the heart of our definition of the role of health educators. Any expansion of health education practice to encompass health advocacy to change corporate behavior will require open and honest dialogue on these and related scientific, ethical, and professional questions.
Supporters of an expanded role for health education practice offer philosophical and pragmatic responses to their colleagues’concerns. First, they argue that public health and health education have always taken on special interests that harm health. Founders of modern U.S. public health, such as Alice Hamilton, C. E. Winslow, Margaret Sanger, Jane Adams, Mayhew Derryberry, and others (Rosen, 1993), tackled the employers, producers, landlords, and medical institutions that sometimes acted against the well-being of the public. Recently, the CDC (1999) identified the 10 greatest accomplishments of U.S. public health in the 20th century. Four of these—improving motor vehicle safety, making workplaces safer, producing safer and healthier foods, and recognizing tobacco as a
health hazard—involved modifying corporate practices that damaged health. Thus, say the supporters, advocacy to change corporate practice is not a new strategy but a return to our public health roots.
Second, borrowing from critics of the concept of scientific objectivity (Parsons, 2003), advocates argue that neutrality is a chimera and often serves to support the status quo by refusing to challenge those with the most power. Expecting health professionals to view the claims of the tobacco industry, for example, with equal credibility as those of public health researchers or advocates of tobacco control defies common sense and a 50-year historical record of deception (Glantz & Balbach, 2002; Kluger, 1997).
Supporters of advocacy campaigns to change corporate practices also reject the claim that the public opposes such action. They point to public opinion polls that show strong support for gun control, restricting tobacco advertising, strong public oversight of the drug industry, regulating pollution, and holding the food industry accountable for its role in the obesity epidemic (Batra, Patkar, Weibel, Pincock, & Leone, 2002; Nestle, 2003; Vernick, Teret, Howard, Teret, & Wintemute, 1993).
Finally, supporters of confronting disease promoters raise a moral imperative. If the mission of health educators is to promote health and the evidence shows that specific actions by corporations damage health, then there is a professional and moral obligation to act to reduce the harm. Failing to pursue promising strategies, they argue, violates ethical standards.
Recent events suggest that both the corporate quest for greater profits and less regulations and advocacy group efforts to modify corporate practices to better protect public health will continue. Public health professionals, including health educators, will need to decide how best to relate to these conflicts. By focusing attention on this emerging domain and by systematically assessing the potential for advocacy to change corporate practices to promote health, we can make informed choices about our future roles.
References [see PDF]
George Hacker is the Director of the Alcohol Policies Project at the Center for Science in the Public Interest and a leading advocate in efforts to change health-damaging practices of the alcohol industry. Corporations and Health Watch (CHW) interviewed Hacker in September 2006 to learn more about his work and the lessons he has learned. We were especially interested to learn more about CSPI’s work on Alcopops, sweetened alcohol beverages produced by the alcohol industry to attract young drinkers. The interview was conducted by CHW staffer Estelle Raboni and is excerpted here.
CHW: What is your role at the Alcohol Policies Project and how did you become involved in
HACKER: I am Director of the Alcohol Policies Project, and I have been on and off since 1982, for all but five years during that period. I became involved with the Alcohol Policies Project because I was looking for a job at that time, and this seemed to be an excellent opportunity to utilize my skills and interest in public health for a good cause with a good organization. It was also a political environment surrounding alcoholic beverages that was quite in its formative stages. There had been no real effort at the national level at that time to promote a range of prevention policy measures at the federal level that could affect per capita consumption and behavior related to alcohol. And so, for me, it was an interesting opportunity to work with a good organization on an issue which was very important, but also something that provided me with an opportunity to learn and also to create something new.
CHW: So how did you get involved in working on Alcopops?
HACKER: Well, the Alcopops issue came about in a number of ways. Number one, we’ve always been interested in the kinds of products that are put out into the marketplace in the alcoholic beverage market and the basic disregard that producers and government have for the nature of the product and their potential for harm to the public. So when the Alcopops phenomenon began in the late 1990s in Europe and in Australia, we were watching closely. And when they made the leap to the United States, we were eager to highlight the way in which this product was designed and later marketed for young tastes and as an entry level alcoholic beverage that targeted mainly underage people. So those two interests came together and, in addition, at around that time we were approached by a pollster who was interested in doing some work with us, and together we found a donor who was willing to support that effort.
CHW: What was your perception of the impact of the alcohol industry’s and the Alcopops’ impact on human, and particularly pre-adolescent girls’ health at the time?
HACKER: Based on what I had been reading in Europe and in Australia, where these products were being put on the market, I was convinced that by the very fact that they were sweet, packaged to look like soft drinks, and tasted like soft drinks, that they were designed specifically for young people, in particular young women. And so we were concerned that this was just another way for the alcoholic beverage industry to bring consumers not only into the alcoholic beverage market, but also eventually to their standard products. In fact, there were quite a few telling comments by executives in the alcoholic beverage industry that illustrate that that was one of the purposes of these beverages.
CHW: Can you explain more about what you mean by standard products?
HACKER: For example, Smirnoff Ice is an Alcopop, or they call them “alternatives.” Yet it has the name Smirnoff on it, and it intended to highlight that name Smirnoff which also has a wide range of distilled products, namely vodka, in that brand. So, essentially, the Alcopop version is intended to make it easier for people to move up the chain to the original Smirnoff product. And we have a couple of great quotes from the Executive at Sky Vodka who considered Sky Blue’s advertising budget to provide a great benefit to Sky Vodka as well.
CHW: And so that was your initial perception of Alcopops and the alcohol industry?
HACKER: My initial perception in 2000 and 2001, which was based not only on my experience, but on anecdotal evidence and phone calls from people around the country, was that these products very much resembled soft drinks. And they resembled soft drinks both in their packaging and in their flavors and, in particular, their sweetness, and to some extent, the carbonation. So they were really alcoholic copies of beverages that were popular among young people and also common to their tastes. We also got calls from adults around the country saying that they would go out, not knowing that these were alcoholic beverages, and buy them for their teenage children mistakenly because they didn’t look very carefully.
We did a number of photographic comparisons in that we took these Alcopop bottles, and we put them out with bottles of non-alcoholic fruit drinks that were popular at the time. And I think those photographs demonstrated how similar the visual appeal of these products was: bright colors, fancy designs, all kinds of elements of the labels’ bright colors that made them attractive in a way that those fruit juices were attractive. And then later we also compared those bottles to their distilled spirit “parents”, to show how similar — the brand was essentially the same.
Sometimes the same logos were on the labels, and the Alcopops were just a smaller version of the liquor bottle.
CHW: Other than create brand loyalty in future customers through these gateway drinks, how do the actions of Alcopop manufacturers affect human health, particularly young girls and women’s health?
HACKER: Well, by creating gateway drinkers and future drinkers, the primary health impact or risk is that they will be creating people with addictions. Because drinking these kinds of sweet beverages allows consumers to begin drinking at a far earlier age because it meets those sort of teen, preteen taste buds. And the data show that the earlier young people start to drink, the more likely that they’ll go on to have alcohol problems and become alcohol dependent.
Now, we don’t know whether that’s a genetic or environmental effect necessarily, but still there are enough genetically high risk people for whom the ease of drinking could be a significant problem. The other impact is the high calorie nature of these products — they probably contribute to obesity among teenagers. Having said that, I don’t know of any real study that shows that. You know, these products make it much, much easier to drink. It’s more than just a gateway drug. It’s like a worm on a hook.
CHW: We’re also interested in the process of mobilizing communities around alcohol issues. The Alcohol Policies Project has also done some earlier work on Power Master, a new sub-brand of the malt liquor Colt 45 that was targeted at African-Americans. Can you tell me about that?
HACKER: Well, PowerMaster was a malt liquor that was designed essentially for the African American market. First of all it probably violated, at that time, the Bureau of Alcohol, Tobacco and Firearms standards relating to promoting the strength of a product, of a beer, given the name itself of “PowerMaster.” And the African American community took tremendous umbrage at the name which brought back all kinds of connotations of slavery, and the protest against that product was enormously successful, and it took three weeks to get that off the market.
CHW: Does CSPI generally tend to collaborate with communities in order to mobilize against these particular products?
HACKER: Oh, absolutely. Since 1982, we’ve been organizing both long standing and temporary coalitions on a variety of issues; and in addition to issue coalitions, we frequently organize petitions and letters that have multiple signatories that involve various constituencies.
Sometimes we focus just on the faith communities. Sometimes it’s a broad-based coalition that mirrors our Coalition for the Prevention of Alcohol Problems. Sometimes we go to the public health schools, or the Health Department Directors in States, and others like that, to get their support for various activities.
CHW: And so was your organization also part of the attempt to get PowerMaster out of those particular cities?
HACKER: Oh, absolutely. On PowerMaster, we were one of several organizations and, as I recall, for strategic reasons, we had African American organizations take the lead on that campaign, although we were pretty outspoken in the media. We also played a role of providing information and government contacts, and coordination, as well as involved in a number of conversations with people at different organizations who were interested in doing something about it. I think that campaign is an example of how targeted communities as well as the advocate organizations that work on these issues can come together rather rapidly to take on a challenge like that. And just that practice in organizing increases the likelihood that future opportunities don’t go unanswered.
CHW: With Alcopops you’re trying to fight against a product not necessarily directed at a particular race or ethnic group, but toward a particular age group, do you find it’s more difficult to organize against that?
HACKER: Well, you know, when we launched the Alcopops effort it was more a public education effort that was intended to boost interest among policy makers, both on the Hill, as well as in agencies like the Federal Trade Commission. It was also an effort to boost the attention of major organizations that had some interest in alcohol policy matters. And, from that perspective, it was relatively successful in that over the years, the American Medical Association has done a number of studies and releases on the Alcopops issue.
The Pacific Institute on Research and Evaluation has launched a fairly aggressive litigation strategy related to the classification of those beverages as one effort to slow them down.
And there have also been numerous efforts in the states and among state alcohol beverage regulators and some Attorneys General to tighten the regulation of Alcopops. At the Federal level, the interest that we generated led to an appropriations measure that directed the Federal Trade Commission to investigate these products. Not that that investigation really changed much, or came out as we had hoped; but it generated a great deal of activity and interest. And, in fact, it helped coin the term “Alcopops” in this country, which we think is an important frame for that kind of a beverage, rather than “alternatives.”
CHW: But despite some of those strategies, Alcopops are still on the market.
HACKER: They are, but their sales have come down dramatically since 2002 or 2003. And not only have their sales come down, but the number of products in the market place has diminished markedly. Many of the products just disappeared. And I’m not sure if our efforts are responsible, or if it’s just been such a cutthroat competition in that area for a beverage that was always marginal.
CHW: Given the different kinds of strategies that have been used to limit the attractiveness of Alcopops to the market, what strategy or strategies do you think would ultimately be successful in restricting Alcopops’ marketing to youth?
HACKER: Well, I think as has been sought in other countries, raising the taxes on Alcopops would be very effective. In fact, we have tried that — it’s the basis of the PIRE litigation effort.
Because many Alcopops have a significant amount of alcohol that derives from flavoring agents that are distilled spirits rather than from a malt beverage, we’ve been arguing that they ought to be taxed as spirits. Classifying Alcopops as distilled spirits would increase the tax on those products fairly dramatically. So far, though, the regulatory structure has gone the other way — to liberalize the rules for Alcopops. It used to be that if a half a percent or more of the alcohol came from a liquor source, it would have to be taxed as liquor. Now you have to have half of the alcohol from a spirit source to require that it be taxed as a distilled spirit.
CHW: How does the alcohol industry promote Alcopops?
HACKER: At the time we did our first poll, there was no television advertising at all. It was just some print advertising around. What we found in that first poll was that the products were dramatically more popular and more likely to be used by underage persons than by adults so we demonstrated their attractiveness and that many young people said that they had consumed them.
And those findings are now regularly corroborated by the Monitoring The Future Study, which has begun to ask high school students about Alcopops (they call them malt beverages or alternatives) and the Center of Alcohol Marketing Youth also issued some corroborating data that showed that young people were being targeted, or at least they were being exposed to a higher percentage of ads for Alcopops than were adults on a per capita basis. So we were showing what these products looked like, and they looked like soft drinks and they tasted like soft drinks and, indeed, young people seemed to like them. That’s what we were trying to demonstrate the first time when we sent that information to the regulators.
CHW: But despite that, you just mentioned that they’ve actually relaxed some of the regulations on how Alcopops are classified and taxed. So what would be the cause of something like that?
HACKER: I think we made a substantial case that these products seem to be very popular among young kids, and later on we showed that kids have the opportunity and, in fact, they seem to be more exposed to the advertising for these products than adults; that the products themselves seem to be favored by folks who don’t like the taste of alcohol; that people in the industry themselves acknowledge that these are “entry level” drinks; that they bring people to their main brands; and that they are basically “starter suds,” as we call them. We demonstrated all that, I think, but the Federal Trade Commission apparently wasn’t convinced or they just didn’t want to do anything about it.
And then, No. 2, the Bureau of Alcohol, Tobacco, and Firearms, which is now called the Alcohol and Tobacco Tax and Trade Bureau got involved. That’s where the battles among the industries occur. For example, one of the major Alcopop producers, Diageo, which makes Smirnoff Ice and its progeny, does battle there with the beer industry. There was a tremendous political battle going on during the evolution of those Alcopop rules, and I think the Alcohol and Tobacco Bureau just reached a political decision. It was a compromise decision that changed the previous rule to allow these products to have some level of distilled spirits, alcohol, in them.
CHW: One of the strategies I’ve heard is to require alcohol manufacturers to list calorie and ingredient content in Alcopops. Is the thinking behind that that young girls who are the main target of Alcopops would be dissuaded from drinking the beverage once they knew what the calorie content was?
HACKER: That’s one of them. Did you see our advertisements that we ran in several college newspapers? It shows a sort of an androgynous expanding waistline, but it was probably supposed to be female with handle bars and a person pinching the large handle bars. And that was an effort to do two or three things. Number one, we placed those ads, as I recall, at many schools, five or six of the schools that had been named “party schools” in the Princeton Review.
That was about the time when this issue of ingredients and alcohol beverage labeling started to come up again. And we wanted to tie it to that so if you read the copy in that ad, it talks about the fact that people are being confused, or at least they’re not aware of the fact that these products have a ton of calories — sometimes two or three times as much as beer. And as a result young women consuming more calories than they might desire. And so it was an attempt, to open people’s eyes to the fattening nature of these products as one means of decreasing the demand for them, but it was also an effort to strengthen support for labeling requirements that would provide that kind of information for consumers, because it’s currently not required. As you may or may not know, CSPI has been petitioning Federal agencies to require ingredient, calorie, and some other labeling of alcoholic beverages since 1972.
CHW: Why do you think it’s taken this long to have it considered?
HACKER: Well, I think that there are powerful interests that are not particularly interested in providing all that information to consumers. And those interests are usually the alcoholic beverage industry. But having said that, there are three producer industries, all of whom have some slightly different interests when it comes to labeling issues, so they’re fighting it out amongst themselves as well. But also the Alcohol and Tobacco Bureau is in the Department of the Treasury, and I don’t think there’s a great interest in alcohol over at the Treasury, especially in this Administration.
CHW: Is the alcohol beverage industry a powerful lobby?
HACKER: Of course. I mean because it’s a multilayered and multilevel lobby. The producers groups, the distributor groups, the retail groups. Then you have hoteliers, and advertisers, can makers — you know, it’s a tremendous lobby plus wine is produced in California, which has the largest Congressional delegation in Congress. As just an example, wine is produced in 49 states so that there’s a political element in each State. The National Beer Wholesalers is one of three or four top PACS in the United States Congress today, and they have a lot of family and other owned businesses around the country that interact regularly with their members of Congress and other politicians and also provide a lot on money independent of the national group. And you have these big corporations like Anheuser Busch and Diageo and SABMiller, Coors — they exert a lot of influence. The other thing that I think is important to remember, part of the mission of the Alcohol, Tobacco Tax and Trade Bureau is to ensure an orderly and legal system for the production and distribution of alcoholic beverages. And so to some extent, that agency is very used to dealing with the industry as their clients, and they serve, to some extent they service that industry as much as regulate it.
CHW: Do you think that representatives of the alcohol industry feel any pressure in scaling back their marketing attempts as a result of the Project’s work?
HACKER: I think that they have changed their behavior as a result not only of our Project’s work but of the work that our Project has spawned over the last twenty years. The fact is that our Project has led to these broad coalitions, has I think stimulated interest in other organizations to do similar work. It has led groups like, M.A.D.D., Mothers Against Drunk Driving, Community Anti-Drug Coalitions of America, Join Together, the American Medical Association and others to focus on some of these issues. And so, together, we have the capacity to bring these kinds of issues to the public’s attention as well as to the attention of policy makers. Now there are some policy makers now who have articulated an interest in strengthening the regulation of alcohol advertising, for example. I think the industry has been forced to change its practices. The way they’ve done that is they’ve, number one, changed their advertising codes and made them more transparent, they have increased the number of their supposed responsibility messages. Actually, many producers have now added a tiny little line in their ads, something like “Drink responsibly.” We don’t think that’s going very far. But on the other hand, I don’t think they would have done many of the things that they’ve done, as well as they’ve been forced to create a tremendous amount of public relations/public education materials and activities in order to buttress their public standing. So they’re all now engaged in a whole lot of face-saving public relations and supposed responsibility endeavors. But a lot of that is, I think, is just called “CYA.” [Cover Your Ass].
Another result of our and our colleagues’ activities, is that they’ve massively expanded their political contributions and their influence on Congress and state legislatures. But, having said all that, I think that the Alcopops advocacy work gave the industry some headaches because no one in their right mind would believe that those products are not youth-oriented. Yet, those products are still out there. They’re available, because of the way they’re regulated at the State level, in the same places that beer is available making them very available to young people. They’re broadly distributed and not, sort of, holed up in liquor stores which are more restricted, and there are fewer of them than convenience stores for example. It’s somewhat hard to say how successful we’ve been. I think that we’ve been more successful since l982, as I’ve said, in getting the industry to change its behavior. Not that its behavior is so stellar today.
CHW: And finally is there anything else that you’d like to add?
HACKER: Well, let me put the Alcopops into a little perspective. The Alcopops fit in with two issues that we were working on. One of them was sole focus on alcohol and young people given how important that connection is in terms of public health and safety, and also how important that is in the context of the alcoholic beverage market. And we think that the alcohol industry’s Achilles heel is that they rely so heavily on recruiting young people, just as the tobacco people did, in order to create a marketplace for the future. And with regard to younger people, the young people are perhaps the heaviest drinkers around. So they consume a substantial amount of the alcohol and they’re a valuable market in themselves. But then, there were other issues that have been boiling since the mid to late 90s that started to get hot in the early 2000s, and that relates specifically to the advent of distilled spirits advertising on television and radio. And part of the Alcopops effort, particularly when we started focusing on the liquor brand names, was focused on undercutting Diageo’s efforts to get liquor on TV because we were demonstrating how many young people were in the audience and how great their access was to TV, how little they were supervised, and that the proposal that Diageo made at that time to air the ads only after nine o’clock on certain shows was totally inadequate and clearly ignored the large number of young people in the audience. So we were looking at trying to get that message out to poison the waters for the distilled spirits advertising as well.
In the last 20 years, in order to reduce prevalence of smoking, the public health community has become actively involved in combating the tobacco industry and its efforts to promote its products, avoid regulation, and mislead the public. Now others are applying these lessons to the food, automobile, firearms and pharmaceutical industries. What can we learn from a closer examination of these experiences?
The Supreme Court’s ruling in January extends the right of political speech to corporations, providing companies with a significant new advantage in their efforts to sway public opinion. In this commentary, media scholar Jessie Daniels analyzes the public health implications of “cloaked websites,” which she predicts will become an increasingly powerful tool for corporations as a result of the Court’s decision.
The Supreme Court’s 5-4 ruling in Citizens United v. Federal Election Commission struck down laws that banned corporations from using their own money to support or oppose candidates for public office. In overturning previously established precedents, the Supreme Court’s decision means that the government may not ban political spending by corporations in candidate elections.
Perhaps the most stunning portion of the ruling is the high court’s expansion of the Constitution’s First Amendment right to protection of political speech to include corporations, further extending to corporate entities the rights of individual persons. The Court had previously offered some First Amendment protection to commercial speech (Virginia State Board of Pharmacy v. Virginia Citizens Consumer Council, 1976). However, the new ruling extends this protection to corporate political speech, providing corporations with a new and significant advantage in their efforts to sway public opinion through the use of media. The court’s decision also has serious implications for the ways corporations influence health, and it may not be only in the ways that CHW readers might expect.
The Citizens United case is fundamentally about corporate propaganda and, in the wake of this decision, we should be braced to see lots more corporate propaganda. The case began when a right-wing conservative “non-profit corporation,” Citizens United, made a 90-minute documentary-style film, called “Hillary: The Movie,” that was extremely critical of Hillary Rodham Clinton. The film coincided with Clinton’s run for president in 2008 and Citizens United wanted to air ads for the anti-Clinton film and distribute it through video-on-demand services on local cable systems during the 2008 Democratic primary campaign. However, federal courts said that the film “looked and sounded like a long campaign ad,” and therefore should be regulated like one. Citizens United advertised “Hillary: The Movie” on the Internet, sold it on DVD, and screened it in a few theaters. Campaign regulations do not apply to DVDs, theaters, or the Internet. The Court first heard arguments in March, then asked for another round of arguments about whether corporations should be treated differently from individuals when it comes to campaign spending. Ultimately, the Court decided that corporations – whether for-profit or not-for-profit – had a right to exercise “free speech” under the First Amendment.
This decision, as lots of folks have pointed out already, is disastrous in a number of ways. For example, Lainie Rutkow and her colleagues at the Johns Hopkins Bloomberg School of Public Health observed in a recent commentary in the New England Journal of Medicine:
“The Court has effectively opened the floodgates to give corporations unprecedented influence over the election of people who determine health policy.”
What I want to call attention to here is effort by for-profit corporations to use their influence in the sphere of public opinion, “values,” and health.
It’s not new that corporations want to influence campaigns, elections, and legislation. For example, this excellent visual display of data at the Good Guide shows which companies have donated to which political parties.
More recently, soda companies like Coke and Pepsi have spent millions to defeat legislative proposals to tax sugar-sweetened beverages, a measure many public health researchers believe could reduce rising rates of obesity. In New York State, for example, the beverage industry has so far spent $3 million to defeat the state soda tax. This legislation is still pending in Albany, but odds are likely that the beverage industry will win out over public health advocates.
What’s new is the Supreme Court’s extension of “free speech” rights to corporations, which may expand corporate attempts to influence not only political campaigns and legislation, but also the wider spectrum of “values.” And, taking the Citizens United case as archetypal, corporations will increasingly be using multimedia in these efforts. We already see this in play in a number of campaigns currently active.
You’ve probably seen the billboards with admirable people’s faces on them and touting some value associated with them. Liz Murray, for instance, who famously went from “homeless to Harvard” is featured on a billboard with this tagline, and then the value associated with it: “Ambition.” Beneath that, the text reads, “Pass it On.” The billboards are sponsored by something called “The Foundation for a Better Life,” which is in fact, a private foundation owned by Philip F. Anschutz. Anschutz is the billionaire co-founder of Qwest Communications, among the largest land-owners in Colorado, a major player in the oil, railroad, and media markets, and according to Forbes, he is the 33rd wealthiest man in America. He also has major investments in sports teams (such as several soccer teams, the LA Lakers, and the LA Kings), stadiums, and newspapers (San Francisco Examiner and the SF Independent). Anschutz is also an active funder of the Republican party, and has donated huge sums to James Dobson’s archly conservative group, “Focus on the Family.” But, you wouldn’t know that Anschutz was sponsoring these ads unless you looked hard for that information because it’s intentionally disguised. “The Foundation for a Better Life” wants to influence people’s values without disclosing their political affiliations or goals.
In many ways, this campaign is similar to the phenomenon I’ve identified as “cloaked websites.” Cloaked websites are published by individuals or groups who conceal authorship in order to deliberately disguise a hidden political agenda. In this way, these sites are similar to previous versions of print media propaganda, such as “black,” “white” and “grey” propaganda. Cloaked sites can include a variety of political agendas. For instance, some cloaked sites, such as http://www.whitehouse.org or http://www.youthforvolpe.ca, are intended as political satire.
Cloaked websites can have very real consequences for health as they can be cloaked to conceal a hidden political agenda connected to reproductive politics, such as http://www.teenbreaks.com, which appears to be a reproductive health website. In fact, the website is a disguise for pro-life propaganda, much like brick-and-mortar “Women’s Health Clinics” which conceal the fact that staff are pro-life counselors who intend to prevent women from choosing abortions. (For more information on cloaked websites, see this recent peer-reviewed article: “Cloaked websites: propaganda, cyber-racism and epistemology in the digital era,” New Media & Society 2009 11: 659-683).
While some news analysts have remarked that the recent Supreme Court decision in Citizens United v. Federal Election Commission is going to result in senators with branded logos on their lapels – or foreheads – I think this is doubtful. Instead, I think that what we’re going to see is an increase in the more subtle and sophisticated corporate branding and, along with this, many more efforts to influence “values” around issues that relate to health.
One such example is a campaign known as “The Responsibility Project” sponsored by Liberty Mutual, a global insurance conglomerate. Unlike the Anschutz-funded billboards, which hide their sponsorship, The Responsibility Project is widely advertised as supported by Liberty Mutual. Launched in January 2008, the Liberty Mutual “Responsibility Project” campaign is heavily advertised on radio and in print, a strategy intended to drive traffic to the website, which includes films from television stars talking about “responsibility,” and a blog that addresses and frames a series of controversial issues and elicits comments from users. The “About” page at their website explains at least part of their intention:
What Does It Mean? Why Is It Important?
As an insurance company, we like responsible people. Because people who believe in doing the right thing don’t just make better people, they make better customers. But the idea of responsibility can be difficult to define. What does it mean? Why is it important? These aren’t questions that can be easily addressed or agreed upon. There are a lot of differing opinions and beliefs involved. And while we may never uncover any definitive answers, we believe the questions are still worth asking.
How It Began
In 2006, Liberty Mutual created a TV commercial about people doing things for strangers. The response was overwhelming. We received thousands of positive emails and letters from people all over the country commenting on the ads. We thought, if one TV spot can get people thinking and talking about responsibility, imagine what could happen if we went a step further? So we created a series of short films, and this website, as an exploration of what it means to do the right thing.
Of course, it makes sense that “As an insurance company, we like responsible people,” if the definition of “responsible people” is meant to include those that don’t file insurance claims. The more “responsible people” who pay their insurance premiums but never file claims, the more profitable Liberty Mutual is. So, they have a vested economic interest in defining the terms of “responsibility” in a variety of areas, but chief among these areas is health. Liberty Mutual takes on a variety of health and health policy issues on their blog, including fast food, childhood obesity, smoking, reproductive rights (here and here), and incarceration.
When the discussion is staged by Liberty Mutual, these issues are framed exclusively within the language of “personal responsibility.” This is a sophisticated rhetorical strategy that makes it very difficult, if not impossible, to reframe the discussion in ways that emphasize corporate responsibility.
So, for example, the post about fast food, titled “Fast Food Limits: Food for Thought or Food Police?” begins this way:
Should government be responsible for deciding what kinds of food you can–and cannot–eat?
Here, Liberty Mutual wants us to think about our personal responsibility as a better alternative than “the government” telling us what we can and cannot eat. What Liberty Mutual doesn’t want us to think about is the way that the four or five agricultural companies which dominate the food industry offer us the appearance of “choice” which in actuality is corn disguised as different forms of fast food.
Similarly, the post about childhood obesity, “Obese Kids: Criminal Neglect by Parents?” asks, “…are you also responsible for what your children eat?” The post then quotes an unnamed “director of a university weight-management center,” who points to a variety of factors, including socioeconomic status, and environmental factors including access to parks and playgrounds, as contributing factors to childhood obesity. Yet, none of these factors are discussed further in the post (or elsewhere on Liberty Mutual’s website). Instead, readers are prompted to:
“Tell us what you think: Should parents be criminally responsible for their obese children? How far should the law go in holding parents directly responsible for any of their children’s behaviors?”
Not surprisingly, a majority of the 56 comments that follow support the idea that parents “should be held criminally responsible” for their children’s weight. Once the terms of the debate have been set with “personal responsibility” as one option, it’s hard to disagree. There’s a lot that’s missing from this discussion, however, such as any discussion of structural inequality that might contribute to childhood obesity, that is, the ways that some kids have access to parks and playgrounds and healthy produce while others do not or the role of the food industry in relentlessly promoting unhealthy products.
The Supreme Court’s decision in the Citizens United case has opened the legal door for corporate propaganda to be given full “free speech” protection under the First Amendment. Not-for-profit corporations, like Citizens United, or foundations like Anschutz’s “Foundation for a Better Life,” or for-profit corporations like Liberty Mutual, now have a constitutionally protected right to engage in political speech. Corporations will not only use their considerable economic power to back particular candidates and shape elections, they will also increasingly use their influence in the sphere of public opinion, “values,” and health.