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The Impact of Corporate Practices on Urban Health

With half the world’s population now living in cities, public health researchers have focused new attention on the health impact of urban living and the development of new approaches to creating healthier cities. Recent reports by UN-HABITAT, the World Health Organization (WHO), the Commission on Social Determinants of Health and others have highlighted the challenges of improving the health of urban populations.

While these reports acknowledge that government, civil society and business all shape the health of urban residents, it is the first two that receive the most attention. UN HABITAT, for example, has called attention to the importance of good local and national governance in improving urban health, and Healthy Cities convened by WHO Europe emphasizes the importance of convening stakeholders in order to improve urban health. In this commentary, I examine the role of business in urban health, with a particular focus on corporations.

How Business Shapes the Health of Cities

Why this special attention to business and why the singling out of their health impact on cities?

Increasingly, it is business decisions that create the urban environments that shape health and disease. The food we eat, the air we breathe, the houses we live in, the conditions at workplaces and communities, our opportunities to meet friends and partners, and our identities as consumers and citizens—all are powerfully influenced by businesses. The choices that businesses make about what to produce, how to market, where to sell and what to charge set the stage for health behaviors, lifestyles and urban social and physical environments.

While business decisions influence the health of all people everywhere, cities are especially important arenas of influence. Cities and corporations have an intimate historical relationship; both are products of the evolution of markets and both were transformed by industrialization. Cities first emerged as agriculture produced surpluses that enabled population concentrations not directly dependent on farming. As populations grew, labor became more differentiated creating ever more specialized markets. Technological developments enabled fewer people to produce sufficient food to sustain humanity, pushing populations out of the countryside and into cities where the availability of cheap labor attracted employers, further concentrating populations. As cities became centers of production and selling, they also became nodes of trade and commerce, amplifying their economic and political position.

From their earliest days, cities were also generators of inequality, enabling some to accumulate wealth and power while large portions of the urban population lived in squalor. Today, cities are the command and control centers of global business, the headquarters of the media empires that market business products, and the dense markets that create the greatest opportunities for profit. Increasingly, the business push for more consumption shapes the physical space of cities, making them a marketing tool for tourism, shopping, eating and romance. As a result, the decisions made in corporate boardrooms often have a greater impact on health than those made by health officials or elected officials.

Why hasn’t the impact of business on urban health attracted more attention? I suggest three reasons. First, many public health professionals believe that the ways in which companies make decisions and operate is not our business. Public health is a government responsibility, they say, and our efforts to improve health have to rely on the powers and capabilities of the public sector. Second, in part as a result of an aggressive public relations effort by business to make its powers seem inevitable, many people believe that business dominance is the only possible economic and political arrangement possible. The demise of most alternative systems with the collapse of state socialism in the 1990s further reinforced the belief that another world is not possible. Finally, most public health professionals lack the knowledge and skills to understand how businesses make decisions, the pathways by which their actions shape health or the strategies we could use to modify health-damaging business practices. Fortunately, we are in control of changing that.

Food, Guns and Tobacco: The Urban Story

The development of strategies to promote health-enhancing and reduce harmful consequences of business practices on cities requires detailed empirical analysis of specific companies, products and practices in specific urban contexts. While business practices can either promote or undermine health, public health officials and advocates often direct their attention to harmful practices given their mandate to protect population health. The following examples illustrate some of the ways that business decisions affect urban health.

  • In 1994, after forceful advocacy by the global food industry, among others, Mexico and the United States signed the North American Free Trade Agreement, making it easier for US companies both to sell low-cost corn, processed food and other goods to Mexican citizens, and to invest US dollars in the Mexican food industry. Between 1988 and 1997, US foreign direct investment in the Mexican food processing industry increased 25-fold. Between 1988 and 1999, the total energy intake from fat in Mexico increased from 23.5% to 30.3 % with the largest increases in urban areas. Between 1992 and 2000, calories that Mexicans consumed from carbonated soft drinks increased by almost 40%. By 2002, the average Mexican was drinking more Coca Cola servings per year than US residents. In this same period, the national prevalence of overweight and obesity increased by 78%, and between 1993 and 1999, the prevalence of diabetes in Mexico increased by 30%. The increases were highest in the densely populated urban areas where targeted marketing and retail density made unhealthy food readily available. Thus, a trade agreement promoted by multinational companies led to changes in the practices of global companies, national supermarket chains and local retail outlets, which in turn contributed to epidemics of obesity and diabetes, concentrated in Mexico’s rapidly growing cities. 1
  • In the 1990s, small arms manufacturers in the United States produced and widely distributed cheap handguns known as Saturday night specials. Handguns accounted for 80% of gun deaths in the US and widespread availability of inexpensive guns put these weapons within reach of gang members, would-be criminals, and worried homeowners. 2Fear of crime and youth violence made cities prime markets for gun makers and these guns played a major role in the increase in urban homicides and gun injuries during this period. Most Saturday night specials were produced by several gun companies in Southern California that were created in the early 1990s to realize a new market opportunity. 3 By the mid 1990s, these companies were producing more than a million guns a year. According to tracing data from the Bureau of Alcohol, Tobacco and Firearms, guns made by these companies were 3.4 times more likely to be involved in a crime than were handguns from other major manufacturers. With supporters from the National Rifle Association and other parts of the gun lobby, these manufacturers were able to resist local, state and national efforts to regulate the sales of these weapons more strictly.
  • As developed countries establish stronger public health measures to control tobacco use, the tobacco industry has moved its marketing to developing nations, where billions of new potential customers can be found in the urban settlements that make efficient and targeted advertising possible. In South Africa, for example, tobacco companies have created marketing campaigns aimed at Black women, showing tobacco use as a new freedom connected to urban living and offering giveaways to encourage use. An important goal of tobacco marketing in developing world cities is to change norms so that tobacco use will be more socially acceptable and to create peer support for smoking, especially among women and adolescents.

Pathways from Business to Health

These three examples illustrate some of the ways that business decisions affect the health of urban populations. First, businesses operate at several levels of organizations and scales. On the global level, multinational companies and trade associations influence trade policies, regulatory regimes and prevailing ideology. For example, the pro-industry neoliberal agenda of deregulation, privatization and lowering of trade barriers has set the tone for global discussions on businesses and health for much of the last two decades. This ideology sets the framework in which national and local health officials propose policies to promote health. On the community level, food, alcohol and tobacco retailers decide which products to offer at what prices, influenced in part by global and national advertising that shape norms and desires and in part by the material living conditions of their customers. The power of business to shape health depends in part on its ability to operate at these multiple levels, creating synergies of impact due to horizontal and vertical integration of its operations.

Second, business has the capacity to operate in several domains, including the commercial, the political, the legal and the economic. It uses media to create and shape desires, lobbying and campaign contributions to influence politics and regulation, public relations and philanthropy to influence values and norms and campaign contributions to affect elections. Again, the ability to operate across sectors magnifies its influence.

Third, businesses have increasingly been able to construct cities to advance their goals. Whether it is the downtown development projects that attract tourists and encourage consumption, the dense markets that create niches for product diversification, the proliferating media that offer new ways to sell to more people or the extralegal and illegal markets emerging in informal urban settlements and slums, cities are places to buy and sell. While alternative urban spaces like peer networks, neighborhood associations, public meeting places and social movements still exist, everywhere they compete, often unsuccessfully, with market forces.

What can public health professionals do?

So what can public health researchers, professionals and advocates do to reduce the impact of harmful business practices on cities?

1. Develop the knowledge and skills to understand and change harmful business practices. To play a stronger role in protecting population health, health professionals will need to learn a new set of skills. Already some public health training programs have begun to take this task on, but more needs to be done. 4

2. Find allies that can magnify our influence. By itself, the public health community has limited influences on business practices. In partnership with advocacy organizations, researchers, and social movements such as the environmental justice, corporate responsibility, global justice and consumer protection movements, we have a greater potential to influence policy.

3. Partner with local government and health departments to make protecting the public against harmful business practices a public health priority. In New York City, for example, the city health department and the Mayor have strengthened public oversight of the tobacco industry, fast food companies and gun sellers. Their successes have created new opportunities for other local, state and national governments.

4. Study business practices as a modifiable social determinant of health. Growing global interest in studying and addressing social determinant of health creates an opportunity to consider business practices as such an influence and to conduct research on the most effective and economical strategies for modifying business practices in order to promote health and reduce disparities in health.

5. Join efforts to create a more level political playing field. As long as business interests can dominate political, electoral, legal, economic and regulatory processes, the public health community will have a limited voice in making policy decision that can modify harmful practices. To change this unfavorable climate, public health professionals can join campaigns to limit corporate influence on politics and create spaces for more equal participation by those most harmed by current practices.

6. Use the assets of cities to contest harmful corporate practices. While urban populations are often the targets of harmful corporate practices, cities also have assets that can counter these efforts. Cities are the cradles of social movements, provide ready access to local and national media, and offer options for more sustainable, democratic and healthier social arrangements. By using these urban resources, public health professionals and advocates can help to create alternatives to the status quo.

By Nicholas Freudenberg, Founder and Director of Corporations and Health Watch and Distinguished Professor of Public Health at Hunter College, City University of New York.


  1. Freudenberg N. Free trade, the food industry and obesity: How changes in US-Mexico food trade contributed to an epidemicCorporations and Health Watch, July 2007.
  2. Nieto M, Dunstan R, Koehler G: Firearm-Related Violence in California: Incidence and Economic Costs. Sacramento, California Research Bureau, 1994.
  3. Wintemute, G. Ring of Fire: The Handgun Makers of Southern California, Violence Prevention Research Program, Sacramento, California, 1994.
  4. See Teaching about Corporations and Health: Bringing Corporate Practices into Public Health Classrooms.Corporations and Health Watch, December 2007 and Corporate Research: The Basics, June 2008.

Teaching about Corporations and Health

As the influence of corporations on population health grows, it will be necessary to prepare researchers, practitioners, and advocates who have the knowledge and skills to analyze and contribute to changing harmful corporate practices. One place to do that is in training programs for public health professionals. In this ongoing series, Corporations and Health Watch offers readers materials about courses on business and health.

William H. Wiist is Professor of Health Sciences at Northern Arizona University and the editor of The Bottom Line or Public Health: Tactics Corporations Use to Influence Health and Health Policy, and What We Can Do to Counter Them (Oxford University Press, 2010). In the past two years, he has taught courses on globalization and health at the University of Chile School of Public Health and at Northern Arizona University.

At the University of Chile, the “Economic Globalization and Health” course was co-taught by Dr. Wiist and Dr. Ron Labonte (from the University of Ottawa, Canada) in January 2009 and 2010. In 2010, 35 students enrolled in the course, including seven from the United States. The topics included:

  • Economic Globalization and the Social Determinants of Health
  • Global Trade and Health Equity
  • Transnational Corporations: Protagonists of Economic Globalization and Their Impact on Health
  • The Tobacco Industry
  • The Pharmaceutical Industry
  • Global Financial System: external debt, international cooperation and development
  • Chile Facing Economic Globalization
  • The Economic Crisis and its Effects on Public Health
  • Globalization from Below: Civil Society Actions to Counter the Adverse Effects of Globalization.

A syllabus provides additional details. [click here to download]

The online course at Northern Arizona is also called “Economic Globalization and Health,” though is less focused on Chile as a case study. Course requirements include reading scientific reports and political analyses, viewing popular films on corporate power, and writing an analysis of the economic determinants of a health problem that students choose. A syllabus [click here to download] gives further details.

CHW readers with other relevant syllabi or teaching materials are encouraged to submit them for posting.

Previous CHW reports on teaching about business practices include:


The Health Impact of Targeted Marketing: An Interview with Sonya Grier

Sonya A. Grier is an Associate Professor of Marketing at the Kogod School of Business at American University. She was previously on the faculty at the Stanford University Graduate School of Business and was a Visiting Scholar at the Federal Trade Commission, where she provided consumer research expertise as part of a presidentially mandated team examining the target marketing of violent movies, music, and video games to American youth. She also spent a semester at the University of Cape Town in South Africa conducting research on social influences on consumer responses to targeted advertising.

In March 2010, Sonya Grier and her collaborator Shiriki Kumanyika published an article in the Annual Review of Public Health entitled, “Targeted Marketing and Public Health,” which explores the complex concerns raised for public health by the use of targeted marketing. In May, Corporations and Health Watch staff person Marissa Anto interviewed Dr. Grier about her interest in targeted marketing, recent trends in the field, and how public health advocates might better harness targeted marketing for their own purposes. What follows is an edited version of the interview.

CHW: How did you become interested in targeted marketing?

SG: I’ve always been interested in the different types of strategies that marketers use to reach specific groups and how they determine what different types of strategies are necessary. My first job out of college in the late 80s was as a market research analyst at Kraft and I remember asking why there wasn’t an ethnically targeted marketing campaign for barbecue sauce. Based on my personal knowledge, it seemed like there was heavy usage in the African American community and I didn’t see that reflected in the ad campaigns that were developed. That led me to understand, especially being a research analyst, how they were using data and information and putting it together to develop these types of strategies and that really started to drive my interest in targeted marketing. I also volunteered in a corporate program for non-profits, and I was assigned to help a Women of Color Theatre Group with audience development. The marketing issue there—this is again in the 80’s—was how to market something that might be perceived as an ethnic product to the core audience, as well to others who might be interested. So these are my first experiences in the professional field of marketing as a practitioner that really drove my interest specifically in targeted marketing.

CHW: In your Annual Review article, you define targeted marketing as “the identification of a group of people who share common needs or characteristics that an organization decides to serve” (p. 350). Can you explain what that means?

SG: My definition is based on the notion that if you speak to consumers in a way that resonates with the way they think, the way they talk, their attitudes, beliefs and values, they’re going to respond favorably to targeted marketing. That’s really the crux and most important part of it. Identifying when and how to do that is the challenging and creative part.

CHW: Why do you think this issue is important for public health professionals?

SG: Well, targeted marketing strategies influence behavior, which is a key goal of many health professionals. More specifically, targeted marketing can be used to influence commercial behavior such as getting people to buy a certain product, to influence health-related behavior such as increasing fruit and vegetable consumption, or some combination of the two. Targeted marketing often influences attitudes and reinforces people’s beliefs about what they think is normal. From a commercial perspective, it attempts to increase consumption of products or services. And this is the environmental context that people face daily as they try to listen to any type of public health message, so this is significant “competition” for public health efforts and that’s why it becomes very important. Think about obesity where people talk about food marketing being a negative influence. If the majority of the messages that come to you based on food marketing strategies encourage overconsumption of less healthy food or discourage physical activity; then this is a reality that people face and public health professionals need to understand the real day-to-day experiences of people in order to change their behaviors.

CHW: That leads into my next question: Are there ways that public health researchers can learn from industries that use targeted approaches to marketing? What do you think are some of the most important concepts we can learn?

SG: Definitely. One specific area is customer orientation, which is generally the basis of all marketing efforts and especially targeted marketing efforts. Marketers work to develop a profile of their target consumers, learning everything they can about the consumer from their perspective. This includes not only how people make choices about buying one specific product—and from a public health perspective, it’s not about just engaging in one specific behavior— but it’s also about how the desired behaviors fit into their lives and the kind of constraints people face, or believe they face. Everything is viewed from the perspective of the target audience. And this may not always be the same as what the professional ‘knows.’ Industry marketers also try to speak to target audiences in their own language, which is something that often doesn’t happen in public health. What I often see in public health is that specific actions are seen as right or wrong from a health perspective. So for public health researchers, a customer orientation might be letting go of preconceived notions of what is right and what is wrong and instead focusing on the person’s perspective, understanding how they make choices and what factors are influential to them.

CHW: What role do you think targeted marketing plays in maintaining or exacerbating disparities in health?

SG: I will use an example from the area I am currently working in which is obesity. The prevalence of obesity in African American and Hispanic children and adults is significantly higher than in White populations. We know this disparity is due not only to differences in income and education, although those factors might play a role. Social marketing programs aimed at obesity prevention often promote increasing the consumption of healthy foods and decreasing that of less healthy foods. So we have to think about what the role of targeted marketing of these less healthy foods is. As I noted, commercial marketing can be in competition with desired behaviors from a public health perspective. So commercial marketing can serve to hinder or prevent prevention. Say there’s a billboard that says, ‘Don’t let your children eat unhealthy foods’ and then right next to it is a billboard for fast food, advertising this very appetizing thing for $1. Which one is going to have the most sway and persuasiveness? Which one is a person going to see a lot more of? Understanding that context becomes really important because it can serve to prevent prevention.

I did a paper with Shiriki Kumanyika in 2008 called “The context for choice: health implications of targeted food and beverage marketing to African Americans” where we conducted a systematic review of the marketing environment for African Americans and we looked at the literature on food and beverage products, promotion, accessibility and prices targeted at African Americans as compared to White consumers. We found that targeted marketing strategies may challenge the ability of African Americans to eat healthfully. The strategies that were directed towards African Americans emphasized low-cost, low-nutrient food products like candy, soda, and snacks, and they were less likely to contain health-oriented messages. We also found that distribution and pricing strategies constrain the ability of African American consumers to purchase healthy food. It’s a challenge for any consumer to eat healthfully when their choices are constrained and they don’t have access, and prices are a lot higher or they are not made aware of these other products.

CHW: Can targeted marketing ever promote health or reduce disparities?

SG: Yes. Targeted marketing is a strategy, it’s a tool, it’s a set of practices and procedures that you put together to reach a particular goal; it’s not necessarily for good or for bad, it’s just a strategy someone uses and it can definitely be used to promote health. Health is a large component of the field of social marketing which has focused on using marketing to promote health, including the reduction of disparities as a goal. [Editor’s note: For more on social marketing and public health, see an article on this topic that Dr. Grier co-authored.]

CHW: Can you discuss some of the most compelling examples where targeted marketing has promoted health and reduced disparities?

SG: One example is the VERB campaign, which was created to increase physical activity in tweens. It was targeted at tweens but it also put particular focus on ethnic minority tweens, especially Hispanic tweens and African American tweens. Some of the research shows that it was effective in improving behaviors.

CHW: How do you think targeted marketing strategies have changed over time? You’ve been in this field since the late ‘80s. What are some of the shifts you’ve seen in the use of targeted marketing to get consumers to use different products?

SG: I think that strategies have moved from relying on one demographic variable like age, race, or gender to thinking about combinations of variables. So advertisers are now getting more into lifestyle and other variables to target a market. They’re not going to target me as a Black person or as a woman or as a baby boomer, but rather, perhaps, as a person who likes live music, buys health foods, and shops at Trader Joe’s, and all these others types of variables. Because there is so much more known now, and this is driven by technology. You also have the micro-targeting of media outlets which has created all these vehicles where you can reach particular groups of people. People can now live in their own marketing worlds without really knowing what’s going on in other worlds. What one group sees may be systematically patterned relative to what another group sees. And we can only to expect this to increase as marketers look for ways to be successful in increasingly competitive marketplaces.

CHW: How has the public health community sought to modify the harmful aspects of targeted marketing? What do you think of counter-marketing?

SG: Counter-marketing is really emerging as an important strategy to modify corporate practices that harm health. By counter-marketing, I’m assuming that we’re talking about the use of marketing techniques to try to un-sell a product or to destroy demand for a product. Research suggests that counter-marketing can be effective. The Truth campaign, for example, exposed the marketing practices used by the tobacco industry and then positioned this information in a way that spoke to youths. They did this by focusing on some of the core values for young people, like a desire for independence and individuality. This is a clear case of the consumer orientation that I was talking about earlier. The Truth message was also marketed just like a commercial brand and it had money behind it and it looked like what the teens wanted to see. Research on the effectiveness showed that it influenced attitudes toward the tobacco industry and tobacco use, and contributed to a decline of smoking prevalence. Research also shows that it was cost-effective because it recouped its cost and averted future medical costs. But at the same time, counter marketing is not really a one-size-fits-all strategy, and would need to be adapted to the particular domain you’re going to use it in.

For example, the success you see in tobacco may not transfer to products like food and beverages. Cigarettes are harmful and it’s illegal to sell them to minors but that’s not the case for food and non-alcoholic beverages. And the foods that may be the least healthy, like fried foods and soft drinks, taste good, are inexpensive, convenient, and they’re the norm. Research has also shown that counter-marketing can contribute to boomerang effects. In terms of alcohol and illicit drugs, some research that shows that attempts at counter-marketing increased positive attitudes towards alcohol and drugs. There’s also research that shows that the industry may pursue efforts to undermine counter-marketing strategies such as forming partnerships or other strategies. I think the big picture is that commercial marketers face few counter-marketing campaigns relative to the messages that are out there that counter health. So that’s an area where research is needed to really understand how do you develop counter-marketing strategies that won’t have boomerang effects and be insulated from things that industry might try to do and that can be effective across different domains.

CHW: In your opinion, what are some of the most important research questions on targeted marketing?

SG: One would be research on counter-marketing. Another is the targeted marketing of healthy products. You often hear store owners say that they won’t carry healthy products because people won’t buy them. Is this because people aren’t aware of those products? Or haven’t received the same type of repetitive messages about the value of those products in a way that speaks to them as they have for less healthy products? Another question related to this is: How do some consumers maintain healthy eating although they might encounter the same marketing strategies that encourage overconsumption? Understanding ‘positive deviance’ may lend important insights. I’d also say at a broad level there is a need for research to understand the extent of corporate consciousness about the aggregate effects of the market strategies they use among particular segments. Do they know that following the basic tenets of marketing they may be providing different messages to different groups about what constitutes a normal and healthy diet? We don’t know. Sometimes there is a discussion of whether targeted marketing on the part of corporations is intentional or not. I know from my experience with corporations that they’re following basic marketing strategy. It’s not like they’re saying, “We’re going to go out and make African Americans and Hispanics fat.” But there is a whole complex web of things that work together and the question is, are they aware of and conscious of those aggregate effects?

Additionally, I think a very important area is digital targeted marketing, especially with regard to the potential negative health effects for ethnic minority youth. Digital media really supports the basic goal of targeted marketing, which is to resonate with consumer characteristics. These strategies may rely on, for example, identity-related concerns of adolescents. Marketers are recognizing both that ethnic minority youth are leaders in the use of a lot of digital media and also that they are fast becoming the majority of the U.S. population, so marketers are putting a lot of money and effort into marketing to ethnic minority youth. And these same youth are dealing with not only basic identity concerns but also ethnic minority concerns. Think about some of the location-based strategies that involve digital marketing. Through these kinds of strategies, marketers might give teens a coupon when they’re near a fast food restaurant via a mobile phone. Research shows that minority youth are frequent mobile phone users, and they’re more likely to live near a fast food restaurant or have one near their school. For these reasons, they are more likely to get a coupon and perhaps will buy something that is affordable and good-tasting but that may contribute to more weight gain in this population. This interaction between technology, health, personal characteristics, and marketing strategies in the digital realm seems like an area where much research is needed from across disciplines and paradigms, within public health as well as from the social sciences, economics, and business.

CHW: What are some current targeted marketing research questions you’re now working on?

SG: I am looking to identify the specific characteristics of African American and Hispanic youth that may make them more responsive to digital targeting, and examining the effectiveness of strategies that might harm their health. I’m also working with the African American Obesity Research Collaborative (AACORN) on a five-year grant from the Robert Wood Johnson Foundation. We’re using community-based participatory research (CBPR) to investigate how targeted marketing strategies encourage healthy eating at the community level.

CHW: What’s your opinion of the use of terms like “organic” and “green” to denote products as being healthy? Do you think it brings these products to a wider audience by making it more mainstream?

SG: I think it can confuse consumers because if there aren’t specific standards to say what it means to be “green”, what it means to be “organic”, what means to be ”all natural,” etc., people may not have an understanding of how these relate to their goals of eating healthier. And I think that’s really what’s needed: Information and knowledge that helps people understand how they can be healthier within the context of the environments that they face and the lifestyles they lead.

CHW: Do you think that corporations and commercial entities can be more responsible in their use of targeted marketing?

SG: Yes, definitely. That’s why one of my current research questions examines consumers’ consciousness of the effect of corporate strategies on specific target markets. Eventually, I want to look specifically at corporate consciousness. I mean, honestly, I’m not even sure they realize this. Companies may read in the newspapers that there’s more targeted marketing of soda to African American youth, but do they know that these are their strategies, that their strategies play a role in that? It’s such a contentious and controversial issue that it’s not like there is an open dialogue typically between companies and public health advocates in this domain.

CHW: Do you think there should be a more open dialogue and greater consciousness surrounding these issues?

SG: You see so much about targeted marketing to kids, but within targeting to kids, you have the sub-groups of African American and Hispanic children who are significantly overweight. A basic marketing principle is that you focus on the heavier users, because those are the people who will keep buying your products. In public health, you would think the focus should be on protecting those with the greatest need. So with all this concern about food marketing to children, there should be a heavy emphasis on looking more carefully at food marketing to ethnic minority youth and you don’t see that. You see lots of discussion of obesity disparities and the horrific statistics, but very little focused effort, especially effort that takes the community perspective as fundamental. From a political or policy perspective, perhaps you don’t get things done if you only focus on one group. At the same time, I don’t think public health can afford to play that policy game and ignore the need to understand these minority groups because if you look at what’s going on with the census, eventually these groups are going to be the majority. So you can ignore this at the peril that in ten years we still have very limited research on groups that by then will be the majority of the marketplace and at highest public health risk.

CHW: Thank you very much for your time and insight.

SG: Thank you for your interest in targeted marketing!

For other related CHW posts see:

Globalization accelerates woes for Toyota, world’s leading car manufacturer

For more than a decade, Toyota customers have reported incidents of sudden acceleration, resulting in crashes, injuries, and deaths. The company now faces charges that it intentionally hid defects from customers. Nick Freudenberg explores what role globalization may have played in accelerating Toyota’s woes, and what can be done to prevent such corporate catastrophes in the future.
About a year ago, Toyota became the world’s largest car manufacturer by sales after General Motors, the previous leader, was hit by the economic crisis. The Japanese company built its reputation and sales by emphasizing safety and quality, contrasting its products with less durable and dependable American vehicles. In the last year, however, Toyota has faced accelerating woes – declining sales, safety problems such as sticky accelerators and faulty brakes, and a spate of lawsuits, regulatory actions and unfavorable media coverage. In this report, CHW examines Toyota’s troubles, analyzes their links to broader global trends, and assesses the implications for automobile safety and public health.

Sticky accelerators and faulty brakes

For more than a decade, Toyota customers have reported incidents of sudden acceleration. At first Toyota attributed these reports to driver problems, then to problems with floor mats. Now both the company and the U.S. National Highway Traffic Safety Administration (NHSTA) have launched major investigations into sticky accelerators. By the end of March 2010, according to Reuters, Toyota had recalled about 8.5 million vehicles around the world. In early April, the New York Times reported that the U.S. Transportation Department (DOT) was seeking a $16.4 million fine against Toyota, the largest allowed, because the company had failed to promptly notify the government about potential problems with accelerator pedals. Toyota seems likely to pay rather than contest the fine.

According to Safety Research and Strategies Inc., an auto safety advocacy group, between 1999 and the end of January 2010, 2,262 cases of sudden acceleration involving Toyota vehicles were reported, resulting in 815 crashes, 341 injuries and 19 deaths. To add to Toyota’s troubles, in February, the U.S. Transportation Department opened an investigation into brake problems in the 2010 Toyota Prius, the company’s best-selling hybrid car. Shortly thereafter, Toyota recalled more than 400,000 cars. The company’s most recent problem was a Consumer Reports “no buy” warning for the Lexus GX 460 due to its rollover risk. Toyota suspended sales of its SUV the next day.

In testimony before a Congressional hearing in February, Akio Toyoda, the company’s president and grandson of its founder, apologized for the company’s missteps. “I fear the pace at which we have grown may have been too quick”, he told House members. “I regret that this has resulted in safety issues described in the recalls we face today, and I am deeply sorry for any accidents that Toyota drivers have experienced.”

Investigations and lawsuits

To determine the causes of the accelerator problems, the U.S. DOT last month asked experts from the National Administration for Space and Aeronautics (NASA) to analyze Toyota’s electronic throttles to determine if they have contributed to unintended acceleration. In an interview with Reuters, Secretary of Transportation Ray LaHood said, “We are determined to get to the bottom of unintended acceleration.” Nine NASA scientists are expected to bring expertise in electronics, electromagnetic interference and software integrity to the DOT investigation.

Key legal questions are what Toyota knew when and what they did with that information. In addition to the fine the DOT is seeking, a bevy of lawyers are pursuing these questions:

  • By early February, Toyota faced at least 30 lawsuits in the U.S. and Canada seeking class-action status on sudden acceleration.
  • In March, Orange County (CA) District Attorney Tony Rackauckas filed a civil lawsuit against Toyota, charging that the company had intentionally hid defects from consumers. “We intend to prove that Toyota ignored, omitted, obfuscated and misrepresented the evidence that was amassing for many years regarding serious safety defects in their cares,” he told reporters.
  • In September 2009, a former Toyota attorney told CBS News that Toyota had illegally withheld evidence in hundreds of rollover deaths and injury cases. The plaintiff, Dimitrios Biller, filed a racketeering lawsuit charging that his complaints about the company’s legal misconduct led to his firing. Company lawyers said that Biller had “breached his ethical and professional obligations…by violating attorney-client privilege.”
  • The inspector general of U.S. Department of Transportation is reviewing the NHTSA’s handling of the investigations into unintended acceleration, and the National Academy of Sciences is examining unintended acceleration and electronic vehicle controls throughout the auto manufacturing industry.
  • In addition, according to Fair Warning, an online publication on health, safety and corporate conduct, Toyota faces a federal criminal investigation and inquiries by the Securities and Exchange Commission, the Connecticut Attorney General, and a U.S. Attorney in New York.

Globalization – the fundamental cause of Toyota’s problems?

For public health researchers, Toyota’s troubles provide a case study of how global market forces can lead companies to engage in practices that threaten health.

How did this happen? First, in an effort to beat its U.S. competitors, Toyota pushed to expand production, move into new markets and dominate the growing market for smaller, more fuel-efficient cars. Although the results of current investigations will not be known for several months, it appears that Toyota cut safety corners to realize these opportunities, as CEO Toyoda tacitly admitted in his apology to Congress.

Second, the current practice of sourcing and using parts around the world means that once a defective part gets into the supply chain, it can cause global problems, a trend Christian Science Monitor reporter David Grant called the “dark side of globalization.” Toyota has blamed the accelerator problem on a faulty accelerator mechanism manufactured by Chicago Telephone Supply Company, a U.S .company founded in Chicago in 1896, now located in Elkhart, Indiana. In additional to its use in Toyota vehicles sold in the United States, the CTS part was also used in 1.8 million Toyotas sold in Europe, a Ford car produced in China and the Pontiac Vibe, formerly made by General Motors. All have now been recalled for repair. Global sourcing may make it easier for producers to lower costs but they also risk spreading dangerous products around the world, as also shown by the global spread of contaminated peanut butter manufactured by the Peanut Corporation of America in Blakely, Georgia last year and the 2007 recall of tainted pet food made in China.

Third, the growth of multinational corporations and the weakening of national regulatory agencies have made it more difficult for governments to keep an eye on big companies. At Congressional hearings on Toyota acceleration problems, NHTSA Administrator David Strickland promised that his agency would take a “hard look” at the power it has. Current authority, he said, may not be sufficient to regulate modern technology. Strickland also told the panel it was unclear whether the agency can regulate “in a way that allows the auto industry to build and sell safe products that the consumer wants to drive.” DOT Secretary La Hood has also called for more resources for regulating auto safety. The $16 million fine proposed by DOT is a drop in the bucket of profits Toyota earned in the decade since accelerator problems were first identified.

Globalization – the possible solution to Toyota’s problems?

Just as multinational company-led globalization created the problems that Toyota now faces, bottom-up globalization may suggest new solutions. The intense international media and consumer group scrutiny of Toyota and regulatory and legal action on many fronts and continents makes it harder for Toyota to ignore the problem and easier for advocates to share information and resources and to plan common strategies.

As public health authorities expand the use of global treaties to regulate tobacco, alcohol and perhaps food, might a Framework Convention on Motor Vehicle Safety follow? Such an approach might slow a race to the bottom in which big companies look for the lowest cost supplies and the quickest route to showrooms, even if such measures compromises safety. An enforceable global treaty could also protect more scrupulous manufacturers from their less responsible competitors. In 2000, a new UN treaty set in motion the development of global standards for automobile manufacturing. Such a treaty could set the stage for future harmonization for technical regulations on vehicles, ranging from pollution and fuel-use standards to anti-theft devices and windshield wipers. However, to date industry groups have dominated this process and enforceable standards are nowhere in sight.

Each year about 400,000 people around the world are estimated to die in automobile crashes and 30% of the victims are under the age of 25, making auto deaths an important cause of overall mortality and premature deaths. Many more die from exposure to automobile pollution that could be prevented by available technology. By adding their voice to the call for stronger auto safety and pollution standards and for tougher oversight of the auto industry, public health advocates can help improve the safety of cars on the road, while also increasing space in the market for safer and more sustainable forms of transportation.

By Nicholas Freudenberg, Distinguished Professor of Public Health at the CUNY School of Public Health at Hunter College and founder of Corporations and Health Watch.

Related CHW reports:

Activists in Review: The Yes Men—taking on corporations, one prank at a time

In their ongoing efforts to reform corporations, advocates have used diverse tactics to expose detrimental practices or push for reform. On the one hand, public health professionals can change business practices that harm health by conducting research that documents the health problems associated with a particular product or industry and then bring these findings to the attention of policy makers. Another approach is to use tactics that expose and ridicule these types of corporate practices in an attempt to provoke media and public attention.

The two leading members of “The Yes Men,” known as “Andy Bichlbaum” and “Mike Bonanno” pose as Exxon oil executives shortly after making the announcement of a human-flesh-derived fuel called “Vivoleum” at the Oil and Gas Expo (GO-Expo 2007) in Calgary, Alberta.

The Yes Men, performance artists and global justice activists who expose corporate wrong doing, have used this latter approach by carrying out pranks and stunts to attract media coverage of dangerous or immoral business practices. In this profile, Corporations and Health Watch describes The Yes Men and analyzes the success of their antics in bringing about corporate change.

The Yes Men Fix the World

Perhaps the best way to explain The Yes Men, founded by performance artists and activists Mike Bonnano (real name, Igor Vamos) and Andy Bichlbaum (real name, Jacques Servin), is to describe some of their stunts.

In 1999, The Yes Men created, a sham version of the World Trade Organization’s website that displays documents and reports satirizing the WTO’s approach to business. For example, a new release was posted stating : “At a Wharton Business School conference on business in Africa that took place on Saturday, November 11, the WTO announced the creation of a new, much-improved form of slavery for the parts of Africa that have been hardest hit by the 500-year history of free trade there.” After being mistaken for the real website, The Yes Men were invited to speak on behalf of the WTO with television reporters, schools and in other public settings.

In 2002, posing as trade experts, The Yes Men gave a lecture at a university in upstate New York proposing new solutions to world hunger. After serving the 100 students attending the talk free Big Macs, the lecturer proposed a new system for recycling Big Macs from human waste and serving them again. He showed a cost-benefit formula that proved the profitability of the recycling scheme, showing benefits for up to ten re-servings. By the end of the lecture, students were booing and hissing, just the reaction The Yes Men hoped to elicit.

In 2004, on the 20th anniversary of the toxic chemical disaster that killed about 20,000 people and left thousands more with chronic illnesses in Bhopal, India, The Yes Men posed as public spokesmen from Dow Chemical, the company that bought the Bhopal plant from Union Carbide. In an interview with BBC World News, the “spokesman” apologized profusely for the accident and promised that $12 billion would be donated to help clean up the waste site and provide compensation to the many people who were injured. Shortly after airing the interview, BBC World News discovered that the interview was a prank, leading it to apologize to its viewers for failing to uncover the deception. Dow denounced the hoax and reiterated their position that they had no responsibility for further compensation. Many newspapers and TV outlets covered the fake apology and the Dow response.

In 2007, Yes Man Andy Bichlbaum posed as an ethicist to deliver a speech to more than 300 oilmen attending Canada’s largest oil conference, GO-EXPO. During the speech, The Yes Men reassured the audience that even if oil procedures continue to cause environmental and health problems, the industry could turn the bodies of human victims into fuel. After lighting a candle of Vivoleum, a fuel allegedly made from human bodies, Bichlbaum was escorted off the stage. Yes Man Mike Bonanno joined the event posing as an spokesperson for Exxon. Later he told reporters, “If our idea of energy security is to increase the chances of climate calamity, we have a very funny sense of what security really is. While ExxonMobil continues to post record profits, they use their money to persuade governments to do nothing about climate change. This is a crime against humanity.”

Expose the Guts, Embarrass the Powerful, Have Fun

Under the teaching section on their website, The Yes Men explain their pedagogical approach:

When trying to understand how a machine works, it helps to expose its guts. The same can be said of powerful people or corporations who work hard to make themselves richer—regardless of consequence for everyone else. By catching powerful entities off guard, you can momentarily expose them to public scrutiny. This way, everyone sees how they work and can figure out how to control them. We call this identity correction. In a Nutshell:

Find a target (some entity running amok) and think of something sure to annoy them—something that’s also lots of fun.

If you’re stumped, imagine the target losing control and acting stupidly. What would it take to make them do that?

Capitalize on the target’s reaction. Write a press release and e-mail it to hundreds of journalists. In 1967, Yippies threw a hundred one-dollar bills from a balcony onto the New York Stock Exchange floor. The journalists they’d brought along told the world how the brokers, consumed with greed, dropped their trading and scrambled around for the money.

Preparing the Press Release. Imagine an “objective” newspaper story about the event. How would it read? Be realistic. Then write that story. (Got qualms? This is just what corporations do every day to sell products or candidates.)

The easiest way to embarrass someone powerful is to show how petty they are. Learn to embrace legal threats and use them as evidence in the court of public opinion.

After a screening of the Yes Men Fix the World at the Roxie, audience members and other members participated in a performance about Chevron.

Yes Men Impact

So what’s the impact of The Yes Men? First, they have been successful in attracting media coverage. The confusion and excitement that their events elicit have brought their message to millions of people not often reached by corporate reformers. In the process, the group has cast a shadow on the public images of several major corporations, including Dow Chemical, Halliburton, ExxonMobil, and McDonalds and business organizations like the Chamber of Commerce and the World Trade Organization.

Two films have been made about The Yes Men and their exploits, The Yes Men (2003) and The Yes Men Fix the World (2009), allowing their messages to reach a wider audience and to educate and raises consciousness among activists and reformers.

Some critics accuse The Yes Men of being insensitive—creating hoaxes that could raise false hopes or deceive victims. Others say they are sophomoric, simply ridiculing companies without leading people to meaningful action. In a review of, The Yes Men Fix the World, the New York Times movie critic Stephen Holden observes: “Whether their high jinks accomplish much beyond momentarily embarrassing the corporations and government agencies they misrepresent at business conferences and public forums is an open question. But it is great fun to watch them do their dirty work.”

To be effective, public health researchers, professionals and activists seeking to change harmful business practices need to use a range of tactics and strategies. The Yes Men suggest a model that warrants consideration.

Angela Donadic is a Masters of Public Health student and writes for Corporations and Health Watch.

The two leading members of “The Yes Men,”, known as “Andy Bichlbaum” and “Mike Bonanno” pose as Exxon oil executives shortly after making the announcement of a human-flesh-derived fuel called “Vivoleum” at the Oil and Gas Expo (GO-Expo 2007) in Calgary, Alberta.


Photo Credits:
1. itzafineday
2. joeathialy
3. ari
4. itzafineday

Cash for Clunkers: who benefits?

The Car Allowance Rebate System, better known as “Cash for Clunkers,” is a federal program that gave car buyers a rebate of up to $ 4,500 on a new car if they trade in an older, less fuel efficient car. The program is meant to stimulate the ailing U.S. economy and reduce pollution caused by cars by committing U.S. tax dollars to the foundering auto industry. Late last month, the federal government ended the Cash for Clunkers program two weeks early because the three billion dollars budgeted for the program had been nearly exhausted. Although hundreds of thousands of Americans took advantage of the rebate opportunity to purchase a new car, and nearly the entire budget was spent, it isn’t clear that Americans (and America) will emerge both economically and environmentally healthier. In this profile, CHW examines the impact of the Cash for Clunkers program on our nation’s health and the environment.

Clash for Clunkers was dramatically more successful in engaging new car buyers than Congress or the White House had imagined: the initial one billion dollar budget intended to last through Labor Day was exhausted so quickly that after just 10 days, Congress funneled another two billion dollars into the program to keep up with demand.

President Obama has declared the program a “proven success” citing the “50% increase in fuel economy” and “$700 to $1000 in annual savings for consumers in reduced gas costs alone…”1 The White House’s assessment of the Cash for Clunkers program has reported some large and impressive numbers to back up their declaration of resounding success: nearly 700,000 cars were sold, $2.9 billion  spent,2 and an estimated 42,000 jobs will be created or saved during the second half of the year as a result of the Cash for Clunkers program. Motor vehicle output added 0.20 percentage point to the second-quarter change in real GDP.3

Has Cash for Clunkers Met its Goals?

Although hundreds of thousands of Americans took advantage of the rebate opportunity to purchase a new car, some environmentalists question whether Americans (and America) will emerge both economically and environmentally healthier. They focus on two issues. First, buyers who took the rebate still had to buy a brand new car at costs coming in somewhere around $25,000 to $30,000. This might have simply shifted consumers spending from one place to another. So instead of spending additional money that they wouldn’t have, new car buyers might now be unable to spend on “appliances, clothes and other stuff that consumers will not buy…now that they have the burden of lease or loan payments for their new vehicles.” 4 If this effect is significant, Cash for Clunkers may end up being simply a government plan to favor the success of the auto industry over the many other industries whose goods American could consider consuming. It is also estimated that 60 percent of the cars purchased under Cash for Clunkers would have been purchased this year anyway, meaning that we might see a post-Clunkers lull in business.4

What about the impact on air pollution? The difference between the average miles per gallon of the trade-ins versus the new cars bought through Cash for Clunkers was about nine miles per gallon.5 According to Jack Hidary, an architect of the Clash for Clunkers program, $700 is the gas savings for driving a car that is 10 miles per gallon more efficient, so it is likely that many buyers will save money by getting a new more fuel-efficient car. The Cash for Clunkers program, however, allowed consumers to trade vehicles in for cars that were only slightly more fuel-efficient.  In the case of passenger cars, consumers could use the rebate to purchase a new car with just four miles per gallon more efficient gas use. In the case of light-duty trucks, the rebate was good for new vehicle purchases that got just one or two additional miles per gallon, emphasizing that reducing emissions was a secondary priority for the program.6

But even if new cars purchased under the program were significantly more fuel efficient, it seems unlikely that the program’s impact will be big enough to improve air quality on its own. One columnist noted that if the new cars purchased under the rebate program get “ten miles per gallon more than the Clunkers they replace, the reduction in gasoline consumption will cut our oil consumption by 0.2 percent per year, or less than a single day’s gasoline use.” 4 Few interventions of any kind can contribute to significant, long-term change unilaterally, so it is not surprising that a program like Cash for Clunkers can’t single-handedly make drastic environmental improvements. Perhaps the only undoubted success of Cash for Clunkers has been its impact on the auto industy: Ford and General Motors saw ten and 21 percent increases in sales in August compared to July.7 Toyota posted even bigger gains.

Measuring Up a “Proven Success”

So was Cash for Clunkers good, bad, or a wash? It is worth remembering that public policies to improve the economy and environment are implemented because unemployment and pollution undermine the long- and short-term health and well-being of human, not because the government or civil society has an interest in the physical environment or job markets in and of themselves. Therefore, measuring the success of the Clash for Clunkers program must compare the opportunities provided and lost to improve public health.

Several news articles have mentioned the safety benefits of Cash for Clunkers: newer cars have better and more safety features, therefore the program will put safer cars on the road. As Consumer Reports mentions:

“…450,778 SUVs and other light trucks that likely lacked electronic stability control and other modern safety equipment [were taken off the road through Cash for Clunker]. The National Highway Traffic Safety Administration has estimated that making ESC standard on new cars would save as many as 10,000 lives a year. This program has taken a significant step toward that goal.”5


This is great news, but thinking about vehicle safety also begs the question: why should the federal government spend three billion tax dollars on bailing out an industry whose products kills and injures so many Americans? In 2008, there were 37, 261 people killed in motor vehicle crashes (a record low) and nearly 2.35 million injured. By those figures alone, the morbidity and mortality caused each year by motor vehicles dwarfs the potential safety gains from Cash for Clunkers. In 2007, a total of 288 people were killed on mass transit of any kind, a number less than 1% of those killed by passenger vehicles.8 In 2006 there were 19, 238 people injured on all forms of mass transit, 122 times fewer injuries than the more than two million caused by motor vehicles.9 Yes, these are absolute numbers- so how do these numbers compare when looking at rates? Motor vehicles kill five times as many people per passenger mile than mass transit.10

Public transportation systems, especially light and heavy rails systems, also create less fuel emissions than motor vehicle, and therefore provide a much longer-term investment in environmental health than Cash for Clunkers can achieve. What if Congress had instead given the auto industry $3 billion to invest in developing new capacities for making mass transit vehicles?

The Cash for Clunkers program also represents a lost opportunity to improve public health in other ways. The nearly three billion dollars spent to boost the auto industy did very little for a key piece of our economic crisis: inequality. The proportion of wealth and earnings by the richest 10% of our communities has steadily risen in the past 30 years. This growing inequality was intimately connected to the underlying causes of the current economic crisis: predatory lending and banking practices that promised to earn executives and their brokers exorbitant amounts of money. Inequality has been documented in public health research as a causal factor in social and health outcomes as diverse as teen birth and mortality. The Cash for Clunkers program, however did little to provide a way for low-income folks to benefit from the government commitment to stimulate the economy. For example, despite the claimed objective to get “clunkers” off the road, cars older than 25 years could not be traded in for the rebate, even though they are the most-polluting, and least fuel efficient and safety advanced vehicles. Also, all cars that were traded in, even if they were fairly new and running well, had to be destroyed under the program’s rules, bringing up the questions of what to do with 700,000 newly junked cars. Will lower-income families who cannot afford a brand new car now have more trouble finding a used (but less than 25 year old) car at all, since trade-ins have to be legally destroyed? Will the destroyed cars pose another set of environmental problems?

As one columnist argued: “…By mandating the destruction of trade-ins, Congress removed 700,000 cars from the used-car market, inevitably driving up prices of the cars that lower-income consumers tend to buy.”4

While no data have come out showing this prediction to be true, it seems that the Cash for Clunkers program did not take advantage of what we know about public health: policy approaches to reduce inequality have economic and health benefits. These same policy approaches, however, also require abandoning the government’s monetary, legislative, and otherwise political support of corporations that harm health. From the subsidizing of harmful industries like the auto industy to the extreme financial deregulation of a decade ago, these pro-corporate polices may appear to be bids for a strong economy, but the impacts are much different. For example, financial deregulation led to the lending practices that disproportionately preyed upon low-income communities and communities of color, and led to the current economic recession.

How About Cash for Buses and Subways?

Why, then, should the federal government’s stimulus efforts ensure that the auto industry survives, as opposed to investing in any other businesses or industries in the United States? An alternative to bailing out a failing industry is to invest in an industry that has seen sharp growth in the past year: mass transit. Currently, mass transit systems across the country are experiencing tremendous cuts to their already inadequate budgets. For example, in July alone the New York City Metro Transit Authority announced 360 jobs cuts, despite having experienced a significant uptick in ridership since the U.S. economy took a downturn. Although mass transit systems are efficient and affordable for riders, urban municipalities that currently maintain such systems do not have sufficient funds to maintain and upgrade them, and fare revenues cover only from 20 to 50% of the costs of maintaining the transit systems.11

src=”uploads/images/old_archives/img/mass_transit_promotion.png” alt=”mass transit promotion by Metro Library and Archive” hspace=”10″ vspace=”5″ width=”250″ height=”250″ align=”right” />A stimulus package that invests in the research, business planning, and workforce to upgrade and create effective mass transit systems has multiple benefits. Cash for Clunkers may have caused an uptick in the employment and earning of auto industry workers, but as many have pointed out, nearly 60% of the sales made under Clash for Clunkers would have happened in the next year anyway, leaving auto workers to brace for another severe dip in demand. Investing in mass transit infrastructure, on the other hand, will lay the groundwork for strong job markets in a variety of fields (from engineering to sanitation) required to support smart, efficient public transportation. The recession has caused a surged in mass transit use across the country, causing its use to reach a 50-year high11,12 and therefore providing a key opportunity to shift transportation trends in the U.S. towards the long-term, permanent growth of these infrastructures. In fact, the Obama Administration’s stimulus package did commit just over eight billion dollars to capital improvements in mass transit systems, including high speed rail lines.12,13 Hopefully this infusion of funds represents more than a temporary stimulus, but a longer-term investment in health promoting industries than can provide sustainable employment, and provide for safe, effective transportation for many times more Americans than just those who can afford a new car.

The gains to the health of U.S. economy and environment as a result of the Cash for Clunkers program can be considered modest at best, and at worst, the U.S. government’s political investment in supporting an industry whose products, cars and trucks, directly contributes to poor health in several ways. The need for government to spur spending, and therefore job growth, could have dovetailed with environmental and public health goals much more effectively. Public policies that foster investments in public transportation is just one of those alternatives. Strengthening mass transit will stimulate job growth and retention in an industry that can be counted on to continue to experience thriving market demand, reduce American consumers’ impact on the environment, and promote public health.



1 Hedgpeth D; Bacon P.With Senate Vote, Congress Refuels ‘Clunkers’ Program. The Washington Post August 7, 2009. Available at: Accessed August 16, 2009.

2 Puzzanghera J; Zimmerman M. ‘Cash for clunkers’ final tally: nearly 700,000 cars sold. Los Angeles Times. Available at:,0,2161518.story?page=2 Accessed August 31, 2009.

3 Bureau of Economic Analysis. Available at: Accessed September 1, 2009.

4 Stelzer I. Seven lessons of Cash for Clunkers’ failure The San Francisco Examiner. August 28, 2009. Available at: Accessed September 1, 2009.

5 Evarts E. Consumer Reports. August 27, 2009. Available at: Accessed September 1, 2009.

6 Fact Sheet: Cash for Clunkers Committee on Energy and Commerce. June 8, 2009. Available at:
. Accessed August 2, 2009.

7 Barth L. September 2, 2009. Available at: Accessed September 2, 2009.

8 United States Department of Transportation Federal Transit Administration. Available at: Accessed September 1, 2009.

9 Bureau of Transportation Statistics. Table 2-33c: Table 2-33a: Transit Safety Data by Modea for All Reported Incidents. Available at:
. Accessed August 25, 2009.

10 Morris EA.The Danger of Safety. Freakonomics Blog from The New York Times.July 2, 2009. Available at: Accessed September 1, 2009.

11 Public Transit Faces New Pressures.  March 10th, 2009. Available at: Accessed September 1, 2009.

12 Epstein, D. For Ailing Transit Systems, Stimulus Windfall Is a Mixed Blessing. June 21, 2009. Available at: Accessed September 2, 2009.

13 Hochberg A. A Hitch For Rail Riders: Getting To Final Destination. September 2, 2009. Available at: Accessed September 2, 2009.


Photo Credits:

The health impact of retail practices: towards a research agenda

Every day, owners and managers of hundreds of thousands of retail establishments across the United States make decisions that influence the health of the American people. They decide what to sell, which products to promote, where to display goods and how much to charge for them, and where to locate new outlets.  Their decisions shape the choices consumers face in the market and make it easier or harder for people to buy tobacco, alcohol, food and beverages, medicines, firearms, automobiles or many other products associated with current patterns of health and disease.  In this review, Corporations and Health Watch provides an overview of the impact of retail practices on health and suggests some directions for future research that can guide policies to encourage health-promoting and discourage health-harming retail practices.

Retail practices are the decisions that owners and managers of retail establishments make about how, where and when to sell what to whom.  These practices, listed below, are shaped by corporate policies, the state of the economy, government regulations, customer behavior and many other factors. Other business practices such as product design, pricing and advertising influence and are influenced by decisions about retailing, making it difficult to isolate the unique impact of decisions about retail operations.

While public health officials and advocates have sometimes looked at specific retail practices such as the sales of tobacco products to minors or food safety procedures in restaurants, few public health agencies or researchers have systematically considered retail practices as an important influence on health or considered alternative approaches to encouraging healthier retail business practices.


Selected Retail Practices

Point of purchase advertising
Local advertising 
Internet merchandising
Location and density of stores
Product placement within stores and on shelves
Shelf space dedicated to various products
Sales and pricing
Labeling and warning signs
Verification of customer eligibility (e.g. tobacco, alcohol and guns)


As we shall see, growing evidence makes a compelling case for studying the health impact of retail practices more carefully and of developing new approaches to preventing their adverse consequences.  First, retail outlets are everywhere, as shown below.  No community and few neighborhoods are without several convenience stores, fast food establishments, tobacco and alcohol outlets and drug stores.  Most Americans can buy a gun or an automobile within a few miles of their home. On any given day, up to 100 million Americans visit a convenience store.1 Thus retail outlets are a ubiquitous part of our social environment that play a major role in determining  patterns of the sale and consumption of healthy and less healthy products.


Prevalence of Selected Retail Outlets in US

19,700 new car and truck dealers 2

30,000 beer, wine and liquor stores 3

35,394  supermarkets with $2 million or more in annual sales4

54,000 federally licensed gun dealers5

56,000 retail pharmacies6

80,000 casual-dining restaurants7

144,875 convenience stores8

195,000 fast-food establishment7


Second, data suggest that number of retail outlets or their size is growing, at least in some categories. Between 1970 and 2001, for example, the number of fast food restaurants in the United States increased more than seven-fold, from 30,000 to 222,000.9 While the overall number of super markets appears to have declined, the number of very large stores has increased significantly. Wal-Mart, for example, the world’s largest public corporation, operated 125 stores in the United States in 1975 and 3,800 by 2005.10 The vastly expanded shelf space available in Wal-Mart superstores puts many more products, some healthy and many unhealthy, at the fingertips of consumers across the United States, profoundly influencing the diet of millions of Americans. Similarly, the growth of pharmacy retail chains puts many drug, food and other products within easy reach.

Third, a growing body of research evidence shows that the characteristics of retail establishments influence health and health behavior. For example, local gun retail availability is significantly associated with increased risk of firearm injury and homicide,11 and alcohol outlet density is associated with self-reported driving after drinking and drinking frequency.12Patients living in areas with fewer pharmacies are less likely to fill prescriptions for medications.13 Exposure to point-of-purchase tobacco advertising is associated with higher tobacco use.14 These and dozens of other studies show that retail practices influence health, making a summary and synthesis of these diverse studies an important priority. For a selected bibliography on the health impact of retail practices in the alcohol, automobile, firearm, food and beverage, pharmaceutical and tobacco industries, click here.

In addition, differences in retail practices in different types of communities may contribute to socioeconomic and racial disparities in health. For example, the differing retail face of the alcohol, tobacco and food industries in better off and poor neighborhoods and in Black, Latino and white areas may explain some of the differences in cancer prevalence among these communities. 15 In some studies, differences in the density of supermarkets and fast food outlets in neighborhoods with different socioeconomic and racial/ethnic characteristics have been associated with differences in rates of obesity.16 17

Convenience stores illustrate well how retail outlets can become amplifiers of ill health. Often sited at gasoline stations, convenience stores sell candy, ice-cream, soft drinks, and processed food as well as other products and perhaps some groceries. They are often located along busy highways, in densely-populated urban neighborhoods, or near transportation hubs. Some are open 24 hours a day. In 1994, there were 98,200 convenience stores in the US, today the count is 144,875, an increase of almost 50%.8 In 2008, as shown below, convenience stores sales of cigarettes and other tobacco products accounted for 36.6 % of in-store sales; packaged beverages, mostly sweetened sodas, accounted for 14.1 %; food service, often high fat, sugar and salt cooked products, accounted for 13.9% and beer for 10.2 %.18 This product mix makes these outlets convenient places to purchase the products associated with the nation’s most serious health problems including heart disease, diabetes, stroke, cancer and alcohol-related motor vehicle accidents.


Percentage of Products Sold at Convenience Stores, 2008

Convenience stores sell the products associated with the nation’s most serious health problems including heart disease, diabetes, stroke, cancer and alcohol-related motor vehicle accidents.


Changing Retail Practices to Improve Health

Fortunately, there are several domains of experience in modifying the health impact of retail practices that provide evidence that can guide policy and practice. As shown below, local, state and federal governments, consumers, corporations and retail owners themselves can each take action to change harmful practices. To date, most of these approaches have been tried somewhere but few studies provide evidence about which strategies or mix of strategies are most effective in promoting health and under what circumstances.


Strategies for Changing Retail Practices to Promote Health and Prevent Disease

Changes initiated by government

  • Regulation of products (what is sold, price (via taxes or subsidies), quality; customers (age, sobriety, mental status, criminal record); store environment (safety, hygiene, etc.)
  • Requirements for posting of labels or warning signs
  • Requirements on density of outlets, distance from schools or churches
  • Regulations on hours of operations

Changes initiated by consumers

  • Community organizing to encourage police or regulatory action
  • Boycotts of stores or products

Changes initiated by corporations

  • Slotting fees to support healthier products
  • Development and promotion to retailers of healthier products

Changes initialed by retailers

  • Voluntary posting of health information
  • Strict enforcement of rules on sales to minors
  • Discounts on healthier products

To illustrate with tobacco, perhaps the industry with the best studied retail practices, change can come about through:

  • Restrictions on sales to minors
  • Requirements for warning labels in stores
  • Zoning laws limiting density of tobacco outlets
  • Requirements for placement of displays of tobacco products
  • Consumer boycotts of merchants who continue to sell to minors
  • Ending tobacco industry payments and incentives to merchants who sell their  products
  • Voluntary retailer agreement to stop selling or displaying tobacco products

A review of the evidence on retail practices provides some grounds for optimism that changes in these practices can contribute to healthier environments, behaviors and health outcomes. For example, the decision by a single gun store owner in Milwaukee to stop selling cheap Saturday night special hand guns was associated with a 96% decrease in recently sold, small, inexpensive handguns use in crime in Milwaukee, a 73% decrease in crime guns recently sold by this dealer, and a 44% decrease in the flow of all new, trafficked guns to criminals in Milwaukee.19 In 2007, New York City required restaurant chains to post prominently the caloric content of the food they sold, a policy subsequently adopted by many other municipalities and states. Preliminary evidence suggests that calorie posting may be associated with changes in consumer behavior and in the products that restaurants offer but more research is needed.20 21 22 23 Synthesizing findings such as these from policy, programmatic, voluntary and mandatory efforts to change retail practices across industries and jurisdictions may contribute to new approaches to primary prevention.

Research Questions on Retail Practices and Health

Available evidence suggests that retail practices influence health, that intentional changes in these practices can promote health, and that some jurisdictions have successfully implemented such changes. Thus, the development of a systematic body of knowledge to guide elected and public health officials and advocates may help to accelerate these changes, thus reducing the prevalence and inequities in chronic diseases, accidents and injuries and other health problems. What are some research priorities for a better understanding of the impact of retail practices on health?

  1. How do retail practices change over time and place?

In the last few decades, the density and size of many retail outlets has increased significantly. Some sectors have become increasingly vertically integrated—think Wal-Mart –giving them far greater influence in the economy and in communities. How do macro-economic forces change retail practices? The current recession seems to be favoring retailers who offer bargains and hurting more high-end outlets. What are the health consequences of these changes? Does the recession present any opportunities for more effective oversight of harmful retail practices? What are the best metrics for studying changes in retail practices? For example, a recent study found that that the cumulative shelf-space allocated to energy-dense snack foods was positively but modestly associated with BMI24, suggesting that the imaginative selection of indicators such as shelf-space may help to assess the impact of changes in retail practices.

  1. What’s the role of retailers in the supply chain and what decisions do they make?

From the time a product is manufactured until it reaches the consumer’s hands, it passes through many other hands, including growers, factory workers, packagers, wholesalers, distributors, and truckers. What is the influence of each of these stages on the health impact of retail practices? What are the opportunities for intervention at each stage? In addition, retailers vary in the degree of vertical integration and autonomy granted to local managers.25 How do the health-related retail practices of a vertically integrated company like Wal-Mart,10 which provides detailed real-time data on purchases to store managers, differ from those of chains that give franchisees more autonomy, such as the Subway fast food chain or independent retailers?

To change retail practices will require identifying who makes what decisions. At McDonald’s, for example, managers have little control over what products to offer, suggesting that campaigns to modify product mix will need to target the national corporate level. Bodegas and grocery stores, on the other hand, could decide to display alcohol and tobacco products less prominently, perhaps in exchange for support from health officials for displaying healthier products. Some chain stores set retail prices nationally, while others give local managers discretion. Mapping decision-making across industries and levels (e.g., global and national corporate, regional and local) might help health officials decide on appropriate levels for intervention to achieve a specified change in practice.


  1. What’s the impact of retail practices on disparities in health?

As noted previously, differences in retail practices in communities with different socioeconomic and racial/ethnic characteristics appear to contribute to health inequities.15 What is the fraction of inequities in obesity, diabetes or heart disease that can be attributed to such differences? What are the windows of opportunity for changing disparity-enhancing retail practices such as higher density of alcohol outlets in poor communities or more lax enforcement of tobacco regulations? Does the human rights perspective or civil rights law offer a way of re-framing these issues? For example, some community groups have charged that higher densities of fast food outlets in Black or Latino neighborhoods constitutes a form of racial profiling that widen disparities in health.

On another front, health advocates need to ensure that health-promoting changes in retail practices do not end up exacerbating health inequities. For example, if a supermarket offers healthier food at a higher price, only better off customers may benefit, widening existing socioeconomic disparities in obesity or other food-related health conditions.

  1. What incentives can health officials use to encourage health-promoting changes in retail practices?

For retailers to change practices voluntarily, the costs of change and the adverse impact on their bottom lines need to be low and the promise of a better reputation and increased sales volume and profits needs to be high. A pharmacist may be willing to offer discounts on some prescription medicine to attract customers or a fast food outlet may add salads or fruits to their menus to entice health-conscious mothers and their children. When do these changes lead to real improvement in health and when are they merely public relations window dressing? Health officials and advocates with a firm grasp of how retailers make decisions might be better able to negotiate meaningful changes than those who have to rely on retailers’ good will. For example, a study of how fast food owners made decisions about their menus found that obstacles to healthier menus included the belief that the demand for healthier foods is low and that healthier menu items have a short shelf life and take more time and money to prepare.26 Finding ways to help managers overcome these obstacles may lead to change.

  1. What advocacy strategies are most effective in changing retail practices?

Only a few studies have compared advocacy strategies across industries27 28, and none appear to have focused specifically on campaigns to change retail practices. Developing evidence-based guidelines for selecting the most effective activities to change practices such as location of retail outlets, point-of-purchase marketing or store-based labeling can help health officials and advocates to make more informed strategic decisions.

From a community organizing perspective, one asset for mobilizing for changes in retail practices is that retail outlets have a visible presence in most communities, making them an attractive target. On another level, small business owners often identify with their communities, making them perhaps more open to moral appeals for changing harmful practices and also less likely to leave for other jurisdictions in response to demands for change.

For retail outlets that are closely controlled by a single corporation – McDonalds, Wal-Mart, Walgreens or CVS Pharmacies — shareholder actions by national consumer groups or corporate campaigns using internet or other new communications media might be an option. For global companies whose brand names and logos are their most valuable asset, the threat of a campaign that could engage customers in boycotts or brand shifting at local outlets around the country or world remains a powerful fear.29

Aggregating and analyzing advocacy and health department experiences from diverse efforts to change retail practices can help to develop a framework for selecting effective and efficient strategies.


  1. How can advocates integrate local and global efforts to reduce the harm of retail practices?

Activists seeking to change corporate practices that harm health have learned that successes in one place can lead to defeats in others. In tobacco control, for example, success in changing the practices of the tobacco industry in the United States and other developed nations has led to more aggressive marketing and public relations campaigns in Africa, Asia and Latin America.  Forcing harmful practices to migrate to another region or country can unintentionally maintain or exacerbate developed and developing nation disparities.  How can public health officials and advocates avoid this outcome as they seek to change retail practices?  One strategy that some corporate reform groups have used is to establish global websites and networks, providing a forum for activists working across issues, industries and continents to share information and debate strategy. Some of these focus more on labor and environmental issues than on the retail consumer practices described here.  The box below shows some sources on monitoring retail practices.


Selected resources and organizations on monitoring of retail practices

Corporate Accountability International Value the Meal

Cruz TB. Monitoring the tobacco use epidemic IV. The vector: Tobacco industry data sources and recommendations for research and evaluation. Prev Med. 2009;48(1 Suppl):S24-34.


Slater S, Giovino G, Chaloupka F. Surveillance of tobacco industry retail marketing activities of reduced harm products. Nicotine Tob Res. 2008;10(1):187-93.


Wagner MM, Robinson JM, Tsui FC, Espino JU, Hogan WR. Design of a national retail data monitor for public health surveillance. J Am Med Inform Assoc. 2003;10(5):409-18.

Wagner MM, Tsui FC, Espino J, et al.  National Retail Data Monitor for public health surveillance. MMWR Morb Mortal Wkly Rep. 2004 Sep 24;53 Suppl:40-2

Wal-Mart Watch


Towards a public health agenda on retail practices 
In sum, retail outlets constitute a critical intermediary between the producers and consumers of products that influence health. A better understanding of the forces that shape retail environments and practices may help to inform new approaches to primary prevention of our most serious health problems in these settings. By defining research, advocacy and policy agendas to enhance health- promoting and discourage health-damaging or disparity-widening retail practices, health professionals can contribute to improved population health.


By Nicholas Freudenberg, Distinguished Professor of Public Health at Hunter College, City University of New York and the founder and director of Corporations and Health Watch.



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17 Morland KB, Evenson KR. Obesity prevalence and the local food environment. Health Place. 2009;15(2):491-5.

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19 Webster DW, Vernick JS, Bulzacchelli MT. Effects of a gun dealer’s change in sales practices on the supply of guns to criminals. J Urban Health. 2006;83(5):778-87.

20 Harnack LJ, French SA. Effect of point-of-purchase calorie labeling on restaurant and cafeteria food choices: A review of the literature. Int J Behav Nutr Phys Act. 2008 ;5:51.

21 Ludwig DS, Brownell KD. Public health action amid scientific uncertainty: the case of restaurant calorie labeling regulations. JAMA. 2009;302(4):434-5.

22 Kuo T, Jarosz CJ, Simon P, Fielding JE. Menu labeling as a potential strategy for combating the obesity epidemic: a health impact assessment. Am J Public Health. 2009;99(9):1680-6.

23 Gerend MA. Does calorie information promote lower calorie fast food choices among college students? J Adolesc Health. 2009;44(1):84-6.

24 Rose D, Hutchinson PL, Bodor JN, Swalm CM, Farley TA, Cohen DA, Rice JC. Neighborhood food environments and Body Mass Index: the importance of in-store contents. Am J Prev Med. 2009;37(3):214-9.

25 Paik Y, Choik DY. Control, autonomy and collaboration in the fast food industry. International Small Business Journal 2007; 25(5):539-562.

26 Glanz K, Resnicow K, Seymour J, Hoy K, Stewart H, Lyons M, Goldberg J. How major restaurant chains plan their menus: the role of profit, demand, and health. Am J Prev Med. 2007;32(5):383-8.

27 Nathanson CA. Social movements as catalysts for policy change: the case of smoking and guns. J Health Polit Policy Law. 1999;24(3):421-88.

28 Freudenberg N, Bradley SP, Serrano M. Public health campaigns to change industry practices that damage health: an analysis of 12 case studies. Health Educ Behav. 2009;36(2):230-49.

29 Jones P, Comfort d., Hillier d. Anti-corporate retailer campaigns on the internet. International Journal of Retail Distribution Management 2006;34(12): 882-891.


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