Navigating conflicting mandates and interests in the governance of the commercial determinants of health: the case of tobacco in Fiji and Vanuatu.

Abstract

The consumption of tobacco, alcohol, and ultra-processed foods and beverages is driving the global noncommunicable disease (NCD) crisis. The commercial determinants of health (CDOH) have been recognized as the practices of industries aimed at increasing the availability, affordability, desirability, and consumption of commodities that are risk factors for NCDs. Addressing CDOH requires policy coherence across multiple government sectors; however, the objectives of these sectors do not always align with public health goals, and conflicting mandates can be aggravated by the interference of harmful commodity industries. Pacific small island developing states (PSIDS) face particular difficulties among low- and middle-income countries (LMICs) in negotiating such governance dilemmas, due to vulnerabilities arising from their small population and economy, geographic isolation, and being scattered across several islands. This is a major issue, because PSIDS are currently undergoing an NCD crisis, thus it is crucial to improve understanding of how their governments can better govern the harmful commodity industries.

This dissertation is focusing on the governance of tobacco, because (i) the ways in which the tobacco industry (TI) influences governments are the most documented among the harmful commodity industries; (ii) the responsibilities of governments to control tobacco are the most binding compared to other harmful commodities; and (iii) there has been increased recognition that the ultra-processed food and beverage and alcohol industries globally have adopted similar strategies and arguments used by the TI, thus there is a growing interest in understanding the transferability of governance approaches from the tobacco control domain.

The literature points towards the importance of interests, ideas, and institutions in shaping the ways governments manage multisectoral work on the regulation of tobacco. However, little empirical evidence is available to examine how these conditions influence PSIDS. This gap is critical, because these countries have a remarkably different social, political, cultural, and economic context than other LMICs, which makes the implementation of practices recommended by health experts to regulate harmful commodities particularly challenging.

This research aims to improve understanding of the conditions that influence how governments in PSIDS address the commercial determinants of NCDs in relation to tobacco. This aim was achieved by applying a qualitative methodology with an exploratory case study approach, with a focus on agenda setting and policy making in tobacco governance. This dissertation expands the evidence base and scholarly knowledge of the interests, ideas, and institutions which influence the way PSIDS governments - more specifically, those of Fiji and Vanuatu - address the commercial determinants of NCDs, with a focus on tobacco. Two key insights have emerged from the findings of this research. Firstly, the vulnerabilities of PSIDS must be taken into account and addressed as major structural drivers in order to successfully govern the commercial determinants of NCDs in these countries. Secondly, the dominant causal ideas must be altered to support the governance of commercial determinants of NCDs. This research has started to build the necessary empirical evidence and academic knowledge to help inform the ways a shift in interests, ideas, and institutions can be realised to enable the control of CDOH in PSIDS.