Alcohol, tobacco, and unhealthy foods contribute greatly to the global burden of non-communicable disease (NCD). Member states of the World Health Organization (WHO) have recognized the critical need to address these three key risk factors through global action plans and policy recommendations. The 2013-2020 WHO action plan identifies the need to engage economic, agricultural and other relevant sectors to establish comprehensive and coherent policy. To date one of the biggest barriers to action is not so much identifying affective policies, but rather how a comprehensive policy approach to NCD prevention can be established across sectors. Much of the research on policy incoherence across sectors has focused on exposing the strategies used by commercial interests to shape public policy in their favor. Although the influence of commercial interests on government decisions remains an important issue for policy coherence, we argue, that the dominant neoliberal policy paradigm continues to enable the ability of these interests to influence public policy. In this paper, we examine how this dominant paradigm and the way it has been enshrined in institutional mechanisms has given rise to existing systems of governance of product environments, and how these systems create structural barriers to the introduction of meaningful policy action to prevent NCDs by fostering healthy product environments. Work to establish policy coherence across sectors, particularly to ensure a healthy product environment, will require systematic engagement with the assumptions that continue to structure institutions that perpetuate unhealthy product environments.

There has been growing tension at the intersection of health and economic policymaking as global governance has increased across sectors. This tension has been particularly evident between tobacco control and trade policy, as the international norms that frame them – particularly the Framework Convention on Tobacco Control and the World Trade Organization (WTO) – have continued to institutionalize. Using five case studies of major tobacco-related trade disputes from the principal multilateral system of trade governance – the WTO/General Agreement on Tariffs and Trade – we trace the evolution of these interacting norms over nearly 25 years. Our analytic framework particularly focuses on the actors that advance, defend and challenge these norms. We find that an increasingly broad network, which includes governments, intergovernmental organizations, non-governmental organizations and members of the epistemic community, is playing a more active role in seeking to resolve these tensions. Moreover, key economic actors are beginning to incorporate health more actively in their messaging and activities. We also demonstrate that the most recent resonant messages reflect a more nuanced integration of the two norms. The tobacco control example has direct relevance to related policy areas, including environment, safety, access to medicines, diet, and alcohol.

Background The preservation of the economic livelihood of tobacco farmers is a common argument used to oppose tobacco control measures. However, little empirical evidence exists about these livelihoods. We seek to evaluate the economic livelihoods of individual tobacco farmers in Malawi, including how much money they earn from selling tobacco, and the costs they incur to produce the crop, including labour inputs. We also evaluate farmers’ decisions to contract directly with firms that buy their crops. Methods We designed and implemented an economic survey of 685 tobacco farmers, including both independent and contract farmers, across the six main tobacco-growing districts. We augmented the survey with focus group discussions with sub-sets of respondents from each region to refine our inquiries. Results Contract farmers cultivating tobacco in Malawi as their main economic livelihoods are typically operating at margins that place their households well below national poverty thresholds, while independent farmers are typically operating at a loss. Even when labour is excluded from the calculation of income less costs, farmers’ gross margins place most households in the bottom income decile of the overall population. Tobacco farmers appear to contract principally as a means to obtain credit, which is consistently reported to be difficult to obtain. Conclusions The tobacco industry narrative that tobacco farming is a lucrative economic endeavour for smallholder farmers is demonstrably inaccurate in the context of Malawi. From the perspective of these farmers, tobacco farming is an economically challenging livelihood for most.

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To address the rise in non-communicable diseases (NCDs), governments are now being urged to 'put forward a multisectoral approach for health at all government levels, to address NCD risk factors and underlying determinants of health comprehensively and decisively' [UN, 2011. Political Declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases (No. A/66/L.1). New York, NY: United Nations]. There is a global consensus that whole-of-government approaches (WG) can be particularly effective in regulating products such as tobacco, pre-packaged foods and alcohol, which are or can be major risk factors for NCDs. Despite the overwhelming push towards interagency arrangements for health policymaking and implementation, including in contemporary efforts to prevent and control NCDs, there has been minimal investigation into how countries have pursued WG and which types of institutional designs and arrangements offer particular utility to achieve health objectives. This article examines these issues through a case study concerning the interagency mechanism that the Philippine government currently utilizes to govern tobacco control, the Interagency Committee-Tobacco (IAC-T). We conducted key informant interviews (n = 33) with government officials, and representatives from civil society organizations, health professional associations and intergovernmental organizations. We targeted informants who have been involved in the work of the IAC-T and/or tobacco control policy more broadly. We also analysed public documents to contribute to our analysis of the structure, functioning and legal status of the IAC-T. Our findings highlight two salient challenges that arose in the Philippines case: (1) the inclusion of industry representation on the IAC-T and (2) the attempt to consolidate the responsibilities of the different departments through a policy of 'balance' between health and commercial interests. We analyse how health proponents navigated this challenging institutional arrangement and the various barriers they faced in achieving the intended health objectives. We draw from this case to discuss the lessons that can inform broad calls for WG to NCDs.