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There is growing recognition that commercial actors can have a significant impact in shaping health determinants and outcomes. The Commercial Determinants of Health (CDoH) are defined as ‘the systems, practices, and pathways through which commercial actors drive health and equity’ (Gilmore et al., 2023, p. 1195). Examples include how global market structures and systems contribute to the concentration of wealth in an increasingly small number of hands, the maldistribution of public goods, the interplay between politics and economics which prioritizes wealth over health and the strategies that corporations may use to undermine public health when their profits are threatened. Some corporations such as tobacco, gambling, alcohol and extractive industries have had well-documented negative impacts on health, including non-communicable diseases (Connor, 2017; Winnall et al., 2020; Levy et al., 2021; Thomas et al., 2023b), infectious illnesses (Hanif, 2018; Lyatuu et al., 2021) and vector-borne diseases (Jones et al., 2018), as well as a range of social harms (Schrecker et al., 2018; Thomas et al., 2023a). In the pursuit of extracting profit from communities, such corporations may also seek to legitimize their role in developing policy responses to the very problems that they have caused (McCambridge et al., 2018). Recent frameworks have provided structures for conceptualizing, researching and responding to the CDoH as risk factors for different population groups (Gilmore et al., 2023). As with the social determinants of health, commercial determinants can also contribute to health and social inequity. Gender provides an important case study of this. While women (and girls) are already at increased risk of health and social inequalities, there are still gaps in our understanding of how commercial determinants may contribute to these risks (Hill and Friel, 2020). This includes how they may be negatively impacted by a range of commercial production and consumption processes, as well as the capture of ‘gender equity’ framing in claimed and often heavily promoted corporate social responsibility initiatives that may be used by industry to deflect and delay regulatory intervention. While CDoH scholarship often focuses on practices (such as marketing) that may influence the consumption of harmful products, we contend that investigations into the impact of the CDoH should also examine how primary, secondary and tertiary production processes may shape women’s health and well-being. From the fashion industry to tobacco companies, structural factors associated with production processes can exacerbate gender inequalities, with women vulnerable to low wages and exploitative conditions, including long working hours, unsafe working conditions and gender discrimination, all of which contribute to the cycle of poverty (International Labour Organization, 2022). Women’s often precarious involvement in agriculture, manufacturing and mining provide some examples of how harmful primary and secondary production processes may disproportionately impact on their health and well-being. Women account for almost half of the world’s agricultural labor force and may be involved in paid and unpaid activities that expose them directly to harmful chemicals that lead to a range of negative health effects, including reproductive risks (Atinkut Asmare et al., 2022). For example, women working as tobacco farm laborers may be exposed to harmful pesticides and nicotine (Singha and Kanna, 2022). While corporations have profited from ‘fast fashion’ and cheap disposable clothing, women in low- and middle-income countries working in the garment industry (who produce 90% of the world’s clothing) may still be subjected to continued unfair labor conditions, inadequate pay, health hazardous environments, and violence (Bick et al., 2018; Akhter et al., 2019). Women working in the mining industry may also experience unique discrimination due to the male-dominated nature of this industry (Parmenter and Drummond, 2022). In some countries, they are often confined to the most menial, lowest paid and most labor-intensive roles as compared to men (Armah et al., 2016). They may also work with children by their side, exposing both mother and child to dust, mercury, polluted water and other toxic chemicals (Armah et al., 2016; Landrigan et al., 2022). There are additional impacts for women’s reproductive health and the health of unborn children, as well as inadequate nutrition and increased risk of infectious diseases due to poor sanitation (Armah et al., 2016; Geenen et al., 2022). There are also distinct gender disparities when it comes to decision-making positions in the private sector (OECD, 2021). Women are still significantly under-represented in positions of influence and senior management within corporations, with less representation in entrepreneurship and self-employment, and significantly fewer women than men perceiving that they have the knowledge and skills to start their own businesses (OECD, 2021). Commercial actors also use a sophisticated range of tactics to strategically appeal to different groups of women. By symbolically appealing to their values and interests, social norms are shaped in relation to women’s consumption of products that may be harmful for their health (Hill and Friel, 2020). For example, the tobacco, alcohol, gambling and firearms industries have used a range of marketing tactics associated with fashion and glamor to promote their products, including promoting and aligning their products with fashion events (such as London Fashion Week), women’s clothing brands and fashion influencers (Atkinson et al., 2022; Ernster, 1986; Thomas et al., 2020; Trotta, 2019). At the same time, many of the risks specifically associated with women’s consumption of these products are downplayed by harmful industries. For example, research has demonstrated that while the alcohol industry has targeted women, they misrepresent the risks of breast cancer (Petticrew et al., 2018), and have opposed pregnancy warning labels on alcohol products (Heenan et al., 2022). The alcohol and tobacco industries have also capitalized on women’s health concerns, particularly in relation to weight management, in product development and health-oriented marketing (Feeny et al., 2021; Cao et al., 2023). Some strategies specifically exploit women’s fears and insecurities for profit, including the framing of promotions around the need for guns (Jordan et al., 2020), commercial weight loss products and services (Mishra, 2017), breast milk substitutes (Pereira-Kotze et al., 2022) and alcohol (Bosma et al., 2022). A range of marketing and framing strategies have also been used to promote female empowerment, aiming to normalize and shift women’s attitudes toward ‘masculine’ products (Atkinson et al., 2019). For example, tobacco companies have portrayed their products as symbols of independence, equality and freedom by using powerful imagery of strong, confident women, marketing cigarettes as part of the female liberation movement (Boyd et al., 2003; Schmidt, 2012). More recently, researchers have shown that the gun lobby has used a range of empowerment narratives to challenge gender ideologies that have prevented women from owning guns, communicating messages about safety, recreational shooting and hunting to socialize women into gun culture (Schwartz, 2021). Perceptions that some alcohol products are ‘masculine’ have led to the development of a range of novel ‘female friendly’ alcohol products (Atkinson et al., 2022). Similarly, the gambling industry has used a range of promotional strategies on social media platforms such as TikTok to engage women in novelty betting markets such as the outcomes of popular reality shows, baby showers and Super Bowl performances (McCarthy et al., 2022; Belot, 2023). Corporations have sought to portray themselves as socially progressive by engaging in discussions and practices about gender equity while simultaneously undermining women’s health. This has involved strategically associating some of their messages with gender equity in communications and through CSR messages, including aligning themselves with women’s causes to create a positive brand image (Hill and Friel, 2020). The alcohol industry has sponsored International Women’s Day events and campaigns (Cousins, 2022), funds cancer charities, and have engaged in ‘pinkwashing’ around breast cancer awareness campaigns (Mart and Giesbrecht, 2015). Sponsorship of entertainment and sporting events popular with women has allowed corporations to create a narrative of progress toward gender equality, simultaneously enhancing their brand image by demonstrating support for women’s events while also expanding their customer base (Morgan, 2019). Tobacco and gambling companies also portray an image of gender equality by highlighting the advancement and empowerment of women in their workforce (Entain, 2021; Philip Morris International, 2022). Broad CDoH frameworks provide important starting points for analyzing the risks that commercial practices may pose to specific population groups. Striving for gender equity must include bold and transformational action in addressing the negative impact of commercial practices on the health and well-being of women (and girls). Collaborating and co-designing programs with women is essential in focusing on issues that matter most to them. This includes moving beyond merely amplifying women’s voices—in market capitalist systems, governments, civil society initiatives, boardrooms and elsewhere—toward involving them as decision-makers in developing solutions to the factors that are driving inequities. While harmful corporations may claim that they are socially responsible in supporting and empowering women, it is important that we do not legitimize the role of these organizations as partners, collaborators, funders or decision-makers. While there is undoubtedly both scope and need for major further initiatives, these should come from governments, health organizations, genuine philanthropists and others—not as part of harmful industry reputational management strategies. As part of action to expose and counter the CDoH, the public health and health promotion communities should continue to cast a spotlight on the powerful commercial structures and systems that create and exacerbate inequity for women and girls. S.M. has received research funding from the Victorian Responsible Gambling Foundation, VicHealth and Deakin University. She is currently social media coordinator of Health Promotion International. H.P. has received research funding from the Australian Research Council Discovery Grant Scheme, the Victorian Responsible Gambling Foundation, the New South Wales Office of Responsible Gambling, VicHealth and Deakin University. She is currently on the editorial board of Health Promotion International. M.H. has received funding for childhood obesity research from the Health Research Board Ireland SPHeRE/2013/1; 2015–2020. She is currently Associate Editor of Health Promotion International. B.J.N. has nothing to declare. She is currently on the editorial board of Health Promotion International. S.T. has received funding for gambling research from the Victorian Responsible Gambling Foundation, Healthway, the Australian Research Council and the Office of Gaming and Racing NSW. She has received funding for research on the CDoH from VicHealth. She has received funding for alcohol, vaping and tobacco research from Deakin University. She is currently Editor-in-Chief of Health Promotion International.
McCarthy et al. (Mon,) studied this question.