US and EU Free Trade Agreements and implementation of policies to control tobacco, alcohol, and unhealthy food and drinks: A quasi-experimental analysis

Abstract

Background Identifying and tackling the factors that undermine regulation of unhealthy commodities is an essential component of effective noncommunicable disease (NCD) prevention. Unhealthy commodity producers may use rules in US and EU Free Trade Agreements (FTAs) to challenge policies targeting their products. We aimed to test whether there was a statistical relationship between US and EU FTA participation and reduced implementation of WHO-recommended policies. Methods and findings We performed a statistical analysis assessing the probability of at least partially implementing 10 tobacco, alcohol, and unhealthy food and drink policies in 127 countries in 2014, 2016, and 2019. We assessed differences in implementation of these policies in countries with and without US/EU FTAs. We used matching to conduct 48 covariate-adjusted quasi-experimental comparisons across 27 matched US/EU FTA members (87 country-years) and performed additional analyses and robustness checks to assess alternative explanations for our results. Out of our 48 tests, 19% (9/48) identified a statistically significant decrease in the predicted probability of at least partially implementing the unhealthy commodity policy in question, while 2% (1/48) showed an increase. However, there was marked heterogeneity across policies. At the level of individual policies, US FTA participation was associated with a 37% reduction (95%CI: −0.51 to −0.22) in the probability of fully implementing graphic tobacco warning policies, and a 53% reduction (95%CI: −0.63 to −0.43) in the probability of at least partially implementing smoke-free place policies. EU FTA participation was associated with a 28% reduction (95%CI: −0.45 to −0.10) in the probability of fully implementing graphic tobacco warning policies, and a 25% reduction (95%CI: −0.47 to −0.03) in the probability of fully implementing restrictions on child marketing of unhealthy food and drinks. There was a positive association with implementing fat limits and bans, but this was not robust. Associations with other outcomes were not significant. The main limitations included residual confounding, limited ability to discern precise mechanisms of influence, and potentially limited generalisability to other FTAs. Conclusions US and EU FTA participation may reduce the probability of implementing WHO-recommended tobacco and child food marketing policies by between a quarter and a half—depending on the FTA and outcome in question. Governments negotiating or participating in US/EU FTAs may need to establish robust health protections and mitigation strategies to achieve their NCD mortality reduction targets.

Multisectoral action to address noncommunicable diseases: lessons from three country case studies

“…For example, when the Thai Food and Drug Administration proposed a law intended to reduce children’s consumption of unhealthy snack foods, by labelling food items, this was challenged by WTO state members which delayed the proposed regulation and subsequently led to an industry-preferred “Guideline Daily Amount” labelling option becoming mandated instead ( 53 ). A recent quasi-experimental analysis has shown that participation in US and European Union (EU) free trade agreements is associated with a significant reduction in the implementation of several WHO-recommended NCD policies that target tobacco, alcohol, and unhealthy foods ( 54 ). The European Commission has also previously prevented countries from introducing public health policies on anti-competition grounds ( 55 ).…”

Economic Gains of Transitioning Towards Reduced-Risk Products: Evidence from Mexico

“…Norström (2005) identified a significant relationship between per capita alcohol consumption and mortality from liver cirrhosis, other alcohol-related diseases, accidents, homicide, and all-cause mortality. Barlow (2023) found that participation in US and EU Free Trade Agreements was associated with a reduced likelihood of implementing WHO-recommended tobacco and child food marketing policies, based on studies conducted in various countries, including the United States, Australia, Denmark, Finland, Hong Kong, Iceland, Russia, Sweden, Switzerland, Canada, and the EU. The economic burden of smoking is substantial, incurring significant healthcare costs in both high-income and low-and middle-income countries.…”

The CPTPP trade deal is a major threat to public health and warrants a health impact assessment

“…In joining the CPTPP, the government hopes to boost trade, improve economic growth, and strengthen the UK’s strategic position as a global rule setter. Free trade deals, however, have serious and wide ranging implications for public health and policy making, as they commit countries to certain regulatory and legal obligations 2345. They can, for example, make it more difficult for governments to regulate for the benefit of health and increase industry influence in public health standard setting, as well as increase the cost of medicines.…”