Department of Health Policy, London School of Economics and Political Science, London, United Kingdom.
Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom.
PLoS Med. 2023 Jan 5;20(1):e1004147. doi: 10.1371/journal.pmed.1004147. eCollection 2023 Jan.
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.
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.
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.
识别和解决破坏不健康商品监管的因素是非传染性疾病（NCD）预防的重要组成部分。不健康商品生产商可能会利用美国和欧盟自由贸易协定（FTA）中的规则来挑战针对其产品的政策。我们旨在测试美国和欧盟 FTA 的参与是否与减少实施世界卫生组织（WHO）建议政策之间存在统计关系。
我们进行了一项统计分析，评估了在 2014 年、2016 年和 2019 年，127 个国家实施 10 项烟草、酒精和不健康食品和饮料政策的至少部分实施的概率。我们评估了有和没有美国/欧盟 FTA 的国家实施这些政策的差异。我们使用匹配法对 27 个匹配的美国/欧盟 FTA 成员国（87 个国家年）进行了 48 项协变量调整的准实验比较，并进行了额外的分析和稳健性检查，以评估我们结果的替代解释。在我们的 48 项测试中，19%（9/48）发现至少部分实施所讨论的不健康商品政策的预测概率显著下降，而 2%（1/48）显示有所增加。然而，政策之间存在明显的异质性。在个别政策层面，美国 FTA 的参与与完全实施图形烟草警告政策的概率降低 37%（95%CI：-0.51 至 -0.22）相关，与至少部分实施无烟场所政策的概率降低 53%（95%CI：-0.63 至 -0.43）相关。欧盟 FTA 的参与与完全实施图形烟草警告政策的概率降低 28%（95%CI：-0.45 至 -0.10）相关，与完全实施限制向儿童推销不健康食品和饮料的政策的概率降低 25%（95%CI：-0.47 至 -0.03）相关。与实施脂肪限制和禁令相关联呈正相关，但这并不稳健。与其他结果的关联并不显著。主要限制包括残留混杂、辨别影响的确切机制的能力有限，以及潜在地对其他 FTA 的概括能力有限。
美国和欧盟 FTA 的参与可能会降低实施世界卫生组织（WHO）建议的烟草和儿童食品营销政策的概率，具体取决于 FTA 和具体结果，降低幅度在四分之一到一半之间。正在谈判或参与美国/欧盟 FTA 的政府可能需要建立强有力的健康保护和缓解战略，以实现其减少非传染性疾病死亡率的目标。
