Fooks et al. Globalization and Health (2019) 15:56 https://doi.org/10.1186/s12992-019-0495-5 RESEARCH Open Access Corporations’ use and misuse of evidence to influence health policy: a case study of sugar-sweetened beverage taxation Gary Jonas Fooks1* , Simon Williams1, Graham Box2 and Gary Sacks3 Abstract Background: Sugar sweetened beverages (SSB) are a major source of sugar in the diet. Although trends in consumption vary across regions, in many countries, particularly LMICs, their consumption continues to increase. In response, a growing number of governments have introduced a tax on SSBs. SSB manufacturers have opposed such taxes, disputing the role that SSBs play in diet-related diseases and the effectiveness of SSB taxation, and alleging major economic impacts. Given the importance of evidence to effective regulation of products harmful to human health, we scrutinised industry submissions to the South African government’s consultation on a proposed SSB tax and examined their use of evidence. Results: Corporate submissions were underpinned by several strategies involving the misrepresentation of evidence. First, references were used in a misleading way, providing false support for key claims. Second, raw data, which represented a pliable, alternative evidence base to peer reviewed studies, was misused to dispute both the premise of targeting sugar for special attention and the impact of SSB taxes on SSB consumption. Third, purposively selected evidence was used in conjunction with other techniques, such as selective quoting from studies and omitting important qualifying information, to promote an alternative evidential narrative to that supported by the weight of peer-reviewed research. Fourth, a range of mutually enforcing techniques that inflated the effects of SSB taxation on jobs, public revenue generation, and gross domestic product, was used to exaggerate the economic impact of the tax. This “hyperbolic accounting” included rounding up figures in original sources, double counting, and skipping steps in economic modelling. Conclusions: Our research raises fundamental questions concerning the bona fides of industry information in the context of government efforts to combat diet-related diseases. The beverage industry’s claims against SSB taxation rest on a complex interplay of techniques, that appear to be grounded in evidence, but which do not observe widely accepted approaches to the use of either scientific or economic evidence. These techniques are similar, but not identical, to those used by tobacco companies and highlight the problems of introducing evidence-based policies aimed at managing the market environment for unhealthful commodities. Keywords: Commercial determinants of health, Agnotology, Corporate misuse of science, Corporate political activity, Sugar tax, Corporate misuse of evidence * Correspondence: [email protected] 1School of Humanities and Social Sciences, Aston University, Birmingham B4 7ET, UK Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Fooks et al. Globalization and Health (2019) 15:56 Page 2 of 20 Background have produced what are effectively insular studies that do Sugar sweetened beverages (SSB) are a major source of not share a common conceptual vocabulary, which is likely sugar in the diet. Although trends in consumption vary to impede the cross-fertilisation of ideas between scholars across regions, in many countries, particularly LMICs, their working within different policy contexts. Moreover, exist- consumption continues to increase [1]. In response, a ing studies tend to examine agnogenic practices independ- growing number of governments have introduced a tax on ently of one another without exploring how they are SSBs as part of broader programmes aimed at reducing combined to support evidence claims. They also tend to sugar consumption [2]. Proposed policies are typically pro- ignore industry claims relating to economic impacts. Both ceeded by public consultations, the increasing use of which of these factors are key to helping policy actors understand reflects a global process of reform that draws heavily on how agnogenesis takes effect and evaluate corporate claims US administrative law and its cost-benefit approach to appropriately. Consequently, we build on existing concep- regulatory review and policy formation [3]. This paper tual frameworks of corporate agnogenesis [5, 34]and takes a case study-approach to examining corporate actors’ develop a synergic, stratified model of industry misuse of use of evidence in written consultation submissions to the evidence, which takes account of how interdependencies South African National Treasury’s proposed tax on sugar between different techniques shape evidence-based narra- sweetened beverages (SSB). Specifically, it explores corpo- tives within corporate submissions. By focusing on South rations’ use of agnogenic practices to shape policy actors’ Africa, we also address the relative dearth of research on understanding of the policy and its effects. corporations’ use of evidence in health policy in low-and- By agnogenic practices we refer to methods of represent- middle income countries. After providing a brief overview ing, communicating, and producing scientific research and of the key claims made within corporate actors’ submis- evidence which work to create ignorance or doubt irre- sions and the extent to which claims are nominally sup- spective of the strength of the underlying evidence [4]. ported by evidence, we outline techniques of agnogenesis, Agnogenic methods of research representation and com- indicating how they interact and support one another. This munication by corporations vary considerably, ranging is followed by a brief section providing a more detailed ex- from discursive practices that demand impossibly high planation of how techniques interlink with and reinforce standards of scientific proof [5, 6] to withholding clinical one another. In the discussion, we examine the relevance trial data [7]. Agnogenic practices relevant to producing of these practices for appraising the merits of involving scientific research and evidence are equally diverse and corporations in health policy-making. include devising research protocols that are more likely to Our selection of SSB taxation as a case study is based on produce desired results [4, 8–10] or simply ensuring that three observations. First, efforts by governments inter- some research is not undertaken in the first place for fear nationally to use fiscal levers as a means of addressing rising of producing unfavourable results. There is now a wealth levels of type 2 diabetes, obesity, and associated cardiovas- of evidence examining the role that corporate actors play cular disease have met with fierce industry opposition [40, in agnogenesis (the production of information or ideas that 41]. This opposition is consistent with (and potentially create ignorance or doubt beyond that merited by empir- prompted by) strong evidence that SSB taxation reduces ical evidence) [6]. This has primarily centred on corporate SSB consumption [42, 43], some evidence that it may also influence in primary scientific research [10–19], systematic drive reductions in sales of diet drinks [44–46], and emer- reviews [16, 18, 20–22], and science communication [12, ging findings that some substitution effects may be 14, 18, 23–26]. And whilst there is an emerging body of captured by other market actors (as in the case of milk or work on the production of ignorance in the context of state coffee) or are not so readily commodified (as in the case of regulatory agencies [27, 28], agnogenic behaviour by cor- water) [47, 48]. That this combination of effects is likely to porate actors in presenting evidence within policy-making reduce sales and corporate earnings significantly increases processes is relatively underexplored despite strong busi- the incentives for corporate actors to engage in what Par- ness dominance in the processes used to collect evidence khurst has termed “strategic technical bias” (questionable which underpin evidence informed policy [29]. uses of evidence that depart from scientific best practice) In addition, much of the existing literature examining [35, 36, 49]. Second, evidence linking SSB consumption to the interface between corporations and policy- relevant sci- obesity and elevated risk of metabolic and cardiovascular ence either simply describes industry influence on science diseases is voluminous, growing, and methodologically di- and its communication or demonstrates its effects [10, 23, verse [50–52]. Combined with the fact that diet-related dis- 30–33], rather than model the discrete techniques corpor- eases have complex aetiologies, and that, historically, ate actors use to shape how science and knowledge are evidence linking SSB taxes to weight loss has been mixed understood. There are some notable exceptions to this [5, [53–55], this