Navigating conflicting mandates and interests in the governance of the commercial determinants of health: the case of tobacco in Fiji and Vanuatu Dorottya Patay March 2021 A thesis submitted for the degree of Doctor of Philosophy of The Australian National University. © Copyright by Dorottya Patay 2021 All Rights Reserved Declaration of originality I, Dorottya Patay, (11/03/2021) hereby declare that the thesis here presented is the outcome of the research project I have undertaken during my candidacy, that I am the sole author unless otherwise indicated, and that I have fully documented the source of ideas, references, quotations or paraphrases attributable to other authors. i Acknowledgments I would like to acknowledge the role of Dr Szabolcs Szigeti whose mentoring was the beginning of my academic career in health governance. He planted the idea of doctoral research in my mind during his supervision of my master’s research, and his encouragement was essential to start my 4-year long journey of PhD research. Moreover, I would like to express my biggest thanks to my primary supervisor, Professor Sharon Friel who recognised the potential in me and encouraged my application to the ANU PhD Program and scholarships. While this dissertation carries my name, there are several people whose guidance and support made the completion of my doctoral program possible. I would like to acknowledge all the efforts of the members of my supervisory panel at the School of Regulation and Global Governance (RegNet, The Australian National University), Professor Sharon Friel, Professor Susan Sell, and Dr Ashley Schram, who have relentlessly read the dozens of versions of my overly long chapters and responded kindly during my numerous PhD ‘break-downs’. I would like to thank Professor Jeff Collin from the University of Edinburgh, who completed my supervisory panel, for providing useful advice and suggestions. I wish to acknowledge that Karin Hosking provided professional copyediting assistance. RegNet has a reputation as a small but nurturing research institute, and the researchers, PhD students, and professional staff certainly made the 4 years of my PhD research most enjoyable and fruitful. Janice Lee, my office roommate, has been my absolute champion all these years. I would also like to thank the friendship and support of Sora Lee, David Naylor, Mary Ivec, Heidi Tyedmers, Johan Van Der Walt, Felicity Gray, Kirsty Anantharajah, Prime Ragandang, Anna Fieldhouse, Nick Frank, Libby Salmon, Ian Zhang, Dr Mel Pescud, Dr Ibi Losoncz, Dr Christoph Sperfeldt, Dr Virginia Marshall, Dr Yandisa Ngqangashe, Dr Christian Downie, Dr Belinda Townsend, Niger Sultana, Danielle Anderson, Hisako Yamauchi, and Veronica Andrianatos. My special thanks go to the professors in RegNet who have never shied away from a quick chat on my project or from reading a longer piece: Professor John Braithwaite, Professor Valerie Braithwaite, Professor Peter Grabosky, Professor Miranda Forsyth, Professor Neil Gunningham, Professor Judith Healy, Professor Kathryn Henne, Professor Veronica Taylor, and Professor Jeroen van der Heijden. I could not imagine a better place to do a PhD than RegNet. ii During this research project I have met several colleagues to whom I wish to express my gratitude for their support. I would like to thank Lana Elliott for her friendship and great conversations, and Dr Owain Williams for all the advice. I would also like to thank the interviewees in Fiji and Vanuatu who took part in this research project and whose participation in the study has been invaluable. Despite all the support of my professors and colleagues, conducting PhD research can often be stressful; the activities of the ANU Mountaineering Club were my best remedy for my worries. I wish to thank all club members who contributed to my mental wellbeing during our adventures in the Australian wilderness, particularly my white water kayaking crew who ensured that I worry about the next rapid rather than the status of my research. This special thanks go to Mel and Peta Stamell, Jess Hudspeth, Will Massey, Jason MacQueen, and our ‘honorary’ ANUMC members, Michael Freeman, Sue Robb, and especially Dr Anna Herring. I would like to express my appreciation to my parents, Ildikó and Gyula, who inspired me to never stop learning. Finally, I would like to thank Ollie, my fiancé (who I met during my fieldwork in Vanuatu), for his never-ending patience, love, and support throughout this journey. Without your morning coffees this dissertation could not have been completed. iii Abstract The consumption of tobacco, alcohol, and ultra-processed foods and beverages is driving the global noncommunicable disease (NCD) crisis. The commercial determinants of health (CDOH) have been recognized as the practices of industries aimed at increasing the availability, affordability, desirability, and consumption of commodities that are risk factors for NCDs. Addressing CDOH requires policy coherence across multiple government sectors; however, the objectives of these sectors do not always align with public health goals, and conflicting mandates can be aggravated by the interference of harmful commodity industries. Pacific small island developing states (PSIDS) face particular difficulties among low- and middle-income countries (LMICs) in negotiating such governance dilemmas, due to vulnerabilities arising from their small population and economy, geographic isolation, and being scattered across several islands. This is a major issue, because PSIDS are currently undergoing an NCD crisis, thus it is crucial to improve understanding of how their governments can better govern the harmful commodity industries. This dissertation is focusing on the governance of tobacco, because (i) the ways in which the tobacco industry (TI) influences governments are the most documented among the harmful commodity industries; (ii) the responsibilities of governments to control tobacco are the most binding compared to other harmful commodities; and (iii) there has been increased recognition that the ultra-processed food and beverage and alcohol industries globally have adopted similar strategies and arguments used by the TI, thus there is a growing interest in understanding the transferability of governance approaches from the tobacco control domain. The literature points towards the importance of interests, ideas, and institutions in shaping the ways governments manage multisectoral work on the regulation of tobacco. However, little empirical evidence is available to examine how these conditions influence PSIDS. This gap is critical, because these countries have a remarkably different social, political, cultural, and economic context than other LMICs, which makes the implementation of practices recommended by health experts to regulate harmful commodities particularly challenging. This research aims to improve understanding of the conditions that influence how governments in PSIDS address the commercial determinants of NCDs in relation to tobacco. This aim was achieved by applying iv a qualitative methodology with an exploratory case study approach, with a focus on agenda setting and policy making in tobacco governance. This dissertation expands the evidence base and scholarly knowledge of the interests, ideas, and institutions which influence the way PSIDS governments – more specifically, those of Fiji and Vanuatu – address the commercial determinants of NCDs, with a focus on tobacco. Two key insights have emerged from the findings of this research. Firstly, the vulnerabilities of PSIDS must be taken into account and addressed as major structural drivers in order to successfully govern the commercial determinants of NCDs in these countries. Secondly, the dominant causal ideas must be altered to support the governance of commercial determinants of NCDs. This research has started to build the necessary empirical evidence and academic knowledge to help inform the ways a shift in interests, ideas, and institutions can be realised to enable the control of CDOH in PSIDS. v Members of Supervisory panel Professor Sharon Friel (Primary Supervisor and Chair of Panel) Professor Susan Sell (Associate Supervisor) Dr Ashley Schram (Associate Supervisor) Professor Jeff Collin (Associate Supervisor) vi Table of Contents ACKNOWLEDGMENTS............................................................................................................................................... II ABSTRACT ................................................................................................................................................................ IV TABLE OF CONTENTS .............................................................................................................................................. VII LIST OF FIGURES .................................................................................................................................................... VIII LIST OF TABLES ........................................................................................................................................................ IX ABBREVIATIONS ....................................................................................................................................................... X CHAPTER 1. INTRODUCTION ..................................................................................................................................... 1 CHAPTER 2. LITERATURE REVIEW: THE GOVERNANCE OF COMMERCIAL DETERMINANTS OF NONCOMMUNICABLE