Chiara Lorini and Claudia Cosma
To what extent does the trend of suicides depend on the behavior of the industries and their ability to condition the decisions of the institutions? A question and possible solutions.
Every year over 700,000 people around the world lose their lives for an act of their own will, many more are the cases of self-harm. Behaviors largely preventable, especially if suicide is achieved through the use of substances without the intent to commit suicide. These are cases involving for example the use of firearms, drugs such as opiate painkillers or pesticides. Tools whose lethality could be drastically reduced, first of all, by limiting their availability and ease of obtaining them. When it comes to suicide, however, what is missing is a broader strategy capable of identifying which interests are at stake capable of limiting public health choices.
A recently published paper by some researchers at the University of Bristol consequently questions the role of commercial determinants, or rather on the reflection that the interests of pharmaceutical, arms and pesticide industries have in the public debate, sometimes even in the scientific one, and finally on the decisions of health authorities and governments… with possible negative repercussions precisely on the safety of people, especially of the more fragile ones. It must be recognized, as the group of researchers led by May Ci van Schalwyk (1) promptly does, that the so-called commercial drivers they are gathering increasing attention in the scientific and institutional world when it comes to public health.
The most obvious example is the treatment reserved for the tobacco industry, recognized both by the World Health Organization and by its Member States as the main actor as a producer of substances that cause harm to health, but also as the main obstacle to the adoption virtuous policies to reduce the consumption of these harmful products. On the other hand, the paper points out, the imprint of commercial determinants on health and suicide trends can be seen both in the production and marketing of harmful products and in the policies that industries manage to deploy to mislead and distort regulators. Basically, the big ones corporation they try to wedge themselves by sowing doubts, shifting blame and holding back the approval of standards. The outcome of this strategy is easily explained: commercial giants and multinationals would essentially be able to delay the moment in which the institutions take action with restrictions and bans with “devastating effects” on the health of people, the environment and the planet.
All this would have important consequences to be investigated in depth even when we talk about suicides, an area that has so far been too neglected and that Bristol scholars try to reveal by framing them in four points.
First of all, the ease of access to alcohol, firearms, opiates, drugs, but also gambling itself which can lead to self-destructive and suicidal lifestyles. Restricting its availability and use would be the sure path to take to improve public health, but this approach is seen as a bogeyman by industries, whose mission is to make a product as accessible as possible to everyone, i.e. present in plenty and well priced. The corporation therefore they prefer to invest in responsible behavior on the part of consumers. Here, however, the second facet of the problem according to the authors of the paper: promoting educational programs or the activities of organizations that have the primary purpose of providing information, in some way, on the dangers associated with the abuse of certain substances, would soon turn into an attempt to transfer and download responsibility on the shoulders of consumers. Conversely, a reflection on the intrinsic risks would suggest the introduction of bans or drastic limitations by law.
The industries, third point of the question, however, go on the counteroffensive trying to condition the scientific debate as well. The goal is to be the solution to the problem, rather than the main part of it. There is no shortage of examples, therefore, of research that manipulates the cancer risks due to the use of alcohol, but also studies of pharmaceutical companies that have not had any scruples about making false papers in order to expand the age range of authorization of some preparation. Finally, the fourth epiphany of commercial determinants, le corporation they can try to divert public discourse in the media, in academia, in the world of research reducing suicide to a mere mental health problem and, therefore, relegated to the problems of the individual.
Two examples are emblematic in outlining the close relationship between industries – and therefore commercial determinants – and suicides: that of gambling and that of the arms industries.
Gambling. From a recent literature review conducted by Rintoul et al. (2) it emerges that there are two main processes linking gambling and suicidal behavior: indebtedness and shame. Such processes can also act as barriers to players seeking help. The determinants of gambling go beyond the individual and can be attributed to sociocultural factors, the environments in which gambling products are supplied, and commercial tactics to promote consumption. Until now, there has been little attention to the environmental and commercial determinants of gambling harm; such determinants include the nature of gambling products and promotions and the characteristics of gambling environments that may appeal to different subpopulations. One population group identified as particularly vulnerable to the environmental and commercial determinants of gambling harm are older adults, who often also have fewer financial opportunities, as well as more time available to engage in gambling. In a very recent editorial published in the BMJ (3), van Schalkwyk writes, referring to the gambling industry: “As we wrestle with a cost-of-living crisis, we must ask why we seem unable to act against a powerful industry which, in effect, serves as a mechanism to move money from the poor and vulnerable to the wealthy and privileged.” As far as our country is concerned, a possible answer can be found in the data processed by Agipronews (IlSole24 ore, 4 January 2023): in 2022, our state collected 10.3 billion euros for bets, scratch cards but above all for poker and online casino. This is a lower revenue (-9%) than that of 2019 – when the Treasury collected 11.3 billion – but clearly higher than 2021 (+22%), the year in which the COVID-19 pandemic had kept the amusement arcades and betting agencies for about 6 months.
Firearms industries. Gun-related violence is a global problem and continues to carry an especially heavy burden of death and disability especially in the United States, which remains the largest civilian-owned firearms market in the world. In 2019, 39,707 firearm-related deaths were reported in the United States, over half of which were suicides. Numerous authors have demonstrated the strong relationship between the availability of firearms and the damage related to their use: iFirearm ownership is associated with an increased risk of firearm-related homicide or suicide in the home. Recent statistics suggest that firearms are now the leading cause of traumatic death for children in the United States, surpassing traffic accidents (4). Hussain et al. (5) conducted a qualitative study to evaluate the sales strategies adopted by the firearms industries and related organizations. Some parallels emerge from the findings with the tobacco and alcohol industries:
the firearms industry and firearms industry-related organizations view firearms and firearms ownership as a matter of personal responsibility, central to individual safety; harm caused by firearms are largely framed in the context of inevitable criminal use and mass shootings, rather than in the context of suicides (which make up the majority of firearm-related deaths) or injuries (fatal and non-fatal) to others The nature of firearm injury evidence is constantly being questioned, denying the applicability of public health – and therefore public health – perspectives to firearm injury.
Van Schalkwyk, suggests taking action, becoming aware of the influences of industries and redistributing the burden of responsibility when it comes to the use of substances and tools dangerous to health. It calls for the promotion and construction of a suicide prevention agenda that recognizes and addresses commercial determinants: an exhortation to act on multiple points, starting with the world of research. It would be advisable, as a start, to proceed with a mapping of the political and market strategies pursued by the corporation to influence decisions on prevention policies, building a scientific basis on how to relate. More generally, academic institutions, journals and international health agencies would do well to strengthen policies to protect the scientific process from attempts at manipulation, including the management of conflicts of interest. In terms of advocacy, it is then considered appropriate to counter the ability of industries to influence the scientific process, decisions and public debate promoting a comprehensive suicide prevention policy that also passes from a better understanding of the phenomenon among the general public, the media and political decision-makers. Furthermore, at the policy-making level, commercial determinants must be addressed and local, national and international conflicts of interest managed, giving priority to interventions based on scientific evidence capable of challenging industries and protecting themselves from their influence.
Finally, on a practical level it is necessary to support and implement prevention strategies, recognizing the attempts at distortion practiced by those with commercial interests at stake, adopting robust governance policies capable of keeping undue interference from the economic sphere away from the institutional and research.
Chiara Lorini, Department of Health Sciences, University of Florence
Claudia Cosma, Department of Health Sciences, University of Florence
Bibliography
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