Who shapes our health? Lessons from Bilbao on commercial influence and public health

A food pyramid, a city street and a nicotine pouch might seem to have little in common. At a JA PreventNCD pre-conference in Bilbao, they helped tell a bigger story: how commercial interests shape our health, and what we can do about it.

More than 70 people registered for Policies and practices to address the Commercial Determinants of Health: From EU to Local Action, held on 10 November ahead of the European Public Health Conference. Organised by JA PreventNCD and EUPHA's Urban Public Health Section, with the collaboration of WHO, the event combined emerging project results with experiences from researchers and policymakers.

The pre-conference was moderated by Rosana Peiró Pérez, who played a central role in organising the event and shaping its programme. Opening the discussions, she outlined a shared ambition: to increase the visibility of commercial determinants of health (CDoH) and strengthen their position on the European political agenda.

As Knut-Inge Klepp explained in his introduction, commercial determinants of health extend well beyond products. Businesses also shape the places we live, the messages we see and the policies affecting everyday life. Following an introduction to EUPHA's urban public health work by Catherine Pérez, Freyr Gudlaugsson showed how CDoH run through multiple JA PreventNCD activities, from monitoring commercial practices to supporting healthier environments and protecting policymaking.

One of the day's highlights was a presentation by Pedro Gullón Tosio, Director-General of Public Health and Health Equity at Spain's Ministry of Health, who offered valuable insights into how commercial influence plays out in practice.

Drawing on real-world experiences, he illustrated how commercial interests can shape public health and seek to influence decision-making, often through policy areas and government departments beyond the health sector.

One particularly memorable example concerned efforts by the wine industry in Spain to have wine included in a healthy eating pyramid, illustrating how commercial interests can seek to influence dietary recommendations and perceptions of what is healthy.

His contribution highlighted the importance of recognising these influences across government, managing conflicts of interest and ensuring that public health considerations remain central to policymaking.

The session on urban environments, moderated by Nina Iszatt, explored how commercial interests influence the design of our cities and the opportunities to create healthier spaces.

Barcelona offered a vivid example. Its Green Axes project has replaced traffic-dominated streets with space for walking, greenery and social life. Catherine Pérez shared figures indicating substantial reductions in traffic, air pollution and road crashes on the transformed streets. Yet the changes have faced legal challenges from business associations.

Jennifer Mindell brought a wider perspective: car-dependent systems shape access, physical activity, pollution and inequality. Their benefits often favour more affluent groups, while the harms fall disproportionately on disadvantaged communities. Transport policies, she argued, should prioritise people's access to opportunities rather than simply more car travel.

Martina Serra offered a practical next step. With La Rochelle, Lyon and Marseille, JA PreventNCD is developing a One Health evaluation tool for car-free areas around schools, looking at benefits for health, communities and the environment. Testing is planned for 2027.

The session on food showed how individual choices are shaped long before anyone reaches the supermarket. Katarzyna Brukało highlighted JA PreventNCD's work on the rules shaping food markets: products, marketing, prices and public procurement, alongside safeguards against undue influence.

Julia Díez examined how unhealthy food outlets cluster around schools and how exposure differs by neighbourhood. Her message was practical: with better data, cities can use zoning, licensing, school meals and community input to improve local food environments.

One particularly interesting example came from Vicky Hobart, who shared London's experience of restricting unhealthy food advertising across the Transport for London network, including the iconic London Underground.

Introduced in 2019, the policy faced challenges and scepticism but has since become an important example of how public authorities can use their influence to create healthier environments. An evaluation found that the restrictions were associated with a 6.7% reduction in calories purchased from products high in fat, salt or sugar compared with expected levels without the policy. The experience also demonstrated how strong political commitment, public consultation and evidence can help overcome barriers to implementation.

Angela Giusti took the discussion back to the earliest stages of life. Infant feeding products, digital marketing, health claims and commercial relationships with healthcare professionals can shape families' options before children are able to choose for themselves. Protecting the first 1,000 days means addressing that wider environment, too.

The final session, moderated by Patrick Sandström from the Finnish Lung Health Association and JA PreventNCD, focused on tobacco and alcohol policies and opportunities for action at national and local levels.

Katri Sääksjärvi used Finland's nicotine pouch regulation to show why Health in All Policies is about more than cooperation: public health must have a strong voice wherever decisions are made.

Jamie Pearce examined the greater concentration of tobacco and nicotine retailers in deprived neighbourhoods and explored measures to reduce availability, including restrictions near children's spaces and controls on retailer density.

Hanna Ollila shared an interesting example from Finland's implementation of the EU Single-Use Plastics Directive. Under the approach presented, tobacco producers are required to cover costs related to litter prevention and clean-up, while being kept out of public awareness campaigns and local prevention activities. Municipalities are advised not to accept industry offers of collection bins, communication materials, training or other cooperation, helping protect public health messaging from commercial influence.

Rafn Jonsson explored alcohol availability and the challenges of protecting public health at the local level. Drawing on mystery-shopping pilots in Slovenia and Iceland, he highlighted significant gaps in the enforcement of age restrictions. In Slovenia, underage shoppers were frequently able to purchase alcohol both in physical stores and online, while findings from Iceland showed that online alcohol purchases often involved no meaningful age verification at checkout or delivery. The findings raised an important question: how effective are age restrictions if they are not consistently enforced?

Different sectors, similar challenges: effective public health policies require not only good legislation, but also strong implementation, oversight and safeguards against commercial influence.

As JA PreventNCD approaches its final year, more of its work is taking shape as practical tools, emerging evidence and lessons that can inform policy. The presentations in Bilbao demonstrated the breadth of expertise across the project, while contributions from external researchers and policymakers offered valuable perspectives on the realities of putting public health policies into practice.

Rosana Peiró Pérez and Freyr Gudlaugsson closed the pre-conference, reflecting on the importance of continued cooperation and turning evidence into action.

JA PreventNCD thanks all speakers and participants for their valuable contributions and engagement, which made the event such a positive and productive experience.

We look forward to continuing the conversations at the European Public Health Conference over the coming days, where colleagues will be happy to exchange ideas and discuss the project's work.