Despite global efforts to reduce health inequities, unfair and avoidable differences in health persist. Over the last decade, there has been a growing recognition of the significant role that commercial determinants of health (CDOH) play in shaping these inequities. CDOH encompass the influence that corporate actors have on health, which can occur through the production, marketing, and distribution of products like tobacco, alcohol, and ultra-processed foods, as well as through broader business practices such as policy lobbying, employment conditions, and environmental impacts. CDOH scholarship has critically engaged with a wide scope of pathways, actors, and methodological approaches, analysing how corporate influence operates across multiple levels, from individual behaviour to policy environments. As this field continues to evolve, an ongoing debate has emerged over how CDOH intersects with—or diverges from—social determinants of health (SDOH). This includes debate over the boundaries between these fields and the extent to which they should be understood as distinct or overlapping analytical perspectives on the forces shaping health.

SDOH are understood as the conditions within which people grow, work, and live. SDOH research has long examined structural drivers of health inequities, defined as the absence of unfair and avoidable differences in health outcomes between groups (Whitehead, 1991). A substantial body of this literature is explicitly policy-oriented, drawing on diverse health equity theories to analyse structural “causes of the causes”, and to identify policy levers through which states shape the distribution of resources important for health. Arguably, however, this body of work has given limited attention to the role of commercial actors (Maani et al., 2020).

Like the SDOH literature, CDOH scholarship frequently emphasises health equity as a central concern. Unlike SDOH research, however, CDOH has yet to fully engage with explicit health equity–focused theoretical frameworks that articulate the mechanisms and pathways through which inequities are generated and sustained. While many contributions describe how commercial power operates within political, economic, and social systems, they often stop short of specifying how these dynamics translate into patterned inequalities between social groups. As a result, much of the CDOH literature is framed around health equity without explicitly situating commercial practices within established theories of health inequity. This absence of an explicit articulation of mechanisms—while not a critique of individual studies—signals a critical conceptual gap. Without a clearer theoretical grounding, CDOH research risks overlooking the processes through which commercial actors disproportionately harm—or, in some cases, benefit—specific populations, limiting its capacity to inform effective and equity-oriented policy interventions in contexts where commercial power is increasingly central to population health.

This paper addresses this conceptual gap by systematically examining established theories of health equity against CDOH literature. In doing so, it clarifies how commercial actors and practices can be interpreted through existing theoretical accounts, making explicit the pathways and mechanisms through which commercial influences contribute to health inequalities. By placing these bodies of work in dialogue, the analysis shows how health equity theories can serve as a conceptual bridge for integrating social and commercial determinants of health.

This study is a theory-informed interpretive review. Unlike standard systematic reviews, which aim to aggregate evidence to estimate treatment effects or establish causality, interpretative reviews are designed to interrogate how bodies of scholarship conceptualise problems, frame mechanisms and generate theoretical insight (Paré et al., 2015). The specific aim of this review is to examine how established health equity theories are engaged within CDOH scholarship and to assess the extent to which these theories are used—or could be used—to specify the pathways and mechanisms through which commercial influences generate and reproduce health inequities.

We draw on six foundational and widely cited health equity theories and explanatory perspectives that offer distinct yet complementary accounts of how health inequities are (re)produced. Much of the historical discourse on health equity has been structured around three primary explanations: the cultural-behavioural, materialist, and psychosocial perspectives. Alongside these core explanatory perspectives, we also draw on formal theories that detail specific mechanisms through which inequities are generated and sustained: fundamental cause theory (FCT), the Diderichsen model, and life course theory.

Given the conceptual nature of our research aim, we employed a purposive sampling strategy aimed to construct a corpus of CDOH scholarship that has shaped the definition, scope, and primary analytical directions of CDOH inquiry. Rather than seeking exhaustive coverage of all empirical studies, the sampling prioritised review, synthesis, and conceptual papers that define and elaborate the scope of CDOH scholarship. This approach is consistent with critical analytical review methods, which emphasise theoretical development and conceptual clarification over comprehensive evidence aggregation (Paré et al., 2015). Our sample included seminal papers and reports that define and elaborate the concept of CDOH, alongside recent review articles that synthesise the empirical and conceptual base of the field. The resulting corpus captures key conceptualisations of CDOH, the industries and practices most frequently examined, and the pathways through which commercial activities are linked to health. The full list of included literature is provided in Appendix 1.

For each health equity theory or explanatory perspective, CDOH documents were examined in terms of: (i) explicit engagement (i.e. where the theory was directly named or applied) (ii) implicit alignment (i.e. where described mechanisms of commercial influence corresponded to the theory’s causal propositions without explicit reference) and (iii) unrealised theoretical opportunities (i.e. where the theory might offer a novel explanatory account of observed commercial practices). In practice, this involved a close reading of each document to identify how commercial actors, practices, and pathways were conceptualised, and then assessing these against the core propositions of each health equity framework. Findings were synthesised first to provide a definition and conceptual account of CDOH overall, and then separately for each perspective and theory.

Results are presented in two stages. First, we summarise how CDOH scholarship defines and conceptualises commercial influences on health, including its dominant empirical and conceptual areas of focus. Second, we analyse how this body of work aligns with established health equity theories.

Earlier debates (Lacy-Vawdon & Livingstone, 2020) about how to define and conceptualise CDOH have been advanced, and to some extent consolidated, by the publication of a Lancet series. (Gilmore et al., 2023) Authors in the series, Gilmore and colleagues (2023), present a conceptual model of CDOH that details how commercial entities interact with structural, social, and political determinants of health across individual, environmental, national, and global levels. This model is now widely cited and embraced by the World Health Organization (WHO) (World Health Organization, Regional Office for Europe, 2024) and provides a crucial systems-level overview. Here the CDOH are defined as “the systems, practices, and pathways through which commercial actors drive health and equity”. (Gilmore et al., 2023) However, while the framework establishes equity as a central concern, it does not explicitly articulate the mechanisms through which commercial influences generate patterned health inequalities.

In terms of areas of focus, early CDOH work centred mainly on a narrow set of industries—those associated with products like cigarettes, alcohol, and health harming foods—and their role in driving noncommunicable diseases. More recently, however, researchers have expanded the scope of inquiry to include a larger set of industries including those associated with gambling (Thomas et al., 2023), extractive industries (Anaf et al., 2019), fossil fuels (Baum et al., 2022; Friel, 2023), firearms (Hyder et al., 2021), the financial sector, and for-profit prisons (Klein & Lima, 2021), alongside a greater number of health conditions including those related to infectious diseases, reproductive health and mental health (Dun-Campbell et al., 2024; Freudenberg, 2023). Despite this rapidly widening scope, however, significant gaps in the literature have been noted, particularly in the areas of employment and environmental concerns. In their recent review of 116 pieces of CDOH literature, for example, Burgess and colleagues (2024) found that CDOH literature discussing employment pathways did so mostly in passing, with only brief reference to practices like unsafe working conditions, poor wages and lack of benefits(Burgess et al., 2024). Similarly, the authors found that environmental practices were not a main topic of concern in the literature. Since the authors’ review however, work in these areas seems to be increasing at pace. (Goldberg & Vandenberg, 2021; McNamara et al., 2024; Singh et al., 2024; Sula-Raxhimi et al., 2019)

Another prominent focus of CDOH research has been the corporate strategies used by health-harming industries to undermine public health. As part of the Lancet series on CDOH, Lacy-Nichols and colleagues analysed these various corporate strategies and developed a “corporate playbook” encompassing eight common corporate strategies including: 1) intimidate and vilify critics (e.g. intimidation), 2) attack and undermine legitimate science (e.g. fund counter- studies), 3) frame and reframe discussion and debate (e.g. narratives promoting individual responsibility), 4) camouflage actions (e.g. leveraging front groups), 5) influence the political process (e.g. lobbying), 6) develop corporate alternatives to policies (e.g. voluntary self-regulation codes), 7) deploy corporate social responsibility and partnerships (e.g. donating to community groups), and 8) regulation and policy avoidance and evasion (e.g. threatening lawsuits). (Lacy-Nichols et al., 2022) While this work provides important insight into how corporations resist public health measures, less attention has been given to how commercial actors shape the broader economic, political, and regulatory structures in which health inequities are produced and sustained, or to how these strategies intersect with established theories of health equity.

Table 1 summarises how existing CDOH scholarship aligns with the six established health equity explanations and theories, highlighting where conceptual engagement is strongest and where important gaps remain. The sections below elaborate these intersections in greater detail.

CDOH literature was found to engage with the three traditional explanatory perspectives to different degrees, with a predominant alignment to the cultural-behavioural explanation. The cultural-behavioural explanation attributes health inequalities to differences in health-related behaviours. The field’s historical focus on industries producing and marketing health harming commodities—namely tobacco, alcohol, and ultra-processed foods—directly corresponds to this explanatory tradition. The vast body of research documenting how corporate practices, like targeted advertising, product formulation, and branding, shape consumption patterns identify diverse commercial influences of health-harming behaviours.

In contrast, engagement with materialist explanations—which focus on how inequitable distributions of income and material resources shape access to health-promoting goods and environments— is more limited, but increasingly visible. Recent studies of the gambling industry for example, link commercial practices to financial insecurity and material deprivation, while analyses of extractive and energy industries describe environmental degradation and constraints on access to essential services such as heating and water, disproportionately affecting lower-income populations (Marko et al., 2023). Work by Wood and colleagues (2021) demonstrates how health harming commodity industries extract wealth from low- and middle-income countries and redistribute it to shareholders concentrated in high-income countries. (Wood et al., 2021)

Finally, in relation to the psychosocial perspective, CDOH scholarship has documented associations between commercially produced commodities (including tobacco, alcohol and ultra processed foods) and mental health outcomes. (Dun-Campbell et al., 2024) However, there is a significant gap in exploring how commercial practices and structures themselves act as direct psychosocial stressors. For example, the potential for precarious employment, algorithmic management, and predatory lending to induce feelings of subordination, lack of autonomy, and chronic stress remains largely unexplored within a CDOH framework. (Agnew et al., 2022; Wood et al., 2019) The psychosocial perspective thus offers an underutilised framework for understanding how individuals’ position within commercially influenced social structures are embodied to produce health inequities.

Although concepts of power and resources are recurring concerns with the CDOH field (Lacy-Vawdon et al., 2022; McKee & Stuckler, 2018), they are yet to be explicitly articulated through the lens of fundamental cause theory (FCT). FCT posits that health inequities persist because advantaged groups are able to deploy flexible resources—such as money, power, prestige, and social connections—to avoid risks and adopt protective strategies as disease profiles and intervention landscapes change.

CDOH scholarship provides extensive empirical documentation of how commercial actors accumulate and exercise power, including through agenda-setting, shaping dominant social narratives, influencing legal and regulatory processes, framing rights, and controlling the production of knowledge. In contrast to social determinants of health research, where FCT is typically applied to individuals or social groups, this body of work illustrates how corporate actors themselves wield the very resources identified by FCT—money, power, and institutional influence—to shape the social, economic, and regulatory conditions within which health risks and protections are distributed. While much CDOH research has focused empirically on downstream cultural-behavioural pathways, a distinctive contribution lies in demonstrating that corporate actors operate at the level of fundamental causes: by controlling key resources that structure entire landscapes of health, determining who is exposed to harm, who is protected, and whose health interests are prioritised at a population level.

More explicit engagement with FCT could allow CDOH research to move beyond documenting discrete commercial practices toward theorising corporate power as a fundamental cause of health inequities in its own right. Commercial actors do not simply influence proximal risk factors; they actively shape the distribution of upstream determinants of health. This includes influencing economic policies that structure income and wealth distributions, labour market arrangements that affect job security and autonomy, and regulatory environments that determine access to health-protective goods and services. Moreover, commercial actors have played a direct role in reinforcing racism as a fundamental determinant of health through practices such as predatory lending, targeted marketing of harmful products like tobacco and infant formula in marginalized communities, and discriminatory employment policies.(Maani et al., 2021) Through these mechanisms, corporate strategies contribute to the reproduction of social hierarchies that systematically advantage some populations while rendering others more vulnerable to health harm.

An FCT perspective also sharpens the equity implications of policy responses to harmful commercial practices. FCT predicts that interventions targeting contextualised risks (e.g., advertising restrictions) are likely to have only limited and transitory impacts on health inequities and may in fact increase them as socially advantaged groups are better positioned to convert new knowledge or protections into health gains. By contrast, interventions that address fundamental causes—particularly the concentration of corporate wealth and power and its capacity to shape political and economic systems—are more likely to produce durable reductions in health inequities. Integrating FCT into CDOH scholarship therefore offers both a conceptual bridge to established health equity theory and an extension of FCT itself, by foregrounding how powerful commercial actors actively produce and maintain the conditions under which health inequities persist.

The Diderichsen framework conceptualises health inequities as arising through four interrelated mechanisms: (1) social stratification, (2) differential exposure to health- damaging conditions, (3) differential vulnerability to those exposures, and (4) differential social consequences of illness. While CDOH scholarship can be mapped onto all four mechanisms, the dominant contribution of the field has been to show how corporate actors structure unequal risk environments (mechanism 2). In this respect, CDOH research provides a powerful account of how commercial practices generate patterned exposure to health-damaging conditions. Including through the targeted marketing of harmful commodities to racialised and economically disadvantaged groups, or the concentration of fast-food outlets in low-income neighbourhoods.

By contrast, the other mechanisms remain comparatively underdeveloped within the CDOH research. Differential vulnerability (mechanism 3)—the idea that disadvantaged groups suffer greater harm from the same exposures —remains largely unexplored. Yet this mechanism is highly relevant. Populations facing constrained access to healthcare, nutritious food, secure housing, and other protective resources are more likely to experience severe consequences from CDOH-related exposures such as smoking, alcohol use, or malnutrition. Without incorporating vulnerability, exposure-based analyses risk overstating behavioural risk while understating structural disadvantage.

Differential consequences (mechanism 4) have also received limited attention. However, chronic conditions linked to commercial practices—such as diabetes, cardiovascular disease, or respiratory illness—carry significant financial and social costs. (World Health Organization, Regional Office for Europe, 2024) The financial burden of managing these conditions, including the costs of medication, treatment, and necessary lifestyle changes, is disproportionately greater for individuals from lower socioeconomic backgrounds who are less able to absorb these expenses. Ill health thus feeds back into socioeconomic position, reinforcing the very inequalities that shape exposure in the first place. This recursive dimension remains insufficiently theorised within CDOH scholarship.

Finally, CDOH can also be understood as shaping health equity through direct stratification (mechanism 1), where commercial actors shape economic structures in ways that initiate or reinforce existing inequalities. Corporate actors for example, shape economic policies by influencing tax regimes, competition laws, and trade policies in ways that safeguard their interests and widen social inequalities. (Lee et al., 2022; Organisation for Economic Co-operation and Development, 2017) The growing disparity between CEO and average worker wages and the expansion of gig and precarious work illustrate how commercial entities contribute to economic and social stratification. (Bivens et al., 2023) Yet this stratifying role remains underdeveloped as an explicit area of CDOH analysis, which tends to begin downstream at exposure.

Overall, these observations suggest that although CDOH scholarship aligns conceptually with all four Diderichsen mechanisms, its empirical and analytic focus has been concentrated on differential exposure (mechanism 2). A more explicit engagement with the full framework would broaden the field’s explanatory scope, integrating how commercial practices contribute not only to differential exposures but also to differential vulnerability, differential consequences, and the structuring of inequality itself.

Life course theory conceptualises health as shaped by the timing, duration, and accumulation of social and material exposures across the lifespan, emphasising how early-life conditions and critical periods structure later health.

We find the CDOH literature to have only engaged with life course theory in a limited way (Clark et al., 2020; Pitt et al., 2024). Most CDOH studies have focused on immediate harms—for example, the effects of marketing on youth consumption or the influence of social media on mental health—without tracing how these exposures shape longer- term health trajectories.

Life course theory, however, provides a framework for understanding how commercial influences impact critical periods of vulnerability, such as early childhood and adolescence, and how effects on health accumulate over time, shaping long-term health inequities. A more explicit focus on life course theory could therefore examine how commercial actors shape exposures during these critical periods, including through their influence on schools, neighbourhoods, and digital environments, while also showing how these early-life exposures are embedded within wider socioeconomic structures that perpetuate disadvantage across generations. For example, beyond direct marketing and consumption patterns, corporate practices—such as discriminatory lending and real estate policies—have historically reinforced residential segregation, entrenching socioeconomic disadvantage across generations. (Bailey et al., 2021) By limiting access to stable housing, quality education, and economic mobility, these practices create enduring structural barriers that shape health outcomes not only in the present but also for future generations, thereby perpetuating health inequities over time.

This review set out to examine how established health equity theories intersect with CDOH scholarship. While health equity is routinely invoked in CDOH literature, explicit and systematic engagement with established health equity theories remains limited. Bringing these bodies of work into dialogue clarifies the mechanisms through which commercial actors and practices can generate and reproduce health inequities. Established health equity frameworks provide a structured account of these processes and offer conceptual tools for extending CDOH scholarship beyond its current analytical scope.

Three important insights stand out.

First, CDOH literature has most clearly developed its explanatory strength around behavioural pathways. By documenting how corporate actors shape consumption patterns, the literature addresses a longstanding criticism of cultural-behaviours perspectives, namely that health- harming behaviours are framed as outcomes of individual choice. By reframing so-called individual behaviours as commercially driven, CDOH scholarship shifts the locus of responsibility away from individuals and communities and toward corporate actors and systems. At the same time, an exposure-focused emphasis, leaves the field less equipped to capture the broader mechanisms through which commercial actors shape the structuring and reproduction of social inequality.

Second, the analysis demonstrates that established health equity theories provide precisely the conceptual tools needed to extend CDOH scholarship beyond exposure. While CDOH research has increasingly examined material and psychosocial pathways, this engagement remains comparatively limited. Greater engagement with materialist pathways, including the role of commercial actors in shaping income security, employment conditions, housing, and access to other essential goods and services, would more fully situate commercial influence within the wider social and economic structures that generate and sustain health inequities. Similarly, deeper engagement with psychosocial pathways, such as experiences of subordination produced through commercial practices, would strengthen understanding of how commercial power becomes biologically embodied through stress-mediated processes.

Fundamental cause theory and the Diderichsen framework, in particular, provide robust conceptual tools for organising and interpreting these dynamics. From the perspective of fundamental cause theory, commercial actors matter not simply because they shape behavioural risks, but because they can influence the distribution of flexible resources and the institutional conditions through which they operate. This helps locate commercial power not just alongside other structural forces but as a driver of them. The Diderichsen framework, meanwhile, specifies the precise mechanisms through which these inequalities are produced, by drawing attention to how commercial actors shape social stratification, differential exposure, differential vulnerability, and the unequal social and economic consequences of ill health. Their explicit integration could help CDOH research move beyond documenting proximal risk environments toward explaining how commercial actors are embedded within, and actively reproduce, fundamental inequalities in wealth, power, and resources.

Third, life course perspectives remain notably underdeveloped within CDOH scholarship. A predominant focus on consumption patterns and immediate health effects obscures the cumulative and intergenerational consequences of commercial practices. The absence of a life course lens limits understanding of how early-life exposures and accumulated harms from corporate products and practices entrench health inequities and social disadvantage across the life course and between generations. Greater incorporation of life course approaches would therefore enable more temporally sensitive analyses of how commercial determinants contribute to the persistence of health inequities over time.

By placing CDOH research in dialogue with established health equity theories, this analysis clarifies both where the field has developed explanatory strength and where deeper engagement with health equity theory is lacking. In this sense, this analysis provides a structured way to interpret the diverse directions in which the field is moving, while identifying theoretical and empirical gaps. Greater engagement between CDOH and health equity theories would sharpen conceptual clarity around the causes and mechanisms of health inequities and could strengthen the capacity of health actors to identify, justify, and critically assess policy approaches that target upstream determinants of health inequities. In practical terms, this would involve more systematic application of materialist, psychosocial, fundamental cause, and life course frameworks to the study of commercial actors and their role in shaping social stratification over time.

An illustrative example concerns state preemption of local public health policymaking. CDOH scholarship has documented how industry actors deploy legal and political strategies to restrict the authority of local governments to enact measures such as taxation or regulatory controls. (Crosbie et al., 2019) Separate strands of research have examined the distributional health impacts of local interventions, including beverage taxes (Krieger et al., 2021), often demonstrating equity-relevant benefits. What is frequently absent, however, is an integrated analysis linking corporate strategies of preemption to their implications for health equity. From a health equity perspective, preemption is not merely a tactic to protect product sales; it is a mechanism through which commercial actors reshape the distribution of policy power, constrain local capacity to address stratified risk environments, and potentially entrench inequalities over time. Integration therefore requires analysing corporate political activity and its equity consequences within the same conceptual frame.

These issues sit within a wider scholarly debate concerning the distinction between the social and commercial determinants of health. Taken together, the findings of this analysis indicate that although distinguishing between “social” and “commercial” determinants may be analytically useful for organising scholarship, such distinctions risk obscuring the extent to which commercial actors are embedded within—and actively shape—the social, economic, and political structures that generate health inequities. From this perspective, any distinction between social and commercial therefore reflects a difference in emphasis—e.g. between analyses centred on state institutions and public policy and those focused on corporate practices and market governance—rather than a separation of the underlying processes that structure exposure, vulnerability, and unequal health outcomes. This also places the analysis in closer dialogue with related work on the political determinants of health, which similarly examines how power, institutions, and governance shape health inequities. (Kickbusch, 2015) The value of this analysis thus lies not in arguing that CDOH fails to address these wider structures, but in showing where deeper engagement with health equity theories can extend and strengthen the framework’s capacity to explain the structural determinants and mechanisms through which health inequities are generated.

These findings should be interpreted in light of several limitations. First, this review is interpretive rather than formally systematic. While the analysis draws on a broad range of CDOH and health equity scholarship, the process of mapping conceptual frameworks necessarily involves selective judgement about which theories and strands of literature are most analytically salient. To reduce potential bias, the analysis focused on synthesis papers and reviews within the CDOH literature and on widely established, highly cited theories of health equity, thereby grounding the discussion in recognised and consolidated bodies of scholarship. Nevertheless, the review centres on a core set of health equity frameworks and does not encompass the full range of relevant theoretical approaches. For example, intersectionality perspectives may offer additional insight into how commercial actors reinforce intersecting forms of inequality structured by race, gender, and class. Moreover, consistent with critical review methods, a purposive sample of influential CDOH literature was used to illustrate patterns of theoretical engagement, meaning that some empirical studies — including work in adjacent domains such as tobacco control, where engagement with structural or life course perspectives is more developed — were not captured. In addition, the CDOH literature itself remains predominantly oriented toward documenting commercial harms rather than systematically evaluating solutions. The findings presented here should therefore be interpreted as indicative of broader tendencies within CDOH scholarship rather than as an exhaustive account of all theoretical engagements or intervention-oriented research. At the same time, the analysis suggests that applying established health equity frameworks clarifies what equity-oriented responses should seek to disrupt: not only exposure to harmful commodities, but the mechanisms through which commercial power produces and reproduces inequity.

In summary, this review identifies a critical yet addressable gap within CDOH scholarship: the underutilisation of established health equity theory. By clarifying where explanatory strengths lie and where deeper theoretical engagement is needed, this review provides a clear orientation for future empirical and conceptual work. The analysis demonstrates that commercial determinants are embedded within and actively shape the social, economic, and political structures that produce and sustain health inequities. Future research should therefore move beyond documenting patterns of differential exposure to draw more systematically on materialist and psychosocial perspectives of health equity including analyses of how corporate actors shape fundamental causes and are embedded in the structural processes that drive social stratification, differential vulnerability, and unequal health consequences across the life course. In doing so, CDOH scholarship can more fully explain how commercial actors contribute not only to immediate harms, but to the enduring reproduction of structural health inequities over time.

Notes

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