1. Introduction 

From where we live, to what we eat, to how we communicate, every aspect of our lives is influenced by the activities of corporations ^[1]. Recognition of this extraordinary influence—and a desire to document and understand its impacts on health—has led to the emerging field of scholarship known as the commercial determinants of health (CDoH) [2,3,4,5,6,7]^{[2][3][4][5][6][7]}. The focus of this field, in both research and practice, has been primarily on the multiple ways in which corporate policies, practices and products influence people’'s health ^[8]. This influence is both subtle and profound, shaping contexts ranging from individual consumption, to urban design, global trade and finance ^[5].

The relevance of the CDoH is particularly evident in the dramatic rise of non-communicable diseases (NCDs) ^[4], a major global health challenge that increasingly affects less advantaged population groups ^[9]. Growth in NCDs is largely driven by the globalised production, marketing and consumption of highly processed foods, drinks and legal drugs, particularly alcohol and tobacco ^[6]. As noted by a former Director-General of the World Health Organization (WHO), this creates a situation where “"efforts to prevent non-communicable diseases go against the business interests of powerful economic operators”" ^[10].

To date, relatively little attention has been paid to the ways in which the CDoH engage with and impact on gender. The concept of ‘gender’' encapsulates socially constructed differences between the sexes, including both gendered roles and behaviours (at the interpersonal level) and the gendered nature of societal norms and organising principles (at the structural level) [11,12]^[11][12]. ‘Gender norms’' refer to prevailing assumptions about the appropriate roles and aspirations of (simplistically) women/girls and men/boys in a particularly society [13,14]^[13][14]. While these norms are most clearly expressed in specific beliefs and behaviours, they reflect the social construction of gender in a particular context ^[13]. Thus, gender norms are embedded across the multiple layers of society, from formal structures and institutions (at the macro-social level) to specific communities (at the meso-level) to more intimate domestic and individual relationships (at the micro-level).

Prevailing gender norms affect everyone and can damage men’'s as well as women’'s health ^[15]. While gendered structural power means men tend to enjoy greater autonomy, authority and economic capital than women, prevailing expectations of ‘masculine’' behaviour mean men are also more likely to engage in risky behaviours - including potentially hazardous use of tobacco, alcohol, motor vehicles and firearms ^[16]. Gendered expectations and norms are likely to be a significant contributing factor to men’'s lower life expectancy ^[17] as well as women’'s higher lifetime morbidity ^[18].

As a powerful social determinant of health, gender provides a salient lens for examining how the commercial determinants intersect with other social determinants of health. While recognising the fluid nature of gender and its influence on the health of men and those with non-binary identities, we focus here on the CDoH and women’'s health. In particular, we examine the ways in which corporations encourage women’'s consumption of unhealthy commodities through the creation and reinforcement of gendered norms and stereotypes. We also highlight the ways in which corporations shape institutional and policy settings, which in turn affect women differently than men.

2. Corporate Practices and Their Implications for Gender Inequalities

Corporations demonstrate a sophisticated awareness of gender in product marketing, which often draws on gendered aspirations and ideals ^[19]. Such strategies may be particularly relevant for products traditionally associated with masculinity but where companies are seeking to create new markets and demand among women and girls.

At the same time, global businesses are increasingly seeking to portray themselves as socially progressive by engaging with discourses around gender equity in their wider practices, including communication with potential investors and CSR. These discursive and instrumental strategies ^[20] demonstrate the importance to corporate actors of shaping their perceived role in public and policy debates, ultimately serving to reinforce their structural power as CDoH.

3. Corporate Strategies, Structural Power and Gender Inequalities

Marketing and CSR practices provide the most obvious illustration of corporate engagement with gender. However, sitting behind these practices are strategies that reinforce the structural and economic power of the commercial determinants of health. These strategies create the conditions that exacerbate gender inequities, undermining various social determinants of health for girls and women.

Corporations structure gender inequities via their strategic engagement with markets, international trade, and domestic policy. These strategies act to protect companies’' market freedoms and economic influence. This aspect of their interaction with gender is largely invisible, since it does not involve the overtly different treatment of women and men. Instead, it relies on structures and processes that reinforce the dominant position of powerful corporations, which indirectly disadvantage women and girls in terms of economic and political power.

Feminist critiques of capitalism emphasise the extent to which the market undervalues work traditionally undertaken by women and girls—including caring, domestic (re)production and early education—while commodifying more typically ‘masculine’' activities [12,81]^[12][21]. This distinction became formalised in the nineteenth century when the creation of the ‘corporation’' effectively consolidated the subordination of non-market to market work ^[12]. The discounting of female endeavour was reinforced through the subsequent privileging of free market goals in development of social and legal systems, producing a ‘market society’' [82]^[22] in which the kinds of work traditionally undertaken by women receive little or no remuneration [81]^[21].

The extension of feminist critiques to economic globalisation highlights how macro-structural models reproduce gender biases ^[12]—a process described by Beneria as “"‘economic man’' gone global”" [81]^[21]. Global changes in the labour market mean women are now overrepresented in low-paid and casual employment while simultaneously bearing primary responsibility for unpaid household and caring work [83]^[23]. At the same time, globalisation has resulted in a “"narrowing of national policy space”" [83]^[23] and reduced public spending in health, education and social care—again, with disproportionate impacts on women.

The resulting gender inequalities are staggering. Women globally are over-represented in vulnerable and informal employment, more likely to be unemployed, and—when they are employed—earn almost a quarter less than men [84]^[24]. At the same time, the value of women’'s unpaid work is estimated at between 10 and 39% of countries’' GDP [85]^[25].

In addition to women’'s economic disadvantage, the dominance of men in positions of power reinforces a more aggressive and confrontational culture in many boardrooms, parliaments and workplaces, resulting in the systemic privileging of ‘masculine’' aspirations and interactions. The Economist estimates that women comprise just 7% of government leaders, 15% of company board members and 3% of chief executives, and that—based on current trends—it would take over 200 years for this gap to close [86]^[26]. The systemic marginalisation of women means their concerns and causes are less likely to be prioritised by those in authority, perpetuating a structurally-embedded gender bias that contributes to gender inequalities in the social determinants of health.

This brief critique of capitalism and economic globalisation highlights the role of the commercial determinants of health as key architects and actors within global market systems, exerting enormous influence on the gendered nature of economic power. In addition, consistent with broader analyses of corporate influence on public policy [87]^[27], the structural power of the CDoH is often implicit and institutionalised. Thus, gender inequities are reproduced and reinforced by the CDoH without overt action or discrimination on the part of the relevant actors, since the prevailing neoliberal economic paradigm is inherently gendered ^[12]. In other words, the strategic actions of powerful corporate entities (including multinational tobacco and alcohol companies) reinforce a prevailing philosophy that privileges economic objectives and market freedom over other social goals, thus buttressing structural inequalities between women and men.

Industries such as tobacco and alcohol play an active role in maintaining this market-based social paradigm and the resulting gender inequalities. Key corporate strategies include the consolidation of these industries and their expansion into emerging markets; the deliberate creation of new markets among women and girls; tactics used to prevent or delay regulation; and exploitation of regulatory gaps or deficiencies, particularly in low- and middle-income settings. These strategies allow corporations to maintain their dominant position in the social and economic landscape, reinforcing the privileging of market power and the subordination of the non-market aspirations and endeavours that form the core of many women’'s lives.

4. Conclusions

This work has examined the relationship between gender and the commercial determinants of health, demonstrating how the strategies and practices of corporate actors interact with the social determinants of health in ways that exacerbate gender inequities and exploit gendered social norms and relationships. Using the tobacco and alcohol industries as examples, we illustrated how large corporations exploit gender norms and stereotypes in their marketing; present themselves as socially progressive actors through their public engagement with women’'s causes; and exacerbate gender inequalities in power by reinforcing their structural dominance and the privileging of the free market.

At the most fundamental level, these activities reinforce unequal gender relations of power by perpetrating the dominance of the market in both domestic and global spheres, reinforcing societies’' focus on economic growth to the detriment of other social goals. Women and girls are multiply disadvantaged by this commercial bias, which systematically undervalues labour undertaken in the domestic or ‘private’' sphere while simultaneously reducing governments’' capacity to redistribute wealth within their populations and ensure the provision of essential services such as education, social care and primary and reproductive health care [83]^[23]. Thus, the actions of these companies reinforce women and girls’' disadvantage in relation to the social determinants of health.

At the meso- and micro-levels, we again see the gendered impact of corporate activities in terms of the physical, social and cultural environments in which women and men live their lives. Multinational businesses exert a profound influence on our everyday surroundings in ways that not only promote unhealthy consumption ^[5] but also create unhealthy expectations. Health damaging industries manipulate prevailing gender norms in advertising their products to women and men, often in ways that reinforced problematic gender stereotypes.

In summary, we argue that the CDoH interact with gender at the micro-, meso- and macro-levels in ways that damage women’'s health, reinforce harmful gender norms and expectations, and perpetuate the structural drivers of gender inequalities. These impacts reflect corporate engagement in marketing and CSR, in shaping policy environments, and in the broader political economy of trade liberalization and economic globalization. While further evidence is needed to understand and unpack these interactions, the concept of the commercial determinants of health is helpful in synthesizing evidence and insights from diverse literatures to examine the relationship between corporations, women’'s health and gender inequalities.