The impacts of global trade and investment liberalization on non-communicable disease risk factors

Non-communicable diseases (NCDs) now account for approximately 60% of the global disease burden; leading risk factors for NCDs include poor diet, and tobacco and alcohol use. By facilitating the manufacture, sale, and marketing of tobacco, alcohol, and highly processed foods and beverages worldwide, global trade and investment liberalization are important structural determinants of the global NCD epidemic. This dissertation contributes to the quantitative literature on the impacts of global trade and investment on NCD risk factors with two natural experiments and one critical review. The first analysis compares trends in consumption of tobacco, alcohol, and seven key food groups, between 1980 and 2013, in 21 countries joining the World Trade Organization (WTO) and 26 non-members, weighted using propensity scores. Results suggest that following accession to the WTO, countries experience large immediate increases in fruit and vegetable consumption, and steady gradual increases in tobacco and alcohol consumption. The second analysis assesses changes in sales of processed foods and beverages, between 2002 and 2016, in ten countries joining U.S. free trade agreements (FTAs) compared to 11 matched countries without U.S. FTAs in force. Results indicate that after joining a U.S. FTA, sales of ultra-processed products, processed culinary ingredients, and baby food all increase annually. The third study is a critical review of methodological approaches used in quantitative research on global trade and investment and diet, tobacco, alcohol, and related health outcomes. A review of eight review articles identifies 34 relevant quantitative studies, which are evaluated using a novel quality assessment tool. Important ways to improve this literature are identified and discussed, international data sources for trade and investment indicators are presented, and key gaps in the literature are identified. Key findings across the three studies include: trade liberalization can lead to increases in selected NCD risk factors; additional research on trade, investment, and alcohol is warranted; substantial country-specific variation in responses to liberalization requires greater exploration; mechanisms linking trade and investment to changes in NCD risk factors are not well understood; and there is potential for expanded use of natural experiment study designs for these topics. This research supports the importance of investing in additional research on global trade and investment as social determinants of health and promoting national and global policies to ensure trade and investment liberalization do not undermine health policy objectives