Interference in public health policy : examples of how the baby food industry uses tobacco industry tactics

Despite countries’ commitments to improve nutrition, starting with the protection of breastfeeding, aggressive marketing of breastmilk substitutes continues to promote their indiscriminate use. The baby food industry appears to use similar interference tactics as the tobacco industry to influence public health, promote their products and expand their markets. Learning from the tobacco experience, this paper assesses whether the baby food industry uses any of the six tobacco industry interference tactics recognized by the World Health Organization (WHO) and summarizes examples of documented evidence. We conclude that the baby food industry uses all six tactics: (1) manoeuvring to hijack the political and legislative process; (2) exaggerating economic importance of the industry; (3) manipulating public opinion to gain appearance of respectability; (4) fabricating support through front groups; (5) discrediting proven science; and (6) intimidating governments with litigation. There is abundant anecdotal evidence. Published evidence is limited and varies by tactic. Examples of interference are provided for the Philippines, Vietnam, Laos, Turkey, Ecuador, Hong Kong, Mexico and the United Kingdom, and most for tactic 3. Interference in public health policies shows commonalities between the two industries. The tobacco control movement offers a useful framework for classifying and addressing interference with public policy by the baby food industry. Revealing the depth and extent of interference used by the baby food industry is critical if countries are to counter interference and implement commitments to improve nutrition.

Acknowledgements The authors would like to thank Dr Howard Sobel from the WHO Regional Office for the Western Pacific for the technical inputs provided during the preparation of the manuscript, including on the framing of the review.

Disclosure statement
• Conflict of interest P.R. holds 20 shares in Nestlé SA (for the purposes of raising concerns at the Annual meeting).Other authors have no conflicts of interest to declare.
• Authorship The original research concept was initiated by S.A.B. and P.R.
The research design and methodology were planned by S.I.G., K.E. and B.M.M.Each author contributed to data collection to some extent.Data analysis was conducted by S.I.G., B.M.M. and K.E.The initial draft was written by S.I.G, with substantial inputs from K.E. and B.M.M. Contributions to successive drafts were provided by S.A.B., P.R. and A.I.Each author has seen and approved the content of the submitted manuscript.
• Ethical Standards disclosure Not applicable.
World Nutrition 2017;8 (2) Introduction A growing body of evidence indicates the importance of optimal breastfeeding practices during the first two years of life and beyond.(Heikkilä et al., 2014;Horta, Loret de Mola, & Victora, 2015;WHO 2017a;Victora et al., 2016;Chowdhury et al., 2015).It is estimated that 823,000 child deaths and 20,000 breast cancer deaths could be prevented each year by achieving universal levels of breastfeeding (Victora et al., 2016;Black et al., 2013a).Furthermore, higher breastfeeding rates could save US$302 billion each year, or 0.49% of the world's gross national income, by reducing the cognitive deficits associated with non-exclusive breastfeeding until at least six months (Rollins et al., 2016).
Breastmilk substitutes (BMS) are rarely medically indicated (WHO & UNICEF, 2009), yet their use is widespread and is increasing.In the Philippines, for instance, one in three infants uses BMS, costing Filipino families over US$680 million per year (Sobel et al., 2012).At the global level, the sales of BMS increased from US$2 billion in 1987 to US$44.8 billion in 2014, and are estimated to reach $70.6 billion by 2019 (Rollins et al., 2016).Four companies (Nestlé, Danone, Mead Johnson and Abbott) account for more than 50% of global sales of BMS (Piwoz & Huffman, 2015).In recent years, the Asia Pacific Region, and China in particular, is the main growth market for the baby food industry (Euromonitor International, 2013).
The World Health Organization (WHO) recommends that babies are breastfed exclusively for the first six months of life, followed by continued breastfeeding with appropriate complementary foods for up to two years or beyond (WHO, 2003a).Breastfeeding is a human rights issue for the child and the mother and marketing practices negatively influence optimal infant and young child feeding (OHCHR, 2016).Recognizing that the marketing of baby feeding products undermines breastfeeding, the World Health Assembly (WHA) adopted the International Code of Marketing of Breastmilk Substitutes (WHO, 1981), and subsequent WHA Resolutions and a Global Strategy (WHO, 2003a) to help countries bring an end to harmful commercial promotion and protect breastfeeding and young child health.Thirty-nine countries have comprehensive legislation or policies reflecting all or most provisions of the Code, and an additional 31 countries have legal measures incorporating many of its provisions.However, enforcement remains challenging and the promotion of BMS is widespread, especially in countries without effective legislation (WHO, UNICEF, & IBFAN, 2016;First Steps Nutrition Trust, 2016;Rollins et al., 2016;IBFAN-ICDC, 2017;WHO, 2017b;Scott, Carriedo, & Knai, 2016;Suzuki & Moon, 2016).
While there is increasing evidence on the influence the food industry has on public health policy making (Sacks et al., 2017;Mialon et al., 2016a;Mialon et al., 2016b, Mialon, Swinburn & Sacks et al., 2015;Gomes, 2015), evidence on the interference of the baby food industry in policy-making remains largely undocumented.This paper assesses whether a framework used to describe the tobacco industry's undue influence on public health (WHO, 2012a) would be useful in documenting the baby food industry's efforts to undermine breastfeeding.The tobacco industry has a welldocumented history of interfering with public health policies in a way that protect industry profits and harms health (Gilmore et al., 2015).Since tobacco and food industries often share ownership, investors, shareholders, experts, advisors, public relations and marketing companies (Smith, 2012;CPI, 2015;WHO, 2000;WHO, 2008;WHO, 2012a), learning from the tobacco control experience could support measures to counter baby food industry efforts to undermine breastfeeding policies.

Methods
In this paper, the baby food industry refers to for-profit companies that manufacture, market or distribute BMS, foods for infants and young children, feeding equipment such as teats, bottles (including those used with breast pumps), and other products and ingredients used for feeding infants, young children, and pregnant and lactating mothers.

Framework for analysis
The framework for this review is the 2012 WHO report Tobacco Industry Interference: A Global Brief (WHO, 2012a), which identified six tactics commonly used by the tobacco industry.They are: (1) manoeuvring to hijack the political and legislative process; (2) exaggerating the economic importance of the industry; (3) manipulating public opinion to gain the appearance of respectability; (4) fabricating support through front groups; (5) discrediting proven science; and (6) intimidating governments with litigation or the threat of litigation.The WHO report supports the WHO Framework Convention on Tobacco Control (FCTC) (WHO, 2003b).We selected this model since the FCTC is the only United Nations (UN) public health treaty, and the only treaty addressing the potential negative impact of an industry in reaching a health goal.

Data sources and search strategy
A literature review was conducted covering the period between 2005 to 2017 to search for examples of the baby food industry using the six tactics described by WHO for the tobacco industry.The search of databases and websites included the Cochrane Library, Medline, Google Scholar, baby food companies' websites, Consumer Action -Class Action Database Business, the Human Rights Resource Centre database, Truth in Advertising, the UK Baby Feeding Law Group, the International Code Documentation Centre (ICDC), the International Baby Food Action Network (IBFAN), First Steps Nutrition Trust, AboutLawsuits.com, the Lobbying Disclosure Act Database, the Center for Responsive Politics and Influence Explorer.We used the following keywords infant formula, baby formula, baby food, (breast) milk substitutes, market*, industr*, corporat*, strateg*, polic*, influenc*, in various combinations.Finally, individuals and organizations were contacted using a snowball sampling method, which led to the identification of additional data for the review, such as letters and grey literature reports.
Each article or report identified was reviewed by at least three authors to define which tactic (or tactics) was represented, and the classification was later confirmed by all authors.In case of disagreement, the authors employed an iterative process until agreement was reached.There was no case where agreement was not reached.
The initial geographic focus of the search was the WHO Western Pacific Region, as the Asia Pacific Region is the main growth market for the baby food industry.The search was expanded to other regions to add to the examples found.Anecdotal data were found but not included in the analysis, because the original sources could not be fully verified and in-depth investigative work was beyond the scope of this study.
The review was not intended to be exhaustive for evidence, or systematic in each of the six areas of tactics, but rather to provide evidence for the use of each of these tactics by the baby food industry.

Results
The baby food industry and industry bodies that represent them were found to use all six tactics used by the tobacco industry, as described by the 2012 WHO report (WHO 2012a).The use of these tactics is not mutually exclusive; on the contrary, they often take place concomitantly, as illustrated by the cases of the Philippines (in which tactics 1, 2 and 6 took place) and Vietnam (tactics 1 and 2).These country case examples are presented in detail after an account of each of the six tactics is provided.Although names of companies are used in some places, it does not mean that companies not mentioned did not use the tactics described.

Tactic 1: Manoeuvring to hijack the political and legislative process
There is evidence that the baby food industry interfered with political and legislative processes, attempting to undermine country efforts to bring in health regulations.They used lobbying, political financing, and other communications to high-level policy makers, including the President's Office and Parliaments (WHO, 2015;Donohue, 2006;Raya, 2008;Pierangelo, 2012).
The baby food industry promoted voluntary self-regulation instead of legally binding legislation (Hawkes, 2005;Sharma, Teret, & Brownell, 2010;FIA, 2013).They promote industry interests by employing former government employees/decisionmakers as lobbyists.According to the United States-based Center for Responsive Politics (CRP), a non-profit, non-partisan research group providing a Lobbying Database, 12 out of 23 lobbyists for a major baby food company in 2015-2016 previously held government jobs (CRP, 2016a;CRP, 2016b) and the baby food industry contributed to political campaigns (CRP, 2016b;CRP, 2016c).
The baby food industry also secured participation of front groups and other industry representatives in international arenas to influence baby food marketing standard setting.For example, during the Thirty-third Session of the Codex Alimentarius Committee (CAC) on Nutrition and Foods for Special Dietary Uses, in 2011, all 5 delegates in the Mexican Delegation were representatives of the private sector (CAC, 2011).This meeting discussed the Nutrient Reference Values (NRVs) for labelling purposes associated with noncommunicable diseases (NCDs), Draft Guidelines on Formulated Supplementary Foods for Older Infants and Young Children, a proposed amendment to the Processed Cereal-Based Foods for Infants and Young Children, and a Proposal to Review the Codex Standard for Follow-up Formula (CAC, 2011).
Tactic 2: Exaggerating the economic importance of the industry This review found evidence that the baby food industry exaggerated the economic importance of their activities and claimed that economic losses would result from strict control measures on the marketing of BMS.For example, Nestlé used economic arguments to justify attempts to block legislation that could affect market share of BMS (Pierangelo, 2012).(See cases of Philippines and Vietnam below.)It also highlighted the industry's employment and job creation contributions (Nestlé S.A., 2007), while not addressing the evidence-based health and socioeconomic burden of their activities (Sobel et al., 2012;Walters et al., 2016;UNICEF & Alive & Thrive, 2016).
Tactic 3: Manipulating public opinion to gain the appearance of respectability A key tactic used to manipulate public opinion is Corporate Social Responsibility (CSR) (WHO, 2012a).Evidence was found that the baby food industry used CSR to increase its appearance of respectability and reputation and gain trust, sponsoring projects unrelated to their core business.For example, in 2013, the Mexican Government launched a project to reduce hunger entitled "Crusade Against Hunger", which involved an agreement signed with food companies, including Nestlé, to jointly address hunger.As part of this agreement, Nestlé would teach 15,000 women in the country's poorest states how to create a small business preparing and selling sweet desserts (Nestlé S.A., 2017).
The baby food industry used the logos of governments and UN without permission, to imply endorsement of their business activities.For example, in 2013, Nestlé distributed pamphlets to hospitals and health centres in Ecuador using the WHO logo.In response, WHO requested the company to immediately cease all use of WHO's logo and name in a manner that implied WHO's endorsement of the company's business approaches and products (Burci, 2013).Inappropriate use of logos has also been reported in Turkey (The Bureau of Investigative Journalism, 2017; The Independent, 2013).
Moreover, the industry promoted sponsorships and prizes for best practices, to persuade civil society organizations (CSOs) to become allies.The image transfer from such groups would increase the appearance of respectability.In 2011, Nestlé created a prize of approximately USD$480,000 for which CSOs in Asia could apply.The Laos offices of eighteen CSOs, including Save the Children, World Vision and Oxfam, refused to apply, knowing their image would be linked to the company.They argued that Nestlé "continues to make millions of dollars of profit, at the expense of infants and children in Asia, through violations of the International Code of Marketing of Breast-milk Substitutes.Unethical marketing by food companies […] contributes to the situation of high infant and child mortality in Laos" (Save the Children Australia, 2011).
The baby food industry was found to distribute discharge packages and other gifts to new mothers in hospitals in many countries, in clear violation of the Code (IBFAN-ICDC, 2017; Save the Children, 2013).Implied in this activity was the endorsement of World Nutrition 2017;8 (2) the industry by hospitals and health professionals, even when that endorsement has not been granted explicitly (Rosenberg et al., 2008).
Finally, the major companies promoted, supported and influenced international ranking initiatives, such as the FTSE4Good Index (FTSE4Good, 2016) and Access to Nutrition Index (ATNI, 2016).Such indices monitor and measure the environmental, social and governance policies and, to a limited extent, the practices of companies.This tactic serves to build trust in the baby food industry's ability and willingness to change and self-regulate, and to encourage investments.This is in conflict with WHA Resolution 49.15 that requires "monitoring …[to be] carried out in a transparent and independent manner, free from commercial influence" (WHO, 1996).Nestlé uses its listing in the FTSE4Good Index as evidence of its compliance with the Code and its Resolutions, despite repeated requests from FTSE not to misrepresent its findings.In 2010, FTSE4Good weakened its criteria, removing the need for compliance with the Code and its Resolutions, making it easier for companies to be included in the Index.In a letter to IBFAN in 2011, FTSE4Good's Chief Executive explained that: 'In the infant food sector we were not able to engage the companies as they were all being excluded from the index' (FSTE, 2011).
Tactic 4: Fabricating support through front groups The baby food industry created and funded groups or individuals to represent its interests while keeping its involvement silent or hidden.These front groups often have health-friendly names, giving the impression of credibility and links with health professionals, such as the Asia Pacific Infant and Young Child Nutrition Association (APIYCNA, 2017a), the Infant and Paediatric Nutrition Association of the Philippines (IPNAP, 2014a) and the Hong Kong Infant and Young Child Nutrition Association (HKIYCNA, 2016).
APIYCNA presents itself as a not-for-profit organization, stating that it "hopes to create a more conducive environment for the infant and young child nutrition industry and our partners and stakeholders, including a conducive market and environment where we can continue to inform and educate consumers about optimal infant and young child nutrition" (APIYCNA, 2017a).It is comprised of six baby food companies: Nestle, Danone/Nutricia, Freisland Campina, Mead Johnson, Wyeth Nutrition (APIYCNA, 2017b).
IPNAP was been created and funded by several baby food companies (IPNAP, 2014b; IPNAP, 2017) right after the Philippine Supreme Court issued the final judgement on the new Implementing Rules and Regulations to restrict marketing of BMS.IPNAP stated that its aim is to protect children and the right of breastfeeding mothers to information and freedom of choice.Nevertheless it has defended private interests in a number of occasions, leading the fight to provide alternative bills to weaken the Philippines legislation on the Code (IPNAP, 2014b).
The HKIYCNA is formed by six baby food companies (Abbott, Danone, FrieslandCampina, Mead Johnson, Nestlé, Wyeth) to "improve the nutritional wellbeing of infant and young child in Hong Kong" and "enhance the image of nutritional products and to ensure the dissemination of accurate information about nutrition products" (HKIYCNA, 2016).It has openly opposed stronger legislation on the Code (HKIYCNA, 2012).
The baby food industry promotes, funds or provides gifts to 'bloggers' and to online media outlets that discuss breastfeeding, breastmilk substitutes and other cross-branded products.The industry organizes events specifically for bloggers, encouraging them to post online product reviews with no transparency about baby food industry funding and potential conflicts of interest (CBS News, 2011;PhD in Parenting, 2017;Huffstutter & Hirsch, 2009; National Alliance for Breastfeeding Advocacy, 2017).

Tactic 5: Discrediting proven science
Several examples of the baby food industry influencing and using scientific research in misleading ways were identified.For decades, the baby food industry claimed that formulas containing hydrolysed proteins reduce the risk of allergies, whilst eminent scientific reviews have found no evidence to support this claim (Boyle et al., 2016).The claims of "hypoallergenic" or "HA" branding is permitted in labelling laws in many countries, despite the evidence for such claims being derived from studies sponsored by the baby food industry, with unsubstantiated results.The original 1989 HA study was retracted by the British Medical Journal (British Medical Journal Publishing Group, 2015; White, 2015) leading some legislators to redraft laws addressing concerns about these misleading claims (European Commission, 2016).Similarly, claims by the baby food industry of the beneficial effect of formula enriched with polyunsaturated fatty acids like DHA are unsubstantiated (Jasani et al., 2017).
The baby food industry provides grants, speaker fees, travel grants and direct funding to researchers, even creating research institutes (Nestlé Nutrition Institute, 2017).Industryfunded research is often selective and more favourable to the use of breastmilk substitutes than independently funded research (Boyle et al., 2016).Further, it sponsored conferences and health professional associations (Academy of Nutrition and Dietetics, 2017;Japan Society of Nutrition and Food Science, Science Council of Japan, 2015;International Nutrition Foundation, 2016;Rollins et al., 2016;Allers, 2013;Costello et al., 2017), using such sponsorship to influence and divert policy decisions and portray their products as necessary.For example, a review of the declared author conflict of interest statements in the Lancet's Maternal and Child Nutrition series (Bhutta et al., 2013), showed that two lead authors were members of Nestlé's Creating Shared Value advisory committee (Black et al., 2013b).The Lancet series placed emphasis on micronutrient-based foods and supplements with eight of the 10 recommended interventions involving industrial products of some kind (Bhutta et al., 2013).The series also called on the private sector to generate "evidence about the positive and negative effects of private sector and market-led approaches to nutrition" (Gillespie et al., 2013), despite research showing that evidence generated by studies funded by the private sector is often biased (Lundh et al., 2012;Nestle, 2016a;Nestle, 2016b).
World Nutrition 2017;8 (2) Tactic 6: Intimidating governments with litigation or the threat of litigation There is evidence of the use of litigation or threats of litigation to intimidate governments by the baby food industry, arguing that strong implementation of the Code constituted a barrier to trade.While industry arguments have been denounced as false, for example by the former UN Special Rapporteur on the Right to Food (OHCHR, 2014), the threat of litigation in itself undermines the resolve of governments to bring in effective legislation to protect public health.The baby food industry has taken to court governments that tried to enact legislation to restrict the marketing of BMS in accordance with the Code (see the case of the Philippines) (WHO, 2015;Raya, 2008) and has initiated lawsuits through front groups to deter legislation or delay its entry into force or implementation, as documented in the United Kingdom (FSA, 2008a;FSA, 2008b).
The industry has also argued that policies to implement the Code would be in breach of World Trade Organization (WTO) agreements, as reported in Hong Kong (Smith, Galtry, & Salmon, 2014).Trade arguments, and breach of trade agreements, have been increasingly used by the tobacco industry and its allies as an argument against tobacco control (Gilmore et al., 2015;WHO, 2012b).

Philippines
In 2006, the Department of Health in the Philippines issued new Implementing Rules and Regulations (IRR) to restrict marketing of BMS.The purpose was to align the country's 1986 Milk Code with the Global Strategy on Infant and Young Child Feeding (WHO, 2003a) and WHA resolutions related to the 1981 International Code of Marketing of Breast-milk Substitutes.The Pharmaceutical and Health Care Association of the Philippines (PHAP), whose members included the baby food industry (PHAP, 2017), took the Government of the Philippines to court, claiming, among other things, that the Department of Health had exceeded its powers in enacting the IRR.The baby food industry also attempted to interfere with the process of enacting the regulations through a series of congressional hearings and letters to the Congress and to the President of the Philippines (WHO, 2015).It also tried to transfer the IRR legislative debate from the Committee on Health to the Committee on Trade of the House of Representatives, with the goal of declaring the IRR void.
The United States Chamber of Commerce sent a letter to the President of the Philippines, stating that the IRR would have a detrimental impact on business as it prohibited all forms of marketing of BMS to children up to three years of age and treated such products as a potential health hazard.It stated that "the country's reputation as a stable and viable destination for investments is at risk", and requested the IRR be re-examined (Donohue, 2006).This resulted in a temporary restraining order against the IRR (Raya, 2008).The US Chamber of Commerce used similar strategies to tobacco control in many countries (Campaign for Tobacco-Free Kids, 2015a; Campaign for Tobacco-Free Kids, 2015b).
In 2007, the Supreme Court issued its final ruling and declared 56 of the 59 provisions of the IRR constitutional, rejecting the baby food industry's claim it was unduly restricting trade (Raya, 2008).The IRR prohibits industry participation in infant and young child feeding policy-making and covers the whole range of BMS.However, this industry-initiated process resulted in a long delay in the finalization and implementation of the IRR (WHO, 2015).

Vietnam
In 2012, the National Assembly of Vietnam approved an amended Law on Advertising (Law No. 16/2012/QH13) (National Assembly of Viet Nam, 2012), expanding the ban on advertisement of foods for infants and young children from age 12 months to 24 months.Two days before the law was to be voted on, a letter from the United States Embassy in Hanoi was sent to the Chairman of the National Assembly in Vietnam, stating that "several US companies have contacted the US Embassy regarding their serious concerns about this proposed prohibition on advertising of formula milk products, which could have a significant negative impact on their business in Vietnam.We share their concerns" (Pierangelo, 2012).The letter further implied that all relevant significant scientific and legal factors had not been considered to promote the change, as they had "not seen a compelling scientific, legal, or economic argument for changing the current regulatory regime for formula milk products" (Pierangelo, 2012).The National Assembly of Vietnam adopted the decree despite this interference from the US embassy and the formula industry.

Discussion
The WHO report (WHO, 2012a) on tobacco industry interference tactics provided a useful framework to explore evidence for the use of similar tactics by the baby food industry.That is not entirely surprising, given the close ties between the tobacco industry and the food industry previously identified (CPI, 2015).Stuckler et al. (2011) identified strategies used by food corporations to influence public health promotion, several of which are common to the tobacco and baby food industry, as described in this review.Suzuki & Moon (2016) also found similar strategies across tobacco, alcohol, food and pharmaceutical industries.Similar findings exist for the food (Hamerschlag, Lappé & Malkan (2015) and beverage (Lancet, 2015;Sacks et al., 2017) industries.The use of common strategies between tobacco and food industries were also indicated by the Special Rapporteur on the Right to Food in her interim report, including the use of sponsorships, CSR activities, promotion of self-regulation and voluntary commitments (e.g.regarding food labelling) and influencing research to the benefit of the industry (UNGA, 2016).Some of our findings have been described in more detail by others, such as the baby food industry's increasing participation in standard setting agencies such as the Codex Alimentarius (Lee, 2010;Halabi, 2015), where industry representation included over 40 per cent of participants, including within government delegations (Lee, 2010;CAC, 2011).
Our findings also showed that some tactics are still commonly used by the baby food industry while their use by the tobacco industry is recommended to be banned.For example, CSR is a key tactic used to manipulate public opinion (tactic 3) by both industries.The WHO Framework Convention on Tobacco Control (FCTC) explicitly recognizes that the tobacco industry is a barrier to achieving the Convention's goals (WHO, 2003b;WHO FCTC, 2016) and recognizes CSR as marketing, recommending that it be banned (WHO FCTC, 2008a;WHO FCTC, 2008b).Policy makers and the public health community should be more vigilant and critical about tobacco companies CSR activities (WHO, 2004).As BMSs are sometimes necessary, the baby food industry has been using CSR strategies extensively to hide their true marketing purpose, while positioning itself as a 'partner' in breastfeeding promotion and nutrition education.Direct sponsorship to health care providers is also still used by the baby food industry (Sobel et al., 2011).This review had limitations.Most notably, the review only included publicly available evidence or original correspondence (e.g.letters).Industry activities in policy-making often remain undisclosed and the full extent of interference in policy-making is unknown.Time and financial constraints did not allow for a systematic review of the literature.The review was designed to confirm the use of such tactics, not to provide a comprehensive list of cases in which they were used.
In spite of these limitations, the review adds to the increasing literature on corporate influence in public health policies.Mialon, Swinburn & Sacks (2015) recently proposed a framework for understanding food industry political activity to influence public health, with several elements in common with the strategies described in our results.Such evidence will help governments gain a better understanding on whether corporate behaviour helps or hinders progress to improve nutrition.Given the similarity of tactics used by the tobacco and baby food industries, efforts undertaken to implement the FCTC could provide a roadmap to improve regulation of the baby food industry and minimize its negative impact on public health.
The Sustainable Development Goals (SDGs) call for a reduction of all forms of malnutrition and incorporated the global nutrition targets and voluntary targets to prevent and control NCDs.Evidence-informed action to improve nutrition and address NCDs includes full implementation of the Code of Marketing of Breast-milk substitutes and subsequent relevant World Health Assembly resolutions (FAO & WHO, 2014;WHO, 2017c;WHO, 2017d).However, interference in policy-making is of increasing concern.As global and national efforts to improve nutrition and address NCDs increase, there needs to be greater awareness of the barriers and facilitators of public health policy.SDG17 on partnerships encourages engagement with the private sector as an appropriate partner in health and in some instances even their involvement in governance.This raises great concerns considering that the development of the SDGs has been influenced by corporate interests, and industries are one of the nine 'major groups' participating in intergovernmental processes on sustainable development (SDG, undated).Engagement with the private sector through multi-stakeholder platforms creates serious risks for public health planning, and increased efforts and safe guards are needed to prevent negative corporate influence on public policies (Lie and Ionata, Richter, 2015;Gomez, 2015;Adams & Martens, 2015).

Conclusion
This review contributes to the growing body of evidence on food industry interference in public health promotion, focusing on the case of baby food industry.More in-depth evidence would help inform the development of regulatory and policy measures to address baby food industry interference in public policy making.The industry's influence on public health is not always obvious and well documented.While a vast literature exists on breastfeeding and on violations of the Code, fewer studies have documented corporate influences on policy setting in the infant and young child feeding arena.(Richter, 2001, Richter, 2002) The globally recognized tobacco industry interference tactics provided a useful framework for classifying baby food industry interference, creating evidence base for the development of policies to counter this interference.Certain industry strategies, including the use of CSR, should be recognized as interference tactics by the general public, the public health community and policy makers.
In line with the Global Strategy on Infant and Young Child Feeding, and the WHO Guidance on Inappropriate Marketing of Foods for Infants and Young Children, governments should adopt independently monitored legislation that forbids all marketing that undermines breastfeeding and poses a risk to the health and survival of infants and young children.If such laws are to protect public health, they must include safeguards against conflicts of interest and industry interference.Even though declaration of all real or perceived conflict of interests may not be sufficient in contextualizing whether or not there could be bias in the results and conclusions of industry-supported authors, it is a necessary measure (Bero, 2017;Bero, Glantz, & Hong, 2005;Loewenstein, Cain, & Sah, 2011).Furthermore, transparency in government engagement with the private sector and increased industry accountability are pivotal to ensure that health policies are not placing corporate profits ahead of public health.