Intended for healthcare professionals


The CPTPP trade deal is a major threat to public health and warrants a health impact assessment

BMJ 2023 ; 381 doi: (Published 12 April 2023) Cite this as: BMJ 2023;381:e073302
  1. Courtney L McNamara , lecturer in public health 1 2 ,
  2. Liz Green , consultant in public health and programme director for health impact assessment 3 4 ,
  3. Pepita Barlow , assistant professor 5 ,
  4. Mark A Bellis , professor of public health and behavioural sciences 6
  1. 1 Population Health Sciences Institute, Newcastle University, Newcastle, UK
  2. 2 Centre for Global Health Inequalities Research, Department of Sociology and Political Science, Norwegian University of Science and Technology, Trondheim, Norway
  3. 3 Policy and International Health, WHO Collaborating Centre on Investment in Health and Wellbeing, Public Health Wales, Wales, UK
  4. 4 Department of International Health, Care and Public Health Research Institute (CAPHRI), Maastricht University, Netherlands
  5. 5 Department of Health Policy, London School of Economics and Political Science, London, UK
  6. 6 Public Health Institute, Faculty of Health, Liverpool John Moores University, Liverpool, UK
  1. Correspondence to: C McNamara Courtney.McNamara{at}

The UK’s decision to join one of the world’s largest free trade agreements has implications for health that need urgent assessment, argue Courtney McNamara and colleagues

Key messages

  • The UK has joined one of the world’s largest free trade agreements, known as the CPTPP

  • This agreement contains many of the same provisions that made a potential US-UK free trade deal controversial from the perspective of public health

  • Joining the CPTPP could increase industry influence in public health standard setting, make it more difficult for governments to regulate for the benefit of health, increase the costs of medicines, and generate economic insecurity and, potentially, job losses, with knock-on effects for health

  • As the government has not pursued a health impact assessment during the accession process, one should be performed by public health scholars and professionals

The UK government has joined one of the world’s largest free trade agreements, known as the Comprehensive and Progressive Agreement on Trans-Pacific Partnership (CPTPP). The CPTPP is not a new trade agreement waiting to be negotiated, but an already active one among 11 Pacific Rim countries (Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, and Vietnam). Joining the CPTPP commits the UK to several rules concerning trade in goods and services that have important implications for health. Although the US is not a member of the CPTPP, the agreement evolved from the Trans-Pacific Partnership, which initially included—and was shaped by—the US before President Trump withdrew the country from the deal in 2017. As such, many provisions, and even entire chapters, of the CPTPP are near carbon copies of other free trade deals negotiated by the US. But despite how much alarm was raised over the potential health effects of a free trade agreement with the US, 1 there has been little discussion of the public health implications of the UK’s accession to this new deal.

A primary force driving free trade agreements is the promise of economic growth. Mainstream economic thinking states that free trade produces a rising tide that lifts all boats by lowering consumer prices and creating new export and employment opportunities. Joining the CPTPP became a main trade policy priority for the UK in 2022 after a potential UK-US deal was pushed to the back burner by the Biden administration. In joining the CPTPP, the government hopes to boost trade, improve economic growth, and strengthen the UK’s strategic position as a global rule setter. Free trade deals, however, have serious and wide ranging implications for public health and policy making, as they commit countries to certain regulatory and legal obligations. 2 3 4 5 They can, for example, make it more difficult for governments to regulate for the benefit of health and increase industry influence in public health standard setting, as well as increase the cost of medicines. Trade deals often also have deleterious economic effects on individual industrial sectors, which can translate into economic insecurity and job loss, with knock-on effects on health.

Scrutiny of the health effects of the CPTPP is crucial because the UK is already facing multiple high stakes health challenges, including those related to new realities (such as the cost-of-living crisis, Brexit, and the covid-19 pandemic) and more longstanding ones (such as tenacious health inequalities and an acceleration in the effects of climate change). Joining the CPTPP has ramifications for health that intersect with these issues and might constrain the extent to which the UK government can intervene in them. A way to limit the health harms of trade deals is to conduct health impact assessments, but one has not been done for the UK’s accession to the CPTPP. We argue that the government should take seriously its commitment to “do no harm” and commission a health impact assessment before signing takes place later in 2023. In the likely event this does not happen, the task should be performed by public health scholars and professionals.

CPTPP poses threats to health

The CPTPP poses several threats to public health in the UK ( table 1 ). The agreement is likely to make it more difficult for the UK government (and governments of all signatory countries) to enact regulatory policies to decrease consumption of tobacco, alcohol, and unhealthy food and drinks. If the UK government wanted to implement an anti-obesity measure, such as calorie labelling requirements, for example, it would need to adhere to a provision in the CPTPP that requires foreign corporations be allowed to contest any such regulation. 2 Although this does not in itself provide corporations with veto power over a proposed regulation, it does create new opportunities for health harming industries to influence public health standard setting. Although the current government might not be interested in regulating health harming products, joining the agreement means these rules are “locked in,” undermining the regulatory efforts of any future government.

Table 1

Possible public health threats of joining the CPTPP

Another way the CPTPP benefits foreign corporations and threatens public health is by imposing on signatory countries the highly contentious investor state dispute settlement (ISDS) system. This system provides foreign corporations with special legal rights to sue the UK government whenever they think that a regulation has undermined their profits. This stands in contrast to standard World Trade Organization rules, which only allow states to initiate legal proceedings against other states. Foreign investors have used this system to challenge a wide range of public health regulations, including measures on tobacco control, taxation, and health insurance. 9 In 2012, for example, Philip Morris International brought an ISDS claim against the government of Australia over the country’s proposed public health legislation to strip tobacco products of logos and brand images. Although the court ultimately ruled in Australia’s favour (albeit over a procedural technicality), the Australian government spent approximately £13m defending the claim and was only awarded half of this in costs and legal fees. Entering into a free trade agreement that enforces the ISDS system might have a chilling effect on public health policies, with policy makers unwilling to consider public health measures that could lead to expensive legal proceedings. 2

Health concerns have also been raised in relation to food quality. Rules around “sanitary and phytosanitary” measures outline how governments can use public health measures to restrict trade without violating trade rules. They are meant to protect human health by, for example, allowing governments to require that imported products do not contain harmful ingredients. Under standard World Trade Organization sanitary and phytosanitary rules, a precautionary approach is allowed whereby member countries can adopt protective measures (such as banning a product) when scientific evidence about a health hazard is uncertain. Language in the CPTPP, however, specifies that public health regulations, like product bans, must be based on “documented and objective scientific evidence,” which effectively rules out the use of the precautionary principle. 2 10

Other health risks relate to the agreement’s effect on generic medicine availability and drug affordability. Specifically, the CPTPP requires that member countries extend the time a drug is under patent any time a drug company makes even minor—often trivial—modifications to an existing medicine. 11 12 This type of patent term extension is called “secondary patenting” and can reduce drug affordability by delaying the introduction of cheaper, generic alternatives. Researchers have estimated that, in Canada, similar rules will increase the costs of medicines by an average of $410m annually (with a minimum estimate of $40m and a maximum of $1.4bn). 13 Although the UK already allows for secondary patenting, it is unclear whether further changes are required to comply with CPTPP rules. Even if no changes are necessary, joining the agreement means that future governments will be unable to amend these rules.

Finally, like all trade deals, the CPTPP will create economic opportunities for some while creating harms for others. The UK government has conceded as much, indicating that the beverage and automotive industries are expected to be beneficiaries of the agreement, whereas the processed food and agricultural sectors are expected to lose out. 14 Thus, although some sectors might see expansions in employment, the agreement is also likely to generate economic insecurity and, potentially, job losses. The health implications of insecurity and job losses are well established. 10 In the US, increased trade with China raised unemployment in sectors that were unable to compete with cheaper imports. This, in turn, was associated with increases in fatal drug overdoses. 8 Health inequalities predating and exacerbated by the covid-19 pandemic could further intensify if industries in already disadvantaged communities are negatively affected. 15

As no health impact assessment has been done, however, the precise effects of the agreement on health and its distribution remain unclear.

Superficial health protections and small economic gains

The UK government has said the agreement will not mean lower health or food standards in the UK. And sure enough, the CPTPP contains stipulations that give the impression that domestic objectives, like protecting the public’s health, will not take a back seat to elements of the agreement intended to facilitate trade. But many caveats render such protections superficial. In a chapter of the agreement on regulatory measures, for example, a provision reads that “nothing in this Chapter shall prevent a Party from adopting or maintaining technical regulations or standards, in accordance with its rights and obligations under this Agreement. 2 In other words, governments can regulate as they wish, but only as long as it does not violate anything else in the agreement. It is precisely this type of caveat that is so often used to challenge regulation of unhealthy products. 6

But what about the economic case for joining the CPTPP? The gross domestic product (GDP) boosting consequences of a free trade agreement could conceivably have positive health effects. Based on the UK government’s own calculations, however, the economic case for joining the CPTPP amounts to no more than a 0.08% increase in the country’s GDP over a 15 year period. 16 In other analyses of free trade agreements, economists have characterised changes in GDP of this magnitude as “little more than rounding errors.” 17 More problematically, the government’s calculations fail to account for the implementation costs of joining the agreement. The potential higher drug prices and the exorbitant public costs of defending ISDS claims, for example, are unaccounted for in these calculations. To our knowledge, no national evaluation has been done to account for implementation costs with respect to changes in regulatory and drug patent terms and dispute settlement rules.

Critical role of health impact assessment

If a priority of the government is to do no harm, a commitment made explicit during Brexit negotiations, 18 then it should take account of the health implications of its trade policies. This has also been called for by the Faculty of Public Health and Public Health Wales. 19 20 But no health evaluations have been carried out for new trade deals that the government has agreed to or is negotiating. The only impact assessment of the CPTPP undertaken by the government simply estimates the overall economic benefits of the agreement, with no mention of effects on health.

Health impact assessment is a well established public health tool that can be used to identify the potential health effects of free trade agreements and areas for health mitigation. Specifically, a health impact assessment collects input from health experts—as well as from government and industry stakeholders—to evaluate the potential benefits and harms of legislation and policy initiatives. It then uses this information to suggest how potential benefits can be supported and to recommend harm mitigation strategies. The findings also make health trade-offs transparent and a matter for the public to evaluate.

In Australia, a health impact assessment undertaken during negotiation of the CPTPP sparked a massive media response and helped suspend several provisions in the agreement, which will go some way to protect the affordability of medicines (although the possibility that they will be reinstated in the future remains) and to ensure that member countries retain a right to regulate tobacco products without the fear of industry litigation. 21 Australia even went so far as to negotiate a side agreement with New Zealand to rule out the use of ISDS between the two countries.

Joining the CPTPP means that the UK too will benefit from these modified rules, but to protect public health from the numerous concerns outlined here, the government should undertake a health impact assessment before the deal is officially signed later in 2023. Even if it is unlikely that, given the government’s poor track record on public health, the findings would influence its accession decision, evidence produced by the assessment will still be extremely valuable by pointing to populations at risk and communities whose health might be safeguarded during the agreement’s implementation. Failing this, it will fall to public health scholars, professionals, and advocates to mobilise and act to undertake this important work.


  • Contributors and sources: This article draws on social scientific research at the intersection of trade and health. CLM has published widely in this area and co-authored recent public health analyses of contemporary free trade agreements. CLM is supported by the Norwegian Research Council for her project “Trade, Labour Markets, and Health” (grant reference: 274995). LG is a consultant in public health at Public Health Wales and is carrying out a PhD in health in all policies and health impact assessment at Maastricht University. She has carried out several health impact assessments, including on Brexit, covid-19, and climate change. PB is an assistant professor at London School of Economics and has published widely in this area including a series of papers evaluating the role of US free trade deals in the global diffusion of “obesogenic” food environments. MAB is director of policy and the WHO Collaborating Centre on Investment for Health and Wellbeing at Public Health Wales and professor of public health at John Moores University, Liverpool. CLM and LG conceptualised the article and led the writing. All authors contributed to successive drafts. CLM is the guarantor.

  • Competing interests: The authors have read and understood BMJ policy on declaration of interests and have no conflicts of interests to declare.

  • Provenance and peer review: Not commissioned; externally peer reviewed.