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© 2003 American Public Health Association
LETTER |
The authors are with the Department of Social Medicine, University of Bristol, England.
Correspondence: Requests for reprints should be sent to Debbie A. Lawlor, MPH, MB, ChB, Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Rd, Bristol, BS8 2PR, England (e-mail: d.a.lawlor{at}bristol.ac.uk).
Bassett points out that our analysis ignores targeted marketing by tobacco companies and that to see smoking prevalence as an outcome only of personal choice is an incomplete view. We, along with Bassett and others, deplore the tactics of the tobacco industry.1–3 We did not claim in our article that the smoking prevalence observed in a population was the result only of personal choice. We pointed out that socioeconomic inequalities acting through lay epidemiology influence smoking prevalence in different populations.4 We concluded that initiatives to reduce smoking prevalence had to take into account the effects of socioeconomic deprivation. Further, we concluded that initiatives aimed at reducing socioeconomic inequalities were more likely to be effective than initiatives aimed at individuals, or indeed initiatives that are aimed at deprived communities but that do not try to tackle issues of poverty and the reduced life chances related to poverty.
The targeted marketing that Bassett describes is to some extent a reflection of the effects of socioeconomic disparities acting through lay epidemiology. First, the outrageous promotion of tobacco products, particularly to youths, in deprived areas would simply not be tolerated in more affluent areas. Second, the tobacco industry goes where it knows the ground is fertile—hence its current concentration on the developing world and on poor communities in the developed world. However, in the past tobacco marketing has been targeted at more affluent groups, in a mutually constitutive process of adapting to and simultaneously modifying the viewpoints of attractive consumer groups.5 Notoriously, this process included both the targeting of and the use of endorsements by doctors (Figure 1
), some of whom received free cigarettes for their services. This initiative was highly successful: in 1928 The Journal of the American Medical Association criticized claims that smoking was healthful, but from the 1930s to 1950s it accepted advertising that made such claims.4
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We believe that tobacco control policy should be multifaceted, but fundamentally it has to address issues of inequalities in health and welfare, an effort that will be helped by an understanding of the process that led to the production, and reproduction, of such inequalities.
References
1. Gemson DH, Moats HL, Watkins BX, Ganz ML, Robinson S, Healton E. Laying down the law: reducing illegal tobacco sales to minors in central Harlem. Am J Public Health.1998; 88:936–939.
2. Gilmore AB, Collin J. The world’s first international tobacco control treaty. BMJ.2002;325:846–847.
3. Davey Smith G, Phillips AN. Passive smoking and health: should we believe Philip Morris’s "experts"? BMJ.1996;313:929–933.
4. Lawlor DA, Frankel DM, Shaw M, Ebrahim S, Davey Smith G. Smoking and Ill Health: Does Lay Epidemiology Explain the Failure of Smoking Cessation Programs Among Deprived Populations? Am J Public Health. 2003;93:266–270.
5. Tate C. Cigarette Wars: The Triumph of "the Little White Slaver." Oxford, England: Oxford University Press; 1999.
This article has been cited by other articles:
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  D. A. Lawlor, G. Davey Smith, R. Patel, and S. Ebrahim Life-Course Socioeconomic Position, Area Deprivation, and Coronary Heart Disease: Findings From the British Women's Heart and Health Study Am J Public Health, January 1, 2005; 95(1): 91 - 97. [Abstract] [Full Text] [PDF]
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