Lawlor et al respond (Correspondence)

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