SMOKING AMONG DEPRIVED POPULATIONS: NOT JUST A MATTER OF CHOICE

Lawlor and colleagues remind us that the reduction in cigarette smoking has been most widespread among the privileged,1 an observation that extends to the adoption of healthier habits as a response to many modifiable risk factors.2 To attribute this difference to ignorance and addiction, they argue, neglects the fact that the poor make judgments, as do the rich. The “lay epidemiology” hypothesis posits that the poor know that they face generally less favorable health outcomes and life expectancy, so that on balance it is seen as “not worth it” to forgo smoking.

These observations are important for prevention efforts, which must address this perception held by the poor. But this analysis ignores the fact that tobacco companies target their marketing efforts to deprived communities.3 In such communities, cigarettes (and other addictive substances) have also been more widely available and their sale less closely regulated. Yes, more poor people smoke, but to see smoking prevalence as an outcome only of personal choice is an incomplete view.

Take Harlem, a poor African American community in New York City. At a time when Harlem lacked even a single large supermarket and had only a handful of pharmacies, there were more than 100 retail outlets for cigarette sales, nearly all of which illegally sold cigarettes, including single cigarettes (“loosies”), to minors.4 Most billboards in Harlem advertised either cigarettes or alcohol. It was not health departments, enforcement agencies, or academic institutions that publicized these sorry facts. It was church leaders and community activists.

Both communities and government agencies must act to promote policies that limit access to unhealthy choices and counteract tobacco marketing strategies.