Alex
Perhaps you could elaborate a bit? Smoking is a personal lifestyle behaviour for many that could be reduced I guess through upstream policies (raising low incomes, narrowing income inequalities etc.), although there is no clear evidence on this as far as I can see (for instance, raising the income of a smoker may lead them smoking more cigarettes). I'm all for raising low incomes and narrowing wide income inequalities of course, but I don't see why one needs to use claims that this would reduce smoking behaviours (even if it does) as an ex ante justification.
I would have thought that downstream policies could potentially be very useful in changing personal lifestyle behaviours (if we feel that it is morally justifiable to alter such behaviours). I say 'potentially' because I guess we don't know. But I don't think they ought to be dismissed before we look at them properly. If smoking can be reduced by downstream policies (which is quite possible), what exactly do you have against them?
In 1980 (or so), the Black Report (as you know) advocated an extensive set of downstream policies at a time of a major economic crisis in the UK, and was almost totally ignored by policy makers as a consequence. We are now in a major economic crisis again, are possibly on the brink of a Conservative Government, and you are suggesting that we ought to be focussing on upstream policies as the sole research and policy focus. Maybe you and I are living in parallel universes or something, but this, to me, is not only totally lacking in realism. It is irresponsible.
Very best,
Adam
________________________________
From: The Health Equity Network (HEN) on behalf of alex scott-samuel
Sent: Sat 2/28/2009 7:31 PM
To: [log in to unmask]
Subject: Tackling health inequalities: the need to refocus upstream
The first longitudinal study linking smoking status, social class and
survival has been published online in the BMJ. The data have, in my
view, profound implications for policy makers who claim that long term
health inequalities can be reduced by addressing 'downstream' / proximal
health determinants and/or disease outcomes. I am circulating details of
the
article and my BMJ rapid response in the hope of generating debate on
this important issue.
Gruer L, Hart CL, Gordon DS, Watt GCM. Effect of tobacco smoking on
survival of men and women by social position: a 28 year cohort study.
BMJ 2009;338:b480
doi:10.1136/bmj.b480
Available online at: http://www.bmj.com/cgi/content/full/338/feb17_2/b480
Scott-Samuel A. What the Renfrew / Paisley data really tell us about
tackling health inequalities: the need to refocus upstream.
Available online at: http://www.bmj.com/cgi/eletters/338/feb17_2/b480
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Dr Alex Scott-Samuel
EQUAL (Equity in Health Research and Development Unit)
Division of Public Health
University of Liverpool
Whelan Building
Quadrangle
Liverpool
L69 3GB
UK
Tel (+44)151-794-5569
Fax (+44)151-794-5588
http://pcwww.liv.ac.uk/~alexss
e-mail [log in to unmask]
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