Annals of Health Law
INTERVENING AT THE RIGHT POINT
corresponding rates of smoking-related disease and resultant health
outcomes follow a fairly steep social gradient, with the global slope
generally increasing over time.39
In turn, what this suggests is that while smoking may be a primary cause
of lung cancer, it is imperative to inquire as to what is causing the cause –
what is responsible for shaping and determining the unequal distribution of
smoking and corresponding rates of lung cancer (and other smoking-related
diseases) across the globe. One of the earliest exponents of the “causes of
the causes,” Justin Joffe, argued in 1996 that
[ i]dentifying environmental causes of developmental defects—such as
radiation, drugs and hormones, chemicals, infections, maternal metabolic
disorders, and so on—does not lead to much insight into what can be
done to prevent adverse outcomes. The problem seems to result from the
fact that exposure to any of the agents or disorders that can produce
adverse outcomes could arise in many different ways, each involving
Joffe concludes that what needs be done is to “identify the causes of the
causes,”41 and to direct resources and interventions to those upstream
determinants. But which determinants? And how far upstream should
attention be targeted?
authorities); Gera E Nagelhout et al., Trends in Socioeconomic Inequalities in Smoking
Prevalence, Consumption, Initiation, and Cessation between 2001 and 2008 in the
Netherlands: Findings From a National Population Survey, BMC PUBLIC HEALTH 2012,
12: 303, available at http://www.biomedcentral.com/1471-2458/12/303 (last visited January
4, 2013); Johan P. Mackenbach, What Would Happen to Health Inequalities if Smoking were
Eliminated? BRITISH MED. J. 2011 342:d3460, available at http://www.bmj.
com/content/342/bmj.d3460 (last visited January 4, 2013); CENTERS FOR DISEASE CONTROL,
CDC HEALTH DISPARITIES AND INEQUALITIES REPORT — UNITED STATES, 2011: FACT SHEET:
HEALTH DISPARITIES IN CIGARETTE SMOKING, available at http://www.cdc.gov/
minorityhealth/reports/CHDIR11/FactSheets/Smoking.pdf; Richard Layte & Christopher
Whelan, Explaining Social Class Inequalities in Smoking: The Role of Education, Self-Efficacy, and Deprivation, 25(4) EUR. SOCIOLOGICAL REV. 399 (2008).
39. See Sam Harper, Global Inequalities in Tobacco Consumption, available at
http://www.sph.umich.edu/rwjhssp/lectures/HarperPresentation.pdf. However, women
belonging to richer population groups in middle-income countries are more likely to smoke
than less affluent women. See N.L. Fleischer et al., Inequalities in Body Mass Index and
Smoking Behavior in 70 Countries: Evidence for a Social Transition in Chronic Disease
Risk, 175(3) AM. J. EPID. 167 (2012); Ahmad Reza Hosseinpoor et al., Socioeconomic
Inequality in Smoking in Low-Income and Middle-Income Countries: Results from the World
Health Survey, PLOS ONE 7(8): e42843 (2012), http://www.plosone.org/article/
info:doi%2F10.1371%2Fjournal.pone.0042843 (last visited January 4, 2013).
Notwithstanding this finding, each of the previous reports notes little question that global
inequities in smoking generally track social gradients.
40. Justin M. Joffe, Looking for the Causes of the Causes, 17(1) J. PRIM. PREVENTION
201, 202 (1996).