Every year we reflect on the tragic loss of life caused by road accidents yet pay almost no attention to the equally tragic loss of life caused by the tobacco industry, whose products kill 13 New Zealanders every day. We critically review the narrative that smoking is a “choice”, a mantra perpetuated by the tobacco industry, that may help explain why people killed by tobacco products seem to merit so little attention. We consider how this narrative has arisen, explain why it is incorrect, and outline potential responses.
Despite declines in New Zealand’s annual road toll (an estimated 343 in 2023), an Automobile Association spokesperson explained why there are no grounds for complacency: "Any year where the road toll is lower than the previous one is positive, but we are still tracking at nearly a death every day." He is right to remind us that road accidents mean the people killed will never realise their hopes and dreams; their whānau will always bear a heavy loss, and their communities will lose skills, connections and ambitions.
Yet while we mourn the tragic deaths caused by road accidents, we rarely reflect in the same way on the equally tragic – and equally avoidable – loss of life caused by smoking (an estimated 5000 people every year). Deaths on our country’s roads make news headlines, particularly during holiday periods when they are especially poignant; however, the 13 people killed each day by tobacco products typically receive no media attention.
How has this difference come about and what has made us so blasé about the people killed by smoking? We suggest a well-propagated “choice” narrative helps explain why deaths caused by smoking receive much less attention and sympathy than deaths caused by road accidents.
To explore how the “choice” narrative evolved, it is helpful to consider how tobacco companies responded to growing evidence their products caused serious, often fatal, illnesses. Studies linking smoking and lung cancer prompted tobacco companies to “manufacture uncertainty” by challenging and denying scientific research evidence.1 The claim “doubt is our product”, allegedly made by a tobacco company executive, explains how the tobacco industry countered the damning evidence against it.2
However, disputing scientific evidence and attacking public health researchers could not withstand the accumulating evidence documenting connections between smoking and harmful health outcomes. Nor could it prevent litigation against tobacco companies. After decades of claiming health researchers had not proven smoking caused fatal illnesses, tobacco companies began arguing that “everyone” knew of smoking’s risks.3,4 Disputing evidence while simultaneously claiming people should nevertheless have relied on it proved an effective defence strategy,4 and it was not until Judge Gladys Kessler’s excoriating judgment in 2006 that tobacco companies’ sustained deception of the US public became a matter of record.4,5
Nonetheless, the evidence tobacco companies had systematically undermined now enabled them to develop the narrative that people smoke, knowing the risks they face. The “choice” narrative allows these companies to argue that, because people have “chosen” to smoke, they should be accountable for the outcomes their choice brings.6,7 NZ politicians have drawn on this narrative, with Winston Peters reportedly describing smoking as a “freedom of choice” issue.
But how valid is this reasoning? First, almost no-one makes a truly free or informed choice to smoke.8Most people who smoke became addicted to nicotine as teenagers, often in response to industry marketing,9 well before they could make the “adult” choice tobacco companies propose occurs. Few young people realise or accept that their casual experimentation will typically lead to daily smoking, driven by their growing dependence on nicotine.8,10 Almost none contemplate the likelihood they would face serious health risks or understand what experiencing those risks would be like.8
Second, once people become addicted to nicotine, withdrawal symptoms (or cravings) cause stress and compel them to smoke to relieve that stress.11 Smoking driven by the need to satiate cravings cannot be described as a free choice.
Third, a large majority of people who smoke regret ever having started smoking.12 In Aotearoa New Zealand, nearly 80% of people who smoke regret smoking; 86% had tried to quit and 74% planned to quit in the future. Yet despite this regret and desire to become smokefree, only 16.2% of New Zealanders who smoke reported quitting during 2022/23. If smoking is a “choice”, we would expect the proportions of people who wish to quit smoking would align with the proportion that become smokefree. The evidence these proportions do not match challenges arguments that smoking is a choice people make freely and suggests it is, instead, one they struggle to relinquish.
How should we respond to this evidence? First, we need to reject the “choice” narrative and recognise tobacco companies as purveyors of a lethal product they engineered to manipulate nicotine delivery. Second, we need to treat tobacco not as an everyday consumer item but as a dangerous good by making it less visible and much harder to access. Third, we need to reverse tobacco product design, which reflects years of research to manipulate smoking’s addictiveness. Finally, we need to recognise that young people have a right to be protected from an industry that has worked deviously to ensnare them in a lifetime of addiction.13
How can we take these steps? Retaining the Smokefree Environments and Regulated Products Amendment Act 2023 would change tobacco products and the environment that makes addiction to smoking so easy. Implementing the measures contained in this law would represent a principled stand that values the lives of people who smoke.
Just as we have an ambitious goal to reduce the road toll, we also have a goal – the Smokefree 2025 goal – to reduce the number of people killed by tobacco products. Politicians have a crucial opportunity to show that the lives of people who smoke matter just as much as the lives of all other people who die prematurely.
What is new in this briefing?
- Every year, tobacco products kill nearly 5000 people, around 14 times the number killed in road accidents; unlike the annual road toll, the annual smoking toll attracts no media attention.
- Despite spending decades denying smoking’s risks, tobacco companies have successfully created “choice” narratives that hold people who smoke responsible for the harms they face.
- People rarely make fully informed choices to smoke; the age at which addiction occurs, the experience of addiction, and high subsequent regret all counter “choice” narratives.
- These findings add further support to measures that change tobacco product design and availability, and that protect young people from the life of addiction almost none can foresee.
Implications for public health practice and policy
- Aotearoa’s world-leading smokefree measures value the lives of people who smoke and would eventually end the annual smoking toll.
- Retaining the world-leading smokefree legislation the coalition government proposes repealing would recognise that the vast majority of people who smoke have not made a free choice but rather have been ensnared by a highly addictive and deadly product.
Professor Janet Hoek, Ellen Ozarka and Emeritus Professor Philip Gendall
All authors are members of ASPIRE Aotearoa, University of Otago.