Summary
Recent comments about the government's role in reducing smoking suggest the state should do no more than ensure people are aware of the dangers—a goal some argue has already been achieved. But what does “knowing the dangers of smoking” mean, and do people who smoke make an informed decision when they begin smoking?
This Briefing probes these questions using a framework proposed by Australian researchers and tested and refined in Aotearoa. Very few people who smoke made considered decisions, understood addiction, or fully appreciated the risks they faced when they started smoking as teenagers. Most regret smoking and want to stop, but find the addiction to nicotine hard to break. For these reasons, governments’ responsibilities should include implementing policies that protect young people from starting to smoke and make it easier for those who smoke to quit.
Associate Minister of Health David Seymour’s claim that people who smoke are “fiscal heroes” attracted strong criticism; his comment about governments’ role in reducing smoking prevalence received less attention but merits closer analysis. He stated: “I think there’s some things government can and should do around smoking… it should ensure people know the dangers, that’s been done…”.
These comments reflect beliefs that people who smoke make “informed choices” because they allegedly know the dangers of smoking. Tobacco companies have often promoted this argument,1 despite spending decades challenging evidence that smoking causes diseases such as lung cancer, even when their own research showed otherwise.2 They have attacked the experts whose work led to these conclusions,3 and funded front groups to continue undermining scientific evidence and the people who produce it.3 Their PR strategy, to “create doubt”,4 likely deterred thousands of people from trying to quit smoking and ensured young people continued to start.
So, what is a truly informed choice to smoke?
Australian researchers suggested informed choices should meet four criteria.5 First, people must be aware that smoking causes health risks. Given extensive health campaigns warning of smoking’s many harmful effects, it is difficult to argue that most people who smoke would not meet this criterion. However, this criterion is not sufficient to ensure an informed choice.
Because awareness of smoking’s harms may be superficial, a second criterion stipulates that people should be aware of the diseases caused by smoking. Their knowledge needs go beyond a general awareness that smoking is risky and should show they understand at least the major specific harms that smoking poses.
Studies examining this question suggest knowledge of smoking’s major harms varies greatly.6 Larger pictorial health warnings have increased knowledge of harms that smoking presents, though understanding of some risks, such as impotence and blindness, remains relatively low.6 Even among adolescents who have grown up with pictorial health warnings and plain packaging, specific awareness of health risks differs considerably.7 While a Canadian study found high awareness of lung cancer among adolescents who currently smoked (89.5%), awareness of bladder cancer and blindness were just 49% and 52%, respectively.7 Thus, while some people may meet the second criterion for informed decision-making, many do not.
Third, informed choice requires that people understand the lived experience of having a disease and know the chances they will develop it. As Chapman and Liberman explained: “few [people who smoke] are likely to actually know what emphysema is, how it perforates lung tissue, and what the quality of the day-to-day life of someone living with emphysema is like”.5 They go on to explain that people making truly informed choices understand future risk probabilities and the likelihood of surviving a disease caused by smoking.
Studies show that many people who smoke underestimate the relative risk of smoking and do not see themselves at greater risk of different diseases than people who do not smoke.8 This optimism bias means they are unlikely to meet the fourth criterion: personal understanding and acceptance of the risk.9
To be fully informed, the fourth criterion requires that people who smoke accept these risks personally, without discounting the relevance or impact of the harms they face. Yet our work has identified many rationalising strategies people who smoke use to discount these risks.10 11 For example, they may challenge the risks shown (“I’ve never seen anyone who looks like that”), set fictional harm thresholds (“I don’t smoke enough to be at risk”), engage in off-setting practices (“I exercise, so I’ll be OK”), believe their genes will protect them (“my nan smoked for years and she was OK”), or think they will have quit before they face harm.
Minimising strategies like these often use heuristics, or quick ways of thinking, which mean people do not appraise risks rationally.12 If people are not undertaking a careful and detailed evaluation, they cannot make truly informed choices.
We explored whether people met these criteria when they began smoking. We talked with young people who had started smoking since they turned 18 (i.e., when they were legally adults) and found many started smoking when drinking and incapable of making logical choices.13 While they knew smoking was addictive, they thought they could withstand or control addiction, but quickly discovered they could not. Many reflected ruefully on the transition from “social” to regular smoking as something that “just happened”. Key informants also rejected “informed choice” arguments, recognising these as cynical rhetorical ploys.14
Where to from here?
People may have a general understanding of smoking’s risks, but most start smoking when adolescents, in circumstances that impede rational consideration, and with little or no reflection on future risks. Any later reflections are undermined by cognitive heuristics and few, if any, make anything like a truly informed choice. Most people who smoke in Aotearoa New Zealand regret ever starting and want to quit.15
These findings mean that preventive measures, such as creating a smokefree generation to end smoking uptake are far from “evil”, as Mr Seymour claimed. Instead, when introduced with measures to reduce tobacco’s addictiveness (by mandating lower nicotine levels in tobacco) and availability, the smokefree generation is a proportionate and responsible policy that avoids blaming people who smoke for outcomes they could not reasonably have foreseen.
What this Briefing adds
- Tobacco companies have long argued that taking up smoking is an “informed choice” and opposed governments’ preventive policies; however, this argument is based on flawed logic and fails to recognise how smoking uptake typically occurs.
- A truly informed choice must go beyond a superficial awareness that smoking is risky and involve a more detailed understanding of the harms caused by smoking and the likelihood these will occur, knowledge of the lived experience of those harms, and full personal acceptance of those risks.
Implications for policy and practice
- Governments cannot assume that a general understanding smoking poses health and other risks is sufficient for people to make informed decisions to start smoking.
- Because cognitive heuristics complicate and undermine rational decision-making, robust tobacco regulation, including the smokefree generation policy and making tobacco non-addictive, are critical to protecting the public from a highly addictive product that kills two thirds of its long-term users.
Authors details
Prof Janet Hoek, Co-Director of ASPIRE Aotearoa Research Centre, and Department of Public Health, University of Otago Wellington | Ōtākou Whakaihu Waka, Pōneke
Dr Jude Ball, Co-Director of ASPIRE Aotearoa Research Centre, and Department of Public Health, University of Otago Wellington | Ōtākou Whakaihu Waka, Pōneke
