There is a time honoured metaphor in public health about a river, a cliff, and people who fall from the cliff into the river. The metaphor describes the expensive ambulances and the heroic rescue and resuscitation services that can be arranged to retrieve and revive those who are drowning. It acknowledges that those drowning are very grateful for these services and conversely, that a lot of politically damaging fuss can be made if innocent or important people are left to drown.

As for the cliff, the metaphor points out that fences erected at the top would prevent a lot of people from falling in. But it points out that fences can be ugly, that they disrupt views, and that as dull, static and unchanging objects they don’t attract the same attention as bright, shiny ambulances or dramatic rescue routines. Above all, a fence does its job when nothing happens, whereas a rescue service is successful when it is very busy. The erection of a fence provides one photo opportunity for a politician whereas dramatic rescues can provide dozens.

At some juncture, some of those who staff the ambulances begin to realise that things have gotten out of hand. They grow tired of providing photo opportunities for politicians and scratch their heads wondering why people continue to fall into the river. Suddenly, they point to the cliffs and gasp at those that are unfenced. Some leave their posts to become fence builders.

Despite the obvious message of the metaphor, there are many unfenced cliffs in tobacco control and many others that are poorly designed and unattended. Yet fences, like advertising bans, significant increases in excise tax, and bans on smoking in workplaces, are the most coveted goals in tobacco control policy because they hold potential to influence every smoker and potential …