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Smoking as an ‘informed choice’: implications for endgame strategies
  1. Janet Hoek1,
  2. Jude Ball2,
  3. Rebecca Gray2,
  4. El-Shadan Tautolo3
  1. 1 Department of Marketing, University of Otago, Dunedin, New Zealand
  2. 2 Department of Public Health, University of Otago, Wellington, New Zealand
  3. 3 Director of the Centre for Pacific Health and Development, AUT University, Auckland, New Zealand
  1. Correspondence to Professor Janet Hoek, Department of Marketing, University of Otago, P. O. Box 56, Dunedin 9054, New Zealand; janet.hoek{at}otago.ac.nz

Abstract

Objective Tobacco companies often assert that adults should be free to make an ‘informed choice’ about smoking; this argument influences public perceptions and shapes public health policy agendas by promoting educative interventions ahead of regulation. Critically analysing ‘informed choice’ claims is pivotal in countries that have set endgame goals and require new, more effective policies to achieve their smoke-free aims.

Methods In-depth interviews with 15 New Zealand politicians, policy analysts and tobacco control advocates examined how they interpreted ‘informed choice’ arguments. We used a thematic analysis approach to review and explicate interview transcripts.

Results Participants thought ‘informed choice’ implied that people make an active decision to smoke, knowing and accepting the risks they face; they rejected this assumption and saw it as a cynical self-justification by tobacco companies. Some believed this rhetoric had countered calls for stronger policies and thought governments used ‘informed choice’ arguments to support inaction. Several called on the government to stop allowing a lethal product to be widely sold while simultaneously advising people not to use it.

Conclusions ‘Informed choice’ arguments allow the ubiquitous availability of tobacco to go unquestioned and create a tension between endgame goals and the strategies used to achieve these. Reducing tobacco availability would address this anomaly by aligning government's actions with its advice.

  • Advocacy
  • End game
  • Public policy
  • Tobacco industry

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Introduction

New Zealand has traditionally shown strong leadership in tobacco control and, until recently, has been at the vanguard of innovative policy measures. In 2011, New Zealand became the first country to set a tobacco endgame goal and declare its aim to become smoke free (<5% smoking prevalence) by 2025.1–3 However, recent analyses suggest key government ministers do not publicly mention or endorse the goal, despite the profound health benefits it could bring.4 Furthermore, despite declines in overall smoking prevalence, the 2025 goal will not be achieved among all population groups without more intensive use of existing policies and adoption of far-reaching new interventions.5 As more countries set specific endgame targets, assessing factors that may impede the realisation of these goals has become crucial.6

Tobacco companies routinely oppose new tobacco control measures by arguing current regulations are sufficient and claiming further attempts to influence smoking would constitute excessive interference in individuals' choices.7 ,8 By describing smoking as an ‘informed adult choice’, tobacco companies hold individuals personally responsible for actively choosing to smoke.9 This stance enables them to promote education as the most appropriate tool to reduce smoking prevalence, thus pre-empting policy measures, and reinforcing perceptions that individual smokers are responsible for harms they experience.

In principle, providing people with information should promote informed decision-making; however, in practice, personal and environmental factors exert a more powerful influence on behaviour than education.10–13 Recognising the challenge of modifying ingrained cognitive biases and entrenched behaviours, many tobacco control researchers have called for environmental changes that actively support cessation and discourage smoking initiation.6 ,8 ,14 These calls challenge tobacco companies' reliance on a flawed ‘rational consumer’ model and question their emphasis on education and youth prevention programmes that have been ineffective.15 ,16 Yet despite the serious logical limitations undermining ‘informed choice’ arguments, many industries still use this reasoning to deflect attention from the harms their products cause and influence policy development.17 ,18 To explore how these arguments have affected government measures to reduce smoking, we probed New Zealand stakeholders' interpretation of ‘informed choice’ and then analysed implications for tobacco control policy.

Methods

Sample and recruitment

We interviewed 15 participants from the New Zealand tobacco control sector, including politicians from varied political parties (n=4), policy analysts (ie, people working in regulatory roles within local or central government) (n=4) and tobacco control advocates (n=7). All had leadership roles in promoting, developing or implementing tobacco control policy. We selected participants purposively to maximise political diversity and responsibility, and recruited five Māori and three Pacific participants to ensure representation of their perspectives. In total, we approached 19 potential participants; of these, four refused or were unavailable (due to travel, health and a perceived conflict of interest).

Because New Zealand's smoke-free 2025 goal has strong multiparty support, we expected the views of politicians interviewed would reflect this consensus. Nonetheless, political parties' differing ideologies, together with diversity within the tobacco control sector, meant we expected to encounter varied views on ‘informed choice’ and how the 2025 goal might be achieved.

Interview protocol and data collection

Using a semistructured interview guide (see online supplementary file 1), we interviewed participants by phone (n=6) or in person (n=9); interviews ranged from 37 to 75 minutes. Our interview guide explored participants' interpretations and analyses of ‘informed choice’ claims, and their perceptions of the appropriate balance between educational and policy (environmental) measures. We also examined participants' views on potential interventions, including personal skill development initiatives to promote resilience, social marketing themes and stronger smoke-free outdoor area restrictions. This paper analyses data elicited on the former two topics (a separate paper analyses perspectives on the interventions examined). With participants' permission, we recorded all interviews and then transcribed these.

Data analysis

We used a manual coding approach to examine the data deductively, using the interview guide framework to structure our analyses. The two lead authors independently coded the transcripts, initially focusing on idea elements participants associated with ‘informed choice’ and then developing overarching themes.19 We adopted a critical realist approach, which recognised that individuals may initiate change, for example, by making a quit attempt, while also acknowledging the social and environmental factors that constrain their agency. This approach allowed us to probe how perspectives on individual agency (or ‘choice’) varied across and within actor groups.

We present participants' quotations to illustrate our findings and acknowledge these as: A (advocates); P (politicians) and PA (policy analysts), followed by a code number (eg, A1). The University of Otago Human Ethics Committee provided ethical approval for the project (11/297).

Results

We identified three themes, reported below; the first explores how participants interpreted ‘informed choice’ while the second examines the balance between educational and policy interventions, and how ‘informed choice’ arguments may have influenced this debate. The final section focuses on what many participants saw as a persistent anomaly, namely the government's willingness to allow tobacco to be widely available, while simultaneously advising people not to use it.

Making an ‘informed choice’: gaps between theory and practice

Irrespective of their background, participants saw three attributes as crucial to informed choices: information, understanding, and a capacity for critical analysis. Visible and easily retrieved risk information, particularly if available on the cusp of behaviour, was a prerequisite for informed choices. As one participant noted: “Making that access [to risk information] um, readily available and constantly available…the proximity of that information to their daily lives is important.” (P3). Some called for comprehensive information that illustrated personal harms as well as social and environmental effects. A1 explained: “The risks if you use a cigarette…so your health risk, but also I have a view that there's a risk to the community…like if you become unwell…your risk is that you may not reach your potential to participate in life in New Zealand or life in your community. Then…what environmentally do cigarettes do?”.

Participants thought young people needed complete information to understand smoking's full ‘consequences’ over time: “[They need] knowledge of the consequences of their actions, both in the long term and the short term.” (A6). A3 explained how this information needed to be germane to each individual: “You know exactly what will happen when you have the cigarette, you know what's in it…the harms, the benefits (if anything)…you have all the information that was relevant to you.”.

Finally, participants recognised that informed choices also depended on personal attributes: “That [informed choice] implies you are dealing with a reasonable person [who] can make common sense decisions.” (PA2). Alongside a capacity for reason, they saw skills in evaluating and applying risk information as crucial to informed choices: “Being able to weigh up the risks and decide that it's okay for them to do what they're going to do.” (A6).

Yet although participants easily identified the attributes required for an informed choice, few thought rational analyses preceded smoking uptake. Politicians explained this disjunction in different ways; some agreed that choices existed, but thought young people lacked the requisite information. One commented: “A choice, yes, totally agree, but I don't think people are informed enough to actually make that choice when it comes to tobacco, and probably alcohol is the same.” (P4). Another thought the information existed, but felt young people lacked the understanding required to use it: “While we think that there's a lot of information out there, I don't think they fully understand the implications at a personal level of those choices that they then make.” (P2).

Even where understanding existed, participants from all groups thought other factors proved more influential and discouraged considered actions. An advocate suggested: “I actually think they [young adults] do understand, but they don't want to understand at times…the desire to be cool or rebellious or different, ah, over-rides that.” (A7). Participants also noted young adults' limited temporal perspective: “People are about the here and now, and they're about instant gratification, they don't think about the consequences.” (PA2). Reflecting on their own youthful experiences consolidated participants’ view that little active decision making occurred: “I still think for young people it would be a pretty rare occurrence for there to be…at any…you know, great level, active decision making.” (P3). Overall, participants argued that young people's immediate social priorities assumed greater relevance and overrode the longer term benefits of remaining smoke free. For some, young people's short-term focus and lack of experience made informed choices a logical impossibility: “There's nothing that prepares them…for the consequences of smoking…for me, informed choice is knowing all the downsides.” (P1).

Discrepancies between definitions of ‘informed choice’ and actual behaviour led several participants to view the term as a cynical industry ploy, used to defend the indefensible. Some observed this phrase originated with the tobacco industry, which they saw as having ulterior motives: “The language comes actually from the tobacco industry, um, trying to defend their right to sell their product in an unregulated way…it is a…self-serving argument.” (PA3). These participants thought ‘informed choice’ arguments had become a means of avoiding and relocating responsibility. For example, an advocate argued: “[It's] a phrase coined by the tobacco industry as a way of…getting out of any responsibility for any tobacco sales or addiction made by people under 18. It's their scapegoat phrase.” (A5). P1 explained further: “It's an argument that's often used by politicians and people in the sector because they don't want to pay for the um, outcomes or the results of smoking, um, they…make it look as if it's your own fault.”. Participants rejected this framing as hypocritical and saw tobacco companies as undermining the behaviour they called on smokers to display. Comments on how tobacco is engineered to enhance its addictiveness highlighted this point: “The makers of the product have made it so that it's very hard to let it go…. how would they continue making money if the product didn't somehow mess with your ability to choose wisely?” (A2). Positioning smoking as the outcome of a reflective and rational analysis bore little relationship to the unthinking addiction they believed occurred among young smokers. Yet despite rejecting ‘informed choice’ arguments themselves, participants felt these arguments had a veneer of plausibility, sat logically with more right-wing philosophies and had influenced the direction of tobacco control policy.

‘Informed choice’, education and policy

Several participants drew parallels between ‘informed choice’ arguments and neoliberal economic principles, which promoted the idea of “willing buyers and willing sellers” (PA3) and “the rights of individuals to effectively do what they like as long as it doesn't harm other people” (PA4). Some saw a strong congruence between these ideas and the current government's philosophies, which they thought militated against comprehensive policy approaches. A politician explained: “We've got a government at the moment that's averse to restricting anyone's choices, whether they're individuals or big companies…they don't really want to put restrictions on people or products.” (P4). Advocates expressed frustration with this ideological desire to avoid regulation and emphasise education, and saw this approach as ineffective: “It's a dream to think that education alone will do it. It won't. We've got to get tougher.” (A1). Instead, they called on the government to change young people's environments, particularly tobacco's widespread availability. For example, one argued: “I think that there's much more of a role for government in actually limiting the availability, and using price and other things to make it difficult for people to get tobacco, rather than putting the onus on an individual.” (A6). For advocates, the need for strong government action was clear and urgent.

Politicians held varying views; some made the strongest calls for regulation and environmental change: “I think it's [the best response] changing the environment around youth.” (P4). However, others favoured diverse strategies that recognised differences in smoker subgroups: “It's still a multi-pronged attack and that—that program needs to be nuanced to particular groups.” (P3). One preferred education, on the grounds that regulation could elicit reactance: “I think…that knowledge is better, having—putting the rules and regulation in place I think might have an adverse effect to what we're trying to get.” (P2).

Variations in politicians' views highlight the challenge of developing and enacting regulation called for by other actors, who saw dangers in more educative approaches. An advocate explained: “It would fit them [tobacco companies] quite nicely if they were to be able to say ‘oh, the Government puts lots of money into education’…‘and they're [smokers] still buying our product’.” (A2). As well as benefiting tobacco companies, some advocates pointed out that governments also profited by adopting ‘informed choice’ reasoning. They suggested this logic enabled politicians to avoid regulating while preserving tax revenue: “The money that is generated by the sales of tobacco for the Government…I mean how do they replace that?” (A3). For these participants, the government's acceptance of ‘informed choice’ arguments failed to recognise that smoking uptake rarely involved an active decision and yet often brought lifelong consequences.

Addressing the contradiction

Several participants saw environmental change as crucial to reducing smoking prevalence and spontaneously reflected on what they saw as tobacco's ubiquitous, and anomalous, availability. Advocates were most likely to call for stronger regulation to reduce tobacco availability, and viewed these measures as crucial, given they thought that few young people made informed choices to smoke. They outlined the anomaly: “It's sort've a contradiction…. That it's bad for you, don't do it, yet it's sold everywhere and it's like a normal product.” (A2), and asked: “How come I can just buy it over the counter?” (A3). Several repeatedly stressed that liberal approaches to tobacco availability created confusion; they thought making tobacco more difficult to access would clearly depict it as a toxic product and support rapid reductions in smoking prevalence.

Advocates were not the only group to focus on this anomaly. One politician also called for a review of tobacco's legality: “If [politicians] admit that people aren't making informed choices, then it does bring into question the whole thing about allowing cigarettes to be sold.” (P1). Endgame goals sat uneasily in this context, where government's lack of action to reduce tobacco's availability undermined its own objective. PA4 summarised the contradiction: “Why are you putting it on me as an individual to make a proper choice? When what you're doing is despite evidence that it's killing 4000 or 5000 New Zealanders every year, you're still just allowing it to be sold in 10 000 places’…I can see young people questioning that, it's a very mixed message.”. This anomaly enabled tobacco companies, and governments, to view smokers as the problem rather than the victim. The participant explained further: “It's that focusing on the individual—if only you guys made better choices—that's the problem here. Ah, we'll give you more and more and more information so you can make better choices when (a) we know that's not necessarily what people do and (b) they see it as a sort've double standard or a mixed message.” (PA4). Participants argued that tobacco's ubiquity challenged and undermined health messages, and called on the government to reduce tobacco's availability. As one advocate noted: “I think that there's much more of a role for government in actually limiting the availability and using price and other things to make it difficult for people to get tobacco.” (A6).

While participants did not dismiss the potential value of health information, they saw reliance on this measure alone as inherently limited and unlikely to change behaviours. An advocate summarised this stance: “That education stuff also suits industry as well, with their argument around ‘it's up to people it's up to the individual, we're a business and…um, we don't force it upon them’.” (A2). This framing represents tobacco companies as neutral—only ‘a business’—without acknowledging either their commercial imperatives or the cynical relocation of responsibility from the actors who create a toxic product to those who face the resulting harms.

Furthermore, participants thought people expected government protection from harmful products: “You kind've are expecting other people to make the decisions in and around laws.” (A3). They thus argued for changes that removed the burden of choice: “Create an environment whereby they're [young people] not exposed to the risk and therefore they don't have to make the choice.” (PA4). Direct intervention to make tobacco less accessible represented a ‘perfect’ solution that would directly affect behaviour: “The more difficult you make it for young people to obtain the cigarette, the harder it [uptake] would be; I think that's perfect.” (P2).

Discussion

Stakeholders interviewed rejected arguments that young adults make informed choices to begin smoking and most regarded educating young people to understand risk as less effective than measures that would change their environment and reduce the risk they faced. Their conclusions align with evidence from young adults themselves, which illustrates the role social and physical environments play in smoking uptake,12 ,13 ,20 and imply that education alone will not ensure smoking is an ‘informed choice’. Until the contradiction that sees a uniquely harmful product sold from numerous outlets is resolved, most participants thought it unreasonable to expect young people to appreciate fully the risks smoking poses.13 ,20

Our findings have national and international implications. For New Zealand, where progress towards the smoke-free 2025 goal has been slow,3 ,21 the government's apparent acceptance that smoking is an informed choice, and reluctance to regulate tobacco's widespread availability, has created a contradiction that puts at risk its smoke-free 2025 goal. Urgent action to remedy this anomaly needs to form part of a broader strategy designed to realise the 2025 goal.22

As more countries adopt endgame goals, our findings highlight the need for a coherent policy framework that recognises the unthinking process of smoking uptake and has duly discounted industry arguments predicated on rational, reflective decision-making. Our findings suggest a need for robust policies that reduce tobacco availability and complement demand reduction strategies. At present, even the Framework Convention on Tobacco Control has only three articles dealing with tobacco supply and availability and, while Article 16 deals with sales to and by minors, there is no specific provision for reducing tobacco's availability.23

Many participants saw ‘informed choice’ arguments as a distraction perpetuating beliefs that smokers are wholly responsible for giving up a product engineered to maintain their addiction. They argued these arguments benefited governments by absolving them from responsibility for restricting access to tobacco, despite examples of relevant policy precedents enacted in other countries.24 Yet although advocates and policy analysts held consistent views that reflected widespread public support for stronger policies,25 ,26 politicians occupied varying positions. Differences in their views illustrate the ongoing challenge of progressing endgame goals in settings where neoliberal governments tacitly accept ‘informed choice’ arguments.

Our study has some limitations; while we identified participants purposively to elicit diverse views, the 2025 goal has multiparty support, thus reducing the likely variety in participants' views. Nonetheless, participants included politicians from different parties whose philosophical approaches varied. Countries declaring endgame goals have adopted different strategies; for example, some call for a tobacco-free generation, while others will only achieve their goal by greatly increasing cessation rates.5 ,27 Because New Zealand's goal requires the latter approach, our findings may not generalise to countries promoting a tobacco-free generation strategy. However, we offer more general implications, particularly with respect to tobacco availability, and outline measures that would also support tobacco-free generation strategies. Future research could address the challenge of fostering policy change by exploring how social movements might succeed where advocacy has not.28 Given the strong public appetite for reducing tobacco availability, channelling this concern may bring more widespread political support.

Calls to remove tobacco from open sale are not new and epitomise frustration with educative approaches, which sustain beliefs that smokers make ‘informed choices’ despite evidence that few make fully reasoned decisions.20 Reducing tobacco's availability would also harmonise policy action with endgame goals.4 Without a stronger alignment between governments' endgame goals and actions taken to achieve these, the goals are at risk of being seen as a cynical attempt to placate the smoke-free community, not a realistic ambition that could deliver profound public health benefits.

What this paper adds

  • Actors from different stakeholder groups saw serious limitations in arguments that smoking is an informed choice, though views on the most effective responses varied.

  • Advocates and policy analysts supported restricting tobacco's availability and regarded tobacco's ubiquity as an anomaly that undermined endgame goals; however, politicians' views varied.

  • Given smoking is rarely a considered choice, governments pursuing endgame goals need to recognise the unthinking nature of smoking uptake; measures that reduce the availability of tobacco would align governments' goals with their actions.

Acknowledgments

The authors would like to acknowledge other members of the ASPIRE2025 collaboration who provided very helpful feedback on the interview guide. In particular, they thank Professor Richard Edwards, Professor Phil Gendall and Dr Heather Gifford. They also thank the research participants who provided the data reported on in this manuscript.

References

Footnotes

  • Contributors JH conceptualised and designed the project, and obtained research funding. JB had substantial input into the interview guide; ES-T and RG also provided feedback. JB and E-ST conducted the interviews. JB and JH led the manuscript development and JH responded to the reviewers' comments. JB, ES-T and RG provided feedback on iterations of the revised manuscript. All authors have seen and approved the final version. JH is the guarantor of the manuscript. Authors are listed in descending order of contribution.

  • Funding This research was funded by a grant from the Royal Society Marsden Fund (grant number 11/134).

  • Competing interests Although the authors do not consider it a competing interest, for the sake of full transparency they note that all authors have previously undertaken work for health sector agencies working in tobacco control.

  • Ethics approval University of Otago Human Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Participants were given an assurance that their data would only be available to the research team. Unpublished data are thus not available to those outside the research team.