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Introduction
Medicine is a social science and politics is nothing more than medicine on a larger scale.
—Virchow
New Zealand received international attention in 2022 when it passed legislation to end tobacco sales to those born after 2008, essentially creating a smoke-free generation (defined as less than 5% of people smoking). The approach would also have decreased the amount of nicotine in cigarettes to non-addictive levels and dramatically decreased the number of retail outlets. The plan had cross-party support including that of the major opposition party (National) which had adopted the 2025 smoke-free goal and supported the subsequent specific measures.1 The UK government’s plan to introduce similar legislation suggests this approach to be at the vanguard of antitobacco laws internationally. However, a change of government (a coalition of National and two smaller parties) resulted in repeal in 2024, hence New Zealand becomes the latest country—following Bhutan, Russia and Malaysia—to fail in its attempts to legislate tobacco out of the lungs of future generations.2
The response from the medical community has been swift and damning.2 3 Tobacco accounts for one in four cardiovascular deaths and 20% of all cancers.4 5 Smokers have a 10-year shorter life expectancy and more than half die from smoking-related disease.6 Tobacco smoke impacts all life stages as a risk factor for dementia and sudden death in infancy.7 8 Internationally, tobacco kills more than 8 million people each year, including 1.3 million non-smokers exposed to secondhand smoke.9 The New Zealand Ministry of Health estimates that the legislation would prevent 5000 deaths annually.10 Recent modelling projected a savings to the strained New Zealand health system of US$1.34 billion (95% UI 1.02 to 1.7) by 2050; savings that could be used to provide medications and treatments available in other countries but not funded in New Zealand due to cost constraints.11 12
The economic impact, however, extends further than direct costs to the healthcare system. The costs of poor health secondary to active and passive smoking have additional indirect economic impacts via absenteeism, premature withdrawal from the labour market, carer burden and the need for residential care. These impacts on productivity, health and social care far exceed any short-term fiscal benefit from tax takes.1 13–15
The harms from tobacco are not in dispute but the repeal also raises important ethical questions about the responsibilities of doctors elected to parliament. While all politicians must balance health benefits against other considerations when making public health decisions, medical practitioners taking positions so unequivocally against the public good is uniquely concerning. We argue that doctors remain bound by the ethical principles of their profession and are not absolved of their duty of care when taking up public office.
Duty of care, medical ethics and the public good
The World Medical Association Code of Ethics states that a physician not only has a duty of care to individual patients but:
has a responsibility to contribute to the health and well-being of the population the physician serves and society as a whole, including future generations.16
Practitioners also commit to acting in the best interests of their patients and are required to practise within an ethical framework that includes beneficence and non-maleficence.17 18
Beneficence is one of the original four principles of Principlism espoused by Beauchamp and Childress.18 Simply put, this is the obligation to ‘do good’, that is, to act for the benefit or in the best interests of the patient. This approach has been fundamental to the development of medical and clinical ethics. Perhaps even more relevant to the action of repeal is the related principle of non-maleficence which holds that there is an ethical obligation to not inflict harm on others. This principle has commonly been known as primum non nocere or ‘first do no harm’. Although it can be argued that austerity policies or tax frameworks that favour individual wealth over social services also harm people (disproportionately those most socioeconomically deprived), tobacco smoking is uniquely lethal and no rigorous economic argument can made in its favour.
With this background, how should the behaviour of New Zealand’s Minister of Health (a general practitioner, GP)—or any doctor—be viewed in supporting repeal of legislation that would substantively decrease harm, save lives and improve health? The evidence is unequivocal in terms of smoking-related morbidity and mortality. Elected officials are obliged to act for the public good, and introduction of a similar legislation in the UK suggests this responsibility cannot be reduced to party politics.19 However, medical practitioners have an additional level of responsibility.16 Doctors generally use their titles in public office and are elected, at least in part, because of their professional background. It is, therefore, expected that doctors act in a way consistent with these professional values.
The health minister has repeatedly highlighted his experience as a doctor. He undertook vaccinations during the COVID pandemic and visited emergency departments citing his privilege as a medical professional to do so. As he aims to benefit from being considered a medical practitioner, then so too he is bound by the ethical and professional standards required of his profession. Doctors in parliament remain part of this social contract and the ethical standards inherent to medical practice. They should not be able to abdicate their ethical obligations on entry to parliament especially when continuing to use their title and citing their professional training and experience in their political role.
The actions of Dr Reti stand in stark contrast to the leadership shown by other medically qualified politicians in tobacco reform internationally such as Uruguay president Dr Tobare Vazquez.20 Closer to home, the actions of Australian Liberal Party member Dr Mal Washer (a GP) perhaps provide a guide for Libertarian doctors. When asked about proposals for plain packaging in Australia, he responded, ‘the tobacco industry is jumping up and down because they’re worried about their businesses. I support these reforms unequivocally and whatever my party decides to do I don’t give a shit.’21 The reforms were passed with cross-party support demonstrating that the action on tobacco-related harm does not need to be reduced to party politics.
Equity and the disproportionate burden of harm
The New Zealand government argues that the legislative status quo is sufficient for reducing smoking rates. This argument ignores the ethical principle of equity, defined by the WHO as:
the absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality (eg, sex, gender, ethnicity, disability, or sexual orientation).22
Equity recognises that different groups require different strategies to achieve the same outcomes. This is important when considering who will be most impacted by repeal.
Internationally, tobacco-related harm falls heavily on Indigenous populations. In New Zealand, the smoking rate for adults is 6.8% but the rate for Māori is 17.1%.23 The controls proposed by the repealed legislation were modelled to achieve a functionally smoke-free (<5% prevalence) population in non-Māori by 2025, and in Māori by 2027.24 Without the legislation, it will take at least another 15 years for Māori to reach the same low level as New Zealand Europeans.
Hence, the speculative and complacent narrative that current law is already effective may have some validity for non-Māori but is clearly false for more socioeconomically deprived ethnicities. The Minister has emphasised his medical work in Northland, a community with high deprivation.25 26 For him to join this false narrative is disingenuous and an ethical affront to the profession. However, we argue that any doctor in politics opposing evidence-based smoke-free legislation fails to meet expected standards. Government intentions to use income tax from cigarettes to fund tax cuts will further exacerbate inequity.27 Doctors acting to reverse laws that would improve the health of the disadvantaged to fund the wealth of those more advantaged is deeply concerning.
Conclusion
The repeal of New Zealand’s smoke-free legislation will cause suffering and cost lives. The burden of illness will disproportionately be borne by the disadvantaged. The repeal breaches the duty of care expected of those trusted to act for the public good. Importantly, the moral complicity of doctors in repeal not only disregards their duty of care as politicians but violates the oaths they took as medical practitioners and the ethical principles they remain bound to.
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Footnotes
Contributors CT and SB conceived the paper. CT wrote the first draft and was responsible for submission. SB, BB and CJ contributed content from their own specialties, edited and reviewed drafts. All authors have accepted responsibility for the entire content of this manuscript and consented to its submission to the journal. CT is the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.