Smokers and informed choice: Myth or reality?
Janet Hoek, Co-Director ASPIRE2025
University of Otago, New Zealand
Overview
• How has the “informed choice” argument evolved?
• A quick review of industry acrobatics
• How might we estimate “informed choice”?
• What evidence do we have about smokers’ decisions?
• What are the implications of this evidence?
• A case for government leadership (aka “nanny state
intervention”)
Industry Position 1
Consistently questioned evidence regarding smoking’s
harms
‘‘[W]e can take out ads . . .that point out the flaws of
the study in question. . . . [T]here is no doubt that
the careful use of these ads would be extremely
embarrassing to those scientists whose methodology,
data and conclusions are demonstrably wrong.’’
‘‘[W]e can send a letter to the [scientist’s] appropriate
dean or department head raising questions about the
validity of a scientist’s work.’’
Industry Position 1
Directly contradicted scientific evidence and provided
reassurance
“We have one essential job -- which can be simply
said: Stop public panic … There is only one problem –
confidence, and how to establish it; public assurance,
and how to create it . . . And, most important, how to
free millions of Americans from the guilty fear that is
going to arise deep in their biological depths –
regardless of any pooh-poohing logic - every time
they light a cigarette.” (Hill and Knowlton, 1953)
Industry Position 1
Lied under oath
In 1963, Addison Yeaman, concluded that cigarette
companies were not really in the business of selling
tobacco products but rather were ‘‘in the business of
selling nicotine, an addictive drug…’’. (Slade et al., 1995; from a
Brown & Williamson document, 17 July 1963)
Industry Position 2
Master Settlement Agreements of late 1990s required
industry to divulge previously secret internal files
Industry Position 2
“Q. Are there substances, foods, plants, substances in
our environment and that we consume which have
the effect of releasing neurotransmitters?
A. Yeah. … many natural substances from food or
plant sources can act on these receptors…
Industry Position 2
Why the change??
• Legal liability if denied risks that the courts had
accepted as real
Implications
IF
Smokers are told smoking is risky
AND
The industry that makes the product they use has told
them so
THEN
They must be making an “informed choice” to smoke
Estimating “informed choice”
Framework proposed by Chapman & Liberman (2005)
People have:
• General risk awareness
• Specific risk awareness
• Risk understanding
• Personal application
So, what’s so difficult?
Rationalisations, heuristics, exemptions…
Cognitive biases undermine choice
Exceptions disprove the rule
Everyone tells you it’s bad for your health – I s’pose it is
yes, but I know people that have had cancer that have
never touched a smoke in their life ... or lung problems,
they’ve never smoked in their life ...
I know a lot of people that HAVE smoked with their
children, and their children are fine, and I know- for
example, my sister doesn’t smoke at all, and she had a
baby that had-has a congenital deformation so...
Lack of agency
Higher powers are at work
I know what I’m doing is
not right, I know it’s not
healthy but then again,
it’s hereditary if
someone’s got bad lungs
or bad heart, it’s gonna
happen.
Looking on the bright side…
Although half of all smokers die early they could’ve
died early any way if they weren’t smoking, from
other natural causes or whatever or ...... there’s just
the other half of all smokers live a long happy life ...
until they’re old ...
Diminished influence
I mean everyone around us smoked and ... yeah ...
like I know it’s probably not good for us when we are
that young, with everything developing but ... it’s just
part of life, that’s the same as pollution in the air at
the moment.
Harm thresholds
Because …when you are
smoking you tend to think
“oh-a little bit or half a
cigarette or a quarter of a
cigarette is not as much as
a whole cigarette, so that’s
less effect”. So you kind of
try and tell yourself it’s not
that bad when you’re
smoking, especially when
you’re pregnant.
Harm thresholds
I don’t see myself as a, to
the point of a, smoker
which is dangerous. Like,
I probably have, maybe, a
couple a day or so.” (F, S
24)
Compensatory behaviours
Someone could smoke a pack a
day and still eat right and exercise
and they’d be fine, but if you
smoke a pack a day and you treat
yourself like crap and eat
McDonald’s every day, I mean
stuff’s going to inevitably happen…
some people do smoke but also
treat themselves, their bodies,
right. (F,28,NZE)
Passing phase
It kind of like goes off in
my head, like a warning
sign, but… I’m like too
young now, so kind of
carefree (laughs), I
guess… I’m not going to
care about this for at least
twenty or thirty years. You
now, I’m not at risk at the
moment of whatever kind
of thing.” (F,M,21)
Passing phase
Because when I see my
future I don’t see myself
as a smoker, I don’t see
myself even as a social
smoker. Like, when I see
successful people, none
of them smoke - and I
want to be successful. (M,
21, SS)
Implications for informed choice
Can we assume smoking is an “informed choice”?
• Risk understanding undermined by rationalisations,
disengagement beliefs, biases and heuristics
It was more so that, it just like, slowly
happened. Like you’d have one, and then
you’d have two or three…then so far down
the road I began thinking “oh yeah, well I
may as well just think of myself as a
smoker. (M, 22, DS)
The real context of informed choice
The real context of informed choice
Environment militates against informed choice
Cognitive biases
• Reduce risk perception
• I’m different
• Alter temporal perspectives
• I’m too young
• Affect risk assessment
• I’m not hard core
• Undermine risk application
• I’m exercising
• Impede risk understanding
• I’ll quit
So what does “informed choice” require?
Decision-making
process
• Active, conscious decision making
Contextual factors
• Decision not impaired or coerced
Knowledge factors
Awareness and understanding of:
• Increased health risks and addiction
• Specific diseases caused by smoking
• Meaning, severity, and probabilities of
developing tobacco-related diseases
• Consideration of long-term as well as
immediate risks and benefits
• Smoking’s addictiveness
• Likelihood of continued smoking
• Probability of quit success and relapse
• Personal acceptance of all the above risks
Leadership is vital
• Reduce retail density
• Extend smokefree bar
areas
• Introduce plain packaging
• Increase excise tax
• Run denormalisation
campaigns
• Enhance on-pack warnings
• Disallow product
flavourings
Smoking and the Nanny State
Sets up a false dichotomy:
Free will vs government control?
• Artificial dichotomy will stifle debate
Government intervention reflects not a “nanny state”
but a “canny state”
• Intervention a pre-requisite for free, informed choice
Kia ora, thank you.
For more information, contact:
Janet.hoek@otago.ac.nz
See:
www.aspire2025.org.nz