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Smokers and informed choice: Myth or reality? Janet Hoek, Co-Director ASPIRE2025 University of Otago, New Zealand Slide 2 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) Slide 3 Industry Position 1 Consistently questioned evidence regarding smokings 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 [scientists] appropriate dean or department head raising questions about the validity of a scientists work. Slide 4 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) Slide 5 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) Slide 6 Industry Position 2 Master Settlement Agreements of late 1990s required industry to divulge previously secret internal files Slide 7 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 Slide 8 Industry Position 2 Why the change?? Legal liability if denied risks that the courts had accepted as real Slide 9 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 Slide 10 Estimating informed choice Framework proposed by Chapman & Liberman (2005) People have: General risk awareness Specific risk awareness Risk understanding Personal application Slide 11 So, whats so difficult? Rationalisations, heuristics, exemptions Slide 12 Cognitive biases undermine choice Exceptions disprove the rule Everyone tells you its bad for your health I spose it is yes, but I know people that have had cancer that have never touched a smoke in their life... or lung problems, theyve 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 doesnt smoke at all, and she had a baby that had-has a congenital deformation so... Slide 13 Lack of agency Higher powers are at work I know what Im doing is not right, I know its not healthy but then again, its hereditary if someones got bad lungs or bad heart, its gonna happen. Slide 14 Looking on the bright side Although half of all smokers die early they couldve died early any way if they werent smoking, from other natural causes or whatever or...... theres just the other half of all smokers live a long happy life... until theyre old... Slide 15 Diminished influence I mean everyone around us smoked and... yeah... like I know its probably not good for us when we are that young, with everything developing but... its just part of life, thats the same as pollution in the air at the moment. Slide 16 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 thats less effect. So you kind of try and tell yourself its not that bad when youre smoking, especially when youre pregnant. Slide 17 Harm thresholds I dont 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) Slide 18 Compensatory behaviours Someone could smoke a pack a day and still eat right and exercise and theyd be fine, but if you smoke a pack a day and you treat yourself like crap and eat McDonalds every day, I mean stuffs going to inevitably happen some people do smoke but also treat themselves, their bodies, right. (F,28,NZE) Slide 19 Passing phase It kind of like goes off in my head, like a warning sign, but Im like too young now, so kind of carefree (laughs), I guess Im not going to care about this for at least twenty or thirty years. You now, Im not at risk at the moment of whatever kind of thing. (F,M,21) Slide 20 Passing phase Because when I see my future I dont see myself as a smoker, I dont 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) Slide 21 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 youd have one, and then youd have two or threethen 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) Slide 22 The real context of informed choice Slide 23 Environment militates against informed choice Cognitive biases Reduce risk perception Im different Alter temporal perspectives Im too young Affect risk assessment Im not hard core Undermine risk application Im exercising Impede risk understanding Ill quit Slide 24 So what does informed choice require? Decision-making process Active, conscious decision making Consideration of long-term as well as immediate risks and benefits Contextual factors Decision not impaired or coerced Knowledge factorsAwareness and understanding of: Increased health risks and addiction Specific diseases caused by smoking Meaning, severity, and probabilities of developing tobacco-related diseases Smokings addictiveness Likelihood of continued smoking Probability of quit success and relapse Personal acceptance of all the above risks Slide 25 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 Slide 26 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 Slide 27 Kia ora, thank you. For more information, contact: Janet.hoek@otago.ac.nz See: www.aspire2025.org.nz