02-07-2025
Can people who smoke make truly informed choices?
Opinion: Do people who smoke truly make informed decisions when they start? Our research, using a framework developed by Australian researchers and refined in Aotearoa, suggests very few people who smoke make considered decisions, understand addiction, fully appreciate the risks they face, or can quit when they choose. These findings support stronger government action to protect young people from taking up smoking and to support those who want to quit.
Associate Health Minister David Seymour's recent comment that people who smoke are 'fiscal heroes' drew widespread criticism. But his less-noticed remark deserves closer scrutiny: 'I think there's some things government can and should do around smoking … it should ensure people know the dangers, that's been done.'
This view reflects a long-standing tobacco industry narrative that people smoke because they make 'informed choices', as if simply knowing smoking is harmful means a decision is rational and free. Yet tobacco companies spent decades denying and undermining evidence of smoking harms, even when their own research confirmed them. They challenged scientists, funded front groups, and ran PR campaigns to create doubt. These tactics delayed quitting for many and helped ensure new generations continued to become addicted.
So, what does making an informed choice to smoke really involve?
The Australian researchers, Simon Chapman and Jonathan Liberman, propose four criteria. First, a person must know that smoking causes health risks. With decades of public health campaigns, most people likely meet this basic threshold.
But awareness alone isn't enough. The second criterion requires knowing specific diseases caused by smoking, not just 'smoking is bad' but knowing it can cause emphysema, bladder cancer, or blindness. Studies show wide variation in this knowledge. While awareness of lung cancer is high, far fewer people – especially youth – know about other serious risks. For example, in a Canadian study, only about half of adolescents who smoked knew smoking could cause blindness or bladder cancer.
The third criterion requires that people understand the lived experience of having a disease and know the chances they will develop it. Few people know what emphysema does to the lungs, or what life is like after a lung cancer diagnosis. People making truly informed choices understand future risk probabilities and the likelihood of surviving a disease caused by smoking five years post-diagnosis.
Finally, informed choice requires accepting these risks as personally relevant. Yet our research finds many people who smoke use mental shortcuts (heuristics) or rationalisations to dismiss risk. Common examples include: 'I don't smoke enough to be at risk,' 'I exercise, so I'll be fine,' or 'My nan smoked and lived to 90'. These beliefs aren't informed reasoning, but cognitive coping strategies that reduce fear and justify continued smoking.
We explored whether people who start smoking after turning 18 make informed decisions. The answer, for most, was no. Many began smoking while drinking, with little capacity for rational evaluation. Most thought they could control addiction but soon discovered otherwise. Nearly all described their shift from occasional to regular smoking as something that 'just happened'.
So, where does that leave us?
Yes, people generally know smoking is harmful. But most start young, in contexts that limit rational thought, and with little understanding of long-term risks. Their decisions are shaped by addiction, industry manipulation, and optimism bias, not informed consent.
These factors are why stronger preventive measures are not only justified but necessary. Policies like the smokefree generation, aimed at preventing youth uptake, aren't, as Seymour claimed, 'evil'. They are proportionate, evidence-based responses to a product designed to create lifelong dependence. They shift responsibility away from individuals and toward systems that can stop the cycle of harm.
Far from overstepping, government action to reduce smoking is a basic duty to protect health, especially when the odds are stacked against people making truly informed choices.
This article was adapted from the Public Health Communication Centre's Briefing – Do people who smoke make truly informed choices?
