Abstract
When lobbying against tobacco control policies, tobacco companies have claimed that people who smoke make an “informed adult choice”. Although in the past most smokers were children when they started to smoke, in recent years smoking uptake has increasingly occurred among young adults. Whilst it is generally considered that children cannot make informed choices about whether to start smoking, the tobacco industry’s logic suggests that young adults can and do. This thesis reports on mixed methods research investigating how an informed choice about smoking can be defined, and whether people who take up smoking as young adults make an informed choice to do so.
Informed choice is defined differently when applied to health related-decisions in a medical context, compared with a commercial context. Individuals are required to demonstrate competency and understanding of risk to their medical practitioner before agreeing to a medical procedure. By contrast, individual consumer choices are generally considered to be informed as long as they have access to relevant information and have not been misled or deceived. People’s use of products that are hazardous to their health may therefore be framed as their own responsibility.
Neoliberal ideas about personal freedom and responsibility have become popular in Western political discourse since the 1980s. The tobacco industry initially denied or obfuscated the link between smoking and health risks. However, since this became no longer tenable, tobacco industry lobbying has increasingly invoked ideological arguments about choice. An analysis of internal industry documents showed that “informed adult choice” statements are used strategically by industry lobbyists. They oppose tobacco control regulation on the grounds that it would limit individual choice, and deny responsibility for harm on the grounds that smokers are exercising their informed choice when they smoke.
This research was initially designed around a framework that proposes four levels of risk awareness that a person should demonstrate in order to be adequately informed about taking up smoking (general and disease-specific awareness, understanding of the severity and probably of risks and acceptance that the risk apply personally). Evidence about some health risks associated with smoking has been highly publicised over recent decades. Therefore the idea that all adults are now aware of risks has some plausibility. However the risks are numerous and complex, and smokers’ risk acceptance is influenced by cognitive and contextual biases. Full awareness, understanding and acceptance are therefore less certain. Two original studies investigated informed choice about smoking among young adult New Zealanders aged 18 to 25 years.
In the first study, fifteen in-depth qualitative interviews with young adults who had started smoking since the age of 18 (the legal tobacco purchase age) explored risk awareness, risk acceptance and participants’ thinking about smoking now and at the time they developed a regular smoking pattern. Structured and thematic analyses of these interviews showed that participants initially avoided personalising risks because they saw smoking as a short-term activity unique to their current life phase. In many cases they had passively adopted smoking behaviour without consciously or deliberately deciding they wanted to become smokers. Despite having had a general awareness that smoking caused health problems, participants reflected that they had not fully understood what those risks entailed before they started smoking. Addiction was particularly difficult to understand without personal experience. Older participants described an upsetting transition from assuming that they were psychologically strong enough to resist addiction to realising that quitting was difficult for them. Younger participants and non-daily smokers were still confident that they could control the amount they smoked and quit once it no longer appealed. The study’s findings indicated that factors other than risk awareness limited young adults’ exercise of informed choice. These included environmental influences and use of alcohol, lack of conscious decision-making, and underestimation of addiction. These factors were added to an updated informed choice framework.
In the second study, an online survey of 522 18 to 25 year old New Zealanders, including 185 smokers, aimed to quantify how informed young adults were about different levels of smoking-related risk and how prevalent certain barriers to informed choice were. Most respondents could, without prompting, name at least one health risk related to smoking. They gave, on average, accurate estimates of the loss of life due to smoking. However, respondents’ detailed awareness of specific risks and their severity was lower. Addiction was particularly underestimated. Those who smoked or were susceptible to smoking were more prone to impulsive and risk-taking decision making, had higher exposure to smoking in their social environments, and took many of the health risks less seriously. A summary of smokers’ responses to questions addressing seven levels of informed choice showed that on average they were probably not informed on five out of seven levels, and definitely not informed for three of the seven levels.
The study’s findings suggest that young adults’ ability to exercise informed choice about smoking is limited by their short-term focus, the mixed messages and competing information they receive about smoking and its risks; and the ubiquity of tobacco in their social environments. Because young adults value a sense of control, they wish to see their smoking as an informed choice and may accept the tobacco industry’s argument, at least initially. However once they have some experience with smoking and its harms, they consider their earlier actions as uninformed. Young adults in both the qualitative and quantitative studies became less sure that they were well informed after participating in the research, indicating that they had not thought in such detail about smoking-related risks before. The study’s major implication is that information alone is not likely to lead to informed choices, particularly given young adults’ low regard for their risk of addiction and high likelihood of starting to smoke without giving the potential consequences serious consideration. Therefore, environmental interventions addressing availability of tobacco are likely to be needed if young adults are to make fully informed choices about whether to take up smoking.