Making an ‘informed choice’: gaps between theory and practice

Irrespective of their background, participants saw three attributes as crucial to informed choices: information, understanding, and a capacity for critical analysis. Visible and easily retrieved risk information, particularly if available on the cusp of behaviour, was a prerequisite for informed choices. As one participant noted: “Making that access [to risk information] um, readily available and constantly available…the proximity of that information to their daily lives is important.” (P3). Some called for comprehensive information that illustrated personal harms as well as social and environmental effects. A1 explained: “The risks if you use a cigarette…so your health risk, but also I have a view that there's a risk to the community…like if you become unwell…your risk is that you may not reach your potential to participate in life in New Zealand or life in your community. Then…what environmentally do cigarettes do?”.

Participants thought young people needed complete information to understand smoking's full ‘consequences’ over time: “[They need] knowledge of the consequences of their actions, both in the long term and the short term.” (A6). A3 explained how this information needed to be germane to each individual: “You know exactly what will happen when you have the cigarette, you know what's in it…the harms, the benefits (if anything)…you have all the information that was relevant to you.”.

Finally, participants recognised that informed choices also depended on personal attributes: “That [informed choice] implies you are dealing with a reasonable person [who] can make common sense decisions.” (PA2). Alongside a capacity for reason, they saw skills in evaluating and applying risk information as crucial to informed choices: “Being able to weigh up the risks and decide that it's okay for them to do what they're going to do.” (A6).

Yet although participants easily identified the attributes required for an informed choice, few thought rational analyses preceded smoking uptake. Politicians explained this disjunction in different ways; some agreed that choices existed, but thought young people lacked the requisite information. One commented: “A choice, yes, totally agree, but I don't think people are informed enough to actually make that choice when it comes to tobacco, and probably alcohol is the same.” (P4). Another thought the information existed, but felt young people lacked the understanding required to use it: “While we think that there's a lot of information out there, I don't think they fully understand the implications at a personal level of those choices that they then make.” (P2).

Even where understanding existed, participants from all groups thought other factors proved more influential and discouraged considered actions. An advocate suggested: “I actually think they [young adults] do understand, but they don't want to understand at times…the desire to be cool or rebellious or different, ah, over-rides that.” (A7). Participants also noted young adults' limited temporal perspective: “People are about the here and now, and they're about instant gratification, they don't think about the consequences.” (PA2). Reflecting on their own youthful experiences consolidated participants’ view that little active decision making occurred: “I still think for young people it would be a pretty rare occurrence for there to be…at any…you know, great level, active decision making.” (P3). Overall, participants argued that young people's immediate social priorities assumed greater relevance and overrode the longer term benefits of remaining smoke free. For some, young people's short-term focus and lack of experience made informed choices a logical impossibility: “There's nothing that prepares them…for the consequences of smoking…for me, informed choice is knowing all the downsides.” (P1).

Discrepancies between definitions of ‘informed choice’ and actual behaviour led several participants to view the term as a cynical industry ploy, used to defend the indefensible. Some observed this phrase originated with the tobacco industry, which they saw as having ulterior motives: “The language comes actually from the tobacco industry, um, trying to defend their right to sell their product in an unregulated way…it is a…self-serving argument.” (PA3). These participants thought ‘informed choice’ arguments had become a means of avoiding and relocating responsibility. For example, an advocate argued: “[It's] a phrase coined by the tobacco industry as a way of…getting out of any responsibility for any tobacco sales or addiction made by people under 18. It's their scapegoat phrase.” (A5). P1 explained further: “It's an argument that's often used by politicians and people in the sector because they don't want to pay for the um, outcomes or the results of smoking, um, they…make it look as if it's your own fault.”. Participants rejected this framing as hypocritical and saw tobacco companies as undermining the behaviour they called on smokers to display. Comments on how tobacco is engineered to enhance its addictiveness highlighted this point: “The makers of the product have made it so that it's very hard to let it go…. how would they continue making money if the product didn't somehow mess with your ability to choose wisely?” (A2). Positioning smoking as the outcome of a reflective and rational analysis bore little relationship to the unthinking addiction they believed occurred among young smokers. Yet despite rejecting ‘informed choice’ arguments themselves, participants felt these arguments had a veneer of plausibility, sat logically with more right-wing philosophies and had influenced the direction of tobacco control policy.

‘Informed choice’, education and policy

Several participants drew parallels between ‘informed choice’ arguments and neoliberal economic principles, which promoted the idea of “willing buyers and willing sellers” (PA3) and “the rights of individuals to effectively do what they like as long as it doesn't harm other people” (PA4). Some saw a strong congruence between these ideas and the current government's philosophies, which they thought militated against comprehensive policy approaches. A politician explained: “We've got a government at the moment that's averse to restricting anyone's choices, whether they're individuals or big companies…they don't really want to put restrictions on people or products.” (P4). Advocates expressed frustration with this ideological desire to avoid regulation and emphasise education, and saw this approach as ineffective: “It's a dream to think that education alone will do it. It won't. We've got to get tougher.” (A1). Instead, they called on the government to change young people's environments, particularly tobacco's widespread availability. For example, one argued: “I think that there's much more of a role for government in actually limiting the availability, and using price and other things to make it difficult for people to get tobacco, rather than putting the onus on an individual.” (A6). For advocates, the need for strong government action was clear and urgent.

Politicians held varying views; some made the strongest calls for regulation and environmental change: “I think it's [the best response] changing the environment around youth.” (P4). However, others favoured diverse strategies that recognised differences in smoker subgroups: “It's still a multi-pronged attack and that—that program needs to be nuanced to particular groups.” (P3). One preferred education, on the grounds that regulation could elicit reactance: “I think…that knowledge is better, having—putting the rules and regulation in place I think might have an adverse effect to what we're trying to get.” (P2).

Variations in politicians' views highlight the challenge of developing and enacting regulation called for by other actors, who saw dangers in more educative approaches. An advocate explained: “It would fit them [tobacco companies] quite nicely if they were to be able to say ‘oh, the Government puts lots of money into education’…‘and they're [smokers] still buying our product’.” (A2). As well as benefiting tobacco companies, some advocates pointed out that governments also profited by adopting ‘informed choice’ reasoning. They suggested this logic enabled politicians to avoid regulating while preserving tax revenue: “The money that is generated by the sales of tobacco for the Government…I mean how do they replace that?” (A3). For these participants, the government's acceptance of ‘informed choice’ arguments failed to recognise that smoking uptake rarely involved an active decision and yet often brought lifelong consequences.

Addressing the contradiction

Several participants saw environmental change as crucial to reducing smoking prevalence and spontaneously reflected on what they saw as tobacco's ubiquitous, and anomalous, availability. Advocates were most likely to call for stronger regulation to reduce tobacco availability, and viewed these measures as crucial, given they thought that few young people made informed choices to smoke. They outlined the anomaly: “It's sort've a contradiction…. That it's bad for you, don't do it, yet it's sold everywhere and it's like a normal product.” (A2), and asked: “How come I can just buy it over the counter?” (A3). Several repeatedly stressed that liberal approaches to tobacco availability created confusion; they thought making tobacco more difficult to access would clearly depict it as a toxic product and support rapid reductions in smoking prevalence.

Advocates were not the only group to focus on this anomaly. One politician also called for a review of tobacco's legality: “If [politicians] admit that people aren't making informed choices, then it does bring into question the whole thing about allowing cigarettes to be sold.” (P1). Endgame goals sat uneasily in this context, where government's lack of action to reduce tobacco's availability undermined its own objective. PA4 summarised the contradiction: “Why are you putting it on me as an individual to make a proper choice? When what you're doing is despite evidence that it's killing 4000 or 5000 New Zealanders every year, you're still just allowing it to be sold in 10 000 places’…I can see young people questioning that, it's a very mixed message.”. This anomaly enabled tobacco companies, and governments, to view smokers as the problem rather than the victim. The participant explained further: “It's that focusing on the individual—if only you guys made better choices—that's the problem here. Ah, we'll give you more and more and more information so you can make better choices when (a) we know that's not necessarily what people do and (b) they see it as a sort've double standard or a mixed message.” (PA4). Participants argued that tobacco's ubiquity challenged and undermined health messages, and called on the government to reduce tobacco's availability. As one advocate noted: “I think that there's much more of a role for government in actually limiting the availability and using price and other things to make it difficult for people to get tobacco.” (A6).

While participants did not dismiss the potential value of health information, they saw reliance on this measure alone as inherently limited and unlikely to change behaviours. An advocate summarised this stance: “That education stuff also suits industry as well, with their argument around ‘it's up to people it's up to the individual, we're a business and…um, we don't force it upon them’.” (A2). This framing represents tobacco companies as neutral—only ‘a business’—without acknowledging either their commercial imperatives or the cynical relocation of responsibility from the actors who create a toxic product to those who face the resulting harms.

Furthermore, participants thought people expected government protection from harmful products: “You kind've are expecting other people to make the decisions in and around laws.” (A3). They thus argued for changes that removed the burden of choice: “Create an environment whereby they're [young people] not exposed to the risk and therefore they don't have to make the choice.” (PA4). Direct intervention to make tobacco less accessible represented a ‘perfect’ solution that would directly affect behaviour: “The more difficult you make it for young people to obtain the cigarette, the harder it [uptake] would be; I think that's perfect.” (P2).