Promoting Informed Choice, Not Prohibition: The Ethics of Asymmetric Paternalism for Smoking Cessation

Smoking remains a leading cause of preventable death and disease worldwide (World Health Organization, 2023), which increasingly become the target of more forceful anti-tobacco measures, such as outright cigarette sales bans (Branston & Gilmore, 2020). The UK’s proposal to raise the legal smoking age every year represents one of the most sweeping efforts yet to create a ‘smoke-free generation’ (Mahase, 2022). It has reignited the longstanding debate over the ethics of paternalism and the limits of government intervention in matters of public health (Kass, 2001; Mill, 1998). This post will argue that while the public health benefits of a smoking ban could be substantial, a more ethically sound and pragmatically viable approach would consist of moderate cigarette taxes combined with a comprehensive educational program.

Paternalism and Harm Principle

Paternalism was defined as ‘the interference of a state or an individual with another person, against their will, and defended or motivated by a claim that the person interfered with will be better off or protected from harm’ (Dworkin, 2020). Paternalistic bans, although have certain benefits (e.g., remove the temptation entirely to address self-control issues, Gruber & Köszegi, 2001), clash with individual freedom and autonomy, according to John Stuart Mill’s (1998) Harm Principle which posits that ‘the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others’.

Therefore, a paternalistically motivated ban on smoking could be regarded as an unjust intervention on personal autonomy, overstepping the moral limits set by Mill and by implication promoting at least a laissez-faire view to the effect that there should be no intervention at all. Even if some interventions are justified by the need to protect people from their own willfulness (and non-paternalistic policies also aim to protect people from their own biases, as well as from the willfulness of others (Kass, 2001), we should still value self-determination and consumer sovereignty (Feinberg, 1982, 1989): (1) treating people as self-governing agents capable of making their own decisions, and (2) the dangers of paternalism and the slippery slope of governmental interventions.

Differently, even if we accept the validity of Mill’s principle, it does not follow that all paternalistic policies are unjustified, especially in the context of addressing ‘bad habits’ (Rabin, 2011) like smoking, the self-regarding nature of which should be reevaluated when considering the role of addiction and the capacity for fully informed decision-making. Then, the question for paternalism is of course ‘When does a bad habit so interfere with the person’s autonomy that its badness lies in the way that this habit affects the conditions under which he may make his choice?’. In the case of smoking, autonomy, that is, self-government, is more than likely (but not necessarily) constrained either by psychological (Gruber & Köszegi, 2001), social (Sarason et al., 1992), or physiological (e.g., addiction to nicotine; Dani & De Biasi, 2001) factors. It also points to the limitations of purely welfarist arguments for smoking bans and the narrow focus of utilitarianism on aggregate welfare, necessitating the consideration of other dimensions of well-being that extend beyond welfare, such as agency and capabilities (Sen, 1979).

From this perspective, interventions to reduce the health harms caused by smoking need not interfere with autonomy; instead, they can contribute to the conditions for the genuine exercise of autonomy. Given the shortcomings of the all-or-nothing positions just considered - either prohibition or not intervening at all - what is needed is to consider imposing an intricately designed level of paternalistic policies that attempt to balance individual autonomy against public health considerations. One such policy is cigarette taxes (Chaloupka et al., 2012).

Continuum of Paternalistic Policies – The Alternative Approach

High cigarette taxes are an example of ‘hard’ paternalism, significantly reducing the affordability and availability of cigarettes for all smokers, regardless of their particular personal circumstances or motivation to smoke (Kapeliushnikov, 2015; Lucas, 2011). The policy likely lowers average cigarette consumption substantially, but such a policy is paternalistic in the same way that a ban on smoking. Nor does it seem entirely fair to impose costs of this magnitude on low-income smokers, for whom budget constraints suggest less capacity to adjust to such a policy (Remler, 2004). On the other hand, low cigarette taxes represent a ‘softer’ form of paternalism, one that aligns with the principles of asymmetric paternalism or what has come to be known as the ‘libertarian paternalist’ approach (Hausman & Welch, 2010). By ‘asymmetric’, this approach recognizes the heterogeneity among smokers, based on which it would restrict the liberty of rational smokers as little as possible (respecting autonomy) while guiding those with self-control issues or limited information towards healthier alternatives (promoting welfare).

In addition, while low cigarette taxes could therefore seem like a more ethical policy option, their effectiveness in promoting informed choice and individual autonomy would be greatly increased if they were combined with a stronger educational component (see Maralani, 2014 for a general review of the link between smoking and education). However, education, in this case, should not be understood in an instrumental sense (as simply providing information, for example), but rather as a set of tax-based strategies designed to help individuals make rational decisions about their own health. That is to say, taxation per se can be reframed as one sort of education; One example would be to make sure that consumers know, at the point of sale, that these taxes exist and what they are used for, so as to prompt them to think more carefully about the costs and consequences of smoking (although the authors are unaware of any studies of this approach, for a systematic review of the effects of such labels on sugar-sweetened beverages, see e.g., Gupta et al., 2021).

Counterarguments and Rebuttal

Before moving on, however, it is important to reconsider some of the potential ethical objections to the ‘low tax + education’ solution. For example, from an orthodox perspective, one might argue that the policy of allowing individual choice, even within the bounds of our adjusted-paternalistic model, is inconsistent with the strong public health imperative to eliminate tobacco use altogether. However, I would respond that the new approach is compatible with a harm reduction strategy, which recognizes that the aim is to reduce the harm caused by tobacco rather than to eliminate smoking per se. This approach is likely to generate more public support, compliance, and engagement than a blanket ban, which may generate resistance, evasion, or other unintended consequences. In addition, an emphasis on education and informed choice should have the beneficial further consequence of promoting a more general culture of health literacy and empowerment that would reinforce other, as yet unidentified, public health and well-being objectives.

Another important objection to the plan is that cigarette taxes are regressive, and thereby penalize lower-income smokers who may be less able to bear the additional burden or pay for quit support services (Malone et al., 2018; Remler, 2004). However, it is important to remember that the baseline of tobacco harm to diseased communities themselves, through direct health effects and through the costs imposed on disadvantaged areas (Healton & Nelson, 2004). Seen in this context, the combination of buoyant taxes and high-quality public education and support services can perhaps be seen as a form of compensatory justice, aimed at giving particularly disadvantaged groups the power to make informed choices and escape from addiction and vulnerability. This approach is reinforced by the fact that the health and financial gains from giving up smoking may be even greater for disadvantaged people, who benefit more than anyone else from improvements in health and life chances, gains in productivity, and reduction in the cost of their health care.

Conclusion

In conclusion, a more ethically justifiable and effective alternative to either a complete ban or a free market in cigarettes is to combine modest cigarette taxes and comprehensive education. Embracing the spirit of asymmetric paternalism, the aim of this strategy is to generate the greatest benefit for rational smokers while nudging those who are not in a position to make fully informed decisions toward healthier alternatives. By making transparent the purpose of the taxes, this approach is respectful of individual preferences and also promotes public health. Furthermore, this approach is compatible with a harm reduction perspective that emphasizes reducing the harms of tobacco use rather than eliminating tobacco use itself. This policy would facilitate sustained reductions in the prevalence of smoking and the development of a health-literate and health-empowered population.

Although concerns about the regressive nature of cigarette taxes are valid, it is important to ask whether the current situation, in which widespread smoking perpetuates health inequalities and socio-economic disparities, is acceptable. Targeted interventions combining financial incentives with education and support services can help break such a cycle of addiction and poverty, promoting greater social justice. This conversation could also be connected to a wider debate about different forms of consequentialist and deontological ethics (Kant & Schneewind, 2002), to be discussed in future conversations.

References

Branston, J. R., & Gilmore, A. B. (2020). The failure of the UK to tax adequately tobacco company profits. Journal of Public Health, 42(1), 69–76. https://doi.org/10.1093/pubmed/fdz004

Chaloupka, F. J., Yurekli, A., & Fong, G. T. (2012). Tobacco taxes as a tobacco control strategy. Tobacco Control, 21(2), 172–180. https://doi.org/10.1136/tobaccocontrol-2011-050417

Dani, J. A., & De Biasi, M. (2001). Cellular mechanisms of nicotine addiction. Pharmacology Biochemistry and Behavior, 70(4), 439–446. https://doi.org/10.1016/S0091-3057(01)00652-9

Dworkin, G. (2020). Paternalism. In E. N. Zalta (Ed.), The Stanford Encyclopedia of Philosophy (Fall 2020). Metaphysics Research Lab, Stanford University. https://plato.stanford.edu/archives/fall2020/entries/paternalism/

Feinberg, J. (1982). Autonomy, Sovereignty, and Privacy: Moral Ideals in the Constitution. Notre Dame Law  Review, 58, 445.

Feinberg, J. (1989). Harm to Self. Oxford University Press.

Gruber, J., & Köszegi, B. (2001). Is Addiction “Rational”? Theory and Evidence*. The Quarterly Journal of Economics, 116(4), 1261–1303. https://doi.org/10.1162/003355301753265570

Gupta, A., Billich, N., George, N. A., Blake, M. R., Huse, O., Backholer, K., Boelsen-Robinson, T., & Peeters, A. (2021). The effect of front-of-package labels or point-of-sale signage on consumer knowledge, attitudes and behavior regarding sugar-sweetened beverages: A systematic review. Nutrition Reviews, 79(10), 1165–1181. https://doi.org/10.1093/nutrit/nuaa107

Hausman, D. M., & Welch, B. (2010). Debate: To Nudge or Not to Nudge. Journal of Political Philosophy, 18(1), 123–136. https://doi.org/10.1111/j.1467-9760.2009.00351.x

Healton, C., & Nelson, K. (2004). Reversal of Misfortune: Viewing Tobacco as a Social Justice Issue. American Journal of Public Health, 94(2), 186–191. https://doi.org/10.2105/AJPH.94.2.186

Kant, I., & Schneewind, J. B. (2002). Groundwork for the Metaphysics of Morals. Yale University Press.

Kapeliushnikov, R. (2015). Behavioral economics and the ‘new’ paternalism1. Russian Journal of Economics, 1(1). https://doi.org/10.1016/j.ruje.2015.05.004

Kass, N. E. (2001). An Ethics Framework for Public Health. American Journal of Public Health, 91(11), 1776–1782. https://doi.org/10.2105/AJPH.91.11.1776

Lucas, G. M. J. (2011). Saving Smokers from Themselves: The Paternalistic Use of Cigarette Taxes. University of Cincinnati Law Review, 80, 693.

Mahase, E. (2022). Legal smoking age in England should rise every year, review recommends. BMJ, 377, o1432. https://doi.org/10.1136/bmj.o1432

Malone, V., Harrison, R., & Daker-White, G. (2018). Mental health service user and staff perspectives on tobacco addiction and smoking cessation: A meta-synthesis of published qualitative studies. Journal of Psychiatric and Mental Health Nursing, 25(4), 270–282. https://doi.org/10.1111/jpm.12458

Maralani, V. (2014). Understanding the links between education and smoking. Social Science Research, 48, 20–34. https://doi.org/10.1016/j.ssresearch.2014.05.007

Mill, J. S. (1998). On Liberty and Other Essays. Oxford University Press.

Rabin, M. (2011). Healthy habits: Some thoughts on the role of public policy in healthful eating and exercise under limited rationality. In A. Oliver (Ed.), Essays in behavioral public policy (pp. 115–139). Oxford University Press.

Remler, D. K. (2004). Poor Smokers, Poor Quitters, and Cigarette Tax Regressivity. American Journal of Public Health, 94(2), 225–229. https://doi.org/10.2105/AJPH.94.2.225

Sarason, I. G., Mankowski, E. S., Peterson Jr., A. V., & Dinh, K. T. (1992). Adolescents’ Reasons for Smoking. Journal of School Health, 62(5), 185–190. https://doi.org/10.1111/j.1746-1561.1992.tb06039.x

Sen, A. (1979). Utilitarianism and Welfarism. The Journal of Philosophy, 76(9), 463–489. https://doi.org/10.2307/2025934

World Health Organization. (2023). Tobacco. Tobacco. https://www.who.int/news-room/fact-sheets/detail/tobacco