an essay about advantages and disadvantages of selling cigarettes

The Advantages and Disadvantages of Selling Cigarettes Essay

The sale of cigarettes has long been a contentious issue worldwide, with significant debate over the advantages and disadvantages it presents. Cigarettes, though legal and heavily taxed in many countries, have profound health, economic, and social implications. This essay explores the various benefits and drawbacks associated with the sale of cigarettes.

Advantages of Selling Cigarettes

• Revenue Generation : The sale of cigarettes generates substantial tax revenue for governments. These funds are often used to support public services such as healthcare, education, and infrastructure development.
• Employment Opportunities : The tobacco industry provides jobs in various sectors, including agriculture, manufacturing, retail, and marketing. This can be particularly important in regions where alternative employment opportunities are limited.
• Personal Freedom : In a free market economy, adults have the right to make their own choices, including the decision to purchase and consume cigarettes. Banning the sale of cigarettes could be seen as an infringement on personal liberties.
• Support for Tobacco Farmers : In some regions, tobacco farming is a major source of income for rural communities. The sale of cigarettes ensures that these farmers can maintain their livelihoods.

Disadvantages of Selling Cigarettes

• Serious Health Issues : Cigarette smoking is a leading cause of various severe health conditions, including lung cancer, heart disease, stroke, and chronic obstructive pulmonary disease (COPD). The health risks associated with smoking are well-documented and significant.
• Secondhand Smoke : Non-smokers exposed to secondhand smoke are also at risk of developing health issues, including respiratory infections, heart disease, and lung cancer.
• Healthcare Expenses : The healthcare costs associated with treating smoking-related illnesses are enormous. Governments and individuals spend billions annually on medical care for conditions caused by smoking.
• Lost Productivity : Smoking can lead to reduced productivity due to illness, disability, and premature death. This has economic implications for both employers and the economy at large.
• Addiction : Nicotine, the addictive substance in cigarettes, creates dependency, making it difficult for smokers to quit. This addiction can lead to long-term health problems and decreased quality of life.
• Youth Smoking : Despite age restrictions, cigarettes are often accessible to minors, leading to early addiction and long-term health consequences. The marketing of cigarettes can sometimes indirectly target younger audiences, perpetuating the cycle of addiction.
• Pollution : Cigarette production and disposal contribute to environmental pollution. Tobacco farming involves the use of pesticides and deforestation, while cigarette butts are a common form of litter that pollutes land and waterways.
• Resource Consumption : The production of cigarettes consumes significant natural resources, including water and arable land, which could be used for other, more sustainable agricultural practices.

Balancing the Pros and Cons

Addressing the pros and cons of selling cigarettes requires a multifaceted approach. Policymakers must balance the economic benefits with the substantial health and social costs. Potential strategies include:

• Higher Taxes : Increasing taxes on cigarettes can reduce smoking rates while generating revenue that can be used for public health initiatives.
• Strict Regulations : Implementing and enforcing regulations on advertising, packaging, and sales can help reduce smoking rates and limit access to minors.
• Education : Public health campaigns can educate people about the dangers of smoking and promote cessation programs. This can help reduce the prevalence of smoking and its associated health risks.
• Support Services : Providing support services for those trying to quit smoking, such as counseling and nicotine replacement therapies, can help reduce addiction rates.
• Diversification Programs : Supporting tobacco farmers in diversifying their crops and finding alternative sources of income can reduce economic dependency on tobacco cultivation and promote more sustainable agricultural practices.

The sale of cigarettes presents both significant advantages and disadvantages. While it contributes to economic stability and personal freedom, it also poses severe health risks, economic burdens, and social challenges. Striking a balance requires comprehensive strategies that include regulation, education, and support for alternative livelihoods. By addressing these issues, societies can mitigate the negative impacts of cigarette sales while considering the economic realities of the industry.

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Morality and the Business of Selling Tobacco

To the Editor:

Re “ The Tobacco Ties That Bind ,” by Peter B. Bach (Op-Ed, April 11):

I can’t begin to express my disappointment with the American Cancer Society because of its unforgivable relationship with Walgreens, which continues to sell tobacco products. As a former cancer patient, I wonder: Is it too much to ask that the “largest cancer charity” be independent of the single most egregious industry on our planet?

Being in bed with the tobacco industry and the pharmacies that promote smoking is simply unethical and a slap in the face of every cancer survivor.

MITCHELL BRODSKY Princeton, N.J., April 11, 2014

Peter B. Bach implies that by ending the sale of tobacco products, CVS pharmacies are some kind of moral actor while Walgreens remains a greedy business. Walgreens’s funding of the American Cancer Society by extension also compromises the moral standing of the society. In truth, they are all businesses.

CVS looks to improve its image and its bottom line. Both CVS and Walgreens sell all kinds of things, from empty-calorie sugary drinks and heart-attack food to dubious health aids; if their primary mission were really to improve people’s health, they would close down their drive-through windows and stop all those idling car engines.

As for the cancer society, its executives take home high six-figure salaries. Such groups spend vast sums on advertising, advocacy, lobbying and more fund-raising in the cycle that perpetuates their existence.

Compared with all this self-righteous hypocrisy, the tobacco industry seems a lot more honest: It admits to being a business and doesn’t pretend to sell anything other than a product that everyone knows is bad for him or her.

DAVID ROMANO Ozark, Mo., April 11, 2014

The pros and cons of a total smoking ban

Plans to phase out the sale of tobacco completely have won cross-party support

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Pro: saving lives

Con: black markets, pro: avoiding poverty, con: risk to civil liberties, pro: environmental protection, con: losing tax revenue.

Rishi Sunak's plans to phase out the sale of cigarettes appears to have gained cross-party backing, making a total smoking ban in the UK a real possibility.

The prime minister used his Conservative Party conference speech to announce plans to raise the age at which people can buy tobacco in England year by year until it applies to the whole population. This would mean a 14-year-old today will never legally be able to buy a cigarette, putting England on a par with the likes of New Zealand, which introduced a similar law last year, in having "some of the strictest smoking laws in the world", Sky News reported.

While an outright ban – even one introduced over several decades – may prove controversial, its chances of coming into law have received a boost after it won support from Labour, as well as Welsh and Scottish governments, where laws on smoking are devolved.

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"Political instincts on this issue are coalescing around a similar position," said BBC political editor Chris Mason, meaning the plan could be both "profound and long-lasting".

Almost six million people in England smoke, and tobacco remains the single biggest cause of preventable illness and death. Tobacco smoke can cause cancer, stroke and heart disease, with smoking-related illnesses costing the NHS £17 billion a year, according to campaign group  Action on Smoking and Health (ASH).

An independent government-commissioned review , which last year recommended proposals similar to those announced by Sunak, argued that tackling tobacco use and supporting smokers to quit would help prevent 15 types of cancer – including lung cancer, throat cancer and acute myeloid leukaemia. Recent data showed that one in four deaths from all cancers were estimated to be from smoking.

Speaking on BBC Radio 4 's "Today" programme, the prime minister said his proposals represented the "biggest public health intervention in a generation", a claim backed up by England's chief medical officer, Sir Chris Whitty, who stressed how beneficial the health improvements would be.

Simon Clark, of smokers' lobby group Forest, told the BBC that "creeping prohibition won't stop young adults smoking" but it will "simply drive the sale of tobacco underground and consumers will buy cigarettes on the black market where no-one pays tax and products are completely unregulated".

The illicit trade in tobacco products "poses major health, economic and security concerns around the world", according to the World Health Organization , which estimates 1 in every 10 cigarettes and tobacco products consumed globally is illicit.

Writing for The Conversation , Dr Brendan Gogarty, of the University of Tasmania, argued that "laws that rely on prohibition to reduce the prevalence and harm from drugs generally fail to achieve their aims".

Smoking causes a disproportionate burden on the most disadvantaged families and communities, last year's independent review found. The average smoker in the North East of England spends over 10% of their income on tobacco, compared to just over 6% in the South East.

This mirrors research from 2015 conducted by University of Nottingham, which found parents who smoke were "plunging nearly half a million children into poverty", The Independent reported.

As smokers quit, said Sudyumna Dahal for The Conversation , household budgets "become easier, facilitating what a study in the British Medical Journal describes as an income transfer from male smokers to females and other family members".

Therefore, argue anti-smoking campaigners, banning smoking would bring greater benefits to the less well-off.

Smokers and the groups who advocate on their behalf argue that their habit is a civil right, even if it kills the smoker. In a report published in 2019, the smokers’ group Forest argued that "smokers are the canaries for civil liberties".

It added that the call for a ban "directly violates the harm principle that assumes a person has autonomy over their own life and body as long as they do not hurt other people".

As The Spectator editor Fraser Nelson pointed out on Twitter , plans to phase out the sale of cigarettes could lead to the absurd situation where pensioners will have to produce ID to prove which side of the ever-moving line of legality they are on.

"I'd love to live in a smoke-free world," wrote Rachael Bletchly in the Daily Mirror . "I wish people would stop wrecking their health with cigarettes. But I don't think it's the job of politicians to police other grown-ups' filthy habits. And I fear that Rishi Sunak's new smoking ban is just well-meaning, populist puff."

Cigarette smoking has several negative environmental impacts and banning smoking would bring these to an end. Smokers release pollution into the atmosphere, cigarette butts litter the environment, and the toxic chemicals in the residues cause soil and water pollution.

Tobacco is commonly planted in rainforest areas and has contributed to major deforestation, said Conserve Energy Future .

A 2013 report in the journal Tobacco Control found that cigarette manufacturing “consumes scarce resources in growing, curing, rolling, flavouring, packaging, transport, advertising and legal defence” and “also causes harms from massive pesticide use”.

Taxation on smoking raises more than £8.8 billion per year for the Treasury, noted Politics.co.uk . The TaxPayers’ Alliance rejected the argument that smokers also cost the taxman more due to their health burden, arguing that smokers who suffer major health problems are more likely to die prematurely, reducing expenditure on state pensions and other age-related benefits.

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Stop Smoking: It's Deadly and Bad for the Economy

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Higher taxes on tobacco products reduce tobacco consumption and improve public health, while also increasing government revenues that can be used to fund priority investments and programs that benefit the entire population.

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Should taxes on cigarettes be increased?

Q. Evaluate the economic case for and against the UK government further increasing the tax on tobacco in order to reduce smoking.

Increasing tax will lead to a fall in demand, although this may only be a small effect because demand is price inelastic. People are addicted and there are no close substitutes.

Cigarettes are a demerit good , therefore, consumers may underestimate the costs of smoking – e.g. they ignore the damage to their own health; this is a reason to try and stop people smoking.

Also, smoking has many negative externalities (passive smoking, the cost to the NHS is estimated to be £1.5 billion) therefore, the social cost is greater than the private cost; if the social cost is greater than the present price, social efficiency can be increased by making smokers pay the true social cost.

Diagram showing the effect of Tax on Cigarettes

A tax shifts the supply curve to the left causing a fall in demand this is more socially efficient because at Q2,  SMC=SMB.

Evidence suggests a higher tax on tobacco have played a role in reducing demand.

Showing rise in tax rates on cigarettes.

Fall in the proportion of people who smoke in Great Britain.

Another advantage of increasing tax on cigarettes is that it will lead to increased tax revenue. This will enable the government to spend money on health care or on campaigns to encourage people to stop smoking. Alternatively, they could lead to lower tax rates, e.g. VAT.

Arguments against increasing tax on cigarettes

• Smokers already pay a lot of tax £7 billion. Also, they do not cost the government much because they die early and save pension and health care spending
• Demand is very inelastic and therefore increasing price will only cause a small fall in demand
• Higher taxes will increase inequality because the poor will pay a higher % of tax than the rich who are more likely to have given up (However the government can use other taxes to reduce inequality if it is concerned about this)
• Higher taxes will encourage people to smuggle illegal cigarettes and avoid paying the tax.

You could argue that smokers already pay the social cost of smoking given the high level of current tax. Therefore the best argument for increasing taxes is the normative judgement that smoking is bad for people and the government should intervene to reduce demand.

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• Volume 29, Issue 6
• An argument for phasing out sales of cigarettes
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• http://orcid.org/0000-0002-4712-513X Elizabeth A Smith ,
• http://orcid.org/0000-0002-3324-2183 Ruth E Malone
• Social and Behavioral Sciences , University of California San Francisco , San Francisco , California , USA
• Correspondence to Dr Elizabeth A Smith, Social and Behavioral Sciences, University of California San Francisco, San Francisco, CA 94143, USA; libby.smith{at}ucsf.edu

The successes of tobacco control in some countries and locales have led to discussions of ending the tobacco epidemic, often called the ‘endgame’. In this paper, we recommend articulating the endgame goal as phasing out sales of cigarettes, a goal once called ‘unthinkable’. We develop a logic and argumentation for ending cigarette sales intended to move the discussion beyond the shadow of ‘prohibition’, proposing an approach that appeals to consumer protection standards and suggesting that the effort be led by low-prevalence communities. While phasing out cigarettes will not happen everywhere all at once, and may unfold differently along several lines, we argue that the gradual phase-out approach we propose will reduce the likelihood of the negative consequences often predicted to come with such a policy. To continue permitting widespread sales of the single most deadly consumer product in history is a public health failure that must be addressed.

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This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/tobaccocontrol-2019-055079

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The idea of developing an ‘endgame’ plan for tobacco has engaged researchers and public health advocates for the last decade. 1–4 Several countries have set endgame goals. 5–9 Endgame framing has encouraged advocates to move beyond an ongoing struggle to ‘control’ tobacco’s impacts to imagine that an endpoint – a specific, measurable outcome marking an end to the tobacco epidemic -- is possible in the foreseeable future, and to begin to develop strategies to achieve it. 2–4 10 11

Although the ‘endgame’ term is used widely, its definition remains ambiguous. There is little consensus on whether new policies are needed, beyond full, effective implementation of the measures called for by the World Health Organization Framework Convention on Tobacco Control. 12 There is also variability in the goals countries have set. For example, Finland has asserted a goal of less than 5% daily tobacco use prevalence by 2030. 6 13 Canadians recently discussed an endgame goal of ‘less than 5 (% prevalence) by 2035’. 5 Denmark’s goal is: ‘none of the children born today smoking in 2030’. 9

It is unsurprising that there is some scepticism regarding the tobacco endgame. Most innovative tobacco control policies were initially regarded as impractical, impossible or extreme before eventually becoming standard features of the policy landscape. Furthermore, everyone working in tobacco control today was born in the ‘cigarette century’ 14 ; thus, no one now alive has experienced a time when commercial tobacco products were not ubiquitously sold (except perhaps recently in Bhutan, which banned tobacco sales and production). 15 These circumstances make imagining an endgame especially challenging. In this paper, we argue that ending cigarette sales, led by jurisdictions with already-low smoking prevalence, should be articulated publicly as the endpoint goal. Ending sales of cigarettes, widely acknowledged to be the most deadly consumer product on the market, would advance public health by treating them like many other (unsafe) products.

As a global oligopoly, the tobacco industry has enough money to influence policy-makers, outspend political opponents, and create social, political and scientific institutions to act on its behalf. These activities have created the current situation, in which jurisdictions struggle to conceptualise a workable policy regime to end the tobacco epidemic. The fact that even tobacco control advocates, who understand the devastation tobacco has caused, often dismiss the idea of ending cigarette sales as naïve, infeasible or unwise, suggests how deeply normalised cigarette sales still remain. While we do not underestimate the magnitude of the effort required to end cigarette sales on a large scale, unwillingness to name it as a goal renders it impossible to achieve.

We define the endpoint as ending sales of cigarettes and similar combusted products (eg, little cigars), because in most countries, they are responsible for the largest part of tobacco-caused morbidity and mortality. They also remain the tobacco industry’s single largest source of profits and power. The place in the endgame of other, apparently less hazardous products (such as low-nitrosamine smokeless tobacco products, heated tobacco products and e-cigarettes), may vary by jurisdiction, as we discuss below. Here, we discuss the evidence suggesting that ending cigarette sales will be an effective endgame approach, and propose a logic and argumentation for phasing out cigarette sales that moves beyond the ‘prohibition doesn’t work’ narrative trope.

Evidence for phasing out cigarette sales

Although the outcome of new policies is always uncertain, evidence suggests that removing cigarettes from the market would result in fewer people smoking. Higher tobacco outlet density is associated with a higher likelihood of smoking initiation by minors 16 and adults, 17 and living near tobacco outlets is associated with unsuccessful quit attempts. 18 19 Emerging evidence also suggests that tobacco retailer reduction is associated with a decline in cigarette pack purchases. 20 In the USA, point of sale promotions are the most visible tobacco advertisements; eliminating such promotions (as would occur if sales were ended) is also associated with reduced odds of regular smoking among adults 21 and adolescents. 22 Ending cigarette sales would also have a powerful secondary impact: further denormalising the cigarette industry. Tobacco industry denormalisation is associated with reduced smoking prevalence among youth and young adults, reduced smoking initiation among youth, and increased intentions to quit. 23

The endgame and consumer product safety

The idea of abolishing cigarette sales frequently raises concerns (at least in the US context) about alcohol prohibition and the various problems that accompanied it. 24 But prohibition is not the only historical and rhetorical parallel; other laws and norms can be drawn on to shape understanding of ending cigarette sales. In 1985, the United Nations unanimously adopted guidelines for consumer protection. The guideline on physical safety states that ‘Governments should adopt or encourage the adoption of appropriate measures… to ensure that products are safe for either intended or normally foreseeable use.’ 25 Beyond these guidelines, in the 20th century, many countries developed more specific laws and regulations aimed at protecting the public. In the countries with the largest multinational tobacco companies (ie, the USA, the UK, Japan and the European Union nations), it is now taken for granted that cars undergo crash tests before they are sold, food manufacturers and processors are held to hygienic standards, and drugs undergo clinical trials to establish safety and effectiveness. Legal consumer products found to be hazardous are regularly pulled from the market, such as toys presenting choking hazards for children; batches of contaminated processed food or individual components of complex goods (eg, batteries, airbags) that work improperly. Manufacturers or retailers sometimes recall goods that appear to malfunction, even without reported injuries. For the most part, consumers assume that products offered for sale are reasonably safe.

Additionally, tobacco control practitioners are using human rights standards. The 2018 Cape Town Declaration on Human Rights and a Tobacco-free World finds that ‘the manufacture, marketing and sale of tobacco are incompatible with the human right to health’, and reaffirms the International Covenant on Economic, Social and Cultural Rights (ICESCR) statement that the ‘failure to discourage production, marketing and consumption of tobacco’ is a ‘violation of the obligation to protect’ the right to health. 26 , 27

The bizarre exception to both standards is the cigarette, shown to kill as many as two-thirds of its long-time users 28 29 yet essentially unregulated. (The regulations in place largely apply to packaging, promotion or sales, not the design or contents of the product itself.) When consumer protection agencies and laws were established, in the early 20 th century, tobacco was omitted. The cigarette continued to be sold even as evidence about its dangers mounted, due to the industry’s political power. 14 30 The US Food and Drug Administration (FDA), for example, had no power to regulate tobacco until recently, as tobacco was excluded from its jurisdiction as not ‘ intended to affect the structure or any function of the body’ (the definition of a drug). 31 (In fact, the tobacco industry intentionally engineered its products in multiple ways to maximise certain effects on the body, but this was not widely known. 32 ) Even now, a decade after the 2009 US Family Smoking Prevention and Tobacco Control Act (FSPTCA) which gave the FDA regulatory power over tobacco products, the FDA has no power to remove these existing, ‘grandfathered’ deadly products from the market, 33 so no national phase-out of cigarette sales would be possible in the USA without Congressional action, a highly unlikely scenario. However, as we discuss below, other options are possible, and for various reasons, probably preferable.

The ‘right’ to use versus the ‘right’ to sell

The tobacco industry defines the central issue of tobacco control as the individual right to use tobacco, 34 35 eliding the issue of a company’s responsibility to sell safe products. This framing has been successful: attempts to discuss removing cigarettes from the market frequently give rise to questions not about the ethics of allowing them to be sold, but about the ethics of restricting consumer freedom, 36 the assertions of the Cape Town Declaration and ICESCR notwithstanding. However, in the USA, at least, it is clear that there is no legal ‘right to smoke’. 37

From the consumer protection standpoint, most people do not believe that people ‘need’, ‘deserve’ or ‘have the right to’ purchase cars that are unsafe to drive, medications that poison them or food that spreads disease. The promulgation of the idea that there is a ‘right’ to buy cigarettes, and the characterisation of the industry as a simple conduit of those products, an inevitability of a naturally occurring market, are arguably the most potent, deceptive and dangerous aspects of tobacco industry power. The ‘right to smoke’ framing obscures the generally accepted ethical obligation of reputable companies to sell only products that do not cause great harm when used as intended.

To plan an end to cigarette sales, therefore, requires comprehending and developing strategies for conveying to the public that the cigarette industry is an extreme outlier in the legal and regulatory landscape of consumer protection, rather than an ordinary business. In terms of consumer protection, the goal is to create a level playing field, in which the tobacco industry must meet normal expectations for product safety. With a consumer protection framing, rational policy-making follows: laws and norms that ensure the safety of consumer products should apply to cigarettes. Tobacco control policy could be truly guided by the principles of Cape Town, ICESCR, and the UN guidelines.

In the USA, tobacco products are exempted from the Consumer Products Safety Act 38 ; however, the Act does not prevent states and other jurisdictions from enacting more stringent standards than those established by the Act, and they often do. Similarly, the 2009 FSPTCA specifically permits state or local jurisdictions to adopt more stringent laws ‘relating to or prohibiting the sale, distribution, possession, exposure to, access to, advertising and promotion of, or use of tobacco products by individuals of any age,’ 33 leaving the door open for states or local governments to end cigarette sales. The 50th Anniversary edition of the US Surgeon General’s Report on the Health Consequences of Smoking explicitly proposes state or local bans on sales of whole classes of tobacco products. 39

Benefits of ending sales

Ending sales deprives the industry of income and represents the most concrete way to denormalise the product. Equally importantly, ending sales could reduce the industry’s influence in government and policy-making by challenging its legitimacy. 40 Notably, however, defining the endpoint as ending cigarette sales does not require that no one could or would ever use tobacco (or other nicotine products). Tobacco is a product that has been used in some form for centuries and some use (both ritual and addiction based) is likely to continue; however, it is only since the commercialisation of cigarettes that the problems its use causes have reached epidemic proportions. 14 32 Not expecting policies to achieve total ‘prohibition’ or zero prevalence recognises this.

Objectors to proposed endgame-advancing policy proposals commonly refer to black markets or the failures and unintended consequences of alcohol prohibition. But these objections, often supported by industry-funded research, typically assume exaggerated proportions of illicit trade. 41 Furthermore, under Prohibition, alcohol use prevalence was high, many users perceived their own use to be unproblematic, and possession and use were criminalised, leading to widespread law-breaking and reduced respect for law enforcement. In contrast, phasing out cigarette sales in a jurisdiction with already-low smoking prevalence (without reference to possession and use) is quite different. Many smokers already perceive their own use to be problematic (eg, they want to quit 42 ) and thus might be less likely to seek out illicitly sold cigarettes. Furthermore, eliminating ready access to cigarettes could enhance success in cessation, since smokers experience stronger cravings when they expect to be able to smoke in the near future. 43 44 While some illegal underground sales (whether home-grown or through neighbouring communities) are likely to occur, these types of activities seem unlikely to represent a black market so substantial that it would become worse for public health than the status quo.

To make phasing out cigarette sales the endpoint goal, it is not necessary to envision it as happening everywhere all at once. Rather, we predict that ending cigarette sales will take place gradually, jurisdiction by jurisdiction, beginning in low-prevalence locales and potentially supported by a new narrative about fairness under consumer protection principles. This is particularly true in the USA, where many cities and counties have the ability to enact innovative laws. This gradual implementation of sales bans city by city, rather than being a problem, could make genuinely substantial black markets less likely to flourish. The combination of a relatively small customer base (due to already-low prevalence in the jurisdictions initiating the policies) and the modest initial extension of distance for consumers to purchase legally would render the risks involved in a highly organised black market operation less attractive.

The history of US tobacco control policy suggests that each location taking this step may enable others to do likewise, and that new policies can change the prevailing narrative about tobacco. For example, Beverly Hills, California is ending sales of cigarettes and other products as of January 2021. 45 Beverly Hills has a population of approximately 34 000 with a low smoking prevalence, and is surrounded by the much larger city of Los Angeles. Assuming it implements the ordinance, cigarettes will still be available in adjacent areas. However, other jurisdictions in the region are already studying this option. If the policy spreads (as, for example, clean indoor air laws did, despite industry efforts) an eventual statewide policy ending cigarette sales would have a significant impact on smoking, and also on the industry and its political influence in the state.

Federal action

There are some indications that the FDA could at some point move to implement a product standard for all cigarettes sold in the USA that would mandate lowering nicotine to minimally or non-addictive levels. 46 Given the extensive time involved in federal rulemaking, it is difficult to predict whether and when such a strategy will be operationalised. However, the very low nicotine content (VLNC) cigarette requirement could actually work in tandem with a gradually executed phase-out of cigarette sales as a complementary strategy, rendering it less likely that consumers would make the additional effort to travel to neighbouring jurisdictions to obtain the less-attractive and less-addictive VLNC cigarettes still being sold there. While a black market in higher nicotine cigarettes is possible, that would be a possibility of the VLNC strategy itself, not a direct consequence of ending cigarette sales in a community with already-low prevalence.

Changing the narrative

Achieving an end to the tobacco epidemic will be an arduous and lengthy process. But advocates must be willing to state publicly their goal. For any endgame plan, the narrative about cigarette sales must shift to end the perception that cigarettes are an ordinary consumer product. Rather, selling cigarettes should be characterised as selling an inherently defective/unsafe product that falls into the same category as contaminated food, asbestos and lead paint. These are products that states find too hazardous to be made available to the public, and regardless of cost (lost tax revenue/increased regulation/jobs eliminated), the government removes them from the marketplace.

Tobacco control advocates may believe that they have already been giving the clear message that cigarettes are too hazardous to use, but by tacitly acceding to the idea that cigarette sales must continue, that message is continually undermined. The confusion this causes is expressed by smokers who ask: if cigarettes are so dangerous, why are they legally and widely available for sale? Some also question whether raising tobacco taxes is less about public health and more for the benefit of the state’s bottom line, at the expense of smokers. Tobacco control advocates have contributed to this perception by advancing tobacco taxes as beneficial for state economies, beyond the reductions in consumption they produce. These lines of argument can give tobacco control proponents a credibility problem that industry apologists exploit.

Industry opposition

Achieving an end to cigarettes sales will require: low tobacco use prevalence rates (particularly in early adopting jurisdictions); an awareness among the public that the current situation is legally anomalous and ethically unacceptable; policy-makers prepared to act to protect public health despite industry opposition, loss of tobacco industry campaign contributions and lost tax revenues from cigarettes; and policy measures that are consistent with those values. Additional strategic legal, constitutional, ethical, historical, political and communications research will be needed to advocate for an end to cigarette sales in various jurisdictions while continuing to implement ‘status quo’ tobacco control measures. The consumer products safety narrative we discuss is just one approach to building the case; in different places, different narratives (eg, human rights and social justice) may be more effective or resonant with existing law and social norms.

However, it is important to note that the tobacco industry no longer exerts the social and political power it once did, particularly in the many locales discussing endgame ideas. Indicators include a recent move towards divestment from tobacco stocks from large portfolios 47–50 ; refusal of journals to publish tobacco industry funded research 51 52 ; refusal of policy-makers to accept campaign contributions from tobacco companies and failure of tobacco industry-sponsored ballot initiatives. 53

Public opposition

Up to 90% of smokers regret that they started 54 and 70% want to quit 42 ; thus in the areas with low smoking prevalence ( < 10%) likeliest to implement cigarette sales bans under our proposal, the total population who would potentially object strongly would be about 1%–3% (ie, the 10%–30% of smokers who do not regret starting and/or do not want to quit). Polling data from various regions and countries indicate that, even in the absence of any campaigns for ending cigarette sales, majorities of non-smokers (and 12%–46% of smokers) support the idea. 3

Gradual versus abrupt approaches

Normally, once a product is determined to be unsafe, sales are stopped as quickly as possible. However, a phased approach to ending cigarette sales seems more practicable from both political and consumer perspectives. One historical parallel is leaded gasoline. As with tobacco, manufacturers knew for decades that leaded gasoline was hazardous and concealed that knowledge. 55 Still, the eventual phase-out of leaded gasoline in the USA took a decade. 56

A gradual approach acknowledges the difficulties associated with eliminating a widely used and addictive product. However, those difficulties should not be overstated. Notwithstanding the popular idea that tobacco is more addictive than heroin, 57 compared with some other addictive substances, withdrawal from nicotine is mild. The legality, ubiquity and cheapness of cigarettes, as well as the lack of immediate visible negative consequences to smoking, make them ‘more difficult to quit than heroin’, not their neurochemical effects or the severity of withdrawal. In places where tobacco control is more advanced a ‘softening’ of the remaining smoking population has occurred, rather than the ‘hardening’ theorised by some proponents of market-based approaches to the endgame. 58 This means that the remaining smokers, while they may find quitting difficult, are less invested in continuing to smoke. Given that 70% of smokers say they want to quit, 42 reducing product availability and accessibility can support smokers by reducing relapse. 43 44 Policy adoption rarely happens quickly, and the debate over ending sales would give smokers motivation to prepare by quitting. Nicotine replacement products (both pharmaceutical and commercial) are readily available. In many places, e-cigarettes or other alternative products would also remain available. Therefore, it would potentially be feasible for jurisdictions to adopt policies with a short phase-out period.

The envisioned jurisdiction-by-jurisdiction approach is in itself a gradual one. If cities or counties adopt sales bans, as in the Beverly Hills case, it is likely that acquiring cigarettes will initially only necessitate travel to nearby areas, becoming inconvenient rather than impossible. While some might interpret such measures as merely ‘symbolic’, virtually every important advance in tobacco control policy began with measures similarly characterised. For example, the initial efforts to achieve smoke-free sections in restaurants were, for all practical purposes, merely symbolic, since smoke still drifted from the smoking section. However, by establishing a different narrative understanding about the boundaries and effects of secondhand smoke, those early policies led the transition from symbolic to material.

Substitute sources of revenue

Another ‘addiction’ to address is that of the tobacco industry and states to tobacco revenue (profits or taxes) 59 and the political power that sustains. Some jobs, particularly those involved in manufacturing, will be lost as cigarette sales decline. However, others may be created or changed. In places with already-low smoking prevalence, retailers will need to transition their business models in any case, as tobacco sales drop. Retailers, perhaps with incentives from governments, will find other products to sell.

Ending sales will mean weaning states from tobacco tax revenue. A moral argument can be made that necessities such as roads and schools should not be dependent on revenue from sales of lethal products. However, advocates and policy-makers will need to plan for sources of replacement revenue, planning that is needed anyway as smoking prevalence drops. In the long run, reduced healthcare costs will offset some revenue losses; in the short run, some financing structures will have to be reconsidered. It is important to note, however, that the money currently spent on cigarettes will not disappear when they are no longer sold: it will largely be spent on other taxed products. 60

Substitute products

Cigarettes are sometimes considered unlike leaded gasoline or asbestos, because acceptable substitutes for those products were available when they were removed from the market. Currently, with the development of e-cigarettes and other tobacco and nicotine products, there are more substitutes for smoked tobacco than ever. Cigarettes are unlike leaded gasoline and asbestos, in that they have no useful cigarette-specific function to be replaced. The functions that cigarettes are advertised or sometimes claimed by smokers to provide (eg, relaxing, focusing and aiding in socialising) are not only desirable to smokers. It seems likely that, in the long run, the functions of cigarettes will be replaced with other products and practices now used by non-smokers, with entirely new products, or, perhaps, with other tobacco or nicotine products with a lower harm profile. The nature of an ‘acceptable substitute’ also changes depending on whether the product being substituted is still readily available. Thus, those who currently choose cigarettes over other nicotine products will likely find other products more ‘acceptable’ once cigarettes are not as widely sold.

Eliminating versus transforming the cigarette industry

Some argue that endgame policies should focus on ‘transforming’ the industry through measures to encourage development, marketing and use of the proliferating variety of alternative nicotine devices instead of cigarettes, a narrative the industry is eager to further. 61 Because the standard being set revolves around consumer product safety, regulators could set product safety standards and those meeting the standard could be sold where sales of such types of products were permitted. 62 Currently, whether and which new products are in fact safe or safer long-term remains undetermined, though there are other existing tobacco and nicotine products currently on the market that research shows have lower harm profiles than cigarettes. 63 64 One important chapter from the history of tobacco control, the introduction of filtered and ‘low-tar’ cigarettes, shows that even products that intuitively seem safer, and even with research evidence demonstrating, for example, reduced toxicant yield—may in fact prove otherwise as actually used. Although it has always been in the power of tobacco companies to transform themselves by ceasing to sell cigarettes (as they have promised to do if they were proven hazardous), 65 66 they continue to sell them. 67 Public health policies that place cigarettes under the same consumer safety regimen as other products are efforts to ‘transform the industry’.

This ‘transformation’ might mean that some cigarette companies are eventually forced out of business, if they cannot develop safe or markedly safer products. Recent actions addressing the bail bonds industry by two US states show that it is possible to enact policies that largely eliminate a thriving industry because it harms individuals and communities. New Jersey(NJ) 68 and, most recently, California, 69 have largely eliminated cash bail, seeing it as unfair and harmful to people who cannot afford to pay it and thus may lose jobs, housing, or custody of children while presumed innocent and awaiting trial. An Atlantic City (NJ) editorial noted: ‘Nationwide, bail bonding in 2016 was a US$2 billion industry … Much of that business is destined to disappear, along with many of the businesses and jobs. That’s unfortunate, but pales compared with the harm to society from a system in which two-thirds of American prisoners have not even been convicted.’ 68 Similar sentiments could apply to the eventual shuttering of cigarette companies.

Our analysis has primarily focused on the US context and the narrative framing of consumer products safety to make the case for phasing out cigarette sales. However, the move to end cigarette sales may unfold differently in other countries depending on their governmental structures, implementation and enforcement mechanisms, cultural contexts, and engagement with various versions of harm reduction. We have argued that a gradual, jurisdiction-by-jurisdiction phase-out of cigarette sales, beginning with low-prevalence jurisdictions, is justified based on consumer product safety standards, that it would be effective in denormalising the product, reducing tobacco use and relapse among smokers trying to quit, and that the potential negative consequences of such measures are mitigable or unlikely to be worse for public health than the current status quo.

The situation in low-income and middle-income countries, where tobacco companies are still aggressively seeking to build markets, may call for consideration of different approaches depending on the political and policy climate. However, being able to say to policy-makers in those countries that many cities in wealthier countries have now ended sales of these products could provide important leverage for advocates. As some tobacco companies have themselves begun to discuss phasing out cigarette sales (in favour of other tobacco or nicotine products they produce), cities or countries ending sales could call the industry’s bluff on cigarettes now, before smoking becomes more widespread.

Developing an endgame requires rethinking common assumptions about what is possible, and this has gradually changed over time. The tobacco industry and its allies have for years accused tobacco control of being ‘prohibitionists’ and ‘health Nazis’ for promoting such ‘radical’ ideas as clean indoor air. Advocates have often responded by denying these accusations, implicitly conceding a ‘right to smoke’ that ends only where it impinges on the health of non-smokers, and tacitly accepting the sale of deadly products. But a different approach is needed now.

Tobacco control suggests that tobacco will always be with us, and this might be true, since it is a naturally occurring plant in some areas. But the cigarette epidemic need not always be with us. That is a product of the 20 th century. Tobacco use on an individual level is perpetuated by addiction, but addiction and relapse are facilitated by widespread availability.

The tobacco endgame is all about understanding that it is time to stop devoting resources to addressing the industrially produced effects of the tobacco epidemic without directly addressing the cause: widespread sales of cigarettes. It is about applying the principles of consumer protection and human rights in a fair and equitable way to halt the sale of a deadly product. While the work to accomplish this will be daunting, it is not impossible, nor is it any longer so ‘unthinkable’, 70 and it is worth doing. The cigarette century 14 is over.

What this paper adds

While discussions of an “endgame” for the tobacco epidemic have been ongoing for the past decade, the cigarette—the single most deadly consumer product in history—remains widely available for sale. This represents a massive public health failure to protect.

This paper, drawing on principles of consumer protection, makes the argument that phasing out sales of cigarettes should be the endgame goal, led first by low-prevalence jurisdictions with strong tobacco control policies. We offer evidence that such an approach would be likely to further reduce smoking and have minimal negative unintended consequences.

Abstract translation

Supplemental material, acknowledgments.

The authors would like to thank Patricia McDaniel and the many reviewers of earlier versions of this paper for their valuable comments.

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Contributors EAS wrote a first draft of the paper. REM and EAS both contributed to subsequent drafts.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests REM owns one share each of Philip Morris International, Reynolds American and Altria stock for research and advocacy purposes and has participated in tobacco control advocacy. See full statement on funding here: https://tobaccocontrol.bmj.com/pages/wp-content/uploads/sites/49/2016/12/RuthMaloneCompetinginterestsstatement.pdf

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• Volume 42, Issue 5
• The case for banning cigarettes
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• Kalle Grill 1 ,
• Kristin Voigt 2 , 3
• 1 Department of Historical, Philosophical and Religious Studies , University of Umeå , Umea , Sweden
• 2 Ethox Centre, Nuffield Department of Population Health, University of Oxford, UK
• 3 Institute for Health and Social Policy & Department of Philosophy, McGill University, Canada
• Correspondence to Dr Kristin Voigt, Ethox Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford OX3 7LF; kristin.voigt{at}ethox.ox.ac.uk

Lifelong smokers lose on average a decade of life vis-à-vis non-smokers. Globally, tobacco causes about 5–6 million deaths annually. One billion tobacco-related deaths are predicted for the 21st century, with about half occurring before the age of 70. In this paper, we consider a complete ban on the sale of cigarettes and find that such a ban, if effective, would be justified. As with many policy decisions, the argument for such a ban requires a weighing of the pros and cons and how they impact on different individuals, both current and future. The weightiest factor supporting a ban, we argue, is the often substantial well-being losses many individuals suffer because of smoking. These harms, moreover, disproportionally affect the disadvantaged. The potential gains in well-being and equality, we argue, outweigh the limits a ban places on individuals’ freedom, its failure to respect some individuals’ autonomous choice and the likelihood that it may, in individual cases, reduce well-being.

• Population Policy
• Public Health Ethics
• Public Policy

https://doi.org/10.1136/medethics-2015-102682

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Introduction

Lifelong smokers lose on average a decade of life vis-à-vis non-smokers. Globally, tobacco causes about 5–6 million deaths annually. 1 This number is expected to grow: a total of one billion deaths are predicted during the 21st century, with about half occurring before the age of 70. 1 , 2 It is against this background that we will argue for a complete ban on the sale of cigarettes. While our argument focuses on tobacco cigarettes, which in many countries are by far the most popular tobacco product and in the aggregate the most harmful, we think it could be extended to include other forms of combustible tobacco as well.

As with many policy decisions, the argument for a ban requires a weighing of its pros and cons, including its impact on different individuals, both current and future. The weightiest factor supporting a ban, we argue, is the often substantial well-being losses many individuals suffer as a result of smoking. These harms, moreover, disproportionately affect the disadvantaged. The potential gains in well-being and equality, we argue, outweigh the limits a ban places on individuals’ freedom, its failure to respect some individuals’ autonomous choice and the likelihood that it may, in individual cases, reduce well-being.

The idea of a complete ban on the sale of cigarettes is not new. Bans were in place in 15 US states from 1890 to 1927, and Bhutan has had a ban since 2004. 3 Bans on the sale of (at least some) tobacco products have also been endorsed by members of the international tobacco control community. 3–6

In order to bring into focus the fundamental normative issues surrounding a ban on sales, we will simplify our discussion in two ways. First, we assume that a ban would be effective. In the real world, of course, any all-things-considered judgement must be informed by an assessment of a ban's likely effectiveness in different contexts, with due consideration of problems such as smuggled cigarettes and black markets. Second, we focus on a complete ban on sales, comparing this only to the status quo and not to the full range of policy alternatives. i We believe that the necessary debate about different policy instruments in various contexts will be greatly facilitated by consideration of the principled argument for a perfectly effective ban, which is what our paper seeks to provide.

We discuss smoking as a global problem, although most real bans would likely be implemented domestically and our argument might have to be adapted to reflect the situation of individual countries or regions. In rich countries, factors such as the greater availability of cessation resources and information about the risks of smoking make a ban less warranted than in countries where much of the population may be unaware of the risks associated with smoking. We therefore focus our discussion on rich countries in order to tackle the most challenging case for our position. This should not detract from the fact that the majority of death and disease a global ban would prevent will occur in low-income and middle-income countries.

We begin by considering the impact of smoking on health and well-being (section ‘Health and well-being’) and the egalitarian effects of a ban (section ‘Equality’), both of which will be central to our argument. We then discuss how individual freedom and autonomy are affected by a ban in the section ‘Freedom and autonomy’. The sections ‘Voluntariness’, ‘Irrationality’ and ‘Preferences and endorsement’ consider three putative aspects of smoking choices that have been emphasised in the literature: non-voluntariness, irrationality and inconsistency with smokers’ endorsed preferences. These aspects do strengthen the argument for a ban, but their role is different from what is often proposed. In  ‘Banning cigarettes: pros and cons’, we bring together these various considerations and explain why overall they speak in favour of a ban. The final section concludes by briefly commenting on how e-cigarettes could help address some of the problems and opposition facing a ban on conventional cigarettes.

Health and well-being

The health risk of smoking naturally varies with the extent of tobacco use. Long-time smokers face significantly increased health risks, including higher risks of lung and other cancers, cardiovascular disease and chronic obstructive pulmonary disease. Significant differences in mortality rates between smokers and never-smokers become apparent from middle age onwards. 8 Studies suggest a 10-year to 11-year difference between the lifespans of long-term and never-smokers. 8 , 9 In addition, smoking is implicated in causing many non-fatal conditions that can substantially lower individuals’ quality of life, ranging from asthma, tuberculosis, digestive problems and gum disease to vision problems, reduced fertility as well as impotence. 10

While heavy tobacco use is of course more harmful than light use, even light use, when long term, yields substantial health risks, in some respects approximating those of long-term heavy use. For example, ischaemic heart disease risk is similar in light, intermittent and heavy smokers. 11 With respect to lung cancer, for men smoking 1–4 cigarettes per day, the risk is three times that of never-smokers; for women, it is five times as high. 12

Conversely, cessation—which an effective ban would ensure—is associated with substantial health benefits. While for those who quit before their 30s excess mortality is reduced almost to the level of never-smokers, even those who quit at the ages of 40, 50 and 60 gain about 9, 6 and 3 years of life expectancy, respectively. 8 , 9

We believe that a comprehensive argument for a ban should look beyond health to overall well-being: improving health outcomes would not be worthwhile if this left people worse off overall. Many health risks are quite reasonably considered worth taking by the individuals concerned because of the benefits they bring in other, non-health areas of their lives.

While there may be disagreement in specific instances, on most accounts of well-being both the premature mortality and various diseases associated with smoking will reduce lifetime well-being. On hedonist views, the pain and frustration associated with non-fatal diseases typically decrease well-being with no countervailing benefit. Regarding mortality, life is, with some tragic exceptions, on balance a positive experience, and so more life is better. On preferentist or desire-based views, more of a person's most important preferences will typically be satisfied, and fewer frustrated, if she lives longer and has better health. A longer and healthier life also advances typical objective list entries such as developing and sustaining human relationships, and various moral and rational pursuits. Even if one refrains from specifying the nature of well-being, in line with liberal neutrality, long life and good health are all-purpose means that contribute to the pursuit of almost any life plan.

Importantly, we do not deny that smoking can also promote well-being in certain respects; in fact, we will emphasise below that it can do so and consider the possibility that there may be individuals for whom smoking leads to an overall gain in well-being. However, in the aggregate, the negative well-being effects of smoking are likely much larger than its positive effects.

Smoking also contributes to inequality. Most obviously, smokers are, to varying degrees, worse off than non-smokers because of the health risks and the monetary costs associated with smoking. Less obviously, because of the denormalisation of smoking, smokers are increasingly stigmatised and discriminated against. 13 , 14

What makes smoking particularly problematic from the point of view of equality is that it disproportionately harms people who are disadvantaged in other regards. In many rich countries, smoking rates are significantly higher among low-income groups. In the UK, for example, smoking prevalence in routine or manual occupations is 30% while in managerial and professional occupations it is 16%. 15 Among the most deprived groups, smoking rates reach >70%; among homeless people sleeping rough, 90% are smokers. 16

Of course, not all disadvantaged people smoke, and not all smokers are disadvantaged, socio-economically or otherwise. In the aggregate, however, a ban could help reduce inequalities in health outcomes. Studies suggest that, in Europe, smoking could be the largest single contributor to socio-economic inequalities in health, particularly among men. 17 In the UK, tobacco is considered the cause of about half of the socioeconomic status difference in death rates. 18

Many factors may contribute to unequal smoking rates. Smoking norms vary substantially across different groups. 19 In deprived communities, smoking often plays an important social role. 20 Support with cessation, including nicotine replacement therapy (NRT), counselling and medical advice, may also be more accessible for those from better-off groups. Further, the tobacco industry has specifically targeted disadvantaged populations, for example by placing its advertising disproportionately in low-income and ethnic minority neighbourhoods 21 , 22 and devising marketing strategies with particular appeal to the homeless and those with mental health problems. 23 These factors may help explain differences in cessation rates: studies suggest that across social groups smokers make similar numbers of cessation attempts but those in better-off groups are more likely to succeed. 24 It is an ongoing concern that many tobacco control strategies have greater effects on cessation rates among better-off groups vis-à-vis disadvantaged groups; 25 ii an effective ban would enforce cessation equally across social groups, avoiding these inegalitarian effects.

The idea that a ban would enhance equality in health outcomes assumes that those who quit as a result of a ban will substitute smoking with something less harmful to their health. The fact that, as we noted above, cessation is associated with such substantially improved health outcomes suggests that those who quit do so in ways that are overall beneficial for their health. It is not implausible that many of those who would quit as a result of a ban (many of whom, as we note below, are very motivated to quit) would see similarly improved health prospect. However, much will depend on how exactly a ban is phased in and the extent to which it is accompanied by measures to help smokers quit.

Our assessment of a ban should be based on its likely effects not only on health inequalities but on inequalities more broadly conceived. One important concern is that, while unequal smoking rates across different socio-economic groups mean that the health loss averted by a ban should be much greater among disadvantaged groups, a ban could also impose additional burdens on these smokers. As Gostin emphasises, a complete ban would leave many highly addicted smokers in withdrawal and distress, 26 many of them from vulnerable populations, including the poor, prisoners and the homeless, as well as those with mental health problems, for whom the immediate effects of quitting might be more complicated and/or more difficult to deal with. 27

More generally, being disadvantaged—be it socio-economically or in other ways—may also affect people's ability to respond or adapt to a ban. Different ways of ‘phasing in’ a ban might help address these concerns, as could the availability of suitable substitutes, such as e-cigarettes. For example, a ban could be accompanied by free NRT for those on low incomes, prison populations or those in mental health institutions.

For some smokers, the burdens imposed by a ban may be so significant that they will not be compensated for by the benefits cessation would bring; smokers in their 80s or 90s might be a case in point. Limited licensing schemes might be a suitable strategy for this group. Importantly, as we explain in more detail below, these concerns arise in relation to the current generation of smokers and will have much less significance with respect to future generations, who—because of the ban—would not become smokers in the first place. We return to this issue in the  section ‘Banning cigarettes: pros and cons’.

Freedom and autonomy

An important concern about our proposal is that a ban would pose an undue restriction on individual freedom and autonomy. Regarding freedom, we accept that any restriction of the available opportunities reduces freedom of choice. iii However, more freedom is not always better, nor is it always preferred. The disvalue of a particular restriction on freedom depends both on the interest people have in using the opportunity that is being removed, and on the interest people have in having or keeping the opportunity as an opportunity , whether or not they use it. Even non-smokers may have an interest in having the opportunity to smoke: this might be quite a specific interest (eg, in resisting temptation) or a more general interest in having a wide range of options.

Autonomy we understand here as self-direction, involving both an internal and an external aspect. Internal autonomy is the absence of internal obstacles to self-rule, such as ignorance, poor self-confidence or sense of self-worth, incoherent desires or preferences, and various psychological conditions such as clinical depression and obsessive-compulsive disorder. External autonomy is the absence of external obstacles to self-rule, most obviously various malign influences from others to manipulate one's deliberations and so undermine one's independence. iv So understood, a ban will not necessarily reduce autonomy. Quite to the contrary, to the extent that a ban frees many smokers of a debilitating addiction, it strengthens their internal autonomy.

A ban may fail to respect individual autonomy. Respecting autonomy, we propose, requires abstaining from frustrating the choices of relatively autonomous people. We accept that there are strong reasons to respect autonomy in this sense. While significant shortfalls from full autonomy reduce our reasons to respect choices, they do not fully eliminate such reasons; interference still requires some justification. v Indeed, since people are typically quite prone to make choices that are far from fully autonomous, we think that almost any choice should warrant some respect. Note that one may choose something even if one does not find the freedom to do so important, or indeed even if one would prefer not to have this freedom. Such choices indicate some sort of inner conflict, but it may still be disrespectful of others to interfere with them.

Freedom and respect for autonomy, as we have described them, can pull in different directions when it comes to evaluating a ban on cigarettes. An autonomous smoker may choose to restrict her own freedom to smoke. For example, she may engage her partner in keeping their shared home free of cigarettes. If someone prevents her from making this arrangement, this protects her freedom to smoke but fails to respect her autonomy. Similarly, smokers may try to engage their government in keeping their society free of cigarettes (in fact, many smokers would welcome a ban imposed by the government; we return to this issue in the section  ‘Preferences and endorsement’); for these smokers, a ban, by restricting their freedom, will respect their autonomy.

Respect for autonomy can also part ways with well-being considerations. A person may autonomously choose to smoke because she does not care about her future well-being or because she falsely believes that a shorter and less healthy life will not decrease her well-being (eg, because she believes, at 21, that she will never want to live past the age of 40 anyway). We have reason both to respect this choice and to protect this person's lifetime well-being.

The next three sections address three related considerations that have been taken to strengthen the case for a ban: the degree to which smoking choices are less than fully voluntary, the limited rationality of these choices and the fact that many smokers do not endorse their smoking choices. Sometimes, these factors are explicitly invoked in relation to freedom or autonomy, sometimes they are invoked as arguments in their own right. As will become apparent, we believe that these considerations can indeed play an important role in the argument for a ban; however, their role has been overstated in the literature and must be qualified in various respects.

Voluntariness

The most comprehensive philosophical argument for strict regulation of smoking (though not explicitly a complete ban on cigarettes) has arguably been put forth by Robert Goodin, especially in his 1989 book, No Smoking: The Ethical Issues . One of Goodin's central arguments for tobacco regulation starts from the idea that because smokers typically have not fully appreciated the risks of smoking, and because smoking is addictive, the associated risks are not voluntarily assumed. This, in Goodin's argument, makes interference with smoking choices much less problematic than interference with other kinds of choices.

Goodin proposes that people are often not sufficiently informed about the consequences of smoking. Being sufficiently informed, on his account, requires not only being able to state the relevant probabilities about risks but also to ‘appreciate them in an emotionally genuine manner’ (ref. 33 , p. 24, citing Gerald Dworkin 34 ). Goodin does not seem to believe that being uninformed completely removes any reasons against regulation, but rather that the less informed a choice is, the less reason we have to abstain from frustrating it (ref. 33 , p. 21).

We share Goodin's concern that smokers must know the risks associated with smoking if we are to fully respect their choice to smoke. Knowledge of the risks of smoking is now well spread in developed countries, but much less so in many developing countries, 35 making the concern about involuntarily incurred risk highly relevant in these countries. This is important not least because 82% of the world's smokers currently live in low-income and middle-income countries. 36

However, Goodin's claim that in order to be sufficiently informed we must also have an emotionally genuine appreciation of these risks amounts to a very strong requirement. It may be very difficult for a 20-year-old to appreciate, ‘in an emotionally genuine manner’, the suffering she might endure as a victim of emphysema 40 years later, especially if she lacks experience of major illness in herself or those close to her. Such a demanding requirement may be more reasonable for choices with immediate effects, but one of the problems with smoking is precisely that people typically start young and suffer the consequences much later. Goodin's criterion of what counts as informed choice may turn out to be too high a bar to clear for most of the choices people make, including our most important choices, such as whether and with whom to have children. On Goodin’s account, we have strong reasons to interfere with such choices if we believe them to be unwise. It is beyond the scope of this article to fully engage with Goodin's arguments on its own terms. However, we believe that the best argument for a tobacco ban does not depend on such a controversial interpretation of informed choice. We think that the argument for a ban can succeed even if we accept that we have strong reasons to respect the choices smokers make, even if they do not fully appreciate the risks of smoking.

The second factor Goodin emphasises is the addictiveness of smoking. He argues that while it is not impossible to overcome addictions, what matters normatively is whether the addictiveness makes it ‘unreasonably costly’ (ref. 33 , p. 25) to do so: if the addiction is so strong “that even someone with ‘normal and reasonable self-control’ would succumb to it, we have little compunction in saying that the addict's free will was sufficiently impaired that his apparent consent counts for naught” (ref. 33 , pp. 25–6, citing Gary Watson 37 ). This condition, Goodin argues, is met in the case of smoking. Thus, a smoker's continuing to smoke cannot be taken as consent to the risks involved. Further, many smokers become addicted below the age of consent and so, Goodin argues, they cannot be taken to have consented to the risk of becoming addicted to nicotine.

While we share some of Goodin's concerns about the implications of addiction, the heterogeneity of smokers means that his argument applies to fewer smokers than Goodin suggests. Consider first the matter of age. It is often claimed that the quota of smokers who become addicted below the age of 21 is extremely high; Goodin puts this number at 95%. However, these numbers are typically based on studies that ask respondents at what age they first started smoking. This question may lead them to focus on their first ever cigarette, which need not indicate the beginning of addiction. Studies that instead ask respondents when they started smoking regularly indicate that the number of smokers who took up smoking as minors is substantially smaller. Surveys of UK smokers indicate that 55–66% start before the age of 18 (ref. 38 , p. 42, ref. 39 , p. 11).

Even regular smoking, however, is not necessarily a good indicator of addiction. Some adolescents may be able to maintain intermittent smoking without developing dependence. 40 Among adults, too, not all smokers become dependent. One study finds that almost 40% of daily smokers fail to meet the criteria of nicotine dependence (though they may exhibit individual symptoms of addiction, such as difficulties abstaining from cigarettes). 41 While there is disagreement about how to define addiction and what proportion of smokers meet the required criteria, there may be a significant proportion of smokers to whom this part of Goodin's argument does not apply.

Furthermore, it is not clear that addiction fully undermines the voluntariness of smoking in all regards. Even if addiction makes it ‘unreasonably costly’ to abstain from one's next cigarette, there may still be scope for devising a longer-term cessation strategy. This kind of long-term planning is arguably less susceptible to the forces of addiction. The addictiveness of tobacco may of course still thwart any cessation attempts smokers do make (we return to this below); but Goodin's argument, by not addressing this issue, proceeds too quickly.

Finally, irrespective of the degree to which addictiveness undermines the voluntariness of smoking, we are more concerned than Goodin that we have some reason to abstain from frustrating even those choices that are substantially non-voluntary. As John Christman notes, “I might know that a person is to some degree under the sway of external pressures that are severely limiting her ability to govern her life and make independent choices. But as long as she has not lost the basic ability to reflectively consider her options and make choices, if I intervene against her will (for her own good), I show less respect for her as a person than if I allow her to make her own mistakes”. 42

Our scepticism about Goodin’s argument should not be taken to imply that we think addictiveness is irrelevant. It is certainly true that many smokers are addicted and have become addicted in their youth; we agree that we have less reason to respect these smokers’ choice to smoke. Moreover, the addictiveness of smoking is often an intermediary cause in people becoming long-term smokers and thus facing substantial health risks. However, the lack of consent argument may apply to a smaller proportion of smokers than Goodin suggests.

More generally, we think that the broader concern here—whether or not smokers voluntarily accept the risks of smoking—should play a somewhat different role in the argument. On the one hand, as we have said, the degree of voluntariness affects the degree to which the choices involved are autonomous and so to what degree we have reason to respect them. At the same time, though, even if risks were accepted in a fully voluntary manner, this does not mean that the resulting harm is not undesirable or that we should not seek to prevent it.

Harms can be undesirable even if they result from risks that are voluntarily assumed. If, for example, I risk my health by donating a kidney to a relative, this does not detract from the undesirability of any ensuing harms. There may be an exception for harms that are actively sought out: a person may want to die, or want to amputate an arm, where this is not merely instrumental to some aim that can be reached in less harmful ways. However, when a person simply accepts a risk of what is for her an undesirable outcome, this is clearly not by itself a reason to disregard the risk or outcome.

Jason Hanna makes a persuasive argument against tying the justifiability of paternalism to voluntarily assumed risks. 43 Hanna gives the example of a reckless hiker who voluntarily abstains from gathering information on which bridges in the area are dangerous. Later on, the hiker unknowingly starts to cross a dangerous bridge, not because he wants to court danger but simply to finish his hike. If respect for autonomy precludes from moral consideration voluntarily assumed risks, then a bystander has no reason to intervene, which seems an unacceptable conclusion (ref. 43 , pp. 424–5). Similarly, we cannot conclude that we should abstain from intervening with smoking simply because smokers have voluntarily assumed the health risks.

Irrationality

A further concern in the normative debate about smoking and about how governments ought to respond to it is that smoking choices are in some sense irrational. This is the argument Sarah Conly pursues in her recent book, Against Autonomy: Justifying Coercive Paternalism , where she argues that we should often disregard, at least to some extent, smokers’ apparent preference for smoking. Goodin takes similar considerations to bolster his argument from lack of consent. The argument from irrationality can start from either impairments in the decision-making of smokers (in particular, cognitive biases) or, relatedly, from a discrepancy between smokers’ own goals and their choices.

Invoking impairment, Goodin argues that intervention into the choice to smoke is especially warranted if smokers’ false beliefs are caused by cognitive biases. Goodin points to evidence that smokers are subject to three biases, which are now most often called optimistic bias (‘wishful thinking’), the availability heuristic (‘anchoring’) and hyperbolic or temporal discounting (‘time discounting’). 33 As is more thoroughly researched and more widely appreciated now than when Goodin wrote his book, these biases are quite general, and not particular to smokers. 44 Therefore, either of two conclusions are possible: either the charge that smoking choices in particular are impaired loses its force or the charge is expanded to very many decisions we make. The latter option is the one pursued by Conly.

Conly cites a wide range of research in behavioural psychology and concludes: “We generally suffer from many flaws in instrumental reasoning that interfere with our ability to make effective and efficient choices” (ref. 45 , p. 23). The same conclusion has motivated Richard Thaler and Cass Sunstein to promote what they call libertarian paternalism—benevolent structuring of choice situations that does not significantly affect the outcomes of the various options in the choice set. 46 , 47 Conly argues that libertarian paternalist measures are insufficient to ensure that people's choices promote their well-being and that we have no good reason to abstain from coercive measures. Her argument, however, is thoroughly consequentialist and does not give a role to respect for autonomy as we understand it. Instead, she assumes that we have reason to respect autonomy only if this is an effective means of promoting some other goal: “the basic premise of liberalism […] is that we are basically rational, prudent creatures who may thus, and should thus, direct themselves autonomously” (ref. 45 , p. 30). Conly rejects this premise and draws the conclusion that “when it comes to respect for autonomy, we can see that our belief that autonomous actions should not be interfered with was based on a mistake” (ref. 45 , p. 192).

Since we believe that there is reason to respect an agent's choices, even when these choices do not promote the agent's well-being, we find the argument from irrationality unpersuasive. Behavioural research may have proven that poor instrumental rationality is a general aspect of human decision-making. This, however, does not necessarily undermine our reasons to respect choices that are about as autonomous as choices typically are. What would be more relevant is if smokers in particular were prone to irrationality. There is some evidence that addiction causes behaviour that may be deemed irrational, though this is disputed. vi

We now turn from the proposal that poor instrumental rationality is an impairment to the more consequentialist observation that poor instrumental rationality, impaired or not, is prone to create a discrepancy between goals and actions. It is clear that people make choices that do not further their own well-being. What has been open to interpretation and debate is whether this means that people fail to effectively promote their goals or whether, instead, they might have goals other than furthering their own well-being. The extensive study of cognitive biases has given us some reason to favour the first interpretation: if people are under the constant influence of cognitive bias, we can expect that they will not effectively further their own goals. Therefore, the fact that they do not promote their own well-being need not indicate that this is not their goal.

Conly argues that “[w]hat we need to do is to help one another avoid mistakes so that we may all end up where we want to be ” (ref. 45 , p. 2, emphasis added). Where we want to be, Conly assumes, there are no cigarettes. She describes smoking as a “bad course[] of action” (ref. 45 , p. 8) and an instance of people “choos[ing] poorly” (ref. 45 , p. 9). Smokers, she says, “spend a disproportionate amount of their income on a habit that will probably leave them in worse health and possibly shorten their life without bestowing compensating benefits ” (ref. 45 , p. 33, emphasis added). Goodin similarly argues that “what is involved here is a weak form of paternalism, working within the individual's own theory of the good and merely imposing upon him better means of achieving his own ends ” (ref. 50 , p. 23, emphasis added).

While we agree that we should be concerned about a possible discrepancy between smokers’ goals and their choices, Conly's argument does not give sufficient weight to the fact that many people find smoking pleasurable and enjoy the taste or the buzz and relaxing effects that come from nicotine. As summarised in a recent study, “nicotine induces pleasure and reduces stress and anxiety. Smokers use it to modulate levels of arousal and to control mood. Smoking improves concentration, reaction time, and performance of certain tasks” (ref. 51 , p. 2298). The behavioural components of smoking may also be experienced as relaxing. 52 It is certainly not obvious that the net effect of smoking on well-being is necessarily negative. While Conly briefly discusses pleasure in the context of tobacco and acknowledges the pleasure addicted smokers experience from cigarettes (mainly the pleasure of alleviating withdrawal symptoms) (ref. 45 , pp. 170–1), she dismisses too quickly the possibility that those who smoke but are not addicted can derive substantial pleasure from cigarettes. vii This is particularly important because, as we noted above, a significant portion of smokers may not in fact be addicted.

Could these pleasures indeed outweigh the risks and so make smoking consistent with the goal of furthering one's own well-being? This, we think, can vary, depending primarily on an individual's level of tobacco consumption. Consider lung cancer, which is one of the most severe conditions associated with smoking (though, of course, not the only one; lung cancer causes less than half of the excess mortality among smokers). 8 For heavy, life-long smokers, studies estimate the risk of developing lung cancer over the course of one's life to be up to 25% compared with 0.2–1% for never-smokers. 54 For these smokers, it seems plausible to claim that the benefits could not possibly outweigh the risks. However, this is much less clear at lower levels of consumption. Though smoking 1–4 cigarettes a day, as noted above, increases the risk of lung cancer by 3–5 times, 12 this must be seen in relation to the very low risk for never-smokers. Further, while the literature emphasises that there is no ‘safe’ or ‘risk-free’ level of tobacco consumption, those who quit before age 30 appear to avoid almost all of the excess mortality risk associated with continued smoking. 8 , 9 , 55 Given that smoking can further such goals as pleasure, manifesting a romantic nonchalance and social belonging, these risks seem potentially quite acceptable. viii Moreover, given that the cost of cessation is typically higher than the cost of not starting, it may be more rational to keep smoking than to start.

Further, even when the harms of long-time smoking and the limited benefits it brings combine to make smoking apparently irrational for the typical smoker, it does not follow that we should completely disregard these choices. Some limited irrationality is common and should not automatically undermine respect for individuals’ choices. At the same time, outright irrationality, caused by smoking-specific cognitive failures or simply inferred from severe lack of goal orientation, may remove or significantly weaken our reasons to respect choice. To the extent that smokers display such irrationality, this strengthens the case for a ban. However, the degree to which this concern applies to individual smokers will vary and we should be cautious in giving it too much weight in our argument.

While the irrationality of smoking has played an important role in arguments for tight tobacco control, we have emphasised two broad concerns in this section: first, smoking choices may be more rational than is often assumed and, second, even irrational choices warrant more respect than is typically allowed in the literature on smoking. Our argument for a ban on cigarettes focuses instead on the well-being losses it would avert; that people may be irrational and not secure these benefits for themselves in the absence of a ban is an additional consideration in its favour but should play a much smaller role in the argument than it does for Goodin and Conly.

Preferences and endorsement

A further factor supporting the case for a ban is that smokers often do not endorse their preference for smoking: They have a preference to smoke but also a preference about that preference : they would prefer not to have it. In a 1991 article, Goodin argues that public policy “can hardly be said to be paternalistic in any morally offensive respect [if] the preferences which it overrides are ones which people themselves wish they did not have” (ref. 56 , p. 48). For Goodin, the fact that smokers typically go through many failed cessation attempts shows that their preference for smoking is often not endorsed. The preference for quitting, on the other hand, typically has second-order endorsement (ref. 56 , pp. 47–48).

Studies indeed suggest that the majority of smokers want to quit. US data puts this proportion at 70%, 57 UK data at 64% of smokers. 39 Further, in a study with participants from Canada, the USA, the UK and Australia, about 90% of smokers agreed with the statement, “If you had to do it over again, you would not have started smoking”. 58 This indicates that many smokers themselves do not find smoking consistent with their goals, lending support both to concerns about irrationality and non-voluntariness, which we discussed above. It also indicates, more directly, that many smokers are unhappy with their smoking.

However, if (endorsed) preferences are to guide policy decisions, then a policy designed to prevent smokers from smoking may also need to be evaluated based on smokers’ preferences about that policy : it is quite possible that I would prefer not to prefer to smoke, but that I also prefer that the government not prevent my smoking. In fact, Goodin seems to assume that smokers will themselves be opposed to regulation (ref. 56 , p. 42). It is not clear why, on his account, such preferences about policy would not tell against a ban.

Looking at preferences about a ban, a somewhat different picture emerges. Many smokers would welcome a ban, though not a majority. Studies from the USA, England, Hong Kong, New Zealand and the Australian state of Victoria suggest that among current smokers about 25–38% would support the introduction of a ban over the next 10 years or so. 59–63

Where does this leave the argument for a ban? Though Goodin’s treatment is not sufficiently sensitive to vast individual variations, the high degree to which smokers want and try to quit certainly weakens those reasons against a ban that are based on respect for autonomy and the value of freedom: it is arguably more important to respect choices that are endorsed by the chooser, and people generally have a greater interest in preserving options that they would like to make use of. We must also consider smokers’ preferences about the ban. As noted, studies from several countries indicate that about a third of them support such a proposal; for these smokers, respect for autonomy actually tells in favour of a ban.

Importantly, people will not have equal ‘stakes’ in this decision. On the one hand, those supporting the ban may be heavy smokers who find themselves unable to quit, seeking to free themselves of a substantial burden on their health, well-being and finances. On the other hand, those who are not addicted and enjoy the occasional cigarette may find that a ban removes a source of pleasure for them. Non-smokers, too, may value the opportunity to smoke; as we noted above, people can value opportunities even if they have no intention of making use of them. However, if—as seems likely—very few non-smokers actually have any intention of using this option, their interest in keeping it open should weigh much less heavily in decisions about tobacco control. Simply ‘adding up’ these different preferences may, therefore, not be an appropriate way to give them the respect they are due. ix

Banning cigarettes: pros and cons

It is time to bring together the various strands of our argument and consider how they inform the desirability or otherwise of a ban on the sale of cigarettes. Much of the literature on strict tobacco regulation focuses on various ways in which smoking choices are significantly less than fully autonomous—involuntariness, irrationality and lack of endorsement of smoking choices are the most prominent considerations in the literature, as we discussed in the preceding sections. We agree that these factors are crucial; however, contrary to how they are viewed by other proponents of strict tobacco regulation (such as Conly and Goodin), these factors do not by themselves establish that a cigarette ban is justified, for two reasons: first, many smokers and/or smoking choices do not in fact meet the identified criterion: a significant proportion of smokers may not be addicted, not all smoking choices reflect an irrational assessment of benefits and risks, and so on. Second, when smoking choices do fall short of requirements of autonomy in these ways, interference with these choices becomes more acceptable but it does not become wholly unproblematic. As we discussed above, the primary concern for us is the well-being loss that is associated with cigarettes. We accept that a ban would interfere with some (reasonably) autonomous choices as well as restrict individual freedom, but these negative implications are far outweighed by the well-being gains a ban would imply for both current and future generations.

What speaks against a ban is, first, its negative effects on freedom, in terms of the loss of a valued opportunity to smoke and, second, its failure to respect the autonomy of the many smokers who apparently choose to smoke. With respect to the first concern, we noted that non-smokers have an interest in keeping the option of smoking open and a cigarette ban will involve a restriction of their freedom, even if they have no intention of consuming cigarettes. While it is important to acknowledge this point, we must also emphasise that this is a fairly minimal cost, especially relative to what is at stake for smokers.

The degree to which smokers value the freedom to smoke is likely to vary. Indeed, about a third would favour a ban, which indicates that they do not value the opportunity to smoke very highly, or at least that this value is outweighed by other considerations. Furthermore, it seems that the majority of smokers plan to quit and wish they had never started. Therefore, the freedom to smoke may be unimportant for many—possibly the majority of—smokers.

Regarding autonomy, we noted that by removing a source of addiction a ban would contribute to many current smokers’ internal autonomy. This is, of course, a strong reason in favour of a ban. At the same time, a ban fails to respect the choices of the many people who currently smoke, especially those who wish to continue. We have discussed how lack of voluntariness, irrationality and lack of endorsement may mean that many smoking choices warrant less respect than choices typically warrant. Of these facts, lack of voluntariness due to early smoking initiation and due to addiction, lack of second-order endorsement of the preference to smoke and a positive preference for a ban strike us as the most significant. However, many choices to smoke are not burdened by any of these factors, and even when they are, they warrant some respect.

These concerns with freedom and autonomy must be weighed against what we considered the two main considerations supporting a ban: first, the well-being gained by averting substantial health losses that many individuals would otherwise face. This includes averting the expected increase from the current 5–6 million annual premature deaths from tobacco, many of which occur in middle age, and eventually reducing this number to zero, as well as avoiding many non-fatal but severe health conditions. Second, the positive effects on equality achieved by removing a source of poor health that disproportionately affects those who are already disadvantaged.

We recognised that some smokers’ well-being might be negatively affected by a ban. This is most likely for two kinds of smokers. First, those who enjoy smoking and only smoke occasionally and thus face much smaller health risks that are outweighed by the pleasures they gain—think, for example, of people who like to smoke a cigar a few times a year. Second, those who, despite substantial cigarette use, will not see substantial benefits from cessation, for example, because they are very old or fatally ill. Cessation support and limited licensing schemes may help this latter group but do not necessarily address this concern fully. While these burdens should not be downplayed, it must be noted that a ban would lower well-being for only a small minority of people and only for the current generation.

The group that stands to gain the most from a ban, on the other hand, are lifelong heavy smokers for whom the pleasures of smoking are not worth the risks and who, because of tobacco's addictive properties, find it extremely difficult or even impossible to effectively act on their preference not to smoke. These smokers are often among the most disadvantaged in society in other regards. Significant well-being gains can also be expected for those who smoke less, and even much less—as we noted above, even low levels of tobacco consumption can be associated with significant health risks.

As far as the current generation is concerned, then, four factors speak in favour of a ban: first, very large benefits in aggregate well-being. Second, reduced inequality in well-being because the benefits accrue largely to the disadvantaged. Third, improvements in internal autonomy for those who would prefer not to smoke. Fourth, respect for the autonomy of that proportion of the smoking population who want a ban (the evidence we cited suggests that this is about a third). These considerations stand against three opposing considerations: first, diminished well-being for those smokers whose well-being is improved by smoking (which we consider to be a small number of smokers). Second, a reduction in freedom that, as we argued, should be given less weight where non-smokers are concerned, and which is unimportant to many smokers (at least to those who want a ban and perhaps also to many who do not but who do not want to smoke). Third, a ban will fail to respect the autonomy of current smokers—though some of our reasons for such respect are weakened by lack of voluntariness, irrationality and lack of endorsement. This failure of respect is arguably greatest with regard to that proportion of smokers who do not favour a ban (about two-thirds). To us, despite the weighty considerations opposing a ban, the balance is very much in its favour.

Consider now all those potential future people who have not yet faced the choice of whether or not to smoke. With an effective ban, these people will not be tempted by the presence of cigarettes. They will not encounter social settings where smoking is advantageous. They may simply regard smoking a historical curiosity. While their freedom is restricted by a ban, it seems likely that the lost option will be quite insignificant to most of them. Some future people might have improved their well-being by smoking, some will surely oppose the ban and some will think they would have liked to smoke. For some of them, the choice to smoke may have been rational and/or endorsed. We expect, however, that this group will form a small minority and a significantly smaller section of the population than is the subsection of the present population who smoke and oppose a ban. For future people, therefore, the arguments against a ban are much weaker than for current people. The arguments for a ban, on the other hand, are just as strong: well-being and equality will be promoted by preventing the harms of smoking, for future people as for current people. With respect to future generations, therefore, the case for a ban seems even more clear-cut than for the current generation.

Some of these future people, it should be noted, are already alive, in the form of children who are too young to have faced the choice of whether or not to smoke. Especially in poor countries, this group is not as large as one would like since children encounter smoking very early. Still, >600 million people are below the age of five. x This group will supply many of the 10 million annually who are expected to face premature death from smoking from 2050 and on. For them, as well as for future people, the case for a ban seems overwhelming.

For those who consider freedom and/or respect for autonomy more important than we do, or promotion of autonomy and/or well-being and/or equality less important, taking a more long-term perspective is likely to shift the balance of reasons to favour a ban. Indeed, it seems to us merely a matter of how long a perspective one takes. If we consider all the people who will be born in this present century, it is hard to see how prevention of the more than one billion expected premature deaths and the substantial individual suffering that comes with it could be outweighed by respect for the choice of some present (and some future would-be) smokers and concern for the restrictions on freedom involved.

One concern we might have about making the case for a cigarette ban is that of a ‘slippery slope’: once we acknowledge the possibility that cigarettes should be banned, what would stop us from banning, say, certain types of food, alcohol or risky sports? In response, it is crucial to emphasise that arguments about banning or legalising any particular substances or activities need to be made on their own terms and focus on the characteristics of the activity or substance in question. Much of the argument we present here relies on a combination of features that is specific to cigarettes and could not be easily extended to other substances—such as the high risks for long-term users and the high level of addictiveness. At the same time, we think that the broad strategy we pursued here—going beyond questions about individual freedom to consider the well-being impact of smoking on different individuals—could be helpful in discussing the status of other substances and activities.

Philosophical arguments for bans typically focus on particular features of smoking choices—that they are irrational, non-voluntary and/or unendorsed—that are taken to make it (fairly) unproblematic for policymakers to interfere. However, these arguments are too quick in two respects: first, many smoking choices do not, in fact, share the identified characteristic. Second, while irrationality, non-voluntariness and lack of endorsement may weaken our reasons for protecting choices, they certainly do not remove them entirely. Much of the opposition to bans rests precisely on the understanding that we have reason to respect people's choices, even when these choices are problematic in various respects. Our argument has sought to stake out a more nuanced position, which acknowledges and gives substantial weight to the potential of a ban to disrespect individual autonomy and restrict freedom but emphasises the well-being losses such a ban could avert.

Of course, the argument for a ban faces not only philosophical but also political opposition. However, the idea is slowly gaining traction in the tobacco control community and various ways of phasing in such a ban are being explored. What is more, electronic cigarettes and the debate surrounding them could provide a helpful entry point towards a serious discussion about a ban on conventional cigarettes. E-cigarettes deliver nicotine to users in a way that is much more similar to conventional cigarettes than other currently available nicotine delivery systems. While the jury is still out on the harmfulness of e-cigarettes to users and bystanders, 65 there is a decent chance that these devices will turn out to be much less harmful than conventional cigarettes. Appropriate regulation could help ensure that these harms remain below acceptable levels. To the extent that e-cigarettes can provide a substitute for conventional cigarettes, many of the costs associated with a ban—in terms of limiting freedom and forcing current smokers to quit—would be alleviated. At the same time, many of the concerns about e-cigarettes—for example, that they would act as a ‘gateway’ to conventional cigarettes 66 and that they would ‘renormalise’ smoking 67 —would fall away if conventional cigarettes are effectively banned.

Some readers may not agree with the weighing we have given to the different pros and cons of banning cigarettes. For these readers, a more cautious conclusion is that it is important to recognise the variety of considerations at stake, as well as the fact that the costs of a ban would diminish with respect to future generations as these would grow up without cigarettes. Our conclusion, however, is that in light of the substantial death and disease it could avert, the case for a complete and effective ban on the sale of cigarettes is very strong.

Acknowledgments

The authors would like to thank Adina Preda for helpful comments on an earlier draft. KG's work is supported by the Swedish Research Council for Health, Working Life and Welfare (grant no. 2009-2189). KV's work is supported by the Fonds de recherche du Québec – Société et culture (grant no. 172569).

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Provenance and peer review Commissioned; externally peer reviewed.

↵ i Note that many proposals are not alternatives to a ban but rather strategies for its implementation. This includes gradual phase-out schemes, such as the Tobacco Free Generation legislation currently under consideration by Tasmania’s government. 7

↵ ii A possible exception to this appears to be increased taxation. However, taxation comes with a set of egalitarian concerns of its own; see Voigt 19 for further discussion.

↵ iii This is in accordance with the mainstream liberal tradition whose proponents include Isaiah Berlin, 28 Joel Feinberg 29 and Ian Carter. 30 This is, we believe, a quite intuitive way to think about freedom.

↵ iv By defining autonomy negatively, we hope to remain somewhat neutral between various more substantial accounts. Sometimes, external autonomy is taken to require freedom (ref. 31 , p. 204). Since we consider freedom separately, we will leave this possibility to the side here.

↵ v For an extensive treatment of respect for less than fully autonomous choice, see Grill. 32

↵ vi For a range of perspectives, see Elster and Skog; 48 for a convincing case that addicts do display some particular irrationality, see Rachlin. 49

↵ vii The idea that smoking might be pleasurable typically receives little attention in the literature. For an interesting discussion of how the relationship between harm and pleasure is viewed in public health discourses about smoking, particularly in the context of e-cigarettes, see Bell and Keane. 53

↵ viii This should not detract from the concern that unfair inequalities can affect the costs and benefits associated with smoking and thereby the extent to which the risks of smoking become acceptable. For example, as we mentioned in the section ‘Equality’, social norms around smoking vary across social groups, with smoking often playing an important social role in disadvantaged communities but much less so in affluent ones; this means that not smoking can come with a cost for those in disadvantaged communities that does not exist for those in wealthier ones. That this can make the risks of smoking more acceptable in some social groups than others should be viewed as an unfair disadvantage. 19

↵ ix On respect for divergent preferences in groups, cf. discussion on group consent by Grill. 64

↵ x CIA World Factbook, https://www.cia.gov/library/publications/the-world-factbook/geos/xx.html

Linked Articles

• Mini-Symposium: Regulating smoking Ethics of tobacco harm reduction from a liberal perspective Yvette van der Eijk Journal of Medical Ethics 2015; 42 273-277 Published Online First: 26 Nov 2015. doi: 10.1136/medethics-2015-102974
• The concise argument Paternalism on Mars Dominic Wilkinson Journal of Medical Ethics 2016; 42 271-272 Published Online First: 25 Apr 2016. doi: 10.1136/medethics-2016-103598

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• Heterogeneity in the measurement and reporting of outcomes in studies of electronic cigarette use in adolescents: a systematic analysis of observational studies Carlos Echevarria et al., Tobacco Control, 2017
• Reducing the addictiveness of cigarettes Jack E Henningfield et al., Tobacco Control, 1998
• Public support for tobacco endgame policies in South Korea: Findings from the 2020 International Tobacco Control Korea Survey Heewon Kang et al., Tobacco Control, 2024
• Pharmaceuticalisation as the tobacco industry’s endgame Yogi Hale Hendlin et al., BMJ Global Health, 2024
• Cigarettes, heated tobacco products and dual use: exhaled carbon monoxide, saliva cotinine and total tobacco consumed by Hong Kong tobacco users Xiaoyu Zhang et al., Tobacco Control, 2023
• Predictors of electronic cigarette use among Swedish teenagers: a population-based cohort study Linnea Hedman et al., BMJ Open, 2020
• Prevalence and predictors of heated tobacco product use and its relationship with attempts to quit cigarette smoking among Korean adolescents Seo Young Kang et al., Tobacco Control, 2020
• One of several ‘toys’ for smoking: young adult experiences with electronic cigarettes in New York City Emily Anne McDonald et al., Tobacco Control, 2015
• Double standards and arguments for tobacco regulation Jessica Flanigan, Journal of Medical Ethics, 2016
• Patterns of electronic cigarette use in current and ever users among college students in France: a cross–sectional study Marie-Pierre Tavolacci et al., BMJ Open, 2016

14 Central Pros and Cons of Smoking Bans

Smoking ban policies are implemented in some American states and cities but the contentions on whether they are necessary and relevant are still heard from supporters and critics. Restrictions on cigarette smoking can be traced back as early the 16th century and up to now, this issue remains to be controversial.

Smoking ban is a policy that prohibits smoking in public places like restaurants, workplaces, parks, malls, government offices and schools, among others. There are policies implemented statewide and there are some that only restrict smoking in public places but not in enclosed areas.

To get an idea on how people are taking smoking bans, here are some of the views expressed by proponents and opponents.

List of Pros of Smoking Bans

1. They reduce the risk of second-hand smoke. Advocates for smoking bans claim that passing a law to prohibit smoking in public places can lessen the possibility of second-hand smoke being inhaled by non-smokers. Second-hand smoke, according to experts, can lead to increased risk to emphysema, cardiovascular disorders and respiratory problems. By restricting the places where smoking is allowed, this can be prevented.

2. They lessen air pollution. Supporters also say that states and cities which have non-smoking policies and prohibited smoking in restaurants and public indoor spaces have better indoor air quality as opposed to cities which still allow smoking public.

3. They improve work productivity. Proponents point out that not all people smoke at the office. If smoking is allowed, non-smokers can still inhale the smoke and it can be bothersome for them to smell the smoke. On the other hand, if it is prohibited, employees can be more productive. They also added that smoking can cause respiratory infections and smokers are prone to these. If employees smoke less, chances are, the risk of getting sick is minimized.

4. They reduce healthcare costs. Advocates maintain their position about the benefits of smoking bans by saying that reports indicate reduced health costs in cities were smoking are restricted. And since health care costs take around 9.3% of the country’s GDP, reducing it can affect the economy in a positive way.

5. They decrease the possibility of fires. Smoking can increase the risks of fire in places with highly flammable materials. There have been instances of fires which started from lit cigarettes. Moreover, accidents related to explosions at work sites can also happen if smoking will not be prohibited.

6. They reduce wastes. Cigarette butts are non-biodegradable and can clog water systems if thrown recklessly. With banning smoking in public places, there will be lesser cigarette butts and lesser toxic garbage that can be stuck in water systems.

7. They contribute to lower energy consumption and personal expenses. If smoking is banned in public places such as malls and restaurants, there will be lesser need to use ventilation and this can result to lesser energy consumption and in effect, lesser expense. As for smokers, advocates say that an individual who smokes a pack a day spends less than $20 each day and around $720 a year. With smoking bans, it can reduce the expense for cigarette purchase of a smoker in half.

8. They result to cleaner areas where food is prepared and manufactured. With restricting smoking, supporters posit that this can ensure cleanliness is observed in food preparation in restaurants and in the streets. Moreover, smoking bans in workplaces and pharmaceuticals also contribute to cleaner indoor quality as well as maintaining cleanliness.

9. They lessen the chance of influencing others to take on the habit. Supporters for smoking bans claim that cigarette smoking is also considered a status symbol and some teenagers can be influenced to smoke just to fit it. If these young people will be exposed to smoking less, they will not be easily tempted to try.

List of Cons of Smoking Bans

1. They take away freedom from people. Some critics see smoking bans as a violation on one’s personal liberty. They argue that people should have the autonomy to decide on what kind of lifestyle they will have. Although they are not totally against banning smoking, they say that it should be a personal choice.

2. They can affect businesses. Business owners who are not in favor of smoking bans as well as smokers who are used to smoking in public places such as restaurants and coffee shops argue that restricting smoking in these places can drive customers away and this can be harmful to businesses. And as for establishments which are already smoke-free, competition will be higher. It will also be harder for them to leverage since there will be more businesses that are smoke-free.

3. They are not effective. Groups not really in favor of smoking bans say that they are not effective since smokers will just be usually told to leave and that penalties are not stiff. Smoking ban policies do not have enough teeth since repercussions are not harsh enough.

4. They drive people to smokers to smoke somewhere else. Some critics contend that banning smoking in some places just leaves smokers no choice but to do it somewhere else. They mentioned that this can even lead to increase cases of DUI fatalities since smokers might drive to other places just so they can smoke.

5. They result to lesser tax revenues for the government. People against smoking bans are concerned on the effect on government revenues if the push for smoke-free states will be implemented. They say that the government earns from high taxes paid by tobacco manufacturers and smokers. If cigarettes will be reduced, this would mean lesser taxes and lesser revenue for the government.

The controversy on smoking bans is not to leave the debate arena soon. There will always be people who will advocate for banning smoking in public places for concerns on health issues and fire hazards. However, there are also those who are firm in opposing it. And although there is a higher percentage of people who are behind smoking bans, imposing these policies nationwide is not going to happen in the near future because the views of people will always be divided.

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The US Cigarette Industry: An Economic and Marketing Perspective

Cancer Prevention and Control, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC;

Frank Chaloupka

Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois;

Eric N. Lindblom

Tobacco Control and Food & Drug Law, O’Neill Institute for National & Global Health Law, Georgetown University Law Center, Washington, DC;

David T. Sweanor

Faculty of Law, University of Ottawa, Canada;

Richard J. O’Connor

Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, NY;

Department of Pediatrics and Oklahoma Tobacco Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK;

Ron Borland

Cancer Council Victoria, Melbourne, Victoria, Australia.

Objectives:

Tobacco company conduct has been a central concern in tobacco control. Nevertheless, the public health community has not taken full advantage of the large economics and marketing literature on market competition in the cigarette industry.

We conducted an unstructured narrative review of the economics and marketing literature using an antitrust framework that considers: 1) market; definition, 2) market concentration; 3) entry barriers; and 4) firm conduct.

Since the 1960s, U.S. cigarette market concentration has increased primarily due to mergers and growth in the Marlboro brand. Entry barriers have included brand proliferation, slotting allowance contracts with retailers and government regulation. While cigarette sales have declined, established firms have used coordinated price increases, predatory pricing and price discrimination to sustain their market power and profits.

Conclusions:

Although the major cigarette firms have exercised market power to increase prices and profits, the market could be radically changing, with consumers more likely to use several different types of tobacco products rather than just smoking a single cigarette brand. Better understanding of the interaction between market structure and government regulation can help develop effective policies in this changing tobacco product market.

INTRODUCTION

In the early 1900s, the American Tobacco Company controlled the US cigarette market, but antitrust laws split the monopoly into four smaller companies: RJ Reynolds, Lorillard, Liggett & Myers, and American Tobacco. Brown & Williamson and Philip Morris later emerged as major cigarette firms, and by 1950 these six major companies dominated the cigarette market. Through various consolidations, the US cigarette industry today is dominated by two major companies – Altria (formerly Philip Morris) and RAI (US subsidiary of BAT), with the remainder comprised of smaller firms (ITG Brands, Liggett Group, Vector Tobacco, and regional and discount firms).

While the tobacco control literature regularly considers tobacco company behaviors (especially marketing and political activity), 1 – 4 it does not often consider market structure and conduct. At the same time, public health experts and policy makers have given limited attention to a large economics and marketing literature that considers the structure of the cigarette market, and how established firms gain and maintain market power (eg, by preventing market entry), and respond to government regulation. That literature considers the impact on market competition of advertising, brand extensions, and slotting allowance contracts (which control pricing and promotions and limited retail shelf space, ads, and product displays), all issues of central importance to tobacco control.

This study presents an unstructured, narrative review of the economics and marketing literature on competition and market power in the cigarette market, using a well-accepted framework for analyzing market competition. Our aim is to help understand the growth and maintenance of market power in the U.S. cigarette market and its relevance to understanding firm behavior in response to past tobacco control policies and potential future policies.

We conducted a systematic search for economic and marketing studies relating to the U.S. tobacco market. We searched online databases (e.g., EconLit, Web of Science, Social Science Research Network, and the Federal Trade Commission website) and reference lists published through December 2016 that included at least one product term (“cigar”, “cigarette”, “cigarillo”, “smokeless tobacco”, or “tobacco”) and one market term (“advertising”, “antitrust”, “cigarette tax”, “competition”, “industry”, “marketing”, “markets”, “price”, “slotting allowance”). Having found few studies that examined other tobacco product markets (eg, cigars), we focus on the cigarette market. After omitting papers not related to market competition (e.g., most demand studies), we identified 108 publications in economics and marketing journals covering a variety of often overlapping topics.

We then conducted an unstructured, narrative review to provide key insights from the literature relevant to tobacco control. Rather than attempting to be exhaustive or determine precise effect sizes, our goal was to identify key results, including inconsistent findings.

As a guiding framework, we applied the four-step antitrust approach described in the U.S. Department of Justice and Federal Trade Commission (FTC) Horizontal Merger Guidelines (HMG): 5 1) defining the relevant market for the evaluation competition; 2) evaluating the level of and changes in market concentration; 3) identifying the level of entry barriers; and 4) examining anticompetitive conduct of firms in the market. 6 While the HMG focus on mergers, they provide a unified framework for analyzing the impact of other industry behaviors on market concentration and competition and are similar to other nations’ antitrust guidelines. 7 , 8

The central concern in the economics literature is the harm to consumers from paying higher prices or having fewer products or product variants available due to “market power.” This perspective differs from a public health concern where harm to consumers is evaluated primarily in terms of reduced negative health outcomes, which may be improved through higher prices. 9 In our discussion below, we attempt to distinguish these conflicting perspectives.

MARKET DEFINITION

When defining the relevant market, the HMG considers whether customers are willing and able to switch to other substitute products when faced with price increases. In the 2014 Reynolds American-Lorillard merger consent decree, the FTC declared that traditional combustible cigarettes alone were the relevant market, because “Consumers do not consider alternative tobacco products to be close substitutes for cigarettes. Cigarette producers similarly view cigarettes and other tobacco products as separate product categories, and cigarette prices are not significantly constrained by other tobacco products.” 10 This 2014 market definition is consistent with 1911 11 and 1946 12 antitrust decisions, and the FTC’s 2004 Reynolds-Brown & Williamson merger analysis. 13

While the 2014 Reynolds-Lorillard merger analysis considered cigarettes to be the relevant market, the FTC noted that “cigarettes are highly differentiated products, and producers compete across a number of dimensions,” especially “brand equity,” with the agency distinguishing premium flagship brands, such as Marlboro and Camel, from other brands. 13 The FTC also considered submarkets, finding the menthol cigarette sub-market important enough to require Reynolds to sell its Kool menthol brand to maintain competition in that sub-market. 10

Consistent with FTC and court analyses, the economics and marketing literature focuses on conventional cigarettes as the relevant market, because of only limited substitution with other products. However, the literature (as described below) was mostly published before 2005, and the use of other nicotine-delivery products, such as little cigars, smokeless tobacco, and e-cigarettes has increased in recent years, 14 , 15 often used in conjunction with cigarettes. 16 Consequently, some of these other products could be seen as complements (ie, used in conjunction) with or substitutes for cigarettes, suggesting a possible change in the market definition, and become particularly relevant from a public health perspective.

Although the FTC and court antitrust analyses have defined the market as the entire U.S., geographic submarkets (eg, states, regions) may also be relevant. For example, Keeler et al. 17 and Gallet 18 found that cigarette companies price discriminate by state, suggesting relevant state submarkets. Geographic sub-markets may also be relevant to public health analyses, given that the prevalence of different types of tobacco use and the tobacco control policies of different states or even cities show considerable variation. 19

MARKET CONCENTRATION

Industry concentration in the defined market is based on the number of firms and their market shares, (eg, firm sales relative to total industry sales). A standard indicator of market power, the Herfindahl-Hirschman Index (“HHI”), adds individual firms’ squared market shares, thereby giving proportionately greater weight to those with larger market shares. The HMG classifies markets with HHI<1500 as unconcentrated (“unlikely to have adverse competitive effects”), 1500≤HHI< 2500 as moderately concentrated (“raises significant competitive concerns”), HHI> 2500 as highly concentrated (“likely… market power”). 5 For example, a moderately concentrated market could have two companies with a 30% market share or one company with a 40% share and other firms having 10% or less.

Figure 1 shows the related trends in HHI based on data from Maxwell Reports 20 and HHI estimates from FTC analyses of the Reynolds-Lorillard merger. 21 Following a dip from 2560 in 1947 to 2000 in 1958, the HHI increased to 2900 by 1991 and the cigarette market has since remained highly concentrated. Much of this increase came from Philip Morris’s market share rising from 7% in 1949 to 42% in 1990, 22 with its Marlboro’s share growing from 5% in 1957 to 30% by 1995. There was a dramatic increase in the number of brands between 1972 and 1998. 23 , 24 While many of the brands were unsuccessful, the introduction of new sub-brands building on the reputation of their established major brands (eg, Marlboro Menthol, Camel Light) appears to have contributed to an increase in major firm’s market shares. 20

Herfindahl Index of Industry Concentration, Cigarette Industry, 1947–2015

Since 1993, concentration has increased primarily from mergers. Brown & Williamson acquired American Tobacco in 1994, and Reynolds acquired Brown & Williamson in 2004 and Lorillard in 2013. By 2015, the HHI was about 3800, 21 with Philip Morris USA’s market share at 47% (and Marlboro at 41%) and Reynolds American at 34%. 21 Although some new firms have entered the market since 1999, their market shares have not exceeded 2%.

Although the public health emphasis is often on the ability of large firms to influence public policy rather than on other impacts of market concentration, 1 – 4 high levels of concentration are important to market power and its related impacts on pricing, market entry, and competition. In addition, market concentration has provided the major cigarette firms with higher profits that they have used to support intensive lobbying, lawsuits, and other activities to block, delay, or weaken tobacco control efforts. In addition, the incentives to lobby against tobacco control policies increase when firms have large market shares, since a larger share of the gains then accrue to those firms.

ENTRY BARRIERS

The ability to maintain high concentration depends on barriers to market entry. According to the HMG, 5 firms are unlikely to exercise market power unless entry barriers are high enough to keep new firms or existing small firms from gaining market share through offering lower prices. Government regulations can impede market entry both by establishing direct restrictions on entry and by increasing the sunk-cost (ie, irrecoverable) investments requirements to introduce a new brand. These sunk cost investments may include the costs of product development, establishing production and distribution capacities, marketing and regulatory compliance. 25 The economics and marketing literature has identified four types of entry barriers relevant to the cigarette industry: advertising, brand proliferation, retail slotting contracts, and legal/regulatory costs.

Advertising

Advertising can create entry barriers when market entrants cannot readily take advantage of the economies of scale that large established firms enjoy in their ongoing advertising or when past advertising has created brand loyalty for existing firms. 26 , 27

While existing firms may produce at a level where advertising economies of scale have been exhausted, entrants may find it difficult to reach that level. The economics literature is mixed on the role of scale economies in cigarette advertising. Brown 28 found advertising economies over a wide range of cigarette sales, especially for new brands, but Peles, 29 Schmalensee 30 and Thomas 31 did not find significant scale economies. However, an efficient scale may be more difficult to reach in recent years with more rapidly declining demand.

Whether or not scale economies apply, the cost of cigarette advertising to establish a new brand may still create an entry barrier. Investments in advertising yield “first mover advantages” to incumbent firms, who have already built a reputation that must be overcome in order to attract customers from those firms. 26 , 27 These disadvantages are enhanced when reputation is gained slowly over time, the transference of brand loyalty from cigarettes to non-tobacco products is limited, and in a declining market demand (eg, due to low levels of initiation or increased cessation).

One study reported short-lived effects of cigarette advertising on sales, implying a limited role for brand loyalty, 28 but others, including a detailed interindustry analysis found slow advertising depreciation. 29 , 32 , 33 , 34 A systematic review of the marketing literature found cigarette advertising to be an important predictor of brand loyalty. 35 Other research found that brand loyalty for cigarettes was high and increasing over time. 36 This was especially true for more popular brands, with Marlboro at the high end. 37 Consistent with brand loyalty, other studies have found that cigarette advertising is associated with higher prices 26 , 38 and consumers were reluctant to switch brands. 39

Much of the public health literature 40 , 41 on cigarette media advertising also focuses on brand loyalty. Much of the focus is on its role in increasing initiation, 15 consistent with the marketing literature 35 (see especially Pollay et al. 42 ).

Brand Proliferation

As noted above, the dominant cigarette companies have taken advantage of consumer familiarity with their most popular brands by marketing sub-brands. Indeed, brand proliferation by established firms can create an entry barrier when brands are densely packed across product dimensions (eg, menthol, light/low, full flavor, women-focused, premium, low-cost). 43 With no market niche available, it is more difficult for new brands to distinguish themselves from established brands and sub-brands. This phenomenon has been identified in empirical inter-industry studies and validated by complementary theoretical models. 44

Cigarettes have been associated with specific product attributes, such as nicotine and tar content, length, flavor and thickness. 45 Labeling and advertising can also create different perceived brand characteristics separate from product attributes, eg, establishing Marlboro as a masculine brand and promoting Virginia Slims as a women’s cigarette. Cigarettes have been found more generally to be differentiated along horizontal (brand attributes, such as light vs regular, length) and vertical (perceived quality, such as premium vs. regular) dimensions. 46

Larger, established cigarette companies have been found to have a distinct advantage from extending their brands into new product lines, with their market share increasing along with the strength and symbolic value of the parent brand. 47 More broadly, one study found that the introduction of new brands rather than advertising was associated with increased demand, 48 and brand extensions became increasingly important over the product life cycle as the relative importance of advertising declined. 49

The public health literature has considered sub-brands primarily as an industry tactic to target specific market segments or mislead customers. 15 For example, menthol brands were used to attract new market segments, 20 and the industry introduced“ low tar” and “lights” in the sixties as a “reduced-harm” alternative to quitting. 50 Often neglected is their role in increasing and protecting market power.

Retail Slotting Allowances

Slotting allowances, whereby firms pay for limited retail shelf space leaves less space available for new entrants. 25 This capability is greatest in markets like cigarettes that are dominated by large manufacturers with a wide range of established brands 25 , 51 , 52 and where there is limited ability to expand the market (ie, indicated by relative insensitivity to price). 53 While some studies suggest efficiency gains from slotting allowances, such as reduced prices, planning shelf space allocations and encouraging retailers to carry new products, 51 , 52 , 54 other analyses show that slotting allowances can limit consumer choice, and increase consumer prices and industry profits. 55 – 59 In the most extensive study across different industries, 60 slotting allowances were found to increase market power more than promote economic efficiency.

The cigarette industry was one of the first US industries to implement slotting allowances. 61 – 63 With limits on most other forms of advertising, slotting allowances became an important part of promotional agreements. 64 While the primary purpose of these allowances was generally to pay for shelf space, slotting allowance agreements often included provisions for product and advertising displays, payments for retailer price promotions, and rewards for meeting sales quotas. 62 , 64 – 66 According to the 2014 FTC Cigarette Report, 50 the major cigarette firms spent $11.2 billion on advertising and promotions, of which 2.8% was for point-of sale displays, 7.5% for promotional allowances, and 66% for retailer price discounts. As discussed below, retailer price discounts can be used to target new entrants or smaller firm, as well as to selectively lower prices to gain new customers. In particular, these agreements can complement brand proliferation strategies which crowd out new brands.

A 2002 antitrust case unsuccessfully challenged Phillip Morris’s Retail Leaders program, which paid retailers increasingly large retail display allowances in exchange for greater commitments of display, advertising, and promotion space. 67 However, in the same year, slotting fees in the smokeless tobacco market were found exclusionary. 67 In evaluating the 2014 RJR-Lorillard merger, the FTC 21 also raised concerns about RJR’s Everyday Low Price Program, which constrained retailers from undercutting the price of RJR’s Pall Mall brand. A 2004 analysis 68 found slotting allowances to be anticompetitive, with Phillip Morris and RJR initially controlling 85% to 90% and increasing to 95% of shelf space after the Reynolds-Brown & Williamson merger. In addition, changes in relative prices, especially those from promotions linked to slotting allowances, have been associated with changes in firms’ market shares. 69

Studies in the tobacco control literature 65 have focused primarily on the role of product displays in encouraging smoking initiation and discouraging cessation through advertising. However, they have largely overlooked the role of slotting fees and the related agreements in enabling established firms’ ability to control the retail marketplace by limiting shelf space and using price promotions to reduce entry.

Legal/Regulatory Costs

The economics literature has examined the impact on market entry and competition from three types of regulatory constraints: 1) the cigarette advertising ban on TV and radio media imposed by the 1971 Federal Cigarette Labeling and Advertising Act (FCLAA), 2) requirements and advertising restrictions of the 1998 MSA, and 3) legal challenges.

Studies find direct links between the FCLAA TV and radio advertising ban and market competition. Firm market shares became more unstable and firm profitability increased, 70 – 72 producing abnormally high stock returns (as reflective of profits). 73 Although one study questioned whether the broadcast ban increased market power, 74 three others found that industry concentration increased, 22 , 75 , 76 and another found that the restrictions facilitated coordinated pricing behavior among established firms. 77 The ban was also found to slow the introduction of new brands, especially those with low tar, suggesting that the bans may have discouraged the entry of firms producing new products. 78

Indirect evidence on the effect of advertising restrictions is provided by studies that consider cigarette demand. With one exception, 79 studies in the economics literature have found minimal effects of advertising on overall cigarette demand in the UK 80 and the US. 81 – 83 An Australian study 84 referred to a “reciprocal cancellation effect,” finding that advertising led to market shares changes rather than increased overall demand. A meta-analysis 85 found that advertising increased cigarette demand prior to 1971, but has since had a more limited effect. This literature suggests that cigarette manufacturers would benefit from uniformly reducing their advertising expenditures to reduce costs and thereby increase profits, as occurred following the FCLAA’s advertising restrictions. 86 , 87

These studies provide a different perspective than those in the public health literature, which focuses primarily on the relationship of advertising restrictions to smoking rates. This literature finds advertising restrictions associated with reduced cigarette sales, especially complete bans, with a stronger association in in high than low income nations. 88 – 90 Consistent with these findings, recent reviews in the marketing literature 91 , 92 have concluded that advertising bans have less effect on consumer demand in more mature markets (typically higher income nations), which is viewed as advertising increasing demand in the early stages of the product life cycle and primarily buildings selective brand loyalty in the later stages. Often neglected in the public health literature is the role that the FCLAA may have played in possibly discouraging the entry of firms producing at lower prices and providing new products.

The 1998 MSA required payments from U.S. cigarette companies to the 46 U.S. states and territories that had not already reached similar individual settlements and established new advertising restrictions. 93 The MSA helped to create new entry barriers for lower-cost firms and brands by requiring states to implement and actively enforce new laws to make non-settling firms pay special non-participating manufacturer fees if they did not join the settlement, make settlement payments, and abide by its advertising restrictions and other requirements. 94

Studies have found direct associations of the MSA with promotions, pricing and market power. One study found 95 that the MSA eventually prompted greater promotional allowances and price discounting at retail outlets. Similarly, an FTC Cigarette Report 50 finds that, soon after the MSA, major firms substantially increased price discounts and promotional allowances at the wholesale and retail levels, indicative of an increasing role of slotting allowances. Another study 96 found that cigarette prices were temporarily reduced during post-MSA price wars prompted by market entry of lower-price firms responding to MSA-related price increases. Prices subsequently returned to a level consistent with market power by established firms. 96 Suggestive of increased market power, stock returns of larger firms showed a decrease in systematic risk and in the cost of capital after the MSA. 97

Beyond the specific effects from new legal requirements such as the FCLAA and MSA, new firms may also face entry barriers from the threat of civil lawsuits and legal liability from marketing addictive and harmful cigarettes. 98 Although past lawsuits provide entrants with a roadmap of actions that may minimize liability risks, and entrants lack a past history of lawsuits that can be used against them, the larger, established firms have more resources and experience than new entrants to fight such lawsuits.

FIRM CONDUCT

In concentrated markets with high entry barriers, established firms may engage in anticompetitive pricing to increase their profits or to prevent market entry. To maximize profits, firms may engage in coordinated pricing through either explicit or tacit collusion. 5 In addition, a dominant firm or coordinated group of firms can also temporarily reduce prices to discourage other firms, already in the industry or as entrants, from undercutting collusive prices.

With few firms, easily detectable price deviations, relatively homogeneous products, price insensitivity by consumers, and significant brand loyalty, 21 the U.S. cigarette market is particularly vulnerable to coordinated pricing. The Supreme Court 99 noted a lack of “significant price competition among rival firms […] List prices for cigarettes increased in lock-step twice a year, for a number of years.” An FTC Report 100 also cited rising prices after 1980 and price wars following the entry of low price cigarette firms in 1991 as evidence of coordinated behavior among the major firms. The 1991 price wars began with Liggett & Myers selling generics. 13 Following major price reductions for Marlboros (known as “Marlboro Friday”), industry concentration increased as smaller firms exited the industry and Marlboro’s market share increased beyond that which it had lost to generics. 101

Economic studies have directly examined cigarette industry pricing, market share and revenue. One 102 was unable to reject the hypothesis of competitive pricing from 1982–1995, and another 72 found unstable firm market shares from 1934–94 as indicative of competitive behavior. However, other studies have found evidence of monopoly power from 1961–97 based on inter-state variations in advertising and pricing policies, 103 and from 1962–92 based on pricing relative to cost. 104 A study found interrelated firm advertising and pricing behavior from 1971–82, consistent with collusive behavior. 79 The interrelated nature of firms’ advertising decisions was confirmed in a study spanning 1955–63. 105

As a gauge of market power, economic studies have also examined the extent to which firms pass on tax increases in the form of cigarette prices. One early study found close to competitive price increases from 1954–78. 106 Studies of more recent time periods, however, found price increases consistent with monopolistic pricing, with prices increasing by more than cigarette tax increases from 1960–1990, 17 price increases doubling the amount of a 1984 tax increase, 107 and post-MSA price increases exceeding federal and state tax increases and the per-pack costs from the MSA. 108 Tax-price studies 109 , 110 that considered coordinated pricing over various time periods found limited evidence of market power, but a later study 74 incorporating advertising found a high degree of market power. Thus, even with increased cigarette taxes, cigarette companies have been able to raise their prices and minimize related reductions to their profits. Economic analysis has shown that companies can profitably increase prices more than the amount of a tax increase if demand becomes increasingly less responsive to price (ie, inelastic demand). 111 This result may occur if price increases lead to a market with increasingly hard-core or otherwise price-insensitive smokers. 111 However, companies can also profitably increase prices by more than a tax increase with declining demand. 112 It is unclear the extent to which price increases reflect tax increases, declining demand or other contributing factors.

Another indication of anticompetitive behavior is price discrimination. 113 , 114 With sufficient market power, firms can increase profits by reducing prices selectively to consumers who are most price sensitive, such as those with lower incomes or youth and young adults. At the same time, prices are increased to consumers who are less price sensitive, such as older, long-time smokers. Cigarette manufacturers engage in price discrimination through offering coupons that more price-sensitive consumers use to reduce price, 115 price promotions and discounts in low income areas, and lower per-pack prices when purchased in cartons instead of individual packs. 116 Price discrimination in the form of volume discounts and coupons has also been discussed in the tobacco control literature, with a particular focus on youth. 117 – 120

Theoretical analyses and empirical evidence from the economics and marketing literature reveal substantial market power by the major firms in the US cigarette market. Market concentration has increased due to mergers, major-firm brand proliferation, and the growth of particular brands. In addition, entry barriers, especially retail slotting allowances and brand proliferation, have been substantial, and have protected market power. With high market concentration and entry barriers, the large, established firms have been able to engage in anticompetitive practices, such as collusive pricing, predatory price-cutting and price discrimination. We have focused on the economics and marketing literature, but the analysis may be supplemented with related legal literature and information gleaned from industry documents.

Standard economic and antitrust analysis disfavors market power and market concentration in favor of more active competition that will make products more readily available and affordable to consumers. However, market power in the cigarette market has benefited the public health to the extent that it has increased prices, thereby reducing smoking levels and related health outcomes. At the same time, increased market power has enabled the more established firms to target smaller firms by selectively reducing prices and proliferating brands, and to price discriminate by selectively reduce price to more price sensitive consumers. While these industry practices have been recognized in the public health literature, 1 – 4 the emphasis appears to mainly relate to their impact on increasing profits, which is then channeled to lobby against potent tobacco control policies.

Although there are important differences between the economic/marketing and public health perspectives, the economic literature provides useful insights for tobacco control. For example, the FCLAA and the MSA have been found to enhance market power by acting to impede firm entry and entrench existing cigarette manufacturers. Neither the 1971 advertising restrictions nor the MSA constrained an important entry barrier, retail slotting allowances. Economic studies show the impacts of slotting allowances on market entry, prices, and retail advertising and promotions. These findings could be used to guide related new tobacco control regulations to promote public health (eg, by helping to reduce price promotions).

More generally, the economics literature could help to guide new tobacco control efforts to discourage market concentration and market power where it hurts the public health (eg, by increasing its ability to protect profits) and to encourage competition when it will produce new public health gains (eg, by shifting the market and smokers from cigarettes to less-harmful tobacco-nicotine products). These opportunities have expanded with the increasing use of non-cigarette nicotine delivery products. 14 – 16 , 121 In particular, unlike earlier studies of cigarette demand, two recent studies 34 , 122 indicate that consumers are highly responsive to both cigarette and e-cigarette prices, suggesting that the relevant market may have expanded beyond just cigarettes.

By 2003, the smokeless tobacco industry included few firms with major brands that had a strong reputation. 123 Reynolds American acquired Conwood Smokeless Tobacco Company in 2006 and soon thereafter introduced Camel Snus, and Altria acquired the U.S. Smokeless Tobacco Company in 2009 and began marketing Marlboro Snus. Together they controlled 85% of the market. 123 Industry documents 124 indicate that the companies also began promoting smokeless tobacco products as a way for smokers to satisfy nicotine cravings in places where smoking was banned. 124 , 125 In addition, marketing expenditures, including price promotions, 126 and the marketing of flavored products increased. 127 However, regulations that limit information on differences in the relative risks of smokeless tobacco and cigarettes or that otherwise limit competition by non-cigarette firms may also reduce incentives for smokers to switch entirely to smokeless tobacco rather than dual use with cigarettes.

Although cigarette companies have gained dominance in the smokeless tobacco market through acquiring the major smokeless tobacco firms, their status is quite different in the market for e-cigarettes. The product is sold by many companies not just in mass market retail, but also through vape shops, internet and other retail. 128 Major cigarette companies, despite acquisitions and their own e-cigarette product development, have not been able to gain significant market share in the vape shop or internet markets, much less the overall e-cigarette market, and have recently even been struggling to maintain their share of conventional retail sales.. While an in-depth analysis is beyond the scope of this paper, there appears to be major impediments to the major cigarette companies being able to dominate the e-cigarette market because of such factors as the diversity of products, including many geared specifically towards providing an alternative to cigarettes, and the substantial sales via the Internet and non-traditional retail (eg, vape shops), which resist major company control. FDA regulations and required prior review of all new or changed products and proposed product relative-risk claims under the 2009 Tobacco Control Act will heavily influence which firms survive and the manner in which they market their products.

Because of the recent ongoing market changes, it is especially important that tobacco control policy consider market structure, barriers to market entry, pricing and product innovation. A better understanding of these influences can help to identify new public health challenges and opportunities, and thereby develop more effective tobacco control strategies. In the past, market concentration and entry barriers dampened price competition and prevented new companies from entering the cigarette market, and the consequences for public health were mixed. Now, however, competition appears to have increased between cigarettes and alternative nicotine products, suggesting a broader market. Nevertheless, a high concentration of cigarette manufacturers in these markets may prevent independent firms from entering with less harmful and better alternatives to cigarettes, or allow cigarette companies to market their e-cigarettes and other non-smoked tobacco products in ways that sustain or increase overall tobacco use and harms. Much will depend on government regulation. To promote the public health, the tobacco control community should build on the insights from the economics literature and carefully consider the existing structures of the different, increasingly interrelated nicotine delivery markets, and consider the impact of potential regulations on those structures.

IMPLICATIONS FOR TOBACCO REGULATION

Since the 1960s, U.S. cigarette market concentration has increased primarily due to mergers and growth in the Marlboro brand. The market has high entry barriers, due to advertising, brand proliferation and slotting allowance contracts, which were encouraged by government regulations. The anticompetitive structure has led to higher prices beyond those from government tax increases, consistent with tobacco control aims, but which has further enriched the major cigarette companies, increasing their ability to influence policies. . With the increase in multiproduct use and the introduction of alternative nicotine delivery products, it will be especially important to consider the market structure of related markets and the role of the cigarette industry in shaping those markets through its ability to exercise market power.

Acknowledgements:

Funding was received by the authors from the National Cancer Institute under grant P01CA200512.

Human Subjects: This study is exempt from review, as this study used secondary data sources..

Conflict of Interests: FJC has served as an expert witness in litigation against the cigarette industry.

Contributor Information

David Levy, Cancer Prevention and Control, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC;

Frank Chaloupka, Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois;

Eric N. Lindblom, Tobacco Control and Food & Drug Law, O’Neill Institute for National & Global Health Law, Georgetown University Law Center, Washington, DC;

David T. Sweanor, Faculty of Law, University of Ottawa, Canada;

Richard J. O’Connor, Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, NY;

Ce Shang, Department of Pediatrics and Oklahoma Tobacco Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK;

Ron Borland, Cancer Council Victoria, Melbourne, Victoria, Australia.

Home — Essay Samples — Nursing & Health — Tobacco — Discovering Advantages and Disadvantages of Tobacco Use

Discovering Advantages and Disadvantages of Tobacco Use

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Should the production and sale of cigarettes be made illegal?

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WRITING TASK 2 You should spend about 40 minutes on this task. One of the consequences of improved medical care is that people are living longer and life expectancy is increasing. Do you think the advantages of this development outweigh the disadvantages? Give reasons for your answer and include any relevant examples from your own knowledge or experience. Write at least 250 words.

In many countries, an increase in crime rate has been blamed on violent images on television and in computer and video games. to what extent do you agree or disagree with this opinion, goverments around the world are spending billions in support of space programs. this money would be better spent on research into improvements in human health. do you agree or disagree, you are invited to a party, however, because of some reasons you didn’t attend. write a letter to the friend who invites you: (1) explain the reason why you didn’t go; (2) express your apology; (3) ask about some details in the party., many people believe that schools should teach students good behavior as well as other subjects. to what extent do you agree or disagree with this statement.

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Advantages and disavantages of selling cigarettes

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Selling cigarettes has both advantages and disadvantages. One of the main advantages is the potential for profits . The health risks associated with smoking are the disadvantage associated with it.

Tobacco companies make billions of dollars every year, and retailers who sell cigarettes can benefit from this demand. Additionally, selling cigarettes can attract customers who may purchase other products from the store. However, the disadvantages of selling cigarettes should not be overlooked. are well-known, and retailers who sell cigarettes are essentially profiting from a product that harms people. This can damage a store's reputation, especially if it is located in a community that is concerned about public health. Moreover, selling cigarettes comes with legal responsibilities . Retailers must ensure that they are not selling cigarettes to minors, and they must comply with various regulations related to labeling, advertising, and taxes. Failure to follow these regulations can result in fines and legal penalties. In summary, while selling cigarettes can provide financial benefits , it also comes with ethical and legal responsibilities. Retailers must carefully consider the potential harm they may be causing by selling cigarettes and weigh this against the potential profits. Ultimately, each retailer must decide whether selling cigarettes is a responsible business decision for their particular situation.

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