Who Benefits from the Status Quo? - Part 1

Public health debates are often presented as contests between evidence and vested interests. The narrative is usually straightforward: researchers produce evidence, governments act upon that evidence, and industries resist change to protect their profits. While there is some truth in that framework, it is also incomplete because public policy is rarely shaped by evidence alone. It is equally influenced by institutions, political realities, economic pressures and systems that develop their own momentum over time.

This raises a question that deserves far more attention than it usually receives: who benefits from keeping things exactly as they are?

The question is frequently misunderstood because people assume it implies corruption or deliberate wrongdoing. It does not. Institutions are made up of individuals who generally believe they are acting in the public interest. Public servants, clinicians, researchers, regulators and politicians usually pursue their careers because they want to improve society, not because they wish to preserve ineffective policies or ignore emerging evidence. Yet good intentions alone do not determine public policy.

Every institution operates within a network of incentives. Some are financial, while others are political, professional, bureaucratic or cultural. These incentives are rarely hidden and are often entirely legitimate. Governments must balance budgets, health departments manage finite resources, researchers compete for grants, advocacy organisations seek funding to continue their work, regulators are expected to minimise risk, and politicians respond to public opinion as well as electoral pressures.

None of these incentives is inherently problematic. The challenge arises when they collectively encourage the preservation of an existing policy framework, even as new evidence begins to challenge the assumptions upon which that framework was originally built.

This phenomenon is not unique to tobacco control. History provides countless examples of institutions struggling to adapt when disruptive ideas or technologies emerge. The medical profession initially resisted handwashing despite evidence of its benefits. Seatbelts took decades to become widely accepted despite clear evidence that they reduced injuries. Needle exchange programmes faced significant opposition before becoming recognised as effective harm reduction interventions. Even nicotine replacement therapy was once viewed with scepticism because it challenged the belief that complete abstinence from nicotine should always be the ultimate goal.

Institutional change is almost always slower than scientific discovery, and there is a simple reason for this. Evidence can change rapidly when new research emerges, but institutions cannot. Laws, regulations, funding arrangements, organisational structures and professional cultures develop over decades. Once established, they create what economists and political scientists describe as path dependence—the tendency for earlier decisions to shape future choices, making alternative pathways increasingly difficult to pursue.

Over time, institutions develop expertise, routines and structures around the problems they are designed to address. These systems provide stability and consistency, but they can also make adaptation more challenging when circumstances change.

Australia’s approach to nicotine policy provides an example of this process.

Australia’s tobacco control strategy has been shaped over decades by a combination of taxation, advertising restrictions, smoke-free laws, plain packaging and sustained public education campaigns. These measures have become deeply embedded within the country’s public health framework, influencing how governments, researchers, regulators and advocacy organisations understand and approach nicotine policy.

Over time, the assumptions underpinning this framework have evolved into accepted wisdom. Entire careers have been built around established approaches to tobacco control. Universities have developed research centres, government departments have created specialised divisions, advocacy organisations have built missions and campaigns around particular strategies, and professional identities have become closely connected to existing models of public health intervention.

Gradually, tobacco control has become more than a collection of individual policies; it has developed into an institutional paradigm that shapes how new challenges and emerging evidence are interpreted.

Like all institutional paradigms, this framework provides stability, consistency and a shared sense of purpose. However, it can also make adaptation more difficult when new technologies, evidence or alternative approaches challenge long-standing assumptions.

This helps explain why countries examining much the same scientific literature have nevertheless reached different conclusions about nicotine vaping. The United Kingdom has approached vaping primarily through the lens of harm reduction, New Zealand has incorporated vaping into its smoking cessation strategy, and Sweden has embraced lower-risk nicotine products as part of a broader effort to reduce smoking-related harm. Australia, by contrast, has largely approached the same products through a framework centred on precaution, restriction and prevention of nicotine use.

The difference cannot simply be explained by science, because scientific evidence does not change when crossing international borders. A more plausible explanation is that different institutional histories create different policy incentives. Countries build regulatory frameworks around past experiences, and those frameworks influence how new evidence is interpreted.

This does not mean one country is acting in bad faith while another is acting rationally. Rather, it reflects the reality that institutions often view emerging challenges through the assumptions and structures they have developed over many years.

One of the clearest examples of institutional incentives can be found in government finances.

Tobacco excise has long been one of Australia’s largest sources of indirect taxation. For many years, it generated billions of dollars annually before revenues began declining as smoking rates fell and illicit tobacco expanded. Although those revenues have decreased in recent years, tobacco taxation remains a significant source of government income.

This fact is sometimes presented as evidence that governments secretly want people to continue smoking. That conclusion is neither fair nor supported by evidence. Smoking imposes enormous economic costs through healthcare expenditure, reduced productivity and premature mortality, and when these broader costs are considered, the burden of smoking is far greater than the revenue generated through tobacco taxation.

Nevertheless, it would be equally unrealistic to ignore the role that revenue plays in government decision-making.

Governments do not prepare budgets using abstract principles. They rely on actual revenue streams. Departments forecast income years in advance, spending commitments are made based on expected revenue, and when a major source of taxation declines rapidly, governments must make difficult choices about expenditure, borrowing or alternative sources of income.

This creates an institutional tension rather than a conflict of interest.

A policy that accelerates the decline of cigarette consumption may be highly desirable from a public health perspective while also creating short-term fiscal challenges. The long-term benefits of reduced disease may take decades to fully emerge, while the financial impact of declining revenue occurs much sooner.

Political systems are rarely designed around outcomes that occur twenty years into the future. Electoral cycles typically last only a few years, and governments are judged on immediate issues such as budgets, economic performance and public sentiment. Future governments may receive the benefits of reforms introduced today, while current governments carry the political costs.

This creates a subtle but important incentive. Policies with immediate costs and delayed benefits are often more difficult to implement than policies that provide immediate political rewards, even when the long-term evidence supports change.

Healthcare systems face similar structural dynamics.

Australia has developed an extensive healthcare system to diagnose, treat and manage diseases associated with smoking. Hospitals care for patients with lung cancer, cardiovascular disease, chronic obstructive pulmonary disease, stroke and many other smoking-related conditions. Researchers study smoking-related illness, universities train specialists, charities support affected communities, government agencies administer prevention programs, and public health organisations advocate for tobacco control policies.

Every part of this system exists for legitimate reasons.

No reasonable person would suggest that healthcare professionals want smoking to continue because it sustains their work. Doctors, nurses, researchers and public health practitioners are overwhelmingly motivated by reducing suffering and improving health outcomes.

However, institutions inevitably adapt to the problems they confront. Over time, they develop funding structures, professional expertise, organisational priorities and strategic goals around those challenges. Healthcare systems have become highly specialised in managing the consequences of smoking because smoking has been one of the leading causes of preventable disease for generations.

Disruptive technologies create difficult questions for systems built around existing approaches.

If a new approach substantially reduces smoking-related disease over time, healthcare systems ultimately benefit because fewer people require treatment. The transition, however, is not immediate. Clinical guidelines must evolve, research priorities may shift, professional education changes, and resources gradually move towards new areas of need.

Large institutions are designed for stability. That stability is one of their greatest strengths because it allows them to deliver consistent services to millions of people. Yet the same stability can also slow adaptation when scientific and technological change moves faster than bureaucratic systems can accommodate.

This is particularly relevant when considering prevention.

The benefits of treatment are immediate and visible. A surgeon removes a tumour, a cardiologist treats a heart attack, or a respiratory physician helps stabilise someone with advanced disease. These interventions can be directly observed and measured.

Prevention is different.

Its greatest achievements are often invisible. The smoker who avoids developing lung cancer because they moved away from combustible tobacco never appears in hospital statistics. The heart attack that never occurs cannot be counted. The family spared the loss of a loved one may never know what tragedy was avoided.

This creates a challenge for policymakers and institutions. The harms prevented through alternative approaches are difficult to measure, while the risks of change are often immediate and visible.

Understanding these institutional dynamics does not require assuming bad faith, hidden agendas or deliberate misconduct. It simply requires recognising that every system develops incentives that favour stability, continuity and established approaches.

The question is not whether individuals intend to resist change.

The more important question is whether the systems within which they work make meaningful change more difficult than anyone realises.