Who Benefits from the Status Quo? - Part 2

This Substack continues from Part 1, where I explored how institutional incentives, path dependence and organisational structures can shape public policy. In Part 2, I examine how these dynamics influence public health philosophy, regulatory decision-making, enforcement, media narratives and political incentives, and why these forces can make meaningful policy change far more difficult than it first appears.

The influence of institutional incentives becomes even more apparent when considering how public health approaches risk. By its very nature, public health is a precautionary discipline. Its purpose is not simply to respond to harm after it occurs but to anticipate potential risks and prevent them wherever possible. This philosophy has saved countless lives through vaccination programmes, food safety standards, clean water, seatbelt laws and restrictions on tobacco advertising. In many areas of public health, acting before every uncertainty has been eliminated has proven to be both prudent and effective.

The challenge arises, however, when precaution is applied to situations where the risks are not evenly distributed. Smoking and vaping are not equivalent behaviours. Cigarette smoking remains one of the deadliest consumer products ever created, responsible for an enormous burden of disease and premature death. Nicotine vaping, while certainly not risk-free, is recognised by many international health authorities as exposing users to substantially fewer toxicants than combustible tobacco. That distinction fundamentally changes the policy question.

The issue is no longer whether vaping is completely safe, because very few products or behaviours are. Instead, the more relevant question is whether it is substantially safer than the behaviour it may replace. This distinction lies at the heart of harm reduction, a philosophy that accepts that while eliminating risk entirely is ideal, reducing risk is often both achievable and worthwhile. Society already applies this principle in many other areas of public health. We encourage the use of seatbelts because they reduce injuries rather than eliminate road accidents. We provide sterile needles because reducing HIV transmission saves lives, even though drug use continues. We prescribe methadone and buprenorphine because preventing overdose deaths is preferable to insisting upon immediate abstinence that many people cannot realistically achieve.

Nicotine policy has proven different. Australia has historically approached nicotine through an abstinence-based framework in which the objective has been not merely to eliminate smoking but, wherever possible, to eliminate nicotine use itself. This philosophical distinction helps explain why many policy discussions focus primarily on nicotine dependence rather than the overwhelming burden of disease caused by inhaling smoke. Once such an abstinence framework becomes embedded within institutions, new products are naturally evaluated according to whether they perpetuate nicotine dependence rather than whether they dramatically reduce exposure to combustion.

Again, this does not imply that policymakers are ignoring evidence. Rather, it illustrates how underlying philosophies influence the interpretation of evidence itself. The same body of scientific data can lead to different policy conclusions depending upon the questions institutions choose to ask. If the primary question is whether a product sustains nicotine addiction, the answer may naturally favour greater restriction. If the primary question is whether it substantially reduces smoking-related disease, the policy response may look very different. Neither question is unreasonable. The difficulty arises when one consistently overshadows the other.

Professional communities can reinforce these dynamics in subtle but important ways. Researchers, regulators and public health practitioners do not work in isolation. They collaborate on research projects, review one another’s publications, participate on advisory committees, attend the same conferences and contribute to the same professional organisations. These networks are essential for advancing science, maintaining standards and sharing knowledge. At the same time, every close professional community inevitably develops shared assumptions, accepted frameworks and prevailing narratives that shape how new evidence is interpreted.

This is not evidence of conspiracy or deliberate exclusion. It is simply how human organisations function. Every profession develops dominant theories that provide stability and consistency, but those same theories can also make genuinely disruptive ideas more difficult to accept. Medical history is filled with examples. The bacterial cause of stomach ulcers was initially dismissed. Hormone replacement therapy was widely embraced before later evidence prompted significant reassessment. Countless innovations have encountered scepticism, not because experts acted irrationally or dishonestly, but because scientific understanding evolves gradually and institutions naturally adapt more slowly than evidence itself.

Tobacco control is unlikely to be immune from these same human tendencies. For decades, its success depended upon communicating a simple and remarkably effective message: smoking kills, nicotine addiction should be avoided, and complete cessation is the safest outcome. That clarity undoubtedly contributed to one of Australia’s greatest public health achievements.

The arrival of lower-risk nicotine products complicated that message. Communicating relative risk is inherently more difficult than communicating absolute risk. Explaining that vaping is not safe but is substantially less harmful than smoking requires nuance, and nuance rarely translates easily into public health campaigns, media headlines or political slogans. Simplicity is often far easier to communicate, but simple messages can become problematic when they no longer reflect the complexity of the available evidence.

Australia’s regulatory response has also created an extensive enforcement infrastructure. Federal agencies monitor imports, Border Force intercepts shipments, police investigate organised crime, health departments conduct compliance operations, state governments establish specialist task forces, legislatures expand enforcement powers and additional funding is allocated to combat illicit trade. These developments are entirely understandable given the rapid growth of Australia’s illegal nicotine market, yet they also illustrate another form of institutional momentum.

Once governments invest heavily in enforcement, the natural response to continuing illegal activity is usually to strengthen enforcement further. More investigators are appointed, more penalties are introduced, and more resources are committed. Success increasingly becomes measured through seizures, arrests and prosecutions, while considerably less attention is devoted to asking whether the regulatory framework itself may be contributing to the size and resilience of the illicit market.

This pattern is not unique to nicotine. History repeatedly demonstrates that prohibition creates enforcement challenges. Alcohol prohibition in the United States fostered organised crime. Drug prohibition continues to generate extensive illicit markets around the world. Whenever strong consumer demand persists while legal supply is heavily restricted, illegal suppliers frequently emerge to meet that demand.

Australia’s experience with tobacco and vaping appears to reflect many of these broader economic principles. The significant expansion of illicit tobacco and vaping markets has required increasingly sophisticated enforcement responses, while organised criminal groups have become involved because prohibition creates substantial profit opportunities. Violence associated with illegal tobacco distribution has become an issue in several jurisdictions, prompting understandable calls for even tougher enforcement. At the same time, these developments should also encourage policymakers to ask whether enforcement alone can resolve problems that may be driven, at least in part, by the underlying policy architecture.

Healthcare regulation presents another important set of institutional incentives. Australia has traditionally preferred nicotine products that fit comfortably within established medical frameworks. Nicotine patches, gum, lozenges and prescription medicines are familiar to clinicians because they are evaluated through pharmaceutical pathways, incorporated into clinical guidelines and prescribed within existing healthcare systems.

Consumer vaping products occupy a very different regulatory space. They are neither conventional medicines nor traditional tobacco products, instead sitting uncomfortably between healthcare and consumer regulation. Throughout history, regulatory systems have often struggled when innovations failed to fit neatly within existing categories. Digital platforms challenged broadcasting laws, ride-sharing disrupted taxi regulation, cryptocurrency challenged financial regulation, and artificial intelligence is now reshaping legal and ethical frameworks across multiple sectors. Nicotine vaping represents a similar regulatory challenge because it does not align comfortably with twentieth-century models of either pharmaceuticals or tobacco control.

When institutions encounter products that fall between established categories, the instinctive response is often caution. Caution is rarely criticised. Approving a product that later proves harmful can generate public inquiries, damaging headlines and lasting political consequences. Delaying access to a product that might have prevented future smoking-related disease creates a very different set of incentives because the consequences are dispersed across thousands of individuals and unfold gradually over decades. There is rarely a single moment when delayed access becomes politically visible.

This creates a profound asymmetry. Regulators bear considerable personal and institutional risk if they approve something that later causes harm, yet they bear far less immediate risk if they delay or restrict something whose benefits are realised gradually and are difficult to measure directly. Unsurprisingly, this encourages conservative decision-making even when the balance of evidence increasingly favours innovation.

Media incentives reinforce many of these same dynamics. News organisations naturally prioritise stories that attract public attention. Youth vaping, illegal imports, product recalls, and sensational health scares generate compelling headlines because they are immediate, visual and emotionally engaging. By contrast, the middle-aged smoker who quietly switches to vaping, experiences improved health and never develops smoking-related cancer is not a news story. Successful harm reduction is remarkably uneventful. Its greatest achievements occur quietly in homes rather than hospitals and over years rather than days. Consequently, public perception can become shaped by highly visible individual incidents rather than the cumulative experience of millions of adults who have successfully moved away from combustible tobacco.

Politicians operate within similar incentive structures. Supporting stricter regulation is politically straightforward because few elected representatives lose votes by promising tougher action against nicotine products. The language of protecting children resonates across the political spectrum and is understandably difficult for political opponents to challenge. Advocating for harm reduction, by contrast, is considerably more complex. Explaining relative risk requires nuance, while supporting regulated access for adult smokers can easily be portrayed as weakening protections for young people, even when the proposed policy explicitly strengthens youth safeguards.

Political incentives therefore tend to reward certainty over complexity and symbolism over nuance. The debate is often framed as a choice between protecting children and supporting vaping, when the real challenge is how to protect children while also reducing smoking among adults. Those objectives are not mutually exclusive, and several countries have demonstrated that both can be pursued simultaneously through carefully designed regulation.

Understanding these institutional incentives does not require assuming that individuals are acting in bad faith. On the contrary, most participants in Australia’s nicotine debate are motivated by a genuine desire to improve public health. The more difficult question is whether the systems within which they operate naturally encourage caution, reinforce established ways of thinking and make policy evolution slower than the evidence itself.

If that is the case, then understanding the persistence of Australia’s current approach requires looking not for villains, but for incentives. And incentives, unlike intentions, often shape outcomes in ways that nobody originally intended.