Who Benefits from the Status Quo? - Part 3 Final

This is the final instalment of the series and continues directly from Part 2. Having explored how institutional incentives, public health philosophy, regulation and political realities can shape policy, this concluding essay examines international comparisons, the opportunity costs of maintaining the status quo, and why understanding the systems behind policy is essential if we are to achieve better public health outcomes.

If Australia were the only country grappling with these questions, it might be reasonable to conclude that the evidence remains too uncertain to justify a different approach. Yet Australia is not making these decisions in isolation. Around the world, countries with comparable healthcare systems, similar public health goals and access to much the same scientific evidence have reached markedly different conclusions about the role of nicotine harm reduction.

The United Kingdom has integrated vaping into its smoking cessation strategy for more than a decade. Public health agencies have consistently communicated that, while vaping is not risk-free, it is substantially less harmful than smoking and can help adult smokers quit. Hospitals have incorporated vaping into cessation programmes, and stop-smoking services routinely recommend regulated vaping products to smokers who have struggled with other methods. The objective has never been to encourage nicotine use among people who have never smoked, but rather to reduce the enormous burden of disease caused by combustible tobacco.

New Zealand followed a similar path. Recognising that smoking rates, particularly among Māori communities, were not declining quickly enough, policymakers adopted a pragmatic harm reduction strategy that restricted youth access while ensuring adult smokers could obtain regulated vaping products. The result has been one of the fastest declines in smoking prevalence seen anywhere in the developed world, demonstrating that reducing smoking and protecting young people do not have to be mutually exclusive goals.

Sweden offers another perspective. Rather than relying primarily on vaping, it has seen widespread substitution from cigarettes to lower-risk oral nicotine products, particularly snus. As smoking has steadily declined to among the lowest levels in Europe, rates of smoking-related disease have fallen alongside it. While snus is not identical to vaping, the underlying principle is the same: encouraging smokers to move away from combustible tobacco can produce substantial public health gains even if nicotine use itself does not disappear.

None of these countries abandoned tobacco control. Instead, they expanded it by recognising that not all nicotine products present the same level of risk. Their regulatory frameworks increasingly distinguish between the harms of nicotine and the harms of combustion, allowing policy to be guided by relative risk rather than treating every nicotine product as though it posed an equivalent danger.

Australia has chosen a different path.

Supporters of Australia’s approach argue that it offers stronger protection for young people and reduces the likelihood of creating a new generation dependent on nicotine. Those concerns are entirely legitimate, and preventing youth uptake should remain a central objective of any nicotine policy. The real question, however, is whether prohibition is the most effective way to achieve that objective, or whether carefully designed regulation might offer better outcomes for both young people and adult smokers.

Australia’s recent experience suggests that prohibition has not eliminated demand. Instead, demand has largely shifted into illicit markets where age verification is inconsistent, product standards are uncertain and organised crime has become increasingly involved in supply. Restricting legal access has not removed the market; it has merely changed who controls it.

This highlights one of the most important principles in public policy: every decision carries an opportunity cost. Opportunity cost is not limited to government expenditure or lost tax revenue. It also includes the benefits society forfeits by choosing one policy path over another.

Every smoker who continues smoking because safer alternatives remain difficult to access represents an opportunity lost. Every individual who repeatedly attempts to quit using methods that have not worked for them, while alternatives remain heavily restricted despite being available in comparable countries, represents another opportunity lost. Every year that smoking declines more slowly than it otherwise might have is measured not only in economic terms, but also in preventable disease, avoidable suffering and lives cut short.

These costs are particularly difficult to quantify because they are largely invisible.

Governments can measure seizures at the border, arrests, prosecutions, illicit tobacco stores, excise revenue and healthcare expenditure with considerable precision. What they cannot easily measure are the smokers who never quit because switching became unnecessarily difficult, the lung cancers that never had the chance to develop under a different policy framework, or the heart attacks that might never have occurred if more smokers had moved away from combustible tobacco.

Nor can we count the families who might have been spared the loss of a parent, partner or grandparent had lower-risk alternatives been more accessible.

In many respects, the greatest costs of maintaining the status quo are the ones that never appear in official statistics.

This helps explain why institutional change is often so difficult. Institutions naturally measure the outcomes they are designed to observe. Health departments monitor compliance. Border agencies count seizures. Police record arrests. Treasury tracks revenue. Hospitals measure admissions and mortality. These are all valuable indicators, yet they rarely capture what might have happened: the events that never occurred because a different policy might have produced a different outcome.

Outcomes that never occurred are inherently difficult for governments to evaluate because political systems reward visible achievements rather than invisible successes. Elections are won on tangible outcomes that voters can see and experience, not on illnesses prevented or deaths that never occurred.

Consequently, changing direction always carries political risk, while maintaining the existing policy offers institutional familiarity and relative safety. If a new approach succeeds gradually over twenty years, the politicians who introduced it may receive little recognition. If it appears to fail within a matter of months, however, responsibility is immediate, public and politically costly.

Faced with these incentives, caution is understandable.

But understandable does not necessarily mean optimal.

History repeatedly demonstrates that major public health advances have required policymakers to accept a degree of uncertainty in pursuit of long-term gains. Harm reduction itself was once fiercely contested in areas such as HIV prevention, opioid dependence and alcohol policy. Today, many of those interventions are regarded as standard public health practice because institutions eventually adapted as the evidence accumulated.

Perhaps nicotine policy is now approaching a similar turning point.

If that is the case, the challenge facing Australia extends far beyond the question of whether vaping should be permitted or prohibited. The deeper question is whether institutions designed to solve yesterday’s problems are sufficiently adaptable to respond to today’s evidence.

Answering that question requires intellectual humility from everyone involved. Researchers must remain willing to reassess long-held assumptions when new evidence emerges. Governments must be prepared to evaluate outcomes honestly, even when those outcomes differ from expectations. Advocacy organisations on every side of the debate should recognise that complex public health problems rarely yield simple ideological solutions. Most importantly, consumers deserve accurate information about relative risk rather than messages that imply all nicotine products carry equivalent dangers when the evidence increasingly suggests otherwise.

Regardless of how Australia’s tobacco control policies are judged historically, they should not be treated as beyond criticism. Science does not progress by defending established ideas; it progresses by testing them, questioning them and revising them when better evidence emerges. Public policy should be no different. The longevity of a policy is not evidence of its continued effectiveness, particularly when international experience and emerging evidence suggest that alternative approaches may achieve better outcomes.

Asking who benefits from the status quo is therefore not an exercise in assigning blame. It is an exercise in understanding how systems operate. Systems create incentives, incentives shape behaviour, behaviour influences policy, and policy ultimately determines outcomes. Recognising those relationships is not cynical; it is essential if public health is to remain genuinely evidence-based rather than selectively guided by evidence that reinforces existing assumptions.

If Australia’s nicotine policies are producing outcomes that increasingly differ from those observed in comparable countries, including persistent smoking among disadvantaged populations, expanding illicit markets, increasing criminal involvement and growing divergence from international best practice, then asking why is not an act of disloyalty. It is precisely what evidence-based policymaking demands.

The question has never been whether governments, researchers or clinicians genuinely want to reduce smoking. There is every reason to believe they do. The more difficult question is whether the structures they have built now make adapting to new evidence more difficult than anyone intended.

History suggests that institutions rarely resist change because they are malicious. More often, they resist change because they have become invested in existing frameworks, established ways of thinking and long-standing policy paradigms. The systems that addressed yesterday’s public health challenges can, almost inevitably, become the systems that struggle to recognise tomorrow’s opportunities.

That is why examining incentives matters. Not to identify villains. Not to undermine public health. But to understand how institutional structures, funding models, professional identities and political realities can unintentionally preserve policies long after evidence begins pointing in a different direction. If public health is to remain true to its scientific foundations, it must be willing to question not only new ideas, but also its own assumptions.

Ultimately, the purpose of public policy is not to defend institutions or preserve the status quo. It is to improve people’s lives. That means remaining willing to question established approaches, learn from international experience and adapt when the evidence points towards better solutions.

The greatest strength of science has never been certainty.

It has always been its willingness to change.