Why People Smoke: Behavioural Economics And Tobacco Control

"Dum maro dum, mit jaein gum" - mantra inspired by Haight-Ashbury in the 1960s to today's 4 pm "chai-sutta" ritual, tobacco use has long offered a quick escape from stress and a medium for social connection. However, tobacco as a social glue has zero health benefits. Zero.

If tobacco dependence does anything definitively, then it increases cancer risk in the lungs, oral cavity and multiple organs, cardiovascular diseases and tuberculosis. It is the topmost preventable cause of millions of deaths globally. In low-income individuals, tobacco use deprives them and their families of food, education and well-being, often pushing millions into poverty. Yet tobacco is legally sold worldwide.

It's common knowledge that tobacco is harmful. But then why do >1 billion individuals use tobacco globally? Why would 39% of men and 4% of women in India ignore the graphic warning that covers 85% of cigarette packaging and engage in self-harm? Why does it take numerous quit attempts, and yet only a fraction of users are successful in quitting tobacco?

These questions may seem rational to economists, yet the reasons people smoke often defy rationality. One survey participant said, "I don't think smoking causes any health problems. Many people I know, or I see smoke, and it doesn't cause any serious health issues. Even if it does, the risks are higher only for those who are addicted to it."

Such responses highlight a gap in the traditional "rational economic person" model, which assumes individuals make choices based on logical self-interest and complete knowledge of risks. In reality, this model has had limited success in reducing tobacco use, as people's choices are frequently shaped by perceptions, social influences, and deep-rooted habits that go beyond purely rational considerations.

Paradoxically, while statistics don't ease stress, smoking does—at least temporarily. This suggests a need for a fresh perspective on tobacco control—one that views smoking as a behavioural issue and chronic relapsing condition shaped by human idiosyncrasies and the external environment. Let's unpack these factors through the  4P Model.

4P model for factors associated with tobacco use

The 4P model suggests that the factors associated with whether a person uses tobacco or not fall into four broad categories: Personal, Peer, Pharmacology, and Policy 

 

 

The personal drivers behind smoking

Smoking often begins in adolescence, spurred by psychosocial factors such as rebellion, low self-esteem, or poor academic performance. For Maya, a 16-year-old from a troubled home, smoking offers a sense of freedom. "I feel liberated when I smoke," she shared. "No one can tell me what to do."

According to the National Family Health Survey-5 (NFHS-5), 14% of Indian adolescent boys and a small proportion of girls start smoking young.  Later in life, factors such as mental health and socioeconomic status influence tobacco use.

As people grow older, factors like mental health and socioeconomic status also play a role. For some, smoking becomes a way to cope with personal setbacks. KS, a student, shared, "I started smoking after seeing my first-year results; I had backlogs." Another participant, PG, added, "I knew I wasn't strong in academics. No matter how hard I tried, I couldn't perform well. That's when I turned to smoking to cope with the disappointment."

Peer influence: The social network effect

Social connections operate both ways to discourage or encourage smoking. Peer influence is a solid factor in initiating and continuing tobacco use, especially among adolescents. Friends, co-workers or spouses often nudge one another into tobacco use, creating a social environment that normalizes smoking. 

Meghna, a 35-year-old mother with a thriving corporate career, said, "I want to quit and have tried it several times. But it's hard to resist when my husband lights up a cigarette. Smoking is how we met—during a sutta break." This affinity for others who share their tobacco habits is known as "selection homophily."

Parents' habits further reinforce such social factors and early-life associations, which can influence children's tobacco habits. For Amit, cigarettes were regular while growing up since his father was a chain smoker.

Pharmacology: The science of nicotine addiction

The pharmacological effects of nicotine on human physiology ensure the tobacco industry wins over policy. Smoking is the fastest way to deliver a relatively high amount of nicotine to the brain. The speed of delivery gives the "kick", making cigarettes addictive. For Ashraf, who initially tried different forms of tobacco, cigarettes offered an effect he couldn't get from other products: "I switched to cigarettes because they hit harder than gutka."

Addiction triggers a craving, a compulsive desire to engage in a behaviour, such as tobacco use. It's a diagnostic indicator of substance use disorders.

Nicotine half-life in blood is two hours. However, nicotine cravings begin shortly after smoking a cigarette and peak approximately 3-6 hours after last use. This nicotine craving and withdrawal symptoms are behind continued tobacco use despite a decline in "liking" and other negative consequences. This experience of discomfort when unable to smoke, which is alleviated upon smoking,  ensures revenue to the tobacco industry.

A vast majority of smokers who attempt to quit relapse within the first month of abstinence. However, nicotine replacement therapy (NRT - gum, transdermal patch, nasal spray, inhaler and sublingual tablets/lozenges), which attenuates withdrawal symptoms, improves the rate of quitting by 50-70%.

Policy: The limitations of tobacco control measures

Tobacco-use policy has immense social, economic, and political implications. While a high tobacco tax has been an important measure to reduce tobacco use, rising disposable incomes in India have increased purchasing power, keeping tobacco products still affordable. Kaustubh said, "Rs. 15 on a cigarette and Rs. 10 on chai. It can't get better than that." His statement suggests that post-GST price hikes have not been impactful in curtailing tobacco use.

Additionally, despite laws, push-and-pull marketing strategies are rampant to nudge users to consume tobacco. With 2-3 shops per street selling cigarettes, including single sticks, tobacco is easy to access and is affordable.

New directions

India, despite the declining smoking trend, is home to one of the most significant numbers of tobacco users globally. Hence, there is an urgent need to develop improved tobacco interventions if we aspire to dislodge ourselves from the first global rank of tobacco-related cancers while reducing the burden of other tobacco-related diseases. Additionally, India wins with net increases in GDP and employment.

Considering the limited success of traditional economic methods in driving tobacco cessation, reframing smoking as a behavioural issue may yield more effective solutions. Behavioural economics acknowledges that people don't always make "rational" decisions, even when informed.

Applying behavioural economics principles to evidence-based practices can boost the effectiveness of economic approaches to tobacco control by leveraging predictable human idiosyncrasies. By combining elements of psychology and economics, novel approaches could be designed for tobacco-cessation interventions and help 33% of Indian tobacco users struggling to quit the habit.

The tobacco industry uses behavioural economics tactics, such as selling single cigarettes, placing them near tea stalls, and point-of-sale marketing, which are "nudges" that encourage use. Such subtle nudges could win over coercive approaches, such as banning and negative framing, explaining the industry's success. 

Similar non-coercive nudges and network effects could discourage tobacco use, making public health policy more effective. Integrating behavioural economics with the 4P Model (Personal, Peer, Policy, Physiology) could lead to novel and targeted tobacco control policies that align with human idiosyncrasies, shaping a healthier India.

(All names are changed to protect privacy)

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Edited by Christianez Ratna Kiruba.

Image by Janvi Bokoliya.