all population health. Implementing the blueprint would reduce tobacco use and the attendant social costs to a degree that exceeds the costs of the proposed interventions. Moreover, studies of cost-effectiveness show that the tobacco control interventions are less costly per year of life saved and per quality-adjusted life year than many other standard public health interventions (see, for example, Cromwell et al. 1997; Tengs et al. 2001; Warner 1997). Admittedly, these traditional public health calculations do not include the “savings” to society in health care costs or social security payments attributable to premature death, but the committee does not regard these “savings” as a social benefit.
Once the question of “savings” due to premature mortality is set aside, the “public health” case for aggressive, cost-effective measures is generally acknowledged to be a powerful one. The main ethical objection raised to tobacco control policies has been raised by people who eschew the public health paradigm in favor of a non-consequentialist ethical paradigm grounded in an analysis of individual rights. In the context of tobacco use, the rights-based framework most often invoked is libertarian. The committee recognizes that strict adherents to this perspective may resist any regulation of consumer products, including tobacco, that is not designed to promote informed choice or to reduce external harms. However, product regulation is common in many domains, dating at least to the Pure Food and Drug Act of 1906, and certain characteristics of tobacco products might make tighter control acceptable even to those who tend to embrace a libertarian approach toward regulation of most consumer products. We outline those characteristics next.
The first point to be noted is that, even within a libertarian framework, each of the subsidiary goals of tobacco policy has some justification: reducing exposure to ETS prevents harm to people other than the smokers themselves, preventing initiation of tobacco use by youth is arguably justified by the recognized shortcomings of adolescent judgment, and promoting cessation helps to restore the liberty of smokers who do succeed in quitting (rather than contracting their liberty). In this respect, it is important to recall that 90 percent of adult smokers eventually regret having become smokers, about 70 percent have tried to quit, and—at any given moment— 40 percent are either actively trying to quit or thinking about making a quit attempt within the next six months (see Chapter 2).
The most ethically controversial policies aiming to reduce tobacco use are those aimed exclusively at reducing use by the minority of adult smokers who do not want to quit. This is the nub of the so-called paternalism problem. However, since every intervention aimed at current smokers serves the interests and the express wishes of the subset of smokers who do want to quit, interventions designed to protect the health of adult smokers do not necessarily rest on a paternalistic foundation. Instead, they entail both