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An Endgame for Tobacco? by the Various Proposals Editorial Tob Control: first published as 10.1136/tobaccocontrol-2013-050989 on 15 April 2013. Downloaded from then to evaluate what might be achieved An endgame for tobacco? by the various proposals. The latter requires contemplation of each strategy’s Kenneth E Warner potential outcomes, good and undesirable, and the political, legal, ethical, economic, regulatory and social barriers to realising ABSTRACT great successes of many national anti- the strategy’s implementation. Finally, the Since its origins in the 1960s, tobacco control smoking campaigns notwithstanding, the very idea of what constitutes the end of has achieved remarkable success against the pandemic persists. In many developed the endgame needs to be addressed. scourge of tobacco-produced disease and countries with the most robust tobacco Strikingly, to date, there has never been a death. Yet tobacco use, especially cigarette control efforts, the decline in smoking serious discussion within the tobacco smoking, remains the world's leading cause of prevalence has slowed to a trickle. control community about what would preventable premature death and is likely to Evidence-based policies seem incapable of constitute a final victory in tobacco do so for decades to come. Evidence-based substantially hastening the demise of control. Would it be a reduction in 5 policies seem incapable of substantially smoking in these countries. In LMICs, smoking-produced deaths to, say, 10% of hastening the demise of smoking. Slowness in smoking is on the rise. The net effect is current levels? Or 5%? Would it, rather, the decline of smoking in developed nations, that, barring more—and more effective— entail reducing cigarette smoking preva- and increasing smoking in many low- and tobacco control, global smoking preva- lence to 10% or 5%? Would it require the middle-income countries has sparked interest lence will remain between a fifth and a end of all smoking? Would victory in novel, even radical 'endgame' strategies to fourth of all adults for at least the next demand the end of all forms of tobacco 6 eliminate the toll of tobacco. This paper 20 years. Unless something dramatically use? Would it, rather, envision the popula- identifies the principal endgame proposals different occurs, smoking will continue to tion’s being nicotine-free? Or would the and, with the other papers in this volume, has be Public Health Enemy #1 for decades end of the endgame be the attainment of the goal of expanding and deepening the to come, killing millions of people every a more modest tobacco harm minimisa- endgame conversation by engaging the single year. tion objective?15 broader tobacco control community. While we This dire prognosis has led several vision- The essence of the endgame requires struggle today with often widely divergent aries to propose endgame strategies, novel, thinking outside the box. This invites con- perspectives and beliefs about what is possible even radical approaches to tobacco control templation of a heresy: Is it possible—is it and how it might be achieved, we all share that, their proponents believe, hold the conceivably desirable—to envision a role the same vision of the final words to this potential of dealing smoking a knock-out for industry in striving for the endgame? copyright. story: ‘The end’. punch. While these endgame strategies vary Philip Morris International has widely in methods and aspirations, they announced its intention to begin selling share two underlying beliefs: (1) that the what sounds like a pulmonary nicotine status quo is unacceptable and (2) that redu- inhaler in various markets in the next few cing smoking substantially will require years.16 A true pulmonary nicotine Since publication of the UK Royal College something new, bold and fundamentally inhaler would be the first of its kind, a of Physicians’ report on smoking in http://tobaccocontrol.bmj.com/ different from the tried-and-true. The highly addictive product that might there- 1962,1 and the US surgeon general’s 2 origins of these proposals lie in a provoca- fore serve as a satisfactory substitute for report in 1964, progress against the 7 tive article published in 1994 in which cigarettes for a subset of cigarette scourge of tobacco-produced disease has Benowitz and Henningfield proposed grad- smokers. (Neither the pharmaceutical been striking: smoking prevalence has ually reducing the nicotine in cigarettes to inhaler nor current e-cigarettes appear to declined by half or more in most devel- non-addicting levels. Nearly a decade later, deliver significant amounts of nicotine to oped nations. Indeed, when measured in Borland advocated a Regulated Market the lung. Rather, their nicotine is terms of premature deaths averted,3 Model for tobacco that would end absorbed through the oral mucosa, much tobacco control is arguably the developed direct-to-consumer marketing through the like nicotine gum or lozenge.17 18) world’s single greatest public health creation of a not-for-profit distribution Although nicotine is not risk-free, a success story of the past half century. 8 agency with a harm reduction mandate. A nicotine-only product would be dramatic- Still, tobacco use—and principally, cig- on September 25, 2021 by guest. Protected subsequent proposal by Callard and collea- ally less dangerous than combusted arette smoking—remains the leading gues also called for the removal of the tobacco. Could a true pulmonary inhaler cause of preventable premature death and profit incentive by transferring the tobacco hasten the demise of the cigarette? Could illness in all those countries, and it is 9 market to a non-profitentity. Only in the the profit motive contribute to movement increasingly achieving that dubious status past 3 years, however, has the explicit toward the end of the horrendous death within low-income and middle-income notion of seeking an endgame for cigarette toll associated with combusted tobacco? A countries (LMICs). According to WHO, smoking found its way into the scholarly lit- profitable substitute for the cigarette—one smoking killed 100 million people world- 10 erature. Ideas range from a sinking lid on that could be taxed, thereby easing gov- wide in the 20th century, and, with cur- 11 supply approach to prohibiting tobacco ernments’ revenue concerns—would con- rently anticipated patterns of tobacco consumption by people born in 2000 or front far fewer political barriers than consumption, will claim 1 billion lives in 12 4 later to outright abolition of would adoption of any of the ‘main- the present century, most in LMICs. The 13 14 smoking. stream’ endgame policies. What is needed now is to familiarise None of the principal endgame strat- Correspondence to Kenneth E Warner, Department the broader tobacco control community egies described in this volume involves of Health Management & Policy, School of Public with the concept of an endgame and pro- cooperation with the industry, however. To Health, University of Michigan, 1415 Washington — Heights, Ann Arbor, MI 48109-2029, USA; posals to achieve it that is the principal the contrary, they all directly and substan- [email protected] purpose of this special supplement—and tially threaten the industry’s economic Warner KE. Tob Control May 2013 Vol 22 Supp 1 i3 Editorial Tob Control: first published as 10.1136/tobaccocontrol-2013-050989 on 15 April 2013. Downloaded from interests, not to mention its very existence. The barriers to adoption of the principal What this study adds endgame policies are formidable and may seem insurmountable; but the history of ▸ The continuing scourge of tobacco-produced disease is unlikely to yield to today's tobacco control suggests that it would be evidence-based interventions. Several public health visionaries have introduced unwise not to contemplate the endgame. tobacco endgame proposals with the goal of substantially reducing, and perhaps As recently as a decade ago, most experts entirely eliminating, the toll of tobacco. likely would have deemed it inconceivable ▸ Endgame proposals include administrative mechanisms to remove the profit incentive that today close to 30 entire countries from selling tobacco products, regulation requiring reduction of the nicotine in would have completely smoke-free work- cigarettes to non-addicting levels, imposition of a 'sinking lid' on the supply of places, including all restaurants and bars.19 tobacco, prohibition of possession of tobacco products by all individuals born in or Australia recently implemented plain pack- after the year 2000, and outright abolition of commercial tobacco product aging, despite fierce industry opposition,20 manufacture and sale. and the country shares with Uruguay21 the ▸ While the endgame proposals represent radical thinking, remarkable innovation has distinction of leading the march toward characterised tobacco control over just the past decade, with smoke-free workplace graphic warnings that cover the large laws, encompassing all restaurants and bars, in nearly 30 countries, large graphic majority of the front and back of cigarette warnings on cigarette packs in dozens of countries and plain packaging initiated in packs. One of Australia’s tobacco control Australia. leaders is now promoting the concept of licensing smokers to purchase cigarettes, with a return of licensing fees if they the lively proceedings. A subset of the endgame studies. We hope this supple- decide to quit.22 Novel developments will authors in this volume were given specific ment will play a similar role for the continue to occur, and we as a public assignments. The originators of the core broader tobacco control community, health community will be far better posi- endgame strategies were all asked to opening up the debate, enlisting a wider tioned to address them sensibly if we can convey the essence of their strategies and array of tobacco control and public health get ourselves to ‘imagine things otherwise,’ to comment on what they have learned professionals, and thereby hastening the as this journal’s editor has characterised about them in the months and years since determination of answers to the challen- 23–28 the endgame discussion.10 We often lose they were first published.
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