With the dramatic reduction in tobacco use in developed nations, a growing number of public health leaders have called for what they describe as an ‘endgame’ strategy and the need for new policies to achieve that goal. In moving forward, it is important not to lose sight of the policies that have been the underpinnings of successful tobacco reduction efforts to date, nor should we allow any discussion of new strategies to decrease the emphasis on fully implementing the Framework Convention on Tobacco Control (FCTC). Any ‘endgame’ strategy should carefully build on the evidence-based strategies that have proven so effective and not be based on the false premise that the policies embraced by the FCTC are incapable of reducing tobacco use far below current levels or to a level where tobacco caused disease is no longer a major public health problem.
- End game
- Public policy
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With the dramatic reduction in tobacco use in developed nations, a growing number of public health leaders have called for what they describe as an ‘endgame’ strategy and the need for new policies to achieve that goal. The new strategies that have been proposed to achieve this goal, for example, range from a call for an outright legal ban on cigarette sales,1 the prohibition on sales to everyone born in 2000 or after,2 reductions in nicotine levels,3 requiring a prescription for purchasing tobacco4 and legally reducing the amount of tobacco available each year.5
If we are not careful, the ‘endgame’ discussion has serious potential risks that could slow, if not divert, global progress. First, it is based in part on the faulty premise that the proven tobacco control measures—higher taxes, strong warning labels, smoke-free air laws, aggressive public education campaigns, packaging restrictions and restrictions on tobacco industry marketing—embraced by the Framework Convention on Tobacco Control (FCTC) are incapable of reducing tobacco use far below current levels6 ,7 or have done as much as they are likely to do.
Despite the continued number of tobacco users globally, these measures have not failed. Countries, such as Australia, Canada, Sweden, Hong Kong and the US8 for example, have seen dramatic reductions in adult daily smoking down to 16% or under using precisely these strategies. (While the US has not ratified the Framework Convention, it has adopted many of the policies called for by the treaty.) Countries, such as Brazil,9 Turkey and Uruguay10 that have adopted these policies more recently have also experienced dramatic declines.
The pace of change globally isn't just in a small number of countries that have long been tobacco control leaders. In the last 7 years 14 countries in South American alone have adopted 100% smoke-free air laws, 14 have adopted FCTC compliant warnings and 12 have implemented new bans or restrictions on tobacco marketing. Since 2004, 35 countries have adopted 100% smoke-free air laws, at least 68 countries mandate graphic warnings covering at least 30% of the pack and 37 countries have banned or severely restricted all tobacco advertising. When fully implemented, these policies have been proven time and again to be effective at reducing tobacco use and changing society's perception of tobacco use and the tobacco industry.
Focusing on the policies called for by the FCTC isn't accepting the status quo or a world where tobacco use continues to thrive. The most recent data in Australia shows that among 15–17-year-olds only 4.4% are daily smokers, 2.2% smoke less often than daily and 89.3% report that they had never smoked.11 In California adult smoking rates are down to 11.9%.12 New York City has reduced current smoking rates among adults to 14.0% and to 7.2% among youth.13
The current problem is not that these policies don't work, it is that they have not been implemented in far too many countries. It isn't time to abandon the focus on adopting and implementing them. It is time to get serious about implementing them everywhere.
We play into the tobacco industry's hands if we fail to recognise that where implemented, these policies have worked. It is not a surprise that Philip Morris says,
‘[t]here is growing consensus that public health policies based solely on prevention and cessation, however, are not sufficient in the real world’ because ‘[m]illions of adults are likely to continue using tobacco products, notwithstanding efforts by government, public health, and others to encourage them not to use tobacco at all.’14
There is no such consensus, but Philip Morris would like nothing more than for public health leaders to divert their energies from these efforts.
Second, the current ‘endgame’ discussion needs to pay heed to two principles. For tobacco control measures to have their desired impact, it is critical to first build a climate that enables government to act as boldly as these new ideas propose.15 Too many countries have not yet done so. Australia was able to adopt plain packaging for cigarettes in November 2012 precisely because it had built public support for strong tobacco control measures over the years. To succeed, tobacco control efforts must be preceded by a concerted effort to educate the public about the magnitude of the harms caused by tobacco and why the proposed policy is needed. Had Australia acted without first building public support, the tobacco industry's attacks—including the attack on the Australian government as a ‘national nanny’—could well have been successful and could have set back long-term progress.
In addition, many of the new proposed ‘endgame’ strategies take a different approach than the strategies that have been successfully implemented. Prior strategies have been well accepted because they focused on protecting youth, more effectively informing consumers, changing economic incentives to promote healthy behaviour and restricting the tobacco industry's ability to appeal to youth and mislead adults. None sought to restrict sales to adults or to restrict the behaviour of adults. If it was important to first gain the support for the strategies called for by the Framework Convention, it will be even more important to pay close attention to public attitudes and social norms with policies that directly impact the behaviour of adults.
The most important lesson for the ‘endgame’ discussion is that what has most often been the missing ingredient for effective tobacco control efforts isn't innovative ideas or effective policies, it is a lack of political will at the highest levels of government. If tobacco control efforts are to move to a point where a true ‘endgame’ is possible, nothing is more important than creating and sustaining the political will to tackle the tobacco epidemic and doing everything possible to fully and aggressively implement the policies that have already been proven to work.
Implementation of proven tobacco control measures, such as higher taxes, smoke-free air laws, strong, graphic warnings, powerful mass media campaigns and prohibitions on tobacco industry marketing have been responsible for dramatic reductions in tobacco use and extraordinary changes in social norms, but very few countries have fully implemented these measures and no country has yet to implement them so completely that they have achieved all that they are likely to achieve.
While it is critical for tobacco control to innovate and to test out new ways to reduce tobacco use, it is also essential that these new efforts not divert attention or resources away from fully implementing the measures that have been shown to work, especially in the many low and middle income countries that have neither implemented the FCTC effectively nor built support for the type of strong action called for by some of the endgame proposals.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.
i Ericksen, Mackay and Ross, The Tobacco Atlas, 4th Edition (2012):30–31.
ii 1989 National Health and Nutrition Survey, 2003 World health Survey, 2008 Global Adult Tobacco Survey.
iii US Food and Drug Administration, Docket No. FDA-2011-P-0573—Comments on Citizen Petition filed by RJ Reynolds Tobacco Company, Altria Client Services, February 6, 2012:2–3.
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