Issues of priority

Endgame proposals have prioritised issues differently. Some aim to phase out all tobacco (TFG), others only cigarettes (harm reduction); some have emphasised the importance of helping adult smokers, others the protection of children. While all these issues are important, this section aims to briefly identify those of higher priority, which warrant the highest levels of intervention or choice restriction.

Among all forms of tobacco, cigarettes are by far the most deadly: cigarettes kill half of those who regularly smoke them, are strongly addictive and negatively affect many non-smokers, particularly children, through passive smoke.1 Although alternative nicotine products are also harmful, and warrant regulatory scrutiny,9 arguably the cigarette presents a more significant problem and deserves the most focus in a tobacco phase out.

For most smokers, addiction to cigarettes is lifelong, acquired before adulthood, and a source of regret.10 It is easier, and perhaps more humane, to prevent nicotine addiction than to halt a nicotine addiction; in other words, a policy that concentrates on preventing smoking initiation will be more effective than a policy that allows people to initiate and later forces them to quit. So, although better cessation options should be provided for smokers, this paper argues that special focus should be put on the protection of children and the prevention of smoking initiation.

A harm reduction endgame

Harm reduction is not usually considered as an endgame strategy because its goal is to reduce rather than to eliminate tobacco-related harm. Typically, it achieves this by encouraging smokers to switch to a less harmful nicotine product such as SLT or ENDS. However, a recent endgame proposal suggested that the tobacco problem could be viewed as two separate issues: first eliminating the most harmful form of nicotine use (cigarettes), then minimising all other tobacco-related harms and nicotine addictions.4 In this way, harm reduction can be conceptualised as an endgame that prioritises the phasing out of cigarettes. However, allowing the use of alternative nicotine products—especially SLT and ENDS—remains controversial.

Smokeless tobacco

SLT is banned under many jurisdictions; in other countries, its use is considered problematic. In South Africa, for example, SLT is affordable and designed to deliver high levels of nicotine, which encourages addiction in adolescence and cigarette smoking later in life.11 In India, SLT use is also common and often results in later cigarette smoking and chronic disease.12 Most people in India are unaware of these harmful effects.13 Moreover, some types of SLT used in India require spitting; this has led to wider concerns over the spread of infectious diseases such as tuberculosis.12 In Sweden, however, SLT use rarely results in cigarette smoking or mortality. Swedish SLT takes the form of a spit-free, moist ‘snus’ with a low nitrosamine (carcinogen) content. It is a popular cigarette alternative and not generally considered as a ‘gateway’ into cigarette smoking.14 Its use among specific groups has led to a steep decline in smoking prevalence and associated tobacco-related diseases.15

Harm caused by permitting the use of SLT seems to depend largely on the regulatory environment. Sweden, often cited as a successful example, provides a stark contrast to the lax regulations in India and South Africa. Still, opinion remains divided on whether policies should permit or prohibit SLT use. SLT is a potential cessation aid for smokers and less harmful than smoked tobacco.14 However, there is in principle an objection to a product that, though safer than cigarettes, is still harmful and addictive. There is also concern over how the industry will use SLT to undermine already effective tobacco control policies. SLT could be designed and marketed to encourage dual use with cigarettes rather than a complete switch to SLT.16 The industry could also market SLT to younger users as a ‘gateway’ into cigarettes; this effect is most likely in countries such as South Africa, where lax regulation has made SLT affordable and highly attractive to adolescents.11

ENDS (e-cigarettes)

ENDS are devices that deliver nicotine to the lungs similarly to cigarettes. They do not contain tars, so are purportedly less harmful than cigarettes. However, they are potentially addictive and little is known on the harms they may cause, other ingredients they may contain (eg, tobacco, propylene glycol, flavourings)17 or the safety of their design.18 Despite this, regulatory loopholes have allowed a rapid growth in the market for ENDS in recent years, especially in areas such as the EU. Demand for ENDS seems to have increased in the context of public smoking bans. Thus, there are concerns over whether loose regulation of ENDS will re-normalise cigarette smoking or act as a gateway product into cigarettes for young people.19 While the growing popularity of ENDS provides a potential opportunity to wean smokers off cigarettes, as with SLT, their proper regulation is crucial.

Regulation of alternative products

Regulating the contents of alternative nicotine products is essential. India's problem with spitting and spreading infectious disease should be controlled by permitting only spit-free SLT. Cancer risk should be reduced by restricting the carcinogen content of SLT, as is done in Sweden. SLT and ENDS should be marketed as cessation aids for smokers, not as recreational drugs; the product should be made less desirable by restricting additives, flavourings and packaging. Use of SLT and/or ENDS for the purpose of smoking cessation should be encouraged through proper information to the public and both products should be under similar restrictions as those recommended for cigarettes in the WHO FCTC. This approach would provide smokers with better weaning or cessation options, while discouraging non-smokers, particularly children, from initiating their use.

Protecting children from the gateway effect

An important issue is that of the ‘gateway’ effect. The literature remains divided on whether SLT or ENDS are gateway products into cigarettes. For now, it may be concluded that, provided that young SLT/ENDS users also have access to cigarettes, there is a potential for later smoking initiation. One way to avoid this problem is to restrict their access to cigarettes. Previously, it was suggested that this could be done by forcing the tobacco industry to commit to a cigarette phase out within the next 10–15 years. Cigarette production could be capped, prices increased and nicotine content reduced.16 Alternatively, nicotine could be eliminated from cigarettes to prevent addiction5 ,20 or for-profit industry replaced with a regulatory authority that aims to phase out cigarette consumption.4 ,21 Another, perhaps simpler option is to introduce a generational cut-off on cigarette sales to younger generations, similar to the TFG proposal.22 This would result in a generation that has access to alternative products, but not cigarettes. The potential of this approach is discussed below.

A tobacco-free generation

A recent endgame proposal from a group in Singapore suggested that tobacco use could be phased out by denying tobacco sales to people born after a certain date, such as 1 January 2000, to create a TFG. Though similar to Proctor's proposal to abolish all tobacco sales,23 the TFG proposal would not directly affect current smokers or force them into withdrawal. In Singapore, it has been promoted in schools and population surveys indicate strong support.22 In Tasmania, TFG received unanimous support in their government's Upper House.24 Policymakers in the British Isle of Guernsey have also expressed interest.25 Thus, TFG is a novel idea that has not yet been tried anywhere, but certainly has potential as an endgame strategy.

The rationale of the TFG proposal is that it protects younger generations from the harms of tobacco and addresses the rite-of-passage effect. Over time it would increase the generation gap between smokers and non-smokers, creating a positive ‘norm cascade’ in which smoking is increasingly viewed as an outdated phenomenon. TFG also targets smoking initiation—a top priority issue since most smokers start before adulthood.6

However, the TFG proposal also raises a number of prospective questions. States still collecting tobacco tax, or growing tobacco, may be reluctant to phase out sales if there is no immediate replacement for lost economic resources. Libertarian critics, the general public and most certainly the tobacco industry could perceive the new law as a draconian restriction on a ‘recreational’ product. Tobacco control efforts have been criticised on these grounds for decades and should not be deterred at the risk of being labelled paternalistic. However, a law perceived as overly prohibitive could become problematic if it results in public resistance, non-compliance and growth in illicit tobacco markets. This in turn raises the moral—and practical—question of whether tobacco endgame policies should prioritise health protection over consumer ‘choice’—no matter how contested the term. The alleged importance of maintaining this ‘choice’ is reflected in measures recommended in the WHO FCTC, all of which discourage rather than prohibit adult tobacco use. Indeed, several states aiming to be tobacco free by a certain year have opted for such measures instead of prohibition.

A smoke-free generation?

The solution is to design an endgame that to some extent conserves consumer choice, while progressively phasing in a cigarette sales prohibition. This sounds like an oxymoron, but is not impossible. As argued, top priorities for endgames should be the protection of children and the phasing out of cigarettes. Thus, policies could start by phasing out cigarette sales with a TFG-type legislation, while allowing nicotine consumption in other forms such as ENDS or SLT. Sales and marketing of these products should be regulated. This would more correctly create a ‘cigarette-free or smoke-free generation’, who would still have access to nicotine products in adulthood, making the law less choice restrictive and perhaps more accepted. Allowing the sale of alternative tobacco products would also help to immediately replace some of the economic losses to the state. In addition, over time reductions in tobacco-related healthcare costs could help replace this decreasing revenue.

Further implementation of WHO FCTC measures

As mentioned, measures based on the WHO FCTC treaty have had success in reducing smoking rates, although now in most developed countries they stall at a plateau of 15–25%.2 However, it has been argued that smoking rates could be pushed down further if these measures were implemented to a higher degree. In most states, taxes could be higher; anti-tobacco campaigns could be more aggressive and targeted to a tobacco-free state; warning labels could be stronger; tobacco packaging plainer; cessation support better; nicotine content in tobacco reduced, and additives eliminated; and more comprehensive smoke-free areas could be made. Thus, WHO FCTC measures should continue to form an integral component of any tobacco endgame strategy.7

Several states aiming to be tobacco free by a certain year—New Zealand (2025),26 Finland (2040)27 and Scotland (2034)28—are using this approach. Policies are tailored to improve support to minority groups who suffer disproportionally from tobacco-related harm. In New Zealand, these are youth and native Maori26; in Scotland, youth and low-income groups. Their approach is to encourage smoke-free homes and an environment in which youth do not want to initiate smoking.28 Thus, New Zealand, Finland and Scotland have all planned strategies based on the WHO FCTC that discourage rather than prohibit and will see gradual effects over the next 10–25 years.

Otherwise, states well placed for a tobacco endgame of this type include those with strong political leadership and a low or rapidly decreasing smoking prevalence. Good examples include Uruguay, Australia7 and the USA.29 In Canada, a position paper was recently published advocating for a tobacco-free country by 2035.30 This was described as a ‘winnable battle’, achieved by implementing FCTC measures to the highest degree possible and providing more support for groups such as youth, low-income adults and aboriginals.

Such measures are advantageous in that they provide a non-prohibitive approach that is not too different from already existing tobacco control measures. They also tackle all aspects of the tobacco problem, including current smokers, passive smoke, initiation in youth and minority groups. This provides an advantage over the TFG proposal, which only targets younger generations, or harm reductive measures which typically target only current smokers.

A WHO FCTC based endgame?

Given the widespread success of WHO FCTC measures, it is possible that stronger implementation overall could create an anti-tobacco climate in which smoking rates drop below 15%.7 However, it is unclear whether these discouragement measures could succeed in achieving a tobacco-free state; so far, the lowest smoking rates observed in countries are around 15%.31 Still, these measures can at least create a climate conducive to tobacco control which may facilitate stronger endgame policies at a later date. Arguably, this was important for the success of Australia, when they defended the world's first plain packaging law against fierce opposition from the tobacco industry.7

Thus, policies could start by ‘preparing the soil’ for an endgame: further implementing FCTC measures, until smoking prevalence is below 10–15% and a climate is created in which stronger endgame policies, such as the TFG or harm reduction, become possible. In this sense, these measures, implemented fully, may be conceptualised as the first step of a tobacco endgame. It appears that a number of states, most notably Scotland, Finland and New Zealand, have already committed to this first step.

An integrated endgame strategy

A possible endgame implementation strategy could integrate ideas from harm reduction, the TFG proposal and the WHO FCTC; its goal would be to gradually create a cigarette-free state that allows the regulated use of alternative nicotine products.

The first step of all policies pursuing any cigarette phase out should be to ensure there is an adequate climate to facilitate it. This is most easily and effectively realised by fully implementing the interventions that states are committed to under the WHO FCTC. Whether there is room for improvement depends on the gaps in each specific tobacco control policy. Most states, however, would benefit from restricting the flavourings and nicotine in tobacco, creating more smoke-free areas, implementing plain packaging, more comprehensive bans on advertising and promotions, tax increases and more intensive campaigning for a smoke-free state, with the endgame goal made clear to the public. This could result in a climate conducive to tobacco control, with smoking prevalence below 15%, and should be the immediate, shorter-term goal of all tobacco control policies that have not yet achieved this.

The next step of this approach would be a generational phase out of cigarettes while allowing the use of less harmful alternative products. States that have banned SLT may be reluctant to permit its sale; they could consider the regulated sale of ENDS as an alternative. Smokers born before the cut-off year would have the option of continuing cigarette use, but should be encouraged to switch to alternative products through, for example, public health campaigns. Those born after the cut-off year would be denied the sale of cigarettes, in the same way that they would have been denied access to all tobacco in the TFG proposal; but they would still be permitted to purchase alternative products. This could protect younger generations from a possible gateway into cigarette smoking, while preserving their choice to consume less harmful nicotine products. It would also fully protect later generations from passive smoke. Essentially, this creates a ‘cigarette-free or smoke-free generation’ rather than a ‘TFG’.

Further considerations

As argued above, the regulation of alternative nicotine products should be taken seriously. Restrictions on SLT/ENDS should be similar to those recommended for cigarettes in the WHO FCTC. Subjecting them to similar taxation as cigarettes would also allow governments to immediately replace some of the revenue lost on cigarette sales.

Another important consideration is timing. When should states that have achieved the goals of the first step start phasing out cigarettes, educating the public about alternative products, warning retailers and the public, and securing regulations on SLT/ENDS? States that already permit the sale of SLT and/or ENDS should start regulating these products immediately. Cigarettes should be phased out once these regulations are secured and some time (eg, 2 years) has been spent preparing the public, retailers and younger generations for the phase out. This time could also be used to collect data on the strength of public support and the possibility of other consequences, such as illicit markets or non-compliance. States that have banned SLT and/or ENDS, but are willing to phase them in, should do so at the same time as cigarettes are phased out to avoid a gateway effect in younger generations. This should also follow a preparatory time period, in which the public and retailers are prepared and proper regulations on the new products are secured.

Potential limitations of the integrated idea

As with other endgames, there are a number of obstacles that this integrated endgame could face: legal challenge, libertarian opposition, and practical issues such as non-compliance and illicit cigarette markets regardless of whether SLT/ENDS are made available. States that have already banned SLT and ENDS may be reluctant to permit their sales, knowing that they are potentially harmful; those that already allow sales of SLT and/or ENDS may experience difficulties in securing proper regulations. Thus, further research, in the international and state-specific context, is encouraged. The development of this integrated idea, and other endgame ideas, would also benefit from a broader discussion on how endgame ideas could be nuanced, integrated and built into a framework that, building up from the WHO FCTC, could set a new precedent for tobacco control policies in countries with a low smoking prevalence. The aim of this paper was to introduce this concept and provide an example on how this could be done. However, more development in this area is needed.