We discuss some of the practical and ethical questions that may arise for a jurisdiction where a sinking lid endgame strategy for tobacco supply is implemented. Such a strategy would involve regular required reductions in the amount of tobacco released to the market for sale, sufficient to achieve the desired level of commercial sales by a target date. Tobacco manufacturers would periodically bid to the government for a residual quota. Prices would increase as supply reduced. The price level would be influenced by demand, which in turn would reflect the impact of other interventions to reduce demand and the changing normality of smoking.
Higher priced tobacco could result in increased smuggling, theft, illegal sales and short-to-medium-term aggravation of some social inequalities. We suggest that the strategy be introduced in conjunction with a range of complementary interventions that would help reduce demand, and thus help ensure that the possible adverse effects are minimised. These complementary interventions include: providing comprehensive best practice smoking cessation support, better information to smokers and the public, strengthened regulation of tobacco retailing and supply, further controlling the pack and product design, measures to restrict supplies that bypass the increases in product price, strengthened enforcement and combating industry attacks.
General prerequisites for a sinking lid strategy include public support for the goal of a tobacco-free society, and strong political leadership. The likely context for initial success in jurisdictions includes geographical isolation and/or strong border controls, absence of significant tobacco production and/or manufacturing and low government corruption.
- tobacco supply
- health policy
- health planning
- tobacco endgame
- public policy
- taxation and price
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The leading edges of tobacco control thinking have, over the past decade or so, begun to address possible ‘endgame’ solutions for tobacco use.1 At least one nation appears to be explicitly planning to become tobacco-free.2 There have been arguments for removing commercial incentives for tobacco supply,3 4 and ideas for regulatory structures that might better hasten the declines in smoking prevalence.5 Others have discussed the progressive reduction of the level of nicotine in tobacco,6 and modelling work suggests that this would help.7 Another suggested regulatory framework is one where the degree of regulation equates to the harmfulness of nicotine-delivery products.8
One endgame proposal for the USA has been to end the ‘making, marketing, or importing [of] tobacco products’ after a 20-year adjustment period, a ‘big bang’ solution.9 Another more nuanced proposal for the USA is to introduce a ‘cap and trade’ system of market share allocation and transfer, where quotas could ‘be used, banked, traded or sold freely on the open market’ and the quotas decrease every year.10 A suggestion for New Zealand has been to allocate reducing smoked tobacco supply quotas to manufacturers and importers, with the aim of ending the availability of commercial smoked tobacco sales in 10 years.11 12 We call this type of forced supply reduction a ‘sinking lid’ strategy. Surveys in the USA, England and New Zealand already indicate some support for governments ending tobacco sales within 10 years.13–15 In New Zealand, before any public advocacy for an endgame policy, 44% of smokers agreed or strongly agreed that ‘if effective nicotine substitutes that are not smoked became available, the government should then set a date to ban cigarette sales in 10 years time’.16
Similar approaches for controlling other hazardous substances have been effectively used in a number of jurisdictions, including sulphur dioxide and nitrogen oxide cap and trade systems in the USA,17 18 and a greenhouse gas emission trading system in Europe.19 We believe that the sinking lid strategy has some key advantages as an endgame solution. For example, it is relatively simple to communicate, and could provide a strategy with a clearly defined time period. A sinking lid strategy could act as an overarching strategy within which all other tobacco control initiatives could function. The aim of this article is to briefly address some of the practical and ethical questions that may arise for a jurisdiction where this type of sinking lid endgame strategy is implemented.
A sinking lid tobacco production and import strategy
The purpose of the strategy proposed is to end the commercial supply of tobacco within a fixed period, in a manner that provides the best possible health and social outcomes for the population of a jurisdiction. The strategy leads to a prohibition of commercial tobacco supply, but not of growing tobacco for personal use. We stress that the prohibition of tobacco sales, but not other clean nicotine products, is different from the historical examples of the prohibition of alcohol. That is, the addictive component in tobacco will be provided via alternative means, for those who cannot quit nicotine. Some of the wider arguments about tobacco prohibition have been addressed elsewhere.1 20 21
Legislation would introduce regular reductions in the allowable amount of tobacco released to customers, sufficient to achieve (near) zero commercial sales within a fixed period. We suggest a period of 10 years, with a reduction of 5% of the initial level every 6 months (ie, to 95%, 90%, etc). This would provide governments with appropriate urgency, and smokers with a clear foreseeable end date as a potent stimulus to quit. Longer time periods are less likely to meet these criteria. Alternatively, the reduction could be until the smoking prevalence was below a fixed level (eg, under 1% for all social and ethnic groups) at which point either a move of all remaining smokers to other nicotine supplies could occur, or a licensed smoker system be instigated.
Tobacco manufacturers would apply periodically bid at government-run auctions for a residual quota, and could trade such quota. With careful implementation, such auctions have been effective for sulphur dioxide allowances,22 and electromagnetic wavelength spectrum auctions.23 A government agency could also take part in the quota auction, in order to limit the effects of any auction rigging by manufacturers, or in case the large commercial tobacco suppliers suddenly left the country. Quota owners could supply retailers through current distribution systems. The strategy differs from general cap and trade systems, as it seeks not merely to limit or reduce the supply or production of a product, but to phase out commercial sales.
If the auction system and commercial market operated effectively, then as the supply decreased, the price would increase so that demand equalled supply. The level of the price, as supply reduced, would be influenced by demand. Demand would reflect the impact of other interventions to reduce demand (see below and figure 1), and the changing normality of smoking. However, very much higher tobacco prices, closer to the real social cost,24 would be an integral part of the strategy, and governments would need to be explicit in communicating this. The policy intention of higher prices should be communicated transparently, so that the price changes are clearly signposted to smokers, and it is made clear that the prices are part of a deliberate strategy to help and stimulate smokers to quit.
If a non-commercial system was needed to replace the commercial market for tobacco (eg, because of tobacco company exits or market rigging), a government-sponsored agency could take over all distribution of tobacco products (thus removing tobacco companies from at least wholesale marketing).3 4 In one model, an agency would be the sole buyer of tobacco products from manufacturers, and would sell unbranded products to retailers or wholesalers.3 Bids (by price and volume) would be made to this agency for the available supply (ie, the price would be determined by a regulated market for the fixed supply). This, and more completely non-commercial models,4 would help remove commercial incentives to maintain or increase demand for tobacco products. However, the establishment costs, processes and time involved of this approach would need to be weighed against the benefits.
Necessary components of the sinking lid approach could include the following. First, simplicity and clarity of intention, timescales and mechanisms, so as to facilitate communication to and understanding among the public, media and key stakeholders. Second, the use of tobacco remaining legal (within smokefree area constraints) with individuals able to legally grow a limited amount of tobacco for personal use (but not for sale or trade).
We consider that in most developed countries (where such a sinking lid strategy might be initially introduced) growing for home use would only be conducted by a small minority, owing to the requirements and difficulties involved (eg, climate, time, materials and space). In particular, plants can be lost to fungal infections if local humidity levels are too high, and if good air flow is not maintained during air-dried curing. Artificial drying and toasting requires careful and constant supervision. Home-growing may decline once new users experience the rough taste of home-grown tobacco, which lacks the blending, the sweeteners and the flavouring of manufactured products. Similarly, the variation in nicotine levels in the final product may count against it developing sustained popularity (relative to the far more consistent nature of manufactured tobacco).
If illegal sales from this source became a significant problem, then we suggest a public health approach to the problem, which focuses on demand reduction (with education and smoking cessation support, etc). If necessary, this approach would be further enabled by a zero-fee ‘tobacco home-growing licence’, for a specific place, for say 20 tobacco plants. That number would allow for around 1 kg of tobacco per year, or around five cigarettes of 0.5 g each per day for a smoker. Where there was any question of tobacco being possessed for sale, a licence could provide proof of legality. Such licensing could also allow these smokers to be provided with additional quitting information, and access to quitting support. Regardless of the popularity of home growing, some public education will be desirable on the health and fire-safety hazards of the home-grown product.
Third, the revenue from quota bidding (in addition to tax revenues) being allocated to massive increases in smoking cessation media campaigns and services, and to fund ongoing and complementary tobacco control activities as described below. Industry profits could be limited by both the cost of quota bids, and increased tobacco taxation. Setting tobacco tax as a percentage of retail price could further reduce chances of excess profiteering by tobacco companies.
Fourth, periodic reviews at regular stages, to ensure policies are adjusted to deal with unexpected consequences, are critical. After reviews, the phase-out period could be shortened or lengthened, and the timing and intensity of complementary tobacco control initiatives reviewed. In particular, a review of policy options when at near-to-zero smoking prevalence could decide on the assistance needed by the few continuing existing smokers. Factors to consider in the reviews, in deciding the speed of quota reduction include: (i) the availability and take-up of alternative nicotine supplies; (ii) the current smoking prevalence and rate of decline (including among key target population groups); and (iii) the success of communication to smokers and the public, as measured by knowledge and support in these groups. The point of the strategy is to get as close as possible to nil smoking prevalence. Once close to nil, there are a number of options for what to offer the remaining smokers—for example, a supply by prescription of tobacco for registered smokers (perhaps with a reducing dose) along with cash incentives to quit and stay quit).
Possible adverse effects
High priced tobacco could result in the following adverse consequences (depending on the jurisdiction): smuggling at significant levels, sufficient to erode the price signal (eg, if border controls are inadequate); increased theft from wholesalers, retailers and smokers (and some consequent illegal sales); and illegal cultivation for commercial sales.
For those smokers who do not quit or reduce tobacco use, or use nicotine replacement therapy as an alternative, these people and their families may have reduced personal and household disposable income.25 26 This may potentially aggravate social inequalities in the short to medium term, particularly if parallel policies (see below) are not strengthened. However, research to date indicates that at a population level, higher tobacco prices may have a net beneficial effect in terms of life saved.27 Smoking elimination is ultimately pro-equity. In this strategy, hardship to those who continue to smoke and their families will be limited in time, there will be substantial economic and health benefits to the greatly increased numbers who quit; and there would be increased cessation support. Easily accessible best practice smoking cessation support (see below) is ethically essential, as much higher prices for highly addictive tobacco products will result in (temporary) additional financial hardship for some continuing smokers and their families.25 26
The sinking lid could result in increased efforts by manufacturers and retailers to maintain or increase demand, so as to maintain their profits. If these efforts were insufficiently controlled by the complementary interventions below, this also could require the introduction of a non-commercial tobacco supply system.
Tenacious and sophisticated tobacco industry attempts to prevent or tarnish an exemplar model can also be expected, in line with their activity against other tobacco control initiatives.28–32 The attempts could include the assembly of opposing coalitions, the infiltration of health organisations and political processes, and the division of tobacco control organisations by exploiting differences of opinion.33 34 In particular, the industry could attempt to position endgame strategies as excessive state interference with personal autonomy and the working of the ‘free market’, and as ‘irresponsible’ and ‘utopian’, while portraying some conventional tobacco control efforts as ‘moderate’.
Industry tactics to try and make the system fail (eg, by manipulating prices and creating artificial shortages), could be negated by various levels of government intervention from the point of the quota auctions onwards. For instance, if a government agency (which would have agreements in place with a tobacco company to supply tobacco products) took part in the quota auction, it could provide a backup supply of tobacco. These consequences and possible adverse effects are addressed further in the complementary interventions below.
A sinking lid system must be introduced in conjunction with a range of aggressive and far-reaching supplementary interventions that would help reduce demand, and thus ensure that the possible adverse effects described above are minimised, and a socially just programme is implemented. Many, but not all, of these interventions are suggested by the Framework Convention on Tobacco Control.
Best practice smoking cessation support
Comprehensive and effective smoking cessation support could be provided,35–38 funded from tobacco excise revenue and/or from quota auction revenue. The expansion and training of the cessation workforce will be essential. The cessation support could include a much wider range of nicotine replacement and other treatments, and targeted community-based cessation support for poorer smokers and the communities most affected by the price increases. Novel initiatives such as alternative nicotine delivery systems may be desirable.8 At present, it appears that if there was demand for long-term nicotine supply by some ex-smokers, then that would be far preferable to continued smoking.
Better resourced and sustained mass media campaigns with greater reach, funded from tobacco excise revenue, could include those to help smokers quit, and those with effective information to the public and smokers on: (i) tobacco industry practices,39–41 (ii) the social impacts of tobacco, and (iii) the justification for the endgame interventions.37
Strengthened regulation around marketing and retailing
Stronger regulations could cover banning all marketing (advertising, sponsorship and point-of-sale tobacco displays); requiring in-store storage appropriate for a highly addictive poisonous substance (to reduce theft); and introducing a greatly restricted retail system (eg, restrictions on location, store density or type of store where tobacco can be sold).42
Further controlling the pack and product
The additional options for controlling these aspects include increasing the size of pictorial health warnings (eg, to 95% of all pack surfaces); requiring standardised packaging and ‘plain brands’ (as planned for Australia)43–45; and removal of all sweeteners and other additives.46 47 The requirement of less addictive or palatable products could be a major factor in reducing demand.48–51 Furthermore, new smoked tobacco products or brand variants could be banned.
Other measures to restrict supplies that bypass the price effects
Other measures could include: banning duty-free sales,52 and all other personal tobacco imports; and ending loose tobacco sales (roll-your-own and pipe tobacco).53 54
Redefining the legal smoker population
Raising the minimum legal age of buying tobacco annually to 25 or more could be considered.55 56 It seems unethical to allow new young adult smokers to legally start purchasing tobacco, when a quit date has already been set for the country. At the end-stage, when smoking prevalence is below say 1%, a licensed-smoker system may be necessary.57
While many of the solutions for most countries lie in international efforts, and will vary with geographical and political contexts, better supply chain controls for national markets,58 59 including requirements for track and trace capabilities,60 are core necessities.
Countermeasures against industry activity
Because of industry attacks on such endgame policies that could occur, necessary actions would include the rigorous implementation of the Framework Convention on Tobacco Control Section 5.3 on tobacco industry influence,61 government and other divestment from the tobacco industry,62 increasing the required disclosures by the industry,63 inoculation against industry funding,64 and the active use of legislation to remove opportunities for litigation by them. As recommended in the major WHO report on industry activity, the following are needed in all situations, not just endgame scenarios; (i) vigorous and ongoing investigation by governments into tobacco company influence on the tobacco control work and policies of those governments; (ii) the constant and in-depth monitoring of tobacco industry activities; and (iii) energetic measures to remedy tobacco companies' past misconduct.34
Tobacco industry exit issues
The issues around industry exit from a national tobacco market include: (a) possible threats to exit the market immediately, and (b) the need to ensure that the tobacco companies remain financially and legally accountable for the consequences of their products.65 One method to prevent an industry from inappropriately exiting the country and leaving costs to others is a bond system (where companies must post a bond to be allowed to operate). Before a tobacco endgame system was introduced by any government, this type of bond would need to be considered. Even if a government did not consider an endgame for the medium term, it may still be wise to have such a bond in place. The issues of industry job losses and the need to transition employees to other industries should be addressed as part of the strategy, particularly the question of possible net job losses or gains for a country.66 67
The ideal context required for a sinking lid strategy
We suggest that before such a strategy could be implemented, there needs to be acceptance by the public and politicians that creating a society free from tobacco is a desirable and necessary goal.66 68 This may require investment by health sectors in advocacy,69–71 and political and organisational leadership,72 73 as well as research to investigate the most effective message, framing and communication strategies. Fortunately, in a number of countries there is already a desire for much greater tobacco product regulation.13 14 74–76
There are also contextual factors that may determine the feasibility of a sinking lid approach. Initially, the most likely countries or jurisdictions for the practical application of the strategy may have geographical isolation and/or strong border controls, the absence of a significant tobacco production or cigarette manufacturing sector and a strong central government with relatively low levels of corruption.77 Working examples of the strategy may then enable other countries to follow suit.
To conclude, we argue that it is time to plan for near-zero tobacco smoking prevalence, and to implement the policies to achieve it within the short-to-medium term. We see it as unethical to observe the slow passing of the tobacco epidemic in nearly all jurisdictions, without proposing methods for a predictable and much more speedy end to it. We propose the above sinking lid policy as the key over-arching mechanism to achieve a society free of tobacco.
The thinking of some of the authors (GT, NW, RE) on this topic has benefited from work on a tobacco control endgame research project supported by the Marsden Fund (grant UOO0716), and work funded by the Health Research Council of New Zealand (the Smokefree Kids Policy Project and the ITC Project).
Funding GT is supported by a Health Research Council of New Zealand (HRC) grant (the Smokefree Kids Project), NW by a HRC grant (ITC Project), RE by the University of Otago and TB by a HRC grant (Health Inequalities Research Programme).
Competing interests The authors have previously undertaken tobacco control work for various non-profit health sector organisations, and for government and international health agencies.
Provenance and peer review Not commissioned; externally peer reviewed.