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The symbolic and the material in tobacco control: both matter
  1. Ruth E Malone
  1. Correspondence to Professor Ruth E Malone, Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, CA 94118, USA; ruth.malone{at}

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For many years, those who care about promoting health acted as though cigarettes fell from the sky and our job was merely to keep kids from picking them up while telling those who did that it was bad for them. Some still see it that way. But the end of the last century pulled back the curtain on the tobacco industry and its global conspiracy to protect its profits at the expense of millions of lives. The collective narrative about tobacco began then to shift as we understood that what we once saw as bad choices made by individuals was an industrially produced disease epidemic on a scale never before seen.1–6 As knowledge about the tobacco industry's behaviour grew, the tobacco control movement was spurred to achieve enormous progress in reducing tobacco use. But even highly optimistic projections suggest that the epidemic cannot be ended with current measures.7 ,8

And ending, not merely containing, is what we must do. Achieving this will require both material (policies, programmes, practices) and symbolic (frames, narratives, images) resources. The immediate global priority remains full implementation of the measures of the WHO Framework Convention on Tobacco Control. That is material work that must be done, and done now. However, at the same time, we must begin to use new symbols and narratives to prepare the ground by planning for an end to the epidemic, not merely continuing an endless process of containment and tobacco industry appeasement.

Going on 4 years ago now, I first used the term ‘endgame’ in an editorial to describe new proposals for stopping the continuous, unfolding global disaster that is the tobacco epidemic.9 At first, many colleagues either ignored it or greeted it with mixed reactions. Some were fired with enthusiasm but not sure how to channel that energy. Some critiqued the endgame metaphor as inapt to describe the current context, while others worried that its use would distract from the immediate work at hand to implement policies such as smoke-free laws, advertising bans and the other major provisions of WHO FCTC. All these are completely reasonable responses when the hard-frozen ground of conventional wisdom remains solid.

But something has happened in the last year. My colleague, Ken Warner, chair of this journal's editorial board and a senior statesman in the tobacco control movement, convened a Robert Wood Johnson Foundation-funded meeting on the topic in the USA that resulted in a special issue of the journal.7 ,10 Several international meetings focused on the topic have been held or are planned for the near future. The frozen ground has begun to thaw and shift beneath our feet, and the idea of really ending the epidemic, rather than continuing an eternal war of attrition with tobacco companies, somehow seems today more possible than it once did—or at least more possible to talk about.

Once such a discussion was virtually taboo, evoking fears of Prohibition, and rejected in favour of more politically palatable goals like ‘reducing death and disease from tobacco.’ But every effective tobacco policy that we now take for granted was initially regarded as too radical, not well enough developed, dangerous because it might open up tobacco control proponents to criticism, or politically infeasible. Yet, the sky did not fall, as these policy achievements were made material. Public health no longer has any adequate justification for not calling on governments to institute endgame planning. Put simply, we now know too much to pretend things can be fixed by continuing what we're doing—even if we are, as in some countries, doing it very well.

The endgame idea has taken root, perhaps more firmly in some countries than in others, and from all over the world interest is being expressed. The current discussion takes up the structural, political and social dynamics that sustain the epidemic, and in some countries (Scotland, Australia and New Zealand) involves calling for a specific end point and a date by which to achieve it. Finland's goal is to end tobacco use altogether.

Exactly how these goals are to be reached is still unclear. In our current moment, the endgame narrative is preliminary and symbolic, not yet demonstrably material, but that narrative may presage an exciting period of reinvention within tobacco control. Social movements need these in order to stay vital, precisely because if they are successful, what once seemed radical becomes the norm. A sense that the mission has been achieved begins to take hold among the public, and even within the movement. Former radicals become the new establishment and have a stake in sustaining the status quo. New narratives may be disruptive. But that is not a bad thing. Disruption can result in new understandings, stronger alliances and novel policy approaches.

We must not forget, as we begin to move toward the tobacco endgame, that past policy battles were won not merely by lobbying for material policy changes, but also by mobilising symbolic resources. The wonderful comparison between having a ‘peeing section’ in a swimming pool and having a smoking section in a restaurant was purely symbolic, but it resonated, was memorable, captured public imagination and helped push material policy changes over the finish line. The narrative of a deceptive industry, capitalising on addiction, has proven very effective at inspiring anger and resistance. Now is the time to engage new symbols, to reframe, to advance a compelling new narrative for the era of the tobacco endgame. This is symbolic work—but though it may sound contradictory, it is essential to remember that the symbolic is also ‘real’—in that symbols shift collective understandings of social phenomena.

For now, perhaps it is enough to let the symbolic narrative of a tobacco endgame develop more fully while we plan how and in what sequence to undertake the material changes it envisions. It's time to dream big, to formulate and refine a narrative that makes putting an end to the tobacco epidemic inevitable. It is our task to help policymakers and the public understand that story—and to realise that the horrible historic progression of the tobacco epidemic was human-made, industrially created—and thus, it can be stopped.


Thanks to Elizabeth Smith for helpful comments on earlier drafts of this editorial.



  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.