• End game
• Public policy
• Global health

During the past month alone, I have had an opportunity to participate in four different meetings—in Utah, Sweden, Canada and the USA—where ideas about how to achieve an ‘endgame’ for the tobacco epidemic were being discussed. Other previous meetings—in India, Finland and the UK—have been held over the last few years, and I know of several other such discussions. Even before the US Surgeon General's 50th Anniversary report on the health consequences of smoking1 called explicitly for achieving a tobacco endgame and suggested a combination of policy strategies to do so, other countries such as Ireland, New Zealand, Finland and Scotland were having conversations that led them to set hard target dates by which they intend to reduce tobacco use and/or smoking prevalence to <5%.

Modelling studies suggest that current measures, even if they are greatly accelerated in countries that are tobacco control leaders, will not achieve these goals within the first half of this century.1 As the target dates move closer, will political leaders seize the opportunity to enact the bolder policy innovations that must be undertaken? Or, will they allow caution and inertia to shape another century of public health catastrophe?

The endgame requires consciously designing interventions to change permanently the structural, political and social dynamics that sustain the epidemic, in order to end it by a specific time.2 Thus, an endgame vision goes beyond ‘business as usual’ and calls for further policy innovations. No one knows how to do it yet, but the endgame conversation3–6 has become mainstream, and the first places that manage to achieve it will herald the beginning of the end of more than a century of industrially produced carnage. Which places will be …