Article Text

Download PDFPDF

Systems perspective for equitable tobacco control in the future
  1. Mirte A G Kuipers
  1. Department of Public and Occupational Health, Amsterdam UMC - University of Amsterdam, Amsterdam, The Netherlands
  1. Correspondence to Dr Mirte A G Kuipers, Department of Public and Occupational Health, Amsterdam UMC - University of Amsterdam, Amsterdam PO Box 22660, 1100 DD, The Netherlands; m.a.kuipers{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Tobacco control has made undoubted progress in the past decades, including wider implementation of tobacco control policies such as smoke-free legislation, health warning labels and advertising bans.1 Although these have contributed to a worldwide decrease in smoking prevalence,1 2 the number of smokers is still increasing.2 Moreover, there are still large socioeconomic inequalities in smoking in many world regions.3–6 Smoking is a persisting problem that has no simple solution.

For the future of tobacco control I am inspired by scholars such as Professor Marmot7 and Professor Meadows,8 and those building on their and similar theories,9–11 who point out that there are complex societal mechanisms underlying smoking, and that such complex problems should be approached from a systems perspective. This means that smoking should be considered a problem that emerges from a complex global system and can only be solved with approach that fundamentally changes this system. I discuss two examples of problems in tobacco control that I believe will benefit from a systems approach.

Tobacco cannot be regarded a solitary problem, separate from other societal problems. Smoking is increasingly concentrating in disadvantaged groups. Disadvantage drives smoking uptake, for example, through the intersection of smoker and class identities,12 and makes quitting more difficult, for example, due to chronic life-stressors.13 In turn, tobacco expenditure exacerbates poverty in low-income households,14 further reducing budgets for healthy foods and sport participation. Disadvantage, obesity and smoking are in part a result of the same system. Tobacco control therefore needs structural policies to ensure basic necessities such as housing, employment, a safe childhood and high-quality education for every person.

Smoking is the result of a global system, not just systems within countries. Many high-income countries have set goals to reach a smoke-free generation by a fixed date in the coming decades.15 New Zealand’s Smokefree Aotearoa 2025 Action Plan16 is a prime example of how these goals may be achieved, and I expect more countries will follow their lead. However, a consequence of increasingly strong policies in high-income countries is a shift in the tobacco industry’s activities towards middle-income countries.17 18 Fighting the tobacco industry globally, without taking a neo-colonialist/hegemonic approach, will be an important challenge for the coming years.

As a tobacco control researcher, I am motivated to contribute to these and other, smaller challenges for the future, in which I think an understanding of the system that drives smoking will be helpful.

Ethics statements

Patient consent for publication

Ethics approval

This study does not involve human participants.



  • Twitter @Mirte_Kuipers

  • Funding The author did not receive funding for this contribution from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None to declare.

  • Provenance and peer review Commissioned; internally peer reviewed.