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What ifs: and what now?
  1. Ruth E Malone
  1. Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
  1. Correspondence to Professor Ruth E Malone, Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA; ruth.malone{at}

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Musing on Twitter about the ongoing struggles within the tobacco control community over the role and regulation of newer tobacco and nicotine products, I observed recently that it would be so much easier to find consensus on those issues if the tobacco industry would just stay out of it. What if those working in public health could agree among ourselves that the number one goal—the very top priority—should be addressing the structural, political and social dynamics that sustain the tobacco epidemic, all of which have industry disease-promoting activities at their root? Then we might find some unanimity in eradicating the industry’s influence and reducing the harm caused by its products while doing more to eliminate the most well-researched, most marketed and most deadly commercial tobacco products rather than arguing endlessly over the science and public health regulatory implications of multiple types of e-cigarettes, heated tobacco products and various new nicotine products.

Instead, in too many places, tobacco control discourse has devolved to a messy catfight focused on whether we should enthusiastically encourage use of more types of addiction products while accepting continued widespread sales of cigarettes and assuming the market will solve everything if only we get out of its way.

This is precisely what the tobacco industry planned, beginning with long-term strategic plans developed more than 20 years ago to fracture the solidarity of the tobacco control movement.1 2 Tobacco companies have long exacerbated and exploited divisions within public health about the proper role and nature of ‘harm reduction’ in tobacco control efforts. Moreover, they have never ceased aggressively promoting cigarettes and fighting against regulations that might reduce their use, including those companies now loudly proclaiming they want a ‘smoke-free future.’

It is time for governments to act boldly and take on the tobacco industry vector directly. Against massive industry pressure, the line has so far been held against tobacco company efforts to insert themselves directly or through intermediaries into the meetings of the WHO Framework Convention on Tobacco Control (FCTC) Conference of the parties and undermine one of the most important provisions ever developed for global public health policy: FCTC Article 5.3, which commits parties to institute measures to protect their public health policies from tobacco industry influence.

At national levels, some governments are proposing to further regulate the supply side through reducing the number of tobacco retailers and reducing nicotine in cigarettes to non-addictive levels, and/or ending sales to those born after a certain year.3 4 Some local governments have begun efforts to end tobacco product sales, either through gradually raising the minimum age to purchase tobacco products5 or through ending sales entirely, as two California cities did in 2021.6 Governments are taking varying approaches in dealing with potentially reduced-exposure products. The common vision motivating the boldest efforts is that—after more than a century of deaths from tobacco products—an endgame for the tobacco epidemic is within our grasp.

What if, back in the 1950s, when it became clear that cigarettes caused lung cancer, governments had told tobacco companies to develop a plan to phase these killer products off the market within the next 12 months, and widely publicised why? Or what if, after the publication of the 1964 US Surgeon General’s Report on smoking and health, tobacco companies had not entered into a multimillion dollar partnership with the American Medical Association to research ‘safer’ cigarettes, in the process perpetuating the idea that more research was needed to be able to say with certainty that cigarettes caused disease?7 8 What if, after the massive US Department of Justice case in the 1990s against the major tobacco companies, the Republican administration had not backed off from the stronger remedies sought by staff and the public health community, with even the remaining weaker remedies still tied up in court decades later?9 10

At so many, many points in time across the last 75 years, bold leadership and the courage to take on a politically entrenched industry with the kinds of measures routinely used to protect the public from other products found to hurt and kill people—restrictions on or full phaseouts of product sales— could have resulted in millions of lives being saved. Millions of grandchildren could have grown up knowing their grandparents. Millions of parents could have lived longer lives and been able to build a more secure financial future for their families. Millions of people could have been spared the struggles with addiction and the suffering from horrible diseases after taking up use of these products as teenagers. Billions of dollars spent on healthcare costs for preventable diseases caused by cigarettes could have been used for other needs.

Instead, time after time, past leaders perpetuated the status quo. They focused primarily on individual behaviour change, trying through education campaigns to dissuade kids from trying products that were marketed aggressively and attractively through multiple channels and normalised as signifiers of adulthood, then trying to persuade adults who became addicted to the products to give them up. Our policies placed the burden of ending the 20th century cigarette pandemic primarily if not exclusively on the shoulders of tobacco users, while continuing to allow cigarette sales everywhere. Why?

The cynical response is that this protected the politically connected, allowed governments to retain tobacco tax revenue and did not engender pushback from the tobacco industry and its allies. However, while this is certainly true for some leaders, a more likely explanation is that even the most well-intentioned policymakers had never experienced and simply could not imagine a world where commercial tobacco products were not an accepted part of the retail landscape, a circumstance that seemingly always was and always would be. Tobacco companies had spent decades shaping and reinforcing the normalcy of selling lethal products.

This began to change within tobacco control circles after the industry’s internal documents came to light in the 1990s. For the first time, people could see with their own eyes clear evidence of how the tobacco companies had covered up what they knew decades before about the diseases caused by their products, about their addictiveness, about their marketing to youth, and about how they had sought to confuse and undermine effective public health policies.9 11

Now it has begun to be possible (and arguably, the climate emergency has made it more urgent and essential) to talk about and seek to enact much stronger regulation of corporate actors. An emerging field of work on the commercial and corporate determinants of health has called attention to the myriad ways unhealthy products, industry practices and market-driven economies have created disease, environmental destruction and inequities.12 In the tobacco control arena, it is now possible to consider that ‘quitting smoking’ is the job of governments, not only of individuals who smoke. This is the world we are now finally trying to imagine into being through endgame planning in many countries.

Sceptics argue this is not the real world. They scoff that asking ‘what if’ questions about what might have been means believing in an alternate universe or trying to reinterpret history. However, it is only when we begin to ask the ‘what if’ questions that we can imagine a world where human flourishing is valued over corporate profit. Courageous policymakers have finally begun to ‘imagine things otherwise’.13

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