Table 1

 Comparison of instrumental choices to manage tobacco supply

FCTC style “comprehensive strategy”3Regulated market model4Non-profit pro-health monopoly model
Market instrumentDepending on country: multinational corporations; domestic tobacco companies; state monopolies (with no health mandate)Existing tobacco manufacturers; non-profit distribution agencyNon-profit tobacco company
Health goalReduce mortality and morbidity associated with tobaccoReduce mortality and morbidity associated with tobaccoEliminate mortality and morbidity associated with tobacco
Policy goalReduce the demand for cigarettes; protect public from second hand smoke; maintain sustainable legal/regulated marketReduce demand for cigarettes; reduce harm for continuing smokersEnd tobacco use
Strategies employedRegulated conditions on the sale of tobacco product (restrictions on advertising, mandatory health warnings); higher prices through taxation; health promotion; bans on smoking in indoor work and public places; curbs on smugglingContinued FCTC style comprehensive strategy; publicly owned monopsony with purchaser influence over for-profit cigarette design and direct control over distribution; development of less harmful forms of tobacco productsContinued FCTC style comprehensive strategy as appropriate; public control over complete tobacco supply chain; integration of cigarette design, manufacture and supply with programmes and policies to reduce smoking
Assumptions (stated and unstated)It is not feasible or practicable to end tobacco use; supply-side approaches should not be used; tobacco companies do not have a legitimate role in the development of public health strategies to reduce smokingBetter controls will not eliminate tobacco use—there will be a continuing demand for tobacco products; World Trade Organization will not allow tobacco monopolies; direct control over marketing of cigarettes will create incentives on tobacco companies to produce harm reducing products; there is worthwhile public health benefit from harm reduced productsIt is possible to end tobacco use once there is no financial interest in maintaining it; tobacco companies will continue to undermine tobacco control measures and will sustain smoking; trade agreements do not prohibit establishment of monopolies if doing so achieves justifiable health objectives and if compensation is provided; acquiring tobacco supply increases capacity to innovate to achieve public health goals
Analogous toConsumer protection regulationsMilk marketing boards, Scandinavian alcohol monopoliesPublic water systems, post offices
Cigarette enterprises motivated toMaximise profits within a regulated marketMaximise profits by developing least harmful cigarettes (according to criteria sets by monopsony distributor)Help smokers quit as quickly as possible and prevent tobacco uptake
Enterprise employees directed toIncrease profits for tobacco company or retail ownersIncrease profits for tobacco company or retail ownersHelp smokers quit as quickly as possible and prevent tobacco uptake
Relationship between enterprise and health authoritiesAntagonisticCooperativeIntegrated and collaborative
Products soldBranded tobacco products (other products that deliver nicotine are regulated under different authorities)Unbranded or less branded tobacco products and less harmful tobacco productsTobacco products progressively designed, manufactured, packaged and delivered in ways that facilitate quitting and discourage uptake
Direct public interest control overDistribution, promotion, packaging, pricingDistribution, promotion, packaging, pricing, product design, retailing
Indirect public interest control overPromotion, packaging, pricing, product designProduct design and manufacture, retailing