Examples of tobacco endgame proposals
| Study | Definition of endgame goal | Approach | Caveats/drawbacks | Industry | Replacement product needed |
|---|---|---|---|---|---|
| Regulate nicotine levels to make cigarettes non-addictive or less addictive | |||||
| Benowitz and Henningfield7 | Reduce tobacco use and prevent development of nicotine addiction | Regulate availability of nicotine in tobacco products to limit maximal obtainable dose; could be reduced gradually, over 10–15 year period | Potential for cheating; smuggling could be a problem | Regulated by Food and Drug Administration | No |
| Gray et al10 | Safer products | 1) Regulation of all nicotine delivering products; (2) improvement in spectrum of clean nicotine products and reduction in attractiveness of tobacco nicotine products; (3) progressive reduction in nicotine content of cigarettes with clean nicotine freely available as substitute | Food and Drug Administration regulation of tobacco | Regulated by Food and Drug Administration | Yes |
| Henningfield et al12 | Less addictive products | Regulation to address addictiveness of tobacco products (not a ban on tobacco products; regulated products would retain capacity to sustain addiction) | Tobacco industry might use efforts to reduce toxicity as marketing tool | Regulated by Food and Drug Administration | No |
| Redesign the cigarette to make it unappealing | |||||
| Peters24 | Eliminate smoking | Remove all cigarette additives; require cigarettes to have a maximal smoke pH and measured nicotine delivery to eliminate addiction | None mentioned | Regulated | No |
| Proctor22 | Prevent tobacco death | Make cigarettes uninhalable by raising smoke pH | None mentioned | Regulated | No |
| Smoker's license | |||||
| Chapman41 | Reduction in tobacco use | All smokers required to obtain yearly smart swipecard license to buy tobacco; maximum purchase limit chosen by licensee at time of application; maximum daily limit of 50 cigarettes per day; new smokers must pass test of risk knowledge; incentive to surrender license | Tobacco industry might find legal implications of informed consent to smoke attractive; difficult for impoverished nations to enact | Regulated | No |
| Restrict sales by year born | |||||
| Berrick54 | Long-term phase in of total ban on tobacco sales/purchase | Individuals born in or after year 2000 prohibited from tobacco purchase | Does not address current smokers; denial of choice for adults; age discrimination | Ultimately phased out | No |
| Khoo et al53 | Long-term phase in of total ban on tobacco | Individuals born in or after year 2000 prohibited from tobacco purchase | Does not address current smokers | Phased out; theoretically less urgency to lobby against policy whose impact will be felt in future | No |
| Ban combustibles | |||||
| Daynard68 | Phase out cigarettes; permit non-smoked nicotine delivery devices | Not specified | Smuggling would be a problem, but manageable | Not specified | Yes |
| Park et al69 | Ban on manufacture and sale of tobacco products | Legal prohibition on sale and manufacture; free cessation assistance; subsidy to farmers for switching crops; government purchase of manufacturing assets | Smuggling; damage to tourism industry | Eliminated or reorganised into different industry; compensated for assets | No |
| Proctor23 | Ban combustible cigarettes | Establish bans in states or localities | None mentioned | Executives repeatedly stated that they would not sell cigarettes if they were proved harmful; proposal ‘helps industry fulfill its promise’ | No |
| Advantage cleaner nicotine products over combustibles | |||||
| Gartner et al74 | End of tobacco smoking | Regulate smokeless tobacco products and e-cigarettes to enhance their use as smoking cessation products (eg, lower taxes, limited marketing to current smokers, phase out of smoked tobacco products) | Public health opposition | Regulated | Yes |
| Hall and Gartner75 | Elimination of tobacco-related harm | Regulate market to advantage low nitrosamine smokeless tobacco products (eg, lower taxes, reduction in nicotine content of cigarettes, tobacco companies that market smokeless tobacco required to phase out manufacture of combustible tobacco) | Illicit tobacco production and smuggling of smoked tobacco | Regulated | Yes |
| Sweanor et al73 | Safer products | Regulate market to disadvantage higher risk products (ie, cigarettes) | Public health opposition to industry in general and tobacco industry in particular reduces likelihood of implementation | Regulated | Yes |
| Regulated market model | |||||
| Borland88 | Regulating industry to encourage development of less harmful products; control commercial communication; move consumers to less harmful alternatives | Regulated market model to control tobacco marketing—monopsonistic agency set up to purchase and market tobacco products produced by manufacturer; control wholesale distribution to retailers | Agency would need an independent board; transparent deliberations. Smuggling could be a problem | Removed from control of market | Harm-reduced nicotine products |
| State takeover of tobacco companies | |||||
| Callard et al92 | Phase out tobacco use or reduce to minimum use levels | Transfer supply of cigarettes to non-profit entity with public health mandate through voluntary or legislated purchase | None mentioned | Transformed; motivated to help smokers quit and prevent tobacco uptake | Less harmful nicotine sources |
| Tobacco control agency | |||||
| Liberman86 | End of for-profit industry | Strong regulation of all aspects of industry with aim of minimising population harms | None mentioned | Regulated; ultimately dismantled | Probably |
| Thomson et al87 | Reduce or remove tobacco-related harm by modifying products, changing marketing, offering substitutes, controlling prices, changing arena in which tobacco industry operates | Establish governmental Tobacco Authority to purchase tobacco from manufacturer, paid for by manufacturer (as recommended by Borland 2003)88 | Will be attacked by tobacco industry and its allies | Removed from control of market | Possible concomitant regulation of alternative nicotine sources/devices |
| Performance-based regulation | |||||
| Sugarman94 95 | Reduced tobacco-related disease and death | Public agency sets goals for reductions in smoking prevalence rates, measures whether goals are met; tobacco companies determine how to meet goals, face substantial penalties for failure | Performance levels and penalties for non-compliance must be set carefully; difficulties may also arise if other public health policies implemented by regulators at the same time | Regulated | No |
| Quota/‘sinking lid’ | |||||
| Thomson et al78 | End of availability of commercial smoked tobacco; near zero smoking prevalence | Reduce smoked tobacco supply quotas to manufacturers and importers, coupled with smoking cessation support, mass media campaigns and stronger marketing and retailing regulations | Non-commercial system may be needed if tobacco industry exits or rigs market. Higher prices may result in smuggling, theft, illegal cultivation for commercial sales and short-term social inequalities | Regulated; ultimately dismantled | Clean nicotine products; limited home-grown product for personal use |
| Wilson et al77 | End of availability of commercial smoked tobacco; near zero (<1%) smoking prevalence | Reduce smoked tobacco supply quotas to manufacturers and importers (through government mandates governing sales/import quotas, or available tradeable quotas, perhaps controlled by non-profit agency), coupled with mass media campaigns, price regulation | If governments wish to maintain constant revenue streams, other types of taxes may need to be raised as tobacco tax revenue starts to decline; risk of smuggling, theft and illegal sales as prices rise | Regulated; ultimately dismantled | Residual smokers switched to pharmaceutical grade nicotine products, self-grown tobacco, or government supplied tobacco (via smoker's license) |
| Price caps | |||||
| Gilmore et al;83 Branston and Gilmore84 | Regulation to limit tobacco industry profits, use of price as marketing tool | Establish independent regulatory agency to set maximum wholesale prices (not retail price); increase taxes to maintain retail price | Counter to trend for less regulation and smaller government; reluctance to establish regulatory agency; increased government revenue might reduce incentive for tobacco control measures | Fewer financial resources for marketing and lobbying; subject to greater regulatory scrutiny | No |
| Integrated endgame strategy | |||||
| Beaglehole et al104 | Phasing out the sale of tobacco products globally by 2040 | Full and accelerated implementation of the Framework Convention on Tobacco Control; reductions in tobacco supply and product modifications; leadership from United Nations | None mentioned | Regulated | Yes |
| Fiore and Baker99 | Elimination of smoking | Tax increases; access to cessation; national clean indoor air law; elimination of nicotine; graphic warning labels; counter marketing; ban on advertising, promotion and sponsorship | None mentioned | Regulated | No |
| Gartner and McNeill105 | Ending smoking epidemic (not further specified) | Multiple: smoker licensing, regulated market model, harm reduction, reduced nicotine and reduced outlets | Reduced nicotine could increase exposure to toxicants; new regulatory structures difficult to enact | Regulated | Possible; low nitrosamine smokeless tobacco or high-dose recreational clean nicotine products |
| Hall and West102 | De facto prohibition of combustibles | Cap and trade combined w/nicotine reduction to phase out smoked tobacco products | None mentioned | Regulated; may become focused on ‘clean’ nicotine products | Yes |
| Institute of Medicine14 | Not specified | Strengthen tested approaches; increase federal regulations to require disclosure of product contents, improved warning labels, ‘tombstone’ style promotions, no industry contact with youth, fewer retail outlets and lower nicotine levels in cigarettes | None mentioned | Regulated | No |
| Laugesen et al100 | Phase out sale of commercial cigarettes and smoking tobacco | Increase tax; cap and trade; reduced nicotine; safer nicotine products | Financial inequity; black markets; reliance on as-yet non-existent new products | Regulation of imports | Yes |
| Laugesen70 | End of sale/use of smoked tobacco | Replacement with snus; toxicity-based taxation; reduction of nicotine content of cigarettes; encourage smokers to switch; declining smoked tobacco product quotas | Slight increased incidence of cancer compared to no tobacco use | Regulated | Yes |
| Malone1 | Death and disease from tobacco virtually eliminated | Nicotine reduction in cigarettes; outlet restrictions; cigarette sales bans | Potential for lawsuits | Regulated | Possibly |
| Tobacco Advisory Group of the Royal College of Physicians103 | End of smoking; subsequently, end of nicotine product use | Establish Nicotine Regulatory Agency to regulate products in line with their toxicity and to implement conventional tobacco control measures (eg, retail licensure, plain packaging, media campaigns) | None mentioned | Regulated; possibly redirected to low hazard products | Yes |
| van der Eijk3 | The end of tobacco-related death and morbidity | Integrate ideas from harm reduction, the tobacco-free generation proposal, and the Framework Convention on Tobacco Control to create a cigarette-free state with regulated alternative nicotine products | Legal challenges, illicit cigarette markets | Regulated | Yes |
| Wilson et al101 | Smoke-free New Zealand by 2025—children protected from exposure to tobacco and minimal risk of starting to smoke | Retailer licensing; plain packaging; sinking lid on sales; 100% smoke-free bars and restaurants; strengthen local government law-making powers; increase alcohol controls and de-linking drink and smoking | None mentioned | Regulated | No |