Table 1

Examples of tobacco endgame proposals

StudyDefinition of endgame goalApproachCaveats/drawbacksIndustryReplacement product needed
Regulate nicotine levels to make cigarettes non-addictive or less addictive
Benowitz and Henningfield7Reduce tobacco use and prevent development of nicotine addictionRegulate availability of nicotine in tobacco products to limit maximal obtainable dose; could be reduced gradually, over 10–15 year periodPotential for cheating; smuggling could be a problemRegulated by Food and Drug AdministrationNo
Gray et al10Safer products1) 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 tobaccoRegulated by Food and Drug AdministrationYes
Henningfield et al12Less addictive productsRegulation 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 toolRegulated by Food and Drug AdministrationNo
Redesign the cigarette to make it unappealing
Peters24Eliminate smokingRemove all cigarette additives; require cigarettes to have a maximal smoke pH and measured nicotine delivery to eliminate addictionNone mentionedRegulatedNo
Proctor22Prevent tobacco deathMake cigarettes uninhalable by raising smoke pHNone mentionedRegulatedNo
Smoker's license
Chapman41Reduction in tobacco useAll 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 licenseTobacco industry might find legal implications of informed consent to smoke attractive; difficult for impoverished nations to enactRegulatedNo
Restrict sales by year born
Berrick54Long-term phase in of total ban on tobacco sales/purchaseIndividuals born in or after year 2000 prohibited from tobacco purchaseDoes not address current smokers; denial of choice for adults; age discriminationUltimately phased outNo
Khoo et al53Long-term phase in of total ban on tobaccoIndividuals born in or after year 2000 prohibited from tobacco purchaseDoes not address current smokersPhased out; theoretically less urgency to lobby against policy whose impact will be felt in futureNo
Ban combustibles
Daynard68Phase out cigarettes; permit non-smoked nicotine delivery devicesNot specifiedSmuggling would be a problem, but manageableNot specifiedYes
Park et al69Ban on manufacture and sale of tobacco productsLegal prohibition on sale and manufacture; free cessation assistance; subsidy to farmers for switching crops; government purchase of manufacturing assetsSmuggling; damage to tourism industryEliminated or reorganised into different industry; compensated for assetsNo
Proctor23Ban combustible cigarettesEstablish bans in states or localitiesNone mentionedExecutives 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 al74End of tobacco smokingRegulate 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 oppositionRegulatedYes
Hall and Gartner75Elimination of tobacco-related harmRegulate 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 tobaccoRegulatedYes
Sweanor et al73Safer productsRegulate market to disadvantage higher risk products (ie, cigarettes)Public health opposition to industry in general and tobacco industry in particular reduces likelihood of implementationRegulatedYes
Regulated market model
Borland88Regulating industry to encourage development of less harmful products; control commercial communication; move consumers to less harmful alternativesRegulated market model to control tobacco marketing—monopsonistic agency set up to purchase and market tobacco products produced by manufacturer; control wholesale distribution to retailersAgency would need an independent board; transparent deliberations. Smuggling could be a problemRemoved from control of marketHarm-reduced nicotine products
State takeover of tobacco companies
Callard et al92Phase out tobacco use or reduce to minimum use levelsTransfer supply of cigarettes to non-profit entity with public health mandate through voluntary or legislated purchaseNone mentionedTransformed; motivated to help smokers quit and prevent tobacco uptakeLess harmful nicotine sources
Tobacco control agency
Liberman86End of for-profit industryStrong regulation of all aspects of industry with aim of minimising population harmsNone mentionedRegulated; ultimately dismantledProbably
Thomson et al87Reduce or remove tobacco-related harm by modifying products, changing marketing, offering substitutes, controlling prices, changing arena in which tobacco industry operatesEstablish governmental Tobacco Authority to purchase tobacco from manufacturer, paid for by manufacturer (as recommended by Borland 2003)88Will be attacked by tobacco industry and its alliesRemoved from control of marketPossible concomitant regulation of alternative nicotine sources/devices
Performance-based regulation
Sugarman94 95Reduced tobacco-related disease and deathPublic 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 failurePerformance 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 timeRegulatedNo
Quota/‘sinking lid’
Thomson et al78End of availability of commercial smoked tobacco; near zero smoking prevalenceReduce smoked tobacco supply quotas to manufacturers and importers, coupled with smoking cessation support, mass media campaigns and stronger marketing and retailing regulationsNon-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 inequalitiesRegulated; ultimately dismantledClean nicotine products; limited home-grown product for personal use
Wilson et al77End of availability of commercial smoked tobacco; near zero (<1%) smoking prevalenceReduce 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 regulationIf 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 riseRegulated; ultimately dismantledResidual 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 Gilmore84Regulation to limit tobacco industry profits, use of price as marketing toolEstablish independent regulatory agency to set maximum wholesale prices (not retail price); increase taxes to maintain retail priceCounter to trend for less regulation and smaller government; reluctance to establish regulatory agency; increased government revenue might reduce incentive for tobacco control measuresFewer financial resources for marketing and lobbying; subject to greater regulatory scrutinyNo
Integrated endgame strategy
Beaglehole et al104Phasing out the sale of tobacco products globally by 2040Full and accelerated implementation of the Framework Convention on Tobacco Control; reductions in tobacco supply and product modifications; leadership from United NationsNone mentionedRegulatedYes
Fiore and Baker99Elimination of smokingTax increases; access to cessation; national clean indoor air law; elimination of nicotine; graphic warning labels; counter marketing; ban on advertising, promotion and sponsorshipNone mentionedRegulatedNo
Gartner and McNeill105Ending smoking epidemic (not further specified)Multiple: smoker licensing, regulated market model, harm reduction, reduced nicotine and reduced outletsReduced nicotine could increase exposure to toxicants; new regulatory structures difficult to enactRegulatedPossible; low nitrosamine smokeless tobacco or high-dose recreational clean nicotine products
Hall and West102De facto prohibition of combustiblesCap and trade combined w/nicotine reduction to phase out smoked tobacco productsNone mentionedRegulated; may become focused on ‘clean’ nicotine productsYes
Institute of Medicine14Not specifiedStrengthen 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 cigarettesNone mentionedRegulatedNo
Laugesen et al100Phase out sale of commercial cigarettes and smoking tobaccoIncrease tax; cap and trade; reduced nicotine; safer nicotine productsFinancial inequity; black markets; reliance on as-yet non-existent new productsRegulation of importsYes
Laugesen70End of sale/use of smoked tobaccoReplacement with snus; toxicity-based taxation; reduction of nicotine content of cigarettes; encourage smokers to switch; declining smoked tobacco product quotasSlight increased incidence of cancer compared to no tobacco useRegulatedYes
Malone1Death and disease from tobacco virtually eliminatedNicotine reduction in cigarettes; outlet restrictions; cigarette sales bansPotential for lawsuitsRegulatedPossibly
Tobacco Advisory Group of the Royal College of Physicians103End of smoking; subsequently, end of nicotine product useEstablish 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 mentionedRegulated; possibly redirected to low hazard productsYes
van der Eijk3The end of tobacco-related death and morbidityIntegrate 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 productsLegal challenges, illicit cigarette marketsRegulatedYes
Wilson et al101Smoke-free New Zealand by 2025—children protected from exposure to tobacco and minimal risk of starting to smokeRetailer 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 smokingNone mentionedRegulatedNo