Table 1.

Synthesis of existing scientific review⁹ on endgame measures and update on tobacco-free generation policies

Policy category	Policy description	Sufficient literaturea	Main evidence	Main evidence gaps
Product-focused	1. Mandate very low nicotine content (VLNC) for smoked tobacco products to make them non-addictive or less addictive.	Yes (26)	Effect on notable reduction in cigarette smoking, smoking prevalence and related harm. Public support for VLNC standard. Impact on the use of other nicotine products or drugs. Impact on people experiencing mental illness, socio-economic disadvantage, pregnancy.	Feasibility. Impact of the policy in terms of mental and physical health outcomes, use of alternative nicotine products, other substance use, and priority populations. Tobacco industry responses. Potential effect on the illicit market. Impact of public communication and education strategies to maximize policy benefits. Nicotine threshold for addiction.
	2. Set product standards for nicotine products that make combustible tobacco products unappealing or removed from the market for exceeding toxicity thresholds.	No (1)	Evidence on public support for the policy for banning menthol.	Feasibility. Tobacco industry responses, e.g. substituting banned constituents with other harmful ingredients.
User-focused	3. Require consumers to obtain a purchaser’s licence or medical prescription to purchase tobacco.	No (0)
	4. Restrict tobacco sales by year born (tobacco-free generation).	No (4)	Modelling population health impact of tobacco-free generation. Key legal and ethical issues of the tobacco-free generation. The implementation of this policy alone in a simulation model is unlikely to achieve a 5% smoking prevalence in 10 years. If combined with policies of denicotinization and retail outlet reduction, this policy could have major impacts on reducing inequities in health. Indirect evidence on youth defiance; universal laws may be better perceived by adolescents; age-specific laws are perceived as a form of youth control.	Policy effectiveness Exact meaning of human rights articles within the sphere of public health.
Market/supply-focused	5. End commercial retail sale of combustible tobacco (abolition).	No (2)	Varying public support (12%–88%).	Empirical evidence on effectiveness in achieving tobacco endgame.
	6. Set a regularly reducing quota on the volume of tobacco products manufactured or imported into a country (‘sinking lid’).	No (2)	Simulation of implementation in New Zealand. Simulated impact on health gain and cost saving.	Policy effectiveness, practicality or legality. Substitution relationships between different tobacco products.
	7. Actions that reduce the commercial viability of tobacco companies, such as a ‘corporate death penalty’, or criminal charges, requiring compensation for full impacts of tobacco use, or limiting profitability.	No (0)
	8. Increases in tobacco tax that make tobacco products generally unaffordable.	Yes (7)	Effect on health improvement and on decrease of smoking prevalence. Decreased health system costs.	Country-specific research on price elasticity variation by age and social groups. Impact of tax increase in conjunction with other policies.
	9. Restrictions on tobacco retailer density/location/type/licensing that substantially reduce tobacco availability.	Yes (10)	Effective for reducing population-level tobacco use and health system costs.	Feasibility in some European countries, e.g. France, Italy and Spain, where tobacconists are exclusive tobacco retailers.
Institutional structure-focused	10. Transfer management of tobacco supply to an agency with a mandate to phase out tobacco sales.	No (0)
	11. Performance-based regulation whereby tobacco companies are required to meet smoking prevalence targets or be fined; or manufacturers pay a levy based on sales volume similar to ‘polluter pays’ schemes.	No (0)

^aSufficient studies: n>5.