Questions for a tobacco-free future

Ritual tobacco use may have an ancient history, but there is nothing ‘natural’ about the way that tobacco now is grown, processed, sold and used. Cigarettes have been engineered for addictiveness, and in the process they have become more deadly.¹ The tobacco industry has worked for a century to create the impression that tobacco use is inevitable and to shape the social mores that enable addiction. The once near-ubiquity of smoking, and the concomitant epidemic of disease, are human constructs. Tobacco control advocates can, and are, changing them.

Considering endgames marks a new phase of tobacco control. Ten years ago such ideas were not on the agenda, advocates perhaps having been intimidated by the spectre of alcohol prohibition and its failures and unintended consequences (a ghost the industry has invoked with alacrity). The very phrase ‘tobacco control’ suggests that tobacco is here to stay, and that its goals should be to restrict the time, place and/or manner of use in ways that do the least harm (particularly to non-users).

The need for an endgame comes from the recognition that we do not have to accept the industrial marketing of tobacco, and that current policies—successful as they have often been—will likely not make the tobacco problem disappear. Those policies were never intended to eliminate the tobacco industry; the best case scenario they offer involves endless skirmishes with the industry's ongoing attempts to expand its markets and thwart regulation. Discussion of an endgame can inspire new visions of the possible.

These new visions will come with new challenges. The shift from a movement focused on control to one aiming towards a tobacco-free future may reveal new rifts. Some of these may come from differing ideas about what a desirable endpoint is. Do some tobacco control advocates believe that eliminating tobacco products is an encroachment on individual choice? Is nicotine addiction a problem in itself, or is it only the ‘dirty needle’ delivery devices of combustible tobacco and some forms of smokeless tobacco that we should aim at? Should we attempt to eliminate a corrupt industry, or would its conversion to cleaner products and more ethical business practices make it acceptable?

Ideas about how to get to these endpoints might also raise new debates. Does tobacco control have any obligation to account for users who ‘can't quit’? Do such users even exist? That is, would a scenario in which smoked (or all) tobacco products were eliminated from the market cause suffering, backlash or other unintended consequences due to users being deprived of nicotine? Or might we assume that users will adapt—as others who are compelled into situations without tobacco (prisons, hospitals, military boot camp) have done? Is it ethical to implement a ‘tobacco-free generation’ system² in which current smokers are allowed to use a product that government has decided is too toxic to allow others to use? Do regulated market models³ place governments in an unacceptable position by actively involving them in sales of tobacco products?

Another challenge for tobacco control will be to balance the incremental approaches that have been successful with the broader vistas an endgame scenario opens. Tobacco control has learned that aiming too low can be counterproductive; a compromise resulting in weak clean indoor air legislation can lead to enforcement problems and a lack of popular support for an ineffective law.⁴ Will the new vision change ideas about what constitutes an unacceptable compromise? It is likely that a process similar to the one already experienced with clean indoor air laws will occur, as different jurisdictions try out new policy proposals. Advocates may find unanticipated measures of success (or failure) to be useful, as for example, relatively recent findings of lowered rates of hospitalisation for AMI in jurisdictions with comprehensive clean indoor air laws.⁵

Tobacco control advocates will also have to balance policy innovation with science. Again, the story of clean indoor air laws is instructive. Advocates initiated clean indoor air campaigns without supporting science, basing their appeal on the perception of SHS as a nuisance which prevented non-smokers from enjoying indoor facilities. Science caught up as the tobacco industry pushed back, and then, as the true toxicity of SHS became known, stronger policy measures followed the science.⁶ Now, medical science surely supports eliminating the most deadly consumer product ever made; the battleground will likely be on the policy level. As we saw with Australia's groundbreaking move to plain packaging, the tobacco industry will challenge any novel policy by claiming it has not been shown to be effective.⁷ What evidence of effectiveness or lack of serious unintended consequences will we consider sufficient, and how will we establish it?

Advocates may also have to consider the problem of how to use the strength of tobacco control at the local level while aiming at multinational corporations. Some endgame proposals are designed to work at a national level. Could a sinking lid or tobacco-free generation policy work at a state or even local level? A few US states have regulated markets for alcohol,⁸ suggesting that this approach could be feasible at a smaller scale. Thinking locally might tip the balance in favour of simpler and less expensive approaches (tobacco-free generation, outright ban on sales) rather than those that require more elaborate regulatory infrastructure (reduced nicotine, regulated markets); countries with strong national health policy regimes might take other paths.

Finally, approaching endgames may raise issues about who is left behind. What if tobacco use essentially vanished in the USA or UK, but TTCs continued to be based in those countries? Will low-income and middle-income countries be left to carry on as countries with more resources solve their own tobacco problem? The beginnings of such a problem can be seen in the USA in microcosm as smoking increasingly is concentrated among disadvantaged individuals,⁹ and many see tobacco as a problem that has largely been solved.

Such questions will come up in abstract discussions of goals and concrete attempts at implementation in places with different political and social structures, histories and industries, which will all influence the answers at which advocates arrive. These questions should not deter advocates, but inspire them to examine their own assumptions and goals. The challenges may lead to new endgame scenarios as we seriously consider the possibilities envisaged here. Tobacco control advocates have wrought remarkable changes in the last 50 years; the papers in this issue of Tobacco Control suggest that the next 50 years will see even more.