Progress, challenges and the need to set concrete goals in the global tobacco endgame

ABSTRACT

The tobacco endgame is rapidly moving from aspirational and theoretical toward a concrete and achievable goal and, in some cases, enacted policy. Endgame policies differ from traditional tobacco control measures by explicitly aiming to permanently end, rather than simply minimize, tobacco use. The purpose of this paper is to outline recent progress made in the tobacco endgame, its relationship to existing tobacco control policies, the challenges and how endgame planning can be adapted to different tobacco control contexts. Examples of implemented policies in three cities in the United States and national policies in the Netherlands and New Zealand are outlined, as well as recent endgame planning developments in Europe. Justifications for integrating endgame targets into tobacco control policy and the need to set concrete time frames are discussed, including planning for ending the sale of tobacco products. Tobacco endgame planning must consider the jurisdiction-specific tobacco control context, including the current prevalence of tobacco use, existing policies, implementation of the World Health Organization’s Framework Convention on Tobacco Control, and public support. However, the current tobacco control context should not determine whether endgame planning should happen, but rather how and when different endgame approaches can occur. Potential challenges include legal challenges, the contested role of e-cigarettes and the tobacco industry’s attempt to co-opt the rhetoric of smoke-free policies. While acknowledging the different views regarding e-cigarettes and other products, we argue for a contractionary approach to the tobacco product market. The tobacco control community should capitalize on the growing theoretical and empirical evidence, political will and public support for the tobacco endgame, and set concrete goals for finally ending the tobacco epidemic.

In recent years, the concept of the tobacco endgame has progressed from a theoretical aspiration confined to academic articles and conference discussions to a concrete, achievable policy goal. Some jurisdictions have started to implement endgame policies, while others are including them in planning. Most organizations working on these goals envision “a world free from tobacco”. However, this focus has historically been implicit rather than explicit within their policy goals. While the term tobacco endgame carries translational challenges, the broad, underpinning principle is one of ending the tobacco epidemic, in contrast to the traditional tobacco control focus on reducing and minimizing tobacco use (1). One useful proposed definition of the tobacco endgame is: “Initiatives designed to permanently change the structural, political and social dynamics that sustain the commercial tobacco epidemic in order to end it within a specific time” (1). This recognizes the complexities behind a seemingly straightforward concept and the need to shift from treating smoking as an individual behavior to a broader focus that includes addressing the availability of tobacco products.

The impetus behind endgame thinking can be summarized by asking: at what point have we satisfactorily controlled the tobacco epidemic? This prompts consideration of the level of tobacco-attributable disease and death that society is willing to accept, and it has particular resonance as countries grapple with determining what is a tolerable toll of death and disability in a future of living with COVID-19. While excess deaths from COVID-19 vary by jurisdiction, for decades smoking has exerted a far greater and more sustained global death toll than the current pandemic (2). At the time of writing, the official number of COVID-19 deaths globally since the start of the pandemic (28 months ago) was slightly more than 6.2 million compared with an estimated 8 million deaths from tobacco each year. In the World Health Organization (WHO) Region of the Americas, deaths were more evenly distributed, with approximately 2.7 million deaths from COVID-19 since the start of the pandemic compared with more than 1 million deaths from tobacco per year (3, 4).

The concept of a tobacco endgame has some parallels with the eradication and elimination of communicable diseases (5). For example, smallpox, a disease that killed 35% of those infected, has been eradicated thanks to coordinated global efforts. Should global society not aspire to accomplish the same for an epidemic that kills more than half of its victims? As WHO’s Director-General Dr. Tedros Adhanom Ghebreyesus said in 2021 at the opening of the Second Session of the Meeting of the Parties of the Protocol to Eliminate Illicit Trade in Tobacco Products, “If tobacco was a virus, it would long ago have been called a pandemic and the world would marshal every resource to stop it” (6). Unlike infectious diseases, the tobacco epidemic is industrially produced: the disease vector exists entirely for profit. The vector is observable and traceable, and its harms have been known for decades, yet while society has effectively eradicated or reduced to negligible levels many infectious diseases, tobacco has remained widely available.

One potential endgame strategy to interrupt transmission of the tobacco epidemic is to eliminate the sale of tobacco products. Although there is no worldwide history of eradicating a non-infectious disease, there are examples of phasing out the sale of products that cause disease or environmental pollution, such as asbestos, lead and naphtha. Argentina, Brazil, Chile, the Dominican Republic, Peru and Uruguay are among the 75 countries that have declared a war on asbestos, a mineral that has multiple industrial uses. Tobacco products are an even more worthy candidate for elimination: not only do they serve no useful purpose but also they are a leading cause of death and disability and impose a global economic burden equivalent to nearly 2% of global gross domestic product (7). Furthermore, there is growing evidence of public support for endgame policies, including ending the sale of tobacco products (8).

The purpose of this paper is to outline recent progress made by the modern tobacco endgame movement, its relationship to existing tobacco control policies, the current challenges and how endgame planning – particularly for ending tobacco sales – can be adapted to different tobacco control contexts to end the tobacco epidemic.

RECENT PROGRESS IN ENDGAME ACTION

The past 2 years have witnessed a significant boost in endgame thinking and action. In 2020, the Netherlands announced a policy to phase tobacco sales out of supermarkets (9). After several years of internal planning, in January 2021 California, United States, announced its endgame initiative (10) to reduce smoking prevalence to below 1.9% by 2035. The announcement was amplified by the implementation of complete bans on tobacco sales, including e-cigarettes, by the city councils of Beverly Hills and Manhattan Beach in January 2021 (11). In December 2021, the New Zealand Ministry of Health published its Smokefree Aotearoa 2025 Action Plan (12), a raft of endgame policies intended to help meet the government’s goal of <5% smoking prevalence by 2025, first set in 2010. The plan mandates low nicotine levels in cigarettes to minimize their addictiveness, restricts other design features that increase the appeal and addictiveness of tobacco products, provides for a significant reduction in the number of tobacco retailers and implements a smoke-free generation policy.

The concept of a tobacco-free generation (TFG) (13), whereby sales of tobacco products are restricted to people born before a set year, was first suggested in 2012 at the Fifteenth World Conference on Tobacco or Health in Singapore. In 2014, a proposal to adopt such a policy was put forward by an independent member of parliament in the Australian state of Tasmania, but it was not adopted. The City of Balanga in the Philippines subsequently implemented the policy in 2016, although it was successfully challenged by the tobacco industry (9). In September 2021, the U.S. city of Brookline, Massachusetts, implemented a TFG policy covering all tobacco products including e-cigarettes (14). And, as noted above, the smoke-free generation policy (excluding e-cigarettes) is also part of New Zealand’s national tobacco control plan. The TFG policy is now featuring in discussions in Spain, and following the launch of New Zealand’s policy, Denmark, Ireland, Malaysia and Singapore announced they will consider adopting TFG policies.

ADAPTING ENDGAME PLANNING TO DIFFERENT CONTEXTS

It is important in planning endgame policies to consider jurisdiction-specific tobacco control contexts. Relevant factors include the current prevalence of tobacco use; implementation status of the WHO Framework Convention on Tobacco Control (FCTC), for national-level policies; existing enforcement infrastructure for tobacco policies; the political climate; tobacco industry interference; and how policies are suited to different levels of government. The public health community recognizes four stages of the tobacco epidemic (15). New Zealand and the three U.S. cities discussed above (Brookline, MA, and Beverly Hills and Manhattan Beach, CA) are in stage 4: prevalence has been dropping for years and the number of deaths has passed its peak. The U.S. cities had already implemented a comprehensive suite of tobacco control policies and had smoking prevalences of around 5%. All three had fostered a broader culture of health and had a history of addressing public interest issues. In this context, moving to the endgame is a logical next step. They are also relatively small jurisdictions in which running for political office is not an expensive undertaking, which blunts the effects of campaign contributions – a key tool used by the tobacco industry to influence politicians in the United States. The potential for illicit markets to develop and the availability of non-combusted nicotine products were of less concern than they would be for state or national level policies. In contrast, New Zealand – with an overall national smoking prevalence of 11.6% that is much higher among specific groups – required a more comprehensive and phased approach, particularly to ensure that the impact of the policy plan fulfills one of its key stated aims: to reduce health inequities. It also tolerates a role for e-cigarettes as part of reducing overall tobacco harms (12).

Jurisdictions in stage 1 of the tobacco epidemic, with a low but rising prevalence of smoking and tobacco-attributable deaths, such as in sub-Saharan Africa (15), may also be poised to achieve the endgame in the short-to-medium term. If tobacco sales are phased out in these countries, they could potentially avoid decades of unnecessary death, disease and economic harm, better enabling them to achieve development and other goals. The tobacco control context across Latin America presents many endgame opportunities. Latin America has among the highest levels of FCTC implementation, and South America was the first WHO subregion where all countries were covered by smoke-free policies (16). Several countries are leaders in tobacco control policy: Brazil has implemented all of the MPOWER measures (i.e. monitoring tobacco use; protecting people from tobacco smoke; quitting tobacco; warning about the dangers of tobacco; enforcing tobacco advertising, promotion and sponsorship bans; and raising taxes on tobacco); Uruguay was among the first countries to implement plain packaging; and the Region of the Americas was quick to adopt pictorial health warning labels. Panama’s smoking prevalence of 5% is equivalent to what is often advocated as an endgame goal (16).

While each national situation is different, there would seem to be necessary precursors to endgame success in the short term, such as strong FCTC implementation; cooperation between the government and civil society organizations; robust enforcement infrastructure, such as border controls and retailer licensing; low or declining prevalence of tobacco use, or both; public support for tobacco control; and protection from industry interference. However, even countries and jurisdictions without all of these factors in place can set endgame plans. In Spain, the national tobacco control coalition, supported by 25 organizations, has called on the government to enact a TFG policy. However, recognizing that this is infeasible in the short term, given that the current smoking prevalence in the country is more than 20%, they have proposed a 10-year policy timeline, with the passage of a TFG policy as a final step (17).

Setting concrete targets is essential in endgame planning. Civil society organizations and health ministries may have a goal of a tobacco-free future, but the date is often far over the horizon, vague and unspecified, like finding the cure for cancer. However, unlike cancer, we already know how to end the tobacco epidemic. Decades of data from successful policy interventions form a guide for any country with the political will to move forward (18). The most important guide is the FCTC itself. Countries that have rigorously implemented and enforced FCTC policies have demonstrated its effectiveness; any shortfall is due to lack of political will at the national level. Once the political will is in position, endgame planning is a vital part of a stepwise approach, even if implementation of the final steps is years away. Regardless of the jurisdiction size and current smoking prevalence, the key is to envision and plan toward a specific date when tobacco sales will end. The timeline will vary, but the goal is the same. Current tobacco control environments are critical considerations for when and how, but not if.

THE ENDGAME AS A GLOBAL MOVEMENT

The tobacco endgame concept is increasingly being embraced by both civil society and governments. Endgame planning in the form of setting ambitious prevalence goals and dates began in 2010 in New Zealand, leading to a healthy race to the top as multiple countries followed; Canada, England, Finland, Ireland, Scotland and Sweden have all set explicit endgame targets. Other countries, including Australia, Bangladesh and the United States, have what are effectively endgame targets for the prevalence of tobacco use even if they are not explicitly stated as such (8).

Following a string of meetings about the endgame concept, Project Sunset was launched in 2018, the first organized global effort to promote ending the sale of combustible tobacco products (authors C.B. and M.H. are co-founders and co-chairs of the movement, and E.B. is a member of the global steering committee) (19). Momentum has accelerated since 2019. In May 2021, Project Sunset released a global letter (20) signed by 148 organizations from more than 30 countries – at all stages of the tobacco epidemic – that called on governments to begin planning for the end of sales of combustible tobacco products. On World Cancer Day, February 4, 2021, the European Commission (21) and French President Emmanuel Macron (22) announced plans to drastically reduce the incidence of cancer during the next two decades. Both made it clear that ending the tobacco epidemic was vital to their goals.

THE HUMAN RIGHTS BASIS FOR THE TOBACCO ENDGAME

The global tobacco control movement has long embraced human rights norms. The WHO FCTC includes human rights language and references several human rights treaties. The foreword describes the purpose of the treaty as reaffirming “the right of all people to the highest standard of health” (23). The Cape Town Declaration on Human Rights and a Tobacco-Free World was adopted in 2018 at the Seventeenth World Conference on Tobacco or Health (24). The language of the Declaration has been adopted by regional tobacco control networks (25, 26) and led to the Global Forum on Human Rights and a Tobacco-Free World (27), held in Romania in 2019. Romanian President Klaus Iohannis and Princess Dina Mired of Jordan attended, as did high-ranking figures from the global public health and human rights communities. The connection between human rights and tobacco control has particular resonance in Latin America because many countries enshrine health as a constitutional human right (16).

Several principles underpin a human rights-based approach to the tobacco epidemic. First, governments have an obligation as well as a right to implement policies to end the tobacco epidemic, in line with the enshrinement of the right to health in many human rights treaties and the WHO Constitution (23). Second, health equity is paramount: human rights apply to all people at all times, and governments are obligated to consider the outcomes of policies and take action to reduce inequities. This concept is particularly important given the decades of marketing by the tobacco industry targeted toward marginalized populations (28, 29). Finally, governments have an obligation to help people who smoke to quit, based not only on the right to health but also on their failure to protect people from the tobacco industry’s predation (30). While many countries may not be able to afford to fund the full suite of smoking cessation services, some are within the means of even the poorest country (31).

After performing a human rights assessment of Philip Morris International, the Danish Institute for Human Rights concluded that the company could comply with human rights norms only by stopping the manufacture, marketing and sale of tobacco products (32). The irreconcilability of human rights with its business model has not stopped the tobacco industry from misusing human rights arguments. The right to privacy under the International Covenant on Civil and Political Rights and other documents (including national constitutions) is fairly broad, sometimes interpreted as the right to “being let alone and not to be interfered with” (33). However, the right to privacy is focused on the individual; the lack of legal impediment to use a product does not necessarily mean a right for businesses to engage in the commercial sale of the product. The right to liberty under the Universal Declaration of Human Rights might also be invoked by opponents of the tobacco endgame. However, as with privacy, it applies to the individual rather than the commercial seller; furthermore it is quite narrow, referring to the right to freedom of movement and against arbitrary arrest.

Taken together, global human rights laws and norms provide a powerful rationale for the tobacco endgame. However, one caveat is that the value of human rights arguments does not extend to endgame laws that mandate against individual possession or use of tobacco products. The public health community must begin shifting its focus from demand and tobacco users to supply and the tobacco industry. In doing so, it must take care to avoid criminalizing smokers.

CHALLENGES TO ENACTING ENDGAME POLICIES

The main barrier to transitioning from tobacco control to the endgame is the tobacco industry itself, given the threat to its viability. Full implementation and enforcement of the FCTC’s Guidelines for Article 5.3, which calls for parties to protect public health policy-making from the industry, are vital. It is nearly inevitable that tobacco companies will launch legal challenges to endgame policies, as they have done repeatedly against policies with far less potential impact on their profits (34). One of the most insidious industry tactics over the past several years is the attempt to own the rhetoric of a smoke-free future, a tactic particularly embraced by Philip Morris International (35). Contrary to its rhetoric, combustible tobacco products constitute the vast majority of its profits. Regardless of any change in the proportion of its profits derived from combustible tobacco, the company’s business model relies on market growth for the addictive products for which the profile of long-term harm is not fully known.

The industry tactic to co-opt smoke-free rhetoric has evoked an understandably negative response to the tobacco endgame from some within the public health community. In particular, there is a concern that an endgame focus on combustible products could be seen as an endorsement of the tobacco industry’s business expansion strategies. We argue that endgame initiatives should prioritize the tobacco products that cause the most disease and death and particularly focus on ending the sale of combustible products. This should not be read as an acceptance of mass addiction to alternative products. Rather, governments should employ a contractionary approach to reduce the availability of all tobacco products, with the most aggressive phase-out timelines focused on the most harmful. In some jurisdictions, phasing out product sales may include e-cigarettes (as in the three U.S. cities discussed above); in others, e-cigarettes may form part of the transition planning (as in New Zealand). Regardless of the approach taken, there is no need for governments to negotiate with the tobacco industry for market access or favorable regulatory treatment for alternative products. With all tobacco products, there remains a fundamental conflict of interests between those of the tobacco industry and those of public health.

There have been other criticisms of the endgame from within the tobacco control community. The first is that it is infeasible, at least on a global scale. While the time frame will vary for different jurisdictions, examples from past tobacco policy campaigns suggest policies that appear radical or infeasible can find rapid acceptance. Toward the conclusion of the negotiations for the FCTC, the concept of smoke-free air was considered so radical that even civil society was split. Yet the first example of a comprehensive, national smoke-free air law emerged the following year in Ireland. Today FCTC Article 8, requiring parties to implement measures for protection from exposure to tobacco smoke, has the highest implementation globally (18). Similarly, after Australia became the first country to adopt plain packaging for tobacco products, other countries rapidly followed (9).

Second, the specter of illicit trade is often invoked in endgame discussions. The industry has made this argument in the face of nearly every meaningful tobacco control policy (36), but in the case of the endgame, it seems quite likely that illegal products will circulate, at least for a time. However, with a policy end point at which there will be no or extremely limited commercial venues permitted to sell tobacco (unlike illicit trade, often used to avoid tax, for example), the public health benefits of endgame policies will not be seriously undermined by products transferring from hand to hand. Controlling the illicit trade is a challenge regardless of the presence of the legal tobacco market. Furthermore, the absence of 100% compliance should not be a deterrent either to policy or legislation.

An additional challenge is that some endgame policies and strategies have limited evidence of real-world effectiveness. Sales bans and TFG or smoke-free generation policies have been implemented too recently to determine their impact on smoking uptake and prevalence, although modelling studies predict a positive impact (8). Very-low-nicotine cigarettes have a strong experimental evidence base, but have not yet been implemented (8). The lack of real-world effectiveness for endgame policies is a criticism that could be applied to almost any tobacco control policy before it was implemented. Fortunately, the examples outlined here of recently enacted, groundbreaking endgame policies will provide real-world evidence of impact and lessons about how such policies can be improved or modified to increase their effectiveness elsewhere. Furthermore, in considering policies that are untested in practice against business-as-usual approaches, it is relevant to consider the impact of a lack of innovation. The history of tobacco control is of implementing policies with a strong theoretical, modelling and experimental evidence base. Implementation always starts with one jurisdiction or a small number of jurisdictions before becoming standard.

Finally, some public health colleagues may view the endgame as a distraction from the FCTC, concerned that endgame proponents may seek to replace the treaty. In fact, the endgame is entirely compatible with the FCTC, whose framers anticipated that new policy initiatives would be needed as the tobacco epidemic evolved. This is addressed by FCTC Article 2, Section 1, which calls on parties to go further than the specific obligations in the treaty (18). The success of the FCTC in driving down prevalence has prepared the ground for endgame discussions, and a continued focus on FCTC interventions is vital, particularly in places that are not ready to implement endgame policies in the near term.

CONCLUSIONS

Public health professionals as well as the framers of the FCTC have long envisioned a world free from tobacco-caused death and disease. For more than 70 years, since it first became clear that tobacco harmed health, that vision has been “some time in the future”. This is rapidly changing as governments begin planning for the tobacco endgame: not in a century, but within a few years. A few cities have already achieved it, and some countries are implementing endgame policies. There are myriad policy paths to the tobacco endgame, but essential components are to plan and adapt strategies to the existing tobacco control context. Theoretical and empirical evidence, political will and public support continue to build; capitalizing on these and setting concrete plans to achieve a tobacco-free world is a task for all in public health.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública/Pan American Journal of Public Health and/or those of the Pan American Health Organization (PAHO).

Funding Statement

MH is the recipient of a Gender Equity Fellowship from the Menzies School of Health Research, Darwin, Australia. She also receives salary support from an Australian National Health and Medical Research Council grant (GNT1198301) from the Centre of Research Excellence on Achieving the Tobacco Endgame through the University of Queensland. Funders had no role in designing, analyzing, writing or the decision to submit this manuscript for publication.