Endgame in tobacco control: Strategic considerations

Background: For more than a decade, researchers and policy thinkers in tobacco control have been proposing policy solutions that step beyond the measures currently in widespread use—not to displace but to enhance them with solutions that may prove more definitive in bringing the tobacco disease epidemic to a halt, as has been done with smallpox and, on the products side, with asbestos and harmful pharmaceuticals. Taken together, all of these ideas have begun to form a body of published academic scholarship and research that forms the “endgame” discourse within tobacco control. Methods: Synthesis of published literature on endgames and analysis of evidence, risks and advantages of selected endgame proposals. Results: Endgame ideas vary widely, from market-based solutions that would create a state-run tobacco market to product regulation approaches such as uniformly reducing nicotine in cigarettes to non-addictive levels. These ideas are at various levels of development, but in some countries are likely to gain traction as smoking prevalence and the political influence of the tobacco industry wanes. Political and economic contexts in various countries influence which approaches seem most practicable. In the US, lack of strong federal leadership will likely render endgame a much more slow and incremental process. Conclusions: Specific endgame approaches will likely have to be selected and tailored by individual countries. The increasing acknowledgment that the tobacco epidemic could be halted, rather than merely contained, represents an important advance in tobacco control.