Key considerations and common myths
- Focus on products and supply: The endgame targets the industry and its products, not those who use them. Stigmatizing people who use tobacco or nicotine and suffer from often life-long dependence must be avoided.
- Integrate effective cessation support into tobacco endgame strategies and measures, particularly to impact health inequalities.
- Prioritize measures with a substantial expected impact, based on the evidence and feasibility
- Resist industry interference: Strictly adhere to Article 5.3 of the WHO FCTC. Scrutinize industry-driven harm reduction initiatives. These are self-serving tactics aimed at maintaining addiction and sales, obstructing policy, and attracting new users. Exercise caution around this concept, especially in areas with weaker regulations.
Further, promoting the commitment of political leaders and the intersectoral and civil society participation is often essential in getting forward-looking measures to the political agenda. Vulnerable population groups (e.g., adolescents, pregnant women, persons with low socio economic position or mental health problems) should be taken into consideration in the development, implementation, and evaluation of tobacco endgame goals. Especially in indigenous populations, it may be beneficial to clearly focus on commercial tobacco.
Common myths
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Truth: A tobacco endgame strategy means moving beyond tobacco control towards a future free of commercial tobacco. Tobacco endgame is often opposed with phrases like "prohibition does not work", but ending the commercial sale is not the same as prohibition of use. Tobacco endgame can be achieved by implementation of various interventions and policies, none of which is banning people the use of these products in line with country specific smoke-free and age of sale legislation.
The focus is on regulating the products to make them less addictive and appealing, and on regulating the industry and supply to reduce the availability of the products, especially for future generations. The strategies are implemented gradually and aimed at manufacturers, distributors, and retailers without sanctioning consumer use or purchase. Some researchers have proposed the term "abolition" to be used in connection with the goal of ending the sales of cigarettes – the single most deadly consumer product in history – to characterize it more accurately as an enlargement of liberty, rather than its restriction.
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Truth: The "right to smoke" has been a powerful argument by the tobacco industry to oppose any regulation. Regulators often need to assess and consider individual rights, especially when it comes to smoke-free environments, from the perspective of property ownership and privacy, but there is no legal right to smoke as such. In contrast, health is a fundamental right of every human being.
It is recognized in the WHO Constitution (1948), the Universal Declaration of Human Rights (1948) and many international and regional human rights treaties, including the Convention on the Rights of the Child (1989). The European Union (EU) mandates high standards of health protection across its policies. Recently, with Resolutions from the Human Rights Council in 2021 (A/HRC/RES/48/13) and the General Assembly in 2022 (A/RES/76/300), the right to live in a clean, healthy and sustainable environment has been added as fundamental human right to the library of internationally recognized rights.
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Truth: The approach, first and foremost, targets the products and the supply. Stigmatizing people who use tobacco or nicotine and suffer from dependence must be avoided. These products are designed to create a strong, often life-long addiction. It is sometimes argued that as smoking prevalence in the population decreases, those who continue to smoke are more dependent and unwilling to quit than previous cohorts of people who smoke, making for example, tobacco endgame measures unjust to them.
However, the evidence does not support this so-called "hardening hypothesis". Among people who continue to smoke, the pattern of use has become more infrequent, and the number of cigarettes per day and tobacco dependence have decreased. Furthermore, there is no sign that the motivation or capability to quit have decreased. It is still essential that cessation support is always integrated into tobacco endgame goals and measures.
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Truth: Instead of merely controlling and reducing the harms caused by tobacco, the emphasis in tobacco endgame is on a permanent, structural, political and social change to protect public health and future generations. This is achieved by gradually phasing out the sales and consumption from society. Achieving a minimal level of use in the general population means that the tobacco epidemic no longer continues to take a toll on society through its health, social, economical and environmental consequences.
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Truth: The harm reduction concept in addiction research originates in illicit drug use, where the prevalence of use is low and there is a need to prevent communicable diseases and reduce short-term risks such as overdoses. Based on research on tobacco industry documents, British American Tobacco and Philip Morris International appear to have adopted the harm reduction -term from a report by the Institute of Medicine in 2001. This report concluded that tobacco harm reduction is feasible and justifiable public health policy only under certain conditions, including its implementation as a component of a comprehensive national tobacco control program that emphasizes abstinence-oriented prevention and treatment.
Yet, the industry proceeded to heavily emphasise it in their corporate messaging. It offered the industry two main benefits: an opportunity to access policymakers, scientists and public health groups to (re-)establish a dialogue and to secure reputational benefits via an emerging corporate social responsibility agenda. Doing so, the industry and related entities have created a self-serving version of the concept that maintains sales and nicotine addiction, claiming that other possible measures have failed or are not applicable.
Their aim is to position themselves as part of the solution to a problem they have created, broaden the product portfolio and increase profit, distract away from the implementation of effective policies, and attract new users. The product design and marketing are especially appealing to young people and adolescents, combined with additives that ease the use and increase addiction potential. Researchers have found no evidence of any tobacco company rapidly progressing towards eliminating conventional products, ceasing to obstruct effective tobacco control measures and taking action to minimise smoking uptake and disparities.
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Truth: One of the common opponents’ arguments for any tobacco control regulation, including measures for tobacco endgame, is that it increases illicit trade. However, researchers have concluded that the likelihood of an illicit market would be relatively small, particularly if cessation services are increased, and other safeguards are put into place. Of these, the key is the full implementation of the WHO FCTC and the Protocol to eliminate illicit trade in tobacco products.
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Truth: By ratifying the WHO Framework Convention on Tobacco Control (WHO FTC), countries commit to supporting tobacco farmers, workers and sellers to identify alternative livelihoods. While these tools are not yet widely used, there are good experiences in different countries, for example, supporting farmers in transferring from tobacco growing to food crops. This is often beneficial not only to the farmer, but for the environment and for the health of persons working in the farms.
As for retailers, some retail store chains have already voluntarily ended tobacco or cigarette sales as part of their commitments to sustainable and responsible trading. Governments can support retailers through different incentives. The gradual nature of phase-out and reduction of supply, which is at the core of the tobacco endgame, is essential to allow for farmers, workers and sellers sufficient time to identify and initiate other more sustainable businesses and sources of income.
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Truth: One of the often used claims by the tobacco industry is that tobacco endgame creates a "Nanny state", a term used to indicate that the state restricts freedom of choice and overregulates how people should live their lives, especially about health-related behaviors and risk factors such as eating, smoking, or drinking alcohol.
However, it should be clear that governments have a responsibility to limit the activities of commercial interests that might harm the individual or society and the economy. Tobacco and nicotine products are no ordinary commodities. Under consumer protection, governments regularly ban the sale of products that are harmful to health, but in tobacco control consumer protection has failed. Governments also have a responsibility to protect youth with still-developing brains and thus susceptibility to nicotine dependence.
From that perspective, protecting people from tobacco, including misinformation and industry manipulation, is the ethical duty of the state that enhances individual liberty and the human right to health and a healthy environment. Using a 'nanny state' argument is not aimed at protecting the people’s freedom of choice but rather serves the industry’s interest. In addition, tobacco control policies are often widely accepted and supported by the population, especially when the focus is on protecting children and youth.
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Truth: While many policy measures related to tobacco endgame focus on reducing the appeal, addictiveness and availability of cigarettes, tobacco endgame can include a range of other products depending on the country’s context. Cigarettes are the deadliest consumer product on the market and the most consumed of existing tobacco products, and phasing out their sales will have a substantial impact on human health as well as the environment.
Yet, it is important to note that especially from the perspective of protecting future generations and preventing nicotine addiction (as by Article 5.2b of the WHO FCTC), focusing on cigarettes will not be enough. Some countries already have goals that also aim to end the use of other tobacco products, and some include even non-pharmaceutical nicotine products such as electronic cigarettes and nicotine pouches. This can be seen as a forward-looking approach to respond to industry strategies that aim to increase product portfolio and profit by attracting new, often young customers. It can also prevent some of the misuse of the tobacco endgame concept by the tobacco industry and related entities.
Tobacco industry is heavily emphasizing smoke-free approaches in its corporate messaging, using it to introduce and promote different new smokeless tobacco and nicotine products. For example, Philip Morris has established a Foundation for a Smoke-Free World, which recently changed its name to Global Action to End Smoking, as an attempt to get involved and influence the movement around tobacco endgame to shape it to industry purposes. Smokeless tobacco and nicotine products are often less regulated than combustible tobacco, providing industry an important channel to enter new markets and promote new products through legislative loopholes.
If new non-smoking generations take up smokeless tobacco or nicotine use, its impact on public health is only negative. Nicotine is a toxic and addictive chemical which has a lasting impact on youth brain development, and it impairs health in many ways even in the absence of tobacco.
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