Most adults initiate smoking as adolescents 12 and now wish they could quit. It has that rare combination of being uniquely harmful to health and heavily addictive, with enormous social and economic costs to families and communities. However, the case for paternalism-interfering with individuals’ liberty to protect and promote their best interests-is particularly powerful in the case of tobacco control. In most other contexts, adults are permitted to make harmful choices that are primarily self-regarding. Adults, even if well informed, may smoke for personal reasons-whether to alleviate anxiety, combat weight gain or simply for pleasure. A generational cutoff, for example, would (in time) prohibit informed adults from purchasing cigarettes. 11 Warning labels inform consumers, clean air laws protect third parties from second-hand smoke, taxes internalise the social costs of smoking, while age limits and marketing restrictions ostensibly protect minors.Įndgames depart from this paradigm. Autonomous decision making is the norm, notwithstanding evidence of nicotine dependence. 10Įxisting tobacco controls encourage prevention and smoking cessation but respect adult autonomy while shielding others from the associated harms and costs. 9 Endgame strategies must avoid the pitfalls of alcohol prohibition-popular revolt and underground tobacco markets-and should not be implemented until prevalence is low (eg, under 15%), governments are strongly committed and public support overwhelming.
‘Endgames’ would shift regulatory focus to the supply side of the market 3: limiting nicotine content below addictive levels 4 raising pH to un-inhalable levels 5 entrusting tobacco marketing and/or supply to a nonprofit agency, mandated to drive sales down 6 7 imposing a ‘sinking lid’ on the supply of tobacco available for commercial sale, driving prices upward 8 and setting a generational cutoff (eg, banning sale to anyone born after 1999).
2Ĭonsequently, there is growing interest in ‘endgame strategies’, following the full implementation of existing measures. 1 This progress risks stalling in double-digit percentages, at the potential cost of a billion lives over the coming century, as established measures reach a point of diminishing returns.
Low-income and middle-income countries are gradually implementing similar measures, and evidence of effectiveness is emerging. Smoking prevalence in high-income countries has dropped considerably due to a suite of population-level strategies: education campaigns, warning labels, advertising restrictions, clean air laws, age limits and taxation.