This is the question several scholars, scientists and policy experts address in a provocative series of articles on various strategies for eliminating tobacco use, if not entirely, at least enough to significantly slow the global death toll estimated at 1 billion people by the end of this century, with the status quo.
It's called the tobacco endgame—unique and radical strategies to end tobacco dependence.
From dramatically reducing nicotine to total abolition of cigarette sales, the series of articles includes six endgame strategies and a number of essays written to encourage public debate, said Kenneth Warner, the Avedis Donabedian Distinguished University Professor of Public Health and professor of health management and policy at the University of Michigan.
"If you had told me 10 years ago that smoking today would be banned in all workplaces, including all restaurants and bars in 30 countries, I would have said, 'You are out of your mind,'" said Warner, who also is the former dean of the U-M School of Public Health.
"There is a newfound interest in discussing the idea of an endgame strategy. The fact that we can talk about it openly reflects a sea change."
Through a grant from the Robert Wood Johnson Foundation, with additional support provided by the American Legacy Foundation, Warner hosted a meeting of 40 top tobacco control advocates last June, during which endgame strategies were discussed. The series of articles, appearing online now in the journal Tobacco Control and in print next month, was an outgrowth of that discussion.
Some of the strategies outlined in the articles include:
- A policy that requires manufacturers to reduce nicotine content to make cigarettes nonaddictive.
- A "sinking lid" strategy that would call for quotas on sales and imports of tobacco, which would reduce supply and drive up prices, thereby deterring the purchase of tobacco.
- A "tobacco-free generation" proposal calling for laws that would prevent the sale of tobacco to those born after a given year, usually cited as 2000, to keep young people from starting to smoke.
- A case for abolition, which calls for a total ban on cigarette sales.
Additional articles address political obstacles to the endgame, ethical and legal challenges, and the likelihood of a black market arising as tobacco becomes less available legally.
Although smoking has declined significantly in most developed nations in the last half-century, due to policy changes and increased education about the health hazards, tobacco control advocates say too many people continue to die from the most preventable cause of premature death and illness.
"What we are doing today is not enough," Warner said. "Even if we do very well with tobacco control, as we have for several decades now, we'll have a huge number of smokers for years to come, and smoking will continue to cause millions of deaths.
It's estimated that worldwide currently some 6 million people a year die from illness caused by cigarettes, including more than 400,000 in the U.S. alone.
"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 been—will likely not make the tobacco problem disappear," said Elizabeth Smith of the University of California-San Francisco, who edited the publication. "Discussion of an endgame can inspire new visions of the possible."
- Articles: http://tobaccocontrol.bmj.com/content/22/suppl_1.toc
- Kenneth Warner: www.sph.umich.edu/iscr/faculty/profile.cfm?uniqname=kwarner
- U-M School of Public Health: www.sph.umich.edu
- Robert Wood Johnson Foundation: www.rwjf.org/en.html