The Endgame

Download book chapter
Call To Action

Policymakers must utilize existing strategies that have been proven effective in reducing tobacco prevalence, and they must explore bold, innovative tactics to achieve the endgame for tobacco use.

Adult prevalence needed to meet WHO target of a 30% relative reduction in prevalence of current tobacco use from 2010 baseline

Full implementation of proven WHO FCTC & MPOWER policies is capable of reducing tobacco use far below current levels. Tobacco control has already resulted in many remarkable changes in the last 50 years, with the abolition of most overt tobacco promotion, smoke-free public and workplace laws, large graphic warnings on cigarette packs in over 60 countries, and plain/standardized packaging initiated in Australia.

Others believe that the tobacco epidemic is unlikely to be ended by today’s evidence-based interventions, and question whether new and radical solutions are required, including fundamental reform of the tobacco industry—whether commercial or government monopoly.

Newly-suggested measures include supply-side strategies to curb the tobacco industry, such as new structures through which tobacco products would be supplied, removal of the profit incentive from selling tobacco products, or even the outright abolition of commercial tobacco product manufacture and sale. Other ideas include harm reduction by reducing the harmful content of cigarettes, or shifting away from smoking combustible products towards potentially safer ways of delivering nicotine. Some jurisdictions are examining prohibition of possession of tobacco products by all individuals born in or after the year 2000, or framing tobacco as a development and poverty issue in order to attract the attention and thus funding of the development community.

The regulatory framework may differ from country to country. For both implementing existing measures OR introducing new measures, all countries will need to put immediate and much greater emphasis on stronger enforcement, particularly of smoke-free areas, price policies and cessation.

Every historical achievement—such as flight, the conquest of Mount Everest, or votes for women—was preceded by many people saying it couldn’t be done, wouldn’t work, or would create new problems. But the benefits of envisioning an endpoint for the tobacco epidemic are far greater than any risks.

Novel Ideas

Some examples of proposals to help reach endgame goals:


  • Reduce nicotine to non-addictive levels
  • Eliminate cancer-producing substances
  • Ban combustibles
  • Make cigarettes less appealing (increase pH level to discourage deep inhalation, remove menthol, remove all ingredients besides tobacco, remove filters)
  • Ban multiple versions of the same brand
  • Ban addition of tobacco to food items (e.g. Gutkha)


  • Nationalize tobacco companies
  • Reporting standards for WHO FCTC Article 5.3


  • Complete prohibition of tobacco
  • Regulate as a controlled substance
  • Make tobacco available by prescription only
  • Require a smoker’s license, renewable annually
  • Require staggered starting fees to discourage beginners
  • Ban supply of tobacco to anyone born after a certain year (e.g. Singapore, year 2000)
  • Stronger licensing laws for selling tobacco
  • Limit the number/types of retail outlets


  • Market control measures (e.g. wholesale price floors, import quotas)
  • $1 tax on all international air travel that goes to departure country’s National Tobacco Control budget


  • Change label legislation from “health warning” to “package message”
  • Integrate brand name into package message, associating brands themselves with message
  • Aim message at party other than the smoker (“Tell Mom to quit”…)
  • Plain/standardized packaging with no color, brand images; only brand name


  • Make cessation services free to all smokers
  • Legalize cytisine, as cheaper, safe alternative to other quit pharmaceuticals


  • Set endgame target date
  • Frame tobacco use within toxic waste/environmental health context
  • Target harm of discarded cigarette butts by banning cigarettes with filters


Warner KE. An endgame for tobacco? Tob Control. 2013 May 1;22(suppl 1):i3–5.

Proctor RN. Why ban the sale of cigarettes? The case for abolition. Tob Control. 2013 May 1;22(suppl 1):i27–30.

Malone RE. Tobacco endgames: what they are and are not, issues for tobacco control strategic planning and a possible US scenario. Tob Control. 2013 May 1;22(suppl 1):i42–4.

Berrick AJ. The tobacco-free generation proposal. Tob Control. 2013 May 1;22(suppl 1):i22–6.

Maubach N, Hoek JA, Edwards R, Gifford H, Erick S, Newcombe R. “The times are changing”: New Zealand smokers’ perceptions of the tobacco endgame. Tob Control. 2012 Jun 16;tobaccocontrol – 2011–050398.

Arnott D. There’s no single endgame. Tob Control. 2013 May 1;22(suppl 1):i38–9.

Borland R. The need for new strategies to combat the epidemic of smoking-related harm. Tob Control. 2012 Mar 1;21(2):287–8.

Myers ML. The FCTC’s evidence-based policies remain a key to ending the tobacco epidemic. Tob Control. 2013 May 1;22(suppl 1):i45–6.

Callard CD, Collishaw NE. Supply-side options for an endgame for the tobacco industry. Tob Control. 2013 May 1;22(suppl 1):i10–3.

Benowitz NL, Henningfield JE. Reducing the nicotine content to make cigarettes less addictive. Tob Control. 2013 May 1;22(suppl 1):i14–7.

Smith EA. Questions for a tobacco-free future. Tob Control. 2013 May 1;22(suppl 1):i1–2.

Khoo D, Chiam Y, Ng P, Berrick AJ, Koong HN. Phasing-out tobacco: proposal to deny access to tobacco for those born from 2000. Tob Control. 2010 Oct 1;19(5):355–60.

Borland R. Minimising the harm from nicotine use: finding the right regulatory framework. Tob Control. 2013 May 1;22(suppl 1):i6–9.

Callard C, Collishaw NE. Exploring vector space: overcoming resistance to direct control of the tobacco industry. Tob Control. 2012 Mar 1;21(2):291–2.


30% relative reduction in prevalence of current tobacco use in persons aged 15+ years from 2010 baseline, by 2025

Prevalence rate of 5% or below by an announced date

2025: New Zealand

10 strategies to reach endgame by 2025

  1. Smoke-free cars
  2. Making cigarettes harder to purchase
  3. Plain/standardized packs
  4. Smoke-free communities
  5. Banning duty-free tobacco
  6. Tax hikes
  7. Mass media shock tactics
  8. Removing all flavor enhancers
  9. Transparency of all tobacco lobbyists’ dealings with government
  10. Quit-smoking support


Impact of implementation of existing policies; global smoking prevalence, 2010–2030

Existing policies have immense potential to greatly decrease global smoking prevalence.

“Together, experience since 1964 and results from models exploring future scenarios of tobacco control indicate that the decline in tobacco use over coming decades will not be sufficiently rapid to meet targets. THE GOAL OF ENDING THE TRAGIC BURDEN OF AVOIDABLE DISEASE AND PREMATURE DEATH WILL NOT BE MET QUICKLY ENOUGH WITHOUT ADDITIONAL ACTION.” -US Surgeon General’s Report, 2014

Tobacco use is the world’s leading cause of preventable premature death, and is likely to remain so for decades to come.


A 2007 proposal in Singapore would ban the provision of tobacco products to any Singaporeans BORN IN OR AFTER THE YEAR 2000; surveys showed a large majority of Singaporeans—including current smokers—would support such a proposal.

If smokers transition to e-cigarettes in large numbers, both the endgame targets and dates may be very different.

Download book chapter