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Tobacco Endgame and Effective Tobacco Tax Policy

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Advancing the endgame for the tobacco pandemic

Advancing the endgame for the tobacco pandemic: Hāpai Te Hauora backs new research to achieve Smokefree 2025.

Hāpai Te Hauora supports new research on tobacco control published by the University of Otago in the British Medical Journal this month. “This is significant for the tobacco control sector” says Zoe Hawke, General Manager of the National Tobacco Control Advocacy Service for Hāpai Te Hauora.

“We have new strategies to advance Smokefree 2025 in Aotearoa and now we have an evidence base to support these strategies. Novel interventions can be difficult to advocate for without a track record to link outcomes to. The evidence presented in this study will go a long way to mitigating those difficulties. It also sends a clear message to decision-makers about the critical crossroads we’re at, and what we need to do if we’re serious about achieving Smokefree 2025.”

The study, titled “Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs: two modelling studies to inform the tobacco endgame” was a trans-Tasman collaboration between the University of Otago and the University of Melbourne. It was specifically focussed on the New Zealand Smokefree 2025 goal and identified major health gains and cost savings could be achieved by utilising:

1. 10% annual tobacco tax increases

2. a tobacco- free generation: a ban on the provision of tobacco to those born from a set year onwards

3. a substantial outlet reduction strategy

4. a sinking lid on tobacco supply

5. a combination of 1,2 & 3

These strategies are new and the study modelled their potential impacts using New Zealand-specific data to achieve their findings. The authors propose that the data are used as modelling-level evidence for countries looking to achieve health gains, cost savings and reduce inequities related to tobacco consumption. They suggest that the findings will be validated and improved upon as the interventions are adopted.

Hawke says supply reduction is the key to achieving Smokefree 2025, but it won’t be easy. “If we think we’ve seen battles with the tobacco lobby, we’ve seen nothing yet. Reducing supply is the final hurdle to removing this harmful product from our communities and you can guarantee it will be fiercely fought by the industry.”

Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs

Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs: two modelling studies to inform the tobacco endgame



There is growing international interest in advancing ‘the tobacco endgame’. We use New Zealand (Smokefree goal for 2025) as a case study to model the impacts on smoking prevalence (SP), health gains (quality-adjusted life-years (QALYs)) and cost savings of (1) 10% annual tobacco tax increases, (2) a tobacco-free generation (TFG), (3) a substantial outlet reduction strategy, (4) a sinking lid on tobacco supply and (5) a combination of 1, 2 and 3.


Two models were used: (1) a dynamic population forecasting model for SP and (2) a closed cohort (population alive in 2011) multistate life table model (including 16 tobacco-related diseases) for health gains and costs.


All selected tobacco endgame strategies were associated with reductions in SP by 2025, down from 34.7%/14.1% for Māori (indigenous population)/non-Māori in 2011 to 16.0%/6.8% for tax increases; 11.2%/5.6% for the TFG; 17.8%/7.3% for the outlet reduction; 0% for the sinking lid; and 9.3%/4.8% for the combined strategy. Major health gains accrued over the remainder of the 2011 population’s lives ranging from 28 900 QALYs (95% Uncertainty Interval (UI)): 16 500 to 48 200; outlet reduction) to 282 000 QALYs (95%UI: 189 000 to 405 000; sinking lid) compared with business-as-usual (3% discounting). The timing of health gain and cost savings greatly differed for the various strategies (with accumulated health gain peaking in 2040 for the sinking lid and 2070 for the TFG).


Implementing endgame strategies is needed to achieve tobacco endgame targets and reduce inequalities in smoking. Given such strategies are new, modelling studies provide provisional information on what approaches may be best.



FSvdD led the writing, intervention specification, adaptation of the established models, analyses and extraction and interpretation of the results. LJC and TB conceived the core aspects of the modelling approach for the BODE3 tobacco forecasting model and the BODE3 multi-state life-table model, but with design contributions from FSvdD for the first model, and from CLC, GK, FSvdD, NN and NW for the latter model. All authors provided advice during analyses, and contributed towards the interpretation of results and drafting of the paper. All authors approved the final manuscript.


FSvdD is supported by a University of Otago Doctoral Postgraduate Publishing Bursary. NW, CLC, GK, LJC, NN and TB are supported by the BODE3 Programme which is studying the effectiveness and cost-effectiveness of various health sector interventions and receives funding support from the Health Research Council of New Zealand (Grant number 10/248).

Competing interests

None declared.

Provenance and peer review

Not commissioned; externally peer reviewed.

Who Still Smokes? Designing the Tobacco Endgame

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Designing the Tobacco End Game

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National Cancer Institute – The Economics of Tobacco and Tobacco Control

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The Race to a Tobacco Endgame

Ruth E Malone

Correspondence to
Professor Ruth E Malone, Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, CA 94118, USA;

Accepted 5 October 2016

During the past month alone, I have had an opportunity to participate in four different meetings—in Utah, Sweden, Canada and the USA—where ideas about how to achieve an ‘endgame’ for the tobacco epidemic were being discussed. Other previous meetings—in India, Finland and the UK—have been held over the last few years, and I know of several other such discussions. Even before the US Surgeon General’s 50th Anniversary report on the health consequences of smoking1 called explicitly for achieving a tobacco endgame and suggested a combination of policy strategies to do so, other countries such as Ireland, New Zealand, Finland and Scotland were having conversations that led them to set hard target dates by which they intend to reduce tobacco use and/or smoking prevalence to <5%.

Modelling studies suggest that current measures, even if they are greatly accelerated in countries that are tobacco control leaders, will not achieve these goals within the first half of this century.1 As the target dates move closer, will political leaders seize the opportunity to enact the bolder policy innovations that must be undertaken? Or, will they allow caution and inertia to shape another century of public health catastrophe?

The endgame requires consciously designing interventions to change permanently the structural, political and social dynamics that sustain the epidemic, in order to end it by a specific time.2 Thus, an endgame vision goes beyond ‘business as usual’ and calls for further policy innovations. No one knows how to do it yet, but the endgame conversation3–6 has become mainstream, and the first places that manage to achieve it will herald the beginning of the end of more than a century of industrially produced carnage. Which places will be first to cross the finish line?

Several factors will likely be decisive.

The first of these is whether the public health community can achieve some rough unity as to the goal and strategies to be employed. We do not have to agree on everything, and some places will do things differently than others, but within any locale, some consensus will be needed or we risk confusing the public and giving policymakers more excuses not to act. There is no doubt that the tobacco industry is eager to exploit and/or create such divisions,7 so compromises will be needed. The controversy over e-cigarettes, for example, has created multiple lines of division among public health proponents. This disunity does not serve well the advancement of new policy measures to end the epidemic.8 Yet, e-cigarettes and the burgeoning list of other non-combustible tobacco and nicotine products could represent potential leverage for accomplishing what once seemed unthinkable: phasing out combustible cigarettes, the single most deadly consumer product ever marketed. Yes, these other products may cause harm. Yes, there may be unintended and unanticipated negative consequences. But we do not require a single additional study to know with absolute certainty that the continued sale and use of cigarettes will reliably deliver more disease, death and suffering than any other product. And we do know that for at least some people who smoke, the use of these alternative tobacco and nicotine products is acceptable as a substitute or a transition to quitting. Let’s keep our eyes on the prize.

The second decisive factor is whether the ground has been sufficiently prepared in getting the public to believe in and support ending the tobacco epidemic. The incongruence of telling the public how bad cigarettes are, while simultaneously continuing to allow their widespread retail sale, contributes to confusion at best and cynicism at worst. In this regard, multiple studies from various countries suggest that the public—including smokers—may be further along the road to an endgame than we public health proponents have allowed ourselves to go. In Canada, for example, data from Wave 9 and preliminary analyses of Wave 10 of the ITC Survey, a nationally representative cohort study, show that more than half of smokers would support a complete ban on cigarettes within 10 years, if the government provided assistance to quit.9 These findings are consistent with several studies conducted in other countries, as well as internal data from tobacco company Philip Morris’s own public opinion surveys, which found that in the USA in 2004, 68% of those surveyed wished there was some way to get rid of cigarettes.10–12 However, such findings have never been used to develop effective campaign messaging to build a constituency for endgame measures.

A third element is whether policymakers in the location are courageous enough to tackle something new and politically risky, about which they will incur attacks from tobacco companies and their allies. Big Tobacco will raise every conceivable argument, arguing that protecting the public from these unreasonably dangerous and defective products infringes on rights, will create vast black markets, and will ruin economies. But governments have an obligation to act to protect public health, tobacco companies themselves have been implicated in black market trading, and to argue that we must keep killing people in order to sustain our economy seems to put the entire social enterprise in question. In addition, the places now closest to achieving a tobacco endgame are those where prevalence has dropped to historical lows, suggesting that the transition to new economic and business models is inevitable: policymakers should be anticipating and preparing for a different kind of economy.

Finally, achieving a tobacco endgame will reflect how well public health proponents work alongside and with the communities that are now most affected by the tobacco epidemic. ‘Nothing about us without us’ is an important principle as smoking and tobacco use become more concentrated among certain population groups, each of which has different resources, needs and priorities. The tobacco industry’s targeting and exploitation is one part of how these disparities in tobacco use came to be, but the whole story is much more complex, especially for indigenous peoples. Now Big Tobacco hides behind these groups, claiming, for example, that tax increases hurt the poor—despite evidence that such increases actually benefit poor people more (because they quit in greater numbers) than wealthier groups.13 But those alliances are beginning to fray. For example, activists in the US African-American community, concerned with the consequences of high menthol cigarette use, are providing aggressive leadership on efforts to pressure government to get menthol out of tobacco products.14 New Zealand Maori leaders’ report in 2010 led to establishment of that country’s Smokefree 2025 goal.15

While for many countries, combustible tobacco products are the biggest issue to be addressed, in others like India, dangerous oral tobacco products proliferate. Some countries already have robust regulatory infrastructures that are trusted by the public; others are only beginning to build the capacity that would allow more radical measures such as limiting sales outlets for cigarettes or setting a timetable for a phaseout. This is why ‘there is no single endgame’, as Arnott16 pointed out several years ago. But even tobacco companies are beginning to realise that the endgame is in sight.

I recently received in the mail a heavy envelope from overseas, containing a ‘Global Compact Report’ from Philip Morris International, along with a personalised letter encouraging me to review it and engage in dialogue. One line jumped out at the end of the first paragraph, which focused largely on spin about the company’s latest reinvention of itself as a responsible, transparent seller of death and disease: a reference to ‘acknowledging and addressing the social harms caused by our products, including the phase out of combustible cigarettes’. This oddly written sentence would be cause for genuine excitement if the report actually said anything specific about phasing out cigarettes, but it did not appear to do that. Nowhere could I find any plan or timetable for such a phaseout, despite the company’s touting of new ‘heat-not-burn’ products and reference to leading an effort to ‘replace’ cigarettes with them. Elsewhere, such products are also reassuringly reported as not ‘cannibalising’ existing cigarette brands in test markets,17 suggesting they are not really seen as substitutes for them any time in the near future. Meanwhile, the industry keeps marketing the same old deadly stuff all over the world. So, we simply cannot count on the tobacco companies to make the endgame happen.

They are getting ready for us to tell them they have to stop. But we have to make them do it. Let’s tell them when this epidemic has to end.

Which country will go first?

Competing interests None declared.

Provenance and peer review Not commissioned; internally peer reviewed.

↵ US Department of Health and Human Services. The health consequences of smoking: 50 years of progress: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
↵ Malone RE, McDaniel PA, Smith EA. Tobacco control endgames: global initiatives and implications for the UK. Cancer Research UK, 2014. http://wwwcancerresearchukorg/sites/default/files/policy_july2014_fullendgame_reportpdf
↵ Malone RE. Imagining things otherwise: new endgame ideas for tobacco control. Tob Control 2010;19:349–50. doi:10.1136/tc.2010.039727 [FREE Full text]
↵ Smith EA. Questions for a tobacco-free future. Tob Control 2013;22(Supp1 1):i1–2. doi:10.1136/tobaccocontrol-2013-051066 [FREE Full text]
↵ Warner KE. An endgame for tobacco? Tob Control 2013;22(Supp1 1):i3–5. doi:10.1136/tobaccocontrol-2013-050989 [Abstract/FREE Full text]
↵ McDaniel PA, Smith EA, Malone RE. The tobacco endgame: a qualitative review and synthesis. Tob Control 2016;25:594–604. doi:10.1136/tobaccocontrol-2015-052356 [Abstract/FREE Full text]
↵ McDaniel PA, Smith EA, Malone RE. Philip Morris’s Project Sunrise: weakening tobacco control by working with it. Tob Control 2006;15:215–23. doi:10.1136/tc.2005.014977 [Abstract/FREE Full text]
↵ Gartner C, Malone RE. Duelling letters: which one would you sign? Tob Control 2014;25:369–70. Google Scholar
↵ Chung-Hall J, Craig L, Driezen P, et al. Canadian smokers’ support for tobacco endgame strategies: findings from the ITC Canada Survey. Ontario, Canada: ITC Project University of Waterloo, 2016. Google Scholar
↵ Edwards R, Wilson N, Peace J, et al. Support for a tobacco endgame and increased regulation of the tobacco industry among New Zealand smokers: results from a National Survey. Tob Control 2013;22:e86–93. doi:10.1136/tobaccocontrol-2011-050324 [Abstract/FREE Full text]
↵ Wang MP, Wang X, Lam TH, et al. The tobacco endgame in Hong Kong: public support for a total ban on tobacco sales. Tob Control 2015;24: 162–7. doi:10.1136/tobaccocontrol-2013-051092 [Abstract/FREE Full text]
↵ Altria [Parrish S]. Corporate affairs societal alignment/regulation update. 2004. https://wwwindustrydocumentslibraryucsfedu/tobacco/docs/znyv0024
↵ Furman J. Six lessons from the US experience with tobacco taxes. World Bank Conference paper: winning the tax wars: global solutions for developing countries. 2016.
↵ Tavernise S. Black health experts renew fight against menthol cigarettes. New York Times. 13 September 2016. Google Scholar
↵ Maori Affairs Committee. Inquiry into the tobacco industry in Aotearoa and the consequences of tobacco use for Maori. 49th Parliament, New Zealand. 2010.
↵ Arnott D. There’s no single endgame. Tob Control 2013;22(Suppl 1):i38–i9. doi:10.1136/tobaccocontrol-2012-050823 [Abstract/FREE Full text]
↵ Caplinger D. Philip Morris International, Inc’s best move so far this year. The Motley Fool. 2016. http://wwwfoolcom/investing/2016/08/26/philip-morris-international-incs-best-move-in-2016aspx