Imagining things otherwise: new endgame ideas for tobacco control

EDITORIAL

Ruth E Malone

Correspondence to
Ruth E Malone, Professor of Nursing and Health Policy, Department of Social and Behavioral Sciences, University of California, San Francisco, 3333 California St Suite 455, San Francisco 94118, USA; ruth.malone@ucsf.edu

Contributors RM wrote the editorial.

Where are we going in tobacco control long-term, and how will we get there? This issue of Tobacco Control features three new contributions to the growing ‘endgame’ literature with possible answers to those questions: big-picture radical ideas that seek to propel the tobacco control movement more quickly towards a time when the global tobacco disease pandemic that began in the 20th century will be ended. Could the multitude of social structures and institutions that sustain the tobacco problem be unlinked? Could altered market forces—price controls, supply controls—render tobacco less attractive to those who profit most from continuing to addict new generations? Could there come a time when cigarettes—the most deadly consumer product ever made—will no longer be commercially sold? Can a stake someday be driven through the heart of the tobacco industry?

Endgame thinkers are the visionaries of the tobacco control movement. Early contributions to this literature, many of which were first published in this journal, included Borland’s regulated market model1; Callard, Thompson and Collishaw’s work on restructuring the industry so that it was incentivised to reduce consumption2; and calls for phasing out smoked tobacco products through various approaches.3–5 Others in this broad genre of work include Chapman’s6 call for licensing smokers, work on nicotine and other types of ingredient regulation to render cigarettes less or non-addictive,7 8 and other ‘big picture’ ideas.9 Increasingly, the idea that tobacco control is fundamentally a systems problem is becoming a part of global discussions.10 Major tobacco control programme successes also suggest that changing what tobacco use (and the tobacco industry) means is foundational to ending the global pandemic.11 12

In this issue, Gilmore and colleagues13 argue that regulating prices of tobacco through capping of manufacturers’ prices could reduce tobacco industry market power by eliminating manufacturers’ ability to disguise price increases and achieve higher profits. As they point out, in higher-tax western countries, the industry’s profits are increasing despite declining sales—profits that are then available to the industry to further promote tobacco use in the emerging markets of low-income countries.14 The thoughtful argument by Gilmore et al extends ongoing conversations about regulatory approaches to the tobacco market1 15 and offers an incentive for governments to act: an increased share of the money.

Khoo and colleagues16 propose a unique idea: end tobacco sales for those born after a certain date. Rather than focusing on preventing tobacco sales to minors, with the implicitly attractive ‘forbidden fruit’ message such approaches cannot avoid, the authors argue that their proposal to end sales to anyone born after the year 2000 would minimise immediate impact on stakeholders and allow time for transitions, while being entirely congruent with the tobacco industry’s assertions that they now seek to market only to existing smokers and not to youth. Interestingly, the authors’ preliminary work suggests strong public support for such an idea. Of course, Singapore is somewhat unique in its regulatory climate, but the idea offers a fresh perspective on ‘youth access’.

Addressing issues of supply is the focus of the proposal by Thomson et al17 for a ‘sinking lid’ on the commercial supply of tobacco, with quotas reduced gradually over a period of 10 years. Government-run auctions, such as those which have been used for other types of policies, would draw manufacturers to bid for a gradually decreasing amount of tobacco. If successful, they argue, such a system would increase the price of tobacco, contributing to reduced consumption. Combined with demand-reduction measures, such an approach could radically alter the tobacco control landscape within a country.

Could any of these latest big picture ideas really work? Perhaps not immediately, but they inspire us all to think beyond the next smoke-free ordinance or tobacco quitline. Perhaps they could not work in one country, but could be done in another—in one with more easily controlled borders, for example, in the New Zealand case, or in a country generally supportive of government regulation, as in the UK and Singapore.

It was through such visionary thinking that we began to understand that the suffering and death tobacco causes is not merely a problem of poor individual health behaviour choices, but of the rise of an entire industry focused on aggressively promoting deadly addictive products. It was through visionary thinking that we began to question whether breathing the smoke from others’ cigarettes might be harmful to non-smokers. It is visionary thinking, combined with skilled advocacy, that pushes governments to act more decisively to protect the public and to rein in the activities of tobacco companies.

Every person who becomes newly involved in the tobacco control movement, whether as an activist, researcher, programme planner or health professional, remembers that first moment of realising: it doesn’t have to be this way. Often, that realisation is coupled with the notion that cigarettes should just be banned, and incredulity that it has not already been done. Then, seasoned veterans explain the interlocking political, physiological, legal and economic webs that constrain such policy change. But the first step towards breaking through those webs is to rediscover our ability to imagine things otherwise.

The public may be more ready for radical changes than most policymakers recognise. Studies suggest there may be fairly strong support for ending tobacco sales.18–20 Earlier work drawing on tobacco industry documents showed that the industry’s own survey data from the early 2000s in the US suggested that a majority wished ‘there were some way to eliminate cigarettes’, supported banning cigarette advertising and felt that ‘the right and responsible thing for cigarette companies to do would be to phase out of the cigarette business.’21 Imagining things otherwise helps us see how to head towards where the public (and any rational person whose livelihood does not depend upon the tobacco status quo) already sees we should eventually go. But the tobacco control problem remains at its core a political problem: How to get governments to take bigger-picture actions to protect public health when a powerful industry opposes measures that threaten profits?

If we fail to exercise our moral imaginations to envision radical change, we are abandoning future generations to suffer and die from the mistakes of the past. We must instead continue to wrestle with, critique, develop and advocate for new visions of tobacco control. It doesn’t have to be this way.