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Time to bid farewell to tobacco with endgame strategy

15 November 2022

By Judith Mackay, ChinaDaily

A bold new strategy has emerged with countries declaring an “endgame” on tobacco, similar to the triumphant winning series of moves of the same name in a game of chess. The tobacco endgame is usually defined as reducing the percentage of smokers to 5 percent or less.

The endgame is an idea that has been long in coming. No commercial enterprise would operate without short- and long-term targets, yet tobacco control has been remarkably slow in adopting goals. One reason is that governments are sometimes uneasy in announcing targets in case these are not met.

Globally, tobacco-control legislation, tax policy and health promotion has increased steadily since the 1960s, yet for every country this has been an ongoing struggle. The obstacles are many: lack of political will, lack of awareness of magnitude of harm (the reality is that two-thirds of smokers die from their smoking), preoccupation with other issues, misperceived economic concerns, no understanding of the environmental consequences, a focus on curative medicine and not prevention, and lack of funds for research and intervention.

However, the biggest obstacle is the tobacco industry’s opposition spelled out in the Tobacco Industry Interference Indexes: by its promotion, distortion of health and economic evidence, financial might, front groups, exaggerating the economic importance of the industry; manipulating public opinion to gain the appearance of respectability, especially in the time of COVID-19; and intimidating governments with threats of litigation or trade restrictions.

The endgame

In a national tobacco conference in Finland in 2006, the keynote speaker, chair of the Finnish Parliament and former prime minister Paavo Lipponen, asked the delegates: “What is your ultimate goal? Why don’t you aim for a tobacco-free Finland by 2040?” The proposal struck a chord, and the idea took hold, initially in Finland, then spreading around the world.

The Finnish Tobacco Act of 2010 was a global landmark in that it included a new objective: to end the use of tobacco by 2040. The Tobacco Act of 2016 was even more ambitious — it included all tobacco and nicotine-containing products and brought the target date forward to 2030. Currently, about 40 jurisdictions have openly committed to endgame targets, including China and its Hong Kong Special Administrative Region.

In announcing targets, countries produce a road map of measures they must take, often accompanied by an interim timeline to check they are on track. Some add bold new moves, such as a “smoke-free generation”, in which all children born after a certain date will never be able to buy tobacco. New Zealand plans to reduce retail outlets to 10 percent of their current level, as well as removing nicotine from tobacco products to remove the addictive craving to smoke.

The latest country to pursue an endgame goal is Malaysia, when it presented a new bill that included a clause to ban sale of tobacco products to those born in 2007 onward. On Sept 30, 2022, prominent international organizations signed a letter of support for Malaysia’s endgame concept. They supported the reduction of the percentage of smokers by applying stringent tobacco control measures according to the World Health Organization Framework Convention on Tobacco Control (FCTC). These include tax increases that reduce affordability, advertising and marketing bans, point-of-sale display bans, public smoking bans, large pictorial pack warnings, plain packaging, mass media campaigns, and support for tobacco cessation.

Many jurisdictions are already on their way, notably without depending on the use of e-cigarettes, such as Hong Kong, Panama and Singapore. Australia allows e-cigarettes only by medical prescription for smokers that have failed other cessation therapies, while Finland includes all nicotine products (such as e-cigarettes) in its 2030 endgame target. In countries where e-cigarettes have been widely available, such as the US, UK, Canada, and New Zealand, e-cigarette use has not accelerated the decline of smoking prevalence.

Opposers to the endgame policy have predictably been Big Tobacco and its front groups and allies, using a slew of misinformation and unsubstantiated claims.

The rationale of pursuing an endgame policy includes the recognition that tobacco products should never have been legalized in the first place. The international organizations noted the fact that cigarettes are still sold legally today is a historical abnormality that should be corrected. In 2021, over 140 organizations around the world called for the phaseout of cigarette sales, noting they kill more than 8 million people globally each year.

An endgame policy offers the confidence that the epidemic can be beaten. It focuses governments on the strategies needed to reach the endgame and ensures an orderly plan of action year by year — there is no longer the need for governments and nongovernmental organizations to spend time and effort lobbying for annual tax increases.

Achieving an endgame, as in chess, requires careful planning. The focus must be on the tobacco industry, not just on tobacco users; on supply, not just demand; on supporting quitting for those already smoking, not just focusing on youth prevention. It requires a human-rights perspective, for the production and marketing of tobacco is irreconcilable with the human right to health. Just by producing and marketing their products, the tobacco industry is a human-rights violator. Governments have a right and duty to end the tobacco epidemic.

Not all governments, especially those with high smoking prevalence rates, are ready to commit to an endgame target of 5 percent. The WHO has suggested an interim reduction for each individual country by the year 2025.

Even at the turn of the century, many would have said that ending tobacco use could not be done. Yet every historical achievement — air flight, eradicating smallpox, women’s suffrage, conquering Qomolangma (Mount Everest) — was preceded by many naysayers, saying it would create new problems, wouldn’t work or couldn’t be done. Fortunately, history also shows that in each and every one of those game-changing events, it’s proved repeatedly that where there is a will, there is a way. And I can see only a positive endgame to this tobacco endgame.

The author is a special adviser to the Global Center for Good Governance in Tobacco Control, a senior policy adviser to the World Health Organization, and director of the Asian Consultancy on Tobacco Control.

The views do not necessarily reflect those of China Daily.