It is time to plan the tobacco endgame

Malone et al. make a strong case for planning "the tobacco endgame" i.e. a world where tobacco consumption declines towards zero through concerted public health/governmental action[1]. The authors do not make clear the geographical scope of the the tobacco endgame. One asumes, one hopes they mean it in a global sense.

As a lifelong non-smoker and doctor with an interest in public health, I agree this is a laudible aim. Only the most recalcitrant contrarians can deny that tobacco is the pre-eminent avoidable threat to global public health.

But alas, whilst an appealing aim, the tobacco endgame is fraught with practical difficulties. The elimination of tobacco cannot be achieved with out comprehensive bans on the production, distribution and sale of tobacco products.

As we have seen throughout history and witness even today, banning an addictive substance guarantees only a proliferation in illegal black market activities. The so-called War on Drugs has cost billions of dollars/pounds yet narcotic drugs are still available on our streets[2]. Unfortunately, to hope that a complete ban on tobacco consumption everywhere is achievable is to dream the impossible dream (with apologies to Mitch Leigh and Joe Darion)[3].

I support ever more drastic tobacco control measures such as plain tobacco packaging for cigarettes[4]and the strategic aim of making smoking socially unacceptable. But a ban on the sale of tobacco would be difficult to implement and create new opportunities for organised and freelance criminals to profit from the addicted.

The Pandora's Box of tobacco was opened centuries ago. I don't think we can close it completely, but we can severely constrain tobacco consumption such that it is only practical/acceptable to smoke in one's own home or on private land. That is a dream worth dreaming.