Intended for healthcare professionals

Observations Tobacco Control

It is time to plan the tobacco endgame

BMJ 2014; 348 doi: (Published 11 February 2014) Cite this as: BMJ 2014;348:g1453
  1. Ruth Malone, professor and chair1, editor in chief2,
  2. Patricia McDaniel, assistant adjunct professor1,
  3. Elizabeth Smith, associate adjunct professor1
  1. 1Social and Behavioral Sciences, School of Nursing, University of California, San Francisco
  2. 2Tobacco Control
  1. ruth.malone{at}

It is essential for the UK to extend its focus beyond tobacco control to plan a tobacco free future

The tobacco disease epidemic is an industrially produced phenomenon. Though people have used tobacco in various ways for centuries, the modern epidemic resulted directly from the industrialisation, engineering, and aggressive marketing of the cigarette—without doubt the single most deadly consumer product ever made.1 2 The industrial production of disease calls for measures that go beyond discouraging unhealthy individual behaviour to tackle policy and social norm changes. Smoke-free policies help, but as long as cigarettes remain ubiquitous, it is easy for people to rationalise: “They can’t be that bad if they are still sold everywhere.” There is a major and increasingly inexplicable lack of congruence between the way cigarettes are regulated and the regulation of many other dangerous products (most of which cause far less disease and death when used as intended).

Yet too many public health professionals remain fearful of even suggesting that to end the epidemic these products should, at some point, no longer be easy to buy. They fear that doing so will incite “nanny state” criticism and charges that government is intruding on consumers’ “choice,” despite the fact that 70% of smokers say they want to quit and almost every smoker regrets having started.3 Despite the carnage of the past, the tobacco industry has been astonishingly effective in convincing even public health leaders that we should censor ourselves and focus primarily on changing individual behaviour.

In a forthcoming report commissioned by Cancer Research UK we recommend that the United Kingdom undertake a serious effort to bring to an end the UK tobacco disease epidemic—the tobacco endgame, as it has become known in tobacco control circles.4 5 We define a tobacco endgame as initiatives designed to change or permanently eliminate the structural, political, and social dynamics that sustain the tobacco epidemic, so as to achieve, within a specific time, an endpoint for the tobacco epidemic. Endgame discourse centres on the idea that it is essential to extend our planning beyond a focus on tobacco control (and its concomitant assumptions that tobacco is here to stay and therefore that the policy objective is to regulate the time, place, and manner of its use) towards planning a tobacco-free future.6

Full implementation of measures called for by the World Health Organization’s Framework Convention on Tobacco Control remains the primary short term goal for tobacco control, and no country in the world has yet achieved this—thus in the immediate future calling for endgame planning would change little. Even in the UK, with its strong commitment to tobacco control, tobacco remains the leading preventable cause of death.7 The key findings of our forthcoming report are:

  • Research shows that even if uptake of smoking entirely ceased, and cessation increased beyond any targets reached to date, there would still be several decades of high healthcare costs attributable to smoking. Without additional measures these costs and the preventable suffering they represent will extend even further into the future.

  • A smoking prevalence of 5% or lower, regarded by many experts as an endpoint to achieve, would be insufficient to end the epidemic.

  • Countries regarded as tobacco control leaders are instituting endgame planning, calling for specific smoking prevalence targets by specific dates, as Scotland has already done.

  • The UK, while a leader in cessation, lags behind other jurisdictions in the use of mass media to “denormalise” the tobacco industry and its products.

Despite the worries of some that the word “endgame” isn’t appropriate or that raising its prospect now may distract from more immediate goals, it has recently begun to capture the imagination of the worldwide tobacco control movement, being a theme of a recent international conference in India and discussed in plenaries at major national, regional, and international meetings. A recent special issue of Tobacco Control highlighted several endgame proposals and commentary.

Research conducted in several Western countries indicates that the public might be more supportive of a tobacco endgame than is generally thought. For example, a survey in England in 2008 found that 49% of people who had never smoked, 41% of former smokers, and 33% of smokers supported phasing in a tobacco sales ban within 10 years.8 In Victoria, Australia, in 2010 53% of adults overall and 42% of smokers agreed that a tobacco sales ban should be phased in within 5-10 years.9 In the United States in 2011 53% of non-smokers and 33% of smokers agreed that cigarettes should be banned in the next decade.10 A new Hong Kong study found that 68% of people who had never smoked, 59% of former smokers, and 45% of smokers supported a ban on tobacco sales within 10 years.11

It is notable that these levels of support were found in the absence of any organised campaign to engage the public in understanding the reasons for and preparing for a tobacco endgame.

It’s time to break through the self imposed silence and declare that a tobacco endgame must be planned. If endgame discussions draw fire from the tobacco companies and their front groups and defenders, that will create opportunities to point out that most reputable companies confronted with the fact that their products killed half their long time users would pull them from the market. One thing is certain: if the public health sector, including government, does not begin the endgame conversation, no one else will. For the sake of future generations we should start now.


Cite this as: BMJ 2014;348:g1453


  • Competing interests: Cancer Research UK commissioned the authors to prepare a report on tobacco endgames for the UK discussed in this article but had no role in this article.

  • News: Major US pharmacy chain plans to stop selling cigarettes (BMJ 2014;348:g1442, doi:10.1136/bmj.g1442); Letter: Smoking prevalence in England is below 20% for the first time in 80 years (BMJ 2014;348:g1378, doi:10.1136/bmj.g1378)

  • Commissioning and peer review: Not commissioned; not peer reviewed.