Scholars Pose Endgame Strategies for Tobacco Use

Apr 24, 2013, 10:45 AM

file Kenneth Warner, University of Michigan School of Public Health

Do we need an endgame strategy to finally end the devastating hold tobacco has on its users? Scholars, scientists and policy experts grapple with endgame proposals in a special supplement to the journal Tobacco Control. Some of the articles are based on a workshop held last year at the University of Michigan, with financial support from the Robert Wood Johnson Foundation and the American Legacy Foundation. The workshop was hosted by Kenneth Warner, PhD, a former dean at the University of Michigan School of Public Health and now a professor at the School.

Although smoking has declined significantly in most developed nations in the last half-century, due to policy changes and increased education about the health hazards, says Warner, too many people continue to die from the most preventable cause of premature death and illness. It's estimated that worldwide six million people a year die from illnesses caused by cigarettes, including more than 400,000 in the U.S. alone."There is a newfound interest in discussing the idea of an endgame strategy. The fact that we can talk about it openly reflects a sea change,” says Warner.

>>Read the articles in the tobacco endgame supplement.

Some of the strategies in the supplement include:

  • Requiring manufacturers to reduce nicotine content sufficiently to make cigarettes nonaddictive.
  • A "sinking lid" strategy that would call for quotas on sales and imports of tobacco, which would reduce supply and drive up price to deter tobacco purchases.
  • A "tobacco-free generation" proposal calling for laws that would prevent the sale of tobacco to those born after a given year, usually cited as 2000, to keep young people from starting to smoke; or ban the sale of cigarettes altogether.

"What we are doing today is not enough," says Warner.  "Even if we do very well with tobacco control, as we have for several decades now, we'll have a huge number of smokers for years to come, and smoking will continue to cause millions of deaths.”

NewPublicHealth recently spoke with Dr. Warner about some of the strategies proposed for ending tobacco use.

NewPublicHealth: Why is there a need for novel, even radical, endgame strategy?

Ken Warner: While a lot of people have quit smoking, if you look at the rate at which people are quitting in the United States, in the last few years it may actually have declined. In Canada, there is some concern that their very low rates of smoking may actually have gone up. In Singapore, which had the lowest smoking prevalence among developed nations, the smoking rate went up from 12.6 percent to 14.3 percent between 2004 and 2010. So what we're observing is that in some of the countries that have had pretty good success with tobacco control, smoking is now being reduced somewhat more slowly, or possibly even increasing. And if we stay at the current rate of smoking, or even if the smoking rate continues to decline slowly, smoking will remain the leading cause of preventable premature death for many years to come.

NPH: What are some of the reasons that we’re seeing a plateau in the reduction of tobacco use?

Ken Warner: Many people have just gotten tired of the issue and believe that it has been solved. And to some of the people who matter in terms of getting policies enacted or getting action going, smoking has become fairly invisible. You can't smoke in most public places, you can't smoke in the workplace, none of their friends smoke, they go to restaurants and bars and nobody's smoking.

When you consider the younger generation, students are not surrounded by smoking at the same level they were 10, 20 years ago. When I think about my campus, the University of Michigan, 20 or 30 years ago if I was walking across campus I would always see a bunch of students walking around with cigarettes in their hands. Today, it's very rare to see students smoking on campus, and it's not even allowed on ours. So I think it's not perceived by the younger generation as being a problem.

Increasingly, people from the lower socioeconomic and educational groups are the victims. The estimates vary, but there are people who have suggested as much as 50 percent of the difference in death rates between high and low socioeconomic groups can be attributed to smoking. There’s probably nothing else you can do that would address health disparities more than getting rid of smoking. 

NPH: Are there any episodes in our public health history that present a model for eradicating tobacco use?

Ken Warner: One that I can think of where there's been true eradication is smallpox. Many of us think of smoking as a socially contagious disease and there is a lot of evidence of social contagion for behaviors like smoking. Given that, we have to think about how we can knock out a contagious illness, and the infectious-disease model is a pretty good one in that regard. But when you think about the smallpox example, you recognize that we needed a sustained, substantial and even dramatic full-court press effort to get rid of the disease. It took a commitment of the nations of the world, the World Health Organization and others, to get the job done.

NPH: What can we learn from innovative efforts throughout the world that might strengthen endgame strategies in the U.S.?

Ken Warner: With two notable exceptions, all of the major endgame proposals come from other countries. The intriguing aspect is that other countries might be able to implement endgame policies at a level that we cannot, or at least haven’t been able to today – and if they do, we'll learn a lot from that. The Kingdom of Bhutan prohibited the sale of cigarettes several years ago and you can't smoke pretty much anywhere at all there in public. It's as close to an endgame scenario as we have in the world, and it seems like not many people are using tobacco there now.

In New Zealand, their idea is “the sinking lid.” You put a cap on the supply of cigarettes and work it downward to the point where you have no supply by, let's say, 10 years from now. That could work in New Zealand because it's an isolated island nation, so they have the ability to control supply far better than we would with our very large and porous borders. So they could undertake the experiment and we could learn from them exactly what kinds of problems would be expected, what kind of success can be achieved.

The concept of prohibiting tobacco possession by anyone born after a certain year, particularly the year 2000, emanates from Singapore, and the government of Tasmania in Australia is seriously contemplating adopting that policy. If they were to do that, it would be a very interesting model.

Even smoke-free workplaces contribute to the idea of the end game. To put that into perspective, today the idea that a state or a nation might prohibit smoking in workplaces, including restaurants and bars, is just kind of par for the course. Thirty states now do that in the U.S., and 30 to 40 countries worldwide. If you had asked me, just 10 years ago, whether I thought banning smoking in all restaurants, bars and workplaces was possible, I would have never thought so.

NPH: Is there room for new strategies here?

Ken Warner: There's no question about it. And we need them. We know that the evidence-based strategies are only taking us just so far. We can't get rid of the tobacco disease burden using the policies and interventions that we know work, even if we do much more with them than we have so far.

I've been working in this field since 1975 and I've seen so much radical and dramatic change in attitudes toward smoking, behavior, and policy. I've learned that I can't predict what's going to happen 10 years from now, and that I shouldn’t expect that radical notions may not one day become the norm.

One thing that’s working in our favor more than probably ever before is that we now have a regulatory environment that creates the potential to get something done in a big way. The new Center for Tobacco Products at the Food and Drug Administration gives the FDA authority to regulate cigarettes and smokeless tobacco. That said, how far they're going to go, and how successful they’ll be, remains to be seen. The political obstacles, and the economic obstacles for that matter, are enormous.

NPH: Is the tobacco control community talking about an endgame strategy?

Ken Warner: We haven't really had this discussion in the tobacco control community; we've never been close enough to the end to discuss what the end should be. We need to have that discussion and I'm hoping that this supplement will, among other things, awaken the tobacco control community to the need to discuss what our goal is, what are we striving to achieve.

My definition of the end is a very pragmatic one; it's minimization of the harm that’s associated with tobacco and nicotine use. I do know that with our current set of policies and interventions, we're not minimizing harm. We've reduced harm, but there are a lot of people smoking who don’t want to be, and if they had the proper assistance they probably wouldn't be. If we had an environment that was devoid of some of the positive imagery associated with smoking in advertising, if we start to see the large, graphic warning labels on packs that, until now, have been held up in the courts, if we had much higher prices from cigarettes, if we had serious regulation that the FDA could actually achieve, that they could actually do some significant things through a regulatory model—we would significantly reduce the damage caused by smoking and other tobacco use. The Center for Tobacco Products in the FDA knows a lot that they could do today that would have that impact, but they don’t have the political power or the will to do it.  We need to help them get create a political constituency.

NPH: What do you hope the next steps will be?

Ken Warner: We need to have a much broader discussion in the public health community. So, it’s a function initially of raising awareness and interest. And the idea of talking about an endgame itself may increase interest, just because it is sort of a radical notion.

In the near term, a critical issue is having the public health and tobacco control communities work with the Center for Tobacco Products to determine how they can do the most good to reduce the harm of tobacco products. A notable example, and perhaps the most important one, is that the law that created the Center also gave it the authority to reduce or require the removal of various ingredients from cigarettes. With regard to nicotine, it prohibited FDA from requiring the removal of all nicotine from cigarettes. However, it did give them the authority to reduce the amount of nicotine in cigarettes, and it appears very clear that they could reduce the amount of nicotine in cigarettes to levels that most experts think would be non-addictive.

All of this said, our current efforts don’t minimize what we’ve already accomplished. There's probably not been any intervention in the second half of the 20th century in developed countries that has done more to reduce the number of deaths, and increase life expectancy, than tobacco control. By the same token, tobacco remains the greatest single cause of preventable premature death in America. The problem now is that we're learning that our tried and true interventions, the time-tested ones, the ones that we know empirically work, are not sufficient to get the next major leap forward in reducing smokin

This commentary originally appeared on the RWJF New Public Health blog.