Appendix 2 Forward-looking (“endgame”) measures in tobacco control

As the prevalence of smoking has declined substantially in high-income countries, there has been increasing interest in policy options that could largely eliminate tobacco use. These forward-looking or “endgame” measures are usually defined as policies that could drastically and rapidly reduce smoking prevalence, often with a goal of reaching a predefined prevalence target within a specified timeframe (e.g., reducing smoking prevalence to <5% by a certain year).^1-3 Examples of such policies are described throughout Tobacco in Australia: Facts & issues and include:

• ‘Tobacco free generation’ policies that would ban the sale of tobacco to those born in or after a specified year
• Reducing the nicotine content in cigarettes to a level low enough that they are effectively non-addictive
• Drastically reducing the number of retailers that can sell tobacco products
• Requiring people who smoke to obtain a licence to purchase tobacco products
• Regulating tobacco products to make them less appealing or palatable
• Substantial increases in tobacco taxation

Other proposed measures include:

• A ‘sinking lid’ (i.e., steadily decreasing quotas) on tobacco sales or imports
• Limiting sale and supply of tobacco products to agencies that receive a fee-for-service for providing users with products and comprehensive information about supports available to treat nicotine addiction, which has been referred to as a ‘regulated market model’^4-6
• A complete phase-out or ban on the sale of tobacco products

While the evidence on these strategies is limited, modelling studies support their potential to lead to substantial health and economic benefits,^7-9 including among priority populations who experience disproportionate harm from tobacco use.⁷

Proponents of such strategies often recommend combining several of these measures. For instance, the Smokefree Aotearoa legislation¹⁰ (passed in late 2022 but subsequently repealed in early 2024)¹¹ included a tobacco-free generation, a significant reduction in the number of tobacco retail outlets, and a dramatic reduction in nicotine content in smoked tobacco products to non-addictive levels.

References

1. Tamil Selvan S, Yeo XX, and van der Eijk Y. Which countries are ready for a tobacco endgame? A scoping review and cluster analysis. Lancet Glob Health, 2024; 12(6):e1049-e58. Available from: https://www.ncbi.nlm.nih.gov/pubmed/38762285

2. Ruokolainen O, Ollila H, Laatikainen T, Patsi SM, Carreras G, et al. Tobacco endgame measures and their adaptation in selected European countries: A narrative review synthesis. Tob Prev Cessat, 2024; 10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/38638446S

3. Ollila H, Ruokolainen O, Laatikainen T, Koprivnikar H, and and J-WPc-a. Tobacco endgame goals and measures in Europe: current status and future directions. Tob Control, 2024. Available from: https://www.ncbi.nlm.nih.gov/pubmed/38886051

4. Borland R. A strategy for controlling the marketing of tobacco products: a regulated market model. Tobacco Control, 2003; 12(4):374-82. Available from: https://tobaccocontrol.bmj.com/content/tobaccocontrol/12/4/374.full.pdf

5. Liberman J. The future of tobacco regulation: a response to a proposal for fundamental institutional change. Tobacco Control, 2006; 15(4):333-8. Available from: https://tobaccocontrol.bmj.com/content/tobaccocontrol/15/4/333.full.pdf

6. Borland R. Why not seek clever regulation? A reply to Liberman. Tobacco Control, 2006; 15(4):339-40. Available from: https://tobaccocontrol.bmj.com/content/tobaccocontrol/15/4/339.full.pdf

7. Ait Ouakrim D, Wilson T, Waa A, Maddox R, Andrabi H, et al. Tobacco endgame intervention impacts on health gains and Maori:non-Maori health inequity: a simulation study of the Aotearoa/New Zealand Tobacco Action Plan. Tob Control, 2023. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36627213

8. Zeng Z, Cook AR, and van der Eijk Y. What measures are needed to achieve a tobacco endgame target? A Singapore-based simulation study. Tob Control, 2023. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37280063

9. Ait Ouakrim D, Wilson T, Howe S, Clarke P, Gartner CE, et al. Economic effects for citizens and the government of a country-level tobacco endgame strategy: a modelling study. Tob Control, 2023. Available from: https://www.ncbi.nlm.nih.gov/pubmed/38050170

10. Ministry of Health. Smokefree Aotearoa 2025 Action Plan. Wellington: Ministry of Health, 2021. Available from: https://www.health.govt.nz/publications/smokefree-aotearoa-2025-action-plan.

11. Andrew A. New Zealand's world-first smokefree legislation 'goes up in smoke': A setback in ending the tobacco epidemic. Health Policy, 2024; 147:105123. Available from: https://www.ncbi.nlm.nih.gov/pubmed/39018787