Tobacco endgames:

What they are, why they are

needed, and why tobacco industry

denormalisation is essential

for achieving them

Ruth E. Malone, RN, PhD

University of California, San Francisco

May, 2012

Acknowledgments

• National Cancer Institute

• California Tobacco Related Disease

Research Program

• California Tobacco Control Program

• Neil Collishaw

• Smokefree Nurses– Grace Wong

• ASH NZ—Ben Youdan

The “secret”

tobacco industry documents

• Released after US state AG lawsuits starting 1998

• Over 70 million pages of material from major tobacco compaies

• Dates 1920s-present

• Ongoing releases

• Include budgets, memos, agendas, minutes, marketing plans, diaries, more

• http://legacy.library.ucsf.edu

Researchers

• Elizabeth Smith

• Valerie Yerger

• Naphtali Offen

• Patricia McDaniel

• Nathaniel Wander

• Laura Tesler

• Gina Intinarelli

• Susan Forsyth

• Quinn Grundy

Overview

• A tobacco endgame: what it is, and what it

is not

• Why endgame is needed

• Endgame scenarios

• Tobacco industry denormalisation’s role in

achieving endgame

• Readiness for the endgame

What is an ‘endgame’?

• Strategic plan to achieve near-zero smoking prevalence within a set transition period

• Addresses tobacco as system issue, not individual behavior issue

• Addresses both health and political aspects of the tobacco disease epidemic

• Fundamental de-normalisation of tobacco use AND industry disease promotion

What an endgame is not

• More of the same: Educational programs

telling kids they shouldn’t smoke

What an endgame is not

What an endgame is not

• More of the same: Telling smokers it is

bad for them and they should quit

What an endgame is not

• Continuing to hope that incremental

change will fix a public health emergency

Why endgames are needed

• Continuing and expanding global epidemic

• Incentives for tobacco companies to

increase consumption

• Interests of tobacco industry are

fundamentally incompatible with interests

of public health

Worldwide Tobacco

More than 5 million deaths/year now

10 million deaths/year by 2030

WHO

“If it’s that bad, why�?”

• Fundamental contradictions

--don’t do it message but ubiquitous

availability

--inconsistent with regulatory policy for other

deadly/dangerous products

--government complicity

Why endgames are needed

• Tobacco industry vector

• Adapts and mutates

• Undermines and counters public health

Before ban on ‘low tar’ descriptors

After ban on ‘low tar’ descriptors

The “anti-tobacco industry”

(ATI)

Endgame discourse:

An evolving conversation

• Gray et al. and others: Regulating nicotine

• Borland: Regulated Market Model

• Chapman: RX to purchase

• Gerace: Toxic-tobacco law

• Gilmore et al.: Tax/price controls

• Thompson, Edwards et al.: End sales

Other Endgame Ideas

• Incentivise industry to reduce consumption

(Callard & Collishaw, others)

• Limit sales outlets to state facilities

• Ban sales of combustibles (Daynard,

Proctor, others)

New Zealand:

Global Leader in Endgame

Discourse

• Vision of smokefree/auahi kore New

Zealand

• Sinking lid, other supply side proposals

• Nicotine reduction/alternatives

• Population research

Industry Denormalisation

“These threats have become manifest recently in

several markets, includingLNew Zealand where

anti-smoking coalitionsLlaunched aggressive

attacks on the industry and market freedoms.”

http://legacy.library.ucsf.edu/tid/dkj52f00

An endgameL

• Accepts that status quo cannot

continue

• Re-orders terms and reframes

• Promotes social norm change

• Advances social justice

Tobacco industry denormalisation

(TID)

• Reversal of the process of industry

normalisation promoted by the cigarette

manufacturers for decades

--Gar Mahood,

Canadian Nonsmokers’ Rights Association, 2004

How does TID advance

the endgame?

• Builds public support for industry regulation

• Builds public resistance to industry manipulation and interference in policy

• Foregrounds social justice issue

• Alters perceptions of normalcy of industry engaged in promotion of deadly products

• Complements other measures

Evidence for TID as

tobacco control intervention

TID as

tobacco control intervention

• Reviewed 60 studies of TID and smoking-

related outcomes

• TID associated with:

--reduced smoking prevalence

--reduced initiation risk

--reduced intention to smoke

--increased intention to quit smoking

California:

TID a key program component

• Social norm change

– --re smoking

– --re tobacco industry

Adult smoking prevalence,

California, 2010: 11.9%

“truth” campaign

• Youth-focused, youth-led campaign using TID message:

“Their brand is lies. Our brand is truth.”

Single most successful youth

smoking prevention campaign

in US history

American Legacy Foundation ‘truth’ branded body bag ad

Risks of not including strong TID

• Allows industry to define itself, forcing

reactive/defensive public health posture

• Allows industry to frame issues

• Lost opportunities to remind that industry

is enemy of public health

• Undermines government credibility

WHO priority issue

Many anticipating endgame

for a long timeL

• Since early 1990s, industry anticipating

• Financial analysts

• Luik: incrementalism vs radicalism

• Public is more ready than we think

Industry anticipating:

Philip Morris VP, early 1990s

Today all the facts seem to indicate

that tobacco is a could be dying

industry.

I think we all believe that our future

lies outside tobacco, and principally

in the food business. I certainly

believe this.

PM 2023027920/7949

Dump tobacco?

If at the end of two years it looks like it is

not working we should implement Option

A and get rid of the tobacco business.

PM 2023027920/7949

Denmark 2025

Sweden 2028

Australia 2030

Iceland 2033

Canada 2040

Norway 2042

Belgium 2051

Japan 2054

UK 2055

Spain 2056

New Zealand 2058

United States 2062

Netherlands 2091

Italy 2091

Finland 2093

France 2118

Greece 2231

Germany 2280

Current industry messages

• Individual choice/right/legal product

• ‘There is no smokefree future’/genie out

• ‘Tobacco control has not worked’

• ‘Better alternatives to radical regulation’ of

tobacco, e.g. address poverty, disease

• Radical agenda is immoral’ (‘quit or die’)

• ‘Harm reduction’ vs. addiction reduction

B&W 690010951/0959

“Doubt is our product” – 1969

“It is also the

means of

establishing a

controversy.”

Public ready:

Philip Morris Public Opinion Data

United States, 2004

Wish there was some way to

eliminate cigarettes 68%

Right and responsible thing to doL

go out of business 59%

tid zpe95a00

How TID Supports Smokefree 2025

• Quitting: Gives smokers additional motivation to quit, helps them anticipate industry activities aimed at preventing it

• Initiation: Appeals to youth/young adult desires for independence, engages tobacco as social justice issue

• Demand/Supply: Changes the conversation, reduces industry power and influence, builds political will

(Re)Defining the tobacco problem

• Sinful activity

• Medical problem

• Poor individual choices

• Youth smoking

• Vulnerable populations

• Environmental effects

• Medical care costs

• Unethical promotion

• Social injustice

• Corporate structure/activity

It doesn’t have to be this way

Industry claims: Black market, public outcry,

policy failure, governments ruined from

lack of taxes, nanny statism

Numerous examples: banned

pharmaceuticals, asbestos, lead paint

“You can’t�”

• Have nonsmoking sections in

restaurants

• Ban smoking on airplanes

• Have smokefree workplaces

• Ban tobacco advertising

Yes, we can—and must

World smoking

100 million dead 20th Century

1 billion dead 21st Century

Sir Richard Peto

Royal Society for Promotion of Health, 2004

NZ Next:

Plain packagingLand thenL?