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?
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