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BackgroundThe Aotearoa/New Zealand Government is aiming to end the tobacco epidemic and markedly reduce Māori:non-Māori health inequalities by legislating: (1) denicotinisation of retail tobacco, (2) 95% reduction in retail outlets and (c) a tobacco free-generation whereby people born after 2005 are unable to legally purchase tobacco. This paper estimates future smoking prevalence, mortality inequality and health-adjusted life year (HALY) impacts of these strategies.MethodsWe used a Markov model to estimate future yearly smoking and vaping prevalence, linked to a proportional multistate life table model to estimate future mortality and HALYs.ResultsThe combined package of strategies (plus media promotion) reduced adult smoking prevalence from 31.8% in 2022 to 7.3% in 2025 for Māori, and 11.8% to 2.7% for non-Māori. The 5% smoking prevalence target was forecast to be achieved in 2026 and 2027 for Māori males and females, respectively.The HALY gains for the combined package over the population’s remaining lifespan were estimated to be 594 000 (95% uncertainty interval (UI): 443 000 to 738 000; 3% discount rate). Denicotinisation alone achieved 97% of these HALYs, the retail strategy 19% and tobacco-free generation 12%.By 2040, the combined package was forcat to reduce the gap in Māori:non-Māori all-cause mortality rates for people 45+ years old by 22.9% (95% UI: 19.9% to 26.2%) for females and 9.6% (8.4% to 11.0%) for males.ConclusionA tobacco endgame strategy, especially denicotinisation, could deliver large health benefits and dramatically reduce health inequities between Māori and non-Māori in Aotearoa/New Zealand.

ObjectiveTo estimate smoking-attributable mortality in the long-term future in 29 European countries using a novel data-driven forecasting approach that integrates the wave pattern of the smoking epidemic and the cohort dimension.MethodsWe estimated and forecasted age-specific and age-standardised smoking-attributable mortality fractions (SAMF) and 95% projection intervals for 29 European countries by sex, 1950–2100, using age-period-cohort modelling with a generalised logit link function. We projected the (decelerating) period increases (women) by a quadratic curve to obtain future declines, and extrapolated the past period decline (men). In addition, we extrapolated the recent cohort trend.ResultsSAMF among men are projected to decline from, on average, 25% in 2014 (11% (Sweden)—41% (Hungary)) to 11% in 2040 (range: 6.3%–15.4%), 7% in 2065 (range: 5.9%–9.4%) and 6% in 2100. SAMF among women in 21 non-Eastern European countries, currently at an average of 16%, are projected to reach peak levels in 2013 (Northern Europe), 2019 (Western Europe), 2027 (Greece, Italy) and 2022 (Central Europe), with maximum levels of, on average, 17% (8% (Greece)—28% (Denmark)), and to decline to 10% in 2040 (range: 4%–20%), 5% in 2065 (range: 3.5%–7.6%) and 4% in 2100. For women, a short-term shift in the peak of the inverse U-shaped age pattern to higher ages is projected, and crossovers between the age-specific trends.ConclusionOur novel forecasting method enabled realistic estimates of the mortality imprint of the smoking epidemic in Europe up to 2100. The high peak values in smoking-attributable mortality projected for women warrant attention.

Much of the progress in reducing cigarette smoking and tobacco-related morbidity and mortality among youth and adults is attributable to population-level strategies previously described in the context of the Tobacco Control Vaccine. The retail environment is used heavily by the tobacco industry to promote and advertise its products, and variations in exposure to and characteristics of the retail environment exist across demographic groups. It is therefore also an essential environment for further reducing smoking, as well as ameliorating racial, ethnic and socioeconomic tobacco-related disparities. This commentary provides an overview of the importance of incorporating strategies focused on the tobacco retailer environment (availability; pricing and promotion; advertising and display; age of sale; and retail licensure) as part of a comprehensive approach to tobacco prevention and control. To reach tobacco endgame targets, such innovative strategies are a complement to, but not a replacement for, long-standing evidence-based components of the Tobacco Control Vaccine.

BackgroundThe tobacco industry targets future generations to maintain its profits. One of its tactics is to maintain its presence noticed at the level of retail environment. Measures to address this high presence are identified in the literature. Our study examines the effects of six of these identified tobacco retail reduction measures in reducing the total number of tobacco retailers and the number of retailers within 500, 1000 and 2000 m from youth-oriented facilities.MethodsData were collected by scraping Google Places on examination points including locations, opening hours, type and subtype of tobacco retailers in addition to educational, youth, health and religious facilities. The six studied measures were enacted using Python codes to assess the reduction percentage. The measures included restricting tobacco retail outlets per density of population, requiring a minimum distance between tobacco retailers, banning tobacco retail outlets within a minimum distance from specific facilities, banning tobacco sale in specific retail outlets, restricting tobacco retail outlets per geographic area and limiting the number of hours in which tobacco can be sold.ResultsThe data collected showed a high presence of tobacco retailers around vital facilities, particularly youth-oriented ones. The six scenarios implemented showcased a positive reduction in the number of tobacco retailers in total and around youth-oriented facilities. The total reduction of retailers varied from 4% up to total elimination of availability.Discussion and conclusionsOur study presents an example of measurable reduction impact of six tobacco retail reduction measures. The high percentage in reduction achieved, especially around youth-oriented facilities, is worth the attention of policy-makers to be considered as countermeasures for the high tobacco industry presence in retail.

The successes of tobacco control in some countries and locales have led to discussions of ending the tobacco epidemic, often called the ‘endgame’. In this paper, we recommend articulating the endgame goal as phasing out sales of cigarettes, a goal once called ‘unthinkable’. We develop a logic and argumentation for ending cigarette sales intended to move the discussion beyond the shadow of ‘prohibition’, proposing an approach that appeals to consumer protection standards and suggesting that the effort be led by low-prevalence communities. While phasing out cigarettes will not happen everywhere all at once, and may unfold differently along several lines, we argue that the gradual phase-out approach we propose will reduce the likelihood of the negative consequences often predicted to come with such a policy. To continue permitting widespread sales of the single most deadly consumer product in history is a public health failure that must be addressed.

BackgroundAotearoa New Zealand passed world-leading legislation to implement tobacco endgame policies, including greatly reducing the number of tobacco retailers. British American Tobacco New Zealand and Imperial Brands Australasia tried to undermine this policy via the ‘Save Our Stores’ (SOS) campaign, which purportedly represented small convenience store owners’ interests.MethodsWe used the Policy Dystopia Model as a framework to review discursive and instrumental strategies employed in the SOS campaign. Specifically, we critically analysed the arguments, narratives and frames employed in the campaign.ResultsMost SOS arguments drew on discursive strategies that emphasised unanticipated costs to the economy and society, and presented a near-apocalyptic future. Adverse outcomes included economic mayhem, thriving illicit trade, increased violent crime, fewer police, and heavier individual tax burdens. The campaign framed the government as an authoritarian legislator with misplaced priorities and used disinformation to bolster these claims. We identified a new normalisation narrative used to present very low nicotine cigarettes (VLNCs) as experimental and, by implication, risky. A metanarrative of lawlessness and decreased public safety connected the different claims.ConclusionTo address the existential challenges they face, tobacco companies used several discursive strategies to oppose the retailer reduction and VLNC policies. Our findings could inform counterarguments, and help international policymakers and advocates anticipate opposition they may encounter when introducing endgame measures, such as reducing tobacco availability.

BackgroundThe endgame literature recommends that, for a tobacco sales ban to be successful, several demand-side preconditions (eg, low prevalence and effective cessation support) should be in place. The South African Government imposed a ban on the sale of all tobacco and vaping products between 27 March and 17 August 2020, as part of the COVID-19 lockdown.ObjectivesTo assess how cigarette smokers responded to the sales ban, to evaluate how the ban impacted the cigarette market in South Africa and to use the South African experience to inform endgame planning.MethodsRegular preban cigarette smokers completed an online questionnaire from 4 to 19 June 2020 (n=23 631), in which they reported on their prelockdown cigarette smoking patterns, quitting behaviour (if relevant) and smoking behaviour during the ban.ResultsAbout 9% of prelockdown smokers in the sample successfully quit smoking. 93% of continuing smokers purchased cigarettes despite the sales ban. The average price of cigarettes increased by 250% relative to prelockdown prices. Most respondents purchased cigarettes through informal channels.ConclusionsThe demand-side preconditions for an effective sales ban were not in place in South Africa, making a sales ban inappropriate. The South African experience suggests that supply-side factors are also important in ensuring the success of a sales ban. These are: (1) the illicit market must be under control before implementing a sales ban; and (2) an effective sales ban needs to be synchronised with a ban on the manufacture, transport and distribution of cigarettes.

BackgroundSmoking is the leading preventable cause of death in Australia, with disproportionate harms experienced by Aboriginal and Torres Strait Islander peoples. Recognising Indigenous perspectives provided impetus for a commercial tobacco endgame in Aotearoa/New Zealand, and Indigenous perspectives may assist policy adoption in Australia.PurposeThe study aimed to identify the necessary conditions for the adoption of endgame policies in Australia, with an emphasis on Indigenous perspectives.MethodsSemi-structured interviews with Australian tobacco control policy actors were conducted between November 2023 and April 2024. We analysed data from 28 people (26 interviews, two written responses), including 6 Indigenous people. Template analysis was guided by endgame goals and policies, the Multiple Streams Framework and the Decolonising Framework. Indigenous perspectives were prioritised in the interpretation.ResultsPolicy failures, particularly the vaping epidemic, were a key theme. There was broad consensus among Indigenous peoples and non-Indigenous members of the dominant policy community for stronger tobacco and vape supply restrictions, and varied views on other endgame policies. Political barriers included tobacco tax revenue and resistance from the commercial sector. Facilitators included the tobacco control playbook, a favourable political environment, the popularity of tobacco-free generation policy and opportunities to broaden the lobby base.ConclusionThe tobacco control playbook will remain important in promoting policy innovation, as will resisting the influence of the commercial sector. Indigenous leadership is essential for all Australians and may open additional policy windows and drive reforms that are equitable, effective, community-driven and commensurate with the scale of harms.

Endgame thinking means transitioning from merely trying to ‘control’ the tobacco epidemic to developing plans and measures to bring it to an end within a specific time, by changing the underlying dynamics that have created and perpetuated it for more than a century. Among the innovative policies characterised as ‘endgame’ policies are so-called ‘tobacco-free generation’ or ‘smoke-free generation’ policies, which prohibit sales of some or all tobacco products to individuals born on or after a particular date. Such birthdate-based sales restrictions (BSR) have intuitive appeal, largely because they do not appreciably disrupt the status quo of retail sales, which continue unchanged for all those born before the designated cut-off date. They also hold the potential for further denormalising tobacco use and sales by anticipating the long-term end of tobacco sales. In this Special Communication, we analyse BSR policies through an endgame lens and propose questions that should be discussed in jurisdictions considering them. We suggest that this policy has potential underexamined pitfalls, particularly related to equity, and that if enacted, it should include policy guardrails and be part of a package of endgame measures.