Should tobacco sales be restricted to state-run alcohol outlets? Perspectives from 10 US alcohol control states.

BACKGROUND AND AIMS: The ubiquity of tobacco retailers helps to sustain the tobacco epidemic. A tobacco retail reduction approach that has not been tried is transitioning tobacco sales to state-controlled alcohol stores (TTS), which are limited in number and operate under some restrictions, e.g. regarding opening hours or marketing materials. This study summarizes policy experts' and advocates' views of TTS, including (1) advantages and disadvantages; (2) feasibility; and (3) potential implementation obstacles. DESIGN: This study was a qualitative content analysis of semi-structured interviews. SETTING: Ten US states with alcoholic beverage control systems were included. PARTICIPANTS: The participants comprised a total of 103 tobacco control advocates and professionals, public health officials, alcohol policy experts and alcohol control system representatives, including two tribal community representatives. MEASUREMENTS: Interviewees' perspectives on their state's alcoholic beverage control agency (ABC, the agency that oversees or operates a state alcohol monopoly) and on TTS were assessed. FINDINGS: Interviewees thought TTS offered potential advantages, including reduced access to tobacco products, less exposure to tobacco advertising and a greater likelihood of successful smoking cessation. Some saw potential long-term health benefits for communities of color, due to the smaller number of state alcohol stores in those communities. Interviewees also raised concerns regarding TTS, including ABCs' limited focus on public health and emphasis on revenue generation, which could conflict with tobacco use reduction efforts. Some interviewees thought TTS could enhance the power of the tobacco and alcohol industries, increase calls for alcohol system privatization or create difficulties for those in recovery. CONCLUSIONS: In the United States, transitioning tobacco sales to state-controlled alcohol stores (TTS) could have a positive public health impact by reducing tobacco availability, marketing exposure and, ultimately, tobacco use. However, tensions exist between alcohol control system goals of providing revenue to the state and protecting public health. Should a state decide to pursue TTS, several guardrails should be established, including building into the legislation an explicit goal of reducing tobacco consumption.

Epidemiological Model for Conventional Tobacco Control Measures and Tobacco Endgame Policies.

Epidemiological models, also known as host-agent-vector-environment models, are utilized in public health to gain insights into disease occurrence and to formulate intervention strategies. In this paper, we propose an epidemiological model that incorporates both conventional measures and tobacco endgame policies. Our model suggests that conventional measures focus on relationships among agent-vector-host-environment components, whereas endgame policies inherently aim to change or eliminate those components at a fundamental level. We also found that the vector (tobacco industry) and environment (physical and social surroundings) components were insufficiently researched or controlled by both conventional measures and tobacco endgame policies. The use of an epidemiological model for tobacco control and the tobacco endgame is recommended to identify areas that require greater effort and to develop effective intervention measures.

Tobacco consumption, sales, and output as monitoring indicators in the era of the tobacco endgame: a Korean example.

OBJECTIVES: The consumption, sales, and output of tobacco products each suggest different areas of intervention for tobacco control. In the era of the tobacco endgame, as increasingly stronger supply-side measures are implemented, multifaceted indicators that assess both supply and/or demand are required. We aimed to estimate the consumption of cigarette and heated tobacco products (HTPs) and sought agreement between the various indicators. METHODS: The annual cigarette and HTP consumption in 2014-2020 was calculated using the frequency and intensity of cigarette use from representative surveys of adults and adolescents by sex and age. Sales and output data were acquired from governmental sources. Spearman correlation coefficients and Bland-Altman plots were used to compare the indicators. RESULTS: Tobacco output, cigarette sales, and cigarette consumption were greatest in 2014. The HTP consumption calculated for 2020 was 292.28 million packs. Cigarette consumption and sales correlated significantly, as did tobacco output and tobacco sales. A Bland-Altman plot comparing the difference between cigarette consumption and sales showed that this difference was largest in 2014, immediately before cigarette prices increased. With the exception of a single year, all cigarette consumption values were within the limits of agreement for cigarette sales and tobacco output. CONCLUSIONS: Our analyses showed agreement between demand-side (tobacco consumption) and supply-side (sales and output) indicators. We recommend using all indicators to monitor the impacts of tobacco control on both demand and supply sides. The systematic use of various indicators is critical to achieve the end of the tobacco epidemic.

Towards Tobacco-Free Generation: implementation of preventive tobacco policies in the Nordic countries.

AIMS: Europe's Beating Cancer Plan set a goal of creating a Tobacco-Free Generation in Europe by 2040. Prevention is important for achieving this goal. We compare the Nordic countries' preventive tobacco policies, discuss the possible determinants for similarities and differences in policy implementation, and provide strategies for strengthening tobacco prevention. METHODS: We used the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) to identify the key policies for this narrative review. We focused on Articles 6, 8, 9, 11, 13 and 16 of the WHO FCTC, and assessed the status of the required (core) and recommended (advanced) policies and their application to novel tobacco and nicotine products. Information on the implementation of strategies, acts and regulations were searched from global and national tobacco control databases, websites and scientific articles via PubMed and MEDLINE. RESULTS: The WHO FCTC and European regulations have ensured that the core policies are mostly in place, but also contributed to the shared deficiencies that are seen especially in the regulations on smokeless tobacco and novel products. Strong national tobacco control actors have facilitated countries to implement some advanced policies - even as the first countries in the world: point-of-sale display bans (Iceland), outdoor smoking bans (Sweden), flavour bans on electronic cigarettes (Finland), plain packaging (Norway), and plain packaging on electronic cigarettes (Denmark). CONCLUSIONS: Collaboration and participation in reinforcing the European regulations, resources for national networking between tobacco control actors, and national regulations to provide protection from the tobacco industry's interference are needed to strengthen comprehensive implementation of tobacco policies in the Nordic countries.

Drawing on Adolescent Psychology to Achieve Tobacco-Free Generations.

Background: In 2021, the European Union called for creation of a "tobacco-free generation." We consider the means to this end. The persistence of youthful noncompliance with current minimum age laws (leading to widespread subsequent addiction, morbidity and mortality) raises questions whether such laws are truly aligned with adolescent psychology. Evidence: The ubiquity of minimum-age laws limits direct evidence of their effectiveness, so we seek indirect evidence. Qualitative findings originally intended for tobacco manufacturers indicate counterproductive aspects of minimum-age laws. Further evidence about adolescent reactions is provided by a recent review and meta-analysis of greater youth defiance of under-age laws than whole-of-life laws in the domain of motorcycle helmets. Policy Options and Recommendations: As an alternative to minimum-age laws, we consider the Tobacco-Free Generation proposal (TFG), which phases out sales on an age cohort basis and has recently gained prominence. Conclusion: The Tobacco-Free Generation proposal (TFG) seems well aligned with adolescent psychology, and is therefore especially worthy of attention. It has recently been introduced or endorsed by a number of jurisdictions, both local and national.

The Tobacco Endgame-A New Paradigm for Smoking Cessation in Cancer Clinics.

Smoking cessation represents an untapped resource for cancer therapy. Many people who smoke and have cancer (tobacco-related or otherwise) struggle to quit and as a result, jeopardise response to treatment, recovery after surgery and long-term survival. Many health care practitioners working in cancer medicine feel undertrained, unprepared and unsupported to provide effective smoking cessation therapy. Many institutions and healthcare systems do provide smoking cessation programs, guidelines and referral pathways for cancer patients, but these may be unevenly applied. The growing body of evidence, from both retrospective and prospective clinical studies, confirms the benefit of smoking cessation and will provide much needed evidence for the best and most effective interventions in cancer clinics. In addition to reducing demand, helping cancer patients quit and treating addiction, a firm commitment to developing smoke free societies may transform cancer medicine in the future. While the Framework Convention for Tobacco Control (FCTC) has dominated global tobacco control for the last two decades, many jurisdictions are starting to develop plans to make their communities tobacco free, to introduce the tobacco endgame. Characterised by downward pressure on tobacco supply, limited sales, limited access and denormalization of smoking, these policies may radically change the milieu in which people with cancer receive treatment, in which health care practitioners refine skills and which may ultimately foster dramatic improvements in cancer outcomes.

The Lebanese Regie state-owned tobacco monopoly: lessons to inform monopoly-focused endgame strategies.

BACKGROUND: Many countries have started pursuing tobacco 'endgame' goals of creating a 'tobacco-free' country by a certain date. Researchers have presented models to attain this goal, including shifting the supply of tobacco to a monopoly-oriented endgame model (MOEM), wherein a state-owned entity controls the supply and distribution of tobacco products. Although not designed to end tobacco use, the Regie in Lebanon exhibits some of the key features identified in MOEM and hence can serve as a practical example from which to draw lessons. METHODS: We comprehensively review previous literature exploring tobacco endgame proposals featuring a MOEM. We distil these propositions into core themes shared between them to guide a deductive analysis of the operations and actions of the Regie to investigate how it aligns (or does not) with the features of the MOEM. RESULTS: Analysing the endgame proposals featuring MOEM, we generated two main themes: the governance of the organisation; and its operational remit. In line with these themes, the investigation of the Regie led to several reflections on the endgame literature itself, including that it: (i) does not seem to fully appreciate the extent to which the MOEM could end up acting like Transnational Tobacco Companies (TTC); (ii) has only vaguely addressed the implications of political context; and (iii) does not address tobacco growing despite it being an important element of the supply chain. CONCLUSION: The implementation of tobacco endgame strategies of any type is now closer than ever. Using the Regie as a practical example allows us to effectively revisit both the potential and the pitfalls of endgame strategies aiming to introduce some form of monopoly and requires a focus on: (i) establishing appropriate governance structures for the organisation; and (ii) adjusting the financial incentives to supress any motivation for the organisation to expand its tobacco market.

Perspective on Cancer Control: Whither the Tobacco Endgame for Canada?

Aims: In 2014, in response to evidence that Canada's tobacco use would lead, inexorably, to substantial morbidity and mortality for the foreseeable future, a group of experts convened to consider the development of a "Tobacco Endgame" for Canada. The "Tobacco Endgame" defines a time frame in which to eliminate structural, political, and social dynamics that sustain tobacco use, leading to improved population health. Strategies: A series of Background Papers describing possible measures that could contribute to the creation of a comprehensive endgame strategy for Canada was prepared in advance of the National Tobacco Endgame Summit hosted at Queen's University in 2016. At the summit, agreement was reached to work together to achieve <5% tobacco use by 2035 (<5 by '35). A report of the proceedings was shared widely. Achievements: Progress since 2016 has been mixed. The Summit report was followed by a national forum convened by Health Canada in March 2017, and in 2018, the Canadian Government adopted "<5 × '35" tobacco use target in a renewed Canadian tobacco reduction strategy. Tobacco use has declined in the last 5 years, but at a rate slower than that which will be needed to achieve the <5 by '35 goal. There remain > 5 million smokers in Canada, signaling that smoking-related diseases will continue to be an enormous health burden. Furthermore, the landscape of new products (e-cigarettes and cannabis) has created additional risks and opportunities. Future directions: A bold, reinvigorated tobacco control strategy is needed that significantly advances ongoing policy developments, including full implementation of the key demand-reduction policies of the WHO Framework Convention on Tobacco Control. Formidable, new disruptive policies and regulations will be needed to achieve Canada's Endgame goal.

Freedom of choice and the tobacco endgame.

Endgame proposals strive for a tobacco-free (or at least cigarette-free) society. Some endgame proposals are radical and include, for example, a complete ban on cigarettes. Setting aside empirical worries, one worry is ethical: would such proposals not go too far in interfering with individual freedom? I argue that concerns around freedom do not speak against endgame proposals, including strong proposals such as a ban on cigarettes. I first argue that when balancing freedom with public health goals in tobacco control, the latter win out. But I also argue that, in principle, a concern with freedom itself already justifies endgame measures. First, such measures can increase people's lifetime freedom, that is, the freedom they have across their entire lives. Second, such measures can facilitate a better interpersonal distribution of freedom by increasing aggregate societal freedom and by reducing inequalities. Overall, freedom does not preclude strict tobacco control but supports it.

California advocates' perspectives on challenges and risks of advancing the tobacco endgame.

In the USA, California's highly-regarded Tobacco Control Program (CTCP) has defined its goal as "ending the tobacco epidemic for all population groups" by 2035. To understand local advocates' perceptions of endgame-oriented policies, we interviewed 28 advocates from California communities that had recently adopted tobacco control policies. There was no consensus among participants on which specific policies would constitute the tobacco endgame in California. There was an agreement, however, that policymakers should promote policies that would impact communities with the highest tobacco use prevalence and that policies should be 'clean', avoiding exemptions. Participants were cognizant of California's history of tobacco control policy innovations beginning locally and eventually being adopted at the state level. Many commented that recent policy innovations in the state had begun a conversation that made more 'radical' ideas seem possible. California tobacco control advocates are engaged in local endgame policy discussions and prepared to advance California's endgame goal.

Positive perceptions of electronic cigarettes relative to combustible cigarettes are associated with weaker support for endgame policies on combustible cigarettes: A population-based cross-sectional study in Hong Kong.

INTRODUCTION: Positive perceptions of electronic cigarettes (e-cigarettes) relative to combustible cigarettes (CCs) may erode support for endgame policies on CCs through smoking renormalization (increasing public acceptance of smoking). We investigated the associations between perceptions of e-cigarettes relative to CCs and support for endgame policies on CCs in Hong Kong. METHODS: Adult respondents (N=2004) were surveyed using landline random digit dialing in 2015. Perceived relative harm and relative addictiveness of e-cigarettes were combined as an overall perception of e-cigarettes relative to CCs with 5 levels and we analyzed individually 'neutral/positive/mixed/unknown' perceptions against the 'negative' perception. Five individual items with dichotomous responses assessed the support for endgame policies on CCs. Support for banning the sale/use of CCs (yes/no) was also assessed. Multivariable regressions yielded adjusted odds ratios (AORs) of supporting endgame policies (individual policy items, all 5 policy items, at least 1 policy item, banning the sale/use of CCs) in relation to perceptions of e-cigarettes relative to CCs, adjusting for age, education attainment, marital status, CC smoking status and ever e-cigarette use. RESULTS: Support for individual endgame policy items (from 51.8% to 80.0%), banning the sale (63.8%) and use (67.5%) of CCs were generally high. Few respondents perceived e-cigarettes as more harmful (16.6%) or more addictive (9.3%) than CCs. Positive perceptions of e-cigarettes (24.0%) were associated with less support for 'ban CC sales in 10 years if there is a product providing nicotine not made from tobacco' (AOR=0.62, 95% CI: 0.40-0.97), 'ban CC use when it's prevalence falls below 5%' (AOR=0.66, 95% CI: 0.44-0.98) and 'banning the sale of CCs' (AOR=0.63, 95% CI: 0.42-0.94). CONCLUSIONS: Positive perceptions of e-cigarettes relative to CCs were associated with less support for endgame policies on CCs in Hong Kong. Public health actions are needed to disseminate evidence-based knowledge of e-cigarettes.

Examining retail purchases of cigarettes and nicotine replacement therapy in Finland.

INTRODUCTION: Finland's success in achieving the goal of its tobacco endgame largely depends on rectifying deficiencies in the delivery of smoking cessation services. One such weakness, which has not been documented with empirical data, is misuse of nicotine replacement therapy (NRT). This study's objective was to examine purchase patterns of NRT for estimating improper use of the medication. The study was based on the assumption that duration of a purchase episode is indicative of either proper use or misuse of NRT. METHODS: The participants (n=728), who purchased at least one NRT product in 2016 (mostly gum/lozenge), were selected through enrollment in a large customer loyalty program in Finland (LoCard). Participants were categorized into one of five groups according to their longest purchase episode of NRT, defined by purchases made in consecutive, 4-week intervals. RESULTS: Most participants, who did not adhere to NRT guidelines, either purchased the medication for too short (≤4 weeks, 63.5%) or too long (>24 weeks, 13.2%) of a purchase episode. Median purchases of NRT in the first month of use were one and four in the former and latter, respectively. In contrast to other groups, persistent users (>24 weeks) did not curtail purchases of NRT across several 4-week intervals, suggesting potential for dependence on NRT. CONCLUSIONS: The observation that most purchase episodes were terminated prematurely is consistent with surveys reporting widespread NRT misuse. Given uncertainty of greater regulation of NRT sales through legislation, it would be prudent for Finnish retailers to promote proper use of the therapy.

Vatican beats Italy 1-0 in the tobacco endgame.

'The Holy See cannot be cooperating with a practice that is clearly harming the health of people'. This is the reason behind Pope Francis banning the sale of tobacco products inside the Vatican in January 2018. Just outside the Holy See, in Italy, cigarette sales produce around €13 billion of fiscal revenues every year. In Italy, proposals to increase tobacco taxation are systematically rejected and new tobacco company plants have been officially inaugurated in recent years by representatives of State. The national branch of the Red Cross also shows ambivalent attitudes towards the tobacco industry, from which it has accepted significant funding in disregard of the recommendations of the International Federation of Red Cross. Against this backdrop, it is wishful thinking to imagine that tobacco sales and consumption in Italy will be substantially reduced in the near future. To counteract this situation, more than 30 Italian scientific associations/organisations launched a Manifesto, so far ignored by public authorities, indicating a set of measures whose gradual implementation at country level may lead to a tobacco endgame within the next few decades. Authors of this article would like to express their support for Pope Francis' enlightened decision and plead with politicians worldwide to follow his example, thus acting more decisively against tobacco.

Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs: two modelling studies to inform the tobacco endgame.

OBJECTIVE: There is growing international interest in advancing 'the tobacco endgame'. We use New Zealand (Smokefree goal for 2025) as a case study to model the impacts on smoking prevalence (SP), health gains (quality-adjusted life-years (QALYs)) and cost savings of (1) 10% annual tobacco tax increases, (2) a tobacco-free generation (TFG), (3) a substantial outlet reduction strategy, (4) a sinking lid on tobacco supply and (5) a combination of 1, 2 and 3. METHODS: Two models were used: (1) a dynamic population forecasting model for SP and (2) a closed cohort (population alive in 2011) multistate life table model (including 16 tobacco-related diseases) for health gains and costs. RESULTS: All selected tobacco endgame strategies were associated with reductions in SP by 2025, down from 34.7%/14.1% for Maori (indigenous population)/non-Maori in 2011 to 16.0%/6.8% for tax increases; 11.2%/5.6% for the TFG; 17.8%/7.3% for the outlet reduction; 0% for the sinking lid; and 9.3%/4.8% for the combined strategy. Major health gains accrued over the remainder of the 2011 population's lives ranging from 28 900 QALYs (95% Uncertainty Interval (UI)): 16 500 to 48 200; outlet reduction) to 282 000 QALYs (95%UI: 189 000 to 405 000; sinking lid) compared with business-as-usual (3% discounting). The timing of health gain and cost savings greatly differed for the various strategies (with accumulated health gain peaking in 2040 for the sinking lid and 2070 for the TFG). CONCLUSIONS: Implementing endgame strategies is needed to achieve tobacco endgame targets and reduce inequalities in smoking. Given such strategies are new, modelling studies provide provisional information on what approaches may be best.

Policy coherence, integration, and proportionality in tobacco control: Should tobacco sales be limited to government outlets?

Multiple factors, including marijuana decriminalization/legalization, tobacco endgame discourse, and alcohol industry pressures, suggest that the retail regulatory environment for psychoactive or addictive substances is a dynamic one in which new options may be considered. In most countries, the regulation of tobacco, marijuana, and alcohol is neither coherent, nor integrated, nor proportional to the potential harms caused by these substances. We review the possible consequences of restricting tobacco sales to outlets run by government-operated alcohol retail monopolies, as well as the likely obstacles to such a policy. Such a move would allow governments more options for regulating tobacco sales, and increase coherence, integration, and proportionality of substance regulation. It might also serve as an incremental step toward an endgame goal of eliminating sales of commercial combustible tobacco.

Big tobacco, E-cigarettes, and a road to the smoking endgame.

The provision of the extraordinarily deadly product of cigarettes is dominated by a small number of large and incredibly profitable shareholder owned companies that are focussed on cigarettes. The legal duty of their managers to maximise shareholder wealth means that such companies vigorously fight any new public health measures that have the potential to disrupt their massive profit making, and have the resources to do so. Protecting the public health is therefore made a lot more difficult and expensive. We suggest that one way to counter this would be to actively design future tobacco control policies so that tobacco companies face mechanisms and incentives to develop in such a way that they no longer achieve the greatest shareholder value by focusing on cigarettes. A proper tobacco diversification and exit strategy for the shareholders of the profit-seeking tobacco industry would protect the public health by addressing the current addiction to the continuation of the cigarette market. The increasing popularity of e-cigarettes presents a particular opportunity in this regard, and we therefore suggest a possible policy response in order to start discussion in this area.

Harm reduction and e-cigarettes: Distorting the approach.

Some supporters of electronic cigarettes have argued that they should be considered a form of harm reduction, analogous to that which has been successful with narcotics. In this viewpoint, we contend that this argument is based on highly selective use of the evidence, coupled with a fundamental misunderstanding of a comprehensive harm minimisation strategy. This includes not only harm reduction but also reduction in demand and supply-two elements that are explicitly rejected by many advocates of electronic cigarettes. We contend that, in the absence of all three elements, there is a danger that electronic cigarettes will delay the achievement of a tobacco-free world.