The tobacco endgame: where are we, and what are the challenges ahead?

The first panel of the second day of the Calisia World Conference on Family Health, held in Kalisz, Poland on 9-10 June 2019, was devoted to one of the defining public health problems of the last century – cigarette smoking. The panel gathered a range of experts, representing fields ranging from economics, through history, to health advocacy, who attempted to summarise the current state of affairs in tobacco control and outline the key challenges ahead.
The panel opened with two presentations putting tobacco control efforts into a wider historical context. First, the audience watched Allan Brandt’s video address, in which he gave a broad introduction to the panel, looking at the history of tobacco control, and in particular of tobacco industry misconduct, in the last century. See the transcription of Allan Brandt’s presentation below, and the key points summarised in Box 1. Second, Mateusz Zatoński spoke about the three stages of the tobacco epidemic in Poland – see slides in Webappendix. Mateusz carried out an in-depth exploration of the history of tobacco control in 20th century Poland in his PhD thesis [1].
Allan Brandt’s video address:
It is wonderful to be here in Calisia with you today, even from this great distance, in this digital format. Many thanks to Mateusz Zatoński for his introduction and especially for including me in this important panel. And I especially want to acknowledge the visionary work of Dr. Witold Zatoński, one of the truly great, historic leaders of public health in the 20th and 21st centuries, whose work has saved lives and preserved the health of millions of people here in Poland, in Europe, and across the globe. All of us who are dedicated to reducing suffering and to preserving good health are in his debt, and this conference clearly indicates the impact that he has had.
My brief remarks this morning are based significantly on my collaboration with Mateusz Zatoński, and I thought this might be a useful occasion to briefly reflect historically as we consider the foundation for critical next steps in tobacco control. My orientation to this stems from the organisation and implementation in the middle of the 20th century of what has widely come to be called the tobacco industry playbook. This strategy emphasised aggressive work on the part of the companies to undermine the science that had demonstrated the harms of tobacco. It did this through industry-funded research by claiming that “the jury is still out”. It did it by promoting what they called safer products, even though there was no scientific or medical evidence that these products actually reduce the harms of smoking. It did it by aggressively promoting tobacco products to children, because they knew that the youth market would be crucial to the continuation of their industry. And they did it by aggressively promoting the notion of individual choice and especially individual responsibility. They intensively resisted product regulation and public health measures and worked through their deep pockets to lobby aggressively in both public and political realms to undermine all forms of successful public health intervention.
This playbook was exposed by exceptional science, public health, legal reform, and policy, but it’s striking that these strategies continue to be utilised. Today we understand that these approaches have been embraced by many other global industries, since its original design and implementation by Big Tobacco in the 1950s and 1960s. Today we see this in the food and beverage industries and many other companies that produce harmful products. In these ways, industries continue to contribute enormously to the health disparities that this conference seeks to address and reduce. Despite the power and effectiveness of this playbook, public health forces, under the leadership of people like Dr. Zatoński, have made remarkable progress against smoking and its myriad harms over the last half century.
Despite these accomplishments, powerful industrial interests continue to create important challenges to public health and health equality. I want to emphasise that at this particular historical moment we’re in an especially complex situation as we examine the future of tobacco control and the impact of nicotine addiction. This is a remarkable inflection point as we consider the future of the tobacco control movement, here in Europe, certainly in the United States, but especially worldwide, especially as tobacco addictions and deaths are moving to the lower and lower-middle income countries. The introduction and aggressive marketing of electronic cigarettes and their promotion as harm reduction has the potential to disrupt the remarkable progress that we’ve made.
Harm reduction is an especially appealing approach to combustible tobacco products, but as the tobacco industry well understands, it is dividing the public health experts and advocates. The term harm reduction is ambiguous, and its evaluation and measurement and implementation is far from clear. How much harm reduction do we need to demonstrate to endorse and promote a new product? A little harm reduction? Just any harm reduction? Considerable harm reduction? Harm reduction for some, perhaps adults, can, for example, lead to significant new harms among children and teenagers. How are we to balance the overall impact on health of a new product as we consider appealing notions like harm reduction? How might we consider harm production by e-cigarettes versus the potential of harm reduction?
There are significant efforts instigated by the industry itself to resist the regulation of e-cigarettes, their promotion, and their use. But in the long term, the longitudinal impact of these new products is threatening and potentially far from clear. We know that public health can be dramatically improved, but, importantly, it can also be reduced as we’re seeing right now in the US with the current epidemic of measles, a disease that was virtually eradicated only 25 years ago. So, as we consider approaches to the tobacco “endgame”, we need to recognise the possibility that a complex market of vaping products as well as combustible tobacco products, could lead to more harm, morbidity, and mortality in the decades and even the century ahead. This regrettably would augment the critical health inequalities that the Calisia Declaration so effectively and humanely seeks to illuminate. Great vigilance and commitment to maintain and expand the successes of the last 50 years in tobacco control will be needed. I know that all of us here today are committed to freeing the world of the harms of tobacco products and its associated addictions. So, it’s really a great pleasure to be included this morning. I want to thank you very much and send my warmest wishes through the success of the work you’re doing there. Thank you very much.

DISCLOSURE

The authors report no conflict of interest.

References

1. Zatoński M. State, society, and the politics of smoking in Poland, during and after communism (1960-2000). PhD thesis London School of Hygiene and Tropical Medicine, 2019. Available from: https://researchonline.lshtm.ac.uk/4653914/2/2019_PHP_PhD_Zatonski_M_images_redacted.pdf (accessed: 25 May 2019).
2. Aaro LE. Declaration from the Calisia World Conference on Family Health 2019. J Health Inequal 2019; 5: 51-52.

AUTHOR’S CONTRIBUTIONS
AB prepared the text based on his video address at the Calisia Conference, as well as the text in Box 1. MZ wrote the introduction and conceptualised the contribution.