Envisioning a world free of tobacco use: progress, challenges, and opportunities for the tobacco endgame

The concept of an endgame for the tobacco epide­mic has received increasing attention and action in recent years. While proposals to set a target for essentially eliminating all tobacco products might have seemed an impossible fantasy a decade or two ago, this goal has moved progressively closer to reality. Just this past November, parties to the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) engaged in discussions around “forward looking tobacco control measures,” including policies aimed at ending the legal sales of tobacco products.
The notion of banning or prohibiting the sale of tobac-co products is not entirely unprecedented. Through­- out the history of tobacco use, there have been efforts to elimi­nate it. Most famously, in 1604, King James I of England authored a pamphlet, ‘A Counterblaste to Tobacco’, portraying it as a significant social and health problem and describing it as “loathsome to the eye, hatefull to the Nose, harmefull to the braine, and dangerous to the Lungs” [1]. Although he did not impose an outright ban, he levied an enormous 4,000% tax on tobacco imported from the colonies to discourage its use. Ultimately, the tax proved insufficient to curb demand, and King James eventually nationalized the tobacco trade, in an effort to control it and, simultaneously, profit from its distribution.
In the United States, as historian Cassandra Tate has documented, between 1890 and 1930 fifteen states (including Washington, Iowa, Kansas, Nebraska, Indiana, and North Dakota) enacted laws to ban the sale, manufacture, possession, and/or use of cigarettes, whith others proposing or considering such legislation. The movement was largely driven by moral reformers associated with the Progressive Era (such as the Women’s Christian Temperance Union) who viewed the cigarette as a corrupting influence, linked to crime and vice rather than specific health risks. However, these laws faced challenges due to poor enforcement, and all were eventually repealed [2].
Critics of Tobacco Endgame approaches have pointed to the experience with alcohol prohibition in the United States from 1920 to 1933. The 18th Amendment to the U.S. Constitution, ratified in 1919, prohibited the manufacture, sale, and transportation of alcoholic beverages in the United States, with the Volstead Act providing a framework for enforcement. How­ever, the prohibition era was marked by an increase in organized crime, widespread corruption among law enforcement and politicians, and health hazards from poor quality, illegal alcohol consumption. Meanwhile, the government lost out on tax revenue from alcohol sales. The amendment was later repealed.
The tobacco industry and opponents of regulation have frequently cited the failure of alcohol prohibition as a cautionary tale [3]. However, as historians have pointed out, the context around alcohol prohibition in the U.S. in the 1920s was unique and complex and does not necessarily support broad generalizations for the control of other products today. Prohibition in the 1920s did succeed in bringing down alcohol consumption, and there was public support for at least restricting its sale, but the economic Depression of the 1930s shifted the priorities of the public and political leaders [4].
More recently, in 2004, Bhutan became the first country to ban the sale of tobacco products and smoking in public places. Individuals were permitted to bring a limited amount of tobacco with them into the country, but it was subject to a 100% tax. The law was further strengthened in 2010 with increased penalties for violations. However, the ban was lifted during the COVID pandemic on the argument that smuggling of tobacco products to circumvent the ban could lead to cross-border transmission of infection [5]. Nevertheless, overall tobacco control measures in Bhutan remain strong, including prohibitions on smoking in most public places.
Recent proposals for Tobacco Endgame goals, however, are more complex and varied than a complete ban or prohibition. While the objective remains to end tobacco use, proponents of the tobacco endgame argue that endgame goals must be sustainable and supported through comprehensive tobacco control policies. Consequently, countries and local jurisdictions have adopted policies that advance towards eliminating or dramatically reducing the tobacco product market by setting target dates, establishing tobacco use prevalence goals, and advancing strong tobacco control measures. This paper describes key progress and approaches seen so far and identifies upcoming challenges and opportunities for the tobacco endgame.

Definitions

There is no single consensus definition of the Tobacco Endgame. A range of policies have been proposed to dramatically drive down tobacco use prevalence and to radically restructure the tobacco product market. In general, endgame proposals aim to move beyond conventional tobacco control policies and interventions (such as warning labels, promoting smoke-free spaces, raising taxes on tobacco products, restrictions on advertising and promoting tobacco products, and cessation support) to measures explicitly aimed at bringing about a tobacco-free future, where products are phased out from the market or very few people chose to use them. One definition, put forward by McDaniel and colleagues, defines tobacco endgame strategies as: “Initiatives desig­ned to change/eliminate permanently the structural, political, and social dynamics that sustain the tobacco epidemic, in order to end it within a specified time” [6]. Countries that have established tobacco endgame targets have often stated a goal of reducing tobacco use pre­valence below a particular level, usually 5%. While this acknowledges some ongoing tobacco use, achieving such a low level is recognized as a major milestone on the way toward ending tobacco use altogether. There is no single pathway to reach this target, but it surely requires a comprehensive approach utilizing multiple evidence-based tobacco control measures.
Another characteristic of endgame proposals is their emphasis on supply-side targets, by restricting product sales or access. In contrast, conventional tobacco control measures often focus on reducing demand, through health warnings, advertising restrictions, tax increases, and smoke-free spaces. Demand-side measures seek to make tobacco use less attractive or to encourage quitting. Supply-side measures, conversely, impose direct restrictions on the market, regulating product sales and access and relying less on influencing consumer behavior.
Some of the endgame policies and strategies that have been proposed include the following:
• Tobacco-free generation: Policies that prohibit the sale of tobacco to individuals born after a particular date. While current adult tobacco users can continue to purchase tobacco, the policy aims to prevent future tobacco use uptake.
• Sinking Lid: Establishes quotas on sales or imports of tobacco products that decrease over time. The reduced availability of tobacco products, in turn, drives up the price over time [7].
• Reducing tobacco sales licenses: Restricts and reduces the number of licensed tobacco retailers, decreasing tobacco retail density over time and making tobacco less easily accessible.
• Banning product classes: A number of countries have banned the sale of particular product categories, notably smokeless tobacco. For example, snus, an oral moist snuff tobacco product, has been banned on the European Union since 1992 (with the exception of Sweden), most recently under the Tobacco Products Directive (2014/40/EU) [8]. Additionally, India has banned gutka, a packaged product containing both tobacco, areca nut, and flavorings, though the ingredients can still be purchased separately [9].
• Reduced nicotine levels: Regulations that require reductions in nicotine levels in tobacco products, possibly to non-addicting levels, with a goal of encouraging cessation and preventing future addiction [10, 11].
• Banning the use of non-tobacco flavorings, such as menthol or other characterizing flavors, to make the product less appealing, particularly to new users [12].

Case studies

Over the past decade, several countries and jurisdictions have adopted specific endgame goals (such as prevalence targets, usually under 5%) or implemented innovative policies (such as generational bans or sales prohibitions). Over a dozen countries have proposed tobacco endgame goals, including Finland, New Zealand, Canada, Ireland, Scotland, Sweden, Malaysia, Bangladesh, the Maldives, Denmark, Netherlands, Australia, France, and the UK. However, not all of these have been enacted through legislation yet, and in a couple of cases legislation adopted was later repealed. Some prominent examples are described here:

Finland

Finland was the first country to set an endgame goal in 2010, aiming to make the country tobacco- and nicotine-free by reducing daily tobacco use prevalence to less than 5%. The initial target date to achieve that goal was 2040, but in 2016 this was moved up to 2030 and expanded to include other nicotine products like e-cigarettes and snus. The strategy involves a range of public health measures, including regular tax increases, a point-of-sale display ban, bans on characterizing flavors in cigarettes and e-liquids, and enforcement of age limits on tobacco sales [13, 14].

New Zealand

In December 2022, New Zealand adopted legislation aimed at achieving a smoking prevalence target of less than five percent, across all population groups, by 2025. The legislation imposed specific measures to achieve that goal, including denicotinising cigarettes, reducing the number of tobacco retail outlets, and implementing a generational ban on smoked products. However, despite widespread support from experts, the public, and indigenous communities, a new government repealed the law in February 2024 [15]. If it had proceeded, this would have been the most comprehensive national endgame strategy to date.

Canada

In 2016, Canada established a tobacco endgame goal of less than 5% prevalence by 2035. Canada has already shown success in reducing tobacco use through established tobacco control policies and programs, though this success has not been uniform across population groups and substantial disparities remain, particularly among low income, rural and indigenous groups. Measures adopted to achieve this goal include plain packaging, a ban on menthol in in cigarettes, and expanded smokefree regulations. However, further work is needed to reach the target goal [16].

Ireland

In 2013 Ireland set a goal of reducing smoking prevalence to less than 5% by 2025. While Ireland has a track record of implementing progressive tobacco control measures, including an early comprehensive smokefree workplace ban, and public support for the endgame goal is high, the country has not yet managed to meet its 2025 goal (smoking prevalence remained at 18% in 2023) [17].

Maldives

Maldives is the first country to introduce a generational tobacco ban, making it illegal for anyone born on or after January 1, 2007, to purchase or use any form of tobacco. The policy aims to create a tobacco-free gene­ration by prohibiting tobacco sales to future generations. The ban went into effect on November 1, 2025, and retailers are required to verify age before any sale [18].

Malaysia

In 2022, Malaysia proposed a “Generational Endgame” policy which would have prohibited anyone born on or after January 1, 2007, from purchasing or using tobacco products, including e-cigarettes. Notably, the initial legislation would have penalized individual purchase and use, in addition to banning commercial sales. However, the legislation that was eventually passed in late 2023 removed the smokefree generation provision entirely. This change was reportedly due to strong lobbying from the tobacco industry and pro-vaping organizations led to the change [19].

UK

The UK has proposed a generational smoking ban under which a person born on or after January 1, 2009, will never be able to legally buy tobacco products in the UK. The ban targets sales rather than use, so it does not penalize smokers. The bill also includes provisions to restrict the sale of vaping products to minors and restricts the use of flavors and packaging that could be appealing to children. A bill has been progressing through Parliament, receiving support in initial votes, but has yet to be enacted.

European Union

The European Commission’s Europe’s Beating Cancer Plan established a region-wide “Tobacco-Free Generation” goal, defined as achieving a tobacco use prevalence of less than 5% by 2040. A number of EU member states have adopted specific endgame goals, while others are developing such proposals. However, the details of these policies, including target dates and how they address non-cigarette tobacco and nicotine products, may differ from country to country [20].

United States

While the U.S. has not established a national endgame target, several U.S. cities have implemented endgame strategies at the local level. In 2021, Brookline, Massachusetts introduced a generational tobacco ban prohibiting the sale of tobacco products and e-cigarettes to anyone born after January 1, 2000. The measure was challenged by retailers but was upheld by the Massachusetts Supreme Court. Subsequently, other towns have passed similar bans. As of November 6, 2025; 19 jurisdictions in Massachusetts have passed tobacco- and nicotine-free generation legislation. Additionally, several California cities have entirely prohibited the sale of tobacco and nicotine products. For example, in 2019, the city of Beverly Hills adopted a ban on sales of tobacco products (with limited exemptions) [21]. Other cities have advanced new endgame policies as well. In Minnesota, the city of Bloomington adopted legislation to end new tobacco retail sales licenses, aiming to reduce the number of tobacco retailers over time [22].

Challenges

While over a dozen countries have set tobacco endgame targets, it remains to be seen whether those targets will be reached. A recent study gathered data from experts in six countries with endgame goals (Canada, Finland, Ireland, New Zealand (Aotearoa), Scotland, and Sweden) around barriers and progress. Although all six countries had implemented strong tobacco control measures and had relatively low smoking prevalence, respondents reported that progress was insufficient to meet their targets and timelines. In particular, they highlighted the need for more aggressive endgame interventions, such as mandatory nicotine reduction or generational bans, to meet their targets. They also pointed to barriers to implementing policies and interventions, including lack of funding or capacity, insufficient political will, and tobacco industry interference [23]. Another survey of key informants across 24 European countries identified similar challenges, emphasizing a need for greater focus on measures that impact product avail­ability, appeal, and addictiveness [24].
Establishing an endgame target is an important and essential first step, but it is unlikely to succeed without a detailed plan for achieving that target. Similarly, adopting legislation for tobacco control must be accompanied by plans for effective implementation and enforcement. The field of implementation science could prove valuable here. Implementation science involves the study of methods to promote the systematic uptake of evidence- based interventions into routine practice, addressing the historical “research to practice” gap in health care [25]. Tobacco endgame proposals are less likely to succeed if insufficient attention is given to plans and strategies for implementation, as well as identifying potential barriers.
Gaps in equity also remain a significant challenge for achieving endgame targets. Experts have raised concerns that endgame efforts have not shown sufficient progress in reducing inequities in tobacco use and related disease [26]. High smoking prevalence remains a concern in certain population groups, even in countries with relatively low smoking prevalence [27]. In the six country study described above, persistent disparities were noted across all six countries, particularly among indigenous populations and groups with lower socioeconomic status. Moreover, while tobacco use prevalence has been declining in high-income countries (HICs), it has remained constant or is increasing in low- and middle-income countries (LMICs). Additionally, tobacco use practices may differ across population groups. For example, in India where chewing tobacco is the predominant form of tobacco use, a narrow focus on combustible tobacco products may be less effective. Thus, the tobacco endgame approaches should be tailored to the country or local context.
Tobacco industry interference represents another major barrier to achieving endgame targets. The tobacco industry itself continues to adapt and respond to efforts to control tobacco use and regulate tobacco and nicotine products. The situation is further complicated by tobacco companies positioning themselves as advocates for harm reduction, through developing and promoting novel nicotine delivery products, such as e-cigarettes and heat-not-burn cigarettes [28]. Countries may lack concrete tools to prevent and counter tobacco industry interference. Projects such as Tobacco Tactics from the University of Bath and CounterTobacco.org have been actively monitoring and reporting on tobacco industry inter­ferences towards endgame goals [29].

Future opportunities

Despite the challenges, there are also opportunities and promising developments for advancing tobacco endgame goals. As various endgame initiatives have been pursued over the past decade, surveys have shown broad and consistent support for tobacco endgame goals across countries and world regions. Support is generally stronger among non-smokers (compared with current smokers) and among those with quit intentions or health concerns, but studies have shown significant support even among current smokers. Support is generally stronger for measures targeted at the product (such as nicotine reduction or bans on flavorings or products categories) and retail access (tobacco-free generation), compared with measures that involve radically restructuring the tobacco product market, such as a government takeover of tobacco sales and distribution [17, 30-33]. It may be that this view reflects lack of understanding or familiarity with more complex economic and regulatory measures.
While explicit tobacco endgame goals have largely originated from HICs, especially those that have had strong, comprehensive tobacco control programs in place for some time, there are important opportunities to advance the tobacco endgame in LMICs as well. Selvan and colleagues conducted a review to classify countries based on their “readiness” for the tobacco endgame [34]. They rated countries by their current smoking prevalence and an FCTC implementation score (reflecting progress in adopting policies aligned with the FCTC). A smoking prevalence of 15% or less was considered the threshold for feasibility. Countries with both an overall smoking prevalence of less than 15% and a strong FCTC score were considered “Endgame Ready.” Those with a strong FCTC score but a smoking prevalence higher than 15% were classified as “Almost Endgame Ready.”
Interestingly, the analysis found that of 28 countries classified as “Endgame Ready”, only five (Bhutan, New Zealand, the UK, Singapore, and Sri Lanka) were already part of tobacco endgame discussions. The remaining 23 were predominantly LMICs in Africa, Latin America, the Middle East, or Asia, which have been largely neglected in the global tobacco endgame movement. At the same time, of 18 countries that have set official endgame targets, most were HICs not yet classified as endgame ready. The authors propose that the global tobacco endgame movement should increase its focus on LMICs with low smoking rates and advanced tobacco policies (“Endgame Ready” countries in Africa, Latin America, and Asia). To address potential resource limitations, the authors propose a stepwise approach starting with earmarked tobacco taxes to fund further tobacco control programs.
One important lesson from the history of tobacco control is that major norm changes and advances in tobacco control often start at the local level. Local jurisdictions play a key role in leading the way with new interventions. In the US, for example, a great deal of tobacco control happens at the state level; some states and cities have taken the lead in going beyond national requirements, such as by adopting comprehensive smoke-free laws or, in recent proposals, to raise the tobacco purchasing age to 21 years. Thus, action at the local level, including in cities, can have a substantial impact in the long run. Additionally, experience with comprehensive tobacco control programs demonstrates the importance of making cessation support an integral part of any tobacco control program. Commentators have urged that access to cessation is a human right and is essential to meeting endgame goals [35].
The agenda for the recent November 2025 WHO FCTC Conference of the Parties (COP) included discussions on “forward-looking” tobacco control measures under Article 2.1 of the treaty, which encourages Parties to implement stricter tobacco control measures that go beyond the minimum requirements. Under Article 2.1, the treaty serves as a floor, not a ceiling, where Parties are free to enact more stringent policies to protect human health. An Expert Group report, released in advance of the COP, identifies and describes such forward-looking measures and studies country experiences to date. The report identifies a range of forward-looking measures that show promise in advancing towards an end to the tobacco epidemic. The list includes a number of measures that have been part of endgame discussions to date, including phasing out sales of tobacco products, reducing the number of tobacco retail licenses, and reductions in nicotine content. The recommendations of the report, that countries consider adopting such forward-looking measures and report on their experience, was adopted on the final day of the COP.
In recent years, the concept of the Tobacco Endgame has made it into mainstream discussions in the global public health and tobacco control community. Envisioning an end to the tobacco epidemic, and to the sale of tobacco products, is no longer a distant fantasy. Countries have proposed, and in some cases adopted, concrete measures and timelines to reduce tobacco use to very low levels and, in time, to end the sales of tobacco products. However, the success of these measures depends heavily on how they are implemented and supported. Thus, continued research and monitoring of tobacco endgame efforts, as well as continued support for comprehensive tobacco control programs, is essential to ensuring success in achieving tobacco endgame goals.

Disclosure

The author declares no conflict of interest.

References