Endgame Policies

“Endgame Strategies” have been defined 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 specific time.” ^[¹^] “Endgame” strategies move towards a tobacco-free future wherein the availability of commercial tobacco products is heavily restricted and their use is phased out. ^[²^] This differs from tobacco control strategies that are based on the continued presence and widespread availability of tobacco products in the consumer market.

Endgame targets

New Zealand: Internationally, New Zealand has lead the way on the endgame. The country has a goal of reducing smoking to below 5% by 2025 and set in motion a multi-part plan to achieve it, with a set of policies that passed in 2022 including:

reducing the number of cigarette retailers from over 6,000 to just 600
reducing the nicotine in cigarettes to below addictive levels

gradually raising the legal age of sale for cigarettes to create a “smoke-free generation” by prohibiting the sale of combustible tobacco products to anyone born on or after January 1, 2009.

New Zealand first set their endgame goal in 2010, and the country’s previous progress toward the endgame also included requiring plain packaging for cigarettes and raising the price of cigarettes to what now amounts to about $20 USD. However, after reviewing their progress, the government changed their strategy to include the 2022 policies to enhance progress overall and specifically to make sure that their endgame target was met for all populations. As noted by Associate Minister of Health Dr Ayesha Verrall,“While smoking rates are heading in the right direction, we need to do more, faster to reach our goal. If nothing changes, it would be decades till Māori smoking rates fall below 5 percent, and this Government is not prepared to leave people behind.” Unfortunately, with a new Prime Minister and coalition government elected in 2023, the country’s inspiring endgame policies are now set to be rolled back to fund tax cuts.

Other countries have also set endgame targets of reducing smoking prevalence to 5% or lower, including Hong Kong, Ireland, Scotland, and Wales.^[³^]

United States: While not specified as an endgame target, the U.S. Department of Health and Human Services has set a goal of reducing U.S. current adult cigarette smoking prevalence to 6.1% by 2030 through the Healthy People 2030 Framework. Research shows that the U.S. will likely not achieve this target without greatly accelerating current progress on tobacco control measures, and that current rates of progress on state cigarette tax increases would not be enough to reach the goal.^[⁴^] However, two proposed federal regulations could help accelerate this progress: prohibiting the sale of menthol cigarettes, which the FDA is expected to announce a final rule for in the fall of 2023, and establishing a maximum level of nicotine in cigarettes, which the agency announced a proposed product standard for in June 2022.

Within the U.S., the state of California has been most aggressive in their efforts to work towards an endgame, setting a goal of ending the commercial tobacco epidemic throughout the state by 2035. See their Endgame Policy Platform and the California Tobacco Endgame Center for Organizing and Engagement for more resources.

Why Retail Strategies as Endgame?

As noted in Boosting the Tobacco Control Vaccine: recognizing the role of the retail environment in addressing tobacco use and disparities, retail-focused strategies are crucial for reaching endgame targets as well as addressing tobacco-related disparities. These strategies complement and build on the core tobacco prevention and control strategies in the original “Tobacco Control Vaccine,” which includes tobacco price increases, smoke-free policies, hard-hitting media campaigns, and cessation access. The Vaccine Booster includes addressing product availability, pricing and promotion, advertising and display, age of sale, as well as implementing retail licensure.

Many endgame strategies focus on reducing the retail availability of tobacco products, because research shows that retail availability of tobacco:

Perpetuates social norms about tobacco use. The ubiquitous presence of tobacco retailers gives the impression that tobacco is available and accessible.
Increases exposure to industry point of sale advertising, marketing and promotions. The tobacco industry channels most of its marketing dollars into the retail environment (Read More).
Reduces search costs for tobacco products. Proximity to tobacco retailers is associated with higher smoking rates^[4] and can reduce the success of quit attempts for people looking to curb their tobacco use.^[^{5 6}^]
Contributes to social and environmental inequities. Tobacco retail outlet density is higher in low income and minority neighborhoods, fueling disparities in tobacco use and its associated health effects.^[⁷^,⁸^,⁹^]Read Tobacco Retail Licensing Policy: A Health Equity Impact Assessment for more on how licensing can help improve health equity in communities.
Contributes to higher smoking rates. Tobacco retail outlet density is associated with high rates of youth ^[¹⁰^,¹¹^,¹²^,¹³^]and adult tobacco use,^[¹⁴^,¹⁵^] as well as higher rates of tobacco use initiation among youth and young adults. ^[¹⁶^,¹⁷^]Recent evidence also shows that higher tobacco retailer density is associated with higher rates of smoking among pregnant women.^[¹⁸^]Additional evidence suggests that adolescents that live in neighborhoods with a greater density of tobacco retailers are significantly more likely to initiate use of alternative tobacco products such as cigars, hookah, and smokeless tobacco. ^[¹⁹^]
Increases perceived availability and accessibility of tobacco products, especially among youth.^[20]Research has found that stores where youth are more likely to shop contain up to twice as much shelf space dedicated to the three brands most popular among youth.^[21]
Increases brand recognition, especially among youth,^[22]which increases odds of smoking.^[23]
Encourages impulse purchases of tobacco products, cues cravings, and undermines quit attempts. ^[²⁴^,²⁵^,²⁶^]

Retail-Focused Endgame Policy Options

Sales Restrictions

Prohibiting the sale of all tobacco products: Beverly Hills and Manhattan Beach, CA have both prohibited all tobacco retailers in their cities, with some limited exemptions for cigar bars and time-limited exemptions for retailers facing hardship to transition to a different business model that does not depend on tobacco.

Restricting or prohibiting the sale of all combustible tobacco products: This could be done with well advanced notice and targeted, increased access to cessation counseling and medication to give people the time and resources to quit, possibly while lifting restrictions on strongly regulated less dangerous nicotine products (e.g. e-cigarettes). ^[²⁷^]Read more about this policy option:
- Not for Sale: State Authority to End Cigarette Sales
- An argument for phasing out cigarettes sales, Tobacco Control
- Navigating the Takings Clause While Ending the Tobacco Epidemic, Public Health Law Center American Lung Association – California
- Project Sunset, Action on Smoking and Health

Tobacco/Nicotine-Free Generation policies: These types of policies prohibit tobacco sales to an entire generation by prohibiting tobacco sales to anyone born after a certain date, essentially annually increasing the minimum legal sale age for tobacco products.
- Brookline, MA has implemented the first of these type of policies in the U.S., prohibiting tobacco sales to anyone born after January 1, 2000. The city also successfully defended tobacco industry challenges to the policy. Learn more about their approach in this webinar from the Public Health Law Center: Tobacco-Free Generation: Brookline’s Model for Ending Tobacco in the U.S.
- Learn more about inclusive framing, examples of these types of policies across the globe, as well as their benefits, challenges, and unknowns in The Nicotine-Free Generation Approach: A Policy Option Review from the Public Health Law Center.
- Note that any age-focused policies should focus on restricting sales rather than on purchase, use, or possession of tobacco products by underage youth to align with equitable enforcement practices.

Tobacco Retailer Reduction

Sunsetting all existing tobacco licenses: Retailer caps can be set at 0, ultimately sunsetting all existing tobacco licenses and phasing out all tobacco sales in a community, as Bloomington, MN and Benton County, MN have both done. Typically, existing tobacco retailers are granted an exemption and allowed to continue operating until they close or sell the business voluntarily, or their license to sell is revoked for tobacco control law violations (e.g., repeatedly selling to underage youth). In addition, many localities in Massachusetts have set jurisdiction-wide caps on the total number of tobacco retailer licenses the city will issue, and this cap can reduce over time in a “cap and winnow” approach.
Limiting tobacco sales to only one type of outlet: Some experts have proposed restricting the sale of tobacco products to only one type of outlet, such as adult-only, tobacco specialty shops or state-run outlets, as some states have done with liquor (e.g., ABC stores). ^[²⁸^] This goes beyond more incremental approaches that limit the location, type, and hours of tobacco retailer (e.g., prohibiting retailers from locating within a certain distance of schools, from other existing retailers, or in certain zones; prohibiting tobacco sales in certain types of retailers, like pharmacies).
See resources on Licensing, Zoning, and Retailer Density for strategies to implement each of these policies.

In addition, product-focused strategies that make tobacco products less appealing, less addictive, and/or less harmful can also contribute to the endgame. For example:

Setting nicotine limits for cigarettes: Nicotine is the addictive component in cigarettes and all other tobacco products and thus what drives continued use of the products even when people want to quit. While only the FDA has the authority to create these types of product standards, they are currently working on doing so. On June 21, 2022, the FDA announced their plan to issue a proposed rule limiting nicotine in cigarettes to minimally or non-addictive levels by May 2023. FDA-funded research published in the New England Journal of Medicine shows that this type of nicotine reduction could result in 5 million more adults quitting within a year of implementation, and by 2100, could result in 33.1 million fewer people becoming smokers, a drop in the smoking rate to as low as 1.4%, and could prevent 8 million tobacco-related deaths. See more here. However, advocacy groups like ACSCAN are also calling for a maximum nicotine level for all combustible products, not just for cigarettes.

Prohibiting the sale of flavored tobacco products, including menthol cigarettes, to make them less appealing: Menthol’s cooling and anesthetic qualities make the smoke from cigarettes and other combustible products less harsh and mask the tobacco taste, making them easier to start and more appealing to youth.^[²⁹^] Menthol can enhance the addictiveness of cigarettes, making them harder to quit. Eliminating menthol would not only mean progress towards the endgame, but also progress towards health equity. Tobacco companies have targeted their marketing to African Americans and other marginalized groups across the country for decades, contributing to disparities in tobacco product use and subsequent harm. Recent research has found that between 1980 and 2018, menthol cigarettes slowed the decline of smoking prevalence by 2.6%, and were responsible for 10.1 million extra smokers, 3 million life years lost, and 378,000 premature deaths.^[³⁰^] With the tobacco industry’s relentless targeted marketing of menthol cigarettes to the African American community, a disproportionate amount of the harm from menthol has fallen on African Americans. While 12% of the U.S. population is African American, African Americans account for 41% of the premature deaths and 50% of the life-years lost during this same time period.^[³¹^] Two states (Massachusetts and California) and at least 170 jurisdictions across the country have banned the sale of flavored tobacco products including menthol cigarettes as of March 2023. The FDA’s proposed rule would create a product standard for cigarettes that would eliminate menthol as a characterizing flavor nationwide at a manufacturer level in addition to a sales ban, and some public health groups have advocated for eliminating menthol as an additive in cigarettes at any level, rather than just at a level high enough for it to be considered a characterizing flavor.
Other possibilities to make cigarettes less appealing include raising the pH of cigarettes and banning cigarette filters, which reduce irritation but also may increase harm^[³²^] and also contribute to environmental waste. ^[³³^]However, these changes would likely need to be made by the FDA through their authority to create product standards.

Incremental Approaches

Other strategies may be characterized as “middlegame” strategies. These strategies represent incremental steps towards the endgame rather fundamentally altering the structures that sustain the tobacco epidemic.

Banning tobacco displays: Policies that prohibit tobacco product displays can help to counteract the tobacco industry’s efforts to attract new, current, and recently quit smokers through power walls. Tobacco product display bans have been implemented in many countries, including Iceland, Canada, Thailand, Australia, New Zealand, Finland, and the United Kingdom, as part of the World Health Organization’s Framework Convention on Tobacco Control. Evidence has shown high retailer compliance, de-normalization of tobacco use, and preliminary support for declines in tobacco use in combination with other comprehensive restrictions on tobacco promotions. ^[³⁴^,³⁵^{, 36,}³⁷^]^.While a full display ban has not been implemented anywhere in the U.S. yet, New York State did pass a law that prohibits the exterior display of both tobacco products and advertisements near schools, and many localities across the country have decreased exterior advertisements through content neutral sign ordinances that limit the total amount of a store’s exterior space that can be covered with any type of ad.
Limiting the number, type, and location of retailers allowed to sell tobacco:Philadelphia and San Francisco have both implemented this type of policy, setting caps per city district in order to reduce disparities in retailer density between different neighborhoods, while also prohibiting tobacco retailers from locating near schools and/or near another tobacco retailer. San Francisco and many other jurisdictions have also prohibited the sale of tobacco products in pharmacies. Internationally, the Netherlands has phased out vending machines and will end tobacco sales in supermarkets by 2024.
Raising the cost of tobacco: Raising the price of tobacco products is one of the most effective strategies for reducing initiation, decreasing consumption, and increasing cessation. It also has a pro-equity effect on smoking.^[³⁸^] This can be done through strong minimum floor pricing laws and price discount bans in addition to high excise taxes, which could also be raised regularly. Other endgame solutions related to price could include price caps, which limit industry profits, reduces price differences between tiers and brands of cigarettes (e.g., discount brands, premium brands), and allows the government more control over the price of tobacco products. Learn more about point of sale pricing policies.

Disincentivizing the sale of tobacco products: This can include raising the cost of licenses and the cost of violations to discourage tobacco sales or incentivizing retailers to give up tobacco licenses. ^[39]

Key considerations

Cessation support: Any retail-focused endgame plan will need to be paired with increased cessation resources that are evidence-based, culturally appropriate, accessible, and focused on the populations most impacted by commercial tobacco.
Readiness: Community readiness is also an important consideration. While a 2021 national survey showed that 57% of adults support ending the sale of all tobacco products,^[⁴⁰^] support will also vary by jurisdiction, and places with high smoking prevalence currently may not be ready for this type of change yet. The jurisdictions in the U.S. that have implemented the most stringent endgame policies (Beverly Hill and Manhattan Beach, CA) already had a relatively low smoking prevalence when the policies were proposed and implemented. Endgame approaches may look different in different communities based on their current tobacco retailer landscape, geography, demographics, and community values.
Health equity impact: Any endgame policy should also consider the given policy’s health equity implications on the ground, especially in terms of impact on disadvantaged populations with greater rates of tobacco use. See more about health equity and point of sale tobacco control.

For more information listen to our podcast episode on the Endgame and view the other resources below.

Resources