The need for new strategies to combat the epidemic of smoking-related harm.

In 2003, I published a paper in this journal arguing for the consideration of a regulated market model (RMM) for tobacco, a mechanism by which the mass marketing, but not manufacture, of tobacco products would be taken out of the hands of forprofit companies and given to an agency with a harm reduction charter. This agency would determine what was sold and under what conditions, and retailers would effectively become its agents. In that time, nobody has identified any conceptual flaw in the model. The arguments against it are that it would not happen (true if no-one argues for it), that regulation is anathema to governments, that it would put government in the embarrassing position of selling harmful products (the paper suggested government control of the agency but that is not essential), that the proposal lacks advocacy appeal as it is a mechanism rather than a solution, and that to pursue it would divert limited energy from more conventional solutions. This critique assumes that we will be able to achieve everything we want with the continuation and expansion of current strategies, something I doubt. 4 The paper had some effects. It was a stimulus to Callard and colleagues 6 to develop a model which would operate outside of government control and was among the first of what is now a steady stream of thinking about endgame solutions. The big questions are whether radical solutions are required for the tobacco problem and whether fundamental reform of the tobacco industry should be part of it. Since 2003, there has been a lot of progress in tobacco control, with the Framework Convention on Tobacco Control (FCTC) coming into force. It has galvanised action from many governments, including some that had previously ignored the problem. Many have been pleasantly surprised at the strength, both of the convention itself and of some of the guidelines that the parties have adopted. Some countries are now moving beyond what the FCTC mandates. Australia is legislating to institute plain packaging, better described as standard packaging as brand names will still be allowed (something only a RMM could remove) along with variant descriptors and it will expand the graphic health warnings. There will remain opportunities for the industry to exploit any areas of difference to promote their products, as they are obliged to do by their shareholders. While companies still compete in the market, we need to watch them carefully to ensure that competition does not result in them adding value to their products, potentially leading to increased use. The legislation to empower the US Food and Drug Administration to regulate tobacco is another extremely important advance. However, I fear progress will be slow and costly because of the inherently antagonistic model of manufacturers resisting what regulators try to control, including by endless litigation, except where manufacturers see a commercial advantage, either absolute or relative to their competitors in the new rules, something that will not stop the others litigating. A RMM would greatly speed up progress to achieving less-harmful products. That nobody has seriously tried to implement a RMM is disappointing but not surprising. More recently, colleagues and I have attempted to analyse tobacco control more systematically, approaching the problem from an open systems perspective and highlighting the inter-related roles of the tobacco industry and tobacco control forces. We then discussed why a systems analysis was insufficient for a solution to emerge and used Actor Network theory to describe the essentially politically contested processes that are needed for fundamental systems change. Progress since 2003 is likely to have had mixed effects on the need to focus on transformation of the industry. Some of the above-mentioned barriers might be dissipating; there is now greater understanding of the power and limitations of unconstrained free-market forces and the need to sometimes curtail them, including consideration of clever regulation (albeit still limited action to implement such approaches). Tobacco is a great example of how the free-market cannot operate effectively when there is not a solution around making the product less harmful while still being consumer acceptable. In the absence of sufficiently harm-reduced products that society is prepared to accept long term, a free-market must be problematic. Every tobacco control conference I attend is full of stories of industry calumny and how they are undercutting our efforts and trying to expand their markets. The FCTC has strict guidelines around Article 5.3 (dealing with the tobacco industry), which makes tobacco companies virtual pariahs. All agree tobacco companies are part of the problem, but few ask if they need to be part of the solution. Do we really need to have them around at all (at least in their present form)? If there is no viable mechanism for a free-market solution to the tobacco problem, would it not be better public policy to remove them from their position controlling the market. More fundamental to resistance to a RMM, at least within sections of the tobacco control movement, is that it implies an ongoing demand for tobacco (else why have a special agency to supply it?) and this seems to be the spectre of a harm reduction agenda, which for some Correspondence to Ron Borland, Nigel Gray Distinguished Fellow in Cancer Prevention, The Cancer Council Victoria, 1 Rathdowne Street, Carlton VIC 3053, Australia; [email protected]