Cultivating the next generation of tobacco endgame advocates.

Long-term success for any tobacco endgame is contingent not only on acquiring political will, but also on sustaining it over a long period of time, perhaps even for decades. Future cohorts of public health professionals with knowledge of tobacco issues are therefore needed to carry on with the endgame strategy (should early attempts fail) and to keep tobacco control salient after an endgame strategy has initially been implemented. The endgame itself offers a unique pedagogical opportunity that could revive interest in tobacco control at schools of public health--an important first step in cultivating the future advocacy base for a tobacco endgame.

The Ann Arbor workshop on endgame strategies in tobacco control evaluated radical, ‘game-changing’ policies that share the common goal of achieving a near-zero tobacco disease burden. These ranged from policies that would ban the sale of tobacco to anyone born after a specified year1 to a gradual ‘sinking lid’ on supply of tobacco.2 Participants addressed questions of feasibility across the various options, anticipating a timeline that could stretch for decades. As the student organiser for the workshop, I wondered whether support for an endgame could be sustained throughout such a timeline, and whether the next cohort of leaders in public health would be receptive to this endeavour.

The next generation of public health professionals is entering an era in which interest in and funding for tobacco control are declining.3 Future cohorts of public health professionals are needed to carry on with the endgame strategy (should early attempts fail) and to keep tobacco control salient even after a strategy has been implemented. How can we expect future public health leaders to sustain tobacco endgame initiatives if circumstances lead them to believe the tobacco problem has already been solved? (Ideas presented here speak of the US experience, but are likely to have broader applications.)

Graduate education in public health represents an important starting point for cultivating the next generation of tobacco control advocates. A previous initiative through the Association of Schools of Public Health and the American Legacy Foundation's Scholarship, Training, Education Program for Tobacco Use and Prevention (STEP UP) offered funding to integrate tobacco control into existing curriculum.4 This was followed by recommendations for ensuring a tobacco control presence in the future public health workforce.5 6 The programme ceased funding in 2006 and remains the last institutional push for tobacco control education at schools of public health.

Curricula development at schools of public health faces numerous constraints, including Council on Education for Public Health (CEPH) accreditation standards, funding availability and faculty and student pressures. STEP UP appreciated the value of graduate education in building a future advocacy base and used funding support to drive curriculum changes. Stronger engagement with CEPH, programme directors and funding agencies to align these external incentives with tobacco control could stimulate tobacco-relevant teaching at schools of public health.

Although there is certainly a lack of graduate education in tobacco control, at issue is the little demand for it. Among key takeaways from STEP UP was the perception at schools of public health that tobacco is ‘no longer considered a public health problem’. To facilitate greater enthusiasm for tobacco control, educators must demonstrate (1) why tobacco must remain a public health priority and (2) how tobacco control is a field ripe with progressive ideas for the future.

The tobacco endgame itself offers a unique pedagogical opportunity. It recasts tobacco-related disease as an epidemic in urgent need of attention, one that can be all but eliminated (not merely ‘controlled’) with some courage and creativity. Teaching the endgame would also complement youth engagement programmes, encouraging potential advocates early in their careers. Endgame education involves exposing students to the strategies discussed at the Ann Arbor workshop, but importantly it asks students to be daring enough to consider unconventional ideas and to make innovation part of what it means to be in public health. Effective tobacco endgame education:

inspires questions about why tobacco receives far less attention relative to other public health problems given the magnitude of the epidemic;

asks students why near eradication and minimal exposure remains the desired standard for other public health problems and not for tobacco;

emphasises exploitative corporate practices as barriers to the tobacco endgame;

draws parallels with other public health endgames achieved as with smallpox and polio;

encourages students to think critically about endgame strategies that have already been proposed and generate new ones for consideration.

Communicating the urgency of the domestic tobacco problem through the lens of the endgame presents an ‘old’ problem in a novel way, and stimulates inventive thinking for future public health practice—a sound plan for cultivating the next cohort of endgame supporters. Unless current public health professionals inspire renewed interest in tobacco control among students, the advocacy base—and with it the likelihood of an endgame achieved—risks dwindling over time. In her editorial introducing endgame ideas in the field, Malone argues that overcoming the hurdles to policy change requires accessing our ability to think radically—she challenges the tobacco control community to ‘imagine things otherwise’. 7 Why not challenge the next generation of leaders in public health to do the same?