The Final Reckoning: What 50 Years of Nicotine Policy Has Achieved—and Failed to Achieve
Fifty years of nicotine policy: smoking prevalence down dramatically, millions of lives saved, and a billion smokers still smoking. The achievements are real. The failures are realer. The reckoning is overdue.
Achievements: smoking prevalence in high-income countries down from 40%+ to under 15%. Millions of lives saved. The cigarette transformed from a glamorous accessory into a stigmatized product. **Failures: a billion smokers still smoke. Smoking is increasingly concentrated among the poor, the mentally ill, and the Global South—populations that the policies were supposed to help. The abstinence framework that dominated policy for decades has reached its limits—and the harm reduction framework that could extend the achievements has been resisted by the institutions that should have championed it.**
**The reckoning: nicotine policy has saved more lives than almost any other public health intervention. It has also failed the populations that needed it most. The next fifty years will be judged by whether we learned from the failures of the last fifty—whether we embraced the evidence, included the people, and pursued the justice that the first fifty years left undone.**
