Dr Margaret Chan Director-General of the World Health Organization
Keynote address at the International Conference on Public Health Priorities in the 21st Century: the Endgame for Tobacco New Delhi, India 11 September 2013
Excellencies, honourable ministers, distinguished scientists, representatives of civil society, ladies and gentlemen,
I thank the government of India for hosting this International Conference on Public Health Priorities in the 21st Century, with its intriguing sub-title: the endgame for tobacco. WHO is proud to be the technical co-sponsor of this event.
Public health has very few opportunities to end threats to health in a definitive way. Most of our work is never-ending. Every new wave of babies needs to be immunized. Bednets wear out. Mainstay medicines develop resistance. One generation learns the importance of safe sex. The next generation forgets.
Disease eradication is one clear opportunity for a definitive end to a health threat. A tobacco endgame is another. Both have tremendous appeal. They promise to improve the world in a permanent way, offering every future generation the perpetual gift of freedom from major diseases.
Speculation about a possible endgame for tobacco has been going on for at least a decade, often expressed as wishful what-if scenarios. For example, what if the tobacco industry simply did not exist?
Tobacco use claimed an estimated 100 million lives during the previous century. On current trends, tobacco use is projected to cause a billion deaths during the 21st century. Think of all the lives saved, the suffering avoided, and the costs averted if the tobacco industry simply ceased to exist.
Another argument goes like this. If all the harms caused by tobacco were known earlier on, tobacco products would never have been approved as safe for human consumption, could never have been marketed and sold like any other consumer product.
Is it really too late to correct this grave historical error? Could tobacco use somehow be eliminated through a brave new plan that responds, retrospectively, to a great mistake?
This wishful thinking first took the form of a concrete proposal three years ago, when the journal Tobacco Control published a paper about "Imagining things otherwise: new endgame ideas for tobacco control".
Concrete proposals expanded last year, when Tobacco Control issued a supplement devoted entirely to an exploration of tobacco endgames. Some striking proposals were put forward, as were some warnings and words of caution.
Ladies and gentlemen,
Let me also offer some advice.
First, be very precise in your definition of what is meant by a tobacco endgame. We learned the importance of doing so when global goals were set for disease eradication or elimination. Progress towards any ambitious goal needs to be measured convincingly. Precise definitions help.
Second, anchor endgame strategies in impeccable science. Arguments for taking action need this water-tight support. Experience tells us that industry will challenge the science, distort the findings, or fund its own studies with a predictable bias. An impeccable scientific foundation is the best defence.
Third, back up goals and strategies with solid feasibility studies. This is another lesson from the eradication experience. Governments need to know what commitment to an ambitious goal really means in practical terms and what the likely pay-backs will be, for economies as well as societies. Good feasibility studies build confidence, and confidence inspires commitment.
Fourth, recognize the diversity of factors that drive the tobacco epidemic in different economic and cultural contexts. These contexts also create their own unique barriers to success. A diversity of endgame strategies, as opposed to a single global strategy, might be needed to accommodate these different contexts. Provision of a menu of strategic and policy options might be another wise way forward.
Fifth, be realistic. Your scientific programmes will consider how the drive for sustainable development and concern about NCDs can bolster support for tobacco endgames. Doing so is promising, yet also faces some challenges.
Concern about NCDs creates a receptive environment for tobacco endgames. Time and time again, ministers of health from the developing world have told me that prevention of NCDs must be the cornerstone of their response. The costs and demands of chronic and acute care are beyond their reach. Prevention is the best option.
My reply: full implementation of the WHO Framework Convention on Tobacco Control would deal the greatest single preventive blow to all of these diseases.
A different situation exists in many wealthy countries, where effective control measures and changing social norms have seen smoking prevalence drop by 50% or more. In these countries, tobacco use is increasingly concentrated in sectors of society with lower levels of education, income, and engagement in the political process.
In other words, the very success of tobacco control has reduced the visibility of smoking as a problem demanding urgent attention. In some cases, obesity is now the most visible epidemic that needs to be stopped.
Success is always good, but must not be allowed to conceal the fact that the job of tobacco control is far from done.
Making tobacco endgames part of overarching development strategies has great policy appeal. In rapidly growing parts of Asia, evidence suggests that the huge costs of NCDs can cancel out the benefits of economic gain. A tobacco endgame makes very good sense as a boost to both health and economic development.
But what are the realistic chances of success?
I see two main barriers to success. First, most of the proposed endgame strategies depend on a strong capacity for regulatory control and enforcement. Throughout much of the developing world, this capacity simply does not exist at present.
Second, tobacco control requires cooperation from multiple sectors of government, from trade, finance, agriculture, education, law enforcement, and the judicial system. Unfortunately, many countries give more importance to tobacco as an issue for trade and commerce than as a severe threat to health.
The tobacco industry ruthlessly exploits this appeal to commercial interests, everywhere. The most recent example concerns efforts on the part of Philip Morris to sabotage the vote on a strong European Directive on tobacco.
A massive army of lobbyists has been deployed to delay or block passage of the law until the European Council presidency moves to Greece, where the company has opened a huge hub for the production and distribution of cigarettes throughout Europe.
Here, industry is counting on the historical pattern, where economic and commercial interests trump public health concerns time and time again. Such tactics give tobacco endgames further appeal as a strategy for putting industry out of business. They deserve it.
My last advice is this. Be careful.
As I said, nearly all endgame proposals require a very high level of legislative and regulatory support. In most cases, this support goes beyond the capacities needed to implement the WHO Framework Convention on Tobacco Control.
Make sure that these proposals do not play straight into the hands of some long-standing and effective industry arguments, actually firing up the level of alarm. I am referring, in particular, to arguments that strong tobacco control measures represent interference of the Nanny State with personal liberties and freedom of choice.
I am referring, too, to arguments that tobacco control interferes with trade and economic policies.
Expect well-orchestrated, well-funded, and aggressive resistance every step along the way. The WHO tobacco treaty has certainly experienced this resistance throughout its history, beginning with its inception. And for a very good reason. It threatens industry profits.
Endgame strategies threaten the very existence of the tobacco industry. Anticipate a strong back-lash, including through the use of litigation.
Ladies and gentlemen,
I have a final comment. Some tobacco control advocates argue that the WHO Framework Convention on Tobacco Control has likely done all it can. Dramatic drops in tobacco use have begun to level off, pointing to the need for some radically different approaches.
I cannot entirely agree with this view. The treaty has been in force for less than a decade. Abundant evidence has demonstrated the impact of its provisions. The evidence is particularly strong for demand-reduction measures, and the evidence holds true for countries at all levels of development.
To help countries implement the treaty, WHO has developed a practical, cost-effective way to scale up implementation of its provisions on the ground. These are the six highly effective measures for demand reduction set out in MPOWER.
A study published in the July issue of the Bulletin of the World Health Organization examined the impact on smoking-related deaths in 41 countries that adopted at least one highest-level MPOWER measure.
In these countries, the estimated number of smokers dropped by 14.8 million, averting a total of 7.4 million smoking-attributable deaths. This demonstrates the tremendous preventive impact of cost-effective measures for demand reduction.
Many endgame proposals attack the supply side of the tobacco epidemic, aiming for its roots. Governments now have an expanded range of options to consider, some with a proven track record, others with visionary policy appeal.
Keep in mind that tobacco endgames will face the same two barriers to implementation that the tobacco treaty has faced. Namely, interference by the tobacco industry and its lobbies, and lack of legislative and regulatory capacity.
Ladies and gentlemen,
The death clock keeps ticking, and the numbers keep growing faster every minute.
I understand, and share, the great sense of urgency, the impatience with the pace of progress, and the desire to seize the brave new promise of a tobacco endgame.
The prospects for doing so are now being given the serious scientific scrutiny set out in the programme for this conference. I wish you every success.