Fighting Noncommunicable Diseases: The Tobacco Component

Eli Y. Adashi, MD; Douglas Bettcher, MD, PhD, MPH

Disclosures

October 10, 2011

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Introduction

Eli Y. Adashi, MD: Hello. I am Eli Adashi, Professor of Medical Science at Brown University and host of Medscape: One-On-One.

Joining me today is Dr. Douglas Bettcher, Director of the Tobacco Free Initiative of the World Health Organization (WHO). Geneva-based but well-traveled, Dr. Bettcher is the global face of WHO's program on tobacco control. Welcome; it's wonderful to have you.

Douglas Bettcher, MD, PhD, MPH: Thank you. Glad to be here.

UN Summit on Non-communicable Diseases

Dr. Adashi: We assume that you are in New York for the High-Level Summit on Non-communicable Diseases of the UN General Assembly. Is that correct?

Dr. Bettcher: Exactly. It's a dream come true and many years in the making. There were many follow-up actions and developments along the way to what is only the second time in the United Nations' history that the General Assembly of the United Nations has focused on a major, pressing, global public health issue. The first was back in 2001 for HIV/AIDS, which of course led to and catalyzed a great deal of global action on HIV/AIDS, and now we're focusing on noncommunicable diseases and their risk factors.

What Is the Tobacco Free Initiative?

Dr. Adashi: Focusing now on tobacco, you, better than most, recognize that tobacco claims 6 million lives a year or 1 person every 6 seconds, thereby accounting for 1 in 10 deaths. Tell us what the Tobacco Free Initiative is and how it interfaces with these rather dramatic metrics.

Dr. Bettcher: The Tobacco Free Initiative has actually gone through an interesting metamorphosis since its first emergence and development in the summer of 1998. This was the same time that former (Norwegian) Prime Minister Dr. Gro Harlem Brundtland took over as the elected Director General of WHO.

There was a feeling that there was a discrepancy between what WHO was saying about the tobacco epidemic, that it was one of the largest preventable causes of death in the world, yet we had a very small budget. I think we had 2 people working at headquarters and very, very few people out in the field working to support our member states in their fight against tobacco. And also on the books, there was a plan to negotiate WHO's first treaty, the WHO Framework Convention on Tobacco Control.

Dr. Brundtland took this to heart as part of her reform of restructuring of the organization. She felt that our budgeting and our priorities should match the big killers; those determinants of major disability and deaths around the world. So she established the Tobacco Free Initiative as a major high-level cabinet project, and the first part of that work was to really support the 190-plus member states of WHO to negotiate their first treaty.

Dr. Adashi: So the Tobacco Free Initiative preceded the convention?

Dr. Bettcher: Exactly. It was kind of a seabed, the Secretariat, the support for our member states to do this unprecedented negotiation for members. It is a treaty like the Framework Convention on Climate Change and the Kyoto Protocol on Climate Warming, which we hear about in the news frequently.

The global community, all the member states of WHO, decided to move forward with this daunting task of doing something that was in our constitution but had never happened: to negotiate the WHO's first ever treaty.

The Tobacco Free Initiative's life course has evolved along with the growing of the WHO Framework Convention on Tobacco Control to a full-fledged adult treaty with 174 parties, with its own Secretariat, and we have morphed or evolved with that work. The Tobacco Free Initiative now is a network, a global network. We have people in more than 20 countries working to assist governments with their laws, advocacy, communication programs, working with partners, helping them to retool and strengthen their surveillance and data-monitoring systems to measure the progress of the tobacco epidemic and achievements. WHO Director General, Dr. Margaret Chan, says, "What gets measured, gets done." That's also one of our big tasks.

We've had the distinct pleasure and honor to work during the last 4 years with partners that have evolved: Mayor Michael Bloomberg of New York City has made one of the largest donations in the history of our networks, particularly on tobacco control. Given the success of tobacco controls in New York City, he felt that this was a scalable endeavor for the world and has donated $375 million to global efforts on tobacco control. Bill Gates and The Gates Foundation also came onboard in 2008 and have donated $125 million. Those funds are being used, at a country level, to support member countries' work to counteract the devious and unacceptable practices of the tobacco companies, which are constantly and ruthlessly looking to accrue profits at the expense of millions of deaths a year. We are part of a partnership network: 5 partners with the Bloomberg Initiative and 3 or 4 partners in Africa involved with the Gates Foundation work that we're doing.

The message is that real differences are being made. We just released our third global report on the tobacco epidemic in early July of this year in Uruguay and we showed that more than 1 billion people now have been newly covered by an effective tobacco control measure since 2008.

Implementing the WHO Framework Convention on Tobacco Control

Dr. Adashi: Let's backtrack just a little bit. Is it accurate to say that one of the rules of the Tobacco Free Initiative is to oversee the implementation, or at least to maximize the implementation of the WHO Framework Convention on Tobacco Control? Is that an accurate depiction of one of the roles of the Tobacco Free Initiative?

Dr. Bettcher: Exactly. When a treaty comes into being, it sets up its own governing body, which is called a "Conference of the Parties." The Conference of the Parties sets up a Secretariat, which is housed in WHO and which is separate from the Tobacco Free Initiative. It's part of the Director General's office. The Tobacco Free Initiative works with this convention Secretariat and uses to our advantage the fact that WHO has a presence in more than 130 countries in the world, mainly in low- and middle-income countries. We have an on-the-ground presence to provide the tactical assistance, communications, awareness-building, and partnership-building that governments need to scale up their efforts and to counteract the very ruthless and pervasive activities of the tobacco companies.

How Many Nations Have Ratified the Convention?

Dr. Adashi: A treaty, or a convention, is as good as the commitment that it receives from the nations who created it and bring it to the table. Signing the treaty is the first level of commitment. Ratifying the treaty is a more advanced form of accreditation.

As far as this convention goes, where do we stand in the tally? How many nations have signed on? How many nations have actually ratified the convention?

Dr. Bettcher: I think it's probably most relevant to refer to the total number of countries that are full parties now, and that's 173 state parties plus the European Union.

Dr. Adashi: Are there nations who have internally improved the treaty or ratified it internally?

Dr. Bettcher: Yes, there has been. A treaty legally binds the entire country; it's a commitment to take specific actions. As far as framework conventions are concerned, these are a type of international law that, typically with environmental treaties, were more general at first and then they generate protocols that are more specific. But the WHO Framework Convention on Tobacco Control is quite unique in that it has very specific provisions and time-limited provisions on things like advertising bans and pack warnings. The type of pictorial warnings that are now being implemented in the United States are encouraged in the treaty. So I'd say it's a very revolutionary treaty because it was WHO's first, and it was revolutionary in the sense that Health Ministries had never had the role of leading a governmental process to ratify a treaty, to bring the cabinets together, write the documents for the parliaments, and move forward this domestic action to ratify a treaty.

When the negotiations were finished, there was some concern that maybe this was going to take some time before we get what is called "entry into force" of a treaty. When a treaty is adopted and it becomes a final text, it's not necessarily binding on countries. You need a number of countries to enter into force. This one was 40. You had to have 40 countries that had become full parties before this process, "entering into force" and becoming the binding for the treaty. Miraculously, this was the power of the process. The commitment of the countries, according to the treaty section of the UN, entered into force faster than probably any other modern treaty in UN history since the creation of the UN in the 1940s.

What Is the United States' Role in the Tobacco Treaty?

Dr. Adashi: Has the United States been a party to the treaty or has it signed it? Where do we stand on that?

Dr. Bettcher: The United States is a signatory to the treaty. There are 168 signatories to the treaty, but a signatory to a treaty is a kind of time-limited thing. It's a kind of a pressure-cooker approach in international law in that you get 12 months from the time that the treaty is adopted to try to encourage countries to sign up and make a commitment that they'll move towards becoming a party to the treaty.

After that, there can't be any more signatories. So there's going to be forever and ever 168 signatories to the treaty. The parties will continue to build because there are other methods that a country that didn't sign could still become a party. Between 2003 and 2004, the US government signed. What signing a treaty does is it indicates that you won't undermine the general objectives of the treaty and you have the right to receive notifications about the status of the treaty.

We understand that the compliance of the United States with the treaty provisions is very good.

Dr. Adashi: So whether it's ratified or not, you're generally satisfied with the stance of the United States as a global citizen in this arena.

Dr. Bettcher: The United States has been very supportive. Many of the major donors are US donors, and the US government and the Centers for Disease Control and Prevention are some of the biggest supporters of global tobacco control. It would be great to have the United States as a party to this treaty and I personally am very optimistic that that will happen, but every country has different processes that they have to go through and sometimes those processes are more politically straight forward and in other cases they are more politically complex. Every country has its own way of doing it. There's no time limit for that to happen so I'm very optimistic and hope that the United States will ratify it in the not-too-distant future.

How Did Tobacco Control Figure Into the Global Strategy on Noncommunicable Diseases?

Dr. Adashi: Going back now to the UN Summit on Non-communicable Diseases, how did tobacco control figure into the deliberations?

Dr. Bettcher: The focus of noncommunicable disease and the global approach to noncommunicable diseases has been evolving for about 11 years. A historic moment was 11 years ago when our World Health Assembly, like the Global Health Parliament that meets in Geneva every May, of our 194 member states adopted a global strategy on noncommunicable disease prevention and control. This was followed by several steps: the adoption of the Framework Convention of Tobacco Control in 2003; a nonbinding strategy on diet and physical inactivity in 2004; and, in 2008, we had the gestation and the formalization of the Global Strategy on Noncommunicable Diseases -- an action plan to kick-start and push countries' capacity to deal with the 4 main noncommunicable diseases that represent the major burden of disease and death.

We set as priorities the diseases that cause the bulk of the 36 million deaths from noncommunicable diseases each year -- cancer, cardiovascular disease (stroke and heart attack), chronic respiratory diseases, and diabetes. Along with those 4 disease groups, we set as priorities the 4 main risk factors (we call it the Four By Four), including tobacco use, unhealthy diets, physical inactivity, and alcohol use. These are all major modifiable risk factors.

The Four By Four is a concrete way of addressing the noncommunicable disease burden, especially in low- and middle-income countries where health systems and prevention strategies are very weak. Globalization, unhealthy diets, and the tobacco industry penetrating the markets in developing countries have led to an increasingly menacing and problematic escalation in noncommunicable diseases.

The framework then moved forward. In 2010, there was adoption at the World Health Assembly of an alcohol strategy. Going into the Noncommunicable Disease Summit, there was a heads of state meeting here and there were over 30 heads of state participating.

Tobacco is one of the major modifiable risk factors for noncommunicable diseases, and tobacco is very unique because it's the only one with a treaty, a binding international law, which is almost universal. Almost 90% of WHO's member states have ratified the treaty and we've had several years of experience through our collaboration with the Bloomberg initiative and the Gates work in Africa to show there are cost-effective measures at the heart of the Framework Convention that are proven to make a difference on tobacco use.

Tobacco Control and the UN Summit on Noncommunicable Diseases

Dr. Adashi: And have those been, to your satisfaction, incorporated into both the deliberations and eventually into the UN Summit's Political Declaration?

Dr. Bettcher: Yes. I sat on the General Assembly plenary and tobacco certainly seemed to be one of the top priorities; the most doable. The proposed measures would lead to a ready impact and measurable impact. Many of the member states in the General Assembly are ready to move toward the full implementation of the WHO Framework Convention on Tobacco Control.

We know that this is doable, it's workable. We have best practices in places like Turkey and Uruguay that have really scaled up their tobacco control programs in a relatively short period of time. Uruguay has some of the toughest tobacco control laws and forced measures in the world and almost complete bans on advertising. They were the first country in this hemisphere to ban smoking in all public places, workplaces, like the ban on smoking that you have in New York City. They offer cessation support counseling and support to population in the healthcare system. They have the biggest pictorial warnings in the world and high taxes to assure that tobacco is less affordable. Countries like Uruguay were able to demonstrate a 25% reduction, this is phenomenal, of tobacco use in adults between 2006 and 2009. This is just proof that tobacco control measures are affordable and they're effective.

Where Did the UN Declaration on Noncommunicable Diseases Fall Short?

Dr. Adashi: Just before we leave the High Level Meeting, were there elements of the discussion, and particularly the Political Declaration, that fell short in terms of your expectations, specifically on the tobacco front? For example, advertising bans and other means that you have mentioned; has all of that more or less lived up to your expectations?

Dr. Bettcher: Yes, the risk-factor approach is incorporated. Looking at the broader agenda, there were some issues going into the negotiations of the Political Declaration. For example, the whole of government approach, the need to take into consideration the health impacts of different sectoral policies, trade and finance, those were the subject of debate among the member states in August, but they have been recognized in a whole chapter of the treaty.

Something that was a matter of much debate was the issue of setting targets. Why the millennium goals were so successful when they were adopted was because they set targets that countries were accountable for following up. There was a great push to have targets for noncommunicable disease reduction and also the reduction of exposure to risk. While the detailed targets aren't included in the Political Declaration, there's now a mapping-out process that WHO will work though its expert networks and also with its member states to advance. Then we'll present the targets to our governing bodies and come back to the General Assembly.

That's going back to the previous theme of, "What gets measured gets done," or hopefully gets done; you've got to have those surveillance systems and those targets in place to hold countries accountable.

Issues like the links between the noncommunicable diseases and the Millennium Development Goals are recognized in the Declaration now. Those were issues that were a bit sensitive during the negotiations but are there. Also, recognition of use of flexibilities of what are known as the "Trade-Related Intellectual Property Agreements of the WTO" for access to central medicines. There's reference now to those flexibilities in the Declaration. There are big challenges ahead; the heads of state summit is a huge milestone, just exciting and honored to be here. But now there's a roadmap of where to go. From here, it's "raise the awareness at the highest levels of government" and so it is a new beginning again at a much higher level.

Was the UN High-Level Summit a Success?

Dr. Adashi: So you would give the High-Level Meeting a very fine grade for its overall performance and for where it puts the noncommunicable diseases on the road to, hopefully, a successful resolution in due course.

Dr. Bettcher: Absolutely and I think the world community has come to the conclusion that they can't avoid the fact that noncommunicable diseases account for more than 60% of deaths, that 9 million of those 36 million deaths are premature deaths, and 90% of those are in lower- and middle-income countries. There's this misperception that this is a high-income country problem, but that's not the case

Dr. Adashi: Diseases of affluence, lifestyle diseases.

Dr. Bettcher: Not at all. These are the highest exposure to risk factors: tobacco use, alcohol use; the marketing and the pushing of the use of these harmful products are now in lower and middle income countries and the most vulnerable are the poorest populations in the lower- and middle-income countries. They have the least access to treatment when they do have a heart attack or get cancer. The health systems are set up, but not even adequately enough to deal with all communicable diseases and maternal child health issues. That's what the Millennium Development Goals focus on. But certainly the noncommunicable diseases of poor families in lower- and middle-income countries can have catastrophic effects at the microeconomic level when their breadwinner dies or gets sick from a noncommunicable disease. First, they can't afford the treatment. This leads to catastrophic health spending, which can destroy a family's whole financing, and then the breadwinner dies. There's no longer a source of financing for the family.

An Investment in Noncommunicable Diseases Is an Investment in the Global Economy

Dr. Bettcher: You might hear some say, "Well, we really can't afford this in the financial crisis." But, in fact, what's come out of this whole consultation process is that there really is no alternative in the times of financial crisis because the cost of noncommunicable diseases to the world's economy is huge. It's estimated that an increase of 10% in noncommunicable diseases in a country reduces gross domestic product 0.5%.

The World Economic Forum, 2 years running, has indicated that noncommunicable diseases are one of the largest threats to global financial stability and that's because they reduce productivity. They are having a devastating effect on health systems in low- and middle-income countries that are ill-equipped to deal with them. In a time with lagging economies and the need to kick-start the world's economy, investing in noncommunicable disease prevention control is an investment in our future. It's an investment in our future well-being health-wise, but also it's an investment into the economic well-being of the world.

Conclusion

Dr. Adashi: Thank you for shedding such wonderful light on noncommunicable diseases in general, but tobacco control in particular. And if we may close on a personal note, you are Canadian by birth, living in Geneva, Switzerland, and somewhere in between you spent time in Ethiopia and in Jamaica.

Dr. Bettcher: Yes.

Dr. Adashi: Can you draw the thread through all of those points in time and perhaps clarify what drew you into this arena and where you would like to go with that?

Dr. Bettcher: I have a friend who says my body has been equally distributed throughout the world in these last 20 or 30 years after leaving medical school in Canada. But I think the thread through my career, whether it was working in a small primary practice in Jamaica or working in a famine camp as a volunteer medical doctor in 1984-1985 in Ethiopia, and then working on a big refugee repatriation project to stabilize and provide development assistance and medical public health assistance to half a million refugees coming back from Somalia, the thread was the need to make a difference and the challenge to make a difference that would improve the world. This is what drove me as a medical doctor. A rather different course in a sense that there aren't too many of us that have gone on and done a PhD in International Relations and Political Economics, which I have done, besides my masters of public health in London.

But it was an inquiry and a discovery side of my personality to put different puzzles together and solve problems, complex problems, which now are so relevant in the big issue of making a difference. When we're discussing the High-Level Summit, it's all about health in policies, a whole of government approach, thinking how trade policies might intersect and cause adverse effects in public health. For me, it's about having the big picture, being a problem solver and having a dedication to public service, and wanting to be part of making a change for the betterment of current and future generations.

Dr. Adashi: Thank you. On this note, sincere thanks to Dr. Bettcher, and to you, our viewers, for joining Medscape: One-On-One. Until next time, I am Dr. Adashi.

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