Tobacco-free Europe achievable: day 1 of Ashgabat conference on noncommunicable diseases

On the first day of the Ashgabat conference on noncommunicable diseases (NCDs), participants considered the impact of NCDs on development and the challenges they pose to health systems, and discussed the proposed Ashgabat declaration, committing countries to joint action for NCD prevention and control.

Opening the conference at the Ryhyyet Presidential Palace, President Gurbanguly Berdimuhamedow warmly welcomed participants to Turkmenistan, and underlined his commitment to addressing NCDs, noting that the health of a country is its main asset, and source of wealth and prosperity.

The conference, on 3–4 December 2013, brings together delegations from 35 Member States in the WHO European Region, international experts and representatives from partner and nongovernmental organizations.

Reflecting on the commitments that Member States have made to address NCDs, Ms Zsuzsanna Jakab, WHO Regional Director for Europe, praised countries for their commitment to securing health for all, reducing health inequalities and strengthening leadership and participatory governance. She explained that a central component of the conference is the opportunity to share examples of cooperation across the whole of government and of society, creating strong people-centred health systems adapted to NCDs.

“We need to strengthen our governance structures and institutional capacities to accelerate action,” she said.

Dr Hans Troedsson, Executive Director of the WHO Director-General’s Office also discussed the need for institutional change, as well as a change in mindset. Today, patients would have a life-long relationship with health care services to address conditions such as hypertension and diabetes, in contrast to the past mentality of “enter, treat, cure and discharge”. Singling out the WHO Framework Convention on Tobacco Control (WHO FCTC), which the vast majority of countries in the European Region has ratified but is not completely implemented, Dr Troedsson concluded that future generations would judge the people of today by the actions they take.

Through personal example, Dr Evelin Ilves, First Lady of the Republic of Estonia, showed how pursuing NCD goals is not always straightforward. In her country, she had suggested that sweet snacks for children that contained trans fats be replaced with healthier snacks and fruit. After initial negative reactions from the food industry, public and mass media and with closer examination of the scientific evidence, attitudes changed and the major confectionery manufacturer in Estonia eventually reformulated its products.

“This, what for me was a personal issue, shows how in the prevention of noncommunicable disease we can initially find ourselves facing a wall of ignorance and lack of understanding. To be successful, even to achieve some partial results, we need perseverance, consistency and like-minded colleagues. … Then we can be strong enough to change people’s habits and attitudes as well as producers’ marketing policies,” said Dr Ilves.

NCDs and development

Chairing the first session, Dr Nurmuhammet Amannepesov, Minister of Health and Medical Industry of Turkmenistan, highlighted a few examples of his country’s work to take a whole-of-society approach to NCD control, using education and putting the right infrastructure in place. For example, Dr Amannepesov hoped that a current initiative would make people more aware of the need for regular checks of blood pressure throughout their lives.

In a video address to participants, Dr Margaret Chan, WHO Director-General, explained the burden of NCDs on the health of populations, patients’ and health care budgets, and health systems and the workforce, as well as the challenge of providing sustainable long-term care. “A tobacco-free Europe would be the strongest possible contribution to the prevention of all noncommunicable diseases,” she added.

The WHO Regional Director for Europe set the scene for discussions on developments in NCD policy, beginning with recent activities in Turkmenistan, which include:

• reviewing the strengths and weaknesses of the  health system in NCD prevention and control;
• reviewing the country’s data and updating the health information system to validate and include them in the WHO European Health for All database;
• making the first national survey of NCD risk factors, using the WHO STEPwise approach to Surveillance (STEPS);
• reviewing and strengthening tobacco legislation; and
• with assistance from the International Agency for Research on Cancer, reviewing the  programme for detection and management of breast cancer.

In addition, Ms Jakab underlined the huge challenge of addressing NCDs, which caused the deaths of 2.4 million people in the WHO European Region aged 30–70 years in 2011. These deaths not only were a great tragedy but also, combined with years of life lived with disability, took a toll on productivity in the Region, especially in the eastern countries, and on health care systems, particularly in the west. “No country or health system is immune,” she said.

Citing the proposed Ashgabat declaration’s focus on a tobacco-free Europe, Ms Jakab noted that WHO tobacco policy at the European level had not been discussed for over a decade, and the Region had the dubious honour of having the highest smoking prevalence rate (28% of adults) of any WHO region.

NCD policies that work, not myths

During his keynote address, Professor Pekka Puska, Director-General, National Institute for Health and Welfare, Finland, discredited many of the common myths about NCDs with evidence and proven policy measures. Those myths included: that NCDs mainly affect old people and males, result from affluence, are difficult and expensive to prevent, have genetic causes and are an individual responsibility.

In the WHO European Region, for example, NCDs cause more than 70% of premature deaths among men, but 77% among women. Changes over time in mortality from diseases of the circulatory system in Europe showed that the primary cause could not be genetic.

Appropriate preventive measures quickly show effects and are cost effective. Professor Puska called for the prevention of avoidable NCDs through social change and stressed the need for strong leadership, combined with good partnership.

Dr David Stuckler, of the University of Oxford, United Kingdom, noted the strong economic argument for investing in NCD prevention, as evidence suggests that every euro invested can yield returns of up to €3.

Progress on NCD prevention and control

Summarizing the good progress in general made by Member States in prevention and control, Professor Sylvie Stachenko, of the School of Public Health at the University of Alberta, Canada, noted that more could be done to make linkages between NCD prevention and social and economic development. For example, while 88% of countries reporting to WHO/Europe included NCDs in their national health plans, only 43% also included them in plans for social and economic development. These findings came from WHO/Europe’s progress report on the prevention and control of NCDs in the European Region, launched on 3 December 2013.

Tobacco-free Europe

New Zealand had an ambitious goal: to achieve an adult prevalence rate below 5% by 2025. Dr Robert Beaglehole, Emeritus Professor at the School of Population Health, University of Auckland, New Zealand, detailed the work done in setting this goal. Noting that 80% of smokers want to stop, Professor Beaglehole explained that there is support for higher taxation on tobacco if it contributes to tobacco-cessation initiatives.

Reflecting on the European Region, he commented, “We have evidence, experience, and the Ashgabat declaration will give us the mandate to work towards being tobacco free. This is a vision, a goal of which we can be proud. Absolutely no one wants their grandchildren to start smoking.”

Dr Haik Nikogosian, Head of the FCTC Secretariat at WHO, believed that the European Region could achieve the tobacco-free goal, as the concept goes deep in public health thinking and, although smoking rates were high, they showed a downward trend in most countries. The tobacco industry was changing its tactics, however, using legal challenges against legal measures. He preferred the term tobacco free to smoke free. Reducing cigarette smoking in the population would be important, but a hollow victory if other forms of tobacco use replaced it. Hence the goal should be freedom from tobacco use, not simply from smoking.

Ms Florence Berteletti Kemp, Director of the European Smoke Free Partnership, raised another note of caution: “The tobacco-free goal is a dream of David versus Goliath. Goliath, the tobacco industry, has arms that stretch around the world. We shouldn’t shift the problem of tobacco to the rest of the world. Being tobacco free must be a global goal.”

European tobacco control status report 2013

Using data collected from Member States, the report, launched on 3 December 2013, showed that WHO FCTC implementation was low, even though many countries had ratified it. For example, only 25 countries had raised tobacco taxes.

Country developments: NCD prevention and control and tobacco policies

Member States and nongovernmental organizations (NGOs) expressed widespread support for the Ashgabat declaration.

• A member of the Armenian delegation explained that the country had adopted legislation to stop tobacco advertising on products. From 2014, the country would work more extensively to strengthen primary health care to improve the prevention and early diagnosis of NCDs.
• The delegation from Montenegro saw a multisectoral approach – promoting equity and social justice, and creating a collective sense of ownership and responsibility through using indicators and involving the private sector – as key to addressing NCDs.
• Uzbekistan identified the need to set national targets; its action plan on NCDs for 2014–2020 included legal measures, risk-factor assessment, advocacy and information provision, research and the involvement of civil society.
• Ms Ingrīda Circene, Minister for Health of Latvia, described a range of national initiatives against NCDs, including annual cardiovascular risk-factor screening for at-risk groups, and the “love your heart” campaign to inform the public about the risk factors for cardiovascular diseases and steps to change them.
• The Minister of Social Affairs of Estonia, Mr Taavi Rõivas, described the need for societal changes, which required all sectors to work together, to achieve a tobacco-free Europe. 
• The delegation from the Russian Federation explained that changes to national legislation in 2013 enabled the country to meet its obligations under the WHO FCTC. The Russian Federation aimed to achieve a 30% reduction in smoking levels by 2020, because smoking among women was likely to increase if action was not taken. 
• Participants from both Norway and the United Kingdom emphasized the need for long-term goals for tobacco control, requiring commitment and ambition over an extended period.
• The NCD Alliance presented a statement on behalf of NGOs in support of the Ashgabat declaration.

Health governance and NCDs

Professor Ilona Kickbusch, Director of the Global Health Programme at the Graduate Institute of International and Development Studies, Switzerland described how to move forward on health governance and NCDs. The new challenge for health systems was co-production.

Professor Kickbusch said, “We are at a turning point regarding health policy. There is a feeling that change is in the air, but countries and systems have to change – not only people and patients, but professionals have to change their role and reach out. But change is not limited to the health sector.”

A recent report from the Organisation for Economic Co-operation and Development (OECD) described its approach to new public governance, which included a long list of initiatives addressing the environment and poverty, but not health. Health governance was changing to become a co-production between communities, citizens and patients in supporting health, health care and health promotion, which can no longer be seen as separate entities.

Co-production also implied a different approach to the design and delivery of services. A patient-centred system is required, with people, patients and citizens powered and empowered by the information technology revolution. The idea that health is created where people live, love, work and play was highly relevant to people with chronic diseases. They did not want to be cared for only in health care settings. Research showed that, with co-production, costs are reduced, and quality and outcomes improve.

Agenda for 4 December 2013

• National responses to NCDs
• Presentation on strengthening the response to NCDs in Turkmenistan by Dr Amannepesov, Minister of Health and Medical Industry
• Launch of the country assessment guide on challenges and opportunities for health systems to secure better NCD outcomes
• Presentation of the Ashgabat declaration