Tobacco free Europe achievable: Day 1 of Ashgabat conference on NCDs

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

Opening the conference at the Ryhyyet Presidential Palace, Gurbanguly Berdimuhamedow, President of Turkmenistan warmly welcomed participants to Turkmenistan, and underlined his commitment to addressing noncommunicable diseases, 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 organizations and the nongovernmental sector.

Reflecting on the commitments that Member States have made to address noncommunicable diseases, Zsuzsanna Jakab, WHO Regional Director for Europe praised countries for their commitment to health for all, reducing health inequalities, 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 whole 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.

The need for institutional change as well as a change in mindset was also developed by Hans Troedsson, Executive Director of the Director-General?s Office at WHO. Dr Troedsson explained the life-long relationship that patients today will have with health care services to address conditions such as hypertension and diabetes, compared to the „enter, treat, cure and discharge? mentality in the past. Singling out the WHO Framework Convention on Tobacco Control (WHO FCTC) that has been ratified by the vast majority of countries in the European Region, but not completely implemented, he concluded that we will be judged by future generations on the actions we take.

Through a personal example, Evelin Ilves, First Lady of the Republic of Estonia, and a medical doctor, explained how pursuing NCD goals is not always straightforward. In her country she had suggested that sweet snacks containing trans-fats should be replaced with healthier snacks and fruits for children. After an initial negative reaction by the food industry, public and media, eventually with closer examination of the scientific evidence, attitudes changed and the major confectionary manufacturer in Estonia 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 producer?s marketing policies,? she said.

NCDs and development

Chairing the first session, Dr Nurmuhammet Amannepesov, Minister of Health and Medical Industry of Turkmenistan, highlighted a few examples of how Turkmenistan is addressing NCD control through a whole of society approach, using education and putting the right infrastructure in place. For example, through a current initiative, he hopes that people will become more aware of the need for regular blood pressure monitoring, and to have their blood pressure checked throughout their lives.

In a video address to delegates, Margaret Chan, WHO Director-General, explained how noncommunicable diseases are of concern in terms of the burden on the health of populations, costs to patients and healthcare budgets, the challenge of providing sustainable long-term care, and the strain these diseases place on health systems and the workforce. „A tobacco-free Europe would be the strongest possible contribution to the prevention of all noncommunicable diseases,? she added.

Zsuzsanna Jakab, WHO Regional Director for Europe, set the scene for discussions on developments in NCD policy, beginning with recent activities in Turkmenistan. These activities include:
?conducting a review of the health system for strengths and weaknesses in the prevention and control of NCDs;
?reviewing the country?s data and updating the health information systems to validate and include them in the Health For All database;
?a near-completion first national NCD risk factor survey using the WHO STEPS methodology;
?reviewing and strengthing its tobacco legislation; and
?with assistance from the International Agency for Research in Cancer, reviewing the country?s breast cancer detection and management programme.

Ms Jakab underlined the huge challenge of addressing NCDS: 2.4 million people in the WHO European Region aged 30 to 70 years died from these diseases in 2011. Not only is this a great tragedy, but combined with years of life lived with disability, they exert a toll on productivity everywhere, especially in countries of the east of the Region, and a burden on the health care systems of the whole region, particularly in the West. „No country or health system is immune? she said. Citing the focus on a tobacco free Europe in the Ashgabat Declaration under discussion, Ms Jakab explained that WHO tobacco policy at European level has not been discussed for over a decade, and the Region has the dubious honour of having the highest smoking prevalence rate of any WHO region – at 28% of adults.

NCD policies that work, not myths

During his keynote address, Professor Pekka Puska, Director-General, National Institute for Health and Welfare, Finland, took many of the common myths concerning NCDs and discredited them with evidence and proven policy measures. These myths, that NCDs mainly affect old people, men, are a result of affluence and are difficult and expensive to prevent, that the causes are genetic and an individual?s responsibility were disproved.

For example, more than 70% of premature deaths among men in the WHO European Region are from NCDs, but the figure is 77% for women. Fluctuating changes over time in levels of mortality from diseases of the circulatory system in Europe prove that these diseases cannot be primarily caused by genetics.

Professor Puska underlined that the effects of appropriate preventive measures can be seen quickly, and are cost effective. He called for the prevention of avoidable NCDs through a social change process and the „need for strong leadership combined with good partnership.?

Dr David Stuckler, from the University of Oxford, also noted that there is a strong economic argument for investing in NCD prevention, as evidence suggests that every Euro invested can yield returns of up to 3 Euros.

Progress on the prevention and control of noncommunicable diseases

Summarizing the „good progress? in general that Member States are making in the prevention and control of NCDs, Professor Sylvie Stachenko, from the School of Public Health at the University of Alberta in 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 back to WHO/Europe include NCDs in their national health plans, only 43% of countries also include them in social and economic development plans.

These findings are from the Progress report on the prevention and control of noncommunicable diseases in the European Region, launched on 3 December 2013.

Tobacco free Europe

New Zealand has an ambitious tobacco free goal – to achieve an adult prevalence rate of under 5% by 2025. Robert Beaglehole, Emeritus Professor at the School of Population Health, University of Auckland, New Zealand, detailed the work undertaken in establishing 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 inititives.

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?.

Haik Nikogosian, Head of the Convention Secretariat, explained that he believed the tobacco free goal in the European Region is achievable, as the concept goes deep in public health thinking, and despite high smoking rates, there is a downward trend in most countries. However, Dr Nikogosian highlighted changing tobacco industry tactics, using legal challenges against legal measures. He supported the use of the term tobacco free as opposed to smoke free. Reducing the proportion of cigarette smoking in the population would be an important achievement but it would be a hollow victory if this was simply replaced by other forms of tobacco use. Hence we should aim for freedom from tobacco use and not simply from smoking.

Another note of caution was raised by Florence Bertelleti Kamp, Director of the European Smoke Free Partnership, who explained, „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, this report, launched on 3 December 2013 shows that although many countries have ratified the WHO Framework Convention on Tobacco Control (WHO FCTC), implementation levels are low. For example, only 25 countries have raised tobacco taxes.

Country developments on NCD prevention and control and tobacco policies

Widespread support for the Ashgabat Declaration was expressed by Member States and non-governmental organizations.
?A member of the Armenian delegation explained that this year they have established legislation to stop tobacco advertising on products. From next year the country will work more extensively to strengthen primary health care to improve the prevention and early diagnosis of NCDs.
?The need for 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 were seen as key to addressing NCDs by the delegation from Montenegro.
?Uzbekistan also identified the need to set national targets, and explained that their action plan on NCDs for 2014-20 includes legal measures, assessing risk factors, advocacy and information provision, research, and the involvement of civil society.
?Ingr?da Circene, Minister of Health of the Republic of Latvia, described a range of national initiatives against NCDs, including annual cardiovascular risk factor screening for at risk groups, and the public health awareness campaign „love your heart? to inform the public about the risk factors for cardiovascular disease and steps to change them.
?The Minister of Social Affairs of Estonia, Taavi Rõivas, described the need for societal changes, only possible if all sectors work together, to achieve tobacco free status in Europe.
?The delegation from the Russian Federation explained that changes this year to national legislation mean that it can now meet its obligations for the Framework Convention on Tobacco Control. The country aims to achieve a 30% reduction in smoking levels by 2020, because if action is not taken smoking among women is likely to increase.
?Delegates 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.

Health governance and NCDs

Ilona Kickbusch, Director of the Global Health Programme, The Graduate Institute of International and Development Studies, Geneva, Switzerland, took the lectern to share her thinking on how to move forward regarding health governance and NCDs. The new challenge for health systems is co-production.

„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,? she commented.

A recent report from the Organisation for Economic Co-operation and Development (OECD) describing its approach to new public governance includes a long list of initiatives covering the environment and reducing poverty but not health. Health governance is changing to become a coproduction between communities, citizens and patients in promoting health, health care and health promotion, which can no longer be seen as separate entities.

Co production also implies a different approach to the design and delivery of services. A patient-centered system is required with people, patients and citizens powered and empowered by the IT revolution.

According to Professor Kickbusch, the idea that health is created where people live, love, work and play is highly relevant to patients with chronic diseases. They do not want to be cared for only in health care settings.

Research shows that with co production costs are reduced, and quality and outcomes improve.

Intervention on behalf of nongovernmental organizations

The NCD Alliance presented a statement on behalf of NGOs in support of the Ashgabat Declaration.

On the agenda for 4 December 2013

?National responses to NCDs
?Presentation on strengthening the response of noncommunicable diseases in Turkmenistan by Nurmuhammet Amannepesov, Minister of Health and Medical Industry, Ashgabat
?Launch of the country assessment guide on health systems challenges and opportunities for better NCD outcomes
?Presentation of the Ashgabat Declaration

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