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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.

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