 Good afternoon and welcome to CSIS. Thank you all for coming. Today, we're very, very fortunate today to have with us a number of key experts and personalities who are coming together to talk about global tobacco control efforts with a view towards the high level meeting on non-communicable diseases that lies ahead in September. We felt that as part of a series of programs that we've put together here starting late last year and extending into this year, trying to bring forward different personalities to talk about this and very important meeting that it was quite important that we be able to put a focus upon tobacco control. As you'll be hearing from Dr. Tom Frieden and his major keynote address here from CDC, this is an instance in which there's been major diplomatic progress with the formation of the FCTC, several years of very concentrated effort and work and putting programs in place and gathering data and attempting to get compliance and raise the political will and that this is a big moment as we look forward at moving events and seizing this opportunity. We're going to break our program into two parts. Dr. Frieden will open up with the end address. We'll have a brief conversation after that and we'll open to you for comments and questions. He'll have to depart in a later than 5.30. And then we'll move into the second part of our program where we'll be having a roundtable discussion with a number of prominent individuals who've come to us today, who I'll introduce as we get seated, who are from their own individual institutional settings are key players in implementing and moving forward the vision for how to achieve much lower prevalence and much greater control over the use of tobacco worldwide. So please join me in welcoming Dr. Tom Frieden today at CSI. Good afternoon, everyone, and thanks very much for being here. As some of you know, I spent over a decade working on tuberculosis control. And then I've spent much of the past decade working on tobacco control. And I've been thinking recently about how those two things differ. So fighting communicable diseases is quite difficult. But I find that fighting non-communicable diseases is even harder. Because microbes such as mycobacterium tuberculosis don't, for example, lobby politicians to allow it to continue to spread. Nor, in fact, do they fund scientists to say that really TB is not so bad. Nor do they rebrand themselves as light or low tar TB that would be less harmful or pay for ads with beautiful people to say that their lives were enhanced by having TB. So there are real problems in non-communicable disease control. And we need to have our eyes open about them, or we will not have success. The CDC has a core role in control of non-communicable disease in several ways. First, surveillance and epidemiology. And you'll be hearing later this afternoon from Sameera Asma, who has worked with WHO on the Global Tuberculosis Surveillance System, which really is the first non-communicable disease surveillance system that is worldwide. And I think a model not just for TB, but for other conditions as well, superb work, well standardized and valid so that you can get comparisons between countries that are valid and comparisons within one country over time that are valid. Identifying risk factors and prevention strategies, linking data to public health action and helping to build national capacity for action. In 1970, there were slightly more deaths among children than among young and middle-aged adults. Over time, child deaths decreased, and adult deaths increased. And that trend has continued steadily so that now there are more than three times as many deaths among adults as there are among children. Deaths among adults, in fact, continue to increase, even as death rates for both adults and children have fallen substantially. As you all know, the global burden of tobacco is enormous. 100 million people killed in the 20th century. In the 21st century, unless urgent action is taken, it will kill 1 billion people. There will be 8 million deaths per year by 2030. It is the leading preventable cause of death killing up to half of people who use it. And the world's leading cause of death is now a man-made product. Tobacco kills 15,000 people every day, one person every six seconds. 600,000 people killed by secondhand smoke. Half of tobacco-related deaths occur during the most productive years of life. One might quibble with whether those are the most productive years of life, but during productive years of life, tobacco, including both health care costs and lost productivity, costs nearly 1% of the total world output of GDP. And tobacco kills more people worldwide than AIDS, TB, and malaria combined. And in fact, if you look at the other leading causes of death, acute respiratory infections and tuberculosis, a substantial proportion of those deaths are in fact from tobacco. Nearly 2 thirds of the world's smokers live in 15 low and middle income countries, 40% living in China and India, 62% in the top 10 countries, which you can see there, which are mostly low and middle income, and then 75% in the top 20 countries of which 13 are low and middle income. So there's an ability to focus and make a big difference, but there's also an ability for any country to make substantial improvements, and we'll see that in a minute. Tobacco will kill an increasing number of people in developing countries, even as deaths decline slightly in high income countries. And tobacco control interventions are proven to work, yet few countries use them. Effective tobacco control is within reach. The FCTC has been signed by nearly all countries in the world and ratified by nearly all as well, the U.S., a notable exception. WHO's Empower Package of Evidence-Based Tobacco Control Measures assists in country level implementation of effective measures, and the Empower Strategy puts together what works in tobacco control. Monitoring tobacco use and prevention policies, and I really compliment the authors of the report that's on your chairs of the Americas, very clear information about what is the status of tobacco control. This is very important to have. It's a core means of promoting accountability of governments and civil society for progress and of encouraging healthy competition among countries. Protecting people from tobacco smoke, secondhand smoke kills, just think if we were allowing people to spew asbestos in workplaces. We would think that was terrible, and yet secondhand smoke is killing people at a much higher rate, and we allow it to continue to occur despite the signatures on the FCTC and the fact that it is well documented that going smoke-free saves lives, doesn't hurt business, and doesn't cost money to implement. Offering help for people to quit tobacco use, warning people about the dangers of tobacco, and you have, again in that booklet, some nice examples of PAC warnings. The US is now implementing PAC warnings. I anticipate that some aspects of the tobacco industry may sue to try to stop that, but it's the law of the land that I anticipate that US will have hard-hitting PAC warnings up by the legislative deadline, and so join the countries that are doing that. But warning isn't just about PAC warnings, it's also about hard-hitting ads, and in fact, this is the only area in tobacco control with a slight possible exception of reducing tax evasion, which requires some government financial investment. It's important to keep tobacco in the world's view, in the view of individuals. If the tobacco industry weren't spending tens of billions of dollars on marketing and promotion, and weren't putting so much nicotine in each cigarette, or ensuring that it's there that they keep people hooked, then maybe it wouldn't be so important to spend this much money on anti-tobacco advertising, but even in these fiscal times, it's crucial that we continue the commitment. Enforcing bans on tobacco advertising promotion sponsorship, and raising taxes on tobacco, which is the single most effective way to reduce tobacco use, should be done in a way that increases the price of the lowest-cost tobacco products, which means using specific taxes whenever possible, as opposed to ad valorem taxes. The specific taxes will result in a more expensive cigarette, otherwise what you get is brand shifting down to cheaper cigarettes, if you just have a percentage tax. But raising taxes also means enforcing and preventing tax evasion. In New York City, the MPOWR intervention has resulted after 10 years of no decline in tax, a no decline in tobacco use, in a substantial decline once taxes were raised, a further decline once people were protected against tobacco smoke. We had regular surveillance and saw that there was a stall after that, so we looked, what else could we do? We ran hard-hitting ads and warning of the dangers of smoking, and that led to a resumption in the decline such that there were 350,000 fewer adult smokers in the course of six years, 100,000 deaths prevented. This was a decline of 25% in adult smoking and of 52% in teen smoking. Why did teen smoking go down more? Well, besides the fact that kids are smarter than adults, it's because they weren't addicted. So it's a lot easier not to start than it is to quit once you're addicted. Now, that was 25% over six years when WHO looked at countries around the world, Uruguay, came out as having the best tobacco control policies of any country in the world, a coordinated package of interventions, the first country in the Americas to go 100% smoke-free, high taxes, a comprehensive ad ban, large pictorial warning labels, 80% of the front and back, banning deceptive terms like late and low tar, and cessation services, Euro monitor, which is generally used by the tobacco industry to monitor the commercial patterns. Noted that there's little scope left for the increased restrictions on tobacco in Uruguay. But give us time, we'll think of ways. But what the results of that were, one in four smokers quit. That's a 25% reduction in two years. So New York City, we thought we were pretty good. We did 25% reduction in six years. This was three times as fast, 25% reduction in two years. I think this is the fastest reduction in smoking ever documented in a large population anywhere. And it shows what's possible. So as we think about targets for the world, where we may be thinking of another 10 or 15, or even longer year timeframe, we need to think about what is the best case scenario with political commitment? Because what made this happen was the president of Uruguay, an oncologist who decided that he was going to do something about tobacco control and left office, term limited out, with an approval rating higher than any president of Uruguay had ever had even office. So political leadership is necessary and will be rewarded, but it requires dealing with the industry that I outlined in my first few slides. Now there has been progress implementing Empower. In 2007, what you see on the Y axis is the proportion of the world covered by the different interventions. And anywhere from 200 million to 600 million people were fully covered by these effective interventions. By 2008, it was further progress, expanding health warnings and smoke free environments. And when WHO looked at the sub national level in large countries, identify quite a few more people who were protected. So significant progress, but far, far, far too little progress. Few people are adequately protected. No single policy intervention has been comprehensively implemented to cover even one in 10 people in the world. And in low income countries, it's even worse. Even lower levels of protection. There is a misconception that tobacco use and obesity for that matter are diseases of affluence. In fact, the reverse is true. What you will see in virtually every country in the world is that usually perhaps after an initial period, but as of today, that rates of tobacco use, rates of obesity, rates of harmful alcohol use are much higher in lower socioeconomic status groups than they are in higher socioeconomic status groups. And this is a major challenge. The Global Adult Tobacco Survey is really a standard. It was completed in 14 high burden countries and it's underway in six more. The results are representative of 3.6 billion people, more than half of the world's population. More than 300,000 people were surveyed in their home in a randomized cluster sample fashion. Core survey questions have been established and are being incorporated now into a wide range of surveys that countries can do and international agencies can do so that we can all finally have a common case definition of what is a smoker? What is an ex-smoker? What is exposure to second hand smoke? And because we have those monitoring tools, we can make much more progress. Those 14 countries which account for about two thirds of the world smokers show about 23% smoking rate, about 30% tobacco use rate, about 50% exposed to second hand smoke either at home or both at home and in the workplace. Tobacco use varies enormously by country including both smoked and smokeless tobacco of all types. You see usage rates that go from over 40% to 16% in Mexico and very different rates of ex-smokers. So you can see, for example, in looking at the data in Uruguay, you can see a rapid decline. Many people who quit smoking in the last one year or five years, whereas in other places, you see very few people who quit. Russia and China have very few former smokers there. In some countries, many people smoke other types of tobacco and so these alternatives are generally less expensive than cigarettes. This is smoking rates including BDs, hand rolled cigarettes, water pipes for countries where these are common and this represents a significant challenge for taxation because the sector may be informal and harder to regulate. Some countries provide far more protection against second hand smoke than others and health warning labels on cigarette packs are much better at motivating cessation in some countries than in others. Now, Empower Policy Intervention Status is not very good and if you look at these countries, 15 high burden countries, you can kind of pick out the green. So there are some countries that have gone fully smoke-free. In fact, there's at least one, other than enforcing ban, there's at least one green in each category but not many more and some partial and a lot of red here. So quite a bit of room for improvement. Implementing tax policies can save lives, increase government revenues. One estimate suggests that just in nine countries, increasing tobacco taxation would generate $40 billion a year in revenues and save 28 million lives by helping more than 100 million smokers to quit. There has been real progress in global tobacco control. The $500 million commitment from the Bloomberg Philanthropies and the Gates Foundation between 2007 and 2008, 19 countries strengthened tobacco control policies. Nearly 400 million people were covered newly by at least one Empower Policy at the highest level of implementation, increasing from 1.2 to 1.6 billion, so about a third increase. And some countries such as Uruguay have had very rapid progress. The Bloomberg Initiative has strengthened a global movement that precedes it and has been joined by the Gates Foundation, but hundreds of organizations are now working on tobacco control in dozens of countries and civil society is getting stronger and stronger and this is crucially important. Governments are also getting stronger and this is crucially important. The third WHO Empower Report will come out in the summer focusing on health warnings, but despite progress, more and faster progress is needed. The level of awareness of the harms of tobacco and the range of those harms is quite low, particularly in certain parts of the world and in some populations. Implementation is scaling up far too rapidly. The tobacco industry continues aggressive opposition. There is in many countries a lack of political will for tobacco control. There is as yet no quantifiable international target for tobacco control and government and private funding for tobacco control remains far too limited. In fact, if you look at even the low levels of taxation that we have now versus the dollars spent on tobacco control globally, tax revenues outpace spending on tobacco control by about 200 to one and even in low and middle income countries where tax revenues are minuscule, tobacco control is microscopic and tax revenues outpace tobacco control spending by about 5,000 to one. In fact, global tobacco control is drastically underfunded compared to other leading causes of death and the message of this slide is not that we need to underfund other things as well but we need to invest in tobacco control as a best buy in health. We estimated that 150 million lives could be saved in the 21st century by achieving a modest target of less than 20 by 2020, less than 20% smoking in any country by the year 2020. This would result in current smokers quitting and future smokers not taking it up. The high level summit, as you all know, provides a unique opportunity. The first in 10 years, the goal is to prioritize prevention and control to focus on developmental and other challenges and social and economic impacts to secure support of government and hands of states for things that they can meaningfully commit to and then be held accountable for. I will say that there is a concern and I've put it a little controversially about avoiding a clinical trap. Now clinical care is very important and for things like blood pressure control can make an enormous difference and should be done but clinical measures are never going to have the population impact that measures can have that are policy and affect all people. So take the example of tobacco control, clinical cessation services are very important and every doctor should be an advocate for tobacco control, every smoker should be advised to quit, every smoker who wants to quit should be prescribed medications which will double or triple their chance of succeeding. That is all true but even if you do that very, very well, you will not have anything like the kind of impact that you'll have by smoke-free environments, hard hitting anti-tobacco ads, tobacco taxation or banning advertising, marketing and promotion. The role of global tobacco control is very important for NCD control. If we can't do tobacco control, we're not going to be able to have success in anything in NCD control. It's the most preventable of all of the NCD risk factors. There are already considerable policy gains and commitments and the approaches that are used can easily be applied to control of other non-communicable diseases and their risk factors, building on the investments already made. Margaret Chan has said that reversing this entirely preventable epidemic must now rank as a top priority for public health and for political leaders in every country of the world. Thank you very much. Thank you very much. Tom, let me open by turning back to the whole question of US policy priority and the upcoming summit, high-level meeting in September. Where do the deliberations internally stand now as to how we want to use our leadership position moving into that? What are the feasible goals and outcomes that would mark this as a successful gathering where US leadership can leave a strong imprint in your view? Well, I think it's a challenge. I think we have a few challenges. On the one hand, there will be pressure from many sources not to be too controversial. On the other hand, there will be challenges from many sources to include as much as possible. And the challenge in any UN undertaking is the risk that you have high-sounding and wonderful, well-written, flowery language, but nothing that's actually actionable, measurable, and accountable. And what we hope to achieve is to identify a limited set, what I hope to achieve. I'm not speaking for the US government as a whole right now. But what I hope will be achieved through this whole process is a limited set of actionable, accountable measures which will enable us to galvanize progress in tobacco control and other leading causes of non-communicable diseases. Can you tell us a little bit more on what might those look like in terms of, I mean, I realize there's still deliberations around this and the Moscow ministerial lies ahead and there's plenty of other moments. But what would success look like in terms of a very targeted effort by the US to shape that? One issue would be specific, measurable outcomes that leaders could commit to. In tobacco control, those might include, for example, prevalence numbers. They might also include policy commitments with specific time frames. In other non-communicable diseases, there's a lot of focus on some of the nutritional battles that we know can be won. And there's a lot of discussions now at the global level on, for example, sodium reduction and what can be done in terms of sodium reduction. These are things that are well done with coordination, so lend themselves to global efforts and also have the benefit of not costing a lot of money. Looking at also in the dietary arena the issue of artificial trans fat and whether that can be phased out over time. Now, one of the comments that people often make who work in this area is that there's been a consistent barrier in leveraging high-level political commitments. And that getting ministries of finance, getting heads of state, getting folks that are really powerfully placed to step forward has been one of the key factors you mentioned in some of your remarks. This meeting that's coming up would look like a pretty choice opportunity to try to, from within our own government and other governments, change that picture a bit. Can you comment a little on that? What might be possible? As you know, the U.S. has signed, has a law that allows us to do a lot more than we could do two years ago in tobacco control. So it puts the U.S. government in a position of being able to say, yes, we're implementing health warnings. Yes, we're requiring disclosure of product contents. Yes, we're looking at ways to further restrict marketing and promotion in the U.S. We hope to see leaders emerge who are willing to do what Tabarevesca has did in Uruguay and say we're going to be an example. And we hope to see really a constructive, healthy competition between countries to see who can achieve the biggest progress. I recall many years ago hearing of two health ministers in Central America. One asked at a news conference, what's your infant mortality rate? And he leaned over to his chief of staff and said, what's, named the other country, 51? Then ours is 49. Now, based on real data from GATS and other sources, we hope that countries will begin competing for having smoke-free environments. And we're seeing some interesting things already where tourism is at potential risk. As more environments become smoke-free, people who are used to smoke-free environments become far less tolerant of being smoked on and exposed to carcinogens. So there are countries that are recognizing that they had better accommodate the growing smoke-free world if they want to maintain their status as desirable destinations. It also expresses a sense of being healthy and forward-looking. The challenge we have, again, is the challenge of the tobacco industry really obscuring the tremendous benefits to governments and society of going smoke-free. I was just reviewing, for some countries, at least a quarter of pregnant women smoke. And the burden of that on the next generation is enormous in low birth weight, in complications of pregnancy, in neonatal intensive care unit stays. And the number of pregnant women exposed second-hand smoke is also a tremendous burden on the next generation. So there's a lot that we have to do to encourage political leadership. And one of the best outcomes from the September summit could be the emergence of countries who are willing to say, we are going to make a difference and we're going to hold ourselves accountable. You saw Putin commit recently to substantial improvements in tobacco control in Russia. What will actually happen, we'll see. But at least now there is a clear commitment of a powerful government to do something about it. And I think you're seeing in an increasing number of countries a recognition of the importance. You're also, through the work of GATS and other surveillance systems, you're beginning to see some countries that thought they were doing better than they're doing, recognized that they too have had a soul in their progress and they had better refresh their strategies and reinvigorate their work if they're going to resume a downward trend. We've seen a lot of progress in Latin America and we'll hear a bit about that from Adriana Blanco and others on our next panel. If you were to, and you mentioned Putin, where else would you see the possibility of a shift? If you were to look out and say, okay, under an optimistic scenario in the next couple of years we could really see some big pivotal change occurring on account of political change. A change of consciousness, a change of leadership position. Where would you point us? You know, there have been glimmers or even more than glimmers of progress virtually all over the world. Some very positive policy changes in Egypt, for example. Even in China, which is really the big challenge for tobacco control, but even in China you're beginning to see a change in the social acceptability of tobacco. A beginning to recognize that giving cigarettes may not be the best thing to do in a socially desirable, harmonious society way. So I think you have the potential to see significant progress in many parts of the world and it's going to take really political leadership. I think this is the key lesson in tobacco control. Look at Uruguay, look at Mexico City. Mexico City decided to go smoke-free and it was really a local decision for a variety of health and other reasons and in the course of just a few months they made the city completely and very effectively smoke-free. A huge population, more than 10 million. I can tell you from personal experience that New York City would not have made the kind of progress it had made for the support of Mayor Bloomberg. So this kind of political commitment and willingness to go to the mat and recognize that there may be controversy for a year or two, but after that no one would ever go back. No one would ever go back to a world of a smoky restaurant or a smoky workplace once they've had a few months or a year or two of living in that smoke-free, pure, cleaner, healthier, more wholesome environment. Can you just talk about the economic interests and the power of industry? It's not just the tobacco industry. I mean, when you're in New York you faced a hailstorm of opposition from restaurants and bars and you had to change public expectations in order to sort of punch through that and get to the other side. There's a lot of claims that the industry in many of the emerging markets and low-income countries that the tobacco industry wields enormous power. Can you just comment a little bit on that and sort of what are the limits or the crevices in that power and what would the strategy look like for tackling that? Because clearly many leaders are not that deterred from thinking anew about, well, my city or my country really does need to begin to recognize this and they have to calculate that against rising costs and a different change of consciousness among their own voting publics. Well, first on the issue of smoke-free environments it's quite clear that going smoke-free doesn't hurt business. That's been shown repeatedly. It's also clear that business has an interest in it being a level playing field. So if you do allow many exceptions that creates economic inefficiency that is harmful both to individual businesses and to business as a whole. So going smoke-free comprehensively is really quite important. The tobacco industry is a formidable enemy to be very blunt about it. They in some African countries for example have begun, even where it doesn't make a lot of sense from an agricultural standpoint they have begun doing tobacco farming by paying kind of above market prices to very prominent individuals, farmers who now become the lobbyists for the tobacco industry. They in many countries have raised the employment issue. So interestingly in China with simply mechanization and rationalization of the tobacco monopoly there have been over 100,000 jobs that have been in excess. That is despite the consumption of cigarettes unfortunately continuing to increase in China but they wave tobacco control as a threat to social stability and employment in many countries. These are real challenges. I think emphasizing the issue of costs and being able to express costs more clearly is very important. In the US it costs about $2,000 more per person per year to take care of a smoker than a non-smoker. Now if you say that well yes but they're going to die sooner so they'll do us all the favor of doing that and they won't have pension costs or health care costs for that longer period of life that's a very crazy argument if you think about it. We have an agreement that we're all not better off dead and we want people to live longer and healthier lives and good evidence from around the world suggests that not only do people who smoke die about 10 years younger but they feel about 10 years older for those shorter years that they live. Being clear about what the metric is per person per year health care costs and driving those down because in every country in the world and certainly in this country we need to be very cognizant of the need to reduce costs in health care. One sensitive issue is around US trade policy and whether we should be making exceptions with respect to tobacco in the way that we go about trade policy. My understanding is that there's been a lot of progress in the way the US has dealt with this issue and what the remaining concerns are and see how the US government could try to address those concerns because I think it's a commitment to do so. Let's open the floor here for questions. There's two microphones in the front. Please introduce yourself and give us a quick comment or question. Tom Gallagher from SAIC and Dr. Friedan I'd like to ask a follow-up to one of the last questions. I lived in Paraguay for a little over a decade and was in a private practice. So many of my young patients smoked and as I saw smoke and decline in Uruguay and decline very, very dramatically in Brazil where you could smoke anywhere not ten years ago now you can't. Paraguay is different because one general owns the concession to bring a tobacco in. Cigarettes today cost a package in Paraguay I don't know 30, 35 cents a package and they have a fairly stable economy. How do you stop cigarette from being sold when there's so much money in it for the government? Is there any power that can intervene somehow in a country like Paraguay? Just to follow that up in my travels in India so many incredibly poor people chew tobacco and I don't remember the cost of chewing tobacco but it was so incredibly cheap I couldn't even imagine they could get it to market for that price. Is there any way to intervene in those kinds of things? Thank you. One of the things that tobacco control has going forward is that governments everywhere need money. Revenue hunger is widespread in governments and tobacco taxation is a triple win. It is something that generates significant amounts of revenue. It is something that saves lives and it is either the most popular or the least unpopular form of taxation there is. So tobacco control has that going forward. There is a unique problem of things like Gudka and Beaties in India and a very thoughtful report suggests that the current government policies actually are in India are kind of warping the market and are preventing the consolidation of manufacturers because of some tax policies that encourage small non-mechanized producers and if those policies were to change you would have a consolidation of the industry which would then enable you to tax and regulate more effectively. There is a lot of efforts in India dealing with Gudka and Beaties and the panel can discuss those with much more detail and knowledge than I can. It is a problem but ultimately it is a political problem. Ultimately it is whether government will allow the tobacco industry to allow people to keep dying in order for them to keep selling their product. Whether the political powers will say we are not going to let any worker be exposed to cancer-causing chemicals on the job and those things can be done. I would be interested in what the panel has to say about your question but I will stop there. Thank you. Do you have other questions? Please. Hello, my name is Marika and I have the pleasure of being Adriana's colleague at the Pan American Health Organization. Thank you for your presentation and especially your interest in Latin American Uruguay. But I notice in your statistics here that while there has been a decrease in smoking among men or young men specifically in Uruguay that young girls are smoking more and that seems to be a trend in our region. I also noticed that in your presentation besides showing the beautiful woman who was indeed targeted that you don't really address this issue and even the convention doesn't really address this issue and there seems to be a difference but certainly the tobacco companies are exploiting and I'd like to hear what you have to say about that. Thank you. Dealing with men and women separately is very important and the trends are just wildly different in different countries. China continues to have a rate of female smoking that's under 5%. Russia has a rate of female smoking that's almost as high as their very high rate of male smoking. Different countries have different patterns and it's very important to address those separately and you're absolutely right that the GITS strongly suggests that increasing smoking among girls and women is a major issue that has to be addressed. Going smoke-free will help with that. Raising taxes will help with that. Running specific hard-hitting ads that address women and counter the actions of the tobacco industry is very important. Looking at the slim and ultra slim and mild and low tar and highlighting those for the hypocrisy that they are I think are important methods but this is definitely an area where we need to both better understand how to counteract it and take action and see what works. In the U.S. we're seeing something slightly different. We're seeing a continuing steady decline of female smoking but the men who of course are not as smart as women are not decreasing their prevalence as much. So I think it is important to look at what works for different subpopulations. The same is true for example some of the racial and ethnic minority populations, tribal populations. American Indians in this country have an extraordinarily high rate of smoking and interestingly educational status has a kind of interesting pattern in many countries where the lowest strata does not smoke the most perhaps because they don't have the economic power but when you get into kind of lower middle or upper lower socioeconomic status you have the highest rates of smoking and that is something that requires a very targeted focused effort. Do you have any other questions? Yes sir. Good afternoon Dr. Friedman and Monty Greenfield I see my question is related to I guess I'll call them again additional social trends. One of the observations as a parent and someone who works in the community with many of our youth there seems to be a trend that with the diversity of cultures that is changing whereas our ads tend to focus on cigarettes and smoking it doesn't necessarily focus on tobacco and the trend that I think we're seeing especially among our youth is moving toward things that are more acceptable in tobacco use which certainly still causes the same problem. As an example hookah is becoming very popular where you now even see in your night clubs your dance halls place where youth as a pop culture get together that it is freely acceptable to have hookah pipes throughout the dance facilities those sorts of things they have hookah restaurants etc etc My question is as these trends continue to make this issue more complex how do you see the role of the CDC or other organizations addressing these other trends that are more focused on other tobacco and cultural issues? Thank you. On the one hand we need to understand them better on the other hand we need to intervene more effectively so other smoked forms of tobacco hookah, beadies one of the things that we've learned is people are very good at rationing life so California ran a very good campaign a few years ago if you're a social smoker you're a smoker any tobacco smoker is a smoker and the harms are quite substantial for any smoked product and the harms are quite substantial for a chewed product one of the things that CDC does very uniquely is our tobacco laboratory in our national center for environmental health our tobacco laboratory has smoking machines perhaps the only smoking machines outside of the tobacco industry and they have been able to document a series of really I think shocking findings for example the increase in free nicotine available in chewed tobacco has been manipulated enormously so that a few years ago there was a huge increase in the amount of free nicotine available from chewed tobacco now free nicotine is essentially crack nicotine it's very rapidly absorbed it's very highly addictive and it's what the industry learned to increase by changing the pH of cigarettes and increasing the addictiveness of cigarettes and we need to understand those trends and then we need to counteract them both with education and where appropriate and feasible with regulation Dr. Naik Prasad from WHO Geneva Dr. Frieden a very interesting presentation you gave you mentioned the one-fourth of the women have a direct secondhand smoke exposure but one thing which you didn't mention which I find a little intriguing is that you did not mention the linkage between tobacco and tuberculosis given your two decades of experience now what is it that prevents the tuberculosis control program accepting that tobacco is a risk for TB and it leads to premature TB deaths there's a whole body of documentation which has been done in the last seven to eight years but we do not see that kind of an interface between these programs now if we need to scale up tobacco control how do we get the TB programs and the maternal child health programs to accept that it is a risk what are the challenges even the USTHI does not have any mention and it treats tobacco as a causative factor for NCDs but nothing to do with the communicable diseases I think there is a consensus on the importance of addressing tobacco in the tuberculosis control world it's important to be specific about what we want the tuberculosis control world to do first off to improve tuberculosis control it would be great to get people to quit smoking but the tuberculosis control program only deals with TB patients so you would want at a minimum every tuberculosis care facility anywhere in the world to be a smoke free facility of course every healthcare facility should be smoke free every work site should be smoke free but at a minimum you'd want for the tobacco control staff to ensure that their facility is smoke free and you'd want the tobacco control professionals to be advocates for tobacco control it's been said that a doctor who smokes is worth $100,000 to the tobacco industry and you would also want to ensure that all the doctors working in that area are smoke free but we also have to be realistic about what can be achieved so the rate of smoking is 25% in population the rate of tuberculosis is measured in per $100,000 so even if you got every TB patient who smoked to quit you would not significantly change the smoking rate in society so for tuberculosis for tobacco control generally what we really want from all healthcare professionals is that they be advocates for tobacco control my name is Jonathan Ewing, I'm a student at GW with the finite amount of political capital and the tobacco control movement because it's not a politically prevalent issue at least right now in the US is it a prudent use of the movement's political capital to push for FCTC ratification and what would be the potential benefits of achieving that goal if the US ratified FCTC would have more say in the conference of parties and in the considerations as part of the FCTC it really comes down to whether the senate would ratify that's the bottom line question and I can't give you a political read on that I can tell you that it's probably less likely than it was a year ago but I can't tell you whether it's possible thank you Dr. Frieden really enjoyed your presentation which I thought was very straightforward and also gave some powerful recommendations moving forward my name is Mark Hayes and I work with Corporate Accountability International I've been involved in global tobacco control work for a while now I thought it was really good how you were able to identify one key criteria which is real true leadership from politicians who have the power to move this forward and I need to acknowledge the vested interests of the tobacco industry and some of the power they're putting forth and one key element of the FCTC that we have worked on closely has been Article 5.3 which deals with safeguards to prevent or restrict tobacco industry interference in implementation of the FCTC and other tobacco control policies and I think my question for you is you know I would make the case that 5.3 is one of the tools in the toolkit the different parties to the treaty have among the other tools you've laid out to push for more successful and thorough implementation so with that in mind at this high level meeting where do you see that tool or discussion that tool fitting in in that conversation and what can the US do to move it forward given as our last speaker described that we still don't have ratification here it would be great to hear your thoughts on that I think you've put it well that think of removing or immunizing countries from tobacco control influence as a critically important process in order to achieve the outcomes of effective policy intervention and tobacco control and this is an issue which is front and center in China where the tobacco control monopoly sits at the table of setting tobacco control policy and there is some hope that that might change over time but getting the industry out of the business of affecting government is going to be a long range and challenging effort in many countries Hello my name is John Bloom I'm a consultant to health groups on tobacco policy issues and I have a question about an executive order that was implemented by the equivalent administration on global tobacco control and I think most of it has been well implemented and is kind of historical now one of the key provisions though was that HHS would be consulted and fully involved in tobacco trade policy issues going forward and in the last administration that seemed to happen when it happened at all in more of a very pro forma last minute way and I'm wondering if that's how that's implemented now is it fully implemented or is that something that is still a work in progress Thanks My understanding is that the situation as I said earlier is far better than it was and there's a real commitment it's not as if we have to convince other parts of the US government to do the right thing, they want to do the right thing and they're working to do that if there are remaining specific concerns on trade policy we should become aware of and address those Tom? Tom Boogie, Center for Global Development Thank you Dr. Friedman for your speech and congratulations on this great event What I wanted to ask you is you made the point that what's critical for tobacco control in low and middle income countries really anywhere is political leadership and for that to extend beyond the health ministry so I think that's probably true for a lot of health issues whether that's HIV or other and I think part of the way that has come about or the role the US government has played in that is by making it clear that it's a global health priority to them and I think CDC has done a lot on international tobacco control but I was wondering in the lead up to the summit what more do you see the US government being able to do to signal that global tobacco control is a priority to it to give the political space for leaders in countries to come forward is it making an explicit part of the GHI what steps can it take specifically One of the things that we're doing is engaging with WHO and other partners to help identify and promote effective measures and goals so that we will have ambitious accountable targets I think this is very very important that we if things go well over the next six months in October we'll say aha we now have specific ambitious accountable targets that have been agreed upon and that we can measure progress in the world again over the next five ten fifteen years and that I think is what we need to work toward in the next few years but I don't think it's merely the US that needs to do this I think we need to ensure that from around the world the commitment to NCD control results in the laser like focus of coming out of September with specific measurable accountable targets that the world will hold itself to We're getting towards the end of the hour and I just ask one closing question about money and we really haven't talked much about money and for many of the emerging economies it's really more about political will and about policy but for low income countries you could make the case that offering incentives to build capacity and make some of the changes which wouldn't necessarily be all that expensive but nonetheless creating some kind of reservoir that can be applied against ambitions to put in place many of these core measures might actually be quite beneficial and Tom Boyke's done a lot of thinking about that at CGD and I wanted to just ask you how important is this and might we see any innovative measures pursued in New York September along those lines might shift the get beyond that 9% of compliance by putting forward some incentives to lift some of those I'm intrigued by the cash on delivery model and how it might be applied to tobacco control to try to get countries at the highest level to buy in to what needs to be done one of the challenges in non-communicable disease control is that so much of what needs to happen is very far afield from the health ministry and the health ministry can advocate the health in various countries the health ministry may be able to administer or document but ultimately it may be the finance ministry or the prime minister's office or the justice ministry that has to actually take the action and it's certainly a model that's well worth exploring as are other models I do think that resources are important to foster progress the ability of the WHO, CDC World Bank, IMF to provide technical support to countries to try to increase taxation and use that to run programs is very important I think one of the lessons we've learned in the U.S. is that although from a purist standpoint there's no reason or it's inefficient to earmark tobacco taxes for tobacco control politically it makes enormous sense but first off it increases even further the political acceptability and popularity of tobacco taxes and second it provides you with a revenue stream that enables you to continue to drive down tobacco use rates and without that you're really challenged to continue to make progress so tobacco taxation is a potential way of generating resources for tobacco control I don't think the world community can rely indefinitely on the Bloomberg and Gates Foundation to fund this bilateral donors are going to be hard pressed to fund non-communicable disease control both because it's a policy issue and because it doesn't have as obvious a self-interested argument so it is going to require leadership at the country level if there will be progress Please join me in thanking Dr. Friedman I'd like to invite our next panel please come forward and we'll get started so we're going to jump right into the next phase of our session here we have four very diverse and very distinguished personalities who work on different dimensions of tobacco control on my right, Yolanda Richardson who's an official with the campaign for tobacco-free kids she's an attorney she has a very broad and diverse background working on issues pertaining to global development to health, to gender empowerment HIV AIDS and lucky for the tobacco-free kids has come over and leading their effort through with the support of the Bloomberg Foundation in building capacities in four or five key areas in a number of 14 or 15 key states Next to me is Dr. Vinayak Prasad from WHO where he's the senior advisor on the tobacco-free initiative he also is very active in that role in building an aggressive effort to build capacity in Africa he comes with an extensive background as a medical doctor and practitioner years of service in the Indian Ministry of Health and Family Welfare work in the Ministry of Finance on taxation and smuggling to my left Samira Asma from CDC Dr. Asma is the chief of the Global Tobacco Control Branch at CDC she has been intricately involved in many of these major global survey efforts that we saw referenced and placed up today the Global Tobacco Surveillance System the Youth Survey the recently completed Global Adult Tobacco Survey she's very involved in the training program the Field Epidemiological Training Program in its application on Tobacco Control Welcome Samira Dr. Adriana Blanco from PAHO Welcome Adriana she's a Tobacco Control Officer a drug dependency expert and comes also with extensive in-country experience from her home Uruguay and the National Tobacco Control efforts there so welcome and thank you all for being with us when we had talked beforehand about how to structure this conversation we wanted to really tap your perspectives because you bring different institutional backgrounds and professional experiences you bring such extensive and granular knowledge about what has happened in these last several years I mean this is a period of a remarkable expansion of effort a remarkable enlargement of the institutions involved and you have in force the first major global health treaty that gives you a framework where expectations are up so maybe you could all share with us and we can just start with Yolanda what when you look back on the last five or six years what have been the major gains what have been the major forms of progress that you've seen and you might add with that also what have been some of the more sobering revelations in this period that also came forward in a period in which it was almost dramatically dollar levels rose expectations in terms of compliance with treaties Yolanda can you keep this off well thank you so much Steve for having me I think one of the clearly exciting things about working on global tobacco control and the opportunity that's really been presented is very much the framework convention on tobacco control which really does give us a global blueprint for how to move tobacco control forward aspect to have as a way of getting to push policy reform at the country level there are now 172 countries that have ratified the framework convention at the national level what we find having that blueprint in place really does provide us with the opportunity to really engage countries because they have already made the political commitment to address tobacco control so I think that underlies real efforts to move tobacco control at the country level interesting progress I think in the last five years have been in surprising places and have also been in places where we think we would have expected it so for example I think certainly in the last couple of years as Tom referenced in his introductory remarks we've been quite surprised to see some real challenges changes happening in places we wouldn't have expected so Russia for example I think is the one that has all had us fairly animated with police recent decision to back a national concept to move tobacco control forward you know what the underlying sort of reasons for that movement are not all that clear some of us feel like it's because of sort of demographic shifts in Russia but it's very clear that a lot of ground work has been laid to make that happen in places like China you're seeing increasing sentiments to support tobacco control in a very tough environment where China is both the world's largest consumer as well as the world's largest producer of tobacco but I think one of the things we felt and certainly the role that the campaign has played is really trying to change both in the country public perceptions of tobacco control both to generate public pressure to make countries feel comfortable who've already made the political commitment to implement tobacco control really move forward to do that and so we engage in a whole range of activities to really bring that public pressure to bear and to really work with non-governmental organizations and effective advocates for tobacco control so we're seeing real changes real shifts in the political climate in a lot of these countries and feel fairly optimistic that that has increased the momentum for the policy reform that governments have already committed themselves to The WHO FCTC provided the first opportunity for the governments to come to one platform and negotiate for a common agreed strategy and that was something which actually unleashed a lot of interest within governments within each country so if we look at that as an opportunity it helped articulate for example with my own limited experience of having worked as a focal point in the ministry of health I could go back to the minister and say minister we ratified this we can do this it's within our mandate we can make a law and he could go to the cabinet and get it done so some things which were within the purview of the ministry of health were easily done are still manageable to be done but there are things within the FCTC which like for example raising taxes it's not within the domain of the minister of health it's still not there so what has happened is the acceptability level on tobacco control has gone up in the ministry of health it's still not reached a stage where we have acceptance of all stakeholders so that's the that's the progress which we have made in the last few years I would say in most of the countries and the summit the way I see it allows us to create that multi sectoral higher level engagement both within the government and between the government on moving to the next big step for tobacco control Samira what have you discovered and seen during the time when FCTC was being negotiated in 1999 there was a loud cry for data from majority of the developing countries there was a clear lack of data on which they could base their arguments that led to the development of the global youth tobacco survey which was initiated in nine countries in 1999 and what we have seen today is now over ten years we have a coverage of GYTS and the data emerging from about 180 countries and this is a system where countries have repeated the survey several times at least up to four times in majority of the countries and they have used during the negotiations the data that was emerging as a result of these surveys facilitated by WHO and CDC that led to many countries even ratifying it even though it was youth specific data but this was the only data that countries could base their arguments it was not only focusing on the prevalence of tobacco use but also the need to back control indicators on which the FCC framework was designed and during the course of that phase where the FCC began its negotiations to its ratification and today we recognize that there was still a need for adult data and that led to the global adult tobacco survey as a result of the investments from the Bloomberg and now we have 14 country data that was presented so I see that we have a very solid database and evidence base that we could evaluate what works and I think the Empower strategies and the articles outclined in the framework convention can really be driven by the data from the countries Thank you, Adriana Well, I agree with all my colleagues here that the milestone is obviously the WHO FCC I think this is not only a milestone for tobacco control and more important I think this shift in the way that public health may be done from now on and I think that the summit will be a win-win situation because I think it's not only will help to enhance tobacco control but I think that they're going to take some experience from the tobacco field because we have some experience to show how controlling for example smoke-free environment has lead very in a short period of time to the decrease of the incidence of infarction of myocardial and this is a very important thing because usually government thinks that tobacco control will have some gains in winning things in the very long future and we are showing then that in short period like one year they can see something important going on on the people so I think this is important and the same time as Thomas Frieden said that it's very important to have concrete goals because I think perhaps one of the weakness of the FCC is that it doesn't have teeth it has a way in order to really make the countries accountable even though we are trying to find some other ways for example one interesting way is to link this treaty with other treaties like for example the one in human rights so it's very important when you are talking about smoke-free environments for example that there is a lot of human rights in involving that and you can take this issue on the field of the human rights and there they have an international court and they have again teeth for taking this and for example in Guatemala was one of the things that was used by a domestic court in order to keep smoke-free environmental legislation that has been sued by the tobacco industry this is very interesting because what I hear you saying is that of the new factors that are at play we have civil society organizations that are appearing that did not exist at the same level of energy and expertise we have ministries of health that are empowered by the treaty to make their case we have the power of new data we have demonstration cases the Uruguays that are proving short-term gains are within reach and having impact and the power of concrete goals now there's a lot of outstanding business to be done and we do have this meeting in September which we'll come back to in a moment because I do want to ask you what you see as the the most achievable robust feasible goals within tobacco control that should be targeted there but before we get to that let's turn things around and I'd like to ask each of you what do you fear the most looking ahead in the next 10 years 5 to 10 years what do you fear the most in terms of realizing the goals that you have seen and which you have all embraced in your own professional existence we don't need to keep in a numerical progression here please just jump in what do you fear the most happening as we speak because one of the latest I was thinking one in every 8 seconds a person dies due to tobacco use and I think that is ticking as the time takes we are losing a lot of people so I think the sense of urgency and coupled with the commitment and resources we know what works and it is about accelerating the actions but what do you see as the major as your major obstacle the major hindrance in being able to achieve the things that you're hoping for we know the industry is an obstacle and we recognize that but despite we have seen examples I'd like the Uruguayan example or the Russia example and I think it is the political commitment that needs to be invigorated and if we see more of Uruguay and more of Russia's leading the way and if there are a group of countries that could become that spotlight leading that change towards summit and beyond this happened with the FCTC negotiations several years ago where the African bloc did lead the negotiations even though they were resource scarce but we saw a result so hopefully that now we can see some major developed countries coming forth as a bloc and saying we can make this into a reality I think one of the things that worries me are the untapped markets that are probably going to get tapped more quickly than we were able to get up to speed among them is what was highlighted by Tom is the gender issue I mean now you've got 3% smoking rates among women in China but if all of a sudden those went to 10, 20% you're talking about a real explosion of both the number of people who are dying from tobacco control so that worries me a lot particularly as we look at the data that shows that increasing numbers of girls are starting to smoke so that demographic is one of real concern and I know all of us are thinking so your fear is should there be a priority in terms of commercial marketing strategy that was effective and locked onto some of those demographic those untapped markets you could see some real major regression some real major uptick in the prevalence rate and then the other big untapped market is Africa the prevalence rates again are very low still there and so it could very well as Africa begins to go through a demographic transition like all countries hopefully will eventually do you'll see you have the potential of having some real problems there as well and all of this is challenged by countries who are constantly struggling to get priorities among many different priorities, development priorities and many different health priorities and because we know the tobacco tends to not show up as immediately or as visibly as other health priorities it doesn't always get the resources or the political capital that's needed to really address those potential threats may I have any fears basically two one is that if you do not have a shared understanding it would be very difficult let's take Bhutan they banned tobacco but they didn't make any progress because everything came in from India so it's not possible for tobacco control to progress if all of us do not agree on certain minimum standards the industry is quick enough to move let's take another example Uganda raised taxes industry moved to Tanzania the industry wanted to make investment in Swaziland and civil society got the government to oppose it they moved to they are no more wanting to move to Lesotho so the industry moves faster and so we need to have a common shared understanding number one the industry is very innovative the industry started looking at dissolvable tobacco products the industry looking at e-cigarettes the industry is looking at as Yulanda said looking at women in Southeast Asia and women do not consume tobacco so much but there's a huge gap they want to tap look at Nigeria for example youth consumption is now reaching almost the same level as Russia whereas adult prevalence is less than half the industry is already there so we have two I have two serious concerns one is the industry moves faster than us and two we do not have a shared understanding we will be in trouble I can say I have concern because we have advanced so much in the last years so I think we keep on advancing but my concern the first one of course is the power of the tobacco industry because in this region specifically we have the experience that they are making a big big effort in every one of the countries trying to undermine all our policies and we have 10 fronts at the same time that we need to face the second thing I think is the I think is the basis of the problem that is the thing, the relationship or the way that the world will see profits versus public health and I think this is something that need to be discussed because today is the tobacco industry but tomorrow with non-communicable diseases will be fault companies many others so we need to begin to think that there should be a limit for profit when there is an involvement of the public health so and I think this will be very difficult because I think there are enormous forces beyond that and the third concern that they have that we people from public health we cannot evolve in the way we need we still even though we say that these things are out of our reach but still we are using the same ways of addressing the problem like the biological approach and this and we need to evolve I think we did we did it in a way but we didn't enough we still need to begin to learn another languages to speak to other publics in order to put them in our side have we entered a phase where the legal challenges from industry are becoming sort of the front edge of the battlefield right now do you think we are seeing that the industry is going farther and farther at the beginning they threatened the countries with a when they are trying to pass a legislation now they are definitely going to make this cases when the legislation is already passed and now Uruguay is an example of that they go to international court and specifically courts that are the trade and from the commercial side in order to push the country to get forward get back of their measures Uruguay is now being sued by the Phil Morris because of an investment treaty that Switzerland has with Uruguay and they are suing with three main things that are the size of the health warning that as Toma Fridesz said is the biggest one in the world the content of the health warning is the product and another legislation that we have in Uruguay that is that this allow it only one presentation per brand and this was done because even Uruguay banned the lights ultralight and this kind of misleading descriptor still the tobacco industry play with colors and with other logos that they have in their marks in order to mislead the people that some brands still are less dangerous than others so in Uruguay if you call Malvoro red, blue or gold you may have only one Malvoro so this is one of the key points of the suit and we are in the World Bank it's not a curve that used to be very good for countries usually they are supporting the private sector more than the countries so it will be a very difficult situation for Uruguay let's turn to the high level meeting, the NCB high level meeting in September and maybe you can share with us each of you what you would think of as the one or two most feasible and valuable kind of achievements or outcomes that could come from that we've heard about policy changes, prevalence changes, targets that seems to be very much in the era of discussion and then how do you get to those you know how do you realize whatever it is you think is the top priority what do you see as the political strategy for bringing those forward and then carrying them forward to see compliance because when you look at the data on the treaty it was a sort of mixed Tom Frieden's presentation sort of mixed set of messages one is the treaty was historic it created a political consensus it gave benchmarks it put people on the hook it also has you know when you start doing the measurement shows you some dispiriting some dispiriting outcomes lack of compliance and teeth enforcement incentives wills all of that so with that in mind as you look forward into into September what is it what is it that we should be thinking about that will not just put us again into a position where where targets are set which aren't necessarily enforceable how do we get to a position where we're stronger rather than weaker or even what's your opinion I think you know by far to me one of the most exciting things about the opportunity represented in high level meetings is to take tobacco control outside of the soul purview of the Ministry of Health I mean the one benefit is that there has been a public health treaty and that's been fantastic and brilliant and has gotten us as far as we've gotten but the opportunity to really bring the full weight of the entire UN system around tobacco control is quite attractive you would have the opportunity to really ask and I think one of our asks ought to be that we make sure that tobacco control is integrated into all of the mechanisms throughout the UN systems and the multilateral banking system so that all of the full weight of the UN system is really directed toward looking at tobacco control so whether it's you know the UN Commission on Women it's looking at the gender dimensions of tobacco control or whether it's UNFPA it's looking at what are the demographic implications of tobacco control or the multilateral banks are having being called upon to say how does tobacco affect our lending programs or our granting programs the full weight of the UN system behind tobacco control would really be for me one of the most promising aspects of what we could get out of the high level meeting. It also as I think Tom rightly said with the framework convention on tobacco control we have an overarching blueprint for tobacco control and so to have the UN system further endorse that by calling on member countries to really make the commitment to fully implement the FCTC. Now while the FCTC doesn't in its architecture have a lot of specifics the guidelines do they don't have the force of law but they have the specificity I think that helps us begin to get some depth around the FCTC so having countries really help hold themselves accountable to the commitment they've made under the FCT and the specificity that's offered by the guidelines really does provide two powerful ways for us to move tobacco control. So there's formal outcomes in terms of targets and specificity and perhaps mechanisms that give greater pressure and incentives for compliance there's the intangible or the more political outcomes that you're talking about which is bringing the right people to the table to stand by this elevating it to another level than where it was before. Sameer what do you think? The fact that there should be a healthy competition and an accountability tied to whatever is being signed off by the governments and the heads of states that would meet in September I think articulating that and getting the commitment there would be important but how do we articulate what those accountability criterias or elements might be could be drawn upon from some of the easy to achieve targets like the smoke free in public places easy target could be set where all the countries could potentially sign off and there could be an interim way to review the progress and independent body could potentially review the commitment that would ultimately be signed in September. So matching the targets with the accountability and a review with an independent body which is not just in terms of paper and pencil but in real action yes I think that it will be a good opportunity because at the moment at the moment that the FCC was negotiated even it may be unbelievable in the countries many of the parliamentaries many of the people in the ministry they don't know they didn't know anything about the FCC. So perhaps now that it's going to be an involvement of the whole government and not only of the Ministry of Health maybe we have a better understanding of the FCC and now is another opportunity to put it forward in the country. But I see that definitely we need to have at least some core set goals like for example prevalence should be one of them and I think that the smoke-free environment is one of the key issues not because as Dr. Friesen said taxes are the most effective individually but I think that the power of the smoke-free environment is how they normalize the use of tobacco and really it's very difficult to counteract by the tobacco industry because now the only thing that they can do they can say is as always the eventual losses in the hospitality sector that we have more and more data that shows that they are not going to happen. So I think these two are key elements that we need. So some concrete targets on prevalence in x period of time see those reductions and then commitments towards totally smoke-free. In addition to concrete prevalence targets the policy outcomes are equally important out of the 172 parties I think our 140 have missed obligation of putting pictorial warnings on all products they have missed obligation of complete ban on advertisements sponsorship and promotions doesn't cost money. So where is it that the political will is lacking if they have committed to doing this they have missed their deadlines 140 can easily make it happen. So that's something which is going to come from political support and getting the multiple stakeholders to be engaged but more important is where is the money going to come from who's going to fund this. Governments themselves need to raise their allocation from their own health allocation from the Ministry of Finance also from international funding for the lower income countries and who gets to implement this is there a body who's going to implement or is it just as Dr. Frieden said we have this beautifully drafted resolution but nobody to help implement where is the implementation body because the secretariat or the convention instrument do not provide for a compliance mechanism where is the compliance mechanism how does it go to come in. Those are kind of key asks for me in the summer. Isn't it true that I mean they're in this period of austerity and crowded a very crowded set of institutions people seem to be moving in a very pragmatic way towards looking at you know okay let's narrow our targets to a couple two or three and as you were saying about advertisements and some of the other policy implementation commitments simply getting a renewal to go back and live up to those obligations in a different context with a little bit more of a spotlight that's powerful potentially powerful but I'm not sure that you're going I'm skeptical I asked this question around well where might money be innovatively raised there's a lot of deliberation around solidarity taxes and the like but I just think there's in this current context that's the money side the broad global initiative new institutional initiative is likely not to be a prominent piece maybe I'm wrong but it just seems to me that you're going to have a more focused effort around setting some targets for policy and for prevalence and trying to leverage the political commitments in a very visible and conspicuous way leaders who have not really been very present or visible and conspicuous up to now but where you might the door might be open to do that I'd like to invite our audience members to come forward and offer some questions and comments please consultant to the Robert Wood Johnson Foundation and some other groups I come from a tobacco background when a 3 cent increase in tobacco taxes was considered a major victory you talked about suing the industry or the industry suing governments have there been examples of public health organizations suing governments for not implementing FCTC is there anything in the FCTC that would give a local NGO an opportunity to bring a lawsuit against a a party that signed the treaty there are a couple of examples that are interesting all that took sort of different sort of takes in Bangladesh there was actually a court decision that ruled that tobacco cultivation was contradictory with food security and there was a government court ruling that basically reaffirmed that tobacco cultivation limiting tobacco cultivation in order to address a food security concern so that was the hook and the angle in Bangladesh in Mexico we look at the right to health as a way to sort of ask the government to fulfill its commitments to health and there was just a recent decision around the Mexico decision where basically Mexico has an interesting procedural limitation in the fact that it doesn't have public interest in litigation so we cleared one hurdle and in the fact that we were allowed to present the argument to case but because there wasn't a remedy the court did not discuss the merits but that was an effort to be proactive in terms of trying to move the tobacco agenda and then most recently in India there's been an effort using an environmental argument to limit the packaging of Gupta which is smokeless tobacco in India to limit the ability for it to be sold in plastic containers using an environmental argument so I think that there are a number of ways in which I think creative advocates are beginning to think about how to use the law not only defensively but offensively to try to get the tobacco industry on its back heels it's tough but there are some real creative things that are being done Any other comments? I think that there is in our region it's difficult the FCC has an article that calls for holding the tobacco industry accountable for the damage they made but I think that in Latin America and specifically we don't have this culture of making suits against a big cooperative corporation in Brazil there have been a couple of attempts from patients going against the tobacco industry but as far as I know not of people going against the country for not implementing the FCC My own experience I had to defend a case in India where civil society group took us to court for not having labs and not regulating the products and we committed to the courts that within a period of two years we would set up labs and do it so we missed that deadline but the government is now almost there with the labs in India Any other comments? Sir? I'm Shin Zhu Lu from Liberty International Center at NIH Together with ANCI and NIDA we have supported the international tobacco research and the training program in the last decades So my question for you is that what do you see the role of research international tobacco research as well as research capacity building activities This is a very very interesting question because there are two parts to this one is how do we excite the top universities in the world to research on tobacco control how do you reduce the cost of care while it is true that it wouldn't have that full scale impact in the beginning but there is still one third of the world's population which is consuming tobacco so we need to make it accessible for them to be treated can't we have NRT which costs something like aspirin so that's something which is missing we do not have that research we do not have that focus and the other area of research is to document some of the work which is done because people do not know what's happening in different parts of the world so there are efforts for example NIH is working now on a global report on smokeless tobacco so it's important to document some of that finding and help countries implement tobacco in this region I can tell you that we have both need the research and the capacity building for research because the countries are constantly asking us for help them to have new data that they need to because you know many of the data that we have is from developed countries so countries need to have their own data in order to push their own authorities to move so really as PAPO we will be very very interested in seeing how we can enhance this in the region and the need that we have I would just echo that as well because what we find are we're very committed to evidence based advocacy so we are constantly being asked when we're engaged in advocacy activities to help us show and make the case whether it's the case that it's not going to have an economic impact it's not going to decrease productivity etc so we're really committed to this and I think this is a very important and critical issue I would say though that you know we haven't mandate, haven't looked at sort of research capacity in that countries but invariably we always hear from countries that they want country based research that it isn't enough just to show the international examples they want to know in their country this would be applied I mean people believe in exceptionalism so and I can tell you that the use of national data is so much powerful we have that in experience in Uruguay for example when we use the nicotine research in order to show this was the first time that people really believe that there was contamination from tobacco smoke in the place because they saw their bars, their hospital they placed it that they know so it's very powerful for our region I would like to make a comment about what type of research I think that distinction needs to be made I think we need to promote research that is relevant for policy and interventions rather than very basic molecular level research data already is available it is about how we build the capacity in the country so that the data can be used to link to the policy interventions and how that policies to be progressive and evaluated so that the governments can take a constant action because the data is being generated at a regular intervals of time via this global tobacco surveillance system so a caution while we need research but what kind of research I think that distinction needs to be made given in this source constrained environment Other comments or questions? Yeah with the Premier Convention Alliance and I think to ensure that we can have adequate implementation of the FCTC I think we've seen a lot of progress in the past few years but to a larger sense a lack of resources and I think this summit is one step towards integrating the FCTC implementation of the FCTC and the tobacco control in the development agenda and ensure that and also increase multi-sectoral approach tobacco policies a lot of the most effective ones are not very expensive from smoker policies ad bands and others that can be done without a tremendous amount of funding as if you compare to some other interventions for other issues and other diseases but we have the summit coming up we're addressing four diseases and four risk factors huge list of demands and I think tobacco control and FCTC implementation especially for tobacco control we have a tool, a global tool which has been now ratified by more than 171 countries in the European Union so to have an increased commitment towards the treaty elevate the awareness then also ensure that it's one step it's not going to be the end of it all it's not going to be a step towards integration in the development agenda because by now it's absent from it thank you why don't I then ask our panelists to offer some closing thoughts in terms of just wrapping up on looking forward to September and beyond and any additional thoughts that we've had and had a chance to comment on them aren't they completely disadvantageable I mean I guess the message is that you know the FCTC just came into effect five years ago so that's a fairly short time horizon so I think reminding ourselves of kind of what a remarkable progress has been made just since the ratification of the framework convention is really important I think I feel gratified because luckily I get to travel and see work on the ground and just see sparks of hope in almost every single country very much as Tom said about either advocates who are getting themselves organized to really be much more effective spokespersons for tobacco control or seeing governments taking baby steps to really try to honor their commitments or groups standing up to the tobacco industry in all kinds of interesting and different ways so I guess I still remain fairly hopeful that we are on an upswing trying to advance our approach to tobacco control and that there are reasons for optimism and hope. Thank you. I would see this as a huge opportunity to share best practices and successes this is an opportunity for example tobacco control advocates to advance similar treaties and similar strong measures for salt reduction for alcohol for other NCD measures it's not just only tobacco and make a more holistic lifestyle promoter preventive approach and bring raise the horizon bring it out in the domain so that it's very much in the space of political mindset to have strong NCD programs in their own countries. I would say that it's still important to be aware that tobacco is the leading preventable cause of death and is one of the drivers to the NCDs so not losing and diluting tobacco control and prevention at the country level within this whole bigger dialogue while we recognize that many of the risk factors are equally important but not to lose that site I think would be very critical leading to September. Thank you. And I think that as I said before that this opportunity for let's say relaunch the FCTC but making more more emphasis now that has been ratified ratified the convention that we need to implement. The convention without national laws means nothing in the country so we need to improve that and I think that we need to move the issue in order to see that these things need to be in an equal level that the millennium develop goals because they are part of the main as Hubert said that the main things influencing development developing development sorry English today is horrible in the word so I think this is a good opportunity that we cannot for them. Well thank you all I mean it's really quite an honor to have you here and we're very grateful for all the great work that you do in your daily lives and I also am very impressed by the sort of optimism and hope that's coming out of this panel and from you and thank you for doing bringing that forward too so please join me in thanking our panel.