Washington, D.C.,
18 March 1999

International Policy Conference on Children and Tobacco

In our struggle for a healthier world, we face as many challenges as there are diseases. Most are difficult, some are tragic and some are exciting because we see real progress in our work. The approach we must take towards all these challenges is one of creativity, patience and stubborn, confident determination.

One of these challenges is unnecessary and it is man-made: the tobacco epidemic.

When I came to WHO last year, the Organization devoted 0.5 man years to tobacco related work. In preparing to take office I went through the broad material on the global burden of disease. I was determined to refocus WHO's work on priority areas where our efforts could make a real difference to the health of people around the world. I wanted solid facts to underpin our priorities.

The evidence told a shocking story. With current smoking patterns, about 500 million people alive today will eventually be killed by tobacco. Tobacco deaths will occur in men already smoking, children who will become smokers, and an increasing number of women smokers.

What I saw was an emerging epidemic. Worldwide mortality from tobacco is likely to rise from about 4 million deaths a year in 1998 to about 10 million a year in 2030. Ten million deaths - that is more than the total deaths from malaria, maternal and major childhood conditions and tuberculosis combined. Over 70 percent of these deaths will be in the developing world. By 2020, smoking will cause about one in three of all adult deaths, up from one in six adult deaths in 1990.

What does it mean: tobacco will cause about 150 million deaths in the first quarter of the century and 300 million in the second quarter. Half of these deaths will occur in middle age - in those between 35 and 69 - with an average loss of 20-25 years of life.

The implications are obvious. Tobacco burdens our health systems. It costs taxpayers money. It hampers the productivity of our economies. Tobacco obviously provides economic benefits to producers. But solid economic analysis clearly concludes that the costs of tobacco exceed by far its estimated economic benefits.

So for me the decision was not difficult to take. WHO had to address this mounting epidemic.

The day I took office, WHO launched its Tobacco Free Initiative. The way it works illustrates the way we wish WHO to work in the future - making the most of our own resources and knowledge - and drawing heavily on the knowledge and experience of others. These are our goals:

• to galvanize global support for evidence-based tobacco control policies and actions;
• to build new partnerships, to heighten awareness and to mobilize resources;
• to accelerate the implementation of national, regional and global strategies.

As a public health agency, we can assemble and distribute the evidence on the health consequences of tobacco consumption. And we can work in partnership with others.

We work with UNICEF to devise strategies to reach out to children and adolescents. We work with the World Bank to address taxation issues and to dispel the myths about the financial benefits of tobacco. We work with the US Centers for Disease Control and Prevention to support global surveillance of tobacco use and its consequences. We work with the Environmental Protection Agency to reach the environmental constituencies.

We work with the National Institutes of Health and with similar bodies in other countries to expand the evidence base. We work with NGOs such as Tobacco-Free Kids to strengthen action at grass-roots level. And we work with the private sector to channel energy and expertise from the pharmaceutical, media and entertainment industries into tobacco control activities.

This is how WHO has shaped its tobacco related work over the last 8 months. We are aware that it is a complex and long term objective to halt the growth in tobacco consumption. In pursuing that goal, we seek inspiration from events like today's meeting of policy makers from many countries.

What are the broad avenues that we must follow?

First we need to focus on individuals.

To change the trends we need to get smokers to quit and non-smokers not to pick up the addictive habit.

Some object and say this is about freedom of choice. Is it really? Adults can choose for themselves, if they have full access to information. But 80 percent of smokers start before the age of 18. Kids often start at the age of 14,15,16. That is not about freedom of choice! Civilized nations normally seek actively to protect their children against habits that have a 50 percent chance of leading to premature death.

The tobacco epidemic is a communicated disease. It is communicated through advertising, through the example of smokers and through the smoke to which non-smokers - especially children - are exposed. Our job is to immunize people against this epidemic.

The victims are teenagers like Mia Katandian, a fourteen year-old girl in the Philippines. Mia's days are similar to those of millions of other teenagers around the world, living under difficult circumstances on the very limited resources of her single mother. The reality of never being able to afford clothes or the other things she craves she tries to make tolerable through some heavy doses of day-dreaming, through hours of strolling through shopping malls and through television.

Wherever Mia goes there are billboards, and whenever she watches on TV there are commercials telling her that "happy people smoke". The rich, who drive fast cars, sit on white beaches with handsome partners and ride horses in the evening sun - they all smoke.

She can not afford their lifestyle, but by sitting in a café and holding her cigarette elegantly the way she has seen in the ads, she can, for a short while, pretend she is one of those rich and beautiful people.

Only her mother tells her not to smoke. But then, what better way to show a bit of adolescent defiance than coming home with smoke on your breath?

Habits start in youth. The tobacco industry knows it, and acts accordingly. A 1990 Regional Overview of marketing opportunities by Philip Morris Asia, makes it clear that Mia and her fellow young are the special targets of tobacco advertisers. Here is what they say:

"Advertising and promotions should be aimed at entry level smokers to keep the franchise young and dynamic,"

And it continues:

"Young adult promotions could help us build the king-size franchise among entry level smokers (...) (The brand) Parliament Menthol could be a line extension to broaden appeal to younger smokers and women."

Other documents show that the tobacco companies' definition of "young adults" is as low as children 14 years old.

What kind of freedom of choice are we talking about? For Mia and millions of others it is the freedom to choose rationally whether or not to take up a habit which is so harmful to their health.

People in government, like many here today, have the power to act. Those actions, both personal and official, will decide if tobacco shall claim new millions of victims in your home countries. Those actions will help prevent the cost of treating hundreds of thousands of cancer and heart disease patients from breaking the back of your health systems in the coming decades. Those actions will see to it that children don't lose their parents prematurely through cancer and heart diseases caused by smoking. Those actions will help prevent teenagers from being fooled into an addiction which gives them only a 50 percent chance of surviving middle age.

WHO will gather, analyse and disseminate evidence on tobacco use, on patterns of consumption and paths that lead to it. That evidence will illustrate that there are many misconceptions. Two of the most frequent ones are that tobacco is a problem of affluent countries, and that tobacco is good economics for national treasuries strapped for cash.

One important message to drive home is that tobacco control is a global challenge. Policymakers ask: How can we increase taxes if our neighbours keep them low? How can we introduce stricter advertisement legislation if the message in many cases reaches us through the satellites? How can we deal more effectively with smuggling?

For the first time WHO will make use of its right to put forward a Framework Convention on Tobacco Control. Our Member States called for this in 1996. The Executive Board in January responded to my proposal and now recommends the World Health Assembly to move ahead.

The aim of this process is to pass the Convention and key protocol agreements no later than May 2003. If a Convention is adopted and enters into force it will be the first time that a convention approach has been applied to address a global public health problem. The Convention will call for cooperation in achieving broadly stated goals - supplemented by protocols which address specific issues, such as advertisement.

As the process gathers steam our determination is to help galvanize national action through the work of the media, NGOs, and the academic and scientific communities: We need to increase public support for truly global action.

This is to a large extent a cultural struggle. Our main battlefield on children and tobacco is in that strange, exhilarating and often confusing landscape called adolescence. We must enter the discotheques, the schools and the sports arenas. In many countries, cigarettes are given out for free on the dance floors. We have to win these spaces back.

There is a long way to go: An agreement between a major Hollywood film producer and a tobacco company contained the following clause:

"As we discussed, your company's cigarettes will be used in our film as the product is intended. Specifically, one of our main characters, Munro Kelly, (…) will be smoking your cigarettes. The only slightly different use is when he offers a cigarette to Amy, the gorilla (…), and she takes it and imitates Munro by smoking."

If we are to prevent tobacco-related deaths from tripling by 2030 to 10 million people each year, we will have to convince our children that smoking isn't cool. Not even for gorillas.

Smoking will continue to be an issue on which every individual will have a personal experience - of his or her personal history or that of a close relative. As we proceed with our work we need to take advantage of this. We know that a majority of smokers would like to leave the pack behind. We should help them - and in doing so we need to base our advice on solid evidence.

One part of the evidence is that the one who smokes not only puts himself in danger; he also endangers the life of the one who doesn't smoke. If the non-smoker is a child, that is especially true. The latest research on the effect of environmental tobacco smoke on children provides disturbing findings:

• children of smoking mothers have a much higher risk of getting lower respiratory illnesses, such as bronchitis, croup and pneumonia;
• they are more vulnerable to ear infections;
• the symptoms of asthma and respiratory irritations, such as wheezing and coughs, increase;
• the risk of low birth weight and intra-uterine retardation increases for babies of mothers who smoke. Birth-weights are affected even when mothers are only exposed to passive smoking;
• infants of mothers who smoke run almost five times the risk of sudden infant death syndrome compared with infants of mothers who don't smoke.
• parental smoking is associated with learning difficulties, behavioural problems and language impairment.

Beside the individual suffering, children's involuntary exposure to tobacco smoke has serious economic consequences. By balancing the figures from several studies, we find that the cost of treating afflictions related to children's exposure to tobacco runs at around $1 billion each year in the United States alone.

Still, these sad facts can be turned around. With the exception of smoking during pregnancy, most risks are quickly reduced when parents quit. There is also strong evidence to show that if one or both parents quit smoking, children are much less likely to begin.

The Convention of the Rights of the Child, our moral obligations, and plain, national-economic logic all commit us to do our utmost to prevent millions of children and young adults becoming victims of the tobacco epidemic.

As we look ahead - as we work out our strategy and bring together our partners, we see how political decision-makers and legislators are crucial. We take this work forward by global consultation and national decision-making step by step.

There are encouraging signs. Many of you who sit here today have already done a lot. WHO will keep track of the lessons learned and make both successes and failures available.

Let me mention a few:

• Several countries in Asia have been moving towards limiting tobacco advertising. So much, in fact, that tobacco companies have found it hard to defend sponsorship of many of the sports events it for some years has funded.
• In Australia, the Health Minister of Victoria State leads the world in dedicating tobacco tax to a health promotion foundation that has replaced sports sponsorship by tobacco and stimulated community-based recreational activities.
• Canada is the first country to call for a global convention on tobacco control and it has been a stalwart in initiating new approaches to tackle youth smoking, including an innovative and effective media program targeting youth to quit.
• China has been building a formidable network of smoke-free schools, passing restrictive tobacco advertising ban laws; and showing leadership in hosting the last World Conference on Tobacco Control in 1997.
• In the Philippines, former Health Secretary and now Senator Juan Flavier has just finished drafting one of the strongest tobacco control laws in Asia. If passed, it will lead to a total ban on the advertising and promotion of tobacco products, and cigarettes will only be sold to those who can prove they are 18 or older. This is excellent news for Mia and her compatriots.
• Egypt should be commended for Sherif Omar's early research over a decade ago showing the economic impact of tobacco in Egypt, and advocating for strong legislative action during the 1980s.
• In France, the Evin law is one of the models of comprehensive approaches to tobacco control. The combination of advertising bans and taxes has reduced consumption by more than ten percent since the law came into force in 1993.
• Sri Lanka and South Africa have promulgated legislation within the last few months to ban tobacco adverts and strengthen protection of children. We know they have done this in the face of formidable tobacco industry pressure.
• The United Kingdom has produced a very impressive new White Paper that achieves coherence between its domestic and international policies. The call in the White Paper for stronger global action is what this meeting is all about!
• Zimbabwe and Minister Stamps must be congratulated for hosting the first All Africa Conference on Tobacco Control in 1993; for stating clearly then and more recently that demand-reduction is a fundamental responsibility of governments; and that special attention should be given to supporting long-term needs of tobacco growers.
• The United States is sending an important message through the recent legal cases against the tobacco industry, not least by making available huge amounts of evidence and information. At the Federal level, we are happy to see the advancing of tobacco control, through regulatory and other approaches.

We have evidence to show that positive results come from concerted action on several fronts: tobacco advertising bans, increases in taxation and a high level of public awareness.

We can sum it up in two key words: legislate and educate.

One of these elements, without the other, will not work. There must be broad support and commitment permeating a government that wants to reduce the damage from tobacco. The Prime Minister, the Health Ministry, the Finance Ministry and all the political leadership at the top must be united and committed to take the battles and the back-lashes that are bound to result from decisive anti-tobacco action.

Let me address a final issue: Tobacco production and employment. What will tobacco control do to tobacco farmers? The questions come from the heart of the United States, from the rural areas of Zimbabwe or from the agricultural regions in China.

We can be frank and clear: we are not attacking those who, by tradition or by lack of other suitable crops, grow tobacco in their fields. We are not blaming those thousands who work in tobacco plants because it is the best - or the only - steady job in their home town. We do care about their future livelihood in our fight against tobacco.

I told the President of China when I met him a few months ago: even if our most optimistic hopes are realized, tobacco consumption will not decline from one day to the other. We may succeed in slowing the growth - then stabilize and hopefully turn the tide of a relentless increase in tobacco consumption. There will be plenty of time to adapt. Tobacco control in China is a long haul operation.

What leaders should really worry about is if the growth in tobacco consumption continues. In addition to the daunting health burden, tobacco farmers may well ask for more land for tobacco production. China - and any other country in the world - could use their agricultural land for much better purposes if we are to succeed in feeding a growing world population.

Ladies and Gentlemen,

We can succeed - and meetings like this should give new inspiration. We can sum up with the four As: Awareness, Action, Assistance and Alliances. We have to counter fiction with fact, we have to dispel ignorance with scientific evidence and we have to tackle inertia with the simple message that tobacco kills.

That it will kill countless young girls like Mia is the greatest tragedy of all. If this policy conference can take us a step further forward to save her and millions like her, we will have begun to make a difference for world health.

Thank you.