Judith Mackay

Priority actions for the non-communicable disease crisis

The UN High-Level Meeting on Non-Communicable Diseases (NCDs) in September, 2011, is an unprecedented opportunity to create a sustained global movement against premature death and preventable morbidity and disability from NCDs, mainly heart disease, stroke, cancer, diabetes, and chronic respiratory disease. The increasing global crisis in NCDs is a barrier to development goals including poverty reduction, health equity, economic stability, and human security. The Lancet NCD Action Group and the NCD Alliance propose five overarching priority actions for the response to the crisis--leadership, prevention, treatment, international cooperation, and monitoring and accountability--and the delivery of five priority interventions--tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies. The priority interventions were chosen for their health effects, cost-effectiveness, low costs of implementation, and political and financial feasibility. The most urgent and immediate priority is tobacco control. We propose as a goal for 2040, a world essentially free from tobacco where less than 5% of people use tobacco. Implementation of the priority interventions, at an estimated global commitment of about US

A tobacco-free world: a call to action to phase out the sale of tobacco products by 2040

9 billion per year, will bring enormous benefits to social and economic development and to the health sector. If widely adopted, these interventions will achieve the global goal of reducing NCD death rates by 2% per year, averting tens of millions of premature deaths in this decade.

Tobacco control in Asia.

The time has come for the world to acknowledge the unacceptability of the damage being done by the tobacco industry and work towards a world essentially free from the sale (legal and illegal) of tobacco products. A tobacco-free world by 2040, where less than 5% of the worlds adult population use tobacco, is socially desirable, technically feasible, and could become politically practical. Three possible ways forward exist: so-called business-as-usual, with most countries steadily implementing the WHO Framework Convention on Tobacco Control (FCTC) provisions; accelerated implementation of the FCTC by all countries; and a so-called turbo-charged approach that complements FCTC actions with strengthened UN leadership, full engagement of all sectors, and increased investment in tobacco control. Only the turbo-charged approach will achieve a tobacco-free world by 2040 where tobacco is out of sight, out of mind, and out of fashion--yet not prohibited. The first and most urgent priority is the inclusion of an ambitious tobacco target in the post-2015 sustainable development health goal. The second priority is accelerated implementation of the FCTC policies in all countries, with full engagement from all sectors including the private sector--from workplaces to pharmacies--and with increased national and global investment. The third priority is an amendment of the FCTC to include an ambitious global tobacco reduction goal. The fourth priority is a UN high-level meeting on tobacco use to galvanise global action towards the 2040 tobacco-free world goal on the basis of new strategies, new resources, and new players. Decisive and strategic action on this bold vision will prevent hundreds of millions of unnecessary deaths during the remainder of this century and safeguard future generations from the ravages of tobacco use.

Smoking cessation treatment in a public-health context

Summary For the purpose of this article, Asia refers to WHOs combined South-East Asia and Western Pacific regions and thus includes Australia and New Zealand. Asia has the highest number of tobacco users and is the prime target of transnational tobacco companies. The future of global tobacco control rests in this region and the challenges are clear. China, India, and Indonesia are key markets and Asia is a frontrunner in tobacco control measures, such as plain packaging of cigarettes. Some countries in Asia have a long history of tobacco control activities beginning in the 1970s, and WHOs Western Pacific Region is still the only region where all countries have ratified WHOs Framework Convention on Tobacco Control. We reviewed the history, research, epidemiology, tobacco control action, obstacles, and potential responses and solutions to the tobacco epidemic in this region. Levels of development, systems of government, and population size are very different between countries, with population size ranging from 1500 to 1·3 billion, but similarities exist in aspects of the tobacco epidemic, harms caused, obstacles faced, and tobacco control actions needed.

The UN High-level Meeting on Prevention and Control of Non-communicable Diseases and its significance for oral health worldwide

1976 www.thelancet.com Vol 371 June 14, 2008 or is this a non-specifi c antioxidant eff ect? Crucially, can this eff ect be seen in patients who are not of Chinese origin in whom the cause of COPD might diff er, or in patients already on treatment that decreases exacerbations? What is clear from PEACE is that rigorous clinical trials of existing drugs can off er new insights into COPD care. These insights should stimulate research into how the eff ects can be improved in future, while off ering a cost-eff ective and well-tolerated way of lessening the burden of exacerbations for the increasing numbers of patients in developing countries aff ected by this chronic and debilitating disorder.

The Next WHO Director-General's Highest Priority: A Global Treaty on the Human Right to Health

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Curtailing tobacco use: first we need to know the numbers

This article was published in the The Lancet Global Health [© 2016 Elsevier Ltd] and the definitive version is available at: http://doi.org/10.1016/S2214-109X(16)30219-4 The Journals website is at: https://linkinghub.elsevier.com/retrieve/pii/S2214109X16302194

Long-term mortality after blood pressure-lowering and lipid-lowering treatment in patients with hypertension in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy study: 16-year follow-up results of a randomised factorial trial

www.thelancet.com Vol 380 August 18, 2012 629 Data, transformed through aggregation and analysis into useful information, are key elements for decision making. This notion is true in general and has become a precept for promotion of health and control of disease. Tobacco use globally is the main preventable contributor to poor health and premature death. In The Lancet, Gary Giovino and colleagues describe the acquisition of high-quality data for tobacco use from 14 countries through the employment of welldesigned and well-implemented surveys, the Global Adult Tobacco Survey (GATS), with 16 countries studied in total. GATS was originally developed by the US Centers for Disease Control and Prevention (CDC) and has been widely applied by host countries working with CDC and WHO. Accurate data are needed on the characteristics of tobacco users (eg, age, sex, income, and occupation), how tobacco is used (smoking cigarettes, bidis, or water pipes vs chewing tobacco or taking snuff ), and where and why people use tobacco. Such data are vital for planning purposes, such as designing interventions and targeting at-risk groups, and for evaluation and programme assessment purposes, such as establishment of the baseline and examination of data after an intervention has been applied (ie, whether or not an intervention works). Eff ective policy development and assessment depend on such data and information. Thus, a reliable measurement technique that can be used by all countries to obtain this information has been desperately needed to address the huge global health threat of tobacco use. GATS off ers such a technique: the standardised questionnaires it employs enable, for the fi rst time, comparative data analysis. Impressively, GATS already covers more than half the world’s population. Giovino and colleagues’ report off ers a spectrum of global tobacco use, and the diff erences between nations are interesting and important. Although many more men than women smoke in all countries surveyed, the prevalence of current smoking for women varies greatly, from 0·5% in Egypt to 24·4% in Poland. How people use tobacco varies substantially, as does the age at which people start tobacco use. These data are not static. With behaviours and lifestyle in fl ux globally and marketing Curtailing tobacco use: fi rst we need to know the numbers Pending such analyses, how should clinicians now apply Wong and colleagues’ data to their patients? We suggest that the two broad indications for treatment that apply to all chronic diseases—loss of quality of life and danger (in this case, a scenario of moderate to severe loss of lung function in association with evidence of continuing disease progression)—should be the basis for intervention. Patients with functionally mild disease should not be treated with long-term azithromycin unless there is major morbidity or evidence of disease progression despite adherence to physiotherapy and the early use of broad spectrum antibiotics for infective exacerbations. We urge researchers designing interventional protocols in any chronic disease to plan to investigate treatment eff ects against baseline measures of disease severity and patterns of disease behaviour. Without these analyses, how can clinicians know with confi dence which patients to treat?

Hit or miss: a window of opportunity for global oral health

BACKGROUND In patients with hypertension, the long-term cardiovascular and all-cause mortality effects of different blood pressure-lowering regimens and lipid-lowering treatment are not well documented, particularly in clinical trial settings. The Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy Study reports mortality outcomes after 16 years of follow-up of the UK participants in the original ASCOT trial. METHODS ASCOT was a multicentre randomised trial with a 2 × 2 factorial design. UK-based patients with hypertension were followed up for all-cause and cardiovascular mortality for a median of 15·7 years (IQR 9·7-16·4 years). At baseline, all patients enrolled into the blood pressure-lowering arm (BPLA) of ASCOT were randomly assigned to receive either amlodipine-based or atenolol-based blood pressure-lowering treatment. Of these patients, those who had total cholesterol of 6·5 mmol/L or lower and no previous lipid-lowering treatment underwent further randomisation to receive either atorvastatin or placebo as part of the lipid-lowering arm (LLA) of ASCOT. The remaining patients formed the non-LLA group. A team of two physicians independently adjudicated all causes of death. FINDINGS Of 8580 UK-based patients in ASCOT, 3282 (38·3%) died, including 1640 (38·4%) of 4275 assigned to atenolol-based treatment and 1642 (38·1%) of 4305 assigned to amlodipine-based treatment. 1768 of the 4605 patients in the LLA died, including 903 (39·5%) of 2288 assigned placebo and 865 (37·3%) of 2317 assigned atorvastatin. Of all deaths, 1210 (36·9%) were from cardiovascular-related causes. Among patients in the BPLA, there was no overall difference in all-cause mortality between treatments (adjusted hazard ratio [HR] 0·90, 95% CI 0·81-1·01, p=0·0776]), although significantly fewer deaths from stroke (adjusted HR 0·71, 0·53-0·97, p=0·0305) occurred in the amlodipine-based treatment group than in the atenolol-based treatment group. There was no interaction between treatment allocation in the BPLA and in the LLA. However, in the 3975 patients in the non-LLA group, there were fewer cardiovascular deaths (adjusted HR 0·79, 0·67-0·93, p=0·0046) among those assigned to amlodipine-based treatment compared with atenolol-based treatment (p=0·022 for the test for interaction between the two blood pressure treatments and allocation to LLA or not). In the LLA, significantly fewer cardiovascular deaths (HR 0·85, 0·72-0·99, p=0·0395) occurred among patients assigned to statin than among those assigned placebo. INTERPRETATION Our findings show the long-term beneficial effects on mortality of antihypertensive treatment with a calcium channel blocker-based treatment regimen and lipid-lowering with a statin: patients on amlodipine-based treatment had fewer stroke deaths and patients on atorvastatin had fewer cardiovascular deaths more than 10 years after trial closure. Overall, the ASCOT Legacy study supports the notion that interventions for blood pressure and cholesterol are associated with long-term benefits on cardiovascular outcomes. FUNDING Pfizer.

Putting teeth into chronic diseases

are calling for a High-level Summit on Chronic Diseases in September 2011 because the international health community has finally realised that the burden of chronic diseases, such as diabetes, cardiovascular diseases and cancer, is growing at alarming rates. The Millennium Development Goals, which focused mainly on infectious diseases, will expire in 2015, giving an opportunity to agree on new international development commitments and health targets. The mantra of the oral health community over the last decade has been that oral health is part of general health, sharing the same risk factors of other chronic diseases. The upcoming summit would be a unique opportunity to mainstream oral health issues in a bigger global context. Wishful thinking? So far, unfortunately, it looks like a ‘miss’. Addressing the neglect of chronic diseases in international health and development assistance was long overdue; a paper in The Lancet recently concluded that ‘neglect of chronic diseases is a political, not a technical, failure since cost-effective interventions are available’. This is equally true for oral health. Caries affects more than 90% of the world’s population, between 40-90% of all 12-year-olds in lowand middle-income countries suffer from it and its consequences, such as pain, chronic infection, lack of concentration and absenteeism from school, low quality of life and significant impact on growth, development and educational performance. Even worse, in low-resource countries almost all caries remains untreated, exacerbating the consequences. For many populations, even in high-income countries, the levels of caries have reached epidemic proportions. Oral diseases are a serious public health problem, but there are realistic and evidence-based solutions available to address them, even in low-resource settings. However, the current public and informal discussions in preparation for the summit largely ignore the most prevalent chronic disease on our planet, caries. While it is perfectly reasonable to focus on conditions such as diabetes, obesity, cancer or cardio-vascular diseases, which are major causes of worldwide morbidity and premature death, the important and worldwide impact of oral diseases, particular caries, on health, health systems and budgets (OECD countries spend 6-12% of their health budgets on oral care) is largely forgotten or underestimated. Is there any visible action from international stakeholders in oral health? So far, once again, it looks like a ‘miss’. In the past, oral health stakeholders have not succeeded in framing the neglect of oral health in a way that resonates directly with broader public health agendas. It would be unfortunate if this was to result in oral health, once again, being neglected in favour of other disease entities simply because they have more visible advocacy campaigns during the high-level meeting on non-communicable diseases in September 2011. We believe that it is time that the global oral health community join forces and embark on a process of alignment and integration with the international health and development agendas. This would require a concerted collaboration, agreement on a common problem definition and the suggested solutions. First of all, it would require international organisations, such as the FDI World Dental Federation, the International Association for Dental Research, the WHO Oral Health Unit, as well as other national and international organisations, to sit and talk. Without joint action and bold leadership no significant changes can be made for the billions affected by oral diseases. The opportunity of the High-level Summit on Chronic Diseases could still be turned into a ‘hit’, but the clock is ticking. We join the WHO Director-General, Dr Margaret Chan, in her assessment during the 120th meeting of the WHO Executive Board in January 2007 when she said, that ‘oral diseases are a neglected area of international health. We have the tools and best practices to address them, but we need to ensure that they are applied and implemented.’ Dental diseases are not a niche area of health. It is only when oral health is incorporated within the current chronic disease discourse that lasting progress will be made. An important milestone in this process is ahead of us – let us not miss this unique window of opportunity!