TOBACCO CONTROL in TURKEY
Nazmi Bilir, MD
Prof. of Public Health
Hacettepe University Institiute of Public Health
nbilir@hacettepe.edu.tr
Presentation Plan
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Tobacco use: Global threat
Tobacco history of Turkey
Legislation for TC
Challenges for implementation
– Civil society intervention
• Results & Keys to Success
– Committment and Leadership
Tobacco use: Global threat
• 1,3 billion smokers worlwide
• 5 million deaths / year
– 14 000 deaths / day
– One death in every 6 seconds !!!
• Most important cause of preventable deaths
* Tobacco producing country (1.7%)
* Smoking is common (GATS 27.1%; M: 41%, F: %13%)
* Among the top 10 countries
Tobacco facts of Turkey
• Turkey has long history and culture of tobacco use
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–
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Since 1600’s
Traditional “coffee-houses” ...
“exclusively male behavior”
“guest cigarettes”: offered to the guests
Children are allowed during ceremonies; wedding, funerals...
Grandfather offers cigarette to grandson !!!
Major points in tobacco control ...
• State Monopoly: TEKEL since 1924
– No advertisement
• 1984: Import of foreign cigarettes
– Advertisements started ... tobacco use increased
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1993: Civil society organization, “National Coalition”
Privatization of TEKEL --- sold (BAT, 2008)
TAPDK: Tobacco Regulatory Authority, 2002
Tobacco Control Department in MoH, 2006
Cigarette sales, Turkey, 1925 - 2011
TC Law, 1996
TC Law, 2008
State Monopoly - TEKEL
• 1980-2000: Cigarette sales “doubled”
• 2.5 times of population increase
Population Increase and Tobacco Sales, Turkey
1935-2010
140
Nüfus
(milyon)
Population
120
118
(million)
Sigara
satış (milyar)
Tobacco
sales
(bilion)
100
94
77
80
58
60
43
40
30
68
73
56
18
20
12
16
21
28
36
45
0
1935
1950
1960
1970
1980
1990
2000
2010
Number of Lung Cancer cases Hospitalized, Turkey, 1964-2004
Number
60000
50000
40000
30000
52865
20000
10000
0
18442
1222
1614
2018
4363
6878
1964
1969
1974
1979
1984
21729
11324
199
1994
1999
Similar increase --- heart dis., COPD...
2004
Second-hand smoking is high, (early 2000’s)
• GYTS: 2003
– 81.6% – at home
– 85.9% – at public places
• Different studies
– 60-90% of smokers --- smoke at home
– 55-85% smoke in presence of children
• Urinary cotinine – students
– 76% of children have high levels
• Turkish coffee-house, CO in breath
– Non-smoker outside: 3.5 ppm
– Non-smoker inside: 8.9 ppm
– Smoker inside: 23.5 ppm
Rationale for Tobacco Control in Turkey
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Tobacco smoking: common: 1 / 4 of adults
Second-hand smoke exposure is too high
More than 100 000 people are killed annually
Half of fires caused by tobacco
Economic aspect
– 50 million USD is spent daily to purchase
(Hacettepe University budget: 250 million USD)
– 30 billion USD / year
(Ministry of Health budget 55 billion USD)
Tobacco control legislation, Turkey
• Prevention of Harms of Tobacco, 1996, No. 4207
• Amendment of the Law 4207, 2008
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Tobacco Regulatory Authority: 2002
WHO FCTC was announced, 2003
Turkey signed and ratified, 2004
TC Directorate established, 2006
National TC Program and Action Plan, 2008-2012
Law on Prevention of Harms of Tobacco Use, 1996
No.4207
• Main items in the Law
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Ban smoking in public places, and public transportation
Ban smoking – health and educational institutions,
Ban “all kinds of” advertisements and promotion
Health warning on the packages
Prohibition of selling to minors – 18 yrs.
TV airtime, 90 min/month – “harms of smoking”
• First Smoking and Health Congress, 1997
– First Anniversary of the TC Law
First National Congress on T-H, 1997
“first age of TC Law”
Amendment of the Law, 4207, 2008
• Covers all indoor public places
– Incl. Hospitality venues (2009)
– Smoke-free country (3rd, after UK and Ireland)
• Inspection improved
– Referring “Misdemeanors Act”, No. 5326
• Resistance from tobacco Industry (hospitality ind.)
• Civil Society Action
– Meetings with the representatives of hospitality industry
Research on effects of the TC Law
• Indor air quality
– PM 2.5 measurement
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Public support to TC Law
Hospital admission data
Complaints of workers at hospitality venues
Tobacco use prevalence
Indoor air quality improved
mcg/m3
Particle (PM 2.5) Levels Before and After
Implemenation of Smoke-Free Law in Some Places
3500
3000
2900
Before
After
2500
1850
2000
1300
1500
930
1000
500
400
580
450
90
80
440
130
80
Boutique
Small
grocery
0
Municipality
office
Stationery
shop
Canteen in
hospital
Hairdresser
Hospitality workplaces
Complaints of workers before and after implementation
60
Percent
52
52
50
50
40
30
23
23
20
10
13
6
10
4
1
3
1
0
Watering in
eyes
Stuffy nose
Dyspnea
Before
Cough
After
Stink on
dress
Disturbance
of odor
Hospitality workplaces
CO levels in breath before and after implementation
Percent
25
22
20
14
15
10
4
5
2
0
Smoker
Before
After
Non-smoker
Hospitality workplaces
Cotinine in urine before and after implementation
mcg/ml
68
67
66
64
63
61
62
60
58
56
56
54
52
50
Smoker
Before
After Non-smoker
Emergency admissions due to cardiac and respiratory diseases
before and after implementation
(percentage of all admissions)
9
14 Percent
12
8
12
7.6
7
10
9.7
8
6
8.5
7.2
6
5
4
4
4.9
2
3
3.9
3.8
2
1
0
0
2008-2009
2009-2010
Cardiovascular
Men
Respiratory
2008-2009
Cardiovascular
Women
2009-2010
Respiratory
Adult Smoking Prevalence in Turkey, 1993-2012
%
Tobacco use prevalence, GATS 2008 and 2012
Tobacco use prevalence, GATS 2008 and 2012
Keys to Success – 1
• Political commitment: “whole government...”
– PM: very supportive
– Parliament:
• other parties: all supported
– Minister of Health, bureaucrats
– Other ministers (Finance, Interior, others ...)
• Tax increase
• Governors, police department …
Keys to Success – 2
• National Tobacco Control Program, Action Plan
– Multi-sectoral participation:
• 130 participants: MoH, other min., Civil Soc., academia …
– 2008-2012:
– 2013-2017:
• targets, responsibilities, obstacles, evaluation
Keys to Success – 3
• Strong partnership
– National partners:
• National Coalition on T-H
• Health professionals societies
• Academia
– International partners:
• WHO, CDC, Bloomberg GI, EU, other countries …
Major activities
(Government & Civil Society)
• Projects (mostly funded by BI)
– Expansion of smoke-free public places in Turkey
– Supporting and Monitoring the Implementation of FCTC
and MPOWER Strategies in Turkey
• Meetings with the stakeholders
– Hospitality industry representatives, general public
• Training
– governors, municipal governors
– health professionals, provincial health directors
– inspection teams
• Participating the Provincial TC Board
Challenges
• Smoking prevalence is still very high
• Resistance from hospitality industry
– Constitutional Court Case
• Tobacco Industry interventions
– Possible influence on Tobacco Regulatory Authority
– Frequent visits to Tobacco Regulatory Authority
• Need to enforcement of inspection mechanism
– Police officers do not pay enough attention
– Violations (bars, night clubs..)
Conclusion
• Turkey achieved big success on TC
• Keys:
– Political stability and whole government approach
– Strong and supportive NGO
– Strong and supportive academia
– Tax increase
– Strong mass media campaigns
• TV, press media, billboards …
Thank you …
nbilir@hacettepe.edu.tr