TOBACCO CONTROL in TURKEY
Nazmi Bilir, MDProf. of Public Health
Hacettepe University Institiute of Public Health
Presentation Plan
• 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– 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
• 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
Population (million)
Tobacco sales (bilion)
Number of Lung Cancer cases Hospitalized, Turkey, 1964-2004
1222 1614 2018 4363 687811324
18442 21729
52865
0
10000
20000
30000
40000
50000
60000
1964 1969 1974 1979 1984 199 1994 1999 2004
Number
Similar increase --- heart dis., COPD...
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
• 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
• 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 – 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
• Public support to TC Law• Hospital admission data • Complaints of workers at hospitality venues • Tobacco use prevalence
Indoor air quality improved
Particle (PM 2.5) Levels Before and After Implemenation of Smoke-Free Law in Some Places
2900
1850
1300
930
580440
80
400 450
90 130 80
0
500
1000
1500
2000
2500
3000
3500
Municipalityoff ice
Stationeryshop
Canteen inhospital
Hairdresser Boutique Smallgrocery
mcg/m3
Before After
Hospitality workplaces Complaints of workers before and after implementation
23
13
52
23
50 52
106
14 3 1
0
10
20
30
40
50
60
Watering ineyes
Stuffy nose Dyspnea Cough Stink ondress
Disturbanceof odor
Percent
Before After
Hospitality workplaces CO levels in breath before and after implementation
22
4
14
2
0
5
10
15
20
25
Smoker Non-smoker
Percent
Before After
Hospitality workplaces Cotinine in urine before and after implementation
67
61
63
56
50
52
54
56
58
60
62
64
66
68
Smoker Non-smoker
mcg/ml
Before After
Emergency admissions due to cardiac and respiratory diseases before and after implementation
(percentage of all admissions)
12
9.7
7.2
4.9
0
2
4
6
8
10
12
14
2008-2009 2009-2010
Percent
Cardiovascular Respiratory
8.57.6
3.9 3.8
0
1
2
3
4
5
6
7
8
9
2008-2009 2009-2010Cardiovascular Respiratory
Men Women
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 … [email protected]
