TOBACCO CONTROL in TURKEY

Nazmi Bilir, MDProf. of Public Health

Hacettepe University Institiute of Public Health

nbilir@hacettepe.edu.tr

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 … nbilir@hacettepe.edu.tr