TOBACCO CONTROL in TURKEY Nazmi Bilir MD Prof

TOBACCO CONTROL in TURKEY Nazmi Bilir, MD Prof. 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 Mo. H, 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 18 20 12 16 21 28 68 36 45 73 56 0 1935 1950 1960 1970 1980 1990 2000 2010

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 (3 rd, 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

Hospitality workplaces Complaints of workers before and after implementation

Hospitality workplaces CO levels in breath before and after implementation

Hospitality workplaces Cotinine in urine before and after implementation

Emergency admissions due to cardiac and respiratory diseases before and after implementation (percentage of all admissions) Men Women

Adult Smoking Prevalence in Turkey, 1993 -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: Mo. H, 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