1. TOBACCO CONTROL in TURKEY Nazmi Bilir, MD Prof. of Public Health Hacettepe University Institiute of Public Health nbilir@hacettepe.edu.tr

2. 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

3. 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

4. * Tobacco producing country (1.7%) * Smoking is common ( GATS 27.1%; M: 41%, F: %13%) * Among the top 10 countries

5. 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 !!!

6. 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

7. Cigarette sales, Turkey, 1925 - 2011 TC Law, 1996TC Law, 2008 State Monopoly - TEKEL 1980-2000: Cigarette sales “doubled” 2.5 times of population increase

8. Population Increase and Tobacco Sales, Turkey 1935-2010 Population (million) Tobacco sales (bilion)

9. Similar increase --- heart dis., COPD...

10. 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

11. 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)

12. 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

13. 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

14. First National Congress on T-H, 1997 “first age of TC Law”

15. 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

16. 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

17. Indoor air quality improved

18. Hospitality workplaces Complaints of workers before and after implementation

19. Hospitality workplaces CO levels in breath before and after implementation

20. Hospitality workplaces Cotinine in urine before and after implementation

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

22. Adult Smoking Prevalence in Turkey, 1993-2012 %

23. Tobacco use prevalence, GATS 2008 and 2012

25. 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 …

26. 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

27. 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 …

28. 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

29. 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..)

30. 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 …

31. Thank you … nbilir@hacettepe.edu.tr