tobacco control in turkey nazmi bilir, md prof. of public health hacettepe university institiute of...
TRANSCRIPT
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]