Tobacco use is one of the key health problems worldwide. It does not just result with well-known smoking-related diseases such as lung cancer, it is also associated with several health problems such as premature deaths and hearth attacks. Additionally, the risk of acquiring one of these diseases does not only arise from smoking, but also exposure to tobacco smoke. Thus, smoking in public spaces threatens non-smokers as well. Studies show that even fetuses can be severely affected by tobacco smoke.
Overall, there is no doubt worldwide that tobacco control is a key topic for preventive healthcare services. It is not just a scientific fact, but also one of the rarest consensus topics worldwide. Yet, tobacco use continues to increase worldwide, in the industrialized world as well as the third world. This is partially because the global tobacco lobby is one of the strongest worldwide along with the arms and oil lobbies.
Turkey is also on the frontline in this issue. According to the World Health Organization (WHO), Turkey is one of 15 countries worldwide with a heavy burden of tobacco-related health problems. WHO's 2013 standardized estimate of smoking prevalence shows that 35.7 percent of men, 9.9 percent of women and 25.4 percent of Turkey's adult population overall are daily tobacco smokers.
Turkey was once a heaven for smokers. Those who are over 30 clearly remember times when at workplaces, offices, public spaces, and even on public transportation, smoking was standard. At that time, people found their way in a public bus amid the heavy fog of smoke.
But this has changed dramatically. For more than a decade, the government has aimed to strengthen the country's capacity for tobacco control and to protect its people from exposure to tobacco and tobacco smoke. In this effort, diverse policy tools are being used, including taxes, bans, public education and expanding addiction treatment facilities. Now, all public are effectively banned to smoke, even electronic cigarettes. Early this year, the country expanded the ban on smoking even further. Now, the country is in the second phase of implementation of its smoke-free policies. Smoking is now prohibited in all public places such as schools, classrooms and courses, as well as places such as restaurants, cafes, cafeterias and pubs. It is partially prohibited to smoke even in outdoor spaces in places such as universities. The approach is to restrict smoking in all outdoor areas nationwide.
How can the country achieve this? This is a quite interesting question to be answered. First, initiatives for tobacco control in Turkey started in 1982 and then again in 1989. In 1996, the country enacted the Law on Prevention and Control of Hazards of Tobacco Products. Yet, despite ambitious aims, these initiatives failed to implement effective control countrywide.
But as the Justice and Development Party (AK Party) came to power in 2002, tobacco control became a priority issue in healthcare policies. By the leadership of President Recep Tayyip Erdoğan, who is a pioneer in tobacco control, the country has gained major steps in implementation. The Healthcare Transformation Program of 2003 gave the utmost importance to tobacco control policies. Turkey became a party to the WHO Framework Convention on Tobacco Control in 2005. Since then, the country is a key partner in the creation and implementation of WHO's jointly organized global tobacco tax strategy.
In 2008, a new law substantially amended the Law on Prevention of Hazards of Tobacco Products. The amendment covered many tobacco control areas, including prohibitions on public smoking, advertising, promotion, sponsorship, packaging, labeling, education campaigns and penalties for violations. Turkey's National Tobacco Control Program and Action Plan for 2008-2012 and later for the 2015-2018 National Action Plan served as frameworks. For his ceaseless efforts, Erdoğan, as prime minister, was presented with the WHO director-general's World No Tobacco Day special recognition certificate in May 2013.
Campaigns to incentivize quitting
Health Ministry figures show that thanks to the quit line call center and expanding healthcare facilities, 2.2 million people quit smoking between 2010 and 2014.
According to the WHO, Turkey is the only country in the world, as of July 1, 2015, to have accomplished all six best buy (MPOWER) measures for tobacco control at the highest level of achievement: M (Monitoring), P (Smoke-Free Policies), O (Cessation Programs), W (Warnings): Health Warnings and Mass Media, E (Advertising Bans), and R (Taxation). Now, WHO presents Turkey as an example to the world and continues to support Turkey in monitoring and maintaining its position as an international leader in tobacco control legislation.
Dr. Pavel Ursu, the WHO representative in Turkey, spoke of this impressive advancement: "Turkey has made impressive progress in controlling the tobacco epidemic. It is commendable that all provisions of the WHO Framework Convention on Tobacco Control are successfully and progressively implemented in Turkey." According to the Health Ministry, from 2008 to 2012, smoking prevalence among Turkish adults dropped from 31 percent to 27 percent and further declined to less than 25 percent by 2014, which is an outstanding achievement in just a few years.
What policies have worked?
There are several successful policy tools Turkey has used in its control strategy over tobacco. Exposing these effective mechanism are of great importance to set an example worldwide for smoke-free policies.
The first policy Turkey successfully implemented is surveillance and monitoring, which aimed to reach evidence-based protocols for tobacco surveys. With support from the WHO, the United States Centers for Disease Control (CDC), Turkish Statistical Institute and the Health Ministry, Turkey conducted Global Adult Tobacco Surveys (GATS) in 2008 and 2012. The second significant step was a tobacco control policy and legislation. By amending the law to a comprehensive ban on smoking in public places, workplaces and in advertising, promotions and sponsorships, Turkey changed the rules of the game on tobacco control. Particularly enforcing point of sale regulations, restrictions on sales to minors, promotions and price discounts were critical in this phase. Increased pictorial health warnings on cigarette packs were also critical, as they have attracted extensive press coverage. In 2009, the WHO also helped Turkey establish a new national quit line. With this line and expanding addiction treatment facilities of the ministry, help became accessible for smokers. By organizing mass media campaigns and repeated health warnings from Erdoğan in his speeches, the country has won the public opinion struggle.
Taxation was also a critical aspect of Turkey's tobacco control policies. In 2011, the Finance Ministry increased tax on tobacco products from 62 percent to 65 percent. It has to be stressed that tobacco taxes have served as an effective tool in the country.
Overall, despite still having a high rate of smokers, Turkey is now drawing international applause as a world leader in implementing smoke-free policies. The WHO confirms that the country has achieved all the six best buy measures to reduce tobacco use at the highest level of achievement. Europeans and Americans, even the most advanced ones, have lots to learn from Turkey on the area of tobacco control.
* Inspector at Republic of Turkey’s Social Security Institution