Tobacco Control in Turkey By: Nazmi Bilir, Banu Çakır, Elif Dağlı, Toker Ergüder and Zeynep Önder ABSTRACT This report was prepared by WHO within the framework of the Bloomberg Global Tobacco Control Initiative in collaboration with the Ministry of Health and the Tobacco and Alcohol Market Regulatory Authority in Turkey. It outlines the current state of tobacco-smoking in Turkey, including the health and social aspects, epidemiological data and economic, legal and political issues. Turkey, until recently one of the major tobacco-producing countries of the world, has made substantial progress in tobacco control in a short time. The initial efforts of the Ministry of Health in the late 1980s received an impetus when Turkey ratified the WHO Framework Convention for Tobacco Control in 2004. Law No. 4207 of 1996 was substantially amended in 2008 and thus became one of the most advanced tobacco control laws in the world. Even so, smoking is still a serious health problem in the country, with one tenth of all the disability- adjusted life-years lost due to smoking. About one third of the population smokes, despite a slight decrease over the last 15 years. Keywords SMOKING – prevention and control TOBACCO INDUSTRY – methods – legislation TOBACCO HEALTH STATUS HEALTH POLICY HEALTH SERVICES TURKEY ISBN 978 92 890 4182 9 Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest). © World Health Organization 2009 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. CONTENTS Page Preface ................................................................................................................................................................. v Acknowledgements ............................................................................................................................................ vii Executive summary .............................................................................................................................................. 1 General information ............................................................................................................................................. 3 Demographics .......................................................................................................................................... 3 Political system and administrative structure .......................................................................................... 5 Economic conditions ................................................................................................................................ 5 History and structure of the health system and health expenditure ......................................................... 6 Conclusions ............................................................................................................................................ 10 Health status of the population ........................................................................................................................... 10 General health statistics ......................................................................................................................... 10 Government health services and health promotion ................................................................................ 11 Mortality data ......................................................................................................................................... 11 Morbidity data ........................................................................................................................................ 13 Conclusions ............................................................................................................................................ 13 Tobacco sector: smoking and related health status of the population .............................................................. 14 Tobacco sales and consumption ............................................................................................................. 14 Prevalence of smoking ........................................................................................................................... 18 Passive smoking ..................................................................................................................................... 25 Tobacco-related mortality and morbidity .............................................................................................. 27 Economic burden of tobacco-related diseases ....................................................................................... 28 Conclusions ............................................................................................................................................ 29 Production and marketing of tobacco products ................................................................................................. 30 History and current status of tobacco cultivation .................................................................................. 30 Production and market share of tobacco products ................................................................................. 34 Evaluation of the current position and suggestions ............................................................................... 37 Marketing strategies of the tobacco majors ........................................................................................... 39 Conclusions ............................................................................................................................................ 42 The role played by multinational tobacco companies in the Turkish market ................................................... 43 The government and the tobacco industry ............................................................................................. 43 Preventing effective tobacco control policies and legislation ................................................................ 43 The impact on laws and regulations ....................................................................................................... 43 International domino effects .................................................................................................................. 44 Corporate responsibility projects ........................................................................................................... 44 Advertising ............................................................................................................................................. 44 Conclusions ............................................................................................................................................ 45 Health care system and its role in tobacco control policy ................................................................................. 45 Government health services and tobacco control activities ................................................................... 45 Nongovernmental organizations active in tobacco control .................................................................... 47 Harmonization with EU legislation on tobacco control ......................................................................... 49 Conclusions ............................................................................................................................................ 51 Economic information related to tobacco......................................................................................................... 52 Real price trends in tobacco products and their affordability.................................................................52 Price elasticity of demand for cigarettes ................................................................................................54