Bulletin of the World Health Organization

Turkey’s transformation

Just three years after adopting tough anti-smoking measures, Turkey’s tobacco consumption is down 15% and quitting is cool. Patrick Adams reports.

When Turkish Prime Minister Recep Tayyip Erdoğan addressed a meeting of the National Tobacco Control Programme in December 2007, he didn’t mince words. “Struggling against the use of tobacco products has become as important as our counter-terrorism struggle,” he told an audience assembled in the lobby of Ankara’s Sheraton Hotel. Those products, he said, “are literally murdering our future generations”.

As a non-smoker Erdoğan was, at the time, in the minority of Turkish men. According to a government survey of tobacco use conducted in 2006, some 33% of adults were daily smokers, including just over half of all men and approximately 16% of women aged 18 and over. In a Gallup poll conducted in 100 countries the following year, two out of three Turkish men said they had lit up the day before they were surveyed, as did one out of three women. That was, Gallup said, “by far the highest incidence reported”. It also confirmed a stereotype common to countries across Europe: that to smoke heavily was “to smoke like a Turk”.

Three weeks later, the prime minister signed into law a ban on smoking in all enclosed public spaces.

The first tobacco control law in Turkey had been signed in 1996, and in 2004 the Turkish parliament ratified the World Health Organization Framework Convention on Tobacco Control (WHO FCTC), committing it to a set of obligations, explained Toker Erguder, tobacco control programme manager at WHO’s country office in Turkey.

A special unit was then established in the Ministry of Health, charged with rolling out a national tobacco control programme and action plan. In 2008, more tobacco control legislation was passed, which made indoor spaces 100% smoke-free, including the hospitality sector. This meant it had some of the most stringent tobacco control measures in the world, alongside countries such as Ireland and the United Kingdom of Great Britain and Northern Ireland.

Toker says: “A key success of the policy on tobacco control is the whole-of-government approach lead by Erdoğan and strong intersectoral collaboration by the health minister, Recep Akdağ, to combat the tobacco epidemic. And the head of parliament’s health commission, Cevdet Erdöl, was instrumental to the preparation and adoption of the tobacco control laws.”

Signs announcing Turkey’s clampdown on smoking in public places hang above customers at a café on Istiklal Street in Istanbul
Patrick Adams
Signs announcing Turkey’s clampdown on smoking in public places hang above customers at a café on Istiklal Street in Istanbul

Passing legislation is one thing. Enforcing it is often quite another. And for all the promise of sweeping change, many doubted the law would have an impact on a smoking culture as strong as Turkey’s. Now, nearly three years after the ban went into effect, Turks and tourists alike express amazement at its widespread acceptance and the degree to which patrons of restaurants and bars have abided by the new rules.

“I would never have imagined that they could implement the ban as well as they have”, says Sarp Ucak, an equity trader with Citibank in Istanbul, home to most of Turkey’s 16 million smokers, out of a population of almost 74 million. “I don’t really like this government, but I have to congratulate them. There are still some restaurants and bars that don’t obey, but only very few. And now many of my friends are quitting.” Ucak is, too, he says. “I’m trying again. I want to quit.”

“It not only brought down the consumption rate, but it also changed public opinion”, says Elif Dağli, chair of the National Coalition on Tobacco or Health, a civil society group formed in 1995 to lobby for the country’s first anti-tobacco law and one of the prime movers in generating support for the FCTC. “It was like changing – not the ‘climate’, that’s too mild,” she says. “It was like changing the religion. And it was amazing; everybody said it would be protested, but then everybody started quitting.”

Turkey’s transformation didn’t occur overnight. Indeed, even after the ban was passed, a battle that had begun nearly twenty years ago – between industry and activists – continued apace. “The tobacco industry thought, OK, we have 18 months to reverse this,” says Dağli. “They said the shopping malls will go bankrupt, the restaurants will lose money, things like that. But we, the community of nongovernmental organizations, had collected all the evidence” – from France, Ireland and Italy –“saying that this would not happen. And we fed that information to government officials and the public. We sort of vaccinated them against the industry’s arguments.”

Yet, it wasn’t only the industry Dağli and colleagues were up against. “We were fighting the media, too”, she adds, citing newspapers’ reliance on revenue from tobacco advertising as the main reason for their opposition to the 1996 law. “In a way, we were actually promoting tobacco when we held a press conference because the newspapers would call the tobacco companies and say ‘Hey these health guys are organizing a meeting, do you want to buy an ad on the same page?’ And the next day there would be a few lines about us next to a giant Marlboro man.”

It was the arrival of that ad icon and his Camel counterpart in the mid-1980s that helped Turkey’s tobacco consumption rates to climb sharply, says Nazmi Bilir, professor of public health at Haceteppe University in Ankara. Over the next two decades, he says, “tobacco use in Turkey nearly doubled”, with cigarette sales going from roughly 98 billion Turkish Lira (US$ 55 billion) to more than 178 billion Turkish Lira (US$ 100 billion) in 2000. That trend was borne out in the health data: Of the five million patients hospitalized in Turkey in 2000, 20% had a smoking-induced disease, and those diseases – primarily cardiovascular conditions – accounted for more than half of all hospital deaths.

“According to our estimation, about US$ 20 billion a year is spent on diagnosing and treating health problems caused by tobacco use”, says Bilir, who adds that smokers themselves spend another US$ 20 billion a year on cigarette purchases. Indeed, as the WHO’s Global Adult Tobacco Survey (GATS) revealed in 2010, smokers in Turkey spent on average 86.7 Turkish Lira on cigarettes every month, or approximately 12.7% of the country’s “lowest monthly salary.”

Already, though, the new law seems to have curbed costs. A recent study by Bilir and colleagues of emergency department admissions in Ankara revealed a sharp drop in acute health problems caused by tobacco use. When compared to data from before the smoking ban went into effect, he says, “we found a 10-12% decrease in these conditions.”

To what does Bilir attribute Turkey’s improbable turnaround? “To me it is the political commitment of the government,” he says. “It’s a very powerful government, and the prime minister and the health minister and the head of the health commission in the parliament – these are very committed persons.” Still, he says, nothing would have been possible without a strong civil society movement. “We worked very closely with the government and the parliament and provided them the scientific data.”

In January 2012, four years on from the implementation of Turkey’s anti-smoking laws, WHO’s Turkey country representative, Maria Cristina Profili, received a special recognition award from Turkey’s health minister, Recep Akdağ
Toker Erguder
In January 2012, four years on from the implementation of Turkey’s anti-smoking laws, WHO’s Turkey country representative, Maria Cristina Profili, received a special recognition award from Turkey’s health minister, Recep Akdağ

Echoing that theme, Tezer Kutluk, president of the Turkish Association for Cancer Research and Control, credited the prime minister’s critical role in deciding a battle for the air Turkey breathes – a David-and-Goliath contest between a patchwork alliance of small but determined NGOs and tobacco giants with a firm grip on the Turkish market. “We were lucky he supported the law,” says Kutluk. “But now the NGOs are more powerful than we were in the past. And we will never stop fighting. There won’t be any chance for tobacco companies in the future. Not in Turkey.”

Tobacco control in Turkey has been a multi-agency effort, with several key organizations involved. It is this approach which has helped bring about change in Turkey.

Douglas Bettcher, the director of the Tobacco Free Initiative at WHO, said: “Turkey has become a model of political commitment and willingness to avert the tobacco epidemic and protect its citizens from the drug. Making Turkey tobacco-free has been a road of successes, as well as challenges.”