Tobacco-related studies are quite common in Turkey, yet most are either small-scale or not representative of the entire population. Besides prevalence studies in different population sub-groups [14
], there have been a number of studies on potential risk factors for smoking [12
] and/or on assessment and monitoring of tobacco control studies in Turkey [15
]. On the other hand, there is still a missing link between such evidence and tobacco-related policy making. It is important to base policy decisions on valid and reliable evidence from population-based, representative studies that are periodically repeated to enable policy makers to monitor the results of their interventions and to appropriately tailor anti-tobacco activities to future needs.
The WHO FCTC calls for countries to use consistent methods and procedures in their surveillance efforts. The GYTS was designed for exactly this purpose (that is, standardized sampling procedures, core questionnaire items, training in field procedures, and analysis of data, all of which are consistent across all survey sites). The GYTS provides indicators for measuring achievement of five WHO FCTC articles (namely, exposure to secondhand smoke, school-based tobacco control curricula, cessation, media and advertising, and minors' access and availability to tobacco products) and results from the 2003 GYTS can be used to set baseline measures that can be used to monitor the five WHO FCTC articles, as discussed below.
Article 8: protection from exposure to tobacco smoke
Law 4207 calls for a ban on smoking in public places; however, the ban is limited to health care facilities, schools, theatres and cinemas, and some public transport (buses, trains, and domestic and international air transport) [3
]. Results of the GYTS (2003) suggest that the vast majority of Turkish teenagers are exposed to secondhand smoke in public places. The MOH is now focusing on developing a proposal to amend Law 4207 to include provisions to prohibit the consumption of tobacco and tobacco products in additional public places. To assist in this effort, the GYTS data show that over 94% of never smokers and 64.1% of current smokers are in support of banning smoking in public places, with no significant difference by gender [6
]. In a similar way, 81.6% of never smokers (slightly higher in girls versus boys) and 55.3% of current smokers (with no significant difference by gender) report that they believe passive smoking is harmful [6
Article 12: education, communication, training and public awareness
From the GYTS data, half of the students in Turkey reported that, during the past school year, they had been taught about the dangers of smoking and one-third had discussed reasons why people their age smoke. This information calls for the development, implementation and evaluation of evidence-based tobacco prevention curricula to be used in schools. The centralized education system in Turkey will facilitate national implementation of a tobacco use prevention curriculum, once an effective program is identified and evaluated.
It is important to note that introducing anti-smoking programs to teenagers is not an easy task. It is not always easy to identify the smoking students, given that they do not want this to be known by their teachers, parents, and other relatives and/or may be scared that they will be punished for smoking. Similarly, because of a fear of stigmatization, for example, teenage smokers are not as open as adults to attending 'quit smoking' centers and/or to receiving help from professionals, even when they want to quit smoking. Training for teachers and parents in how to approach a teenager who smokes is important in this respect.
Article 13: tobacco advertising, promotion and sponsorship
Law 4207 prohibits mass media advertising of cigarettes and other tobacco products, as well as the sponsorship of all sports and cultural events by tobacco companies. Data from the GYTS show one-third of the students reported seeing cigarette advertisements on billboards and 28% saw advertisements for cigarettes in newspapers or magazines. In other countries that have conducted the GYTS, billboards often refer to posters seen at point of sale locations and newspapers and magazines refer to international publications. Turkey does not have a ban on advertisements in international publications.
The GYTS also includes information on indirect advertising by the tobacco industry. Students were asked if they have an object (cap, shirt, knapsack, and so on) with a tobacco company logo on it. One in 10 students in Turkey had such an object. The working group formed by the MOH could use this information as support for amending Law 4207 to include stronger provisions regarding direct and indirect advertising of tobacco products.
Article 14: demand reduction measures concerning tobacco dependence and cessation
The GYTS results show 7 in 10 current smokers wanted to stop smoking and over 7 in 10 have tried to stop during the past year but have failed. Turkey has some cessation clinics in select universities and hospitals, but these cessation efforts focus largely on adults. This finding indicates a need to develop, pilot test, and evaluate potential youth cessation programs. Once effective programs have been identified, they need to be made widely available throughout Turkey. The evidence is currently insufficient to support the efficacy of smoking cessation programs in young people [16
Article 16: sales to and by minors
The GYTS data show that almost half of the current smokers (all aged 13 to 15 years and, thus, minors) usually buy their cigarettes in a shop and many of them were not refused purchase because of their age. Clearly, enforcement of the minors' access law is a major issue facing Turkey, as well as amendment of the prohibition of tobacco sale near educational facilities. These efforts can complement other population-based intervention efforts to reduce tobacco use in Turkey.