Changes in Smoking Patterns in Turkey Before and After the Ban on Loose Cigarettes: An Ecological Perspective From Global Tobacco Surveillance Data.

Introduction: Loose or individual cigarettes sold without packaging pose a unique challenge for tobacco control, which is the leading cause of premature and preventable mortality worldwide. This study aims to assess the changes in smoking patterns following the ban on loose cigarettes in 2008 in Turkey.

Method: Gender-stratified trend analysis of smoking patterns before and after the ban on loose cigarettes was done using the Global Tobacco Surveillance data (adults: Global Adult Tobacco Survey (GATS) 2008, 2012, and 2016; youth: Global Youth Tobacco Survey (GYTS) 2003, 2005, 2009, 2012, and 2017) from Turkey. The trends in smoking patterns were triangulated with the introduction of the loose cigarette ban and other laws in Turkey.

Result: From GATS 1 in 2008 to GATS 2 in 2012, there were initial declines in adult smoking patterns, including current smoking and daily smoking, with increased quit intentions. However, these trends were reversed by the time of the GATS 3 in 2016, when both current smoking and daily smoking measures were higher, especially among females. Monthly cigarette expenses consistently increased across all survey years. Among youths, the overall prevalence increased sharply from 6.9% in 2003 to 23% in 2005, then decreased to 8.4% in 2009, again increased to 10.4% in 2012, and finally returned to 7.7% in 2017. Triangulation of these trends against the implementation of the loose cigarette ban in 2008 produced no clear association between the ban and smoking patterns.

Conclusion: The overall marginal decline in smoking behaviors over two decades in Turkey needs to be fast-tracked, specifically the rise of smoking among the female population, which needs to be addressed through evidence-based tobacco control interventions. The loose cigarette ban was implemented as part of a comprehensive tobacco control law, and the GATS or GYTS data is not sufficient to assess the effect of this provision. The tobacco control effort in Turkey should collect evidence for changes in smoking patterns following the implementation of tobacco interventions, which is also a mandate of the Global Tobacco Surveillance System (GTSS).