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Turkish Journal of Cancer
2008, Volume 38, Number 3, Page(s) 099-112
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Patterns and dynamics of female tobacco use: A comparative perspective of Turkey and the United States
BELGÝN ERTEN1, DÝLEK ASLAN2
1Tulane University, Department of Public Health, Mandeville, LA-USA
2Hacettepe University, Department of Public Health, Ankara-Turkey
Keywords: Tobacco use, female, Turkey, USA
Summary
The United States and Turkey differ in their level of development on a global scale and this fact contributes to explain the differences observed in their trends of female tobacco use. In this paper, the patterns and dynamics of women’s tobacco consumption in both US and Turkey will be discussed. Currently almost 25 million Turkish smokers help comprise 1.3 billion smokers worldwide. A staggering 45.3 million American smokers help comprise an even larger portion of that figure. Despite there being nearly double the number of smokers in the United States, 30% of the Turkish population are purposefully inhaling tobacco fumes on a daily basis, faring higher than the US with a 23.4% smoking population. To provide another point of comparison, one may look at both genders for a greater perspective and learn that in 2005 the prevalence amongst females over 15 years of age was found to be 21.5% in the US and 19.2% in Turkey and for males over 15 years of age, 26.3% in the US and 51.6% in Turkey. Women have a number of reasons unique to those of men for taking up smoking like weight control, increasingly high stress due to responsibilities of caring for children, growing careers, female physical health issues and dealing with the hectic nature of urban lifestyles. Additionally, tobacco marketing strategists recognize a cultural shift in developing countries, and have responded with cleverly designed advertisements that implant manipulative ideas of consumerism and false ideas of the necessity of cigarettes to becoming independent. Solutions for prevention of smoking increase among females need a holistic approach. [Turk J Cancer 2008;38(3):99-112]
  • Top
  • Summary
  • Introduction
  • Conclusion
  • References
  • Introduction
    The United States (US) and Turkey have shared a friendly coexistence throughout the modern era as two relatively new countries. A similar culture is something they do not share, however, and perhaps it is that difference, whether historical, religious or cultural that is clear especially when it comes to the habit of smoking. In fact, it is one of the first things a foreigner might notice in Turkey. An attention grabbing development in the country regarding the increase in female tobacco use has particularly begun to cause concern and ignite attempts at explaining the reasoning behind this development, especially when other countries such as the United States have experienced decreases in female tobacco use. Women are increasingly playing a major part in the tobacco reliant Turkish culture, possibly as a byproduct of their increasing independence. As both the US and Turkey collaborate on international and national approaches to the detriments of tobacco, they encounter similarities such as the challenges presented by the tobacco industries’ heavily female oriented target marketing, yet they are distinguished by their differences in traditional and popular culture.

    In this paper, the patterns and dynamics of women’s tobacco consumption in both US and Turkey will be discussed.

    PATTERNS
    Smoking prevalence in developing countries
    The United States and Turkey differ in their level of development on a global scale and this fact alone explains the differences observed in their trends of female tobacco use. Countries are classified as either developed or developing, and development is measured based on a modern physical and institutional infrastructure as well as prolific economic system[1]. The United States is a major world power and one of the strongest economic and military forces on the globe, thus it has been classified as developed[2]. Turkey’s status is more uncertain because of its entrance as an emerging market and rapidly expanding economy, therefore it is classified as one of the more developed developing countries[3].

    Today, developing countries contain 75% of the world’s smokers and even with an overall prevalence decrease of 1%, the number of female smokers is predicted to reach 259 million in 2025 from 218 million in 2000[4,5]. By 2030 70% of deaths from tobacco related diseases will be in developing countries. Currently, 22% of females in developed countries and 9% of females in developing countries smoke and these statistics are quickly changing so that females in developing nations will reach those in developed nations[6]. Unless smoking patterns change, the future health of women in developing countries like Turkey is looking more and more grim as conditions on this front in the US improve.

    US and Turkey smoking prevalence
    There are 1.3 billion smokers worldwide, a number representing over one sixth of the world population[7]. A staggering 45.3 million American smokers help comprise an even larger portion of that figure[8]. Despite there being nearly double the number of smokers in the United States, 30% of the Turkish population are purposefully inhaling tobacco fumes on a daily basis, faring higher than the US with a 23.4% smoking population[9]. To provide another point of comparison, one may look at both genders for a greater perspective and learn that in 2005 the prevalence amongst females over 15 years of age was found to be 21.5% in the US and 19.2% in Turkey and for males over 15 years of age, 26.3% in the US and 51.6% in Turkey[10].

    An increasing economic independency in Turkish women may provide an explanation to the increasing prevalence of female smokers. Some of the main determinants of economic independency are marital status, level of education, use of earnings, presence of income, and area of residence. These factors can be assumed as largely cultural, as they are often driven not by economic influences but by social influences. Key data was correlated from these determining factors so that the common characteristics of female smokers could thus be assessed based on the 2003 Turkey Demographic and Health Survey results of 10,836 households and 8,075 ever-married women ages 15-49[11].

    From the following statistics, interrelated characteristics can be determined. Of the ever-married women surveyed 95% were still married, 3% divorced and 2% widowed. Being that almost all these women had experienced marriage and were still currently married, it shows the likelihood that Turkish women will be married or stay married. Thus, leading a single lifestyle after reaching an age in which marriage is appropriate or even later in life appears infrequently. Perhaps, it is incongruous with a typical Turkish lifestyle and culture. The same cannot be said of the United States.

    A great shift is being experienced in the level of education being attained by younger female generations of Turkey, yet the disparity between male and female education is unfortunately still old news. While 28.1% of urban men have achieved a high school or higher education, only 18.8% of urban women have and in rural areas the comparison is 10.1% of men to only 4.4% of women. In terms of imbalance between genders, these figures report a travesty of the education system in Turkey. Although both male and female numbers in education call for improvement, the gap between the two groups suggest a cultural inclination to withhold women from school and favor men’s educational career ambitions.

    Yet, upon closer look at the different rates amongst women, more nuanced conclusions may be reached. 21.8% of all the women surveyed were reported to have had no education, 53.7% had a first level primary education, 7.4% second level primary education and 17.0% a high school education or higher. These figures aren’t anything to boast about, yet even they shed some hope for the future. In fact, the amount of women who have received second level primary education increased from 15 percent to 24 percent in a span of ten years in 2003, a roughly 60 percent increase. The predicament of one in five Turkish women receiving no education is actually seen as a positive shift in direction for women compared to the past. The Data also exhibits a steady increase in women with higher education and decrease in women with no education with each younger age group. For example, 24.5% of women in the ages 24-29 have had high school or higher education, compared to 17.8% between the ages 30-34, 15.5% between the ages of 35-39, 14.8% between the ages of 40-44 and 12.5% between the ages of 45-49. What this displays is an increase and spread in higher education opportunities with every year, and more career fields opening their doors to women as time goes on. Not only are more women attending high school, but they are also being accepted into more universities, successfully graduating and entering the workforce in areas where usually only men were previously found[12].

    This leads to data regarding residence, particularly those of women living in urban areas. Of the urban women surveyed, 21.8% had received a high school or higher education and 18% had received no education. Of rural women, on the other hand, only 5% of them had received a high school or higher education and 31% had received no education. Women living in the East of Turkey were noted to have the lowest levels of education, and women in the northwest, the highest levels of education in the country. There is a great inequity in the dispersion of education throughout the different regions, which inhibits unified progress and results in different parts of the country progressing at different rates. This can promote internal conflicts within Turkey if all regions do not receive the same attention from national systems.

    Receiving education ensures a more promising future with the higher likelihood of not only employment in the individual, but an enhanced family income. What has come to pass in today’s society is that with a stable sufficient income, a woman is supplied with a more comfortable stable and therefore personally satisfying lifestyle. Looking at the data regarding employment, there is a significant variance between employment rates of women of differing marital status. Thus, a strong association was found to exist between employment and marital status, indicating that either the need, desire or both, to be economically self-sufficient and hold an occupation is stronger in single Turkish women or, that once married, women discontinue work. Correlating with this matter however is the fact that employed women do not necessarily control their own earnings and this matter too shows variance. When employed urban and rural women were compared, as could be guessed, employed urban women were found to have more control of their earnings. When comparing employed women of differing education levels, independent decision making was least common among women with less education. Only 1% of high school or higher educated women had absolutely no say in their earnings, compared to the 22% of women with no education that had no say in their earnings. When looking at marital status and its relationship with women’s control of earnings, predictably a vast 84.6% majority of non-married women were in sole control of their earnings, compared to 32% of married women.

    What this reveals is that an economically independent Turkish woman statistically lives in an urban residence, controls her earnings, holds a high school or higher education, and increases her chances of this independency by being single. The typical characteristics of this prototype of woman strongly clash with the traditional role of the Turkish female. This phenomenon of women picking up smoking as they gain economic independence could provide a solid explanation behind the increase in female smoking prevalence in European countries. Of European countries surveyed, Turkey was determined to be tenth from the bottom in this category. While being on the bottom half of the list does not sound alarming in itself, this indicates that women are not traditionally smokers and what this low percentage of female smokers essentially does is distract from the increase in the prevalence. Also the high percentage of male and low percentage of female smokers makes the gender gap in smoking prevalence very wide. Turkey is eighth from the top in this category in European countries. Turkey’s having such a high gap coincides with previously mentioned gaps within Turkey such as educational backgrounds[13]. The causes of these gaps are undoubtedly tied to Turkey’s cultural tendency to view actions like smoking and attending school to be more masculine habits.

    The United States female smoking prevalence has been steadily dropping. The number of female smokers is decreasing at separate rates amongst different ethnicities and socioeconomic levels throughout the country. These rates are notably determined in cohorts in which women smokers are classified into their birth years and judged from there[1]. According to the 2001 Surgeon General’s Report, women born in the 1920’s and 1940’s were found to have the highest prevalence in the 20th century. Set off by a major decline starting from 1974, the prevalence of current smoking reached a low of 22% in 1998 and continues to steadily decrease in women[14]. From this, it is evident that American culture is experiencing a decline in the desire or will to smoke despite its history of women smoking for quite some time.

    The numbers of American and Turkish smokers today are important figures to consider, yet it is the prevalence trends of these two countries that chiefly demand attention. An increase or decrease in prevalence marks the public health progress of a nation. This progress suggests the country’s either positive or negative direction in terms of its tobacco prevention programs, strength of its antismoking legislation and effectiveness of tobacco industry restrictions. If these components are being effectively implemented, the prevalence appropriately receives a drop. Also, from these details not only can we ascertain that the number of smokers does not reveal a country’s increasing or decreasing smoking prevalence rate but also, based on the size of the gap in gender smoking prevalence, the two countries obviously differ in the relationship between gender roles and smoking.

    An increase in female smoking prevalence is an especially worrisome topic in Turkey and other developing countries as their habits have very dramatic effects on their families[15]. As the primary caregivers in the home, when their health suffers, the entire family likely suffers along with them. People in low-income families are found to quit less often and cannot afford the healthcare required for tobacco related diseases, thus leaving them with even more financial burden[5]. Additionally low-income occupations commonly require physical labor and demand healthy bodies to carry out work. Smoking is pushing those in developing countries even further into the ground by using up what little resources they have and causing health defects that inhibit them from being able to sustain themselves economically. Thus, those that are the least able to afford such losses in productivity and health are succumbing to the tobacco industry’s messages[16].

    DYNAMICS
    Cultural influences
    Women have personal reasons unique to those of men for taking up smoking like weight control, increasingly high stress due to responsibilities of caring for children, growing careers, female physical health issues and dealing with the hectic nature of urban lifestyles[17]. Turkey is also a nation in a state of cultural fluctuation and change. The traditional past of Turkish history containing specific male and female dynamics is up against a modern world of new developments such as economic globalization and the free exchange of liberal ideas and beliefs through media outlets and the internet. The balancing of old with new directly relates to the differing lifestyle habits shifting between men and women.

    This all points to a positive chain of events that must continue for further progress, but is also resulting in dramatic cultural changes of traditional female roles in Turkey. What was, is no longer. Turkish women are feeling the winds of empowerment, fueled by their education and employment. It is giving them strong foundations to build a self-sufficient lifestyle, which is affecting their marital status and control of monetary earnings. This could lead to a country of more economically independent women, which ultimately would lead to national change and consequently, traditional gender behavioral shifts. In becoming or wanting to become economically independent, more women are opening up to the experiences of personal decision making, as well as feelings of expanded freedoms and emancipation from traditional female roles. Hence, the idea of the ‘Turkish Modern woman’ is becoming a mainstream goal for younger generations with the aid of progressive social developments in the country. It must be added here however, that certainly not all segments of Turkish society view this as a positive development. Centuries of patriarchal culture do not disappear in a decade or even one generation. On a negative note, the increase in cigarette consumption amongst Turkish females may possibly prove to be an unfortunate serious side effect of this growing economic independence[18].

    This isn’t to say that a number of modern economically self sufficient women in the United States don’t smoke for similar reasons, but a link between independence and tobacco hasn’t been made due to the fact that prevalence is decreasing. Also, American women have been breaking traditional gender stigmas and barriers with a louder force for many years. Feminist literary works and organizations have pushed for all sorts of women’s rights like birth control information, contraceptive availability and workplace non-discrimination that have endowed many American women with the feeling that their independence is encouraged and more importantly, that this will not be judged as a negative thing[19]. Thus, cigarette smoking in the United States is seen not as a stamp of independence, but simply as a harmful habit for which the prevalence is decreasing, than it does perhaps in Turkey where prevalence is increasing.

    Tobacco industry marketing
    Tobacco marketing strategists recognize a cultural shift in developing countries, and have responded with cleverly designed advertisements that implant manipulative ideas of consumerism and false ideas of the necessity of cigarettes to becoming independent. Advertisements are often similar or identical between the US and Turkey because Turkey’s tobacco industry will copy its competitors in hope of staying afloat in new target markets. Cigarettes have been conveyed in advertisements of both countries as a main component of an image that women ought to covet. This image goes something like this: an extremely slim, attractive young woman in an expensive suit with a briefcase in hand, standing confidently in an affluent city avenue, is smoking a cigarette as an attractive man slowly passes her by with a hungry eye. The objectives that tobacco advertisements wants to achieve through these sorts of marketing strategies is to strike at women’s vulnerabilities. These vulnerabilities typically found in women who have been fueled by the new global economy and the opportunities for freedom and independence, are the wish to be thin, attractive, financially successful, independent, and therefore socially and sexually desirable. Women in developing countries typically experience gender inequities on heavier levels than those in developed countries so these women are also more affected by marketing messages[20].

    The United States has certainly had its share of shrewd advertisement slogans. US Tobacco advertising has been geared towards women as early as the 1920’s with messages like, ‘’Reach for a Lucky (brand name) instead of a sweet,’’ leading women to believe cigarettes should be smoked to maintain a slim figure when no connection has been definitively made, though studies on the link between weight and smoking continue. Even if cigarettes were determined to be an effective weight loss aid, such a claim would be comparable to encouraging millions of women to ingest a daily poison for mostly superficial causes. Yet, these deceitful and manipulative tobacco slogans have been distributed for almost a hundred years. This message was quite effective in that it produced a 300% increase in sales that year. Virginia Slims cigarettes have employed, ‘’It’s a woman thing,’’ to their cigarettes which feed women the idea that they should smoke just as much or more than men. Once more the silent competition or rivalry with men is slipped into the images associated with tobacco consumption. Virginia Slims also used ‘’You’ve come a long way, baby’’ to denote success and women empowerment and ‘’Find Your Voice’’ another absurd overstatement dwells on women’s empowerment once again[21]. The effect female consumers can have on sales is astounding and gathers the interest of not only tobacco industries, but a majority of other industries as well.

    By craftily taking advantage of the shifting attitudes in Turkish women towards smoking, Turkey has an even greater leverage to pull in new female smokers. As a country it need not even put in as much effort for tobacco advertising as the United States does, being that the use of tobacco has already long been established as part of their culture. Tobacco reached Turkey roughly in the 16th century and took hold immediately as a favorite past time, though primarily in men. Before the Turkish Revolution, the Ottoman Turks perfected methods of growing and using tobacco with Macedonian seeds imported from Greece[22]. ‘Hookah’ a multi-stemmed water pipe used for smoking, has been around for centuries and grew in popularity 500 years ago when it made its way to Turkey[23]. When tobacco has been engrained in the society’s culture for hundreds of years it becomes even harder to eliminate a traditional Turkish comfort. Both countries are re-introducing the concept of hookah smoking to women as a more enjoyable, social activity that feels like going back into time and enables them to taste sweet non-caloric flavors like cappuccino, peach and banana[24]. Because the hookah, what Turks also call ‘nargile’ or ‘shisha’ is an already prevalent and well known form of tobacco use amongst Turkish people, its resurgence as a popular activity throughout Eastern Europe was less of a marketing triumph on Turkey’s standpoint but more of a profitable utilization of the country’s traditional past and the younger generations’ eagerness to connect with their ancestral heritage[25].

    The US Surgeon General report of 2001 named advertisements as a primary influential factor in female smoking because of their recognition and success of taking advantage of women’s desires and playing with their notions of self-esteem. There is irony to be found that marketing advertisements and their counterpoint pro ban propaganda are both so successful, despite their opposing aims. Female adolescents are found to be extremely susceptible to marketing ploys and yet, they are also quite responsive to a lack of cigarette marketing[26]. Whatever advertisements feed or do not feed, young women act like sponges to media influence. A national study on the sales of cigarettes found that tobacco consumption experiences a 16% decline after a country enforces advertising bans[27]. What is most troubling though is how malleable the female market is when it comes to anything, as the studies prove.

    Role models and the media
    Another explanation for the differing smoking patterns among the female population of the United States and Turkey may have to do with none other than Hollywood. The rich and famous that set the trends, are celebrities who often have an influence on what direction the youth take by dictating what is ‘cool’. Young Americans look up to celebrities and the decrease of young American women smoking might be due to their healthier choice of role models.

    Role models are figures that children or even adults look up to or follow for guidance, especially through emulation of their particular social and moral behaviors. A role model does not necessarily engage in exemplary actions and can be idolized for an infinite array of reasons. One may take interest in studying the psychological reasoning behind a society, community or individual’s role model choices and find among other things, that there is an perverse propensity for human nature to be fascinated by role models of both ‘socially praised’ and ‘socially condemned’ behavior. While the title of a role model generally connotes morality and advancement, role models can earn their popularity through partaking in a hazardous or self-destructive act or lifestyle pattern, like smoking. Whatever the reasons behind this conflicting duality, there lies the answer to why women choose to emulate figures that encourage smoking and similar harmful behavior in some countries and not in others.

    In the past ten years, a health craze has set upon the American public. In supermarkets, all groceries, drinks and food products now broadcast in loud print antioxidant contents, heart benefits, cancer fighting ingredients and other health benefiting promises. The American population, spurred by an aging baby boomer population which hopes to never grow old, has demanded stricter government control over food and health products which in turn has led to industries devoted to better health. There is a sort of obsession with health in the United States now more than ever, and Hollywood has undoubtedly aided this. On television, singers offer personal healthy meal recommendations, longevity tonic recipes, exercise moves and detox regimens[28].

    The media is full of role models for adolescent girls. Adolescents are the most vulnerable age group of women towards not only tobacco, but other influences as well. At a certain age in which they are no longer under strict supervision by their parents, they still haven’t acquired sufficient wisdom and experience to make correct lifestyle choices. Reasonably, young women look to an outside person who is separate from their family and whom seems socially popular, in which case the media most conveniently presents itself with a menu of public figures. Magazines, television shows, films, fashion and music are only some of the main media outlets in which females tie their ideas, beliefs and aspirations.

    Smoking is the last thing a wise celebrity would want to bring up in a magazine or television interview, because not only is it portrayed as a ‘dirty’ habit in the United States but cigarette addiction habits have proved to be extremely detrimental to famous reputations. Celebrities take great care not to smoke in public in the United States, hiding their smoking habits or stopping altogether because of the inconsistency smoking presents with the image of healthy living considered so attractive particularly in California.

    This topic has achieved much attention in the film industry, and even stirred movie scripts and projects. Some motion pictures might have depicted the intensity of the American public’s attitude against tobacco use and television characters tossed their cigarettes away, implying that even the most fashionable, sexy women on television are done with tobacco. Such is not the case in Turkey, however, and besides a few celebrities coming out in public against cigarette smoking, Turkish pop culture and famous icons are drenched with a public image that promotes smoking when socializing. Female celebrities don’t have a social stigma against smoking to worry about so when a movie premiere interview begins they thoughtlessly light their cigarettes up. Resultantly, young women in the United States have a relatively higher chance of picking a role model that doesn’t publicly smoke than the young women in Turkey who don’t have to lift their heads twice to find a celebrity smoker.

    Turkey and US tobacco industry
    Tobacco companies have moved business away from developed countries since 1990 by increasing the shares of world cigarette production and consumption in developing countries. From 1980 to today, this share has increased from 50% to 70%[29]. Without change, consumption in developing countries is predicted to reach 71% by 2010, increasing from 4.2 million tons in 1999 to 5.09 million tons[30]. In addition to Turkey, countries such as the Dominican Republic, Indonesia and Mexico, tobacco industries are pressuring the government to block tax increases and marketing restrictions and support the tobacco markets in buying majority stakes. As a result, tobacco companies get away with fallacies and the public does not know any better to reject the misleading information that they are being fed[2]. As a matter of fact, 40% of the world’s population live in countries that do not prevent use of misleading packaging terms such as ‘’light’’ and ‘’low-tar’’ which are terms that do not reduce health risk but appear to[31].

    Not surprisingly, Turkish cigarette consumption rose 44% between the 1994 and 2000, and increased from 100 billion cigarettes a year to 121 billion in the year 2000. To further demonstrate Turkey’s alarming situation, from 1990 to 1999 Turkey was the second among countries with the highest growth in cigarette consumption, trailing behind Pakistan alone[32]. Turkey also harvested 261,809 metric tons of tobacco and claimed the sixth spot amongst the largest global tobacco producers in 1998. By that year, land devoted to tobacco cultivation increased by 66% in a span of thirteen years totaling at 725,000 acres[33]. All this growth signals an industry that is growing tremendously and shows no sign of stopping soon. Recently from 2001 to 2006 the tobacco market was noted to have increased at an annual rate of 3.7%[34]. This rapid growth in Turkey’s tobacco economy renders the country even more reliant on tobacco revenue.

    As Turkey becomes a contender in the global tobacco market, this would certainly not be a wise time to invest in the US tobacco business. Since 1982, the US Tobacco Production, Consumption, and Export Trends Congress Report shows that both cigarette consumption and cigarette exports have been decreasing and consequently, the industry has seen drops in almost every measured growth trend. The total number of cigarettes consumed declined from 640 billion in 1981 to 420 billion in 2002. Interestingly enough, the world has seen an increase in tobacco exports these past three decades with the single exception of the United States. US grown tobacco has been experiencing a decline since 1975 from 1.941 billion pounds to 1.121 billion pounds or 560,500 metric tons in 2001, exhibiting a 42% decrease. The US share in world exports has decreased from 27% in 1969 to 7% in 2002 as other countries’ tobacco industries like Turkey’s gain strength[35].

    The tobacco industries of both United States and Turkey are important in the scheme of the global economy, as well as in their own national interest. They manage multi-billion dollar businesses and their success ensures jobs for thousands of employees and their employers. As for the primary tobacco industry in Turkey, it is the sole manufacturer and distributor of all tobacco products in the country. Despite all the harmful effects of tobacco use, if one were to defend the tobacco industries and their hopes in dragging in more female consumers, one could draw on the economic importance of those invested in the industry professionally. Yet, even this would not be a convincing argument being that in the United States $97.6 billion is lost every year in productivity due to smoking and the annual public and private health care expenditures caused by smoking has amounted to $96.7 billion[36].

    The industries, themselves, are at the root of smoking prevalence and have been up against great opposition ever since the first General Surgeon’s Report in 1964 brought in a team of health experts to crush their influence. In light of this, tobacco users are not the only ones to blame. Tobacco industries consisting of teams of producers and manufacturers help indirectly kill 100,000 Turks and 400,000 Americans a year as a by product of their business[37]. Objectively speaking, the cigarette is a unique product on the market today in that in one aspect, it is unlike any other legally sold product. A cigarette is the only legally available consumer product that kills through normal use and so it is necessary to set restrictions on such a product being that it is still permitted[38]. There are, in fact, 599 government approved additives used for the manufacture of cigarettes that were kept secret for years by major tobacco companies[39].

    In visiting the websites of a major Turkish and American tobacco company some noticeable differences can easily be made. The Turkish website does not advertise any tobacco products, stating, ‘‘In accordance with the Act No 4207 on Prevention of Harmful Effects of Tobacco Products, we do not advertise our tobaccos and tobacco products.’’ The American website does contain several pages in which it flashes pictures of cigarette packs across the screen and claims no such restriction on its advertisements. Based on appearance alone, the Turkish company would appear to be more committed to its consumers’ health due to its web page background of green landscapes and healthy children. Both websites include a ‘Smoking and Health’ page. The Turkish ‘Smoking and Health’ website page speaks in a seemingly genuine and honest manner, showing a wish to stop smoking among younger generations as it willingly accepts all the facts regarding harmful effects of tobacco. It even goes as far as claiming membership in anti-smoking programs in Turkey. It is difficult to not remain skeptical, however, when names of anti-smoking programs or further information is lacking and what harmful effects of tobacco they admit to aren’t brought up in much detail. The font type is very casual and cheery, as is the background, and the attitude maintained throughout is one of nonchalance and even optimism at the notion of anti-smoking and smoking platforms working together within the Turkish community, though this is a seemingly contradictory idea. All this could easily give the impression that the tobacco company’s concern for smoker’s health is forced and not to be taken seriously[40]. Turning attention to the American website’s ‘Smoking and Health’ page, the blatant differences come into view here. The font of the writing is extremely small and hard to read and the background colors are a bland and unpleasant greenish grey tint, as if the web page designer wanted the reader to become frustrated with the font and nauseated by the color and stop reading. Nevertheless, the information provided on the American website is surprisingly in-depth. Lists of public health information, health links, surgeon general reports and organizational websites such as that of the American Heart Association, American Cancer Society and the CDC are given[41]. From the differences in the Turkish and American websites, one can assume that because the United States tobacco industries have been hit with so many law suits and public defamations over purposeful distortion of cigarette’s harmful effects in the past, there has been an increased pressure to lay everything out on the line very explicitly. In fact this has been a condition imposed upon the tobacco industry by the American government, as a compromise to outright banning the manufacture of cigarettes.

    MEASURES FOR PREVENTION
    Global approaches
    At this point what must be done lies in the hands of the government and the people, and their cooperative efforts in making a healthier population both at a national and global level. The strongest efforts of a solution are undoubtedly coming from collaborative global organizations like the World Health Organization (WHO) that has placed the United States and Turkey in the same boat and enabled them to work out their problems hand in hand. WHO has been instrumental on the front of tobacco prevention by uniting nations all over the globe and supporting two major projects: The Framework Convention on Tobacco Control (FCTC) and the Tobacco Free Initiative.

    The FCTC is an international project initiated in May 1995 at the 48th World Assembly that presents a treaty that countries can sign to promise allegiance to certain tobacco control measures. So far, there are 156 parties and 168 signatures. Turkey became a party member in April of 2004 and ratified the treaty in December of that same year. In May of 2004 the United States signed on to the FCTC, as well[42]. Affiliated countries are made aware and responsible for controlling the female targeted marketing of tobacco industries. The official FCTC publication updated in 2005 claimed in the preamble that all parties were to be alarmed of the increase in female tobacco and strive for ‘full participation at all levels of policy-making and implementation and the need for gender specific tobacco control strategies’. Purposes, obligations, objectives and measures are subsequently outlined in great detail to join the parties together on similar issues[43].

    The WHO MPOWER outlines six of the most effective policies that the US and Turkey are recommended to follow and they are: monitoring tobacco use and prevention, protecting people from passive smoking, offering help to those who wish to quit, warning people about the dangers of tobacco, enforcing bans on tobacco advertising, and raising taxes on tobacco products[44]. WHO MPOWER encourages countries to care about the rest of the world and not be narrow-minded in thinking that their own national interest is of sole importance. Through collaborative world progress, every country benefits and no one gets left behind. For this reason WHO stresses the importance of reaching out to developing countries that don’t have the resources to control tobacco related problems.

    National measures
    In both countries, a self-destructive disregard for one’s own health has become apparent through continued use of tobacco, revealing that information is simply not enough. Many specific national measures have been taken to reduce the use of tobacco products. Through taxation and price policies, aiming at people’s wallets has proven to be more of a deterrent strategy than disseminating information alone. For the United States, the Surgeon General Report of 1989 estimated every ten percent increase in cigarette prices to result in an average drop of 4.7 percent in the number of cigarettes demanded[45]. Many health organizations put pressure on governments to heavily tax tobacco products with a preventative motive in mind. The European Tobacco Control Report presents tables of annual price variations and tobacco taxation figures in EU countries, however Turkey was one of the few countries in which no information was available on these matters. Compared to other European countries and the United States there is an inadequate or inferior amount of data collection, recording and analysis to make parallel observations with Turkey. Turkey’s cigarettes have apparently experienced waves in total taxation incidence, or percentages of taxation in the retail price, though cigarettes still stand at a lower price than foreign brands. Much of the cigarette taxation in Turkey is influenced by other factors besides revenue such as inflation, natural disaster tolls and internal government changes. Domestic cigarettes purchases in Turkey are notably less expensive than those in the US and have even resulted in the transportation and underground reselling of products for illegal profits. Overall, more affordability is offered to Turkish smokers[3].

    Generally, the public norm is to smoke as one socializes in Turkey. For this norm to be changed there must be change in how one socializes. This includes not only the female smoking population but male population. Changing the social norms of Turkey starts from the ground up. In this case, the ground represents the foundation of smoking education provided for younger generations to dissuade their smoking inclinations, curiosity and misin- formation. Because habits are so hard to break, smokers keep at their habits despite a noticeable deterioration in their health. One needs all the weapons in an arsenal to combat this habit. There is a highly organized and thoroughly developed tobacco use prevention infrastructure and education system found in the United States where it was found if social influences are directly addressed, educational programs prevent the onset of smoking in up to 40% of adolescents[46].

    The European Tobacco Control Report of 2007 states that in Turkey there is no definitive education about the addiction and health hazards of tobacco use in schools, public awareness campaigns or counter advertising. This is a promoting factor for the Turkish smoking culture and appears as a great national blunder that despite all of the information on the harmful effects of tobacco and the reality of Turkey’s smoking reputation, children are not receiving definitive anti-smoking education. Perhaps Turkish government officials are afraid that educating the young will turn them against their smoking parents. The young are a profoundly positive influence on their parents. In the United States, many individuals have stopped because of the constant scolding they received by a son or daughter presenting them with the facts of the destructive habit of smoking. The prevention element in an effective anti-smoking program would minimize this difficulty. Although there is a general awareness of tobacco use’s harm, the extent of that harm is not widely known, ignorance has stubbornly adhered to the minds of those who do not wish to believe in that harm’s extent and knowledge is frequently limited and misconstrued.

    Yet, Turkey’s perspective on this is that at young ages in school-going children, exposure of any knowledge or images of smoking that may promote curiosity of tobacco should not be permitted. Instead, the hope that parents will abstain from smoking near their children with the avoidance of the topic altogether persists as a method for tobacco prevention for children. This type of outlook may reflect Turkish culture’s distaste of confrontation between generations. It would seem to fly in the face of respect for one’s elders, so much a part of Turkish norms. The idea that Turkish children will be able to avoid exposure to tobacco use in their daily lives better if it isn’t presented in the school curriculum, however is truly misguided. Perhaps in a utopian society, in which every single citizen can successfully hide their cigarettes, make every advertisement disappear, and every cigarette on the ground become invisible in the presence of a child, this method might work. Unfortunately, young children will be exposed to forms of tobacco one way or another. Even if their parents or teachers pretend tobacco doesn’t ‘exist’, the eyes of children cannot be shielded from the rest of the world. Non-confrontation has rarely been effective in alleviating troublesome issues, and thus if children are to see or hear anything tobacco related it should preferably be a message that is firmly anti-tobacco and provided through their education. Smokers will usually try their first cigarette and become addicted at school-going ages and thus this presents a major challenge in Turkey[47].

    As part of a solution, US anti-smoking programs are greater in number and are developed to a greater extent because of their head start, yet this does not undermine Turkey’s efforts to change. The National Tobacco Control Program (Ulusal Tütün Kontrol Programý), was first formed in 2005 with the clear objective of lessening Turkish reliance on tobacco products and improving the health of Turkish citizens with emphasis on the years spanning 2008 to 2012[48]. With 130 national counterparts and stakeholders participating in joint efforts, the program was presented to the Minister of Health for his approval and launched in the presence of the Turkish Prime Minister on December 12, 2007. Turkey has managed the Cigarette and Health National Committee (Sigara ve Saðlýk Ulusal Komitesi, SSUK) as well, which aims for a ‘united tobacco free world’ and holds a National Cigarettes and Health Congress since 1999[38]. As one of the prominent anti-smoking organization SSUK are one of the path pavers for a healthier Turkey that vows for change.

    The United States’ head start has enabled the country to reach all sorts of demographics that tackle issues on every front, while simultaneously empowering women with the hope of rejecting tobacco and the means for smoking cessation. The US Girl Scouts are an outstanding example of an organization that promotes a sense of well-being and confidence in young girls and regularly issues publications that inform girls of the hazards of tobacco use, the manipulative methods of tobacco advertisements, and tobacco use avoidance. Organizations affiliating themselves with all sorts of nationalities (The National Smoking Cessation Campaign for African American Women), religious groups (Young Women’s Christian Association), state specific organizations (State of Oregon Prevention and Education Program), and higher education and research foundations (the American Nurses Association) leave women with infinite ways of rejecting this harmful habit. Other United States programs emphasize the power younger generations have to direct the course of America’s future. Campaign for Tobacco Free Kids was firmly established with 130 organizational partners and arranges festivals, fairs and projects like the thirteenth annual Kick Butts Day on August of 2008. Additionally, it is trying to pass bills to grant the Food and Drugs Administration (FDA) more power in placing more restrictive laws on tobacco products. Over 630 groups have come out to support this legislation, which reveals just how vast and influential Campaign for Tobacco Free Kids has been and hopefully will continue to be[49]. The extensive list of programs have made it a top priority to combat tobacco issues for many years now and help provide an explanation to why the prevalence rates are what they are. Above everything, the United States has more financial means than Turkey to reach out to areas in need, thus they are greater global contributor as well, and able to supply money like the recent sum of 17 million dollars to developing countries in addition to their national tobacco preventative measures[50].

    Moreover, countries affiliated with the same organizations do not progress at an equal pace. Only 15 countries, representing 6% of the world population, mandate pictorial warnings that cover at least 30% of the principle area of cigarette packets[51]. Dozens of countries have implemented laws requiring health warning messages and demand they be of a certain size, font and location on the product to attract enough attention. Turkey is one of the countries that place large warnings on cigarette packs, while the US has one of the most disappointing health message warning criteria. Cigarettes in Turkey include on the front disturbing fact messages that are more direct and blunt than the US warnings such as, ‘’Smoking will slow blood flow and cause impotence’’ and ‘’Smoking can cause a slow and painful death.’’ Such warnings have an increased deterrent effect on smokers and create a reminder that every cigarette pulled from one’s packet is causing that warning message to occur. If the US were to take the next big move in decreasing smoking prevalence at a faster pace, it should implement stronger warning messages on cigarette packets.

    Not only the smoking population but non-smokers are affected through passive smoking. In passive smoking the second-hand smoke, also called environmental tobacco smoke, from another is inhaled by surrounding people. The risks associated with smoking like heart disease and cancer are the same for passive smokers and therefore smoking restrictions have been set nationwide through legislation of both of the countries[52]. In the US, smoking bans have been determined by state law and for this reason, the times that the bans were put into place vary from state to state. Yet the US took a much more rapid approach to the growing information on tobacco health hazards. The state of Arizona initiated a smoking ban in public places back in 1973, California followed in 1994 and so other states continued, while even enforcing stricter rules with time. For instance, in Hawaii state smoking is prohibited twenty feet from the entrance of a public building and the same goes for Washington State with its ban of twenty-five feet[53].

    Perhaps the high prevalence of smoking is now even more noticeable because of a newly implemented smoking ban of Law 5727 in Turkey forcing everyone to take their smoking outside or pay the price of 62 YTL[54]. The nationwide smoking ban in health, educational and public facilities in Turkey was brought into action on May 19 2008 and has become an increasingly hot topic in the country today[55]. The Turkish Prime Minister and Minister of Health were among the many that boldly pushed for this great public health step forward. On January 3, 2008 Turkey passed the Law 4207, which aims to shield vulnerable citizens like pregnant women, elderly, children and the ill from the detrimental effects of environmental smoking. This ban will affect bars and restaurants within the following year[56]. Although the smoking ban is new and therefore relatively undetermined in its state of effectiveness and level of public conformance, the country shares both a view of optimism in the prospects of a healthier future and a view of skepticism from those who perceive it as a change too radical and too unlike Turkey. Turkey is only minimally behind other European nations that have only just begun to strictly implement bans[57]. Yet the nation’s readiness to adhere to the ban is what sets their progress apart. The difference in public willingness to abide by a smoking ban is apparent between the US and Turkey. According to a poll in Turkey, four-fifths of Turks support the smoking ban, although a third of them express heavy doubts of its effectiveness[58]. Whether smoking directly underneath a doorway, puffing covertly out a window or carelessly walking in and out of a building with a cigarette, discrepancies have arose in the midst of this ban in Turkey that cast a shadow over the public health progress it purports to represent.

  • Top
  • Introduction
  • Conclusion
  • References
  • Conclusion
    There will always be groups of people that oppose progressive steps against tobacco use because of claims that other national and global issues require more attention. This reoccurring problem of how to evaluate the importance of different public health issues and appropriately distribute the available resources into that issue comes up often. Smoking need not be the most feared issue in the world for it to be taken seriously. If countries focus all their attention in one issue at the expenses of others the overall condition of a country may suffer. Times are changing and these two countries are changing with it but the condition of the public’s health must always be a priority. It is up to the governments to keep in mind their purpose by analyzing their national trends, implementing effective policies and maintaining a successful infrastructure against smoking.

    When making comparisons of tobacco use between the United States and Turkey, the prevalence rate trends are what truly reveal their progress. The United States is experiencing a decline and Turkey an incline in number of female smokers with every year. Turkish women are increasingly acquiring beneficial opportunities like education, with more reaching a status of the independent ‘Turkish Modern Woman’ than ever before. Unfortunately data shows that this independence correlates with increased female smoking rates. Tobacco industries are taking advantage of this cultural change and directing advertisements solely to women. Women in Turkey also feel the social pressure to smoke because of their culture, where as in the United States the current social norm promotes a healthier image of womanhood. Meanwhile the tobacco industry is growing in Turkey and the United States tobacco industries are losing market share. Making increasing strides in the effort to limit tobacco use brings hope to this situation. Global works like the FCTC founded by WHO provide the strongest anti-smoking efforts. Other national works like the US’s Campaign for Tobacco Free Kids and Turkey’s National Tobacco Control Program have done wonders and continue to pave the way to two healthier nations. In the future, there must also be strengthened efforts in protecting developing countries from the tobacco industries’ new found interest in them.

  • Top
  • Introduction
  • Conclusion
  • References
  • References

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