Yearning to breathe free

There was no smoking outside the doors of the Tel Aviv University hall during the coffee and tea breaks – one would hardly be expected to light up while attending the country’s first academic conference on “Tobacco or Health.” But is a not-too-distant future when outside every conference hall, in any vehicle, on any street or even in any home, no one smokes an achievable dream? If so, it would be an about-face from the time when, a quarter of a century ago, I had to suffer the constant smoke from a newsroom colleague just a meter from my cubicle.

Or when, eight months pregnant, I was ejected from a Knesset committee meeting by an MK sitting in front of me after I politely asked – twice – if he would put out his cigarette.

Today, we are in a new era. Perhaps we can revert beyond the time, over a century ago, when physicians stared with amazement at a rare patient with tumor-filled, tar-encrusted, nicotine-tinted lungs. The onus today is not only on the smoker to observe the law but on the owner of the premises to enforce it.

The right of the citizen to breathe clean air is a given, while even the government has realized that slashing the costs of treating victims of tobacco offsets losses in tax income.

The adult smoking rate has dropped from 45 percent a generation or two ago to 20.6%, and a target of 10% doesn’t seem imaginary anymore.

It is inevitable that “the days of organized tobacco around the world are numbered” as exemplified by the declaration of the government of New Zealand, which will be completely-smoke free by 2025 along with a growing number of other countries, said long-time smoking-prevention lawyer Amos Hausner, the head of the Israel Council for the Prevention of Smoking, who personally masterminded most of the country’s nosmoking legislation.

Hausner, the son of Gideon Hausner – Israel’s late attorney-general and prosecutor of Nazi arch-murderer Adolf Eichmann – referred to the phrase “banality of evil.” He said that this phrase was wrongfully used in connection with the Nazis, but could however be used to describe an industry that knowingly kills half its customers, amounting to some 5.7 million people a year.

“Unlike the Nazis, who were motivated by hate, anti-Semitism and vicious racism, the tobacco companies are motivated by greed,” he said. They continue to make and market them aggressively. In addition to suing the conglomerates for the damage they caused, it is also appropriate that companies and individuals be tried for “homicide,” said Hausner.

Just as pre-Civil War America never dreamed slavery would be abolished within a few years, he continued in his TAU address, “we are in the midst of an irreversible process that will lead to the termination of organized tobacco. The environment will be tobacco-free. This is what people all over the world want.”

“We are working to make smoking history in this country,” said conference initiator Dr.

Leah Rosen of the department of health promotion at TAU’s Sackler Faculty of Medicine’s School of Public Health. But the country’s decisionmakers may not know what the public wants. She and her colleagues conducted a survey in 2010 not only on what Israelis want by way of smoking legislation but also what decisionmakers think the people want.

“If they read the [Hebrew] papers, they may think the people don’t care about secondhand [sidestream] smoke. The newspapers published negative publicity about recent anti-smoking legislation,” she said.

By contrast, it should be noted that The Jerusalem Post has for many years refused to accept tobacco advertising; in the Hebrew press, dependency on this advertising unavoidably affects the scope and the nature of the coverage of the smoking issue.

Rosen asked both decisionmakers and a randomized sample of adults whether they favored or opposed prohibiting smoking in lobbies and stairways of apartment buildings, private cars with child passengers, the entrances to healthcare facilities, train platforms, bars and pubs, open areas on college campuses, beaches, outdoor pools and the like.

The vast majority of Israelis (including many smokers) favored smoking bans outside medical facilities, in vehicles carrying children and even at bars and pubs. Eighty percent wanted their apartment buildings’ common areas smoke-free. The figure was lower for college campuses (where such prohibitions are growing in the US). But in every case, policymakers underestimated the public desire for smoke-free environments, said Rosen.

Israel Cancer Association director-general Miri Ziv, who has been with the organization for the past 30 years, said that even though enforcement of laws is still inadequate, “we were among the first 10 countries in the world to pass legislation against smoking in public places. We have attained tangible achievements, but we still have to eradicate smoking.”

HE IS a practicing Catholic of Irish origin, but Prof. Gregory Connolly – a leading Harvard University School of Public Health observer of the tobacco industry and how to minimize smoking – finds himself visiting Israel regularly to give advice. Originally a dentist, Connolly worked for years as head of the Massachusetts Tobacco Control Program, cutting the number of smokers by a third and tobacco consumption by a half.

Every year, over five million people around the globe are killed by tobacco, he said. If significant action is not taken, the figure could rise to eight million by 2030, and even a billion people in the whole 21st century, as the conglomerates shift their merchandising to the Third World, which is too weak to fight back.

“Today, four large tobacco companies control 90 percent of the world’s tobacco sales.

It’s hard for governments to deal with them,” Connolly said, “as they have a lot of power. They have bought into other industries...

My pension fund at Harvard is heavily invested in Philip Morris, the world’s largest tobacco company. One year’s tobacco profit is equal to the gross domestic product of a trillion people at the poverty line.”

While Israel’s Dubek company used to rule the local market, this has changed, with Philip Morris now number one in this country, Connally revealed.

“Israeli smokers are controlled by foreign industry. The money goes to the US, Britain, China and Japan. Whoever owns Marlboro Country control the lungs of young people around the world.”

Philip Morris, he continued, “targets young people and women, producing a pellet that the customer crushes to release menthol; it is claimed to be ‘lighter,’ as it is easier to inhale. Customers are hooked on tobacco more easily. This type of cigarette is marketed in Israel and all over Western Europe and Asia.”

Marlboro Gold cigarettes are sold with an image of being “good and safe.” Marlboro Black, with heavy nicotine content, are handed out outside military bases inducting new draftees. Cheap L&Ms are sold in Russia, with immigrants to Israel bringing them along. Smokers in countries with strict nosmoking laws that have to rush outside for their “smoking breaks” are lured by short, high-nicotine cigarettes that give them their nicotine fix quickly, Connally said.

The Harvard expert added that tobacco companies file complaints against limitations that “hurt company freedom” and “compromise intellectual property.” The World Trade Organization, which coordinates the rules of trade between nations, pushes for lower tariffs, he said, “and WTO boards decide things even though they have very little expertise. Tobacco companies complain to the WTO, and under bilateral treaties, try to prevent enactment of national tobacco control policies.”

Connolly added that while Philip Morris earned $54 million last year from its tobacco sales in Israel, the country spent billions of shekels to treat victims of tobacco-related diseases. The direct and indirect expenses to Israel reach NIS 48 per pack compared to the NIS 17 per pack that the companies earn.

The average tobacco company, he continued, earns as much as NIS 10,000 for each Israeli smoker from the time he first lights up until he dies from smoking its products.

“Israel has sovereignty. Fight for it. Don’t let large multinational corporations that devalue human life determine your health policies. There is no silver bullet, but raise tobacco taxes and save lives. Prohibit smoking throughout schools,” advised Connolly.

“Kids must not see their teachers smoke.

They’re a bad example.”

Nearby Cyprus has been known for its high smoking rates, especially among men, and with alarmingly increasing rates among women. But two years ago, the country implemented legislation to bar smoking in public places. Prof. Costas Christophi, an expert in epidemiology and occupational health at the Cyprus University of Technology (who also teaches at Connolly’s School of Public Health at Harvard) came to the Tel Aviv conference to describe progress.

His studies compared particulate matter associated with secondhand smoking, affecting employees in hotels and restaurants before and after the implementation of laws – and found a dramatic improvement.

“We conclude that smoke-free legislation, when enforced, is highly effective in improving the air quality. You need a strong political will, with active enforcement of the authorities and public support of the laws.

Even in nations with high smoking prevalence, laws can be effectively implemented and have no negative effect on accommodation, food and beverage services,” the Cypriot concluded.

Cotinine – a chemical in urine, blood and saliva that indicates exposure to nicotine – was tested in the urine of Israeli adults in a study headed by Health Ministry chief toxicologist Dr. Tamar Berman. Her team found that the cotinine levels of non-smokers was significant, even though they they themselves did not light up. The conclusion was that secondhand smoking was a serious threat, making it clear that laws to protect non-smokers were very important.

Facebook and other social networks, said Haim Geva-Haspil, in charge of the ministry’s health education and promotion effort for the the struggle against smoking, is rife with smoking subjects – both negative and positive. The tobacco companies use them to market their products and promote games, parties and raffles. But the other side, usually not those in the establishment, use it so fight smoking, especially by complaining about violations of no-smoking laws and demanding enforcement by the authorities.

With new laws, tobacco promotion will be barred from Israeli websites, the ministry official said, but foreign sites cannot be touched. The ministry official promised to set up a website to accept complaints related to smoking violations and even giving locations via GPS so establishments are fined.

Ministry director-general Prof. Ronni Gamzu said: “We are in a battle. We have to be more sophisticated and determined.”

He conceded that the ministry’s handling of smoking issues was not always adequate, as its failure to push through vigorous changes via the Allon Gillon committee to reduce smoking; despite commitments to the highest court, it never even produced its promised report of recommendations.

Cigarette vending machines will finally be banned in 2014 (as implementation was postponed for two years under pressure from owners); laws will be interpreted more broadly to increase restrictions. Gamzu said that after moving from director of Ichilov Hospital to his current post two years ago, he had no idea how difficult tobacco lobbying was to overcome.

“Tobacco advertising in the [Hebrew] newspapers constitutes more than 2% of their advertising income. I tell them to advertise other things instead. We won’t give up. Forcing tobacco companies to use only plain packets without logos will come too.

But we can’t do it alone. We need help from the four health funds and others.”