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A breath of fresh air
By JUDY SIEGEL-ITZKOVICH
25/01/2014
The US surgeon-general’s pioneering report declaring that tobacco smoking kills was issued exactly 50 years ago.
 
It was a complete turnover. After decades of claims by advertisers – along with physicians and journalists well-paid by tobacco companies – that cigarettes are “healthful” and “improve concentration,” US surgeon-general Dr. Luther Terry officially publicized exactly 50 years ago that smoking is linked to deadly diseases, especially lung cancer.

Added to direct harm from smoking, it was discovered later that secondhand exposure to others’ smoke was no less deadly and that smoking is addictive like heroin and cocaine. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service was a landmark document that changed perceptions around the world.

Nearly three dozen more major reports have been issued by the office of the surgeon- general – the highest-ranking doctor in the US – since January 1964, adding more tobacco-linked diseases to the list of bodily systems that can be harmed by smoking. They include stroke, age-related macular degeneration (a major cause of blindness), colorectal and liver cancer, type 2 diabetes, erectile dysfunction, rheumatoid arthritis and many more. Being exposed to toxic tobacco smoke can also weaken the immune system, worsen asthma and cause cleft lips and palates in fetuses.

Measures to restrict smoking in the US have saved an estimated eight million lives in that country over the past 50 years and contributed to longer life expectancies.

The smoking rate has dropped from nearly 50 percent of the population to around 18% in the US and about 20% in Israel.

About 100,000 lives have been saved in Israel, according to Amos Hausner, a leading lawyer, head of the Israel Council for the Prevention of Smoking and the architect of all smoking prevention legislation in the last 30 years.

On the dark side, smokers today have a much higher risk of developing lung cancer and nicotine addiction than those in the 1960s because of changes in the design and composition of cigarettes over time that the industry made more addictive.

Age of initiation is much younger today than in the 1960s. Children are still exposed to subliminal cigarette advertising on TV and online.

FORMER NEW York City mayor Michael Bloomberg – a self-made billionaire who took a hard line in favor of public health – prohibited smoking in restaurants and bars way back in 2002, and in 2011 in parks, beaches and many other outdoor spaces in his city. Most recently, he barred sale of tobacco to young people under the age of 21 instead of 18, which is still the minimum age in Israel. Although disparaged by tobacco companies as a “health dictator,” Bloomberg is credited with saving thousands of lives. For the first time, there are more former smokers in the US than current smokers. And some addicted to nicotine are using electronic cigarettes and non-combustible tobacco whose safety is not assured. The former mayor also contributed hundreds of millions of dollars from his personal resources, along with Bill and Melinda Gates, to smoking prevention in undeveloped countries.

Nearly 50 million Americans continue to burn some form of tobacco – cigarettes, pipes, cigars and hookahs – with much higher rates among the poor, the mentally ill, alcoholics, drug abusers and others.

Some 20 million Americans died during that half-century from active and passive smoking. Each year, an estimated 450,000 Americans and 10,000 Israelis die from tobacco-related diseases. The US wastes $280 billion and Israel tens of billions of shekels annually in direct medical costs and indirect losses to productivity from premature deaths.

Israel was among the first to pass legislation restricting smoking in workplaces and other public places as long ago as the early 1980s. One doesn’t suffer from secondhand smoke in elevators, cinemas, taxis, health-fund clinics, lecture halls or buses anymore. There is less smoke in wedding halls and restaurants. Israel voted for and then ratified in 2005 the World Health Organization’s 2003 Framework Convention on Tobacco Control along with 176 other countries, but it still hasn’t implemented many of its guidelines, including those that restrict contacts between lobbyists and politicians or state employees and require transparency and public disclosure of such contacts when allowed.

Nevertheless, although smoking rooms in workplaces and other public spaces are being outlawed and abandoned in most of the world, these still exist here – legitimizing smoking, exposing employees in smoking- only sections to health risks and circulating tobacco toxin into the rest of the buildings. No legislation anywhere in the world since 2003 has allowed smoking rooms in public places, said Hausner. It was he who successfully eliminated “smoking sections” in planes flying to and from Israel so airline staff would not be exposed against their will to passengers’ smoke.

“You can’t enforce a law when there is smoke around. The Health Ministry should get the public used to the idea that smoking rooms are passé. Then, and only then, will officials be able to make people understand that outdoor smoking should be banned because it is so dangerous. If some toxins exist legally indoors, the public will not be able to get the message that they are dangerous,” Hausner continued. “It would be relatively easy to get rid of them, as it can be done through secondary legislation.”

Smoking rooms, the lawyer said, “are ancient history. At the time of New York City mayor Rudolph Giuliani in the 1990s, when they were allowed, public places were full of smoke. Only when Michael Bloomberg took the matter seriously and completely banned smoking in all enclosed public places in New York did residents realize that smoking was harmful for all.

The Health Ministry here is currently abandoning hundreds and thousands of people who work in coffee shops, restaurants, pubs and the like and forcing them to serve customers in smoking rooms, risking their lives from secondhand smoke due to tobacco toxins.”

Nearly two years ago, the Health Ministry pushed through laws prohibiting smoking at railway (including Jerusalem’s Light Rail) stations and bus stops with a roof over them, but these are widely ignored because the ministry failed to issue regulations setting down sign requirements, and enforcement of laws is consistently minimal or nonexistent. Although the police were originally given responsibility for enforcement, they try to evade their legal duties, said Hausner in his recent complaint to the Justice Ministry, but he has not yet received an answer.

The municipalities can pocket NIS 1,000 per individual violator and NIS 5,000 per proprietor of public places that fail to ensure that the law is observed. Yet many bars and clubs remain full of smoke, and they post guards to alert owners and customers that an inspector has arrived. The current law allows giving them a fine only when violators are caught in the act, even if the place is full of smoke.

The law that prohibits the sale of cigarettes singly – which encourages children to smoke – is not enforced, and open, small packets can be found on display in kiosks around the country, without any real attempts at enforcement. Only since January 1 have vending machines easily accessible to children been outlawed, but some remain in public places.

A 2000 law that Hausner initiated requires the Health Ministry to issue an annual Smoking Report to the Knesset, which must hold a meeting to discuss the findings. One provision requires reporting on enforcement of smoking bans. Unfortunately, many city inspectors – who give parking tickets and examine food establishments as well – avoid giving out tickets. It’s easier to put a ticket under the windshield wiper on a car’s front window than to argue with a smoker irate over getting a NIS 1,000 fine for smoking illegally in a public place.

Another factor is that municipalities and their mayors want to avoid conflicts with owners of facilities. So when the health minister holds his annual press conference on the report, the list of fines per municipality is embarrassing. While Ra’anana, for example, excels, inspectors in the capital and largest city – Jerusalem – hand out only about three per day! Cigarette butts are regularly seen strewn on the pavement of the 23 light rail stations in both directions, testifying to the fact that the 130,000 daily passengers are exposed to illegal smoking while waiting for a train. No ticket has ever been handed out to any of them since the light rail began operating in the summer of 2011.

When this reporter formally requested to interview for this article an official in charge of enforcing the no-smoking laws in the city, the spokesman of Mayor Nir Barkat asked for questions in writing and then issued a complete refusal. This is surprising when the health-minded mayor is a marathon runner who jogs from his Beit Hakerem home to the municipality several times a week.

Wouldn’t it be logical for the municipality to hire more armed security guards who are present all along the light rail from 6 a.m. to midnight so they could give out NIS 1,000 fines to smokers at the stations – their salaries covered by this income within a short time? The mayor’s office rejected the idea.

ENFORCEMENT IS a weak link in anti-tobacco activities, and the Health Ministry knows it. Director-general Prof. Ronni Gamzu has in recent years become aware of the importance of disease prevention and health promotion. The health costs of treating tobacco-related diseases continue to mount up. A few months ago, he decided to give responsibility for promoting enforcement of no-smoking laws (which really belonged to no one in the ministry) to Mickey Arieli, a pharmacist who headed the unit fighting pharmaceutical crime.

The three-staffer office in Jerusalem’s Givat Shaul neighborhood was expanded into a branch of seven people responsible not only for fighting smuggling of counterfeit drugs but also promoting enforcement of no-smoking laws and preventing alcohol abuse and catching phony medical practitioners, along with preventing the use of dangerous medical equipment.

“Nobody really did these things before,” said Arieli.

Even though the municipalities and local authorities have been solely in charge, the new branch focuses on initiating enforcement of the no-smoking laws in public places such as restaurants, cafes, medical facilities, swimming pools, bus stations, workplaces and more. “This enforcement activity is being carried out in cooperation with many factors, including the police, local authorities, Customs Authority and others,” Arieli said in an interview with The Jerusalem Post.

The work, coordinated by newcomer Effie Schaeffer (who previously worked in food supervision in the Ramle district health office), has begun to hold seminars for and advise inspectors, raise awareness of tobacco damage, write recommendations and guidelines and deal with public complaints.

The WHO Framework Convention on Tobacco Control requires a total ban on tobacco advertising. The Israeli government approved such a ban in May 2011; it passed the first reading of the bill and was sent to the Knesset Economics Committee.

Yet this body showed itself to be heavily influenced by tobacco lobbyists. More than 70 countries have already completely banned tobacco advertising in newspapers and magazines.

“This is our problem today,” continued Arieli. The committee chairman, Labor MK Avishay Braverman, conducted the session on January 7. Many of the bill’s supporters referred to the committee session as a “farce.” The main speaker there was former deputy health minister Ya’acov Litzman, who is now only an opposition MK and not a member of the committee.

Litzman vigorously opposed the bill that he himself had initiated as deputy minister.

Gamzu, who came to speak, was attacked by MKs who defended the tobacco companies, and during the session the MKs were seen whispering with lobbyists for the tobacco industry and Hebrew newspapers. There was screaming and name-calling by opponents of the government bill, with Litzman taking a major role as he denounced Gamzu – whom he had appointed as director-general five years before. (The committee session can be observed at http://main.knesset.gov.il/Activity/ committees/Economics/Pages/CommitteeTVarchive.

aspx under January 7.) When Litzman, supported by Braverman and Likud MK Gila Gamliel, insisted that papers be allowed to continue to publish tobacco ads and place a few others (funded by tobacco companies) about the health dangers of smoking, Gamzu objected, explaining that the pro-tobacco ads legitimize smoking and that the government bill preventing pro-tobacco ads were of utmost importance. Litzman and Braverman called Gamzu “just a bureaucrat” who had to obey the decisions of legislators like them. The committee session, where defenders of tobacco tried to water down the ministry’s bill, ended without reaching a decision. The session will resume on January 29.

Gamzu told the Post that the enforcement of laws prohibiting smoking “has to be a multiple struggle, not only by the municipalities and the police but by public institutions as well. His office is promoting a bill that would give government workers the ability to fine violators. “We passed new laws and established the new branch. There are smoking-cessation courses in the basket of health services,” he said.

Still in shock over what he had seen in the committee, Arieli said he was worried that MKs were “concerned about economic aspects of tobacco rather than to health.” He added that the economic costs of treating tobacco-related diseases far outweighed the loss of advertising in newspapers.

Schaeffer urged residents to file complaints about still-existing cigarette vending machines, illegal smoking and other violations. “We don’t have inspectors all over, but we send warning letters and work with the police.” The best way is by emailing the branch at prevent@moh.health.

gov.il or calling the ministry’s information number *5400, called Kol Briut. The website section [www.health.gov.il/UnitsOffice/ HD/Enforcement_Monitoring/ Pages/default.aspx] is only in Hebrew so far but it’ll be expanded to English and other languages. We’ve received 70 or 80 complaints since we started in March,” he said.

“Gamzu’s determination should be appreciated,” Hausner said, “but we are behind most of the world. “He is well meaning, but he is ignoring other health advocates who want to help. The lobbyists for tobacco are very powerful, but the director-general doesn’t consult with his allies. We want to help him. We are nevertheless optimistic,” concluded Hausner, and added his prediction based on recent developments that “the days of organized tobacco throughout the world are numbered.”
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