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The average Israeli doesn't like to get advice about anything from foreigners - and the same is usually true of government offices. But the Health Ministry's Healthy Israel 2020 project on preventing disease and promoting good health - headed by Dr. Leah Rosen and Dr. Eli Rosenberg - is keen on learning from everyone.
Aware that tobacco is the leading cause of preventible death - killing 10,000 Israelis a year - and that the smoking rate has remained steady at about 25% of the population despite strict (but often unenforced) no-smoking laws, they recently invited Prof. Paul McDonald, a smoking prevention expert at Ontario's University of Waterloo, to counsel senior ministry officials and outside experts. Although it was his first visit to Israel and he had to be briefed about the Israeli situation, including legislation and enforcement, McDonald quickly found his bearings and discussed his ideas in an interview with The Jerusalem Post.
Learning that Health Minister Ya'acov Ben-Yizri, 79, has been smoking two or three packs a day for six decades but has vowed not to do it in public, McDonald said: "I would tell him it's never too late to stop. Even at his age, it can add months or years to his life and improve his quality of life. It's important to set an example for children and young adults, especially as health minister." Hearing that Prime Minister Ehud Olmert is a longtime cigar smoker but tries not to get caught by a camera, the Canadian expert said it was "unfortunate, but at least he and the health minister don't do it in public."
As co-director of his university's Health Behavior Research Group and faculty member at the Department of Health Studies and Gerontology, McDonald has conducted numerous studies about smoking, including how to discourage youth from getting hooked and how to get longtime smokers unhooked, including telephone support and nicotine patches.
"I began as a clinical psychologist, interested in the relationship between mind and body, chronic pain, anxiety disorders, weight control and smoking cessation," he said. "I briefly did smoke at the age of 18 or 19," he confessed. "Like most of my peers in Canada, I started because my friends were smoking, and I wanted to fit in. I smoked for about a year and then decided it wasn't a smart thing to do. I was one of those lucky people able to stop by himself. You often hear about those who are very addicted, but not everyone is hooked on nicotine. There have been studies of genes that give certain people a greater predisposition to getting addicted to nicotine, but I have found that psychological and environmental influences - such as friends', spouses' and parents' behavior - are much more likely to determine whether people start or stop smoking."
THERE IS NO single magic solution to tobacco control, McDonald continued. In China, for example, the government owns the tobacco monopoly and takes in a great deal of income from cigarette sales, so it has little incentive to reduce smoking, he said. But he added that some ideas can be effective everywhere. "For example, take comprehensive warning labels to sensitize people to the dangers of smoking, or raising tobacco taxes, especially for young people, or a toll-free number that must be printed on the cigarette package and offers advice on how to quit."
Having heard that Israel has for years, even decades, had increasingly strict anti-smoking laws on the books but that they are widely disregarded, McDonald said: "I am learning more and more about local enforcement. Israelis don't understand the importance of the issue. If they think it is unlikely they will be punished for violating the law, they will ignore it. In Ireland, for example, when tobacco was outlawed in smoky pubs, the government made it clear it would enforce the law, and educated the public on why this was important.
"Every culture is unique, but public policy is a major tool we have. You have to find the right combination for each country."
One of McDonald's studies found that smokers who work where smoking is unrestricted (whatever the workers' educational and income levels) were 2.3 times more likely to be daily smokers than those who worked where smoking was totally banned. They were also more likely to kick the habit if smoking were completely barred on the job.
He liked this reporter's proposal for improving enforcement of the no-smoking laws in Israel (presented in person to the last four health ministers, but ignored because it would require new legislation): The government would issue a public tender for a private company that would send inspectors riding motorcycles/bikes around the country to reach offenders within a few minutes. The company would train its (young) employees about the smoking laws, give them badges and uniforms, and advertise a toll-free number in all the media. When a citizen observes someone smoking illegally, or illegal sales to minors or of individual cigarettes, he would call the toll-free number and give information anonymously, allowing the inspector to rush over, catch the violator in the act and issue a steep fine. The money would be divided between the company and a special fund for educating the public about smoking dangers and subsidizing smoking-cessation courses.
McDonald commented that this idea would make it more likely that a violator is caught and punished, and certainly he would be less likely to continue breaking the law.
RAISING TOBACCO taxes has triggered claims that it will lead to cigarette smuggling. "In Canada, taxes vary according to jurisdiction. Sometimes cigarettes cost twice as much as in nearby American states, and sometimes they're cheaper." The smuggling claims, insisted McDonald, "are largely propagated by the tobacco industry. In Canada, we were told that higher taxes lead to smuggling, but we took the tobacco industry to court. It turned out that the industry was doing the smuggling; they wanted it to become a problem. When it became clear that the industry was behind it, we were able to raise taxes."
McDonald criticizes the US government for being among the minority of countries that hasn't ratified the World Health Organization Framework Convention on Tobacco Control (FCTC), which sets down a long list of restrictions on tobacco, including the barring of advertising in the print media, cigarette vending machines and duty-free sales.
"Unfortunately, there are connections between the tobacco manufacturing/grower industry and politicians. They contribute huge amounts to political campaigns and have many powerful shareholders. It's like opponents to gun control. Failure to ratify the FCTC will make the US the laughingstock of the world unless it realizes it is being left behind."
As for enforcement of tobacco policies, he said Canada is very good, better than the US, "which is a bit of a patchwork. Many parts of Europe have recently come on board. India has a huge population with great variations, but has made tremendous strides in five years, and smoking rates there have come down very significantly."
Since December, 2000, Canadian cigarette smokers have been encountering the world's largest and most graphic warning labels. The labels cover half of the principal display surface - both front and back - of tobacco packages. Many include vivid photographs of some of the ravaging consequences of smoking.
Among the text warnings are: "Studies have shown that tobacco can be harder to quit than heroin or cocaine," "Cigarettes may cause sexual impotence due to decreased blood flow to the penis; this can prevent you from having an erection"; "Your children are twice as likely to smoke if you do; half of all premature deaths among life-long smokers result from tobacco use"; "Tobacco use during pregnancy reduces the growth of babies during pregnancy. These smaller babies may not catch up in growth after birth, and the risks of infant illness, disability and death are increased"; "Second-hand smoke contains carbon monoxide, ammonia, formaldehyde, benzoapyrene and nitrosamine, which can harm your children"; and "Tobacco smoke can cause the arteries in your brain to clog; this can block the blood vessels and cause a stroke, disability and death."
A STUDY conducted at the University of Waterloo examined whether the new labels are more noticeable and salient, whether high school pupils thought more about the consequences of smoking because of them, if youngsters' beliefs about the dangers of smoking changed, and if smoking rates have declined as a result.
"There are very clear data around the world that such warnings increase knowledge about risks and translate into action. Smokers exposed to them are much more likely to try to stop," McDonald added.
The Canadian warning labels have set the standard throughout the world, persuading Brazil to come out with similar graphic warning labels and Australia, the European Union and Thailand, among others, to plan their own versions. Israel has no graphics and fairly low-key warnings that do not cover as much space as in Canada.
McDonald advocates the prohibition of tobacco ads in newspapers. "This will make a huge difference, as ads are one of their principle means to promote smoking. It is absolute nonsense that billions of dollars are spent around the world merely to get smokers to switch from one brand to another." The Canadian said he advocates using a six-item smoker assessment tool to help those who want to quit determine what they need - printed materials, medications or support groups. "Those with a high level of nicotine dependence and those prone to depression, for example, need special help. People with high levels of social support and a lot of self confidence and determination need less. We have found that smokers who are prone to depression or anxiety during the first four weeks will struggle more than those who are free of these emotional problems."
Healthy Israel 2020 co-director Rosen, who invited McDonald to come after hearing him speak abroad, commented: "He discussed ways to deal with issues that we struggle with day in and day out.We want to build strategies on the basis of evidence, and since we don't have enough Israeli data - Israeli universities, especially schools of public health, have been slow to produce them - we will have to depend on strategies and tactics that have worked around the world. And when we find those that have failed, we can learn from them too.
"We we want to decide on our goals and objectives on the basis of what's causing the most disease and death and harming the quality of life. Once objectives are set on the basis of burden, we will identify evidence-based strategies. Paul has given us tools to help decide among these strategies. He has shown us, for example, that knocking down the average age of quitting from 50 to 40 can double the extra years of life gained," Rosen said. "And even though self-help books for smokers are less effective than nicotine patches, he has helped us realize that using them can reach many more people and thus benefit more with a limited budget to spend. He discussed under what circumstances population-based approaches to prevention and promotion are preferable to individual-based approaches. He also addressed the issue of inequalities and suggested a way to quantify decreasing inequalities in our society."