Can Israel learn a lesson in smoking control from the US - the tobacco capital of the world?
By JUDY SIEGEL-ITZKOVICHcigarette butts 88(photo credit: )
When Mitch Zeller was an American kid in the 1960s, his arts and crafts teacher had the class make clay ashtrays as a gift for parents. "It wasn't even questioned; it was a normal thing," he marvels in retrospect. Zeller, a lawyer, is now one of the world's leading anti-smoking activists and - between 1994 and 2000 - was the US Food and Drug Administration's associate commissioner and director of its tobacco control office.
Now, while serving as a senior staffer at a Maryland-based consultancy company, Zeller travels the world to advise governments and anti-tobacco organizations on how to fight the tobacco industry. "After my family, tobacco control is my first love," he says.
Zeller came to Jerusalem last week at the initiative of Dr. Leah Rosen, the Health Ministry's National Coordinator for Healthy Israel 2020, which aims to set health targets for the population and realistic strategies to achieve them. One of the targets is the smoking rate, which has dipped a bit below 25% of the adult Israeli population. The Healthy Israel 2010 initiative is being conducted under the auspices of ministry associate director-general Dr. Boaz Lev and run by Dr. Leah Rosen and Dr. Elliot Rosenberg.
Because tobacco is the leading preventable cause of death, developing a national strategic plan for tobacco control is a key element in the program.
In the US, the percentage of people smoking was close to zero in 1900, peaked in the Sixties at almost a majority of the adult population and has dropped to 21% today. America's goal is to further reduce this to 12% by 2010, but this target, says Zeller, seems unrealistic.
It's difficult to push anti-smoking laws through Congress, state legislatures and city councils, but once they are passed, they are almost universally observed by Americans, even without the threat of fines. In Israel, however, where stringent laws are in effect, many smokers flout them and the local authorities almost universally fail to enforce them. Can America's experience be the basis for a comprehensive program to bring down Israel's smoking rate, which is around 25% among adult Israelis but 45% among men who complete their military service, and rising among young women?
Zeller - who lectured on the subject before three dozen policymakers, researchers and anti-smoking advocates from the government, Israel Defense Forces, non-profit organizations, hospitals and media - thinks it can, even though the two countries have different cultures.
ZELLER HAS plenty of experience - two decades of working in the regulatory, legislative and communications fields with federal health agencies on public health policy, including the treatment of tobacco dependence, and the regulation of tobacco products and pharmaceuticals. He has also published papers in several leading medical and public health journals. A graduate of Dartmouth College and American University-Washington College of Law, Zeller was chosen to travel to Moscow on behalf of then-president Bill Clinton to accept the World No Tobacco Day medal from the World Health Organization in recognition of the Clinton Administration's groundbreaking work on tobacco.
He clearly loathes the tobacco industry, which he regards as diabolical.
"There is no other product in the world that kills at least a third of its users," says Zeller. And, to his shame, most of the largest tobacco companies are based in the US. Because many of their customers have either died or stopped using their products, they are now targeting developing countries such as China, where 65% of adult males smoke. Philip Morris - the world's largest tobacco company - exports 320 billion cigarettes a year.
Over a billion people around the world smoke. An estimated 500 million adults and 250 million children now alive will die of tobacco-related causes. Each year in the US alone, 440,000 people - or 1,200 per day - die from smoking. Four thousand American children and teenagers - regarded by the tobacco industry as "replacement customers" - start smoking every day. In the 20th century, Zeller says, 100,000,000 people around the globe were killed by tobacco; in the 21st century, if current trends continue, the death toll will be 1,000,000,000.
TOBACCO ADDICTION makes people oblivious to the risks. According to surveys, 28% of American women smokers said they prefer to face the increased risks of cancer rather than gain two or three kilos after quitting. Some 50% of heart attack patients resume smoking after their coronary infarction, and 38% of hospitalized lung cancer patients start smoking again even before they are discharged. Zeller has also seen many a throat cancer patient sticking lit cigarettes into the hole in their neck (tracheostomy) after surgery.
The primary addictive component in tobacco is nicotine, the former FDA official continues. It was learned from informants and tobacco company documents released by court order that the manufacturers control the amount of nicotine by blending types of tobacco.
"The companies deal with hundreds of millions of tons in the form of one-ton 'hogsheads.' They shoot infrared light at each and in a split second can download the nicotine content into computer databases." The companies can thus plan ahead to deliver a specific amount of nicotine to satisfy the cravings of customers.
"The cigarette is deliberately designed to create and sustain addiction. Cigarettes are drug-delivery devices," says Zeller, who cites previously secret tobacco company documents going back as far as 40 years. The companies also add ammonia and other compounds to release more nicotine, similar to the addictive substances found in free-base cocaine; other additives mask nicotine's unpleasant taste .
So how can tobacco use be controlled? Zeller says with disappointment that due to high-pressure lobbying on the US government, it has not yet ratified the World Health Organization's Framework Convention on Tobacco Control (FCTC), which was passed by over 160 countries and ratified so far by 115 of them (including Israel). But the language of the FCTC is fuzzy enough to allow each country to interpret some clauses according to its own policies. Israel has not yet barred tobacco advertising in the print media and the Internet, or prohibited cigarette vending machines or duty-free sales.
Zeller, who has visited Japan twice in the past year, says the government there is the major stockholder in Japan Tobacco, and there is even a Tobacco Business Law. Anti-smoking legislation is thus not well-enforced, and tobacco interests rule tobacco control policies. Before her appointment as Japan's "anti-tobacco czar," a state official told Zeller she did not believe nicotine is addictive, even though this has been proven unequivocally.
The US Centers for Disease Control and Prevention (CDC) has set down its strategies to reduce tobacco use by keeping the young from starting; promoting cessation among smokers; raising taxes on products; fighting passive ("sidestream") smoking; identifying disparities in smoking habits such as those found among the poor and less educated; promoting educational and community programs; and improving enforcement. But studies have shown that focusing on only four - prevention of smoking in children and teenagers, helping smokers quit, smoke-free legislation and hiking the price of tobacco products through taxes - makes for a highly effective program.
Hard-hitting educational and media campaigns have been very successful in "denormalizing" smoking in the US, Zeller says. Some videoclips, for example, show young demonstrators depositing 1,200 body bags outside tobacco firms' corporate headquarters.
"This is countermarketing. Children and adolescents hate the idea of being manipulated, and when they learn what tobacco companies have done to target them, they get very angry and disgusted. Not smoking becomes 'cooler' than smoking."
Laws can be very effective, especially in countries where the population are law abiders. In hard-puffing Ireland, observers were amazed to see that strict no-smoking laws are being followed, even in the pubs. And studies show that once laws are enacted, even smokers overwhelmingly favor them: A survey of 1,000 Irish smokers found that 79% of those who quit credited the law, and 90% said the law helped them stay off cigarettes.
And Israel, which is now where the US was in the 1970s or 1980s as far as the smoking rate among men who complete military service, is reducing its smoking rate only gradually while some 11,000 Israelis die each year from tobacco.
Zeller said the FCTC requires that ratifying countries like Israel set up a centralized tobacco control office, preferably well-funded and located in the Health Ministry, to coordinate efforts. Asked later by The Jerusalem Post whether the ministry would establish such an office on its own, Lev said this would be difficult because the Treasury has opposed this due to the many millions of shekels in taxes on tobacco products it collects and because it fails to look at the long-term benefits in health, life and reduced medical costs. "Tobacco control is an evolutionary process," Lev declared.
The ministry does not have a sterling record in the battle against smoking. Several health ministers, including some recent ones, have been unabashed smokers. Most anti-smoking bills were introduced in the Knesset as private member's bills rather than as ministry-initiated legislation.
The Gillon Committee, appointed by then-health minister Shlomo Benizri in 1999 to consider the designation of tobacco and nicotine as "dangerous drugs" and propose ways to lower the smoking rate, heard witnesses for over a year, but six years later, committee chairman Judge Alon Gillon has still not presented his recommendations, and Health Minister Dan Naveh has broken several promises to get them issued.
Perhaps Mitch Zeller - a Jew with a daughter studying in Israel - would like to accept the rarely coveted post of health minister, now that Naveh seems set to resign by order of Likud chairman Binyamin Netanyahu.
