Tobacco policy in Israel: 1948–2014 and beyond

The recommendations are described below and summarized in Table 4. For each recommendation, we note if it was included in the National Tobacco Control Plan (NTCP), Healthy Israel 2020 (HI2020), the FCTC (with Article), or MPOWER (with appropriate letter underlined).

Though the NTCP was written with the hope of obtaining substantial funding, in practice this did not occur. Consequently, the actions to date have been concentrated on requirements and prohibitions, not accompanied by sufficient educational or enforcement measures (which require greater funding). This lack could be rectified by legislating that a small percentage of the billions of NIS (6.1 billion NIS in 2013) procured annually through tobacco taxation be funneled to tobacco control. To date, the Treasury has refused to consider this, as part of its economy-wide policy of opposing earmarked taxes. Another possibility would be to institute a “user fee” on the tobacco industry, such as was done by the U.S. Congress to fund the F.D.A Center for Tobacco Products.

The limited extent of the advertising restrictions, and the existence of tobacco promotion and sponsorship, represent a severe limitation of current Israeli tobacco control policy. Tobacco companies have increased their funding for marketing, advertising, and promotion substantially in recent years, from 37.6 million NIS in 2007 to 61.3 million NIS in 2012 [4], p72-.73). Internet advertising is restricted in the same manner as other advertising, with restrictions on advertisements aimed at youth, but the restrictions are not enforced. Newspaper advertising remains legal, and the ongoing promotion and sponsorship of tobacco products severely limit the effectiveness of tobacco control measures.

Significant educational effort requires extensive investment on part of the government, in terms of both money and expertise. Educational initiatives as well as resources may also originate in the voluntary sector, including the cancer associations and HMOs. In Israel, the Israel Cancer Association has taken an active role in educational efforts.

Data from European countries show that educational campaigns, which clearly explained that smoke-free legislation is intended to protect people against harm from exposure to secondhand smoke, can influence smokers’ support for tobacco control laws [46]. The fact that Israel’s smoke-free legislation is not well adhered to [47-49] may be partly attributable to the lack of media campaigns and other educational efforts accompanying the legislation. This lack is especially critical in view of the fact that over 60% of non-smoking Israelis are regularly exposed to tobacco smoke [15]. Particularly among the poorly educated, who have higher smoking rates [50], and less awareness of the dangers of smoking [51], knowledge imparted by educational efforts and media campaigns may increase support and cooperation with tobacco control policies.

In the absence of education regarding harm related to second hand smoke, and incomplete public compliance to no-smoking requirements, the need for effective enforcement is clear. Yet this also has not been given sufficient attention. Local authorities were found to implement incoherent and limited enforcement activity, while the municipal inspectors were found to be uncomfortable assigning high cost penalties [48]. Supporting these findings is the low number of fines given [4], implying a low level of law enforcement in areas which are legislated to be smoke-free but documented to have high levels of smokiness [47]. Indeed, the smoking ban’s enforcement by Israeli authorities has been so sparse that it prompted the Israeli Supreme Court to allow for “civil enforcement” of the ban, through private damage claimsⁱ.

Full realization of the Israeli smoking ban requires additional training of the ban’s enforcers, in order to increase the knowledge of inspectors regarding the hazards of second hand smoke, and to convince them that they are saving lives when they impose a fine [48]. In addition, intervention at the level of the Municipalities and monitoring inspector behavior could be helpful.

In 2013, a Smoking Prevention Division was established inside the MoH’s department for enforcement and supervision. Amongst other activities, the division is planning to train and educate local smoke-free inspectors on the importance of the proper application of their authority [4]. [pp. 62–63] However, the legislation to allow MoH employees themselves to enforce smoke-free laws has not yet been finalized.

Children are especially vulnerable to the hazardous effects of tobacco smoke exposure [1] and need special protection, whether in public or private spheres. Current laws against smoking in schools are not enforced, and teacher smoking rooms remain legal. There are no laws in Israel preventing smoking in cars carrying children, in spite of the high levels of tobacco smoke exposure in vehicles where smoking takes place [52,53]. Such laws have been recommended by major organizations, including the U.S. Environmental Protection Agency [54], the American Lung Organization, and the U.S. Institute of Medicine [55], and have been passed in places such as Ontario, Canada and Oregon, U.S. [56] Policies which protect children at home, in cars, in school, and in public places should be carefully considered, in light of the potential to protect future generations and the complexity of regulating the private sphere.

There are many alternative and emerging forms of tobacco and smoking around the world. Because the magnitude and scale of risk differs with different forms of use, some professionals argue that harm reduced products should be encouraged. Others maintain that abolition of tobacco is the most practical path to improved population health [57]. Snus, widely used in Sweden but banned from other European countries, is credited with very low levels of tobacco-caused disease in Sweden [58]. (p. 76, p.198) In recent years, electronic cigarettes (e-cigarettes) have dominated the harm reduction debate. The tobacco control and public health communities abroad and in Israel are divided as to whether e-cigarettes represent a less dangerous alternative to smoking, with the potential to save lives and improve health, or whether it will re-normalize and re-glamorize smoking, thus acting as a gateway to cigarette smoking, and ending decades of progress in tobacco control [59]. Though a complete picture of the short and long-term risks from e-cigarettes, including their potential effect on population-level smoking of combustible products, is unknown, the present data indicate that e-cigarettes are far less deadly than traditional combusted cigarettes [60].

In Israel, a wise policy for recreational use of electronic cigarettes would include: restrictions on advertising, marketing and promotion (including prohibition of e-cigarettes sales to minors and a complete ban on internet advertising); quality assurance; appropriate warnings (particularly so as to prevent deaths from ingestion of e-liquid, and clearly inform the public of known and unknown risks); and disclosure of ingredients. Policy should be reexamined as new information becomes available.

The current policy of an unrestricted electronic cigarette market (excluding for medicinal purposes) ensures that market forces, with capital gains as the primary endpoint, dominate the landscape. This will continue until the government takes strong policy action.

At present, there is no formal plan for scientifically evaluating the effectiveness of the NTCP or other tobacco control policies in Israel, nor are there dedicated funds for this or for core tobacco control research. A small amount of research has been conducted on assessment of the laws enacted, primarily by academic researchers [47-49]. The MoH does internally review progress on implementation of the plan, but this information is not available to the public. The annual report of the Health Minister is submitted to the Knesset and discussed there, but does not specifically address evaluation of the NTCP. Cigarette smoking behavior is currently monitored by the MoH with its Knowledge, Attitudes, and Behavior (KAP) survey. A stronger research plan would include monitoring of: all elements of the NTCP; use of tobacco in any form and smoking products, including electronic cigarettes; public opinion and social norms regarding tobacco and tobacco control policies; objective measurement of tobacco smoke exposure among Israelis; tobacco industry activities, and content of tobacco and smoking products. The Population Assessment of Tobacco and Health (PATH), which is being conducted in the US [61], is an important example of core tobacco control research. This type of research would carefully monitor changes in use of various tobacco and smoking products by the Israeli public, and identify areas for intervention.

The NTCP, while based on the important sources of tobacco control both within and without Israel, is a document based on information and challenges relevant at the time it was written. New issues – such as electronic cigarettes – have emerged since then; new information is available on the implementation and failure of some of the NTCP’s components; and innovative approaches to tobacco control, such as plain packaging in Australia, are being discussed and implemented elsewhere. “Endgame” scenarios, in which cigarette smoking and tobacco use is drastically reduced into a marginal activity by a small percentage of the population, largely through innovative regulatory actions, have received a fair amount of attention [62]. Some researchers have even called for abolition of smoking [57] to battle the enormous toll of tobacco on society. These issues need addressing now, and others will arise in the future. We recommend that a periodic review of novel approaches and issues be conducted, in light of tobacco control progress in Israel and elsewhere.