Environmental tobacco smoke (ETS) is a mixture of solid particles and gases containing toxic chemicals, including oxidative gases, heavy metals, cyanide, formaldehyde, and nicotine. In adults, exposure to ETS increases the risk of lung cancer, ischemic heart disease, and asthma. In children and fetuses, exposure to ETS is causally associated with a wide range of developmental and respiratory effects, including low birthweight, sudden infant death syndrome, lower respiratory tract infections, middle ear infections, symptoms of upper respiratory tract irritation, slight reductions in lung function, asthma, lifelong cardiovascular effects, type 2 diabetes, and obesity(2). The International Agency for Research on Cancer (IARC) has classified ETS as carcinogenic to humans. There is sufficient evidence that ETS causes lung cancer and suggestive evidence that ETS may increase the risk of breast cancer, nasal sinus cavity cancer, and nasopharyngeal cancer in adults; and the risk of leukemia, lymphoma, and brain tumors in children(10).
Policy and Regulations
Smoking is prohibited in Israel in most closed public places, including hospitals, trains and buses, restaurants, pubs, places of worship, and all government buildings, as well as in some open spaces, including swimming pools, railway platforms, and 75% of outdoor areas in pubs, restaurants, and wedding halls. New regulations from 2014 stipulate that smoking in sports stadiums is restricted to designated areas of no more than a third of the entire seating area. As of February 2016, all schools, universities, and student dormitories are required to be entirely smoke-free, including the perimeters of schools.
There are significant gaps in regulations to reduce public exposure to ETS. Pubs are allowed to set aside a quarter of their space for smokers, as long as it is in a separate room. Smoking is permitted in most private offices and non-governmental buildings, as well as in open and semiopen public spaces, such as gardens, museums, and zoos. Designated smoking areas are still permitted in universities, train stations, and other public places such as banks, post offices, and the Israeli parliament. The prohibitions on smoking in public places do not apply to new tobacco products, such as electronic cigarettes. Proposed legislation restricting smoking in playgrounds and in cars in the presence of children under the age of 16 was not approved by the Ministerial Committee on Legislation. The Ministry of Health (MoH) is currently developing legislation to restrict smoking in playgrounds, outdoor areas of cafés, and zoos, and to extend the restrictions on advertising and smoking in public places to electronic cigarettes.
Data on Exposure to Environmental Tobacco Smoke in Israel
Despite extensive legislation to prevent exposure of the non-smoking population to ETS, data from surveys show that most of the Israeli population is exposed to ETS. In a national survey of students in 2015-2016 (National Health and Nutrition Survey in Adolescents, Young MABAT), over 50% of high school students reported that others smoke near them in recreational areas, and over 30% reported that others smoke near them in school (Figure 1)(6).
In an effort to assess ETS exposure, data from questionnaires and urine samples were collected in the 2015-2016 National Health and Nutrition Survey (Rav-MABAT), which included 100 children ages 2-12, but results have not yet been published. According to MoH data published in 2014, 25% of Jewish infants and 52% of Arab infants are exposed to ETS at two months of age, probably by parents and relatives who smoke.
In addition to data from national surveys, there is sporadic data on the exposure of several populations to ETS. Self-reported exposure to ETS among non-smoking Arab women was high among women with acute coronary heart disease (92%) and in the control group (53%)(1). In a survey of medical, dental, and pharmacy students, and employees of the School of Pharmacy at the Hebrew University Hadassah Medical School at the Ein Kerem campus in Jerusalem, 60.2% of non-smokers reported exposure to a smoky environment at least once a week(3).
Data on Health Effects of Exposure to Environmental Tobacco Smoke in Israel
- Researchers at the MoH and the Hebrew University-Hadassah Braun School of Public Health and Community Medicine reported that exposure to polycyclic aromatic hydrocarbons (PAHs) was high among non-smokers exposed to ETS(9).
- Researchers from Tel Aviv University are currently conducting research on the use of measures of tobacco smoke in air and nicotine in children’s hair to persuade parents to adopt smoke-free homes and thus reduce the harm to children from tobacco smoke in the home. A study based on in-depth interviews with parents of young children in families of smokers in central Israel showed that non-invasive biomarker testing of children was acceptable from the parents’ perspective, and that such testing is a promising tool for educating, counseling, and motivating parents to protect their children from ETS(11).
- Urine samples were collected from 100 children and 200 adults who participated in the 2015-2016 National Health and Nutrition Survey (Rav-MABAT), and an analysis of the urinary cotinine levels of the samples is underway. Estimates of exposure to ETS based on urinary cotinine measurements will be compared to estimates of self-reported exposure to ETS, based on the data collected in a questionnaire as part of the survey.
- Researchers from the Hebrew University-Hadassah Braun School of Public Health and Community Medicine and Assaf Harofeh Medical Center analyzed urinary cotinine levels in children treated in the emergency department in order to compare exposure to ETS in children with respiratory symptoms, to exposure in the control group. Preliminary results indicate exposure to ETS among most children in the study.
Progress Since 2014
In Environmental Health in Israel 2014, the major challenges to the reduction of public exposure to ETS in Israel included enforcement of legislation prohibiting smoking in public places and protection of children from exposure to ETS in schools. Additional challenges included the need to minimize gaps in national data on the prevalence of asthma in children, and in biomonitoring data on exposure to ETS.
Significant progress has been made in protecting children from exposure to ETS in schools. Since February 2016, schools are required to be smoke-free. Some progress has been made in collecting national data on the prevalence of asthma and in collecting human biomonitoring data. Analysis of urinary cotinine levels in children is underway as part of the 2015-2016 National Health and Nutrition Survey (Rav-MABAT).
Some progress has been made toward developing analytical techniques to measure urinary cotinine levels at the Public Health Services Laboratory at the MoH. There has been little or no progress toward other goals.
The most significant challenge in reducing public exposure to ETS in Israel is the fact that over 20% of the adult population smokes (22.7% according to the 2016-2017 Survey on Physical Activity Among Israeli Citizens)(7,8). After decades of steady decline, smoking rates have increased among Jewish and Arab men since 2013. There is a critical need to shape social norms to deter smoking.
Enforcement of legislation prohibiting smoking in public places continues to be a major challenge. The prohibition of smoking on school grounds is not enforced and there is no legal requirement to place “No Smoking” signs in schools. The 2015 Ministry of Health Report on Smoking highlights the ongoing failure of local authorities to enforce the law prohibiting smoking in public places(7). The MoH established a new department in 2013 to advance enforcement of anti- smoking laws by local authorities, to conduct inspections in public places, and to ensure that specific public complaints receive attention by the authorities. Local authorities are required to submit an annual report to the MoH on fines issued for smoking in public places, yet the vast majority of municipalities fail to do so.
In 2016, Israel Railways was required to pay NIS 6 million in a class action suit for failure to enforce the smoking ban on train platforms.
This chapter and all other chapters in the report was written by a team of scientists and professionals from the Ministry of Health, in collaboration with Environment and Health Fund.
(1) Awawdi, K., Steiner, H., Green, M. S., & Zelber-Sagi, S. (2016). Association between second-hand smoking and acute coronary heart disease among Arab women with multiple risk factors. The European Journal of Public Health, 26(1), 141-145. https://doi.org/10.1093/eurpub/ckv143
(2) Centers for Disease Control and Prevention (updated 2017). Health effects of secondhand smoke. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/ (retrieved May 2017).
(3) Feldman, I., Donchin, M., & Levine, H. (2016). A smoke-free medical campus in Jerusalem: Data for action. Israel Journal of Health Policy Research, 5, 20. https://doi.org/10.1186/s13584-016-0080-9
(4) Ginsberg, G. M., & Geva, H. (2014). The burden of smoking in Israel-attributable mortality and costs (2014). Israel Journal of Health Policy Research, 3, 28. https://doi.org/10.1186/2045-4015-3-28
(5) Israel Center for Disease Control, Israel Ministry of Health. Israel National Health Interview Survey (INHIS-3), 2013-2015 (Hebrew). http://www.health.gov.il/PublicationsFiles/INHIS_3main_findings.pdf (retrieved November 2017).
(6) Israel Center for Disease Control, Israel Ministry of Health. National Nutrition and Health State Survey for 7th-12th graders, 2015-2016, (Young MABAT 2) (Hebrew). https://www.health.gov.il/PublicationsFiles/mabat_youth_2015_2016.pdf (retrieved November 2017).
(7) Israel Ministry of Health (2016). Minister of health's report on smoking in Israel, 2015 (Hebrew). http://www.health.gov.il/PublicationsFiles/smoking_2015.pdf (retrieved November 2017).
(8) Israel Ministry of Health (2017). Minister of health's report on smoking in Israel, 2016 (Hebrew). https://www.health.gov.il/PublicationsFiles/smoking_2016.pdf (retrieved November 2017).
(9) Levine, H., Berman, T., Goldsmith, R., G צen, T., Spungen, J., Novack, L., ...Grotto, I. (2015). Urinary concentrations of polycyclic aromatic hydrocarbons in Israeli adults: Demographic and life-style predictors. International Journal of Hygiene and Environmental Health, 218(1), 123-31. https://doi.org/10.1016/j.ijheh.2014.09.004
(10) National Cancer Institute (updated 2011). Second hand smoke and cancer. https://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco/second-hand-smoke-fact-sheet (retrieved May 2017).
(11) Rosen, L., & Kostjukovsky, I. (2015). Parental risk perceptions of child exposure to tobacco smoke. BMC Public Health, 15, 90. https://doi.org/10.1186/s12889-015-1434-x