The adverse effects of environmental tobacco smoke (ETS) mirror those associated with active smoking. For example, in adults ETS increases the risk of lung cancer and heart disease. In young children, exposure to ETS increases the risk of sudden infant death syndrome, asthma, bronchitis, and pneumonia.
In Israel today, smoking is prohibited in most closed public places, including hospitals, trains, public pools, restaurants, bars and pubs, places of worship, and all government buildings. However, under the current law, bars and pubs are allowed to set aside a quarter of their space for smokers, as long as it is in a separate room, and smoking is permitted in private offices and in most open spaces. The Ministry of Health (MoH) is currently developing legislation that would extend the ban on smoking in public places to electronic cigarettes and nargilehs, allow the MoH to authorize inspectors to enforce the law, and extend the current prohibition on smoking in public places to include stadiums, public parks, and other open spaces.
Exposure to Environmental Tobacco Smoke in Israel
Despite extensive legislation to prevent exposure of the non-smoking population to ETS, data show that most of the Israeli population is indeed exposed to ETS. According to the 2010 Israel Central Bureau of Statistics Social Survey, 71.3% of non-smokers aged 20-74 reported that they had been exposed to ETS during the last month, with 17.9% reporting a high level of exposure. In a representative survey of Israeli adults (N=505) in 2010, 80.2% reported exposure to ETS, and 33.9% reported daily exposure. In a national survey in 2008 of over 11,000 adolescents, 20.5 % reported that only their father smoked at home, 5.3% reported that only their mother smoked at home, and 6.2% reported that one or more of their siblings smoked at home. Overall, 13.8% reported that more than one family member smoked, including both parents (11.3%), and 3.9% reported that all family members smoked.
Biomonitoring data (urinary cotinine concentrations) from 2011 also indicate widespread exposure to ETS in the adult population in Israel. In a study by the MoH, 62.2% of non-smokers had levels equal to or above the level of quantification (LOQ). Proportions equal or above the LOQ were significantly higher for males compared to females, for subjects with lower levels of education, and in the younger age group.
Based on MoH data on infant exposure to smoking, published in 2014, 25% of Jewish infants and 52% of Arab infants are exposed to ETS at two months of age.
Figure 1: Exposure to ETS at Age 2 Months
Data on Health Effects of Environmental Tobacco Smoke in Israel
There are limited data in Israel on the health effects of exposure to ETS. Data from 2008 show that incidence of atopic eczema or allergic rhinitis in children ages 13–14 was not affected by smoking by at least one family member. However, asthma was higher in children who had a parent who smoked (Figure 2).
Figure 2: Self-Reported Asthma in Children Age 13–14, by Parental Smoking
In a study on asthma prevalence in Israeli-born children of Ethiopian origin, households reporting parental smoking had a higher asthma rate compared to households that were smoke-free.
Research on Exposure to Environmental Tobacco Smoke in Israel
- Researchers at the Technion Center of Excellence in Exposure Science and Environmental Health (TCEEH) are currently studying the indoor dynamics of different constituents of tobacco smoke, in particular nicotine and its progenies (SVOCs), and their chemical effects on molecular and enzymatic changes in saliva. Research at the Technion has shown that exposure to third-hand smoke ozonation products in the indoor environment may pose significant health risks.
- Researchers from the Helen Schneider Hospital for Women showed that the pregnancy rate in women undergoing in vitro fertilization with high quality embryos is affected by active but not passive smoking.
- Researchers from the Hebrew University–Hadassah School of Public Health and Assaf Harofeh Medical Center are currently conducting a case-control study on ETS exposure (including cotinine measurements) among children attending the emergency room with respiratory symptoms compared to a control group.
- Researchers at Tel Aviv University are studying ways to reduce child exposure to tobacco smoke, including studies on parental perceptions of childhood exposure to tobacco smoke, reviews of intervention programs to encourage parental cessation, and a randomized controlled trial of an intervention program to protect children from tobacco smoke.
- The MoH is planning to measure urinary cotinine in Israeli adults and children in 2015 to estimate exposure of non-smokers to ETS.
Progress and Challenges
- One of the major challenges in reducing public exposure to ETS is that 18.7% of the adult population in Israel smokes (data from 2013, based on self-report). According to recent data from the Organisation for Economic Co-operation and Development (OECD), Israel is ranked 12th (lowest) out of the 40 OECD countries in smoking rates.
- There are major challenges in enforcing legislation regarding smoking in public places in Israel. The MoH Report on Smoking highlights the fact that many municipalities fail to report on their activities related to prevention of smoking in public places.
- There is a discrepancy between the relatively strict legislation forbidding smoking in public places and the extensive data showing widespread exposure of the non-smoking population to ETS. While Israel was once a leader in legislation regarding smoking in public places, it now lags behind many other countries, both in legislation and enforcement.
- Further measures are needed to protect the Israeli population, especially children, from ETS. For example, schools are still not completely smoke-free in Israel.
- While asthma prevalence in children is one of the health indicators related to ETS exposure (and to exposure to ambient air pollution), national data on asthma prevalence in children are limited to periodic surveys of adolescents. National data on emergency room visits for asthma in children are limited by differences in hospital reporting, while data regarding asthma medication use in children are not collected on a national basis. In addition, data on asthma medication use, and other relevant endpoints are collected separately by the four large Health Maintenance Organizations in Israel, each of which maintains an electronic medical record database.
- The only biomonitoring data available in Israel on exposure of the general population to ETS are from a 2011 study of adults. More research should be directed at measuring biomarkers of ETS in susceptible populations, such as children and pregnant women. Biomonitoring should be used to monitor trends in exposure of the non-smoking Israeli population to ETS.
- There is no certified laboratory in Israel to analyze cotinine or other biological markers of ETS in biological samples (urine, serum, saliva).
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.
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