Using All Means to Protect Public Health in Israel From Emerging Tobacco Products

Emerging tobacco products have begun to occupy an increased share of the global tobacco market in recent years. An electrically heated cigarette smoking system (EHCSS) is the most recent product to be aggressively introduced and marketed worldwide. Traditional tobacco products are formally regulated in many countries and, hence, heavily restricted by law in terms of sales, advertising, and banning of use in many public areas.

By contrast, regulation of emerging tobacco products, such as EHCSS cigarettes, is ill defined in many countries, where these products are only partially regulated or even allowed to be used, sold, and advertised with no restrictions. Such is the recent case in Israel, where a multinational tobacco producer benefited from an absence of regulations to establish intensive unrestricted market penetration of EHCSS cigarettes, an unprecedented scenario to the best of our knowledge. The case study described here could provide important lessons for public health professionals, stakeholders, and policymakers in other countries.

TOBACCO CONTROL IN ISRAEL

As of 2016, the prevalence rate of smoking in Israel’s general adult population (aged 21 years or older) was 22.5% (approximately 1.2 million smokers).¹ That year was the first in more than three decades in which an increase in the national smoking prevalence had been observed. The highest smoking prevalence rate in Israel is among Arab men (43%), whose rate is 1.6 times higher than that among Jewish men. It has been estimated that smoking is responsible for approximately 8000 deaths per year in Israel, about 800 of which are deaths among nonsmokers exposed to secondary, forced smoking.^1,2 The overall annual cost to the economy in 2016 as a result of smoking was estimated as 12.85 billion NIS (US $3.6 billion), or 1.5% of the annual gross national product.¹

Since 1983, tobacco control laws in Israel have defined tobacco products as products containing tobacco in any form. The heaviest tax level is imposed on traditional cigarettes. Also applied are legal restrictions on marketing and advertising as well as use of these products in public places. Along with mandatory health warnings on cigarette packages, there are bans on billboard, radio, and television advertising and, partially, advertising in the press.³

There is currently no sweeping ban, however, on advertising tobacco products, and advertising is allowed in certain sections of the press and on the Internet with no restrictions. Current regulations do not mandate use of graphical image warnings or plain package use. There are no restrictions on displays of tobacco products and advertising at sale points. Tobacco companies are also legally allowed to provide sponsorships for certain public events.³ Overall, tobacco control policies in Israel have been lagging in recent years.

INTRODUCTION OF EHCSS CIGARETTES IN ISRAEL

Against this background of substantial, nondeclining smoking rates in the country’s population, accompanied by outdated tobacco control regulations and legislation, the Israel Association of Public Health Physicians of the Israel Medical Association established a coalition with other nongovernmental organizations to properly address the rapid unrestricted introduction of EHCSS products and the accompanying growing concern for public health.

The coalition issued several firm detailed warnings to the general public and policymakers, including the state attorney and other high-ranking officials in the Ministry of Justice. In brief, according to these well-reasoned warnings, the country’s public health was being severely compromised through the unrestricted marketing and advertising of an emerging tobacco product. The aggressive marketing measures used included national media advertising campaigns and press articles with prominent positive EHCSS marketing content published by leading journalists after fully financed public relations visits to Japan and Switzerland, where pilot EHCSS efforts had already begun in 2014 and 2015, respectively.⁴

This rapid entry of a new, unregulated tobacco product marketed in an unrestricted manner with a presumably “sophisticated” appeal to young people is a clear public health emergency that could reverse Israel’s achievements in tobacco control. EHCSS cigarettes are also likely to reverse current smoking norms and public antismoking sentiment; hence, smoking could once again become a regular habit in public places, cessation efforts would be harmed, and, eventually, smoking rates will increase.

Moreover, there are currently few studies on these emerging products, and most of the research has been carried out or funded by tobacco companies themselves.⁴ Only recently have independent researchers published data indicating that smoke released by EHCSS cigarettes contains the same harmful elements found in conventional cigarette smoke. These data are, of course, in contrast to the heavily advertised “harm reduction” claims of the manufacturer.⁴

Despite this evidence, the Israeli Ministry of Health formally declared on March 1, 2017, that no tobacco control regulations will be imposed on EHCSS cigarettes as long as the US Food and Drug Administration has not approved the product for marketing in the United States, an unprecedented real-life oxymoron. It is noteworthy that this highly controversial executive decision was made in the face of a strong opposing professional, legal, and political consensus.⁵

THE SUPREME COURT AS THE LAST LINE OF DEFENSE

On April 4, 2017, the Israel Supreme Court issued a tentative legislative order in response to an urgent petition by one of the nongovernmental organizations that were part of the antismoking coalition.⁵ This interim ruling reaffirmed the recent Ministry of Justice official position that EHCSS cigarettes are indeed a tobacco product. Notably, the ministry’s legislative stand was consolidated only after the Israel Association of Public Health Physicians had publicly sent the state attorney and the Ministry of Health legal adviser a warning letter clearly explaining and professionally reasoning why EHCSS cigarettes should be rapidly declared a tobacco product, as with conventional cigarettes, and thus all current legal restrictions on tobacco products in Israel should apply to these cigarettes as well without any further delay by the executive branch.⁵

This expected legislation may be less effective than desired owing to insufficient regulations in Israel on conventional cigarettes (i.e., an absence of plain packaging and pictorial warnings on packages, nonrestricted Web advertising). However, it is the only current regulation that can be rapidly applied in an effort to contain the propagation of an emerging tobacco product. In addition, any relaxation of this minimum threshold could create a false public impression of a “safer” tobacco product.

The public health importance of the Israel Supreme Court ruling is immense, and its implications should be considered as relevant to other countries as well. Of note, not until a civil society coalition was formed that actively petitioned the Supreme Court was the public’s health protected from the grave reality of unlimited exposure to smoking hazards.

RECOMMENDATIONS FOR PUBLIC HEALTH POLICYMAKERS

We recommend that all emerging tobacco products be promptly and fully regulated, under the principles of the Framework Convention on Tobacco Control,^6,7 within current national regulations on tobacco products and in accordance with existing tobacco control measures on advertising, marketing, taxation, and, importantly, prohibition of sales to minors. In addition, we recognize that more stringent measures are needed for these types of products. Effective public health lines of defense, including independent regulatory authority separated from the executive branch, a strong judicial infrastructure, and vigilant civil society watchdog organizations, are necessary for all countries to mitigate the rapid worldwide propagation of emerging tobacco products.