Commentary on a smoke-free medical campus in Jerusalem: data for action
© The Author(s). 2016
Received: 8 June 2016
Accepted: 11 June 2016
Published: 28 June 2016
Over the past 30 years, Israel has made great progress in attitudes and practices about smoking; probably nothing else has contributed more to the health of its population. Yet, a recent survey about a non-smoking ban at an Israeli health sciences campus found incomplete enforcement. In addition, smoking rates among health sciences students, though lower than the general population, were higher than might be expected based on rates in other developed countries. Whether the ban is—as the authors speculate—“an intrusive life style intervention” or a justifiable public health intervention, cuts to the heart of the history of tobacco control efforts and their opposition by the tobacco industry. Despite concerns that the Israeli population is not ready to accept smoke-free bans, experience in other countries suggests otherwise.
In 1987 I had the privilege of serving as visiting professor at the Ben Gurion Medical School (now Goldman School) in Beersheva. During that month I frequently accompanied senior internal medicine professors on ward rounds, and also engaged in conversations on diverse medical topics. Although there were many similarities between how medicine was practiced and taught at the Soroka/Ben Gurion hospital and my own institution—the University of California San Francisco (UCSF)—there was one stark difference: most of the (male) professors smoked cigarettes, often and robustly. One of my favorite hosts—a barrel-chested combat veteran—offered an explanation for this apparent paradox: “We know that smoking is bad for us, but when the future of your country is uncertain, it’s hard to abandon current pleasures for potential future benefits”.
Progress and challenges
In the almost three decades since that encounter, it is clear that Israeli attitudes and practices about smoking have come a long way, paralleling the impressive declines in smoking in the rest of the developed world [1, 2]. Probably no other trend has contributed more to the health of the Israeli population . Yet, as the paper by Feldman illustrates, there is still more to do . For one, although the smoking rates found among medical (6.9 %), dental (11.6 %) and pharmacy (8.7 %) students are substantially below the 19.8 % of the general population, they are higher than health professional smoking prevalence rates in the United States, where, for example, physician smoking rates hover between 1–2 % [5–7]. Another difference is the ambivalence about the acceptability of smoke-free areas. Like the Ein Kerem campus of Hebrew University, UCSF is also a stand-alone health science campus. But it exists in a state—California—where smoking has become progressively de-normalized to the extent that social norms now suffice to enforce non-smoking bans. When UCSF became smoke-free, the only controversy was that smokers migrated off campus and left cigarette butts in residential neighborhoods. The ban was almost universally accepted, and official enforcement was not necessary.
Feldman’s survey of school of pharmacy staff and health science students revealed incomplete enforcement of the Ein Kerem campus non-smoking ban. In his discussion, he labels the ban as “an intrusive lifestyle intervention,” and speculates whether the time and politics are sufficient to justify such coercion. The assertion that freedom to smoke was a personal right undergirded campaigns of the tobacco industry in opposition to clean indoor air laws in the United States several decades ago. Ultimately, that argument was defeated by the desire of non-smokers to avoid exposure to second-hand smoke. Surprisingly, many surveys also found that a majority of smokers (though fewer than non-smokers) also supported such ordinances. Feldman articulates many reasons why such a ban is needed: second hand smoke exposure avoidance; appropriate role modeling for other health professionals as well as patients and their families; and its efficacy as a tobacco control policy. Another benefit is avoidance of extensive litter from used cigarette butts. If the experience of the United States and European countries is any guide, acceptance of smoke-free bans will not be as difficult as Feldman fears, and the enforcement will be pretty much self-governing.
I just wish that my Israeli host had lived long enough to witness these changes. I hope he would take pride in the ongoing de-normalization of smoking in Israel.
UCSF, University of California San Francisco
Funding support was provided by The Robert Wood Johnson Foundation and the Truth Initiative.
Dr. Schroeder directs the Smoking Cessation Leadership Center at UCSF. He is the former president and CEO of the Robert Wood Johnson Foundation, and the former chair of the International Advisory Review Committee, Goldman Medical School, Ben Gurion University, where he is an honorary professor.
Availability of data and materials
N/A. No data was used for this commentary, all references are provided.
The author declares that he has no competing interests.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Ng M, Freeman MK, Fleming TD, Robinson M, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980–2012. JAMA. 2014;311:183–92.View ArticlePubMedGoogle Scholar
- Rosen LJ, Peled-Raz M. Tobacco policy in Israel: 1948–2014 and beyond. Isr J Health Policy Res. 2015;4:12.View ArticlePubMedPubMed CentralGoogle Scholar
- Ginsberg GM, Geva H. The burden of smoking in Israel—attributable mortality and costs (2014). Isr J Health Policy Res. 2014;3:28.View ArticlePubMedPubMed CentralGoogle Scholar
- Feldman I, Donchin M, Levine H. A smoke-free medical campus in Jerusalem: data for action. Isr J Health Policy Res. 2016;5:20.View ArticlePubMedPubMed CentralGoogle Scholar
- Association of American Medical Colleges Center for Workforce Studies. Physician behavior and practice patterns related to smoking cessation. Washington, DC: Association of American Medical Colleges; 2007.Google Scholar
- Tong EK, Strouse R, Hall J, Kovac M, Schroeder SA. National survey of U.S. Health Professionals’ smoking prevalence, cessation practices, and beliefs. Nicotine Tob Res. 2010;12:724–33.View ArticlePubMedGoogle Scholar
- Sarna L, Aguinaga SA, Nandy K, Antonio ALM, Yang Q. Changes in smoking prevalences among health care professionals from 2003 to 2010–2011. Research letter. JAMA. 2014;311:197–9.View ArticlePubMedGoogle Scholar