Position Paper – July 2017
Rikaz – Center for Social Research, The Galilee Society
Prepared by: Dr. Muhammad Khatib
Smoking, in all its different types, forms one of the central public health issues and counts as one of the main causes of high morbidity and mortality rates among smokers and their family members. Additionally, smoking is a financial burden on the smoker and the family, both directly and indirectly – buying cigarettes, tobacco, and hookahs, as well as the costs of morbidity and even death.
In recent years there has been an increase in the number of smokers in Arab society, in contrast to trends of reduced smoking in Jewish and international society. In a reality where one in two Arab men smokes, usually inside his home or at work, the consequences are far reaching for over half the Arab population in Israel. This includes pregnant women, infants, children, and elderly people who are exposed to smoking and its damages on a daily basis. If we examine the life course of a baby born here in 2016 we can assume that there is a high chance they will be exposed to smoking on a daily basis, even as an infant; both at home, in family gatherings and events, on playgrounds and more. Because smoking begins at a young age, there is a reasonable concern that they will start smoking in their teenage years and by doing so be defined as a smoker already between the ages of 13-15, and so join the grim statistics relating to smokers in the Arab society.
The combination of the scale and the smoking habits in Arab society forms a direct and indirect health hazard to most of Arab society in Israel! This situation requires an immediate, multi-system intervention which combines changes in lifestyle, not only in regards to the prevention of smoking at a young age and stopping it as early as possible, but also guidance for smokers not to do so inside their homes, at their workplace, inside event halls, or in public areas next to children, pregnant women, elderly people, and the sick. Decreasing the degree of exposure to passive smoking, alongside prevention and decreasing the number of new smokers, can help in creating a new generation for whom smoking is not a part of daily life, which in turn will reduce the circle of new smokers later one. This in addition to smoking cessation programs adapted for younger ages as well as adults.
The Dimensions of Smoking in Arab Society
The Ministry of Health’s report, which examined the tendencies in cancer types tied to smoking between the years 1999 and 2013, found that while the occurrences of cancers cause-related to smoking amongst Jews is strong, the tendency is usually stable or declining. Amongst Arab men, the occurrences of the same types of cancers is usually stable or rising. It was also found that 60.5% of all new cancer diagnoses is related to smoking.
According the report about smoking in Israel for the year 2015, the percentage of the smokers in the Israeli population in general stands at 19.7%, with 26.2% of men smoking vs. 18.5% of women. The highest percentage of smokers is among Arab men and it reaches 43.9% (two times higher than Jewish men, and 6.6 times higher than Arab women). The findings of the 2015 Socio-Economic Survey done by Rikaz in the Galilee Society show that over 30% of the Arab population above age 15 smokes, and that 50.4% of the men and 9.2% of the women smoke, with 30-40 age group containing the highest number of smokers at 59.7%.
According to the Ministry of Health’s report, in the younger age group (21-34) 44.1% of men smoke compared to 28.8% of Jewish men, with this number rising with the 35-49 age group (47% compared to 22.2%). Among men smokers ages 18 and up, 47.1% smoke between 10 to 20 cigarettes a day, while 34.3% smoke over 20 cigarettes a day. This means that one in six Arab men smokes twenty or more cigarettes a day!
The mid-nineties to the first decade of the millennium saw a decrease in the percentage of male Arab smokers (from 50% in 1996 to 40% in 2006), afterwhich there was a steady increase in the percentage of smokers. Though the three socio-economic surveys and the 2015 health survey from Rikaz show that in the last decade there has been a continuous increase in the percentage of smokers, from 43.9% in 2004, to 50.4% in 2015 (graph no. 1), it is important to note that they also showed an increase in the number of teenagers smoking.
Cigarette Smoking Among Teenagers
According to the Ministry of Health’s 2015 report, 14.4% of Arab students in the 6th to 10th grades smoke cigarettes at least once a week (22.3% of boys, 6.5% of girls), while 8.3% smoke cigarettes at least once a day (12.2% of boys, 4.4% of girls).
According to Rikaz’s health and environment survey, 8.2% of Arab teenagers ages 15-17 (high school students) smoke (11.5% of boys, 4.8% of girls).
Over the past decade, there has been an even steeper rise in the percentage of hookah smokers. The findings of the last three socio-economic surveys done in the last decade at the Galilee Society show that the percentage of hookah smokers doubled itself among Arab men and even more among Arab women. The findings of the 2015 health and environment survey show that 12.6% of ages 15 and up smoke hookahs, while half (49.2%) of all hookah smokers are in the 18-29 age group. Hookah smoking is also increasing among Arab women at 7%.
Coerced smoking causes lung, head, and neck cancer, infections in the breathing passages, and obstructive pulmonary diseases. The exposure of non-smoking women to coerced smoking by her husband increases the risk of death from any factor by 15% and increases the risk of dying from coronary heart disease and vascular diseases.
A research conducted at HaEmek Medical Center in Afula examined the relation between coerced smoking and morbidity of acute coronary heart disease among Arab Israeli women in the north and showed that in the last five years the risk to acute coronary heart disease is 6.1 times higher due to exposure to coerced smoking after marriage. Additionally, exposure in childhood increases the risk of the disease in adulthood by 1.4 times.
Among Arabs, 63.5% of Arab men who don’t smoke and 54.7% of Arab women who don’t smoke are exposed to coerced smoking, compared to 30.3% of Jewish men and 26.6% of Jewish women. Arab women are most like to be exposed to smoking at home (72.0% exposure among women).
Cessation From Smoking
Around a third of Arab men who do smoke express their interest in quitting, 27% of them noted that they had tried quitting but did not succeed due to different reasons relating to will and social pressure. 60% tied it to the lack of supporting frameworks.
An important finding relating to those who did quit smoking is that 75% noted they quit smoking too late in their life and they are not satisfied with their overall health. They noted the importance of an intervention for ages 15-25 as a crucial time period for prevention and rehabilitation.
In fact, among those who quit smoking, the high rate of doctor visits stands out (86.2%), which is higher than the rate for smokers (61.5%) and non-smokers (63.3%). This could be explained by the late point at which they stopped smoking, i.e. after the health damage resulting from smoking was done.
What is Being Done on the Ground
Due to the critical condition of the Arab community in all that relates to smoking, the Ministry of Health created a professional committee “with the aim of preparing and recommending a culturally adapted, fact-based national program for decreasing smoking in the Arab community.”
We are happy with the Ministry of Health’s decision to take action and create a program specific to the Arab population, though we would be interested in knowing and understanding at what stage the planning or executing of the plan is – what has been done already, what is being planned both long-term and short-term. In addition, we would like professional representation and intervention by experts from the Arab community in the Ministry’s work to prevent and stop smoking, representation which is still missing at this time.
As a rule, smoking cessation programs by the Ministry of Health and health funds are focused on ages 18 and up, with no investment in smoking prevention programs for the extremely crucial younger ages. In addition, there is a shortage of smoking prevention and cessation programs in Arabic; programs which were developed specifically for the Arab population. Programs are developed for the Jewish population and then translated into Arabic but are not culturally adapted to the Arab population. As an example, the findings from the Rikaz survey show that smoking habits including smoking inside residential homes next to children and women, which increases the number of people exposed to smoking damages and the need for intervention programs which deal with halting smoking in homes. In addition, there still exist workplaces and public institutions where smoking is common, in comparison to workplaces and public institutions in Jewish society where smoking is not common. Smoking prevention and cessation programs need to take into account factors such as this and guide smokers on how not to harm their surroundings.
To summarize, the problem of smoking (both cigarettes and hookah) is one of the main health problems in the Arab society and greatly impacts the health situation of this population. From the details above we see very high rates of smokers among the Arab population, especially among men, high rates of smokers among the younger population alongside far too low rates of smoking cessation among the younger population, as reported by those who quit and the data concerning doctor visits.
Despite the great efforts done by different organizations and the different government ministries (Health and Education), these actions are still not enough and do not achieve the objectives of prevention and decreasing the smoking rates in the general population, and the Arab population specifically. This objective requires a comprehensive multi-field intervention on the local, regional, and national level.
Our position is that taking the following steps will help decrease the smoking rates among the Arab population:
- Announcement by the Ministry of Health that this is an urgent issue to be addressed immediately, including immediate implementation of planning and budgeting for long-term and broad-scale;
- Expanding the national program to battle smoking and making it accessible to the Arab population; it is our recommendation that this plan be developed in cooperation with a multidisciplinary team of experts from the Arab society.
- Setting milestones and measures to assess the success of the Ministry of Health’s actions to decrease the number of smokers, as well as follow up of their implementation;
- Operate smoking prevention programs in all educational frameworks, workplaces, event halls, and cooperation with local players;
- Allocate budgets for initiatives and programs developed by the local community and civil society organizations, health committees and forums to promote health and decrease smoking;
- Massive media campaign to decrease smoking in the Arab society;
- Adapting the content to the age of the participants, create cessation programs that are accessible culture and language-wise to the Arab society.