Can a Cigarette Pack's Cancer Warning Be Too Jarring?

The message on Israeli tobacco is mild compared to other countries’, and the health minister prefers it to stay that way.

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Cigarette label-warnings in Australia.
Cigarette label-warnings in Australia.Credit: Reuters

Health Minister Yaakov Litzman has long opposed requiring graphic warning pictures on cigarette packages sold in Israel, despite their demonstrated effectiveness in helping to curb smoking in other countries. “We don’t need to make the country ugly with pictures,” he has said. “It’s unaesthetic.”

He made these arguments to the Knesset over a period of years, between 2011 and 2014 at Knesset debates about the issue. Israel is a decade and a half behind other countries when it comes to warning labels on cigarette packs. The required warning in Israel is small, does not include pictures and the required wording hasn’t changed since 2004.

Sixteen years ago, Canada became the first country to require warning pictures on cigarette packs. The pictures are shocking depictions of the damage caused by smoking, from sick children wearing oxygen masks to patients with neck tumors. The Canadian approach was ground-breaking and daring. And it proved itself in short order, prompting 105 other countries to follow suit. They included Third World countries, among them countries bordering on Israel, such as Egypt and Jordan.

In 2014, the European Union issued a directive requiring European Union member countries to pass legislation requiring graphic warnings, including text and pictures, on 65 percent of the surface of cigarette packages. The required pictures are more powerful than what most EU countries had previously required. Since then, most of the countries have passed national legislation.

Such labeling requirements are considered the most effective means of curbing smoking - other than increasing cigarette taxes and other than preventing new potential smokers from even starting the habit. Labeling provisions are also viewed has having a favorable cost-benefit basis.

No cost to the government

The expense of printing the warnings falls on the tobacco companies, so it costs the government nothing. In addition, it provides the public with a constant stream of warnings about the harm that smoking causes. Someone who smokes a pack a day will be exposed to the warnings 7,000 a year. No country could afford to fund such a pervasive campaign conveying such messages by any other means.

There are countless studies on the effectiveness of the graphic warning labels. They are clear and consistent. The findings of the International Tobacco Control Policy Evaluation Project, based on results from 19 countries, show that smokers say the warnings reduce their smoking habit and increase their motivation to quit.

Israeli Health Minister Yaakov Litzman.Credit: Hadas Parush, Flash90

Several countries, following Australia’s lead in 2012, have banned brand advertising on cigarette packaging altogether, requiring uniform labeling - a prominent warning along with modest uniform mention of the name of the brand.

Israel, on the other hand, is lagging. A written warning on packaging has only been required since 2004, three years after Canada was already requiring graphic pictures on cigarette packs. Israel’s warnings only cover 30% of the surface of the packs, while in other countries it can range up to 75% and even 90%.

The wording of the warning hasn’t changed in Israel even though researchers have established that the labeling should be changed so that people don’t become inured to it. Years of seeing the same message day after day and smoke after smoke makes it effectively invisible.

“The most important thing for us is to reduce the number of people entering the addiction cycle, and they are young people,” says Dr. Rachel Dahan, the chairwoman of the Israel Medical Association’s organization dedicated to smoking prevention. Young people, she explains, are particularly interested in cigarette packaging – the color, the logo and the brand.

“When everything is uniform, the attraction of cigarettes is greatly weakened,” she says, adding that researchers have even found that cigarettes placed in packaging from another brand are perceived as tasting different “because clearly the brand is part of the experience.”

A hint as to why Israel is such a laggard can be found in what transpired at Knesset committee deliberations on the issue between 2011 and 2014 after the cabinet adopted a plan to reduce smoking in Israel. The program details were contained in a report issued by a committee headed by Health Ministry director general at the time, Roni Gamzu, who is major opponent of smoking. It included plans to include graphic pictures on cigarette packaging.

Litzman, who was deputy health minister at the time, but in practice headed the ministry, would have been the one to push for legislation on the matter. But at a hearing at the Knesset’s Labor, Welfare and Health Committee on the bill, he didn’t sound too enamored by it.

“We don’t need to make the country ugly with pictures,” he said.

After that a new government took office. Litzman left the ministry, joining the ranks of the Knesset opposition and Yael German became Health Minister. German reintroduced Litzman’s bill with some changes, including giving the health minister authority to order uniform cigarette packaging.

Perhaps one gauge of the effectiveness of such a measure is the degree of opposition it has met with from the tobacco industry. The large graphic warnings and even more so, the requirement of uniform packaging, are precisely what the industry has feared, as reflected at two sessions of the Knesset’s Economic Affairs Committee in 2014.

The first session was attended by lobbyists and other representatives of no fewer than 21 tobacco companies and importers.

Some of the lawmakers present, including Litzman, appeared particularly attentive to what they had to say. Knesset members came ready to do battle against the uniform packaging proposal, armed with original arguments such as the proposition that it would mean that cigarette companies would then only compete in price and that is in the country’s interest to have prices as high as possible, as Knesset member Robert Ilatov of Yisrael Beiteinu said at the time.

Litzman, who was in a combative mood at the hearing, called the labeling “unaesthetic,” to which the head of the ministry’s anti-smoking division, Haim Geva Haspil, retorted that lung cancer is unaesthetic, too. Health Minister Yael German said she was amazed at Litzman’s stance considering he was a former deputy health minister.

Uri Sudri, a lawyer representing a tobacco company, accused the bill’s proponents of seeking to expropriate his client’s trademark rights. After acrimonious debate, the bill got the committee’s backing, but a comment was appended to the uniform packaging provision stating that consultations would be held with the economy minister.

Sentencing young people to death

At the second committee session, held a considerable time later, the agenda included a suggested change to the bill, proposed by Ilatov. It was a representative of the Economy Ministry who voiced concern at the hearing over the proposed uniform packaging provision. The concern, the ministry representative said, was prompted by a challenge filed with the World Trade Organization by three countries against Australia.

German told the committee that it needed to decide if it really wanted to prevent smoking “or if we want to be half-pregnant, meaning that we want to fight but we don’t want labeling.”

In the end, the bill never passed. The government at the time was replaced by another.

Litzman is now health minister. Recently, after the ministry came in for criticism over its alleged inaction in combatting smoking, Deputy Director General Itamar Grotto, who heads the ministry’s public health services, said the ministry was pushing for a law that would require graphic pictures on cigarette packs and that the subject of uniform packaging would also be considered.

“Not only is it essential. It’s free. It’s effective intervention that has no budgetary implications,” Dahan said. “In essence, we are sentencing our young people to be sick and to die from smoking. Who are we hurting the most? The future generation, the children of all of us. No one thinks it could be their own child or grandchild,” she said, but added that there was a ray of hope on the horizon. “

The Health Ministry said in response: “In the context of discussions, the Health Minister related to revising smoking legislation, among the subjects that have come up are warnings and their size and the legislation will be revised accordingly.”