The Istituto Superiore di Sanità and tobacco control: the state-of-the-art since 20 years of the enforcement of the law to protect non-smokers| Tabaccologia

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Twenty years ago, on January 10, 2005, the law banning smoking in enclosed public places - also known as the “Sirchia Law”, named after the Minister of Health who proposed it - came into force. It was the nationwide implementation of the provisions of Law No. 3 of 16 January 2003 (Art. 51) “Protection of the health of non-smokers”, which was the main regulatory intervention in Italy on tobacco.

According to the Italian National Institute of Statistics 2023 data on tobacco use, smokers in Italy were 19.3% of the population aged 14 years and over (23.1% men and 15.7% women). Differently, in 2005, the smokers were 22.0% (28.3% men and 16.2% women), decreasing by 2.7 % in 18 years. This drop was mostly due to a reduction of the percentage of male smokers (-5.2 %), while female smokers decreased only by 0.5 % (16.2 % in 2005, 15.7 % in 2023). Therefore, the gender gap in tobacco use has narrowed significantly (the difference between male and female smokers decreased from 12.1 % in 2005 to 7.6% in 2023) [1].

The decline of conventional cigarette smokers has been clearly influenced by the introduction of e-cigarettes and heated tobacco products onto the market. Data presented by the National Centre on Addiction and Doping (in Italian Centro Nazionale Dipendenze e Doping, CNDD) of the Istituto Superiore di Sanità (ISS) during the World No Tobacco Day 2023 conference, showed that users (occasional and regular users, ≥ 15 years old) of e-cigarettes are 2.5% of the population (about 1.3 million people). On the other hand, the survey data indicate that users of heated tobacco products, including both the occasional and regular users, are 3.7% of the population (around 1.9 million Italians) [2].

A matter of concern is the prevalence of tobacco and nicotine in young users. This generation of boys and girls initiated tobacco and nicotine use also through the devices for electronic smoking. The survey, conducted during the 2023/2024 school year by the CNDD of ISS in secondary schools, presented at the World No Tobacco Day 2024 conference, showed that 30.2% of Italian students aged 14 to 17 years (about 700.000 young people) reported using at least one type of tobacco product, including conventional cigarettes, e-cigarettes, and heated tobacco products. Specifically, 18.5% students reported using e-cigarettes, while 18.7% reported using heated tobacco products [3]. Notably, girls reported a higher rate of product consumption compared to boys for all types of products investigated, reversing the historical gender gap observed among conventional cigarette smokers in Italy. A key concern is the prevalence of poly-use, defined as the concurrent use of two or more products, including traditional cigarettes, e-cigarettes, and heated tobacco products. This phenomenon affects 62.4% students who reported using at least one of these products [3]. Poly-use among the very young students should prompt policy makers and health care personnel to consider at least two issues of primary concern for public health protection:

1. E-cigarettes and heated-tobacco products are being marketed as alternatives for smokers who are unable or unwilling to quit. However, these products are actually recruiting individuals, who do not currently smoke and probably would have never started smoking, thereby creating a new group of nicotine-dependent people, and in fact, the use of these products is common among very young students;
2. The simultaneous use of two or more tobacco or nicotine-containing products has the potential to induce health harms that are not fully understood yet, and cannot be quantitatively assessed by merely adding up the harms caused by the individual product. The adverse effects could also be determined by the interaction between the variety of substances present in different products (both in terms of ingredients and emissions).

Over the years, non-smokers have clearly benefited from smoking bans, but the most important effect of the law has definitely been to raise awareness of the harm caused by second-hand smoke. As early as 2005, 90% Italians were in favor of creating smoking spaces in public places and banning smoking outside of them. In 2006, just a year after the enforcement of the new law, according to the CNDD survey, 88.2% of respondents indicated that there was a high degree of compliance with the ban in the population.

Twenty years after the law enforcement, compliance with the ban on smoking in enclosed spaces has mostly become a widespread habit throughout Italy. According to the PASSI surveillance data of the National Center for Disease Prevention and Health Promotion of ISS, in the years 2022-2023, compliance with the ban on smoking in workplaces is 95%, while compliance with the ban on smoking at home is 85.3% [4].

The introduction on the market of novel tobacco and nicotine products (particularly e-cigarettes and heated tobacco products) as alternatives to conventional cigarettes and the need of an updated legislation that should include the new market scenarios, are questioning the education on respectful behavior toward non-smokers (renormalization of smoking behavior). The CNDD survey on Italian students revealed that, despite the ban on smoking in schools and its outdoor areas, a significant percentage of students reported having seen professors, students or other people using conventional cigarettes (58%), heated tobacco products (46%) or e-cigarettes (59%) inside school premises [3].

Over the years, CNDD has addressed the prevalence of tobacco and nicotine consumption in the Italian population by implementing a variety of measures to tackle this concerning public health issue.

Since the year 2000, CNDD has activated the Antismoking helpline (TVF, 800554088), an anonymous and toll-free national service, that operates from 10 am to 4 pm, Monday to Friday. Following the enforcement of the Sirchia Law, the number of calls from citizens to the helpline increased significantly from 2.600 in 2005 to more than 15.000 in 2017. This increase has been mainly due to the wider dissemination throughout the country of the toll-free number on the packaging of all tobacco smoking products (Decree Law 12/01/2016 No. 6). In recent years, the volume of calls has stabilized at an average of 8.000 per year.

CNDD has expanded its services to citizens through an online platform, “Smettodifumare” [5], funded by the Ministry of Health, with the aim of reaching as many smokers as possible and supporting them in the process of quitting. The platform is a resource to increase the chances of success to quit tobacco use, by providing information on all aspects of tobacco use dependency and tobacco cessation, including information about smoking and its effects on health, the benefits of quitting in the short, medium and long-term, and the risks of exposure to second-hand smoke. Moreover, it offers support in the quitting process, including self-help materials for those who wish trying to quit on their own, and it directs people to smoking cessation centres. CNDD also coordinated the panel of experts for the development of the “Guideline for the treatment of tobacco and nicotine dependence”, published in 2023 and available on the “Smettodifumare” platform.

CNDD has been conducting a census of smoking cessation centres for 25 years. These are public or private social services dedicated to supporting individuals who wish to quit smoking and which play a central role in the cessation process. The services offer specialised and varied pathways to smoking cessation, providing evidence-based interventions such as pharmacotherapies, individual and group counselling and psychotherapy, psycho-educational groups, supported by a multidisciplinary team of professionals including doctors, nurses and psychologists. In 2005, when the “Protection of the health of non-smokers” law came into force, 334 centres were detected by the census of CNDD. In the following years, the number of centres generally increased, reaching a maximum of 396 in 2010. However, a concerning reversal of this trend has been observed in the last five years, resulting in only 223 active services in 2024.

ISS is also active at European level. From 2017 to 2024 CNDD participated in the European projects Joint Action on Tobacco Control 1 and 2 [6], which aimed to strengthen cooperation between the Member States and the Commission in the field of tobacco control and to provide support for the implementation of the European Tobacco Products Directive (TPD) and the Tobacco Advertising Directive (TAD).

As a consequence of that, CNDD will also take part in the Joint Action on Health Promotion and Disease Prevention including Smoke and Aerosol Free Environments, which aims to support the European initiative on non-communicable diseases and the implementation of the Europe beating cancer plan, including the creation of a tobacco-free generation by 2040. Among the planned actions, is to support the implementation of the Council Recommendation on Smoke- and Aerosol-Free Environments [7].

References

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