Prevalence and trend of tobacco smoking in Italy in the XXI century| Tabaccologia

Abstract

Introduction: Smoking is one of the leading preventable causes of mortality worldwide, with a devastating impact on public health. In Italy, despite an initial phase of decline in smoking prevalence at the beginning of the 21st century, a worrying interruption of the trend has been observed since 2014. This study aims to analyse the historical trend in the prevalence of cigarette smoking in Italy, with particular attention to differences by sex and age, using the most recent data available.

Methods: Data collected annually from 2001 to 2024 through cross-sectional surveys conducted by DOXA on representative samples of the Italian population were analysed. Point prevalences of smoking were calculated for each year and stratified analyses by sex and age were conducted.

Results: From 2001 to 2013, smoking prevalence decreased significantly from 29.2% to 20.6%. However, a reversal trend has been observed since 2014, leading to a peak of 25.4% in 2024. In this year there are therefore an estimated 13 million smokers in Italy. In 2024, women showed a prevalence of 21.6%, the highest value since 2009, while a prevalence of 29.5% was reached among men. The stratified analysis by age and sex in 2024 showed a higher prevalence among young women (15-24 years) than among men in the same age group.

Discussion: The inversion of the trend observed since 2014 could be attributed, among other causes, to the introduction of new smoking products, which may have contributed to the renormalisation of smoking habit. The increase in the last year was more pronounced among women, suggesting possible changes in social behaviour patterns. Differences in prevalence by sex and age indicate the need for a targeted approach in tobacco control policies.

Introduction

Smoking is the leading preventable cause of mortality and morbidity worldwide, with a devastating impact on public health. Tobacco use is estimated to be responsible for about 8 million deaths worldwide each year, of which about one million are due to passive smoking [1,2]. In the 20th century, more than 100 million deaths were attributable to tobacco smoking. Projections for the 21st century are even more alarming: if current consumption trends continue, the number of tobacco-related deaths could reach one billion [1].

In Italy, as in many other countries, tobacco use is a major health problem and one of the greatest threats to public health. An estimated 96,000 deaths per year in Italy are attributable to tobacco use, accounting for 15% of all deaths in the country, with a higher prevalence among men (20.6%) than women (7.9%) [3]. If no effective tobacco control measures are implemented, almost 300,000 premature deaths attributable to tobacco smoking are expected to occur in Italy by 2040 [4].

The trend in smoking prevalence in Italy showed a long period of decline in the early 2000s, thanks to growing awareness of the risks associated with smoking and the introduction of control measures. Since 2013, however, this decline has stopped and a worrying trend reversal has been observed. In 2022, the prevalence of cigarette smoking rose to 24.2%, the first significant increase since 2009 [5].

In the light of these worrying trends, this study aims to analyse the current prevalence and historical trends of cigarette smoking in Italy, using the most recent data available. The aim is to provide a detailed picture of historical smoking trends in the 21st century, highlighting the dynamics that have led to the reversal of trends in recent years. It also examines specific smoking prevalence in 2024, stratified by age and sex, to better understand the groups most affected and the recent dynamics that may have influenced these trends.

Methods

The data used in this analysis come from a series of annual cross-sectional surveys. Until 2023, the surveys were carried out by the Istituto Superiore di Sanità in collaboration with the Istituto di Ricerche Farmacologiche “Mario Negri” (IRFMN), with the fieldwork entrusted to DOXA [6]. In 2024, the same survey was carried out by the IRFMN, again with the support of DOXA, as part of a project funded by the AIRC Foundation for Cancer Research. The samples, of approximately 3,000 people per year until 2023 and 2,000 in 2024, are representative of the Italian population aged 15 and over in terms of sex, age, geographical area and socio-economic characteristics. Due to the COVID-19 pandemic, it was not possible to carry out the planned interviews in 2020 and 2021, which temporarily interrupted the data collection for this period.

Participants in the survey were selected using a multistage representative sample. In the first stage, municipalities from all 20 Italian regions were selected using two selection criteria: region and size of municipality. In the second stage, an appropriate number of electoral districts were randomly selected in each municipality. In the third stage, individuals were randomly selected from the electoral rolls within strata defined by sex and age group. Young people aged 15-17, whose names were not on the electoral rolls, were selected using the quota method (by sex and exact age).

The interviews were conducted by specially trained interviewers using a structured questionnaire in a computer-assisted home interview. In addition to general information on socio-demographic characteristics, data on smoking status (non-smoker, ex-smoker and smoker) and the number of cigarettes consumed per day were collected. Subjects who reported smoking fewer than 100 cigarettes in their lifetime were considered never smokers. Among those who reported smoking 100 or more cigarettes in their lifetime, participants who reported quitting smoking for at least one year were identified as former smokers. Participants were therefore identified as smokers if they reported at least 100 cigarettes in their lifetime and either continued to smoke or had quit smoking for less than a year.

During data processing, statistical weights were applied to ensure representativeness of the Italian population aged 15 years and older. Statistical analyses were performed to examine trends in smoking prevalence from 2001 to 2024. Point prevalence was calculated for each year and stratified analyses were performed by age and sex.

Results

The analysed sample of data previously collected from 2001 to 2023 has an average annual sample size of approximately 3,100 individuals. The sample of data collected in 2024 consists of 2,119 individuals. Data on smoking prevalence, both overall and stratified by sex, are shown in Figure 1. Overall, the prevalence of smoking decreased significantly in the early 2000s, from 29.2% in 2001 to 20.6% in 2013. However, this downward trend stopped in 2014, with an increase to 21.7%. In the following years, prevalence continued to fluctuate, peaking at 24.2% in 2022. Although there was a decrease to 20.5% in 2023, a new increase was observed in 2024, reaching 25.4%, the highest level since 2009. As the population aged 15 and over in Italy is 52 million, the number of smokers in Italy is around 13 million.

Figure 1.Trends in cigarette smoking prevalence in Italy (2001-2024), total and stratified by sex.Three-year moving average of cigarette smoking prevalence.

Among women, smoking prevalence decreased from 23.6% in 2001 to 15.3% in 2013. After a series of fluctuations, smoking prevalence increased to 18.5% in 2022, before decreasing slightly to 16.3% in 2023. However, a further increase is observed in 2024, with a prevalence of 21.6%, the highest level since 2009. A similar trend is observed for men: after a decline to 23.9% in 2010, prevalence rises again to 30.2% in 2022. It then falls to 25.1% in 2023, before rising again to 29.5% in 2024.

The analysis of smoking prevalence in 2024, stratified by age and sex, is illustrated in Figure 2. The data reveal that, in general, smoking prevalence is higher among men, with the exception of the 15-24 age group, where women show a higher prevalence than men. Specifically, in the 15-24 age group, the prevalence of smoking is 25.7% among women, compared to 17.8% among men. Among men, smoking prevalence peaks in the 25-44 age group, while for women it is highest in the 45-64 age group, at 26.2%. The lowest smoking prevalence is observed for both sexes in the 65 years and over age group, with a prevalence of 17.0% among men and 14.2% among women.

Figure 2.Smoking prevalence in Italy in 2024, stratified by age and sex.

Discussion

The results of this study show a complex picture of smoking prevalence in Italy from 2001 to 2024. After a long period of decline, the prevalence of cigarette smoking has reversed since 2014, culminating in a significant increase in 2024. This trend is worrying and suggests that tobacco control strategies may no longer be sufficiently effective and may need to be updated to respond to changes in smoking behaviour.

Possible causes of the trends observed in recent years include the COVID-19 pandemic, which may have had a temporary impact on smoking habits [7,8]. Another factor that may have contributed to the reversal of the trends observed since 2014 is the introduction and growing popularity of novel tobacco products, such as electronic cigarettes and heated tobacco products, the latter of which was introduced in Italy in 2014. It has been suggested that the emergence of these devices may have had a significant impact on the renormalisation of smoking [9]. These products, often promoted as safer alternatives to traditional cigarettes, may have changed the perception of smoking and made it more socially acceptable, leading to an overall increase in the prevalence of tobacco use. It is important to consider whether the promotion and availability of these new products have influenced smoking habits, particularly among young and new smokers.

The increase in smoking prevalence in 2024 was observed for both sexes, but most markedly for women, who reached their highest level in 2024 since 2009. This may reflect not only the impact of new products, but also changes in social and cultural behaviours that deserve further investigation.

Stratified analysis by sex and age shows that men tend to have a higher prevalence of smoking in all age groups, except among young adults (15-24 years), where women have a higher prevalence. This may indicate that younger women are more influenced by social and cultural factors that encourage smoking. Furthermore, the age groups 25-44 years for men and 45-64 years for women show the highest prevalence for each sex, suggesting that smoking habits may stabilise or intensify during these periods of life. Overall, the differences observed between sexes and age groups suggest that tobacco control policies may need to be more targeted.

In conclusion, although there was a significant decline in smoking prevalence in the early 2000s, the recent increase indicates the need to review and strengthen tobacco control policies. It is essential to develop age- and sex-specific interventions and to carefully assess the impact of new tobacco products. Future research should examine in detail the factors contributing to these trends and assess the effectiveness of existing policies in the current context.

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