Evaluation of support for smoke-free generation and Tobacco 21 strategies among the Italian population| Tabaccologia

Abstract

Background: Innovative tobacco control policies, such as raising the minimum age for tobacco purchase to 21 years (Tobacco 21, T21) and banning tobacco sales for those born after a certain year (smoke-free generation, SFG), aim to reduce the prevalence and initiation of smoking among youth. This study aims to assess the support of the Italian population for these measures.

Methods: A survey was conducted on a representative sample of 2,119 Italian adults. Support for T21 and SFG laws was assessed based on socio-demographic characteristics and smoking status. We then estimated adjusted odds ratios (aOR) for support for both laws, adjusting for sex, age, education, and smoking status.

Results: Overall, 74.4% and 68.3% of respondents said they were either fairly or very supportive of adopting T21 and SFG, respectively. Support was higher among non-smokers, while current smok-ers were significantly less supportive both measures (aOR = 0.18 for T21; aOR = 0.21 for SFG). Individuals over the age of 25 were more favorable than those younger than 25, with the highest support recorded in adults aged 45-64 (aOR = 4.04 for T21; aOR = 2.17 for SFG). Compared with individuals with a middle school diploma or less, those with high school diplomas were less supportive of both regulations (aOR = 0.74 for T21; aOR = 0.74 for SFG), while those with a bachelor’s degree were significantly less likely to support SFG (aOR = 0.64).

Discussion: There is widespread public support in Italy for T21 and SFG laws, particularly among non-smokers and in higher age groups. Public awareness campaigns should aim to increase support among smokers, young people, and other less supportive groups. 

Background

Tobacco use remains one of the leading causes of preventable death worldwide, with approximately 8 million deaths attributable to smoking each year [1]. In this context, the need for innovative and effective tobacco control strategies is evident. Recent legislative proposals, such as raising the minimum age for purchasing tobacco to 21 (Tobacco 21, T21) and banning the sale of tobacco to people born after a certain year (smoke-free generation, SFG), are gaining international attention [2,3]. The main objective of both measures is to prevent young people from taking up smoking by denying them legal access to tobacco products during the critical period of addiction development for T21 and throughout their lives for SFG [2,3].

The T21 law has already been successfully implemented in several US states, demonstrating a significant reduction in smoking initiation rates among young adults [4]. At the same time, the UK is considering proposing a smoke-free generation act by banning the sale of tobacco to those born since 2009 for their entire lives [5].

Despite the potential of these regulations, their success is highly dependent on public support. Laws restricting access to tobacco, and SFGs in particular, may be perceived by the public as a restriction on personal freedom. Available data on support for such legislation is still limited and comes mainly from countries where such measures have already been adopted or proposed [3,6,7].

Aim

This study aims to assess the level of support for the T21 and SFG regulations in Italy, using a representative sample of the Italian population.

Methods

We conducted a survey using CAPI (Computer Assisted Personal Interview) methodology between March and May 2024 on a sample of 2119 Italian adults representative of the general Italian population (15 years and older). The sample was weighted to reflect the demographic distribution of Italy by gender, age and geographical area. The questionnaire collected socio-demographic data and responses regarding support for the T21 and SFG regulations, including all tobacco and nicotine products (i.e. conventional cigarettes as well as heated tobacco products and electronic cigarettes).

Responses were analysed using multivariate logistic regression models to estimate adjusted odds ratios (aOR) for regulatory support with 95% confidence intervals (95% CI), adjusting for variables such as age, sex, educational level and smoking status (non-smoker, ex-smoker, smoker).

Results

Overall, 74.4% of respondents indicated that they were fairly or very supportive of the implementation of the T21 legislation in Italy, and 68.3% expressed support for the SFG legislation (Figure 1). The weighted percentages of support for the T21 and SFG laws and the results of the multivariate analysis are shown in Table 1. Support was found to vary significantly by socio-demographic characteristics and smoking status.

Figure 1.Support for Tobacco 21 and smoke-free generation legislation in a sample of 2,119 adults representative of the Italian adult population.

Differences by sex

Women were slightly more supportive of the T21 regulation than men (77.5% vs. 71.1%), while men were slightly more supportive of the SFG regulation (69.0% vs. 67.8%). Multivariate analysis showed that compared to men, women were more likely to support T21 (aOR = 1.20; 95% CI 0.97-1.50), but significantly less likely to support SFG (aOR = 0.80; 95% CI 0.65-0.98).

Differences by age

Support for both regulations increases significantly in the highest age groups (71.9% for T21 and 65.8% for SFG among 25-44 year olds; 77.2% for T21 and 69.4% for SFG among 45-64 year olds; 80.6% for T21 and 73.3% for SFG among 65+ year olds) and is lower among the youngest (55.8% for T21 and 58.7% for SFG among 15-24 year olds). Multivariate analysis showed that all other age groups were significantly more likely to support T21 and SFG compared to young people aged 15-24.

Differences by educational level

Participants with a higher education degree showed less support than those with a middle school diploma or less, with those with a university degree being significantly less likely to take the SFG (aOR = 0.64; 95% CI 0.46-0.88) and those with a high school diploma being significantly less likely to take both measures (T21: aOR = 0.74; 95% CI 0.57-0.97; SFG: aOR = 0.74; 95% CI 0.58-0.95).

Differences by smoking status

Current smokers were significantly less favourable than never smokers for both T21 (aOR = 0.18; CI 95% 0.14-0.23) and SFG (aOR = 0.21; CI 95% 0.17-0.26). Former smokers were also less favourable than never smokers, although to a lesser extent than current smokers (T21: aOR = 0.52; CI 95% 0.37-0.74; SFG: aOR = 0.63; CI 95% 0.46-0.88).

Discussion

The results of our study showed a high level of support for both laws among the Italian adult population, but with some significant differences according to age, smoking status and other socio-demographic characteristics. Overall, about two-thirds of the adult population in Italy would support the introduction of T21 laws, raising the minimum age for purchasing tobacco from 18 to 21, and SFG laws, banning the sale of tobacco and nicotine products to those born after 2010. This support is particularly strong among older people and non-smokers, suggesting that these groups see such regulations as essential measures to protect public health. The support of these groups for stricter tobacco regulations could be due to an increased awareness of the health risks of smoking, but also to the fact that these regulations would not directly affect the habits of these groups. Conversely, the lower support observed among smokers and young people suggests greater resistance from those who may perceive these regulations as a threat to their personal choices.

Another relevant finding of our study is the relatively lower level of support for SFG among graduates. This result may be indicative of greater concerns about issues of individual freedom, which appear to be more pronounced in this group. It is therefore important that the development of regulations such as T21 and SFG is accompanied by awareness-raising campaigns that emphasise the long-term benefits of these regulations, not only in terms of reducing smoking prevalence, but also in terms of positive effects on the population and the environment [8].

The results of this study are consistent with those of a previous study that examined support for the T21 and SFG laws in a larger convenience sample of Italian adults [9]. Both surveys, albeit with some differences, show significant support for the regulations, especially among non-smokers. However, the present study, conducted on a representative sample, confirms and strengthens these conclusions, showing more support among older age groups and greater reluctance among smokers.

Italian politicians may feel encouraged to promote the adoption of legislation such as T21 and SFG, which have the support of around two out of three Italians and also a significant proportion of the more sensitive groups (young people and smokers). However, the differences in opinion between the various groups must be taken into account and communication campaigns should be aimed at broadening support for these initiatives, in particular by involving young people, smokers and people with a higher level of education in the debate.

Funding

The work was supported by the AIRC Foundation for Cancer Research, as part of the MFAG 2021 project - ID. 25840 project - P.I. Alessandra Lugo.

References

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