Prevention and smoking control: perspectives and criticalities
In Italy, the prevalence of smokers (both who consume traditional tobacco products and who use newly conceived ones), also in relation to the young population groups, enforces the need to confirm a specific strategic approach: to combat smoking behavior protecting the non-smokers from emissions, preventing people from initiation, and supporting for cessation. It is essential to reaffirm that multidisciplinary policies are needed to achieve these objectives, alongside the integration between regulatory interventions and health promotion, prevention, and treatment actions. This is a complex process for which the advocacy action of the health sector towards other administrations is fundamental, as well as the constant relationship with the European Union (EU) is vital to continue the path of regulating tobacco products. These efforts aim to achieve the World Health Organization (WHO) target: a relative reduction of 30% in smoking by 2025 compared to 2010, which for Italy means to reach a prevalence of smokers of 16%. Much has happened in 2020 and 2021, despite the slowdowns associated with the COVID-19 pandemic.
At the European level, the analysis of non-compliant notifications for e-cigs continued within the framework of the JATC, the traceability system for tobacco products entered into force, and the evaluation of Tobacco Products Directive (TPD) 2014/40/EU was completed with the 1st report of the EU Commission 5 years after its application (2016). While this report highlighted a steady decrease in smoking rates and tobacco consumption, on the other hand it indicated the need to strengthen the application at the national level, and to pay more attention to new market developments. The presentation by the Commission in February 2021 of the European Plan against Cancer was very important to strengthen European strategies against smoking; the presentation sets a clear and ambitious goal, namely to create a generation without tobacco in Europe where less than 5% of people use tobacco by 2040. This implies a more rigorous application of EU tobacco legislation and the need to adapt to new market developments.
At the national level, despite the limitations due to COVID-19 and the related lockdowns, in 2020 2,576 checks were carried out by the NAS (Nuclei Antisofisticazioni e Sanità), and conformity assessment activities were carried out on some products. This led to the withdrawal from the market of a product considered similar to snus (which is prohibited in Italy), and the initiation of a procedure towards a product based on nicotine salts for oral use, which was placed on the market in the absence of specific regulations. Thanks to a prevision of the Legge di Bilancio No 178 of 30th December 2020, with a provision of the Agenzia delle Dogane, and after having heard the opinion of the Ministry of Health and the Istituto Superiore di Sanità (ISS, the Italian National Institute of Health), the presence of health warnings was extended. These warnings, which were already provided for liquid products containing nicotine to be inhaled, now will be also present for products not containing nicotine; the following phrase will be inserted “Product containing chemicals potentially harmful to health - for info call the toll-free number 800554088 of the Istituto Superiore di Sanità”.
In 2020, the evaluation of the National Prevention Plan (PNP) 2014-2019 ended. None of the objectives envisaged for smoking has been achieved: as regards the prevalence of smokers, there has been a reduction in almost all Regions (in some of them statistically significant) and good results have also been achieved with regard to compliance with the smoking ban in the workplace. The worst result concerned the goal of the family doctor’s advice to quit smoking: it was very far from being achieved and in some cases it even decreased. However, with the Intesa Stato-Regioni of 6th August 2020 the new PNP 2020-2025 was adopted, whose vision and objectives are consistent with the 17 Sustainable Development Goals and the UN Agenda 2030. The PNP invests in establishing in all Regions collective prevention programs which proved to be effective, and it forecasts the implementation either based on evidence of effectiveness, on consolidated and documented good practices, or in compliance with national and international strategies and recommendations. This would be done through the so-called “Programmi predefiniti”, which are in common and binding for all Regions, and monitored through predefined indicators.
Macro-objective 1: Chronic diseases” aims to “Promote the conscious adoption of a healthy and active lifestyle in all ages and in life and work settings, integrating individual change and social transformation”, through the development of health promotion programs (Figure 1). Those programs would be also transversal to the main risk factors, and shared between health and social health services, educational institutions and employers, thus they will activate local networks and communities. As part of the macro-objective 1, it is envisaged to fight against tobacco and nicotine products consumption, to also implement the Annex 1 at Livello Essenziale di Assistenza (LEA) “Collective prevention and public health, letter F4 Prevention and fight against smoking”.
It was important to reiterate that “harm reduction”, as proposed by the tobacco and e-cigarette industries, is not a public health strategy today (Figure 2). In June 2020, then-Under-Secretary of Health Sandra Zampa, in responding to a parliamentary question about the subject of heated tobacco products, stated that: “The manufacturing companies support them in light of reduced harm. In the current state of knowledge, this approach cannot be adopted as a public health strategy, which instead aims at quitting smoking and the use of tobacco or nicotine-containing products. [...] Independent studies are desirable. To date, we have no information about the effects of their prolonged use”. Furthermore, to counter the interference of the tobacco industry in health policies and in the smokers’ healthcare choices, in November 2020, a note was sent to the Health Departments and Scientific Societies, signed by the DGs of Health Prevention and Health Professions to “reaffirm that the only strategy that can be pursued is the total cessation from smoking and from the consumption of other tobacco products. Moreover, once the favorable opinion of the political summit of the Ministry will be obtained, to request the collaboration of Institutions and Bodies, recommending them to ensure that all National Health Service (SSN) bodies, including affiliated entities, Universities, and medical and scientific societies, will guarantee their independence from tobacco companies in scientific debate venues. Additionally, to request their advocacy to raise awareness on the consequences of interference from the tobacco industry and “importance of making preventive and therapeutic choices based exclusively on consolidated scientific evidence, in the interest of the individual and the community”.
Many other initiatives, however, have not yet been completed. For example, Italy did not yet ratify the WHO Protocol on the illicit trafficking of tobacco products (which entered into force on 28th September 2018) because the necessary resolution of the Council of Ministers is still missing. Neither the process for the issue of the Decreto Interministeriale on tariffs to be paid by manufacturers and importers has yet been completed. These tariffs are those necessary to cover the costs associated with the following: laboratories measurements to verify the maximum levels of tar, nicotine, and carbon monoxide (TNCO) in cigarettes, data collection and data analysis on ingredients and emissions of tobacco products and electronic cigarettes, assessment of characterizing aromas and the use of prohibited additives or flavorings.
Finally, the main challenges for the near future are concerning the possibility of updating the Sirchia Law Act, extending it with the introduction of further bans in other outdoor places, including heated tobacco products and electronic cigarettes, eliminating the existence of smoking rooms; it is also necessary to update the law on advertising, promotion and sponsorship of tobacco and nicotine products, so that it is extended to heated tobacco products and electronic cigarettes as well. The issue of adjusting fiscal measures and prices is also important, as a tool for reducing demand, on which the primary responsibility lies with the Ministry of Economy, an entity which should have a more proactive role towards tobacco control.
Another challenge is to witness a convinced adherence of all health professionals, starting with general practitioners, to a public health vision that rejects the theory of a “harm reduction with tobacco industry products” and a conscious and motivated commitment in supporting the deterrence that is able to motivate, direct, prescribe, as appropriate.
Figures and tables
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