- Email: [email protected]
Effects of new smoking regulations in Italy
Annals of Oncology 17: 346–347, 2006 doi:10.1093/annonc/mdj070 Published online 7 November 2005
original article
Effects of new smoking regulations in Italy S. Gallus1*, P. Zuccaro2, P. Colombo3, G. Apolone1, R. Pacifici2, S. Garattini1 & C. La Vecchia1,4 1 Istituto di Ricerche Farmacologiche ‘Mario Negri’, Milan, Italy; 2Dipartimento del Farmaco, Istituto Superiore di Sanita`, Rome, Italy; 3Istituto DOXA, Gallup International Association, Milan, Italy; 4Istituto di Statistica Medica e Biometria, Universita` degli Studi di Milano, Milan, Italy
Received 21 August 2005; revised 30 September 2005; accepted 6 October 2005
original article
We conducted a population-based survey to provide information on attitudes towards smoking regulation and to disentangle the impact of the smoking ban on tobacco consumption. Patients and methods: We considered data from a survey on smoking, based on 3114 subjects aged 15 or over, representative of the general adult Italian population in terms of age, sex, geographic area and socioeconomic status. Results: Once smoke-free policies were introduced, support for them in the public opinion tended to increase. In Italy, smoke-free policies accounted for around 8% decrease in cigarette consumption in the short run. Moreover, tobacco bans were almost universally accepted, and the smoke-free legislation did not seem to unfavourably affect the business of restaurants or cafes. Conclusions: The results of our study on the first extensive smoking ban in a large country show the advantages of smoke-free legislations, which may have major public health implications. Key words: Italy, population survey, smoking bans, tobacco smoking, workplace smoking
introduction From 10 January 2005 the Italian government banned smoking in all indoor public places, including cafes, restaurants (except for a few with separate and regulated smoking areas), airports, railway stations, as well as in all public and private workplaces. Italy, therefore, is the fourth European country, after Ireland, Norway and Malta [1, 2], providing comprehensive and strict regulation for smoke-free areas. Besides reducing passive smoking [3, 4], smoke-free policies increase smoking cessation [5] and reduce tobacco consumption [6, 7]. After the ban came into force, we conducted a survey on a representative sample of the Italian adult population to provide information on attitudes towards smoking regulation in Italy. Moreover, we compared smoking consumption from subsequent nationally representative population-based surveys and from official legal sales over time in order to disentangle the impact of the smoking ban on tobacco consumption.
patients and methods We considered data from a survey on smoking, conducted during March–April 2005 in Italy [8] by DOXA, the Italian branch of the Gallup International Association, on a sample of 3114 subjects (1511 men and 1603 women) aged 15 years or over, who represented the general adult Italian population in terms of age, sex, geographic area, habitat, education and working status. The sample was defined through a representative multistage *Correspondence to: Dr S. Gallus, Istituto di Ricerche Farmacologiche ‘Mario Negri’, Via Eritrea 62, 20157 Milan, Italy. Tel: +39-02-39-014-526; Fax: +39-02-33-200-231; E-mail: [email protected]
ª 2005 European Society for Medical Oncology
sampling of adults from 149 municipalities (the smallest Italian administrative division) in all of the 20 Italian regions (the largest Italian administrative division), identified in order to be representative of the geographical areas sampled. In the municipalities considered, individuals were randomly selected from electoral rolls, within strata of sex and age group. Wherever the selected subjects were unavailable, they were replaced by selecting among neighbours (living in the same floor/building/street) from the same gender and age group. Subjects aged between 15 and 17 years whose names did not appear on the electoral lists, were chosen by means of the ‘quota’ method (by gender and exact age) using the same approach. The data were collected by ad hoc trained interviewers using a structured questionnaire in the context of a computer assisted personal in-house interview. Besides general information on socio-demographic characteristics, data were collected on tobacco consumption, including smoking status and number of cigarettes smoked per day. Some specific questions referred to the attitudes towards the new smoking regulation. Legal sale data were derived from official publications.
results Overall in 2005, 25.6% of Italian adults described themselves as current smokers (29.3% of men, 22.1% of women). Current smokers consumed a mean of 14.6 cigarettes/day (16.3 for men and 12.4 for women). Using data from official legal sales, 28.3 million kg of cigarettes were sold in Italy during the period January–April 2005. The corresponding value for the same period in 2004 was 31.1 million kg. This corresponds to a decline in cigarette sales by 8.9%. This compares well with a 7.6% fall in consumption revealed by the comparison between results from the 2005 survey and those from a companion
Downloaded from http://annonc.oxfordjournals.org/ at Robertson Library University of prince Edward Island on August 27, 2015
Background: From 10 January 2005 the Italian government banned smoking in all indoor public places.
original article
Annals of Oncology
Table 1. Attitudes towards smoking regulation, based on a representative sample of 3114 Italian adults interviewed in March–April 2005 Separate smoking areas in cafes, restaurants and other areas open to the public, and smoking ban in their absence Current All the smokers population only (%) (%)
Current All the population smokers only (%) (%) 55.5
33.5
31.3
35.3
7.7 2.9 2.7
19.1 8.5 3.5
24.4 44.7
23.2 45.6
17.3
17.2
3.6 10.0
5.0 9.0
In 2001, 83.3% were favourable to a smoking ban in public places, such as pubs or restaurants [9], and this figure increased to over 90% after the ban came into force. This study confirms, therefore, that the support for smoke-free policies increased once the policies were introduced [6]. Moreover, the study quantified the fall in cigarette sales since the ban came into force in Italy at around 8%, confirming the decrease in the short run found in selected US states and in Ireland [7]. The new smoke-free legislation seemed to affect women and the younger population more frequently, although the estimate for the young was based on a small number of subjects and hence had a wide confidence interval. Furthermore, in Italy the legislation is almost universally observed, at least in pubs, cafes and restaurants. Out of about 6000 checks by the police and other civil forces, less than 100 (1.5%) violations were observed. Moreover, these results suggest that smoke-free legislations do not unfavourably affect the business of restaurants or cafes.
acknowledgements This work was conducted with the contribution of Italian Ministry of Health, the Italian League Against Cancer and the Italian Association for Cancer Research. The authors thank Ms M. P. Bonifacino for editorial assistance.
references survey conducted in March–April 2004: smoking prevalence decreased by 2.3% (a difference of 0.6% in absolute terms) and the mean number of cigarettes per smoker per day decreased by 5.5% (from 15.4 to 14.6). The fall in consumption from 2004 to 2005 was apparently greater for the young (23.0% for the 15–24 year age group) and for women (10.5%). Table 1 shows the attitudes of the population towards smoke-free policies after the implementation of the tobacco regulation. Overall, 90.4% were moderately to strongly in favour of smoke-free areas in public places such as cafes and restaurants and 86.8% supported the total ban of smoking in all workplaces, public and private. The corresponding estimates for current smokers were 76.3% and 68.8%, respectively. Almost 90% of the population had the perception that the smoking bans were observed in bars and restaurants, and 70% in the workplace, including small workplaces. Overall, after the introduction of the new policies, 9.6% of subjects reported to go more frequently and 7.4% less frequently to cafes and restaurants.
Volume 17 | No. 2 | February 2006
1. McElvaney NG. Smoking ban – made in Ireland, for home use and for export. N Engl J Med 2004; 350: 2231–2233. 2. Howell F. Ireland’s workplaces, going smoke free. Br Med J 2004; 328: 847–848. 3. Farrelly MC, Nonnemaker JM, Chou R et al. Changes in hospitality workers’ exposure to secondhand smoke following the implementation of New York’s smoke-free law. Tob Control 2005; 14: 236–241. 4. Siegel M, Albers AB, Cheng DM et al. Effect of local restaurant smoking regulations on environmental tobacco smoke exposure among youths. Am J Pub Hlth 2004; 94: 321–325. 5. Longo DR, Johnson JC, Kruse RL et al. A prospective investigation of the impact of smoking bans on tobacco cessation and relapse. Tob Control 2001; 10: 267–272. 6. Jamrozik K. Population strategies to prevent smoking. Br Med J 2004; 328: 759– 762. 7. Anonymous. Ireland’s smoking ban is an admirable achievement. Lancet 2005; 365: 1282. 8. Gallus S, Pacifici R, Colombo P et al. Smoking in Italy 2003, with a focus on the young. Tumori 2004; 90: 171–174. 9. La Vecchia C, Garattini S, Colombo P et al. Attitudes towards smoking regulation in Italy. Lancet 2001; 358: 245.
doi:10.1093/annonc/mdj070 | 347
Downloaded from http://annonc.oxfordjournals.org/ at Robertson Library University of prince Edward Island on August 27, 2015
Degree of support of the legislation Strongly in 68.1 44.4 favour Moderately 22.3 31.9 in favour Moderately against 5.1 15.2 Strongly against 2.7 6.6 Not known/not 1.8 1.9 answered Degree of observation of the legislation Strongly observed 43.5 48.5 Moderately 43.8 41.6 observed Not frequently 8.2 6.6 observed Not observed at all 1.0 0.9 Not known/not 3.5 2.4 answered
Extension to forbid smoking in every workplace, including private ones
discussion
original article
Effects of new smoking regulations in Italy S. Gallus1*, P. Zuccaro2, P. Colombo3, G. Apolone1, R. Pacifici2, S. Garattini1 & C. La Vecchia1,4 1 Istituto di Ricerche Farmacologiche ‘Mario Negri’, Milan, Italy; 2Dipartimento del Farmaco, Istituto Superiore di Sanita`, Rome, Italy; 3Istituto DOXA, Gallup International Association, Milan, Italy; 4Istituto di Statistica Medica e Biometria, Universita` degli Studi di Milano, Milan, Italy
Received 21 August 2005; revised 30 September 2005; accepted 6 October 2005
original article
We conducted a population-based survey to provide information on attitudes towards smoking regulation and to disentangle the impact of the smoking ban on tobacco consumption. Patients and methods: We considered data from a survey on smoking, based on 3114 subjects aged 15 or over, representative of the general adult Italian population in terms of age, sex, geographic area and socioeconomic status. Results: Once smoke-free policies were introduced, support for them in the public opinion tended to increase. In Italy, smoke-free policies accounted for around 8% decrease in cigarette consumption in the short run. Moreover, tobacco bans were almost universally accepted, and the smoke-free legislation did not seem to unfavourably affect the business of restaurants or cafes. Conclusions: The results of our study on the first extensive smoking ban in a large country show the advantages of smoke-free legislations, which may have major public health implications. Key words: Italy, population survey, smoking bans, tobacco smoking, workplace smoking
introduction From 10 January 2005 the Italian government banned smoking in all indoor public places, including cafes, restaurants (except for a few with separate and regulated smoking areas), airports, railway stations, as well as in all public and private workplaces. Italy, therefore, is the fourth European country, after Ireland, Norway and Malta [1, 2], providing comprehensive and strict regulation for smoke-free areas. Besides reducing passive smoking [3, 4], smoke-free policies increase smoking cessation [5] and reduce tobacco consumption [6, 7]. After the ban came into force, we conducted a survey on a representative sample of the Italian adult population to provide information on attitudes towards smoking regulation in Italy. Moreover, we compared smoking consumption from subsequent nationally representative population-based surveys and from official legal sales over time in order to disentangle the impact of the smoking ban on tobacco consumption.
patients and methods We considered data from a survey on smoking, conducted during March–April 2005 in Italy [8] by DOXA, the Italian branch of the Gallup International Association, on a sample of 3114 subjects (1511 men and 1603 women) aged 15 years or over, who represented the general adult Italian population in terms of age, sex, geographic area, habitat, education and working status. The sample was defined through a representative multistage *Correspondence to: Dr S. Gallus, Istituto di Ricerche Farmacologiche ‘Mario Negri’, Via Eritrea 62, 20157 Milan, Italy. Tel: +39-02-39-014-526; Fax: +39-02-33-200-231; E-mail: [email protected]
ª 2005 European Society for Medical Oncology
sampling of adults from 149 municipalities (the smallest Italian administrative division) in all of the 20 Italian regions (the largest Italian administrative division), identified in order to be representative of the geographical areas sampled. In the municipalities considered, individuals were randomly selected from electoral rolls, within strata of sex and age group. Wherever the selected subjects were unavailable, they were replaced by selecting among neighbours (living in the same floor/building/street) from the same gender and age group. Subjects aged between 15 and 17 years whose names did not appear on the electoral lists, were chosen by means of the ‘quota’ method (by gender and exact age) using the same approach. The data were collected by ad hoc trained interviewers using a structured questionnaire in the context of a computer assisted personal in-house interview. Besides general information on socio-demographic characteristics, data were collected on tobacco consumption, including smoking status and number of cigarettes smoked per day. Some specific questions referred to the attitudes towards the new smoking regulation. Legal sale data were derived from official publications.
results Overall in 2005, 25.6% of Italian adults described themselves as current smokers (29.3% of men, 22.1% of women). Current smokers consumed a mean of 14.6 cigarettes/day (16.3 for men and 12.4 for women). Using data from official legal sales, 28.3 million kg of cigarettes were sold in Italy during the period January–April 2005. The corresponding value for the same period in 2004 was 31.1 million kg. This corresponds to a decline in cigarette sales by 8.9%. This compares well with a 7.6% fall in consumption revealed by the comparison between results from the 2005 survey and those from a companion
Downloaded from http://annonc.oxfordjournals.org/ at Robertson Library University of prince Edward Island on August 27, 2015
Background: From 10 January 2005 the Italian government banned smoking in all indoor public places.
original article
Annals of Oncology
Table 1. Attitudes towards smoking regulation, based on a representative sample of 3114 Italian adults interviewed in March–April 2005 Separate smoking areas in cafes, restaurants and other areas open to the public, and smoking ban in their absence Current All the smokers population only (%) (%)
Current All the population smokers only (%) (%) 55.5
33.5
31.3
35.3
7.7 2.9 2.7
19.1 8.5 3.5
24.4 44.7
23.2 45.6
17.3
17.2
3.6 10.0
5.0 9.0
In 2001, 83.3% were favourable to a smoking ban in public places, such as pubs or restaurants [9], and this figure increased to over 90% after the ban came into force. This study confirms, therefore, that the support for smoke-free policies increased once the policies were introduced [6]. Moreover, the study quantified the fall in cigarette sales since the ban came into force in Italy at around 8%, confirming the decrease in the short run found in selected US states and in Ireland [7]. The new smoke-free legislation seemed to affect women and the younger population more frequently, although the estimate for the young was based on a small number of subjects and hence had a wide confidence interval. Furthermore, in Italy the legislation is almost universally observed, at least in pubs, cafes and restaurants. Out of about 6000 checks by the police and other civil forces, less than 100 (1.5%) violations were observed. Moreover, these results suggest that smoke-free legislations do not unfavourably affect the business of restaurants or cafes.
acknowledgements This work was conducted with the contribution of Italian Ministry of Health, the Italian League Against Cancer and the Italian Association for Cancer Research. The authors thank Ms M. P. Bonifacino for editorial assistance.
references survey conducted in March–April 2004: smoking prevalence decreased by 2.3% (a difference of 0.6% in absolute terms) and the mean number of cigarettes per smoker per day decreased by 5.5% (from 15.4 to 14.6). The fall in consumption from 2004 to 2005 was apparently greater for the young (23.0% for the 15–24 year age group) and for women (10.5%). Table 1 shows the attitudes of the population towards smoke-free policies after the implementation of the tobacco regulation. Overall, 90.4% were moderately to strongly in favour of smoke-free areas in public places such as cafes and restaurants and 86.8% supported the total ban of smoking in all workplaces, public and private. The corresponding estimates for current smokers were 76.3% and 68.8%, respectively. Almost 90% of the population had the perception that the smoking bans were observed in bars and restaurants, and 70% in the workplace, including small workplaces. Overall, after the introduction of the new policies, 9.6% of subjects reported to go more frequently and 7.4% less frequently to cafes and restaurants.
Volume 17 | No. 2 | February 2006
1. McElvaney NG. Smoking ban – made in Ireland, for home use and for export. N Engl J Med 2004; 350: 2231–2233. 2. Howell F. Ireland’s workplaces, going smoke free. Br Med J 2004; 328: 847–848. 3. Farrelly MC, Nonnemaker JM, Chou R et al. Changes in hospitality workers’ exposure to secondhand smoke following the implementation of New York’s smoke-free law. Tob Control 2005; 14: 236–241. 4. Siegel M, Albers AB, Cheng DM et al. Effect of local restaurant smoking regulations on environmental tobacco smoke exposure among youths. Am J Pub Hlth 2004; 94: 321–325. 5. Longo DR, Johnson JC, Kruse RL et al. A prospective investigation of the impact of smoking bans on tobacco cessation and relapse. Tob Control 2001; 10: 267–272. 6. Jamrozik K. Population strategies to prevent smoking. Br Med J 2004; 328: 759– 762. 7. Anonymous. Ireland’s smoking ban is an admirable achievement. Lancet 2005; 365: 1282. 8. Gallus S, Pacifici R, Colombo P et al. Smoking in Italy 2003, with a focus on the young. Tumori 2004; 90: 171–174. 9. La Vecchia C, Garattini S, Colombo P et al. Attitudes towards smoking regulation in Italy. Lancet 2001; 358: 245.
doi:10.1093/annonc/mdj070 | 347
Downloaded from http://annonc.oxfordjournals.org/ at Robertson Library University of prince Edward Island on August 27, 2015
Degree of support of the legislation Strongly in 68.1 44.4 favour Moderately 22.3 31.9 in favour Moderately against 5.1 15.2 Strongly against 2.7 6.6 Not known/not 1.8 1.9 answered Degree of observation of the legislation Strongly observed 43.5 48.5 Moderately 43.8 41.6 observed Not frequently 8.2 6.6 observed Not observed at all 1.0 0.9 Not known/not 3.5 2.4 answered
Extension to forbid smoking in every workplace, including private ones
discussion