The National Tobacco Report 2021| Tabaccologia

Every year, on May 31, the World Health Organization (WHO) celebrates the World No Tobacco Day with the aim of highlighting the risks associated with tobacco use and promoting effective policies to reduce the tobacco consumption. Within this event, all countries undertake initiatives to address the tobacco epidemic and its impact on public health.

With the campaign “Committed to quit” the WHO dedicates the 2021 World No Tobacco Day to support smokers in the cessation path and to encourage governments to implement key strategies, including the extension of smoke-free areas, the implementation of new taxes and pricing policies, the regulation of advertising and ingredients in tobacco products, and above all, increasing the offer of support for smoking cessation promoting a greater access to cessation services and empowering tobacco users to quit successfully.

On May 31, 2021, the XXIII National Conference Smoking and National Health Service was held at the Istituto Superiore di Sanità (ISS). The event was an opportunity to deepen the theme proposed by the WHO, but also to present the National Report on smoking, 2021.

Smokers in Italy

During the last 15 years the cigarette sales on the national territory are in constant decrease and a reduction of 4.5% was observed in 2020 compared to the previous year. Consumers seem to have turned to “shredded” tobacco (+6.8% compared to 2019) but also to alternative products such as electronic cigarettes (e-cig) and heated tobacco products (HTP). In 2020, in fact, sales of electronic cigarette refills increased by 616%, whereas sales of heated tobacco products increased by 1089% compared to 2017 (Figure 1).

In May 2021, the ISS, in collaboration with the Istituto di Ricerche Farmacologiche “Mario Negri”, the Università Vita-Salute S. Raffaele (UniSR) and the Istituto per lo studio, la prevenzione e la rete oncologica (ISPRO), carried out a survey aimed at investigating the tobacco and nicotine consumption habits of the Italian population.

The survey involved a representative sample of the Italian population (18-74 years) according to the main socio-demographic characteristics and the interviews were delivered anonymously through an online questionnaire, using a computer assisted web interviewing system (CAWI).

The study showed that there are 11.3 million smokers in Italy (26.2% of the population): 5.5 million men (25.7%) and 5.8 million women (26.7%). The average number of cigarettes smoked per day is 10.8 with higher consumption among men (M 11.4 vs F 10.1) and among smokers in the age group 55-74 (18-34 years 8.7 sig/day; 35-54 years 10.9 sig/day; 55-74 years 12 sig/day).

Regarding the use of new products alternative to traditional cigarettes, the study found that e-cig users (occasional + regular) represent 9% of the population with an average consumption of 30 puffs per day. It is noticeable that a further 19% of respondents reported to have had contact with this product, having tried it once or twice (11%) or having used it in the past but not in the 30 days before the interview (8%).

Considering liquids in electronic cigarettes, 67% of consumers declares to use predominantly (37%) or exclusively (30%) liquids containing nicotine; 65% of consumers declares to use rechargeable devices, 22% prefers to use those with big tanks and 13% uses disposable e-cig.

With regard to heated tobacco products, 7% of the population uses them occasionally or regularly and, 11% of respondents reported to have tried the device once or twice (7%) or have used it in the past but not in the 30 days before the interview (4%).

The “Telefono Verde contro il Fumo” (TVF)

It is an anonymous and free national service, held by the ISS since 2000. TVF consists in a service of telephone counselling on tobacco and nicotine addiction and is aimed at supporting smokers in the process of cessation, former smokers at risk of relapse and their families.

Since its beginning, TVF has handled 89,300 telephone calls, of which 8,000 in its last year of operation (May 2020 - April 2021). Historically, the service was mainly used by smokers (94%), but also from family members asking for suggestions to more effectively help their loved ones in quitting smoking. The two-thirds of users are men (M 67% vs F 33%) and the most represented age group is 46-55 years (M 16% vs F 21%).

Calls come from all Italy (40% North; 39% South and Islands; 21% Center) with a greater representativeness for Lombardy (17%), Lazio (12%), Campania (11%) and Sicily (10%). Cigarette packs remain the almost exclusive sources of knowledge of the service (98%).

Main smokers’ requests are related to receive help for quitting smoking (96%), usually subsequently to previous failed attempts. In fact, 68% of smokers calling the service declares to have already made at least one attempt to quit smoking. Further requests relate to information on Anti-smoking Centers, health and current legislation on novel tobacco products (Figure 2).

Over time, the team of psychologists working at the service has diversified and customized the offer to better meet the changing needs of users and now offers different types of intervention aimed at smoking cessation, including orientation towards Anti-smoking Centers (CAFs), support through telephone counselling paths (where the user calls the operator from time to time), the offer of self-help material produced by the Service for those who want to try to quit smoking independently.

Since 2021, in order to enhance the effectiveness of smoking cessation support, the service offers, on an experimental basis, the activity of proactive telephone counselling based on a reference model provided by the WHO. In the proactive mode, the consultant, in compliance with the legislation related to privacy, contacts the smoker on the basis of a schedule of agreed appointments, to offer support and to avoid a relapse.

This activity responds to the need expressed by users to be able to choose the type of intervention most appropriate to their needs, to overcome difficulties of users in accessing resources on the territory but also on the basis of what is demonstrated by the scientific literature: it has been shown in fact that the probability of successfully quitting through a path of telephone counselling increases with increasing the number of calls received by the consultant.

Another experimental activity is the extension, for a few months, of the operating time of the service (10.00-18.00 instead of 10.00-16.00) to better explore the needs of users in a time slot of high telephone inflow.

Local tobacco smoking cessation services

According to users’ requests, the TVF operates with the aim of promoting continuity with the system of territorial care, promoting the activity and facilitating access to the Anti-smoking Centers.

These are several dedicated structures of the National Health Service, Lega Italiana Lotta ai Tumori (LILT) and the “Privato Sociale” that play a central role in the process of overcoming the addiction, offering specialized and heterogeneous paths based mainly on pharmacological therapies, individual and group interventions, involving doctors, professional nurses and psychologists.

Since 2000, the ISS has been in charge of the census and the annual updating of the personal information and the welfare offer of the Anti-smoking Centers, work that has led to the creation of a network, in the national panorama, constantly updated.

The COVID-19 pandemic has affected the activity of many Anti-smoking Centers that, sometimes, had to employ pneumologists in the COVID-19 departments of hospitals or had to reconvert the physical spaces in COVID Centers and therefore to re-modulate their offer of assistance offering support at distance (phone, text, video call). For this reason, the 2020 update reported only partial data.

Despite the persistence of the emergency, taking advantage of the availability of service operators, the update was regularly restored in 2021 and it accounts for 268 anti-smoking centers (234 pertain to the National Health Service; 54 to the LILT; 4 are structures of the Privato Sociale) distributed throughout the national territory with greater numbers in Piedmont (48), Lombardy (37), Emilia-Romagna (28) and Veneto (25).

The services of the Anti-smoking Centres can be accessed in several ways and forms of contributions: some of them are completely free of charge and others require the payment of the health ticket or other types of contributions (membership fee, voluntary contribution).

Figures and tables

Figura 1.Il trend delle vendite dei prodotti a tabacco riscaldato e delle sigarette elettroniche: anni 2017-2020.

Figura 2.Telefono Verde contro il Fumo: motivo della chiamata.