Round table Associations for a smoke-free Italy| Tabaccologia

Article

Professor Girolamo Sirchia, Italian Minister of Health from June 2001 to April 2005, began the round table with some reflections on the results obtained at national and international level in Tobacco Control.

The first reflection is that in Italy, in the last decade, there have been no significant changes in the reduction of the number of smokers. While in 2005, when the “Sirchia law” (Law Act No. 3/2003), the law for the protection of non-smokers that bears his name, came into force there was a reduction of about half a million smokers, in the last decade there have been no significant changes.

But why, Professor Sirchia asks, have no significant results been achieved? The answer is disconcerting: politics has not been up to its task!

And this situation of stagnation is not only characteristic of Italy, unfortunately it is common to many countries. For example, in the United States, the American project Million Hearts® 2022 of the Department of Health and Human Services was relaunched on this World No Tobacco Day (in collaboration with the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services), precisely because, due to political inertia, it had not brought the expected results. The goal of Million Hearts® 2022 is to prevent one million heart attacks and strokes by 2022(1), through various evidence-based initiatives, including reducing the number of smokers. This goal is extremely important because the damage tobacco causes to humanity is enormous: 8 million deaths worldwide, 700,000 in Europe, 80,000 in Italy.

To these sad numbers, we must add the social, human, and economic costs that tobacco causes.

In many cases we are talking about premature deaths which, by taking people out of work at an early age, endanger the livelihood of many families, as well as clearly causing a great deal of suffering.

Various economic assessments have been made, including one that some years ago estimated that a smoker costs society about three dollars a day, split equally between health and social costs.

Faced with these figures, other considerations arise as to why society accepts such damage, given that tobacco is not an essential element of life, i.e. no one is born with the need to smoke. In fact, it is a harmful need induced for the economic benefit of certain groups.

And then, why, in Italy, as in other countries in the world, does politics not move, or pretends to move, or moves badly? Professor Sirchia outlines the main reasons, in his opinion.

In Italy, the tobacco industry provides employment (i.e. jobs and income) for around 200-250,000 people and it is clear that politics takes this into account. Secondly, tobacco companies have huge revenues from their work, which allows them to be munificent towards all possible sources of opposition to the policies of selling their products. There is evidence; various documents in courts around the world, especially in the United States, confirm that politicians, journalists, doctors, Universities (and the list could go on and on), have had advantages in not obstructing or favouring the products of the tobacco industry. Thirdly, the industry in question has great marketing skills, it knows how to exploit all opportunities for advertising, direct or indirect. We all know about the advertisements for smoking in films and television series, regardless of the type of character – good or bad – or the advertisements put out by influencers, mainly for new products and aimed mainly at young people, who must be attracted and persuaded to become habitual consumers to be “trendy”, to be important, by repeating cliques already seen in the past. The vision, the example, proposed as a normal and attractive behaviour, induces imitation, thus determining the start or resumption of smoking. We all remember the tobacco industry's contamination of sporting events, which is now being revived at medical congresses, for example, but not only. Lastly, the tobacco industry's holdings of shares in related companies, such as those in the food industry, are very important. In Italy, then, controls have almost disappeared; the police and the Local Health Units, which by law have the duty to check that there is no smoking in the workplace, do not comply with this obligation.

So, faced with economic power and the power of advertising penetration, which have neither ethical nor economic limits to their actions, we can explain why political action has been paralyzed.

The Law Act No. 3/2003 succeeded because it overcame the opposition of Parliament, where there is both “friendly fire” and “enemy fire” against tobacco measures, as we saw in the latest draft of the 2021 Finance Act, when an increase in tobacco excise duty was included but promptly cancelled in less than twelve hours!

Parliament is the first to be genuinely opposed to the fight against tobacco; in fact, it only approves very formal measures, which will then not be applied, in order to satisfy that part of public opinion, which is the majority, that is against tobacco smoking.

According to Professor Sirchia, we are therefore faced with an inertia (provoked and unprovoked) that makes us understand why tobacco control is and will still be a long way from being seriously implemented at a political level.

To aggravate the situation there are also the new policies that the tobacco industry is pursuing with “front groups” such as the Foundation for a Smoke-Free World (FSFW) (a foundation financed by Philip Morris International - PMI) which promotes the passage from traditional tobacco to heated tobacco through new devices, or the declarations of the new Managing Director (again of PMI), who hopes that the tobacco industry will be included in the world of pharmaceuticals, for example in palliative care, given the experience acquired in the administration of chemical substances by inhalation.

So, the minister asks, what can be done to truly liberate humanity from the tobacco catastrophe? And the answer is to implement Associationism!

So many people are harmed by smoking that there are 21 diseases attributed to tobacco! Diseases that affect by creating mortality and above all morbidity (30 times higher than mortality), which determines that very high number of chronically ill people in our country that absorbs a lot of health spending. Then there are all the 'sensible' people who do not want to be harmed by tobacco and who are also tired of being taken for a ride by the tobacco industry and politicians. Today's invitation is therefore to unite all these realities to form one big force, an alternative to the tobacco industry, which cannot be ignored by politicians, and which will be able to give a “gentle push” (nudge) to implement serious actions to combat smoking.

The floor was given to Dr Francesco Schittulli, national President of LILT (Lega Italiana per la Lotta contro i Tumori), which has been helping to combat smoking through courses and the SOS LILT toll-free number since the 1950s. After thanking Professor Sirchia for “his” law act, Dr Schittulli declared himself in full agreement with what Professor Sirchia had outlined and supported the idea of creating an alliance or federation of associations, from FNOMCeO (National Federation of the Orders of Surgeons and Dentists) to FOFI (Federation of Italian Pharmacists Orders), from CONI (Italian National Olympic Committee) to ANCI (National Association of Italian Municipalities) in addition to the associations and scientific societies that are already interested in and committed to the fight against smoking. Dr Schittulli, reflecting on the data showing an increase in tobacco consumption during the COVID-19 pandemic, questioned why tobacco shops were always open, like grocery shops, during the lockdown. Awareness of the damage caused by smoking needs to be raised and LILT is contributing to this aim with the ministerial project Guadagnare salute con la LILT (Gaining health with LILT), which involves training primary and nursery school teachers so that children can also convey messages to promote cessation of smoking.

Professor Maria Sofia Cattaruzza, Vice President of the Italian Society of Tobaccology (SITAB), after thanking the organizers of the round table for choosing such an important topic, pointed out that associations are born with the aim of coming together to achieve a common goal, in this case the protection of health, the environment and human (but also animal) rights, all sectors that are heavily damaged by tobacco. The key to gaining strength is to build and/or implement synergies between the various associations working in society to combat tobacco use. Patient associations, consumer associations, scientific societies, institutions, municipalities, environmentalists... all those who, for various reasons, are carrying out tobacco control initiatives, are supporting them or are interested in doing so, should join forces and coordinate. To do this, it is also important to identify ‘key’ people, i.e. motivated and trained people who will actually work on the proposed initiatives.

A case in point is the European Cancer Patient Coalition (ECPC), the largest umbrella organization in Europe, involving more than 450 cancer patient organizations. The ECPC, only recently following a change in leadership, has taken steps to undertake tobacco control initiatives, such as the inclusion of tobacco in the "white paper" on the impact of cancer-related complications and comorbidities (editor’s note: European Community documents on specific topics which should then be transformed into concrete actions) or the organization of webinars to disseminate the importance of tobacco cessation in cancer patients, which leads to improved chemotherapy treatments with lower doses and less risk of side effects and therapy discontinuation.

Another key element is to ensure the independence of associations and scientific societies from the tobacco industry to provide clear and transparent evidence-based contributions and information. SITAB is collaborating and providing scientific support, for example to the Association “Benessere SenzaFumo” (Wellness WithoutSmoke®), the first national association of non-smokers, with great potential for development; the Association “I Borghi del Respiro” (Breathing Villages), a national association born from the collaboration between pulmonologists, patients, experts and politicians of the territory and air quality to promote not only health, but also tourism and economic aspects; the “Associazione Liberi dal Fumo” (ALIBERF), a voluntary Association of ex-smokers and non-smokers aimed at raising awareness of the environmental damage of tobacco. Future potential could involve student associations, which are very sensitive to environmental and human rights issues, teachers, sportsmen and women, religious people, etc. The whole of civil society could and should be involved, also using the themes of the 2030 Agenda. In fact, there are many Sustainable Development Goals related to tobacco (SDG 1 poverty, SDG 2 hunger, SDG 3 health, SDG 4 education, SDG 5 gender equality, SDG 6 water, SDG 8 work, SDG 10 inequalities, SDG 11 cities; SDG 14 life under water, SDG 15 life on earth, SDG 16 peace, SDG 17 partnership), as indicated in the World Health Organization publication “Tobacco control for sustainable development”.

Dr Stefania Di Vito of Legambiente then spoke on environmental issues, reporting in particular on the dispersion of cigarette butts and the work of Legambiente, which has been committed for years to monitoring waste by applying protocols for counting and classifying it and tracing its origin. Awareness of “marine litter”, i.e., the pollution of the seas, is increasing all over the world and the latest data show that in Italy 10% (in Europe 18%) of the waste collected on beaches consists of cigarette butts; on average there are 70 butts every 100 meters of beach. The recent directive on single-use plastics, which examines the 10 most common types of waste on Italian beaches, includes cigarette butts among the disposable plastic waste. Legambiente also monitors city parks and here the figures rise dramatically, with smoking-related waste (cigarette butts, cigarette packets, lighters, etc.) accounting for 40% of all waste found. Another important problem is the use of manholes as ashtrays, with the consequent dispersion of cigarette butts directly into rivers, lakes, and seas. Legambiente is also pursuing various initiatives, including “plastic-free” beaches, which work if they are shared by several municipalities on the same stretch of coastline.

Dr Salvatore D'Antonio, President of the Italian COPD Patients Association, reports that patients with chronic obstructive pulmonary disease (COPD) are greatly underestimated, probably because spirometry, which is essential for diagnosis, is not as widespread. In fact, the Association is working hard to spread the use of spirometry and identify COPD patients at an early stage. These patients, estimated to be around 6 million in Italy, are patients aged 60 years and over who are smokers and who have lived in an era, the 1950s and 1960s, in which people were not aware of the damage caused by smoking. On the contrary, cigarettes were considered a moment of growth, of emancipation, of ostentation of elegance, a means of remuneration for soldiers, and an aid to work, especially at night. This population has a heritage of smoking: 28% stopped smoking less than 5 years ago, 15% are still smokers and there is also a significant percentage of people who smoke in oxygen therapy and do so secretly, because the prescription of oxygen is prohibited if you are a smoker, due to the risk of spontaneous combustion.

The association interviewed COPD patients during the lockdown to understand adherence to therapy and found that a small percentage of patients returned to smoking and/or increased their number of cigarettes. The association is the creator of the “I Borghi del Respiro” (Breathing Villages) initiative, which was set up together with the Council for Agricultural Research and Analysis of Agricultural Economics (CREA), the Italian Proloco and the Italian Thoracic Society-Italian Association of Hospital Pulmonologists (ITS-AIPO) to promote tourism and health. Twenty or so municipalities in Abruzzo, Lazio, Umbria, and Emilia-Romagna, united by the excellent quality of their air, have signed a pact to promote a “culture of health” and at the same time revitalize small communities. The pact, in addition to guaranteeing targeted hospitality for people sensitive to environmental allergies, provides for a ban on tobacco smoking in outdoor public places (such as gardens, open-air venues, Schools, health areas), promoting sustainable mobility (including pedestrian islands, at least during the summer) and facilitating the use of places of natural value.

The round table of the Congress closes with the intervention of lawyer Corrado Mattarelli, associate and lawyer of Asso-Consum, an Association that provides assistance and guidance to consumers and is engaged in actions to protect citizens’ rights, especially from unfair commercial practices and misleading advertising messages. Asso-Consum does not have as its exclusive “mission” the fight against smoking, but since 2018 it has come across issues related to the tobacco market by undertaking a series of actions against some major manufacturers of electronic cigarettes to protect consumers’ rights. In particular, since 2017, massive and invasive advertising campaigns aimed at directly or indirectly sponsoring e-cigarettes and refill liquids have been launched in the market, on social media and the internet. In these campaigns, a new message is conveyed, in which the electronic cigarette is proposed not only as a valid alternative to the traditional cigarette, but even as capable of producing benefits for the consumer: it is socially more accepted, it does not produce odors, it is technological and cutting-edge, so people are led to believe that it is safer, it is associated with natural or agri-food products, which are considered harmless or healthy. In short, the main message, conveyed as a leitmotif by these advertising campaigns, is that the use of electronic cigarettes is certainly less harmful, and the risk associated with them is only 5% compared to traditional cigarettes. The increase in the use of e-cigarettes, especially among the very young, coincided with the entry of “big tobacco” into the e-cigarette market and the launch of these misleading advertising campaigns. All advertising for traditional tobacco has been prohibited since 1962, and for electronic cigarettes by the 2014 European Directive (2014/40/EU), transposed in Italy by the Legislative Decree No 6 of 2016. Asso-Consum, in this context, has detected this illegal commercial advertising practice, which is detrimental to consumers’ rights, and has initiated interlocutions with the main tobacco manufacturers aimed at obtaining an end to these campaigns and a review of the advertising message conveyed. These interlocutions were unsuccessful and Asso-Consum decided to take on this battle for legality and, at the end of 2018, brought an injunction action at the Court of Rome, suing the main manufacturer of electronic cigarettes in Italy and requesting a declaration of the illegality of these commercial practices on the Internet and an injunction order against the manufacturer. The Court of Rome accepted the association's arguments and with the ordinance of 11/5/2019 confirmed the unlawfulness of the advertising campaigns on electronic cigarettes and ordered their termination. Following a precautionary appeal brought by the manufacturer against the ordinance, the court once again confirmed the unlawfulness of the conduct. New legal actions have been initiated against other manufacturers and are pending at the court of Milan; it is hoped to obtain a uniformity of views to clearly identify the limits within which electronic cigarette manufacturers can operate in conveying their advertising messages. Faced with illegitimate advertising campaigns that violate a European Directive and an Italian Legislative Decree, only a consumer Association has taken action; the absence of legal initiatives on the public side is very surprising. It is the battle of David against Goliath. If the same action had been taken by several associations, it would have had a greater impact, including in the media.

Professor Sirchia thanked everyone for the interesting topics discussed and the keen interest shown by the various speakers for a proposal that could unite and coordinate the forces of “tobacco control”.

He concluded by saying that there are many forces to counter the organized interests of the tobacco lobby, starting with the people who are tired of being manipulated and seeing their rights trampled underfoot. What we need to do, as experts, associations, and institutions, is to unite and organize ourselves in order to give voice to this popular will and create an alternative force to the tobacco lobby, which is visible in society and which forces politicians to take decisions in the interest of the majority, to protect health and the environment.

References

1. Million Hearts®. 2022. Publisher Full Text
2. World Health Organization (WHO). World Health Organization: Regional Office for South-East Asia New Delhi; 2017.