Tobacco smoking and use of novel nicotine-containing products in Lombardy: a study by LILT| Tabaccologia

Abstract

Introduction: The use of cigarettes and novel tobacco products represents a public health risk, especially for young people. This study aims to provide information regarding the used products and the experiences and habits of smokers in Lombardy, and awareness among the citizens of Milan of the “Milan Smoke Free 2026” project, the process that will lead to the complete ban on smoking in outdoor public areas after 2025.

Methods: The first survey, conducted in 2022, involved 895 smokers from Lombardy aged 18 to 70 years. Information about the products used and the age at first smoking experience was collected through a questionnaire. The second survey was based on 460 residents of Milan (smokers and non-smokers), and assessed their sensibility to environmental pollution related to smoking products, as part of the “Milan Smoke Free 2026” project.

Results: Traditional cigarettes still emerge as the most commonly used product (73% of the sample use them), although there is a widespread use of heated tobacco devices (32%) and electronic cigarettes with nicotine (26%). Among those aged 18-24 years, the use of roll-your-own cigarettes (51% of young people in the sample use them) and heated tobacco products (44%) is more common. The first experience with a nicotine-containing product occurs on average at age 16. Although only 49% of the citizens of Milan are aware of the “Milan Smoke Free 2026” project, the initiatives proposed by the Milan municipality are appreciated and largely shared (63-79% of the Milanese responded positively to the stop smoking proposal), even by the smokers themselves (51-63%).

Discussion: Widespread use of heated tobacco products and electronic cigarettes was observed among smokers in Lombardy, especially among young people. It is necessary to implement actions to avoid nicotine exposure among young or even underage people. Milanese citizens show broad sensibility to environmental issues and good adherence to tobacco control strategies, such as those currently carried out by the “Milan Smoke Free 2026” project.

Introduction

In the last decades, there has been a substantial decrease in sales of tobacco products in most high-income countries, which has occurred as a result of effective dissemination by the independent scientific community about the harmful effects of smoking on health. Increased awareness in the public, and the resulting pressure on policymakers, have enabled the introduction of effective fiscal and regulatory rules to control smoking. A similar trend has been observed in Italy: since the late 1950s, when the prevalence of smokers among Italian adults was over 35%, there has been a continuous decline in prevalence, which has fallen to nearly 20% in both sexes [1]. However, with the introduction of electronic cigarettes and, much more so, heated tobacco products (HTP), there has been a reversal of the favourable trend. In fact, an increase in the prevalence of conventional cigarette smokers was observed in Italy in 2022 (+2.2% compared to 2019), after decades of a downward trend [2].

The introduction of these new products has led to a great debate among public health experts about their impact on health and tobacco control. The World Health Organization (WHO) has warned about the use of these products as a smoking cessation tool, and several studies have shown that the use of electronic cigarettes and HTPs has harmful effects on health, specifically causing multiple respiratory disorders [4, 5]. In addition to safety issues, much of the controversy concerning electronic cigarettes and HTPs focuses on public health consequences, such as the re-normalization of conventional cigarette smoking and the ineffectiveness of these products in reducing conventional cigarette smoking in a non-clinical setting. Moreover, these novel products should theoretically be addressed to adult smokers who intend to quit smoking, but they are actually advertised and targeted to young people, often acting as gateways to conventional cigarette smoking [3,6,7].

This article presents the results of two surveys conducted by the Italian League Against Cancer - Lega Italiana per la Lotta contro i Tumori (LILT) Milano Monza Brianza APS. The first survey was conducted on a sample of adult smokers in Lombardy, collecting information regarding the devices used and the experiences and habits of smokers. A further survey was conducted on a sample of people living in Milan regarding the Milan municipality’s initiative, here called “Milano Smoke Free 2026”, a project that defines a series of actions aimed at improving environmental quality in the city, including a ban on smoking in the City of Milan in all outdoor public areas [8,9].

Methods

This study uses data from two convenience surveys conducted through online interviews using the CAWI (computer-assisted web interview) method between April 29 and May 4, 2022. Respondents, aged between 18 and 70, were selected from a panel composed of members of the adult population of Lombardy (northern Italy), with a specific oversampling of the population living in the territory of the Municipality of Milan.

The first survey collected information from a sample of 895 smokers living in Lombardy. The questionnaire was aimed at collecting information regarding the used devices and the experiences and habits of smokers, such as age at first experience.

The second survey involved 460 citizens (239 smokers and 221 non-smokers) living in the Municipality of Milan. The questionnaire focused on the respondents’ sensibility to the issue of pollution, specifically related to smoking products, and monitored the knowledge and agreement of the “Milan Smoke Free 2026” project by Milan citizens.

Results

The majority of smokers in Lombardy occasionally or regularly consume conventional cigarettes (73%). Moreover, 32% consume roll-your-own (RYO) cigarettes, 32% HTPs, 26% electronic cigarettes with nicotine, 23% electronic cigarettes without nicotine, and 19% cigars or cigarillos. In addition, 16% consume cannabis and 12% light cannabis. Figure 1 shows the percentage of use (occasional or regular) of various tobacco products or novel devices in Lombard smokers, stratified by gender and age group. Younger subjects, aged 18-24 years, are characterized by a larger proportion of RYO cigarettes users (51% of young smokers use them) and HTPs users (44%) than other age groups, while in 25–34-year-olds the use of cannabis (31%) and light cannabis (24%) stands out.

Among smokers in Lombardy, the first smoking experience occurs on average at 16.3 years, with a lower age of initiation among the youngest (15.4 years for 18–24-year-olds; 16.2 years for 25–34-year-olds; 16.7 for 35–54-year-olds; 16.6 for 55–70-year-olds). Only 29% of respondents who provided an answer to the question stated that they started smoking after reaching the age of majority.

The 460 Milanese citizens involved in this survey showed significant annoyance at seeing cigarette butts on the street (on a scale of 1-not at all to 10-very much, mean score: 8.7), higher among non-smokers (mean score: 9.1) than smokers (mean score: 8.2). In expressing their annoyance with street garbage, Milanese people placed cigarette butts after bottles, glasses and cans (mean score: 9.0) and dog droppings (mean score: 8.8), at the same level as masks (mean score: 8.7), and before wastepaper (mean score: 8.4). Sixty-three percent of respondents believe that smoking-related pollution is a serious problem that needs to be carefully addressed in order to reduce it as much as possible (53% among smokers and 72% among non-smokers; Figure 2).

The Milan Municipality’s decision to stop smoking even in outdoor public areas is seen as “correct” by 79% of Milanese (63% among smokers and 91% among non-smokers) and it is seen as an option that will “improve the quality of the environment in the city” by 65% of respondents (51% among smokers and 78% among non-smokers). Eleven percent of respondents are familiar with the “Milan Smoke Free 2026” project, 38% are familiar with it but do not know exactly what it is, and 51% have never heard of it (especially among non-smokers: 53%, and adults aged 55-70 years: 55%).

Discussion

Although conventional cigarettes remain the most widely used products among smokers in Lombardy, the frequency of use of HTPs and electronic cigarettes is high, with HTPs being now the most widely used electronic device in Lombardy. Moreover, this picture highlights how the world of tobacco has changed after the introduction of electronic devices, with a multiplication of consumption styles and habits that mix traditional and electronic devices. In this context, young people are distinguished by wider use of RYO cigarettes, which are cheaper, and on which it is necessary to intervene so as to limit their accessibility [10]. It is also alarming the high proportion of young people who are users of electronic devices, which has already been observed at a national level [11, 12]. Plausibly, dual users use electronic devices where smoking is prohibited [13, 14]. It is therefore a product that adds to the consumption of conventional cigarettes, increasing the frequency and amount of nicotine intake and making the addiction even stronger.

Today in Lombardy young people start smoking before the age of 18, despite the fact that selling to minors is forbidden. The new generations even seem to anticipate the average age of first smoking experience [15]. Importantly, according to scientific evidence, those who do not start smoking by the age of 20 are unlikely to start later [16]. Today with electronic cigarettes and HTPs, which are considered fashionable and less harmful than conventional cigarettes, it is even more difficult to avoid nicotine exposure by underage teens. Several studies have shown how the use of these products can act as a gateway to the consumption of conventional cigarettes, such that those who smoke electronic devices are up to 9 times more likely to start smoking than those who have never used them [6].

Electronic devices should theoretically be targeted at adult smokers, but are instead being advertised with the intention of making them “fashionable” and appealing primarily to a younger audience [17]. This type of advertising aimed at young people should be banned, with a special focus on social networks where young people, often underaged, are exposed to less controlled sponsorships and advertisements.

The initiatives carried out by the “Milan Smoke Free 2026” project turned out to be appreciated and largely shared by Milanese citizens. Even smokers, albeit with less enthusiasm, support the City’s proposals and recognize the problem of pollution related to smoking products. Less positive is the finding regarding awareness of the project, which is unknown or almost unknown to the vast majority of Milanese. It would certainly be useful to better involve the population in future initiatives by improving communication strategies aimed at both smokers and non-smokers.

The non-representativeness of the sample analysed represents a possible limitation of the study. In fact, the results obtained from the surveys are not generalizable to the population of Lombardy and Italy. In addition, the questionnaire was administered online and not in person by interviewers specifically trained to collect the study variables.

The results of this study highlight the need to take measures to prevent nicotine exposure by young or even underage people. As a first action, we recommend banning advertisements for electronic cigarettes and HTPs that are basically targeted, especially on social media, to younger people.

Figures and tables

Figure 1.Prevalence (%) of use (occasional or regular) of different products among 895 smokers in Lombardy, across sex and age group strata. Lombardy (Northern Italy), 2022.

Figure 2.Percentage (%) of positive response to questions related to the Milan Smoke Free 2026 project, submitted to 460 Milan citizens, in the total sample, in the smoking group (n=239) and in the non-smoking group (n=221). Milan, Lombardy (Northern Italy), 2022.

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