Tobacco control in Italy| Tabaccologia

Article

Considering all types of risk factors, either metabolic or environmental or occupational or behavioural, in Italy tobacco smoking is firmly the main risk factor in terms of years of life lost (or lived with disability). It overtakes high blood pressure, dietary factors, obesity, alcohol and air pollution [1].

To face the spread of tobacco, there are certain policies that can be adopted at country level that have shown effectiveness in controlling tobacco. The Tobacco Control Scale (TCS) quantifies across European countries the level of implementation of six policies identified by the World Health Organization and the World Bank as the most effective:

1. price increases through increases in taxation (item that counts 30 points out of 100 in the TCS);
2. smoking bans in public and private places (22 points out of 100);
3. funding of public information campaigns (10 points out of 100);
4. advertising bans (13 points out of 100);
5. health warnings on cigarette packs (10 points out of 100);
6. access to smoking cessation treatments (10 points out of 100) [2].

It is important to highlight that the TCS only quantifies policies related to conventional tobacco, and does not consider the adoption of policies related to novel products, such as electronic cigarettes and heated tobacco products. The level of adoption of these policies in Italy in the latest version of the TCS (2021) is shown in Figure 1.

Price (TCS score for Italy: 13/30=4.3): increasing taxation - and consequently prices - of tobacco products is undoubtedly the most effective tobacco control policy. Indeed, increasing prices decreases smoking initiation, prevalence and consumption, and increases tobacco smoking cessation [3]. The price elasticity of demand for cigarettes in high-income countries, including Italy, is estimated to be -0.4 [3, 4]. This means that a 10% increase in prices will result in a 4% decrease in consumption. Economists teach us that with an elasticity of demand between -1 and 0, as in the case of tobacco products in Italy, a price increase also raises tax revenues. Therefore, raising taxation pays off from both a public health and a fiscal point of view. This has been well understood by France (TCS rating for price 21/30=7.0) and England (TCS rating 27/30=9.0), where the price of a pack of cigarettes now exceeds 10€, but not by Italy where the price of a pack of cigarettes remains very low (stable at 5-6€ for several years).

Smoke free places bans (score for Italy: 18/22=8.2): the Sirchia Law (2003) has been effective in reducing not only secondhand smoke exposure but also smoking prevalence and tobacco consumption [5]. The smoking ban should be extended to selected outdoor areas (such as playgrounds, beaches, and parks) to preserve the health of young people and the environment.

Information campaigns (score for Italy: 0/10=0.0): nowadays, ironically, the main funder of information campaigns and research projects on tobacco control is the tobacco industry (Philip Morris International alone allocated $1 billion to fund harm reduction research). In contrast, public funding in Italy, as in almost all major European countries, is negligible or non-existent.

Advertising bans (score for Italy: 9/13=6.9): advertising bans work reasonably well for conventional tobacco products.

Health warnings on packages (score for Italy: 5/10=5.0): today, health warnings (text and pictures) cover 65% of a cigarette package. However, Italy does not yet adopt the plain package, which does not use the colours, logo and other typical aspects of product brands, but only standard shapes, colours and styles [6]. It has been shown how the generic pack further reduces the attraction, especially among young people, and the prevalence of smoking among youth and adults. The plain package is already adopted in Europe by some countries, including France (TCS rating for warnings 9/10=9.0), England (TCS rating 9/10=9.0) and Turkey (TCS rating 10/10=10.0).

Treatment (score for Italy: 6/10=6.0): in Italy, 268 smoking cessation centres offer support to smokers, including effective treatments, both pharmacological (varenicline, bupropion or nicotine replacement therapy) and psychological. Despite the availability of these treatments, supports are not reimbursed for all smokers by the National Health Service (Servizio Sanitario Nazionale, SSN). This, by contrast, already happens in England (TCS rating for treatments 9/10=9.0). The bad news is that the manufacturer of varenicline (by far the most effective cessation drug) has suspended its distribution after more than 10 years of use. This is because concentrations above levels considered acceptable of a potentially carcinogenic substance were detected on some batches of the product, “coincidentally” just weeks before the patent expiration of the drug. The good news is that the evidence is consolidating that cytisine is highly effective as a smoking cessation treatment, a galenic treatment that is not only safe and effective, but also very cheap [7, 8]. This drug emerges as an excellent candidate to receive reimbursement from the SSN in Italy.

The prevalence of smoking in Italy, which has always been declining, has not decreased in the past 10 years [9]. This unfavourable trend is partly due to the lack of adoption of effective new policies since the Sirchia Law. In fact, compared with other European countries, Italy has gradually lost positions in the adoption of effective policies from eighth place (out of 30 countries) in the 2006 TCS to eighteenth place (out of 37 countries) in 2021 [2]. We can say that in Italy we have wide room for improvement in the adoption of tobacco control policies. One proposal of ours that could be implemented immediately (as it would not burden Italian finances, but on the contrary would bring in new revenues) is to significantly increase taxation for tobacco products and allocate part of the increased revenue for the reimbursement of cheap and effective smoking cessation treatments, such as cytisine.

The unfavourable trends of the last decade are undoubtedly mainly due to the spread of novel products, such as electronic cigarettes and heated tobacco, which do not help to quit but are an incentive for non-smokers and ex-smokers to start conventional cigarette smoking or relapse, respectively [10]. Consequently, electronic cigarettes and heated tobacco products, which today benefit from impressive and unjustifiable fiscal and regulatory benefits in Italy, should be regulated on par with conventional cigarettes.

Figures and tables

Figure 1.Tobacco Control Scale (TCS) scores related to the adoption of major tobacco control policies in the most populated European countries. TCS, 2021.

References

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