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Smoking in Italy 2013-2014, with a focus on the young

Abstract

Aims

To update smoking prevalence trends in Italy among adult and young populations; to determine the recent spread, particularly among young smokers, of roll-your-own (RYO) cigarettes (which cost approximately half the price of manufactured cigarettes); and to evaluate the effects of 2013 legislation increasing the minimum tobacco purchasing age from 16 to 18 years in Italy.

Methods

Two surveys on smoking were conducted in 2013 and 2014 in Italy, on a total sample of 6052 individuals, representative each year of the national population aged ≥15 years, where we collected data on type of tobacco most frequently smoked and on the perception of the enforcement of the tobacco sales-to-minors legislation.

Results

A total of 21.1% of the population surveyed were smokers (25.5% of men and 17.0% of women). Prevalence of current smoking among young participants (15-24 years) was 19.9% (21.7% of male participants and 18.0% of female participants). Overall, 6.9% of smokers, and 13.3% of young smokers, reported RYO cigarettes as the most frequently smoked tobacco product. More than 80% of Italian adults had never seen a tobacco retailer refuse to sell cigarettes to minors (i.e., aged <18 years) or request their identification or age.

Conclusions

Although adult and young smoking prevalence rates substantially decreased over the last few decades, neither of them have significantly changed since 2007. Use of RYO cigarettes is increasing, particularly among the young. Our study highlights the need to equalize the costs of different types of tobacco products and to improve the enforcement of the current tobacco sales-to-minors legislation.

Tumori 2015; 101(5): 529 - 534

Article Type: ORIGINAL RESEARCH ARTICLE

DOI:10.5301/tj.5000311

Authors

Alessandra Lugo, Rosario Asciutto, Roberta Pacifici, Paolo Colombo, Carlo La Vecchia, Silvano Gallus

Article History

Disclosures

Financial support: Supported by the Italian Ministry of Health and the Italian League Against Cancer (Milan) (S.G.).
Conflict of interest: None.

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Introduction

Despite increased awareness of the dangers of smoking on human health and global efforts to control tobacco use, tobacco smoking remains the main cause of preventable mortality worldwide, leading to nearly 6 million deaths (12% of total mortality) every year (1), with cancers being responsible for approximately one-third of the deaths (2).

In Italy, adult smoking prevalence consistently decreased since recording started in 1957 (3, 4). This fall is partially due to effective tobacco control strategies, which have been adopted at a national or community level over the last few decades. In 2005, Italy was the first large country to introduce a comprehensive smoking ban, which resulted in a further acceleration of the decreasing trend of smoking prevalence in both sexes (5, 6). Since 2005, no relevant tobacco control measures have been further implemented for adults (7). Consequently, smoking prevalence levelled off over the last few years (3).

Scanty information is available on the trend in smoking prevalence for the young generation. On the one hand, a decrease in smoking prevalence is expected, at least for adolescents, given that following the policies of the Framework Convention of Tobacco Control of the World Health Organization, since January 2013, the Italian government reinforced the sales-to-minors legislation, increasing the minimum age of purchasing tobacco from 16 to 18 years. Moreover, the recent economic crisis increased the youth unemployment rate from 21% in 2008 to 43% in 2014 (8), resulting in decreased ability to afford tobacco products.

Compliance with the restrictions on cigarette purchasing for adolescents has been limited in Italy (9). Moreover, the tobacco industry took advantage of current national tax regulation loopholes to market affordable tobacco products, offering young smokers the possibility to downtrade (10). Consequently, roll-your-own (RYO) cigarettes, costing approximately half the price of manufactured cigarettes, have become more widespread, particularly among young smokers (3).

Monitoring smoking prevalence and trends among young adults is imperative to quantify the effects of the latest interventions and to identify the best strategies to control tobacco. Therefore, in the present study, we combined data from 2013 and 2014 nationally representative surveys to provide updated and detailed information on smoking prevalence in Italy, with a focus on the young.

Methods

Two surveys on smoking were conducted in Italy in 2013 and 2014, using methods similar to those described in previous investigations (3, 11). Data were collected during ­February-May 2013 and February-April 2014 by DOXA, the Italian branch of the Worldwide Independent Network/Gallup International Association. The overall sample consisted of 6052 individuals (2906 men and 3146 women; 3000 in 2013 and 3052 in 2014), representative each year of the general Italian population aged 15 years and over, in terms of sex, age, geographic area, and socioeconomic characteristics.

Participants were selected through a representative multistage sampling. The first stage was used to select municipalities (the smallest Italian administrative division) in all of the 20 Italian regions (the largest Italian administrative division), in order to be representative of the geographic areas sampled. Thus, taking as criteria 2 characteristics, region and size of municipality, we identified 116 municipalities, providing a reproduction of the Italian universe of municipalities (method known as proportional stratified sample). In the second stage, in each municipality, an adequate number of electoral wards was randomly extracted (each ward corresponding to a given district of the municipalities). In the third stage, individuals were randomly sampled from electoral rolls, within strata defined by sex and age group, in order to be representative of the demographic structure of the population. For adolescents aged 15-17 years, we used the same sampling approach for the first 2 stages. According to the third stage, adolescents, whose names are not included in the electoral lists, were selected by means of a quota method (by sex and exact age).

Field substitution was used as the preferred strategy to deal with nonresponders. Therefore, nonresponders, including potential participants refusing to participate and unavailable and ineligible participants, were substituted by their neighbors (living in the same floor/building/street) with the same sex and age group. In the phase of processing the data, statistical weights were also generated to assure representativeness of the Italian population aged 15 years or over.

Ad hoc trained interviewers conducted interviews in ­Italian language using a structured questionnaire in the context of a computer-assisted personal in-house interview. Besides general information on sociodemographic characteristics, data were collected on smoking status (never/ex/current smokers), mean age at starting smoking, and number of cigarettes smoked per day. Ever smokers (current and ex-smokers) were participants who had smoked 100 or more cigarettes in their lifetime. Among ever smokers, ex-smokers were participants who had quit smoking since at least 1 year, and current smokers were individuals continuing smoking or having stopped since less than 1 year. Education was categorized into low (up to middle school diploma), intermediate (high school), and high (university). Geographic area was categorized as northern (8 regions), central (4 regions), and southern Italy (8 regions, including islands).

Two specific questions on the type of tobacco smoked, including manufactured and RYO cigarettes, pipe, cigars, cigarillos, and smokeless tobacco, were formulated as follows: “Which type of tobacco product do you most frequently consume?” and “Which other type of tobacco products do you consume, even occasionally?” Any use was built as the sum of most frequently used and occasionally used tobacco products.

In the 2013 survey, participants were asked whether the current tobacco sales-to-minors law was observed, with the following question: “Have you ever seen a retailer refusing to sell cigarettes to a minor, or requesting the minor’s identification document to verify the age?”

Data analysis

Percent distribution of smoking habits, and the corresponding 95% confidence intervals (CI), were computed overall and in strata of sex. p values for comparisons were derived using t test for continuous variables and χ2 test for categorical ones. We estimated the odds ratios (OR) and corresponding 95% CIs, overall and separately for men and women, for current smokers vs nonsmokers, using unconditional multiple logistic regression models after adjustment for sex, age, level of education, geographic area, and survey year.

Results

Table I shows the percent distribution of smoking habits of the Italian population aged 15 years or over, and among the young (15-24 years), in the 2013 and 2014 surveys combined. Overall, 66.0% of Italian adults described themselves as never smokers, 12.9% as former smokers, and 21.1% as current smokers (25.5% of men and 17.0% of women; p<0.001). Among the young, the prevalence of current smoking was 19.9% (21.7% in male participants and 18.0% in female participants; p = 0.234). The average daily number of cigarettes per smoker was 13.4 in the overall sample (14.6 in men and 11.9 in women; p<0.001), and 11.0 in the young (10.5 in male participants and 11.5 in female participants; p = 0.341). Mean age at starting for current smokers was 17.6 years overall (17.3 in male participants and 18.0 in female participants; p = 0.106). More than 95% of current smokers started smoking regularly before 25 years of age.

Percent distribution (and corresponding 95% confidence interval) of smoking habits in the Italian population aged ≥15 years and among the young, overall and by sex: Italy 2013-2014

Smoking status Total sample (≥15 years), % (95% CI) Young (15-24 years), % (95% CI)
Total Male Female Total Male Female
CI = confidence interval; SD = standard deviation.
Never smokers 66.0 (64.8-67.2) 56.3 (54.5-58.1) 75.0 (73.4-76.5) 78.6 (75.6-81.7) 76.5 (72.1-80.9) 81.0 (76.7-85.2)
Ex-smokers 12.9 (12.1-13.7) 18.2 (16.8-19.6) 8.0 (7.1-9.0) 1.4 (0.5-2.3) 1.8 (0.4-3.2) 1.0 (0.0-2.1)
Current smokers 21.1 (20.1-22.2) 25.5 (24.0-27.2) 17.0 (15.7-18.4) 19.9 (17.0-22.9) 21.7 (17.4-25.9) 18.0 (13.9-22.2)
Mean cigarettes/day (SD) 13.4 (6.8) 14.6 (7.1) 11.9 (6.1) 11.0 (6.0) 10.5 (6.2) 11.5 (5.7)
Total number of participants 6052 2906 3146 690 361 329

Smoking prevalence steadily declined from 29.2% in 2001 to 21.7% in 2014 (i.e., a 26% relative reduction), consistently in both sexes (Fig. 1). The decrease in smoking prevalence was even more marked in the young, falling from 34.1% in 2001 to 19.6% in 2014 (i.e., 43% of relative reduction). However, both in the adults and in the young, no significant change in smoking prevalence has been observed since 2007.

Trends in smoking prevalence in the Italian population aged ≥15 years and among the young, according to 14 DOXA surveys, overall and by sex. Moving averages based on a 3-year period. Italy 2001-2014.

Smoking prevalence was 12.8% among teenagers aged 15-19 years, 26.0% among young adults aged 20-24 years, 26.5% in participants aged 25-44 years, 24.6% in participants aged 45-64 years, and 9.7% in the elderly. Excluding teenagers, as compared to participants aged 20-24 years, the ORs were 0.98 (95% CI 0.76-1.26) for 25-44, 0.82 (95% CI 0.63-1.06) for 45-64, and 0.24 (95% CI 0.18-0.33; p for trend <0.001) for those aged ≥65 years.

Table II shows overall and sex-specific ORs for current smokers vs nonsmokers. Women were less frequently current smokers than men (OR 0.62; 95% CI 0.55-0.70). A significant inverse trend in smoking prevalence was observed overall and in both sexes according to level of education: as compared to low level of education, ORs were 0.82 (95% CI 0.71-0.95) for intermediate and 0.59 (95% CI 0.48-0.72) for high level of education. No specific pattern was found according to geographic area in men or women. A higher smoking prevalence was observed in 2014 as compared to 2013 in women (OR 1.30, 95% CI 1.07-1.57), but not in men (OR 0.94, 95% CI 0.79-1.12). Among the young, no significant differences were ­observed in terms of smoking prevalence according to sex, level of education, geographic area, or survey year.

Odds ratios of current smokers vs nonsmokers (never and ex-smokers) and corresponding 95% confidence intervals according to selected characteristics in the overall sample (≥15 years) and in the young (15-24 years): Italy 2013-2014

Total sample (≥15 years) Young (15-24 years)
No. % OR of current smokers (95% CI) No. % OR of current smokers (95% CI)
Total Male Female Total Male Female
CI = confidence interval; OR = odds ratio.
Odds ratios were estimated using unconditional multiple logistic regression models after adjustment for sex, age, level of education, geographic area, and survey year.
aReference category.
Total 6052 21.1 690 19.9
Sex
 Male 2906 25.5 1a 361 21.7 1a
 Female 3146 17.0 0.62 (0.55-0.70) 329 18.0 0.80 (0.55-1.16)
Education
 Low 2396 19.8 1a 1a 1a 135 19.2 1a 1a 1a
 Intermediate 2725 23.4 0.82 (0.71-0.95) 0.79 (0.65-0.97) 0.87 (0.69-1.09) 438 20.5 1.09 (0.68-1.77) 1.40 (0.71-2.75) 0.81 (0.39-1.65)
 High 931 18.1 0.59 (0.48-0.72) 0.49 (0.37-0.66) 0.72 (0.53-0.97) 117 18.5 0.99 (0.52-1.90) 1.07 (0.42-2.75) 0.84 (0.34-2.03)
 p for trend <0.001 <0.001 0.029 0.989 0.760 0.691
Geographic area
 Northern Italy 2781 20.9 1a 1a 1a 280 17.1 1a 1a 1a
 Central Italy 1196 21.2 1.03 (0.87-1.22) 1.20 (0.96-1.50) 0.82 (0.63-1.07) 121 21.3 1.32 (0.77-2.26) 1.83 (0.90-3.72) 0.86 (0.36-2.05)
 Southern Italy and islands 2075 21.4 0.98 (0.84-1.12) 1.00 (0.82-1.21) 0.94 (0.76-1.16) 290 22.1 1.39 (0.91-2.11) 1.63 (0.92-2.89) 1.13 (0.61-2.11)
Survey year
 2013 3000 20.6 1a 1a 1a 349 20.3 1a 1a 1a
 2014 3052 21.7 1.09 (0.96-1.23) 0.94 (0.79-1.12) 1.30 (1.07-1.57) 341 19.6 0.95 (0.66-1.39) 1.01 (0.61-1.78) 0.87 (0.50-1.54)

Overall, 92.1% of current smokers reported manufactured cigarettes as the most frequent type of tobacco product used, 6.9% RYO cigarettes, 0.5% cigarillos, 0.4% cigars, 0.1% pipe, and 0.1% smokeless tobacco (Tab. III). The use of RYO cigarettes was similar in male (8.0%) and female smokers (5.4%; p = 0.073), and was more frequent among smokers aged 15-24 years (13.3%) compared to those aged 25-44 (8.4%), 45-64 (4.9%), or ≥65 years (1.5%; p for trend <0.001). Among young smokers, 15.4% of boys and 10.5% of girls most frequently smoked RYO cigarettes. Prevalence of any use of RYO cigarettes among current smokers was 13.4% in the overall sample (16.3% in men and 9.4% in women) and 26.6% among the young (33.9% in boys and 17.0% in girls). This prevalence increased from 9.5% in 2013 to 17.0% in 2014 in adults and from 22.5% to 31.0% in the young.

Percent distribution of current smokers according to the most frequently smoked and occasionally smoked tobacco products, overall and among the young: Italy 2013-2014

Total sample (≥15 years) Young (15-24 years)
Total Male Female Total Male Female
aThe sum exceeds the total because multiple choices were admitted.
No. 1278 742 536 137 78 59
Type of tobacco most frequently smoked
 Manufactured cigarettes 92.1 90.2 94.6 86.7 84.6 89.5
 Roll-your-own cigarettes 6.9 8.0 5.4 13.3 15.4 10.5
 Cigars/cigarillos/pipe 1.0 1.7 0.0 0.0 0.0 0.0
 Smokeless tobacco 0.1 0.2 0.0 0.0 0.0 0.0
Any usea
 Manufactured cigarettes 96.0 94.8 97.4 96.1 96.4 95.7
 Roll-your-own cigarettes 13.4 16.3 9.4 26.6 33.9 17.0
 Cigars/cigarillos/pipe 3.8 5.7 1.1 1.6 2.9 0.0
 Smokeless tobacco 0.2 0.3 0.0 0.0 0.0 0.0

In 2013, among participants reporting to be tobacco shop customers (n = 1741), 84% had never seen a retailer refusing to sell cigarettes to a minor (i.e., aged <18 years) or requesting the minor’s identification or age, 7% have seen it once, 7% sometimes, and 2% often.

Discussion

In 2013-2014, we found an overall smoking prevalence among Italian adults of 21% (26% of men and 17% of women). This is in broad agreement with recent data from a large household survey (based on 60,000 families and 130,000 individuals) conducted in 2013 by the National Institute of Statistics, showing an adult smoking rate of 21% (26% in men and 16% in women) (12). We also confirm the steady decreasing trend observed over the last 5 decades in men and over the last 2 decades in women (3). These patterns suggest that Italy has passed into stage IV (final stage), characterized by an inverse trend in smoking prevalence for both sexes, of the model of the tobacco epidemic described by Lopez and colleagues in 1994. In this stage, tobacco control measures should target women and smoking cessation among adults (13).

However, no significant decrease in terms of smoking prevalence has been observed in men or women between 2007 and 2014. This likely reflects the lack of adoption of relevant additional antismoking measures after the successful ban introduced in 2005 (7).

We confirm the inverse trend according to educational status in both sexes. Whereas for men this finding was consistently observed in previous Italian surveys (14, 15), less than a decade ago age-adjusted smoking prevalence was still higher in highly educated women (14). Today, multivariate analysis shows a significant inverse trend with education not only in men, but also in women.

Smoking prevalence trend among the young (15-24 years) reflects that of the general adult population. Despite the new regulation, in force since 2013, prohibiting the purchase of tobacco to minors, smoking prevalence estimates in the young did not change after the legislation. This may be due to lack of enforcement of the tobacco sales-to-minors law. A large ­majority of Italians (more than 80% of tobacco shop customers) have never seen a tobacco retailer refusing to sell cigarettes to minors or requesting their identification or age. Young adults represent the crucial segment of tobacco consumers, since nearly all tobacco users begin during youth (16-17-18), and the earlier the age at which a person begins to smoke the more likely he or she persists in this habit into adulthood (19). Also, in our dataset, more than 95% of smokers reported to have started smoking at 25 years of age or earlier. However, the overall prevalence of smokers of about 20% in the young is appreciably lower than that observed in previous generations, approaching 35% in the early 2000s and having been observed at over 30% since recording in the 1960s (20, 21). Since starting smoking is infrequent after age 25 years, while stopping smoking increases with age, the recent Italian trends for the young will likely result in an appreciably lower smoking prevalence in the future for middle-aged and elderly populations.

The tobacco industry is aware that it needs to attract young people towards nicotine addiction to assure the existence of future tobacco customers, implementing strategies to encourage young people to smoke. Among those strategies, the tobacco industry exploits fiscal loopholes to sell certain types of tobacco at an affordable price for young individuals (10). Thus, RYO cigarettes are sold at around half the price of manufactured ones. Overall, we found that 7% of smokers, and 13% of young smokers, reported RYO cigarettes as the most frequently smoked tobacco product. Furthermore, in Italy, today, over one-quarter of young smokers smoke RYO cigarettes. As a consequence of the recent economic downturn, a proportion of (young) smokers switch to cheaper types of tobacco (3, 22): 10 years ago, RYO cigarette consumption was negligible in Italy, whereas in 2011 smokers reporting RYO cigarettes as the most frequently used tobacco product increased to 3.4%, and more than doubled in only 4 years, passing to 5.9% in 2012 (3), 6.0% in 2013, up to 7.7% in 2014. Among the young, smokers reporting RYO cigarettes as the most frequently used tobacco product increased from 4% in 2010 (23) to 9% in 2011-2012 (3), up to 13% in 2013-2014. The increase in RYO cigarette use over the last few years was also observed in several other high-income countries, including the United States (24, 25), UK (25, 26), Germany (27), and Spain (10, 28), particularly among the younger generations (26). The number of RYO cigarette users in Italy remains substantially lower compared to that observed in other European countries (29), including in particular the United Kingdom, where the proportion of RYO cigarettes on total tobacco products is around 30% (26, 29).

A limitation of the present survey is the relatively small number of adolescents aged 15-17 years. This did not allow us to estimate smoking prevalence and other determinants in this subgroup of the population. Moreover, the self-reported assessment of the enforcement of the tobacco sales-to-minors law through a population-based survey may be affected by misreporting or information bias, and future research should confirm our findings using more appropriate study designs. The strengths of this study include the face-to-face survey design and the national representativeness of the sample. Moreover, the annual collection of data using the same methodology allowed us to observe time trends for smoking prevalence and other endpoints.

Our study highlights the need to enforce the current tobacco sales-to-minors legislation and to equalize the costs of different types of tobacco products, in order to protect the health of the young generation and consequently the future health of Italians.

Disclosures

Financial support: Supported by the Italian Ministry of Health and the Italian League Against Cancer (Milan) (S.G.).
Conflict of interest: None.
References

Authors

Affiliations

  • Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan - Italy
  • Department of Sciences for the Health Promotion and Mother and Child Care “G. D’Alessandro,” Hygiene Section, University of Palermo, Palermo - Italy
  • Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome - Italy
  • Istituto DOXA, Worldwide Independent Network/Gallup International Association (WIN/GIA), Milan - Italy
  • Department of Epidemiology, IRCCS - Istituto di Ricerche Farmacologiche “Mario Negri,” Milan - Italy

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