La législation Italienne pour la La législation Italienne pour la prévention du tabagismeprévention du tabagisme

Daniela Galeone, MD

Ministry of Health – ITALY

Ministero della Salute

• Population: 57 million (the first “great” European country to ban smoking)

• Smokers: 23.9% of Italian adults (2003)• Higher prevalence in men (31% versus 17.4%)• High prevalence in young people• Passive smokers: 26.5% of Italians • Cigarettes sold in tobacco shops, some bars,

vending machines (opened from 9 p.m. to 7a.m.)• Cost/pack: from 3.00 to 4.00 euros

BACKGROUND (2003)BACKGROUND (2003)

SMOKING ATTRIBUTABLE DEATHS SMOKING ATTRIBUTABLE DEATHS ITALY-2000ITALY-2000

Cause Males Females TOTAL

Cancer 31,365 4,504 35,869

Cardiovascular 22,028 7,187 29,215

Respiratory 12,220 4,551 16,771

Total 65,613 16,242 81,855

ESTIMATED EFFECTS OF SECONDHAND ESTIMATED EFFECTS OF SECONDHAND SMOKE IN ITALY SMOKE IN ITALY

(DEATHS OR ILLS A YEAR)(DEATHS OR ILLS A YEAR)

HOME EXPOSURE Children with smoking parents

CASES: 216,392 (acute respiratory infections, asthma, chronic respiratory symptoms, acute otitis, SIDS)

WORKPLACE EXPOSURE

CASES: 2,592(low birth weigh - for pregnancy exposure -, lung cancer, ischaemic heart diseases)

ITALIAN STRATEGY ON ITALIAN STRATEGY ON TOBACCO CONTROLTOBACCO CONTROL

• Protecting non-smokers’ health

• Reducing prevalence of new smokers

• Promoting smoking cessation

- 2004- 2004

Protecting no smokers’

health

SMOKING BANSMOKING BAN :

1975: Schools, Hospitals, Cinemas, Museums, Libraries, Public

transports

1995: Public offices (open to citizens)

2005: Smoking banned in ALL indoor places open to the public, including private offices, bars, restaurants, clubs and discos

ITALIAN STRATEGY ON TOBACCO ITALIAN STRATEGY ON TOBACCO CONTROLCONTROL

2005 – the Italian Smoking Ban2005 – the Italian Smoking Banthe process of approvalthe process of approval

Enabling factors:-- Leadership of 2 Ministry of Health (both prestigious

physicians)-- First bill presented from Umberto Veronesi on May, 2000Minister Sirchia’s Strategy:a) Nov 2001: four-fold increase in fines for people who

smoked in public places where smoking was already forbidden by previous restrictions

b) Jan-May 2002: “inserted” the smoking ban within a framework bill on public administration: a tactic branded the “Trojan horse” strategy by journalists.

c) After three attempts, the smoking ban has been approved on January, 2003

Limiting Factors:-- the 6-months delay in approving the

regulation on smoking rooms.-- the 1.5-year delay in approving the

regulation establishing owners’ responsibility for enforcing the ban in hospitality premises

-- the legal action in August 2005, which shifted responsibility for enforcement from public places owners to police

2005 – the Italian Smoking Ban2005 – the Italian Smoking Banthe process of approvalthe process of approval

Press Release,1998-2008, 50 Italian newspapers Key-words: smoke, cigarettes, Minister’s surname

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Press releasePrint media coverage peaked around key stages in

the policy process highlighting the value of engaging with the media to support the smoke-free policy process.

Press devoted a lot of attention to the political debate surrounding the ban. However, the long legislative process of the bill and its related regulations (2000-2004), stimulated journalists to publish articles informing people about tobacco control issues.

Press articles reported the smoking ban was almost unavoidable after 4 presentations by 2 Ministers of Health, both of whom were important physicians

2005 BAN – LAW 3/20032005 BAN – LAW 3/2003

• Designed to protect non-smokers health in all indoor spaces

• No-smoking signs must be posted up• Clear identification of enforcement

responsibilities• Fines for persons found smoking € 275• Fines for managers or owners € 220• Smoking areas allowed, but must meet strict

criteria (enclosed, negative-pressure ventilated to prevent no-smoking areas pollution)

IMPLEMENTATION PHASEIMPLEMENTATION PHASEMULTIMEDIA EDUCATION CAMPAIGNSMULTIMEDIA EDUCATION CAMPAIGNS

• Spots and debates on tv and radio

• Billboards and posters

• Inserts in newspapers and magazines

• Booklets

• Stickers

2003-2004: Before law enforcement2003-2004: Before law enforcement

2005: after 2005: after law enforcementlaw enforcement

In cooperation with: “Italian Association Against Cancer” LILT “National Institutes of Health (ISS)”

Give suggestions, clarifications, explanations about the law

HEALTH MINISTRY PHONE “HOT LINE” HEALTH MINISTRY PHONE “HOT LINE” PROVIDING INFORMATION ON THE NEW PROVIDING INFORMATION ON THE NEW

LAW (Jan-Feb 2005)LAW (Jan-Feb 2005)AIMS

Detect critical aspects to the application of the ban Identify stakeholders, their needs, doubts, opinions and concerns about the law

IMPLEMENTATION PHASEIMPLEMENTATION PHASE

IMPLEMENTATION PHASEIMPLEMENTATION PHASEHEALTH MINISTRY PHONE “HOT LINE” HEALTH MINISTRY PHONE “HOT LINE” PROVIDING PROVIDING

INFORMATION ON THE NEW LAW (Jan-Feb 2005)INFORMATION ON THE NEW LAW (Jan-Feb 2005)

FIRST MONTH RESULTSFIRST MONTH RESULTS > 4,000 CALLS RECEIVED– 13% on first day– 55% during first week– 60% from smokers– 98% for clarifications about law application (no-smoking signs, definition of “public indoor

space”)– <1% complaints about the law

• Thousands more accessed Ministry website, updated daily on the basis of most FAQ

Controversial questions and weak points

Gazebo

newsstand

Shopping center

Protected patios of restaurant, bar…

Courtyard

Apartment building

Stadium

Club (only for associated)

Open market

Jails

Terapeuthic communities

Rest homes

Psichiatrical wards

“Problematic places”

“Peculiar places”

HEALTH MINISTRY PHONE “HOT LINE” PROVIDING INFORMATION ON THE NEW LAW

(Jan-Feb 2005)

What did it work?

Staff prompt to deal with a great level of job condensed in a very short period

back-office of experts who can aid in technical questions and grant accuracy and reliability of the answers

Analisys in real time of the data, quick updating of manuals for the staff and of the informations loaded on the website. Press releases permitted a broad dissemination of the information

Give ear to stakeholders

Critical points Allies

Groups to support

HEALTH MINISTRY PHONE “HOT LINE” PROVIDING INFORMATION ON THE

NEW LAW (Jan-Feb 2005)

OPINION ON THE SMOKING BANOPINION ON THE SMOKING BAN

““ENFASI”ENFASI” STUDY ON STUDY ON PUBS/RESTAURANTSPUBS/RESTAURANTS

OPINIONS AND BEHAVIOURS OF OPINIONS AND BEHAVIOURS OF CLIENTS AND OWNERSCLIENTS AND OWNERS

BEFORE AND AFTER LAW BEFORE AND AFTER LAW ENFORCEMENTENFORCEMENT

Source: National Health Institute 2004-2005

““ENFASI”ENFASI” STUDY ON PUBS/RESTAURANTS STUDY ON PUBS/RESTAURANTS

• Self-administered questionnaire for owners or managers• Observational component: no-smoking signs, presence

of smoke/smokers during peak business hours• 1,600 locals visited

BEFORE LAW ENFORCEMENTBEFORE LAW ENFORCEMENTOWNERS OPINIONOWNERS OPINION

• High knowledge level about law• High knowledge of potential health risks of passive smoke• 25% expecting financial losses• 40% smokers themselves

Source: National Health Institute 2004-2005

OPINION ON THE SMOKING BANOPINION ON THE SMOKING BAN

STUDY OF PUBS/RESTAURANTSSTUDY OF PUBS/RESTAURANTS “ENFASI” “ENFASI”

AFTER LAW ENFORCEMENT AFTER LAW ENFORCEMENT OWNERS OPINIONOWNERS OPINION

• 10% asked smokers to put out their cigarettes

• 2% had clients disagreeing

• 76% reported favourable clients opinion

• Only 11% reported significant financial losses

Source: National Health Institute 2004-2005

STUDY OF PUBS/RESTAURANTSSTUDY OF PUBS/RESTAURANTSAFTER LAW ENFORCEMENT AFTER LAW ENFORCEMENT

OBSERVATIONAL COMPONENTOBSERVATIONAL COMPONENT

• Owners themselves are smoking less:27% “a lot less” 33% “a little less” 15% reported stopping

• 0.2% premises had currently smoking people

• All premises had no-smoking signs

• Less than 2% had “smoking roms”

Fear of economical effects

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Remarkable Loss Slight Loss No Loss/ I ncrease Don't know

Tobacco control strategyTobacco control strategy

based on modification of environmental

and social factors

part of a national strategy for prevention

of non communicable diseases (“Gaining

health: making healthy choices easier”)

““Gaining health” Gaining health” What is it What is it ??

A coordinated action plan

for counteracting physical inactivity, poor

nutrition, alcohol abuse,

tobacco consumption

the 4 leading risk factors for non-communicable

diseases (cardiovascular and respiratory

disorders, cancer, diabetes mellitus)

““Gaining health” Gaining health” What is itWhat is it??

A Government initiative

• led by the Ministry of Health

• based on:• Institutional alliance with Regions and

Municipalities• Partnership with food industry,

distribution networks, consumer associations, NGOs

““Gaining health” Gaining health” Why ?Why ?

It is already possible to prevent

non-communicable diseases by

reducing risk factors prevalence

Interventions atInterventions at individual levelindividual level

Actions on social and Actions on social and environmental conditionsenvironmental conditions

““Gaining health” Gaining health” Why Why ??

• To make healthy choices easierTo make healthy choices easier

• To promote better social conditions

• To protect vulnerable people (children, old

people, poor people)

• To reduce health inequalities

An ethical program

Health in all policiesHealth in all policies

Agricultural

Agricultural

PoliciesPolicies

School WorldSchool World

Transport andTransport and

urbanistic policies

urbanistic policiesEconomicalEconomical

PoliciesPolicies

Youth and Youth and Leisure timeLeisure time

Health SystemHealth System

• Protecting non-smokers’ health

• Reducing prevalence of new smokers

• Promoting smoking cessation

TOBACCO CONTROL STRATEGYTOBACCO CONTROL STRATEGY

in “Gaining Health”in “Gaining Health”

Prize for the excellence to

“Sistema Italia”

Ministry of Health, Regions, LILT, CSPO/Florence, CPO/Turin, IOR/Forlì,

INT/Milan

For the optimum activities in preparation, application and monitoring of the Italian smoking ban

An incisive instrument for the protection of non smokers and for the promotion of public health

Edinburgh - September, 10th 2007 

Tobacco Control StrategyTobacco Control Strategy

Monitoring of the law’s implementation is still ongoing and focuses on six aspects

1. Surveillance (prevalence, behaviours)2. Sales of tobacco products3. Effects on Health4. Compliance with the Law5. Smoking cessation 6. Prevention and communication

activities

THANKS!THANKS!

Ministry of Health

Prevention Department

Daniela Galeone

Lorenzo Spizzichino