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• La législation Italienne pour la prévention du
  tabagisme
• Daniela Galeone, MD
• Ministry of Health ITALY

Ministero della Salute
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BACKGROUND (2003)

• 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

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SMOKING ATTRIBUTABLE DEATHS ITALY-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

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ESTIMATED EFFECTS OF SECONDHAND SMOKE IN ITALY
(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)

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ITALIAN STRATEGY ON TOBACCO CONTROL
- 2004

• Protecting non-smokers health
• Reducing prevalence of new smokers
• Promoting smoking cessation

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ITALIAN STRATEGY ON TOBACCO CONTROL

• SMOKING 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

Protecting no smokers health
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2005 the Italian Smoking Banthe process of
approval

• Enabling factors
• -- Leadership of 2 Ministry of Health (both
  prestigious physicians)
• -- First bill presented from Umberto Veronesi on
  May, 2000
• Minister Sirchias Strategy
• Nov 2001 four-fold increase in fines for people
  who smoked in public places where smoking was
  already forbidden by previous restrictions
• Jan-May 2002 inserted the smoking ban within a
  framework bill on public administration a
  tactic branded the Trojan horse strategy by
  journalists.
• After three attempts, the smoking ban has been
  approved on January, 2003

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2005 the Italian Smoking Banthe process of
approval

• 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

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Press Release,1998-2008, 50 Italian newspapers
Key-words smoke, cigarettes, Ministers surname
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Press release

• Print 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

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2005 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)

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IMPLEMENTATION PHASEMULTIMEDIA EDUCATION
CAMPAIGNS

• Spots and debates on tv and radio
• Billboards and posters
• Inserts in newspapers and magazines
• Booklets
• Stickers

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2003-2004 Before law enforcement
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2005 after law enforcement
In cooperation with Italian Association Against
Cancer LILT National Institutes of Health
(ISS)
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HEALTH MINISTRY PHONE HOT LINE PROVIDING
INFORMATION ON THE NEW LAW (Jan-Feb 2005)AIMS
IMPLEMENTATION PHASE

• Give suggestions, clarifications, explanations
  about the law

• Detect critical aspects to the application of
  the ban

• Identify stakeholders, their needs, doubts,
  opinions and concerns about the law

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IMPLEMENTATION PHASE

• HEALTH MINISTRY PHONE HOT LINE PROVIDING
  INFORMATION ON THE NEW LAW (Jan-Feb 2005)
• FIRST MONTH RESULTS
• gt 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)
• lt1 complaints about the law
• Thousands more accessed Ministry website,
• updated daily on the basis of most FAQ

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Controversial questions and weak points
Problematic places
Peculiar places
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
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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

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HEALTH MINISTRY PHONE HOT LINE PROVIDING
INFORMATION ON THE NEW LAW (Jan-Feb 2005)

• Give ear to stakeholders

• Critical points

• Allies

• Groups to support

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OPINION ON THE SMOKING BAN

• ENFASI STUDY ON PUBS/RESTAURANTS
• OPINIONS AND BEHAVIOURS OF CLIENTS AND OWNERS
• BEFORE AND AFTER LAW ENFORCEMENT

Source National Health Institute 2004-2005
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• ENFASI 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 ENFORCEMENT
• OWNERS 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
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OPINION ON THE SMOKING BAN

• STUDY OF PUBS/RESTAURANTS ENFASI
• AFTER LAW ENFORCEMENT
• OWNERS 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
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STUDY OF PUBS/RESTAURANTS

• AFTER LAW ENFORCEMENT
• OBSERVATIONAL 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

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Fear of economical effects
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Tobacco 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)

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Gaining health 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)

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Gaining health What 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

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Gaining health Why ?

• It is already possible to prevent
• non-communicable diseases by
• reducing risk factors prevalence

Actions on social and environmental conditions
Interventions at individual level
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Gaining health Why ?

• To 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

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Health in all policies
Health System
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National Platform on nutrition, physical
activity and tobacco
Local and other Institutions
Ministries - Departments
NGOs

• Health
• Education
• Agriculture
• Economy
• Transport
• Environment
• Family Policy
• Young People and Sports

• Regions for public health services
• Association of municipalities
• National Health Institute
• Institute for Nutrition Research
• Institute for Occupational Health and Safety

• Food Industry
• Consumers Associations
• Trade Unions

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Gaining health

• Which objectives?
• Building up a shared culture health is a
  concern to government, society and community
• Implementing integrated actions on risk factors
  and their determinants across several sectors
• Promoting health supportive environments and
  improving equity in health
• Setting-up evidence-based interventions, with
  clear roles for different stakeholders,
  development and support of social networks at
  local level

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TOBACCO CONTROL STRATEGY in Gaining Health

• Protecting non-smokers health
• Reducing prevalence of new smokers
• Promoting smoking cessation

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• 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
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Tobacco Control Strategy

• Monitoring of the laws implementation is still
  ongoing and focuses on six aspects
• Surveillance (prevalence, behaviours)
• Sales of tobacco products
• Effects on Health
• Compliance with the Law
• Smoking cessation
• Prevention and communication activities

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THANKS!

• Ministry of Health
• Prevention Department
• Daniela Galeone
• Lorenzo Spizzichino