Smoking in Italy between established habits and new trends
Closing of the year, time to take stock. Among the good resolutions for the coming year, there will be many, even for this 2021, who will set as a goal to become former smokers.
As part of the activities of the Eurispes-Enpam Observatory on Health, Social Security and Legality, a series of field surveys(*) have been carried out, over the past three years, with the aim of exploring the habits of smokers, the relationship with new instruments, the inclination to quit smoking or switch products, as well as the effectiveness of currently available cessation methods and the positions of the medical-scientific world on one hand and the institutions on the other. Thus, two sample surveys of smokers (2018-2019) and, at the same time, three surveys of users of combustion-free devices (2018-2020) were conducted. Most of the data encapsulated in the Report “Smoking in Italy between established habits and new trends. The role of new instruments in the logic of risk reduction” is unpublished.
To this day the smoking market is slightly decreasing (especially in Western countries), however, WHO predicts that in the next 10 years the number of smokers in the world will exceed 1 billion. In Italy, the numbers have stabilized: between 11 and 12 million smokers, and tobacco-related diseases produce 80.000 deaths each year; unfortunately, the decrease in the number of smokers that was seen in the first decade of the new century has gradually stopped.
Thus, questions need to be asked about how smoke-free policies can evolve by flanking the usual cessation-focused treatments with policies aimed at harm reduction for those adult smokers who do not want to quit, despite the established health harms of smoking.
The survey on smokers
Among Italian smokers, the traditional cigarette remains the most popular product (81.4%), followed by cut tobacco (28.2%). The electronic cigarette is used by about one in five smokers (20.8%), a result essentially unchanged from 2018; cigar and pipe users also increased slightly in 2019, smoked in 12.1% and 5.1% of cases, respectively. For heated tobacco products, there is an increase in prevalence of about three percentage points compared to 2018, surpassing pipes with 7.2% of users. Snus is still not very popular in Italy (2.1%).
The alternative products to the traditional cigarette
Of the sample, 64.3% declare themselves fairly and very informed about the differences between traditional cigarette and electronic cigarette, while 35.7% say they are not very or not at all informed. In 61% of cases (summing the answers “not at all” and “a little”) there is no knowledge at all about the differences between heated tobacco products and the traditional cigarette; while the “very” and “quite” informed reach a share of 39%.
How many have tried electronic cigarette and heated tobacco?
A total of 34.8% of the sample has never tried it and 29.3% have tried it without choosing to continue using it. Of those who have smoked it, 23.6% have used it for a limited period of time and 12.3% use it regularly.
Although the constant use of the electronic cigarette remains limited to just over one in ten smokers, compared to 2018 there is a decrease in those who have never tried this product (-4.4%), an increase in smokers who have used it for a limited period (+5%) and those who continue to use it regularly (+0.7%). The electronic cigarette intrigues, therefore, but does not completely convince Italian smokers, inducing them to forget the traditional cigarette. As for heated tobacco products, compared to 2018, smokers who say they have never tried them have decreased by 12 percentage points (from 75% to 62.7%), consequently, Italians who have only tried them are on the rise (from 19% to 22.2%) and, even more, those who have used them (more than doubled compared to 2018) and those who use them regularly (4%), which tripled compared to the previous survey, when they stopped at 1.2%.
Do you really want to quit?
Nearly a third of the sample (30.5%) say they should quit smoking, but do not want to; 26.3% should, but do not believe they can. Slightly more than one in five smokers (21.9%) have no intention of quitting, while 12.3% of respondents would like to quit but not anytime soon, and only 9% aim to do so within six months.
The sample was then asked whether their primary care physician had ever given them any guidance about their smoking habit. In most cases (56.6%) this did not happen; 31.5% said, however, that they were urged to quit smoking, and 11.9% were suggested to switch to a less harmful product, such as an electronic cigarette or heated tobacco.
The willingness to find alternatives
Despite the fact that it is never easy for a smoker to change his or her habits and tastes, 2019 again confirms a certain propensity to change with 40.4% of smokers saying they would probably be willing to change product type if they learned of the existence of a less harmful product than the one they are used to, joined by 21.5% (up from 2018) who would definitely do so. Negative responses, on the other hand, come from 30.5% of the sample who would probably not be able to switch products and 7.6% who definitely would not (-2.2% compared to 2018).
Smoke-free centers
Based on recent surveys conducted by Eurispes, the substantial ineffectiveness of the 292 smoke-free centers in the country is confirmed, which assist an average of only 13,000 citizens annually who intend to quit, with very limited results. More than 90% of smokers surveyed by Eurispes (2019) say they have never visited a smoke-free center. Among the few smokers who have done so, about one-third rated the experience markedly negative (32.4%), 25.7% did not comment, and 4 in 10 did positively (41.9%).
The survey conducted by Eurispes between 2019 and 2020 at smoke-free centers distributed throughout the country gave the floor to the operators of the facilities who report, in the vast majority of cases, a very high rate of recidivism in those assisted (50 to 75 percent).
The identikit of consumers of heated tobacco products (IQOS).
The sample survey was carried out between February and July 2020 on a probability sample (346 questionnaires) consisting of users of the IQOS instrument, one of the two heated tobacco devices in our country, but encountering almost 99% of the specific market.
Consumers of combustion-free products prefer to use heated tobacco products exclusively in 82.7% of cases; 11.8% use electronic cigarettes, while only 5.5% habitually smoke both products.
Of those, 60.7% have been using combustion-free products for 6 months-1 year, and 22.8% for less than six months, for a total of 83.5% new consumers in the past year.
The choice of preferring the consumption of combustion-free products as an alternative to the traditional cigarette is motivated in 47.7% of the cases by the lower negative impact of these products on the body (teeth, skin, nails…); 37.3% of the sample say they use them because they feel better physically than when they smoked traditional products, while 15% believe that combustion-free products bother those around them less.
In switching to combustion-free products, 52.3% of consumers found fairly positive effects on their quality of life to which is added 36.4% expressing a very positive opinion.
A total of 61.3% of the sample derive the same degree of satisfaction from combustion-free products as they do from traditional smoking; gestures also do not seem to be particularly affected: in fact, 74% of vapers say they do not miss the gestures of cigarettes.
What sources are considered most authoritative for receiving information about the risks associated with smoking? Forty-five percent of the sample relies mainly on official documents (Ministry of Health, World Health Organization, etc.); about one in five respondents place particular trust in the primary care physician (21.1%), and slightly more than one in ten considers information obtained from the Web to be authoritative (11.3%). Of smokers, 3.8% prefer information from family, friends and acquaintances, and 3.2% trust the opinions of other smokers. Even less trustworthy are considered to be radio and television (2.3%); newspapers and/or magazines (2%); and manufacturers, tobacconists, and industry professionals (1.7%). Of smokers, 1.2% cite other sources of information, 0.3% say they have never obtained information about the risks associated with smoking, and 8.1% cannot indicate an answer.
The questionnaire next delved into some topics regarding taxation: 64.7% of the sample said they were certain that they would have an incentive to continue consuming the new products if prices were lowered due to lower taxation, and 25.7% would probably continue to use them; for 5.2% lowering prices would probably not be a valid incentive, and for 4.3% it definitely would not.
The identikit of electronic cigarette (e-cig) users
The sample survey was conducted among a probability sample of attendees at the Verona International Vaping Fair, Vapitaly, and at specialized retail outlets. The questionnaires (265) were administered between May and July 2019.
More than 90% of consumers surveyed replaced traditional cigarettes with electronic cigarettes; 3.4% preferred heated tobacco products; while 4.9% used both. These are in most cases long-term users: 43.4% have been using them for 2-4 years and 23.4% for more than 4 years; 18.9% are those who started 6 months-1 year and 14% those who have been using them for less than six months.
Word of mouth seems to be the main channel for the diffusion of e-cigs, with 57% of consumers saying they learned about them because they were used by friends/acquaintances/relatives. Experience with combustion-free products is rated very positive by 74.7% of the sample, while it is fairly positive for 23.8%; only 1.1% say they had a fairly negative experience.
Of those surveyed, 96.6% say they find the aroma of electronic cigarettes pleasant and 95.5% believe they do less harm to their health and also feel better physically than smoking traditional cigarettes; for 91.7%, they are a useful tool for quitting smoking; 89.8% find no particular difficulty in maintenance or use; and 81.9% of vapers agree with the statement that combustion-free products do not bother those around them. Only 22.6% of respondents believe that such products are too expensive, compared to 75.5% negative responses, while just over one in four respondents (26.8%) suffer from the lack of gesture associated with traditional cigarettes, and even more respondents say they do not derive the same satisfaction from them (35.8%). The least convincing aspect for e-cig users concerns the fact that they are addictive: although for 58.5% this is not the case, 39.6% say that these products are also addictive.
But how do e-cigarettes affect the habit of smoking traditional cigarettes? Of the respondents, 66.4% say they have completely stopped smoking them after trying combustion-free products, and 22.6% have decreased their consumption. The positive evaluation of the experience with the electronic cigarette is confirmed by 92.8% of users who recommended other smokers to try such products.
Among the reasons that often discourage the use of combustion-free products are the costs associated with them. Therefore, it was asked whether lower prices due to lower taxation of these products would be an incentive in continuing to use them: most (76.2%) were certain that such a measure would encourage their use.
Is it appropriate for e-cigarettes and heated tobacco to be subject to taxation? For 64.2% of consumers these products should be excluded from taxation, while for 14.3% they should be taxed; the share of respondents who cannot express an opinion is high (21.5 %).
Finally, respondents were asked to indicate which of the sources cited is the most authoritative for receiving information about the risks associated with smoking. Of the sample, 30.6% rely on the attending physician; 24.2% on official documents from the Ministry of Health or the WHO; and 16.6% consider information found on the Internet to be most reliable. Newspapers or magazines are the most qualified source for 6.8% of respondents; professionals for 4.5%; radio and television for 4.2%; 3.4% trust the opinion of family/friends/acquaintances and 2.3% trust the opinion of other smokers. Only 0.4% of the sample say they have never obtained information about it; while 1.9% rely on sources other than those listed and 5.1% cannot express an opinion.
The report is available at the following link after registering on the Eurispes website https://eurispes.eu/ricerca-rapporto/il-fumo-in-italia-tra-abitudini-consolidate-e-nuove-tendenze-2020/
