Article Text
Abstract
Objectives To estimate the attitudes of Italians on the extension of the smoking ban to selected public outdoor areas.
Methods The authors considered data from two Italian surveys on smoking conducted in 2009 and 2010 on a total sample of 6233 individuals, representative of the Italian population aged 15 years or over.
Results 64.6% of Italians supported smoke-free policies in public parks, 68.5% in sports stadiums, 62.1% in beaches, 85.9% in school courtyards and 79.9% in outdoor areas surrounding hospitals. Among current smokers, the corresponding estimates were 32.9% for parks, 38.2% for stadiums, 31.2% for beaches, 67.6% for schools and 55.3% for hospitals.
Conclusions Extension of the smoking ban to selected outdoor areas is supported by the large majority of the Italian population. The overwhelming majority of support for smoke-free school grounds and outdoor areas surrounding hospitals indicates that legislative action is required.
- Epidemiology
- Italy
- population survey
- smoking ban
- tobacco smoking
- public opinion polls
- public policy
- surveillance and monitoring
Statistics from Altmetric.com
- Epidemiology
- Italy
- population survey
- smoking ban
- tobacco smoking
- public opinion polls
- public policy
- surveillance and monitoring
Introduction
In order to reduce the harmful effects of secondhand smoke (SHS),1 comprehensive smoke-free legislation banning smoking in all indoor public places came into force in January 2005 in Italy.2–4 This law was effective in removing SHS exposure in indoor workplaces5–7 and resulted in reduced cardiovascular and respiratory events, particularly in non-smokers.8–10 Moreover, this highly supported and almost universally observed legislation led to decreased smoking prevalence and consumption of tobacco in Italy.2–4
An extension of these restrictions to outdoor areas surrounding schools, universities, hospitals, public parks, recreational areas and beaches has been recently suggested. Accordingly, the International Olympic Committee and the Fédération Internationale de Football Association have promoted smoke-free open-air stadiums in the latest editions of the Olympic Games and the Football World Cup.
To date, however, outdoor smoking bans remain uncommon.7 11 12 Consequently, scanty data are available on the impact of outdoor smoking bans on SHS exposure and smoking prevalence. However, a recent US survey of 1910 counsellors and 417 administrators from substance abuse treatment organisations showed that current tobacco users were less frequent in organisations with comprehensive bans regulating outdoor areas, compared with organisations with indoor-only smoking bans.13 Non-smokers are exposed to SHS in outdoor areas also14–16 and any exposure to SHS is harmful, even in outdoor areas with small buffer zone distances (eg, bus stops, sport stadiums, hospital grounds, areas surrounding schools, universities, outdoor bars and restaurants).17 18 Furthermore, outdoor restrictions on smoking may help make tobacco use less socially acceptable, by establishing positive smoke-free role models for youth7 11 17 19 20 and reducing (youth) opportunities to smoke, fire hazards and the pollution generated by cigarette butts (non-biodegradable litter) in public parks and beaches.7 11 19–21 Thus, extension of smoking regulations to outdoor areas is a relevant tool for tobacco control.13 22 23
The process of adoption of smoke-free legislation in any jurisdiction occurs within both a social and a political context.7 One of its main determinants is the support for restrictions in the community.7 Given the limited information available on the issue, particularly in Europe,7 11 we investigated attitudes on the extension of the smoking ban to selected outdoor areas in Italy, a country where the smoke-free legislation did not regulate outdoor areas and voluntary outdoor bans are only rarely adopted in the hospitality industry as well as in other settings, including schools and hospitals.
Materials and methods
We analysed data from two Italian face-to-face, computer-assisted, personal in-house interview surveys on smoking.24 25 The first survey was conducted from March to April 2009 on a sample of 3213 individuals (1546 males and 1667 females)25 and the second one from March to April 2010 on a sample of 3020 individuals (1453 males and 1567 females).24 The individuals were representative of the Italian population aged 15 years or over in terms of age, sex, geographic area and socioeconomic characteristics.
The questionnaires included general information on sociodemographic characteristics and on smoking habits, including smoking status (never/ex-/current smoker) and number of cigarettes smoked per day. Current smokers were participants who smoked 100 or more cigarettes in their lifetimes; never smokers were participants who did not smoke more than 100 cigarettes in their lifetimes and ex-smokers were participants who had quit smoking more than 1 year ago. The 2009 questionnaire included two questions referring to the degree of support of the smoking ban implemented in 2005. Both surveys included questions on the attitudes towards extension of smoke-free regulation to selected outdoor areas, including public parks, gardens and stadiums. Furthermore, the 2009 survey included one question on the attitudes towards extension of smoke-free regulation to beaches, and the 2010 survey to school courtyards and gardens and courtyards or outdoor areas of hospitals. Each question had a structured four-item score (strongly in favour, moderately in favour, moderately against and strongly against).
The odds ratios (OR) and the corresponding 95% confidence intervals (CI) for being moderately to strongly in favour versus moderately to strongly against various smoking bans, according to selected characteristics, were derived using unconditional multiple logistic regression models after adjustment for sex, age, geographic area, level of education, smoking habit and year of interview.
Results
Overall, jointly considering the surveys conducted in 2009 and 2010, 23.6% of Italians aged 15 years or over described themselves as current cigarette smokers (26.4% of males, 21.0% of females).
Figure 1 shows the attitudes of the Italian population towards the (extension of the) smoke-free legislation that came into force in 2005. Four years after the implementation of the indoor smoking ban, 95.8% (89.0% of current smokers) were moderately to strongly in favour of smoke-free policies in public areas and 93.9% (85.4% of current smokers) in indoor workplaces. Overall, 64.6% of Italians supported smoke-free public parks, 68.5% sports stadiums, 62.1% beaches, 85.9% school courtyards and 79.9% in outdoor areas surrounding hospitals. Among current smokers, the corresponding estimates were 32.9% for parks, 38.2% for stadiums, 31.2% for beaches, 67.6% for schools and 55.3% for outdoor areas surrounding hospitals.
After adjustment for several covariates including tobacco smoking, women were systematically more frequently in favour of both the 2005 smoking ban and the extension of the smoking ban to outdoor areas (table 1). A direct relation with age was evident, the young being less favourable to the extension of the smoking ban. Subjects from central and southern Italy were systematically more frequently in favour of the extension of the smoking ban to outdoor areas. No specific pattern was evident according to level of education. Compared with never smokers, current smokers were less in favour of various smoking restrictions, the multivariate ORs ranging between 0.1 and 0.2. Also, former smokers were systematically less favourable than never smokers to an extension of the smoking bans, the ORs ranging between 0.5 and 0.7 for various outdoor areas considered. Italians supporting an extension of the legislation significantly increased between 2009 and 2010 for gardens and parks and sports stadiums.
Discussion
This is one of the first studies—and to our knowledge the first European study—providing national data on the attitudes towards smoke-free outdoor areas. In our study, approximately two-thirds of the Italian population support an extension of the smoking ban to outdoor public places, including public parks, stadiums and beaches, and more than four out of five Italian adults are in favour of smoke-free policies in school courtyards and in outdoor areas surrounding hospitals, with an appreciable support also among current smokers. Support for smoke-free parks and stadiums significantly increased between 2009 and 2010.
Our findings are in agreement with a few US studies.7 A survey of 1501 adults from Minnesota in 2004 showed that 70% of the general public supported smoke-free parks (77% of non-smokers, but only 33% of smokers).20 In 2006, a population survey showed that 59% of Californians preferred smoke-free public beaches; in 2007 this prevalence increased to 67%.26 In the 2002 California Tobacco Survey, 43% supported smoke-free regulations in outdoor workplaces, 52% in outdoor public places, 63% outside building entrance, 79% in campus student housing and 91% in kids' playing yards/fields.27 These estimates increased in the 2005 California Tobacco Survey.28 Moreover, in four California Tobacco Surveys conducted between 1993 and 2002 on approximately 24 000 adolescents aged 12–17 years, students strongly supported smoke-free school grounds (more than 85% each survey year for non-smokers, and from 56% in 1996 to 69% in 2002 among current smokers).29
Thus, support for extension of outdoor smoking bans is increasing,11 mirroring the experience with indoor restrictions.3 7 In Italy, for example, in 2001 83% of the population was in favour of banning smoking in all indoor public areas, including restaurants and bars.30 This increased to 90% in 2005, immediately after the implementation of the Italian legislation,2 to 94% in 20063 and to 96% in 2009. Similar patterns were observed also with reference to indoor workplaces. These findings suggest that support for smoking bans increased after the adoption of the legislation.2 11 31 32
Obtaining a broad consensus in the community about smoke-free policies facilitates the adoption of the regulation and its compliance.7 Once smoking ban policies are adopted, compliance can be improved: for example, a study conducted in a US college campus showed that the use of a multiple component package, including moving receptacles, marking the ground, improving signage and distributing reinforcements and reminder cards, substantially increases the proportion of smokers complying with the smoking ban policy.33
Potential limitations of the study include those inherent to the sampling design, such as selection bias and information bias due to self-reporting. Moreover, in our surveys we asked about support for smoke-free bans, but not priorities. Strengths of our surveys include the relatively large sample size and its representativeness of the Italian adult population.
In conclusion, the large majority of the Italian population supports the extension of smoking ban to selected outdoor areas, including parks, sports stadiums and beaches. The high levels of support, particularly for smoke-free school grounds and areas surrounding hospitals, indicate that further legislative action is required in Italy. Our findings confirm the feasibility of extending smoke-free legislation to outdoor areas and provide priority indicators of where to enact these policies.
What is already known on this subject
Extension of smoking regulations to outdoor areas is a promising tool for tobacco control, but outdoor smoking bans remain uncommon.
The successful adoption of smoke-free legislation is influenced by public support for restrictions. Scanty information is available on the issue, particularly in Europe.
What this paper adds
Using data from two representative surveys conducted in Italy, we found that extension of smoking restrictions to selected outdoor areas is supported by the large majority of the Italian population.
Our findings confirm the feasibility of extending smoke-free legislation to outdoor areas and provide priority indicators of where to enact these policies.
References
Footnotes
Funding This work was conducted with contributions from the Italian Ministry of Health, the Italian League Against Cancer and the Italian Association for Cancer Research.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.