Prevalence of tobacco smoking and electronic cigarette use among adolescents in Italy: Global Youth Tobacco Surveys (GYTS), 2010, 2014, 2018
Introduction
Tobacco use is the world's leading cause of preventable morbidity and mortality, resulting in 6.4 million deaths in 2015–11.5% of global deaths (GBD 2015 Tobacco Collaborators, 2017) – and in >650,000 deaths in the European Union (EU) – >15% of deaths (Tiessen et al., 2011). Among adolescents aged 15–16 years, current (past 30 days) smoking prevalence in Europe declined from 36% in 1999 to 22% in 2015 – a 35% reduction – with significant differences among countries: Finland, Sweden, and Ireland recorded a >50% decline, whereas Italy, Croatia, and Slovakia recorded a stalling or a slight decrease, from 37%–40% to 31%–37% (ESPAD Report, 2015; Gorini et al., 2019). In England, among 11–15-year-old students, current smokers decreased from 17% in 1998 to 6% in 2016 (NHS Digital, 2019). In USA, current smokers in high school students (commonly aged 14–18 years) declined from 15.8% in 2011 to 8.1% in 2018 (Cullen et al., 2018).
A global picture of electronic cigarette use among adolescents in the European Union (EU) is not available, because surveys have been conducted in few countries and not every year. Ever users ranged from 16.6% in Greece in 2014 in adolescents aged 15 years to 38.5% in Romania (Greenhill et al., 2016). In UK in 11–18-year-old students, current vapers increased from 1.6% in 2014 to 3.4%, in 2018 (McNeill et al., 2019). In USA, current users among high school students increased from 1.5% in 2011 to 11.7% in 2017, and even to 20.8% in 2018 (Cullen et al., 2018).
In Italy, tobacco smoking among adolescents is still high and stalling in the last decades (37% in 15–16 year old students; 23% in students aged 13–15 years in 2014–2015) (Gorini et al., 2019). Moreover, Italy has a regulatory environment on electronic cigarettes quite different from other countries (Gorini et al., 2017a; Gorini et al., 2017b): up to 2014, electronic cigarettes were and are still sold as consumer products, no rules on their use in smoke-free public areas were implemented; advertising was allowed. Then, a ban in schools, and a sale ban to minors were introduced in 2013 (Draisci et al., 2016), and the 2016 EU Tobacco Products Directive (TPD) with its transposition into Italy, introduced advertising ban on electronic cigarettes and other measures designed to prevent smoking initiation and electronic cigarette use among adolescents, and to restrict youth access to and availability of cigarettes and electronic cigarettes: introducing larger and mandatory pictorial health warnings covering 65% of cigarette packaging; a ban on characterising flavours including colourings, caffeine and taurine; a ban on selling cigarette packs with <20 cigarettes and roll-your own tobacco packs <30 g. Moreover, the TPD imposes a nicotine limit of 20 mg/ml for electronic cigarettes, and the information leaflet in electronic cigarettes and refill products must report that the product is not recommended for use by young people and non-smokers. In the electronic cigarette packet, the health warning must cover 30% of the surfaces stating “This product contains nicotine which is a highly addictive substance. It is not recommended for use by non-smokers” (Directive 2014/40/EU of the European Parliament and of the Council of 3 April 2014, n.d.).
The 2016 transposition of the TPD into Italy (Law 6/2016) reaffirmed the sale ban to minors of electronic cigarettes and refill containers with nicotine (Legislative decree, 2016), that was already introduced in Italy in 2013 (Draisci et al., 2016). The transposition introduced additional measures not provided by the TPD to restrict youth access to cigarettes and electronic cigarettes: monitoring that all vending machines are provided with age verification; stricter enforcement of the sale ban to minors, i.e. higher fines, suspension or revocation of license for tobacco retailers who sell tobacco products, electronic cigarettes or e-liquids to minors. Other measures of the transposition were added to protect minors from second-hand smoke exposure: smoking ban in cars with minors and pregnant women; smoking ban in outdoor areas of Pediatric and Gynecologic Departments of hospitals (Legislative decree, 2016).
Main aim of this paper was to study trends in tobacco smoking and electronic cigarette use among adolescents in Italy through three repeat national cross sectional surveys conducted before (in 2010, 2014) and after (2018) the 2016 introduction of the EU-TPD and its transposition, and before Juul entered the Italian market in 2019.
Section snippets
Methods
The Global Youth Tobacco Survey (GYTS) is a nationally representative school-based, paper and pencil, cross-sectional survey of students in school grades associated with ages 13–15 years. GYTS has been carrying out in 61 countries worldwide. Further details are reported elsewhere (World Health Organization, n.d.; The Global Youth Tobacco Survey Collaborative Group, 2002). Briefly, GYTS uses a global standardized methodology that includes a two-stage sample design with schools selected with a
Tobacco smoking and electronic cigarettes use
Total ever use of cigarettes and/or electronic cigarettes non-significantly increased from 46.0% in 2010 to 52.2% in 2018. (Fig. 1; Table 1, Table 2) Similarly, combined current cigarette smokers and/or electronic cigarette users non-significantly increased from 20.7% to 27.9% (Fig. 1; Table 1, Table 2, Table 3). Although smokers stalled around 20% from 2010 to 2018, a non-significant decrease of both ever and current smokers was observed from 2014 to 2018 (Fig. 1; Table 1), and, adjusting for
Discussion
Adolescents who currently smoked tobacco cigarettes and/or used electronic cigarettes non-significantly increased from 21% in 2010 to 28% in 2018, and a 3-fold significant increase of exclusive electronic cigarette users were recorded in Italy. Moreover, even though smoking prevalence stalled from 2010 to 2018, significant but little decreases in smoking prevalence from 23% in 2014 to 20% in 2018, and from 18% to 10% among exclusive tobacco cigarette smokers, and a significant increase from 6%
Conclusions
After 2 years from its implementation in 2016, the EU-TPD does not seem to have slowed down the increase in vaping among Italian adolescents. In UK, instead, an increase in vaping among adolescents was not recorded after the EU-TPD introduction. Additional research is needed in order to show a clear association between regulatory changes introduced by EU-TPD and the impact on electronic cigarette use and smoking among adolescents in Italy, UK, and the EU.
Funding statement
This study was funded by the Ministry of Health, Italy (MADES project, chapter 4100/22). The work of SG is partially supported by the Italian League Against Cancers (LILT, Milan).
Declaration of competing interest
None to declare.
Acknowledgments
Andrew Snell, World Health Organization (WHO) – Regional Office for Europe - Copenhagen, Denmark; Linda Anton, Paul Hunting, Krishna Palipudi, Center for Disease Control and Prevention (CDC) - Atlanta, Georgia, USA.
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