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Objectives: to estimate the prevalence of smoking while driving a car or a motorcycle, and its determinants, and to analyze the trends of these habits before and after the transposition of the European Directive 40/2014 (Legislative Decree 6/2016) adopted in 2016, which bans smoking in cars in the presence of minors., Design: eight different population-based surveys conducted in Italy by Doxa between 2007 and 2018., Setting and Participants: 21,807 subjects aged >=18 years, representative of the Italian adult population., Main Outcome Measures: prevalence of smokers who smoke while driving a car, with and without minors, or a motorcycle. Prevalence of non-smokers exposed to second-hand smoke (SHS) in cars, with or without minors. Estimate of multivariate odds ratios (ORs) and 95% confidence intervals (CIs), using multiple logistic regression models adjusted by gender, age, education, geographic area, and year of survey., Results: the prevalence of smokers who smoked in cars decreased from 69.6% in 2007-2008 to 57.5% in 2016, and to 51.5% in 2017-2018. Those who smoked in cars in presence of minors were 20.9% in 2011-2012 and 11.7% in 2017-2018. The prevalence of smokers who smoked while driving a motorcycle decreased from 15.0% in 2007-2008 to 6.5% in 2017-2018. Smoking while driving a car in presence of minors decreased with increasing age (p=0.004) and education level (p=0.029) and was more frequent in Southern than in Northern Italy (OR 4.40; 95%CI 2.21-8.74). In 2017-2018, 16.2% of non-smokers reported being exposed to SHS in cars. Of these, 42.3% were exposed also in presence of minors., Conclusions: the tobacco control legislations adopted over the last 15 years, in particular the last one adopted in 2016, have largely contributed in reducing smoking in private vehicles, even in the presence of minors. This notwithstanding, 50% of Italian smokers smoke while driving and more than 15% of non-smokers are exposed to SHS in cars. It is suggested to adopt informative campaigns that inform people about the risks associated with smoking in cars, both for drivers and for passengers, and to increase the fines for those who smoke in cars in the presence of minors or driving a motorcycle.

Objectives: to evaluate smoking prevalence in adolescents by Italian region from the Health Behaviour Study in School-aged Children (HBSC) of 2014 and to correlate it with the presence, in the 2014-2018 Regional Prevention Plans (PRPs), of school-based smoking prevention interventions., Setting and Participants: the 2014 HBSC surveillance system provided data on 48,000 adolescents aged 11, 13, and 15 years; Ministry of Health provided data for each PRP on interventions with a tobacco control component and, among them, school-based smoking prevention interventions., Main Outcome Measures: weekly smoking prevalence; proportion of school-based smoking prevention interventions out of prevention interventions with tobacco control measures., Results: regions with the highest weekly smoking prevalence were Sardinia and Apulia for all age groups, Abruzzo for 11- and 15-year-old children, Basilicata for 15-year-old children, Bolzano for girls aged 13 years old; Liguria for females, Molise, Calabria, and Veneto for males. In the regions with the highest prevalence of smoking in 2014, in girls aged 11 and 13 years (Sardinia, Apulia, Basilicata, Liguria, Bolzano), a greater proportion of school-based smoking prevention interventions to be developed in the period 2014-2018 have been recorded., Conclusions: smoking prevalence in Italian adolescents is high, especially in 15-year-old children. Implementing policies recommended by the World Health Organization - Framework Convention on Tobacco Control (higher tobacco taxes, anti-tobacco mass media campaigns, plain tobacco package) could work synergistically with school-based interventions in order to decrease tobacco initiation among adolescents in Italy.

Objectives: to estimate the number of deaths from noncommunicable chronic diseases (NCD) attributable to behavioural risk factors (tobacco smoking, unhealthy nutrition, physical inactivity, overweight, and excessive alcohol use) in 2016 for Italy and for the Italian regions., Design: descriptive study., Setting and Participants: mortality data were obtained by the Italian National Institute of Statistics. Causes of deaths from NCD associated with the five RFs were selected. Italian attributable fractions were obtained by the 2016 estimates of the Global Burden of Disease Study and applied to the mortality data. Regional prevalence of risk factors was obtained by the national surveillance system PASSI for the years 2013-2016., Main Outcome Measures: absolute number of attributable deaths, joint attributable fraction, proportion of total deaths attributable to RFs (MAprop)., Results: about 191,000 out of 614,307 deaths occurred in Italy in 2016 were attributable to combined RFs (about 37% in males; 26% in women). Joint MAprop was between 33% in men (24% in women) from Val d'Aosta and 40% in men (31% in women) from Campania. In Italy, 17% and 6% of the total amount of deaths were attributable to smoking in men and women, respectively; 6% and 3% to alcohol abuse; 7% and 8% to overweight; 13% and 12% to dietary RFs, and 2% and 3% to low physical activity. The higher proportion of attributable deaths by age-group was recorded in people aged 40-59 years (43% in men; 28% in women). Regional differences in attributable deaths are confirmed by regional RF prevalence recorded by the PASSI surveillance system for the years 2013-2016., Conclusions: these are the first estimates of the number of deaths due to NCDs attributable to behavioural RFs estimated for each region and for Italy as a whole. Effective primary prevention policies should be reinforced, since these RFs are potentially modifiable.

Objectives: to study regional differences in Italy of quit smoking attempts and of successful abstinence, in relation to socioeconomic status, cigarettes per day (cig/die), and smoking cessation method in a representative sample of the population resident in Italy., Design: cross-sectional survey., Setting and Participants: in 2014-2017, PASSI survey (the ongoing Italian behavioural risk factor surveillancesystem) gathered data on smoking and sociodemographic characteristics of 35,157 smokers; 13,130 aged 18-69 years made >1 quit attempt in the previous year, 1,176 of them were successful quitters for >6 months., Main Outcome Measures: proportion of smokers who tried to quit; proportion of smokers who successfully quitted., Results: about 35% of smokers made >1 quit attempt in the last year. Northern Italians and smokers with many economic difficulties were more likely to make a quit attempt, whereas heavy smokers were less likely. About 10% of attempters were abstinent for >6 months: from 6% in Campania and Abruzzo to 17% in the Bolzano province. Attempters who smoked <20 cig/die had higher likelihood to be abstinent, compared to those smoking <20 cig/die. Attempters with many economic difficulties had the lowest likelihood to be abstinent (7%), with no differences by region, educational level, quitting method. Attempters with no economic difficulties recorded the highest cessation rates (12%). Among them, those from Northern Italy, Tuscany, Marche, and Lazio (Central Italy), and Apulia (Southern Italy) compared to attempters from most Southern regions, and those with high education level or using traditional quitting methods compared to those using electronic cigarettes or unaided were more likely to be abstinent for >6 months., Conclusions: smokers with many economic difficulties in all Italy, and those with no economic difficulties residing in Umbria and in most Southern Italian regions, except for Basilicata and Puglia, recorded lower chances to quit. Regional differences may have two possible explanations integrating each other: Northern-Central regions are in a slightly more advanced stage in the tobacco epidemic; regions which developed specific tobacco control interventions in their Prevention Plans recorded higher quitting rates. Not-yet-implemented interventions could promote smoking cessation in smokers from Southern Italy and in those with lower socioeconomic status: reimbursement of smoking cessation treatments, a well-developed national Quitline linked to a webplatform and to mobile phone application or text-messaging, an opt-out smoking cessation service offered systematically to all smokers at every encounter in hospitals or health services.

"Non-communicable diseases cause more than 80% of deaths in europe and, among these, 20% are caused by cancer. Modifiable lifestyle factors considered in the italian national programme "Guadagnare salute" (Gaining health), such as tobacco smoking, unhealthy diet, physical inactivity, overweight, and excessive alcohol use, are amongst the major causes of cancer deaths. The aims of this study was to estimate the number of deaths attributable to lifestyle factors for italy and for italian regions in 2013 and to describe its variation in relation to the regional prevalence of risk factors exposure. For Italy and for each italian region, deaths attributable to lifestyle factors were estimated using the methodology of the Global Burden of disease (GBd) study. italian mortality data of 2013 and risks attributable to these lifestyle factors for each cancer site for italy from the GBd study were used. Prevalence of exposure to lifestyles in Italy and in each Italian Region was collected for the period 2008-2013. In 2013, at least 66,605 cancer deaths in italy were attributable to lifestyle factors, accounting for 37.9% of all cancer deaths: 34.1% of cancer deaths in men and 9.0% in women were attributable to smoking; in men and women, respectively, 3.3% and 2.8% were attributable to excessive alcohol consumption; 5.3 % and 6.7% to overweight; 10.1% and 7.1% to dietary risk factors; 1.9% and 4.2% to physical inactivity. A moderate variability of percentage of deaths attributable to modifi able lifestyle factors by region was also detected due to different prevalence values of exposure to lifestyles occurred in last decades. At least 45,000 cancer deaths in men and 21,000 in women occurred in 2013 were attributable to modifi able risk factors, whose prevalence varied by region and which could be averted through the implementation of primary prevention interventions."

"The multinational corporations producing tobacco, alcohol, soft drinks, and processed foods have a role of vectors in the increase of chronic diseases, so that one can speak of manufacturing epidemics. The main aim of this paper is to conduct a literature review on different approaches in population-based interventions to stem the rise in consumption of unhealthy products. Different approaches were found: • command-and-control regulations: the route is definitely more advanced for tobacco with the implementation of an international treaty, which requires 180 ratifying states to implement a series of tobacco control policies. Similar regulations have been partially adopted to reduce alcohol use and to increase taxes of sugar-sweetened beverages; • multinational corporations in few Countries can voluntarily adopt recommendations on media campaigns and on labelling of soft drinks and processed foods; • in order to reduce salt in foods, many Countries developed voluntary agreements with industries with monitoring systems to assess compliance. Population-based interventions to try to align the interests of multinational corporations with those of public health are described in literature: • the "Health Footprint" programme; • the performance-based regulation which could oblige industry to take responsibility to reduce the harmful consequences of the use of their unhealthy commodities; • the price-cap regulation, usually applied to the utilities sector, would set a cap on the price of the tobacco industry, raising the tobacco taxes by 500 million euros per year. In order to reduce the burden of chronic disease, one of the objectives of the Italian National Prevention Plan, a working group including non-governmental organizations and experts in communication, social marketing, and lifestyles should be organized by the Ministry of Health in order to identify which population-based interventions could be implemented in Italy in next years to stem the rise of consumption of unhealthy products. ".

Among Italian smokers--about 10 millions in 2013--about 600,000 began using electronic cigarettes (e-cigs) in last years. About 10% of e-cig users quitted smoking tobacco, whereas the 90% was dual users. Among them, about three out of four decreased the number of cigarettes smoked per day (cig/day), but did not quit. How many fewer cigarettes a smoker has to smoke to obtain significant health benefits? Is there a threshold? In order to observe a significant 27% reduction in the risk of developing lung cancer, a smoker must reduce the number of cig/day by at least 50%, while for the other smoking-related diseases (acute myocardial infarction - AMI, stroke, chronic obstructive pulmonary diseases), halving the number of cig/day did not drive to a significant risk reduction. Even smoking 5 cig/day increases the risk of AMI, whereas it significantly lowers the risk of lung cancer. Obviously, quitting smoking is the best choice to highly reduce risks for all smoking-related diseases. Therefore, in order to achieve significant risk reductions, e-cig users should quit smoking as first choice, or, if they feel it is impossible to them, reduce the consumption of traditional cigarettes to less than 5 cig/day.

Objective: to evaluate the impact of avoidable mortality (AM) on the changes in life expectancy at birth (LE) in Tuscany Region (Central Italy) in two periods (1987-1989 and 2006-2008)., Setting and Participants: a list of AM causes previously published was used. The AM were divided into two groups: AM by Health Policy Interventions (HPI), AM by Health System Interventions (HSI)., Main Outcome Measures: years of potential life lost (PYLLs), rates of PYLL standardized on the European population (TSPYLLs), and LE were examined., Results: in 2006-2008, LE increased with a gain of 5.2 in men and 3.8 in women in comparison to 1987-1989 LE (respectively 79 and 84,9 years). If AM did not have occurred, LE would have further increased of 2 years in men and 1.5 in women. AM recorded a 39% decrease: from 25.3% of overall mortality in men in 1987-1989 to 16.1% in 2006-2008; in women from 14.3% to 8.4%. Injury/poisoning and lung cancer are the most frequent IPP. The only increasing AM is lung cancer in women. Disentangling LE increases by group of causes, 25% of the increases in 2006- 2008, compared to 1987-1989, was attributable to HSI reduction, and 4% in women and 16% in men to HPI reduction., Conclusions: AM recorded a 39% decrease from 1987-1989 to 2006-2008 in Tuscany. In 2006-2008, about one third of LE increase in women and 2/5 in men was attributable to AM decrease, while 2/3 in women and 3/5 in men to increased survival in eldest people.

In the European Union almost 300,000 tons of raw tobacco are produced every year, contributing for 4% of the world production. In Italy, tobacco crop produces around 90,000 tons/year and is concentrated in Veneto, Tuscany, Umbria and Campania Regions. In 1970, Common Market Organisation provided a virtually unlimited support for European tobacco production. After 2004, funds progressively has been cut by half, even though the other half has been given for restructuring or reconversion of tobacco farms through the Rural Development Plan. The Framework Convention on Tobacco Control recommends conversion of tobacco crops, although there are no effective measures. Tobacco production requires large quantities of chemicals (pesticides, growth regulators, fertilisers), with significant workers' exposure if applied without personal protective equipments. Pesticides may have genotoxic, teratogenic, immunotoxic, hormonal, and carcinogenic effects. Tobacco itself may cause also a disease called "Green tobacco sickness" syndrome, as a consequence of nicotine dermal absorption due to skin exposure to tobacco leaves. In Italy, financial resources for tobacco production and restructuring/conversion to other crops of previously tobacco planted fields are available. On the contrary, anti-smoking media interventions do not receive funds comparatively relevant as those for tobacco production.

In Italy, every year about 72 billion of cigarette butts are thrown away in the environment. Cigarette butts represent 50% of the wastes of urban areas (parks, roads) in the world, and 40% of Mediterranean Sea wastes. In particular, total polluting load is constituted of 1,872 Bq millions of Polonium-210, assuming 75 mBq per cigarette butt, and 1,800 tons of volatile organic compounds. As a matter of fact, according to several surveys, cigarette butts are considered by smokers and non-smokers as a common and acceptable waste in the environment. In 2008, European Union issued a Directive on wastes considering the «extended producer responsibility» (i.e., every industry is liable for costs of collection, transport and disposal of its own products). In October 2012, the Italian Parliament proposed a bill that classifies cigarette butts as special wastes in the frame of this responsibility. It could be interesting in the future to follow the legislative process of that bill in the Italian Parliament in order to show how strong it will be supported.

Objective: to evaluate differences in terms of smokers' attendance to National Health System (NHS) Stop-Smoking Services with a prevalent individual approach (SSSi), and to those with a prevalent group approach (SSSg). To identify predictive characteristics of success, in terms of quit rates at the end of treatment (QR0) and after 6 months (QR1), according to SSS type (SSSi/SSSg), treatment (individual/ group counseling with/without pharmacologic treatments), 5 SSS scores: type of structure (S), number and hours per week of SSS health professionals (P), SSS involvement in local tobacco control networks (N), and type of smokers' assessment (A); and 3 principal components of SSS characteristics., Design: survey to 19 SSSs, and survey to smokers attending these SSSs, with a six month follow-up., Setting and Participants: 1,276 smokers attending 19 SSSs (664 at 7 SSSi; 612 at 12 SSSg) in 9 months in the period 2008-2010., Main Outcome Measures: smokers' attendance to scheduled sessions; QR0; QR1., Results: even though SSSi treated more smokers per month (12 vs. 8 in SSSg), SSSi scheduled fewer treatment sessions (7 vs. 9 sessions) in a wider treatment period (3 months vs. 2 in SSSg). SSSg recorded lower P and higher A scores. Four out of 5 smokers attending SSSg and 2/5 of smokers attending SSSi completed treatment protocols. Considering all smokers, QR1 in both types of SSS were around 36%. Smokers treated with pharmacotherapy, those more motivated and with high self-efficacy, and those non-living together with smokers were more likely to recorded higher QR1., Conclusions: the most relevant interventions in order to increase the number of smokers treated at SSS and to improve cessation rates among them were: for SSSi, increasing completion to treatment protocol; for SSSg, improving the P scores to increase the number of treated smokers; for all SSS, increasing the use of pharmacotherapy in combination with individual/group counseling to sustain abstinence.

There is no clear regulation on electronic cigarettes (e-cig); their health effects are not yet fully investigated and there is insufficient standardisation and quality control of the product. Moreover, the e-cig could be a gateway for young people to nicotine addiction and traditional cigarette smoking. In Italy, the Ministry of Health banned the sale of e-cig with nicotine firstly to adolescents aged <16 years, then to people <18 years. Until further scientific evidence is available, it is mandatory to regulate the production and marketing of e-cigs, to make them less attractive, to forbid their use in enclosed areas, and prevent them from being promoted. E-cigs, however, seem to be much less dangerous than traditional cigarettes, although the few studies conducted are not sufficient to demonstrate either a clear therapeutic efficacy of e-cig or their total harmlessness. If e-cig had a known content, were made according to clear rules and in certified laboratories, without toxic substances, it could be used to help heavy smokers to quit, or at least to reduce smoking habits. There is a large proportion of smokers who are unable to quit. The revision of the European Directive (the proposal is being evaluated and we are waiting for its final approval) on tobacco recommends free sale for a minority of e-cigs only, those with a nicotine content <4 mg/ml. This will be difficult, considering that the business is just the free sale of e-cig and the much more dangerous tobacco cigarettes are still sold without any restriction.

During the 60s and the 70s strategies for decreasing initiation or quitting have been developed, in order to find those with high success rates. Unfortunately, interventions with an individual approach involved few smokers, so their impact in decreasing smoking prevalence was limited. The socio-ecological model offers a theoretical framework to community interventions for smoking cessation developed during the 80s, in which smoking was considered not only an individual, but also a social problem. In the 80s and the 90s smoking cessation community trials were developed, such as the Community Intervention Trial for Smoking Cessation (COMMIT). Afterwards, policy interventions (price policy; smoking bans in public places; advertising bans; bans of sales to minors) were developed, such as the American Stop Smoking Intervention Study for Cancer Prevention (ASSIST). California has been the first State all over the world to develop a comprehensive Tobacco Control Program in 1988, becoming the place for an ever-conducted natural experiment. All policy interventions in tobacco control have been finally grouped together in the World Health Organization - Framework Convention on Tobacco Control (WHO-FCTC), the first Public Health Treaty. Study designs have changed, according to the individual, community, or regulatory approaches: the classical randomized controlled trials (RCTs), in which the sampling unit is the individual, have been carried out for the evaluation of smoking cessation treatments, whereas cluster RCTs, in which the sampling unit is the community, have been conducted for evaluating community interventions, such as COMMIT. Finally, quasi-experimental studies (before/after study; prospective cohorts, both with a control group), in which the observational unit is a State, have been used for evaluating tobacco control policies, such as ASSIST and the International Tobacco Control Policy Evaluation Project. Although the successes of the last 20 years, tobacco control is at a critical point: in a reductionist approach, we tried to study its parts, but few efforts have been done to consider tobacco control as a complex network that needs an alternative approach to be understood, the systems thinking approach. New attempts of understanding and solving contradictions within tobacco control using a systems thinking approach are presented.

Potentially reduced exposure products (PREPs), already sold in USA and in some European Countries, are low-nitrosamine cigarettes, low-nitrosamine smokeless tobacco (e.g., the Swedish Snus), cigarette-like products, and medicinal nicotine products. Even e-cigarette delivers nicotine. With the exception of snus and medicinal nicotine, studies on the health effects of PREPs have not been carried out, although some PREPs are already sold and promoted as products that effectively reduce health risks. Thus, a second disaster similar to that occurred for light cigarettes could happen in the next years. Only medicinal nicotine and snus could be valid candidates to become PREPs, even if they pose some significant health risks. The World Health Organization, following a precautionary approach, has recently published a list of 9 carcinogens or toxicants recommended for mandated lowering (the tobacco-specific nitrosamines NNN and NNK, acetaldehyde, acrolein, benzene, benzo[a]pyrene, 1-3 butadiene, carbon monoxide, formaldehyde), and 9 carcinogens or toxicants for monitoring in usual cigarettes (not PREPs), underlining that tobacco companies cannot use this reduction strategy as a promotional message, as it occurred for light cigarettes in the 70s and 80s. The present status quo, in which cigarettes are freely available, medicinal nicotine, being a drug, is available under a regulated market, and Snus is prohibited, actually denies smokers the right to choose safer nicotine products. The solution suggested by the UK Royal College of Physicians is to balance the nicotine market, framing tobacco products and medicinal nicotine in the same regulation system; establishing a nicotine and tobacco regulatory authority;making medicinal nicotine more available; evaluating the feasibility of the introduction in the English market of Swedish Snus. California Government remarks that the nicotine maintenance is not a valid strategy, because it could induce smokers not to try to quit.Thus, California Department of Health Services prohibits promotion of snus and medicinal nicotine as a harm reduction strategy. However, the US Federal Family Smoking Prevention and Tobacco Control Act, signed by President Obama in 2009, places tobacco products under FDA jurisdiction: FDA must define criteria for lowering carcinogens and toxicants in tobacco products, making more available medicinal nicotine, evaluating PREPs, creating a federal Tobacco Control Agency.Which approaches is Italy going to follow?

The Italian smoking ban entered into force on January 10th, 2005, and banned smoking from enclosed workplaces and hospitality premises (HPs), even though provided separated smoking areas. Actually, only 1-2%of HPs built these areas, while no figures are available on the prevalence of smoking rooms in workplaces other than HPs. Italians were more in favour of the law after the ban. In 2008 Italians were the Europeans most in favour of a national smoking ban (88%). Measurements of environmental nicotine and particulate matter with a diameter <2.5 μm (PM2.5) collected in some Italian towns before and after 1-2 years from the implementation of the ban, recorded a 60-97%reduction. Second-hand smoke exposure decreased at home. After the ban, the highest exposures were recorded in some discos. In outdoor areas of HPs, covered in winter, second-hand smoke (SHS) exposure was similar to that recorded before the ban in enclosed areas. Enforcement controls carried out in 2005-2009 showed the compliance was good: out of 20,550 controls, in only about 2%of cases people were smoking.Whereas 80-90%of interviews in national surveys reported the ban was respected in HPs, only 70% said the same for workplaces. Controls in HPs and workplaces should become routine activity for technicians of National Health System Prevention Departments. Cigarette consumption decreased annually by 2% in 2004- 2010 (from 98.9 to 87 millions of kilos), and smoking prevalence annually decreased by 1-3% in men and by 0.4-2.0% in women. In 2005, cigarette consumption decreased by 6.2% and 3.5% of this reduction was attributable to the introduction of the ban. In 2005 medicinal nicotine sales increased by 69%. Out of 5 studies on reduction of acute myocardial infarction after the ban, four recorded a 11-13% reduction in persons aged <60 years. Despite the protests of hospitality sector against the ban in 2004, no studies on impact of the ban on hospitality industry businesses were conducted in Italy. We used the conceptual model for the evaluation of the impact of smoke-free policies, proposed by the International Agency for Research on Cancer (IARC), to compare Italian and Scottish evaluations of the bans. The Scottish evaluation was planned some years before the implementation, and was based on a network of researchers of different disciplines. The quantification of decrease in second-hand smoke (SHS) exposure in the general population and in hospitality workers was one of the main objectives of the Scottish evaluation. The Italian evaluation devoted more attention to distal (reduction of hospital admissions) and incidental effects of the law (trend in smoking prevalence, cigarette consumption). Qualitative studies in bars, homes, and communities recording changes in attitudes on tobacco smoking after the introduction of the ban, were conducted only in Scotland. In Italy the main problem was to develop and fund a network of researchers involved on a shared evaluation plan.

Background: The Italian law of January 2005 that banned smoking in enclosed public places, also banned smoking in the workplace., Results: This law led to the elimination of exposure to passive smoking for non-smokers, more smokers who gave up smoking, and a fall in the number of cigarettes smoked per day among smokers. Enforcement of the ban needs to be strengthened in discotheques and at the workplace and in outdoor smoking premises. In covered outdoor areas set up for smokers in winter, passive smoking exposure is high., Discussion: A Cochrane review conducted in 2005 on workplace smoking bans did not conclude that bans helped employees to quit, while another review found that totally smoke-free workplaces are associated with a 3.8% reduction in smoking prevalence, and 3.1 fewer cigarettes smoked per person per day., Conclusions: Workplaces are ideal settings for health promotion, since it is feasible to organize individual interventions, such as counselling, combined with environmental measures (e.g., smoking bans) in order to support behavioural changes in employees. It is difficult to evaluate these complex interventions using standard evaluation methods such as cluster randomized controlled trials. We describe two workplace interventions conducted in Tuscany based on methods described by Sorensen.

Background and Objectives: The aim of this study was to investigate mortality of a cohort of 1,767 male workers employed in a sugar refinery plant located in the Province of Arezzo, Italy, where asbestos had been used from the 1960's for the insulation of thermohydraulic systems and for furnaces. In 1987-88 workers removed the asbestos-cement insulation from the plant., Methods: The cohort was composed by male workers who were employed in the plant between 1 March 1962 and 1 February 1996, and had worked for at least 2 months. Follow-up started on 1 March 1962, and ended on 31 May, 2003. The population mortality for Tuscany Region was used as the reference. The relative risk was estimated by Standardized Mortality Ratio (SMR) and the confidence intervals were calculated at a 95% level (95% CI)., Results: The majority of workers were employed during the summer only. Significant decreases in mortality were observed for overall mortality (SMR = 78; 95% CI = 69-88), all cancers (SMR = 80; 95% CI = 65-97), cardiovascular diseases (SMR = 64; 95% CI = 50-81), lung cancer (SMR = 66; 95% CI = 43-98), and gastrointestinal diseases (SMR = 53; 95% CI = 26-98). Non-significant increases were observed for kidney cancer (SMR = 229; 95% CI = 92-472), and diseases of the nervous system (SMR = 155; 95% CI = 71-294). Kidney cancer mortality for workers employed for > = 5 years was significantly higher (SMR = 508; 95% CI = 105-1485)., Conclusions: Mortality for asbestos-related diseases did not show any increase. The higher kidney cancer mortality for workers employed for > = 5 years could be due to exposures to various carcinogens, that occurred not only in the sugar refinery plant, given that the workers were seasonal and did other jobs during the rest of the year. Asbestos-related deaths could occur in the future among some workers who in 1987-88 were employed on the removal of asbestos-cement insulation from the plant.

Background: Arterial blood pressure, both systolic (SAP) or diastolic (DAP), has been widely investigated and some studies have shown an association between an increase in these parameters and mortality. The most frequently studied risk factors of arterial hypertension are use of alcohol, smoking and ethnic origin referred to both genetic differences and nutritional habits, while professional factors have been rarely and less deeply considered although significant differences have been found in mean arterial pressure in subjects conducting different professional activities. It seems in fact that "blue collar" workers are more at risk that "white collar" ones., Objectives: Our aim is to evaluate if work conditions or job strain related to professional activity or to life styles represent a risk factor for arterial hypertension and whether this effect of hypertension is independent of age. In fact, specific factors that may explain this connection have still not been clearly defined., Methods: Our research method was similar to french inquiries ESTEV (Derriennic, Touranchet, Volkoff) and VISAT (Marquie, Jansou) applied in 6 Italian Regions and involved workers employed in different productive sectors and belonging to 5 age cohorts: 32, 37, 42, 47, 52 years. Information were obtained by occupational health physicians, using 3 questionnaires:--working conditions (exposure to certain risks or job strain);--life styles and self evaluation of health (Nottingham Health Profile);--objective information on health status. The present work consider only parameters that in other studies have been found associated with CVD morbidity, including: (1) working conditions, (2) subjective assessment of work, (3) specific job strain perceived Hypertension was considered as SAP > or =160 mm/Hg and/or DAP > or =90 mm/Hg, or current antihypertensive treatment., Results: The results refer to 1104 workers, 76% men and 24% women. Prevalence of hypertension was found to be higher among the men than women (33% Vs 22%) and was higher with advancing age. Risk estimation showed a statistically significant association with certain work-related factors such as: shift work (O.R. 1.33), awkward posture (O.R. 1.71), exposure heat (O.R. 1.43), sitting work (O.R. 1.48), doing several tasks simultaneous (O.R. 1.41), being interrupted at work (O.R. 1.35), not being able to take eyes off work (O.R. 1.61). The multivariate analysis by logistic regression showed that the variables referred to cognitive aspects and work organization tended to be associated to arterial hypertension even when exposure ceased., Conclusions: We observed that both some physical aspects of work and cognitive organisation aspects, are strongly associated with arterial hypertension. An important element was found to be the subjective assessment that workers give to their work. From an intervention point of view, this aspects should be considered as possible reducible risk factor.

Background and Objectives: The aim of this study was to investigate the mortality of 262 workers (200 men and 62 women) employed in an asbestos cement plant located in Carrara, Italy, exposed to a mixture of chrysotile and crocidolite asbestos in a ratio of 2:5., Methods: Follow-up started on 1 January, 1963. The vital status and causes of death were ascertained on 31 December, 2003. The Tuscany population mortality was used as reference. The relative risk was estimated by Standardized Mortality Ratio (SMR) and the confidence intervals were calculated at 95% level [95%CI]., Results: Among men, a significant increase in mortality was observed for respiratory disease (14 deaths; SMR = 244.1; IC95% = 133.4-409.5), particularly for pneumoconiosis (10 deaths; SMR= 1,800; IC95% = 856.9-3,300.0; of which 5 deaths due to asbestosis; SMR = 120,000; IC95% = 37,000-270,000), and for pleural cancer (4 deaths; SMR = 2,500; IC95% = 676.8-6,400.0). Non-significant increases were also observed for lung cancer (10 deaths; SMR = 114.2; IC95% = 54.8-209.9), and gastric cancer (7 deaths; SMR= 167.1; IC95% = 67.2-344.3). Among women, significant increases were observed for pneumoconiosis (1 death; SMR = 17,000; 95%CI = 425-93,000), and for liver cancer (3 deaths; SMR = 765.0; IC95% = 157.8-2,200.0)., Conclusions: For males our results were consistent with other mortality studies on asbestos-cement workers. No other cohort studies on asbestos cement workers have dealt with mortality of female workers.

Introduction: a law banning smoking in enclosed public places entered into force in Italy on January 10th 2005., Objective: to compare the SHS exposure before and after the coming into force of the new anti-smoking law, with direct measurements in public venues and workplaces., Methods: vapour-phase nicotine was measured using passive samplers, with personal and environmental sampling., Setting: samples were collected in 10 municipality offices, 10 industry buildings and 11 public venues (4 discos and 7 pubs) in two towns (Florence and Belluno) from november 2004 to march 2005., Results: during the pre-ban period a wide range of nicotine concentrations was observed. Offices and industry sector exhibited very low concentrations, 0,47 e 0,40 microg/m3 in median, respectively. Highest concentrations were measured in pubs and discos (35,59 and 127,16 microg/m3). After the smoking ban, a noteworthy reduction in nicotine concentrations was found with a stronger effect in pubs and discos (95% of decrease)., Discussion: the introduction of a national smoking ban led to a clear reduction in SHS exposure, with stronger results in environments less protected by previous regulations.

Background and Objectives: Three malignant pleural mesotheliomas occurred among workers of a small factory that manufactured drying machines for the textile and paper mill industries using asbestos cement (crocidolite, amosite and chrysotile) as insulating panels. The Occupational Medicine Unit of the Local Health Unit of Pistoia, Italy, carried out an intervention programme in the plant in order to 1) assess past asbestos exposure via analysis of the fibre content of samples from drying machines, and of dust samples collected in the factory. Information on the characteristics of occupational exposure was also collected; 2) investigate cancer mortality by means of a mortality study of the employees and, 3) carry out a health intervention programme in workers formally exposed to asbestos in the past., Methods: Samples from the drying machines and dust samples collected in the factory were analysed using X-ray diffractometric methods. Information on the characteristics of occupational exposure were collected by interviewing plant workers. Two-hundred and fifty employees who had worked in the factory between 1962 and 2000 were included in the mortality study. Follow-up was performed from 1962 to 2002. Health intervention in workers exposed to asbestos in the past involved general practitioners and occupational physicians (first level medical examinations); pneumologists and radiologists (second level medical examinations) of the local health unit., Results: Asbestos fibres were found both in samples from drying machines and in dust samples collected in the factory. Interviews with workers showed that asbestos exposure varied considerably. The SMR for mesothelioma and lung cancer in 234 male workers were 37.0 (95%CI: 4.47-130.0), and 1.29 (95%CI: 0.26-3.78), respectively, based on mortality rates for Tuscany region. Sixty-two workers underwent first level medical examinations; 57 second level examinations. Chronic obstructive lung disease was found in 3 workers; restrictive lung disease was found in 3 employees, one of whom had pleural plaques., Conclusions: Further investigation is needed in order to identify unknown asbestos exposures in small metal engineering factories.

Objective: We evaluated if work conditions or job strain related to professional activity or to life styles represent a risk factor for arterial hypertension and whether this effect of hypertension is independent of age., Design: through data collection of epidemiological inquiries ESTEV and VISAT, applied in Italy on a cohort of workers, 32-52 year-old, employed in different productive sectors, we analyzed the relationships on working conditions (exposure to certain risks or job strain), life styles and self evaluation of health and arterial hypertension. Hypertension was considered as SAP > or =160 mm/Hg and/or DAP > or =90 mm/Hg, or current antihypertensive treatment., Results: the results refer to 1104 workers, 76% men and 24% women. Prevalence of hypertension was found to be higher among the men than women (33% vs. 22%). Risk estimation in multivariate analysis, by logistic regression model, showed a statistically significant association with certain work-related factors such as: shift work, awkward posture, standing work, doing several tasks contemporarily, being interrupted at work, not being able to take eyes off work. The variables referred to cognitive aspects and work organization tended to be associated to arterial hypertension even when exposure ceased., Conclusions: both physical and cognitive organisational aspects of work are strongly associated with arterial hypertension. The subjective assessment that workers give to their work is a relevant element. This aspects should be considered as a possible reducible risk factor.

Objectives: Measurements of the environmental tobacco smoke (ETS) exposure in public places in Florence. This study was part of the first European multicenter project, intended to measure ETS exposure in public places in a number of European Cities (Florence, Barcelona, Paris, Oporto, Athens, Wien and Orebro)., Design: Nicotine vapour phase was measured using passive samplers, composed of a sodium bisulphate treated filter held in a plastic cassette with a windscreen on one side. The filters were analysed at the Laboratory of the Public Health Agency of Barcelona, Spain, by gas-chromatography/mass spectrometry (GC/MS)., Main Outcome Measures: Nicotine concentration (in microg/m3) by public place, by smoking policy, and, for restaurants with separated areas, by smoking and non-smoking section., Setting: Nicotine measurements were conducted in 5 schools, 3 university departments, 5 hospitals, 1 railway station, 1 airport, 7 bars, 7 restaurants, and 4 discotheques in Florence., Results: The average nicotine concentration in discotheques and restaurants were respectively 26.78 microg/m3 and 2.32 microg/m3. In the other public places the concentration was about 1 microg/m3. In smoke-free public places the average concentration was 0.85 microg/m3; in public places where smoking is allowed concentration was higher (11.53 microg/m3). In the smoking section and non-smoking section of restaurants with separated areas the average concentration was respectively 2.54 and 2.14 microg/m3., Conclusion: The highest nicotine concentrations were recorded in discos and restaurants. A smoke-free public place is effective in reducing ETS exposure. Smoking and non-smoking sections in restaurants without a separate ventilation system seem not to solve ETS exposure.

Background: "Environmental Tobacco Smoke (ETS) exposure in a sample of European cities" is the first European multicentre project intended to measure ETS exposure in public places in a number of European cities., Objectives: To present results of measurements of nicotine concentration in a number of bars, restaurants and discotheques in Florence, Italy., Methods: The ETS marker was vapour-phase nicotine sampled by passive monitors. At least two monitors were placed in each of seven bars (five in hospitals; one at an airport; one at a railway station), and seven restaurants (three with smoking and non-smoking sections), and left in place for several days. In each of four discotheques two nicotine passive monitors were used as personal samplers., Results: The average nicotine concentration in discotheques, restaurants and bars was respectively 26.78 micro/m3, 2.32 microg/m3 and 0.83 microg/m3. In the smoking section of restaurants with separated areas for smokers and non-smokers the average nicotine concentration was 2.54 microg/m3, which was similar to that measured in non-smoking sections (2.14 microg/m3).

This report presents the impact of smoking habits on Italian mortality in 1998. Estimates of smoking-attributable fraction (FAF), smoking-attributable mortality (MAF), and years of potential life lost (YPLLf) were calculated using the SAMMEC software (CDC, USA), and the Peto method. During 1998, using the SAMMEC software, smoking caused approximately 83,650 premature deaths in Italy (67,600 in men, 16,000 in women, and 45 in infants), equal to 15.1% of mortality in adults above the age of 35 years (24.4% of mortality in men and 5.8% in women). YPLLf were about 900,000 in men, 221,000 in women, and 3,500 in infants. Using the Peto method, smoking-attributable deaths were about 70,200 (59,600 in men and 10,600 in women), equal to 12.7% of mortality in adults older than 35 years (21.5% of mortality in men and 3.9% in women). YPLLf were about 806,000 in men and 142,000 in women. Among adults, for both methods most smoking-related deaths were attributable to lung cancer, ischemic heart disease, chronic airways obstruction, and cerebrovascular disease. Differences between the estimates of the two methods underline the gap between a more conservative estimate (Peto method) and a less restrictive one (SAMMEC software). Given validity for both methods, it is likely smoking habits caused between 70,000 and 83,000 deaths in Italy during 1998.

Movies influence fashion, lifestyles, and represent smoking as an acceptable behaviour. In fact the greatest tobacco companies built relationships with Hollywood's actors and producers, in order to show smoking and cigarette brands in films. All over the world laws have been developed, in order to restrict smoking and tobacco advertising. Films showing tobacco do not violate these laws, even in those states where tobacco advertising is restricted. Moreover, films are better than any other commercial advertisements because the audience is total unconscious of the sponsor's involvement. Stanton Glantz, Medicine Professor at San Francisco University, is the voice of the movement for smoke-free movies. A lot of studies show that cigarette smoking is more frequently in '90s movies than in 60's and 70's movies. The smoking actors seem to be attractive, strong, healthy and successful. Films showing smoking influence tomorrow's customers: adolescents. Teenagers watching "smoking films" are the most exposed to start smoking. Hence the need to educate Hollywood industry, in order to have smoke-free movies.

In the period 1988-1999, the Tuscan Mesothelioma Registry (ARTMM) recorded 436 cases of pleural malignant mesothelioma (MMP); 81% were males. The Tuscan MMP incidence rate (age standardized on European population; per 100,000 per year), was 0.97 in 1988-1993, 1.64 in 1994-1999 for males; 0.22 and 0.23 for females, respectively. In the period 1988-1999 the Tuscan Mortality Registry (RMR) recorded 676 pleural cancer (TMP) deaths (ICD IX 163; 464 in males). In the periods 1988-1993 and 1994-1999 Tuscan TMP mortality rate (per 100,000 per year) was 1.54; 1.70 for men; 0.46 and 0.53 for women, respectively. The highest incidence and mortality rates for males were recorded in Massa Carrara (MMP incidence in the period 1994-1999: 5.20) e Livorno (MMP incidence in the period 1994-1999: 4.64) provinces. In order to study differences between incidence and mortality for males, an analysis of distribution of incident MMP cases and TMP deaths by municipality in Tuscany was carried out. It is usually assumed for projections of MMP mortality that the ratio of MMP mortality to TMP mortality is 1:1. However, in order to evaluate more precisely projections of MMP mortality, the exact ratio was calculated for men. In the period 1994-1999, 82% (154/188) of the male MMP deaths were correctly coded as TMP deaths in the RMR; 60% (154/256) of male TMP deaths were definite MMP cases, as they were recorded in ARTMM. The ratio of MMP mortality to TMP mortality is, therefore, 0.73:1 (0.60/0.82) for males in Tuscany.

Background: The Tuscany Mesothelioma Register (ARTMM) records pleural malignant mesothelioma cases of Tuscany residents, diagnosed by histological, cytological, or clinical (radiography or computerized tomography) examinations. The ARTMM began in 1988 and estimates mesothelioma incidence in Tuscany and collects information on past asbestos exposure of mesothelioma cases., Objectives: The aim of this paper was to describe the incidence of pleural mesothelioma cases in Tuscany and to analyse their possible past asbestos exposures., Methods: We considered pleural mesothelioma cases recorded in ARTMM in the period 1988-2000 and interviews collected for these cases. In order to identify past asbestos exposure in the occupational and non-occupational history of patients, interviews were carried out using a standardised questionnaire., Results: In the period 1988-2000, 494 pleural malignant mesothelioma cases were recorded in the ARTMM; 82% were males. In the periods 1988-1993, 1994-1997, 1998-2000 the incidence rates, standardised on the Italian population (per 100,000), were respectively 1.15, 1.57, 2.58 among males; 0.29; 0.27; 0.29 among females. Information on occupational history was collected for 418 mesothelioma patients (85% of recorded cases): 173 mesothelioma cases were directly interviewed; for 245 cases relatives or work colleagues were interviewed. Occupational asbestos exposure was ranked as certain, probable or possible in 72% of the interviewed cases (80% of males; 20% of females). Environmental and non-occupational asbestos exposure was identified in 1% of males, and 3% of females. In 24% of the interviewed cases (15% of males; 74% of females) no known asbestos exposure was identified. Occupational asbestos exposure occurred in maritime activities (shipyards, dock work, merchant and regular Navy), the building industry, railway carriage construction and maintenance, rail transport, textile industries (mainly rag sorting), electricity production, asbestos cement manufacture, chemical, iron and steel industries and in glass manufacturing. In Tuscany two areas are distinguished for their well-documented and massive use of asbestos: the coastal areas (Livorno and Massa Carrara) for maritime activities, and the areas of Pistoia and Arezzo for railway carriage construction and repair. Mesothelioma incidence rates in these areas are the highest in the whole region., Conclusions: Further investigation is needed in order to identify unknown asbestos uses and consequent exposure, in particular for females. Uncertainty as regards occurrence of asbestos exposure persists in the textile industries where the mesothelioma epidemics have not yet declined. Research hypotheses are addressed on the re-use of jute bags previously containing asbestos, therefore collection of further information on periods and methods of this recycling activity is essential.

A survey was carried out in a pharmaceutical industry, in order to know the exposure to environmental tobacco smoke (ETS) in the workplace, and attitudes of workers toward workplace smoking restrictions and bans. In the three plants of the industry (Bergamo, Milan, Reggello-Florence) workers were exposed to ETS in every workplace areas, except for the production area, even if there were no-smoking warning notices in the plants. Non-smokers were more favorable than smokers about the introduction of workplace restrictions on smoking. In order to decrease exposure to ETS, it would be desirable to develop workplace smoking restrictions or bans, effective and low-cost interventions.

The Italian League against Cancer organizes a group behaviour therapy program for smoking cessation in Milan and Rome. Groups meet for 8-9 sessions; sessions are managed by a therapist. In the analized courses participants are 43-44 years on the average, with a middle/high level of education. They are heavy smokers with a high level of nicotine dependence and they greatly trust in the program. At the end of the program 67% of participants in Milan and 76% in Rome declare they no longer smoke. One year later, phone interviews show that 22% of participants in Milan and 25% in Rome are still non smokers. At the end of the program quitting-smoking predictors are: attendance at at least 6-7 sessions, smoking less than 30 cigarettes a day before the course and male gender; one year later attendance at at least 6-7 sessions, and scarce nicotine dependence (smoking less than 30 cigarettes a day before the program or a low score at the Fagerström Tolerance Questionnaire).

The Italian League against Cancer, section of Florence, organizes courses for smoking-cessation groups. Groups meet for 10 sessions throughout 6 weeks; sessions are managed by a psychologist with a cognitive-behavioral approach. In the 53 analyzed courses registered people (693 persons) are mainly women, aged 31-50, with a middle-high level of education. They are heavy smokers with a high level of nicotine dependence and they greatly trust in the course in spite of their previous quit attempts. At the end of the program 66% of registered people (69% of men; 63% of women; p > 0.05) asserts not to smoke anymore. One year later, phone interviews show that 33% of participants (41% of men; 28% of women; p < 0.01) are ex-smokers. After the end of the program the first three months are the higher risk period of relapsing. At the end of the program quitting-smoking predictors are: attendance at at least 7 sessions (OR = 4.26), no more than a high school educational level (OR = 1.71) and smoking less than 30 cig. a day before the course (OR = 1.56). One year later quitting-smoking predictors are: attendance at at least 7 sessions (OR = 2.08), scarce or medium nicotine dependence according to the Fagerström Tolerance Questionnaire (OR = 1.42) and male gender (OR = 1.40).

Equilibrium pool scintigraphy was performed in 11 obese subjects (BMI 34 +/- 2) and in 14 normal control subjects. Temporal and spatial smoothing of the data was then performed followed by time-activity curve generation using a semiautomatic second derivative edge-detection algorithm. The increase in counts during the first third of diastole divided by the total change in number of counts during diastole was determined as the one-third filling fraction. This index of diastolic filling was significantly decreased in obese subjects as compared to the control group. These findings indicate that diastolic abnormalities may be an early finding in obesity-linked heart disease, occurring in the presence of normal systolic function (E.F. = 65 +/- 5%).