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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: The aim of this study was to elucidate the pathway of associations linking gambling, alcohol intake, smoking habit, cannabis consumption between each other and with demographic and socioeconomic variables., Setting and Participants: A survey was conducted in 2017 on a representative sample of 15 602 Italian 14-year-olds to 17-year-olds attending 201 secondary schools., Outcome Measures: Structural Equation Models analysis was used to assess the pathway between gambling, alcohol intake, smoking, cannabis consumption, demographics and socioeconomic factors., Results: Irrespective of socioeconomic or demographic variables, gambling is positively associated with alcohol and cannabis consumption, while cannabis consumption is predicted by smoking and by alcohol intake, smoking is predicted by alcohol intake. Adolescents with a higher weekly income are more at risk of gambling, drinking alcohol and smoking, while the degree of economic dissatisfaction was positively associated with alcohol intake, cannabis consumption and smoking. Maternal employment appeared to be positively associated with adolescents' smoking, alcohol intake and cannabis consumption., Conclusions: This is one of the first studies to shed light on the pathways of associations connecting various health-risk behaviours among adolescents with demographic and socioeconomic factors., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Main aim was to describe youth smoking prevalence in Italy over the last two decades, and to provide recent trends in knowledge, attitudes towards smoking, awareness of anti-tobacco mass media campaigns, second-hand smoke (SHS) exposure and access to cigarettes., Methods: Figures from three surveillance systems, with 12 representative cross-sectional surveys (about 43 000 participants): European School Survey Project on Alcohol and Other Drugs, 15-16-year-old students, 1995-2015; Health Behaviour in School-aged Children, 11-, 13-, 15-year-old students, 2002-14 and Global Youth Tobacco Survey, 13-15-year-old students, 2010, 2014., Results: Among 11- and 13-year-old students, daily and non-daily smokers decreased by 30-50% from 2002 to 2014. Among 15-16-year-old adolescents, ever smokers significantly decreased by 10% in the period 1995-2015, whereas current and daily smokers have been stalling or even increased. Appeal of smoking increased in 2014 compared to 2010, perception of SHS as harmful, and awareness of recent anti-tobacco mass media campaigns decreased. Moreover, a significant 30% reduction in reporting retailers did not refuse to sell cigarettes to adolescents and a decrease in reporting to buy cigarettes were reported., Conclusions: Policies enforced in Italy over the last 20 years slightly reduced ever smokers, but did not decrease current and daily smokers in 15-16-year-old adolescents, and determined an impact among younger adolescents. Stricter rules on youth tobacco access reduced ease of access to cigarettes, but did not affect adolescents' tobacco use. Stronger tobacco control measures are urgently needed in order to determine a steeper decline in smoking prevalence in adolescents.

Introduction: The epidemiology of lung cancer is changing worldwide, with smoking being the key driver of lung cancer incidence and mortality. Our aim is to analyze the incidence, survival and mortality trends in Italy in the framework of the 2017 survey on smoking behavior in Italy., Methods: AIRTUM 2017 reports on cancer survival and incidence; 2017 survey on smoking behavior in Italy., Results: Men achieved progress in lung cancer control characterized by a decrease in incidence and mortality and an increase in survival. The decreasing use of tobacco in men (from 60% in the 1960s to 24% in 2017) was most likely responsible for the decreasing incidence and mortality. Women showed no progress: although survival improved slightly, the incidence and mortality were both on the rise. This was most likely due to the increasing smoking rates in women in the 1970s and 80s. Of major concern is the accelerated rise in the number of smoking women from 4.6 million in 2016 to 5.7 million in 2017 compared to the decrease observed in men (from 6.9 to 6 million)., Conclusions: The incidence and mortality trends in males clearly demonstrate that primary prevention is the most effective way to reduce lung cancer mortality. By contrast, a 24% increase in the prevalence of smoking among women in just 1 year is extremely worrying for the future, and calls for immediate action by targeted strategies to reduce tobacco consumption in women and avert the dreadful prospect of a lung cancer epidemic in Italy.

Purpose: In 2016, a series of selective tobacco regulations, which did not affect tobacco price, came into force in Italy. To understand how Italians accepted the new norms, we analyzed data from our 2 most recent surveys among those we annually conduct on tobacco., Methods: In 2015 and 2016, we conducted 2 representative cross-sectional studies focused on the new forthcoming tobacco legislation on a total sample of 6,046 Italians aged ≥15 years., Results: Overall, 21.4% of Italians (26.0% of men and 17.2% of women) were current smokers, showing a small but significant decrease in smoking prevalence since 2007 (p for trend = 0.004). No change in smoking prevalence was observed over the last decade among the young (i.e., 15-24 years; 20.1% in 2015-2016). Roll-your-own cigarettes were the most frequent tobacco product for 8.3% of adult smokers and 19.7% of young smokers. According to the attitudes of Italians towards the new regulations, 91.3% supported the smoking ban in cars in presence of minors, 90.2% a more stringent enforcement of the tobacco sales-to-minors regulation, 74.3% the introduction of shocking pictorial images on tobacco packs, and 63.2% the removal from the market of small cigarette packs, usually purchased by the young., Conclusions: Smoking prevalence only marginally decreased over the last decade among adults, but did not decrease among the young. Roll-your-own tobacco is increasingly used by adults and young people. Before the entrance of the new norms, Italians largely supported them, particularly those targeting children.

Objectives: Studies investigating whether smoking increases or decreases during economic downturn provided contrasting results. For the first time, we used direct questions to analyse changes in smoking behaviour due to the 2008 financial crisis, comparing socio-economic characteristics of smokers who changed with those who kept their smoking intensity., Study Design: Cross-sectional survey., Methods: We used data from three annual surveys conducted in Italy in 2012-2014 on representative samples of the Italian general population aged ≥15 years., Results: A total of 1919 current smokers were asked specific questions on the influence of the economic crisis that started in 2008 on their smoking behaviour. Overall, 77.4% of 1919 current smokers reported not to have changed their smoking behaviour, 19.1% to have reduced, and 3.5% to have increased their smoking intensity as a consequence of the economic crisis. The reduction in cigarette smoking increased with age: compared to the respondents aged <25 years, the multivariate odds ratio (OR) for those aged 25-44, 45-64 and ≥65 years were 0.65, 0.46 and 0.33, respectively (P for trend<0.001). Reduction was significantly lower among intermediate (OR = 0.68 compared to low) and high education levels (OR = 0.28; P for trend<0.001). A significant inverse trend for increasing consumption was observed with age (P = 0.022), education (P = 0.003) and family income (P < 0.001)., Conclusions: The large majority of current smokers did not change their smoking habit following the economic crisis. However, there are specific vulnerable subgroups of smokers, constituted by the young and subjects with low socio-economic status, that were reactive to the global economic crisis. These groups are more prone to change their smoking behaviours, either for better or -, in a smaller proportion -, for worse., (Copyright © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Aims: To update smoking prevalence trends in Italy among adult and young populations; to determine the recent spread, particularly among young smokers, of roll-your-own (RYO) cigarettes (which cost approximately half the price of manufactured cigarettes); and to evaluate the effects of 2013 legislation increasing the minimum tobacco purchasing age from 16 to 18 years in Italy., Methods: Two surveys on smoking were conducted in 2013 and 2014 in Italy, on a total sample of 6052 individuals, representative each year of the national population aged ≥15 years, where we collected data on type of tobacco most frequently smoked and on the perception of the enforcement of the tobacco sales-to-minors legislation., Results: A total of 21.1% of the population surveyed were smokers (25.5% of men and 17.0% of women). Prevalence of current smoking among young participants (15-24 years) was 19.9% (21.7% of male participants and 18.0% of female participants). Overall, 6.9% of smokers, and 13.3% of young smokers, reported RYO cigarettes as the most frequently smoked tobacco product. More than 80% of Italian adults had never seen a tobacco retailer refuse to sell cigarettes to minors (i.e., aged &lt;18 years) or request their identification or age., Conclusions: Although adult and young smoking prevalence rates substantially decreased over the last few decades, neither of them have significantly changed since 2007. Use of RYO cigarettes is increasing, particularly among the young. Our study highlights the need to equalize the costs of different types of tobacco products and to improve the enforcement of the current tobacco sales-to-minors legislation.

Objective: To analyse the prevalence and correlates of smoking in cars as well as attitudes towards the extension of smoking bans in private vehicles among Italian adults., Methods: We used data from two surveys conducted in 2011 and 2012 on an overall sample of 6167 individuals representative of the Italian population aged ≥15 years., Results: The prevalence of smoking while driving was 65.5% among adult smokers. There was a negative trend with age and a positive one with education level. Smoking while driving was more prevalent among men, heavy smokers and smokers who believe there is little or no increased risk of accidents from smoking while driving. Among smokers who smoke while driving, 20.9% smoke in cars carrying children. Overall, 79.6% of Italians (88.2% non-smokers and 48.8% current smokers) support a ban on smoking in cars, and 92.5% (95.0% non-smokers and 83.5% current smokers) support such a ban in cars carrying children., Conclusions: Despite the high percentage of smokers who smoke in private vehicles, the majority of the Italian population (including smokers) support the introduction of a smoking ban in cars, particularly in cars carrying children. Smoke-free laws should therefore be extended to private vehicles, particularly if they are carrying children. Moreover, warning labels on cigarette packages should include information on the increased risk of accidents when smoking while driving. Mass media campaigns should also consider targeting this topic.

Objective: To provide updated information on smoking prevalence in Italy, with a focus on type of tobacco product, including hand-rolled (HR) cigarettes., Method: Two nationally representative surveys were conducted in 2011 and 2012 in Italy on a total sample of 6167 adults. Information on type of tobacco most frequently smoked was collected., Results: Current smokers were 21.7% (22.7% in 2011 and 20.8% in 2012) overall, 25.3% among men and 18.4% among women. Among smokers, 94.6% most frequently consumed manufactured cigarettes, 4.6% HR cigarettes, 0.5% cigars, 0.2% cigarillos, and 0.2% pipe and none smokeless tobacco. HR cigarette use was more frequent in men (6.9%) than in women (1.7%), in 2012 (5.9%) than in 2011 (3.4%), and among the young (15-24 years; 9.1%). The average estimated price of one HR cigarette was 0.09€ and that of a manufactured cigarette was 0.18€., Conclusion: In 2012 we observed the lowest reported overall smoking prevalence in Italy, though change since 2008 has been limited. The proportion of HR cigarettes on total tobacco trade has appreciably increased, particularly among young male smokers, who appear to switch to affordable cigarettes in a period of economic crisis. Fiscal policies aiming to equalise the cost of different cigarette types are needed in Italy., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Most studies investigating the reasons for smoking initiation are based on adolescents or young individuals. We considered the issue in a large dataset on the general Italian population. Six population-based surveys on smoking were conducted annually from 2005 to 2010 on representative samples of Italian individuals aged 15 years or over, involving more than 3000 individuals each year. A specific question on the main reason to start smoking was asked to 7469 ever smokers. Overall, 59.9% of ever smokers started smoking before 18 years of age and 33.6% started smoking before 16 years of age. Among ever smokers, 61.1% reported having started smoking because of the influence of friends, 15.6% for enjoyment and satisfaction, 9.0% to feel mature and independent, 6.6% because of the influence of partner/family, 2.5% because of stress, 1.9% to feel more secure and 1.8% for curiosity. The finding that the majority of Italian men and women - particularly those who started smoking at a young age - started smoking because of the influence of friends suggests that antismoking campaigns should consider social influence, resistance and the dimension of self-esteem. An improvement in the legislation prohibiting the purchase of tobacco products by minors aged less than 18 years and a smoking ban in school courtyards are urgently required in Italy.

Scarce information is available, particularly from Europe, on why smokers quit. We analyzed this issue in a large dataset of Italian ex-smokers. Six population-based surveys on smoking were annually conducted in 2005-2010 on a representative sample of the Italian adult population, which included more than 3000 participants each year. A specific question on the main reason for quitting smoking was answered by a total of 3075 ex-smokers (1936 men and 1139 women). Overall, 43.2% of ex-smokers mentioned a current health condition as the main reason to stop smoking, 31.9% stopped to avoid future health problems, 6.3% stopped because of pregnancy or child birth, 4.0% because of imposition by the partner/family, 3.7% because of a physician's recommendation, 3.0% because of the economic cost, 0.5% because of smoking bans, and 4.6% because of other reasons. Statistically significant differences in the motivation to quit smoking have been found according to sex, age, social class, and smoking history. The majority of ex-smokers quit because of tobacco-related health conditions. Only a minority of ex-smokers quit to avoid future illness. Physicians should be encouraged to assist smokers to quit. The current prices of cigarettes in Italy are not sufficiently high to discourage people from continuing smoking.

Background: Depression is a potential risk factor for mortality among the aged and it is also associated with other chronic diseases and unhealthy lifestyles that may also affect mortality. The purpose of this study was to investigate the association between depressive symptoms and mortality, controlling for health, nutritional status, and life-style factors., Methods: A cohort of elderly people (N = 167) was followed-up for ten years. Information on socio-demographic characteristics, medical history, smoking, and alcohol consumption was collected. The primary outcome was all-cause mortality; the secondary outcome was cancer-specific mortality. The Geriatric Depression Scale (GDS-15) was used to assess depression. Using a multivariable Cox proportional hazards regression, we examined the association between depressive symptoms and mortality., Results: Elderly people with depression (scoring above the depression cut-off of 7) had a 53% increased risk of mortality (relative risk (RR) 1.53; 95%CI: 1.05-2.24) compared to non-depressed subjects. The combination of depressive symptoms with smoking was associated with a particularly higher risk of mortality (RR: 2.61; 95%CI: 1.28-5.31), after controlling for potential confounders., Conclusions: Depressive symptoms are associated with a significantly increased risk of all-cause mortality. The combination of depressive symptoms and smoking shorten life expectancy among the aged.

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.

Aims and Background: To monitor smoking prevalence and trends of young and adult populations in Italy. METHOD AND STUDY DESIGN: A survey on smoking was conducted during March-April 2009 on a sample of 3213 participants (1546 men and 1667 women), representative of the Italian population aged 15 years or over. Data from a simplified questionnaire were collected in an over-sample of 1010 young individuals, reaching a total of 1390 participants aged 15-24 years (713 males and 677 females)., Results: In 2009, 25.4% of Italians described themselves as current cigarette smokers (28.9% of men and 22.3% of women). Among young people, male smoking prevalence steadily declined from 38% in 2001 to 29% in 2009. Smoking prevalence in young females decreased from 30% in 2001 to 19% in 2008, but increased to 23% in 2009. Among both males and females aged 15-17 years, smoking prevalence was around 10%. This increased in the 18-24 year age group, with 37.6% of current smokers among males and 28.9% among females. Among young current smokers, 45.5% reported that they would reduce the number of cigarettes smoked per day, 11.1% would quit smoking, and 4.3% would switch to hand-rolled cigarettes, assuming that the minimum price of a pack of cigarettes increased to € 5., Conclusions: Our findings indicate that smoking prevalence has decreased over recent years, particularly in the young. Still, over one-fourth of Italian adults are smokers. An increase in cigarette price represents an effective strategy to control tobacco, particularly in the young.

We investigated acute and chronic exposure to environmental tobacco smoke (ETS) in a cohort of young adolescents using urinary cotinine and hair nicotine testing after recent implementation of Italian smoke free legislation. Study subjects were 372 Italian young adolescents, between 10 and 16 years of age from the principal city of Sicily, Palermo. Urine and hair samples were collected between November 2005 and May 2006, when the legislation to ban smoking in all the enclosed places of employment (including bars, restaurants, pubs) was completely enforced. An exhaustive questionnaire including sociodemographic characteristics and active and passive exposure to cigarette smoking was completed. Urinary cotinine was analyzed by radioimmunoassay and hair nicotine by a validated GC/MS method. Based on urinary cotinine results, 2.1% and 89% of the study participants, respectively, showed non-exposure and low acute exposure to ETS, whereas only 1.6% presented very high exposure or a hidden active smoking habit in the recent past. Hair nicotine disclosed non-exposure and low exposure to ETS in 11.8% and 65.6% of the young adolescents, respectively, taking into consideration a larger time-window. High repeated exposure, suggesting active smoking in some cases was observed in 8.6% of the study subjects. Hair nicotine was inversely related to educational level of the adolescents' parents. Overall, due to the implementation of smoke-free legislation and information campaign against smoking, a significant trend toward low exposure to ETS was observed in this study cohort with no association between exposure to ETS and respiratory illnesses., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

Hardcore smokers are described as heavy smokers who have not attempted to quit and have no future intentions to quit. The objectives of this study were to characterize hardcore and nonhardcore smokers in Italy. The data for this analysis were collected from 3057 Italians aged 15 years and older in March and April 2007 who were randomly selected to be representative of the population. Hardcore smoking, defined as consuming 15 or more cigarettes per day with no earlier quit attempts and no future intention to quit, was examined in individuals who were aged 26 years and older. Hardcore smokers were compared with their nonhardcore counterparts with respect to sociodemographic and smoking characteristics, perceived stress, and attitudes and beliefs about smoking. The smoking prevalence overall was 23.5% (27.9% among males and 19.3% among females). An estimated 7.8% of individuals were hardcore smokers (9.7% among males and 6% among females), which translates into 33.1% of all smokers in Italy. Age at smoking initiation, occupation (among males), home smoking rules, and perceived stress (among females) distinguished hardcore from nonhardcore smokers. This is the highest prevalence of hardcore smoking that has been reported in the literature to date. This reflects the general attitude toward smoking cessation in Italy. Although the indoor smoking ban has helped to reduce the rate of smoking, it is clearly not enough. Stronger tobacco control measures are warranted.

Objective: Apart from cancer, cardiovascular and respiratory diseases, smoking is associated with an increased risk of accidents and injuries. Many of these can be accounted for by dangerous smoking behaviors such as smoking in bed or while driving. We estimated therefore the prevalence of these hazardous smoking behaviors and the perceived risk of accidents associated with them in Italy., Methods: Data were derived by a survey on smoking on 3057 subjects, representative of the Italian population aged > or =15 years. Specific questions were included on prevalence and risk perception of smoking while driving or in bed., Results: Of all current smokers (23.5% of the Italian population), 12% reported smoking while in bed, 69% reported smoking while driving a car, and 17% reported smoking while driving a motorcycle. Predictors of smoking while driving were younger age, male sex, and being a heavy smoker. Of the total population, 81% reported that smoking while driving increased the risk of accident, but public perception was lower in men, the young, current smokers, and among the subjects engaging in these behaviors. About 7% of car injuries in Italy could involve a subject who smokes while driving., Conclusion: Efforts should be taken, therefore, to disseminate knowledge about the smoking behaviors associated to high risk of injuries.

Aim: We investigated foetal exposure to cigarette smoke following maternal active and passive smoking at the end of the pregnancy in a cohort of mother-infant dyads after recent implementation of the Italian smoke-free legislation and information campaigns against smoking., Methods: Study subjects were 979 mothers and their newborns attended at one of the major Florence hospitals between the end of 2004 and during 2005, when smoking banning legislation in all the enclosed places of employment was completely enforced. A structured questionnaire was completed by mothers and cord serum cotinine was used as a biomarker of foetal exposure to maternal smoke at the end of the pregnancy., Results: Women (53.9%) declared to be non-smokers not exposed to environmental tobacco smoke (ETS), 33.5% to be exposed non-smokers, while 12.6% reported daily smoking during pregnancy. Based on the levels of cord serum cotinine, 78.9% newborns were not exposed to ETS, 13.5% were exposed to ETS and 7.7% were exposed to active maternal smoke., Conclusions: Smoke-free policies can be an effective strategy for reducing both first-hand and second-hand exposure to cigarette smoke in pregnant women and their newborns. Due to the implementation of smoke-free legislation and information campaigns against smoking, a significant trend towards less active smoking during pregnancy was observed in our study cohort, as well as a minimal exposure to ETS in non-smoking pregnant women and their newborns.

Objective: On 10 January 2005 Italy became the first large European country adopting a comprehensive smoke-free legislation. We provide information on smoking prevalence in Italy and evaluate the effects of the 2005 regulations., Methods: We considered data from three companion surveys on smoking, conducted in 2004, 2005 and 2006 in Italy. Each survey included more than 3000 subjects aged 15 years or over, representative of the general Italian adult population., Results: Current smokers declined from 26.2% (30.0% of men, 22.5% of women) in 2004, to 25.6% (29.3% of men, 22.2% of women) in 2005 and to 24.3% (28.6% of men, 20.3% of women) in 2006. Whereas no significant difference was found comparing smoking prevalence in 2003-2004 vs. 2001-2002, the drop in smoking prevalence in 2005-2006 vs. 2003-2004 was significant (p<0.05) in the total population, in men and in subjects aged 15-44 years. Smokers consumed a mean of 15.4 cigarettes per day in 2004, 14.6 in 2005 and 13.9 cigarettes per day in 2006. Italians reported to go more frequently to restaurants and cafes., Conclusion: The drop in smoking prevalence and consumption is due, at least in part and particularly for younger generations, to the comprehensive smoke-free legislation adopted in Italy.

Aim: to describe the characteristics and effectiveness of various smoking cessation programs offered by Italian treatment services operating within the National Health Service., Design: prospective longitudinal multicentre study involving 41 smoking cessation services in 16 Italian regions., Study Population: the study population includes patients entering smoking cessation programs between April 2003 and June 2004. The "study population" includes 1226 patients (54.2% males and 45.4% females), mean age 47 years. Patients have a middle/high level of education and a long history of smoking; most are highly dependent on nicotine and report previous attempts to quit smoking., Methods: treatment effectiveness in smoking cessation is assessed six months after entering treatment service. Logistic Regression Model was used to determine the predictors of successfiul cessation, independent of treatment typology. The predictors were included as confounding variables in the logistic regression model that was used to evaluate the effectiveness of treatments. Besides the effect of treatment completion on smoking cessation was estimated., Results: predictors of successful smoking cessation are: being male, presence of a partner, strong motivation to quit, previous attempts to give up smoking, mild nicotine dependence, and not suffering from mood disturbances. All treatments are effective in helping people to stop smoking: cessation rate ranges between 25.00% for patients receiving a single session of motivational counselling and 65.3% for those receiving nicotine replacement therapy combined to group therapy. Compared to a single session of motivational counseling, nicotine replacement therapy combined to group therapy is the most effective therapeutic program (OR 5.4; 95%CI 12.5-12.0). Treatment completion is a strong determinant ofsuccess (OR 4.8; 95%CI 3.5-6.4)., Conclusion: enrolling people in any type of therapeutic program, in particular nicotine replacement therapy combined with group therapy increases the probability of successfully quitting smoking; moreover, patients that begin a smoking cessation program should be encouraged to complete the therapy

Altered behavior due to prenatal smoke exposure was examined in 25 neonates born from smoking mothers who consumed at least 5 cigarettes/d during the entire gestation. Data were compared with 25 matched neonates born from nonsmoking mothers. Neonatal behavior was evaluated using the Brazelton Neonatal Behavioral Assessment Scale (BNBAS). Antenatal exposure to tobacco smoke at the end of the pregnancy was determined by measurement of urinary cotinine. Newborns from smoking mothers showed significant lower scores in various BNBAS items compared with neonates from nonsmoking mothers. A strong correlation was observed between infant irritability and urinary cotinine in newborns from smoker and nonsmoking mothers and with number of daily smoked cigarettes and maternal nicotine daily intake of infants exposed to active maternal smoking. Linear regression analysis showed that urinary cotinine was the best predictor of infant irritability (r(2) = 0.727). The latter was also associated to the neonate's low level of attention and poor response to inanimate auditory stimuli. Among infants from nonsmoking mothers, paternal smoking significantly correlated with infant urinary cotinine and infant irritability, being also the best predictor of irritability (r(2) = 0.364). Neonatal behavior can be significantly altered in a dose-dependent manner even after modest prenatal exposure to tobacco smoke.

Environmental tobacco smoke (ETS) decreases pulmonary function and increases both airway reactivity and frequency of child asthma exacerbations. True exposure is related not only to parents smoking and to the number of cigarettes that they smoke, but also to involuntary smoking in public places. The aim of this study was to evaluate, by measuring urinary cotinine levels, the exposure to ETS in asthmatic children and the contribution of unapparent smoke exposure. Twenty asthmatic children (aged 7-12 years) were evaluated on the 1st day (TO) and after a week (T1) in a "smoke-free house." The mean level of urinary cotinine in children was 15.8 +/- 2.7 ng/mg of creatinine at TO and 4.2 +/- 0.6 ng/mg of creatinine at T1 (p < 0.0001). The urinary cotinine concentrations were higher in children living with smoking parents (21.8 +/- 3.4 ng/mg creatinine) compared with children not exposed to parental smoke (6.8 +/- 3.0 ng/mg creatinine; p = 0.017). The number of cigarettes smoked by parents correlates with the urinary cotinine levels (p = 0.005; r = 0.64). Urinary cotinine levels significantly decreased after the avoidance of ETS in children exposed to parental smoke (21.8 +/- 3.4 ng/mg at TO; 5.0 +/- 0.8 ng/mg at T1; p < 0.001) and also in children whose parents declared to be nonsmokers (6.8 +/- 1.2 ng/mg at TO; 3.0 +/- 0.8 ng/mg at T1; p = 0.006). Our data confirm the widespread indirect and undetected tobacco smoke exposure in children with chronic asthma and the relevance of an evaluation with an objective method of the exposure to second-hand smoke.

Background: From 10 January 2005 the Italian government banned smoking in all indoor public places. We conducted a population-based survey to provide information on attitudes towards smoking regulation and to disentangle the impact of the smoking ban on tobacco consumption., Patients and Methods: We considered data from a survey on smoking, based on 3114 subjects aged 15 or over, representative of the general adult Italian population in terms of age, sex, geographic area and socioeconomic status., Results: Once smoke-free policies were introduced, support for them in the public opinion tended to increase. In Italy, smoke-free policies accounted for around 8% decrease in cigarette consumption in the short run. Moreover, tobacco bans were almost universally accepted, and the smoke-free legislation did not seem to unfavourably affect the business of restaurants or cafes., Conclusions: The results of our study on the first extensive smoking ban in a large country show the advantages of smoke-free legislations, which may have major public health implications.

Aims and Background: To update trends in smoking prevalence in Italy to 2004, and describe the attitudes towards forthcoming regulation of smoking., Methods: Population-based face-to-face survey conducted in March-April 2004 on a sample of 3050 individuals (1509 men and 1541 women) aged 15 or over, representative of the general adult Italian population in terms of age, sex, geographic area, habitat, education and working status., Results: Overall, 26.2% of the Italians aged 15 or over described themselves as current cigarette smokers (30.0% of men, 22.5% of women); 19.1% of men and 11.2% of women smoked 15 or more cigarettes per day. Ex-smokers were 17.9% (24.8% of men, 11.2% of women). The difference in smoking prevalence between men and women was greater in the elderly. More educated men, and those residing in northern Italy were less frequently current smokers. Conversely, women with a low level of education (19%) were less frequently current smokers than those with higher education (24%). More than 85% of Italian adult population were in favour of restrictions of smoking in public places, such as cafes and restaurants, and to ban smoking in workplaces., Conclusions: Self-reported smoking prevalence is decreasing in men but not in females. There is widespread support for smoking restriction in public areas.

Background: Limited information is available on the role of smuggling and of perceived influence of cigarette price on tobacco consumption in Italy. To elucidate the issues, we included specific questions in a survey on smoking in Italy., Methods: Between March and April 2004, we conducted a survey on 3050 individuals aged 15 or over, representative of the general adult Italian population. The questionnaire included the estimate of the role of various channels of cigarette distribution and information on the self-reported perception of influence of prices on cigarette consumption in the young., Results: Among current smokers, 85.6% bought cigarettes from tobacco shops, 7.5% from vending machines, and 6.9% from other channels of distribution, including smuggling, and internet (plus offered cigarettes). Overall, 35.9% of ever smokers (37.9% of males and 32.8% of females) reported that the prices had an intermediate to high influence on cigarette consumption in the young. Younger and less educated smokers were not more prone to report an influence of prices., Conclusions: These data indicate that in Italy smuggling now covers a limited proportion of cigarette sales, while cigarette prices have a substantial influence on tobacco consumption in the young.

Objective: [corrected] A population-based survey was conducted to know the attitudes towards new Italian smoke-free regulations and its impact on tobacco consumption., Material and Methods: We considered 3,114 subjects aged 15 or over, representative of the general adult Italian population., Results: Once smoke-free policies were introduced, support for them tended to increase. Smoke-free policies accounted for 8% decrease in cigarette consumption in the short run. Tobacco bans were almost universally accepted, and do not seem to unfavourably affect the business of restaurants or cafes., Conclusions: The results of our study, show the advantages of smoke-free legislations, which may have major public health implications.

Background: Measures of tobacco dependence are mainly used in the clinical setting, but limited information is available on tobacco dependence on a population level., Materials and Methods: To obtain estimates of tobacco dependence on a population level, a six-item Fagerstrom questionnaire was used in two surveys, conducted in 2002-2003 on a sample of 6773 individuals aged 15 years or over, representative of the Italian adult population., Results: Overall, 27.1% of Italian adults described themselves as current cigarette smokers (32.2% of men, 22.4% of women). Of all smokers, 42.8% were classified as very low dependent, 28.6% as low dependent, 11.0% as intermediate, 13.8% as high and only 3.8% as very high dependent. The proportions of very low/low dependent were 67.4% in men and 76.8% in women. Those of high/very high dependent smokers were 21.4% in men and 12.5% in women, but only 2.8% at age 15-17 years and 8.4% at age 18-24 years. Only 23% of smokers, moreover, found it difficult to avoid smoking in places where smoking was forbidden., Conclusions: The observation that over two-thirds of smokers on a population level in Italy report low or very low dependence has useful implication for intervention on stopping smoking, particularly in the young, who appear to be low dependent. However, in this age group cessation rates were comparatively low.

Aims and Background: To update trends in smoking prevalence in Italy to 2003, with specific focus on the young., Methods: A population-based, face-to-face survey conducted in February-April 2003 on 3,535 individuals aged 15 or over, representative of the whole Italian adult population, plus an over sampling of 426 subjects aged 15 to 24 years., Results: Overall, 27.6% of Italians described themselves as current cigarette smokers (33.2% men, 22.5% women); 20.1% of men and 8.0% of women smoked 15 or more cigarettes per day. Ex-smokers were 16.6% (22.5% men, 11.2% women). No appreciable difference with reference to geographic area was observed. Less educated men, but more educated women, were more frequently smokers. As compared to previous years, no noticeable change was observed in overall smoking prevalence. However, an appreciable decline was observed in the young (15 to 24 years), from 37.6% in 2001 to 32.6% in 2003 for men, and from 30.4% to 20.7% for women. Among current smokers, 40.6% had tried at least once to stop. Of these, only 6.8% had used some pharmacological and 1.8% some psychological support., Conclusions: Overall self-reported smoking prevalence had not appreciably changed over the last few years. However, prevalence of smoking appears to have declined in the young. Compared to legal sale data, tobacco consumption is substantially under reported.

Background: In Italy National regulations forbidding smoking inside hospitals have existed since 1975. Current International medical standards for staff include refraining from smoking as an intervention of health education aimed at promoting healthy lifestyles as well as reinforcing smoking cessation advice, which staff should give patients. According to a National survey 33.3% of staff are active smokers and up to 80% of them admit to smoking in the workplace. This study was aimed at asking the hospital administrative authorities about the current situation of smoking control, according to their experience and about activities and policies they think could be effective in implementing smoking control., Methods: As a part of a European survey, financed by the EC, 217 questionnaires were sent by mail to the General Managers of various hospitals in Italy, selected at random. The letter introducing the questionnaire was also signed by the unit of smoking control of the National Institute of Health (Rome)., Results: Out of the 217 questionnaires sent (56.8% in Northern Italy, 19.8% in Central Italy, 23.4% in Southern Italy), 85 (39.2%) were returned, 56.5% from Northern Italy, 22.3% from Central Italy, 21.2% from Southern Italy. Even if a smoking control policy is reported by the 82% of our sample, only 37.3% reported a complete ban of smoking. In 72% of hospitals there are no areas designated for smokers; only 51.3% provide help for smoking cessation and 83.2% report that no financial support is given to this policy. When asked about a point for smoking control the majority (72.9%) think of education of staff and half of the sample of reinforcing controls and repression as well as free smoking cessation treatments. Finally, when evaluation of compliance to existing rules is asked an insufficient or absent compliance is reported in 25.4% and the majority (50.7%) reported no smoking cessation clinic or service inside. Due to the low redemption rate, our sample cannot be considered as representative of the national hospital network. However, considering that only managers referring a good or sufficient smoking control have probably answered our questionnaire, we can conclude that the situation enlightened by our sample could be worse but not better in reality., Conclusions: In Italy the control of smoking in hospitals is far from reached. An implementation of smoking control needs support for cultural changes as well as a comprehensive policy towards smoking staff.

To describe serum cotinine levels in a rural Italian population and to examine its usefulness as an epidemiologic biomarker of nicotine exposure, cross-sectional data collected in 1993 for the MATISS Project (2098 men and 1352 women, aged 20-79 years) were used. The study population consisted of 977 current smokers, 882 nonsmokers reporting exposure to environmental tobacco smoke (ETS) and 1520 nonsmokers reporting no ETS exposure. Mean values of serum cotinine measured by radioimmunoassay for never smokers, ex-smokers and current smokers (including four categories of cigarette consumption), and for categories of ETS exposure in all nonsmokers were calculated. In univariate analysis, there was a positive association between self-reported nicotine exposure and serum cotinine levels in all groups. Using self-reported status as truth, sensitivity and specificity for various cotinine cutoff points were estimated to distinguish nonsmokers from smokers. The value of 15 ng/mL represented the best combined levels of sensitivity (95%) and specificity (96%). Using this cutoff point, the overall misclassification rate for self-reported nonsmokers was 2.1% and about two times greater for the more vs. the less educated. In multivariate analysis, reported ETS exposure among nonsmokers was significantly associated with serum cotinine even after adjusting for age, socio-demographic and behavioural factors, though the strength of the association was not strong. In conclusion, serum cotinine represents a reliable epidemiological marker of nicotine intake and may be helpful when studying ETS exposure. Improved information collection is needed to reduce misclassification among nonsmokers and enhance our understanding of the relationship between ETS and cotinine measures.

Background: Smoking during pregnancy poses a health risk for the fetus which may later extend to the child and adult, with higher probability of respiratory problems. The aim of this study was the to investigate the correlation between smoking during pregnancy and the neonatal characteristics and sociodemographic determinants of smoking habit during pregnancy., Patients and Methods: Study subjects were 419 mothers and their newborns in Barcelona, Spain. Data on smoking habits were collected using a structured questionnaire. We measured cotinine in umbilical cord blood as a biomarker of exposition to tobacco smoke. Concentrations of cotinine were determined using a radioimmunoassay., Results: 29% interviewed mothers declared daily cigarette consumption during the third trimester of pregnancy, while the biomarker test showed that 34% mothers were smoking at the end of pregnancy. Smoking habit during pregnancy, assessed by means of either the questionnaire or the biomarker, correlated negatively with anthropometric parameters (weight, length and head circumference) of the newborn. The smoking habit was not associated with social class and age, although it was lower in primigravid mothers., Conclusions: Unlike other European countries, there is a widespread smoking consumption during pregnancy in Spain, regardless of the social class and maternal age. Reduction of both active smoking and exposition to environmental tobacco smoke represent key elements in the prevention of newborns' morbidity and mortality.

Progression of atherosclerosis is currently believed to involve interactions between leukocytes and vascular endothelium. Epidemiological risk factors for atherosclerosis such as hypertension and smoking are known to cause endothelial dysfunction, which is an early event in the atherosclerotic process; they also may be considered in the light of their effects on adhesion molecule expression and release. Little is known about the additive effect between these two risk factors on endothelial adhesion molecule expression and nitric oxide release. Soluble adhesion molecules and the nitric oxide were quantified in smoking hypertensive patients in comparison to those from patients with hypertension alone. Cotinine, a stable metabolite of nicotine, has been used to identify smokers. One hundred and three hypertensive patients were selected: 51 smokers (plasma cotinine levels >25 ng/ml) and 52 non-smokers. Plasma concentrations of soluble intercellular cell adhesion molecule-1 (sICAM-1), soluble endothelial leukocyte adhesion molecule-1 (sELAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-I) were quantified with ELISA methods. Plasma concentration of nitric oxide metabolites was measured by HPLC, whilst plasma concentration of cotinine was measured by RIA. Significant increases of sICAM-1 and sVCAM-1 were demonstrated in smokers (p<0.001 and p<0.05, respectively). In the same patients, a positive significant correlation between sVCAM-1 and plasma cotinine levels was observed (p<0.002). Nitric oxide metabolites were reduced significantly (p<0.04) in smokers. In conclusion, our data show that the two risk factors, smoking and hypertension, are additive risk factors in generating endothelial dysfunction and vascular damage, which plays a key role in atherogenesis.

This study investigated the association between biomarkers of fetal exposure to cigarette smoke at the end of pregnancy, cotinine in cord serum and in maternal and newborn urine samples, and quantitative measurement of smoking intake and exposure evaluated by maternal self-reported questionnaire. Study subjects were 429 mothers and their newborns from a hospital in Barcelona, Spain. A questionnaire including smoking habits was completed in the third trimester of pregnancy and on the day of delivery. Cotinine concentration in cord serum was associated with daily exposure to nicotine in nonsmokers and with daily nicotine intake in smokers. The geometric mean of cotinine concentration in cord serum statistically discriminated between newborns from nonexposed and exposed nonsmoking mothers, and between these two classes and smokers, and furthermore was able to differentiate levels of exposure to tobacco smoke and levels of intake stratified in tertiles. Urinary cotinine levels in newborns from nonsmoking mothers exposed to more than 4 mg nicotine daily were statistically different from levels in two other categories of exposure. Cotinine concentration in urine from newborns and from mothers did not differentiate between exposure and nonexposure to environmental tobacco smoke (ETS) in nonsmoking mothers. Cord serum cotinine appeared to be the most adequate biomarker of fetal exposure to smoking at the end of pregnancy, distinguishing not only active smoking from passive smoking, but also exposure to ETS from nonexposure.

A solid-phase extraction, using Extrelut-1 glass columns, has been applied to urine samples of both passive and active smokers for high-performance liquid chromatographic determination of nicotine and its metabolites cotinine and trans-3'-hydroxycotinine. Chromatography was performed using a reversed-phase LC8DB column and a mobile phase consisting of water-acetonitrile (80:9, v/v) containing 5 ml triethylamine, 670 mg/l sodium heptanesulphonate, and 0.034 M each of K2HPO4 and citric acid (pH 4.4), at a flow-rate of 1.6 ml/min. The results obtained indicate that solid-phase extraction is a reliable and quick procedure which can be applied also to other nicotine metabolites.

A simple and reliable reversed-phase high-performance liquid chromatographic method with ultraviolet detection is described for the quantitation of nicotine and its metabolites cotinine, trans-3'-hydroxycotinine, norcotinine and cotinine N-oxide in human serum. The analytes and the internal standard, N-ethylnorcotinine, were extracted by solid-phase extraction before chromatography. Two different columns and mobile phases with gradient systems were used. The detection limit of the assay was 10 ng/ml for nicotine, 3 ng/ml for cotinine N-oxide and 5 ng/ml for cotinine, trans-3'-hydroxycotinine and norcotinine. The concentrations of nicotine and its metabolites in the serum of 12 cigarette smokers are reported.

Sperm samples from 44 cigarette smokers and 50 nonsmokers attending an infertility clinic were examined by high-performance liquid chromatography (HPLC) assay and HPLC-mass spectrometry for the presence of nicotine (NIC), cotinine (COT), and trans-3'-hydroxycotinine (THOC) in seminal plasma. Smokers were found to have levels of COT and THOC in seminal plasma that were similar to those found in serum. The level of NIC was significantly increased in seminal plasma compared to serum. Total motility of spermatozoa was significantly and negatively correlated to COT and THOC levels in seminal plasma. Forward motility of spermatozoa was correlated only with cotinine semen levels. On the basis of these results, we suggest that the presence of tobacco smoke constituents in seminal plasma could provide a warning of the adverse effects of cigarette smoke on the physiology of reproduction.

The relationship between nicotine intake and steady-state cotinine concentration was studied in a sample of 125 subjects who smoked their usual brands of cigarettes. Nicotine and tar yield of cigarettes was determined with a smoking machine, under standardized conditions. Blood was drawn about 8 hours after the last cigarette was smoked and serum cotinine was measured by high performance liquid chromatography. Cotinine levels ranged from 11 to 400 ng/ml, and nicotine daily intake ranged from 1 to 33 mg/day. Regression analysis and the correlation coefficient, r = 0.919, significant at p less than 0.0001, showed that steady-state cotinine level was linearly and directly related to daily available nicotine, with an increase in correlation coefficient directly related to the increase in tar and nicotine yield. From the findings we also conclude that smokers of low-tar cigarettes do not tend to compensate for lower yields of nicotine.