Press Release N° 31/2021 Smoking: Smokers increased by 1.2 million during the pandemic. Negative contribution of e-cigarettes and heated tobacco products. 1 in 5 students used tobacco and nicotine products

ISS, May 31th 2021 -

The pandemic has significantly changed the habits of Italians with respect to smoking: after a reduction in April 2020 compared to January 2020 (pre lockdown) there was an increase in smokers in May 2021, with a prevalence of 26.2 (approximately 11,3 million) compared to November 2020 (24%). Furthermore, the number of young consumers has not decreased: 1 in three youngsters aged between 14 and 17 has already experienced tobacco smoking and almost 42% have used electronic cigarettes.
These are the data that have emerged from a longitudinal study of the Istituto Superiore di Sanità - ISS (Italian National Institute of Health), carried out in collaboration with the Mario Negri Pharmacological Institute and presented today, 31 May, on the occasion of the World No Tobacco Day. Three surveys were carried out on a sample of 3,000 individuals aged between 18 and 74 that was representative of the Italian population according to the main socio-demographic variables on the following dates: January 2020 (pre lockdown), April 2020 (full lockdown), November 2020 (partial lockdown), May 2021 (partial reopening).
"The new tobacco products (heated tobacco cigarettes, HTP) and e-cigarettes have played a key role in increasing the number of smokers - says Roberta Pacifici, director of the National Centre for Addiction and Doping of the ISS. In fact, in Italy these products contribute to the increase in the number of people who start smoking and to the relapses of traditional cigarettes smokers. They are therefore an obstacle for people who want to quit smoking and a major incentive in the spiralling of the smoking epidemic".

With respect to first-time smokers, the study notes that of the never smokers of traditional cigarettes in November 2020, 4.7% had become smokers by April (during the hard lockdown). Indeed, while 2.1% of people who have never used e-cigs have become smokers of traditional cigarettes, the e-cigarette users who have also become smokers were almost ten times as many, i.e. 19.6%. Similarly, while 3.2% of people who have never used HTP have become smokers, 19.3% of HTP users have also become smokers of traditional cigarettes.

With respect to relapses, it should be noted that of the people who in April during the hard lockdown were former smokers of traditional cigarettes, 17.2% of these individuals had returned to consuming traditional cigarettes by November. Also in this case, the consumption of HTP and e-cigarettes played an important role as risk factor.

In fact, while 7.7% of people who had never used e-cig took up smoking again, as many as 39.1% of e-cig users relapsed into the consumption of traditional cigarettes. Similarly, while 11.2% of people who had never used HTP took up smoking again, 58.3% of those who used HTP also returned to consuming traditional cigarettes.
With respect to quitting, we find that in November 14.6% of individuals who were smokers of traditional cigarettes in April during the hard lockdown, managed to quit and become former smokers. Also in this case, the use of new generation products such as HTP and e-cigarettes played a negative role in becoming ex-smokers.
In fact, 15.4% of those who have never used e-cigs have managed to quit smoking, only 6.7% of e-cigarette users have succeeded in quitting. Similarly 15.5% of those who had never used HTP have managed to become ex-smokers, while none of those who use HTP have managed to become ex-smokers.

The data
"With the restriction of freedom and stress caused by the pandemic, the number of men and women smokers grew by over 1 million”, points out Prof. Silvio Garattini, honorary president of the Mario Negri Institute of Pharmacological Research. “In May 2021 the prevalence of smokers in Italy was 26.2% (estimate of 11.3 million) of which 25.7% were males (5.5 million) and 26.7% were females (5.8 million)”.
The longitudinal study shows that after a reduction in the percentage of smokers observed in April compared to January (pre lockdown) (21.9% versus 23.3%) there was a significant increase in the number of smokers which had risen to 24% in November 2020, and 26.2% in May 2021. The same phenomenon was reported among male and female smokers, respectively (males 24.4% - 22.9% -24.6% - 25.7%) (females 22.2 % - 20.9% - 24.5% - 26.7%).
The number of cigarettes smoked per day in the May 2021 survey returned to being the same as in the pre-lockdown situation, which was on average 10.8 cigarettes per day (11.4 males, 10.1 females).
In May 2021, 9.0% of the population either regularly or occasionally used electronic cigarettes (e-cig), with an average number of 30 vapes per day. 65% used the rechargeable type more frequently, 22% used the e-cigarettes with a large tank more frequently and 13% used the disposable vapes. 67% used the e-cigs with liquids containing nicotine. The percentage of pre-lockdown e-cig users which was 8.1%, rose to 9.1% in April 2020 and remained unchanged in both November 2020 and May 2021.
In May 2021, 7% of the population regularly or occasionally used the heated tobacco cigarette (HTP). The percentage of HTP users increased significantly during the pandemic, in fact consumption went from 4.1% in January 2020, to 4.4% in April 2020 up to 7% in November 2020 and remained stable at 7% in May 2021.

Focus on young people
According to the sample survey carried out by the ISS, in collaboration with the Explora Company - Centre for Research and Statistical Analysis of Padua - on a sample of 2775 students aged 14-17 attending a secondary school, 37.5% of the interviewees had already experienced tobacco smoking and 41.5% had used electronic cigarettes.

52.5% of students had started using tobacco or e-cigarettes in high school, although 47.5% of them had started earlier - in elementary school (4.1%) or middle school (43, 4%). The product used for the first time was mainly the traditional cigarette (77.6%), but some had started with the electronic cigarette (20.1%) or the heated tobacco cigarette (2.3%). These latter data are of particular concern as just under one in four students are first-time users of the very products marketed in recent years and addressed specifically to traditional cigarette smokers. Among the 14-17 year olds who instead declared that they smoked traditional cigarettes or alternative products, 18.5% mainly used electronic cigarettes with (9.4%) or without (9.1%) nicotine, while 16.3% mainly used heated tobacco cigarettes. The WHO, on the other hand, points out that children who use electronic cigarettes are twice as likely to become smokers of traditional cigarettes in the course of their lifetime compared to their peers who do not use electronic cigarettes.
Among traditional cigarette smokers, 26.3% smoke ten or more cigarettes a day, and of these, 1.5% smoke more than 20 a day; the latter are also those who spend more money than their peers without parental control: in fact, while 45.4% of non-smokers declare that they do not spend money without their parents’ consent, this percentage drops to 12.3% among occasional smokers and 11.5% among regular smokers. Totally comparable percentages are recorded among the users of electronic cigarettes.
The occasional or habitual consumption of traditional tobacco or electronic cigarettes is more frequently associated with unhealthy behaviours. Indeed, the smokers of traditional cigarettes and users of electronic cigarettes engage more frequently in practices such as binge drinking, the consumption of cannabis and of the new psychoactive substances. Thus, while 1.0% of non-smokers reported they would drink until they lost control 3 or more times in the last month prior to the interview, that percentage rose to around 7.0% among individuals who were occasional or habitual smokers of traditional cigarettes and about 9.0% among consumers of electronic cigarettes. Similarly, 1.1% of non-smokers and 2.2% of young people who do not use e-cigarettes said they consume cannabis: this percentage rose to over 30.0% among smokers and e-cigarette users, 50.0% among habitual smokers and 37.0% among habitual users of electronic cigarettes.
The same trend is observed among consumers of the new psychoactive substances (NPSs): 3.2% of occasional smokers, 9.3% of regular smokers, 5.1% of occasional electronic cigarette users and 15.2% of regular users stated they made use of psychoactive substances, compared to 1.0% of those who do not smoke or vape.

Telefono verde

The Toll Free Helpline Against Smoking 800554088 of the Istituto Superiore di Sanità, a national service, which maintains anonymity and is free of charge, has been supporting smokers in the quitting process for decades through various initiatives and solutions, objectives that are in line with the theme chosen by WHO for the World No Tobacco Day 2021.

Since its inception (2000), the Toll Free Helpline has handled approximately 89,300 phone calls, of which 8,000 during this last year.

Smokers remain the main users of the service (94%); the packet of cigarettes continues to be the main source that advertises the toll-free number, and thanks to the immediate availability of the number, the number of young people who contact the service has been increasing.

The main motivation that drives smokers to call is the desire to quit smoking (96%) and for this reason the service offers solutions that meet the different needs of the users such as referring them to the Anti-Smoking Centres (71%), providing self-help materials to quit autonomously (28%), access to quit-lines that offer coaching over the telephone (6%)

Anti-Smoking centres
The COVID-19 pandemic has affected the operation of many Anti-Smoking Centres which, at times, have had to employ pulmonologists at the service of the COVID-19 wards or convert their environments into COVID Centres.
Despite the persistence of the problems due to the pandemic and thanks to the availability of the operators of the service, the census launched in 2021 was nevertheless carried out and found that there are 268 Anti-Smoking Centres in operation in the Country. As in previous years, updated figures are included in the "Guide to territorial services for quitting tobacco smoking".

The sale of cigarettes and last generation products
In 2020, the sale of cigarettes dropped by 4.5 percentage points compared to the previous year. Instead the sale of cut products has continued to increase (by more than 6.8%) and the sale of heated tobacco cigarettes has increased by 1089% since 2017, when they first appeared in the marketplace. The sale of e-cigarettes has increased by 616% since 2017.