Competing interest statement
Conflict of interest: the author declares no potential conflict of interest.
When Italy introduced a comprehensive ban on smoking in public places in 2005, it was in the forefront of tobacco control in Europe, with the pioneers, Ireland and Norway, having done so only a year previously. The Italian ban achieved very high levels of compliance,1 attracting strong public support. A Eurobarometer study conducted in 2009 finding that it was welcomed by 95% of Italians, more than in any other country in Europe.2
The ban had been introduced in the face of intense opposition from the tobacco industry. Its arguments took several forms. First, it enlisted, or in some cases, created, groups purporting to represent bar and restaurant owners, arguing that a smoking ban would hit their profits and, possibly, cause them to close. In fact, as a later systematic review showed, the only research showing that smoking bans reduced takings were those funded by the tobacco industry itself.3 Second, it appealed to the concept of personal freedom, arguing that smokers were being denied the right to do as they please. Obviously, this disregarded the right of non-smokers to be free from the effects of second-hand smoke. Third, it portrayed second-hand smoke as no more than an irritant, with little or no consequences for health. Moreover, it argued, falsely, that any irritation could be addressed easily by having separate smoking areas or improve ventilation.4
Tobacco control advocates often use the scream test. The tobacco industry, with its massive resources, is best placed to recognise which policies will damage its sales, or as public health professionals might say, reduce smoking. Consequently, the louder the industry protests about a proposed measure, the more effective it is likely to be. This was definitely the case with smoking bans. The industry poured vast resources into lobbying against them, employing the classic tactics of denialism.5 It engaged in a major operation to undermine the scientific basis for the bans. For example, Philip Morris operated a biological testing company in Germany, kept secret even within the corporation, with communications passed between the home addresses of those involved rather than through formal corporate channels.6 The intention was to create a climate of doubt around the growing evidence linking second-hand smoke to disease. Of course, the real test of smoking bans would come when they were implemented. Would they bring about improvements in health? In fact, the impact was far greater than almost anyone had anticipated.
The first evidence that smoking bans were having a major impact on health came from Helena, the capital of Montana. After it introduced a smoking ban in 2002, hospital admissions for myocardial infarction fell by 40%.7 This seemed quite remarkable, however, it should be noted that Helena has a small population and the confidence intervals were quite wide. Consequently, it was important to see if these results were replicated elsewhere. And they were. In Italy, a study in Piedmont reported an 11% drop in admissions.8 A subsequent study for Italian regions reported 13% fewer admissions than predicted on the basis of previous trends, with the decline concentrated among men of working age, who were most likely to spend time in bars.9 Finally, a nationwide confirmed the reduction, and though the overall effect was smaller, it was again greatest in younger people who are more likely to use bars.10 In 2014, a report by the US Surgeon General brought the existing evidence on smoking bans together and concluded that they were associated with an overall reduction in hospital admissions for myocardial infarction of between 12% and 18%.11
But surely, given this overwhelming evidence, the case for smoking bans is now firmly established? Apparently not. As recently as March 2017, one of the regular commentators in the British newspaper The Times, who also a member of the House of Lords, dismissed the findings from Helena, describing them as spurious correlation, before arguing that the vast majority of studies find no evidence that secondhand smoke causes heart attacks. The Helena effect was a fluke.13 Meanwhile, the populist UK Independence Party argues for rescinding the existing smoking ban.13 Fortunately, as a political party, it is so chaotic that it has no realistic chance of achieving power. Nonetheless, it is a reminder of the ability of what is now termed Fake News to gain traction among sections of the public.
This matters, because the struggle against tobacco is not yet won. The tobacco industry continues to produce misleading evidence, most recently in relation to the introduction of standardised packaging. The industry has commissioned reports to cast doubt on what is now recognised as the tremendous success of this measure in Australia, by means of highly selective analysis of the data.14 Many leading journals refuse to publish tobacco industry funded research, and with good reason.15
There is, however another worry. The tobacco industry is diversifying. It now dominates the market for electronic cigarettes and is blurring the boundaries between these products and traditional cigarettes, with products that heat rather than burn tobacco. There are considerable concerns about the industry’s role in how these products are portrayed, and in particular in the production of the widely quoted, but unsubstantiated claim that they are 95% safer than ordinary cigarettes,16 a figure that constrasts starkly with mounting evidence of their harmful effects on the cardiovascular system.17,18 Yet, incredibly, a few tobacco control advocates seem willing to work with the tobacco industry to promote these products,19 seemingly unaware of how the industry has used scientists in the past.20
In 2016, Italy introduced a new package of tobacco control laws, including a ban on smoking in cars transporting children, prohibition of advertising of electronic cigarettes, and stricter regulations on tobacco-related litter. These are to be welcomed. However, there is still more to be done, including a ban on cigarette vending machines and standardised packaging, to take Italy once more to the forefront of tobacco control in Europe. When it does, it can expect strong opposition from the tobacco industry, which can be expected to produce lots of evidence supporting its case. Given its record, anything it says should be treated with the most extreme sceptcism.