RESEARCH AND METHODOLOGIES
Il processo di sviluppo della legge per ambienti liberi da fumo in Italia attraverso l'iter parlamentare del progetto di legge (2000-2005) e la rassegna stampa sul fumo (1998-2008)
Giuseppe GoriniI; Laura CurrieII; Lorenzo SpizzichinoIII; Daniela GaleoneIII; Maria J. LopezIV
ISC Epidemiologia Ambientale Occupazionale, Istituto per lo Studio e la Prevenzione Oncologica (ISPO), Florence, Italy
IITobacco-Free Research Institute, Dublin, Ireland
IIIMinistero della Salute, Rome, Italy
IVPublic Health Agency, Barcelona, Spain
The objective of this article is to describe the process of approval of the Italian smoking ban, enacted in 2005. The method is to conduct a review of proposed and approved legislation 20002005, and of articles published in Italian newspapers, 1998-2008. Enabling factors in the process were: the leadership of two consecutive Health Ministers, both physicians, who introduced the bill four times between 2000-2002; the repeated presentation and final approval of the bill as an amendment within a bill on public administration which enabled timely approval of the ban; and the stringent air quality standards in the 2003 regulation that made building smoking rooms impracticable and prohibitively expensive. Limiting factors in the process were: the 6-month delay in approving the regulation on smoking rooms; the 1.5-year delay in approving the regulation establishing owners' responsibility for enforcing the ban in hospitality premises and the legal action in August 2005, which shifted responsibility for enforcement to police. Eighty-three percent of the 808 articles published on smoking in 1998-2008 were released between 2000-2005, during the policy process. While the press devoted considerable attention to the issues raised by the hospitality sector, the long legislative process of the bill and its regulations also stimulated coverage on tobacco control issues.
Key words: smoking ban, second-hand smoke exposure, Italy, policy analysis.
L'obiettivo dell'articolo è descrivere l'iter per l'approvazione della legge 3/2003, articolo 51. Il metodo usato è stato la ricostruzione del'iter parlamentare della legge nel 2000-2005, e della rassegna stampa in Italia sul fumo, 1998-2008. Tra i risultati ottenuti, la strategia per l'approvazione del disegno di legge (DDL) anti-fumo presenta alcuni punti di forza: la leadership di due medici-ministri della sanità (Veronesi e Sirchia) che hanno presentato 4 DDL nel 2000-2002; l'aumento di 4 volte delle sanzioni per i divieti già vigenti nel 2001; l'inserimento nel 2002 per 3 volte del divieto come articolo all'interno di una legge-quadro, per far approvare velocemente il bando; gli standard restrittivi della qualità dell'aria dei sistemi di ventilazione previsti nei locali fumatori dal regolamento attuativo DPCM 23/12/2003. I punti negativi dell'iter sono stati: il ritardo nell'approvazione dei requisiti per le aree fumatori e dei responsabili dei controlli; l'annullamento del TAR del Lazio nell'agosto 2005 della responsabilità degli esercenti nel controllare l'osservanza del divieto. Risultano pubblicati oltre 800 articoli sul fumo nel 1998-2008, di cui l'83% durante l'iter di approvazione della legge. Anche se la stampa ha dedicato molta attenzione alle rivendicazioni dei ristoratori, il lungo iter parlamentare ha favorito la pubblicazione di articoli sulla prevenzione del tabagismo.
Parole chiave: divieto di fumare, esposizione a fumo passivo, Italia, analisi di interventi legislativi.
The Italian smoking ban was implemented and enforcedon January 10, 2005, earlyinthe "epidemic" of nation-wide smoke-free laws in Europe (2004-2009). At that time, Italy had signed but not yet ratified the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC). This international Public Health Treaty rightly recommends 100% smoke-free laws, because other approaches have repeatedly been shown to be ineffective . While the Italian law allows separated smoking rooms, in practice only 1-2% of hospitality premises (HPs) built smoking rooms, due to the associated cost of adhering to the tight standards on air quality defined by the implementation regulation of the law . How did Italy introduce smoke-free legislation and what can we learn from the Italian case?
The main aim of this article is to describe the process of approval and implementation of the Italian smoking ban (article 51, Law no. 3/2003)  through the analysis of two dimensions: the process of presentation and approval of the bill and of its implementation regulations in the Italian Parliament and Senate Assemblies (2000-2005), and the review of press articles on smoking published in Italian newspapers and magazines (1998-2008).
MATERIALS AND METHODS
The process of presentation and approval of the bill and of its implementation regulations from 2000 onwards, was analyzed considering documents of the Parliament and Senate Assemblies . Press review was carried out through the Italian Parliament press review research engine available on the Internet . We collected articles published between 1998-2008 from 50 Italian press newspapers and magazines including: Corriere della Sera, La Repubblica, Il Sole 24 ore, La Stampa, Il Giorno, Il Giornale, Il Tempo, L'Unità, Libero, Liberazione, L'Indipendente, Il Mattino, Il Messaggero, L'Osservatore Romano, Il Manifesto, La Nazione, Il Resto del Carlino, Il Secolo XIX, Avvenire, La Gazzetta del Mezzogiorno, La Padania, Il Popolo, Il Riformista, Il Secolo d'Italia, Oggi, L'Espresso, Panorama. The following key-words were used in Italian: "tobacco smoking", "surname of Ministers of Health" in charge in the period 1998-2008 (Bindi, Veronesi, Sirchia, Storace, Turco, Sacconi), and "cigarettes".
Legislative process of the bill and of its implementation regulations
On May 17, 2000 the President of Philip Morris-Europe declared for the first time that smoking causes lung cancer. The day after this announcement, the Italian Minister of Health, Prof Umberto Veronesi, an influential Italian oncologist, who acted as Minister for only one year (April 2000 to June 2001), answered that he was writing a new bill to ban smoking in all enclosed public and private workplaces. Veronesi's bill provided separated smoking rooms for HPs and workplaces, as well as fines of 25.8-155 for smokers who did not comply with the ban, and 516-1550 for the persons responsible for the enforcement of the law. The Council of Ministers approved the bill on September 1, 2000. The Italian Association of HPs (FIPE), which represents more than 200 000 HP owners, argued against the bill claiming owners would have to make large investments to build smoking rooms. On October 2000 the Committee of Social Affairs of the Parliament began analyzing Veronesi's bill. One hundred and ten amendments were presented by all the parties. Most amendments related to the reduction of fines, the exemption of some workplaces (particularly private offices) or HPs, and the definition of governmental incentives for building smoking areas. The government lead by Central-Left Parties was approaching the end of session and there were some concerns that the bill would not pass through the legislative process in time. Even though the Committee of Social Affairs approved the bill on February 2001, it was never discussed in the Parliament before the close of the government (May 2001).
In the new Government, lead by Central-Right Parties, the new Minister of Health was an influential haematologist, Prof. Girolamo Sirchia. In November 2001, the new Minister presented an amendment to the 2002 State Budget Law (no. 448/2001) of a fourfold increase in fines for people who smoked in public places where smoking was already forbidden by previous restrictions. In fact, the Law no. 584/1975 banned smoking in hospitals, cinemas, schools, public transportation, museums, and waiting rooms; whereas the Directive of the President of Council of Ministers of December 14, 1995, banned smoking from front-offices of public administrations, and a Ministerial Letter (no. 4 - March 28, 2001) was issued including information to facilitate the interpretation of the Directive of December 14, 1995, and to enforce the existing legislations in matters concerning the smoking ban. Since the end of 2001, fines were 6-60; after the amendment approval to the 2002 State Budget Law, fines increased to 25-250. In January 2002, a specialized group of the Carabinieri Corps (NAS) began controlling compliance of previously implemented restrictions. NAS fined 372 smokers during 701 inspections (53%) throughout Italy. Thus, at the beginning of 2002 about half of Italian premises covered by the legislation were not complying with the restrictions.
At the end of January 2002, Minister Sirchia presented a bill almost identical to that previously presented by Veronesi, as an amendment within a framework bill on public administration. The "smoking ban amendment" began its legislative process in the Committee of Constitutional Affairs of the Parliament, but was judged inadmissible because its objective, the protection of health of non-smokers exposed to second-hand smoke (SHS), was very different from those of the bill in which it was placed, a plan for the streamlining of public administration. The expedient used by Minister Sirchia was to "hide" the smoking ban within the framework bill: a tactic branded the "Trojan horse" strategy by journalists.
At the end of March 2002 the Government tried once again to present the smoking ban as an amendment in the Senate discussion of another framework bill, this time on environmental issues. Again, the amendment did not pass.
In May 2002, for the third time, Minister Sirchia presented the smoking ban as an amendment to the same framework bill on public administration he used the first time. The Committees of Budget and of Constitutional Affairs of the Senate approved the bill in July 2002. Press articles reported the smoking ban was almost unavoidable after 4 presentations by 2 Ministers of Health, both of whom were important physicians. The bill passed the Senate Assembly on November 2002, and was finally approved by both Senate and Parliament in December 2002 .
After the bill passed, the government had 4-6 months to write regulations on technical requirements for smoking rooms, while the governments of Italian Regions had to write law enforcement regulations. Exactly one year after the first regulation on smoking rooms had been approved, the smoking ban was due to take effect. The FIPE and the Association of Traders declared that owners needed more time to build smoking areas given that most Italian HPs were less than 100 square meters. In April 2003, the regulation on smoking rooms was publicly released. It stated that separate smoking rooms had to be less than half of the premise area, have sliding doors, be under negative pressure inside and have a ventilation system with a flow rate of at least 22L per second per person considering a crowding rate of 0.7 persons per square meter. The Minister of Productive Activities attempted to obtain a dispensation for owners of small restaurants, but he was unsuccessful. The regulation was then sent to the Conference of State and Regions for the final approval. After a six-month delay, it was signed by the Premier in December 2003 . Thus, the smoking ban was set to enter into force on December 2004. The only change made before the final approval of the regulation was to increase the flow rate of the ventilation system from 22L to 30L per second per person.
In 2004 there was an even longer delay in the presentation of the law enforcement regulation, which identified fine procedures and the persons responsible for enforcement activities. In November 2004, it was announced that the implementation of the smoking ban would be delayed by 10 days and would take effect on January 10, 2005. Moreover, a 10% increase in fines for people who smoke in places where smoking is forbidden was announced; the fines would be range from of 27.5 to a maximum of 275. At the beginning of December 2004, with only one month remaining before the ban was scheduled to take effect, it was still unclear who should be fined - the individual smoker who broke the law or the HP owner who did not enforce the law. Finally, the regulation of the Ministry of Health dated December 17 2004 was approved and enforcement responsibilities were agreed . In public administrations, managers designated employees who were responsible for enforcing the law and issuing fines to people who did not comply with the ban, while in HPs, owners or their designated employees were responsible for requesting that customers stop smoking and calling the police or traffic police for fining the customer if they failed to comply with this request. HP owners did not like being "sheriffs" and enforcing this law with their customers and, on their behalf, FIPE announced their intention to launch an appeal to the Administrative Court requesting that they no longer be responsible for enforcing the ban.
On August 2005, Lazio Region Administrative Court accepted the appeal issued by the FIPE, and from August 2005 onwards HP owners were no longer responsible for enforcing the ban. Consequently, technicians belonging to some local health authorities who already control compliance with food and water and occupational health and safety regulations, have been trained to enforce the ban in workplaces and HPs .
At the end of 2004 and in 2005, during the process of implementation and enforcement of the ban, a free-phone number of the Minister of Health was activated to answer to people responsible for enforcing the ban in workplaces and hospitality industries. Moreover, the Italian National Institute of Health (ISS) published a guide for the implementation of the smoking ban .
More than 800 articles on smoking were published between 1998-2008: 13% of them in 2000, when the first bill was presented; 18% in 2002, when the fourth bill began the legislative process and was approved; and 23% in 2005, the year the smoking ban came into force (Table 1).
In December 2004, immediately before and after the approval of the law enforcement regulation outlining fine procedures and assigning responsibility for enforcement, 24 press articles were published (26% of the 2004 articles). In January-February 2005, immediately before and after the coming into force of the ban, 56 articles were published (30% of the 2005 articles).
Press devoted a lot of attention to the political debate regarding the legitimacy of the ban and the protests of HP owners specifically relating to the question of building smoking areas in small restaurants and the assignment of responsibility for enforcing the ban in HPs. In addition, articles reported on interviews with the two Ministers of Health and other tobacco control specialists focusing on: the health risks of SHS exposure and tobacco smoking; health gains of quitting smoking; news on compensation trials issued by non-smokers exposed to SHS at work and affected with SHS-related diseases in Italy and worldwide; the involvement of tobacco companies in cigarette smuggling in Europe; litigation against tobacco companies in the USA; the prevalence of smoking and the depiction of smoking in national and international movies and television programmes. Interestingly, since March 1, 2004, almost one year before the smoking ban, new Intercity trains became completely smoke-free. No articles reported that the most exposed workers to SHS were hospitality workers, and that they could have significantly and immediately improved their health after the introduction of the ban. Similarly, no articles reported Trade Unions gave a significant contribution to the process of approval and enforcement of the ban.
In 2006-2008, media interest declined with only 13.5% of reviewed articles published during this period. The main focus during the latter two years was on local ordinances of smoking bans in outdoor parks in Italy and the implementation of similar nation-wide smoking bans in other European Countries.
Factors which lead to the approval of the bill were: the leadership of two consecutive Health Ministers, both physicians, who introduced the bill four times between 2000-2002; the repeated presentation and final approval of the bill as an amendment within a framework bill on public administration which enabled timely approval of the ban; the tight standards on air quality that made building smoking rooms impracticable and prohibitively expensive . Presenting a 100% smoke-free bill did not seem practicable in 2000 and 2002, even before Italy had ratified FCTC, because Italians did not seem ready for such a measure. In fact, NAS inspections carried out in 2002 following the four-fold increase in fines, suggested that almost half of Italians did not comply with existing smoking restrictions in hospitals, cinemas, and offices. The choice of tight air quality standards was a practical way to circumvent the request repeatedly raised by the hospitality sector to allow the provision of smoking rooms. The strategy of increasing the amount of fines and NAS controls, promoted increased compliance and attracted print media attention to the problem of SHS exposure in public places.
Limits of the process of approval of the bill and of its implementation regulations were: the 6-month delay in approving the regulation outlining the technical requirements for smoking rooms; the 1.5-year delay in approving the regulation establishing that owners were responsible for enforcing the ban in HPs; and the legal action in August 2005, through which FIPE successfully overturned the law enforcement regulation requiring HP owners to enforce the ban and shifted responsibility to police and traffic police.
The obstacles created by the hospitality sector during the policy process were in part due to the fear of economic losses. At this time (2004) at least one comprehensive literature review had already been published reporting no economic losses for HPs . Despite cultural and political differences, tobacco industry strategies to subvert legislation in Italy were almost identical to those used in other countries such as America and Europe [12-14].
Print media coverage peaked around key stages in the policy process highlighting the value of engaging with the media to support the smoke-free policy process. Of the 808 articles under review, 83% were published between 2000-2005, the period during which the bill was navigated through the legislative process and implemented. Press devoted a lot of attention to the political debate surrounding the ban, and to the interests of the hospitality sector. However, the long legislative process of the bill and its related regulations (2000-2004), stimulated journalists to publish articles informing people about tobacco control issues, such as the health gains of smoke-free HPs, or of quitting smoking. No articles focused on the issue of workers heavily exposed to SHS, such as hospitality workers. In Italy Trade Unions did not actively participate to the process of approval and enforcement of the ban.
In 2006-2008 relatively fewer articles were published. Little attention was given to the health and economic impacts of the ban once it was introduced. For example, only two newspaper articles reported the unexpected decrease in hospital admissions for acute myocardial infarction observed in some Italian areas after the ban [15-17]. Moreover, despite the arguments from the hospitality sector that the ban would result in economic loss, no studies on the impact of the ban on businesses of hospitality sector were conducted in Italy and there was no reporting on this matter after the ban.
While the successful appeal by FIPE in August 2005 to rescind HPs owners' responsibility for enforcement of the ban threatened to undermine enforcement efforts in HPs, compliance levels have been high and the smoking ban has been widely accepted among most Italians. Each year since the ban, DOXA - the Italian branch of the Gallup International Association - has carried out a survey on a representative sample of the Italian population aged 15 years and over. According to the 2005-2008 DOXA surveys, 82-90% of respondents reported that customers complied with the ban in HPs [18-20]. In addition, enforcement controls carried out in 2005-2009 showed that compliance was high. Out of 14 291 NAS site visits in public places (airports, train stations, schools and universities, HPs, hospitals, museums, penny arcades), smoking was observed in only 2.4% of premises and only 6.7% failed to comply with no-smoking signage requirements [21, 22]. In Italy in 2008, levels of public support for a statewide smoking ban were among the highest in Europe, with 88% of Italians in favour of the ban .
In conclusion, the persistent health advocacy by two consecutive Health Ministers, both of whom were respected physicians, drove the legislative process of the bill in the Senate and Parliamentary Assemblies. At the same time, print media gave a significant contribution in changing public opinion against SHS exposure. Moreover, Officers of the Health Ministry drafted official documents, such as the Ministerial letter 4/2001, favouring the pre-2005 smoking restrictions. On the contrary, opposition to the ban, led by the hospitality sector, negatively influenced political debate and print media coverage, and lead to delays in the legislative process and the annulment of the law enforcement regulations in the hospitality sector. Anyway, all these actions lead Italy to become the third European Country and the first among the "Big Six" of the European Community to enforce an almost comprehensive smoking ban.
This paper was partially funded by the European Commission's Executive Agency for Health and Consumers through the IMPASHS project (Evaluation of the impact of smoke-free policies in Member States on exposure to second-hand smoke and tobacco consumption; www.impashs.eu/). We would like to thank Stephen Babb, Center for Disease Control, Atlanta, USA, and all the partners of the IMPASHS Study.
Conflict of interest statement
None to declare.
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Address for correspondence:
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Received on 18 January 2011.
Accepted on 18 May 2011.