Smoke-free policy development in Italy through the legislative process of the ban 2000-2005, and press media review 1998-2008.

Abstract

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 2000- 2005, 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.

Full text

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ReseaRch and Methodologies
Summary. 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 2000-
2005, 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 amend-
ment within a bill on public administration which enabled timely approval of the ban; and the strin-
gent 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’ re-
sponsibility 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 proc-
ess of the bill and its regulations also stimulated coverage on tobacco control issues.
Key words: smoking ban, second-hand smoke exposure, Italy, policy analysis.

Riassunto (Il processo di sviluppo della legge per ambienti liberi da fumo in Italia attraverso l'iter par-
lamentare del progetto di legge (2000-2005) e la rassegna stampa sul fumo (1998-2008)). 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’inter-
no 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.
Smoke-free policy development in Italy
through the legislative process of the ban
2000-2005, and press media review 1998-2008
Giuseppe Gorini(a), Laura Currie(b), Lorenzo Spizzichino(c), Daniela Galeone(c)
and Maria J. Lopez(d)
(a)SC Epidemiologia Ambientale Occupazionale,
Istituto per lo Studio e la Prevenzione Oncologica (ISPO), Florence, Italy
(b)Tobacco-Free Research Institute, Dublin, Ireland
(c)Ministero della Salute, Rome, Italy
(d)Public Health Agency, Barcelona, Spain
INTRODUCTION
The Italian smoking ban was implemented and en-
forced on January 10, 2005, early in the “epidemic” of
nation-wide smoke-free laws in Europe (2004-2009)
[1]. At that time, Italy had signed but not yet ratified
the World Health Organization (WHO) Framework
Convention on Tobacco Control (FCTC). This in-
ternational Public Health Treaty rightly recommends
100% smoke-free laws, because other approaches have
repeatedly been shown to be ineffective [2]. While the
Address for correspondence: Giuseppe Gorini, SC Epidemiologia Ambientale Occupazionale, Istituto per lo Studio e la Prevenzione
Oncologica (ISPO), Via di S. Salvi 12, 50135 Florence, Italy. E-mail: g.gorini@ispo.toscana.it.
ann ist supeR sanità 2011 | Vol. 47, no. 3: 260-265
doi: 10.4415/ann_11_03_04

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Italian law allows separated smoking rooms, in prac-
tice only 1-2% of hospitality premises (HPs) built
smoking rooms, due to the associated cost of adher-
ing to the tight standards on air quality defined by
the implementation regulation of the law [3]. 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 proc-
ess of approval and implementation of the Italian
smoking ban (article 51, Law no. 3/2003) [4] through
the analysis of two dimensions: the process of pres-
entation and approval of the bill and of its imple-
mentation regulations in the Italian Parliament and
Senate Assemblies (2000-2005), and the review of
press articles on smoking published in Italian news-
papers 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 [5]. Press review
was carried out through the Italian Parliament press
review research engine available on the Internet [6]. We
collected articles published between 1998-2008 from
50 Italian press newspapers and magazines includ-
ing: 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 “cig-
arettes”.
RESULTS
? 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 announce-
ment, the Italian Minister of Health, Prof Umberto
Veronesi, an influential Italian oncologist, who act-
ed 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 work-
places. 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 invest-
ments to build smoking rooms. On October 2000 the
Committee of Social Affairs of the Parliament be-
gan 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 govern-
ment 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 proc-
ess 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 four-
fold increase in fines for people who smoked in public
places where smoking was already forbidden by previ-
ous restrictions. In fact, the Law no. 584/1975 banned
smoking in hospitals, cinemas, schools, public trans-
portation, museums, and waiting rooms; whereas the
Directive of the President of Council of Ministers of
December 14, 1995, banned smoking from front-offic-
es of public administrations, and a Ministerial Letter
(no. 4 – March 28, 2001) was issued including infor-
mation 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 spe-
cialized group of the Carabinieri Corps (NAS) began
controlling compliance of previously implemented re-
strictions. NAS fined 372 smokers during 701 inspec-
tions (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 pub-
lic 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 amend-
ment in the Senate discussion of another framework
bill, this time on environmental issues. Again, the
amendment did not pass.

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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 impor-
tant physicians. The bill passed the Senate Assembly
on November 2002, and was finally approved by
both Senate and Parliament in December 2002 [4].
After the bill passed, the government had 4-6
months to write regulations on technical require-
ments for smoking rooms, while the governments of
Italian Regions had to write law enforcement regula-
tions. 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 regu-
lation was then sent to the Conference of State and
Regions for the final approval. After a six-month de-
lay, it was signed by the Premier in December 2003
[7]. 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 pres-
entation of the law enforcement regulation, which
identified fine procedures and the persons respon-
sible 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 maxi-
mum 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 [8].
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 des-
ignated employees were responsible for requesting
that customers stop smoking and calling the po-
lice 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 long-
er responsible for enforcing the ban. Consequently,
technicians belonging to some local health authori-
ties who already control compliance with food and
water and occupational health and safety regula-
tions, have been trained to enforce the ban in work-
places and HPs [9].
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 enforc-
ing 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 [10].
Press?review?
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).
Table 1 | Key-points of the legislative process of the Italian
smoking ban
PeriodFacts
May 2000First presentation of the bill by Health
Minister Veronesi
November 2001New Health Minister Sirchia increased fines for
public places where smoking was already forbidden
January 2002 Second presentation of the bill as an amendment
within a framework bill: the “Trojan horse”
strategy
March 2002Third presentation of the bill within a framework bill
May 2002Fourth presentation of the bill within a
framework bill
December 2002The bill was finally approved
December 2003The regulation on technical requirements for
smoking rooms passed
December 2004The regulation on law enforcement passed
January 2005The smoking ban entered into force on January 10th
August 2005Hospitality premise owners were no longer
responsible to enforce the ban

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In December 2004, immediately before and after the
approval of the law enforcement regulation outlining
fine procedures and assigning responsibility for en-
forcement, 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 as-
signment of responsibility for enforcing the ban in HPs.
In addition, articles reported on interviews with the two
Ministers of Health and other tobacco control special-
ists 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 hospital-
ity workers, and that they could have significantly and
immediately improved their health after the introduc-
tion 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 smok-
ing bans in other European Countries.
DISCUSSION
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 ena-
bled timely approval of the ban; the tight standards
on air quality that made building smoking rooms im-
practicable and prohibitively expensive [7]. 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 meas-
ure. In fact, NAS inspections carried out in 2002 fol-
lowing the four-fold increase in fines, suggested that
almost half of Italians did not comply with existing
smoking restrictions in hospitals, cinemas, and of-
fices. 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 compli-
ance 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 de-
lay 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 successful-
ly 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 dur-
ing 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 [11].
Despite cultural and political differences, tobacco in-
dustry 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 engag-
ing 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 legisla-
tive 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 jour-
nalists to publish articles informing people about
tobacco control issues, such as the health gains of
smoke-free HPs, or of quitting smoking. No arti-
cles 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.
Table 2 | Frequency distribution of articles published in
50 Italian newspapers and magazines between 1998-2008.
Key words used for selecting articles: tobacco smoking, cig-
arettes, and surnames of Health Minister in charge
YearFrequency%
Before the presentation of the bill1998
1999
5
8
0.6
1.0
The build up of the bill2000106 13.1
The battle of the bill2001
2002
62
147
7.7
18.2
Delays and derailments2003
2004
91
92
11.3
11.4
Introduction of the ban200518823.3
Post- ban implementation2006
2007
2008
27
49
33
3.3
6.1
4.1
Overall808 100.0

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ReseaRch and Methodologies
In 2006-2008 relatively fewer articles were pub-
lished. 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 sec-
tor were conducted in Italy and there was no report-
ing 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 ef-
forts 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 respond-
ents 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 universi-
ties, HPs, hospitals, museums, penny arcades), smok-
ing was observed in only 2.4% of premises and only
6.7% failed to comply with no-smoking signage re-
quirements [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 [23].
In conclusion, the persistent health advocacy by two
consecutive Health Ministers, both of whom were re-
spected physicians, drove the legislative process of the
bill in the Senate and Parliamentary Assemblies. At
the same time, print media gave a significant contribu-
tion in changing public opinion against SHS exposure.
Moreover, Officers of the Health Ministry drafted of-
ficial documents, such as the Ministerial letter 4/2001,
favouring the pre-2005 smoking restrictions. On the
contrary, opposition to the ban, led by the hospital-
ity sector, negatively influenced political debate and
print media coverage, and lead to delays in the legis-
lative process and the annulment of the law enforce-
ment 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 compre-
hensive smoking ban.
Acknowledgments
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 poli-
cies in Member States on exposure to second-hand smoke and to-
bacco 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.

Received on 18 January 2011.
Accepted on 18 May 2011.
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