Smoking at the workplaces in Italy after the smoking ban in the Lazio Region.

BACKGROUND: In Italy, an anti-smoking law was issued in 2003, with the aim of reducing tobacco smoking inside public places.
OBJECTIVES: The aim of the study was to assess the observance of the smoking ban in Italy, during the period 2010-2014, in several workplaces and to evaluate the perception of workers, both smokers and non-smokers, on this issue.
METHODS: This cross-sectional study analyzed data resulting from a self-administered questionnaires in 59 companies, from several working sectors (transport, healthcare and building), in the Latium Region in Italy.
RESULTS: Out of 7200 questionnaires, 6996 were included in the analysis: 43.7% of the employees think that the smoking ban is respected in the workplace; women are more prone to think that the ban is not observed. Smokers tend to perceive the ban to be respected (AOR: 0.69; 95% CI: 0.62-0.77) while non-smokers feel more exposed to second-hand smoke (AOR: 1.57; 95% CI: 1.39-1.77). Workers in intellectual and highly specialized professions (AOR: 1.63; 95% CI: 1.25-2.13), technical professions (AOR: 1.64; 95% CI: 1.28-2.10) and craftsmen, skilled workers and farmers (AOR: 1.42; 95% CI: 1.09-1.85) tend to perceive the smoking ban not to be observed and the last two classes are the ones who feel the most exposed to second-hand smoke (AOR: 6.68; 95% CI: 0.50-0.90; AOR: 0.52; 95% CI: 0.38-0.70). DISCUSSION: The results of this study can be used as a starting point for the implementation of new strategies to reduce tobacco addiction, beginning from the compliance with the ban on smoking in the workplace and the promotion of a healthy lifestyle.

- Tobacco smoking is still prevalent in Italy, particularly among young people and the smoking ban at work is not always respected.

- Perceived compliance with the ban of smoking at the workplace is different in current as compared to former/never smokers.

- Tobacco control policies should be more strict and severe to ensure the compliance with the ban. Support for smoking cessation offered by the company would be welcome by smokers.

Introduction

Tobacco smoking is a well-known risk factor for several pathologies including lung and bladder cancer, cardiovascular diseases and chronic lung diseases, such as chronic obstructive pulmonary disease (COPD), asthma and dyspnea. In general, both active and second-hand smoking, leads to a diminished health status (6, 19) and maternal smoking has been linked to health consequences for both the mother and the newborn (e.g., low birth weight) (6, 19).

The proportion of adults who smoke daily varies dramatically in EU countries: with lowest rates in Nordic countries (11-15%) and highest rates in Bulgaria, Greece, Hungary and Cyprus (26-28%) (17).

In Italy there are 11.7 million smokers who represent 22.3% of the population; the former smokers are 12.6% and the never smokers 65.1%. There is a decreased gap between males and females with regards to the smoking habit (23.9% vs 20.8%). The age group which smokes the most is the one from 25 to 44 years (28%) but there is an increasing number of people smoking the first cigarette before they are 15 years old (12.2%). A difference in smoking habit has also been observed between different Italian areas. While in the Centre of Italy there is a high prevalence of males who smoke (26%) while in the North there are more women than men smoking (24.6% vs 22%) (8).

Since 1975 several laws aimed at controlling tobacco use have been enacted in Italy, but the main innovation in the Italian legislation for tobacco control was introduced by the a law named “Sirchia” (art. 51, Law No. 3 dated 16 January 2003, otherwise known as “Safeguarding the health of non-smokers”). The “Sirchia” law follows the official acknowledgment of the WHO Framework Convention on Tobacco Control (FCTC) by the World Health Assembly (21, 24, 28) and extends the smoking ban to all indoor public spaces and workplaces, with the exception of private houses and of reserved smoking areas (3). The ban came into effect on 10 October 2005, after an increased number of deaths related to tobacco smoking, with an expense of 6.5 billion €/year for sanitary support (24) had been reported in Italy. This law also represents one of the first smoke-free legislation introduced in Europe, aiming at controlling smoking habits in all the public and private places such as bars and restaurants in order to protect non-smokers.

Although ever since the law came into effect there has been a significant change in the consumption and attitude of smokers, tobacco smoking remains a serious public health concern in Italy (8, 18). According to the law, in the workplace smoking is allowed only in restricted areas, yet only 2% of workplaces have smoking rooms available. A possible explanation is that the costs for such rooms are high and that meeting the tight standards on air quality as defined by the ban are challenging (16).

Surveillance of the tobacco smoking is performed by PASSI, coordinated by the Italian National Institute of Health (i.e., Istituto Superiore di Sanità) which is a system that provides information about risk factors for chronic diseases and adherence to preventive measures (1, 2, 5, 11, 13).

The smoking ban is well known and “No Smoking” signs are mandatory in the workplace, but the ban is not respected everywhere (Dunbar et al, 2018; Pianori et al, 2017) even though, in general, there is an increasing tendency to the enforcement of the ban, with a significant difference in perception between current and never smokers (9, 16). Nearly everyone thinks that whoever breaks the law should be penalized by the majority of people, though few face a colleague who smokes, but just say nothing or step away (20).

Worldwide, the overall adherence to the ban is controversial. In the Netherlands it is very high (28), whereas in Italy and China several studies highlight the inobservance of the ban due to lack of respect by the smoking colleagues and lack of interest about this issue by the employees (12, 20, 29). In general, there is a decreasing difference in compliance between the several working sectors (28) but despite the specific laws and precise regulations, Italian hospitals still cannot be called smoke-free, because both of healthcare personnel and of visitors (20, 22).

As smoke-free culture can be established among substantial occupational groups, as described in New Zealand (10), policy makers should provide the best possible protection for workers against exposure to second-hand smoke, in particular with enforcement of the smoking ban and smoking cessation courses (١٢): actually, workplace health promotion plans are being implemented in several countries (26) and both employers and employees express their satisfaction with smoke-free workplace programs and workplace cessation support activities (14, 23, 25). Moreover, working in smoke-free workplaces is associated with increased rates of quitting smoking (15).

This study sought to investigate whether the smoking ban is respected in several workplaces and to evaluate the role of perception of the workers, both smokers and non-smokers, on this issue, in Italy.

Methods

Background

The “Service for Prevention and Safety at Workplace” (SPreSAL) of Latium Region in Italy, through educative and informative interventions targeting workers and prevention professionals included in the project 13_2.9.3 of the Regional Prevention Plan (Piano Regionale della Prevenzione), started to play an important role in increasing the awareness of the risk related to bad lifestyle habits, and in promoting health in the workplace. This study is mainly addressed professionals who work in sectors with a high risk for accidents at work or for the safety of third parties, in accordance to the Attachment I of the Intesa Conferenza Stato Regioni of 16th March 2006 (4, 27).

Study design and procedure

This cross-sectional study took place in Italy in the period between June 2010 and December 2014. Workers participated in a survey about smoking habits, knowledge about the risks, socio-demographic characteristics, and perception of the smoking ban in the workplace. The participation of both the workers and the companies was voluntary.

The overall aim of the survey was to investigate the reduction of tobacco consumption in the workplaces through the adoption of no smoking policies.

A total of 59 companies, from several working sectors such as transport, healthcare and building, participated in the study. Educational meetings were held in the companies, and a self-administered questionnaire was distributed to both employers and the employees. Participation was voluntary and anonymous.

The questionnaire contained 30 questions, investigating several aspects of smoking at the workplaces.

The completed questionnaires were uploaded by the staff of the participating Local Health Units (Azienda Sanitaria Locale) in a database handled by the Workplace Health Promotion Center of the Latium Region. The data collected in the database were compared with the one reported in the questionnaire papers and, in case of discordance, mistakes were fixed.

Statistical analysis

The statistical analyses included descriptive statistics, univariate analysis and multivariate analysis. Sample characteristics such as gender and smoking habits are described as frequencies and percentages, and recoded into dummy variables if necessary. For gender, for example, male and female coded into ‘1’ and ‘0’. Three age groups were considered for the analyses: 18-34, 35-49, >50 years.

A multivariate logistic regression was performed to study the association between independent variables (gender, age group, smoking habits) and the dependent variables (knowledge, attitude, behavior). Odds ratio (AOR) and 95% confidence intervals (CIs) were calculated for all the categories, adjusted for age, gender, smoking status and working sector. The goodness-of-fit for the logistic regression model was assessed with Hosmer and Lemeshow’s test. Participants with missing values for one or more of the variables were excluded from the analysis.

All statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) version 24.0 for Windows (SPSS Inc. Chicago, Illinois, USA).

Results

In total, 7200 questionnaires were distributed, and 6996 responses were collected (response rate 97.2%). Consequently, two hundred and four questionnaires (2.8%) were excluded from the analysis. Table 1 and Table 2 show the descriptive statistics and sample characteristics.

Table 1

Descriptive analysis

Variable	Stratification	No. %
Age (y/o)	18-34	1274 (18.2%)
	35-49	3327 (47.6%)
	> 50	2395 (34.2%)
Gender	M	3253 (46.5%)
	F	3743 (53.5%)
Education	Primary school	68 (1%)
	Secondary school	842 (12%)
	High School	2682 (38.3%)
	Professional courses	668 (9.5%)
	Graduation	2693 (38.5)
Istituto nazionale di statistica (ISTAT) Professions Classification	Legislators. entrepreneurs and senior management	115 (1.6%)
	Intellectual. scientific and highly specialized professions	1089 (15.6%)
	Technical professions	2373 (33.9%)
	Executive professions in office work	2155 (30.8%)
	Qualified professionals in commercial activities and services	3 (0.0%)
	Craftsmen. skilled workers. and farmers	975 (13.9%)
	Plant operators. stationary and mobile plant workers and vehicle drivers	1 (0.0%)
	Unqualified professions	285 (4.1%)
Sector	Manufacturing Activities	783 (11.2%)
	Water Supply; Sewerage Networks Waste Management and Rehabilitation Activities	407 (5.8%)
	Wholesale and Retail Trade; Repair of Motor Vehicles and Motorcycles	54 (0.8%)
	Transportation and Warehousing	413 (5.9%)
	Accommodation and Catering Services Activities	265 (3.8%)
	Information and Communication Services	377 (5.4%)
	Financial and Insurance Activities	19 (0.3%)
	Professional. Scientific and Technical Activities	119 (1.7%)
	Public Administration and Defense; Compulsory Social Insurance	398 (5.7%)
	Instruction	84 (1.2%)
	Health and Social Assistance	4073 (58.2%)
	Other Service Activities	4 (0.1%)
Current smokers
Would like to stop smoking?	Yes	1244 (61.7%)
	No	773 (38.3%)
Have you ever tried to stop smoking?	Yes	1218 (60.4%)
	No	799 (11.4%)
How many times have you tried to stop smoking?	Once	426 (46.9%)
	More than once	483 (53.1%)
How many cigarettes do you smoke a day?	1-10 cigarettes	1011 (50.1%)
	11-20 cigarettes	845 (41.9%)
	>20 cigarettes	160 (7.9%)
If the company offered to take part in a smoking cessation course. Would you agree to participate?	Yes	915 (55%)
	No	750 (45%)
Forner Smokers
How many years ago did you quit smoking?	1-5 years	414 (39.7%)
	6-10 years	240 (23%)
	11-15 years	128 (12.3%)
	16-20 years	119 (11.4%)
	21-25 years	67 (6.4%)
	26-30 years	57 (5.5%)
	>30 years	17 (1.6%)
Smokers
When did you start smoking?	<15 years old	516 (25.8%)
	16-25 years old	1359 (68%)
	26-35 years old	99 (5%)
	>36 years old	24 (1.2%)

Table 2

Characteristics of the current smokers

Smoking habit		Age groups (years)			Gender		Total
		18-34	35-49	>50	Female	Male
	Yes	475	919	622	1030	986	2016 (28.8%)
		37.3%	27.6%	26.0%	27.5%	30.3%
	No	677	1988	1271	2225	1711	3936 (56.3%)
		53.1%	59.8%	53.1%	59.4%	52.6%
	Ex	122	420	502	488	556	1044 (14.9%)
		9.6%	12.6%	21.0%	13.0%	17.1%

Characteristics of participants and smoking status

Overall, 46.5% of the respondents were males and 53.3% were females. The majority of respondents was aged between 35 and 49 years (3327; 47.6%). A total of 2016 workers were current smokers, of which 1030 were females and 986 were males. More than half of the participants got a high school diploma (2682; 38.3%) and a degree (2693; 38.5%). Several categories of occupations were interviewed including healthcare personnel (4073; 58.2%), manufacturing workmen (783; 11.2%) and employees in transportation and warehousing (413; 5.9%). In general, the occupation group with the higher percentage of smokers included craftsmen, skilled workers and farmers (41.5%) as well as the technical professions (24.1%).

Regarding current smokers, 61.7% of them indicated that they would like to quit smoking and 60.4% states to have already tried to do quit smoking at least once. Around 50% of smokers stated to smoke less than 10 cigarettes daily, 41.9% of them declared to smoke 11-20 cigarettes daily and 7.9% stated smoke more than 20 cigarettes daily. A total of 915 workers also indicated that they would take advantage of the possibility to attend smoking cessation courses if offered by their employees.

Perception of the smoking ban in the working place

Around 44% of employers think that the smoking ban is respected within the workplace. This might due to an increased awareness on this issue (41.6%) and self-discipline among smokers (61.3%). There is lack of confidence regarding the benefit from the company policy (26.1%), incentives (0.5%) and active surveillance (15.2%).

Among those workers who think that the smoking ban is not respected (circa 56%), 56.8% indicated that this is due to lack of respect 55.6% stated that it is due to smoking addiction. 28.5% of workers indicate that they are exposed to second-hand smoke and 57.4% think that the introduction of the smoking ban has changed the quality of interpersonal relations.

Knowledge

In general, addiction, both physical and psychical, is well recognized by all workers (80.2%). The perception of damage caused by tobacco smoking is high (51.8%). Most participants expressed a good knowledge about possible health consequences including consequences on the respiratory system, such as the exasperation of asthma (71.3%), chronic bronchitis (76.9%) and lung cancer (92.6%). Also awareness about the risks of myocardial infarction is also high (64.4%). The correlation between smoking habit and risk of bladder cancer is not well known (29.4%).

Table 3 shows the results for the univariate analysis. Results indicate differences among gender, age group and current/never/former smoker workers.

Table 3

Univariate analysis

			Smoking habit				Gender			Age Groups
			Smoker	No	Ex smoker	p- value	Female	Male	p-value	18-34 years	35-49 years	>50 years	p-value
Is the smoking ban respected in all the workplaces?		Yes	1013	1653	392	<0.001	1494	1564	<0.001	606	1425	1027	0.010
			50.3%	42.0%	37.6%		39.9%	48.1%		47.6%	42.9%	42.9%
		No	1002	2279	651		2247	1685		668	1897	1367
			49.7%	58.0%	62.4%		60.1%	51.9%		52.4%	57.1%	57.1%
If yes. because of:	Increased sensitive to the issue	Yes	333	753	174	<0.001	645	615	0.029	192	588	480	<0.001
			33.2%	46.0%	44.5%		43.6%	39.7%		31.8%	41.6%	47.2%
		No	670	885	217		836	936		411	824	537
			66.8%	54.0%	55.5%		56.4%	60.3%		68.2%	58.4%	52.8%
	Self-discipline of the smokers	Yes	649	964	245	0.009	929	929	0.110	403	854	601	0.006
			64.7%	58.9%	62.7%		62.7%	59.9%		66.8%	60.5%	59.1%
		No	354	674	146		552	622		200	558	416
			35.3%	41.1%	37.3%		37.3%	40.1%		33.2%	39.5%	40.9%
	Efficient company policy	Yes	223	464	104	0.002	371	420	0.204	168	398	225	0.002
			22.2%	28.3%	26.6%		25.1%	27.1%		27.9%	28.2%	22.1%
		No	780	1174	287		1110	1131		435	1014	792
			77.8%	71.7%	73.4%		74.9%	72.9%		72.1%	71.8%	77.9%
	Rewards	Yes	5	10	1	0.677	6	10	0.363	5	6	5	0.508
			0.5%	0.6%	0.3%		0.4%	0.6%		0.8%	0.4%	0.5%
		No	998	1628	390		1475	1541		598	1406	1012
			99.5%	99.4%	99.7%		99.6%	99.4%		99.2%	99.6%	99.5%
	Active surveillance	Yes	185	209	66	<0.001	196	264	0.004	110	220	130	0.011
			18.4%	12.8%	16.9%		13.2%	17.0%		18.2%	15.6%	12.8%
		No	818	1429	325		1285	1287		493	1192	887
			81.6%	87.2%	83.1%		86.8%	83.0%		81.8%	84.4%	87.2%
If not. where ban is not respected in	Office	Yes	279	862	287	<0.001	796	632	0.057	166	694	568	<0.001
			13.8%	21.9%	27.5%		21.3%	19.4%		13.0%	20.9%	23.7%
		No	1737	3074	757		2947	2621		1108	2633	1827
			86.2%	78.1%	72.5%		78.7%	80.6%		87.0%	79.1%	76.3%
	Ward	Yes	164	425	117	0.002	308	398	<0.001	131	394	181	<0.001
			8.1%	10.8%	11.2%		8.2%	12.2%		10.3%	11.8%	7.6%
		No	1852	3511	927		3435	2855		1143	2933	2214
			91.9%	89.2%	88.8%		91.8%	87.8%		89.7%	88.2%	92.4%
	Toilet	Yes	345	1160	327	<0.001	1038	794	0.002	296	929	607	0.003
			17.1%	29.5%	31.3%		27.7%	24.4%		23.2%	27.9%	25.3%
		No	1671	2776	717		2705	2459		978	2398	1788
			82.9%	70.5%	68.7%		72.3%	75.6%		76.8%	72.1%	74.7%
	Restroom	Yes	229	640	199	<0.001	569	499	0.873	195	510	363	0.983
			11.4%	16.3%	19.1%		15.2%	15.3%		15.3%	15.3%	15.2%
		No	1787	3296	845		3174	2754		1079	2817	2032
			88.6%	83.7%	80.9%		84.8%	84.7%		84.7%	84.7%	84.8%
	Outside	Yes	763	1544	460	0.003	1614	1153	<0.001	497	1326	944	0.859
			37.8%	39.2%	44.1%		43.1%	35.4%		39.0%	39.9%	39.4%
		No	1253	2392	584		2129	2100		777	2001	1451
			62.2%	60.8%	55.9%		56.9%	64.6%		61.0%	60.1%	60.6%
They keep on smoking at workplaces because:	Lack of respect	Yes	321	1453	405	<0.001	1203	976	0.001	331	1080	768	0.002
			33.3%	65.1%	63.4%		54.6%	59.8%		50.7%	58.5%	57.4%
		No	642	780	234		1000	656		322	765	569
			66.7%	34.9%	36.6%		45.4%	40.2%		49.3%	41.5%	42.6%
	Smoking is enjoyable	Yes	181	203	77	<0.001	239	222	0.010	64	229	168	0.158
			18.8%	9.1%	12.1%		10.8%	13.6%		9.8%	12.4%	12.6%
		No	782	2030	562		1964	1410		589	1616	1169
			81.2%	90.9%	87.9%		89.2%	86.4%		90.2%	87.6%	87.4%
	Smoking causes addiction	Yes	591	1179	375	<0.001	1290	855	<0.001	370	1023	752	0.831
			61.4%	52.8%	58.7%		58.6%	52.4%		56.7%	55.4%	56.2%
		No	372	1054	264		913	777		283	822	585
			38.6%	47.2%	41.3%		41.4%	47.6%		43.3%	44.6%	43.8%
	Lack of surveillance	Yes	210	954	259	<0.001	788	635	0.047	229	705	489	0.318
			21.8%	42.7%	40.5%		35.8%	38.9%		35.1%	38.2%	36.6%
		No	753	1279	380		1415	997		424	1140	848
			78.2%	57.3%	59.5%		64.2%	61.1%		64.9%	61.8%	63.4%
	Lack of company policy	Yes	109	423	136	<0.001	368	300	0.176	103	332	233	0.437
			11.3%	18.9%	21.3%		16.7%	18.4%		15.8%	18.0%	17.4%
		No	854	1810	503		1835	1332		550	1513	1104
			88.7%	81.1%	78.7%		83.3%	81.6%		84.2%	82.0%	82.6%
Are you exposed to second hand smoke?		Yes	475	1218	303	<0.001	1070	926	0.911	370	1032	594	<0.001
			23.6%	30.9%	29.0%		28.6%	28.5%		29.0%	31.0%	24.8%
		No	1541	2718	741		2673	2327		904	2295	1801
			76.4%	69.1%	71.0%		71.4%	71.5%		71.0%	69.0%	75.2%
Do you think tobacco can cause addiction both physical and psychical?		No	106	110	34	<0.001	120	130	<0.001	39	118	93	0.043
			5.3%	2.8%	3.3%		3.2%	4.0%		3.1%	3.5%	3.9%
		Low	302	286	92		337	343		151	289	240
			15.0%	7.3%	8.8%		9.0%	10.5%		11.9%	8.7%	10.0%
		High	1497	3237	876		3090	2520		1004	2707	1899
			74.3%	82.2%	83.9%		82.6%	77.5%		78.8%	81.4%	79.3%
		Don’t know	111	303	42		196	260		80	213	163
			5.5%	7.7%	4.0%		5.2%	8.0%		6.3%	6.4%	6.8%
Perception of the damages associated with smoking habits		Insufficient	301	481	105	<0.001	368	519	<0.001	138	398	351	<0.001
			15.2%	12.3%	10.1%		9.9%	16.1%		10.9%	12.0%	14.8%
		Low	302	611	145		534	524		193	479	386
			15.2%	15.6%	14.0%		14.4%	16.3%		15.3%	14.5%	16.3%
		Sufficient	368	843	187		797	601		260	703	435
			18.5%	21.5%	18.0%		21.4%	18.7%		20.6%	21.3%	18.3%
		Good	524	953	290		1039	728		360	880	527
			26.4%	24.3%	27.9%		27.9%	22.6%		28.5%	26.6%	22.2%
		High	489	1027	312		982	846		312	844	672
			24.6%	26.2%	30.0%		26.4%	26.3%		24.7%	25.5%	28.3%
	Exacerbation of asthma	Yes	1358	2849	778	<0.001	2807	2178	<0.001	956	2375	1654	0.001
			68.4%	72.8%	74.9%		75.5%	67.7%		75.7%	71.9%	69.8%
		No	626	1066	261		913	1040		307	929	717
			31.6%	27.2%	25.1%		24.5%	32.3%		24.3%	28.1%	30.2%
	Chronic bronchitis	Yes	1565	2979	835	0.003	3028	2351	<0.001	980	2578	1821	0.552
			78.9%	76.1%	33		81.4%	73.1%		77.6%	78.0%	76.8%
		No	419	936	204		692	867		283	726	550
			21.1%	23.9%	19.6%		18.6%	26.9%		22.4%	22.0%	23.2%
	Myocardial infarction	Yes	1279	2496	729	0.001	2468	2036	0.007	830	2186	1488	0.024
			64.5%	63.8%	70.2%		66.3%	63.3%		65.7%	66.2%	62.8%
		No	705	1419	310		1252	1182		433	1118	883
			35.5%	36.2%	29.8%		33.7%	36.7%		34.3%	33.8%	37.2%
	Lung cancer	Yes	1793	3703	983	<0.001	3493	2986	0.064	1191	3105	2183	0.006
			90.4%	94.6%	94.6%		93.9%	92.8%		94.3%	94.0%	92.1%
		No	191	212	56		227	232		72	199	188
			9.6%	5.4%	5.4%		6.1%	7.2%		5.7%	6.0%	7.9%
	Bladder cancer	Yes	555	1152	351	0.004	1097	961	0.734	347	961	750	0.020
			28.0%	29.4%	33.8%		29.5%	29.9%		27.5%	29.1%	31.6%
		No	1429	2763	688		2623	2257		916	2343	1621
			72.0%	70.6%	66.2%		70.5%	70.1%		72.5%	70.9%	68.4%
The introduction of the smoking bad has caused changes in social interaction.		Yes	1115	2267	632	0.020	2138	1876	0.643	714	1881	1419	0.070
			55.3%	57.6%	60.5%		57.1%	57.7%		56.0%	56.5%	59.2%
		No	901	1669	412		1605	1377		560	1446	976
			44.7%	42.4%	39.5%		42.9%	42.3%		44.0%	43.5%	40.8%
Perception of the utility of several intervention to prevent damages from smoking habits	Periodic checks to make workers respect the ban	Not at all	155	113	48	<0.001	162	154	0.518	70	147	99	<0.001
			8.5%	3.0%	4.9%		4.6%	5.1%		5.7%	4.7%	4.6%
		Few	295	358	144		433	364		187	354	256
			16.2%	9.6%	14.6%		12.4%	12.0%		15.1%	11.3%	11.8%
		Enough	572	945	258		977	798		364	827	584
			31.4%	25.3%	26.2%		27.9%	26.2%		29.4%	26.3%	27.0%
		High	512	1322	296		1124	1006		402	1037	691
			28.1%	35.3%	30.1%		32.1%	33.1%		32.5%	33.0%	31.9%
		Very high	289	1004	237		809	721		215	780	535
			15.9%	26.8%	24.1%		23.1%	23.7%		17.4%	24.8%	24.7%
	Educational training	Not at all	141	236	71	<0.001	246	202	0.020	98	229	121	<0.001
			7.8%	6.5%	7.4%		7.1%	6.8%		7.9%	7.4%	5.8%
		Few	376	655	183		662	552		280	581	353
			20.8%	18.0%	19.1%		19.2%	18.6%		22.7%	18.8%	16.9%
		Enough	538	890	217		905	740		366	764	515
			29.8%	24.4%	22.6%		26.3%	24.9%		29.7%	24.8%	24.6%
		High	486	1062	275		919	904		308	896	619
			26.9%	29.1%	28.6%		26.7%	30.5%		25.0%	29.0%	29.6%
		Very high	267	802	214		714	569		181	616	486
			14.8%	22.0%	22.3%		20.7%	19.2%		14.7%	20.0%	23.2%
	Courses for smoking cessation offered by the employees	Not at all	179	326	93	0.061	246	202	0.115	130	295	173	<0.001
			9.8%	9.0%	9.6%		7.1%	6.8%		10.6%	9.5%	8.3%
		Few	399	773	195		662	552		317	668	382
			21.8%	21.4%	20.2%		19.2%	18.6%		25.9%	21.6%	18.2%
		Enough	455	968	239		905	740		338	775	549
			24.9%	26.7%	24.8%		26.3%	24.9%		27.6%	25.1%	26.2%
		High	414	915	248		919	904		258	773	546
			22.6%	25.3%	25.7%		26.7%	30.5%		21.0%	25.0%	26.1%
		Very high	381	638	189		714	569		183	580	445
			20.8%	17.6%	19.6%		20.7%	19.2%		14.9%	18.8%	21.2%
	A specific company regulation	Not at all	206	163	58	<0.001	207	220	0.006	77	191	159	<0.001
			11.7%	4.5%	6.0%		6.1%	7.5%		6.3%	6.3%	7.7%
		Few	354	487	172		517	496		194	473	346
			20.0%	13.5%	17.9%		15.2%	16.9%		15.8%	15.5%	16.8%
		Enough	507	937	241		906	779		371	773	541
			28.7%	26.0%	25.1%		26.6%	26.6%		30.3%	25.4%	26.3%
		High	419	1171	279		1005	864		374	925	570
			23.7%	32.5%	29.1%		29.6%	29.5%		30.5%	30.3%	27.7%
		Very high	282	843	210		765	570		210	686	439
			16.0%	23.4%	21.9%		22.5%	19.5%		17.1%	22.5%	21.4%

Gender

Men were more likely to be smokers (30.3%) compared to women (27.5%). A significant difference was also detected for the perception of the respect of the ban: significantly more women stated that the ban is respected within the workplaces (60.1%). Furthermore, women are more conscious than men about the health damaging effects of smoking such as asthma (75.5%) and chronic bronchitis (81.4%).

Age

Younger workers aged between 18 and 34 years, were more likely to be smokers (37.3%) compared to older workers. In general, there are not many significant differences in the perception of the ban and its issues among different age groups.

Smoking status

Table 3 shows significant differences between current smokers, non-smokers and ex-smokers. Ex-smokers (62.4%) and non-smokers (58.0%) had a higher perception of the ban not being respected compared to current smokers (49.7%). In addition, more non-smokers than smokers indicated that an increased sensibility to this issue (66.8%) is missing.

Former smokers and non-smokers stated that a lack of respect of the smoking ban is due to either a lack of surveillance (40.5% and 42.7% vs 21.8%) or the absence of a company policy (21.3% and 18.9% vs 11.3%). The Perception of exposure to second-hand smoke also varies greatly. While 30.9% of non-smokers and 29.0% of former smokers feel exposed to second-hand smoke; only 23.9% of smokers feel exposed.

As for the damage caused by smoking, the former-smokers have a better knowledge of the health damaging effects than both current and non-smokers. Former smokers are overall more aware about the negative effects on the respiratory system such as an aggravation of asthma (74.9%), chronic bronchitis (80.4%), but also about the increased risk for a myocardial infarction (70.2%), lung cancer (94.6%) and bladder cancer (33.8%).

National institute of statistics (ISTAT) professions classification

Focusing on the ISTAT Professions Classification, the ban is mostly not observed by the workers in intellectual, scientific and highly specialized professions (60.6%) and in technical professions (60.1%). Craftsmen, skilled workers and farmers are the ones who feels the most exposed to second-hand smoke (36.7%).

Multivariate logistic regression

Multivariate logistic regression analysis was conducted to explore the relationship between dependent variables (perception, knowledge, attitude) and independent variables (gender, age, smoking habits and ISTAT Professions Classification). Data are presented in Table 4.

Table 4

Multivariate logistic regression analysis

Questionnaire items			Age groups (years)		Gender	Smoking habitsL
			35-49 vs 18-34*	>50 vs 18-34*	M vs F*	Current smoker vs Nonsmoker*
			AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)
Is the smoking ban respected in all the workplaces?		y/n*	0.862 (0.756 - 0.982)	0.851 (0.742 - 0.977)	1.386 (1.260 - 1.525)	1.420 (1.278 - 1.576)
If yes. because of:	Increased sensitive to the issue	y/n*	1.479 (1.207 - 1.812)	1.870 (1.511 - 2.314)	0.839 (0.724 - 0.972)	0.607 (0.518 - 0.712)
	Self-discipline of the smokers	y/n*	0.769 (0.629 - 0.940)	0.735 (0.595 - 0.908)	0.888(0.767 -1.029)	1.227 (1.048 - 1.437)
	Efficient company policy	y/n*	0.995(0.804 - 1.232)	0.708 (0.560 - 0.893)	1.145(0.972 - 1.349)	0.722 (0.604 - 0.863)
	Rewards	y/n*	0.509(0.154 - 1.679)	0.566(0.162 - 1.978)	1.604(0.580 - 4.439)	0.870(0.300 - 2.523)
	Acrive surveillance	y/n*	0.852(0.662 - 1.098)	0.665 (0.504 - 0.879)	1.358 (1.110 - 1.661)	1.406 (1.145 - 1.726)
If not. where ban is not respected in	Office	y/n*	1.674 (1.392 - 2.013)	1.974 (1.633 - 2.386)	0.896(0.796 - 1.008)	0.558 (0.483 - 0.644)
	Ward	y/n*	1.149(0.931 - 1.418)	0.673 (0.531 - 0.854)	1.614 (1.378 - 1.890)	0.700 (0.582 - 0.842)
	Toilet	y/n*	1.201 (1.032 - 1.399)	1.049(0.893 - 1.232)	0.860 (0.772 - 0.959)	0.490 (0.430 - 0.559)
	Restroom	y/n*	0.961(0.802 - 1.151)	0.940(0.777 - 1.137)	1.024(0.898 - 1.168)	0.629 (0.538 - 0.736)
	Outside	y/n*	1.019(0.892 - 1.164)	1.017(0.884 - 1.170)	0.726 (0.659 - 0.800)	0.915 (0.822 - 1.018)
They keep on smoking at workplaces because:	Lack of respect	y/n*	1.225 (1.015 - 1.479)	1.126(0.925 - 1.372)	1.310 (1.144 - 1.500)	0.272 (0.233 – 0.318)
	Smoking is enjoyable	y/n*	1.450 (1.078 - 1.951)	1.486 (1.091 - 2.023)	1.272 (1.045 - 1.549)	2.200 (1.792 - 2.701)
	Smoking causes addiction	y/n*	0.977(0.815 - 1.172)	1.026(0.848 - 1.241)	0.771 (0.677 - 0.877)	1.362 (1.172 - 1.583)
	Lack of surveillance	y/n*	1.045(0.864 - 1.265)	0.950(0.777 - 1.160)	1.181 (1.032 - 1.351)	0.378 (0.319 - 0.449)
	Lack of company policy	y/n*	1.106(0.867 - 1.411)	1.046(0.810 - 1.351)	1.144(0.966 - 1.354)	0.528 (0.424 - 0.659)
Are you exposed to second hand smoke?		y/n*	1.062(0.921 - 1.225)	0.773 (0.663 - 0.901)	1.019(0.918 - 1.132)	0.693 (0.614 - 0.781)
Knowledge of damages caused by smoking:	Exacerbation of asthma	y/n*	0.793 (0.682 - 0.922)	0.727 (0.621 - 0.850)	0.687 (0.618 - 0.763)	0.785 (0.700 - 0.880)
	Chronic bronchitis	y/n*	1.026(0.877 - 1.200)	0.985(0.835 - 1.161)	0.619 (0.552 - 0.693)	1.135(0.999 - 1.290)
	Myocardial infarction	y/n*	1.014(0.884 - 1.163)	0.880(0.762 - 1.015)	0.880 (0.797 - 0.972)	0.971(0.870 - 1.083)
	Lung cancer	y/n*	0.879(0.665 - 1.163)	0.650 (0.489 - 0.862)	0.860(0.711 - 1.041)	0.526 (0.433 - 0.639)
	Bladder cancer	y/n*	1.073(0.928 - 1.240)	1.207 (1.037 - 1.404)	1.015(0.916 - 1.126)	0.901(.802 - 1.011)
The introduction of the smoking bad has caused changes in social interaction.		y/n*	1.010(0.886 - 1.151)	1.125(0.980 - 1.292)	1.021(0.928 - 1.123)	0.893 (0.804 - 0.991)
Perception of the utility of several intervention to prevent damages from smoking habits	Periodic checks to make workers respect the ban	low*/high	1.300 (1.137 - 1.486)	1.211 (1.051 - 1.397)	1.091(0.988 - 1.205)	0.518 (0.464 - 0.579)
	Educational training	low*/high	1.419 (1.240 - 1.624)	1.629 (1.411 - 1.881)	1.098(0.995 - 1.213)	0.704 (0.630 -0.787)
	Courses for smoking cessation offered by the employees	low*/high	1.387 (1.210 - 1.591)	1.611 (1.393 - 1.863)	0.903 (0.817 - 0.998)	1.040(0.931 - 1.161)
	A specific company regulation	low*/high	1.162 (1.016 - 1.329)	0.988(0.856 - 1.141)	0.905(0.819 - 1.000)	0.543 (0.485 - 0.608)

Males have a higher perception of the smoking ban to be respected (AOR: 0.74; 95% CI: 0.675-0.825).When the ban is not respected, males are more prone to think this is caused by a lack of respect by the colleagues (AOR: 0.792; 95% CI: 0.686-0.914) and by the pleasure associated with smoking (AOR: 0.730; 95% CI: 0.593-0.898), while women are more likely to think this is related to the tobacco addiction (AOR: 1.209; 95% CI: 1.054-1.386). In general, women were more aware of the damage smoking can cause such as exasperation of asthma (AOR: 1.267; 95% CI: 1.132-1.418) and chronic bronchitis (AOR: 1.417; 95% CI: 1.255-1.599).

Age

Younger workers are more likely to perceive the ban not being respected (AOR: 1.157; 95% CI: 1.014-1.321; AOR: 1.178: 95% CI: 1.022-1.357) due to lack of self-discipline on the part of the smokers (AOR: 0.822; 95% CI:0.679-0.994)) while older employees perceive an increased sensitivity to this issue (AOR: 0.737: 95% CI: 0.598-0.908; AOR: 0.651: 95% CI: 0.521-0.813).

In general, older employees (>50 years old) feel less exposed to secondhand smoke at the workplaces (AOR: 1.199: 95% CI: 1.024-1.405).

Regarding health damages caused by smoking, younger workers are more awaree of the association between smoking and exacerbation of asthma (AOR: 1.30; 95% CI: 1.115-1.515; AOR: 1.559; 95% CI: 1.325-1.834) than older workers. In addition, older employees are also less likely to know that smoking can cause bladder cancer (AOR: 1.788; 95% CI: 1.339-2.387).

Middle aged workers think that the ban would be more respected using periodic checks (AOR: 1.172; 95% CI: 1.026-1.339; middle and older aged workers believe that educational training (AOR: 1.172; 95% CI: 1.026-1.339; AOR: 1.254; 95% CI: 1.087-1.447) and smoking cessation courses (AOR: 1.301; 95% CI: 1.135-1.492; AOR: 1.303; 95% CI: 1-127-1.508) offered by the employers/companies would be useful strategies.

Smokers tend to perceive the ban to be respected (AOR: 0.693; 95% CI: 0.623-0.771) while non-smokers feel more exposed to second-hand smoke (AOR: 1.565; 95% CI: 1.385-1.769). The first are more confident in the self-discipline of the smokers (AOR: 0.815; 95% CI: 0.694-0.957) while non-smokers do not perceive an increased sensitivity to the issue (AOR: 0.607; 95% CI: 0.518 - 0.712) and think there is not an efficient company policy (AOR: 1.379; 95% CI: 1.148-1.657). Smokers have a higher perception of the active surveillance (AOR: 0.733; 95% CI: 0.594-0.904) and would not welcome periodic checks on the ban by the employers (AOR: 0.513; 95% CI: 0.461 – 0.571).

Smokers have a worse knowledge of the effects of smoking on the health (asthma: AOR: 1.196; 95% CI: 1.063-1.345; lung cancer: AOR: 1.796; 95% CI: 1.475-2.187).

Non-smokers would welcome the introduction of a specific company regulation (AOR: 0.513; 95% CI: 0.461 - 0.571) and specific educational training to prevent damage caused by smoking (AOR: 0.701; 95% CI: 0.630 – 0.781).

Workers from intellectual and highly specialized professions (AOR: 1.634; 95% CI: 1.251-2.133), from technical professions (AOR: 1.641; 95% CI: 1.279-2.105) and craftsmen, skilled workers and farmers (AOR: 1.419; 95% CI: 1.086-1.854) tend to perceive the ban not to be observed and the last two classes are the ones who feel the most exposed to second-hand smoke (AOR: 6.679; 95% CI 0.501-0.904; AOR: 0.518; 95% CI: 0.382-0.701). The general knowledge of the adverse effects of smoking are well known in all the professional classes.

Discussion

The present study investigated the relationship between sociodemographic factors and smoking habits among Italian workers and their perception of smoking ban in the workplace. Data were collected from a large sample of Italian workers through a survey.

Even though the existence of the smoking ban is well-known and no-smoking sign are displayed in the workplaces, more than half of the respondents declared that the ban is not respected in the workplace. In particular, this was noted by workers who deal with outdoor activities, which is referred to be related to a lack of respect by the colleagues and to nicotine addiction, as it was previously suggested by Pianori et al and Giraldi et al (9, 12, 20).

Younger workers seem to be more prone to smoking cigarettes even though they are more conscious of the damages caused by tobacco consumption.

The analysis showed that never and former smokers have a higher perception of the ban not being respected than current smokers. This is in line with research conducted by Minardi et al and Doruk et al (9, 16). On the contrary, never smokers think that there is an inadequate company policy to enforce respect of the ban.

The study was part of a large project, which aimed to investigate the presence of unhealthy lifestyles, particularly alcohol (27) and tobacco smoking, among workers interested in activities potentially risky towards other people, in the Latium Region in Italy. The study focused on companies that belong to the area of competence of the Local Health Unit Roma 5 and the Local Health Unit Viterbo, according to the Regional Prevention Plan. All companies participated voluntarily, and this needs to be considered with care since it could represent both one limitation of this study as well as a strength since data come from a very large group of workers.

The results of this study confirmed that Italy is not a virtuous country regarding smoke-free policies (16, 20) and, considering that the smoking ban was introduced in 2003, more than 15 years ago, this is a worrying data to take into consideration to make some changes in the future as it can be framed as a serious Public Health problem. From this point of view, it is reassuring to know that nonsmoking workers would welcome the introduction of specific regulation and educational training aimed at reducing tobacco consumption and to prevent smoking-related damages (as the data showed that there is still ignorance about the risks of this habit), enhancing a smoking-free culture among colleagues as suggested by Edwards et al and Giraldi et al, who underlined the importance of this kind of courses and their efficacy (10, 12, 30).

Interesting is also the willingness of current smokers to try to quit smoking and the fact that they would welcome the support for smoking cessation offered by the company.

The results of this study can be used as a starting point for the implementation of new instruments to reduce tobacco addiction, beginning from promoting good habits in the workplace and, hopefully, enhancing a healthy lifestyle.

The study as strengths and weaknesses that should be taken into account. A key strength of this study is the large sample size of Italian workers who participated in the survey, though a possible selection bias limits its external validity. Other limitations related to its study design include possible recall and response bias, as data collection relied on self-administered questionnaire, which made it impossible to truthfully assess the actual smoking status. For example, the study did not evaluate the relationship between declared smoking habit and the level of urinary cotinine, which would have allowed both the identification of actual tobacco smokers and the quantification of smoking intensity.

In conclusion, given the known health risks of tobacco smoking and second-hand exposure to tobacco smoke, policy makers together with employers must provide the best possible health protection for workers. The enforcement of the smoking ban and he implementation of additional smoking cessation trainings are necessary to protect employee’s health as well as to maximize potential benefits for both workers and employers.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.