Houghton F, O’Doherty D, McInerney D, Duncan B. Anti-tobacco text warnings in Italy: Geography, language, and South Tyrol (Short report). SEEJPH 2019, posted: 21 May 2019. DOI 10.4119/UNIBI/SEEJPH-2019-218 Page 1 of 4 SHORT REPORT Anti-tobacco text warnings in Italy: Geography, language and South Tyrol Frank Houghton1, Diane O’Doherty1, Derek McInerney2, Bruce Duncan3 1 Department of Applied Social Sciences, Limerick Institute of Technology, Moylish, Limerick, Ireland; 2 Department of Sport, Limerick Institute of Technology, Moylish, Limerick, Ireland; 3 Hauora Tairawhiti, Gisborne, New Zealand. Corresponding Author: Frank Houghton, PhD, MPHe, MA, MSc, Director HEALR Research Group; Department of Applied Social Sciences, Limerick Institute of Technology, Limerick, Ireland; Telephone: +353-87-7101346; Email: Frank.Houghton@LIT.ie Houghton F, O’Doherty D, McInerney D, Duncan B. Anti-tobacco text warnings in Italy: Geography, language, and South Tyrol (Short report). SEEJPH 2019, posted: 21 May 2019. DOI 10.4119/UNIBI/SEEJPH-2019-218 Page 2 of 4 The global death toll from tobacco is now estimated to be in excess of 6 million annually, with projections of this burden reaching 8 million by 2030 (1). The impact of smoking on morbidity is equally alarming, as well as it having a significant adverse impact on individual and family finances. Focusing on Italy, the Tobacco Atlas notes that 28.3% of men aged 15 and over, and 19.7% of women of a similar age smoke (2). The annual death-toll of 93,300 from tobacco-induced illness, and an economic cost of 26041 million Euro. Although smoking is not highly regulated in Italy (2), under European Union legislation all tobacco products sold there carry mandated combined graphical and text warnings. An example of one of the current Italian cancer warnings contained on cigarette packets is given in Figure 1a. As the one official language of the Italian State, it is perhaps no surprise that this warning is written in Italian. However, this one-size-fits-all approach glosses over important linguistic differences within Italy, most notably in relation to South Tyrol (Südtirol [German] / Alto Adige [Italian]) in the Northeast of the country. Previously part of the Austro-Hungarian Empire, the South Tyrol region was annexed by Italy following the end of World War One. Although German speaking, the region was subject to a policy of Italianization and Italian in- migration during the fascist era under Mussolini. Although agreement on a solution was reached between Hitler and Mussolini, de facto annexation of the region by occupying German forces occurred after Italy surrendered and then joined the Allies in World War II. In 1946 Italy and Austria signed the Paris Treaty which secured cultural, economic and linguistic rights for the region. Fifteen years later this treaty had still not been enacted, which led to a campaign of violence in support of the rights of the German speaking population. This culminated in debates in the UN and ultimately the 1972 Second Autonomy Statute, known as the ‘Package’. This agreement officially ended the dispute between Austria and Italy over the status of South Tyrol in 1992. This agreement created an autonomous zone in South Tyrol and contained over 130 measures designed to safeguard the German- speaking minority there (3). The South Tyrol population is 511,750, the majority of which is (62.3%; 314,604) German speaking (Italian Census, 2011). Less than a quarter of the population (23.4%; 118,120) speak Italian, with the third recognized linguistic group, Ladin speakers, constituting just 4.1% (20,548) of the populace. These statistics are important because emerging evidence from anti-smoking research in Ireland (4) supports basic marketing communication theory which stresses the importance of language ability and preference in health warnings, as well as the need for ease and speed in health communications. Under primary and secondary elements of the ‘Package’ the South Tyrol rgion already has a legal remit in relation to matters of language, health and public health. The South Tyrol region therefore should strongly consider legislation to require either bilingual (German then Italian), or preferably trilingual anti- smoking text warnings (German then Italian, followed by Ladin). South Tyrol would then join other areas within the EU with more than one language in its combined graphical anti-smoking warnings. Such linguistic diversity is currently reflected in the anti-smoking warnings in the Five countries that are officially bilingual (Malta [see Figure 1b), Ireland, Finland, Cyprus, & Luxembourg) and Belgium which is officially trilingual (see Figure 1c). Houghton F, O’Doherty D, McInerney D, Duncan B. Anti-tobacco text warnings in Italy: Geography, language, and South Tyrol (Short report). SEEJPH 2019, posted: 21 May 2019. DOI 10.4119/UNIBI/SEEJPH-2019-218 Page 3 of 4 The relatively small population of South Tyrol is not a reason to justify continuing with an ‘Italian only’ approach on the combined text and graphic warnings. The population of the region is considerably larger than that of Malta (approximately 430,000), an EU State with its own unique requirements in anti- smoking warnings. As can be seen from Figure 1b current Maltese legislation requires warnings in both English and Maltese (5). Figure 1. Examples of current anti-smoking combined graphic and text warnings from Italy, Malta & Belgium 1a- Italian Warning 1b- Maltese Warning 1c- Belgium Warning It is easy to overlook the importance of text warnings in an era of graphic pictorial warnings. However, evidence suggests that text based warnings are still an important element of health education and in some ways may be more influential than graphic warnings (6-8). It is also notable, as Noar et al. point out, that if one assumes an average consumption of 20 cigarettes per day for a year, this equals a total of 7,300 potential opportunities to view the combined text and graphic warnings annually (9). This form of direct marketing to smokers therefore may achieve incomparable penetration to the target audience. The damage wrought by smoking is such that continuing with a generic Italian only approach is no longer acceptable. Every effort must be taken to reduce smoking using a multiplicity of approaches. This proposal has two crucial factors in its favour. Most importantly, the population in South Tyrol, like those elsewhere within the EU, are familiar with, and largely accepting of, combined text and graphic anti-smoking warnings. As such this initiative is largely a fine-tuning of current protections, rather than a new development. Therefore it is unlikely to encounter significant opposition, and given the strength of feeling towards language exhibited by the German-speaking population of South Tyrol, may well be welcomed. An additional advantage of this approach is that the cost of this intervention is borne solely by the tobacco producers. This development therefore is attractive to regulators and policy makers operating in fiscally constrained environments. Conflicts of interest: None. Houghton F, O’Doherty D, McInerney D, Duncan B. Anti-tobacco text warnings in Italy: Geography, language, and South Tyrol (Short report). SEEJPH 2019, posted: 21 May 2019. DOI 10.4119/UNIBI/SEEJPH-2019-218 Page 4 of 4 References 1. World Health Organisation. WHO Report on the Global Tobacco Epidemic, 2011. Geneva: World Health Organisation; 2011. 2. Italy | Tobacco Atlas [Internet]. Tobacco Atlas. 2018 [cited: 5 November 2018]. https://tobaccoatlas.org/country/italy/ (accessed: 13 May 2019). 3. Alcock A. From tragedy to triumph: The German language in South Tyrol, 1922-2000. In: Hogan-Brun G, ed. by. National varieties of German outside Germany: A European perspective. Bern, Switzerland: Peter Lang; 2000. p. 161-94. 4. O’Doherty D, Houghton F, McInerney D. Tobacco control in Ireland: How effective are dual health warnings on tobacco packaging? Tob Prev Cessat 2018; 4(Supplement):A72. DOI: https://doi.org/10.18332/tpc/90316. 5. O’Doherty D, Houghton F, McInerney D. Asleep at the helm? Language and Malta's new combined tobacco control warnings. Public Health 2018;163:155- 7. 6. Pepper JK, Cameron LD, Reiter PL, McRee, A-L, Brewer NT. Non- Smoking Male Adolescents’ Reactions to Cigarette Warnings. PLOS One 2013;8:e65533. DOI: 10.1371/journal.pone.0065533. 7. Sabbane LI, Lowrey TM, Chebat J. The effectiveness of cigarette warning label threats on nonsmoking adolescents. J Consum Aff 2009;43:332-45. 8. Evans AT, Peters F, Shoben AB, Meilleur LR, Klein EG, Tompkins MK, et al. Cigarette graphic warning labels are not created equal: They can increase or decrease smokers’ quit intentions relative to text-only warnings. Nicotine Tob Res 2017;19:1155-62. 9. Noar SM, Hall MG, Francis DB, Ribisl KM, Pepper JK, Brewer NT. Pictorial cigarette pack warnings: a meta- analysis of experimental studies. Tob Control 2016;25:341-54. ______________________________________________________________________________________ © 2019 Houghton et al; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.