A long way to go: 20-year trends from multiple surveillance systems show a still huge use of tobacco in minors in Italy.

Background: Main aim was to describe youth smoking prevalence in Italy over the last two decades, and to provide recent trends in knowledge, attitudes towards smoking, awareness of anti-tobacco mass media campaigns, second-hand smoke (SHS) exposure and access to cigarettes.

Methods: Figures from three surveillance systems, with 12 representative cross-sectional surveys (about 43 000 participants): European School Survey Project on Alcohol and Other Drugs, 15-16-year-old students, 1995-2015; Health Behaviour in School-aged Children, 11-, 13-, 15-year-old students, 2002-14 and Global Youth Tobacco Survey, 13-15-year-old students, 2010, 2014.

Results: Among 11- and 13-year-old students, daily and non-daily smokers decreased by 30-50% from 2002 to 2014. Among 15-16-year-old adolescents, ever smokers significantly decreased by 10% in the period 1995-2015, whereas current and daily smokers have been stalling or even increased. Appeal of smoking increased in 2014 compared to 2010, perception of SHS as harmful, and awareness of recent anti-tobacco mass media campaigns decreased. Moreover, a significant 30% reduction in reporting retailers did not refuse to sell cigarettes to adolescents and a decrease in reporting to buy cigarettes were reported.

Conclusions: Policies enforced in Italy over the last 20 years slightly reduced ever smokers, but did not decrease current and daily smokers in 15-16-year-old adolescents, and determined an impact among younger adolescents. Stricter rules on youth tobacco access reduced ease of access to cigarettes, but did not affect adolescents' tobacco use. Stronger tobacco control measures are urgently needed in order to determine a steeper decline in smoking prevalence in adolescents.