Smoking prevalence and patterns in Italy were analyzed using data from the 1990-1991 Italian National Health Survey, based on a sample of 27, 135 males and 28,854 females aged 15 years or over, randomly selected within strata of geographic area and size of the place of residence and of the household, in order to be representative of the general Italian population. Overall, 26.9% of the Italians aged 15 years or over described themselves as current smokers (37.2% males, 17.4% females), and 14.0% as ex-smokers (22.2% males, 6.4% females). The difference in smoking prevalence between males and females was 65% below age 45, but increased substantially with increasing age up to 5-fold above age 65. Moderate smokers (< 15 cigarettes per day) were 12.6% of males and 10.4% of females, intermediate smokers (15 to 24 cigarettes per day) 17.7% of males and 5.5% of females, and heavy smokers (> or = 25 cigarettes per day) 6.3% of males and 1.5% of females. Pipe or cigar smokers were 0.6% of males. The average number of cigarettes per smoker per day was 16.6 (17.9 for males, 14.0 for females). The overall smoking prevalence of 26.9% was the lowest registered since 1949, thus confirming the long-term steady decline of smoking, particularly among males. Smoking prevalence, however, has remained constant over the last 15 years among females, after substantial rises in previous calendar years. These falls in overall self-reported smoking prevalence were reflected in declines of legal sale figures (-15% between 1986 and 1991), although it is difficult to quantify the impact of smuggling on total tobacco consumption. Thus, at least part of the falls in self-reported tobacco consumption is attributable to increased underreporting. In males, but not in females, smoking was less frequent in northern (and wealthier) areas of the country, and in more educated individuals. The opposite pattern was observed in females, indicating that even more educated Italian women have not yet recognized the accumulated evidence on the health consequences of smoking. These patterns in smoking are reflected by recent trends in lung cancer, which show some decline in males but persistent upward trends in females, although still on much lower absolute values.