It is widely believed that spaghetti with meatballs was an innovation of early 20th-century Italian immigrants in New York City. The National Pasta Association (originally named the National Macaroni Manufacturers Association) is said to be the first organization to publish a recipe for it, in the 1920s.
Italian writers and chefs often mock the dish as pseudo-Italian or non-Italian  because, in Italy, meatballs are smaller and only served with egg-based baked pasta.
However, various kinds of pasta with meat are part of the culinary tradition of the Abruzzo, Apulia, Sicily, and other parts of southern Italy. A recipe for rigatoni with meatballs is in Il cucchiaio d'argento (The Silver Spoon), a comprehensive Italian cookbook known as the "bible" of Italian Cooking. Other dishes that have similarities to spaghetti and meatballs include pasta seduta 'seated pasta' and maccaroni azzese in Apulia.
Some baked pasta dishes from Apulia combine pasta and meat where meatballs, mortadella, or salami are baked with rigatoni, tomato sauce, and mozzarella, then covered with a pastry top.
Other pasta recipes include slices of meat rolled up with cheese, cured meats and herbs (involtini in Italian) and braciole (bra'zhul) in Italian-American and Italian-Australian slang, that are cooked within sauce but pulled out to be served as a second course.