Policies and Strategies
for Alcohol Abuse in Italy
Dr Bastiana Pala
Direction General for Health Prevention
Office VII
The study of the structure and models of alcohol use
in a population is a very important aspect for defining
appropriate policies and strategies aimed at the
prevention of alcohol abuse
Since 1998, the consumers of alcoholic beverages
in Italy account for about 70% of the population
over 14 years of age
In 2010, 65,7% of the Italian populationover 11 years of age consumed at least
one alcoholic beverage
Prevalenceis much higher among males(78,9%)
than females (53,4 %)
In both sexes, the most common alcoholic beverage is wine,
followed by beer, aperitif, bitter, spirit (graph.1)
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
2003 2007 2008 2009 2010
Bevande alcoliche 56,0 56,3 56,3 56,9 53,4
Vino 40,4 41,3 40,7 41,3 40,4
Birra 30,8 30,6 31,2 31,9 32,3
Aperitivi alcolici 18,3 18,6 18,5 19,4 19,9
Amari 15,3 14,3 13,9 14,2 14,4
Super alcolici 13,1 11,9 11,0 13,0 12,8
fem
min
e
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
2003 2007 2008 2009 2010
Bevande alcoliche 82,1 81,0 80,5 81,0 78,9
Vino 68,8 68,5 66,9 67,5 67,2
Birra 61,7 60,3 59,7 60,8 60,6
Aperitivi alcolici 42,3 41,0 39,9 40,5 40,4
Amari 43,0 40,8 38,8 39,2 38,1
Super alcolici 37,6 35,3 33,9 35,5 35,8
mas
chi
GRAPH. 1 PREVALENCE (%) OF CONSUMERS OF ALCOHOLIC
BEVERAGES FOR GENDER (YEARS 2003, 2007, 2008, 2009, 2010) Source: National Institute of Health on data of the National Institute of Statistic
In Italy the per capita annual consumption of
pure alcohol on average is 8.02 liters (2006)
This value is much lower compared to the
average consumption in the other European
Countries (10.68 liters)
Only Iceland, Sweden and Norway have an
average consumption of alcohol
lower than Italy (graph. 2)
Graph. 2 – PER CAPITA ANNUAL CONSUMTION OF PURE ALCOHOL
AMONG THE POPULATION OVER 15 YEARS OF AGE IN SOME EUROPEAN
COUNTRIES
YEAR 2006 (VALUES IN LITERS PER CAPITA) C O NSUMO ANNUO PRO -C APITE DI ALC O L PURO NELLAPO PO LAZIO NE
C O N PIU DI 15 ANNI DI ETA' IN ALC UNI PAESI DELLA REGIO NE EURO PEA
Anno 2006 (valori in litri pro capite)
0 2 4 6 8 10 12 14 16 18
Repubblica di Moldavia
Repubblica Ceca
Irlanda
Lituania
Austria
Bielorussia
Slovenia
Germania
Romania
Andorra
Regno Unito
Let tonia
Federazione Russa
EU
Danimarca
Slovacchia
Serbia
Paesi Bassi
Polonia
Svizzera
Finlandia
Spagna
Belgio
Italia
Islanda
Svezia
Norvegia
With respect to the European Union, in Italy
the number of teetotallers is higher
the incidence of binge drinking is lower
(binge drinking means the consumption of large
amounts of alcohol, 6 or more alcoholic units, in a
single occasion)
In 2010, 13.4% of males and 3.5% of females over
11 years of age reported having drunk at least once
with binge drinking modalities (Graph. 3)
Graph 3 - PREVALENCE (%) OF BINGE DRINKING CONSUMERS FOR GENDER AND CLASS OF AGE - YEAR 2010 - Source: ISS on ISTAT data
1,6
10,3
23,3
18,8
12,4
6,53,3
13,4
1,5 3,6
9,7
5,12,7 1,2 1,1 3,5
0
5
10
15
20
25
30
11-15 16-17 18-24 25-44 45-64 65-74 75+
Classi di età ≥ 11 anni
Maschio Femmine
But in Italy we drink more frequently!
• 25% (1/4) of the population consumes alcohol every day:almost twice as much as the European average (14%)
• the percentage of those who drink alcohol 4-5 times/week(13%) is much higher in respect to the European average (9%)
• the percentage of those who drink once a week(19%) is much lower in respect to the European average (26 %): it is the lowest value in Europe after Portugal (15%).
The situation is summarized in Table 1
Tab. 1 – CONSUMPTION OF ALCOHOLIC BEVERAGES IN THE LAST 30 DAYS IN
THE COUNTRIES OF THE EUROPEAN UNION (in percentage)- YEAR 2009 – Source:
ISS on Special Eurobarometer 331-72.3 data
Tutti Frequenza settimanale Frequenza mensile
Non
ricordo/
Paesi i giorni 4-5 volte 2-3 volte 1 volta 2-3 volte 1 volta Rifiuto
EU 27 14 9 23 26 16 11 1
Belgio 14 9 24 26 17 10 0
Bulgaria 14 14 26 25 13 8 0
Repub.Ceca 7 7 18 29 23 16 0
Danimarca 12 9 25 26 19 9 0
Germania 9 10 21 32 16 11 1
Estonia 4 3 12 28 31 21 1
Irlanda 3 4 27 36 17 11 2
Grecia 13 10 24 28 13 12 0
Spagna 23 10 22 26 12 7 0
Francia 20 6 21 27 16 9 1
Italia 25 13 24 19 12 6 1
Cipro 6 4 23 34 19 14 0
Lettonia 2 3 9 22 33 31 0
Lituania 1 4 12 24 25 34 0
Lussemburgo 17 8 23 25 12 15 0
Ungheria 11 11 14 23 22 19 0
Malta 17 5 19 36 14 9 0
Paesi Bassi 21 12 27 20 14 6 0
Austria 7 15 32 25 14 6 1
Polonia 1 5 19 26 24 23 2
Portogallo 43 10 16 15 9 7 0
Romania 13 13 18 25 15 13 3
Slovenia 13 6 17 29 22 12 1
Slovacchia 4 4 15 30 27 20 0
Finlandia 3 6 20 30 27 14 0
Svezia 1 6 24 31 25 12 1
Regno Unito 11 11 30 24 14 9 1
These data are related to the model of traditional
consumption in Italy
The so called “Mediterranean” model
characterized by:
- consumption of small quantities of alcohol
- mostly wine
- mostly during meals
- often daily
This drinking modality is still very widespread in
Italy, and is socially accepted
Nevertheless, the most recent data in Italy show:
that an evolution is ongoing towards different models of consumption, deriving from the cultural influence of North European Countries
that the new models are mostly used by the younger population, while the elderly remain linked to the traditional alcoholic beverages and models of consumption
In particular
during the decade 2000-2010
an increase
of alcohol consumption between meals
was recorded both
in men and in women (Graph.4)
Graph. 4 - PREVALENCE (%) OF WINE OR ALCOHOL CONSUMERS BETWEEN
MEALS AGED ≥14 YEARS - PERIOD 2000-2010- Source: ISS on ISTAT data
35,1
37,8
35,1
38,0 38,539,3 38,8
38,0 37,4 37,8
12,4 13,112,1
14,315,3 15,4 14,9 15,2 15,7
14,6
5,0
10,0
15,0
20,0
25,0
30,0
35,0
40,0
45,0
2000 2001 2002 2003 2005 2006 2007 2008 2009 2010
Maschio Femmina
In 2010, wine or alcohol consumers between
meals accounted for about 25%
of the population over 11 years of age,
with a marked gender difference
(M=36,6%; F=14,2%)
The increase in consumption between meals is
particularly evident among young and very young
people
Table 2 shows the increase in the consumption
between meals in young people aged 14-17 years in
the last 15 years
Tab. 2 - PREVALENCE OF CONSUMERS (%) OF ALCOHOLIC BEVERAGES BETWEEN
MEALS, AGED 14-17 YEARS, DURING THE PERIOD 1995-2010 - Source:ISTAT
1995 1997 1998 1999 2000 2001 2002 2003 2005 2006 2007 2008 2009 2010
Maschi 12,9 18,4 15,2 18 16,8 17,1 18,3 20,7 20,6 24,2 22,7 22,7 20,4 19,11
Femmine 6 10,8 9,7 12,8 12,2 13,8 11,5 16,2 15,6 16,8 17,9 14,4 17,4 14,6 Fonte: ISTAT
In the decade 2000-2010
an increse
of binge drinking in both sexes
was recorded (graph.5)
Graph. 5 - PREVALENCE (%) OF CONSUMERS BINGE DRINKING FOR
GENDER AND CLASS OF AGE - YEARS 2003-2010 - Source: National
Institute of Health on data of the National Institute of Statistic
11,8
14,2 13,913,1
12,1 12,4
13,4
2,9 3,0 3,3 3,12,8
3,13,5
0,0
2,0
4,0
6,0
8,0
10,0
12,0
14,0
16,0
18,0
2003 2005 2006 2007 2008 2009 2010
Maschio Femmina
The increase in binge drinking is particularly high among very
young people
Table 3 shows the increase in the prevalence of the binge drinking
among young students aged 15-19 years
Tab. 3 – BINGE DRINKING AMONG STUDENTS AGED 15 - 19 YEARS AT LEAST
ONCE IN THE LAST 30 DAYS - YEARS 1999-2010
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
31,3% 31,5% 33,7% 35,6% 34,9% 35,9% 35,3% 37,5% 39,5% 35,4% 33,0% 35,5% Fonte:PROGETTO ESPAD®Italia
The new habits of consumption are undoubtedly a cause of
concern:
exposure of the population, especially the youngest, to the
new risks derived from alcohol consumption
in between meal consumption
high alcohol content
alcohol abuse
additional risks on top of traditional consumption, with daily
and protracted use, that still persists in our Country and which
can be very harmful if not accompanied by due restraint
For several years now, the National Institute of Health has used a
synthetic risk consumption indicator based on the WHO guidelines
According to the NHI indicator, consumers at risk are:
males consuming more than 40 gr/day alcohol, drinking any
alcoholic beverage
females consuming more than 20 gr/day alcohol
elderly people over 65 years of age and young people of 16-18
years consuming more than one alcoholic unit/day
adolescents under 16 years of age not completely banning alcohol
consumption
people who consume a large amount of alcohol in a short period of
time (binge drinkers)
In 2010
the prevalence of consumers at risk
in the population over 11 years of age
according to the NHI criteria
was
25.4% among males
7.3% among females
So, more than 8.600.000 persons in Italy consume alcoholic
beverages without following the public health indications,
being at risk of alcohol related pathologies.
Risky consumtion habits are much more widespread
among males than among females
But
In the age group 11-15 years, there are no statistical
differences between males and females.
Consumers at risk are more numerous in the 65 + age
group due to consumption of wine exceeding the
recommended amounts
Another group at risk is that between 18-24 years, due to
the consumption of alcohol between meals and binge
drinking, as shown in graph 6
Graph. 6 - PREVALENCE (%) OF CONSUMERS AT RISK (CRITERIA
NATIONAL INSTITUTE OF HEALTH) BY GENDER AND AGE - YEAR
2010 - Source: ISS on ISTAT data
15,211,5
24,6 21,9 20,2
47,440,3
25,4
12,04,9
10,05,7 4,2
13,39,6 7,3
0
10
20
30
40
50
60
11-15 16-17 18-24 25-44 45-64 65-74 75+
Classi di età ≥ 11 anni
Maschio Femmine
All this evidence shows that
significant part of the Italian population
is exposed
to the risk of alcohol related pathologies
The Ministry of Health addressed these problems
adopting policies and strategies at national level,
starting in the 1990s
Year 1993
Decree of the Ministry of Health 3 August 1993
“Guidelines for the prevention, care, social inclusion and epidemiological
surveillance of alcohol addiction”
Objective
Fight against alcohol addiction
Tools
Planning and regulation of
prevention
monitoring
treatment
rehabilitation
Health Services involved
Network of social and health care services of the Local Health Agencies approved
at Regional level
Resources
No specific allocation of resources
Use of the human resources and the budget of the National Health System
Year 1999
Agreement between the State , the Regions and the Autonomous
Provinces on January 21 1999 “Reorganization of the health care
services for drug addicts”
Alcohol-related objectives :
Inclusion of prevention, monitoring, treatment and rehabilitation
activities for alcoholics in the Departments for Addiction, to be created
inside the local Social and Health Care Services of the Local Health
Agencies
Setting up of an interdisciplinary working group in each Department of
Addiction, to be used as a focal point for diagnosis, treatment and
rehabilitation. The aim is also to improve co-ordination with hospitals,
no profit organizations, social associations and self help groups already
existing at local level
integrated interventions, including medical, psychological and social
aspects
Year 2001
Agreement between the State, the Regions and the Autonomous
Provinces on November 22 2001 on essential Levels of Health Care
Alcohol-related objectives :
inclusion of health care and social services for alcoholics in
the free of charge National Health System (the so called
“Essential Levels of Assistance”)
planning of outpatient social and health care services at the
community level, at home and for residential and semi-
residential rehabilitation
All these provisions led to the current system for alcohol
addiction at local level
In fifteen years:
The number of services for alcoholics increased from
280 in 1996 to 514 in 2009.
New hospital and university services for alcohol abuse
were created. In any case, the main local services for
alcohol abuse are still provided within the Department of
addiction (tab.4; graph.1)
Tab.4
NUMERO DI SERVIZI O GRUPPI DI
LAVORO PER TIPOLOGIA
ANNI territoriale ospedaliera universitaria non
indicata TOTALE
1996 256 20 2 2 280
1997 266 19 4 0 289
1998 245 16 2 5 268
1999 320 12 2 10 344
2000 299 13 3 0 315
2001 307 14 2 1 324
2002 398 14 9 2 423
2003 412 14 10 1 437
2004 427 18 10 2 441
2005 390 13 9 0 412
2006 432 13 8 2 455
2007 452 10 10 0 472
2008 440 12 7 0 459
2009 488 17 9 0 514
Source: Ministry of Health-Direction General for Prevention-Office VII
Graf.1 - TIPOLOGIA DEI SERVIZI O GRUPPI DI LAVORO RILEVATI
ANNO 2009
ospedaliera
3,3%
territoriale
95,0%
universitaria
1,7%non indicata
0,0%
Source: Ministry of Health-Direction General for Prevention-Office VII
Also users of alcohol addiction services are
increasing
Year 1996 Users: 21.509
Year 2009 Users: 65.360
Graph. 5 shows the trend of total users, of
new users and users already cared for in the
past
Graf.5 - UTENTI DEI SERVIZI O GRUPPI DI LAVORO RILEVATI
0
10000
20000
30000
40000
50000
60000
70000
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
anni
n°
ute
nti
totale utenti nuovi utenti utenti già in carico o rientrati
Source: Ministry of Health-Direction General for Prevention-Office VII
Total number of people working in the field of alcohol
addiction is
3579 people, of whom
685 full time (19.1% of the total)
2894 part-time (80.9% of the total)
Professional qualifications:
-physicians
-psychologists
-socio-health operators
-administrative staff
Activities available in the local alcohol addiction services
(according to the guidelines mentioned in the Agreement
between the State and the Regions 21/1/1999
“Reorganization of the system of assistance for drug addicts”)
prevention
referral, examination and diagnosis
definition and implementation of therapeutic and
rehabilitative programs in coordination with other public health
services, with primary care physicians, with private and non
profit sectors, residential and social co-operatives, self-help
groups, hospitals, social services
epidemiological surveys
training and retraining of personnel
All Regions implement these activities but with a high
variability among different Regions
These alcohol abuse prevention and treatment units
cooperate with self-help groups and in particular with
• CAT (Clubs of Alcohol addicts under Treatment)
• Alcoholics Anonymous
In 2009
42.8% of services collaborate with CATs
33.9% with Aas
10.5% with other groups
At national level on average each unit
collaborated with
26 CATs
7 AA groups
The collaboration with the following bodies is also very
common:
Residential and semi-residential therapeutic
communities (37.7% of services)
Social co-operatives for job placement
(36.8% of services)
In this case differences among Regions are very high
At national level, on average, in 2009, each service
for alcohol addicts collaborated with
9 therapeutic communities
14 social co-operatives
Year 2001
Act 30.3.2001 n.125 “Framework Law on alcohol and
alcohol related issues”
For the first time in Italy, this law deals with alcohol related
issues with an intergrated and an interinstitutional approach
It governs
• social and health aspects (prevention, treatment and
social reintegration of alcoholics)
• social and cultural aspects (safe driving, industrial
safety, advertising, sales, training of health
professionals, drugs)
The main novelties introduced under Act 125/2001
• reduction of alcohol upper limits for safe driving from 0.8
to 0.5 per thousand, thus aligning Italy with most European
Countries
• advertising restrictions for alcoholic beverages, especially
to protect minors
• limitations to the sales hours on motorways for spirits
• ban on alcoholic beverages for jobs with a high risk of
industrial accidents for both workers and other people
• free drugs to fight against alcohol abuse and craving
• promotion of community services and self help associations,
also together with public services
Main tasks of the Ministry of Health under Act
125/2001
• Guidance and coordination of Regions in the field of
-social and health care services
-information and prevention
-monitoring of data on alcohol abuse and alcohol
related issues
• Ad hoc funding of national information and prevention
campaigns
• Annual reporting to Parliament on the actions
implemented under the law on the basis of the reports
submitted by the Regions
Main tasks of the Regions and of the Autonomous
Provinces under Act 125/2001
• Planning of prevention, treatment, rehabilitation and
social reintegration of subjects with alcohol problems
and alcohol related diseases
• Identification of public service providers, including
hospitals and universities
• Staff training
•Annual reporting to the Ministry of Health on the
initiatives implemented under the law
Year 2007
Approval of two important strategic plans
• National Alcohol and Health Plan
• Health Improvement Program
National Alcohol and Health Plan
-it is specifically designed to fight against
alcohol- related issues
-for the period 2007-2009
-it is the transposition of the I°European Alcohol
Action Plan adopetd by the World Health Organization
-it is designed to promote activities at the regional level
National Alcohol and Health Plan
Priority Strategic Areas
1. Information/education
2. Drinking and driving
3. Working places
4. Treatment of alcohol abuse and addiction
5. Accountability of the production and distribution
industry
6. Development of social skills to combat alcohol-related
risks
7. Strengthening volunteer services
8. Monitoring of the alcohol-related adverse effects and
of policies to curb alcohol abuse
National Alcohol and Health Plan
Main activities implemented
National monitoring Alcohol and Health Plan ( PNMAS)
It is a consensus paper defining objectives, actions and indicators to
monitor alcohol consumption at a national level
• Four annual reports on the health impact of alcohol in Italy
• Project “Training for early detection and short interventions to
prevent alcohol-related problems in working environments and in
primary care”
- The method adopted was validated and standardized within
the framework of some projects promoted by the World Health
Organization and by the European Commission (PHEPA project)
- Training courses have been organized in 13 Italian Regions on
methods to early detect high-risk consumers and on short
motivational and counseling interventions to help them change
their consumption habits
Government Plan “Health Gains”
• it focuses not only on alcohol but on all the four major
avoidable health risk factors
• it adopts an intersectoral approach: cooperation with all the
institutional partners and all the stakeholders who may
promote healthy behaviours and life styles, including the
alcoholic beverage production and distribution industry
Some objectives of the Plan
-restrictions to the availability of alcoholic beverages in working and living
environments
-correct information to consumers
-strengthened primary care prevention strategies
-alliances with social partners
-protection of minors from alcohol-related risks
-prevention of drunk driving accidents
-training of health care professionals
2010
National Prevention Plan (PNP) 2010-2012
•The PNP is the most recent instrument adopted by the
Ministry of Health to foster prevention strategies in all fields
of health
•The 2010-2 PNP was approved by the State and the
Regions in 2010
In this PNP, alcohol abuse:
-is fully recognized as an important health risk factor in
Italy
-is included among unhealthy habits, behaviours and
lifestyles to be decisevely counteracted
PNP prevention strategies of alcohol-related issues
• health promotion
• education
• training
• communication
Main Objectives
1. reduction in the highest risk consumption
patterns
• between meal consumption
• daily alcohol abuse
• binge drinking
• drunk driving
• work-related consumption
2. transposition of the strategic guidelines
of the 2007-2009 National Alcohol and Health Plan
3. agreements with distributors and sellers of
alcoholic beverages to promote greater
accountability
The evaluation of the reduction in risky alcohol consumption
will be conducted
•at a national level through a number of State agencies
(National Institute of Statistics, Higher Health Institute)
•at a local level with ad hoc surveillance methods
(through Local Health Units)
Alcohol abuse prevention will also be included in
• broader and integrated prevention programs in middle
and high schools and in formal and informal youth
recreational facilities and places to prevent all avoidable
risk factors
Objective: increase the knowledge of personal and social risk
factors and of adolescent emotional-relational patterns
• programs and strategies to early detect risky and
borderline cases
Objective: immediately refer these subjects to specialized
units
Regional Prevention Plans
On the basis of the National Prevention Plan, the Regions have
prepared agreed and shared three-year Regional Prevention Plans
specifying the actions, the timing and the assessment methodologies
to be adopted
The Regional Plans include projects and programs on different areas
and have to be approved by the Ministry of Health
These Plans specify:
- actions
- timing
- evaluation indicators
Regional Prevention Plans priorities to prevent alcohol abuse are
-youth and drunk driving
-alcohol consumption in youth recreational facilities
-alcohol consumption in the working environment
-training health care professionals in the field of prevention
2010
National Health Plan 2011-2013 (PSN)
•In Italy the National Health Plan is the main planning instrument for
health protection
•The National Health Plan is proposed by the Ministry of Health with
the agreement of the Regions and is launched by the Government
The 2011-2013 National Health Plan identifies some
ambitious objectives to prevent alcohol abuse
in line with:
-the implementation of the EU Strategy to reduce
alcohol-related harm
-the prevention culture developed within the Regions
that allows for strengthening the fight against alcohol-
related problems
Objectives of the 2011-2013 National Health Plan
• raise the cultural awareness of risky alcohol
consumption behaviours
• disseminate precise and targeted information
on the risks related to alcoholic beverages
• adopt ad hoc prevention policies and risk
reduction actions for different population groups
(youth, elderly people, women, adolescents)
• adopt targeted prevention actions and policies
on driving, work, pregnancy and addiction
• promote early detection and short treatment
strategies to prevent alcohol-related issues in
primary care and working environments
• make appropriate therapies accessible and
available for subjects with alcohol abuse and
addiction problems
• develop ad-hoc long-term care protocols
integrated with social and health services
and efficacy evaluation techniques
• strengthen monitoring and surveillance on
alcohol consumption, on its adverse effects on
health and social and health care services and
on policies to combat the problem
Thank you for your attention