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