Italy between drinking culture and control policies for alcoholic beverages.

Substance Use & Misuse, 49:1646–1664, 2014 C 2014 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2014.913386

ORIGINAL ARTICLE

Italy Between Drinking Culture and Control Policies for Alcoholic Beverages Allaman Allamani1 , Fabio Voller1 , Pasquale Pepe1 , Michela Baccini2 , Giulia Massini3 and Francesco Cipriani1 1 3

Agenzia Regionale di Sanità Toscana, Firenze, Italy; 2 Department of Statistics, Florence University, Firenze, Italy; Semeion, Roma, Italy umented (e.g., Babor et al., 2003; Anderson, Møller, & Galea, 2012). Generalizable scientific evidence is mainly based on data from North European and North American countries. In Europe, considering the period between 1960 and 2000, the Mediterranean countries manifested a steady decrease in alcoholic beverage consumption before any comparable policy measure was adopted, while in the other European areas consumption has generally increased. When one compares Southern European countries especially with Northern countries, where the consumption increased was experienced despite active, albeit loosened, alcoholic beverage control policies this divergence is remarkable. This raises the question about the extent to which factors other than the “planned” alcohol control policy factors are responsible for changes in alcoholic beverage consumption and alcoholic beverage consumptionrelated harms? Some previous studies suggested that “unplanned” factors like urbanization, women emancipation, and economic affluence can impact on alcoholic beverage consumption (Allamani & Beccaria, 2007; Simpura, Karlsson, & Läppanen 2002; Sulkunen, 1989). This paper focuses on Italy during the period 1961–2006 and examines the following questions:

This paper focuses on whether the on-going dramatic decrease in alcohol consumption in Italy, especially of wine, during 1961–2008, was associated with which parallel sociodemographic and economic changes and with alcohol control policies. The study, using both time series (TS) and artificial neural network (ANN)-based analyses documents that its selected sociodemographic and economic factors, and particularly urbanization, had a definite connection with wine consumption decrease, spirits decrease, and the increase in beer consumption over time. On the other hand, control policies showed no effect on the decline in alcohol consumption, since no alcohol control policy existed in Italy between 1960 and 1987. A few policies introduced since 1988 (BAC and sale restrictions during mass events) may have contributed to reducing or to maintaining the on-going reduction. Study limitations are noted and future needed research is suggested. Keywords sociodemographic and economic factor, alcohol control policies, time series analysis, artificial neural network analysis, alcoholic beverage as symbol

1. the extent to which selected demographic and economic changes are most strongly associated with the changes in alcoholic beverage consumption and types of consumption-related harms; and 2. the extent to which alcoholic beverage control policy measures influence alcoholic beverage consumption and their-related harms, considering the effect of socio-demographic and economic factors on alcoholic beverage consumption.

INTRODUCTION

This study is part of the European study AMPHORA, work-package 3, that includes 12 European countries,1 and in particular Italy (Allamani et al., 2011; AMPHORA, 2013). The effectiveness of some intervention policy measures (e.g., tax policies and regulations on availability) on the consumption of alcoholic beverages, and on their direct or indirect-related harm is rather well doc-

Thanks to Karin Pantzer, Francesco Maccari, and Giulia Carreras, for their contribution in the collection, management, and analysis of data; to Franca Beccaria, Stefano Casini, Paolo Buscema, Deborah R. Gordon, Guido Maurelli for their suggestions during the drafting of the text. 1 The 12 countries involved in this study were Austria, Finland, France, Hungary, Italy, Netherlands, Norway, Poland, Spain, Sweden, Switzerland, and the United Kingdom 1 Address correspondence to Allaman Allamani, Via P. Toselli, 140, 50144 Firenze, Italia; E-mail: [email protected]

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ITALY AND ALCOHOLIC BEVERAGES

TABLE 1. Average annual values (with standard deviation) of socio-demographic and economic variables, bread and meat consumption (different national/international sources, see text) and recorded alcoholic beverage consumption per inhabitant, 15 years and older (World Health Organization, 2011) in Italy, according to 5 decades, 1960–2009 Variables Males > 65% male pop. Price of wine index number Income international dollars Urbanization% residents in larger cities Mother’s age at childbirths mean Female education% fem. completing tertiary edu. Female employment% fem. Bread cons. kilos per capita Meat cons. kilos per capita Wine cons. litres pure alc per capita Beer cons. litres pure alc per capita Spirits cns. litres pure alcohol per capita Total cons. litres pure alcohol per capita

1960–1969

1970–1979

1980–1989

1990–1999

2000–2009

8.5 ± 3.0 119.4 ± 4.1 11.149 ± 1557 61.5 ± 1.4

10.1 ± 5.7 112.4 ± 8.5 16.405 ± 1532 65.4 ± 0.7

11.2 ± 3.7 96.0 ± 2.8 21437 ± 1693 66.7 ± 0.0

13.7 ± 9.5 106.3 ± 4.7 26.230 ± 1037 66.9 ± 0.1

16.47 ± 7.1 112.0 ± 4.3 11.149 ± 1557 67.6 ± 0.3

28.7 ± 0.2 0.5 ± 0.7

27.7 ± 0.3 0.92 ± 3.5

28 ± 0.4 1.7 ± 6.4

29.6 ± 0.5 3.4 ± 6.4

30.7 ± 0.2 5.4 ± 1.4

21.3 ± 1.5 164.6 ± 4.6 39.9 ± 7.6 16.3 ± 0.6 0.6 ± 0.1 2.0 ± 0.2

20.4 ± 9.6 173.9 ± 3.1 62.4 ± 4.5 14.6 ± 1.4 0.9 ± 0.1 2.5 ± 0.1

23.5 ± 8.2 165.0 ± 2.6 76.3 ± 3.1 9.9 ± 1.5 1.3 ± 0.1 1.5 ± 0.1

24.9 ± 7.9 160.6 ± 2.1 81.8 ± 0.9 7.2 ± 0.5 1.5 ± 0 0.8 ± 0.2

29.0 ± 1.4 162.1 ± 0.2 89 ± 5.1 5.9 ± 0.6 1.7 ± 0 0.3 ± 0

18.9 ± 0.7

18.1 ± 1.4

12.8 ± 1.5

9.6 ± 0.7

8.0 ± 0.6

Italy and its Drinking Culture from the 1960s to the 2000s

Italy covers an area of 301,318 km2 with a population of about 60,000,000 in 2011 (ISTAT, 2012a). Major changes have occurred during the 1950s and at the beginning of the 1960s when Italy was transformed from being a predominately agricultural to being a predominately industrial economy, with a massive migration of 9 million of people from the poor South, toward the major cities undergoing industrial expansion in the North (Tusini, 2007). The percentage of employees shifted from 42% in agriculture, 32% in industry, and 26% in the tertiary sector in the 1950s to, respectively, 20%, 40%, and 40%, during the 1970s and 5%, 32%, and 63% at the beginning of 2000s.

Socio-Demographic and Economic Factors The following socio-demographic and economical factors have been constantly growing since 1960 in Italy, as it has in the other European countries (Table 1; see Voller, Maccari, Pepe, & Allamani, 2014). More than the other European countries, however, Italy’s population has become older over time. Males over 65, a reasonable indicator of the population’s aging, were on the rise, from about 8% of the total Italian male population in 1960 to 16% and more in the 2000s (ISTAT, 2010). Urbanization, that is the rate of residents in larger cities, rose steeply during the 1960s and 1970s, and more slowly during the following decades, from 59.4 per 100,000 population in 1960 to 68.2 in 2009 (World Bank, 2011a). The rates of individuals living alone grew three times as much, reaching 8% of males and 12% of females in the 2000s, and single fathers and especially single mothers are on the increase, with 1.3% and 6.0% in the 2000s, respectively (ISTAT, 2012a).

Two indicators of changes in Italian society, mother’s average age at all childbirths and female employment (rate of age 15–64 employed females for the age 15–64 female population), were on the rise, respectively, from about 27 to 31 years during 1970s–2000s and from about 20% to 30% during 1960s–2000s (EUROSTAT, 2012; OECD, 2011). Also female tertiary education (rate of females who complete tertiary education per 15 year and older female population), which may adequately indicate the level of education attained in the country, has impressively increased from 0.4% in 1960 to 6.4% in 2009 (World Bank, 2011b). All these figures represent a remarkable change in the role of women in Italy during these 5 decades. In turn this change appears to have weakened the traditional family rites, such as family meals at home, with fewer opportunities for eating meals with traditional food and wine together (Tusini, 2007). Income has had a constant remarkable increase from 8,850 in 1960 to 27,960 in 2009 (but 30,200 in 2007) gross domestic product pro capita (data in constant 2005 international dollars) (World Bank, 2011c). Regarding immigration from other countries the 2011 Italian ISTAT census data informs that in 2011 there was 6.34% immigrants (nearly 4,000,000) while in 2001 the rate was 2.34 (about one million), coming from Morocco, Albania, Philippines, Eastern Europe, Africa, and South America (ISTAT, 2012b). These figures should be doubled when including the number of the illegal immigrants. Religiosity In Italy, the dominant religion is Roman Catholicism (86% of the population), followed by 2% of Christian Orthodox, 1.2% of Protestant, and 0.06 of Jews; the recent immigration can also account for the 2.2% of adherents to Islam (Caritas/Migrantes, 2008). Moreover, new age or new

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religions, like Buddhism (0.2%), have been recently represented, while the percentage of people who indicated that they do not believe in God grew from 5.2% in 1987 to 17.3% in 2007 (Garelli, 1991, 2011). This was associated with transformations in Western societies, where traditional social and religious ties have weakened, parallel to the rise of education and of technological information (Smith, 2012). Food Consumption Notable change in food consumption occurred in Italy, especially between 1970 and 2001, with increased eating of meat (from 54 to 82 kilos pro capita), and milk (from 67 to 82 L pro capita); also fruit and vegetable intake increased between 1970 and 1997, from 88 to 145, and from 98.6 to 211.0 (kilos pro capita), respectively. Bread consumption, however, decreased (from 173 kilos pro capita in 1970 to 152 in 2001) (Cipriani, 2007; ISTAT, 2013a). Health Behavior Smoking may be an adequate indicator of people’s concern about their health. The number of daily smokers in the Italian population dropped from 34.9% of smokers—14 years old and over- in 1980 to 23.9% in 2003 and 21.1% in 2010, with 81,855 smoke-attributable deaths in 2000 (Epicentro, 2013; World Health Organization, 2010). Since 1975 a law has banned smoking in public transportation and specific public places, while in 2005 the ban was extended to all public indoor spaces. The effective implementation of these laws may be interpreted as being part of an increase in health awareness and behavior concerning smoking and lifestyles among Italians. Since it is a common statement that laws are partly or rarely enforced in Italy, this raises the issue of what makes a culture law abiding or not—a country transparency, a government promulgating norms scarcely supported by the public opinion, relative divergence between policy makers and local populations. Wine Production Italy, together with France, has been a top world producer of wine, wine production being about 54 and 47 million hectolitres in 2000 and 2011, respectively (ISTAT 2012b). Already in the 1970s the increased wine production at the European level had resulted in a surplus of wine. In 1976 the European Economic Community (EEC) introduced a regulatory system of planting rights, which banned any further vineyard plantations: from 1988 to 1996 European Union (EU) policy encouraged the grubbing up of overproductive vines, but after 1996 these restrictions were weakened (European Commission, 2006; Gazzetta ufficiale della Repubblica italiana, 1976). While it is not clear to what extent this regulation effectively reduced the wine production, it did appear to both keep the level of wine surpluses of low quality lower, and to promote the production of better quality wines (Meloni & Swinnen, 2012).

Drinking in Italy In Italy the consumption of all alcoholic beverages, after reaching a peak of 19.89 L of pure alcohol consumed per inhabitant 15 years and older in 1973, started to progressively and dramatically diminish, dropping by 45% to 9.8 L in 1990 (Figure 1). A further 58% drop occurred during the next 19 years, reaching 6.94 L in 2009 (World Heath Organization, 2011). Altogether there was a 65% decrease in consumption between 1973 and 2009. The Italian alcoholic beverage consumption level is currently among the lowest in Europe. Most of this unpredicted drop in alcoholic beverage consumption is due to the decrease of wine consumption during the last 40 years, even if Italy remains, today, as a country of wine drinkers. At the same time, relatively speaking, beer intake has increased enormously. While in 1961 wine accounted for 90% of the overall consumption of alcoholic beverages, beer for 2% and spirits for 8%, in 2009 the rates were, respectively, 72%, 23%, and 5%; in other terms, from 1961 to 2009 wine consumption dropped by 71%, while beer drinking rose by 75% (World Health Organization, 2011). WHO data are recorded data; however, according to some estimates, unrecorded alcoholic beverage consumption in Italy would be only 1–2% of the total alcohol consumed (see SMART, 2010). The traditional Mediterranean pattern of moderate alcoholic beverage consumption with meals—wine as a food and not as an intoxicating beverage—still prevails, among women in particular (70% of women as opposed to 47% of men) (Scafato, Ghirini, Galluzzo, Farchi, & Gandin, 2009). However, there has been an increasing trend of people who do not drink (during the previous 12 months), which in the last decade rose from 28% (14.7% males and 40.3% females) in 2001 to 33.1% (18.6% males and 46.5% females) in 2011 among ≥ 14 years old in the population (ISTAT 2013b). A decrease of “hazardous drinkers” has been recently reported by the Higher Institute of Health (which uses an inclusive definition of “hazardous drinking”2 ), from 15.9% in 2008 to 13.8% in 2012 among ≥ 11 years population (ISTAT 2009). Regarding gender, male alcoholic beverage consumers exceeded female consumers, less regarding wine (in 2010 males consuming wine in the last month were 67.8% vs. 50.2% of females) than spirits (31.5% vs. 14.3%) (Salamon, 2012)—even if, compared to previous decades, in 2010 more women drank alcoholic beverages (ISTAT, 2009). The first taste of wine may often occur around ages 7–8 years old, on special occasions and in a family context during meals. This has been interpreted to be a protective

2

The National Institute of Heath defines a hazardous drinker, in terms of average grams of pure alcohol per day, as any man 22–65 years old drinking more than 20 g (2 units); any woman 22–65, and any person aged 18–21 and over 65 drinking more than 10 (1 unit); and any adolescent below age 18 who drink any amount of alcoholic beverage (Scafato, Gandin, Galluzzo et al., 2013).

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25,00

liters per capita p er year

20,00

15,00

10,00

5,00

1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

0,00

wine

beer

spirits

other

Tot

FIGURE 1. Recorded alcoholic beverage consumption (total and per wine, beer, spirits and other) in litres of pure alcohol per inhabitant 15 years and older, Italy, 1961–2009. Source: WHO (2011)∗. Other = all wines that are not grape wine, all beers not made from malt, cocktails, mixed drinks, fortified wines, cider, and the like. Data were collected through AMPHORA work package 2, thanks to Jürgen Rehm and Margaret Rylett.

factor3 contrasting the future development of abuse4 (Beccaria 2010; Kuntsche et al., 2013; Strunin et al., 2010). Regular drinking behavior begins later. According to the Health Behavior in School-aged Children (HBSC) survey in 2010, 6.8% of 11-year-old children and 32.0% of 15year-old children consumed an alcoholic beverage at least once a week (Charrier, 2013). There is some evidence that

Italians begin to drink rather regularly at about 15 years old, frequently during meals or when consuming some food; beer being preferred to wine intake. This presumably may be as a reaction to family rules following the impact of peers. Celebrating getting a job, marrying and having a baby are again associated with a preference for the traditional wine-drinking pattern (Voller, 2007).

3

The reader is reminded that the concepts of “risk factors,” as well as “protective factors,” are often noted in the literature, without adequately noting their dimensions (linear, non-linear; rates of development and decay; anchoring or integration, cessation, etc.), their “demands,” the critical necessary conditions (endogenously as well as exogenously; from a micro to a meso to a macro level) which are necessary for either of them to operate (begin, continue, become anchored and integrate, change as de facto realities change, cease, etc.) or not to and whether their underpinnings are theory-driven, empirically based, individual and/or systemic stake holder- bound, based upon “principles of faith doctrinaire positions “personal truths,” historical observation, precedents and traditions that accumulate over time, conventional wisdom, perceptual and judgmental constraints, “transient public opinion.” or what. This is necessary to consider and to clarify if these term are not to remain as yet additional shibboleth in a field of many stereotypes, tradition-driven activities, “principles of faith” and stakeholder objectives. Editor’s note. 4 The journal’s style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor’s note.

Drinking Contexts and Economy Bars and cafés are often open in urban Italy until late in the night and are usually allowed to sell alcoholic beverages as well as soft drinks, and coffee. They have undergone some changes from tradition, especially since the 1980s, providing an environment in which a mixed clientele, mainly youngsters or young adults, can socialize, standing or sitting at tables. The number of places selling alcoholic beverages on the premises has risen from 303,821 in 1971 to 501,844 in 2009, while the off-premises decreased from 811,265 in 1971 to 384, 852 in 2009 (Infocamere, 2009). Since the 1970s especially the beer and liquor industries began to invest in newspapers, radio, and TV advertising. Even if the figures on the costs of alcoholic beverage advertising are not reliable, coming from

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different and non-comparable sources, expenses for alcoholic beverage advertising have been reported to be by and large on the rise. For example, in 2006 196.54 million of Euros were spent for advertising alcoholic beverages (EACA, 2011). Prices for the three principal alcoholic beverages, i.e., beer, wine, and spirits, which are expressed in price index numbers, show an overall drop in the period 1960s–2000s. Wine price index decreased from about 120 in the early 1960s to less than 100 during the 1980s, when it started to rise, reaching 114.99 in 2009, and paralleling the industry’s new strategy to produce high-quality wines at the detriment of low-quality ones. Beer prices, after a peak of 138.78 in 1961, showed a declining curve down to 91.76 in 1997, with a more recent rise to 100.93 in 2009. Price of spirits, reaching 143 in 1971 began to drop in the following years; then, after slight increases and decreases, the price index was 92.17 in 2009 (AMPHORA, Part 1, the Study, Unplanned determinants of alcoholic beverage consumption change; ISTAT 2013a; Voller et al., 2014). While income had steadily increased, and price of beer and wine manifested an irregular decrease, the expenditure on alcoholic beverages (expressed as the percentage of alcohol expenditure on the total household expenditure) has shown a constant drop from 3.2% in 1970 to 0.7% in 2009 (AMPHORA, Part 1, the Study, Unplanned determinants of alcohol consumption change; ISTAT 2013a). Overall, it is difficult to speculate about any generalizable connection between the long-term decrease in Italy’s alcoholic beverage consumption and the many factors that were described earlier. Moreover, for some factors, we do not have enough data to allow any reasonable attempt to associate the variables. Urbanization, aging of population, changes in women’s role and in food consumption, and economic factors, appeared to be more able, hypothetically, to explain the consumption changes, reflecting the conclusions of a previous large study in Italy (Allamani & Beccaria, 2007) and also having the advantage that the relative figures were available for a long period of time. Problems and Detrimental Consequences Hazardous drinkers. The prevalence of at least one binge drinking occasion (drinking more than 6 glasses of any alcoholic beverage) among current drinkers during the previous 12 months was estimated at approximately 11% in 2009; figures that are in line with, or lower than, those in previous years (Scafato et al., 2009). In 2010 among young people (13–24) 14.6%, mostly between 18 and 24 reported binge drinking in the last three months, while 5.9% reported one or more episode of drunkenness in the last three months (figures were 4.1% in 1993, and 6.9% in 2005) (Salamon, 2012; Scafato et al., 2009). Regarding mortality related to consumption of alcoholic beverages, between 1980 and 2008 there has been a decreasing trend in deaths from chronic liver disease and cirrhosis, from 32.89 (all ages per 100,000 of general population) in 1980, to 9.05 in 2008 (World Health Organization, 2010)—which in Italy may be explained by the de-

creasing amount of alcoholic beverage consumption. Another indicator of alcohol consumption-related harm, road traffic death data, in Italy decreased from 24.73 deaths in 1970 to 801 deaths in 2008 (all ages per 100,000 general population) (World Health Organization, 2010). Considering the latter decrease, one should also consider the improvement in the safety of motor vehicles and of roads as an important factor in cutting down traffic deaths. A recent study focusing on total mortality attributable to alcoholic beverage consumption based on available data in 2004, indicated that it was responsible5 for 4.9% of all deaths for women and 6.3% of all deaths for men between 15 and 64 years of age, with a total of approximately 25,000 deaths (Shield, Rehm, Gmel, Rehm, & Allamani, 2013). The percentage of the total health burden attributable to alcoholic beverage consumption, as measured in DALYs (combining years of life lost due to premature mortality and years lived with), was 1.6% for women and 4.5% for men in 2004 (Figure 2). These data show that harm figures place Italy among the lowest positions in Europe. Public Concern About Alcohol Italians have always maintained a liberal attitude towards alcohol and its consumption, and alcoholism has often been considered as being an individual and not a social problem as has been the case both for illicit drug consumption and cigarette smoking—subjects of nation-wide educational campaigns. During the 1970s and 1980s the first Alcoholic Anonymous groups, followed by Clubs for Treating Alcoholics6 spread through the country, giving the public awareness that alcoholism was more common than had usually been thought to be. The growing number of alcoholic treatment services contributed to making the diagnosis of alcoholism less stigmatising and more acceptable, even for women (Allamani, 2008; Patussi, Tumino, & Poldrugo, 1996). Since the 1980s, daily TV and newspapers presented dramatic stories of alcohol abuse, especially among youngsters, causing road accidents and violence. Beginning with the last part of the 1980s the issue of alcohol and alcohol drinking-related problems started to be considered by a few politicians and public administrators.

5

The reader is referred to Hills’s criteria for causation that were developed in order to help assist researchers and clinicians determine if risk factors were causes of a particular disease or outcomes or merely associated (Hill, A. B. (1965). The environment and disease: associations or causation? Proceedings of the Royal Society of Medicine 58: 295–300.) as well as to Tilly, Charles (2008). Credit and Blame Princeton Univ. Press. Princeton, NJ for an important analysis about “blame.” Editor’s note. 6 The non-governmental Clubs of Treated Alcoholics (CAT), are an adaptation of Alcoholic Anonymous in the context of socialist Yugoslavia that was developed in Zagreb during the 1960s, spread to Italy in the 1980s and subsequently to Spain and to a few other European countries (Patussi, Tumino, & Poldrugo, 1996).


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FIGURE 2. Chronic liver disease and cirrhosis mortality rate per 100,000 pop. (1970–2009) and transport accident death rate per 100,000 pop. (1979–2009), Italy. Source: WHO (2010).

Prevention Policies Two alcoholic beverage control policy measures, for a long time active in Italy, were contained in the Rocco Code in 1931: (1) minimum age limits—it is forbidden to supply or sell any alcoholic beverage to individuals younger than 16, to drunkards, and to the mentally ill; and (2) arrest for drunkenness. In 2012 a national law (“Balduzzi” law, Gazzetta Ufficiale della Repubblica italiana, 2012) changed the age limit for buying alcohol to 18. During the period 1960–2008, 46 restrictive and 2 permissive (licenses to sell alcoholic beverages) countrywide policy measures were introduced in Italy (see Allamani, Beccaria, & Voller, 2010). The first VAT taxes for alcoholic beverages were introduced as a consequence of the general introduction of VAT in Italy in 1973, and a minor change in regulation for licences to sell wine, beer, and spirits was promulgated in 1974. However, the first national measure for drinking control was introduced only in 1988, when a Ministerial Decree first established a BAC level of 0.8 g/L as the threshold above which driving was not permitted. Three years later (1991) a national law allowed Police or Mayors to prohibit the sale of beverages with more than 21% alcohol by volume during concerts, sporting events, or other events with a massive presence of youngsters. In the nineties restrictions on the sale of alcoholic beverages in public places, and an increase in VAT taxes on alcoholic beverages were approved by the Italian Parliament. During the first decade of 2000s further restrictions on BAC and on the sale to youngsters were introduced. Since the drop in consumption of alcoholic beverages began in the early 1960s, and after a modest rise during the second part of that decade resumed its trend after 1973, one cannot reasonably attribute to the control measure introduced in 1988, and later, any effect on the consumption decrease occurred about 15–25 years earlier. Control policy measures in Italy may be viewed as being a late

“comer” to the dynamic multi-dimensional outcome of Italians decreasing their drinking during the 1960s–1970s. One might hypothesize that the introduction of the alcohol control policies might at their best have partly contributed to the already falling consumption curve. This will be the aim of the analysis of the impact of policy measures on alcoholic beverage consumption in Italy. STUDY AIMS, VARIABLES, AND METHODS

The aim of the Italian AMPHORA study focused on investigating the following questions (AMPHORA, 2013): (1) How do selected socio-demographic and economic factors affect consumption of alcoholic beverages? (2) How do changes in food consumption impact on alcoholic beverage consumption? (3) How do alcoholic beverage control policies affect alcoholic beverage consumption? (4) To what extent does the interaction between selected socio-demographic/economic factors and alcohol control policies explain changes in alcoholic beverage consumption? (5) How do control policies and socio-demographic/ economic factors affect alcohol consumption-related deaths? The Study Variables

Consumption of Alcoholic Beverages and Related Harm Data available for Italy from 1961 to 2006 on per capita recorded total alcoholic beverage consumption in those aged 15 years and older were provided through 2009 Global Information System on Alcohol and Health (GISAH) dataset (World Health Organization, 2011). Liver disease and liver cirrhosis (or simply liver disease) mortality indicates the extent of high and

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continuous alcoholic beverage consumption, whereas the number of persons killed or harmed in transport accidents indicates single intoxication events (Rehm & Scafato, 2011). WHO Health For All Database Italian mortality standardized death rates (SDR) for both genders and all ages per 100,000 inhabitants were used (see World Health Organization, 2010). For Italy, there is a complete liver mortality series for 1970–2008, and a complete transport mortality series for 1979–2008, with missing data in 2004–2005 for both series. Selected Socio-Demographic and Economic Variables Seven factors were selected for the quantitative analysis of AMPHORA project for Italy (as well as for the other 11 European AMPHORA countries). They concern indicators of (a) economic changes: income; prices of wine and beer, the most drunk alcoholic beverages in Italy, (b) socio-demographic changes: proportion of older people, proportion of people living in larger cities, and three indicators of women’s emancipation: average age of mothers at their child births; proportion of working women; level of women’s education (AMPHORA, 2013). Data were collected from national sources, but since some variables had missing data, information coming from the international sources, like World Bank (WB), (World Bank, 2011a 2011b, 2011c), EUROSTAT (ES) (EUROSTAT, 2012), and the International Organisation for Economic Co-operation and Development (OECD) (OECD, 2011) databases, was also taken into account. Food Consumption In keeping with the AMPHORA study protocol that considered five categories of food, bread (or wheat), meat, milk, fruit, and vegetables were taken into account (AMPHORA, Part 1, the Study, Unplanned determinants of alcoholic beverage consumption change). Prevention Policy Measures to Reduce Alcohol-Related Harm A limited number of policy measures, consensually set at 6 main ones, were considered appropriate to better analyse the effect of policies based upon a time series (TS) analysis (see AMPHORA, 2013, Part 1, Collection and selection of variables; Allamani, Beccaria, & Voller, 2010). The six measures, all restrictive, that were selected by the Italian authors were the following: 1. 1988: a Ministerial Decree, August 1988, established a BAC level of 0.8 g/L as the threshold above which driving was not permitted. 2. 1991: According to national law 25 August 1991, Police or Mayors can prohibit the sale of beverages with more than 21% alcohol by volume (and sometimes less than 21%) during concerts, sporting events or other events with a massive presence of younger people in order to prevent public disorder. 3. 1995 (considered in Artificial Neural Networks (ANN) analysis, but not considered in TS analysis): the excise tax for beer was set at 2,710 lire per hectolitre

(€ 140), for other intermediate products at 87,000 Lire (€ 44.93), for spirits at 1,146,000 (€ 591.46) per anhydrous hectolitre. Wine tax was kept at zero. 4. 1998: the Italian highway society code prohibited the sale of alcoholic beverages containing more than 21% alcohol by volume from 10 p.m. to 6 a.m. in bars and restaurants on motorways. This prohibition became article 14 of the 2001 Italian Alcohol Draft Law, with fines between 2,500 and 5,000 Euros for transgressors. 5. 1999 (considered in ANN analysis, but not considered in TS analysis): a VAT tax of 20 per cent has been applied to all alcoholic beverages including wine. 6. 2001: a general policy law concerning alcohol and alcohol drinking-related problems was also aimed at regulating the advertising of alcoholic beverages, and at setting BAC level threshold at 0.5 g/L for drivers. Since measures relating to tax variation were thought to be strongly correlated with alcoholic beverage prices, which are already included in the model as an unplanned economic indicator, they were excluded in the TS analysis (but not in the ANN analysis). METHODS OF ANALYSIS

Since the country sources sometimes had missing values, ES, OECD, and WB were also used, and a multiple imputation procedure was applied in order to produce 5 imputed datasets. All of the planned statistical analyses were separately performed on each of the 5 imputed datasets, and the 5 results combined according to the procedure described elsewhere (AMPHORA, 2013, Part 1, the study; Baccini & Carreras, 2014). Time Series Analysis

Since both the dependent variables (per capita consumption, liver cirrhosis, and transport accident mortality) and the independent variables (the selected sociodemographic and economic factors, and policy measures) were investigated over the long period of approximately 50 years, the TS model was considered to be appropriate for this analysis drawing on pre-existing studies (Box & Jenkins, 1976; Norström & Skog, 2001; Pridemore & Snowden, 2009; Jiang et al., 2013). A linear regression was used with a time trend among the variables (see AMPHORA WP3, 2013, Part 1, Methods for country-specific analysis, consumption; Baccini & Carreras, 2014). Three of the aforementioned seven socio-demographic and economic variables—income, alcohol prices of wine and beer and males over 65 in the population—after a logarithmic transformation, were taken into account in a core model that was specified for the logarithmic transformation of the pro capita total alcoholic beverage consumption, and to which a time trend was added. The other four variables—i.e., female employment, female education, mothers’ age at all childbirths, and urban level-again after a logarithmic transformation, were inserted into the core model one at a time, and the best of the resulting four models was identified by means of Akaike information


criterion (AIC, that is a measure of the relative quality of a statistical model) (Baccini & Carreras, 2014). Each control policy measure was estimated one at a time in a model adjusted for urbanization (the sociodemographic and economical indicator that provided the minimum AIC in Italy) and for the core model. The potential effect of each policy measure in changing consumption was considered equal to all the other measures, and the policy was modelled as immediate and constant over time, with no accumulation with other policy measures that could be implemented before, during, or after (Baccini & Carreras, 2014). Regarding harm, both the indirect effect of policy measures on harm—i.e., the effects on harm mediated by alcoholic beverage consumption changes in the population, in keeping with the total consumption theory (see Ledermann, 1956; Bruun et al., 1975)—and the direct effect of policy measures on harm—i.e., the effect of policies measured independently from the consumption changes in the population—were considered (AMPHORA WP3, 2013, Part 1, Methods for country-specific analysis, harm). In case of indirect effects a relatively lengthy process of (1) policy-reducing the mean consumption of the population, and, as a consequence, (2) the consumption decrease impacting alcoholic beverage consumption-related harm, would be expected. In case of direct effects, an impact on alcohol drinking-related harm, without any change in alcoholic beverage consumption—as in the case of the introduction of a BAC policy measure, with drinkers who may stop drinking while driving but drinking more when they do not drive—could be expected. Moreover, due to the limitations of WHO Health For All Database series, one of the sources of AMPHORA project—it was possible to analyse the effect of policies on liver deaths only after 1970, and on transport deaths only after 1987 (World Health Organization, 2010). Furthermore, the consumption of five main food items and the total alcoholic beverage consumption were analysed on the basis of a Pearson correlation in each of the 5 imputed dataset. A Method Based on an Artificial Neural Network

A relatively new method based on an ANN architecture, i.e., the Auto Contractive Maps (AutoCMs), that spatialize the correlation among variables, was also used in this study (Buscema, Massini, & Maurelli, 2014). The connections between any couple of variables, that also contemporarily take into account all the other connections between all the variables, have a connection weight, which can be transformed into values between 0 (minimum strength) and 1 (maximum strength). To maximize the information contained in the matrix of relationships between variables, graphs named Minimum Spanning Tree (MST), and Maximally Regular Graph (MRG) were calculated, where the highest-value relationships, or connections (lines in the graph) between variables (= nodes in the graph) are expressed in visually transparent notions of closeness and distance. In addition to graphs, a connect-

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ing value table is also used describing all the interactions among the different types of variables. ANN-based analysis used all the variables that were analysed by means of the TS analysis, but 1 imputed dataset instead of 5 was uses; the total consumption of alcohol was split into wine, beer and spirits; all the selected policy measures, including taxes, were taken into account; and liver and transport accident deaths were analysed in connection with consumption, policy measures, and socio-demographic and economic factors. Increase and decrease trends in consumption and in deaths were treated using both the original variable with its observed trends over time, and a factitious variable representing the inversion of the original trend. e.g. in case of beer, whose consumption increased over time in Italy, variable “beerMax” is the original variable, which raises as a function of time, while “beerMin” is a transformed variable decreasing over time. RESULTS Consumption Changes of Alcoholic Beverages and Selected Socio-Demographic and Economic Factors—Time Series Analysis

According to the TS analysis, the model with urbanization generates the minimum Akaike information criterion, i.e., it is the best model for the interpretation of results. Table 2 reports the positive correlation of this variable with total alcoholic beverage consumption, indicating that the increase of urbanization is associated with 6.96% increase of alcoholic beverage consumption. The lower-quality model with mothers’ age at all their childbirth is negatively correlated with a 4.01% decrease of consumption, while the lowest quality model with female education is correlated with a minimal 0.1% of consumption increase. A fourth model (female employment) is not statistically significant. Consumption Changes of Alcoholic Beverages and Policy Measures—Time Series Analysis

Table 3 indicates that the four policy measures implying both BAC and restrictive alcoholic beverage availability measures gave a confidence interval containing the value 0, indicating that no policy measure had any significant correlation with total alcoholic beverage consumption decrease. Consumption Changes of Alcoholic Beverages, Socio-Demographic and Economic Factors, and Policy Measures—Artificial Neural Network Analysis

An ANN analysis was implemented simultaneously for the two effects of the socio-demographic and economic factors, and the policy measures on consumption, investigating the drinking changes of the three main types of beverages: decreasing wine and (to a lesser extent) spirits, and increasing beer consumption. Table 4 documents that the decrease in wine drinking (Wine min in Figure 3) is very strongly (0.99) connected with the increase of income and of urbanization,

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TABLE 2. Regression coefficients describing the relationship between 15+ per capita recorded alcoholic beverage consumption (Source: WHO, 2009) and four selected socio-demographic variables in Italy∗ , with 90% confidence intervals (CI 90), and Akaike information criterion (AIC) values (1961–2006)

VARIABLES

COEFF (90% CI)

Female education

0.10 (0.06, 0.14)

Female employment

0.11 (-0.11, 0.33)

Urbanization

6.96 (6.31, 7.61)

Mother’s age, all childbirths

-4.01 (-4.52, -3.50)

-7.6

0

7.6

∗ Results from four separate regression models for each unplanned factor, adjusted for time trend, income, proportion of males > 65 of age, and prices of spirits and beer.

and strongly connected (0.98) with population aging on the one hand, and with the 1988 introduction of 0.8 BAC norm controls and with the 1991 introduction of the prohibition of alcohol sales during concerts on the other hand. The same strong connections also exist with the increase

in beer consumption (Beer max in Figure 3). Weaker connections (0.97–098) are also observable for the decrease in spirits’ consumption (Spirit min in Figure 3). Employment of women, and average age of mothers at their childbirths also had a relatively strong connection

TABLE 3. Correlation coefficients of 15+ per capita recorded alcohol consumption (Source: WHO, 2009) and four selected main policy measures in Italy∗ , with 90% confidence intervals (CI, 90) (1961–2006)

POLICIES

COEFF (90% CI)

Avail Restr 1991

3.00 (-1.00, 7.00)

Avail Restr 1998

-2.00 (-6.00, 2.00)

BAC Establishment 1988

3.00 (-2.00, 8.00)

BAC Reduction 2001

-2.00 (-6.00, 2.00) 0.30 (-2.08, 2.67)

-8 alcoholic beverage consumption decrease %

0

8 alcoholic beverage consumption increase %

∗ Effects adjusted for lower AIC unplanned indicator (urbanization) and for time trend, income, proportion of males >65 of age, and prices of spirits and beer.

0.98 0.98 0.98

0.96 0.96 0.96

Educ Femal 0.97 0.97 0.97

0.99 0.99 0.98

0.69 0.78 0.82

Price beer 0.93 0.94 0.95

Price wine 0.71 0.79 0.83

price spirits 0.99 0.99 0.98

income 0.97 0.97 0.98

Moth. age at child births 0.93 0.95 0.94

Bread

Food

0.99 0.99 0.98

Meat

0.99 0.98 0.98

1988 BAC >0.8g

0.98 0.98 0.98

0.97 0.96 0.97

0.94 0.94 0.95

0.93 0.93 0.94

0.89 0.89 0.90

1991 1995 1998 sale excise sale 1999 VAT 2001 prohib. tax prohib tax (all -BAC in mass (beer & on alcohol. >0.5g events spirit) highwy bev.) -ads regul

Food Policy measures consumption

Figures in the table are weight values, which represent the degree of non-linear association between two variables. Every weight of the matrix of association is scaled between 0 and 1. Bold numbers indicate the strongest connections.

Wine decrease Beer increase Spirits decrease

M>65

Urbani Empl Femal sation

Socio-demographic and economic factors

TABLE 4. Trends of wine, beer, and spirits consumption of selected socio-demographic and economic factors, of food consumption and policy measures, Italy (1961–2006). ANN-based analysis, connection values


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(0.97–098), while the increase in female tertiary education also had weaker connection (0.96) with decreased wine and spirits drinking, and increased beer consumption. Wine price showed a lower connection, and beer price and spirits price manifested little connection, with these changes. Among the remaining policy measures, the 1995 increase of excise taxes on beer and spirits had relatively less strong connections (0.96–0.97), while the 1999 VAT on all the alcoholic beverages, the 1998 sale of spirits prohibition on highways, and the 2001 0.5 BAC norm (and alcoholic beverage advertisement regulations) had lower associations with wine and spirits decreased drinking and an increase in beer consumption (Figure 3). Further, the Maximally Regular graph obtained from auto-contractive mapping in Figure 3 confirms that the highest-value relationships occurs between the close wine consumption decrease and urbanization and income, on the one hand, and on the other among the close differently directed consumption changes of the three alcoholic beverages: wine drinking decreased, spirits’ decreased, and beer consumption increased. Two of the control policies show a relatively high-value relationship, the 1991 alco-

holic beverage sale prohibition during mass events, and especially the 1988 BAC drunk driving limit. This graph also shows that the selected sociodemographic and economic factors on the one side, and the group of policy measures on the other, are both well separated and distant. Consumption Changes of Food, Alcoholic Beverages and Changes in Food Consumption

A negative correlation between total alcoholic beverage consumption and particularly vegetables (r = −0.95, CI = −0.97, −0.92) and meat consumption (r = −0.87, CI = −0.92, −0.81) was observed, while a positive correlation exist between alcoholic beverage consumption and bread or wheat consumption (r = 0.77, CI = 0.59, 0.87). Consumption of fruit was not significantly correlated with consumption of the alcoholic beverages. ANN-bases analysis documented a very strong (0.99) correlation between meat consumption, a decrease in wine drinking and an increase in beer consumption. The consumption of bread is indirectly associated with the decreasing trends of wine and spirits consumption

FIGURE 3. Trends of wine, beer, and spirits consumption of selected socio-demographic and economic factors, of food consumption and policy measures, Italy (1961–2006). ANN-based analysis, Maximally regular Graph. Figures in the graph are weight values, which represent the degree of non-linear association between two variables. Every weight of the matrix of association is scaled between 0 and 1. Min = decreasing trend; Max = increasing trend.

0.99

0.99

0.99

0.99

0.99

0.99 0.98

0.98

M >65 0.96 0.95

0.97

Empl Femal

0.98

Educ Femal

0.98

0.98

Urban isation

0.86

0.8

Price Beer

0.98

0.98

Price wine

Socio-demographic and economic factors

0.91

0.9

price spirit

0.99

0.99

0.99

0.99

Moth age all childincome births

0.99

0.99

1988 BAC >0.8g

0.99

0.99

1991 sale prohib mass event

0.98

0.98

1995 exc tax beer spirit

0.96

0.97

0.94

0.95

0.87

0.88

1998 1999 2001 sale VAT tax -BAC prohib (all >0.5g on alcol. –adv highw bev.) regul

Policy measures

Figures in the table are weight values, which represent the degree of non-linear association between two variables. Every weight of the matrix of association is scaled between 0 and 1. Bold numbers indicate the strongest connections.

Liver death decrease Transp. death decrease

Wine decr Beer incr

Spirit decr

Consumption of alcoholic b.

TABLE 5. Trends of chronic liver disease & cirrhosis-related deaths and transport accidents deaths, selected socio-demographic & economic factors, and control policy measures associated with beer, wine, spirits consumption in Italy, 1980–2006, Italy. ANN based analysis, connection values


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(Figure 3). Vegetables and milk were not considered in this analysis. Harm Related to Consumption of Alcoholic Beverages and Selected Independent Variables

The analysis of direct and indirect effects indicates that the: (1) BAC level reduction introduced as a control policy in 2001 had a significant direct association with the decrease of liver deaths, (2) the policy measures appear to have had no significant direct, or indirect, association with liver mortality and transport accident deaths, but (3) the 1991 measure prohibiting the sale of alcoholic beverages during mass events is significantly correlated with an increase in liver-related deaths. No significant direct or indirect association was found between policy measures and transport accident mortality. The ANN-based analysis (for the period 1980–2006) shows that the decreasing trend in liver mortality is very strongly associated (connection value 0.99) with urbanization, increased income, and mother’s age at their childbirths on the one hand, and also with the introduction of BAC levels in 1988 and the 1991 prohibition of selling alcoholic beverages during mass events on the other hand (Table 5). Decreasing deaths have the same connection (0.99) with the decrease of wine intake, but also with the increase of beer consumption. All this holds true also for transport mortality. DISCUSSION

In a way, if any, did this study provide adequate answers to the questions that were posed at the beginning of this article? The answers elicited from the analysis are not obvious. In general, we found that consumption of alcoholic beverages is a more variable and less predictable phenomenon when studied in relation to selected demographic, social, or economic phenomena. In addition, during the data analysis we acknowledged the relative inadequacy of traditional statistical tools such as multiple regression analysis and TS to deal with the difficulties presented by the amount of data generated by the study variables over 50 years, which frequently proved to have collinear changes over time. As a result of this we also chose to include another data analytic method based on ANNs, which appears capable of appropriately handling large numbers of variables, even if its lack of prior use in the alcohol field could evoke some misunderstanding. Study Limitations

More generally, there are a number of limitations in the study’s generalizability. First, the AMPHORA study investigated the variations in the amounts of alcoholic beverages, while consumption patterns were restricted to the three main types of beverages, i.e., wine, beer, and spirits (as they were available in GISAH dataset). Other aspects of consumption patterns, such as place, time, context, and the functions of drinking, for individuals as well as networks and systems, were not considered for lack of information over the study period. Furthermore,

the available datasets were unable to provide adequate information, over time, to study the relationship among youth drinking and related problems on the one hand, and socio-demographic and economic conditions, and alcoholic beverage control policies on the other. Studies in this area would be very much welcome. The drinking-related harms that were analysed were limited to chronic liver disease-related mortality and cirrhosis, and to transport accident deaths. Due to lack of data over the period under study, other alcohol-attributable problems like violence and cancer, as well as the diseases that could be prevented through moderate drinking, such as coronary heart disease, diabetes, Alzheimer (Anderson & Baumberg, 2006; Schütze et al., 2011; Shield, Kehoe, Gmel, Rehm, & Rehm, 2012), were not taken into account. In addition, the analysis of alcoholic beverage control policy measures is affected by some limits. In particular, even if other studies consider a different scaling of alcohol ¨ control policies across countries (Karlsson & Osterberg, ¨ 2001; 2007; Karlsson, Lindemann, & Osterberg, 2012), the effect of each policy in the AMPHORA study was assumed as having the same value. It was also assumed to be constant over time and has been evaluated individually, without accounting for the impact of other policy interventions. Moreover, the analysis did not consider the level of consumption at the time of the introduction of a policy measure. Also, since the policies are analyzed one at time, the effect estimated for each policy estimates the changes in the mean total alcoholic beverage consumption values before and after the policy implementation, up to the end of the study period, resulting in an underestimation of the policy effect. The two main methods used in the analysis—the classical time series (TS) analysis, and the newer analysis of ANNs—are not commensurable. The first one is based on statistical probability, the second one on the circular interaction of data. Nevertheless, they allowed to perceive and to consider the phenomena being studied from two different viewpoints, sometimes permitting a mutual confirmation of outcomes. CONCLUSIONS

The consumption of the alcoholic beverages in Italy began to decrease from its top amounts partly during the 1960s and most definitely at the beginning of the 1970s, and has steadily decreased until now. Italy became only one of the three European countries (the other two being Spain and Poland) that had achieved the European target of a 25% reduction of alcoholic beverage consumption compared to 1992 (World Health Organization, 2000) by 1998. The AMPHORA study has also shown that, similarly but not equally so to other European countries, most of the study’s selected socio-demographic and economic factors in Italy have been on the rise during the 1960–2006 period; an index of the progressive well-being achieved in the country during the decades after WW II (Voller, Maccari, Pepe, & Allamani, 2014). This had a definite connection with the change in the consumption


of alcoholic beverages over time, i.e., with the significant decrease in wine, the moderate decrease of spirits, and the relatively sharp increase in beer consumption. Among these factors, urbanization appeared to be most connected with the changes in drinking, according to both the TS analysis and ANN-based analyses. Nevertheless, the TS analysis outcome, showing that urbanization is positively associated with the increase in the total consumption of alcoholic beverages—1% increase in urbanization being related to about 7% of increase of alcoholic beverage consumption—creates a problem of interpretation, since it contrasts the observed evidence that during five decades urbanization has grown and consumption of alcoholic beverages has dropped (see Table 1). As it was pointed out earlier, this result might be related to the high correlation within the study’s socio-demographic and economic variables, and between the latter and time trend—that is, to the collinearity of variables. However in the ANNbased approach, where time trends were not considered, and also the total alcohol consumption was divided up into the three categories of wine, beer, and spirits, the interconnection of urbanization and consumption was more clearly shown as being positive only for beer, with wine and spirits being negatively linked with urbanization. In other words, living in an urban context in Italy appears to have encouraged a relatively larger use of beer and a corresponding lower consumption of wine, and to a lesser extent, of spirits. In addition, ANN-based analysis indicates a strong connection between income and aging of Italy’s population, and both a decrease in wine consumption and an increase in beer consumption. Also the older age of mothers at all childbirths according to TS analysis, and the increased female employment (according to ANN, but not to TS), that are indicators of the changing role of women in Italian society, are associated with the alcoholic beverage consumption changes. These results confirm with more details a previous study showing that in Italy urbanization, and related socio-economical factors such as rising income and changed role of women, impacted the usual behavior of daily wine drinking during meals (Cipriani, 2007). For example, working in factories or offices usually far from home, and work which required greater attention, in all likelihood resulted in the gradual disappearance of the afternoon siesta, while more traditional fieldwork occurred close to home, including wine as part of the shared meal. In addition the increasing employment of women gave them less opportunity for preparing lunches at home (Cipriani & Prina, 2007). Our results also supports other conclusions of the same study, that the reduction of wine was accompanied by less consumption of bread, both symbolizing the old poor rural behavior, and by more consumption of meat, felt as appropriate for a more affluent urban comportment (Cipriani 2007). However, differently from the findings of Cipriani and Tusini (2007), our results document the relevance of population aging in the reduction of wine consumption over time. The relevance of economic factors (Wagenaar, Salois, & Konro, 2009) on alcoholic beverage consumption

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appears to be re-dimensioned by this analysis. According to the ANN analysis, the real wine price had a relatively weak connection (connection value 0.93) with decreased wine drinking, and the real beer price had little connection (0.83) with increased beer drinking, over the study period, while income had stronger connections with wine and beer consumption changes. Both types of prices mainly decreased during the 1960s and 1970s, and began to increase approximately during the second half of the 1980s. This occurred more than 10 years after wine consumption had started to decrease in Italy. However, between 1960 and 2009 wine prices had an overall decrease of 7% and beer of 25% (see Table 1). Thus, particularly wine in Italy ¨ appears substantially price-inelastic (see Osterberg, 2012). During the AMPHORA study period the expenditure for alcoholic beverages compared with the total household expenditure dropped by 78%, from 3.2% in 1970 to 0.7% in 2009. These results confirm and extend previous analyses that had shown that between 1926 and 1978 the real price of wine had decreased by 20%, and wine expenditure over total household expenditure had fallen by 83% in Italy (Cianferoni, 1982). The conclusion that the decline of wine prices in Italy cannot explain the drop in wine consumption is supported by the findings of the ECAS study: “since the consumption actually has gone down in Southern Europe, it means that the sum of other factors influencing the consumption downwards has a stronger explanatory power than real alcoholic beverage prices and real incomes” (Leifman, 2002, p. 77). In conclusion, the extensive move from the country to the cities, and from the rural to the urban culture, that occurred in Italy during the 1960s and earlier, was strongly reflected in major changes in: (1) the consumption of wine and beer, (2) women’s emancipation from traditional roles of housewives and mothers, and (3) the new employment requirements that modified urban Italy’s meal rituals (see Tusini, 2007). However, Italian drinking has still retained a major association with food (see Scafato et al., 2009). Given the ongoing concerns about and the sociopolitical construction of substance use and misuse as a local as well as global problem, it is reasonable to ask whether or not the public health policies introduced in Italy were effective in decreasing the alcoholic beverage consumption trends and the harms which are known as well as believed to be related to alcoholic beverage consumption? The generalizable findings from this study do not support that the legislated control policies had any effect on the decline in alcoholic beverage consumption during their 18-year period 1961–1988. The simple reason is that there was no alcohol control policy until the introduction, in 1988, of the first Italian law about drinking and driving. Therefore it should be assumed that various understood as well as yet-to-be understood social changes have also been relevant change agents in the decrease of consumption of alcoholic beverages in Italy (see Cipriani & Prina, 2007). This change in Italian drinking practices, not “led by above,” has been called “self-regulation” by some authors (De Rita, 2012). This implies that a

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community is able to control its own behavior even without interventions by the government-local or nationaland that historical, political, cultural, and religious events are relevant factors shaping the informal norms and values. Self-regulation would be an autonomous response to the changed social practices in the population. The tradition of considering wine and food as part of a meal makes drinking adaptable to the everyday needs, the same way as a hearty, tasty, aromatic, and colourful plate of pasta can be refused if a challenging task is about to be faced. Is it reasonable to assume that, and to question7 whether policies, although unable to affect a reduction in consumption until 1988, were at least able to contribute to, or to maintain, the reduction after 1988 and in the subsequent years, when other restrictive policies were introduced? The ANN-based analysis (but not Time Series analysis) showed positive connections of two policy measures: the 1988 introduction of the BAC law (but not the 2001 norm reducing BAC to 0.5 g/L), and the 1991 prohibition of alcohol sale during mass events, with the decrease of wine and spirit drinking on the one hand, and the increase of beer consumption on the other. This may be explained by the hypothesis that policy measures may have been effective on the targeted traditional country beverages, like wine and spirits, while a relatively novel and lower alcohol-content beverage, like beer, may not have been perceived as being the prevention target. Conversely, the decrease of wine and spirits consumption could have been able to promote the introduction of policy measures, through a changed perception of risk among Italians. The ANN analysis does not give any support to any effectiveness of policies developed and legislated to control alcoholic beverage advertising, and little support for the effectiveness of the 1995 excise tax. These findings raise critical issues which the AMPHORA study was not designed to study: what were the underpinnings of these policies? For example, were they theory-based, empirically-driven, “principle-of-faith” rooted, tradition conceived, budgetary limited, or promulgated by politicians to comply public opinion, and what were the states of the relevant policy making stakeholders’ awareness, expectations, judgments, decision-making, and man’s many “appetites”? This is an important area for future needed research. Thus, alcohol policies had no role in drinking changes in Italy between 1960 and 1988, while they had a minor role in supporting the on-going decline thereafter, when

compared to the social, economic, demographic, political, and cultural phenomena occurring in the country and the country within a globalizing world of past and ongoing “Big Events”8 . This smaller role is confirmed by the correlation of all the policy measures and all the contextual factors with the total consumption of the alcoholic beverages, the former being about 10% and the latter about 90% (see Allamani, Voller, Baccini, Massini, & Pepe, 2014). In general, this is not surprising if we consider the great complexity of Italian society, compared to limited human efforts, such as formal policies, to induce and to sustain a better quality of life over time for increasing parts of the population. This study supports the idea that consumption changes of the different alcoholic beverages are inter-linked. In fact, according to ANN-based analysis, the decrease of wine consumption is strongly connected with the increase of beer drinking, and this could be explained with the hypothesis of competition between drinks. These results supports the idea of replaceability of alcoholic beverages, in keeping with the observation of Ronald Knibbe and his colleagues, who argued that in any country the traditional beverages are partly replaced by new beverages over time that become popular among the more innovative and educated groups of society (Hupkens, Knibbe, & Drop, 1993; Knibbe, Drop, & Hupkens, 1996). In Italy, this would be the case of beer, a partial substitute of wine. From another perspective, this “competition” thesis also raises the possibility of competition between the opportunities for satisfying the range of man’s sating appetites; “chemical,” social ritual as well as others. Alcoholic beverage consumption has served many functions and needs throughout all of man’s history; other options may challenge it as societal realities change. This is another area for theory crafting as well as research. While liver and transport accident mortality had a remarkable decrease in Italy during the last decades, the Time Series analysis does not provide any evidence of the impact of contextual factors or of control policy measures on these deaths. However, the ANN-based analysis allows us to note that the improved economic and social conditions (income, urbanization, older age of mothers at their childbirth), as well as the decreasing consumption of wine, and the 1988 (but not the 2001) BAC law, are relevant factors in the reduction of deaths. In any case, these results should be taken with caution since they may not be entirely reliable for the limited period of time under investigation (1980–2006).

7

The reader is asked to consider the cyberneticist Heinz Von Foerster’s thesis that there are two types of questions; legitimate and illegitimate ones. The former are those for which the answer is not known and is, perhaps, even unknowable during a given state of knowledge and technology An illegitimate question is one for which the answer is known, or, at the very least consensualized. The asking of illegitimate questions has been, and remains, by and large, the acculturated norm. Heinz Von Foerster, Patricia M. Mora, and Lawrence W. Amiot, “Doomsday; Friday, 13 November, A.D, 2026,” Science, 132, 1960. pp. 1291–1295. The reader is referred to Pablo Neruda’s The Book of Questions for a poetic exploration of legitimate questions. Editor’s note.

8

This relatively new term, introduced into the intervention literature by Friedman et al (Samuel R. Friedman, Diana Rossi, Peter L. Flom. (2006). “Big events” and networks: Thoughts on what could be going on. Connections 27(1): 9–14.) refers to major events, such as mega –disasters, natural, as well as man-made, famine, conflict, genocide, disparities in health, epidemics, mass migrations, economic recessions, etc., which effect adaptation, functioning and quality-of-life of individuals as well as systems. Existential threat, instability and chaos are major dimensions and loss of control over one’s life is experienced. Editor’s note.


A concluding question would be—in what ways, if any, can our results support the planning, implementation, and assessment of necessary future effective intervention designed to reduce the range of problems related to the consumption of alcoholic beverages in Italy ? The fact that alcohol control policies were non-existent or only partially effective during previous decades, as our study has documented, does not permit us to leave the drinking problems to self-regulation or to the naive transfer of programs that have been only effective in other cultures and their relevant micro to macro conditions. The emerging Italian problems, such as drinking practices both of young people, of the elderly, and of immigrants, as well the recent documented aspects of alcoholic beverage consumptionrelated harm (i.e., cancer, road accidents, violence in public places or within the family) (Beccaria, 2010; Anderson & Scafato, 2010) should be now faced taking into account the specific Italian features that have been evidenced by the results of this research, as well as the issues of equity (World Health Organization, 2013). The variable values of income, urbanization, education, employment, and the changing role of women, should be included in any new public health program and its necessary policies, since they accurately represent the complexity of the Italian context and are able to appropriately shape the design of future alcoholic beverage control policy program. Among other tools, the use of appropriate ANNbased simulation technique (Buscema, 1995) may be of help when preventive interventions are to be planned, implemented, and assessed. Declaration of Interest

The authors declare no conflicts of interest. The authors alone are responsible for the content and writing of the paper. The research leading to these results has received funding from the European Community’s Seventh Framework Program (FP7/2007–2013) under grant agreement no. 223059—Alcohol Measures for Public Health Research Alliance (AMPHORA). Partners in AMPHORA are: (1) Coordination: Hospital Cl’ınic de Barcelona (HCB), Spain; (2) Agenzia Regionale di Sanit‘a della Toscana (ARS), Italy; (3) Alcohol & Health Research Unit, University of the West of England, UK; (4) Anderson, Consultant in Public Health, Spain; (5) Anton Proksch Institut (API), Austria; (6) Azienda Sanitaria Locale della Citt‘a di Milano (ASL MILANO), Italy; (7) Budapesti Corvinus Egyetem (BCE), Hungary; (8) Central Institute of Mental Health (CIMH), Germany; (9) Centre for Applied Psychology, Social and Environmental Research (ZEUS), Germany; (10) Chemisches und Veterin”aruntersuchungsamt Karlsruhe Technische Universit”at (CVUAKA), Germany; (11) Dutch Institute for Alcohol Policy (STAP), Netherlands; (12) Eclectica snc di Amici Silvia Ines, Beccaria Franca & C. (ECLECTICA), Italy; (13) European Centre for Social Welfare Policy and Research (ECV), Austria; (14) Generalitat

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de Cataluna (Gencat), Spain; (15) Institute of Psychiatry and Neurology (IPIN), Poland; (16) Institute of Psychiatry, King’s College London (KCL), UK; (17) Istituto Superiore di Sanità (ISS), Rome, Italy; (18) Institut za raziskave in razvoj (UTRIP), Slovenia; (19) IREFREA, Spain; (20) Liverpool John Moores University (LJMU), UK; (21) National Institute for Health and Welfare (THL), Finland; (22) Nordiskt valf’ardscenter (NVC), Finland; (23) Norwegian Institute for Alcohol and Drug Research (SIRUS), Norway; (24) State Agency for Prevention of Alcohol-Related Problems (PARPA), Poland; (25) Stockholms Universitet (SU), Sweden; (26) Swiss Institute for the Prevention of Alcohol and Drug Problems (SIPA), Switzerland; (27) Technische Universitat Dresden (TUD), Germany; (28) Trimbos-instituut (TRIMBOS), Netherlands; (29) University of Bergen (UiB), Norway; (30) Universiteit Twente (UT), Netherlands; (31) University Maastricht (UM), Netherlands; (32) University of York (UoY), UK.

THE AUTHORS Allaman Allamani, M.D., Psychiatrist; Family Therapist; Researcher. He has been coordinator of the Alcohol Centre, Florence Health Agency (1993–2009); since 2009 he has been consultant to the Region of Tuscany Health Agency for research on social epidemiology and prevention policy First non-alcoholic trustee of Italian Alcoholics Anonymous (1997–2003). He is a member of the editorial board of “Substance Use and Misuse.” Coordinator of a few Italian projects on alcohol prevention and policies, he has co-lead work package 3 of the European Commission-funded AMPHORA project. Author and co-author of more than 170 articles, editor, and co-editor of 16 books.

Fabio Voller, Ph.D., is a Sociologist at the Epidemiology Observatory of the Region of Tuscany Health Agency. He has worked on epidemiological studies of lifestyle, alcohol consumption, and psychoactive drug use in the Tuscan population. Among his publications, he is the co-author of a number of monographs about the health consequences of alcohol consumption in Italy. He is a work package 3 leader of the AMPHORA project.

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Pasquale Pepe, MSc, is a Senior Statistician at the Epidemiology Observatory of the Region of Tuscany Health Agency. He has worked for several years on medical statistics, clinical trials, and epidemiological studies. He has co-authored more than 30 papers. He has worked in the statistical analysis of the AMPHORA project.

Michela Baccini, Ph.D., is researcher in medical statistics at the University of Florence. Author of several papers in the field of environmental epidemiology and biostatistics, she worked on time series analysis, meta-analysis, health impact assessment, multiple imputation.

Giulia Massini, Senior Researcher of Semeion—Research Center of Sciences of Communication, Rome (Italy). She is inventor of new algorithms of Neural Networks and Adaptive Artificial Systems. She is responsible of the application of Neural Computation mainly in medical and social field. She is the author of many research software packages. She has published several scientific papers in peer reviewed journals and book chapters. Francesco Cipriani, MD, Medical epidemiologist, nutritionist, and gastroenterologist, is Director of the Regional Health Agency (ARS) for Tuscany (Italy) since October 2011, where he also has been chief of the Epidemiology Observatory since January 2009. He was Director of the Epidemiology Unit of the Local Health Authority in Prato, Italy, and also worked in the epidemiology services of the Florence Local Health Authority and the Centre for Oncological Study and Prevention, carrying out regional, national, and international multi-centric epidemiological studies about nutrition, life styles, addictions, alcohol and alcoholism, tumors, injuries, road traffic accidents, and environmental problems. He has published more than 130 papers.

GLOSSARY

Alcoholic beverage as symbol: The values attributed by people to the different beverages. For example, wine symbolising the old rural life, beer symbolising the new societal context. Alcohol control policies: Restrictive countrywide measured introduced by the government in order to prevent and reduce the harms associated with drinking alcoholic beverages. Artificial neural network analysis: A method that spatializes the connections among all the study variables, using a connection weight. The information may be represented through graphs. Sociodemographic and economic factors: Represent indicators of (a) economic changes: income; prices of wine and beer, the most drunk alcoholic beverages in Italy, (b) socio-demographic changes: proportion of older people, proportion of people living in larger cities, and three indicators of women’s emancipation: average age of mothers at their child’s birth; proportion of working women; level of women’s education. Time-series analysis: A linear regression with a time trend among the variables. REFERENCES Allamani, A. (2008). Views and models about addiction: Differences between treatments for alcohol-dependent people and for illicit drug consumers in Italy. Substance Use & Misuse, 43, 1704–1728. Allamani, A., Beccaria, F., & Voller, F. (2010). The puzzle of Italian drinking. Trends in alcohol consumption, harms and policy: Italy 1990–2010. Nordic Studies on Alcohol and Drugs, 27(5), 465–468. Allamani, A. & Beccaria, F. (Eds.), (2007). Contemporary Drug Problem 34(Summer) 2007. Allamani, A., Voller, F., Baccini, M., Massini, G., & Pepe, P. (2014). Europe. An analysis of changes in the consumption of alcoholic beverages: The interaction between consumption, related harms, contextual factors and alcoholic beverage control policies. Substance Use & Misuse, 49. Allamani, A., Voller, F., Decarli, A., Casotto, V., Pantzer, K., Anderson, P., . . . Gmel, G. (2011). Contextual determinants of alcohol consumption changes and preventive alcohol policies: A 12-Country European study in progress. Substance Use & Misuse, 46(10), 1288–1303 print/1532–2491 online DOI: 10.3109/10826084.2011.572942. AMPHORA Workpackage3 (2013). Report of an analysis of European alcohol-related cultural, social and policy interactions and their impact on alcohol consumption and alcohol-related harm http://amphoraproject.net/w2box/data/Deliverables/AMPHORA WP3 D3.2.pdf Anderson, P., & Baumberg, B. (2006). Alcohol in Europe. A Public Health perspective. A report for the European Commission. England: Institute of Alcohol Studies. Anderson, P., & Scafato, E. (2010). Alcohol and older people—A public health perspective. Report for the Vintage project. www.epicentro.iss.it/vintage Anderson, P., Møller, L., & Galea, G. (2012). Alcohol in the European Union. Consumption, harm and policy approaches. World Health Organisation, Regional Office for Europe, Copenhagen.


Babor, T. F., Caetano, R., Casswell, S., Edwards, G., Giesbrecht, N., Graham, K., . . . Ros, I. (2003). Alcohol: No ordinary commodity. Oxford University Press. Baccini, M., & Carreras, G. (2014). Analyzing the effect of policy measures and socio-demographic factors on alcohol consumption in Europe within the AMPHORA project: Statistical methods. Substance Use & Misuse, 49. Beccaria, F. (2010). Drinking styles of the young generations: Twenty years’ qualitative research. Salute e Società suppl. IX(3), 58–78. (English version). DOI: 10.3280/SES2010-SU3005-ing, 1: 21. Box, G. E. P., & Jenkins, G. M. (1976). Time series analysis: Forecasting and control. Revised version. San Francisco, CA: Holden-Day. Buscema, M. (1995). Squashing theory: A prediction approach for drug behavior. Drug & Society, 8(3–4), 103–109. Buscema, P. M., Massini, G., & Maurelli, G. (2014) Artificial Neural Networks: An overview. Substance Use and Misuse. 49. Caritas/Migrantes (2008). Immigrazione Dossier Statistico 2008 [Immigration. Statistical dossier] IDOS - Centro Studi e Ricerche. http://www.dossierimmigrazione.it/docnews/file/I12 scheda sintesi.pdf Charrier, L. (2013). Comportamenti a Rischio [Hazardous behavious]. In F. Cavallo, M. Giacchi, A. Vieno, D. Galeone, A. Tomba, A. Lamberti, P. Nardone & S. Andreozzi (Eds.), Studio HBSCItalia (Health Behaviour in School-aged Children): rapporto sui dati 2010 [report od 2010 data]. Rapporti IstiSan 13/5: 74–78 http://www.iss.it/binary/publ/cont/13 5 web.pdf Cianferoni, R. Problemi economici della produzione vitivinicola in Toscana [Economic problems in wine production in Tuscany], in: Regione Toscana (1982). Alcool, Aspetti Economici Sociali Medici Psicologici [Alcohol: Economical, Social, Medical and Pychological aspects]. Atti, Nuova Serie/6. Firenze, Giorgi e Gambi. Cipriani, F. (2007). Temporal trends in wine and food consumption in Italy. Contemporary Drug Problem, 34(2), 227–243. Cipriani, F., & Tusini, S. (2007). A demographic interpretation of the decrease of alcohol consumption in Italy. Contemporary Drug Problem, 34(2), 245–252. Cipriani, F., & Prina, F. (2007). The research outcome: Summary and conclusions on the reduction in wine consumption in Italy. Contemporary Drug Problem, 34(2), 361–378. De Rita, G. (2012). L’autoregolazione vent’anni dopo [Selregulation 20 years afterwards]. In: M. Contel & E. Tempesta (Eds.), Alcol e giovani [Alcohol and Youth] (pp. 131–134). Carocci, Roma. EACA (European Association of Communications Agencies) (2011). EU Advertising Spend Statistics, Alcoholic drinks http:// www.eaca.be/ff/search.asp?search=1&year=§or=Alcoholic± Drinks&country=2011. Epicentro (2013). Fumo [Smoke] http://www.epicentro.iss.it/ temi/fumo/dati.asp European Commission (2006). Ex-post evaluation of the CMO for wine Tender AGRI/EVALUATION/2002/6 http://ec. europa.eu/agriculture/eval/reports/wine/4.pdf. EUROSTAT (2012). website http://epp.eurostat.ec.europa.eu/portal/ page/portal/statistics/ search/ database, March 2012. Garelli, F. (1991). Religioni e Chiesa in Italia. [Religions and Church in Italy] Il Mulino, Bologna. Garelli, F. (2011). Religione all’italiana L’anima del paese messa a nudo. [Religion a` l’Italien. The soul of the country unveiled]. Il Mulino, Bologna. Gazzetta Ufficiale della Repubblica Italiana (2012). Legge 8 novembre 2012, con Disposizioni urgenti per promuovere lo

1663

sviluppo del Paese mediante un piu’ alto livello di tutela della salute. [law, November 2012, with urgent indications for promoting the country development by means of a higher level of health protection]. Gazzetta Ufficiale, 263, 10-11-2012, Suppl. Ord. 201 Gazzetta ufficiale della Repubblica italiana (1976). Regolamento (CEE) n. 2034/76 n. L 226 del 18/08/1976, 10-13. Hupkens, C. L. H., Knibbe, R. A., & Drop, M. J. (1993). Alcohol consumption in the European community: Uniformity and diversity in drinking patterns. Addiction, 88, 1391–1404. Infocamere. (2009). http://www.infocamere.it/ (access2011) ISTAT. (2010). Noi Italia [Us Italy]. Istituto Nazionale di Statistica, Roma. http://www3.istat.it/dati/catalogo/20100409 00/ NoiItalia2010.pdf). ISTAT. (2012a). Censimento Italia 2011 [2011 census in italy] http://www.tuttitalia.it/statistiche/censimento-2011/ http:// www.urbistat.it/AdminStat/it/it/demografia/dati-sintesi/italia/ 380/1 ISTAT. (2012b). Wine production in Italy in 2011 (6 aprile 2012) http://www.inumeridelvino.it/2012/04/produzione-di-vino-initalia-nel-2011-fonte-istat.html ISTAT. (2013a). I consume delle famiglie [Household consumpions] http://www.istat.it/it/archivio/95184 ISTAT. (2013b). L’uso e abuso di alcol in Italia, anno 2012 [The use and abuse of alcohol in Italy, year 2012] http://www.istat.it/it/files/2013/04/stat report alcol 2012.pdf ISTAT. (209). L’uso e abuso di alcol in Italia, anno 2008 [The use and abuse of alcohol in Italy, year 2008] http://www3. istat.it/salastampa/comunicati/non calendario/20090423 00/ testointegrale20090423.pdf Jiang, H., Livingston, M., Room, R., Dietze, P., Nortst˝om, & Kerr, W. C. (2013). Alcohol consumption and liver disease in Australia: A time series analysis of the period 1935–2006. Alcohol & Alcoholism, 49(3), 363–368. ¨ Karlsson & Osterberg (2001). A scale of formal alcohol control policy in 15 European countries. Nordic Studies on Alcohol and Drugs. English supplement 18, 117–131. ¨ Karlsson, T. & Osterberg, E. (2007). Scaling alcohol control policies across Europe. Drugs: Education, Prevention & Policy, 14, 499–511. ¨ Karlsson, T., Lindeman, M., & Osterberg, E. (2012). Does alcohol policies make any difference? In P. Anderson, F. Braddick, J. Reynolds, & A. Gual (Eds.), Alcohol Policy in Europe: Evidence from AMPHORA. http://amphoraproject. net/view.php?id cont=45. Knibbe, R. A., Drop, M. J., & Hupkens, C. L. H. (1996). Modernization and geographical diffusion as explanations for regional differences in the consumption of wine and beer in the European community. Substance Use & Misuse, 31(11–12), 1639–1655. Kuntsche, E., Rossow, I., Simons-Morton, B., Bogt, T., Kokkevi, A., & Godeau, E. (2013). Not early drinking but early drunkenness is a risk factor for problem behaviors among adolescents from 38 European and North American countries. Alcoholism: Clinical and Experimental Research, 37(2), 308–314. Ledermann, S. (1956). Alcool, alcoolisme, alcoolisation. Donnés scientifiques de caractére physiologique, e´ conomique et social [Alcohol, Alcoholism, and Alcoholisation. Scientific data referring to physiological, economical and social aspects]. Presses Universitaires de France. Leifman, H. (2002). Trends in population drinking. In Policy Responses in 15 European Countries (pp. 49–81). National Institute of Public Health. Stockholm: Almqvist & Wiksell. Meloni, G., & Swinnen, J. (2012). The Rise and Fall of the World’s Largest Wine Exporter, LICOS Centre for Institutions

1664

A. ALLAMANI ET AL.

and Economic Performance & Department of Economics. University of Leuven http://www.wine-economics.org/aawe/wpcontent/uploads/2013/02/AAWE WP134.pdf Norström, T., & Skog, O.-J. (2001). Alcohol and mortality: Methodological and analytical issues in aggregate analyses. Addiction, 96(Suppl. 1), S5–S17. OECD the International Organisation for Economic Co-operation and Development. (2011). http://www.oecd.org/home/ 0,2987,en 2649 201185 1 1 1 1 1,00.html (access 2011). ¨ Osterberg, E. (2012). Pricing of alcohol. In P. Anderson, L. Møller, & G. Galea (Eds.), Alcohol in the European Union. Consumption, harm and policy approaches (pp. 96–102). World Health Organisation, Regional Office for Europe, Copenhagen. Patussi, V., Tumino, E., & Poldrugo, F. (1996). The development of the Alcoholic Treatment Club System in Italy: Fifteen years of experience. Contemporary Drug Problems, 23(1), 29–42. Pridemore, W. A. & Snowden, A. J. (2009). Reduction in Suicide Mortality following a New National Alcohol Policy in Slovenia: An interrupted Time-Series Analysis. American Journal of Public Health, 99(5), 915–920. Rehm, J., & Scafato, E. (2011). Indicators of alcohol consumption and attributable harm for monitoring and surveillance in European Union countries. Addiction, 106(Suppl. 1), 4–10. Salamon, E. (2012). Gli Italiani e l’alcol: consumi, tendenze e atteggiamenti. Sesta indagine Osservatorio Permanente sui Giovani e Alcool-Doxa [Italians and alcohol: consumption, tendencies and attitudes. Sixth survey of the Osservatorio Permanente sui Giovani e Alcool-Doxa]. In M. Contel, & E. Tempesta (Eds.), Alcol e giovani [Alcohol and Young People] (pp. 45–68), Caroccio, Roma. Scafato, E., Gandin, C., Galluzzo, L., Martire, S., Di Pasquale, L., Ghirini, S.; per il Gruppo di Lavoro CSDA (Centro Servizi Documentazione Alcol) (2013). Epidemiologia e monitoraggio alcol-correlato in Italia e nelle Regioni. Valutazione dell’Osservatorio Nazionale Alcol—CNESPS sull’impatto del consumo di alcol ai fini dell’implementazione delle attività del Piano Nazionale Alcol e Salute. Rapporto 2013. [Istituto Superiore di Sanità Epidemiology and alcohol-related monitoring in Italy and in the Regions. Evaluation of the National Observatory on Alcohol—CNESPS on the impact of the alcohol consumption in support for the implementation of the activities of the National Alcohol and Health Plan. Report 2013.] Roma: Istituto Superiore di Sanità; 2013. (Rapporti ISTISAN 13/3). Scafato, E., Ghirini, S., Galluzzo, L., Farchi, G., & Gandin, C. (2009). Rapporto su raccolta e analisi centralizzata dei flussi informativi e dati per il monitoraggio dell’impatto dell’uso e abuso dell’alcol sulla salute in Italia. [Report on the centralised collection and analysis of information and data about monitoring the impact of alcohol use and abuse on health in Italy] Rome, Italy: Osservatorio Nazionale Alcol CNESPS, Istituto Superiore di Sanità. Schütze, M., Boeing, H., Pischon, T., Rehm, J., Kehoe, T., Gmel, G., . . . Bergmann M. M. (2011). Alcohol attributable burden of incidence of cancer in eirht EuropeaAlcohol attributable burden of incidence of cancer in eight European countries based on results from prospective cohort study. British Medical Journal. DOI: 10.1136/bmj.d1584. Shield, K. D., Kehoe, T., Gmel, G., Rehm, M. X., & Rehm, J. (2012). Societal burden of alcohol. In: P. Anderson, L. Møller, G. Galea (Eds.), Alcohol in the European Union. Consumption,

harm and policy approaches (pp. 10–28). Copenhagen: World Health Organisation, Regional Office for Europe. Shield, K. D., Rehm, G., Gmel, G., Rehm, M. X., & Allamani, A. (2013). Alcohol consumption, alcohol dependence, and related mortality in Italy in 2004: Effects of treatment-based interventions on alcohol dependence. Substance Abuse Treatment, Prevention, and Policy, 8, 21. DOI: 10.1186/1747-597X8-21. Simpura, J., Karlsson, T., & Leppänen (2002). European trends in drinking patterns and their socio-economic background. In T. Norström (Ed.), Alcohol in Postwar Europe: Consumption, Drinking Patterns, Consequences and Policy Responses in 15 European Countries (pp. 83–114). National Institute of Public Health. Stockholm: Almqvist & Wiksell. SMART. (2010). Standardizing Measurement of Alcohol-Related Troubles http://www.alcsmart.ipin.edu.pl/ Smith, T. W. (2012). Beliefs about God across Time and Countries. Report for ISSP and GESIS http://www.domradio. de/comet/pdf/beliefs about god report.pdf Strunin, L., Lindeman, K., Tempesta, E., Ascani, P., Anav, S., & Parisi, L. (2010). Familial drinking in Italy: Harmful or protective factors? Addiction Research and Theory, 18(3), 344–358. Sulkunen, P. (1989). Drinking in France 1965–1979. An analysis of Household Consumption Data. British Journal of Addiction, 84, 61–72. Tusini, S. (2007). The decrease of alcohol consumption in Italy: Sociological interpretation. Contemporary Drug Problem, 34(2), 253–285. Voller, F. (2007). Trends in alcoholic beverages in Italy. Contemporary Drug Problem, 34(2), 227–243. Voller, F., Maccari, F., Pepe, P., & Allamani, A. (2014). Changing Europe: Trends in Social, Economic Demographic factors, alcoholic beverage drinking and prevention policies between 1960s and 2000s. Substance Use & Misuse, 49. Wagenaar, A. C., Salois, M. J., & Komro, K. A. (2009). Effects of beverage alcohol price and tax levels on drinking: A metaanalysis of 1003 estimates from 112 studies. Addiction, 104, 179–190. World Bank. (2011a). (urbanization) World Bank indicator SP.URB.TOTL.IN.ZS [refers to data from United Nations World Urbanization Prospects) (access 2011). World Bank. (2011b). [education] - http://web.worldbank. org/WBSITE/EXTERNAL/TOPICS/EXTEDUCATION/0,cont entMDK:20528432∼menuPK:617592∼pagePK:148956∼piPK: 216618∼theSitePK:282386∼isCURL:Y,00.html (access 2011). World Bank. (2011c). [income] http://data.worldbank.org/ indicator/ NY.GDP.PCAP.PP.KD (access 2011). World Health Organization. (2000). European Alcohol Action Plan 2000–2005 EUR/LVNG 01 05 01 WHO Regional Office for Europe, Copenhagen. World Health Organization. (2010). European Health for All Database (HFA-DB). Copenhagen: WHO Regional Office for Europe. Retrieved February 2010, from http://www.euro. who.int/hfadb World Health Organization. (2011). Global Information System on Alcohol and Health (GISAH) [online database]. Geneva: World Health Organization (http://who.int/globala/alcohol). World Health Organization (2013). Review of the social determinants and the health divide in the WHO European Region: final report. Copenhagen: WHO Regional Office for Europe.

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