Strategie e interventi per la prevenzione primaria delle dipendenze patologiche

[Machine translation] Intro The use of psychoactive substances, including tobacco and alcohol, is currently the leading cause of health problems in developed countries. In Europe, tobacco smoking is responsible for 27-32% of deaths among males and 4-7% of deaths among women, depending on the geographical area considered, and alcohol causes 14.6% of premature deaths. A Canadian study has shown that substance abuse causes a total of 31% of deaths, and 25% of years of life lost, as well as 19.5% of days of hospitalization under 70 years of age. In the European Community, tobacco smoke alone is responsible for 520 000 deaths a year. In addition to the direct impact on health, the use of psychoactive substances has effects in terms of personal safety, mental health and social well-being. Substance addiction is now considered a chronic, relapsing condition, characterized by the effects of prolonged use of the substance and the behavioral disorders caused by its compulsive search. This definition unites drug, alcohol, and tobacco addiction. The objective of this paper is to describe effective interventions and strategies in order to prevent addictions to psychoactive substances. Materials and methods Overview of secondary publications, such as systematic reviews, reports from international agencies and guidelines, identified by consulting the Cochrane Library, Medline, the websites of the main international agencies interested in issues related to substance use, NICE, CDC, European Union, WHO, SIGN, NIDA and EMCDDA. On interventions for which references were not found in secondary publications, evaluation studies were sought, RCT if the intervention was randomized, other study designs for non-randomized interventions (ITS, B&A, etc.). Results Mass media campaigns. Studies evaluating these interventions are infrequent, and they are mostly Before&After studies. The main reviews seem to conclude that these are effective interventions for smoking cessation and for the prevention of alcohol and smoking. Some conditions seem to increase effectiveness, such as intensity, the simultaneous activation of other interventions (e.g. school). They are generally useful both for modifying the normative belief (the perception of the prevalence of the phenomenon in the population) and for focusing the attention of the political agenda on the related objects. Campaigns on illegal drugs have no evidence of effectiveness, and some evaluations suggest their possible boomerang effect. Pricing and availability policies. The increase in the price of tobacco products and alcoholic beverages, through excise duties, is a powerful tool for reducing the incidence of new users and reducing the use of current users. A 10% increase in the price of cigarettes results in a 2.5-5.0% reduction in use, while a corresponding increase in the price of alcoholic beverages results in a reduction in mortality from cirrhosis of 8.3-12.8%. Availability policies, in particular restrictions on sales of tobacco and alcohol, by age or time slots or even under special conditions, are effective, provided that control and support interventions are carried out. Workplaces. Policies that regulate the use of alcohol and tobacco in the workplace have both a direct effect on the consumption of alcohol and cigarettes and on health, such as road accidents, and an indirect effect on the population's regulatory beliefs, contributing to the reduction of the incidence of new consumers. School interventions. School interventions seem to be mainly effective against alcohol and drugs, while on tobacco smoking they seem to have limited short-term effects. This is presumably due to the greater social pressure to smoke. In particular, only interventions based on theories of social influence are effective, while informational interventions, especially if based on frontal lessons, have numerous proofs of ineffectiveness. Other interventions. Family interventions have proven effective, especially on the use of alcohol and drugs, but, due to their high cost, they are reserved for at-risk young people. In general, multicomponent programs seem to be effective, that is, in which numerous effective interventions are disseminated at the level of a population. Discussion Three reflections can be attempted on the basis of the data briefly summarized above. The first is that interventions to prevent the use of psychoactive substances are far from having the richness one would expect based on the relevance of related health problems. The evaluation methods still seem crude with regard to non-randomized interventions (regulations, changes in product prices, etc.), although the available data suggest that these are the interventions with the best cost/effectiveness ratio. These reflections underline the need to define efficacy criteria for public health interventions other than those typical of clinical interventions. The impossibility of carrying out a randomized evaluation must lead to adequate rigorous evaluation studies. On the other hand, however, the demonstration of effectiveness obtained through these studies should make it possible to recognize the intervention as effective on a par with those evaluated by randomized studies. The second is that, at least for alcohol and tobacco, population interventions seem to have a more favorable cost/effectiveness than individual ones, such as school or family interventions. The third is that, despite the poverty discussed above, sufficient information is available to the policy maker to build complex prevention strategies based on programs and interventions with evidence of effectiveness. The alibi of the absence of evidence of effectiveness, or the ineffectiveness of prevention tout court, often used to justify the scarcity of resources allocated to prevention, can be easily dismantled.