The attitude and knowledge of Italian family doctors in respect to early identification and brief intervention on alcohol & tobacco: a controlled study.

Struzzo Pierluigi, General Practitioner, Community Research Center, Martignacco Udine, Italy.
Tel 0039 335 6138380; Fax 0039 0432 657126; email: (corresponding author)
Gianmoena Beatrice, Trainee, University of Udine, Public Relation Course, Via A. Diaz 5 Gorizia, Italy
Kodilija Renata, Professor, University of Udine, Public Relations Course, Via A. Diaz 5 Gorizia, Italy

Key Words: Brief intervention, Alcohol and tobacco, Primary care, attitudes, knowledge.


This article summarises the results of a controlled study on the attitudes and knowledge of general practitioners in respect to early identification and brief intervention of risky drinkers and tobacco smokers in two areas of northern Italy. The identified sample was investigated with a 25 questions survey and data were analysed taking into consideration previous experience or training with early intervention strategies. 110 GPs decided to answer the questions and most of them demonstrated the same attitude in respect to the implementations of this new methodology in our Country, where previous experiences only identified abstainers and alcoholics but not moderate or risky drinkers. Only the non-scheduled, unexpected volunteer implementation of a short training course allowed some differences to come through between the two samples.
This experience, in disagreement with previous studies, demonstrates that even GPs with a negative background on brief intervention, maintain a positive approach to alcohol and tobacco issues. The good outcome of any community action in primary care, maybe depends on how experts and policy makers will implement the proposed actions.


Alcohol abuse and tobacco smoking are well-documented causes of major social, legal, economic and health complications. Low doses of tobacco inhalation are clearly related to health loss while low doses of alcohol intake are sometimes not related to health damage . A direct relationship between the degree of abusive drinking and risk of fatal injury has been observed . In this respect, Italy was the first country that succeeded in reducing yearly pro-capita consumption of more than the 25%, in the period 1982-2000 , as proposed by the WHO. Public campaigns on quitting smoking are now proposed in the media by the national Government. Nevertheless, alcohol related problems and tobacco smoking still put an heavy burden on public health and affect mostly young people .
Screening and brief intervention (SBI) is a well - known technique, provided by primary care workers, aiming at behavioural modification of risky lifestyles. It can be considered as a consultation of short duration after a person at risk has been identified. A primary care systematic use of this methodology could, thus, be linked with high percent of risk reduction. On the other hand, even if the evidence of the effectiveness of brief intervention is widely increasing - , primary health care workers, and general practitioners in particular, do not seem to accept it for their routine work.

Previous medical approaches to drinking misuse in Italy were based on the concept that it is better not to drink. A moderate alcohol intake was not considered compatible with an healthy life because leading to possible alcoholism . Up until recently, identifying risky consumers and brief advice were not part of the general practitioners' tasks as most alcohol related problems were left to the competence of more specialist Alcohol and Drugs Services.

The lack of a well defined approach often led to conflicting relationships between general practitioners and non-harmful alcohol consumers.
The spreading in Italy of a WHO collaborative study on "the development and application of country-wide strategies for the widespread, routine and enduring implementation of PHC early identification and brief intervention", introduced these new concepts and new strategies are now being implemented locally in support to the aims of these objectives .
If for tobacco health objectives seem clear (even one cigarette or passive smoking is bound to health damage), for alcohol use Italian practitioners and specialists still need to find an agreement on a recommended threshold for drinking limits and for the role of primary care at local level. "There is the need to reframe the understanding of alcohol issues"

The following article is presenting the results of a baseline survey, part of the WHO Phase IV collaborative study, exploring the knowledge and attitudes of the whole population of general practitioners living in two different but comparable areas. An intervention area (City of Udine), where a previous research activity (a pilot study on SBI) was proposed to the GPs without preventive involvement nor performing any training. A control area (City of Gorizia) where no previous activities were scheduled but an unexpected short training was proposed, on a voluntary basis, right before the survey.

The aims of the following study are to understand General Practitioners' basic knowledge of risky drinking in absence of an official recommended drinking threshold and their attitude towards performing routine brief intervention, on alcohol and tobacco, with their clients. Differences between the two areas were recorded and analysed.

The study was performed to assess baseline measures before a targeted communication strategy, to spread SBI, is implemented at regional level.
It is part of a national strategy where different institutional actors, with different agendas, will try to find possible common guidelines.

Subjects and methods

After a first telephone contact, participant GPs were interviewed on site by students of the University of Udine. The questionnaire, a 25 questions tool, explores perceived drinking limits for moderate, risky and harmful drinking, tobacco smoking knowledge and the number and the order of possible answers was modified from the Finnish original questionnaire .
It is composed by 4 biographical questions, 7 questions about GPs' attitude and self-efficacy towards A&T issues, followed by other 8 questions about knowledge of limits in heavy drinking and about training. Finally, opinions, suggestions and questions about personal habits were also asked. Most of the questions were structured, only a few were open or asked for a personal opinion.
Microsoft Excel was used for the gathering of data, then SPSS 10.0 statistical software was used in the specific analyses: descriptive statistics and frequencies at the beginning (for all questions), then oneway and multi-variate tests, tests of between-subjects effects, cross-tabs, factor and reliability analysis for groups of questions. In this respect, it was clear that central question, from 5 to 12, formed a homogeneous questionnaire with a high reliability index (Cronbach's alpha = .70)
Differences emerging from one-way and multi-variate tests and from tests of between-subjects effects were considered statistically significant for p < 0.05.
At the end a separate analysis was made for open questions, dividing them into same kind of answers.


110 GPs (72% of the whole sample of 152GPs) accepted to answer the questions. No significant differences were noted between the two cities as regarding answering rate (71%), gender (66% male, 34% female), age (50% from 43 to 51yrs/old), experience (10 to 23 years of practice) and workload. 56% of those who refused to answer the questionnaire it was because they were too busy, 10 (22%) because they were not interested. The vast majority of the GPs demonstrated a positive attitude (97%) to ask their patients about A&T and found relevant or very relevant (99%) and useful (94%) to identify and counsel risky patients (women are more interested and show a better attitude. More experience, better attitude).
In their opinion, patients react positively or neutrally (85%) when asked about A&T by their GP. Most of the respondents (60%) have no difficulties in talking about these issues with their clients, while only the 23% have some difficulty. GPs think they are somewhat (35%) to slightly (26%) successful at motivating patients to undergo treatment. Only the 14% think they are unsuccessful When enquired if they think patients follow their suggestions, they are somewhat (55%) to slightly (22%) good at influencing them, (self-efficacy)(no significant differences were found among the GPs of the two areas).
In respect to the knowledge of the content of the BI on alcohol, Gorizia GPs seem to have a better knowledge, 90% have from enough to very good knowledge while in Udine 39GPs (72%) have from enough to very good knowledge (Tab.1). In Gorizia they have a better knowledge of other screening tools for risky clients (female more than male) but the 53% was not able to mention any. As regarding drinking limits, most of the GPs (85% in Udine and 91% in Gorizia) indicated the first two choices (20 to 40 gr./day/men and 150 to 200 gr./week/men) which were the lowest possible .
If asked about specific training received in the past year the 92,6% of Udine GPs didn't receive any, while the 64,3% in Gorizia did.
When analysed separately, Udine GPs feel they need less training to identify abusive drinkers (43%) compared with Gorizia (36%)(Tab.2) and also less training to carry out BI ( 33% needed little or no training at all compared with the 18% of Gorizia). When asked to list the three most important things to increase the success of SBI they mentioned specific information, more practical and personal training. It is interesting to note that financial incentives were one of the last items to be mentioned.


There has been open and sometimes strong international debate on how to fit early identification and brief intervention in everyday general practice. Beich's study set a point of doubt on the efficacy of the proposed methodology proposed by WHO. We need to know if practitioners' views and experience on BI are still to be investigated or if different approaches have to be considered while trying to modify their everyday practice. In this first Italian controlled trial, we investigated the knowledge and attitude of two separate but comparable groups of GPs. One with a non-planned, unexpected, recent short training and another with direct involvement but without any sort of training. The working setting is a Nation with twenty years background of dichotomist approach to alcohol related problems (abstainers - alcoholic). Screening and brief advice for alcohol misuse was deliberately proposed with questions on smoking because it was judged that the approach to alcohol drinkers is considered difficult and the less direct questions are put, the better. The first involved area was the city of Udine (95.000 inhabs.), were all the 76 general practitioners were involved, in 1998, without previous training or information, in a pilot study to test the SBI (as part of the WHO Strand III pilot). At that time, all the GPs were contacted but only 20 decided to participate, screening 581 patients in a period of 4 weeks. 17 of these answered the proposed questionnaire and are included in the present study (they represent the 31% of Udine GPs). The city of Gorizia (38.000 inhabs.) plus other large towns to cover the sample, where none of this was performed but only a short (2-3 hours), unexpected, training on SBI was proposed on a voluntary basis.

No significant differences were noticed between the two areas as far as sample characteristics such as gender, age, experience and reasons why not to answer. Even if deriving from two distinct cities, with the same background but with different involvement, they showed the same attitude towards BI. The vast majority had a positive or very positive attitude (97%) to ask their patients about alcohol & tobacco. The 94% of the GPs think it is useful to enquire about A&T. The 98% consider relevant for their practice to ask patients about A&T. No difference between the two groups was also noticed when addressing self-efficacy (success at motivating to modify lifestyle or influencing patients' drinking pattern). As regarding their opinion of possible drinking limits, they gave (62% -71%) the first answers either for one occasion and for weekly doses (for men and women) demonstrating to choose the lowest possibility.
The only differences that were found between the two groups regarded the knowledge of different screening tools on alcohol and tobacco and the need for training. The fact that Udine GPs think they need less training than in Gorizia is maybe explained by the lack of feed-back after the WHO Strand III pilot and lack of an appropriate communication campaign. When analysing the question on training the 17 GPs that participated in the pilot study were equally distributed among the possible answers, only 4 GPs gave a negative answer.

The results of this study show that the implementation of a short period of Early identification and brief intervention in general practice has no significant negative effect on the attitude, efficacy and commitment of general practitioners in Italy.
It can be added that more actions will have to be proposed in order to improve the efficacy of the implementation plan, they suggested: more information on efficacy of BI, more practical and personal training, information to the patients (depliandts and brochures), governmental involvement, more time and involvement of the practitioner is a point of strength. Money incentives were only mentioned at the very last.
Italian practitioners have a positive attitude towards screening and brief intervention on A&T and they are at the very beginning of introducing a new methodology in their daily work. In respect to Beich's study, it seems like it will mostly depend on how researchers and policy makers will implement and adjust this methodology according to the GPs' specific needs.

Tab. 1
Knowledge on how to perform a Brief Intervention

Area very good good somewhat enough not enough
UDINE 5 (9.6%) 11 (21%) 16 (30%) 7 (13,4%) 13 (25%)
GORIZIA 2 (3,6 %) 23 (41,9%) 19 (34,5%) 6 (11%) 5 (9%)


Tab. 2
Need for training to identify risky people

Area A lot Quite a bit Some Nothing
UDINE 6 (11%) 25 (46,3%) 20 (37,1%) 3 (5,6%)
GORIZIA 7 (12,5%) 29 (51,8%) 16 (28,6%) 4 (7,1%)

Tab. 3
Need for training to perform Brief Intervention

Area A lot Quite a bit Some Nothing
UDINE 13 (25%) 21 (40,3%) 13 (25%) 5 (9,7%)
GORIZIA 15 (26,8%) 31 ( 55,4%) 9 (16%) 1 (1,8%)



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First published September 2003