Alcohol in Spain: is it different?

Authors


INTRODUCTION

‘Spain is different’ was a popular slogan in the 1960s that helped to situate Spain as one of the most popular tourist destinations in Europe. Because this series of editorials on national experiences aims to show that ‘the world of drinking is still one of very diverse experiences’[1], it seems logical to test if drinking patterns in Spain have relevant differential trends.

TRENDS IN PER CAPITA CONSUMPTION AND DRINKING PATTERNS

Spain has, undoubtedly, a long-lasting tradition of alcohol consumption. It is clearly part of the so-called ‘wet drinking cultures’[2] which means not only high levels of alcohol consumption but also that social tolerance to the harm produced by alcohol is high. In spite of this, Spain experienced a sustained decrease in per capita alcohol consumption in the period from 1975 (14.2 litres) to 1995 (9.3 litres) of pure alcohol per inhabitant aged 15–65 years and per year. The reasons for this ‘healthy change’ are probably not attributable to effective preventive strategies, but to the fact that the beer industry succeeded in shifting drinking habits from wine to beer [3]. During this period wine consumption decreased by 60% (from 76 to 30.3 litres/inhabitant/year), while beer consumption increased by 40% (from 47 to 66 litres/inhabitant/year), and spirits consumption remained almost stable [4]. The change in wine consumption represents a decrease in pure alcohol consumption of 5.8 litres per inhabitant per year, while the increase in beer accounts for 1 litre. As the drop in the period 1975–95 was 4.9 litres, it is clear that the shift between wine and beer explains this phenomenon.

The decrease in drinking seems to have remained stable, or even to have deepened, as per capita alcohol consumption has remained around 9–10 litres of pure alcohol per inhabitant per year in recent years, and in 2002 beer was, for the first time, the principal contributor to per capita alcohol consumption, with a share of 38% of total alcohol consumption in 100% alcohol, while wine accounted for 37% and 25% was due to spirits. These figures are not far from those predicted by Simpura as future European standards [5]. Because some ‘beer-drinking countries’ are experiencing a sustained increase in their wine consumption, it is difficult to assess to what extent the changes in Spain are attributable to the beer industry or to the homogenization process. A differential trend might be found in the frequency of drinking, where Spain leads the European ranking with Portugal and Italy [6], with 19 or more drinking days per month.

From the alcohol viewpoint Spain is a society in transition, where traditional drinking patterns persist in older and rural populations, while young urban people clearly adhere to the new drinking patterns which tend to harmonize all over Europe.

Traditional drinking patterns are characterized by drinking daily, during meals and avoiding intoxication, while the new drinking patterns are characterized by intermittent drinking, mainly during the weekend, in leisure hours and often leading to intoxication. These new drinking patterns show particular features in Spain due to two facts: first, our ‘wet culture’ makes alcohol easily available for all young people; and secondly, the Spanish climate allows people to drink outdoors the whole year round. The end result is known as the ‘Botellón’ phenomenon. Every weekend hundreds of young people gather in popular places in most of the large cities of Spain and they drink to intoxication with no control at all. This phenomenon has raised concern among authorities, but it is regarded as a social problem and not as a health issue. In fact, Spain is becoming famous for its unending weekend nights where people can buy drinks easily all night long, and can drink both in bars and off premises. Because alcohol is cheap, the weather allows year-round outdoor drinking and the ‘wet culture’ is permissive, these new habits have spread at enormous speed throughout the whole country. No data allow us to quantify the extent of the Botellón, but the transcription of a few lines from a journal suggest the tone of the prevailing familial and social responses to it [7]:

Mothers look at their children going to the Botellón as if they were going to the war. A real war. The Botellón war, where death appears every Friday and Saturday night. Death in the roads, death in the streets . . . People used to drink in taverns, where children used to go, with tears in their eyes, to help their drunken parents return home. Now, parents have to rescue their children from the tavern of the street.

This phenomenon is reflected partially in official statistics: in youth aged 14–18 years data from the school survey show an increase in last-month drunkenness from 19% in 2002 to 35% in 2004 [8]. It is worth noting that Spain also has the greatest frequency in Europe of drinking in ‘bars, pubs and discos’ (85 times per year for men and 38 for women) [9]. The Spanish ‘fiesta’ seems to be well reflected by the statistics.

Since 1995 [10] Spain has had reliable information on alcohol consumption through a household survey carried out every 2 years by the National Plan on Drugs, and since 1994 a 2-yearly survey on drug use in the adolescent population aged between 14 and 18 years has also been conducted [11]. According to these data the Botellón phenomenon has had an impact on young people but has not significantly influenced the drinking patterns of the general population, which have remained relatively stable during the last 10 years.

As can be seen in Table 1, almost 90% of the Spanish population have drunk alcoholic beverages in their life-time, three-quarters have drunk in the previous year, two-thirds drank during the last month and half the population admit to drinking weekly. The proportion of daily drinkers (14.1%) and hazardous drinkers (16.7%) is similar. It is also relevant that one in five Spaniards admits to have been drunk at least once during the last 12 months. Gender differences are still important in the general population and women tend to drink less, and less often, than men. They also tend to start drinking at an older age (17.6 versus 15.9 years) and become drunk less often (12.7% versus 29.6% were drunk in the last 12 months). These gender differences disappear when we look at the 14–18-year-old population. In 2004 boys and girls began drinking at a similar age (13.6 versus 13.9 years), and this is encouraging: the figures in 1994 were 13.0 and 13.8 years, respectively.

Table 1.  Evolution of drinking patterns in the Spanish population aged 15–65 (1997–2003).
Years1997199920012003
  1. Source: National Plan on Drugs. Household surveys on drugs 1997–2003.

Sample size12 30412 23414 11312 033
Life-time alcohol consumption    91%    87%    89%    89%
Alcohol consumption, last 12 months    79%    75%    78%    77%
Drunkenness episode, last 12 months    19%    19%    19%    21%
Alcohol consumption, last 30 days    64%    62%    64%    64%
Weekly alcohol consumption, last 12 months    48%    46%    48%    48%
Daily alcohol consumption, last 12 months    13%    14%    16%    14%
Hazardous drinkers    16%    13%    17%    16%
Mean age to start drinking    16.8    16.9    16.9    16.7

The data shown in Table 1 offer an overview of the drinking trends of the Spanish population, which seem to remain stable over the period of time analysed. However, on closer examination, the data (see Table 2) show relevant differences concerning drinking patterns and age. For example, in the population aged between 25 and 29 years weekly drinking has increased consistently in both men and women, while daily drinking shows a clear tendency to decrease in both genders. Interestingly, this phenomenon can be seen in people aged between 25 and 40 years but not in older people, who still show the traditional drinking patterns, nor in younger people, where changes probably happened before 1997, as can be seen in Table 2.

Table 2.  Evolution of drinking patterns in different age ranges* according to the Spanish National Household Survey.
Drinking patternsAge range1995199719992001
MaleFemaleMaleFemaleMaleFemaleMaleFemale
  • *

    Results shown in percentages of drinkers [20].

Drink weekly during the last 12 months15–193623403138263926
20–245630664462415936
25–295827663563386839
30–345724683467336135
40–645720673164276730
Drink daily during the last 12 months15–19 2 1 1 0 2 0 3 0
20–24 6 1 3 1 4 1 7 2
25–2913 311 211 4 4 3
30–3423 718 418 517 5
35–3932 823 629 728 9
40–6538 934 933103711
15–6524 621 521 624 7

These changes reflect a scenario where the relative price of alcoholic beverages is decreasing. Wine-drinking countries seem to be less sensitive to price fluctuations than northern and central European countries [12], and in the case of Spain the relative cost of alcoholic beverages has remained stable since 1992, as can be seen in Fig. 1, but in the same period of time the purchasing power of the population has increased by 35.9% in real terms [13] (data obtained from http://www.ine.es/daco/ipc.htm. The national disposable income has increased in constant millions of Euros from 376.364 in 1992 to 576.241 in 2005. The population has grown from 39 137 979 in 1992 to 44 108 530 in 2005). So, in real terms, alcoholic beverages have become less expensive for the Spanish population but this has not led to an increase in alcohol consumption.

Figure 1.

Evolution of the relative price of alcoholic beverages. Source: Instituto Nacional de Estadistica [19]

Another relevant issue is that the perception of alcohol as a health risk seems to be decreasing. Table 3 shows how the perception of risks associated with alcohol and tobacco seem to follow divergent trends. It is somewhat surprising, and certainly a clear sign of a ‘wet culture’, that the social perception of risks associated with alcohol consumption tends to decrease while the figures for alcohol-related problems such as traffic casualties or domestic violence are among the highest in western Europe.

Table 3.  Rate of population aged 15–64 who think this behaviour can produce many problems.
Behaviour199719992001
  1. Results shown in percentages of drinkers. Source: Ministerio de Interior. National plan on drugs, Spanish Observatory on Drugs, Report no. 6, 2003.

Drink 5–6 beers daily545651
Drink 5–6 beers weekend202121
Smoke 1 pack cigarettes/day373945

Alcohol is imbibed in the Spanish culture in such a way that it is used in combination with other available drugs. As stated above, three-quarters of the Spanish population (76.6%) admit to have drunk during the last 12 months, but this percentage rises to 95.9% in cannabis users, 98.3% of cocaine users, 99.1% of amphetamine users and 86.4% of heroin users [14]. In summary, almost 100% of drug users in Spain tend to combine their drug of preference with alcohol. Again, there is a paradox here, with high social concern on addictions but no relevance given to the fact that almost all addictions are complicated by alcohol consumption.

TREATMENT FACILITIES

The Spanish Addictions Treatment Network was created in the 1980s to face the heroin epidemic but has undergone a profound change, as most of their clients are now alcohol- or cocaine-dependent. Where statistics are available alcohol is now the first drug of abuse and, unexpectedly, the previous heroin epidemic led to the development of a wide treatment network which offers treatment for alcoholism all over the country and within the public health system.

This treatment network is far from being homogeneous, as every region has developed its own approach. In some regions the treatment of addictions is dealt with by the social services departments, while in some others it is dealt with by the health department. In only a few cases are these treatment centres integrated fully into the primary health care network.

Professionals in these centres have also experienced a profound change in their professional practice, as the treatment of heroin addiction is substantially different from the treatment of cocaine and alcohol dependence, which are the most prevalent diseases they have to face. Treatment teams are in all cases multi-disciplinary and addictions are treated from a biopsychosocial approach. A basic team is usually formed by a physician (psychiatrist or general practitioner), a nurse, a psychologist and a social worker. Self-help groups are not part of the treatment network, but may sometimes cooperate with professional teams. In most of the treatment facilities group therapies are conducted by professionals as part of the treatment programmes.

PREVENTION STRATEGIES

In the early 1980s terrorism and the heroin epidemic were the principal concerns of the Spanish population. Drugs became a high priority for politicians and funds were allocated to treat and prevent addictions. Fortunately, most of the preventive programmes designed at that time did not neglect alcohol, and the public debate on drugs placed alcohol on the agenda. In a wet culture, to present alcohol as a drug created shock, but the emergence of new drinking patterns leading to severe intoxication and the high number of alcohol-related road casualties has helped tremendously to change population attitudes. Also, school preventive programmes (which would never have been developed without the heroin epidemic) include alcohol and tobacco.

As a result of all these facts social attitudes towards alcohol have changed dramatically and, for example, underage drinking has become unacceptable, even though it has been rooted in old tradition. Together with France, in recent years Spain has experienced the biggest increases in the stringency of alcohol policy [6] in Europe. Some examples are the legal drinking age (raised from 16 to 18 years in most regions), the legal blood alcohol concentration (BAC) for driving (lowered from 0.8 g/litre to 0.5 g/litre), the enforcement of routine BAC tests, especially during weekends, and progressive restrictions on alcohol advertising.

Another area where preventive activities have been remarkable is within primary health care. Various trials on brief interventions for risky drinkers have been published, including a meta-analysis, and intervention packages have been developed by scientific societies [15] and government agencies [16]. Dissemination of interventions has reached a regional level in some areas [17], allowing leadership in the development of European guidelines [18] and training packages [19] concerning screening and brief interventions in primary health care.

CONCLUSIONS

Spain is becoming less and less different from other western European countries. This tendency to homogenization that goes beyond alcohol and involves all aspects of life has been mainly beneficial, as alcohol consumption has decreased and underage drinking is no longer socially acceptable.

Spain is a society in transition where alcohol still plays an important role, as it does in all wet cultures. On the other hand, the population is reacting strongly to new drinking patterns, of which the Botellón phenomenon is probably the most popular.

It is not yet clear what will be the long-term impact of the new drinking patterns in a wet culture that still puts few limits on alcohol accessibility. No reliable data are available on the Botellón phenomenon, but this new drinking pattern seems far from declining. Certainly the alcohol field has benefited from the public concern heroin raised in the 1980s, and as a result not only has social awareness towards alcohol increased, but both the treatment network and surveys on alcohol consumption have improved markedly.

However, the situation is probably not as stable as the statistics appear to show. We will need some years to see if the new drinking patterns have helped to raise social concerns about alcohol, or if our wet society has become a perfect cultural broth to again increase alcohol consumption through these new drinking patterns. The challenge is now to engage politicians, mass media and the general population in the first of those two options.

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