Alcohol & Health Research Centre, City Hospital, Greenbank Drive, Edinburgh EH10 5SB, UK
ABSTRACT
A survey of the drinking, smoking and illicit drug use of more than 90 000 teenage school students was carried out in 1999. This exercise, known as the European School Survey Project on Alcohol and other Drugs (ESPAD), revealed marked differences in the substance use patterns of those surveyed in different countries. Teenagers in a group of northern countries reported the highest rates of heavy drinking and intoxication (drunkenness). Teenagers in southern Europe reported much lower levels of such behaviours and experiences. Some of these findings are presented and discussed in relation to aetiology and health promotion.
INTRODUCTION
During 1995 a major investigation, the European School Survey Project on Alcohol and other Drugs (ESPAD), was conducted for the first time. This study examined drinking, smoking and illicit drug use among representative samples of 1516-year-old school students in the UK and in 22 other European countries. Students in all countries completed a common core questionnaire' under supervised exam conditions' while in school. Thus, it was possible to elicit comparable survey information from young people in very varied social contexts. This was the first time that either a UK-wide study or such a major international survey had been conducted into these potentially risky behaviours among young men and women (Miller and Plant, 1996). It emerged that teenagers in the UK and a number of other Northern European' countries reported the highest levels of heavy drinking and intoxication (drunkenness) (Hibell et al., 1997
).
A second ESPAD study was carried out in 1999. This venture involved more than 90 000 students from a total of 30 countries. These ranged from Russia to Greenland. This is probably the largest international study of the social and behavioural aspects of alcohol epidemiology ever attempted. A detailed report on this survey was released in February 2001 (Hibell et al., 2001), which attracted considerable media attention.
INTERNATIONAL DIFFERENCES
The new survey has revealed that illicit drug use in the UK appears to have declined somewhat since 1995 (Plant and Miller, 2000). However, UK teenagers retained their position as those most likely in all the 30 countries to have used illicit drugs.
Self-reported alcohol and tobacco use among UK teenagers had remained almost constant since the earlier 1995 study (Miller and Plant, 2001). Furthermore, UK teenagers, together with those in Denmark, the Faroe Islands, Finland, Greenland, Iceland and Ireland, reported the highest levels of alcohol consumption. Countries in which reported alcohol consumption was low included Cyprus, France, Greece, Italy, Malta and Portugal.
More than half of all the teenagers in the countries surveyed had smoked at some time in their lives. UK teenagers reported a high rate (20%) of daily smoking by the early age of 13 years.
The differences in alcohol consumption revealed by the two ESPAD ventures are fascinating. These differences are set against the context of major changes in levels of per capita alcohol consumption levels in some European nations (Plant, 1997; Thurman, 2000
). Alcohol consumption has remained fairly stable in the UK in recent years. In contrast, the Italians have halved their per capita consumption, while the French have cut theirs by a third. In some Eastern European nations, alcohol consumption and rates of alcohol-related problems have reportedly been rising. ESPAD showed that, in most of the participating countries that had taken part in both studies, teenage alcohol consumption had remained fairly stable or had risen between 1995 and 1999. The only countries in which teenagers appeared to have reduced their alcohol consumption levels were Cyprus and Italy.
OLD HABITS PERSIST
Many people have commented over the years on the obvious fact that drinking patterns vary markedly between different social and national groups (Pittman and Snyder, 1962; Pittman and White, 1991
). The two ESPAD investigations have cast fresh light on this old theme. In fact, what emerges from ESPAD is that, although there have been some major changes in drinking habits, traditional patterns of alcohol consumption appear to be persistent.
In keeping with their long-standing reputations, those reporting the highest levels of intoxication included the Danes, the Finns, the British, the Irish and the Icelanders. Those reporting the lowest levels of intoxication included the Cypriots, Italians, Romanians, French and Portuguese (Fig. 1). As one might expect, teenagers from high intoxication' countries reported much higher levels of periodic heavy/binge drinking, than those from low intoxication countries. In other words, the commonly intoxicated Northern Europeans were far more likely to consume alcohol in relatively heavy sessions. Researchers from these high intoxication countries report that these sessions typically occur as weekend evening carousing. Consistent with this pattern of periodic heavy drinking, teenagers in high intoxication countries also reported some of the highest levels of adverse effects (individual, sexual, relationship and delinquency) associated with their drinking. Strangely, however, some of these same teenagers were among those most likely to report that they believed that drinking would produce positive consequences. This curious phenomenon could be deemed a lovehate relationship' with alcohol.
|
THE ROLE OF PARENTS
The young are likely to regard themselves as invulnerable to health risks stemming from their behaviours (Plant and Plant, 1992). This way of thinking has been termed the personal fable' (Elkind, 1984
), and may be summed up by the phrase it won't happen to me'. ESPAD suggests that there may be a practical acceptance that periodic heavy drinking and intoxication have led to problems, but that young people continue to engage in such behaviours. It should be noted that past attempts at curbing youthful drinking (or illicit drug use) have not been notably successful (Plant and Plant, 1997
), even though Wright (2000) has outlined an evidence-based approach to this challenging subject. It is emphasized, however, that there are clearly limits to what school-based health promotion may achieve. Young people are strongly influenced by their outof-school social contacts, relatives and friends. Many young people are exposed to abusive drinking within the family. Moreover, ESPAD has shown that, in some countries, including the UK, many teenagers report that their parents do not know where they go on a Saturday evening. This may imply that many parents may fail to communicate with their sons and daughters and may also fail to establish reasonable boundaries, which are necessary to restrain and protect.
THE WAY FORWARD?
One conclusion that may be surmised from ESPAD is that countries in which teenagers drink less and with fewer problems are those in which parents typically teach their children to drink from an early age within the context of a controlled home environment. This may be a powerful way of ensuring that the young learn to drink in a moderate and sensible manner. Even so, it should be emphasized that drinking styles are the result of centuries of tradition and are influenced by a host of subtle and powerful social and psychological factors. In short, it may prove difficult to export' drinking styles, at least in the short-term. It is also a problem that in some countries in which youthful heavy drinking is widespread (such as Iceland and the UK), many adults strongly believe that it is wrong to teach children to drink. The consequence of this appears to be that they will drink anyway, though often in risky situations and without constraint.
ACKNOWLEDGEMENTS
The UK component of ESPAD 1999 was supported by the Alcohol Education and Research Council, the Health Education Authority (now known as the Health Development Agency), the Department of Health and Social Services, Belfast and the Wates Foundation. Additional support was provided by an anonymous charity, Allied Domecq plc, the North British Distillery Company Limited, the PF Charitable Trust, the Sir James Miller (Edinburgh) Trust and the Drapers' Fund.
FOOTNOTES
* Author to whom correspondence should be addressed.
REFERENCES
Elkind, D. (1984) Teenage thinking: implications for health care. Pediatric Nursing 10, 383385.[Medline]
Hibell, B., Andersson, B., Bjarnason, T., Kokkevi, A., Morgan, M. and Narusk, A. (with Miller, P. et al.) (1997) The 1995 ESPAD Report: Alcohol and other Drug Use among Students in 26 European Countries. Swedish Council for Information on Alcohol and other Drugs, Stockholm.
Hibell, B., Andersson, B., Ahlström, S., Balakireva, O., Bjarnason, T., Kokkevi, A. and Morgan, M. (with Miller, P. et al.) (2001) The 1999 ESPAD Report: Alcohol and other Drug Use among Students in 30 European Countries. Swedish Council for Information on Alcohol and Other Drugs, Stockholm.
Miller, P. and Plant, M. A. (1996) Drinking, smoking and illicit drug use among 15 and 16 year olds in the United Kingdom. British Medical Journal313, 394397.
Miller, P. and Plant, M. A. (2001) Drinking and smoking among 15- and 16-year olds in the United Kingdom: a re-examination. Journal of Substance Use 5, 285289.
Pittman, D. J. and Snyder, C. R. (1962) Society, Culture and Drinking Patterns. Wiley, New York.
Pittman, D. J. and White, H. R. (1991) Society, Culture and Drinking Patterns Revisited. Rutgers Center of Alcohol Studies, New Brunswick, New Jersey.
Plant, M. A. and Miller, P. M. (2000) Drug use has declined among teenagers in United Kingdom. British Medical Journal 320, 15361537. (Erratum submitted on September 26th.)
Plant, M. A. and Plant, M. L. (1992) Risk Takers: Alcohol, Drugs, Sex and Youth. Tavistock/Routledge, London.
Plant, M. A. and Plant, M. L. (1997) Alcohol education and harm minimisation. In Alcohol: Minimising the Harm: What Works?, Plant, M. A., Single, E. and Stockwell, T. eds, pp. 193210. Free Association Books, London.
Plant, M. L. (1997) Women and Alcohol: Contemporary and Historical Perspectives. Free Association Books, London.
Thurman, C. (2000) Alcoholic drinks: demand and supply. In The Alcohol Report, Plant, M. A. and Cameron, D. eds, pp. 79122. Free Association Books, London.
Wright, L. (2000) Evidence-based alcohol education in schools. In The Alcohol Report, Plant, M. A. and Cameron, D. eds, pp. 206234. Free Association Books, London.