Are The Times A-Changin’? Trends in Adolescent Substance Use in Europe Ludwig Kraus1,2, Nicki-Nils Seitz1, Daniela Piontek1 & The ESPAD Group 1) IFT Institut für Therapieforschung München 2) Centre for Social Research on Alcohol and Drugs (SoRAD), Stockholm Universität, Stockholm Lisbon Addictions 2017 October, 24-26 2017, Lisbon, Portugal

Background: Changing Behaviours Wide divergences in substance use practices in Europe, both between and within countries, reflecting particular historical experiences and often cultural traits A consistent theme in the analysis of trends has been the convergence in European drinking (Room, 2007) In general, the world has become more interdependent: immigration, open borders, the internet, and the globalization of the economy A common international culture, characterized by common behaviours, consumption patterns and values might emerge (Clarke, 2004)

Background: Changing Behaviours Health Behaviour in School-aged Children (HBSC) (Kuntsche et al, 2011) Results decline in cultural differences due to an increase in the frequency of drunkenness in Eastern European countries and a decrease in Western countries Explanations transition to market economies of the formerly planned- economy societies opening of borders and increasing alcohol advertising targeted to young people

Background: Change in Drinking (Kuntsche et al, 2011)

Background: Change in Drinking (Kraus et al, 2015)

Change in Youth Substance Use? What's known Decreasing per capita consumption in Europe, North America and Australia with trends in the total population considerably varying by country and World region Decrease in consumption of tobacco and alcohol use in youth in some countries of the Western World Mostly abstention and volume; rarely binge or heavy episodic drinking What's not known Is there a common pattern of temporal trends in the use of alcohol, tobacco and cannabis in different parts of Europe? Are there regional differences in these trends?

Methods: ESPAD Survey European Schoool Surevy Project on Alcohol and Other Drugs (ESPAD) Since 1995 6 waves (every 4th year)  30 countries Same instrument and survey methodology Substance use among 15‐ to 16 year-old students in regular schools Tobacco, alcohol, illigal drugs: patterns of use, attitudes, risk perception, substance-related problems

Methods: Data & Indicators Data selection Cross-sectional survey at five time points: 1999, 2003, 2007, 2011, 2015 (Hibell et al, 2000; Hibell et al, 2004; Hibell et al, 2009; Hibell et al, 2012; Kraus et al, 2016) Trend data on 28 countries with data on at least 4 of the 5 time points and response rate ≥ 45% Missing data: 1999: n=6; 2015: n=1; all other years complete Ireland and U.K. had to be dropped !! n = 223,814 boys and n = 211,712 girls Missings ranged between 0.4% for cigarette use and 2.6% for heavy episodic drinking among girls

Methods: Data & Indicators Indicators (time frame: last 30 days) Prevalence of daily cigarette use: any amount Prevalence of weekly alcohol use: ≥ 1 time Prevalence of monthly heavy episodic drinking (HED): 5+, ≥ 9 cl ethanol Prevalence of monthly cannabis use: ≥ 1 time

Methods: European Regions European regions (adopted from United Nations, 2016) Northern Europe: Denmark, Faroe islands, Finland, Iceland, Norway, Sweden Southern Europe: Cyprus, Greece, Italy, Malta, Portugal Western Europe: Belgium (Flanders), France, Germany (Bavaria), Netherlands Eastern Europe: Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Russian Federation (Moscow), Slovak Republic, Ukraine, Balkan States: Bulgaria, Croatia, Romania, Slovenia

Methods: Analyses Analyses Trend analysis: multilevel mixed-effects logistic models with time as a linear, or linear and quadratic predictor Regional trend comparisons: multilevel mixed-effects logistic models with survey year (linear and quadratic), region and the interaction region x survey year (full model) as predictors Wald-Tests for pairwise regional differences (linear or quadratic)

Methode: Samples 1999 2003 2007 2011 2015 Country n %a)   1999 2003 2007 2011 2015 Country n %a) Northern Europe Denmark 1546 56 2504 65 877 46 2181 42b) 1670 26b) Faroe Islands 413 100 582 97 552 557 511 Finland 3003 99b) 3219 4988 99 3744 81 4049 85 Iceland 3457 3313 98 3510 3333 95 2663 79 Norway 3753 86 3745 77 3482 58b) 2938 28 2584 53 Sweden 3271 89 3212 87 3179 2569 80 2551 83 Southern Europe Cyprus - 2142 98b) 6340 4243 76 2098 Greece 2195 94 1891 3060 88 5919 3202 Italy 4073 4818 9981 4837 4059 Malta 3635 3443 3668 3377 3326 Portugal 3577 2919 3141 1965 90 3456 96 Western Europe Belgium (Flanders) 1291 1889d) 54b) 1798e) 1771e) 56b) France 2266 2277 2916 2572 2714 93 Germany (Bavaria) 810 85c) 814 91c) 724 52c) 862 57c) Netherlands 2613d) 94f) 2068d) 2091d) 2044d) 50b) 1684d) 43b)

Methode: Samples 1999 2003 2007 2011 2015 Country n %a) Eastern Europe   1999 2003 2007 2011 2015 Country n %a) Eastern Europe Czech Republic 3543 99 3149 100 3901 3913 98 2738 96b) Estonia - 2431 80 2372 90 2460 95 2452 Hungary 2726 92 3109 2817 94 3063 85 2735 93 Poland 3269 84f) 5842 2120 5934 11822 Latvia 2296 2816 97 2275 2622 1119 42 Lithuania 5028 2411 2476 2573 Russian Federation 2918 1883 1973 96 b) 1757 77 Slovak Republic 2437 2122 2468 2009 2208 Ukraine 2958 97b) 4114 2447 2210 2350 The Balkans Bulgaria 2666 2353 2217 2922 Croatia 3555 2852 3008 3002 2558 Romania 2368 4323 2289 2770 3500 Slovenia 2347 2758 3085 3186 3484

Results: Daily Cigarette Use

Results: Weekly Alcohol Use

Results: Episodic Heavy Drinking

Results: Monthly Cannabis Use

Results: Regional Differences Wald-Test   N vs. S N vs. W N vs. E N vs. B S vs. W S vs. E S vs. B W vs. E W vs. B E vs. B Linear time trend Chi2 f) Chi2 Daily cigarette use Boys 1.37 f) 0.05 f) a) 5.92f) 1.36 f) 1.49 f) 4.83f) Girls 0.46d) Weekly alcohol use b) -- Heavy episodic drinking Monthly cannabis use 2.80 e) 1.00 e) 0.50 e) 1.56 d) Quadratic time trend c) 0.21e) 2.02e) 3.97 e) Weekly alcohol use b) 0.44 g) 9.29 g) 27.30 g) 20.76 g) 8.27 g) 33.21 g) 21.32 g) 2.46 g) 2.48 g) 0.13 g) 0.76 f) 32.35 f) 5.47 f) 20.76 f) 6.28 f) 6.38 f) 3.83 g) 9.00 g) 4.00 g) 1.72 g) 2.88 g) 15.84 g) 0.16 g) 17.99 g) 3.59 g) 9.05 g) 36.08 d) 16.77 d) Notes: N=Northern Europe; S=Southern Europe; W=Western Europe; E=Eastern Europe; B=Balkans; a) one or both trends not linear; b) logistic regression models did not converge ; c) one or both trends not quadratic; d)-g) Bonferroni adjusted p-values: d) p=0.05; e) p=0.017; f) p=0.008; g) p=0.005;

Discussion: Changes in Substance Use General decrease in cigarette use in all regions General decrease in alcohol use + HED in NE; decrease since 2007/11 in all other regions Decrease in cannabis use in NE, WE and EE, increase in SE and B Highest levels of use Cigarette use: Eastern Europe & the Balkans Alcohol use: Western & Southern Europe HED: Similar with exception of Northern Europe Monthly cannabis use: Western Europe Convergence No signs of general regional convergence Cigarette use among girls rather diverging Narrowing of gender differences in HED: boys de- and girls increase

Are the Times A‘Changin ? Nordic States outstanding A homogeneous and clear downward trend with the lowest levels of use in Europe across all substances observable in Northern Europe Reasons for reduced substance use among youth Not subject of the present analyses, although one might speculate Many and overlapping factors influencing youth substance use Cross-cultural as well as longitudinal research needs to be intensified and complemented by qualitative approaches Viewing the broader spectrum of youth risk behavior as a consequence of structural, social, economic and cultural changes that emerge at particular times, future research also needs to incorporate a historical and generational perspective

Vielen Dank kraus@ift.de