Building Blocks This evidence based study has five empirical building blocks (see figure 1.1):

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1 CONCEPTS AND OBJECTIVES Objectives of this project The consumption of alcohol among young people in Europe has risen during the past years. Several studies indicate that one quarter to one third of all adolescents drink alcohol. Not only the number of young people drinking alcohol is growing; problematic drinking (e.g. drunkenness and binge drinking) is an issue of growing importance. Especially among 12 to 14 year olds the use of alcohol has increased. The proposed multilevel research project aims to study the different possible effective strategies for the prevention of alcohol abuse among adolescents in different European countries. It will analyse existing environmental strategies at different governance levels and confront these with outcomes of a study identifying and analysing risk factors which influence the initiation of alcohol use among young people in Europe. The study will build upon a previous survey of self reported delinquency and substance (ab)use among young people in 30 countries, realised with active involvement of the research consortium of the present proposal. The (intermediate) outcomes of the proposed study will be largely disseminated through regional experts and stakeholders seminars in different European regions and through a web based prevention policy guideline. Relation to the topic of the call As asked for in the call, the present proposal will analyse the effect of current environmental strategies for the prevention of substance abuse on adolescents in Europe. Based upon a previous survey among young adolescents (13-15 year) the proposal will concentrate on alcohol use, being often a stepping stone to other substance use. The project will create a solid evidence base for assessing the current prevention policies and interventions in 26 countries. It will assess these policies and discuss the outcomes with policy makers and practitioners. Finally, by creating a web-based guideline, including an inventory of effective policies and interventions it will create a precious resource for further improvement of prevention strategies throughout Europe. Building Blocks This evidence based study has five empirical building blocks (see figure 1.1): 1. Comparative data of 30 countries: The study will be built on comparative empirical data of alcohol and drug use among young people in 30 countries 1 ; 2. Science based research on problems and determinants: Comparative epidemiology, population based research to identify risk factors and determinants associated with patterns of alcohol consumption among youth; 3. Multilevel analyses of data of youth and countries: Empirical multi-level study of alcohol use among youth per country and profiles. 4. Multilevel analyses of prevention policies in countries: Multi-level analyses of policies in the field of alcohol abuse prevention of youth in the countries. 5. Possible effective strategies for the future: Research on effective prevention policies and interventions on different levels to reduce drinking and developing strategies for use of effective prevention policies and interventions on a broader scale. 1 Twenty European Union countries, Belgium, Cyprus, Denmark, Germany, Estonia, Finland, France, Scotland, Hungary, Ireland, Italy, Lithuania, Netherlands, Austria, Poland, Portugal, Slovenia Spain, Czech Republic, Sweden. Three associated European countries: Switzerland, Norway and Iceland; Three countries which are ICP countries: Russia, Bosnia Herzegovina and Armenia; Four countries overseas: the US, Venezuela, Surinam and the Dutch Antilles.

2 Figure 1.1. The conceptual model underlying this study Building Block 3 Multilevel analyses of data on youth and countries Building Block 1 Building Block 2 Building Block 5 Comparative data of 30 countries Science based research on problems and determinants Building Block 4 Possible effective strategies for the future at EU, national and local levels Multilevel analyses of prevention policies in countries Central assumptions The misuse of alcohol of adolescents is a problem in all European countries. Early adolescence remains a time of high vulnerability for initiating alcohol use. Better understanding of the interrelationships between the influence of individual developmental characteristics on the one hand and societal, school and family contexts on the other hand will contribute to environmental prevention strategies. Cross-national studies on the prevalence and etiology of substance use and related behaviours can make significant contributions to prevention science and successful policy. State-of-the-art The consumption of alcohol among young people in Europe is rising the past years. Research on adolescent alcohol and drug (ab)use and on effective prevention strategies has been dominated by studies of U.S. samples (e.g., Alsaker & Flammer, 1999; Hunt & Barker, 2001). This has prompted calls for studies of adolescent development and drug use behaviour that compare samples from two or more countries to distinguish between universal and context-specific influences on behaviour across countries and cultures (Brook, Brook, Zhang, Cohen, & Whiteman, 2002; Jessor et al., 2003; Unger & Pardee, 2002). Cross-national studies on the prevalence and etiology of substance use and related behaviours can make significant contributions to prevention science (Beyers, Toumbourou, Catalano, Arthur, & Hawkins, 2004; Hosman, 2000). Cross-national studies regarding alcohol use are difficult to realise as a consequence of differences in registration, in definitions and conceptualizations used and in age groups involved in national or local surveys (Trimbos, 2004b). The World Health Organization therefore uses sales figures to estimate alcohol use, taking into account illegal import and production (Rehm et al., 2004).

3 Another option to measure the consumption of alcohol and drugs are self report surveys such as the ESPAD (The European School Survey Project on Alcohol and Other Drugs) or the International Self Report Delinquency (ISRD). The ESPAD is a self report survey that was conducted in It investigated the use of alcohol and other drugs among students aged in a number of European countries (Hibell, Andersson et al 2004). At this age about half of the students (in some countries less) have been drinking alcohol 40 times or more in their lifetime, boys more so than girls. The prevalence rates of this behaviour do not differ much between the countries involved in the research. The highest proportion was reported in Greece (55%) and the lowest in France (39%). The number of students that have been drunk 20 times or more in their lifetime differs substantially between the countries. Sweden ranks highest: in this country half of the students (49%) had this experience. In the three Mediterranean countries in the survey, only one fifth of the students reported this. In the remaining three countries, Latvia, Poland and the Slovak Republic, about one fourth had been drunk that often. In all countries this is a behaviour that is more common among boys than among girls. Very frequent drunkenness (three times or more during the past 30 days) is again reported most by the Swedes. One fourth of the Swedish students reported this, as compared to percent in Italy, Latvia, Poland and the Slovak Republic, and 7 percent in France and Greece. In all countries this is predominantly male behaviour, but the gender gap among the Greek students is not very wide. As regards frequent binge drinking, differences between the countries are less evident, although the country with the highest proportion of students reporting this behaviour (3 times or more during the past 30 days) is still Sweden (26%). The ESPAD also gives insight in the use of illicit drugs. Overall, cannabis use dominates. There is, however, a rather wide gap between the high and low prevalence countries. The highest prevalence rates for the use of hashish or marijuana are found in France (59%) and Italy (43%). In Poland and the Slovak Republic just over one third (around 38%) and in Latvia one fourth (26%) of the students reported to have been using cannabis. In Greece and Sweden, however, only around 15 percent had ever used cannabis. Another self report survey is the ISRD which focuses on a younger age group than ESPAD. In 2006, the ISRD investigated the use of alcohol and other drugs among students aged year. The results show that the increase in the number of students that have started to drink alcohol is the largest between the first and third grade of secondary school. In the first grade 51% have never drunk alcohol or used drugs, while in third grade (grade 9) this applies to less than a quarter (24%). There is in this age group no large difference in use between boys or girls. The abstinent figure never used alcohol or drugs for girls (38%) and boys (36%) is approximately the same. Empirical evidence from a large number of American studies has shown that early initiation predicts later misuse (DeWit, Adlaf, Offord, & Ogborne, 2000; Grant & Dawson, 1997; Kosterman, Hawkins, Guo, Catalano, & Abbott, 2000, National Institute on Alcohol Abuse and Alcoholism, 1997; ) Similar evidence has been found in European studies for both alcohol and marijuana use and later related drug use problems (Anderson, 2003; Kraus, Bloomfield, Augustin, & Reese, 2000; Pitkanen, Lyyra, & Pulkkinen, 2005). Studies have also shown that adolescent substance use is associated with other problem behaviours, such as delinquency and violence (Junger-Tas et al., 2003; Verdurmen, Ketelaars, & van Laar, 2005), which, in turn, are predictors of later alcohol and drug dependence. Given this evidence, there is some recognition of the importance of delaying early onset of substance use in Europe. On the other hand, the primary assumption is that experimentation with alcohol and other substances is a normal and inevitable part of adolescent development and does not necessarily lead to later problem use. For instance in the Netherlands the experience is that for most people the use of alcohol and soft drugs (i.e. marijuana, cannabis, hashish, and mushrooms) is a passing phase in life, and most consumers abstain after trying soft drugs a few times (de Kort & Cramer, 1999).

4 These are temporary conclusions which have to be researched more solidly. To develop effective prevention strategies, in particular for vulnerable youth, more knowledge is needed on the interrelationships between individual developmental influences on the one hand and societal aspects (among which policy differences), school and family contexts on the other hand. This is one of the central purpose of the present research project. Comparative data of 30 countries (building block 1) This project has the advantage that we have a unique cross-national dataset as a starting point for the research we are planning to do. We will use the ISRD data, a student questionnaire that has been developed and validated. The countries participating in the ISRD project are twenty European Union countries, three associated European countries, three ICP countries and four countries overseas. The research project will be based on this database, which has been developed to measure and explain self reported delinquency among year old school children. It is a cross-national study designed to examine variability in patterns of self-reported delinquency behaviour and victimization, to measure the relative rank-ordering of prevalence of different types of juvenile delinquency and victimization in industrialised countries, and to assess the crossnational variability in the correlates of self-reported delinquent behaviour and victimization. The database also contains information about the use of alcohol, marihuana and hard drugs (LSD, Cocaine, Heroin, ecstasy and speed) of the adolescents in the past month, past year and life time use. The dataset gives us the opportunity to analyse substance use in relation to anti-social behaviour or risky behaviour and to evaluate the many correlates of use with background variables such as age, gender, ethnicity and social class. But also risk factors such as lack of self-control, specific lifestyle and lack of social bonds with the family or school, the risky behaviour of friends and attitudes towards alcohol will be included in the analysis. We will analyse different patterns of use, based on dimensions such as age of onset and intensity of the use, in relation to the policies of the participating countries regarding alcohol and drug use. The dataset also includes some local, regional and national indicators. Science based research on problems and determinants (building block 2) In this study, built on the abovementioned dataset, we want to compare samples from 26 countries to distinguish between universal and context-specific influences on behaviour across countries and cultures (Brook et al., 2002; Jessor et al., 2003; Unger et al., 2002). Generalization of findings across countries will add evidence as to whether or not risk and protective processes are universal predictors of alcohol use. Cross-national studies on the prevalence and etiology of alcohol and illicit drug use and related behaviours can make significant contributions (Hosman, 2000) to prevention science. Extending the study of risk and protective factors and testing theories in different cultural contexts are important steps towards developing a more universal understanding of underlying processes, including equifinality (multiple trajectories to the same outcome) and multifinality (similar trajectories to multiple outcomes) (Cicchetti & Rogosch, 1996; Schulenberg et al., 2001), and for informing general and culturally specific interventions (Beauvais & Oetting, 2002; Unger et al., 2002). Cross-national studies can also assist in identifying new predictors due to potentially increased but overlapping variation in predictors and outcomes between countries. Better specification of the variation in the patterns of adolescent alcohol use, their association with other adolescent behaviours, and the extent of common versus specific risk influences can support the targeting of prevention efforts (Toumbourou & Catalano, 2005). While processes of risk and protection have been investigated rather extensively within countries, the international validity (Reuband, 1992) of these etiological processes has not yet been demonstrated. International comparative studies may assist in disentangling universal

5 from country specific components of these processes (Hurrelmann & Hamilton, 1996). In part, this lack of international comparison has been due to the lack of standardized methodology in measuring risk and protection. International research collaboration can help to identify the developmental similarity and differences of patterns of alcohol use, abuse and dependence and the similarity and differences in factors contributing to these developmental patterns. Through international study in multiple countries it will be possible to increase our understanding of whether these processes are the same or different in different cultural contexts. In addition to individual, family and peer predictors, international studies provide the possibility of examining school, state and national policy and other contextual influences on alcohol use patterns that may not show sufficient variation within a single country where these patterns are more homogeneous. This type of analysis will yield new information on the local and crossnational influences on early adolescent alcohol use and symptoms of alcohol use disorders, potentially enabling the cultural generalization of risk influences and alcohol consequences to be investigated. The influence of environment (e.g., school policy, family alcohol practices, state and national policy, socioeconomic status and rural location) can also be explored together with the effects of individual influences (e.g., pubertal development, behaviours, personal adjustment and attitudes). Multilevel analyses of data of youth and countries (building block 3) The importance of context and environment is hard to overestimate and strongly influences the development and behaviour of people. Today these contexts are more open and different than they were before. Complexity is big. For governments it is hard to control and restrict influences on all the different moments and levels. They have to search for other and more open ways without neglecting the importance of these contextual influences. Risk factors are present at different levels. For alcohol use it is important to separate the influence of different levels but also to see the restrictions as well as the possibilities on these levels. For alcohol use for example individual behaviour, culture (e.g. ethnicity), local environment (e.g. accessibility of alcohol) and national environment (e.g. national policy) are important. We want to incorporate in our project this multilevel methodology as well as multilevel governance. The stark figures on alcohol use by young people strongly suggest the need for more knowledge about the initiation of alcohol use among young people within Europe and between different European countries. Although alcohol use among youth is clearly a serious problem in specific countries especially (e.g. Ireland, Netherlands and the UK), other countries are not immune for this social problem either. Therefore, it is important to examine this issue in a broader and cross-national perspective at European level (and sometimes more international level, when we compare this with USA and Latin American countries). In order to do this, data from multisite studies are needed, particularly from cross-national studies that provide sound epidemiological data using standard, uniform methodological approaches (Pirkis et al., 2003). As described, the present project uses the ISRD database. The use of a common instrument for measuring alcohol and drug use (as well as risky behaviour and anti social behaviour) in 26 European countries provides a rare opportunity for comparative epidemiology in the context of different policies and cultural settings. The expansion of the research regarding adolescent alcohol use is especially important since the use of alcohol is rising among young people in different European countries, as mentioned earlier. Alcoholic drinks are now starting to be recognized as drugs with major health risks (Verdurmen et al., 2005). The proposed project offers the opportunity to study the role of European and national policy in prevention and health promotion, because the data are collected in different countries using a similar sample design and identical measurement, making the international data truly comparable. Identifying the individual and national-level correlates of alcohol use will expand the knowledge base needed to develop effective strategies. Multilevel analyses of prevention policies in countries (building block 4) But besides this empirical knowledge about the initiation of alcohol use it is important to have clear insight in the alcohol prevention policies and programmes aimed at influencing the use of

6 alcohol among youth. To this purpose, multilevel data analyses of young people will be contrasted with analyses of multilevel policies and programmes (governance) in this field. We understand this multi-level governance to be the sharing of policy-making competences in a system of negotiation between nested governments at several levels (supranational, national, regional and local) on the one hand and private actors (NGOs, producers, consumers, citizens, et cetera) on the other (Van Tatenhove & Liefferink, 2003: 13). Multilevel governance is also relevant in another sense. As we will explain in more detail in section 1.2.1, in the new paradigm of multilevel governance, horizontal governance arrangements gain weight and civil society organisations become more important. Many environmental strategies for the prevention of alcohol abuse on adolescents have been developed in collaboration with civil society, social partners, non-governmental organisations and other relevant organisations. Local and national governments set up the preconditions for this, for instance by providing information about prevention of alcohol abuse, or by supporting specific groups. But civil society organisations are as important as governments, for example as stepping stones for young (disadvantaged) people to become involved in different forms of environmental strategies. Some important local and national level statistical indicators have already been collected, other important indicators for alcohol use by young people will be collected for the purpose of our project. Especially the ways in which policy instances react to the growing alcohol (ab)use by young people will be reviewed and analysed. Research questions relevant to our project are: What is the role and influence of abstinence? How is alcohol use related to other substance abuse (cigarettes, soft drugs and hard drugs) and how is it related to anti social behaviour in the different countries? But also: what is the influence of the alcohol market in different countries, the criminalization of alcohol use and other important national indicators (e.g. social economical conditions in different countries)? The data set and the international cooperation between different European countries give us the opportunity to elaborate on this upstream perspective. In this multilevel study we contrast analyses of data of youth in different countries with structural, cultural and policy indicators that lie behind differences in alcohol use in the different countries. Possible effective strategies for the future (building block 5) The proposed multilevel research project aims to identify different possible effective strategies for the prevention of alcohol abuse by adolescents in different European countries. As explained, it will analyse existing environmental strategies of public and private actors at different governance levels and confront these with the outcomes of a study identifying and analysing risk factors that influence the initiation of alcohol use among young people in Europe. The policies and care toward alcohol and drug use of young people differ, not only between countries but also within the countries. In this project we want to make an inventory of the current environmental strategies which are used by the European countries involved in the ISRD-study. We will analyse the effect of current environmental strategies for the prevention of substance abuse on adolescents in Europe. Furthermore, we will include in our study existing research evidence on the degree to which these interventions are associated with reductions in levels of targeted risk factors and adolescent substance use in the participating countries. This research will advance knowledge on the effectiveness of environmental prevention strategies, the role of normalisation around drug use and associated problem behaviours, and the spin-off effect of environmental prevention strategies on illicit drug use. As a result of this study all strategies or interventions which are proven to be effective will be published in a web based guideline. The guide with tested and effective programmes gives countries an overview of which effective strategies may be used regarding different domains

7 (families, school, peers, peers and communities), different age-groups and different risk and protective factors. In this way the project will have a major contribution to the development of evidence based policy. But also possibilities of implementation of these effective and promised interventions on a broader scale in different countries and Europe will be part of this collaborative project. Moreover, the interactive character of the web-based guideline will allow different stakeholders (experts, policy makers, practitioners, youth) to collaborate to the further development of the knowledge base.