Prevalence of youth gambling and potential influence of substance use and other risk factors throughout 33 European countries: first results from the 2015 ESPAD study.

BACKGROUND AND AIMS: Although generally prohibited by national regulations, underage gambling has become popular in Europe, with relevant cross-country prevalence variability. This study aimed to estimate the prevalence of underage gambling in Europe stratified by type of game and on-/off-line mode and to examine the association with individual and family characteristics and substance use. DESIGN: Our study used data from the 2015 European School Survey Project on Alcohol and Other Drugs (ESPAD) cross-sectional study, a survey using self-administered anonymous questionnaires. SETTING: Thirty-three European countries. PARTICIPANTS: Sixteen-year-old-year-old students (n = 93 875; F = 50.8%). MEASUREMENTS: The primary outcome measure was prevalence of past-year gambling activity. Key predictors comprised individual behaviours, substance use and parenting (regulation, monitoring and caring). FINDINGS: A total of 22.6% of 16-year-old students in Europe gambled in the past year: 16.2% on-line, 18.5% off-line. High prevalence variability was observed throughout countries both for mode and types of game. With the exception of cannabis, substance use shows a higher association with gambling, particularly binge drinking [odds ratio (OR) = 1.46, 95% confidence interval (CI) = 1.39-1.53), life-time use of inhalants (OR = 1.57, 95% CI = 1.47-1.68) and other substances (OR = 1.78, 95% CI = 1.65-1.92)]. Among life habits, the following showed a positive association: truancy at school (OR = 1.26, 95% CI = 1.18-1.35), going out at night (OR = 1.32, 95% CI = 1.26-1.38), participating in sports (OR = 1.30, 95% CI = 1.24-1.37). A negative association was found with reading books for leisure (OR = 0.82%, 95% CI = 0.79-0.86), parents' monitoring of Saturday night activities (OR = 0.81, 95% CI = 0.77-0.86) and restrictions on money provided by parents as a gift (OR = 0.89, 95% CI = 0.84-0.94). CONCLUSIONS: Underage gambling in Europe appears to be associated positively with alcohol, tobacco and other substance use (but not cannabis), as well as with other individual behaviours such as truancy, going out at night and active participation in sports, and is associated negatively with reading for pleasure, parental monitoring of evening activities and parental restriction of money.

The TOBg Tobacco Treatment Guidelines for Adolescents: A real-world pilot study.

INTRODUCTION: We conducted a pilot study to: 1) obtain feedback from prevention practitioners in terms of their satisfaction, knowledge, and self-efficacy following exposure to the Tobacco Treatment Guidelines for Adolescents (TOBg Guidelines); and 2) examine the effectiveness of a school-based intervention based on the TOBg Guidelines on quit rates among a sample of adolescent tobacco users. METHODS: Two parallel studies were conducted. In Study 1, prevention practitioners were exposed to a 1-day training in the TOBg Guidelines with assessment occurring before, immediately after, and at 6 months following the training. In Study 2, participating adolescent smokers were exposed to a 3-session group-based smoking cessation intervention that drew on the TOBg Guidelines and was delivered by practitioners trained in Study 1. The primary outcome measure was self-reported smoking status assessed at 1 month and at 6 months following baseline. RESULTS: A total of 18 prevention practitioners and 65 adolescent tobacco users participated in the pilot study. The majority of practitioners reported high rates of satisfaction with the TOBg Guidelines and indicated that the guidelines positively influenced the manner in which they addressed tobacco use with adolescents. Prevention practitioners' self-efficacy for intervening with adolescent smokers was also significantly increased following exposure to the TOBg Guidelines and training. Among adolescents exposed to the school-based intervention, 62.5% and 23.1% had reduced smoking by 50% or more at 1 month and at 6 months follow-up, respectively. No significant change in smoking abstinence was documented. CONCLUSIONS: The TOBg Guidelines for adolescent smokers were well received by prevention practitioners and were feasible to implement in a real-world school setting.

Social Capital, Perceived Economic Affluence, and Smoking During Adolescence: A Cross-Sectional Study.

BACKGROUND: Smoking is among the health risk behaviors taken up by many adolescents with lifelong consequences and associations with multiple health risk behaviors. Smoking and smoking initiation in adolescence involves an interaction between micro-, meso-, and macro systems, including neighborhoods and the greater community. OBJECTIVES: To examine the associations of individual social and economic capital with self-reported health, life satisfaction, and smoking behavior in adolescents. METHODS: Using a multistage random sampling of junior high school students (16-18 years old) in Crete, Greece, 703 adolescents (90.2% 16 years old; 55.6% girls, participation rate 84.2%) completed an anonymous questionnaire based on HBSC study and the Youth Social Capital Scale (YSCS) during April-June 2008. Multiple logistic regression models were performed adjusted for potential confounders. RESULTS: Adolescents with high participation in their neighborhoods and communities (higher structural social capital) displayed lower odds for daily smoking; those feeling unsafe (lower cognitive social capital) were at greater odds of daily smoking. Adolescents with less friends and acquaintances had lower odds of having tried tobacco products. Smoking was not related to any economic capital variables (perceived affluence, paternal and maternal employment status). Adolescents with low/medium versus high total social capital were at higher odds for low life satisfaction and fair/bad versus excellent self-rated health. Conclusions/Importance: Social capital theory may provide a better understanding in identifying the social context that is protective or harmful to adolescents' smoking. Public health organizations at all levels need to incorporate social capital theory in their interventions.

Prevalence and correlates of electronic cigarette use among adolescents in Greece: a preliminary cross-sectional analysis of nationwide survey data.

INTRODUCTION: This study reports the prevalence of electronic cigarette (e-cigarette) use among adolescents in Greece and explores how dual smokers of e-cigarettes and combustible (conventional) cigarettes differ from smokers of only combustible cigarettes across socio-demographic, familial, psychosomatic health and substance use characteristics. METHODS: Self-reports on smoking were collected from a nationally representative sample of 1320 15-year-old Greek students in the 2014 Health Behaviour in School-aged Children study. Bivariate and multivariable logistic regression analyses were carried out with dependent variables a) lifetime smoking conventional cigarettes and b) lifetime e-cigarette use among lifetime smokers. RESULTS: About 36.9% of 15-year-olds reported lifetime smoking of conventional cigarettes, and 16.6% lifetime use of e-cigarettes, mostly experimenting (0.5% reported current e-cigarette use). Six in 7 ever e-cigarette smokers had smoked conventional cigarettes. Peers who smoke and lifetime cannabis use were significant correlates of both lifetime conventional cigarette and e-cigarette smoking, but more strongly for smoking conventional cigarettes. Alcohol use and low parental monitoring correlated with tobacco smoking but not e-cigarette use. Girls were more likely than boys to report lifetime use of tobacco, but, among lifetime smokers, boys had almost seven times the odds of girls of e-cigarette use. In lifetime smokers, low life satisfaction in females and current smoking of conventional tobacco were independently associated with the experimentation with e-cigarettes. CONCLUSIONS: Experimental use of e-cigarettes is relatively widespread among adolescents in Greece. Targeted interventions should focus on male smokers and the role of peer processes and cannabis use in the risk of experimenting with e-cigarettes.

Rejection attitudes, poor parental bonding, and stressful life events in heroin addicts' families.

BACKGROUND: The influence of family factors on the development and/or on maintenance of heroin addiction still remains unclear. OBJECTIVES: The aim of this study was to investigate family factors, which might be associated with heroin addiction in a sample of male individuals. METHODS: A group of 40 heroin addicts' families was compared with a group of 17 families with a member presenting schizophrenia and a group of 27 families with mentally healthy members in regard to (1) parents' rejection attitudes toward their adult child, (2) quality of parental bond, as perceived by the adult child, and (3) stressful life events in the nuclear family. RESULTS: The main findings showed that the degree of rejection by the fathers in the heroin addicts' families as well as in the subjects with schizophrenia was significantly higher compared to the fathers' degree of rejection in the control group. Moreover, the degree of rejection by mothers in the heroin addicts' families was significantly higher compared to the mothers' degree of rejection in the control group. Heroin addicts reported that they had perceived less care from their fathers than healthy controls. The total number of stressful life events in the nuclear family was higher in the patients with schizophrenia in comparison to the healthy controls. Also, in the heroin addicts' group, a significantly higher number of fathers presented a current or past psychiatric disorder. CONCLUSIONS: The findings of this study showed the importance of negative family factors in the course of heroin addiction.

Do societal wealth, family affluence and gender account for trends in adolescent cannabis use? A 30 country cross-national study.

AIMS: To examine cross-national changes in frequent adolescent cannabis use (40+ times consumed over life-time at age 15) over time and relate these trends to societal wealth, family affluence and gender. DESIGN: Data from three cycles (2002, 2006, 2010) of the Health Behaviour in School-aged Children (HBSC) Study were used for cross-sectional and trend analyses of adolescent cannabis use. SETTING: Representative surveys in 30 European and North American countries. PARTICIPANTS: A total of 160 606 15-year-old students. MEASUREMENTS: Respondents' life-time cannabis use, demographics, family affluence (FAS) and frequency of peer contacts were measured individually. Indicators of wealth (gross domestic product per capita, GDP) and perceived availability of cannabis were obtained from national public data bases. FINDINGS: The frequency of life-time cannabis use decreased over time among adolescents in Europe and North America, particularly in western European countries and the United States (relative risk (RR) = 0.86: confidence interval (CI) 0.79-0.93). This trend was not observed consistently in rapidly developing countries in eastern, central and southern Europe. Over time (2002-10), cannabis use became: (i) less characteristic of high GDP countries in contrast to lower GDP countries (RR = 0.74: CI 0.57-0.95); (ii) less characteristic of youth from high FAS families in contrast to youth from low FAS families (RR = 0.83: CI 0.72-0.96); and (iii) characterized by an increasing gender gap, i.e. consumption was higher among males (RR 1.26: CI 1.04-1.53). Perceived availability of cannabis and peer contacts remained strong predictors of frequent cannabis use. CONCLUSIONS: Among 30 European and North American countries, cannabis use appears to have 'trickled down' over time, with developing countries taking on the former (heavier) use pattern of richer countries, and less affluent youth taking on the former (heavier) use pattern of more affluent youth. Cannabis use continues to be more common among adolescent males than females.

Not early drinking but early drunkenness is a risk factor for problem behaviors among adolescents from 38 European and North American countries.

BACKGROUND: Many studies have reported that the earlier the age at first drink (AFDrink) the higher the later drinking levels and related problems. However, unless adolescents proceed into drunkenness, it is unclear why consuming small quantities at early age should lead to later problems. This study investigates the link between AFDrink and problem behaviors (smoking, cannabis use, injuries, fights, and low academic performance) among 15-year-olds who did and did not proceed into drunkenness. Among those with drunkenness experience, we tested whether AFDrink predicted problem behaviors over and above the age at first drunkenness (AFDrunk). METHODS: Multilevel structural equation models were estimated based on a sample of 44,801 alcohol-experienced 15-year-olds from 38 North American and European countries and regions who participated in the Health Behaviour in School-aged Children cross-national survey. RESULTS: Overall, there was a significant association between AFDrink and all 5 problem behaviors. However, this was the case only among those with drunkenness experiences but not among those never drunk. Among the former, AFDrunk was a strong predictor for all 5 problem behaviors, but time from first drink to first drunk did not predict problem behaviors. CONCLUSIONS: Not early alcohol initiation but early drunkenness was a risk factor for various adolescent problem behaviors at the age of 15, that is, there was not consistent relationship for the time before the first drunkenness (i.e., since first drinking). Besides targeting early drinking, particular efforts are needed to impede early drunkenness to prevent associated harm in adolescence and beyond.

Multiple substance use and self-reported suicide attempts by adolescents in 16 European countries.

Substance use and suicide attempts are high-risk behaviors in adolescents, with serious impacts on health and well-being. Although multiple substance use among young people has become a common phenomenon, studies of its association with suicide attempts are scarce. The present study examines the association between multiple substance use and self-reported suicide attempts in a large multinational sample of adolescent students in Europe. Data on multiple substance use (tobacco, alcohol, tranquillizers/sedatives, cannabis, other illegal drugs) and self-reported suicide attempts were drawn from the 2007 European School Survey Project on Alcohol and Other Drugs (ESPAD). The ESPAD survey follows a standardized methodology in all participating countries. The present study is based on 45,086 16-year-old adolescents from 16 countries that had used the optional "psychosocial module" of the questionnaire, thereby including the question on suicide attempts. Logistic regression analyses were performed to examine the associations of any self-reported suicide attempt (dependent variable) with substance use controlling for country and gender. The strongest association with self-reported suicide attempts was for any lifetime tranquillizer or sedative use (odds ratio 3.34, 95 % confidence interval 3.00-3.71) followed by any lifetime use of illegal drugs other than cannabis (2.41, 2.14-2.70), 30-day regular tobacco use (2.02, 1.84-2.21), 30-day frequent alcohol use (1.47, 1.32-1.63) and any 30-day cannabis use (1.37, 1.18-1.58). The odds ratio of reporting a suicide attempt approximately doubled for every additional substance used. These findings on the association between multiple substance use, including legal drugs (tranquillizers or sedatives and tobacco), and the life-threatening behavior of suicide attempts provide important cues for shaping prevention policies.

Substance use, violence, and unintentional injury in young holidaymakers visiting Mediterranean destinations.

BACKGROUND: Young people's alcohol and drug use increases during holidays. Despite strong associations between substance use and both violence and unintentional injury, little is known about this relationship in young people holidaying abroad. We examine how risks of violence and unintentional injury abroad relate to substance use and the effects of nationality and holiday destination on these relationships. METHODS: A cross-sectional comparative survey of 6,502 British and German holidaymakers aged 16 to 35 years was undertaken in airports in Cyprus, Greece, Italy, Portugal, and Spain. RESULTS: Overall, 3.8% of participants reported having been in a physical fight (violence) on holiday and 5.9% reported unintentional injury. Two thirds reported having been drunk on holiday and over 10% using illicit drugs. Levels of drunkenness, drug use, violence, and unintentional injury all varied with nationality and holiday destination. Violence was independently associated with being male, choosing the destination for its nightlife, staying 8 to 14 days, smoking and using drugs on holiday, frequent drunkenness, and visiting Majorca (both nationalities) or Crete (British only). Predictors of unintentional injury were being male, younger, using drugs other than just cannabis on holiday, frequent drunkenness, and visiting Crete (both nationalities). CONCLUSIONS: Violence and unintentional injury are substantial risks for patrons of international resorts offering a hedonistic nightlife. Understanding those characteristics of resorts and their visitors most closely associated with such risks should help inform prevention initiatives that protect both the health of tourists and the economy of resorts marketed as safe and enjoyable places to visit.

Nightlife young risk behaviours in Mediterranean versus other European cities: are stereotypes true?

BACKGROUND: Mediterranean lifestyle has long been hailed as protective against certain risk behaviours and diseases. Mediterranean drinking patterns of moderate alcohol consumption as part of daily life have often been assumed to protect young people from harmful alcohol consumption, in contrast to Northern European drinking patterns. Nightlife environments are strong related to alcohol and drugs use, and other health risk behaviours but few cross-national studies have been undertaken amongst young Europeans frequenting bars and nightclubs. This study aims to understand differences in nightlife risk-taking behaviours between young nightlife users from Mediterranean and non-Mediterranean cultures, including alcohol and illicit drug use, unprotected sex, violence and driving under the influence of alcohol. METHODS: A total of 1363 regular nightlife users aged 16-35 years were surveyed in nine European cities by means of a self-reported questionnaire. Sample selection was done through respondent driven sampling techniques. RESULTS: after controlling for demographic variables, no differences among the Mediterranean and non-Mediterranean samples were found in current alcohol, tobacco, cannabis, or cocaine use, neither in violent behaviours, but Northern people were more likely to get drunk [adjusted odds ratio (AOR) = 0.53], while Mediterranean were more likely to have unprotected sex (AOR = 2.01) and to drive drunken (AOR = 5.86). CONCLUSION: Our data suggest that stereotypes are partially confirmed, and that Mediterranean lifestyle is protective for some risk behaviours (drunkenness, ecstasy and amphetamines current use), but not for all of them. Further research in depth is needed in order to clarify the relations between cultural patterns, social norms and nightlife risk behaviours assumed by the young people.

Changes in associations between psychosocial factors and suicide attempts by adolescents in Greece from 1984 to 2007.

BACKGROUND: Suicide is the second commonest cause of death among adolescents and young adults aged 15-35 years in Europe. Suicide attempts are a strong risk indicator for suicide. This article examines psychosocial factors associated with self-reported suicide attempts in adolescents in Greece and whether the reported increase in suicide attempts from 1984 to 2007 was accompanied by changes in the pattern of related psychosocial factors. METHODS: Data were taken from nationwide probability sample surveys of Greek high school students aged 14-18 years in 1984 (n = 10,507) and 2007 (n = 9873). Logistic regression analysis was used to relate any self-reported suicide attempts to basic sociodemographic and psychosocial variables including family and psychological characteristics, and substance use. RESULTS: Female gender, smoking, illicit drug use, low socio-economic status, not living with both parents, dissatisfaction with relationship with parents, visits to a doctor for psychological problems, depression, anti-social behaviour and low self-esteem were risk factors for self-reported attempted suicide by adolescents in both surveys. Significant interaction terms showed that the effects of gender and illicit drug use were smaller in 2007 than in 1984. However, low self-esteem became significantly more important. CONCLUSIONS: Several common psychosocial factors seem to be steadily related to self-reported suicide attempts by Greek adolescents in 1984 and 2007. However, the increase in self-reported suicide attempts between 1984 and 2007 has been accompanied by changes in the relative importance of correlates.

Decrease in adolescent cannabis use from 2002 to 2006 and links to evenings out with friends in 31 European and North American countries and regions.

OBJECTIVE: To compare adolescent cannabis use between 2002 and 2006 and to investigate links to the frequency of evenings spent out with friends. DESIGN: The Health Behavior in School-Aged Children study, an international study carried out in collaboration with the World Health Organization/Europe. SETTING: A total of 31 mostly European and North American countries and regions. PARTICIPANTS: A total of 93 297 students aged 15 years. OUTCOME MEASURE: Cannabis use in the last 12 months in relation to the mean frequency of evenings out with friends per week. RESULTS: A decrease in the prevalence of cannabis use was found in most of the 31 participating countries and regions. The most marked decreases were found in England, Portugal, Switzerland, Slovenia, and Canada. Increases occurred only in Estonia, Lithuania, Malta, and among Russian girls. The more frequently adolescents reported going out with their friends in the evenings, the more likely they were to report using cannabis. This link was consistent for boys and girls and across survey years. Across countries, changes in the mean frequency of evenings spent out were strongly linked to changes in cannabis use. CONCLUSIONS: The findings are consistent with the hypothesis that by going out less frequently in the evenings with friends, adolescents had fewer opportunities to obtain and use cannabis. Future research is needed to learn more about the nature of evenings out with friends and related factors that might explain changes in adolescent cannabis use over time.

Prevalence, patterns, and correlates of tranquilizer and sedative use among European adolescents.

PURPOSE: To examine the prevalence, patterns, and correlates of nonmedical use of tranquilizers or sedatives in 85,000 adolescent students from 31 European countries participating in the European School Survey on Alcohol and Other Drugs (ESPAD) in 2003. METHODS: Surveys in each country followed a standardized protocol. Logistic regression analysis was performed to identify sociodemographic and risk behavior correlates of medical and nonmedical tranquilizer or sedative use. RESULTS: Lifetime nonmedical tranquilizer or sedative use was reported by 5.6% overall. Medical tranquilizer or sedative use multiplies the odds of nonmedical use by 10.7 (95% confidence interval 9.1-12.5) for boys and 7.2 (6.3-8.3) for girls. Nonmedical tranquilizer or sedative use is also associated with the use of tobacco (odds ratio 1.3, 1.1-1.5), alcohol (1.3, 1.2-1.5), and illicit drugs (3.5, 3.1-3.9). Further correlates are truancy (1.4, 1.2-1.6), tranquilizer or sedative use by friends (6.0, 5.5-6.7) and siblings (2.7, 2.2-3.4), and dissatisfaction with relationships with parents. Medical tranquilizer or sedative use shares to a large extent the same correlates. CONCLUSIONS: Findings indicate similarities in adolescent tranquilizer or sedative use between Europe and United States. The implications of the results for prevention policies are discussed.

Daily exercise and anabolic steroids use in adolescents: a cross-national European study.

AIM: The aim of this paper is to investigate the association between anabolic steroid (AS) use and intensive physical exercise among adolescents. DESIGN/SETTING: The 1999 cross-sectional European School Survey Project on Alcohol and Other Drugs (ESPAD). Data collection by standardized methodology using anonymous self-administered questionnaires completed in the classroom. PARTICIPANTS: National probability samples of a total of 18,430 16-year-old high school students from six European countries (Bulgaria, Croatia, Cyprus, Greece, the Slovak Republic, and the U.K.) MEASUREMENTS: Besides AS use and physical exercise, questionnaire items selected for this study included tobacco, alcohol, and illicit drug use, indicators of other deviant behavior (self-harming thoughts and behavior, truancy, aggressive behavior), friends' use of AS, and perceived availability. Backward elimination with likelihood ratio tests was used to select the variables to be retained in a mutlifactorial model. Interactions of other independent variables with country were checked. FINDINGS: Logistic regression analysis of lifetime AS users compared to nonusers showed that the odds of lifetime AS use are 1.4 times higher for students who exercise almost daily and 1.8 times higher for boys compared to girls. Significant associations of AS use were also found with current frequent alcohol use, lifetime use of tranquilizers/sedatives and cannabis, and with the perceptions of friends' use of AS and of easy availability of the substance. CONCLUSION: Findings indicate that daily exercising appears to increase the risk of anabolic steroid use in adolescents. However, a more general pattern of closely interlinked deviant types of behavior, such as other drug use and aggressive behavior, is prominent. Preventive interventions are needed targeted towards adolescents involved in intensive exercise and sport. These should take into account both the idiosyncrasy and setting of the sporting culture and the special characteristics of this group.

Psychosocial correlates of substance use in adolescence: a cross-national study in six European countries.

AIMS: To examine the psychosocial correlates of substance use among adolescents in six European countries. DESIGN: Cross-sectional school population survey (ESPAD) based on standardized methodological procedures. SETTING: High schools in six European countries: Bulgaria, Croatia, Greece, Romania, Slovenia and UK. PARTICIPANTS: Representative samples of a total sample of 16,445 high school students whose 16th birthday fell in the year of data collection. MEASUREMENTS: Anonymous self-administered questionnaire. Self-reported substance use was measured by core items on tobacco, alcohol, marijuana and any illegal drug use. Psychosocial correlates included scales of self-esteem, depression, anomie and antisocial behavior, and items pertaining to family, school and peers. FINDINGS: Logistic regression analyses for each potential correlate adjusted for country, taking into account the clustered sample, showed statistically significant associations with each substance use variable separately, in almost every case. Particularly strong associations were found between smoking and going out most evenings and having many friends who smoke, while cannabis and illegal drugs were strongly correlated with having friends or older siblings who used these substances. The self-esteem scale score was not correlated with substance use. Anomie and antisocial behavior were more strongly associated than depression with substance use. In the case of depression, anomie and most of the other items examined, associations were stronger for girls than for boys. CONCLUSION: The present cross-national study identified correlates of legal and illegal substance use which extend outside specific countries, providing grounds to believe that they can be generalized. They provide evidence for the need to address both the use of the gateway drugs and deviant behavior in conjunction with environmental risk factors when designing and implementing preventive interventions in schools.

Further investigation of psychological and environmental correlates of substance use in adolescence in six European countries.

AIM: To study the multifactorial correlates of adolescents' use of legal and illegal substances in six European countries and to assess whether a common pattern of factors exists irrespective of the countries' different sociocultural backgrounds. DESIGN: Cross-sectional European school population survey (ESPAD) following standardized methodology. PARTICIPANTS: National probability samples of 16-year-old high school students from Bulgaria, Croatia, Greece, Romania, Slovenia and the UK. Total sample 16,445. MEASUREMENTS: Anonymous questionnaire self-administered in the classroom. Self-reported use of tobacco, alcohol, marijuana and other illegal drugs. Correlates examined: environmental, such as peer culture and family-related; behavior-related such as antisocial behavior, truancy and anomie; and psychological factors such as self-esteem and depressive mood. FINDINGS: Separate logistic regressions for the two genders produced a set of psychosocial correlates common to the use of all legal and illegal substances. The strongest were peer and older sibling models of use, and peer-oriented lifestyle, followed by patterns of antisocial behavior and truancy. Family-related variables such as not living with both parents, parental monitoring and relationships with parents were less significant. Self-esteem and depressive mood were not significant. Girls' use of substances, especially illegal ones, showed stronger associations than boys' with a deviant behavior pattern. Few interactions between country and other correlates were significant. CONCLUSIONS: Common correlates can be identified across countries. Older siblings' and peers' substance have a strong impact on adolescents' use. Preventive interventions should include all substances with addictive potential.

Early initiation of cannabis use: a cross-national European perspective.

PURPOSE: To examine the relationship of the early initiation of cannabis use with other high risk behaviors and with psychosocial and health-related correlates in 15-year-old adolescents in six European countries. METHODS: This study reports on nationwide cross-sectional surveys in six European countries in 2001-2002, within the framework of the World Health Organization's collaborative study, Health Behaviour in School-aged Children (HBSC). Data were collected through anonymous questionnaires self-completed in classrooms. Descriptive and multivariate analyses were used to assess differences between countries in age of first cannabis use and associations with health and related psychosocial variables. RESULTS: The prevalences of lifetime and last-year cannabis use ranged from 30.7% and 27.5%, respectively, in the Czech Republic, to 5.4% and 4.1%, respectively, in Greece. Age at first use was lower in the high prevalence countries than in countries with lower prevalence. For 15-year-olds, frequent use of tobacco and alcohol and other risk behaviors were correlated with early (13-15 years old) and especially very early (< or = 13 years old) cannabis initiation. CONCLUSIONS: Although different patterns of prevalence and age of initiation were observed between participating countries, early cannabis use was almost uniformly associated with higher odds of more frequent use of cannabis and other substances, and with a common set of other problems. Our findings suggest that prevention of drug abuse must commence in preadolescence.