Young people and alcohol, drugs and tobacco

Young people and alcohol) drugs and tobacco

WHO Regional Publications European Series No. 66

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Publication Series of the European Alcohol Action Plan

Evaluation and monitoring of action on alcohol, by Peter Anderson and Juhani Lehto .

Approaches to alcohol control policy, by Juhani Lehto. Th e economics of alcohol policy, by Juhani Lehto. Alcohol and the media, by Marjatta Montonen . Community and municipal action on alcohol, by Bruce Ritson . Alcohol and primary health care. by Peter Anderson. Treatment approaches to alcohol problems, by Nick Heather. Young people and alcohol, drugs and tobacco, by Kellie Anderson. Alcohol and the workplace, by Marion Henderson, Graeme

Hutcheson and John Davies.

The World Heal th Organization is a specialized agency of the United Nations with primary responsibility for international health matters and public health. Through thi s Organization. which was created in 1948, the health professions of over 180 countries exchange thei r knowledge and experience with the aim of making possible the attainment by all citizens of the world of a level of health that will permit them to lead a socially and economically productive life.

The WHO Regional Office for Europe is one of six regional offices throughout the world , each with its own programme geared to the particular health problems of the countries it serves. The European Region embraces some 850 million people liv­ ing in an area stretching from Greenland in the north and the Mediterranean in the south to the Pacific shores of Russia. The European programme of WHO therefore concentrates both on the problems associated with industrial and post-industrial soci­ ety and on those faced by the emerging democracies of central and eastern Europe and the former Soviet Union. In its strategy for attaining the goal of heal th for all the Regional Office is arranging its activities in three main areas: lifestyles conducive to health, a healthy environment, and appropriate services for prevention. treatment and care.

The European Region is characteri zed by the large number of languages spoken by its peoples. and the resulting difficu lties in disseminating information to all who may need it. Applications for rights of translation of Regional Office books are there­ fore most welcome.

World Health Organization Regional Office for Europe

Copenhagen

Young people and alcohol, drugs and

tobacco

by

Kellie Anderson Alcohol Research Group, University of Edinburgh,

United Kingdom

WHO Regional Publications, European Series, No. 66

Tex t editing by M ary Stewart Burgher

WHO Library Cataloguing in Publi ca ti on Data

Anderson, Kellie Young people and alcohol. drugs and tobacco I by Kellie Anderson

(W HO reg ional publi cations. European series : No. 66)

I .A lcoholi sm - prevention and contro.l 2.Substance abuse - prevention and contro l 3.Smoking - prevention and control 4.Adolescence 5.Europe I.Title II.Series

ISBN 92 890 1230 3 ISSN 0378-2255

(LC Classifi cation: HY 5 135)

The Regional Offi ce for Europe of the World Hea lth Organi zati on welcomes requests for permi ssion to reproduce or translate its publications. in part or in full. Appli ca­ tions and enquiries should be addressed to the Offi ce of Publications, WHO Regional Office for Europe. Scherfigsvcj 8. DK-2100 Copenhagen 0. Denmark. which wi ll be glad to provide the latest informati on on any changes made to the tex t, plans for new editions, and reprints and translations already ava ilable.

©World Health Organization 1995

Publications of the World Hea lth Organi za tion enjoy copyri ght protection in accord­ ance with the provis ions of Protoco l 2 of the Urnvcrsal Copyright Convention. All rights reserved .

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The mention of specific companies or o f certain manu facturers' products does not imply that they are endorsed or recommended by the World Hea lth Organi za tion in preference to others of a similar nature that arc not mentioned. Errors and omis­ sions excepted. the names of proprietary products are distingui shed by initial capital letters.

The views expressed in thi s pub li cation are those of the author and do not nec­ essarily represent the decisions or the stated poli cy of the World Hea lth Organization .

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CORRIGENDA copyright page, WHO Library Cataloguing in Publication Data: correct ISBN is 92 890 1330 3 back cover, last line: correct ISBN is 92 890 1330 3

Contents Page

Introduction ... .................... ............ ........... ....... .... .......................... ... . Substance use and related problems in Europe .............. ... ... ... .... .

I. Drinking and young people.. ... .... ........... .. ..... ......... ..... .... ........ .... . 4 Drinking behaviour ................ ...... .... .. ....... ..... ... ..... .. ... ... ..... ... . 5 Deve lopment of drinking styles.. ... .. ............ .... ........ ... ... ..... .... 9 Why some young people drink ................... ............................ I 0 Harm from inappropriate use of alcohol by young people ..... 12 Conclusions ....... ............ ......... .............. .............................. ..... 14

2. Drug use and young people ....... ........................... ... ....... ....... ... .... 15 Drug use by the general population .. . . .. .. ... .. .. . .. .. .. ... .. .. .. .... ..... 16 Drug use by young people . .. .. . . .. .. . .. .. .. .... .... ........ .. ... ....... .. .. . ... 17 Why young people use drugs ...... ............ ... ........... .. .... ...... ... ... 20 Harm from drug use .. .. ................ ...... ............... .......... ..... ........ 2 1 Conclusions .... .... ....... ..... .. .... ..... ....................... ...... ... ....... ....... 22

3. Tobacco use by young people ......... ........ ... ..... ........ ......... ............ 24 Harm from tobacco use ....... .. ... .......... .... ... .... .. ... ... .... ............. . 25 Determinants of tobacco use ............. ... ..... ... ... .......... ... ...... ..... 27 Prevalence of smoking ............ ....... .... ...... ... ...... ........ ......... .. ... 30 Harm to young people ....... ........ .. .. .... .. .... ........ ........ ............ .... 32 Conclusions ... .. ................. ...... ... ... .. ... .... ... ....... ......... ... .......... .. 32

4. The school as a setting for hea lth promotion ....... ...... .... ... ..... ... ... 34 The health promoting school .................... .............. ......... ..... .. 35 Relationships with the community ........ ..... .. ... ....... .... .... .. .. .... 40 Working with other agencies ................... ... ... .. .. ....... ......... ..... 43 Relationships with parents ... ... ... ...... .. ..... ....... ... .... .. ..... ......... .. 44 Conclusions ..... .. .... .... ... ...... ....... .............. .. .. .......... ........ ..... ..... 46

Ill

5. Education in schools ... ........ .......... ....... .... ..... ..... ... .. .... .... .... ..... .. .. 48 Current approaches .......... ................. .... ..... ...... .................... ... 49 Conclusions ......... ............................................................ ..... ... 55

6. Policies for developing prevention in school s ............................. 62 Developing policy and procedures ....... .... .............................. 63

7. Youth organizations ...................... .......... .. .............. .. .................. . 67 Traditional organi zati ons ........................................................ 67 Community sports groups ...................................................... . 68 Prevention clubs ...................... ............ .... .......... ........... ........ ... 69 Organizations for young people at ri sk ...... ............................. 70 Supportive policies and procedures ........................................ 71 Conclusions ........... ......... .......... ........ ..... ...... .... ............ .... ... ..... 71

8. Prevention-related events and projects ........................................ 74 A national activity .. .. ........................................... .................... 75 Local activities ... ............................... ....... ... .............. ... .... ....... 75

9. Conclusions .. ............. ... ................... ....... ........................... ........... 78

References . . .. . .. .. . . . .. . .. . .. . .. .. .. . .. .. .. .. .. .. .. . .. .. .. .. .. .. . . .. . .. . . . . . .. . .. .. .. .. . .. . .. .. . .. 79

IV

Introduction

This booklet :

• examines the etiolog ical, epidemi o logica l and preventi on literature on substance use by sc hoo l-age young people;

• g ives informati on on and examples of preventive approaches and programmes in schools and co mmunities; and

• provides guide lines for people do ing preventive work.

The breadth of thi s field of inquiry limits the amount of detai l that cou ld be de voted to any one subject. Issues less direct ly linked to prevention , such as the influence of advertising, price and availability, are largely un addressed . Nevertheless, these facto rs influence alcohol and tobacco experimentation and use, and people involved in preventive work with young people should take them into considerati on. These issues are discussed e lsew here in this series.

SUBSTANCE USE AND RELATED PROBLEMS IN EUROPE

Hi story shows that humankind has always had an appetite for psychoactive substances . Alcohol, opiates, cannabi s, tobacco or other mood-altering substances have been used at some time in most countries, even in those that now proscribe the ir use. Depending on the country and time. the use of psychoactive substances has various soc ial and cultural meanin gs . This seems espec ially true of a lcohol. For example, in grain-producing regions, one usua lly finds a partia lity fo r beers and spirits, while wines are favoured in vine-growing areas . Tobacco use is more g lobal: nicotine addiction and seductive tobacco advert isin g have penetrated even the most re mote areas of the world.

Young people and alcohol , drugs and tobacco

The use of other substances is much more c losely a ligned with cultu ra l preferences and legal status. In European countries, the use of tobacco and alcohol certainl y carries far fewer lega l restric ti ons than that of other psyc hoacti ve substances. As is we ll known, even the use of legal substances can lead to persona l and social harm .

The costs to the indi vidual and soc iety of the inappropri ate use of a lcohol are numerous and well documented. The morbidity and premature morta lity assoc iated with alcoho l-related di seases, acc;: idents and vio lence not onl y affect indi vidua ls but impose on soc iety an undue burden on the health. soc ia l we lfa re and criminal justice systems. The health problems assoc iated with alcohol use inc lude various types of cancer (especially of the di gesti ve organs), live r c irrhosis, cerebrovascul ar di sease, and temporary and chronic harm to mental health . Alcohol is implicated in many road traffic acc idents in vo lving vehic le occupants, pedestrians and cyc li sts, and in public order offences . In addition, alcoho l-re lated vio lence, separation and economic in stability can harm fa mily life . In the workplace, probl em drinking lowers producti vity th rough absenteeism, decreased work performance and accidents. The total cost to soc iety of alcohol­ related proble ms cannot be calculated, but the economic price has been tentati ve ly estimated at 5-6% of the gross national or domestic product of any wes tern country.

In general, tobacco- re lated harm is seen as more pe rsona l, although the morbidity and mortality assoc iated with envi ronmental tobacco smoke rece ive increasing recogniti on. Smoking has been established as a cause of lung cancer and some respi ratory di seases, and a fac tor in the development of some other cancers, heart di sease and stroke. Tobacco is the single most damaging psychoacti ve substance. Its use accounts for six times as many deaths as all other avoidable causes combined . Recent research has noted that ha lf of a ll smokers will die from smoking-related di seases. Maternal smokin g is known to impai r the development of the fe tus, while parenta l smoking can adversely affect the health and development of children. Although the dangers are well estab lished, the worldwide use of tobacco products continues to rise.

Harm from the use of psychoacti ve drugs, both prescribed and illic it, varies wide ly depending on the substance. In general, however,

2

Introduction

the use of drugs is seen as inherentl y harmful and somethin g to avoid . Because of the ir relati ve inex perience, phys ical vulnerability and poss ible predilecti on fo r taking ri sks, young people are the main targets of messages against drug use. Some messages, such as "Just say no!", are unambiguous and have both political and popular appeal. Such messages however. ignore the various internal and exter­ nal fac tors that influence one's dec ision to use or to avoid a given substance. Encouragingly, po licy- makers, researchers, health and education profess ionals and others are deve loping and implementing strategies and programmes to pre vent substance use by young people that address these fac tors.

Thi s publication describes some of the strategies and programmes that have been implemented in the WHO European Region. To pl ace such initiati ves in context, the etio logical and epidemi ological aspec ts of substance use by young people are first di scussed . Because of the di versity of not onl y substance use and prevention goals but also political agendas and structures, and methods of data collection, the information and guide lines presented are stated in general terms. It is neverthe less hoped that thi s publication provides a useful overview of prevention priorities and actions in a selec tion of European countries . Jt gives spec ia l emphas is to programmes in schools and communities and, where appropri ate, c ites research and experience from outside the Region.

3

1

Drinking and Young People

Although cultures vary widely across the Region, many young people grow up in an environment in which the consumption of alcohol is a normal part of li fe. Whether the cultural norm is to have a litre bottle of wine with the midday meal, or a round of drink s in the pub after work, most drinking is seen as a legitimate and enjoyable pursuit. In many cultures, alcohol is an essential ingred ient of spec ial occasions and rites of passage, as well as an aid to personal and social relax a­ tion . In addition, the possible protect ive effects of moderate alcohol consumption , particu larly aga inst heart disease, have been wide ly dis­ cussed . The notion that alcohol has therapeutic properties is not new: hot red wine has long been a breakfast drink for children in some rural areas of Greece .

Many people drink alcohol without obv ious harm . Some, how­ ever, consume a lcohol in a way that causes harm to the m and others. At its most severe, heavy or inappropri ate drinking may have fatal consequences, mainly from liver di sease but also from dependent and nondependent use and toxic effects. In the European Region, deaths attributed to liver di sease vary widely in rate but in general are higher in southern countries, although these deaths have been declining in most age groups since the late 1960s. Norway, the Netherlands and the United Kingdom have experienced an increase in mortality rates, but these are sti ll lower than those in southern, eastern and central Europe. In 1992, the age-standardized li ver c irrhosis mortality rates ranged from a low of 2.9 per I 00 000 in Ire land to a high of 54.8 in

4

Drinking and young people

Hun gary. Nati onal beverage pre ference was not linked to inc idence: both beer- and wine-drinking countries fi gured in the hi gher rates.

Most harm incurred by young people is re lated to the assoc iated e ffec ts of intox icati on, namely hangovers, acc ide nts, and soc ial and lega l probl ems. These immedi ate proble ms and the need to prevent future harm from the in appropri ate use of alcohol make it important to monitor the use of a lcohol by young people and to imple ment ap­ propri ate educational and public policy strategies .

DRINKING BEHAVIOUR

The consumption of alcohol by young people is not uncommon. Despite restricti ons on drinking by those under a certa in age, a sig­ nificant proportion of sc hool-age youth consumes a lcohol at least occas ionall y. Accurate fig ures on use. however. are difficult to de­ termine. Surveys prov ide most of what we know about whether, how much and what young people drink . Because of diffe rences in the methodologies and crite ri a of surveys, as we ll as in the soc ial accept­ ability of drinking, comparisons within and between countries are not always he lpful. For example, interpretati ons of drinker categories (such as li ght or occas iona l) differ. as do definit ions of a young per­ son. The re li ability of se lf- reported survey data is a lso a potential probl em. Some people certainl y underreport the ir drinking habits, while othe rs exaggerate . Even so. surveys and other reports from various countries of the Region re veal interestin g in fo rmation when viewed indi vidually . In add it ion. a few recent cross-nationa l studies re veal general trends in the use of alcohol by young peopl e. In fo rma­ tion from such studies, as well as reports from in formants contacted during the compil ation of thi s publication, are used to di scuss drink­ ing by young people in the European Region.

Prevalence

Most surveys reveal that most people have at least tasted an alcoho lic drink by the age of 18. For exampl e. a WHO survey on the health be­ hav iour of sc hool-age children (HBSC) examined the prevalence of experimentation in three age groups (childre n aged 11 , I 3 and 15 years) in 1989- 1990. The HBSC survey revealed that only a very small min ority had never tasted a lcohol by the age of 15 (/). Across

5

Young people and alcohol , drugs and tobacco

the age groups, more students in Wales and Scotland reported having tas ted alcohol than in all other countries, with Norwegian students reporting the least experimentation. By the age of I 5, however, the variation between children in different countries was not very great . Of the I I countries for which comparable data were ava ilable (Austri a, Belgium, Canada, Finland, Hungary, Norway, Poland, Spain, Sweden, and Scotland and Wales (United Kingdom)), only Norway showed an experimentat ion prevalence of less th an 90%. As to gender differences, males reported more experimentation than fe­ males at the age of 11 but I 5-year-o lds showed few gender differ­ ences. M any other studies confirm this pattern. There is a distinct gender difference in the amount of alcohol consumed: worldwide, older males consistentl y drink more than older fema les.

Further, the HBSC survey examined weekly use of alcohol by age and gender. The proporti ons of weekly drinkers at age 11 were relatively low for all respondents, but were substantiall y higher in those aged I 5. The percentage of I 5-year-old males who drank at least weekly ranged from 10% in Poland to 47% in Wales, with most countri es falling between 32% (Scotl and) and 42% (Spain). Females were the least likely to drink at least week ly, but as w ith males, prevalence rose with age. At the age of 15, respondents from Wales and Spain were nearly ten times more likely to report weekly drinking than their Poli sh counterparts (35 %, 29% and 3%, respectively) .

A 1990 European Community (EC) cross-country study of to­ bacco and alcohol use by children aged I 1- 15 years overlapped with the HBSC survey; it covered Belgium, Denmark, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain and Great Britain (United Kingdom) (2). This survey noted that young people from Greece and Italy were the most likely to drink on a week ly basis, while those from Ireland were the least likely. On ly 2% of Irish males and I % of Irish females aged 13- 15 years reported thi s drinking pattern. An Irish stud y conducted in 1990, however, found that 23% of respondents (average age I 5) drank once or twice a week. The EC study confirmed that weekly drinking greatl y increases with age, with females tending to drink less often th an males. Further, nei ther of the cross-national surveys found daily drinking to be preva lent.

6

Drinking and young people

Results from the HBSC survey indi cate that a lcohol intox icati on is not uncommon. By the age of I 5, 24-70% of fe males and 42-74% of males reported having been drunk at least once. Young people in Po land and Wales, respec ti ve ly. were least like ly and most like ly to report ever hav ing been intoxicated . Again, preva lence increased with age. Countries outside the HBSC survey have re ported simil ar find­ in gs. For example, nearly half of recently surveyed Slovenian youth ( 14- 15 years o ld) had been intox icated . For some young people, in­ toxication is a result of unpremeditated overindul gence and inexperi ­ ence. For others. it is a goal in itse lf and may be sy mptomatic of problem drinking. Many young people do not consider occasional drunke nness to be harmful.

Beverage Preferences

In contrast to adults, young people show quite uniform beverage pref­ erences. Overall, reports indicate that young people demonstrate a di stinct preference fo r beer. followed by wine and spirit-based cock­ tail s. The Mediterranean mode l of wine drinkin g is gradually losing its predominance among southe rn European youth . Sweet liqueurs and so-ca lled nationa l drinks, suc h as raki in Turkey and c ider in the United Kingdom, also fi gure in young people's preferences .

A worrying trend in the United Kin gdom is the popularity with childre n and young ado lescents of strong, sweet, flavoured c ider drinks. Manufacturers seem de liberate ly to target the market of young drinkers with inexpens ive, trendil y packaged cocktail-type drinks. For example, they produce strong ciders with kiwifruit-banana and straw­ berry-van i Il a flavours in containers shaped like li ght-bulbs, stick s of dynamite or test tubes. Young males and females find these drinks a quick, cheap and palatab le way of becoming intox icated .

As to gender differences, males in the HBSC survey tended to drink more beer than any other beverage, except in Hungary; a lmost a ll drank wine at least occas ionally . Females, on the other hand, pre­ ferred wine , although more Swedi sh females drank beer and more Austrian fe ma les drank spirits. Other surveys indicate that distinc­ tions between soc iali zation and tran sgress ion in drinking are such that males were more inclined to the latter ; fema les' drinking had more to do with seek ing approval and wanting to belong. Males, regardless of age, consumed much greater quantities of alcohol more frequently ,

7

Young peo ple and a lcohol, drugs and tobacco

and we re more like ly to drink to intox ication. The cho ice o f beverage also mirrored thi s dic hotomy: ma les more often drink spirits. which were seen as a means of tran sgressi on. The worst prob le ms of exces­ sive and inappropri ate alcohol use we re ty pica ll y assoc iated with spirits, a lthough beer drinking was more like ly to have thi s assoc ia­ tion in Germany and the United Kin gdom (J) .

Settings for Drinking

Settings fo r drinkin g different beverages are fa irl y uni fo rm . Young people are more like ly to drink wine and aperitifs with a mea l at home. and to consume other alcoho lic beverages with the ir peers at parties. sportin g events. public houses and other unsupervised venues . Alcohol consumpti on by young peopl e, regardless of beverage type, is more like ly to take pl ace away from the home and other pl aces that exert soc ia l contro l. Because drinking away from parental cont ro l is e ither proscribed or heavi ly regul ated in many countries, young peo­ ple usua ll y favo ur locations with the least perce ived contro l. Alth ough legislati on may have the pote nti al to limit unde rage con­ sumption in the public houses and bars of some countries , it se ldom does so. These venues are ve ry popul ar wi th youn g people in most areas of the Region.

Other pl aces where ado lescents soc ia lize and drink a lcohol in­ clude di scos, ni ghtc lubs, dance hall s. parties and , in Greece. fas t food restaurants and cafeterias. Students in urban areas of France congre­ gate in cafes , as we ll as bars. Countries differ in the legal avail ability of alcohol to young people. and in restrictions on age, type of be ve r­ age, whether food is concurrently consumed and settings or locati ons. Enfo rc ing legislation that restricts underage drinkin g can affect, if not covert experimentation, the levels of overa ll consumption and re lated prob le ms.

Although youn g people sometimes drink on weekdays, o ft en with the fa mil y, they do most of the ir dri nking on weeke nds, away from the home. Thi s is the case e ven in countries such as Hungary and Spain, where the proportion of drinkmg in the company of fa mil y members remains hi gh. Public drinking is strongly assoc iated with age. The o lder the ado lescent , the more like ly he or she is to drink away from home. The age at which ado lescents drink in public ap­ pears to have fall en in the past two decades. Aside from the gradual

8

Drinking and young people

lifting of soc ia l taboos on public drinking by young people, espec ially fe males . young people today tend to be virtuall y indi stingui shab le from adults. In addition, geography fig ures highl y in the choice of d rinkin g location. Young people in urban areas usua lly have more choices than thei r ru ral counterparts of places where they can drink with some anonymity.

Trends in Consumption

Trend s in whether and how much young peop le drink are much less clear. The collection of in fo rmati on on drin king habits in thi s age group is a fa irl y recent activ ity in most countries . For thi s reason, onl y a limited bas is ex ists fo r monitorin g trends in alcoho l use by the young. Even so, a number of studies indicate that the proporti on of absta iners is ri sin g in many countries, such as Germany and Sweden. Data on levels of consumption per epi sode have proved very difficul t to compare, but some countries have noted an increase, such as the Netherl ands and Spain . Overall , drinkin g appears to be less frequent and more epi sodic in young people than in adults, although adults are more like ly to consider themselves to be nondrinkers. Sweden, how­ ever, has shown a di stinct dec line in consumption levels in young people.

DEVELOPMENT OF DRINKING STYLES

Most young people will have had a sip of an a lcoholic drink , or even a small glassful , at a very early age. Thi s experimentation takes pl ace primarily under the guidance of an adult famil y member. De liberate drinkin g usuall y begins at a somewhat later age. Thi s age varies be­ tween countries and has been decreas in g in most western European countries , except the Netherlands. By the age of 15, most youths who have made the dec ision to drink are do ing so, invari ably in the com­ pany of peers. Habits and styles of d rinking among young people change rapidl y and are very much influenced by peer use, adverti sing, availability and price. The influence of peers is particul arly strong during early adolescence, when young people begin to assert the ir independence from their parents and form fri endship groups. During thi s transition from childhood to adulthood, adolescents ex periment with a variety of ro les and behaviours that they see as part of adult life. Be ing an alcohol drinker is one of these roles. It is a lso not

9

Young people and alcohol, drugs and tobacco

unusual for adolescents to begin to engage in a variety of risk-taking behaviour to test their limits and to combat parental restrictions. Breaking legal and social rules is not uncommon . Because adu lts in most western societies accept alcohol consumption, it is not surpris­ ing that most people start drinking in adolescence.

The drinking styles of young people in the Region often differ considerably, in quality and quantity, from those of their parents . Even so, the strongest external influence on whether and how much young people drink appears to be their parents' use of alcohol and styles of drinking. Young people begin to learn about alcoho l from an early age by watching parents' and others' behaviour.

In some countries, extremes of parental alcohol use appear to have a distinctly negative influence on the style in which their offspring drink . The children of heavy drinkers and of abstainers are more likel y to drink heavily or with problems . Chi ldren born into Muslim families or in areas of low availability and use of alcohol, such as parts of the Scottish Highlands and Islands, however, are exceptions. Even in homes where alcohol is not used, children are undoubtedly aware, to some extent, of alcohol and its effects. Research into children's awareness of and attitudes about alcohol indicates that alcohol education should begin earlier than is the norm in most countries (usually in secondary sc hool) and that parents should take part (4). Children tend to underestimate the risks involved in alcohol use. Appropriate, age-targeted education may help to equip children better for the time when they will need to make decis ions about their use of alcohol. The content and teaching methodologies should take account of norms about alcohol and children's experiences of the attitudes and beliefs of their families.

WHY SOME YOUNG PEOPLE DRINK

Young people drink for many reasons, which vary with their personal and social circumstances. Some of the most commonly cited reasons include wanting to belong or not to be different, boredom, pleasant taste, and a belief that alcohol makes one fee l better or more sociable. Many young people, however, are unable to identify a specific reason .

Drinking and young people

Thi s suggests that there are many influences, most probably re latin g to normative social behaviour.

Most young people drink among groups of fri ends, when alcohol is usually a part of soc ia lizing. Music, dancing, sport, celebration or just re laxed conversation is o ften the focus of gatherings, with a lcohol an essential but secondary ingredient. Members of the group invari a­ bly drink for different reasons and effects, a lthough the belief that everyone drinks is probably one of the primary reason s. Intoxicati on among these drinkers is largely unpremeditated, but not infrequent .

Some young people, on the other hand, may drink heavily and frequently for the purpose of intoxicati on. Drug tak in g and other ri sky behav iour is more assoc iated with this style of drinking, and proble ms and negative coping strategies contribute to its development and con­ tinuation . While a di stinction is made between soc ial and heavy drinkin g, the former is not without probl ems. Many soc ial drinkers consume a lot of alcohol at one time and become intox icated quite regul arl y, increas in g the potential for incurring harm .

The underlyin g factors in young people's drinking choices are numerous and often interre lated . They change in importance as young people approach adulthood. Views of these factors, however, vary across the Region , and the various perspectives have muc h to do with the tradition s and practices of each country . While there is no univer­ sal ri sk profile for young a lcohol or drug users, researchers cite many factors, de pending on the ir theoretical perspective. Some of the soc ial, demographic, psychological and social environmental factors inc lude:

I . know ledge of and previous experience with alcohol

2. other lifestyle- re lated health be haviour

3. persona l or psychological predisposition (such as coping strate- gies or sensati on seek ing)

4 . motivation to drink or abstain

5. hedoni sm

6. se lf-medication

7 . gende r

11

Young people and alcohol. drugs and tobacco

8. re li g ion

9. level of curios ity. a li enation and boredom

I 0. peer pressure or peer use

I I . parental use and attitudes

12. re lati onship with parents

13 . sibling use

14 . pressure fro m or images in the mass medi a

15. famil y soc ioeconomic status

16 . frequenting of di scos and other public entertainment venues

17. poc ket money or all owance

18. price and ava il ability of alcoho l

19. pe rception of peer norms and societal and cultu ra l norms

20. other hi storica l, cultu ra l. po litical and economic fac to rs re levant to the country or area concerned.

HARM FROM INAPPROPRIATE USE OF ALCOHOL BY YOUNG PEOPLE

Some young people suffe r from the consequences of the ir drinking. Although the proportion of adolescents who consider themselves to be drinkers has probably dec lined . ev idence on consumption leve ls points to an overall increase. Even in areas where consumpti on has not risen, some drink inappropriate ly and ex perience adverse e ffects. Most young peop le in the Region drink at least occasionally. The vast majority experience intoxication and other minor short-te rm conse­ quences . A minority, howe ver, drink heavily, increas ing the ri sk of more serious and long- lastin g harm. The etio logy of such a lcohol use by young people remains uncertain (5). Even those who do not drink heavily can come to harm. or harm others. th rough the inappropriate use of a lcoho l. Some evidence suggests that heavier drinkers are more like ly than other adolescents to use illic it drugs and engage in other ri sky fo rms of behav iour (such as unprotected sex and drink-dri ving)

12

Drink ing and young peopl e

e ven if they do not remain heavy drinkers (6) . In general , drinkers a re more like ly to use tobacco products.

Intoxication and heavy , freq uent drinkin g are assoc iated with a s izeable pro portio n of acc idents and public o rder offe nces. As ide from the phys ical sy mpto ms of intox icati on, the conseq ue nces are often hard to quanti fy. It is not a lways c lear, even if a person has been drinking heavil y, to what ex tent a lcoho l may be respo nsibl e fo r a given pro blem. People react d iffe rentl y to the same quantity of alco­ hol, depending on such fac tors as mood, the phys ical and soc ia l envi­ ronme nt , the time span of the drinking epi sode, and whether they have eaten beforehand. Even so, heavy drinkin g and intox icatio n are assoc iated with much crimin al and anti socia l behav iour by youth. To summarize, the types of harm assoc iated with the inappropriate use of a lcoho l by young people inc lude:

I . hangover sy mptoms (such as headac he, sickness. di a rrhoea, tem­ porary short -term memory loss and temporari ly dulled cognition) ;

2. decreased educationa l achievement in the med ium or long te rm;

3. arguments or fig hts;

4. o ther vio lent behav iour. some c rimina l be hav iour o r public d is- order proble ms;

5. impul sive behav iour;

6. in appropri ate behav iour:

7. acc idents resulting in injury or death ;

8. mood change:

9 . accidenta l poisoning;

10. increased like lihood of partaking in other potent ia ll y harmfu l behav iour such as un protec ted sex o r drug expe rimentat ion; and

I I . re lated fa mi ly and/or soc ia l problems.

Some governments have taken steps to reduce the risk of prob­ lems by e nacting legislation that restricts a lcohol consumption in areas that a re assoc iated wi th offences re lated to drunkenness. Scot­ land, for example. has restrictions on the carriage, sale and

13

Young people and alcohol, drugs and tobacco

consumption of alcohol at sportin g events, particul arly soccer matches, and on tra in s and buses carrying spectators to such events. In addition, public drunkenness in Scotland has been decrimina li zed to some extent ; some peop le who mi ght fo rmerly have been convicted of public orde r offences are instead referred for alcohol coun sellin g or treatment.

CONCLUSIONS

At a ll ages, most young people who drink do so in modest amounts. A significant min ority, however, drink heav il y, and thi s proportion seems to ri se with age . The vast majority of alcoho l-related problems among young people re late not to alcohol dependence or even chronic heavy drinking, but to the unpleasant side effects of acute intox ication. One can say that young people are onl y mirroring the popularity and acceptability of alcohol in soc iety at large. Neverthe less, alcoho l can cause personal and soc ia l harm if used inappropriate ly. Alcohol's enduring popul arity ensures that children and young people will always fi nd it attractive. It is fo r thi s reason that priority should be given to po licy and education that foste r the formati on of appropriate attitudes .

14

2

Drug Use and Young People

Drugs of one kind or another have been a feature of most cultures th roughout hi story . People have long used herbs, as we ll as fe rmented beverages, fo r various purposes: to re lieve pain , cure illness, induce altered states of consciousness, escape fro m painful experiences and situati ons, and enjoy themselves. Religious and cultu ral customs play a major ro le in the acceptability and use of drugs. Some drugs are an integral part of certa in reli gious rituals; some cul tures and religions fo rbid all drug use.

Most people in the European Region engage in some fo rm of drug taking, which is mainl y legal and sometimes highl y enj oyabl e. People in most European countries use alcohol, caffeine and pharma­ ceuticals to some extent and, fo r the most part, incur litt le or no harm. All drugs by the ir very nature, however, have the potential to cause harm if used heavily, chronically or inappropriate ly. For this reason, most drugs have contro ls on the ir manufacture, di stribution and use. These range from the so-called child-proof packaging of many over­ the-counte r analges ics, to the availability of tranquillizers on prescription only to the complete prohibition of such drugs as 3,4 methylenedi oxymethamphetamine (MOMA or "Ecstasy"). Many countries forbid the sale of alcohol and tobacco to children.

Despite measures in most countries of the Region to control the suppl y of illic it and prescribed drugs, some people seek to obtain money by selling them illegall y. The market for illic it and illic itly obtained drugs is part of a complex web of international changes in

15

Young people and alcohol, drugs and tobacco

the agricultural, economic and political structures of many developing countries, the spread of organized crime, and the increase in inter­ national travel and trade. The ava ilability of different substances var­ ies, but many potentially harmful ones are readily found in a ll coun­ tries. particularly in urban areas .

Even though the use of illic it drugs appears to cause littl e harm in comparison with other, more widespread health problems such as heart disease and cancer, it can have a devastating effect not only on users but also on their families and society . This effect inc ludes, apart from short- and long-term health consequences, harm re lated to be­ haviour, family and soc ial life, empl oy ment and schoolin g. The mani ­ fold attractions of illicit drugs, coupled not onl y with their re lative ly widespread ava il ability but also with the reasons people use them, ensure that the prob lem of drug use will not be eas il y solved.

DRUG USE BY THE GENERAL POPULATION

In comparison with legal substances, such as a lcohol and tobacco, illicit drugs are not widely used . Even so, the proportion of people who have ever used them has increased over the past decade. Data from general population surveys indicate that, in the 1980s, most western European countries had prevalence fi gures of 5- 10% (7). Surveys conducted since 1989 have noted a preva lence of lifetime use for cannabi s or illic it drug use of 6% (in peop le aged 15-74 years in Fi nland in 1992) and 22% (in people over 16 in Denmark in 1989/1 990) . Most countries have experienced a rather marked in­ crease in li fetime prevalence since the earl y 1980s. In 1992, for ex­ ample, 17% of those surveyed in the Un ited Kingdom had ever used drugs, compared with 5% in 198 1 (a lthough the 1992 survey covered a larger age group). Spain is a notable except ion, havi ng registered a steady dec rease in prevalence from 20% in 1980 to 12% in 1989. This may be due, in part. to a change in research methodology.

An examination of surveys that distinguish between age groups, reveals that much of the overall increase in prevalence may be due to use among young peop le. Prevalence did not rise in the o lder groups surveyed. In Switzerl and , for exampl e, a 1992 survey noted lifetime use prevalence figures of 21 % for peop le aged 17-30 years and 14%

16

Drug use and young people

for those aged 31--45. Drug use among the Swiss appears to be in­ creas in g among the younger cohorts, and decreasing among older co­ horts. This may a lso be true of other countries of the Region.

DRUG USE BY YOUNG PEOPLE

Surveys of drug use among young people have yielded very little in­ formation for international comparison. The 1995 Pompidou Group survey of adolescent alcohol, tobacco and drug use in 26 countries, however, will do much to rectify this deficiency. Surveys of self­ reported drug use among young people are fair ly recent, although Finland, the Federal Republic of Germany, Sweden, the United King­ dom and some other countries have conducted them since the early 1970s. Such surveys often cover wide age bands, such as people aged 15-29. and detail s of use patterns by age can become blurred . Because the prevalence of drug use by European school-age youth is quite low, it is difficult to attach meaningful interpretations to any changes over time. As mentioned, apparent changes in prevalence can be attributed to change in research methodology . There are other problems, too . Gathering reliable information on the use of any sub­ stance is notoriously difficult, especially when it comes to children and adolescents . Surveys of young people are beset by problems re­ lated to under- and overreporting. Underreporting is acknowledged to be a significant problem in interpreting surveys on alcohol use, which is legal; interpreting the results of drug use surveys very probably in­ volves even greater limitations. The proscription of and restrictions on the use of many substances by children, however, means that anonymous surveys are one of the few ways to measure the use of a given substance by young people.

Despite their flaw s, surveys indicate the approximate scale and patterns of use and availability of drugs. Other, indirect indicators of levels of drug use include treatment, mortality and crime statistics. These, however, may say more about the functioning and policy of the health and justice systems than about drug prevalence level s. Most drug users, whatever the ir age, do not come to the attention of official agencies .

17

Young people and alcohol, drugs and tobacco

Although no comparable cross-nati ona l data are yet ava il able on the prevalence of drug use among school-age youth , the first Euro­ pean summary on drug abuse notes a trend that re lates indirec tly to thi s age group (8). Over the period 1985 to 1990 , the ave rage age of drug users (namely. those in treatment) increased in nearl y all report­ ing countries . Other reports, however, note that the age of those ex­ perimenting with drugs is becoming lower. Thi s may imply that, a lthough drug use is beginning earlier in life, e ither youn g people are limiting themse lves to experimental or occasional use, or the ir pattern of use (drug ty pe and method of use) does not yet affec t the type of treatment services avail able. In the Uni ted Kingdom, at leas t. young people certainl y appear to be mov in g away fro m opio ids towards halluc inogens and stimul ants. The service profil e is shiftin g to meet the new needs of an emergin g group of young chronic non-opio id us­ ers, whil e still he lpin g the o lde r opio id users. Regardless of users' age or country. cannabi s products are by fa r the most frequentl y used drugs. Most cannabi s users never come in to contac t with treatment agenc ies or the po lice.

Recent in fo rmation from indi vidua l countries on the use o f drugs by young people indicates a mixed and inconc lusive picture. For ex­ ample, while surveys in Norway show a small decrease in the propor­ tion of people aged 15-20 who have ever used drugs (from 3. 1 % in 1986 to 2.66% in 1993), the re has been a small increase in reported cannabi s use. The Netherl ands notes that, among people aged 12- 18, the preva lence of lifetime use of cannabi s use rose from 5% to 13% between 1984 and 1992. Over the past two decades, Sweden has seen a steady dec rease in the number of adolescents who have eve r used illi c it drugs.

Some countries have noted stability in the proportions of those ever usin g drugs. Between 1989 and 1992, the fi gure for people aged 12- 18 years in Portugal remained at 5%. In the Federal Republic of Germany , the figure for people aged 12-25 remained at 17% over the period 1986- 1989. In the fo rmer German Democratic Republic, however, the lifetime preva lence fo r people aged 12- 29 years rose from I. I% in 1990 to 2.7% in 1992. A 1993/1 994 survey showed that the fi gure for people aged 12- 17 in Germany was 7%.

18

Drug use and young people

Although re liable data on current use are more diffi cult to obtain than those on lifetime use. the available evidence suggests that the proportion of current users among young people has increased over the past decade, although it is in variabl y smaller than that of young people who have ever used drugs. Some studies indicate that the fo r­ mer in genera l compri ses one sixth to one third of the latte r. The pro­ portion of regular drug users (at least once a month) appears to become hi ghe r as young people enter their late teens. Most illic it drug use begins sooner than in previ ous decades - usuall y between the ages of 13 and 17 - although countries such as Norway have noted an increase in the age of first use . Some young people, however, start their drug use career much earlie r. Numerous studies have shown that few people try drugs for the first time after the age of 20. Regardless of age. most people use ill ic it d rugs ne ither heavily nor habituall y.

Overall. adolescents appear to differ very little from adults in the ir drug preferences: 75- 90% of drug users in the European Region use cannabis on its own , or with other drugs. Two key diffe rences, however. appear in most countries. First, children and young adoles­ cents in many countries (such as Finland. France, Norway, Portugal, Romania, Spa in and the United Kingdom) have a penchant for vo la­ tile substances (inhalants) such as solvents and gases. Thi s preference is ma inly opportuni stic. Volatile substances are readily fo und in most homes, and are cheapl y ava il able in shops. Second, the use of ha llu­ c inogens, espec ially stimulants, has rapidl y increased among o lder adolescents and young adults in many European countries. In some countries, stimulants are not considered illic it drugs, but the ir non­ prescribed . recreational use is growing 1n popularity . In countries such as Be lgium and Greece, pharmaceuticals such as tranquilli zers are preferred to illic it drugs. Drugs that are increasing in popularity inc lude amphetamines, lyse rg ic ac id diethylamide (LSD) and MOMA . Cocaine and heroin use among school-age young people ap­ pears very low. a lthough multiple drug use. previously the preserve of the older user. is increas in g in some areas. Such popularity, at least initi ally, is assoc iated with increased ava ilability and lower price.

Most school-age young people do not use illic it drugs . Certain areas and subgroups. however, have a hi gher prevalence of drug us­ ers. as well as increased like lihood of harmful behaviour, such as drug injection and equipment sharing.

19

Young people and alcohol , drugs and tobacco

WHY YOUNG PEOPLE USE DRUGS

Many factors help to determine whether a person will try drugs and continue to use them. The complex nature of drug use has made it difficult to determine whether ex pe rimentation with and use of one drug serves as a gateway to the use of other, harder drugs. Although some people experiment with a drug such as cannabis, or hashi sh, fa r fewer continue using it and fewer still go on to use other illegal drugs. What is known about the establi shment of a drug career is that the use of tobacco and the heavy use of alcoho l are assoc iated with the use of illicit drugs (6) . In add ition , drug ex perimentation and use usually begi n in adolescence. People who go on to use drugs frequently are more like ly to use a variety of drugs.

Table I shows factors assoc iated with drug use . These are corre­ lates only : causal links are as yet unidentified. A significant propor­ tion of these factors can a lso be associated with people who do not use drugs, while very few may affect some drug users. Three of the most frequently cited in assoc iation with experimentation include cu­ riosity , availability and peer group use. Availability and price, as well as peer group use, have been linked to continued drug use. Harmful or heavy drug use appears to be related more to social and psychological disadvantage, such as unemployment, family di sruption and other stressful life events. Survey-elicited reasons why people aged 15-25 used drugs include (9):

• behaving like one's friends

• forgetting problems

• family problems

• relational problems

• lone liness

• scholastic or profess ional failure

• gaining self-confidence

• increasing performance

• making fri ends .

20

Drug use and young people

Table 1. Factors associated with drug use

Individual factors

Personality Stress Intelligence Predisposition to take risks Self-destructiveness Attitudes towards use Empowerment, control over life Gender Need for power Psychological health Hedonism Sensation seeking Use of other substances Anxiety Age Life events Curiosity Intentions to use Scepticism about prevention efforts Biological/genetic predisposition

Source: adapted from Plant & Plant (6).

HARM FROM DRUG USE

Environmental factors

Socioeconomic status Family background Religion Truancy Job opportunities Legal arrangements Parental absence Parental and sibling drug use Poverty Peer pressure/peer use Educational opportunities Drug availability Anomie Historical factors Parental concern {lack of) Delinquency Tradition Educational disturbances Drug price Alienation Parental permissiveness Over- and underdomination by parents

For many young, inexperienced users, taking illicit and unprescribed drugs is a largely pleasurable experience. Whether they want to feel more sociable, energetic or relaxed , or to numb themselves to un­ pleasant feelings and experiences, young people find drug use an increasingly attractive and available option . While some young peo­ ple emerge from drug use suffering little more than a lighter purse, many others encounter more significant consequences.

The immediate physiological effects of drug intoxication are numerous, depending on the drug. Using cannabis can lead to

21

Young people and alcohol, drugs and tobacco

temporary short -term memory loss and lethargy; using amphetamines and LSD, palpitatio ns and rai sed blood pressure; us ing LSD, halluc i­ nati ons; us in g sedatives and minor tranqui lli zers, impaired motor co­ ordination; and us ing solvents and hero in and other opiates, s lowed breathing rate. Some of these immed iate effects can inc rease the ri sk of acc idents. In ra re in stances, death can occur from the first use of a drug or after consumin g a norma l dose of for exampl e, heroin or MOMA .

Effects in the lo nger term are highly variable. The type of drug(s), the mode and frequency of use and, depending on the drug, genetic predi spos ition he lp to determine the impact of prolo nged drug use. Long-term, frequent use o f almost any illic it drug carries the ri sk of permanent damage to physica l and mental health . There is a lso the ve ry real ri sk of premature death, through accidents, acc idental po i­ soning or overdose, and impurities. People who inject drugs, such as heroin, amphetamine sulfate or sedat ives, run the ri sk of abscesses , septicaemi a and gangrene and, if they share injecting equipment with others, the ri sk of contracting HIV and hepatiti s.

Although most young people do not use drugs frequently or over a prolon ged period, some do so. Harmful drug use can adversely af­ fect family and soc ia l re lationships, as we ll as lessen educat ional ac hievement. Some ex perts be lieve that truancy and drug invo lvement are linked . It has been suggested that reducing truancy may reduce some young people's ri sk of becoming in volved with drugs (Pl ant, M.A. , personal communication, 1994). Young users of drugs, regardless of the frequ ency of the ir drug taking or the ir c hoice of illic it drugs, are indul ging in a c riminal act. The des ire for or dependence on drugs may in turn beget other c riminal acts such as theft , drug dealing and prostitution, to finance drug purchases.

CONCLUSIONS

Drug use exacts a fin anc ial toll on soc iety through costs assoc iated with the criminal justice system, and the medical and soc ial care of illicit drug users and the ir famil ies . The pervas iveness of drug taking in many countries can negatively affect entire communities . Although primarily seen as an urban problem, illicit drug use is fast becoming

22

Drug use and young people

more preva lent in rural areas. In some areas. drug takin g is considered normal behaviour. The failure adequately to respond to the factors that fuel this notion (and indeed, fact) will exact a high price from individual drug users and soc iety as a who le. Drug use clearly fl ouri shes in areas of deprivation, and where there is alienation and a

lack of opportuniti es. Nevertheless. all young people are potential drug users.

The indicati ons are that the prevalence of establi shed drug use among young people 1s low in general, although ex perimentati on leve ls show much variati on by country, substance and soc ial group. Bearing 111 mind the comparab le data on trends. there appears to be

little change in the proportions of European young peop le using drugs.

Appropriate drug education and a soc ial and physical environ­ ment conducive to the adopti on and maintenance of a hea lthy lifesty le increase the likelihood that today's youth will turn into healthy and

productive adults.

23

3

Tobacco Use by Young People

Tobacco use is not a recent phenomenon. People in Europe have been smoking or chewing tobacco si nce the discovery of the Americas at the close of the fi fteenth century. Tobacco quick ly became a much sought-after substance, and has been an extremely valuable cash crop, at times displ ac ing even gold in importance . During the mid­ nineteenth centu ry, advances in c igarette manufacture technology great ly increased tobacco's avail ability, while lowering its cost. Many people took up smoking, regarding it as fas hionable. Manu fac turers and even doctors ex to lled its health-giving properties to a recepti ve public. Tobacco was promoted not onl y as a stress reducer but also, incredibly, as a fumi gant aga inst germs. Like the use of alcohol, the use of tobacco eventuall y cut across all soc ioeconomic c lasses, a phe­ nomenon that has only recently altered . During the earl y decades of the twentieth century, c igarette smok ing increased sharpl y in most European countries. Owing possi bl y to d iffe rences in levels of aware­ ness and tobacco cont ro l policies in countries, smoking prevalence has fa llen at di fferent rates and times since the 1960s. At present , the proportion of adult smokers in many countries has remained re la­ tive ly stable or is slowl y dec lin ing. No country has yet achieved the target of the WHO Action Plan on Tobacco : 80% of the population non-smokers by 1995. In genera l. the prevalence of smokin g is slightly lower in women than in men, and men are more like ly than women to be classed as heavy smokers ( 10 c igarettes or more a day) and ex-smokers.

24

Tobacco use by young people

Most industri a li zed countries show an in verse re lation shi p be­ tween soc ioecono mic status and smok ing. Studies have fou nd hi ghl y signifi cant diffe rences between groups based on both number of years in full-time education and occupational c lassification . People with less education (those educated to age 16 only) and/or a manual occu­ pation seem more like ly to smoke and to smoke heav ily than peop le with more education and/or a no nmanual job. Poss ibl e ex planati ons for these differences inc lude: fewer workplace restrictions o n th ose in nonprofess ional occupati ons and the phenomenon of soc ia l smoking, whereby those in professional occupati ons may restric t the ir smoking to soc ia l occas ions ( I 0).

HARM FROM TOBACCO USE

In the past few decades, tobacco has come to be known not for giving health but for takin g life. It has been estimated that just over I milli on people in the European Region die of tobacco- re lated di seases each year. Just under ha lf of these death s occur in peop le under 65 years. Tobacco smoking is the greatest cause of premature, preventable death . It has been sa id ( / /) that : "tobacco is the only consumer prod­ uct that can kill you if you use it exactly as inte nded by the manufac­ turer" . The hig hly addi cti ve constituent of tobacco, nicotine, height­ ens the ri sk of death : once started, smokin g is o ften very difficult to g ive up. The addict iveness of nicotine has been likened to that of heroin and cocaine.

The scope of tobacco-related ill health is lite ra lly breathtaking: lung cancer, heart di seases. e mphysema, chronic bronchiti s, as well as stomac h ulcers and stroke. People who smoke tobacco are at ri sk of seriously damagi ng their health , but th ose who c hew to bacco are at ri sk of de veloping cardi ovascul ar di seases and cancer of the oral cav­ ity . Tobacco consumption, including environmenta l tobacco smoke, may account for up to 20% of deaths in some countries. An exact fi g­ ure is difficult to determine, but the death rate in some countries is so great that it completely overshadows the number of deaths attribut­ ab le to other external factors, such as a lcohol, suicide and road traffic accidents. The Briti sh Royal College of Physicians put into context the sheer magnitude of the problem of tobacco consumption by noting that , of 1000 young men in England & Wales who smoke cigarettes,

25

Young people and alcohol , drugs and tobacco

on average about I will be murdered. 6 will be killed on the roads and 250 will die before the ir time fro m tobacco (/2) .

Warnings about the dangers of smok ing have been publi shed since the mid- I 950s. In I 971. the Briti sh Roya l College of Physicians took an unequivocal stance aga in st tobacco ( 13):

The suffering and shortening of li fe resu lti ng from smok ing cigarettes have become increasingly clear as the ev idence accumulates. Cigarette smoking is now as important a cause of death as were the great epidemic diseases such as typhoid. cholera, and tubercul osis that affected previous generations in this country. Once the causes had been establi shed they were gradually brought under control ... But despite all the publi ci ty of the dangers of cigarette smoking people seem un willing to accept the fac ts and many of those who do are unwilling or unable to act upon them.

In 1975, the WHO Expert Committee on Smoking and its Effects on Health made an equall y damnin g report. The Committee concluded that (/4):

The evidence that cigarette smoking greatl y increases the incidence of lung cancer is now irrefutable. It can therefore be forecast that. if cigarette smoking were to stop or i f cigarettes free from the ri sk of cancer were to be produced, the world-wide epidemic of a disease that at present kill s hundreds of thousands of smokers every year would be arrested .. .

Tobacco use also harms nonsmokers. Since the 1970s, many studies have conc luded that environmenta l tobacco smoke is assoc i­ ated with an increased ri sk of lung cancer in nonsmokers. Thi s ri sk may be in the range of 10-30%. In response to thi s and re lated ri sks, many policies now restrict or prohibit smokin g in specified areas of workplaces and public pl aces. Unfortunate ly, although tobacco smoke adversely affects fetuses and young children, they are re lative ly un­ protected by public policies. The evidence indicates that smoking is associated with numerous complications, including ectopic preg­ nancy, placental abnormalities, bleeding during pregnancy and low birth weight in babies . In addition, women smoking 20 or more ciga­ rettes a day have an increased risk of spontaneous abortion . Sudden infant death syndrome is more likely in babies whose mothers

26

Tobacco use by young people

smoked during pregnancy and after givin g birth . The harm continues after infancy. The children of parents who smoke have hi gher rates of pneumonia, bronchiti s and other respiratory ailments, and chronic middle ear infections. Consequently, such children spend more day s absent from school than the ir peers from non smoking households. Finall y, smokin g in pregnancy may affect the physical and mental deve lopment of children.

In adults, sickness due to cigarette smoking contributes to pro­ longed i 11 health. work absenteeism and decreased productivity . Al­ though tobacco does not have the assoc iations that alcohol and illicit drugs have with crimin al and other anti soc ial behav iour, it c learly harms smokers and others . As predicted in 1975 by the WHO Ex pert Committee. countries in which tobacco use has decreased have seen a later but c lear reduction in tobacco-related ill health . An interre lated combination of he ightened public awareness of the harm rel ated to tobacco, healthy public policy and changi ng soc ial norms about the acceptability of smoking may be responsible for much of the decrease in tobacco use.

DETERMINANTS OF TOBACCO USE

The limited success of educat ion to prevent tobacco use is shown in the fact that, despite awareness of the deadly risk s, many young peo­ ple continue to take up smoking. As with other substance-rel ated be­ haviour, the acquisition of a smoking habit most often occurs during adolescence . Smoking is a relatively visib le phenomenon; it is not unusual, at least in urban areas, to see groups of teenagers standing around puffing away on cigarettes . Neverthe less, the process of be­ coming a smoker is not yet ful ly understood . For a substanti al minor­ ity of adolescents, knowledge and attitudes do not seem to have much bearing on smokin g behav iour.

It is widely accepted that various psychological and social fac­ tors contribute to the onset of smoking. These include demographic factors (such as soc ioeconomic status), the soc ia l environment (such as family and peers), personality, psychosocial factors (such as self­ image and anxiety leve ls) and biological factors ( 15). Such factors

27

--- ,

Young people and alcohol, drugs and tobacco

intermingle and affect each other. For example, soc ioeconomic status influences the soc ial environment.

Examinations of child and ado lescent smokin g behav iour have consistently demonstrated that smoking onset occurs in a se ries of consecuti ve stages. These stages evo lve from preparation and anti ci­ pation, to initi ati on, experimentation and fi nally maintenance of regul ar smoking ( 16). The re lati ve infl uence of the afo rementioned facto rs seems to vary according to the smok in g stage, although the relationships are fa r from clear-c ut. Famil y and soc ioeconomic influ­ ences are th ought to be of paramount importance at the preparati on and antic ipation stage, when young people are fo rming be liefs, va lues and attitudes. Attitudes towards smoking, however, do not always predict intended or actua l smoking behaviour. Many young people, inc luding smokers, have very negative attitudes to smokin g.

Initiation and ex perimentation appear to be strongly influenced by peer use of c igarettes, with famil y use and attitudes waning in in­ fluence. Peer group pressure, however, may be overe mphas ized as a sing le influence. T here is ev idence that child ren and ado lescents te nd to fo rm fri endshi ps with those most like the mse lves, much of thi s se­ lect ion hav ing to do with both personality and soc ioeconomic statu s. Thi s implies that dec isions about behaviour have more to do with mutua lity of intention than undue pressure to confo rm . In compari son wi th persuas ion, pressure and encouragement, less overt influences such as modellin g may have a greater impact (/7) . In any case, more persona l psychosoc ia l fac tors largely drive continued experimenta­ tion . T he pharmacological effec ts of tobacco - nicot ine dependence - heav il y in fl uence the progression to regular smok ing. T hi s can occur quite early in the smok in g career, even wi th in two years. Many young smokers show social, psycho logical and pharmacologica l motives to smoke.

Vari ous stud ies (/ 8) have noted that, beyond the preparation and antic ipation stage, " the re lati ve influe nces of the soc ial environment, intrapersona l fac tors, and phys iological react ions may be contingent on the function of smok in g fo r the indi vidual". Research into the various functions of smoking fo r ado lescents postul ates three ma in categories of disposition: soc ial compl iers, affect regulators and self-de fin ers. Put simply, the soc ia l complier uses the soc ia l setting as

28

Tobacco use by young people

a cue to smoke; the affect regulator uses tobacco to he lp control feel­ ings, as a coping strategy , and the self-defi ner smokes primarily out of rebellion. One should not, however, assume that these constructs are immutable. An adolescent may ex hibit characteristics of a ll three categories to varying degrees, de pending on the situation and devel­ opmenta l stage.

Overall, the soc ial e nvironment is the sing le most important de­ terminant of smok in g onset. Planners of prevention policy and educa­ tion must therefore take into consideration the elements that compri se thi s category of influence. Smoking by parents, s iblings, peers and o lder students is assoc iated with an increased ri sk of smoking initia­ tion by sc hoo l-age youth. Table 2 li sts other important e le ments or

Table 2. Factors associated with smoking onset

Factor

Being female

Living with a lone parent

Not intending to be in full-time education after the legal school-leaving age

Having less negative views about smoking

Feeling alienated from school and the values it represents

Having ever been drunk

Having a boy or girl friend

Having a best friend who smokes8

Knowing at least one cigarette brand8

Having a favourite cigarette brand8

Not knowing or not accepting any of the health risks8

Having at least one parent who smokesb

Positive beliefs about smoking, such as looking grown-up; calming nervesb

8 More predictive in males.

b More predictive in females .

Reference

19

19

19

19

20,21

22, 23

22,23

24

24

24

24

24

24

29

Young people and alcohol, drugs and tobacco

facto rs that may foster smokin g and the references that c ite them. A study of people aged 11 - 15 in the 12 countries of the European Community showed that fac tors influencing changes in young peo­ ple's smokin g behav iour incl ude smoking by best fri end , frequency of alcohol drinking, permi ss ive attitude towards tobacco in parents, vis­ its to di scos, amount of pocket money and smoking statu s of parents (25). The study d id not fi nd tobacco educat ion at school to be a sig­ ni fica nt influence.

The re la ti onships between the various internal and external influ­ ences on young people to smoke are complex and sometimes di s­ puted . Regardless of the e tio logical perspecti ve, however, one should recogni ze that young people are not a homogeneous group . The very individual life ex periences and needs of adolescents shape the ir in­ tenti ons and actions. A ll of these change as adolescents grow older.

The design and implementation of preventi ve programmes need to take account of the varyin g influences on young people to smoke. while recogni zing that education can have only limited impact. Fur­ thering health y publi c po licy at the local and nat ional levels (by such means as c igarette price increases re lati ve to inflation, adverti sing and promotion control s, and restrictions on smokin g at work and in pub- 1 ic) may he lp to re in fo rce and boost educati onal e ffo rts. Such actions address some of the know n externa l influences on young people . Re­ search into the factors that precipitate smoking and the mechani sms that contribute to changes in smoking status should continue, and its results should be widely disseminated.

PREVALENCE OF SMOKING

Most young people in Europe do not smoke , although they will have tried smoking at least once by the age of 15 ( / ). Taking account of di ffe rent methodological criteria, numerous studies have noted that very few school-age young people smoke regul arly. For example, the study of young people in the European Community revealed the prevalence of regular or current (weekly) smokers to be 5% (25). Prevalence varied considerably. The tota l prevalence of regular smoking ranged from 3% in Greece and Italy to 6% in Denmark, France, Germany, the Netherl ands and Spain . For all countries,

30

Tobacco use by young people

smok ing prevalence increased strongly with age. The prevalence of regular smok in g in people aged 11 - 12 was 0-2%. For people aged 13- 15 . prevalence ranged from 2% in females in Ita ly to 12% in males in Germany. Males were more like ly to report regular smok in g, alth ough females had hi ghe r rates in Denmark, Ire land and the United Kingdom (Great Britain) . In the Netherlands and Spain . prevalence showed no significant difference by gender (25).

The WHO HBSC survey used a broader interpretation of current smoki ng, including daily, week ly and occasional (less than once a week) smoking(/). This led to the recording of higher rates of current tobacco use . Prevalence ranged from 3% to I 0% in I I-year-old boys in Austria and Poland, respect ive ly, and from I% to 5% in girl s in Austria and Wales, respectively . By age 15. prevalence ranged from 19% in Wales to 39% in Hungary for males, and from 16% in Poland to 39% in Finland for females . The occasional smokers of the HBSC survey appear to account for a sizeab le proportion of the current smoker category in the European Community survey . A comparison of the prevalence of daily smoking in people aged 15-16 years in se­ lected countries during 1985/ 1986 and 1989/1990 reveals no statisti­ cally s ignificant changes (26).

Reports from countries note findings as diverse as the method­ ologies employed . Bearing in mind the immense difficulties of mak­ ing internat ional comparisons. one can find a few consistencies among the small sample of studies exami ned:

1. the approximate proportion of nonsmokers up to age 16, includ­ in g ex-smokers, is 60- 70%;

2. females are more like ly than males to consider themselves as smokers;

3. where smoking is in decline, the higher socioeconomic groups quit first, and the decrease is in general more marked among males;

4. the prevalence of lifetime smok in g and the number of cigarettes per day increase with age:

5 . there is a general associat ion between being a current smoker and living in an urban area;

31

Young people and alcohol, drugs and tobacco

6. the age of smokin g onset is in general between 11 and 16 years, although it is as early as age 9 in some areas; and

7. smokeless (oral ) tobacco use has increased among Norwegian and Swedi sh males .

HARM TO YOUNG PEOPLE

The ill health assoc iated with tobacco use is more prevalent in middle-aged and elderly people. Although some young people suc­ cumb to tobacco- re lated di seases, the vast majority of premature deaths re lated to tobacco results from a long and susta ined smoking career; fo r many smokers. the habit begins in adolescence or even childhood, and becomes firml y entrenched by earl y adulthood. Never­ theless, some young smokers show some of the health consequences of tobacco use. For example, young smokers are more like ly to have bronchitis and other respi ratory compl aints, coughs, colds and short­ ness of breath than their nonsmok ing peers (27). They are a lso more like ly to be absent from school as a result of the health consequences of smoking, and they have an increased risk of using illicit drugs and drinking heavily.

Although the negati ve effects of smoking are re lati ve ly well known , thi s knowledge has apparently done little to deter the onset of smoking amo ng children and adolescents. The consequences of to­ bacco use seem remote to young people. The immediate perceived benefit s of soc ia l cac het. rebellion and the like seem to obscure the spectre of possible future illness and death . As mentioned, the phar­ macological effects of nicotine have a huge influence fo r continued use. Although the rewards of continued smoking are unclear, avoiding the unpleasantness of nicotine withdrawal may be "more important than any positi ve ly rewarding effects" (28) .

CONCLUSIONS

Although there is ev idence of a general dec line in smoking and an increase in ex-smokers, young people, especially females, are still takin g up the habit, despite increased public knowledge of the asso­ ciated health ri sk. Although most young people are nonsmokers, there

32

Tobacco use by young people

has been little evidence of a decline in the number who never try smoking. European countries vary widely in the prevalence of daily smoking among young people.

The relationship between the determinants and maintenance of smoking is unclear, but the social environment appears to be espe­ cially influential. The long-term nature of tobacco-related illness seems to be an obstacle to achieving the goal of discouraging young people from taking up smoking. In addition to preventive work under­ taken in schools and through campaigns aimed at the young, initia­ tives that target adult tobacco use must be considered. Parental use is a key factor in children's experimentation, so measures that decrease parental use may result in children's growing up in homes and envi­ ronments where smoking is unacceptable. Measures for both young people and adults include general and targeted education, cessation support, increased taxation and more nonsmoking areas. Because tobacco use by young people is primarily opportunistic, the availabil­ ity of cigarettes and tobacco products should be restricted. Along with restrictions on advertising and promotion, such measures have been associated with reductions in tobacco consumption by young people in some countries.

33

4

The School as a Setting for Health Promotion

Di verse inte rventions have been used to prevent substance use. Meas­ ures fo r young people range from persuasive and educational pro­ grammes a imed at influenc ing attitudes and behaviour, to action aimed at changing the environments of substance use, such as restric­ tion s on the sale and control s on the price of alcohol and tobacco products. Although increasi ng evidence supports the effect iveness of the environmenta l approach, the value of preventi ve work in schools should not be underest imated. Even so. many recognize that effica­ c ious education on substance use cannot be conducted in isolation from wider preventi ve and health promoting efforts.

The Ottawa Charter fo r Health Promotion (29) defines health promotion as "the process of enabling people to increase contro l over and to improve the ir health" and links it to five strategies:

• building healthy public policies

• creating supporti ve environments

• strengthening community action

• deve loping personal skills

• reorienting health services towards health promotion and disease prevention.

Any or all of these approaches can be used as a framework to promote not only the genera l health of students and people in the wider

34

The school as a setting for health promotion

community, but also the va lues and attitudes compatible with respon­

sible dec isions about substance use.

THE HEAL TH PROMOTING SCHOOL

Children learn not onl y in the classroom but also th rough everyday experience and interaction with the people around them. For thi s rea­ son, it is being increasingly recognized that the messages and in for­

mation on health that are received and practi sed in the classroom must be rein fo rced and supported outside it . Problems o f credibility are certain to ari se when children receive education to prevent smok­

ing, yet smell smoke outside the school staff room or see their parents

smoke at home. Y oung people may become confused, or even angry, if they are gi ven messages about the responsible use of alcohol and other substances, but see few examples of thi s message in practice.

The recognition of the potential dichotomy between the health

promotin g messages within the classroom and the not-so-healthy ex­ amples outside it gave ri se to the concept of the health promoting school. The overall aim of the health promoting schoo l is to achieve (JO):

healthy lifesty les for the total school population by developing suppor­ tive environments conducive to the promotion of health . [The concept] offers opportunities for. and requires commitments to. the provi sion of a sa fe and health-enhancing soc ial and phys ical envi ronment.

Collaboration between WHO. the Commiss ion of the European Communities (CEC), the Council of Europe (CE) and other interna­

tional organi zations resulted in the establishment of a network of health promotin g schoo ls in parti cipating European countries . Thi s network prov ides a system for the di ssem ination of models of good practice. T he network operates at several levels, in vo l v ing manage­ ment and coord ination in schools and w ithin and between countries . A proj ec t support centre prov ides guidelines, coord ination, tra ining and informati on to partic ipating schools in each country. As of June 1995 the network covers 33 countries (Albania, Austria, Belgium (Flemish-speaking and French-speaking regions), Bulgari a, Croatia, Cyprus, the Czech Republic, D enmark , Estonia. F inland, France,

35

Young people and alcohol, drugs and tobacco

Germany, Greece. Hungary, Ire land , Latvia, Lithuania, Luxembourg, Mal ta. the Netherl ands, Norway, Poland , Portugal. Romania, the Russ ian Federation, Slovakia. Slovenia, Spain , Sweden, Switzerland, The Former Yugos lav Republic of Macedoni a, Ukra ine and the United Kingdom) and 5 more (Ice land , Israel, Italy, San Marino and Turkey) are ex pected to join.

The success of th is initiati ve and the achievement of its goal of health y and empowered children depend on the "full and susta ined support of leaders at all levels in education, health and soc ioeconomic development" (JO).

WH O, CEC and CE have identified characteri stics towards which partic ipating schools should aspire. They represent ideal con­ ditions, indicating only "the range of possibilities fo r the promotion of health within a health promoting school" (3 1) . The health promot­ ing school (JO) should :

• provide a health -promoting environment fo r working and learn­ in g th rough its buildings, pl ay areas . catering faci lities, safety measures, etc. ;

• promote individual, family and community responsibility fo r health;

• encourage healthy lifestyles and present a rea li stic and attracti ve range of health choices fo r schoolchildren and staff;

• enable all pupils to f ulfil their physical, psychological and social potential and promote self-esteem;

• set out clear aims fo r the promotion of health and safety fo r the whole school community (schoolchildren and adults);

• fos ter good staff- pupil and pupil- pupil relationships and good links between the schoo l, the home and the community;

• exploit the availabili ty of community resources to support acti on fo r the promotion of health ;

• plan a coherent health education curriculum with educationa l methods that acti ve ly engage pupils;

36

The school as a setting for health promotion

• equip pupils with the knowledge and skills they need both to make sound dec isions about the ir personal health and to preserve and improve a safe and healthy physica l environment; and

• take a wide view of school health services as an educational re­ source that can he lp pupil s become effecti ve health care consumers.

Three main strands in the health promoting school are the health education curriculum, the hidden curriculum and the health and car­ in g services. Each has its own important place in the prov ision of health education.

The Health Education Curriculum

Health education can appear in the curriculum in a number of ways : as a di stinct e lement in the curriculum with its own designated time, as an essentia l e lement in other subjects in the curriculum, or when teachers use opportunities as they ari se (32) . Educati on to prevent substance use is amenable to any of these curricular approaches, but should ideall y be set in the context of other issues that are important to students.

Materia ls are increas in gly being des igned for use not only in health education, but also in other subjects and as the need ari ses. It is not necessary, however. to re ly on a shelf full of resources and pack­ ages . There are numerous ways to educate students about substance use and to empower them with skill s for use now and later in life. For example, creati ve and aesthetic subjects may offer scope for acting out a situation in which drugs are offered, or fo r in venting rec ipes for nonalcoholic drinks and designing an ad verti sing campaign for the one voted by students and teachers as the most like ly to appeal to those who like alcohol. Opportunities to broach the subject can ari se from the pages of the local newspaper or as a response to mi sinfor­ mati on c irculatin g in the school playground . Some areas may have an awareness campaign, on sensible drinking perhaps, to which schoo l health education may be linked . Connecting with and supporting wider health promotion efforts are good ways not only to re inforce the message but also to make optimal use of limited resources. The chances to integrate health education into most areas of the cur­ riculum are endless, limited only by the imagination of teachers and

37

Young people and alcohol, drugs and tobacco

students. Even so, one should remember that fo rmal educat ion is but one of myriad influences on attitudes towards and the use of alcohol and other substances .

The knowledge and techniques of teachin g staff should be up­ dated to refl ect changes in the understanding of the etiology and epi ­ demiology of substance use, as well as of issues and approaches in

prevention. Outside agenc ies can be invaluable to thi s process .

The Hidden Curriculum

The hidden curriculum has been defined as (33) :

the whole ethos established by the atmosphere of the school. its code of discipline, the prevailing standards of behaviour, the attitudes adopted by staff towards pupils, and the va lues implicitly asserted by its mode of operation.

This view recogni zes that the interactions of staff with students and wi th each other are a powerful influence (32):

Standards, attitudes, va lues and ways of behaving have a profound ef­ fect on pupils' socia l development. That th is is the case should be rec­ ogni zed by the school.

Students notice not onl y whether the behaviour of staff is con­ gruent with that expected of students but also courtes ies, concern, to l­ erance, and the physical state of the school and the types of food available in the canteen . All of these affect the development of stu­ dents' se lf-esteem. The school shou ld make every e ffort to convey concern about all of its students and to create opportunities , in both the formal and informal curricula , fo r developing caring and respon­ sibl e attitudes in its students. To thi s end, teachers should encourage students furth er to develop their social skill s and to take responsibility for the ir actions and decis ions. Students can pract ise these skill s in the classroom by taking responsibility fo r some of the ir own learning, including setting personal goals, and by interacting with adults vi sit­ ing the school and with community groups that use the school prem­ ises, such as mother and baby groups and elderly people. In addition, involvement in community service is also a way of developing a sense of self-worth and responsibility in young people. These

38

The school as a setting for health promotion

personal characteri stics have been linked to avoiding substance use and other health-damagi ng behaviour.

Adolescents often seek out new experiences and take risks. For some young people, experimentation with a lcohol, tobacco and other substances is a part of growing up. The school can provide a positive outlet for young people's need for stimulating ex periences by offering a choice of enjoyab le act ivities, which can include anything from painting, music and drama, to cultural exchanges, field trips and rock climbing. Thrill seekin g, however, is only one of the many reasons why young people use a lcohol and other substances.

Although sc hools cannot be expected to prevent all substance use by students, they can adopt and implement firm policies that make clear thei r position on substance use on schoo l premises. Schools should have equivalent policies for staff members. A pos itive state­ ment of the school' s ethos, stress ing the importance of the school community and re lationships between staff and students, should ac­ company the necessary li st of prohibited behaviour. Many schools have fo und thi s combinat ion to be helpful.

In addition to caring about the health and welfare of students, the hea lth promoting school also promotes the health of staff. Senior managers in schools have a responsibility to create, as far as they are able, the physical and psychological conditions that allow staff to per­ form well. A structured system of support should be available to all staff throughout the school (see Chapter 6).

The Health and Caring Services

The health and caring services affi liated with the school are impor­ tant. They can provide not onl y necessary screening and immuni za­ tion but also further support to the school' s health promotion programme. The spec iali st knowledge and skill s of health profes­ sional s can be used to increase the motivation and understandin g of students, parents and staff in re lation to health-re lated issues .

Various pi lot programmes have been conducted in the European Region to increase the links between schools and health services. These programmes include preparatory lessons by teachers on the purpose and methods of an upcoming medical examination. While the

39

Y oung people and alcohol, drugs and tobacco

students await the examination , they play re lated educational games; students are often provided with a card on which to record their visits to health services and the results. When students return to the class­ room, the teacher gives follow-up lessons to demystify the role of the health care provider, as well as to answer any questions about the ex­ amination. The aim of such programmes is often to enable students to feel more in charge of their health .

Less e laborate and ambiti ous links can prove just as valuable. Presentations by doctors and nurses on various aspects of substance use can be integrated into a planned programme of health education. In addition to their traditional duties, the school's psychological services can provide training for teachers and run workshops for par­ ents on drug use.

RELATIONSHIPS WITH THE COMMUNITY

The notion of usin g schools as a setting for promoting health in com­ munities is a re lative ly recent one. Although the school has long been recognized as a proper setting fo r prov iding young people with health education and, more recently, fo r shaping their values, attitudes and behaviour, it is just now being seen as a tool to empower staff, par­ ents, family and the wider community . The school is a lso increas ingly noted as a means to link students with outside resources that may en­ hance their health and wellbeing (32).

The establi shment of a health promoting school depends for its success on each of the partners in the home-school-community relationship play ing its part. Personal development takes place to a large ex tent in a social context with other people, within human relationships . Our own personal development is bound up not only with the improvement of the quality of our own lives but also the li ves of those around us.

Community service he lps to fulfil thi s objective by showing stu­ dents not only how the local community provides care but also how they can positive ly affect the lives of the people around them. It is hoped that, by working to help others, students will gain self­ confidence and self-awareness. Although young people can acquire these attributes inside or outside the school, the encouragement of such links with the community sends a clear message to students,

40

T he school as a setting for health promotion

parents and others about the relation ship between the school and the community.

Aside from he lpin g students to acquire skill s and a ttributes that will prepare them fo r adulthood, the school can provide practica l sup­ port to others in the community. Many schools are not just for stu­ dents. Outs ide of school hours, buildings can provide meeting space for co mmunity groups; groups and individuals can use the sporting fac ilities and health fa irs, di spl ays and theatri cs can in fo rm, entertain and spark action within the community. There are many exce llent ex­ amples of thi s type of link between the school and the community .

Strategy for lntersectoral Cooperation in Germany

The Bundesverband der Betriebskrankenkassen, the head assoc iation of occupationa l s ickness in surance fund s in Germany, suggested that a pane l di scuss ion be he ld on the theme of "drug prevention: different approaches - co mmon responsibility". This emphas ized that handling tasks in thi s fi e ld can require multidisc iplin ary action and networking. In practical terms, a ll instituti ons in the health and education sectors must identify the ir particul ar approac hes and work together to prevent substance use by young people.

lntersectoral Cooperation in Denmark

In the beginning of the 1990s, the Dani sh Counc il on Smoking and Hea lth , in cooperati on with the Dani sh Cancer Soc iety and Dani sh Heart Foundati on, introduced a campaign ca lled "When education goes up in smoke" . The campaign focuses on the smokin g polic ies of a ll primary and lower secondary schools. T he short-te rm aim is to provoke debate on polic ies on and habits of smokin g in both teachers and pupil s . The long- term aim is that schools should adopt a smokin g policy that does not all ow pupil s to smoke at school, and permits staff to smoke onl y in staff rooms.

Past and Proposed Action in Schools in Copenhagen

The Copenhagen Health Services' campaign on alcohol in 1991/1 992 showed that pl ac ing two buses at the di sposal of stude nts to produce theatrical shows and videos was a great success . Many of the partici­ pating sc hool s stated that, in addition to the exchange of fact s, thi s method had strengthened the students' confidence, se lf-esteem and

41

Young people and alcohol , drugs and tobacco

feeling of community in c lasses. Based on this experience, the Co­ penhagen Health Services (34) proposed that "durin g a period of three years attempts will be made to establi sh a ' Healthy Bus Project', to help schools to create theatrical shows focus ing on one or more health subjects".

Such a bus is thought necessary because younger students appear to respond more readily to shows than to videos. A medi a bus for older students is already in operat ion. During the schoo l ho lidays, the buses would be ava il ab le to recreation centres and city youth clubs. In addition, the project would support ex ist ing campaigns so that, during periods when specific health issues (such as smoking or drug use) are in foc us, classes wishing to address the issues can use the bus fac ili ­ ties . Everyone involved recognizes that mobile fac ilities of this type are a useful tool in prevention educat ion.

Community-based Action in Finland

A project team, and staff from schools, libraries and outpatient c linics, organi zed an event ca lled "Liquor Week" for the c ity of Lahti . The main public library was the scene of a display of reading mate ria ls on alcohol and drug use, and other consumer, health and cultural issues, tasting demonstrations, plays, lectures and videos. The aim was to use ex istin g materials to present information on alcohol and drugs in a way that was entertaining, nonjudgementa l and re levant to the audience.

The library is a very important institution in Finland, providing both informati on and entertainment. About 70% of the population uses a lib rary. It was felt that the main library would be a neutral venue in whi ch to reach the population of the city. The organizers, inc luding school staff, brought to the event the ir own skill s and experti se.

Over 60 000 people visited the library during the event, taking 40 000 leaflets, or about I per family. Of the leafl ets taken, about one third re lated to leisure or consumer issues and two thirds addressed health issues.

42

The school as a setting for health promotion

WORKING WITH OTHER AGENCIES

Li aison with the community need not be limi ted to the sharin g of fa­ c ilities. Ideally there should be a mechani sm th rough which schools and other local bod ies exchange ideas and in fo rmati on. In many areas and c ities, departments of educat ion are represented on intersec toral groups and commi ss ions.

Educati on about health is not the exc lusive task of the depart­ ment of educat ion. Many other agencies have an interest in or even a responsibility for educating people about health and substance use. Intersec toral lin ks he lp to avoid duplication or conflic ting messages, as we ll as increase awareness of prevention efforts unde rtaken by the school. Such links a lso a llow other agenc ies to partic ipate in school and schoo l/community initiati ves.

Teachers possess spec ialized knowledge and experience that can he lp to inform and influence the health-re lated work of other profes­ siona ls. Conversely, other agenc ies can usefull y contribute their ex­ perti se to school and community in iti ati ves and developments. Thi s is espec ia ll y true in dealing with issues re lated to substance use, when spec ia li st know ledge and guidance from drug pre vention agencies, the po lice and researchers can be extre me ly useful. In addition. the mass medi a can be used to publ ic ize school-based and school/community preventi on in iti atives . One department of education (35) collaborates with outside organi zations and agenc ies by:

• inviting representatives from other agencies to jo in its commit­ tees and working groups, and be ing represented on those of other agenc ies;

• de ve loping coll aboration not onl y between management rep­ resentatives but also among practitioners;

• cooperating with and initi atin g research and evaluati ons;

• jointl y funding ventures suc h as theatre workshops and relevant staff training courses;

• taking part in national and local initiatives re lated to, for exam­ ple , drug prevention weeks, World AIDS Day and smoke-free generati on clubs;

43

Young people and alcohol, drugs and tobacco

• in viting other agencies to contribute to or take part in staff training, reciprocatin g in other agencies ' training, conducting joint training and developing multidisc iplinary training;

• publici zin g and sharing good prac tice in preventin g substance use through work with community groups, schools and special projects; and

• ac tive ly looking for ways to promote joint work at a ll levels.

Outside bodies, too, should be encouraged to share their re­ sources and experti se in a direct way. Examples of this include drama-based workshops that encourage students to explore issues sur­ rounding HIV/AIDS, a business-sponsored essay contest on the theme of a lternatives to drug use, and a mobile multimed ia presentation on responsible alcohol use . Although the focus and themes related to substance use and its prevention vary. the means of highlighting them are often useful in a number of situations.

RELATIONSHIPS WITH PARENTS

The health promoting school a lso en