Alcohol drinking cultures in Europe 581

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29 Shonkoff JP, Garner AS. The lifelong effects of early childhood adversity and toxic
stress. Pediatr Dent 2012;129:e23246.
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use and problems. J Gen Psychol 2006;133:35774.
31 Shonkoff JP, Boyce WT, McEwen BS. Neuroscience, molecular biology, and the
childhood roots of health disparities: building a new framework for health
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.........................................................................................................
The European Journal of Public Health, Vol. 26, No. 4, 581586
 The Author 2016. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/ckw033 Advance Access published on 31 March 2016
.........................................................................................................
Alcohol drinking cultures of European adolescents
Astrid B. Braker, Renate Soellner

University of Hildesheim, Institute for Psychology, Hildesheim, Germany

Correspondence: Renate Soellner, Institute for Psychology, University of Hildesheim, Universitatsplatz 1, 31141
Hildesheim, Germany, Tel: + 49-(0)5121/883-10916, Fax: + 49-(0)5121/883-10900, e-mail: soellner@uni-hildesheim.de

Background: Adolescent alcohol use varies across Europe. Differences in use might be due to variations in social
drinking norms. These norms become apparent, e.g. in different proportions of alcohol drinking types per country.
This studys purpose is to cluster European countries according to prevalence rates of alcohol drinking habits
among adolescents aged 1216. Methods: Based on results of previously done cluster analyses regarding
alcohol use patterns in Europe, a second level hierarchical cluster analysis is performed. To do so, the proportions
of each drinking pattern per country (non, mild, episodic, frequent and heavy episodic use) across 25 European
countries (N = 48 423, M = 13.83 years, 48.5% male) are used as classifying variables. Results: Three country clusters
are extracted that differentiate between eight countries with mainly non-using adolescents, six countries with
adolescents who use alcohol in a mainly mild but frequent way and 11 countries that show the highest propor-
tions of (heavy) episodic drinking adolescents. Conclusions: When applying and developing intervention
strategies, differences in adolescent alcohol drinking cultures (i.e. social drinking norms) within Europe should
be focused on. Alcohol policies and prevention programs should take cultural aspects like social drinking norms
into account.
.........................................................................................................

Introduction To date, many studies have proposed classifications of drinking

uropean adolescents attract public attention because of their high
Ealcohol consumption 1
but adolescent alcohol use varies consid-
erably across as well as within European countries. Studies like the
European School Survey Project on Alcohol and other Drugs
(ESPAD),2 the Health-Behaviour in School-aged Children Study
(HBSC)3 or the cross-national research-project Alcohol Abuse
among AdolescentsEffective environmental strategies for
Prevention (AAA-prevent)4 point to the widespread drinking
habits of 1116 years old from 25 to 36 European countries. They
show that there are countries with relatively low (e.g. Armenia) as
well as countries with very high (e.g. Denmark) consumption rates.
By comparing these studies, Soellner et al.5 revealed that Northern
and Eastern European countries, e.g. show a higher alcohol affinity
than Southern or Western countries.
While those studies mostly reported univariate indicators of
alcohol use, such as prevalence rates, it was claimed that multiple
indicators should be used to describe patterns of alcohol use in
order to draw a more comprehensive picture of adolescent alcohol
use.6,7
cultures based on alcohol use data or on theoretical assumptions (for
an overview cf. Ref. 8). First, Sulkunen9 contrived the typology of
wine-, beer- and spirit-cultures, according to which countries are
grouped based on the beverages that are traditionally preferred (e.g.
Italy is labelled a wine-country). This typology was reconsidered
and modified by Leifman10 who distinguished between wine-,
beer- and former-spirit-drinking countries. Another popular
approach was proposed by Room and Makela,11 who, according to
a countrys common alcohol drinking style differentiated between
wet and dry countries. In a wet country (e.g. Italy), moderate
amounts of alcoholic beverages are consumed frequently, whereas in
dry countries (e.g. Norway), alcohol is seldom consumed but when
it is, it is consumed in large quantities.12
Class labels based on regional habits like historical traditions,
product preferences, drinking habits and social reactions to
alcohol use were proposed by Iontchev13 for Central and Eastern
European countries. In this respect, a country from the
Mediterranean class is characterised by a preference for wine (e.g.
Bulgaria), which is consumed on a daily basis, but intoxication is
socially damned. In countries from the Central class, beer is
582 European Journal of Public Health
Table 1 Variable means per cluster (N = 48 423)
Variables
Non
Frequency of drinking occasions in the previous 0 0.62
month (beer, wine or breezers)
Intake on last drinking occasion (glasses/bottles/cans 0 1.52
of beer, wine or breezers)
Frequency of drinking occasions in the 0 0.12
previous month (spirits)
Intake on last drinking occasion (glasses of spirits) 0 0.56
N 20 770 (42.9%)
preferred and consumed on a daily basis (e.g. Czech Republic). In
countries with a Northern consumption pattern, mostly spirits are
consumed. In these countries, there is a pattern of weekend binge
drinking and drunkenness is publicly accepted (e.g. Poland).
It is mostly assumed that these classifications reflect the general
drinking habits of a country and thus also apply to adolescents
because they belong to the same social group or geographical
region.8,14 Even though these former approaches have been widely
accepted, they are highly problematic because most of them are
based in theory instead of derived empirically.13
The present study aims to fill this void by offering a new classi-
fication for alcohol drinking cultures in Europe based on empiric-
ally derived patterns of adolescent alcohol use.15 In line with this, a
countrys drinking culture is understood as the most prevalent
drinking style within the country reflecting the idea that the
prevalence of drinking habits shows a countrys drinking norms.
The novelty of this study lies in the analysis of multivariate
alcohol use patterns with regard to their variation across Europe.
On the basis of this variation, a classification of countries according
to their drinking culture (i.e. the drinking habits of adolescents) will
be developed. This study aims to answer the central research
question of whether homogeneous European regions of adolescent
alcohol drinking habits exist.
Methods
Statistical analysis
To identify country clusters, a two-step approach was chosen: (1)
Hierarchical and k-means cluster analyses were performed in a
previous study. By clustering frequency and quantity of current
alcohol use at the individual level, five distinct use patterns were
distinguished.15 The results built the foundation for developing an
adolescent drinking culture typology in step 2. (2) The proportions
of these five use patterns per country are analysed in this study by
means of a second order cluster analysis.
To categorise the 25 European countries, an exploratory hierarch-
ical cluster analysis was performed in accordance with Wards
method.16 Starting with each country as a single cluster in the
beginning, these clusters were subsequently combined stepwise
according to their proximity.17,18 The squared Euclidean distance
served as a measure of dissimilarity in the agglomerative clustering
process with a dendrogram as a basis for the final decision and
interpretation of the cluster solution. The average proportions of
each alcohol use pattern per country cluster determined the cluster
labels.19
Sample
Within the project AAA-prevent, a subsample of N = 48 423
European adolescents aged from 12 to 16 years was analysed.
Data were collected in a three-step sampling procedure (cities,
schools, classes) with eight countries (Bosnia and Herzegovina,
Use patterns
Mild Episodic Frequent Heavy episodic
1.92 12.59 3.37
5.46 6.17 15.47
0.95 4.71 2.03
3.77 4.69 7.22
20 359 (42%) 5527 (11.4%) 703 (1.5%) 1064 (2.2%)
Czech Republic, Estonia, France, Hungary, Portugal, Spain and
Switzerland) using a national sampling strategy. However, at least
one large city was included in their samples to ensure comparability
between all countries regarding large- and medium-sized cities.4,20
Thus, even though the sample is not representative on the country
level regarding age, the random city-based sampling of secondary
schools may be seen as representative regarding grades (seventh
grade: n = 16 722, 34.5%, eighth grade: n = 16 409, 33.9%, ninth
grade: n = 15 292, 31.6%). Male and female students were repre-
sented equally (male: n = 23 422, 48.5%) and more than three-
quarters were natives (n = 37 645, 77.9%). The mean age was 13.83
years (standard deviation, SD = 1.06) ranging from 12 to 16 years.
Age variation was similar across countries with a mean SD of 0.980
ranging from 0.507 (Iceland) to 1.144 (Belgium) and without sig-
nificant differences (P > 0.05).
The second level cluster analysis was conducted on the
25 European countries Armenia, Austria, Belgium, Bosnia-
Herzegovina, Cyprus, Czech Republic, Denmark, Estonia, Finland,
France, Germany, Hungary, Iceland, Ireland, Italy, Lithuania,
Netherlands, Norway, Poland, Portugal, Russia, Slovenia, Spain,
Sweden and Switzerland [participants per country: M = 2310.84,
SD = 907.17; Min = 587 (Iceland), Max = 3582 (Switzerland)].
Measures
Five patterns of use were identified based on information about
frequency and quantity of alcohol intake. Students were asked to
specify the frequency of drinking occasions during the previous
month, as well as the number of alcoholic beverages they had
consumed on their last drinking occasion. They were asked to
indicate the number separately for beer, wine or breezers and
spirits (gin, rum, vodka, whisky). The amount of spirits
consumed was measured by the glass (how many glasses), the
amount of beer, wine or breezers consumed by the sum of
glasses, (small) bottles and cans.
Non-using adolescents, mild users, episodic users, frequent
users and heavy episodic users were identified by hierarchical
and k-means clustering following Wards method (see table 1).
For a further description, see Braker et al.15
Non-users (42.9%) were those adolescents who had never
consumed alcohol in their lifetime. Mild users (42%) drank on
average 1.52 units of beer, wine or breezers or 0.56 units of spirits
on the last drinking occasion and drank this amount less than once a
month (0.62 and 0.12 times). Episodic users (11.4%) drank on
average 5.46 units of beer, wine or breezers, or 3.77 units of spirits
on 1.92 or 0.95 drinking occasions per month. Frequent users
(1.5%) drank more frequently (12.59 or 4.71 times a month) but
on average only one alcoholic drink more than the episodic users
(6.17 or 4.69 units on the last drinking occasion). Finally, heavy
episodic users (2.2%) drank alcohol two to three times during the
previous month (3.37 or 2.03 times), averaging 15.47 units of beer,
wine or breezers, or 7.22 units of spirits on the last drinking
occasion. On average, non-users were the youngest with a mean
 Alcohol drinking cultures in Europe 583

Table 2 Percentages of alcohol user types per country (sorted by proportions of non-users)

Non-users Mild users Episodic users Heavy episodic users Frequent users Risky users

Iceland 81.1 14.2 3.6 0.4 0.7 4.7

France 72.5 22.1 4.0 1.0 0.5 5.5
Bosnia-Herzegovina 71.5 24.0 3.7 0.6 0.2 4.5
Portugal 62.3 28.9 7.9 0.6 0.3 8.8
Cyprus 59.1 34.0 5.2 1.0 0.7 6.9
Sweden 55.7 30.9 10.9 1.7 0.8 13.4
Norway 55.3 29.7 12.3 2.2 0.5 15
Spain 54.4 29.9 12 1.9 1.9 15.8
Slovenia 45.5 46.0 6.0 2.3 0.3 8.6
Italy 44.6 45.3 7.9 1.0 1.1 10
Belgium 43.3 40.7 12.2 2.1 1.6 15.9
Austria 42.5 39.2 13.9 2.6 1.8 18.3
Switzerland 42.3 38.4 13.1 3.3 2.9 19.3
Ireland 40.2 32.4 22.8 3.2 1.4 27.4
Netherlands 39.5 39.3 14.8 4.4 2.0 21.2
Germany 38.6 42.3 13.1 3.6 2.3 19
Poland 36.1 44.6 14.2 4.0 1.0 19.2
Russia 34.9 54.6 7.8 1.3 1.4 10.5
Denmark 34.3 35.3 23.3 4.8 2.3 30.4
Finland 33.0 40.0 21.5 5.1 0.3 26.9
Armenia 32.5 63.1 3.7 0.1 0.6 4.4
Lithuania 24.0 57.9 13.8 3.1 1.1 18
Hungary 21.5 59.8 12.4 1.6 4.8 18.8
Czech Republic 20.1 63.6 12.9 2.1 1.2 16.2
Estonia 19.1 56.3 18.6 1.7 4.3 24.6
Means 44.16 40.50 11.66 2.23 1.44 15.33

Note. Risky users represent the sum of the proportions of episodic, heavy episodic and frequent users per country.

age of 13.50 years (SD = 1.02), whereas mild users were, on average,
13.93 years (SD = 1.01) old. Episodic, heavy episodic and frequent
users average age was very similar: 14.43 years (SD = 0.92), 14.59
years (SD = 0.97) and 14.58 years (SD = 0.98), respectively. However,
the adolescents ages range from 12 to 16 years within each cluster.
Thirteen years old represent the biggest group of non-users (35%),
whereas 36.5% of mild users are 14 years old. Fifteen years old
represent the largest group of episodic (39.8%), heavy episodic
(40.4%) and frequent (37.2%) users. While gender distribution
was fairly even among non-users (52.9% female) and mild users
(52.7% female), the proportion of male students was higher in the
clusters with more intense use habits (heavy episodic use: 66.5%,
frequent use: 65.3%, episodic use: 52.8%).
The proportions of each adolescent alcohol user group per
country were used as clustering variables in the second order
cluster analysis. Percentages were used to account for different
sample sizes per country. Additionally, a group of risky users was
built by summarising the proportions of episodic, frequent and
heavy episodic users per country. As all these three drinking styles
fulfil the criteria of heavy episodic drinking (at least five drinks on a
single drinking occasion), so that an objective criterion for high risk
alcohol use is present.2
Results
Aggregating the patterns of use per country resulted in the distribu-
tion presented in table 2. In all countries, a substantial part of the
adolescent population did not drink alcoholic beverages at all
[M = 44.4%, SD = 16.5, Min = 19.1% (Estonia), Max = 81.1%
(Iceland)] or only mildly [less than once a month or less than one
drink on the previous drinking occasion; M = 40.5%, SD = 13.1,
Min = 14.2% (Iceland), Max = 63.6% (Czech Republic)]. By
combining the three more intense patterns of use (episodic,
frequent and heavy episodic use) into one category, an average of
15% (SD = 7.53) of adolescents across all countries can be classified
as risky users. Denmark has the highest proportion of risky users
(30.4%), whereas Armenia has the lowest (4.4%). Although there is a
lot of variation among the 25 countries with regard to the
proportion of episodic users (SD = 5.79), the proportion of
heavy episodic users (SD = 1.40) and frequent users (SD = 1.18)
are more similar although proportions do vary from 0.4% (Iceland)
to 5.1% (Finland) for the former and from 0.2% (Bosnia-
Herzegovina) to 4.8% (Hungary) for the latter.
The hierarchical cluster analysis on country level resulted in a
three-class solution, which differentiates between (i) countries with
mainly non-using adolescents (n = 15 587; 27% of total sample), (ii)
countries with mainly mild but frequently using adolescents
(n = 14 474; 25.1%) and (iii) countries with a high proportion of
the intense using patterns episodic and heavy episodic use
(n = 27 710; 48%) (figure 1). The first cluster (mainly non-users)
includes Sweden, Norway, Portugal, Cyprus, Bosnia-Herzegovina,
Spain, France and Iceland. In these countries, the majority of ado-
lescents do not drink alcoholic beverages at all (64.0%). Mild
(26.7%), episodic (7.5%), frequent (0.7%) and heavy episodic
users (1.2%) are less prevalent (see table 3).
The second cluster includes the Eastern European countries
Estonia, Czech Republic, Lithuania, Russia, Armenia and Hungary.
In these countries, the majority of adolescents drink frequently but
only mildly. In contrast to the first cluster, the proportion of non-
using adolescents is rather low (25.4%). Out of the three clusters,
this cluster has the highest proportion of mild users (59.2%) and
frequent users (2.2%), whereas 11.5% and 1.7% of adolescents are
classified as episodic and heavy episodic users, respectively.
The third cluster includes the Central European countries The
Netherlands, Germany, Switzerland, Austria, Belgium, Poland,
Italy, Slovenia, Denmark, Finland and Ireland. In these countries,
the majority of adolescents do not drink alcoholic beverages at all
(40.0%) or only mildly (40.3%). However, out of the three clusters,
this cluster has the highest proportion of (heavy) episodic users
(18.1%). An average of 1.6% of adolescents are frequent users.
This decision for a three-cluster solution is based on the
compromise between choosing a sufficient number of clusters to
picture the complexity of the behaviour in question and as few
clusters as possible for reasons of clarity.21 The alternative two-
584 European Journal of Public Health
Figure 1 European adolescent alcohol drinking clusters on country level. Middle grey: mainly non-users (cluster 1), dotted: mainly mild but
frequent users (cluster 2), dark grey: highest proportion of (heavy) episodic users (cluster 3)
Table 3 Mean percentages of use patterns per country cluster
Country cluster Non-users
Cluster 1: mainly non-users 64.0
Cluster 2: mainly mild but frequent users 25.4
Cluster 3: highest proportion of (heavy) episodic users 40.0
cluster solution shows the highest squared Euclidean distance of 10
688.58 but only discriminates between the eight countries with
mainly non-using adolescents and the remaining countries. The
four-cluster solution separates Iceland into its own fourth cluster.
In both cases, a meaningful and practicable interpretation was less
obvious, which is why the three-cluster solution was chosen as the
best fitting solution with a sufficient coefficient of dissimilarity of
3662.04.
Discussion
The aggregation and clustering of patterns of alcohol use in adoles-
cence across 25 European countries resulted in a three cluster
solution. Cluster 1 includes the eight countries with the highest
proportion of non-using adolescents. Cluster 2 includes the six
countries with the highest proportion of mild but frequent users.
Cluster 3 includes the 11 countries with the highest proportion of
(heavy) episodic users compared with the other clusters. This ex-
ploratory approach offers the first categorisation to be empirically
Mild users Episodic users Heavy episodic users Frequent users
26.7 7.5 1.2 0.7
59.2 11.5 1.7 2.2
40.3 14.8 3.3 1.6
derived by using a multivariate procedure, based on self-reported
alcohol use data and previously determined alcohol use patterns, and
thus reflects current adolescent drinking cultures in Europe.
The first cluster with mainly non-using adolescents comprises
those countries that have often been subsumed as wet- or wine-
drinking-cultures according to prior classifications, e.g. France.9,11
In contrast, the present study reveals that Italy seems to no longer be
a part of this cluster, whereas Norway now is. This might reflect a
recent change in national drinking habits.22,23 Although in Italy the
consumption of wine has decreased in favour of beer among the
younger generation, the consumption of wine and spirits in Nordic
countries has increased.22,24,25
Eastern European countries (e.g. Hungary or Lithuania) form the
cluster with mainly mild but frequent users. Even the Czech
Republic, which is geographically located right in the middle of
more intensively drinking cultures like Austria or Poland (cluster
3), showed this mild but frequent pattern of use. In contrast to
Iontchevs classification13 Hungary showed no similarities to
countries from the Mediterranean class, but belongs to the

second cluster of mainly mild but frequently using countries like
other Eastern European countries.
The largest cluster, consisting of 11 countries, cuts a north-south-
swath right through Central Europe from Finland to Italy (with
Ireland as a geographical outlier) that separates the mainly non-
using countries in the West from the mainly mild but frequently
using countries in the East of Europe. Here, in the centre of Europe,
non-use, mild use and frequent use of alcohol are all common
drinking styles. However, in addition, the patterns of alcohol use
that are regarded as most risky for adolescent health (episodic and
heavy episodic use) are comparably more prevalent and therefore
determined the cluster label. In accordance to Iontchev,13 Poland
was also classified in the Central European cluster of countries in
this study.
The present study provides further evidence for an alcohol use
map of the European continent that is different for adolescents than
for adults and that has undergone a change in the last years.11,22
However, discrepancies between the cluster labels and the compos-
ition of the clusters in the present study are obvious, too.
In countries with mainly mild but frequent users (cluster 2),
11.5% of adolescents are grouped as episodic users, whereas a
relatively large amount of adolescents in countries with the highest
proportion of intense drinkers (cluster 3) do not use alcohol at all
(40.0%) or only mildly (40.3%). Because this studys focus was on
the proportion of use patterns in comparison between countries,
cluster labels are derived from the between and not within cluster
comparison.
Given the huge differences in the drinking habits of 1216 years
old even within one age group, clustering their drinking habits
within one analysis is questionable. The confounding of alcohol
use habits and age is evident within the clusters. Non-users or
mild users turned out to be younger, whereas episodic, frequent
and heavy episodic users were comparably older. In this study, no
standardisation according to age was applied in favour of an epi-
demiological instead of a developmental perspective.
Since figures from the AAA-prevent study show many similarities
compared with the ESPAD and HBSC results from 2007 and 2005/
2006, validity of the self-reported data seems to be evident.5 But
because the original focus of the ISRD-2 study was on delinquent
behaviour, the alcohol-related variables lack some details. Wine, beer
and breezers as types of beverages, e.g. were not differentiated and
the amount of pure alcohol consumed on a single drinking occasion
could not be determined because information on the sizes of the
alcoholic beverages used was not requested. Finally, though the
sample is not nationally representative, it is a school-based sample
for large and medium cities. Thus, data are internationally
comparable in terms of grades but participants of the ISRD-2
survey cannot be assumed to be representative for adolescents of
their respective country, e.g. for adolescents in rural areas or small
towns.
The clusters are based on prevalence rates of drinking styles per
country and therefore reflect a countrys social norm regarding
alcohol consumption. Whether these social norms effect the devel-
opment of certain drinking and whether adolescents attitudes
towards alcohol differ according to the drinking patterns in their
countries should be the subject of future research.
Taking non- and mild using patterns as favourable outcomes, we
might conclude that in each country cluster the majority (over 80%)
of 1216 years old are not at risk. However, drinking alcohol
frequently in that age is problematic because of habituation,
whereas drinking episodically (i.e. seldom but in large amounts) is
problematic because of the harmful consequences of intoxication.26
This phenomenon of episodic use might reflect weekend alcohol
consumption and was found in all clusters in high numbers.
Heavy episodic use (i.e. more frequent and larger amounts than
episodic use) is not as common but reflects the most dangerous
behaviour, combining the risk resulting from frequent intake with
that of consuming large amounts of alcohol. According to this
Alcohol drinking cultures in Europe 585
perspective, Western European countries clearly show the least
whereas Central European countries show the most problematic
behaviour when summarising episodic, frequent and heavy
episodic users as a group of risky users.
Within the last decades in the European Union, a homogenisation
of alcohol control policies as well as of environmental preventive
efforts can be observed through, e.g. increases in taxes and similar
legal age limits for purchasing alcohol.10,27 Some policy strategies,
especially price regulations, have proven to be effective and lower
adolescent alcohol use.1,28 However, given the large differences
regarding adolescent drinking habits within Europe, the question
arises as to why this growing harmonisation in alcohol policies is
not associated with similar alcohol drinking habits across countries.
The missing link between policy and behavioural outcomes might
be the strength of implementation of policy efforts. Regarding the
implementation of policy or prevention, it might be helpful to learn
from the experiences of other countries, which might not suffer from
the same problems, e.g. regarding prevention strategies.
High frequency and intensity of adolescent alcohol use increase
the probability of substance use problems29 and various health or
social problems.30,31 Thus, adolescent drinking regulation is a topic
with major public health relevance. Many efforts for cross-national
agreements and guidelines regarding alcohol regulation (e.g. for
parents) have already been established.28,3234 This study suggests
a new country classification and shows that it is important to
consider the differences in alcohol use and drinking culture
between European regions.
Acknowledgements
Members of the AAA-Prevent research group were Majone Steketee,
Harrie Jonkman, Claire Aussems and Jessica van den Toorn
(Verwey-Jonker Institute, Utrecht, The Netherlands); Nicole
Vettenburg and Hans Berten (Ghent University, Ghent, Belgium);
Anna Markina and Kristjan Kask (University of Tartu, Tallinn,
Estonia); Uberto Gatti, Alfredo Verde and Gabriele Rocca
(University of Genoa, Genoa, Italy); Jiri Burianek and Zuzana
Podana (Charles University Prague, Prague, Czech Republic);
Herbert Scheithauer and Kristin Gobel (Freie Universitat Berlin,
Berlin, Germany); Renate Soellner and Astrid-Britta Braker
(University of Hildesheim, Hildesheim, Germany).
Funding
The project AAA-Prevent was funded by the European Commission,
Seventh Framework Programme [Grant Agreement No 242204].
Conflicts of interest: Authors report no conflicts of interest.
Key points
 Three alcohol drinking cultures for European adolescents
can be identified that distinguish between eight countries
with mainly non-using adolescents, six countries with ado-
lescents who use alcohol in a mainly mild but frequent way
and 11 countries that show the highest proportion of
(heavy) episodic drinking adolescents.
 In comparison to former classification approaches, this
studys second-order clustering is derived empirically with
a multivariate approach based on individual patterns of
alcohol use.
 For the development and design of health policies and
substance use prevention it is recommended that countries
work in groups to learn from each other and to better
understand the European variability in adolescent alcohol use.
586 European Journal of Public Health
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