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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
MEDICAL ACADEMY FACULTY OF MEDICINE
Gil Gregory Kotlarevsky
ADOLESCENCE,
FAMILY INVOLVEMENT AND HARMFUL SUBSTANCE USE
(HBSC STUDY RESULTS)
In the Department of Preventive Medicine
Submitted in partial fulfilment of the requirements for the degree of
Master of Medicine
Scientific supervisor:
Apolinaras Zaborskis, dr. habilitatus, professor
50 pages
June 2017 Kaunas
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TABLE OF CONTENT
Summary...3
1. Introduction...4
2. Aim and Objectives...5
3. Literature review...7
3.1 Adolescents 7 3.2 Harmful substance use among adolescents 8 3.3 Family 11 3.4 Family sphere as core protective factor 13 3.5 Summary 15 4. Methods...16
4.1 Subjects and Study Design 16
4.2 Ethics 16
4.3 Instruments and measurments 16
4.4 Statistical Analysis 19 5. Results...23
5.1 Family characteristics 23
5.2 Prevalence of substance use 25
5.3 Association between prevalence of substance usage and familial determinants 27
6. Discussion...36
7. Conclusions...43
8. Abreviations...44
9. Declarations...44
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SUMMARY
Title: ADOLESCENCE, FAMILY INVOLVEMENT AND HARMFUL SUBSTANCE USE
(HBSC STUDY RESULTS)
Author: Gregory Gil Kotlarevsky
Scientific supervisor: Apolinaras Zaborskis, dr. habilitatus, professor
Department of Preventive Medicine, Faculty of Public Health, Medical Academy, Lithuanian University of Health sciences, Kaunas; 2017, 50 pages.
Background: Adolescence is considered to be a cornerstone period in which an individual’s
personality is actively developed. It has been hypothesized, that the level of family involvement plays a crucial factor in the occurrence of harmful substance use among adolescents, however, data in this field of research is scarce.
Aim of the study: To evaluate the association between determinants of family involvement and
harmful behaviour (smoking, drunkenness and cannabis use) among representative sample groups of adolescents from Bulgaria, Czech Republic, Israel, Lithuania, Poland, and Slovakia.
Objectives: 1) To analyse family involvement in adolescent lives by various parameters. 2) To
assess prevalence of harmful substance use in group samples of adolescents from representative countries. 3) Study the relationship between family variables and substance use in adolescents and compare associations between countries.
Subjects and Methods: Study subjects (N= 10,291) were 15-years old adolescents from schools in
6 countries (Bulgaria, Czech Republic, Israel, Lithuania, Poland, and Slovakia) who were surveyed in the Health Behaviour in School-aged Children (HBSC) cross-national survey carried out in 2013/2014 with the support of the World Health Organization (WHO). The survey was conducted by means of self-report standardized questionnaires that were administrated in school classrooms ensuring confidentiality and anonymity of the participants. Relationship between variables was estimated by methods of logistic regression analysis.
Results: Drunkenness was the most prevalent risky behaviour across countries. Prevalence of
smoking was highest among adolescents from Bulgaria; prevalence of drunkenness was highest among adolescents from Bulgaria and Lithuania; the prevalence of cannabis use was highest among adolescents from Poland, Czech Republic and Bulgaria. Univariate analysis revealed variations in the superiority of relevance of familial variables across regions. Multivariate analysis adjusted for gender and family affluence revealed that parental control over the child, especially the mothers, living with both parents, and having high satisfaction with relationship in family were established to be the most substantial protective key factors against use of harmful substances among 15-year-old adolescents. These determinants were highly significant for all three investigated harmful behaviours and increased their risk nearly by two folds. Time with the family and communication with the parents were less predictive factors for harmful behaviours.
Conclusions: Prevalence of smoking, drunkenness and cannabis use varies greatly across countries
and there are significant differences in gender distribution. Parameters of family involvement in adolescent lives also vary between countries and regions. However, all risk behaviours of adolescents are associated with matters of family, including non-intact family structure, poor parental supervision (especially the mothers’) and low satisfaction with family relationship. For all countries, mothers play more significant role than the fathers both in communication with the child and controlling his daily activity. These findings must be considered in preventive programmes of harmful substances use in adolescence.
Keywords: Adolescents. Family. Parents. Health behaviour. Harmful substances. Smoking.
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SANTRAUKA
Pavadinimas: PAAUGLYSTĖ, ŠEIMOS ĮSITRAUKIMAS IR PAVOJINGŲ SVEIKATAI
MEDŽIAGŲ VARTOJIMAS (HBSC STUDIJOS REZULTATAI)
Autorius: Gregory Gil Kotlarevsky
Mokslinis vadovas: Apolinaras Zaborskis, habil dr., profesorius
Lietuvos sveikatos mokslų universitetas, Medicinos akademija, Visuomenės sveikatos fakultetas, Profilaktinės medicinos katedra. Kaunas, 2017. 50 psl.
Įvadas: Paauglystė – tai ypatingas asmenybės vystymosi amžiaus tarpsnis. Vyrauja nuomonė, kad
šeima turi didelį vaidmenį paaugliams įsitraukiant į pavojingų sveikatai medžiagų vartojimą, tačiau mokslinių tyrimų šiuo klausimu nėra daug.
Tyrimo tikslas: Ištirti ryšį tarp šeimos veiksnių ir paauglių rizikingo elgesio (rūkymo, svaiginimosi
alkoholiu ir kanapės vartojimo) reprezentatyviose paauglių grupėse, ištirtose įvairiose šalyse.
Uždaviniai: 1) Išanalizuoti veiksnius, charakterizuojančius šeimos įtraukimą į paauglių gyvenimą.
2) Įvertinti žalingų sveikatai medžiagų vartojimą tarp penkiolikmečių paauglių tyrime dalyvavusiose šalyse. 3) Nustatyti ryšį tarp šeimos veiksnių ir žalingų sveikatai medžiagų vartojimo tarp paauglių ir šį ryšį palyginti tarp skirtingų šalių.
Tiriamieji it tyrimo metodai: Buvo analizuojami penkiolikmečių paauglių tyrimo duomenys (N=
10,291), surinkti atlikus Pasaulio sveikatos organizacijos koordinuojamą tarptautinį „Mokyklinio amžiaus vaikų gyvensenos ir sveikatos (HBSC)“ tyrimą 2013/2014 mokslo metais 6 šalyse (Bulgarijoje, Čekijos Respublikoje, Izraelyje, Lietuvoje, Lenkijoje ir Slovakijoje). Tyrimas buvo vykdomas pagal standartizuotą metodiką mokyklose, naudojant vienodus klausimynus ir užtikrinant tiriamųjų anonimiškumą ir duomenų konfidencialumą. Ryšys tarp kintamųjų įvertintas logistinės regresinės analizės metodu.
Rezultatai: Iš visų tirtųjų paauglio žalingo sveikatai elgesio formų labiausiai buvo paplitęs
girtavimas; jis labiausiai pasireiškė Bulgarijoje ir Lietuvoje. Didžiausias paauglių rūkymo paplitimas stebėtas Bulgarijoje; kanapių vartojimas - Lenkijoje, Čekijos Respublikoje ir Bulgarijoje. Vienaveiksnė analizė atskleidė, didelę šeimos veiksnių įvairovę tirtose šalyse. Daugiaveiksnė analizė, suvienodinus duomenis pagal lytį ir šeimos turtingumą, atskleidė, kad tėvams, ypač motinai, kontroliuojant kasdieninę paauglio veiklą, gyvenant su abiem biologiniais tėvais ir esant geriems tarpusavio santykiams šeimoje, reikšmingai sumažėja penkiolikmečių paauglių žalingo elgesio rizika. Šie veiksniai buvo ypač reikšmingi visoms žalingo elgesio formoms ir sumažino jų riziką daugiau negu du kartus. Kartu su tėvais leidžiamas laikas ir darnus bendravimas su tėvais buvo mažiau reikšmingi penkiolikmečių žalingo elgesio apsauginiai veiksniai.
Išvados: Nežiūrint skirtumų tarp žalingų sveikatai medžiagų vartojimo paplitimo ir šeimos veiksnių
charakteristikų įvairovės, visose šalyse paauglių sveikatai žalingas elgesys dėsningai siejasi su šeimos veiksniais. Tokio elgesio riziką didina pažeista šeimos struktūra (paauglys gyvena ne su abiem biologiniais tėvais), nepakankama paauglio veiksmų kontrolė (ypač iš motinos pusės), nepasitenkinimas šeimos narių tarpusavio santykiais. Visose šalyse stebėtas didesnis motinos nei tėvo vaidmuo bendraujant su paaugliu bei kontroliuojant kasdieninę jo veiklą. Tyrimo duomenys gali būti reikšmingi kuriant paauglių žalingo elgesio prevencines programas.
Raktiniai žodžiai: Paaugliai. Šeima. Tėvai. Gyvensena. Sveikatai žalingų medžiagų vartojimas.
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1. INTRUDUCTION
Smoking tobacco, drinking alcohol and cannabis use are three very common, different risk taking behaviours among adolescents of the world. The use of these substances have be proven to have multiple consequences on both physical and mental aspects of young adult health and devastating outcomes such as addiction, drunkenness and social withdraw.
Over the past few decades, an increase interest and efforts of researchers, educators and healthcare providers around the globe has been observed in understanding the phenomena of use and misuse of harmful substances. It has been suggested that those who start at early ages are likely to continue well into adulthood. For that reason, scientific research is focusing particularly at adolescents. Actions taken by health care providers and policy makers to increase health policies interventions and implement them in the world as part of active substance use control actions are being constantly evaluated for efficiency. Resent data point that despite actions such as, restrictions on tobacco advertising and smoking in public places, tobacco taxes, visual warnings on tobacco products, law enforcements and sanctions on liquor shops for selling products to under aged teenagers, countless cessations of cannabis from drug dealers, introduction of adolescents’ prevention programs in educational facilities, limited effects have been observed in decreasing the occurrence of use among young adults.
Adolescence may be defined as the period within the life span when most of a person's biological, cognitive, psychological, and social characteristics are changing from what is typically considered child-like to what is considered adult-like. As the family is the earliest and most primitive framework an adolescent has in their lives, focused attention was given by researchers and professionals into understanding the development of adolescents and the dynamics of the family role in predicting positive development of youth and as part of it, the effects it has on the development, onset and prevalence of substance use. According to research, there is a strong association between the predisposition of adolescents to harmful substance use and their interrelationship within their family.
The rationale for the conduction of this study is embedded in the following reasons:
(1) Risk taking behaviour among young adults reflects the status of our society. High prevalence of substance use around the world despite the widespread knowledge of the dangers accompanying it require further continuous investigations to understand and face the problem properly.
(2) Modern prevention methods seem to have limited effect on decreasing the prevalence of harmful substance use among adolescents since the numbers are still disturbingly large. Different approaches are necessary to be considered and studied for the appropriate direction of the society efforts and resources to eradicate harmful behaviour among adolescents.
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2. AIM AND OBJECTIVES
Aim
The study will attempt to evaluate the association between determinants of family involvement in adolescents’ life and harmful behaviour (smoking, drunkenness and cannabis use) from a cross national prospective. The representative sample groups of adolescents are from Bulgaria, Czech Republic, Israel, Lithuania, Poland, and Slovakia.
Objectives
1) To analyse family involvement in adolescent lives by various parameters such as family structure, parental control, communication with the parents, satisfaction with relationship in the family, frequency of time spent with family
2) To assess prevalence of tobacco smoking, drunkenness and cannabis use in group samples of adolescents from the representative countries.
3) To study the relationship between family variables and substance use in adolescents and compare results between countries from the representative countries.
Our study will attempt to evaluate association from a cross national prospective, however, there are limitations by possible cultural, social- economical and trend of use patterns between countries. The study might be useful in order to generalize findings of adolescent’s populations from other countries.
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3. LITERATURE REVIEW
3.1 Adolescents
Adolescence is a period in the human maturation and development that occurs after childhood and before early adulthood, between ages 10 to19. It represents one of the most important transitions in the life span of a human being, and characterized by a tremendous pace in growth and changes that are second only to that of infancy. For all human, it is mostly, the biological processes that drive many aspects of this growth and development with the beginning of puberty marking the onset of passage from childhood to adolescence. The biological determinants of adolescence are quite similar and vary little; however, this period properties, experiences, duration and characteristics have multiple variations across time, cultures, costumes as well as socioeconomic status. In the past it has often been relatively rapid, and in some societies it still is. In many countries, however, this is changing. Time between childhood and adulthood is lasting longer, puberty is starting earlier in many countries. At the same time, basic social transformations to adulthood are postponed until well after biological maturity. More attention and time is given to education and training from young people, their expectations from life have changed, and the increasing availability of contraception for prevention of pregnancy results in young people take on adult roles and responsibilities such as family formation and employment much later in life [1, 2].
In addition to physical and sexual maturation, several key developmental tools are being learned. These include progression toward social and economic independence and development of identity, Acquisition of skills needed to carry out adult relationships and roles, learn to manage emotions and acquire the capacity for abstract reasoning. These are very important tools for making responsible decisions with issues such as alcohol drinking, tobacco smoking, Cannabis use and other substance use. While adolescence is a time of tremendous growth and potential, it is also a time of considerable risk during which the social contexts of the rapidly increased exposure to a bigger circle of acquaintances and external information such as the mass digital media, start to exert powerful influences over ones personality. The tools mentioned above, which are formed from the impressions and experience of all stimulations surrounding an individual during these period, in the beginning, mostly affected by the parents and family environment. Adolescence period is an opportunity window for the parent to develop a healthy form of relationship with the young adult. A connection which will allow the parent to deliver useful, experienced insights in proper timing and way [3].
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During the past century, the world society met many changes such as the global urbanization, industrial globalization, High Tech revolution, Internet, mass digital media, smartphone, sex equality with career choosing, changes in attitude toward sexual orientation and diverse sexual behaviour acceptance. These changes, that occur at a very rapid pace create a much different environment for children to grow and develop in, and as integrated from the former, different environment for parenting [4]. For some countries in central, eastern, northern Europe and Asia drastic changes in political, socio-economical views during the last decade of the 20th century tragically affected the structure of the family [5]. With increased number of divorces, decline in birth rate and increase in extramarital births, Changes as such, brought alongside with them an enormous amount of modifications in the ability to supervise and monitor adolescents in the family construct, and according to studies increased the prevalence of tobacco smoking, drinking and drug use among adolescents [6,7].
3.2 Harmful substance use among adolescents
Tobacco, alcohol and cannabis use are all classified as substance use. However, each one of them poses different health hazards, outcomes, and circumstances of use initiation in context of youth. The occurrence of risk taking behaviour have multiple implications on the individual level, family environment and society. As the future of drug policy in the U.S. and other countries continues to be debated, there is an increased likelihood that youth will have greater access to some substances, particularly marijuana. It is within this context that the need to understand the effects of using marijuana, alcohol, tobacco, and other drugs becomes more urgent than ever before [8,9].
Tobacco
“The saddest part of life right now is that science gathers knowledge faster that society gathers wisdom” Issac Asimov.
According WHO, Tobacco use is the leading global cause of preventable death. Direct tobacco smoking kills nearly 6 million people and nearly 600,000 deaths due to second hand smoking each year. Most of these deaths occur in low- and middle-income countries, and this disparity is expected to widen further over the next several decades. Over the course of the 21st century, tobacco use could kill a billion people or more unless urgent action is taken [10]. It poses a serious health threat to youth and young adults in the world and has significant implications for the global public and economic health in the future. Tobacco prevalence is highest among young adults between ages 18-24 and decrease with further progression with age. In times of increased sensitivity to normative influences, tobacco use is less tolerated in public areas and there are fewer social or regular users of
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tobacco. There are evidence of prevalence reduction among youth in some countries, however research show that prevalence increase with age [43].
Although the impact of cigarette smoking and other tobacco use on chronic disease, is well-documented and undeniable, and progress has been made since the beginning of acknowledgment of the harms of tobacco in preventing smoking among young people, nearly one in four high school seniors and one in three young adults under age 26, smoke. Of every three young smokers, only one will quit, and one of those remaining smokers will die from tobacco-related causes. Most of these young people never considered the long-term health consequences associated with tobacco use when they started smoking; and nicotine, a highly addictive drug, causes many to continue smoking well into adulthood, often with deadly consequences. As most young smokers become adult smokers one-half of adult smokers die prematurely from tobacco-related diseases [11, 12].
Despite multiple programs to reduce youth smoking and even much larger amount of media stories on the dangers of tobacco use, generation after generation continues to use these deadly products, and family after family continue to struggle with the consequences of tobacco products use. From gathered evidence, nearly all tobacco use begins in childhood and adolescence.In all, 88% of adult smokers who smoke daily report that they started smoking by the age of 18 years. This is a time in life of great vulnerability to social influences [13, 14]. The 1994 Surgeon General’s Report which focuses solely on young people, suggested that if young people can remain free of tobacco use until 18 years of age, most will never start smoking. The report present tobacco as a gateway drug because its use can precede and increase the risk of using other illicit drugs [19].
Rapid increase of the circle of acquaintances in school and in extracurricular activities, direct and subliminal efforts of the tobacco companies to market tobacco products by using attractive role models as in movies, TV shows and flashy advertisements, spread of the smart personal mobile devices worldwide and the growing exposure to social media, all contribute to the phenomena of social influence, which have especially strong effects on the young [15-17].
Alcohol
One of the most widely available and most commonly used drugs for adolescents. Although youth drink less often than adults do, when they do drink, they drink more. In 2014, 8.7 million young people in the US aged 12–20 reported that they drank alcohol beyond “just a few sips” in the past month. 12 – 20-year-olds drink 11 percent of all alcohol consumed in the United States [20]. It is estimated that on average, alcohol is a major factor in the deaths of 4,358 young people under age 21 each year. This includes: 1,580 deaths from motor vehicle crashes; 1,269 from homicides; 245 from alcohol poisoning, falls, burns, and drowning; and 492 from suicides. Consumption of alcohol
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can have an impact not only on the incidence of diseases, injuries and other health conditions, but also on the course of disorders and their outcomes in different individuals. Alcohol-related harm is determined, apart from environmental factors, by three related dimensions of drinking: the volume of alcohol consumed, the pattern of drinking and, on rare occasions, also the quality of alcohol consumed [21].
Adolescence is a vigorous period of discovery and experimentation during which many young people begin to explore what they perceive as adult behaviours, such as drinking alcohol. Young people may use alcohol to fulfil social and personal needs, intensify contacts with peers and initiate new relationships. This may be interpreted as a natural, perhaps even healthy, curiosity about transitioning to adult life in which alcohol is used, but not misused. Nevertheless, Alcohol constitutes a major public health concern in many European and North American countries and regions. Risky drinking, including early and frequent drinking and drunkenness, is associated with adverse psychological, social and physical health consequences, including academic failure, violence, accidents, injury, use of other substances and unprotected sexual intercourse [1-3,22]. Moreover, it has also been suggested that drinking alcohol during adolescence may negatively affect brain development and functioning [23]. Lack of knowledge regarding the limits for safe alcohol consumption and social motivation to experience drunkenness means that for some adolescents, experimentation can turn into excessive rates of use, with the physical, mental and social risks it brings [24].
Cannabis
The most frequently used drug in Europe, with 14.6 million young adults using it in 2014. It is the illicit substance used most frequently by school aged children across Europe, North America and Canada. Recently, many countries have introduced new regulatory approaches and policies to enable the prescription of cannabis for medical purposes and public debate on legalization for recreational use is growing. 8 states of the United States including Washington DC and countries as Netherlands, Uruguay, Argentina and Belgium have implemented policies that legalize cannabis for recreational use for people over the age of 21. In addition, many countries in Europe and worldwide direct their policy toward low level of surveillance over cannabis use and decriminalization policies are implemented there. Surveys show that whether there is strict or minor surveillance, prevalence seems to be growing globally and equally with age in both genders [25].
Adolescents use the drug for a variety of reasons, including experimentation, mood enhancement, social enhancement and peer conformity [26]. In comparison to Alcohol and tobacco smoking, scientific research is inconclusive about significant physical addiction or mortality
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associated with cannabis use. However, evidence proves that cannabis is a very dangerous substance for children and young people, especially for those who use it regularly. Early onset and heavy and accelerating use are related to problems such as impairment in brain development and degeneration of brain cells, low height and weight, anxiety attacks, short-term memory loss, risk-taking behaviour, aggression and delinquency, depression and anxiety, and other cognitive disorders. The development of the so-called lack-of-motivation syndrome can cause deteriorating school performance and dropout. Cannabis use may trigger mental disorders and psychosis especially in those who are predisposed genetically to the disorder [27-32].
Recent population surveys show that the perception of cannabis-associated risk has declined significantly as a result of the ongoing debate, political and pro-media movements on the topic [33]. Since the legalization/decriminalization of cannabis for recreational and medicinal use in many countries, studies reported variety of results, with some countries seeing an increase in prevalence, other countries report a decline in the prevalence of cannabis use among adolescents, while other show no significant impact [34, 35, 102].
Family and parents have reasonably high influence over the phenomena of cannabis [36]. Adolescents who have family member who use cannabis are more likely to use cannabis. Studies point that adolescents who experience either low parental involvement and reinforcement or high levels of coercive discipline are more likely to use cannabis [37, 38].
3.3 Family
“There is no school equal to a decent home and no teacher equal to a virtuous parent.” Mahatma Gandhi
By many definitions in dictionaries, Family may seem like a simple concept. In its most basic term, a family is a group of individuals who share a legal or genetic bond, but in fact, there is no simple definition of family as for many people, family plays different meanings, and even the simplest idea of genetic bonds can be more complicated than it seems.
Throughout the past few decades, changes introduced by the transformations in political, social and exceptional views around the world created a diversity in structures of family formations. In present time, family may exist in Variation such as Intact nuclear (biological, adoptive, homosexual/heterosexual), Single parent (biological, stepparents, adoptive), Intergenerational (sister/brother act as parent), Extended without parent (uncles as parents), institution families (Foster Care Homes, Group Homes, Psychiatric hospitals), Residential treatment facilities, Juvenile detention facilities and non-structured families such as homeless children [39].
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Despite family structure variation and cultural differences between regions, the key functions of a family seem to be remained the same for all. The goal of a family that desire to have children, in macro resolution, is to raise the young person in the healthiest possible way. The parent obligation in modern world society is to provide the child with a safe, secure, nurturing, and supportive environment, one that allows the child to have a healthy, happy youth. Consequently, the term parenting is the actions done by the parent to accomplish these obligations, and thus, parenting is the major function of the family. Parents carry out their responsibilities through the provision of a structured environment in which a child lives and organizes his or her daily life, by showing their own attitude and values concerning development, education and social norms and by daily interaction [40].
In micro resolution, family is a multifarious structure composed of various psychological and social factors. Parents and family life and their influence on adolescents’ development can be examined by many perspectives, such as: communication, monitoring, personal example of parents, parenting styles, familial values and norms, the psychological support and involvement of the parents and the extended family [41].
The issue of family and parenting with regards to harmful substance use and harmful behaviour was studied extensively. Factors such as family affluence, family structure, family connectedness, parent–child communication, parental modelling, and self-example have been proven to affect the multi-dimensional construct of the adolescence experience and have been identified to have association with the phenomena of harmful substance use. Research show that adolescents who report living with both parents, positive relationships and good communication with their parents are less likely to engage in various risk behaviours, including smoking tobacco; drinking alcohol; cannabis use; other drugs and early sexual intercourses. However, differences across regions are noted and associations to family determinants expressed variously.
One study by Garmienė et al. (2006) suggested that deficits of family time spent together, and parental habitual examples of alcohol and smoking underlie development of alcohol and smoking addictions in children to some extent [42]. A study by Zaborskis and Sirvyte et al. (2015) suggested that prevalence of smoking among adolescents of Lithuania is associated with an intact family structure as well as weaker parental support and bonding. However maternal monitoring is particularly important protective factor, particularly among girls, while the father's role seems to be diminishing in changing society. The results of this study also showed that smoking was more prevalent in those who reported low level of family satisfaction with family relationship [43]. A study by Branstetter et al. (2011) suggested that mother-adolescent relationship support was associated with lower levels of concurrent substance use, as well as lower levels of harder drug use
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over time. However, his findings highlighted the need to examine parents and peers simultaneously and the importance of parental relationships and peer behaviour on adolescent substance use [44]. Torney et al. (2013) suggested parental monitoring to be associated with positive effects on adolescent substance use with a reduction of consumption and a lower probability of having consuming peers, which seems to protect adolescents against potentially negative peer influence. The study also suggested that monitoring activities and friendships by establishing rules about what is allowed or not is a way to limit the negative influence of consuming peers on adolescent substance use [45]. A study results by Fleming et al. (2015) found that family functioning might be a significant factor in determining adolescent healthful behaviour. Family function may be helpful for understanding the process of adolescent development and internalization of health behaviors [46]. A study by Chen C et al. (2005) Found that lower parental involvement and reinforcement and higher coercive parental discipline were associated modestly with a greater risk of cannabis exposure through years of adolescence and into early adulthood, however estimated impact of parental monitoring was less durable [47]. The results of study by Luk JW et al. (2010) concluded that among sons, father communication was protective against cannabis use and mother communication was protective against smoking, however, neither father nor mother communication were protective for daughters [48]. Forehand et al. (1997) suggested that while ease of communication with parents reflects positively on general parent-child relationship however, it does not necessarily indicate the degree to which parents know about their sons’ and daughters’ substance use behaviours [49]. An article by Griffin et al. (2010) that reviewed evidence based program for preventing substance use in adolescents, found that family-based prevention program have proven to be an effective measure in terms of changing harmful behaviour among adolescents. Those family interventions that combine parenting skills and family bonding components appear to be the most effective [50].
3.4 Family as the main protective sphere
Current substance preventive methods such as law enforcement actions and bans are implemented in order to decrease the availability of the substance, however since the beginning of implementation of such methods, results of studies showed limited efficiency [51, 52, 54]. In fact, illegal industries such as the cannabis industry was pursued by law enforcement for decades with no significant results in lowering prevalence of use nor decreasing availability [51, 52]. Recently an alternative approach is starting to be implemented in many countries, similar to the one used at the end of the Prohibition-era in the year of 1933 in the United States for the illegal alcohol industry, legalization [53]. Legalization of cannabis for medicinal/recreational uses and governmental taxes
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with supervision plans are now the present policy for many countries in the world and probably the future for others. Since legalization/decriminalization of cannabis for recreational and medicinal purposes in the US and other countries worldwide, studies reported by these countries found no conclusive results nor significant impact on prevalence [51, 52, 54]. It is suggested by researchers that a firm conclusion regarding the effect of the changes in policy will be available only with time as it is too early to be certain at this stage. The ongoing debate and the increasing general public acceptance for using the substance have created similar situation as with tobacco and alcohol: a substance, with very little scientific background on its dangers and benefits is distributed in stores for the public to purchase in many countries. This might be interpreted not as a bad progress as cannabis was sold as an over-the-counter about a century ago and in those days prevalence was much less than present days [55]. However, in condition as such, there is an increased risk of substance ‘leakage’ from stores to underage people due to increased availability, same as with other substances currently on the markets such as alcohol and tobacco [112].
Current active preventive methods seem to miss the purpose of eradicating substance use in adolescents, however, they help policy makers increase revenues from taxes, instead of solely losing from health damage to its productive labour force and tax payers [11, 12, 14, 16, 20, 21, 27, 28, 29, 31]. The burden of taxes eventually fall on the end consumer, who then can choose to absorb the financial impact and continue to use the substance, change to a cheaper alternative, or quit using it [56]. From the adolescent point of view, the role model that they see in adults who continue to use tobacco, alcohol and cannabis despite the extensive efforts to prevent use of these substances is negative and contribute to the natural curiosity. The increased price and danger elements may add to the perception of rebellion, glamour and excitation in young adults and increase the potential of experimentation in early age. According to the National Institute of drug abuse publications, addiction to substances depends mainly on early age of experimentation and other factors such as personal characteristics, lack of parental supervision, lack of emotional support and negative relationships [57, 58]. It was suggested that the earliest years of human life, when the brain capabilities to learn and absorb information is at its pick, is the time spent within family environment. Evidence from recent human brain imaging and animal studies suggest that there is a heightened responsiveness to incentives and socio-emotional contexts during this time, when impulse control is still relatively immature [59]. These suggestions outlines that family related factors design major parts of our personality, consciousness and sub consciousness. Therefore, nurturing the family sphere and emphasizing on parents and adolescent education could potentially create a more profound impact on prevalence of harmful behaviour.
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3.5 Summary
According to literature, adolescence is considered to be very important period in life, during which rapid physical and sexual maturation occur in addition to key developmental tools, social skills and identity. However, it is a time of considerably greater susceptibility to social influences from digital media and increasing number of peers. Family matters are crucial factors in the process of acquiring these skills and tools and they partially design everyone’s identity.
The occurrence of harmful behaviour among adolescents is a very common growing phenomena worldwide and it has been a major topic for scientific research and debate for many decades. Since most of the smokers start smoking during their adolescents and continue well into adulthood, majority of scientific based work is focusing on adolescents keeping in context the fact that the parent is a major role model and important figure in their lives.
Global reports and studies show that epidemiology of smoking, drunkenness and cannabis use among adolescents varies between countries and regions ,however, gender convergence and an increase of prevalence is seen with an increase in age in many developed regions.
Transformations in family formations, changes in dynamics of our society, gender equilibrium, digital media exposure, and changes in the perception of risk behaviours such as smoking, drunkenness and cannabis use over the past century created different realities to cope with in regards to substance use both for adolescents and parenting. The association of harmful substance use between family matters was established long ago, however, on the level of political conversation, the significance of these facts are not being prioritized.
The current status of substance use and harmful behaviour among adolescents together with literature review of the protective factors a good family interrelations have against the risks of harmful behaviour lead us to hypothesis that the root to a healthier society is embedded in the most basic form of society, the family unit and in order to deal with the future changing reality, it is necessary to focus the attention and direct resources toward public education and supporting couples and families with adolescents.
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4. SUBJECTS AND METHODS
4.1 Subjects and Study Design
The data presented here were obtained from the Health Behaviour in School-aged Children (HBSC) study, a cross-national survey, which was completed in 2013/2014 by support of World Health Organization (WHO, Europe) in 42 countries. More detailed background information about the study is provided in its international report (Inchley et al. 2016) and website: www.hbsc.org (HBSC 2017) [60]. Due to reasons of available data on adolescent family, this study includes data from the following six countries only: Bulgaria, Czech Republic, Israel, Lithuania, Poland, and Slovakia. Although the population selected for sampling was 11-, 13- and 15-year-old adolescents, only the oldest group was in focus in the current study.
Participants were selected using a clustered hierarchical sampling design, where the initial sampling unit was the school class. Data collection methods ensured that the samples of students were country representative. The data were collected by means of self-report standardized questionnaires. The surveys were administrated in school classrooms ensuring students’ confidentiality. Response rates at the school, class and student level exceed 80% in the majority of countries (Inchley et al. 2016) [60].
The verified data were obtained via HBSC Data Centre (Bergen University, Norway). The original data file included 10,291 individual records on 15-year-old children. Table 1 indicates the samples by countries. There was a still slight variation of the weight of country sample sizes in the total sample size; it ranged from 14.4% in Poland to 18.1% in Israel.
4.2 Ethics
The study conformed to the principles outlined in the Declaration of Helsinki. National and local educational institutions agreed upon the study protocol. Ethical approval was obtained for each national survey according to the national guidance and regulations at the time of data collection. Researchers strictly followed the standardized international research protocol to ensure consistency in survey instruments, data collection and processing procedures (HBSC 2013).
4.3 Instrument and Measures
We used the standard HBSC international questionnaire adopted after its translation from the Standard English version [61] into national languages and retranslated back into English. The questionnaire consists of a mandatory (obligatory) section that each country is required to include
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for the production of an international HBSC database, and optional packages, e.g. an optional package "Family Culture" [62] that was employed in the present study. Description of variables in detail is given in the HBSC Protocol for 2013/2014 survey (2013).
In the present study, the outcome variables were focused on the usage of dependence producing substances measured as: 1) current smoking; 2) drunkenness; and 3) cannabis lifetime use. These variables were assessed in the mandatory section of the questionnaire. The list of independent (explanatory) variables included gender and a series of familial variables from the mandatory section and “Family Culture” optional package, which was employed in the above mentioned six countries only, however, the data of full set of familial variables were available for Bulgaria and Lithuania only.
Current smoking
Adolescents were asked how often they smoke tobacco at present. The answer alternatives ranged: 'every day', 'at least once a week, but not every day', 'less than once a week', and 'I do not smoke'. The findings presented here are two proportions of respondents: those who reported 'I do not smoke' (not smokers), and those who reported all stages of smoking (smokers).
Drunkenness
Adolescents were asked whether they had ever had so much alcohol that they were really drunk. Response options ranged from never to more than 10 times. Findings presented in this study show the proportions who reported having been drunk on two or more occasions.
Cannabis lifetime use
Fifteen-year-olds only were asked how many days they had used cannabis in their lifetime. The analysis was focused on the proportion of adolescents who had used cannabis at least once in their lifetime.
Family wealth
The variable plays twofold role as it is a familial social measure and a confounder in association between adolescent risk behaviour and other familial variables. Family wealth was measured by the Family Affluence Scale (FAS), which was specially developed for the international nature of the HBSC study [63, 64]. The scale is simple and ease to answer even for young adolescents. FAS includes six questions with answers: Does your family own a car, van or truck? 0=no, 1=yes one, 2=yes two or more; Do you have your bedroom for yourself? 0=no, 1=yes; During the past 12
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1=once, 2=twice, 3=more than twice; How many computers does your family own? 0=none, 1=one, 2=two, 3=more than two; How many bathrooms (room with a bath/shower or both) are in your
home? 0=none, 1=one, 2=two, 3=tree or more; Does your family have a dishwasher at home? 0=no,
1=yes. A FAS score was calculated by summing the points to these six questions. Then, the respondents from each country were classified into three relative groups of family affluence. The first group included young people in the lowest 20% (low affluence), the second group included those in the medium 60% (medium affluence), and the third group included those in the highest 20% (high affluence) of the ridit-based FAS score in the respective country [HBSC Report 2016].
Family structure
Family was defined as 'the persons you live together with'. On the list of adult people ('father', 'step-father', 'mother', 'step-mother', and etc.), the respondents were asked to indicate the persons living in their family. The respondents who indicated both 'father' and 'mother' were included into a group of adolescents living in intact families (living with both biological parents), while all remaining
respondents were considered as adolescents living in not intact families, which included lone parent families, stepfamilies or reconstituted families, and looked after children, i.e. in a foster home or children's home. The family structure measure was validated using reports to other questions that included the answer option 'I don't have or see this person'.
Communication with parents
In the mandatory section there were four questions about ease of communication with the
respondent’s parents. The respondents were asked “How easy is it for you to talk to the following
persons about things that really bother you?” A checklist of close people including ‘father’,
‘stepfather’, ‘mother’, and ‘stepmother’ was then given. Five response options were provided: 1=very easy, 2=easy, 3=difficult, 4=very difficult and 0=don’t have/see this person. The highest response to the questions about ease of communication with fathers and stepfathers was selected the level of “talk to father”. If a respondent did not respond or responded “0” to both items, the
resulting “talk to father” variable was coded as missing. A similar process was used to compute the variable “talk to mother”. The resulting child-parents communication variables were dichotomized and recoded as 0=very easy/easy and 1=difficult/very difficult. The decision to dichotomize the answering categories was in accordance with suggestions from the HBSC Family Culture focus group concerning the application of this variable in the international analyses [65]. The option 'don’t have/see this person' was used for either ‘mother’ or ‘father’, and these data indicated on respondent's living in not intact family. The rest familial variables were taken from the optional "Family Culture" package.
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Family time together
The evaluation of joint family activity was based on 8 items: (1) watching TV or a video, (2)
playing indoor games, (3) eating meals, (4) going for a walk, (5) going places, (6) visiting friends or relatives, (7) playing sports, (8) sitting and talking about things. Respondents were asked how often did they do any of these activities and spend time together in shared activities. The response options ranged from 'never' (coded as 1) to 'every day' (coded as 5). In 1-factor analysis of the scale using the method described below a binary variable was created. Two categories of this variable 'frequent' and 'rare' corresponded to more often and less often respondent's suggestion of doing several joint family activities. Reliability of the family time together scale was assessed as very good
(Cronbach's Alpha was 0.81 in the sample of all countries, Table 2).
Child’s parental monitoring
The measure of parental monitoring was based on the scale developed by Brown et al. [66], which asks young people about how much their father and mother (repeated for each of them) knows about five issues: "Who your friends are"; "How you spend your money"; "Where you are after
school"; "Where you go at night"; and "What you do with your free time". The answer score ranged
from 1 'don't know anything' to 3 'know a lot', where higher scores represents higher levels of parental knowledge about child's matters. In the scale reliability analysis Cronbach's Alphas were over 0.85 for the father's and mother's answers in all six countries (Table 2). In further analyses, the undertaken 1-factor scores calculation (see below) defined two binary variables (for father and mother) with positive and negative factor score values that corresponded to the 'high' and 'low' level of parental monitoring.
Satisfaction with family relationships
This variable was measured by means of an item based on Cantril's ladder [67] asking respondents people to rate their satisfaction with relationships or global atmosphere in their family. A
quantitative score was obtained that ranged from 0 'we have very bad relationships in our family' to 10 'we have very good relationships in our family'. On the basis of frequency analysis of this score, the answers were dichotomized with those who considered relationships 'high' (8-10 scores) as one group and the rest of the answers as another ('low') group.
4.4 Statistical analysis
The analyses were stratified by countries. In addition, the analyses were conducted on the data of all six countries, N=10,291 (Table 1).
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Reliability analysis with Cronbach's Alpha measure was used to establish the level of internal consistency of various multi-item scales (Table 2).
Explanatory 1-factor analysis with a Principal Component analysis was adopted for each scale to construct reliable one-dimensional variables. The factor scores were calculated within
subsamples of each country in such way that higher factor scores indicated a higher/better level of family life expected by the respondents. A regression method with estimated factor scores
coefficients was adopted in this procedure. Next, using 0 as a cut-point, factor score values were dichotomized into positive and negative groups, which corresponded to respondents' inclination for higher and lower scores in the scale.
Table 3 presents’ factor score coefficients, which were estimated from country data files with the purpose to calculate factor scores of three new factorial variables: family time together, child’s father monitoring and child’s mother monitoring. These data indicate which items have the highest weight in assessing factorial variables. For example, with small variation between countries, ‘go for a walk’ and ‘go places’ had the highest weight in assessing factorial variable ‘family time together’, and parents’ knowledge about child’s activity after school and at night seemed to have the highest values in estimation of factorial variables of child’s monitoring. An approach of factorial variables plays an important role in reducing of number of items to be involved into analysis, however, it confronts with several loss of information. In total sample, the total variances explained by factorial approach were 50.3%, 81.4% and 65.9% correspondingly for family time together, child’s father monitoring and child’s mother monitoring variables. Due to the high level of reducing of item number these figures are quite relevant.
Associations between familial measures and usage of substances were estimated using odds ratios (OR) with 95% confidence intervals (95% CI) in a binary logistic regression analysis. We used Enter method in multivariate analyses with all variables irrespective of their significance found in a univariate analysis. Interactions between familial variables were tested. Multicollinearity
between independent variables in multivariate models was also tested: Tolerance ranged 0.70-0.96, and Variance Inflation Factor (VIF) ranged 1.04-1.41. These estimations did not indicate
multicollinearity, therefore pairwise correlations between variables defined for the father and mother showed moderate correlation (e.g., correlation coefficient between child’s father and mother monitoring was 0.46). All analyses were performed with SPSS (version 20.0; SPSS Inc., Chicago, IL, 2010). p≤0.05 was considered statistically significant.
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Table 1. Sample size, by countries
Country Sample size N % Bulgaria 1650 16.0 Czech Republic 1760 17.1 Israel 1864 18.1 Lithuania 1698 16.5 Poland 1484 14.4 Slovakia 1835 17.8 Total 10291 100.0
Table 2. Reliability statistics of the scales, by countries
Scale
Cronbach’s Alpha Bulgaria Czech
Republic
Israel Lithuania Poland Slovakia Total Family Time Together 0.88 0.81 0.87 0.84 0.84 0.85 0.86 Child’s Father
Monitoring 0.88 0.88 n/d 0.86 n/d 0.86 0.87 Child’s Mother
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Table 3. Component Score Coefficients in assessing factorial scores of Family Time Together and
Child’s Parental Monitoring, by countries
Scale and Items
Component Score Coefficients Bulgaria Czech
Republic
Israel Lithuania Poland Slovakia Total
Family Time Together:
Watch TV/video 0.15 0.16 0.15 0.15 0.19 0.15 0.15 Play indoor games 0.17 0.20 0.17 0.19 0.18 0.19 0.18 Eat a meal 0.14 0.17 0.16 0.16 0.17 0.17 0.16 Go for a walk 0.19 0.21 0.19 0.20 0.21 0.21 0.19 Go places 0.19 0.21 0.19 0.20 0.21 0.20 0.20 Visit friends/relatives 0.18 0.17 0.18 0.18 0.18 0.16 0.18 Play sports 0.17 0.19 0.18 0.18 0.19 0.18 0.18 Sit and talk about things 0.15 0.19 0.16 0.17 0.17 0.17 0.17
Total Variance Explained (%)
54.4 44.3 53.0 47.7 46.4 49.4 50.3 Child’s Father
Monitoring: n/d n/d
Father knows who
friends 0.22 0.22 0.21 0.22 0.22 Father knows how spend
money 0.23 0.22 0.22 0.22 0.22 Father knows after
school 0.23 0.23 0.22 0.23 0.23 Father knows go at night 0.23 0.23 0.22 0.23 0.23 Father knows free time 0.23 0.22 0.22 0.23 0.22
Total Variance Explained (%)
77.9 81.5 84.0 79.4 81.4
Child’s Mother
Monitoring: n/d n/d
Mother knows who
friends 0.23 0.24 0.23 0.23 0.23 Mother knows how
spend money 0.24 0.23 0.24 0.24 0.24 Mother knows after
school 0.26 0.26 0.26 0.26 0.26 Mother knows go at
night 0.25 0.25 0.26 0.26 0.25 Mother knows free time 0.25 0.25 0.25 0.26 0.25
Total Variance Explained (%)
67.7 67.0 64.8 64.0 65.9
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5. RESULTS
5.1 Family characteristics
Characteristics of the studied samples by familial variables are presented in Table 4. The sample was balanced by gender and FAS. From the total sample across regions the division of respondents by gender was approximately equal (Boys 50.5%; Girls 49.5%). By FAS, 20% reported low level of family wealth, 60.7% reported medium and 19.4% reported high.
73% of the total sample reported living with both parents. Highest rates were reported from Israel while the highest rates of adolescents reporting living in disrupted families were from the Czech Republic and Lithuania.
The results showed significant difference in respondent’s opinion about the difficulty of communication with the mother and father. Easy communication with the mother (79.8%) was reported more frequently than with the father (64%) across all regions. Bulgaria and Israel reported the highest rate of easy communication with both parents while Czech Republic and Slovakia reported highest rates of difficult communication with the father and Lithuania and Slovakia report highest rates of difficult communication with the mother.
Reports of frequent family time together varied greatly between countries. Highest reported rates were from Israel (71.8%), Poland (70.9%) and Slovakia (71.2%) while the lowest rates reported by Lithuania (46.7%) and Czech Republic (33.8%).
Maternal monitoring over the adolescent dominated over the paternal across all regions. Most frequent reports of high maternal and paternal monitoring were from Czech Republic and Slovakia while the most frequent reports of low maternal and paternal reports where from Lithuania.
Adolescents from Bulgaria reported higher rates of high level satisfaction from their family relations, while Lithuania reported lower rates.
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Table 4. Gender and family characteristics in studied country samples Item and
Response categories
n (%) Bulgaria Czech
Republic
Israel Lithuania Poland Slovakia Total
Gender: Boys 910 (55.2) 852 (48.4) 857 (46.0) 904 (53.2) 700 (47.2) 971 (52.9) 5194 (50.5) Girls 740 (44.8) 908 (51.6) 1007 (54.0) 794 (46.8) 784 (52.8) 864 (47.1) 5097 (49.5) Family wealth: Lowest 20% 324 (20.7) 333(19.3) 309 (17.0) 366 (22.0) 266 (18.9) 352 (22.2) 1950 (20.0) Medium 60% 943 (60.2) 1070 (62.0) 1124 (62.0) 943 (56.7) 886 (62.8) 960 (60.4) 5926 (60.7) Highest 20% 300 (19.1) 324 (18.8) 380 (21.0) 353 (21.2) 259 (18.4) 277 (17.4) 1893 (19.4)
Living with both parents: Yes 1138 (72.2) 1121 (64.9) 1553 (84.0) 1135 (67.5) 1100 (74.9) 1286 (77.0) 7333 (73.5) No 438 (27.8) 607 (35.1) 295 (16.0) 547 (32.5) 368 (25.1) 385 (23.0) 2640 (26.5) Communication with father/stepfather: Easy 1035 (69.5) 1002 (60.8) 1259 (71.0) 936 (63.5) 899 (65.7) 881 (53.5) 6012 (64.0) Difficult 455 (30.5) 645 (39.2) 514 (29.0) 539 (36.5) 470 (34.3) 765 (46.5) 2288 (36.0) Communication with mother/stepmother: Easy 1323 (85.6) 1392 (81.2) 1502 (85.5) 1167 (73.9) 1155 (79.8) 1222 (72.6) 7761 (79.8) Difficult 222 (14.4) 323 (18.8) 255 (14.5) 412 (26.1) 293 (20.2) 462 (27.4) 1967 (20.2) Family time together: Frequent 965 (58.5) 595 (33.8) 1338 (71.8) 793 (46.7) 1052 (70.9) 1307 (71.2) 6050 (58.8) Rare 685 (41.5) 1165 (66.2) 526 (28.2) 905 (53.3) 432 (29.1) 528 (28.8) 4241 (41.2) Child’s father monitoring: n/d n/d High 1008 (61.1) 1367 (77.7) 762 (44.9) 1495 (81.5) 7980 (77.5) Low 642 (38.9) 393 (22.3) 936 (55.1) 340 (18.5) 2311 (22.5) Child’s mother monitoring: n/d n/d High 1096 (66.4) 1466 (83.3) 963 (56.7) 1520 (82.8) 8393 (81.6) Low 554 (33.6) 294 (16.7) 735 (43.3) 315 (17.2) 1898 (18.4) Satisfaction with family relations: n/d n/d n/d n/d High 1129 (70.8) 1120 (67.1) 2249 (68.9) Low 465 (29.2) 550 (32.9) 1015 (31.1) n/d - no data.
25 5.2 Prevalence of substance usage
Table 5 presents the prevalence of harmful behaviour activities reported by adolescents and balanced by gender and countries. According the total sample, boys are more frequent to engage with harmful behaviour than girls. The most frequent reported harmful behaviour is drunkenness. More than one out of every four adolescents (27.5%) experienced two or more drunkenness episodes in lifetime.
Table 5. Prevalence of harmful substance use, by gender and countries
Substance use Gender
% Bulgaria Czech
Republic
Israel Lithuania Poland Slovakia Total Current smoking Total 29.3 20.9 16.4 23.3 22.7 23.2 22.6 Boys 25.2 17.7 25.5 27.7 22.3 22.5 23.5 Girls 34.4*** 23.9*** 8.9*** 18.3*** 23.0 24.0 21.8* Drunkenness Total 34.1 30.0 9.1 36.9 25.8 27.6 27.5 Boys 37.6 31.5 14.6 40.6 25.8 29.1 30.6 Girls 29.9*** 28.6 4.8*** 32.7*** 25.9 25.8 24.4***
Cannabis use Total 22.7 23.1 6.5 15.1 23.6 16.8 18.2
Boys 22.6 22.8 11.0 19.2 25.9 19.5 20.4
Girls 23.0 23.3 2.9*** 10.4*** 21.7 13.8** 16.0***
* p≤0.05; ** p≤0.01; *** p≤0.001, z test comparing girls with boys.
Current smoking
According to the total sample more than one out of every five (22.6%) adolescents reported smoking tobacco weekly. with the highest reports from Bulgaria (29.3%) and the lowest from Israel (16.4%). By gender difference, boys (23.5%) were more frequent to report smoking than girls (21.8%) however, many differences were observed across regions. Figure 1 presents the great variation of smoking prevalence between genders across regions. Girls from Bulgaria and the Czech Republic significantly reported higher rates than boys, boys from Israel and Lithuania reported significantly higher than girls, while, Poland and Slovakia reported no significant difference between genders, with insignificant inclinations towards girls.
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Fig.1. Prevalence of current smoking among 15-year-old boys and girls in six selected countries
Drunkenness
According the total sample, more than quarter (27.5%) of the respondents reported to have two or more drunkenness episodes in life. Figure 1 shows the main differences of reported data between the participating countries. Czech Republic, Poland and Slovakia showed no significant differences between genders while Bulgaria, Israel and Lithuania showed significant difference between genders, with boys reporting more frequent drunkenness phenomena. The highest rates of reports were from Bulgaria (34.1%) and Lithuania (36.9%) while the lowest from Israel.
Fig.2. Prevalence of drunkenness at least twice in lifetime among 15-year-old boys and girls in six
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Cannabis Use
According the total sample approximately one out of every five (18.2%) adolescents used cannabis at least once in their lives. Highest rates were reported by adolescents from Bulgaria (22.7%), Czech Republic (23.1%) and Poland (23.6%) while the lowest rates from Israel (6.5%), Lithuania (15.1%) and Slovakia (16.8%). Figure 3 outlines the prevalence variations between genders across regions. Boys reported significantly higher rates of use in the total sample as well as in Israel, Lithuania and Slovakia separately, However, girls from Bulgaria and Czech Republic reported higher rates of use than boys, although not significantly.
Fig.3. Prevalence of cannabis usage in lifetime among 15-year-old boys and girls in six selected
countries
5.3 Association between substance usage and familial determinants
Current smoking
Table 6 presents the association of current smoking with various family determinants with the data being adjusted for gender and FAS.
Univariate analysis in Table 6-A showed that boys were more prone to tobacco smoking than girls (OR=0.91), however, in Bulgaria and Czech Republic girls had significantly more association with smoking. In the total sample, adolescents from low affluence families had significantly stronger association to smoking than adolescents from both medium (OR=0.79) and high (OR=0.81) affluence families. All the countries showed the similar associations except Bulgaria that had more frequent smoking among adolescents from high affluence families.
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Smoking was significantly associated with family structure, where higher prevalence was seen among adolescents not living with both parents (OR=1.86). Similar associations were seen in all countries.
For most countries, difficult communication with the father is related with higher smoking prevalence (OR=1.14) while in Lithuania an opposite effect is seen (OR=0.94). Difficult communication with the mother was found to be significantly related to higher prevalence of smoking (OR=1.4). Adolescents from families who rarely spend time together are more likely to smoke (OR=1.33) except for Israel who showed an inverted association, although not very significant. Analysis from all the four countries who used the questions from the family culture additional package reveled, that low level of control over the child from both mother’s and father’s doubles (OR=2.13) the risk of smoking among young adults. Adolescents who reported Low satisfaction from family relations were as twice more likely to smoke tobacco (OR=1.91).
Multivariate analysis (Table 6-B) revel that low maternal control over the child is the key risk factor for smoking (OR=1.81), while low paternal control has somewhat less effect on smoking prevalence (OR=1.41). Living in disrupted families is the second risk factor after low maternal control for smoking tobacco (OR=1.66). Communication with the mother did not showed any association with smoking, however, easy communication with father showed an inverse association which is not lined with the rational assumption, suggesting that adolescents who find it easy to talk with their father are more likely to smoke (OR=0.78). Satisfaction with family was also significant but less powerful element (OR=1.5).
Drunkenness
Univariate analysis presented in Table 7-A show that except Poland who did not show any difference in association between gender with drunkenness, boys are more likely to report drunkenness episodes than girls (OR=0.76). Except Bulgaria who showed significant association of drunkenness among adolescents from high (OR=2.19) and medium (1.41) FAS, adolescents from low FAS were more likely to report drunkenness than adolescents from medium FAS, while those from high FAS were more likely to report drunkenness than adolescents from low FAS, although not significantly for the total sample. Our data showed that not living with both parents (OR=1.60), difficult communication with both parents (father, OR=1.32; mother, OR=1.58), rarely spending time together with family (OR=1.51), low parental control over the child (father, OR=1.70; mother, OR=2.09), and low level of satisfaction with the family relationship (OR=1.70) are all related to drunkenness among adolescents across the participating regions, however, the level of significance varies between countries.
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Multivariate analysis presented in Table 7-B show the relationship of all family parameters taken together in association to drunkenness. In the total sample our result show that adolescents from high (OR=2.01) and medium (OR=1.49) FAS was most significant risk factor associated with drunkenness, although, half of the countries showed no associations at all. Not living with both parents was related to drunkenness in all countries, although not significantly in two out of six countries. Easy communication with parents revealed no associations, with the mother showing inverted association, although, no significantly (father, OR=1.02; mother, OR=0.99). Low maternal control over the child, is the second risk factor after High FAS to be strongly associated with drunkenness (OR=1.77), while low level of satisfaction from family relationship have significant (OR=1.36) but less effect on drunkenness prevalence than maternal control.
Cannabis use
Table 8-A presents the associations between different familial determinants and cannabis use from a univariate analysis. From gender prospective in the total sample, we found that girls were significantly less associated with cannabis use than boys (OR=0.74). However, in two out six countries (Bulgaria, OR=1.02; Czech Republic, OR=1.03) girls had higher association than boys, even though not significantly. Higher FAS (OR=1.19) were more associated with cannabis use than low FAS, with five out of six countries reported similar association except Israel who reported inverted association, while, medium FAS (OR=0.97) had less association than low FAS. Adolescents reporting not living with both parents had significantly stronger association with cannabis use (OR=1.67). Adolescents living in families that rarely spent time together were at higher risk to use cannabis (OR=1.41), except in Israel, where spending frequent time together was found as a risk factor (OR=0.57). Cannabis use was found to be significantly more prevalent among young adults who reported low level of parental control (father’s, OR=1.66; mother’s, OR= 1.92) as well as among those who reported low level of satisfaction with relationship in the family (OR=1.65).
Multivariate analysis in Table 8-B present the association between various familial and demographic determinants taken together with cannabis use among adolescents from six countries. Our study results show that in the total sample high and medium FAS are significant determinants of cannabis use, with high FAS increasing the risk almost two fold (OR=1.92). According the total sample, easy communication with parents is shown to be a risk factor, although not significant (father, OR=0.82; mother, OR=0.88). Low maternal (OR=1.91) and paternal (OR=1.5) control over children are the second and third major risk factor after high FAS. Low satisfaction with the relationship in the family appeared to have the least impact (OR=1.28).
