Estonia is the smallest of the three Baltic countries on the east coast of the Baltic Sea with an area of approximately 45 215 square kilometres and a population of 1.34 million (01.01.2011) (Statistics Estonia, 2011) which was an independent state in 1918–1940. Estonia regained its independence in August 1991 after the collapse of the Soviet Union. This had enormous implications for health and for the political and economic transition during the succeeding years. In 2004, Estonia became a member of the European Union associated with introduction to the common European market and general pressure towards convergence in

The years 1991–1994 represented the period of transition. In terms of economic development, the year 1994 was characterized by significant unemployment (7.6%) and the relatively low gross domestic product (GDP) at current prices (1370 Euros per person) (Statistics Estonia, 2011). In the period of economic growth unemployment was the lowest (4.7% in 2006) and GDP the highest (12 161 Euros per person in 2008). During the following economic downturn unemployment increased to 16.9% and GDP decreased to 10 674 Euros

It is estimated that alcohol consumption is responsible for about 4% of the total disease burden in the world (WHO, 2007). While regular light to moderate alcohol intake is associated with some reduction in total mortality (Di Castenuovo et al., 2006; Rehm et al., 2009), heavy drinking has been regarded as an important contributor to the high premature mortality rates in central and eastern Europe, particularly in the countries of the former Soviet Union (Chenet et al., 1998; Leinsalu, 2002; Leon et al., 1997; McKee et al., 2000;

Alcohol consumption per capita (based on legal sale) increased from 5.6 litres of pure alcohol in 1994 to 15.2 in 2007 and thereafter decreased to 12.8 in 2009 in Estonia (Estonian Institute of Economic Research, 2008, 2010). Since 2006, the estimations were made about the quantity of alcohol beverages that tourists consume in Estonia and export from Estonia. Hence, the consumption of alcohol by Estonian inhabitants was 12.6 in 2007 and 10.2 in 2009 (Estonian Institute of Economic Research, 2010). In 1996–2006, alcohol consumption increased especially among men in Estonia. The proportion of men drinking more than

**1. Introduction**

many policy areas.

Popova et al., 2007).

in 2010 (Statistics Estonia, 2011).

## **Alcohol Consumption Among Adolescents in Estonia 1994 – 2010**

Kersti Pärna1, Mariliis Tael2, Inge Ringmets1 and Katrin Aasvee2 *1Department of Public Health, University of Tartu 2National Institute for Health Development Estonia*

## **1. Introduction**

Estonia is the smallest of the three Baltic countries on the east coast of the Baltic Sea with an area of approximately 45 215 square kilometres and a population of 1.34 million (01.01.2011) (Statistics Estonia, 2011) which was an independent state in 1918–1940. Estonia regained its independence in August 1991 after the collapse of the Soviet Union. This had enormous implications for health and for the political and economic transition during the succeeding years. In 2004, Estonia became a member of the European Union associated with introduction to the common European market and general pressure towards convergence in many policy areas.

The years 1991–1994 represented the period of transition. In terms of economic development, the year 1994 was characterized by significant unemployment (7.6%) and the relatively low gross domestic product (GDP) at current prices (1370 Euros per person) (Statistics Estonia, 2011). In the period of economic growth unemployment was the lowest (4.7% in 2006) and GDP the highest (12 161 Euros per person in 2008). During the following economic downturn unemployment increased to 16.9% and GDP decreased to 10 674 Euros in 2010 (Statistics Estonia, 2011).

It is estimated that alcohol consumption is responsible for about 4% of the total disease burden in the world (WHO, 2007). While regular light to moderate alcohol intake is associated with some reduction in total mortality (Di Castenuovo et al., 2006; Rehm et al., 2009), heavy drinking has been regarded as an important contributor to the high premature mortality rates in central and eastern Europe, particularly in the countries of the former Soviet Union (Chenet et al., 1998; Leinsalu, 2002; Leon et al., 1997; McKee et al., 2000; Popova et al., 2007).

Alcohol consumption per capita (based on legal sale) increased from 5.6 litres of pure alcohol in 1994 to 15.2 in 2007 and thereafter decreased to 12.8 in 2009 in Estonia (Estonian Institute of Economic Research, 2008, 2010). Since 2006, the estimations were made about the quantity of alcohol beverages that tourists consume in Estonia and export from Estonia. Hence, the consumption of alcohol by Estonian inhabitants was 12.6 in 2007 and 10.2 in 2009 (Estonian Institute of Economic Research, 2010). In 1996–2006, alcohol consumption increased especially among men in Estonia. The proportion of men drinking more than

Alcohol Consumption Among Adolescents in Estonia 1994 – 2010 189

internationally comparable data on schoolchildren's health behavior, health and wellbeing in their social context (Roberts et al., 2007). The target groups of the survey are 11-, 13- and 15-year-old adolescents, in Estonia respectively schoolchildren from grades 5, 7

Schoolchildren fill an anonymous questionnaire in classroom during one school hour. A person outside from school is present, schoolchildren who miss the class are left out from the survey. The questionnaires are sealed in envelopes in front of schoolchildren to ensure

Methods used in this survey are the same in all participating countries and this gives a chance to monitor the changes in schoolchildren health, health behavior and social environment over years in different countries (Aasvee et al., 2007). HBSC survey has been conducted in Estonia in the following periods: February 1994 (King et al., 1996), February– March 1998 (Currie et al., 2000), November–December 2001 (Maser, 2004), February–March

Databases from Statistics Estonia were used to compile the sample. Estonian counties were divided into 12 stratums according to language of instruction and urbanization. Sample sizes were calculated according to the number of children in grades 5, 7 and 9 in 12 stratums

In HBSC survey it is required that the number of schoolchildren in each age group is approximately 1500 (Roberts et al., 2007). To ensure equal inclusion probabilities the selection was made in two phases. In the first phase schools were selected. Inclusion probabilities were equal to the total number of grades 5, 7 and 9 in the selected school. This means that schools having more classes of these grades had higher probability to get into the sample. In second phase one class from each parallel was randomly chosen. While compiling the age groups, 90% of schoolchildren had to be within ±6 months of the mean age for each age group and remaining 10% no more than 12 months from the mean age. In chosen schools the school board decided whether they wanted to participate in the survey or not. Schoolchildren had the right to refuse filling the questionnaire if they themselves or their parents wanted that way. Over years the non-participation rate has been below 0.5% of

Data files from countries that have participated in the survey have been checked and cleaned in Norwegian Social Science Data Services, where international database was

This chapter focuses on 13- and 15-year-old adolescents self-assessed alcohol consumption

Frequency of alcohol consumption variable was based on different alcoholic drinks (beer, wine, strong alcohol, liqueur, cider, light alcoholic beverages, alcopops) consumption

the confidentiality of data (Aasvee et al., 2007; Maser, 2004).

2006 (Currie et al., 2008), February–April 2010.

created and is preserved (Aasvee et al., 2007).

and episodes of drunkenness in 1994–2010.

and 9.

**2.2 Participants**

(Aasvee et al., 2007).

the whole sample.

**2.3 Measures**

**2.3.1 Alcohol consumption**

280 g pure alcohol per week increased from 7.4% to 16.2%, and the proportion of women drinking more than 140 g pure alcohol per week increased from 2.7% to 4.7% between 1996 and 2006 (Pärna et al., 2010). In 2006, prevalence rate of non-beverage alcohol consumption was 2.3% among men (Pärna & Leon, 2011). In Estonia alcohol-related mortality was the lowest in 1988–1991 (3.5% of all deaths) and increased to 9.1% in 2002–2005 (Rahu & Pärna, 2009). At the same time, in Estonia age-standardized mortality rates of alcoholic liver cirrhosis increased from 9.7 to 37.5 per 100 000 men and from 2.2 to 16.1 per 100 000 women aged 25–64 in 1996–2006 (Pärna & Rahu, 2010).

Although the vast majority of alcohol-related deaths occur in middle-aged and elderly people, alcohol consumption behaviour is undeniably established in adolescence. Early adolescence is a critical time, where behavioural habits (including alcohol consumption) are developing (Lintonen et al., 2000). Moreover, individuals who begin alcohol consumption at a younger age have an increased risk of becoming regular alcohol drinkers in adulthood. According to schoolchildren's self-estimation, they consume alcohol due to boredom, stress and desire to fit in the group (Milgram, 2001). The use of alcohol may become a means of escaping from situations that youth feel powerless to change (United Nations, 2005). As among adults, alcohol consumption among adolescents is associated with road accidents, suicides, depression, memory problems, fighting, rape and unprotected sexual intercourse which could increase the risk of getting infected with HIV and other sexually transmitted diseases (Williams & Knox, 1987). Alcohol consumption may cause decrease of learning ability, which in turn causes learning difficulties due to which adolescent might fall out of school (Scheier et al., 2000). In addition, the existing evidence about the relationship between adolescent drinking behaviour and family related factors are inconsistent and even contradictory. While some studies have identified a higher risk of excessive adolescent drinking behaviour among lower socio-economic groups (Geckova et al., 2002; Lintonen et al., 2000; Lowry et al., 1996), others have found no or even inverse social gradients in schoolchildren's alcohol consumption (Shucksmith et al., 1997). Living in non-intact families and bad family relationships have been risk factors for alcohol drinking among adolescents (Challier et al., 2000; Shucksmith et al., 1997).

The aim of this chapter is to describe trends in the prevalence of alcohol consumption and episodes of drunkenness and to analyze associations between alcohol consumption, episodes of drunkenness and demographic and family related factors among schoolchildren in Estonia in 1994–2010.

## **2. Material and methods**

#### **2.1 Setting and sampling**

This study was based on international survey of health behavior among school-aged children (HBSC survey) conducted among 11-, 13- and 15-year-old schoolchildren in 1993/1994, 1997/1998, 2001/2002, 2005/2006 and 2009/2010 academic year in Estonia. To ensure the clarity of work results, hereafter the end year of the study (1994, 1998, 2002, 2006, 2010) was used while referring to the academic year.

HBSC survey is a World Health Organization collaborative study, in 2010 43 countries participated in the survey. The main objective of HBSC survey is to collect high-quality internationally comparable data on schoolchildren's health behavior, health and wellbeing in their social context (Roberts et al., 2007). The target groups of the survey are 11-, 13- and 15-year-old adolescents, in Estonia respectively schoolchildren from grades 5, 7 and 9.

Schoolchildren fill an anonymous questionnaire in classroom during one school hour. A person outside from school is present, schoolchildren who miss the class are left out from the survey. The questionnaires are sealed in envelopes in front of schoolchildren to ensure the confidentiality of data (Aasvee et al., 2007; Maser, 2004).

Methods used in this survey are the same in all participating countries and this gives a chance to monitor the changes in schoolchildren health, health behavior and social environment over years in different countries (Aasvee et al., 2007). HBSC survey has been conducted in Estonia in the following periods: February 1994 (King et al., 1996), February– March 1998 (Currie et al., 2000), November–December 2001 (Maser, 2004), February–March 2006 (Currie et al., 2008), February–April 2010.

## **2.2 Participants**

188 Public Health – Social and Behavioral Health

280 g pure alcohol per week increased from 7.4% to 16.2%, and the proportion of women drinking more than 140 g pure alcohol per week increased from 2.7% to 4.7% between 1996 and 2006 (Pärna et al., 2010). In 2006, prevalence rate of non-beverage alcohol consumption was 2.3% among men (Pärna & Leon, 2011). In Estonia alcohol-related mortality was the lowest in 1988–1991 (3.5% of all deaths) and increased to 9.1% in 2002–2005 (Rahu & Pärna, 2009). At the same time, in Estonia age-standardized mortality rates of alcoholic liver cirrhosis increased from 9.7 to 37.5 per 100 000 men and from 2.2 to 16.1 per 100 000 women

Although the vast majority of alcohol-related deaths occur in middle-aged and elderly people, alcohol consumption behaviour is undeniably established in adolescence. Early adolescence is a critical time, where behavioural habits (including alcohol consumption) are developing (Lintonen et al., 2000). Moreover, individuals who begin alcohol consumption at a younger age have an increased risk of becoming regular alcohol drinkers in adulthood. According to schoolchildren's self-estimation, they consume alcohol due to boredom, stress and desire to fit in the group (Milgram, 2001). The use of alcohol may become a means of escaping from situations that youth feel powerless to change (United Nations, 2005). As among adults, alcohol consumption among adolescents is associated with road accidents, suicides, depression, memory problems, fighting, rape and unprotected sexual intercourse which could increase the risk of getting infected with HIV and other sexually transmitted diseases (Williams & Knox, 1987). Alcohol consumption may cause decrease of learning ability, which in turn causes learning difficulties due to which adolescent might fall out of school (Scheier et al., 2000). In addition, the existing evidence about the relationship between adolescent drinking behaviour and family related factors are inconsistent and even contradictory. While some studies have identified a higher risk of excessive adolescent drinking behaviour among lower socio-economic groups (Geckova et al., 2002; Lintonen et al., 2000; Lowry et al., 1996), others have found no or even inverse social gradients in schoolchildren's alcohol consumption (Shucksmith et al., 1997). Living in non-intact families and bad family relationships have been risk factors for alcohol drinking among adolescents (Challier et

The aim of this chapter is to describe trends in the prevalence of alcohol consumption and episodes of drunkenness and to analyze associations between alcohol consumption, episodes of drunkenness and demographic and family related factors among schoolchildren

This study was based on international survey of health behavior among school-aged children (HBSC survey) conducted among 11-, 13- and 15-year-old schoolchildren in 1993/1994, 1997/1998, 2001/2002, 2005/2006 and 2009/2010 academic year in Estonia. To ensure the clarity of work results, hereafter the end year of the study (1994, 1998, 2002, 2006,

HBSC survey is a World Health Organization collaborative study, in 2010 43 countries participated in the survey. The main objective of HBSC survey is to collect high-quality

aged 25–64 in 1996–2006 (Pärna & Rahu, 2010).

al., 2000; Shucksmith et al., 1997).

in Estonia in 1994–2010.

**2. Material and methods 2.1 Setting and sampling**

2010) was used while referring to the academic year.

Databases from Statistics Estonia were used to compile the sample. Estonian counties were divided into 12 stratums according to language of instruction and urbanization. Sample sizes were calculated according to the number of children in grades 5, 7 and 9 in 12 stratums (Aasvee et al., 2007).

In HBSC survey it is required that the number of schoolchildren in each age group is approximately 1500 (Roberts et al., 2007). To ensure equal inclusion probabilities the selection was made in two phases. In the first phase schools were selected. Inclusion probabilities were equal to the total number of grades 5, 7 and 9 in the selected school. This means that schools having more classes of these grades had higher probability to get into the sample. In second phase one class from each parallel was randomly chosen. While compiling the age groups, 90% of schoolchildren had to be within ±6 months of the mean age for each age group and remaining 10% no more than 12 months from the mean age. In chosen schools the school board decided whether they wanted to participate in the survey or not. Schoolchildren had the right to refuse filling the questionnaire if they themselves or their parents wanted that way. Over years the non-participation rate has been below 0.5% of the whole sample.

Data files from countries that have participated in the survey have been checked and cleaned in Norwegian Social Science Data Services, where international database was created and is preserved (Aasvee et al., 2007).

This chapter focuses on 13- and 15-year-old adolescents self-assessed alcohol consumption and episodes of drunkenness in 1994–2010.

#### **2.3 Measures**

### **2.3.1 Alcohol consumption**

Frequency of alcohol consumption variable was based on different alcoholic drinks (beer, wine, strong alcohol, liqueur, cider, light alcoholic beverages, alcopops) consumption

Alcohol Consumption Among Adolescents in Estonia 1994 – 2010 191

associations between weekly alcohol consumption, at least two episodes of drunkenness and demographic and family related factors among 13- and 15-year-old schoolchildren. Weekly alcohol consumption (I model) and at least two episodes of drunkenness (II model) were used as binary variables and demographic and family related factors were used as independent variables in logistic regression analysis models. Odds ratios (OR) and corresponding 95% confidence intervals (CI) were computed for both models. OR that equals 1 refers to the base comparison group. OR's of weekly alcohol consumption and at least two episodes of drunkenness were adjusted to all demographic and family related

The present analysis is based on 13- and 15-year-olds (N=12244), 5861 boys and 6383 girls through the study waves (Table 1). Questionnaires, where the correspondents hadn't answered about their age (10 questionnaires) and alcohol consumption (99 questionnaires) were left out from the analysis. Questionnaires that lacked information about episodes of drunkenness were left out from the drunkenness analysis (62 questionnaires).  Number of respondents by gender, age and study year, HBSC Survey, Estonia

In 2010, the number of 13- and 15-year-old adolescents studied was almost equal (Table 2). There was about 77% of Estonian and nearly one fourth non-Estonian schoolchildren. About 63% of adolescents were living with both biological parents, approximately 20% with one parent, 15% with parent and a step-parent, and 2% had some other family structure. Almost half of the schoolchildren evaluated their family wealth to be good, 46% found it was average and about 4% said it was bad. Approximately 38% of schoolchildren had high, one third middle and 27% low FAS. About 77% of adolescents evaluated their family

factors in logistic regression analysis.

related factors were excluded from logistic regression analysis.

Boys

Girls

relationships good, 19% average and 3% bad.

1994–2010

**3. Results**

Statistical analysis was conducted with Stata 10 (Hills & Stravola, 2007).

**3.1 Demographic and family related characteristics of respondents**

question. Possible answers were 'yes, every day', 'yes, every week', 'yes, every month', 'yes, less than once a month' and 'no, never', 'For the purposes of analysis, schoolchildren were categorised as drinking at least weekly (weekly alcohol consumption) or less often.

## **2.3.2 Drunkenness**

Frequency of drunkenness was assessed by asking whether schoolchildren had ever had so much alcohol that they were really drunk. Possible answers were 'no, never', 'yes, once', 'yes, 2–3 times', 'yes, 4–10 times', and 'yes, more than 10 times'. Responses to this question were grouped into two categories: drunkenness never or only once in life and at least two episodes of drunkenness.

## **2.3.3 Demographic factors**

Sex, age and nationality were used as demographic factors. In accordance with *age groups*, schoolchildren were either 13- or 15-year-old, from grades 7 and 9 respectively. According to *ethnicity* two groups were formed: Estonians and non-Estonians (mainly Russians).

## **2.3.4 Family related factors**

Family structure, family wealth, family affluence scale and family relationships were used as family related factors, that influence health and health behaviour of schoolchildren.

Based on *family structure*, schoolchildren were divided into four groups: 1) two biological parents; 2) one parent; 3) one parent and one step-parent; 4) other combinations (i.e. parent and grandparent, foster home etc.).

Based on *family wealth*, schoolchildren responses were distributed into three groups: 1) bad (very bad and bad); 2) average; 3) good (very good and good).

*Family affluence scale (FAS)* was calculated on the basis of four items 1) does your family own a car (0, 1, 2 or more), 2) how many times did you travel away on holiday with your family during the past 12 months (0, 1, 2, 3 or more), 3) do you have your own bedroom for yourself (0, 1) and 4) how many computers does your family own (0, 1, 2, 3 or more). A composite FAS score was calculated by summing the responses to these four items ranging from 0 to 9 (Richter et al., 2006). The scores were subsequently recoded into tertiles and respondents were divided into three groups respectively. In 2010 the FAS tertiles were as follows: low (0–4 points); middle (5–6 points); high (7–9 points) (Currie et al., 2008).

*Family relationships* were evaluated on an 11 item scale, where 0 meant very bad relationships and 10 very good ones. Based on the scale, schoolchildren were divided into three groups: bad relationships (0–3); 2) average relationships (4–6); 3) good relationships (7–10).

#### **2.4 Statistical analysis**

Prevalence of alcohol consumption and episodes of drunkenness were calculated separately for 13- and 15-year-old boys and girls. Logistic regression analysis was applied to assess the associations between weekly alcohol consumption, at least two episodes of drunkenness and demographic and family related factors among 13- and 15-year-old schoolchildren. Weekly alcohol consumption (I model) and at least two episodes of drunkenness (II model) were used as binary variables and demographic and family related factors were used as independent variables in logistic regression analysis models. Odds ratios (OR) and corresponding 95% confidence intervals (CI) were computed for both models. OR that equals 1 refers to the base comparison group. OR's of weekly alcohol consumption and at least two episodes of drunkenness were adjusted to all demographic and family related factors in logistic regression analysis.

The present analysis is based on 13- and 15-year-olds (N=12244), 5861 boys and 6383 girls through the study waves (Table 1). Questionnaires, where the correspondents hadn't answered about their age (10 questionnaires) and alcohol consumption (99 questionnaires) were left out from the analysis. Questionnaires that lacked information about episodes of drunkenness were left out from the drunkenness analysis (62 questionnaires). Additional questionnaires that lacked information about questions related to demographic and family related factors were excluded from logistic regression analysis.

Statistical analysis was conducted with Stata 10 (Hills & Stravola, 2007).

Table 1. Number of respondents by gender, age and study year, HBSC Survey, Estonia 1994–2010

## **3. Results**

190 Public Health – Social and Behavioral Health

question. Possible answers were 'yes, every day', 'yes, every week', 'yes, every month', 'yes, less than once a month' and 'no, never', 'For the purposes of analysis, schoolchildren were

Frequency of drunkenness was assessed by asking whether schoolchildren had ever had so much alcohol that they were really drunk. Possible answers were 'no, never', 'yes, once', 'yes, 2–3 times', 'yes, 4–10 times', and 'yes, more than 10 times'. Responses to this question were grouped into two categories: drunkenness never or only once in life and at least two

Sex, age and nationality were used as demographic factors. In accordance with *age groups*, schoolchildren were either 13- or 15-year-old, from grades 7 and 9 respectively. According to *ethnicity* two groups were formed: Estonians and non-Estonians (mainly Russians).

Family structure, family wealth, family affluence scale and family relationships were used as family related factors, that influence health and health behaviour of schoolchildren.

Based on *family structure*, schoolchildren were divided into four groups: 1) two biological parents; 2) one parent; 3) one parent and one step-parent; 4) other combinations (i.e. parent

Based on *family wealth*, schoolchildren responses were distributed into three groups: 1) bad

*Family affluence scale (FAS)* was calculated on the basis of four items 1) does your family own a car (0, 1, 2 or more), 2) how many times did you travel away on holiday with your family during the past 12 months (0, 1, 2, 3 or more), 3) do you have your own bedroom for yourself (0, 1) and 4) how many computers does your family own (0, 1, 2, 3 or more). A composite FAS score was calculated by summing the responses to these four items ranging from 0 to 9 (Richter et al., 2006). The scores were subsequently recoded into tertiles and respondents were divided into three groups respectively. In 2010 the FAS tertiles were as follows: low (0–4 points); middle (5–6 points); high (7–9 points) (Currie et

*Family relationships* were evaluated on an 11 item scale, where 0 meant very bad relationships and 10 very good ones. Based on the scale, schoolchildren were divided into three groups: bad relationships (0–3); 2) average relationships (4–6); 3) good relationships

Prevalence of alcohol consumption and episodes of drunkenness were calculated separately for 13- and 15-year-old boys and girls. Logistic regression analysis was applied to assess the

categorised as drinking at least weekly (weekly alcohol consumption) or less often.

**2.3.2 Drunkenness**

episodes of drunkenness.

**2.3.3 Demographic factors**

**2.3.4 Family related factors**

and grandparent, foster home etc.).

al., 2008).

(7–10).

**2.4 Statistical analysis**

(very bad and bad); 2) average; 3) good (very good and good).

#### **3.1 Demographic and family related characteristics of respondents**

In 2010, the number of 13- and 15-year-old adolescents studied was almost equal (Table 2). There was about 77% of Estonian and nearly one fourth non-Estonian schoolchildren. About 63% of adolescents were living with both biological parents, approximately 20% with one parent, 15% with parent and a step-parent, and 2% had some other family structure. Almost half of the schoolchildren evaluated their family wealth to be good, 46% found it was average and about 4% said it was bad. Approximately 38% of schoolchildren had high, one third middle and 27% low FAS. About 77% of adolescents evaluated their family relationships good, 19% average and 3% bad.

Alcohol Consumption Among Adolescents in Estonia 1994 – 2010 193

Yes 274 52.4 266 72.5 520 75.5 557 77.3 377 54.8 every day 2 0.4 5 1.4 19 2.8 19 2.6 15 2.2 every week 35 6.7 21 5.7 82 11.9 66 9.2 39 5.7 every month 54 10.3 47 12.8 116 16.8 131 18.2 84 12.2 seldom 183 35.0 193 52.6 303 44.0 341 47.3 239 34.7 No 249 47.6 101 27.5 169 24.5 164 22.8 311 45.2 Total 523 100 367 100 689 100 721 100 688 100

Yes 260 41.8 279 62.8 482 65.7 552 74.8 462 64.3 every day 1 0.2 4 0.9 5 0.7 9 1.2 4 0.6 every week 8 1.3 10 2.3 50 6.8 47 6.4 53 7.4 every month 38 6.1 38 8.6 83 11.3 103 14.0 107 14.9 seldom 213 34.2 227 51.1 344 46.9 393 53.3 298 41.5 No 362 58.2 165 37.2 252 34.3 186 25.2 256 35.7 Total 622 100 444 100 734 100 738 100 718 100 Table 3. Distribution of alcohol consumption among 13-year-old schoolchildren by gender,

Yes 428 78.5 213 84.9 541 87.4 716 89.6 535 81.2 every day 6 1.1 10 4.0 19 3.1 1 2.4 12 1.8 every week 68 12.5 44 17.5 177 28.6 195 24.4 121 18.4 every month 108 19.8 66 27.0 136 22.0 202 25.3 164 24.9 seldom 246 45.1 93 37.1 209 33.8 300 37.6 238 36.1 No 117 21.5 38 15.1 78 12.6 83 10.4 124 18.8 Total 545 100 251 100 619 100 799 100 659 100

Yes 468 74.8 281 84.4 569 87.8 700 89.4 627 85.1 every day 5 0.8 3 0.9 7 1.1 7 0.9 4 0.5 every week 25 4.0 32 9.6 122 18.8 130 16.6 95 12.9 every month 85 13.6 78 23.4 163 25.2 231 29.5 213 28.9 seldom 353 56.4 168 50.5 277 42.8 332 42.4 315 42.7 No 158 25.2 52 15.6 79 12.2 83 10.6 110 14.9 Total 626 100 333 100 648 100 783 100 737 100 Table 4.  Distribution of demographic and family related factors among 13- and 15-year-old schoolchildren by gender, HBSC Survey, Estonia, 2010

#### **3.2 Alcohol consumption**

Prevalence rate of alcohol consumption has been quite high among Estonian adolescents over study years. After 2006 the prevalence rate decreased in all age groups.

Among 13-year-old boys the alcohol drinking in 2010 (54.8%) was almost on the same level as in 1994, when it was 52.4% (Table 3). Compared to year 2006 the prevalence rate decreased 22.5%.

Although alcohol consumption rate among 13-year-old girls decreased 10.5% after 2006, it was more than 20% higher in year 2010 than in 1994. Also for the first time, alcohol consumption of girls was higher compared to boys in 2010 (64.3% and 54.8%, respectively).

Alcohol Consumption Among Adolescents in Estonia 1994 – 2010 193

Girls (n=1455)

% % %

Total (n=2802)

Boys (n=1347)

13-year old 51.1 49.4 50.2 15- year old 48.9 50.7 49.8

Estonian 76.8 77.6 77.2 non-Estonian 22.5 22.1 22.3 missing 0.7 0.4 0.5

two parents 65.8 60.6 63.1 one parent 18.6 21.0 19.8 parent and step-parent 13.1 15.8 14.5 other 2.2 2.1 2.1 missing 0.4 0.5 0.4

good 51.8 47.4 49.5 average 44.0 47.6 45.9 bad 3.1 4.5 3.8 missing 1.1 0.6 0.8

low 24.4 29.5 27.1 middle 32.6 33.4 33.0 high 40.2 35.7 37.9 missing 2.8 1.4 2.0

good 80.5 73.8 77.0 average 16.6 21.9 19.4 bad 2.4 4.1 3.3 missing 0.5 0.2 0.4

Table 2. Distribution of demographic and family related factors among 13- and 15-year-old

Prevalence rate of alcohol consumption has been quite high among Estonian adolescents

Among 13-year-old boys the alcohol drinking in 2010 (54.8%) was almost on the same level as in 1994, when it was 52.4% (Table 3). Compared to year 2006 the prevalence rate

Although alcohol consumption rate among 13-year-old girls decreased 10.5% after 2006, it was more than 20% higher in year 2010 than in 1994. Also for the first time, alcohol consumption of girls was higher compared to boys in 2010 (64.3% and 54.8%,

over study years. After 2006 the prevalence rate decreased in all age groups.

Variables

Ethnicity

Family structure

Family wealth

Family affluence scale

Family relationships

**3.2 Alcohol consumption**

decreased 22.5%.

respectively).

schoolchildren by gender, HBSC Survey, Estonia, 2010

Age

Table 3. Distribution of alcohol consumption among 13-year-old schoolchildren by gender, HBSC Survey, Estonia, 1994–2010

Table 4. Alcohol consumption distribution among 15-year-old schoolchildren by gender, HBSC Survey, Estonia, 1994–2010

Alcohol Consumption Among Adolescents in Estonia 1994 – 2010 195

Yes 96 18.5 122 33.3 309 44.8 329 45.9 234 34.4 >10 times 5 1.0 3 0.8 37 5.4 40 5.6 28 4.1 4–10 times 6 1.2 11 3.0 33 4.8 43 6.0 29 4.3 2–3 times 24 4.6 41 11.2 100 14.5 102 14.3 66 9.7 once 61 11.8 67 18.3 139 20.2 144 20.1 111 16.3 No 423 81.5 244 66.7 380 55.2 387 54.1 446 65.6 Total 519 100 366 100 689 100 716 100 680 100

Yes 43 6.9 66 14.9 209 28.5 219 29.7 221 31.1 >10 times 2 0.3 2 0.5 16 2.2 15 2.0 24 3.4 4–10 times 2 0.3 2 0.5 17 2.3 28 3.8 29 4.1 2–3 times 8 1.3 13 2.9 60 8.2 72 9.8 69 9.7 once 31 5.0 49 11.1 116 15.8 104 14.1 99 13.9 No 577 93.1 377 85.1 525 71.5 519 70.3 490 68.9 Total 620 100 443 100 734 100 738 100 711 100

Tabel 5. Distribution of episodes of drunkenness among 13-year-old schoolchildren by

Yes 256 47.0 150 60.2 460 74.3 566 71.1 445 67.6 >10 times 30 5.5 31 12.5 152 24.6 164 20.6 99 15.1 4–10 times 29 5.3 31 12.5 76 12.3 110 13.8 97 14.7 2–3 times 81 14.9 48 19.3 123 19.9 181 22.7 119 18.1 once 116 21.3 40 16.1 109 17.6 111 13.9 130 19.8 No 289 53.0 99 39.8 159 25.7 230 28.9 213 32.4

Yes 160 25.6 132 39.6 387 59.8 487 62.4 428 58.2 >10 times 4 0.6 12 3.6 55 8.5 60 7.7 66 9.0 4–10 times 7 1.1 16 4.8 64 9.9 77 9.9 76 10.3 2–3 times 50 8.0 49 14.7 153 23.7 192 24.6 167 22.7 once 99 15.8 55 16.5 115 17.8 158 20.2 119 16.2 No 465 74.4 201 60.4 260 40.2 294 37.6 307 41.8

Total 545 100 249 100 619 100 796 100

Total 625 100 333 100 647 100 781 100

Table 6.  The prevalence rate increased until 2006 and then dropped by 8.4% from 89.6% to 81.2% in 2010. Alcohol consumption among 15-year-old girls increased from 1994 to 2006, when it reached 89.4% and then dropped by 4.3%. For the second time during the study period the prevalence rate of alcohol consumption was higher among girls compared to boys: first in 2002, when difference was 0.4% and then in 2010, when difference was 3.9%.

Prevalence rate of weekly alcohol consumption mostly decreased since 2002, except among 13-year-old girls (Figure 1). The prevalence rate among 13-year-old girls increased from 1.5% in 1994 to 7.9% in 2010. Among 13-year-old boys weekly alcohol consumption prevalence rate decreased from 14.7% in 2002 to 7.9% as among 13-year-old girls in 2010. In 2002 31.7% of 15-year-old boys and 20.0% of the same aged girls consumed alcohol weekly. The prevalence rate decreased from 2002 to 2010, 11.5% among 15-year-old boys and 6.6% among 15-year-old girls.

Fig. 1. Prevalence rates of weekly alcohol consumption among 13- and 15-year-old schoolchildren by gender, HBSC Survey, Estonia, 1994–2010

#### **3.3 Drunkenness**

The prevalence rate of at least one episode of drunkenness mostly increased from 1994 to 2006 and then decreased. Compared to boys, prevalence rate among girls was only slightly lower in 2010 (Table 5). Among 13-year-old boys the prevalence rate of at least one episode of drunkenness more than doubled in the period of 1994–2006 and after that decreased 11.5% from 45.9% to 34.4%. Among 15-year-old girls the prevalence rate increased since 1994, the difference between years 1994 and 2010 was five-fold (6.9% in 1994 and 31.1% in 2010).

Alcohol Consumption Among Adolescents in Estonia 1994 – 2010 195

Alcohol consumption among 15-year-old boys in 2010 (81.2%) was quite similar compared to 1994 (78.5%) (Table 4). The prevalence rate increased until 2006 and then dropped by 8.4% from 89.6% to 81.2% in 2010. Alcohol consumption among 15-year-old girls increased from 1994 to 2006, when it reached 89.4% and then dropped by 4.3%. For the second time during the study period the prevalence rate of alcohol consumption was higher among girls compared to boys: first in 2002, when difference was 0.4% and then in 2010, when difference

Prevalence rate of weekly alcohol consumption mostly decreased since 2002, except among 13-year-old girls (Figure 1). The prevalence rate among 13-year-old girls increased from 1.5% in 1994 to 7.9% in 2010. Among 13-year-old boys weekly alcohol consumption prevalence rate decreased from 14.7% in 2002 to 7.9% as among 13-year-old girls in 2010. In 2002 31.7% of 15-year-old boys and 20.0% of the same aged girls consumed alcohol weekly. The prevalence rate decreased from 2002 to 2010, 11.5% among 15-year-old boys and 6.6%

Fig. 1. Prevalence rates of weekly alcohol consumption among 13- and 15-year-old school-

The prevalence rate of at least one episode of drunkenness mostly increased from 1994 to 2006 and then decreased. Compared to boys, prevalence rate among girls was only slightly lower in 2010 (Table 5). Among 13-year-old boys the prevalence rate of at least one episode of drunkenness more than doubled in the period of 1994–2006 and after that decreased 11.5% from 45.9% to 34.4%. Among 15-year-old girls the prevalence rate increased since 1994, the difference between years 1994 and 2010 was five-fold (6.9% in 1994 and 31.1% in

children by gender, HBSC Survey, Estonia, 1994–2010

was 3.9%.

among 15-year-old girls.

**3.3 Drunkenness**

2010).

Tabel 5. Distribution of episodes of drunkenness among 13-year-old schoolchildren by gender, HBSC Survey, Estonia, 1994–2010

Table 6. Distribution of episodes of drunkenness among 15-year-old schoolchildren by gender, HBSC Survey, Estonia, 1994–2010

Alcohol Consumption Among Adolescents in Estonia 1994 – 2010 197

15- year old 2.78 (1.95–3.96) 1.62 (1.14–2.31) 4.14 (3.18–5.39) 3.47 (2.69–4.48)

Estonian 2.63 (1.58–4.36) 2.23 (1.31–3.80) 2.45 (1.74–3.45) 2.03 (1.46–2.83)

one parent 1.21 (0.79–1.88) 1.33 (0.85–2.09) 1.32 (0.95–1.87) 1.55 (1.13–2.13)

other 1.73 (0.62–4.79) 1.20 (0.39–3.70) 2.01 (0.82–4.90) 2.65 (1.19–5.92)

average 0.83 (0.58–1.18) 1.16 (0.80–1.69) 0.89 (0.67–1.16) 1.44 (1.10–1.87) bad 1.13 (0.46–2.75) 2.38 (1.15–4.92) 1.12 (0.53–2.36) 1.96 (1.07–3.57)

middle 0.74 (0.46–1.19) 1.35 (0.84–2.17) 1.12 (0.79–1.60) 1.29 (0.93–1.78) high 1.41 (0.91–2.20) 2.05 (1.27–3.32) 1.35 (0.95–1.92) 1.95 (1.39–2.73)

average 1.71 (1.14–2.58) 2.27 (1.54–3.35) 1.76 (1.26–2.46) 1.85 (1.38–2.48) bad 3.82 (1.65–8.88) 3.30 (1.68–6.47) 3.43 (1.53–7.71) 2.47 (1.36–4.47) Table 7. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) for weekly alcohol consumption (I model) and for at least two episodes of drunkenness (II model) pending on demographic and family related factors among 13- and 15-year-old schoolchildren by

The present chapter focused on alcohol consumption among adolescents in Estonia in

Before discussing the results, one has to consider the limitations of the survey. Limitations are mainly related to questionnaire survey and its validity. Some studies have demonstrated that there is tendency to under-report when asking questions on such a sensitive risk taking behaviour like alcohol consumption (Newell et al., 1999). To deal with this potential bias of self-reporting all possible efforts to guarantee anonymity of responses were made. Despite of some limitations, this study provides basic data and several inferences can be drawn.

AOR (95% CI) AOR (95% CI) AOR (95% CI) AOR (95% CI)

1.05 (0.64–1.71) 1.32 (0.83–2.09) 1.72 (1.19–2.49) 1.45 (1.04–2.03)

Repeated drunkenness (II model)

Weekly alcohol consumption (I model)

13-year old 1 1 1 1

non-Estonian 1 1 1 1

two parents 1 1 1 1

good 1 1 1 1

low 1 1 1 1

good 1 1 1 1

Age

Ethnicity

parent

Family wealth

Family structure

parent and step-

Family affluence scale

Family relationships

**4. Discussion**

1994–2010.

gender, HBSC Survey, Estonia, 2010

**4.1 Limitations and strength of the survey**

Variables Boys Girls Boys Girls

Among 15-year-old boys the prevalence rate of at least one episode of drunkenness increased from 1994 (47.0%) to 2002 (74.3%) and then decreased (Table 6). Compared to year 1994, in 2010 the rate was higher by 20.6%. Among 15-year-old girls the prevalence rate increased from 1994 (25.6%) to 2006 (62.4%) and then decreased by 4.2%. The prevalence rate has more than doubled over the whole period.

The prevalence rate of at least two episodes of drunkenness decreased after 2006 among 13 and 15-year-old boys (Figure 2). The prevalence rate among 13-year-old boys in 2006 was 25.8% and in 2010 18.1%. Among 15-year-old boys the rate decreased from 57.2% in 2006 to 47.9% in 2010. Among 13-year-old girls the rate increased since 1994, when it was 1.9%, to 17.2% in 2010. Among 15-year-old girls the rate was stable since 2002, when it was 42.0%. However, compared to year 1994 the rate increased approximately 4 times from 9.8% to 42.0% in 2010.

Fig. 2. Prevalence rates of at least two episodes of drunkenness among 13- and 15-year-old schoolchildren by gender, HBSC Survey, Estonia, 1994–2010

#### **3.4 Alcohol consumption and drunkenness by demographic and family related factors**

In 2010, weekly alcohol consumption and repeated drunkenness were higher among 15-year-olds (*versus* 13-year-olds) and among Estonian (*versus* non-Estonian) boys and girls (Table 7). Family structure was not associated with drinking alcohol weekly. Compared to schoolchildren living with both parents, odds for repeated drunkenness was higher among girls living with one parent, and among boys and girls living with parent and step-parent. Family wealth and FAS were associated with alcohol consumption and drunkenness only among girls. Odds to drink alcohol weekly and to have at least two episodes of drunkenness was higher among girls living in families with lower perceived wealth, but having higher FAS. Compared to adolescents with the good family relationships, odds to consume alcohol weekly and to have at least two episodes of drunkenness was higher among boys and girls with average and bad family relationships.

Table 7. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) for weekly alcohol consumption (I model) and for at least two episodes of drunkenness (II model) pending on demographic and family related factors among 13- and 15-year-old schoolchildren by gender, HBSC Survey, Estonia, 2010

## **4. Discussion**

196 Public Health – Social and Behavioral Health

Among 15-year-old boys the prevalence rate of at least one episode of drunkenness increased from 1994 (47.0%) to 2002 (74.3%) and then decreased (Table 6). Compared to year 1994, in 2010 the rate was higher by 20.6%. Among 15-year-old girls the prevalence rate increased from 1994 (25.6%) to 2006 (62.4%) and then decreased by 4.2%. The prevalence

The prevalence rate of at least two episodes of drunkenness decreased after 2006 among 13 and 15-year-old boys (Figure 2). The prevalence rate among 13-year-old boys in 2006 was 25.8% and in 2010 18.1%. Among 15-year-old boys the rate decreased from 57.2% in 2006 to 47.9% in 2010. Among 13-year-old girls the rate increased since 1994, when it was 1.9%, to 17.2% in 2010. Among 15-year-old girls the rate was stable since 2002, when it was 42.0%. However, compared to year 1994 the rate increased approximately 4 times from 9.8% to

Fig. 2. Prevalence rates of at least two episodes of drunkenness among 13- and 15-year-old

**3.4 Alcohol consumption and drunkenness by demographic and family related factors**  In 2010, weekly alcohol consumption and repeated drunkenness were higher among 15-year-olds (*versus* 13-year-olds) and among Estonian (*versus* non-Estonian) boys and girls (Table 7). Family structure was not associated with drinking alcohol weekly. Compared to schoolchildren living with both parents, odds for repeated drunkenness was higher among girls living with one parent, and among boys and girls living with parent and step-parent. Family wealth and FAS were associated with alcohol consumption and drunkenness only among girls. Odds to drink alcohol weekly and to have at least two episodes of drunkenness was higher among girls living in families with lower perceived wealth, but having higher FAS. Compared to adolescents with the good family relationships, odds to consume alcohol weekly and to have at least two episodes of drunkenness was higher among boys and girls

schoolchildren by gender, HBSC Survey, Estonia, 1994–2010

with average and bad family relationships.

rate has more than doubled over the whole period.

42.0% in 2010.

The present chapter focused on alcohol consumption among adolescents in Estonia in 1994–2010.

#### **4.1 Limitations and strength of the survey**

Before discussing the results, one has to consider the limitations of the survey. Limitations are mainly related to questionnaire survey and its validity. Some studies have demonstrated that there is tendency to under-report when asking questions on such a sensitive risk taking behaviour like alcohol consumption (Newell et al., 1999). To deal with this potential bias of self-reporting all possible efforts to guarantee anonymity of responses were made. Despite of some limitations, this study provides basic data and several inferences can be drawn.

Alcohol Consumption Among Adolescents in Estonia 1994 – 2010 199

**4.3 Alcohol consumption and drunkenness by demographic and family related factors**  Weekly alcohol consumption and repeated drunkenness were associated with demographic factors like gender and age as described above. In addition, compared to non-Estonian adolescents alcohol drinking was more pronounced among Estonians. At the same time, weekly alcohol consumption was higher, but the amount of pure alcohol consumed per week was lower among adults of ethnic majority in Estonia (Pärna et al., 2010). However, in Lithuania, in schools with Lithuanian teaching language, Polish and Russian adolescents

Drunkenness, but not weekly alcohol consumption was associated with family structure among boys and girls. Living in non-intact families was a risk factor for repeated drunkenness. Also, Bjarnason et al. (2003) reported that schoolchildren living with both biological parents engaged less frequently in heavy alcohol consumption than those living in other arrangements. According to world-wide literature, higher supervision in intact families and supportive family environment might be associated with lower alcohol consumption among adolescents in these families (Cookston, 1999; Shucksmith et al., 1997). Similar association was found between alcohol consumption, repeated drunkenness and family wealth among girls. Lower family wealth was a risk factor for heavy alcohol use among girls in Estonia. Zaborskis et al. (2006) found inverse relationship between alcohol consumption and the perceived family wealth in all three Baltic countries. In 1994–2002, girls in Estonia, but boys in Latvia and Lithuania from the families perceived by them as wealthy were more likely to drink weekly as compared to adolescents from the families perceived by them as not wealthy. This inconsistency in these findings might be explained

Weekly alcohol consumption as well as repeated drunkenness was associated with family affluence scale among girls, but not among boys. At the same time, there was not found any relationship between repeated drunkenness and FAS among 11–15-year-olds in Estonia in 2002 (Richter et al., 2006). Again, this inconsistency in these results might be explained with different age groups and study years used in these studies. Moreover, Richter et al. (2006) found very limited evidence for a close consistent relationship between episodes of drunkenness and parental FAS in almost all other participating countries (27) in the same study. Kuntsche et al. (2004) have pointed out that while adults problem drinking seems to be more common in less affluent groups, this direction might be reversed for adolescents, where accessibility to financial resources is more limited. Also, higher FAS as well as family wealth might be not directly associated with higher education. Inconsistency in association of alcohol drinking with family wealth and FAS could be explained by the fact, that distribution of perceived family wealth among adolescents is quite different as compared to FAS. Adolescents who estimated the family wealth 'not so well-off' or 'not at all well-off' was in 2010 survey 3.2%, by FAS tertiles low economic situation was in 27% of students.

In addition, there might be other factors during adolescence, which may have a greater impact on drinking behaviour than family related factors and parental socioeconomic status. For instances, the specific character of adolescence as a stage of experimenting with behaviours associated with adult status (Richter et al., 2006) or situations that youth feel

were more exposed to alcohol consumption (Šumskas et al., 2010).

by time difference in these studies (they were conducted in different years).

Evidently, FAS shows more objectively the financial situation of the family.

powerless to change (United Nations, 2005).

Strength of this survey is related to the possibility to make cross-national comparisons as standard approach was employed according to the study protocol to use the same questions in each participating country.

## **4.2 Trends in alcohol consumption and drunkenness**

Weekly alcohol consumption increased from 1994 to 2002 and thereafter decreased among boys and girls in Estonia. Only among 13-year-old girls drinking alcohol weekly increased during the whole study period. Nevertheless, compared to the year 1994, prevalence of weekly drinking was much higher in 2010. In 1994–2002, similar increasing trend of alcohol consumption was found among adolescents in neighbouring countries Latvia and Lithuania (Zaborskis et al., 2006).

Similar pattern emerged with drunkenness. Prevalence of at least two episodes of drunkenness increased from 1994 to 2006 and thereafter slightly decreased among boys and girls. Among 13-year-old girls weekly alcohol consumption increased during the whole study period. Throughout the study period prevalence of drunkenness increased more among girls. Again, compared to the year 1994, prevalence of weekly alcohol consumption was much higher in 2010.

At the same time, Simons-Morton et al. (2009) reported world-wide cross-cultural patterns in alcohol consumption. The Northern European countries showed a declining trend, but Eastern European countries (including Estonia) experienced increasing trend in alcohol consumption and drunkenness. The variability of trends by country might reflect alcohol and marketing policy differences by country. Estonia has experienced significant political and economic changes during the last two decades. A lot of effects on alcohol related issues in Estonia could be associated with economic changes of the former Soviet Union as well as with the joining the European Union in 2004.

Gender differences in alcohol consumption among adolescents were pronounced. Throughout the study period, drinking and drunkenness remained higher among boys compared to girls, but the gap between boys and girls declined and girls appeared to be catching up with boys especially among 13-year-olds. Also, gender gap was shrinking in almost all countries participating in HBSC Survey (Simons-Morton et al., 2009). The variability in trends by gender in Estonia could be due to increased effectiveness of contemporary marketing practices or relative ineffectiveness of policies and programs with girls. However, these changes in prevalence could also be due to changes in the social roles of women, allowing girls greater autonomy and wider range of social options (Rahav et al., 2006).

Prevention of alcohol consumption among adolescents is very important because it prevents problems among adults in the future (Hingson et al., 2006). It has been found that the most effective prevention measures are those that are targeted to schoolchildren and to their parents at the same time (Smit et al., 2008; Wu et al., 2003). However, it has to be taken into account that every country needs it's own implementation of a specific program due to cultural differences (Koning et al., 2010). Simons-Morton et al. (2010) compared alcohol consumption of adolescents in USA, Canada and Netherlands and found that there were higher odds to consume alcohol and get drunk in the Netherlands, where minimum age to purchase alcohol is 16 compared to Canada (minimum age 19) and USA (minimum age 21).

Strength of this survey is related to the possibility to make cross-national comparisons as standard approach was employed according to the study protocol to use the same questions

Weekly alcohol consumption increased from 1994 to 2002 and thereafter decreased among boys and girls in Estonia. Only among 13-year-old girls drinking alcohol weekly increased during the whole study period. Nevertheless, compared to the year 1994, prevalence of weekly drinking was much higher in 2010. In 1994–2002, similar increasing trend of alcohol consumption was found among adolescents in neighbouring countries Latvia and Lithuania

Similar pattern emerged with drunkenness. Prevalence of at least two episodes of drunkenness increased from 1994 to 2006 and thereafter slightly decreased among boys and girls. Among 13-year-old girls weekly alcohol consumption increased during the whole study period. Throughout the study period prevalence of drunkenness increased more among girls. Again, compared to the year 1994, prevalence of weekly alcohol consumption

At the same time, Simons-Morton et al. (2009) reported world-wide cross-cultural patterns in alcohol consumption. The Northern European countries showed a declining trend, but Eastern European countries (including Estonia) experienced increasing trend in alcohol consumption and drunkenness. The variability of trends by country might reflect alcohol and marketing policy differences by country. Estonia has experienced significant political and economic changes during the last two decades. A lot of effects on alcohol related issues in Estonia could be associated with economic changes of the former Soviet Union as well as

Gender differences in alcohol consumption among adolescents were pronounced. Throughout the study period, drinking and drunkenness remained higher among boys compared to girls, but the gap between boys and girls declined and girls appeared to be catching up with boys especially among 13-year-olds. Also, gender gap was shrinking in almost all countries participating in HBSC Survey (Simons-Morton et al., 2009). The variability in trends by gender in Estonia could be due to increased effectiveness of contemporary marketing practices or relative ineffectiveness of policies and programs with girls. However, these changes in prevalence could also be due to changes in the social roles of women, allowing girls greater autonomy and wider range of social options (Rahav et al.,

Prevention of alcohol consumption among adolescents is very important because it prevents problems among adults in the future (Hingson et al., 2006). It has been found that the most effective prevention measures are those that are targeted to schoolchildren and to their parents at the same time (Smit et al., 2008; Wu et al., 2003). However, it has to be taken into account that every country needs it's own implementation of a specific program due to cultural differences (Koning et al., 2010). Simons-Morton et al. (2010) compared alcohol consumption of adolescents in USA, Canada and Netherlands and found that there were higher odds to consume alcohol and get drunk in the Netherlands, where minimum age to purchase alcohol is 16 compared to Canada (minimum age 19) and USA (minimum age 21).

in each participating country.

(Zaborskis et al., 2006).

was much higher in 2010.

2006).

with the joining the European Union in 2004.

**4.2 Trends in alcohol consumption and drunkenness**

#### **4.3 Alcohol consumption and drunkenness by demographic and family related factors**

Weekly alcohol consumption and repeated drunkenness were associated with demographic factors like gender and age as described above. In addition, compared to non-Estonian adolescents alcohol drinking was more pronounced among Estonians. At the same time, weekly alcohol consumption was higher, but the amount of pure alcohol consumed per week was lower among adults of ethnic majority in Estonia (Pärna et al., 2010). However, in Lithuania, in schools with Lithuanian teaching language, Polish and Russian adolescents were more exposed to alcohol consumption (Šumskas et al., 2010).

Drunkenness, but not weekly alcohol consumption was associated with family structure among boys and girls. Living in non-intact families was a risk factor for repeated drunkenness. Also, Bjarnason et al. (2003) reported that schoolchildren living with both biological parents engaged less frequently in heavy alcohol consumption than those living in other arrangements. According to world-wide literature, higher supervision in intact families and supportive family environment might be associated with lower alcohol consumption among adolescents in these families (Cookston, 1999; Shucksmith et al., 1997).

Similar association was found between alcohol consumption, repeated drunkenness and family wealth among girls. Lower family wealth was a risk factor for heavy alcohol use among girls in Estonia. Zaborskis et al. (2006) found inverse relationship between alcohol consumption and the perceived family wealth in all three Baltic countries. In 1994–2002, girls in Estonia, but boys in Latvia and Lithuania from the families perceived by them as wealthy were more likely to drink weekly as compared to adolescents from the families perceived by them as not wealthy. This inconsistency in these findings might be explained by time difference in these studies (they were conducted in different years).

Weekly alcohol consumption as well as repeated drunkenness was associated with family affluence scale among girls, but not among boys. At the same time, there was not found any relationship between repeated drunkenness and FAS among 11–15-year-olds in Estonia in 2002 (Richter et al., 2006). Again, this inconsistency in these results might be explained with different age groups and study years used in these studies. Moreover, Richter et al. (2006) found very limited evidence for a close consistent relationship between episodes of drunkenness and parental FAS in almost all other participating countries (27) in the same study. Kuntsche et al. (2004) have pointed out that while adults problem drinking seems to be more common in less affluent groups, this direction might be reversed for adolescents, where accessibility to financial resources is more limited. Also, higher FAS as well as family wealth might be not directly associated with higher education. Inconsistency in association of alcohol drinking with family wealth and FAS could be explained by the fact, that distribution of perceived family wealth among adolescents is quite different as compared to FAS. Adolescents who estimated the family wealth 'not so well-off' or 'not at all well-off' was in 2010 survey 3.2%, by FAS tertiles low economic situation was in 27% of students. Evidently, FAS shows more objectively the financial situation of the family.

In addition, there might be other factors during adolescence, which may have a greater impact on drinking behaviour than family related factors and parental socioeconomic status. For instances, the specific character of adolescence as a stage of experimenting with behaviours associated with adult status (Richter et al., 2006) or situations that youth feel powerless to change (United Nations, 2005).

Alcohol Consumption Among Adolescents in Estonia 1994 – 2010 201

alcohol consumption among adolescents. Root beer (0.5% and 0.8%) and non-alcoholic cider (1.2%) should be considered as alcoholic beverages. Also raising the minimum age to

Alcohol consumption among adolescents in Estonia is a serious public health problem. Demographic and family related factors influence alcohol use of adolescents, especially among girls. The results of this study may guide the development of policy and

Additional research is needed on the nature of differences in drinking attitudes and patterns among boys and girls and their parents. Also, it might be interesting to look at the alcohol consumption within the context of other, possibly more relevant factors such as peer or

This study was carried out in the framework of the Health Behaviour in School-aged Children (HBSC) Survey, WHO/EURO collaborative international study. This chapter reports data from Estonia (Principal Investigator Katrin Aasvee). The International HBSC Coordinator is Candace Currie (University of St Andrews School of Medicine, St Andrews, Scotland). The Data Management Centre Manager is Oddrun Samdal (University of Bergen,

This study was supported by the Estonian Ministry of Education and Science (target funding SF0180060s09) and the Estonian Ministry of Social Affairs (Strategy of Prevention of

Aasvee, K., Poolakese, A., Minossenko, A. & Kurbatova, A. (2007). *Eesti kooliõpilaste tervise-*

Bjarnason, T., Andersson, B., Choquet, M., Elekes, Z., Morgan, M. & Rapinett, G. (2003).

Challier, B., Chau, N., Predine, R., Choquet, M. & Legras, B. (2000). Associations of family

Cookston, J.T. (1999). Effects on adolescent problem behaviors. *Journal of Divorce &*

countries. *Journal of Studies on Alcohol*, Vol.54, No.2, pp. 200–208

adolescents, *European Journal of Epidemiology*, Vol.16, No.1, pp. 33–42 Chenet, L., Leon, D., McKee, M. & Vassin, S. (1998). Deaths from alcohol and violence in

*käitumise uuring, 2005/2006. õppeaasta. Tabelid (tulemused kaalutud andmete alusel). [Health behaviour of school-aged children among adolescents in Estonia, 2005/2006. Tables*

Alcohol culture, family structure and adolescent alcohol use: multilevel modeling of frequency of heavy drinking among 15–16 year old students in 11 European

environment and individual factors with tobacco, alcohol, and illicit drug use in

Moscow: socio-economic determinants. *European Journal of Population,* Vol.14, No.1,

purchase alcohol from 18 to 21 would be an effective preventive measure.

interventions tackling alcohol consumption among adolescents in Estonia.

school influence and other parental factors.

Bergen, Norway). For details, see www.hbsc.org.

*(results based on weighted data)].* Tallinn, Estonia

*Remarriage,* Vol.32, No.1/2, pp. 107–122

Cardiovascular Diseases 2005–2020).

**5. Conclusion**

**6. Acknowledgment**

**7. References**

pp. 19–37

Weekly alcohol consumption and repeated drunkenness were associated with worse family relationships among boys and girls in this study. According to world-wide literature, a supportive family environment (Shucksmith et al., 1997) and parent-child communication is associated with lowered prevalence of alcohol consumption (Luk et al., 2010).

## **4.4 Alcohol policy in Estonia**

During 1996–2006 alcohol policy was virtually nonexistent in Estonia. There was a national alcoholism and drug abuse prevention programme for 1997–2007, which was continued since 2004 under national drug abuse prevention strategy (1994–2012). This programme mainly focused on the creation of a nationwide information system to evaluate the damage caused by alcohol and drug abuse.

In 1996–2006 the prices of alcoholic beverages increased in Estonia (1.3 times for domestically produced beer and 1.4 times for vodka). However, the average price increase has been slower than the increase in the consumer price index, as well as slower than the income increase of inhabitants, which most likely has also contributed to the increase of alcohol consumption (Estonian Institute of Economic Research, 2008).

Compared to the 2004 level, excise tax increased 45% by the beginning of 2010. The highest tax increases (30% altogether) occurred in 2008 when the economic crisis started to affect the Estonian economy (Lai & Habicht, 2011). This was the first time when affordability of alcoholic beverages decreased after many years.

A nation-wide restriction on the time of off-premise sales of alcoholic beverages was introduced in the summer of 2008. Currently, off-premise sale of alcoholic beverages is prohibited from 10 p.m. to 10 a.m. throughout Estonia.

There is still wide availability of alcohol sales outlets: 198 alcohol retail shops per 100 000 inhabitants in Estonia in 2010, while 6.5 in Finland and 4.5 in Sweden (Estonian Institute of Economic Research, 2010).

Since 2008 advertising of alcoholic beverages on television and radio has been prohibited from 7 a.m. to 9 p.m. in Estonia. Before, prohibition of TV advertisement ended at 8 p.m. for alcoholic beverages other than spirits (Lai & Habicht, 2011).

Interventions on a personal level such as alcohol counselling have had very low focus in Estonia. A pilot study to evaluate the methods of early identification of risk drinking and counselling in the primary health care was carried out in the beginning of 2010. It was found that early identification of risk drinking and counselling are feasible. Continuous practical training, considering the specificity of primary health care, is necessary in order to promote the counselling skills of primary health care specialists (Saame et al., 2011).

In Estonia, further alcohol policy actions should include the reduction of the density of alcohol outlets, more comprehensive advertisement bans, clearer separation of alcoholic beverages from other goods in retail stores and full implementation of brief alcohol interventions in primary health care (Lai & Habicht, 2011).

In addition to previously mentioned policy actions, there should be an alcohol consumption prevention program targeted to adolescents and their parents. Higher price for light alcoholic beverages and consistently asking for ID-card while selling alcohol would lower alcohol consumption among adolescents. Root beer (0.5% and 0.8%) and non-alcoholic cider (1.2%) should be considered as alcoholic beverages. Also raising the minimum age to purchase alcohol from 18 to 21 would be an effective preventive measure.

## **5. Conclusion**

200 Public Health – Social and Behavioral Health

Weekly alcohol consumption and repeated drunkenness were associated with worse family relationships among boys and girls in this study. According to world-wide literature, a supportive family environment (Shucksmith et al., 1997) and parent-child communication is

During 1996–2006 alcohol policy was virtually nonexistent in Estonia. There was a national alcoholism and drug abuse prevention programme for 1997–2007, which was continued since 2004 under national drug abuse prevention strategy (1994–2012). This programme mainly focused on the creation of a nationwide information system to evaluate the damage

In 1996–2006 the prices of alcoholic beverages increased in Estonia (1.3 times for domestically produced beer and 1.4 times for vodka). However, the average price increase has been slower than the increase in the consumer price index, as well as slower than the income increase of inhabitants, which most likely has also contributed to the increase of

Compared to the 2004 level, excise tax increased 45% by the beginning of 2010. The highest tax increases (30% altogether) occurred in 2008 when the economic crisis started to affect the Estonian economy (Lai & Habicht, 2011). This was the first time when affordability of

A nation-wide restriction on the time of off-premise sales of alcoholic beverages was introduced in the summer of 2008. Currently, off-premise sale of alcoholic beverages is

There is still wide availability of alcohol sales outlets: 198 alcohol retail shops per 100 000 inhabitants in Estonia in 2010, while 6.5 in Finland and 4.5 in Sweden (Estonian Institute of

Since 2008 advertising of alcoholic beverages on television and radio has been prohibited from 7 a.m. to 9 p.m. in Estonia. Before, prohibition of TV advertisement ended at 8 p.m. for

Interventions on a personal level such as alcohol counselling have had very low focus in Estonia. A pilot study to evaluate the methods of early identification of risk drinking and counselling in the primary health care was carried out in the beginning of 2010. It was found that early identification of risk drinking and counselling are feasible. Continuous practical training, considering the specificity of primary health care, is necessary in order to promote

In Estonia, further alcohol policy actions should include the reduction of the density of alcohol outlets, more comprehensive advertisement bans, clearer separation of alcoholic beverages from other goods in retail stores and full implementation of brief alcohol

In addition to previously mentioned policy actions, there should be an alcohol consumption prevention program targeted to adolescents and their parents. Higher price for light alcoholic beverages and consistently asking for ID-card while selling alcohol would lower

associated with lowered prevalence of alcohol consumption (Luk et al., 2010).

alcohol consumption (Estonian Institute of Economic Research, 2008).

**4.4 Alcohol policy in Estonia**

caused by alcohol and drug abuse.

Economic Research, 2010).

alcoholic beverages decreased after many years.

prohibited from 10 p.m. to 10 a.m. throughout Estonia.

alcoholic beverages other than spirits (Lai & Habicht, 2011).

interventions in primary health care (Lai & Habicht, 2011).

the counselling skills of primary health care specialists (Saame et al., 2011).

Alcohol consumption among adolescents in Estonia is a serious public health problem. Demographic and family related factors influence alcohol use of adolescents, especially among girls. The results of this study may guide the development of policy and interventions tackling alcohol consumption among adolescents in Estonia.

Additional research is needed on the nature of differences in drinking attitudes and patterns among boys and girls and their parents. Also, it might be interesting to look at the alcohol consumption within the context of other, possibly more relevant factors such as peer or school influence and other parental factors.

## **6. Acknowledgment**

This study was carried out in the framework of the Health Behaviour in School-aged Children (HBSC) Survey, WHO/EURO collaborative international study. This chapter reports data from Estonia (Principal Investigator Katrin Aasvee). The International HBSC Coordinator is Candace Currie (University of St Andrews School of Medicine, St Andrews, Scotland). The Data Management Centre Manager is Oddrun Samdal (University of Bergen, Bergen, Norway). For details, see www.hbsc.org.

This study was supported by the Estonian Ministry of Education and Science (target funding SF0180060s09) and the Estonian Ministry of Social Affairs (Strategy of Prevention of Cardiovascular Diseases 2005–2020).

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**11**

*Australia*

**Public Health and**

**Indigenous Australian Gambling:**

Helen Breen, Nerilee Hing and Ashley Gordon

*Centre for Gambling Education and Research,*

**Risky Lifestyle or Harmless Recreation?**

*School of Tourism and Hospitality Management, Southern Cross University, Lismore NSW*

Gambling and particularly gambling-related problems give rise to a complex range of issues. Understanding gambling issues has tended to focus on the individual and their behaviour in the past but is increasingly being recognised as a public health concern (Blaszczynski & Nower, 2007; Shaffer & Korn, 2002). The public health perspective generally considers gambling behavior as a continuum from recreational gambling to low risk and moderate risk gambling and then problem gambling. This perspective focuses attention on the prevention of gambling problems, on minimization of gambling harms and on treatment for those suffering severe gambling problems (Productivity Commission, 2010). A public health view of gambling invites examination of its influences and impacts on populations and communities. Thus the focus of this chapter is on gambling by Indigenous Australians from several communities but belonging to one tribal group in regional Australia.1 This chapter also draws on a model of gambling derived from the public health literature to analyse risk and protective factors associated with gambling within these communities. The usefulness of public health concepts and models to the study of gambling are demonstrated

in this chapter. As well, it makes an empirical contribution to a little studied area.

Gambling has long been recorded as a recreational activity in many cultures. Over 300 years ago, regular visits by Macassan fishermen and traders to northern parts of Australia brought card gambling to Indigenous Australians (Breen, 2008). Card gambling remains a widespread and popular form of contemporary recreation in many Indigenous communities, while the expansion of commercial forms of gambling such as poker machines, casinos, lottery-type products, sports betting and wagering has broadened Indigenous participation in gambling (McMillen & Donnelly, 2008). However, there is limited knowledge about Indigenous gambling or gambling-related problems (Belanger,

1 Being aware of the debate around titles used to describe Aboriginal and Torres Strait Islander Australians, in this chapter we use the terms Indigenous Australian and Aboriginal interchangeably

**1. Introduction**

**2. Background**

depending on source.

http://www.who.int/substance\_abuse/expert\_committee\_alcohol\_trs944.pdf

## **Public Health and Indigenous Australian Gambling: Risky Lifestyle or Harmless Recreation?**

Helen Breen, Nerilee Hing and Ashley Gordon *Centre for Gambling Education and Research, School of Tourism and Hospitality Management, Southern Cross University, Lismore NSW Australia*

## **1. Introduction**

204 Public Health – Social and Behavioral Health

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*consumption.WHO technical report series 944. Second report.* World Health

Gambling and particularly gambling-related problems give rise to a complex range of issues. Understanding gambling issues has tended to focus on the individual and their behaviour in the past but is increasingly being recognised as a public health concern (Blaszczynski & Nower, 2007; Shaffer & Korn, 2002). The public health perspective generally considers gambling behavior as a continuum from recreational gambling to low risk and moderate risk gambling and then problem gambling. This perspective focuses attention on the prevention of gambling problems, on minimization of gambling harms and on treatment for those suffering severe gambling problems (Productivity Commission, 2010). A public health view of gambling invites examination of its influences and impacts on populations and communities. Thus the focus of this chapter is on gambling by Indigenous Australians from several communities but belonging to one tribal group in regional Australia.1 This chapter also draws on a model of gambling derived from the public health literature to analyse risk and protective factors associated with gambling within these communities. The usefulness of public health concepts and models to the study of gambling are demonstrated in this chapter. As well, it makes an empirical contribution to a little studied area.

## **2. Background**

Gambling has long been recorded as a recreational activity in many cultures. Over 300 years ago, regular visits by Macassan fishermen and traders to northern parts of Australia brought card gambling to Indigenous Australians (Breen, 2008). Card gambling remains a widespread and popular form of contemporary recreation in many Indigenous communities, while the expansion of commercial forms of gambling such as poker machines, casinos, lottery-type products, sports betting and wagering has broadened Indigenous participation in gambling (McMillen & Donnelly, 2008). However, there is limited knowledge about Indigenous gambling or gambling-related problems (Belanger,

<sup>1</sup> Being aware of the debate around titles used to describe Aboriginal and Torres Strait Islander Australians, in this chapter we use the terms Indigenous Australian and Aboriginal interchangeably depending on source.

Public Health and Indigenous Australian Gambling: Risky Lifestyle or Harmless Recreation? 207

The Model of Influences on Gambling Behaviours and Outcomes has been developed specifically to examine influences on the behaviour of gamblers and the consequences of their gambling activities (Thomas & Jackson, 2004). Three important elements of gambling uptake are integral to this model. These elements are the propensity to gamble, the influence of gambling products and services on gambling behaviour and the consequences of gambling behaviour. Each of these three elements has accompanying risk, moderating and protective factors. Leaving aside moderating factors, risk and protective factors may vary according to the propensity to gamble by different populations and by the nature and availability of different forms of gambling. Risk and protective factors associated with gambling outcomes may encourage further gambling for some gamblers but not for others. Thus, designing appropriate public health strategies to address problematic gambling requires a sound understanding of the risk and protective factors associated with gambling

by the targeted population. For a depiction of this model, see Figure 1.

Fig. 1. Model of influences on gambling behaviours and outcomes (Thomas & Jackson,

A variety of influences contribute to gambling uptake and to gambling-related problems. Thomas and Jackson (2004, 2008) propose that behavioural characteristics, sociological and cultural factors strongly influence gambling uptake. In considering gambling uptake and the influence of risk and protective factors associated with it, risks relating to the propensity to gamble might include a faulty understanding about the nature of chance and random events underpinning many forms of gambling, boredom, social isolation, depression and a variety of cultural and ethnic issues (Korn & Shaffer, 1999; Thomas & Jackson, 2004, 2008). Gambling risks relating to the nature of the gambling products and services may include access to gambling, gaming venue characteristics, the nature of the games and the nature of rewards offered (Hing & Haw, 2010; Productivity Commission 1999, 2010). Risk factors potentially affecting gambling outcomes and thus encouraging further gambling might

2004:44)

2006, 2011). Internationally, various Indigenous populations appear to have a higher prevalence of problem gambling than the general population (Conner & Taggart, 2009; Dyall, 2010; Williams, Stevens & Nixon, 2011). While research in Australia is limited, results suggest higher problem gambling rates among Indigenous Australians compared to non-Indigenous Australians, although prevalence rates have not been rigorously measured (Stevens & Young, 2009).

Nevertheless, Indigenous Australians are considered an at-risk group for gambling problems, given their social and economic disadvantage. Lower socio-economic groups, particularly those who experience poverty, unemployment, welfare dependence, homelessness and low education, usually have higher rates of gambling-related problems than the general population (Shaffer & Korn, 2002; Volberg & Abbott, 1997). Further, gamblers on low incomes suffering from problems with their gambling experience losses that are borne disproportionately (Shaffer & Korn, 2002). In New Zealand, people in lower socio-economic groups, especially Maori and Pacific Island peoples, tend to experience higher rates of problem gambling (Ministry of Health, 2009). A variety of socio-economic factors negatively affect the health and welfare of some Indigenous Australians. Indigenous Australians generally have a lower life expectancy, higher unemployment records, lower education levels, live with poverty and experience higher levels of psychological distress compared to non-Indigenous Australians (Australian Bureau of Statistics (ABS), 2010; Holland, 2011). Livingstone and Adams (2010) maintain that Australian gaming taxation mainly draws from disadvantaged groups of gamblers, adding to their financial hardship and marginalisation. Thus structural deficiencies and inequalities aligned with individual life circumstances may accumulate and impact on gambling issues for Indigenous Australians.

Given that little research has been conducted into gambling by Indigenous Australians, research on identifying and explaining underlying risk factors that contribute to gambling problems appears to be a useful addition to the sparse knowledge in this field. Additionally, research into protective factors, those that assist gamblers in controlling their gambling appears to make a similar contribution, adding balance to this topic. In this research, problem gambling is defined as 'difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or for the community' (Neal, Delfabbro & O'Neil, 2005, p. i).

### **2.1 Theoretical approach**

Risk and protective factors associated with gambling can arise from multiple influences. Identifying and analysing risk factors contributing to gambling-related problems form a major component of public health gambling research (Perese, Bellringer & Abbott, 2005). Risk factors, those that exacerbate negative gambling consequences and encourage further gambling (Thomas & Jackson, 2008), are largely unknown for Indigenous gamblers (Breen, Hing & Gordon, 2010). The situation is similar for protective factors, those that protect or reduce gamblers' exposure to harmful gambling consequences (Breen, 2011). Once identified, risk factors can be appropriately targeted for early intervention and prevention even if causal relationships are not established. Additionally, protective factors, those that assist gamblers to make decisions to protect them from harmful outcomes, can potentially inform appropriate public health promotion and education strategies.

2006, 2011). Internationally, various Indigenous populations appear to have a higher prevalence of problem gambling than the general population (Conner & Taggart, 2009; Dyall, 2010; Williams, Stevens & Nixon, 2011). While research in Australia is limited, results suggest higher problem gambling rates among Indigenous Australians compared to non-Indigenous Australians, although prevalence rates have not been rigorously measured

Nevertheless, Indigenous Australians are considered an at-risk group for gambling problems, given their social and economic disadvantage. Lower socio-economic groups, particularly those who experience poverty, unemployment, welfare dependence, homelessness and low education, usually have higher rates of gambling-related problems than the general population (Shaffer & Korn, 2002; Volberg & Abbott, 1997). Further, gamblers on low incomes suffering from problems with their gambling experience losses that are borne disproportionately (Shaffer & Korn, 2002). In New Zealand, people in lower socio-economic groups, especially Maori and Pacific Island peoples, tend to experience higher rates of problem gambling (Ministry of Health, 2009). A variety of socio-economic factors negatively affect the health and welfare of some Indigenous Australians. Indigenous Australians generally have a lower life expectancy, higher unemployment records, lower education levels, live with poverty and experience higher levels of psychological distress compared to non-Indigenous Australians (Australian Bureau of Statistics (ABS), 2010; Holland, 2011). Livingstone and Adams (2010) maintain that Australian gaming taxation mainly draws from disadvantaged groups of gamblers, adding to their financial hardship and marginalisation. Thus structural deficiencies and inequalities aligned with individual life circumstances may accumulate and impact on gambling issues for Indigenous

Given that little research has been conducted into gambling by Indigenous Australians, research on identifying and explaining underlying risk factors that contribute to gambling problems appears to be a useful addition to the sparse knowledge in this field. Additionally, research into protective factors, those that assist gamblers in controlling their gambling appears to make a similar contribution, adding balance to this topic. In this research, problem gambling is defined as 'difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or for the

Risk and protective factors associated with gambling can arise from multiple influences. Identifying and analysing risk factors contributing to gambling-related problems form a major component of public health gambling research (Perese, Bellringer & Abbott, 2005). Risk factors, those that exacerbate negative gambling consequences and encourage further gambling (Thomas & Jackson, 2008), are largely unknown for Indigenous gamblers (Breen, Hing & Gordon, 2010). The situation is similar for protective factors, those that protect or reduce gamblers' exposure to harmful gambling consequences (Breen, 2011). Once identified, risk factors can be appropriately targeted for early intervention and prevention even if causal relationships are not established. Additionally, protective factors, those that assist gamblers to make decisions to protect them from harmful outcomes, can potentially

inform appropriate public health promotion and education strategies.

(Stevens & Young, 2009).

Australians.

community' (Neal, Delfabbro & O'Neil, 2005, p. i).

**2.1 Theoretical approach**

The Model of Influences on Gambling Behaviours and Outcomes has been developed specifically to examine influences on the behaviour of gamblers and the consequences of their gambling activities (Thomas & Jackson, 2004). Three important elements of gambling uptake are integral to this model. These elements are the propensity to gamble, the influence of gambling products and services on gambling behaviour and the consequences of gambling behaviour. Each of these three elements has accompanying risk, moderating and protective factors. Leaving aside moderating factors, risk and protective factors may vary according to the propensity to gamble by different populations and by the nature and availability of different forms of gambling. Risk and protective factors associated with gambling outcomes may encourage further gambling for some gamblers but not for others. Thus, designing appropriate public health strategies to address problematic gambling requires a sound understanding of the risk and protective factors associated with gambling by the targeted population. For a depiction of this model, see Figure 1.

Fig. 1. Model of influences on gambling behaviours and outcomes (Thomas & Jackson, 2004:44)

A variety of influences contribute to gambling uptake and to gambling-related problems. Thomas and Jackson (2004, 2008) propose that behavioural characteristics, sociological and cultural factors strongly influence gambling uptake. In considering gambling uptake and the influence of risk and protective factors associated with it, risks relating to the propensity to gamble might include a faulty understanding about the nature of chance and random events underpinning many forms of gambling, boredom, social isolation, depression and a variety of cultural and ethnic issues (Korn & Shaffer, 1999; Thomas & Jackson, 2004, 2008). Gambling risks relating to the nature of the gambling products and services may include access to gambling, gaming venue characteristics, the nature of the games and the nature of rewards offered (Hing & Haw, 2010; Productivity Commission 1999, 2010). Risk factors potentially affecting gambling outcomes and thus encouraging further gambling might

Public Health and Indigenous Australian Gambling: Risky Lifestyle or Harmless Recreation? 209

within the larger constructs of the Thomas and Jackson (2004) model for the propensity to gamble, the use of gambling products and services and the consequences of gambling on

For the results, risk factors, those that exacerbate and intensify adverse consequences of gambling, are presented first. These are followed by protective factors, those that assist people in making informed choices to protect them from harmful gambling consequences. Please note: all quotations are from Indigenous Australians unless described otherwise.

Using the Thomas and Jackson (2004) model, risk factor results were analysed by propensity to gamble, by the use of gambling products and services and by gambling outcomes and

Risk factors including personal, family, financial, historical and cultural risks were identified by the research participants as increasing the propensity to gamble. Personal risks were seen as gambling to escape from grief and loss, from boredom, due to peer pressure, after consuming alcohol or drugs, from being unemployed and having time to gamble, from

Explaining escape from historical grief and cultural loss, some respondents said 'memories come up from the past and people push the memories down ... people turn to something, drinking, drugs, gambling, when the old memories surface'. Escape sometimes meant looking for some time away from stressful situations, either at home or at work. Several people mentioned escape in terms of 'time out alone' or a break away from heavy responsibilities. Other respondents saw that boredom was a gambling risk especially when people were unemployed, had plenty of free time to gamble and where alternative entertainment options were very limited. Risks arising from peer pressure were explained as '(some friends) won't talk to you unless you're with them when playing the (poker) machines'. Similar remarks were '(I) go to a venue with friends, and the next thing they are all on (poker) machines. If I want to talk to them I have to go over to the (poker) machines

The use of alcohol and drugs with gambling was described as 'a cycle involving low selfesteem that leads to drink and drugs'. Some gamblers were seen as being 'vulnerable to making poor choices, but most want to get out of the cycle'. Several people commented that 'Aboriginal people are used to being broke and having no money, so when gambling and the money is gone they do not seem to worry'. For some people it was 'acceptable to be poor in Aboriginal community, where some learnt to live in Struggle Street, used to having nothing'. Explaining budgeting problems and gambling, one person felt many people had 'not learned to control things in the welfare cycle, they need to learn skills ... need to learn to budget'.

Family risks were said to include generational exposure to gambling, normalisation of youth gambling and a lack of education generally. Gambling was reported to be learnt from

having literacy and numeracy problems, and to obtain relief from abuse.

gambling behaviour. These results are provided below.

**4.1 Risk factors for indigenous australian gambling**

too. Then next thing you are putting money in too'.

**4. Results**

consequences.

**4.1.1 Propensity to gamble**

include financial problems, legal troubles, relationship breakdown, depression and/or suicide (Korn & Shaffer, 1999; Thomas & Jackson, 2008; Productivity Commission 1999).

In contrast, protective factors affecting gambling uptake might arise through the propensity to gamble to socialise and relax with others and enjoy any economic outcomes (Korn & Shaffer, 1999; Shaffer & Korn, 2002). For gambling products and services, the influence of responsible gambling strategies publicised by signs and information in the gaming venues, through self-exclusion from venues and from media messages may be protective (QLD Treasury, 2004). For gambling outcomes, having adequate assets to budget for gambling and to provide a buffer against gambling losses (Thomas & Jackson, 2004; Productivity Commission, 1999, 2010) and having family support to help reduce or cease gambling if gambling problems arise (McMillen & Bellew, 2001) may be protective. Any or all of these potential risk and protective factors depend on personal, social, economic and cultural contexts. More risk factors have been identified in prior research than protective factors. In order to provide some balance in this analysis of gambling, the purpose of this chapter is to analyse risk and protective factors associated with gambling by Indigenous Australians in one region of New South Wales (NSW) Australia in order to inform public health measures directed at problem gambling.

## **3. Methods**

An appropriate research design should be culturally sensitive as well as methodologically sound. An interpretative qualitative research design (Guba & Lincoln, 1989) was seen as being culturally appropriate (Martin, 2008). Being based on respectful communication and mutual cooperation, this approach provided rich in-depth data and valuable information. After consultations and discussions, permission was sought and granted by Indigenous Elders in this region and by a university ethics committee for this research to be carried out.

For the setting, in northern New South Wales the eastern corner is comprised of six adjoining local government areas (LGAs). Each LGA has a different geographic, social and economic profile but the Indigenous people of the six LGAs make up one tribal group. To request appropriate permissions for interviews and gather support for the research, we visited the six LGAs several times to explain the project. From an initial list of contacts of Indigenous people and organisations already known, each person interviewed was asked if they could identify other organisations and people relevant to the research. This sampling method, often called snowball sampling, was brokered by someone already known. It was useful in developing confidence and trust between people over time. Snowball sampling was used until all locations were visited and saturation was reached (Creswell, 2007). This process yielded interviews with 169 Indigenous Australians, 21 non-Indigenous Australian gaming venue managers and 10 non-Indigenous Australian gambling counsellors. On average, 30 Indigenous Australians were interviewed in each LGA, although only 20 were interviewed in one LGA where the population was small and widely dispersed. Semistructured interviews (single or in small groups of two or three) were mainly conducted in workplaces, community and health centres and coffee shops. The three researchers, one Indigenous man and two non-Indigenous women, conducted the one hour interviews in pairs, depending on cultural and gender issues.

All interview notes and recordings were transcribed, then coded with N'Vivo software and analysed using thematic analysis (Braun & Clarke, 2006). The data were coded and analyzed within the larger constructs of the Thomas and Jackson (2004) model for the propensity to gamble, the use of gambling products and services and the consequences of gambling on gambling behaviour. These results are provided below.

## **4. Results**

208 Public Health – Social and Behavioral Health

include financial problems, legal troubles, relationship breakdown, depression and/or suicide (Korn & Shaffer, 1999; Thomas & Jackson, 2008; Productivity Commission 1999).

In contrast, protective factors affecting gambling uptake might arise through the propensity to gamble to socialise and relax with others and enjoy any economic outcomes (Korn & Shaffer, 1999; Shaffer & Korn, 2002). For gambling products and services, the influence of responsible gambling strategies publicised by signs and information in the gaming venues, through self-exclusion from venues and from media messages may be protective (QLD Treasury, 2004). For gambling outcomes, having adequate assets to budget for gambling and to provide a buffer against gambling losses (Thomas & Jackson, 2004; Productivity Commission, 1999, 2010) and having family support to help reduce or cease gambling if gambling problems arise (McMillen & Bellew, 2001) may be protective. Any or all of these potential risk and protective factors depend on personal, social, economic and cultural contexts. More risk factors have been identified in prior research than protective factors. In order to provide some balance in this analysis of gambling, the purpose of this chapter is to analyse risk and protective factors associated with gambling by Indigenous Australians in one region of New South Wales (NSW) Australia in order to inform public health measures

An appropriate research design should be culturally sensitive as well as methodologically sound. An interpretative qualitative research design (Guba & Lincoln, 1989) was seen as being culturally appropriate (Martin, 2008). Being based on respectful communication and mutual cooperation, this approach provided rich in-depth data and valuable information. After consultations and discussions, permission was sought and granted by Indigenous Elders in this region and by a university ethics committee for this research to be carried out. For the setting, in northern New South Wales the eastern corner is comprised of six adjoining local government areas (LGAs). Each LGA has a different geographic, social and economic profile but the Indigenous people of the six LGAs make up one tribal group. To request appropriate permissions for interviews and gather support for the research, we visited the six LGAs several times to explain the project. From an initial list of contacts of Indigenous people and organisations already known, each person interviewed was asked if they could identify other organisations and people relevant to the research. This sampling method, often called snowball sampling, was brokered by someone already known. It was useful in developing confidence and trust between people over time. Snowball sampling was used until all locations were visited and saturation was reached (Creswell, 2007). This process yielded interviews with 169 Indigenous Australians, 21 non-Indigenous Australian gaming venue managers and 10 non-Indigenous Australian gambling counsellors. On average, 30 Indigenous Australians were interviewed in each LGA, although only 20 were interviewed in one LGA where the population was small and widely dispersed. Semistructured interviews (single or in small groups of two or three) were mainly conducted in workplaces, community and health centres and coffee shops. The three researchers, one Indigenous man and two non-Indigenous women, conducted the one hour interviews in

All interview notes and recordings were transcribed, then coded with N'Vivo software and analysed using thematic analysis (Braun & Clarke, 2006). The data were coded and analyzed

directed at problem gambling.

pairs, depending on cultural and gender issues.

**3. Methods**

For the results, risk factors, those that exacerbate and intensify adverse consequences of gambling, are presented first. These are followed by protective factors, those that assist people in making informed choices to protect them from harmful gambling consequences. Please note: all quotations are from Indigenous Australians unless described otherwise.

## **4.1 Risk factors for indigenous australian gambling**

Using the Thomas and Jackson (2004) model, risk factor results were analysed by propensity to gamble, by the use of gambling products and services and by gambling outcomes and consequences.

## **4.1.1 Propensity to gamble**

Risk factors including personal, family, financial, historical and cultural risks were identified by the research participants as increasing the propensity to gamble. Personal risks were seen as gambling to escape from grief and loss, from boredom, due to peer pressure, after consuming alcohol or drugs, from being unemployed and having time to gamble, from having literacy and numeracy problems, and to obtain relief from abuse.

Explaining escape from historical grief and cultural loss, some respondents said 'memories come up from the past and people push the memories down ... people turn to something, drinking, drugs, gambling, when the old memories surface'. Escape sometimes meant looking for some time away from stressful situations, either at home or at work. Several people mentioned escape in terms of 'time out alone' or a break away from heavy responsibilities. Other respondents saw that boredom was a gambling risk especially when people were unemployed, had plenty of free time to gamble and where alternative entertainment options were very limited. Risks arising from peer pressure were explained as '(some friends) won't talk to you unless you're with them when playing the (poker) machines'. Similar remarks were '(I) go to a venue with friends, and the next thing they are all on (poker) machines. If I want to talk to them I have to go over to the (poker) machines too. Then next thing you are putting money in too'.

The use of alcohol and drugs with gambling was described as 'a cycle involving low selfesteem that leads to drink and drugs'. Some gamblers were seen as being 'vulnerable to making poor choices, but most want to get out of the cycle'. Several people commented that 'Aboriginal people are used to being broke and having no money, so when gambling and the money is gone they do not seem to worry'. For some people it was 'acceptable to be poor in Aboriginal community, where some learnt to live in Struggle Street, used to having nothing'. Explaining budgeting problems and gambling, one person felt many people had 'not learned to control things in the welfare cycle, they need to learn skills ... need to learn to budget'.

Family risks were said to include generational exposure to gambling, normalisation of youth gambling and a lack of education generally. Gambling was reported to be learnt from

Public Health and Indigenous Australian Gambling: Risky Lifestyle or Harmless Recreation? 211

and visual features of poker (slot) machines, their attractive marketing and promotion, and the emotional attachment some people have to a lucky machine or favourite form of gambling. Access to the gambling environment was reported as usually easy and free services enhanced the appeal of staying in a venue to gamble. Social access and acceptance

The attraction and risk of using poker machines was explained as 'Aboriginal people like the features of the machines, such as free spins ... like the noise, lights and jackpots'. Others saw attachment to poker machines as being a risk. 'People like to go to the same machines for luck because they think they know what features are needed to win'. Faulty beliefs were evident. 'People believe you win money on machines after a win, that is, have a win and believe it's easy to win (again) so they keep playing'. Superstitious beliefs were apparent when gamblers ask 'What did you come and talk to me for? I was winning; now I have stopped winning because you started talking to me'. As one person explained, 'People don't know the

Marketing risks were described as 'Clubs always have marketing stuff to keep you in there ... venue advertisements, things you can win, free coffee'. Gambling advertising was seen as 'very attractive and is in your face all the time'. Others reported acceptance as a risk: 'People get sucked in by lights and surroundings of a comfortable venue … air conditioned … no

Access to gaming venues, such as hotels or pubs and clubs in urban areas, was generally easy. They provided food, drinks and a variety of hospitality and sports services. Many respondents agreed risks included attractive venue characteristics saying '(Gaming) venues are appealing because you can drink and socialise ... it's all there … meeting place, alcohol, food, gambling' and 'poker machines in the indoor/outdoor area for smokers, very easy to get access'. Therefore, participants reported risks associated with the use of gambling products and services as physical and sensory features linked to gambling as well as freely

Risk factors relating to addressing problematic consequences of gambling largely were found to be barriers faced in addressing gambling-related problems. These barriers seemed to fall naturally into two groups, intrinsic or personal barriers and extrinsic or external barriers. Intrinsic barriers were identified as shame, denial, depression and social and cultural norms. In the majority of interviews shame, denial and a subsequent loss of selfesteem were mentioned as barriers. People seemed to 'find it hard to admit … a problem with gambling'. Some gamblers were said to be too ashamed to ask for help and become defensive about their problems. This was partly due to pride and partly because of historical discrimination suffered by Indigenous Australians. 'Ways to resolve problems and arguments were removed in the oppression of our culture; it was not replaced, left with no way to resolve problem'. For other gamblers, 'depression, schizoid and paranoid' comorbidities arose as barriers to their seeking gambling help. People with depression were

seen to have limited ability to cope with pressure from gambling-related problems.

Indigenous gambling was very much seen as a social and cultural norm. 'Gambling is seen as a normal thing to do. For many people it's a routine to be going down to the pub or club'.

probability of a machine to pay and don't understand the outcomes of losing money'.

were also risks for some gamblers.

available physical and social access to gambling.

**4.1.3 Consequences of gambling**

hassles'.

parents, family and grandparents where young people learn from exposure and experience. Childhood exposure to gambling and gamblers was apparent to some participants. 'Kids learn the behaviour from parents and older generations ... when it's generational it is very hard to break the cycle'. Some people stated that gambling experiences started early. 'Generations, kids learn to drink and gamble from their parents … then these kids have their own kids and their habits continue'. In one location numeracy and literacy problems were high with one person claiming that not everyone can 'read or write, cannot read signs in the pub (hotel)'. This was further explained as a consequence of some parents not being home to send children to school regularly.

Financial risks were reported as gambling to increase income and to repay debts; and being used to being poor so gambling losses made no great difference to a life of poverty and a cycle of dependency for some. Gambling to increase incomes and reduce financial pressures 'has gone down from generation to generation. It's not dealt with, it's on-going'. Being financially pressed can exacerbate gambling problems leading to 'desperation for money, hoping to win the big jackpot one day'. Some gamblers were reported to believe that a big win would help solve their financial problems, assist them to repay debts and remove the need to borrow from family and friends. Linking gambling to social and economic disadvantage some participants explained 'gambling is linked to unemployment, they have more time to gamble but getting a job is hard'. This can affect self-esteem. 'People think that they are not good enough to get a job, you need experience and no-one gives Indigenous a go'. Summarising financial risks associated with gambling, an Indigenous respondent commented 'Aboriginal people are always broke and are always looking for a quick fix even if they have only \$5 left'. A major theme identified by participants was concern about financial risks.

Historical risks were said to include the longevity of gambling as an Indigenous recreation activity and borrowing money for gambling from family and kin. An overwhelming risk was reported thus: 'If you hang out with others at the venue, then you either gamble or are asked for money to support others gambling, especially younger people ... cultural values fall away with alcohol consumption and drugs and gambling'.

Cultural risks were believed to be a loss of Indigenous values, respect and discipline and a deterioration of traditional reciprocity when used for gambling. Cultural losses were seen as diminishing leadership. 'Aboriginal men had a role in society, now they don't ... lost their way'. Others felt there was a 'lack of leadership, there is a struggle to find great leaders in the community, Elders'. Many participants were saddened by the loss of Elders. 'A whole generation of Elders died early, some people have never had Elders to nurture them'. Keeping Indigenous values and culture alive was hard where 'there are less numbers of Elders to get advice'.

Thus, risks associated with propensity to gamble reported by these participants included many personal characteristics, family and cultural factors. More structural risks were linked to financial and historical factors.

#### **4.1.2 Gambling products and services**

Risks reported to be associated with gambling products and services were a variety of physical and sensory experiences connected to gambling. These included the sound, light and visual features of poker (slot) machines, their attractive marketing and promotion, and the emotional attachment some people have to a lucky machine or favourite form of gambling. Access to the gambling environment was reported as usually easy and free services enhanced the appeal of staying in a venue to gamble. Social access and acceptance were also risks for some gamblers.

The attraction and risk of using poker machines was explained as 'Aboriginal people like the features of the machines, such as free spins ... like the noise, lights and jackpots'. Others saw attachment to poker machines as being a risk. 'People like to go to the same machines for luck because they think they know what features are needed to win'. Faulty beliefs were evident. 'People believe you win money on machines after a win, that is, have a win and believe it's easy to win (again) so they keep playing'. Superstitious beliefs were apparent when gamblers ask 'What did you come and talk to me for? I was winning; now I have stopped winning because you started talking to me'. As one person explained, 'People don't know the probability of a machine to pay and don't understand the outcomes of losing money'.

Marketing risks were described as 'Clubs always have marketing stuff to keep you in there ... venue advertisements, things you can win, free coffee'. Gambling advertising was seen as 'very attractive and is in your face all the time'. Others reported acceptance as a risk: 'People get sucked in by lights and surroundings of a comfortable venue … air conditioned … no hassles'.

Access to gaming venues, such as hotels or pubs and clubs in urban areas, was generally easy. They provided food, drinks and a variety of hospitality and sports services. Many respondents agreed risks included attractive venue characteristics saying '(Gaming) venues are appealing because you can drink and socialise ... it's all there … meeting place, alcohol, food, gambling' and 'poker machines in the indoor/outdoor area for smokers, very easy to get access'. Therefore, participants reported risks associated with the use of gambling products and services as physical and sensory features linked to gambling as well as freely available physical and social access to gambling.

### **4.1.3 Consequences of gambling**

210 Public Health – Social and Behavioral Health

parents, family and grandparents where young people learn from exposure and experience. Childhood exposure to gambling and gamblers was apparent to some participants. 'Kids learn the behaviour from parents and older generations ... when it's generational it is very hard to break the cycle'. Some people stated that gambling experiences started early. 'Generations, kids learn to drink and gamble from their parents … then these kids have their own kids and their habits continue'. In one location numeracy and literacy problems were high with one person claiming that not everyone can 'read or write, cannot read signs in the pub (hotel)'. This was further explained as a consequence of some parents not being home to

Financial risks were reported as gambling to increase income and to repay debts; and being used to being poor so gambling losses made no great difference to a life of poverty and a cycle of dependency for some. Gambling to increase incomes and reduce financial pressures 'has gone down from generation to generation. It's not dealt with, it's on-going'. Being financially pressed can exacerbate gambling problems leading to 'desperation for money, hoping to win the big jackpot one day'. Some gamblers were reported to believe that a big win would help solve their financial problems, assist them to repay debts and remove the need to borrow from family and friends. Linking gambling to social and economic disadvantage some participants explained 'gambling is linked to unemployment, they have more time to gamble but getting a job is hard'. This can affect self-esteem. 'People think that they are not good enough to get a job, you need experience and no-one gives Indigenous a go'. Summarising financial risks associated with gambling, an Indigenous respondent commented 'Aboriginal people are always broke and are always looking for a quick fix even if they have only \$5 left'. A major theme identified by participants was concern about

Historical risks were said to include the longevity of gambling as an Indigenous recreation activity and borrowing money for gambling from family and kin. An overwhelming risk was reported thus: 'If you hang out with others at the venue, then you either gamble or are asked for money to support others gambling, especially younger people ... cultural values

Cultural risks were believed to be a loss of Indigenous values, respect and discipline and a deterioration of traditional reciprocity when used for gambling. Cultural losses were seen as diminishing leadership. 'Aboriginal men had a role in society, now they don't ... lost their way'. Others felt there was a 'lack of leadership, there is a struggle to find great leaders in the community, Elders'. Many participants were saddened by the loss of Elders. 'A whole generation of Elders died early, some people have never had Elders to nurture them'. Keeping Indigenous values and culture alive was hard where 'there are less numbers of

Thus, risks associated with propensity to gamble reported by these participants included many personal characteristics, family and cultural factors. More structural risks were linked

Risks reported to be associated with gambling products and services were a variety of physical and sensory experiences connected to gambling. These included the sound, light

fall away with alcohol consumption and drugs and gambling'.

send children to school regularly.

financial risks.

Elders to get advice'.

to financial and historical factors.

**4.1.2 Gambling products and services**

Risk factors relating to addressing problematic consequences of gambling largely were found to be barriers faced in addressing gambling-related problems. These barriers seemed to fall naturally into two groups, intrinsic or personal barriers and extrinsic or external barriers. Intrinsic barriers were identified as shame, denial, depression and social and cultural norms. In the majority of interviews shame, denial and a subsequent loss of selfesteem were mentioned as barriers. People seemed to 'find it hard to admit … a problem with gambling'. Some gamblers were said to be too ashamed to ask for help and become defensive about their problems. This was partly due to pride and partly because of historical discrimination suffered by Indigenous Australians. 'Ways to resolve problems and arguments were removed in the oppression of our culture; it was not replaced, left with no way to resolve problem'. For other gamblers, 'depression, schizoid and paranoid' comorbidities arose as barriers to their seeking gambling help. People with depression were seen to have limited ability to cope with pressure from gambling-related problems.

Indigenous gambling was very much seen as a social and cultural norm. 'Gambling is seen as a normal thing to do. For many people it's a routine to be going down to the pub or club'.

Public Health and Indigenous Australian Gambling: Risky Lifestyle or Harmless Recreation? 213

Using the Thomas and Jackson (2004) model, protective factor results were analysed in relation to the propensity to gamble, the use of gambling products and services and

Protective factors identified in relation to the propensity to gamble were grouped into personal, family, financial and cultural themes. Personal protective factors were seen as selfcontrol in controlling gambling activities, self-respect, having a purpose in life and high aspirations, being employed and earning money, learning from experience and religious