Journal of Adolescence 37 (2014) 945e951
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Alcohol use among adolescents, aggressive behaviour, and internalizing problems €ki a, *, Virve Kekkonen b, Hannu Valtonen c, Tommi Tolmunen a, b, Petri Kivima Kirsi Honkalampi d, Ulrich Tacke a, e, Jukka Hintikka f, g, Soili M. Lehto a, h, Eila Laukkanen a, b a
School of Medicine, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland Department of Adolescent Psychiatry, Kuopio University Hospital, P.O. Box 1777, FI-70211 Kuopio, Finland Department of Health and Social Management, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland d School of Educational Sciences and Psychology, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland e Department of Addiction Psychiatry, Kuopio University Hospital, P.O. Box 1777, FI-70211 Kuopio, Finland f School of Medicine, University of Tampere, FI-33014 University of Tampere, Finland g €ija €t-Ha €me Central Hospital, Keskussairaalankatu 7, FI-15850 Lahti, Finland Department of Psychiatry, Pa h Department of Psychiatry, Kuopio University Hospital, P.O. Box 1777, FI-70211 Kuopio, Finland b c
a b s t r a c t Keywords: Adolescence Alcohol use Aggressive behaviour AUDIT-C ASEBA-YSR
Alcohol use is common among adolescents, but its association with behavioural and emotional problems is not well understood. This study aimed to investigate how selfreported psychosocial problems were associated with the use of alcohol in a community sample consisting of 4074 Finnish adolescents aged 13e18 years. Aggressive behaviour associated with alcohol use and a high level of alcohol consumption, while internalizing problems did not associate with alcohol use. Having problems in social relationships associated with abstinence and lower alcohol consumption. Tobacco smoking, early menarche and attention problems also associated with alcohol use. © 2014 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
Introduction Typically, alcohol drinking starts in adolescence, followed by increasing consumption in the early twenties (Chen & Kandel, 1995). The consumption of large quantities of alcohol on a single occasion (binge drinking) is common among youths (Miller, Naimi, Brewer, & Jones, 2007). Early adolescent alcohol use is a predictor of alcohol dependence as well as other mental health problems and delinquency. Furthermore, adolescence is a unique developmental period, and it has been shown that excessive alcohol use may cause abnormalities in brain development, as well as neuropsychological conditions possibly as a consequence of neural damage (Ezzati, Lopez, Rodgers, & Murray, 2004, chap. 12; Harper & Matsumoto, 2005) and degradation of white matter in the brain (Bühler & Mann, 2011). There appear to be gender-related differences in these problems (Giedd, 2004; Medina et al., 2008). Studies have revealed a comorbidity of alcohol use disorders with mood and disruptive disorders among adolescents (Armstrong & Costello, 2002; Deas & Brown, 2012). A relationship between conduct problems in childhood and alcohol
* Corresponding author. Tel.: þ358 44 7175106; fax: þ358 17 173 599. €ki). E-mail addresses: petri.kivimaki@iki.fi, petri.kivimaki@uef.fi (P. Kivima http://dx.doi.org/10.1016/j.adolescence.2014.06.011 0140-1971/© 2014 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
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€ et al., 2006), with an earlier start and a more rapid increase in problems in later life has been demonstrated in boys (Niemela consumption than in controls (McArdle, 2008). In an Australian longitudinal study (N ¼ 1590), peer aggression at the age of 14 associated with later mental health and substance use problems (Moore et al., 2014). Motives for binge drinking among adolescents are mainly associated with either positive outcome expectations or the regulation of negative affect (Stolle, Sack, & Thomasius, 2009). Poor coping with negative emotions is associated with harmful drinking habits (Blumenthal, LeenFeldner, Frala, Badour, & Ham, 2010; Kuntsche, Knibbe, Gmel, & Engels, 2006). According to the self-medication hypothesis, adolescents can learn to use alcohol to alleviate their depressive symptoms and social anxiety (Tomlinson & Brown, 2012). Biological factors may also be associated with an early initiation of alcohol use (Kaltiala-Heino, Marttunen, Rantanen, & €, 2003). Rimpela Although alcohol use disorder (AUD) has been associated with psychiatric conditions, adolescent alcohol use or problem behaviour does not usually meet the criteria for any disorder (Deas & Brown, 2012). To our best knowledge, only two previous studies have evaluated the associations between adolescent alcohol use and dimensions of psychiatric symptoms measured with the Achenbach System of Empirically Based Assessment: Youth Self-Report for ages 11e18 years (ASEBA-YSR). In an American study on 14- to 17-year-old adolescents (N ¼ 822), externalizing problems increased the likelihood of early alcohol initiation, and problems in social relationships associated with fewer drinking friends (Kuperman et al., 2013). In a study on 11,943 Taiwanese 15- to 18-year-old adolescents, attention and thought problems as well as somatic complaints in ASEBA-YSR associated with more experience of alcohol use (Chen et al., 2008). As drinking cultures vary between countries, we aimed to contribute to the previous literature by examining the associations between ASEBA-YSR scales and alcohol consumption in Finland, where binge drinking is quite common among adolescents. In Finland, where the present study was conducted, there has been a threefold increase in per capita alcohol use over a 40-year period, the most significant increase being among women. During this period, the level of alcohol consumption has increased 5.8-fold in women and 2.2-fold in men. Since 1976, heavy drinking episodes have become increasingly popular €kela €, Tigerstedt, & among 15- to 29-year-old Finns, and the popularity of binge drinking is above the European average (Ma Mustonen, 2012). Based on the earlier literature, we hypothesised that symptoms of depression and anxiety as well as aggressive behaviour would associate with increased alcohol consumption. Secondly, we hypothesised that an early onset of puberty and a large number of friends would associate with high alcohol consumption. Thirdly, we aimed to examine whether the associations mentioned above would depend on gender. Our observations were based on a large and representative cross-sectional sample of Finnish youths (N ¼ 4074) and the analyses were adjusted for various confounding variables. Material and methods Participants For this study we used a dataset that had been collected from cohorts of 13- to 18-year-old pupils from all local schools (excluding schools for pupils with impaired cognitive skills) in Kuopio, a city in Eastern Finland with approximately 95,000 inhabitants. The data were collected with structured self-report questionnaires, which were handed out in comprehensive, upper secondary and vocational schools. For pupils under 15 years of age, written consent was obtained from one of their parents. Ethical approval was received from the Research Ethics Committee of Kuopio University Hospital and the University of Kuopio (now the University of Eastern Finland). A total of 6421 adolescents met the inclusion criteria for the study. Among the 13- to 15-year-olds, 1031 did not participate, and 666 of these did not receive consent from their parents. Among the 16- to 18-year-olds, a total of 1851 did not participate for unknown reasons. As a result, 4214 (65.6%) adolescents participated in the study, although 140 of these had to be excluded due to invalid data, leading to a final sample of 4074 participants (53% female). The types of school were comprehensive school for 1840, upper secondary school for 1474 and vocational school for 900 participants. Alcohol use and tobacco smoking The Alcohol Use Disorders Identification Test (AUDIT) is a structured questionnaire originally designed by the World Health Organization for assessing adult alcohol use (Saunders, Aasland, Babor, la Fuente, & Grant, 1993). The instrument has also been tested in young people and its validity for detecting heavy alcohol use has been demonstrated. For 14- to 18-yearold adolescents (N ¼ 538) visiting medical clinics, a cut-off score of 2 for the complete 10-question AUDIT with maximum score of 40 was optimal for identifying problematic alcohol use, and 3 for identifying alcohol use disorder (AUD), diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (Knight, Sherritt, Harris, Gates, & Chang, 2003). In this study we used a shortened version of AUDIT, AUDIT-C (items 1e3; range 0e12), which only includes the questions on the level of consumption (“How often do you have a drink containing alcohol?”, “How many drinks containing alcohol do you have on a typical day when you are drinking?” and “How often do you have six or more drinks on one occasion?”) (Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998). According to Kelly, Donovan, Chung, Bukstein, and Cornelius (2009), AUDIT-C performs well in screening 18- to 20-year-old adults for AUD with a cut-off point of 6 for males (77% sensitivity; 68% specificity) and 5 for females (77% sensitivity; 78% specificity). We screened current tobacco smoking by asking how often the participants smoked tobacco (“daily”, “occasionally” or “never”).
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Psychosocial problems Social competence, adaptive functioning and psychosocial problems were assessed with the ASEBA-YSR, which is an instrument examining multiple aspects of adolescent behaviour and well-being (Achenbach & Rescorla, 2001). The questionnaire consists of basic demographic questions and 20 competence items concerning participation in various activities, social relationships and schoolwork. The ASEBA-YSR has a total of 112 items measuring symptoms: internalizing problems (anxious/depressed, withdrawn/depressed, somatic complaints; 32 items), externalizing problems (rule-breaking behaviour, aggressive behaviour; 30 items), social problems (8 items), thought problems (7 items) and attention problems (9 items). In this study sample, Cronbach's a for the ASEBA-YSR scales was 0.82 for anxious/depressed, 0.71 for withdrawn/depressed, 0.83 for aggressive behaviour, 0.70 for rule-breaking behaviour, 0.77 for somatic complaints, 0.70 for social problems, 0.76 for thought problems and 0.70 for attention problems. One of the two externalizing problems subscales of the ASEBA-YSR (rule-breaking behaviour with 11 items) contains a question about substance use and therefore overlapped with AUDIT-C. Since regression analysis was applied, only the 19-item aggressive behaviour subscale was used for statistical analysis. Number of friends, parental marital status and onset of puberty Questions concerning the number of close friends and the marital status of the parents are included in the ASEBA-YSR (Achenbach & Rescorla, 2001). The number of friends was elicited by asking “How many close friends do you have?” Four response options were provided: “no friends”, “one friend”, “two to three friends” and “four friends or more”. Regarding the marital status of the parents, responses could be chosen from four options: “married”, “living with a partner”, “divorced” and “other”. Parental divorce was then recoded into a single dichotomous variable with values “divorced” or “not divorced”. The onset of puberty was estimated to the nearest month according to the self-reported time of menarche in girls and the first nocturnal emission in boys. Similar questions have been used in Finnish school health surveys and previous studies (KaltialaHeino et al., 2003). Statistical analysis Gender-related differences in age, the AUDIT-C score and ASEBA-YSR scales were assessed with the ManneWhitney U-test due to the non-normal distributions. The onset of puberty was normally distributed and the differences were therefore assessed with the Student's t-test. In the regression models, explanatory variables for the AUDIT-C score were the ASEBA-YSR scores (i.e., aggressive behaviour, social problems, thought problems, attention problems and internalizing problems), age, type of school, the number of close friends, smoking, parental divorce and timing of the onset of puberty. Tobacco smoking was recoded into a dichotomous variable. The interactions between gender and other explanatory variables in explaining AUDIT-C were tested with level and slope dummy variables. There were statistically significant interactions with gender in both alcohol use (Wald test, p ¼ 0.037) and the level of alcohol consumption (Wald test, p < 0.001). Being dependent on gender, the models were estimated separately for females and males. The question concerning the onset of puberty was answered by 90% of females but only 46% of males. The AUDIT-C responses were viewed as count data with a skewed distribution. The Poisson distribution would have been a natural choice for count data, but as the variance of the AUDIT-C scores was not equal to the mean (likelihood ratio test for over-dispersion, a ¼ 0: males p ¼ 0.072, females p ¼ 0.497), we used negative binomial regression models. Because a large proportion (38.2%) of the study subjects did not drink alcohol, resulting in a large number of zero AUDIT-C scores, zeroinflated negative binomial (ZINB) regression models were chosen for the statistical analysis (Cameron & Trivedi, 2009). As verification for the performance of the modelling, the abstinence parts of ZINB models were compared with logistic regression models and the level of consumption parts were compared with ordinary least squares (OLS) regression models. As AUDIT-C had not been validated among the 13- to 17-year-olds, we aimed to test whether a single model could be used for the whole age span. Therefore, participants were divided into two age groups: the young teenage group of 13- to 15-yearold participants and the old teenage group of 16- to 18-year-old participants. Intercept and slope dummy variables were then included in regression models to test the interaction between age and other explanatory variables. There were small but statistically significant interactions between age and other covariates in the model for the level of male alcohol consumption. In other words, the association of alcohol use and age was non-linear, and to adjust the regression models for this, we added an age2 variable to the models. Multicollinearity was assessed by calculating the variance inflation factor (VIF) for each of the explanatory variables. All the VIF values were 3 or less which rules out multicollinearity. Misspecification was tested with the Ramsey Regression Equation Specification Error Test (RESET) and no specification problems were found. The OLS model was tested for heteroskedasticity with the Breusch-Pagan/CookeWeisberg test, and no heteroskedasticity was found. The estimated standard errors were robust for heteroskedasticity. Vuong's closeness test verified that ZINB should be preferred over a negative binomial distribution (males p < 0.001, females p < 0.001). With respect to the statistical significance and the sign of the coefficients, the results from technically different logistic and OLS regression models were qualitatively the same for most of the variables. Thus, the results did not depend on the chosen statistical method. Finally, the coefficients of the ZINB model (b) were expressed as odds ratios (OR) for any alcohol use (for the abstinence part, OR ¼ eb) and as incidence rate ratios (IRR), expressing the impact of a one-unit increase in cofactors (while other variables remain constant) on the AUDIT-C score (for the level of consumption part, IRR ¼ eb; please see examples in Table 3).
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P-values below 0.05 were interpreted as statistically significant. The software packages used for data analysis were SPSS (version 19) and STATA (version 11). Results Alcohol and tobacco use, psychosocial problems, parental divorce and the number of close friends Alcohol use was high (Table 1). In the age cohorts of 17- and 18-year-old, males had higher AUDIT-C scores than females, but there were otherwise no gender-related differences in alcohol consumption. Female adolescents had a greater frequency of self-reported internalizing and externalizing problems, as well as problems in attention, thinking and social relationships measured with the ASEBA-YSR (Table 2). Among females, occasional tobacco smoking was more common than among males, but no difference between genders was found in daily tobacco smoking. Female adolescents reported two or three close friends more often than males, while male adolescents reported four or more close friends more often than females. Factors associated with alcohol use Alcohol use and high alcohol consumption both associated with aggressive behaviour and tobacco smoking (Table 3). Abstinence from alcohol and low alcohol consumption both associated with problems in social relationships. Attention problems associated with alcohol use, but not with alcohol consumption. The level of alcohol consumption positively associated with the number of close friends. There also were some gender-related differences in the models. Among females, an early onset of puberty and parental divorce were associated with an increased probability of alcohol use. The models were also adjusted for age and the type of school. As age moderated the associations between alcohol consumption and some of the covariates in men, the models were also adjusted for the non-linear effect of age with the variable age2. Among older males, the negative association between the AUDIT-C score and problems in social relationships, as well as the association between the AUDIT-C score and the number of close friends, were stronger and steeper than among younger male adolescents. The association between the AUDIT-C score and smoking was stronger and steeper among the younger males than the older male adolescents. Discussion Main findings In this community sample of 13- to 18-year-old Finnish adolescents, aggressive behaviour, but not internalizing problems, associated with alcohol use and the level of alcohol consumption. Smoking associated with both alcohol use and the level of alcohol consumption. A lack of problems in social relationships and a higher number of friends associated with drinking among the 13- to 18-year-olds. Comparison with the existing literature The association between aggressive behaviour and alcohol consumption is likely to be bi-directional. Unfortunately, we could not distinguish the direction of causation in our cross-sectional study setting. This association may be pronounced in adolescence due to brain development. Brain areas responsible for impulse control are under development, and alcohol use may be a distinct risk factor for adolescent aggressive behaviour (Stephens & Duka, 2008). Contrary to the previous literature, girls reported more aggressive behaviour than boys in our study (Rescorla et al., 2012). This is a novel finding that has not been Table 1 Alcohol use measured by the AUDIT-C score in a Finnish sample of 13- to 18-year-old male and female adolescents. AUDIT-C ¼ 0 indicates no alcohol use. Age
13 14 15 16 17 18 Total
Male (N ¼ 1938)
Female (N ¼ 2229)
AUDIT-C ¼ 0
AUDIT-C > 0
N (%)
N (%)
192 165 190 136 75 23 781
44 83 248 318 277 187 1157
(81%) (67%) (43%) (30%) (21%) (11%) (40%)
(19%) (33%) (57%) (70%) (79%) (89%) (60%)
AUDIT-C ¼ 0
AUDIT-C > 0
Median (Q1eQ3)a
N (%)
N (%)
1 2 4 5 6 6 5
210 174 197 127 82 29 819
55 111 297 374 343 230 1410
(1e2) (1e6) (1e6) (3e7) (4e8) (4e8) (2e7)
(79%) (61%) (40%) (25%) (19%) (11%) (37%)
Difference between genders (Z)b Median (Q1eQ3)a
(21%) (39%) (60%) (75%) (81%) (89%) (63%)
2 4 4 4 4 5 4
(1e3) (1e5) (2e5) (3e6) (3e6) (3e6) (2e6)
*p < 0.05, **p < 0.01, ***p < 0.001. a The first quartile (Q1) and third quartile (Q3) are equal to the 25th and 75th percentiles, respectively. b The ManneWhitney U-test (Z) was used to test whether the distributions of the AUDIT-C scores differ between genders.
0.75 1.28 0.82 1.66 3.83*** 4.39*** 1.54
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Table 2 Descriptive statistics for age, onset of puberty, symptoms of psychosocial problems measured with the Youth Self-Report questionnaire, smoking and number of friends in a Finnish sample of 13- to 18-year-old adolescents.
Agea Onset of pubertyb Youth Self-Report - Internalizing problemsa - Aggressive behavioura - Social problemsa - Thought problemsa - Attention problemsa Number of friends - No close friends (%)c - One close friend (%)c - Two or three (%)c - Four or more (%)c Smoking - No smoking (%)c - Occasional smoking (%)c - Daily smoking (%)c Divorced parents (%)c a b c
Male (N ¼ 1897)
Female (N ¼ 2177)
Median (Q1eQ2)/Mean (SD)/Proportion
Median (Q1eQ2)/Mean (SD)/Proportion
16 (15e17) 12.8 (1.5)
16 (15e17) 12.4 (1.1)
0.82 8.14***
5 6 2 1 4
11 (6e17) 7 (5e11) 2 (1e3) 2 (0e3) 6 (4e7.75)
22.95*** 10.66*** 6.15*** 10.00*** 14.25***
(3e10) (3e9) (1e3) (0e2) (2e6)
Difference between genders (Z/t)
0.4 6.8 32.9 58.0
0.6 7.9 45.9 44.7
1.02 1.31 8.20*** 8.88***
71.3 10.9 15.0 24.2
66.5 15.6 16.2 28.8
3.91*** 4.20*** 0.93 2.97**
Showing median, first quartile (Q1), second quartile (Q2) and differences between genders assessed with the ManneWhitney U-test (Z). Showing mean, standard deviation (SD) and differences between genders assessed with the Student's t-test (t). Showing proportions and differences between genders assessed with the ManneWhitney U-test (Z).
reported earlier, and may reflect some new trend in behaviour among girls in a similar way to their increasing level of alcohol consumption. For those with problems in social relationships, alcohol may be harder to obtain. Selling alcohol to, or possessing alcohol as individuals under 18 years of age is illegal in Finland. One possible explanation for the relationship between alcohol consumption and the number of friends could be that people with more friends are more likely to have friends who drink. Older friends may supply alcohol to their younger peers. In this study, alcohol use was slightly less common than in previous national surveys (Kinnunen et al., 2013, chap. 4), but the level of alcohol consumption was high. Median AUDIT-C scores for the age cohorts of 14 years old and older were 4 or above, and as a matter of fact, any alcohol use between the ages of 12 and 15 years can be a signal of alcohol-related problems (Chung et al., 2012). No association was found between alcohol use and internalizing problems. Consequently, our results did
Table 3 A zero-inflated negative binomial regression model (ZINB) explaining alcohol use (AUDIT-C > 0) and the level of alcohol consumption (AUDIT-C score) in a Finnish sample of 13- to 18-year-old male and female adolescents.
Ageb Age2b Internalizing problems Aggressive behaviour Problems in social relationships Thought problems Attention problems Number of close friends Smoking Divorced parents Age at puberty onset Upper secondary school Vocational school
Odds ratios for any alcohol use, the inflate part of the model
Incidence rate ratioa for a change in AUDIT-C score, the negative binomial part of the model
Male (N ¼ 1773)
Female (N ¼ 1929)
Male (N ¼ 1773)
OR
95% CI
IRR
95% CI
8.19 0.95 1.02 1.11 0.75 1.04 1.09 1.33 8.49 1.93 0.80 1.65 1.97
1.21e55.49**, c 0.89e1.01 0.99e1.04 1.06e1.16*** 0.68e0.83*** 0.97e1.12 1.01e1.18* 1.08e1.64** 5.48ee13.14*** 1.40e2.65*** 0.70e0.90*** 1.07e2.55* 1.17e3.32*
4.98 0.96 1.00 1.03 0.93 1.02 1.00 1.15 1.40 1.02
2.67e9.26***, 0.94e0.97*** 0.99e1.01 1.02e1.04*** 0.91e0.96*** 1.00e1.03 0.99e1.02 1.09e1.21*** 1.32e1.49*** 0.96e1.09
1.26 1.25
1.12e1.41*** 1.11e1.40***
OR
95% CI
6.59 0.96 1.00 1.09 0.75 1.06 1.08 1.15 7.70 1.29
1.06e41.14***, 0.91e1.02 0.97e1.03 1.05e1.13*** 0.68e0.83*** 0.98e1.15 1.00e1.16* 0.94e1.40 5.07e11.71*** 0.96e1.73
1.11 0.89
0.73e1.68 0.57e1.38
c
Female (N ¼ 1929)
c
IRR
95% CI
1.61 0.99 1.00 1.02 0.95 0.99 1.01 1.07 1.60 1.07 1.01 1.06 1.24
0.94e2.75***, 0.97e1.00 1.00e1.01 1.01e1.02*** 0.93e0.97*** 0.98e1.01 1.00e1.03 1.02e1.12** 1.51e1.70*** 1.01e1.13* 0.99e1.04 0.95e1.19 1.11e1.39***
c
*p < 0.05, **p < 0.01, ***p < 0.001. a For binary variables, e.g. the boys who smoke have an AUDIT-C score 1.22 points higher than those who do not, when all other variables in the model remain constant. For continuous variables, e.g. when problems in social relationships increase by one unit, the expected value of AUDIT-C is multiplied by 0.94, which equals a 6% decrease. b Due to the non-linear association of age and AUDIT-C scores, the model is adjusted for both Age and Age2 variables. c Significance is the joint significance of the variables Age and Age2.
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not support the hypothesis of self-medication with alcohol, which may not occur until an older age is reached. Tomlinson and Brown (2012) speculated in their study that individuals with social anxiety may develop alcohol-related problems if they learn to use alcohol as a social lubricant. In girls, the association of alcohol use with the parents being divorced and the onset of puberty may be mediated by various factors such as a dysfunctional family, conflicts in the family, a lack of parental support, parental alcohol problems, and financial and psychosocial stressors in general. Moreover, early-maturing adolescents face additional psychosocial stress due to the adult role models and peer feedback. Parental divorce and early maturation may both involve interpersonal psychological stressors, which have a more adverse impact on well-being in girls than boys (Oldehinkel & Bouma, 2011). On the other € et al. (2006), teachers in Finland reported that drunkenness in older teenage boys associated hand, in the study of Niemela with a non-intact family and externalising problems in childhood. Strengths and limitations This study had a large sample and a high participation rate, considering that the participants were teenagers. The sample covered over 65% of the age groups from 13 to 18 years in the Kuopio area. Moreover, the questionnaire mainly utilized wellvalidated measures, and the observations were confirmed through multiple statistical approaches. There were also some limitations in this study. First, the cross-sectional study setting did not allow the examination of causality or trajectories for alcohol use. Second, no data other than marital status was collected concerning the research subjects' families, although the number of older siblings, the home neighbourhood and the parenting style, mental health, alcohol use and income of the parents could also have affected the alcohol use of their offspring. Third, adolescent self-report questionnaires were used, which may have caused method bias in the results. Using a personal interview would have improved the precision of our observations regarding alcohol use. Fourth, AUDIT and AUDIT-C were not designed for assessing alcohol consumption specifically among adolescents, and AUDIT-C has not been validated among 13- to 18-year-olds. The validity of the puberty onset question is also unknown, although it is used in school surveys in Finland and has been used in € jd, 2011). A more other questionnaire based studies (Kaltiala-Heino et al., 2003; Kaltiala-Heino, Koivisto, Marttunen, & Fro accurate assessment of pubertal status could only have been obtained by examining past school health care registers. Fifth, among the male subjects, there was a low response rate for the pubertal onset question. Conclusions Aggressive behaviour, smoking and social relationships associated with both alcohol use and the level of alcohol consumption in this study. However, alcohol use among adolescents did not associate with internalizing problems. Many underage adolescents use alcohol and some of them use it very heavily. Interventions targeted at alcohol use should start early as part of the school health care system, involving both teenagers and their parents. Acknowledgements The authors report no conflicts of interest. All authors have contributed to and approved the final manuscript. €ki was supported by Kuopio University Hospital EVO funding (Research ID 5702804). 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Journal of Adolescence journal homepage: www.elsevier.com/locate/jado
Alcohol use among adolescents, aggressive behaviour, and internalizing problems €ki a, *, Virve Kekkonen b, Hannu Valtonen c, Tommi Tolmunen a, b, Petri Kivima Kirsi Honkalampi d, Ulrich Tacke a, e, Jukka Hintikka f, g, Soili M. Lehto a, h, Eila Laukkanen a, b a
School of Medicine, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland Department of Adolescent Psychiatry, Kuopio University Hospital, P.O. Box 1777, FI-70211 Kuopio, Finland Department of Health and Social Management, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland d School of Educational Sciences and Psychology, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland e Department of Addiction Psychiatry, Kuopio University Hospital, P.O. Box 1777, FI-70211 Kuopio, Finland f School of Medicine, University of Tampere, FI-33014 University of Tampere, Finland g €ija €t-Ha €me Central Hospital, Keskussairaalankatu 7, FI-15850 Lahti, Finland Department of Psychiatry, Pa h Department of Psychiatry, Kuopio University Hospital, P.O. Box 1777, FI-70211 Kuopio, Finland b c
a b s t r a c t Keywords: Adolescence Alcohol use Aggressive behaviour AUDIT-C ASEBA-YSR
Alcohol use is common among adolescents, but its association with behavioural and emotional problems is not well understood. This study aimed to investigate how selfreported psychosocial problems were associated with the use of alcohol in a community sample consisting of 4074 Finnish adolescents aged 13e18 years. Aggressive behaviour associated with alcohol use and a high level of alcohol consumption, while internalizing problems did not associate with alcohol use. Having problems in social relationships associated with abstinence and lower alcohol consumption. Tobacco smoking, early menarche and attention problems also associated with alcohol use. © 2014 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
Introduction Typically, alcohol drinking starts in adolescence, followed by increasing consumption in the early twenties (Chen & Kandel, 1995). The consumption of large quantities of alcohol on a single occasion (binge drinking) is common among youths (Miller, Naimi, Brewer, & Jones, 2007). Early adolescent alcohol use is a predictor of alcohol dependence as well as other mental health problems and delinquency. Furthermore, adolescence is a unique developmental period, and it has been shown that excessive alcohol use may cause abnormalities in brain development, as well as neuropsychological conditions possibly as a consequence of neural damage (Ezzati, Lopez, Rodgers, & Murray, 2004, chap. 12; Harper & Matsumoto, 2005) and degradation of white matter in the brain (Bühler & Mann, 2011). There appear to be gender-related differences in these problems (Giedd, 2004; Medina et al., 2008). Studies have revealed a comorbidity of alcohol use disorders with mood and disruptive disorders among adolescents (Armstrong & Costello, 2002; Deas & Brown, 2012). A relationship between conduct problems in childhood and alcohol
* Corresponding author. Tel.: þ358 44 7175106; fax: þ358 17 173 599. €ki). E-mail addresses: petri.kivimaki@iki.fi, petri.kivimaki@uef.fi (P. Kivima http://dx.doi.org/10.1016/j.adolescence.2014.06.011 0140-1971/© 2014 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
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€ et al., 2006), with an earlier start and a more rapid increase in problems in later life has been demonstrated in boys (Niemela consumption than in controls (McArdle, 2008). In an Australian longitudinal study (N ¼ 1590), peer aggression at the age of 14 associated with later mental health and substance use problems (Moore et al., 2014). Motives for binge drinking among adolescents are mainly associated with either positive outcome expectations or the regulation of negative affect (Stolle, Sack, & Thomasius, 2009). Poor coping with negative emotions is associated with harmful drinking habits (Blumenthal, LeenFeldner, Frala, Badour, & Ham, 2010; Kuntsche, Knibbe, Gmel, & Engels, 2006). According to the self-medication hypothesis, adolescents can learn to use alcohol to alleviate their depressive symptoms and social anxiety (Tomlinson & Brown, 2012). Biological factors may also be associated with an early initiation of alcohol use (Kaltiala-Heino, Marttunen, Rantanen, & €, 2003). Rimpela Although alcohol use disorder (AUD) has been associated with psychiatric conditions, adolescent alcohol use or problem behaviour does not usually meet the criteria for any disorder (Deas & Brown, 2012). To our best knowledge, only two previous studies have evaluated the associations between adolescent alcohol use and dimensions of psychiatric symptoms measured with the Achenbach System of Empirically Based Assessment: Youth Self-Report for ages 11e18 years (ASEBA-YSR). In an American study on 14- to 17-year-old adolescents (N ¼ 822), externalizing problems increased the likelihood of early alcohol initiation, and problems in social relationships associated with fewer drinking friends (Kuperman et al., 2013). In a study on 11,943 Taiwanese 15- to 18-year-old adolescents, attention and thought problems as well as somatic complaints in ASEBA-YSR associated with more experience of alcohol use (Chen et al., 2008). As drinking cultures vary between countries, we aimed to contribute to the previous literature by examining the associations between ASEBA-YSR scales and alcohol consumption in Finland, where binge drinking is quite common among adolescents. In Finland, where the present study was conducted, there has been a threefold increase in per capita alcohol use over a 40-year period, the most significant increase being among women. During this period, the level of alcohol consumption has increased 5.8-fold in women and 2.2-fold in men. Since 1976, heavy drinking episodes have become increasingly popular €kela €, Tigerstedt, & among 15- to 29-year-old Finns, and the popularity of binge drinking is above the European average (Ma Mustonen, 2012). Based on the earlier literature, we hypothesised that symptoms of depression and anxiety as well as aggressive behaviour would associate with increased alcohol consumption. Secondly, we hypothesised that an early onset of puberty and a large number of friends would associate with high alcohol consumption. Thirdly, we aimed to examine whether the associations mentioned above would depend on gender. Our observations were based on a large and representative cross-sectional sample of Finnish youths (N ¼ 4074) and the analyses were adjusted for various confounding variables. Material and methods Participants For this study we used a dataset that had been collected from cohorts of 13- to 18-year-old pupils from all local schools (excluding schools for pupils with impaired cognitive skills) in Kuopio, a city in Eastern Finland with approximately 95,000 inhabitants. The data were collected with structured self-report questionnaires, which were handed out in comprehensive, upper secondary and vocational schools. For pupils under 15 years of age, written consent was obtained from one of their parents. Ethical approval was received from the Research Ethics Committee of Kuopio University Hospital and the University of Kuopio (now the University of Eastern Finland). A total of 6421 adolescents met the inclusion criteria for the study. Among the 13- to 15-year-olds, 1031 did not participate, and 666 of these did not receive consent from their parents. Among the 16- to 18-year-olds, a total of 1851 did not participate for unknown reasons. As a result, 4214 (65.6%) adolescents participated in the study, although 140 of these had to be excluded due to invalid data, leading to a final sample of 4074 participants (53% female). The types of school were comprehensive school for 1840, upper secondary school for 1474 and vocational school for 900 participants. Alcohol use and tobacco smoking The Alcohol Use Disorders Identification Test (AUDIT) is a structured questionnaire originally designed by the World Health Organization for assessing adult alcohol use (Saunders, Aasland, Babor, la Fuente, & Grant, 1993). The instrument has also been tested in young people and its validity for detecting heavy alcohol use has been demonstrated. For 14- to 18-yearold adolescents (N ¼ 538) visiting medical clinics, a cut-off score of 2 for the complete 10-question AUDIT with maximum score of 40 was optimal for identifying problematic alcohol use, and 3 for identifying alcohol use disorder (AUD), diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (Knight, Sherritt, Harris, Gates, & Chang, 2003). In this study we used a shortened version of AUDIT, AUDIT-C (items 1e3; range 0e12), which only includes the questions on the level of consumption (“How often do you have a drink containing alcohol?”, “How many drinks containing alcohol do you have on a typical day when you are drinking?” and “How often do you have six or more drinks on one occasion?”) (Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998). According to Kelly, Donovan, Chung, Bukstein, and Cornelius (2009), AUDIT-C performs well in screening 18- to 20-year-old adults for AUD with a cut-off point of 6 for males (77% sensitivity; 68% specificity) and 5 for females (77% sensitivity; 78% specificity). We screened current tobacco smoking by asking how often the participants smoked tobacco (“daily”, “occasionally” or “never”).
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Psychosocial problems Social competence, adaptive functioning and psychosocial problems were assessed with the ASEBA-YSR, which is an instrument examining multiple aspects of adolescent behaviour and well-being (Achenbach & Rescorla, 2001). The questionnaire consists of basic demographic questions and 20 competence items concerning participation in various activities, social relationships and schoolwork. The ASEBA-YSR has a total of 112 items measuring symptoms: internalizing problems (anxious/depressed, withdrawn/depressed, somatic complaints; 32 items), externalizing problems (rule-breaking behaviour, aggressive behaviour; 30 items), social problems (8 items), thought problems (7 items) and attention problems (9 items). In this study sample, Cronbach's a for the ASEBA-YSR scales was 0.82 for anxious/depressed, 0.71 for withdrawn/depressed, 0.83 for aggressive behaviour, 0.70 for rule-breaking behaviour, 0.77 for somatic complaints, 0.70 for social problems, 0.76 for thought problems and 0.70 for attention problems. One of the two externalizing problems subscales of the ASEBA-YSR (rule-breaking behaviour with 11 items) contains a question about substance use and therefore overlapped with AUDIT-C. Since regression analysis was applied, only the 19-item aggressive behaviour subscale was used for statistical analysis. Number of friends, parental marital status and onset of puberty Questions concerning the number of close friends and the marital status of the parents are included in the ASEBA-YSR (Achenbach & Rescorla, 2001). The number of friends was elicited by asking “How many close friends do you have?” Four response options were provided: “no friends”, “one friend”, “two to three friends” and “four friends or more”. Regarding the marital status of the parents, responses could be chosen from four options: “married”, “living with a partner”, “divorced” and “other”. Parental divorce was then recoded into a single dichotomous variable with values “divorced” or “not divorced”. The onset of puberty was estimated to the nearest month according to the self-reported time of menarche in girls and the first nocturnal emission in boys. Similar questions have been used in Finnish school health surveys and previous studies (KaltialaHeino et al., 2003). Statistical analysis Gender-related differences in age, the AUDIT-C score and ASEBA-YSR scales were assessed with the ManneWhitney U-test due to the non-normal distributions. The onset of puberty was normally distributed and the differences were therefore assessed with the Student's t-test. In the regression models, explanatory variables for the AUDIT-C score were the ASEBA-YSR scores (i.e., aggressive behaviour, social problems, thought problems, attention problems and internalizing problems), age, type of school, the number of close friends, smoking, parental divorce and timing of the onset of puberty. Tobacco smoking was recoded into a dichotomous variable. The interactions between gender and other explanatory variables in explaining AUDIT-C were tested with level and slope dummy variables. There were statistically significant interactions with gender in both alcohol use (Wald test, p ¼ 0.037) and the level of alcohol consumption (Wald test, p < 0.001). Being dependent on gender, the models were estimated separately for females and males. The question concerning the onset of puberty was answered by 90% of females but only 46% of males. The AUDIT-C responses were viewed as count data with a skewed distribution. The Poisson distribution would have been a natural choice for count data, but as the variance of the AUDIT-C scores was not equal to the mean (likelihood ratio test for over-dispersion, a ¼ 0: males p ¼ 0.072, females p ¼ 0.497), we used negative binomial regression models. Because a large proportion (38.2%) of the study subjects did not drink alcohol, resulting in a large number of zero AUDIT-C scores, zeroinflated negative binomial (ZINB) regression models were chosen for the statistical analysis (Cameron & Trivedi, 2009). As verification for the performance of the modelling, the abstinence parts of ZINB models were compared with logistic regression models and the level of consumption parts were compared with ordinary least squares (OLS) regression models. As AUDIT-C had not been validated among the 13- to 17-year-olds, we aimed to test whether a single model could be used for the whole age span. Therefore, participants were divided into two age groups: the young teenage group of 13- to 15-yearold participants and the old teenage group of 16- to 18-year-old participants. Intercept and slope dummy variables were then included in regression models to test the interaction between age and other explanatory variables. There were small but statistically significant interactions between age and other covariates in the model for the level of male alcohol consumption. In other words, the association of alcohol use and age was non-linear, and to adjust the regression models for this, we added an age2 variable to the models. Multicollinearity was assessed by calculating the variance inflation factor (VIF) for each of the explanatory variables. All the VIF values were 3 or less which rules out multicollinearity. Misspecification was tested with the Ramsey Regression Equation Specification Error Test (RESET) and no specification problems were found. The OLS model was tested for heteroskedasticity with the Breusch-Pagan/CookeWeisberg test, and no heteroskedasticity was found. The estimated standard errors were robust for heteroskedasticity. Vuong's closeness test verified that ZINB should be preferred over a negative binomial distribution (males p < 0.001, females p < 0.001). With respect to the statistical significance and the sign of the coefficients, the results from technically different logistic and OLS regression models were qualitatively the same for most of the variables. Thus, the results did not depend on the chosen statistical method. Finally, the coefficients of the ZINB model (b) were expressed as odds ratios (OR) for any alcohol use (for the abstinence part, OR ¼ eb) and as incidence rate ratios (IRR), expressing the impact of a one-unit increase in cofactors (while other variables remain constant) on the AUDIT-C score (for the level of consumption part, IRR ¼ eb; please see examples in Table 3).
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P-values below 0.05 were interpreted as statistically significant. The software packages used for data analysis were SPSS (version 19) and STATA (version 11). Results Alcohol and tobacco use, psychosocial problems, parental divorce and the number of close friends Alcohol use was high (Table 1). In the age cohorts of 17- and 18-year-old, males had higher AUDIT-C scores than females, but there were otherwise no gender-related differences in alcohol consumption. Female adolescents had a greater frequency of self-reported internalizing and externalizing problems, as well as problems in attention, thinking and social relationships measured with the ASEBA-YSR (Table 2). Among females, occasional tobacco smoking was more common than among males, but no difference between genders was found in daily tobacco smoking. Female adolescents reported two or three close friends more often than males, while male adolescents reported four or more close friends more often than females. Factors associated with alcohol use Alcohol use and high alcohol consumption both associated with aggressive behaviour and tobacco smoking (Table 3). Abstinence from alcohol and low alcohol consumption both associated with problems in social relationships. Attention problems associated with alcohol use, but not with alcohol consumption. The level of alcohol consumption positively associated with the number of close friends. There also were some gender-related differences in the models. Among females, an early onset of puberty and parental divorce were associated with an increased probability of alcohol use. The models were also adjusted for age and the type of school. As age moderated the associations between alcohol consumption and some of the covariates in men, the models were also adjusted for the non-linear effect of age with the variable age2. Among older males, the negative association between the AUDIT-C score and problems in social relationships, as well as the association between the AUDIT-C score and the number of close friends, were stronger and steeper than among younger male adolescents. The association between the AUDIT-C score and smoking was stronger and steeper among the younger males than the older male adolescents. Discussion Main findings In this community sample of 13- to 18-year-old Finnish adolescents, aggressive behaviour, but not internalizing problems, associated with alcohol use and the level of alcohol consumption. Smoking associated with both alcohol use and the level of alcohol consumption. A lack of problems in social relationships and a higher number of friends associated with drinking among the 13- to 18-year-olds. Comparison with the existing literature The association between aggressive behaviour and alcohol consumption is likely to be bi-directional. Unfortunately, we could not distinguish the direction of causation in our cross-sectional study setting. This association may be pronounced in adolescence due to brain development. Brain areas responsible for impulse control are under development, and alcohol use may be a distinct risk factor for adolescent aggressive behaviour (Stephens & Duka, 2008). Contrary to the previous literature, girls reported more aggressive behaviour than boys in our study (Rescorla et al., 2012). This is a novel finding that has not been Table 1 Alcohol use measured by the AUDIT-C score in a Finnish sample of 13- to 18-year-old male and female adolescents. AUDIT-C ¼ 0 indicates no alcohol use. Age
13 14 15 16 17 18 Total
Male (N ¼ 1938)
Female (N ¼ 2229)
AUDIT-C ¼ 0
AUDIT-C > 0
N (%)
N (%)
192 165 190 136 75 23 781
44 83 248 318 277 187 1157
(81%) (67%) (43%) (30%) (21%) (11%) (40%)
(19%) (33%) (57%) (70%) (79%) (89%) (60%)
AUDIT-C ¼ 0
AUDIT-C > 0
Median (Q1eQ3)a
N (%)
N (%)
1 2 4 5 6 6 5
210 174 197 127 82 29 819
55 111 297 374 343 230 1410
(1e2) (1e6) (1e6) (3e7) (4e8) (4e8) (2e7)
(79%) (61%) (40%) (25%) (19%) (11%) (37%)
Difference between genders (Z)b Median (Q1eQ3)a
(21%) (39%) (60%) (75%) (81%) (89%) (63%)
2 4 4 4 4 5 4
(1e3) (1e5) (2e5) (3e6) (3e6) (3e6) (2e6)
*p < 0.05, **p < 0.01, ***p < 0.001. a The first quartile (Q1) and third quartile (Q3) are equal to the 25th and 75th percentiles, respectively. b The ManneWhitney U-test (Z) was used to test whether the distributions of the AUDIT-C scores differ between genders.
0.75 1.28 0.82 1.66 3.83*** 4.39*** 1.54
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Table 2 Descriptive statistics for age, onset of puberty, symptoms of psychosocial problems measured with the Youth Self-Report questionnaire, smoking and number of friends in a Finnish sample of 13- to 18-year-old adolescents.
Agea Onset of pubertyb Youth Self-Report - Internalizing problemsa - Aggressive behavioura - Social problemsa - Thought problemsa - Attention problemsa Number of friends - No close friends (%)c - One close friend (%)c - Two or three (%)c - Four or more (%)c Smoking - No smoking (%)c - Occasional smoking (%)c - Daily smoking (%)c Divorced parents (%)c a b c
Male (N ¼ 1897)
Female (N ¼ 2177)
Median (Q1eQ2)/Mean (SD)/Proportion
Median (Q1eQ2)/Mean (SD)/Proportion
16 (15e17) 12.8 (1.5)
16 (15e17) 12.4 (1.1)
0.82 8.14***
5 6 2 1 4
11 (6e17) 7 (5e11) 2 (1e3) 2 (0e3) 6 (4e7.75)
22.95*** 10.66*** 6.15*** 10.00*** 14.25***
(3e10) (3e9) (1e3) (0e2) (2e6)
Difference between genders (Z/t)
0.4 6.8 32.9 58.0
0.6 7.9 45.9 44.7
1.02 1.31 8.20*** 8.88***
71.3 10.9 15.0 24.2
66.5 15.6 16.2 28.8
3.91*** 4.20*** 0.93 2.97**
Showing median, first quartile (Q1), second quartile (Q2) and differences between genders assessed with the ManneWhitney U-test (Z). Showing mean, standard deviation (SD) and differences between genders assessed with the Student's t-test (t). Showing proportions and differences between genders assessed with the ManneWhitney U-test (Z).
reported earlier, and may reflect some new trend in behaviour among girls in a similar way to their increasing level of alcohol consumption. For those with problems in social relationships, alcohol may be harder to obtain. Selling alcohol to, or possessing alcohol as individuals under 18 years of age is illegal in Finland. One possible explanation for the relationship between alcohol consumption and the number of friends could be that people with more friends are more likely to have friends who drink. Older friends may supply alcohol to their younger peers. In this study, alcohol use was slightly less common than in previous national surveys (Kinnunen et al., 2013, chap. 4), but the level of alcohol consumption was high. Median AUDIT-C scores for the age cohorts of 14 years old and older were 4 or above, and as a matter of fact, any alcohol use between the ages of 12 and 15 years can be a signal of alcohol-related problems (Chung et al., 2012). No association was found between alcohol use and internalizing problems. Consequently, our results did
Table 3 A zero-inflated negative binomial regression model (ZINB) explaining alcohol use (AUDIT-C > 0) and the level of alcohol consumption (AUDIT-C score) in a Finnish sample of 13- to 18-year-old male and female adolescents.
Ageb Age2b Internalizing problems Aggressive behaviour Problems in social relationships Thought problems Attention problems Number of close friends Smoking Divorced parents Age at puberty onset Upper secondary school Vocational school
Odds ratios for any alcohol use, the inflate part of the model
Incidence rate ratioa for a change in AUDIT-C score, the negative binomial part of the model
Male (N ¼ 1773)
Female (N ¼ 1929)
Male (N ¼ 1773)
OR
95% CI
IRR
95% CI
8.19 0.95 1.02 1.11 0.75 1.04 1.09 1.33 8.49 1.93 0.80 1.65 1.97
1.21e55.49**, c 0.89e1.01 0.99e1.04 1.06e1.16*** 0.68e0.83*** 0.97e1.12 1.01e1.18* 1.08e1.64** 5.48ee13.14*** 1.40e2.65*** 0.70e0.90*** 1.07e2.55* 1.17e3.32*
4.98 0.96 1.00 1.03 0.93 1.02 1.00 1.15 1.40 1.02
2.67e9.26***, 0.94e0.97*** 0.99e1.01 1.02e1.04*** 0.91e0.96*** 1.00e1.03 0.99e1.02 1.09e1.21*** 1.32e1.49*** 0.96e1.09
1.26 1.25
1.12e1.41*** 1.11e1.40***
OR
95% CI
6.59 0.96 1.00 1.09 0.75 1.06 1.08 1.15 7.70 1.29
1.06e41.14***, 0.91e1.02 0.97e1.03 1.05e1.13*** 0.68e0.83*** 0.98e1.15 1.00e1.16* 0.94e1.40 5.07e11.71*** 0.96e1.73
1.11 0.89
0.73e1.68 0.57e1.38
c
Female (N ¼ 1929)
c
IRR
95% CI
1.61 0.99 1.00 1.02 0.95 0.99 1.01 1.07 1.60 1.07 1.01 1.06 1.24
0.94e2.75***, 0.97e1.00 1.00e1.01 1.01e1.02*** 0.93e0.97*** 0.98e1.01 1.00e1.03 1.02e1.12** 1.51e1.70*** 1.01e1.13* 0.99e1.04 0.95e1.19 1.11e1.39***
c
*p < 0.05, **p < 0.01, ***p < 0.001. a For binary variables, e.g. the boys who smoke have an AUDIT-C score 1.22 points higher than those who do not, when all other variables in the model remain constant. For continuous variables, e.g. when problems in social relationships increase by one unit, the expected value of AUDIT-C is multiplied by 0.94, which equals a 6% decrease. b Due to the non-linear association of age and AUDIT-C scores, the model is adjusted for both Age and Age2 variables. c Significance is the joint significance of the variables Age and Age2.
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not support the hypothesis of self-medication with alcohol, which may not occur until an older age is reached. Tomlinson and Brown (2012) speculated in their study that individuals with social anxiety may develop alcohol-related problems if they learn to use alcohol as a social lubricant. In girls, the association of alcohol use with the parents being divorced and the onset of puberty may be mediated by various factors such as a dysfunctional family, conflicts in the family, a lack of parental support, parental alcohol problems, and financial and psychosocial stressors in general. Moreover, early-maturing adolescents face additional psychosocial stress due to the adult role models and peer feedback. Parental divorce and early maturation may both involve interpersonal psychological stressors, which have a more adverse impact on well-being in girls than boys (Oldehinkel & Bouma, 2011). On the other € et al. (2006), teachers in Finland reported that drunkenness in older teenage boys associated hand, in the study of Niemela with a non-intact family and externalising problems in childhood. Strengths and limitations This study had a large sample and a high participation rate, considering that the participants were teenagers. The sample covered over 65% of the age groups from 13 to 18 years in the Kuopio area. Moreover, the questionnaire mainly utilized wellvalidated measures, and the observations were confirmed through multiple statistical approaches. There were also some limitations in this study. First, the cross-sectional study setting did not allow the examination of causality or trajectories for alcohol use. Second, no data other than marital status was collected concerning the research subjects' families, although the number of older siblings, the home neighbourhood and the parenting style, mental health, alcohol use and income of the parents could also have affected the alcohol use of their offspring. Third, adolescent self-report questionnaires were used, which may have caused method bias in the results. Using a personal interview would have improved the precision of our observations regarding alcohol use. Fourth, AUDIT and AUDIT-C were not designed for assessing alcohol consumption specifically among adolescents, and AUDIT-C has not been validated among 13- to 18-year-olds. The validity of the puberty onset question is also unknown, although it is used in school surveys in Finland and has been used in € jd, 2011). A more other questionnaire based studies (Kaltiala-Heino et al., 2003; Kaltiala-Heino, Koivisto, Marttunen, & Fro accurate assessment of pubertal status could only have been obtained by examining past school health care registers. Fifth, among the male subjects, there was a low response rate for the pubertal onset question. Conclusions Aggressive behaviour, smoking and social relationships associated with both alcohol use and the level of alcohol consumption in this study. However, alcohol use among adolescents did not associate with internalizing problems. Many underage adolescents use alcohol and some of them use it very heavily. Interventions targeted at alcohol use should start early as part of the school health care system, involving both teenagers and their parents. Acknowledgements The authors report no conflicts of interest. All authors have contributed to and approved the final manuscript. €ki was supported by Kuopio University Hospital EVO funding (Research ID 5702804). 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