Journal of Adolescent Health 48 (2011) 182188

www.jahonline.org

Original article

Effects of a School-Based Prevention Program on European Adolescents

Patterns of Alcohol Use
Maria Paola Caria, M.Sc.a,b,*, Fabrizio Faggiano, M.D., Ph.D.b,c, Rino Bellocco, Sc.D.d,e,
Maria Rosaria Galanti, M.D., Ph.D.a, and the EU-Dap Study Group
a
Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
b
Department of Clinical and Experimental Medicine, Avogadro University, Novara, Italy
c
Piedmont Centre for Drug Addiction Epidemiology, Grugliasco, Turin, Italy
d
Department of Statistics, University of Milano-Bicocca, Milan, Italy
e
Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden

Article history: Received November 11, 2009; manuscript accepted June 2, 2010
Keywords: School-based prevention; Alcohol abuse; Randomized controlled trial; Comprehensive social inuence model; Program
evaluation

A B S T R A C T

Purpose: School-based substance abuse prevention programs are widespread but are rarely evaluated in
Europe. We aimed to evaluate the effect of a new school-based prevention program against substance use on
the frequency of alcohol consumption and alcohol-related problem behaviors among European students.
Methods: During the school year 2004 2005, a total of 7,079 students aged 1214 years from 143 schools in
seven European countries participated in this cluster randomized controlled trial. Schools were randomly
assigned to either control (65 schools, 3,532 students) or to a 12-session standardized program based on the
comprehensive social inuence model (78 schools, 3,547 students). Alcohol use and frequency of alcohol-
related problem behaviors were investigated through a self-completed anonymous questionnaire at baseline
and 18 months thereafter. The association between intervention and changes in alcohol-related outcomes
was expressed as odds ratio (OR), estimated by multilevel regression model.
Results: The preventive program was associated with a decreased risk of reporting alcohol-related problems
(OR .78, 95% condence intervals [CI] .63.98), although this reduction was not statistically signicant in
the subgroup of 743 current drinkers at baseline. The risk for alcohol consumption was not modied by
exposure to the program (OR .93, 95% CI .79 1.09). In the intervention group, nondrinkers and occasional
drinkers at baseline progressed toward frequent drinking less often than in the control group.
Conclusions: School curricula based on the comprehensive social-inuence model can delay progression to
frequent drinking and reduce occurrence of alcohol-related behavioral problems in European students. These
results, albeit moderate, have potentially useful implications at the population level.
2011 Society for Adolescent Health and Medicine. All rights reserved.

Alcohol misuse is increasing among youth in Europe [1,2]. In a
recent study among students aged 1516 years from 35 Euro-
pean countries [1], an upward trend for problem drinking was
reported, although indicators of frequency of alcohol consump-
tion were relatively unchanged during the same period. For in-
* Address correspondence to: Maria Paola Caria, M.Sc., Department of Clinical
and Experimental Medicine, Avogadro University, Via Solaroli 17, 28100 Novara,
Italy.
E-mail address: maria.paola.caria@ki.se
stance, the proportions of students reporting alcohol drinking
during their life (90%) or during the past 30 days (60%) were
unchanged between 2003 and 2007. In contrast, the prevalence
of binge drinking during the past 30 days increased from 40% in
2003 to 44% in 2007, and the proportion of students who had
experienced problems in relation to their own use of alcohol
during the past 12 months increased from 6% in 2003 to 10% in
2007.
Worldwide, alcohol use is linked to the three leading causes of
death among young people: unintentional injuries, homicide,

1054-139X/$ - see front matter 2011 Society for Adolescent Health and Medicine. All rights reserved.
doi:10.1016/j.jadohealth.2010.06.003
 M.P. Caria et al. / Journal of Adolescent Health 48 (2011) 182188
and suicide [3,4]. Underage drinking is also associated with a
range of behavioral and psychiatric problems [5]. Early initiation
of alcohol consumption increases the risk for alcohol-related
problems later in life [6,7] and is associated with staggering
economic and related societal costs [8]. Thus, many institutional
bodies, including the World Health Organization and the Euro-
pean Union [9], have called for increased action to prevent the
harm caused by alcohol consumption to young people.
Primary prevention in the school setting is believed to be one
of the most appropriate strategies to tackle substance use be-
cause they reach a large number of young persons [10].
Although school-based substance use prevention programs
that focus on the social inuence model are widespread, they are
rarely evaluated in Europe [11]. Promising effects of some of
these programs in changing patterns of youth alcohol use have
been shown in studies conducted in North America and Australia
[1215]. However, cultural and societal inuences may play a
crucial role in the effectiveness of substance use prevention [16].
Consequently, there is a need to replicate the effectiveness of
evidence-based program across cultural contexts [17]. A partic-
ularly important question of such evaluation is how to identify
the behavioral end-points. The majority of school-based sub-
stance use prevention programs are aimed at delaying initial use
of alcohol and at reducing consumption [18]. Accordingly, re-
searchers have used a variety of alcohol consumption outcomes.
Few studies have addressed problematic consumption [15,19].
The EU-Dap (European Drug Abuse Prevention) study was the
rst European trial designed to evaluate the effectiveness of a
new school-based program (Unplugged) for substance use pre-
vention [20]. A decreased frequency of episodes of drunkenness
in the past 30 days was reported by students who participated in
the experimental curriculum compared with usual curricula 18
months after baseline [21]. The aim of this paper was to report on
the overall program effects on alcohol use and problem drinking
at the 18-month follow-up. We hypothesized that students in
the intervention arm would show lower rates of all alcohol-
related outcomes than those in the control arm.
Methods
The EU-Dap trial took place simultaneously in seven Euro-
pean countries: Austria, Belgium, Germany, Greece, Italy, Spain,
and Sweden. The research protocol was approved by the Ethical
Boards at the respective study centers.
Experimental design and sample
The study was a cluster randomized controlled trial
(ISRCTN18092805) among students attending junior high school
in the geographical areas of the participating centers. A total of
170 schools were selected on the basis of inclusion criteria and
willingness to cooperate. Schools were sampled to achieve a
balanced representation of high, medium, or low socio-economic
area level and were randomized into the experimental or control
conditions within these groups. Students in the experimental
condition participated in a substance abuse prevention program
consisting of 12 1-hour sessions taught by regular classroom
teachers over a period of 3 months. The intervention was not
provided to students in the control group, who participated in
the programs usually delivered in their schools, if any. Before the
baseline survey in October 2004, of 170 schools 27 withdrew
from the study leaving a baseline sample of 7,079 students aged
183
1214 years (3,532 in 65 control schools and 3,547 in 78 inter-
vention schools). Post-test data were collected in May 2005 and
2006, that is, at least 6 and 18 months, respectively, after base-
line. The questionnaires were labeled with a 9-digit individual
code generated by the student on the basis of stable personal and
parental characteristics. The code was used to match data from
subsequent surveys [22]. Of the baseline records, 78.3% could be
linked to those generated at the 18-month follow-up leaving an
analytical sample of 5,541 students (mean age, 13.2 years; 49%
female). Additional information on the study design and study
population is provided elsewhere [20].
Program
The Unplugged program targets students aged 1214 years,
and is designed to tackle both experimental and regular use of
alcohol, tobacco, and illicit drugs. This new curriculum is based
on the Social Inuence model [23], being interactive, and adding
components of knowledge, life skills training and normative
education. It consists of 12 units (lessons) aggregated in three
blocks. The rst part (units 1 4) deals mainly with adolescents
knowledge on tobacco, alcohol, and illicit drugs. The second part
(units 5 8) deals with social skills (effective communication,
interpersonal relationship skills, self awareness). This set of les-
sons includes normative education to correct misperceptions on
prevalence and social acceptance of substance use. The nal part
(units 9 12) deals with strengthening intrapersonal skills. The
students are instructed to practice refusal skills, assertiveness,
critical thinking, coping strategies, goal setting, decision making,
and problem solving. The curriculum was designed by a group of
psychologists and experts of substance abuse, with particular
concern on issues of implementation in the school systems of
European countries. Further details on the curriculums theory
base and content are reported elsewhere [24].
The teachers who delivered the curriculum were trained dur-
ing a 3-day course in interactive teaching techniques. The proto-
col of the program implementation was carefully standardized.
Data collection and measures
Self-reported substance use was assessed by an anonymous
paper-and-pencil questionnaire along with relevant cognitive,
attitudinal, and psychometric variables. Questionnaires were ad-
ministered in the classroom without teachers participation. Stu-
dents were reassured about the condentiality of their reports
and the anonymous code procedure was explained. Apart from
language adaptation, the same questionnaire and assessment
procedures were used across all countries and all data collection
points. Most questions were retrieved using instruments pro-
vided in the Evaluation Instruments Bank of the European Mon-
itoring Centre for Drugs and Drug Addiction (http://eib.emcdda.
europa.eu/html.cfm/) that was assessed in 2004. In a test-
retest evaluation of the survey instrument we found a
concordance higher than 90% for variables reporting use of ciga-
rettes, alcohol and drugs, about 4 weeks after the date of the rst
survey [22].
Frequency of alcohol use and alcohol-related problem behav-
iors were the outcomes of interest in the present study. The
average frequency of consumption of any alcoholic beverage
(even a small amount) was assessed using a ve response alter-
natives: Never, Seldom, Every month, Every week, and
Every day. A question from the Health Behaviour in School-
184 M.P. Caria et al. / Journal of Adolescent Health 48 (2011) 182188

Aged Children Survey, available in several languages, was the data with students (level 1) nested within classrooms (level
adopted [25]. For the purpose of the regression analysis this item 2) which in turn were nested within centers (level 3).
was dichotomized into Any current drinking versus No cur- The following predictors were considered as potential con-
rent drinking and into an indicator of frequent drinking (Drink- founders in all models: baseline status of the outcome, age,
ing at least weekly versus Other). In a descriptive analysis of family living situation, family alcohol use, perceived school per-
transitions in the intensity of alcohol use between baseline and formance, and perceived parents tolerance concerning alcohol
follow-up, frequency of consumption was broken down into drinking. All analyses were performed using the statistical pack-
three mutually exclusive categories: no use, occasional use (less age MLwiN 2.02 [28].
than weekly), and frequent use (at least weekly). To quantify a possible attrition bias we assessed the robust-
Problem behaviors related to the use of alcohol were assessed ness of the main ndings based on different assumptions on
by asking whether in the past 12 months the students had expe- missing data present in the outcome variable. We analyzed the
rienced any of the following problems because of their drinking: program effects on the basis of the last available values of each
quarrel or argument, ghting, accident or injury, loss of money or student (last observation carried forward method). Also, we re-
other valuable items, damage to object or clothing, relationship peated the analyses under the extreme assumptions that missing
problems, poor school performance, victimization by robbery, values were either all negative (best case scenario) or all positive
and hospitalization. To this end, a question from the European (worst case scenario).
School Survey Project on Alcohol and Other Drugs, available in
several languages, was used [26]. Because the baseline preva- Results
lence of each problem was very low (range, .22%1.26%) we
collapsed these responses into a dichotomous outcome of No The baseline characteristics of the study sample are shown in
problem versus Any problem. In addition, we explored some Table 1.
psycho-social characteristics as possible modiers and/or con- Despite the randomization procedures, certain characteris-
founders of the relationship between exposure to the program tics at baseline were unbalanced between the experimental
and behavioral outcome. Perceived school performance was in- arms, with the control group having a higher proportion of older
vestigated by asking the adolescents how they compared their students and of students with reports of behavioral problems
grades with those of their classmates using a 4-point Likert scale related to their drinking.
ranging from Much better to Worse. Responses were catego-
rized into a dichotomous variable Worse versus As good or Alcohol use
better. Exposure to siblings alcohol use was assessed by asking
the students Does any of your siblings usually get drunk?, with Missing information at baseline was negligible for each of the
Yes/No responses. Children without siblings were considered assessed characteristic (at the most 2.3%, data not shown). As
unexposed to the inuence of siblings alcohol use. A single item expected, baseline prevalence of alcohol use increased with
assessed the perceived parents tolerance concerning alcohol grade level in grade 7 12% of the students were classied as
drinking: If you wanted to drink alcohol (or already do so), do frequent drinkers, whereas the corresponding proportions in
you think your father and mother would allow you?, with pos- grade 8 and 9 were 17% and 37%, respectively. Behavioral prob-
sible responses: Would allow me to drink, Would not allow
me to drink at home, Would not allow me to drink at all, I
Table 1
dont know. This item was dichotomized into Would not allow Baseline characteristics of the study sample, the EU-Dap Study 2004 2006
me to drink at all versus Others. Socio-demographic measures
2 p-value
included gender, age, school-grade, and the family living situa- % Intervention % Controls
tion coded as Living with both parents versus Other living (n 2,811) (n 2,730)
situation.
Gender 3.33 .068
Boys 51.9 49.5
Statistical analysis Individual age 49.79 .01
12 years 25.8 26.8
Intra-class correlation coefcients from the baseline data 13 years 39.7 31.2
were .080, .056 and .030 for lifetime smoking, drunkenness epi- 14 years 34.5 42.0
Current drinking 2.87 .413
sodes and cannabis use, respectively; and .039, .015, and .003 for
Seldom or never 84.6 84.3
the corresponding past 30-day behaviors. These coefcients Every month 6.3 5.8
were very similar to those estimated from school surveys in Every week 7.6 7.9
Greece and Sweden, which were used at the stage of the study Every day 1.5 2.0
design to assess the statistical power of the study. Alcohol-related 2.9 3.9 4.30 .038
problems
Descriptive statistical analyses were performed to summa-
Siblings drinking 7.4 6.8 .81 .368
rize the main characteristics of the study sample. Differences in Parents allow alcohol 39.8 38.5 .92 .338
baseline distributions of outcomes and predictors of interest drinking
were tested using chi-square tests with the appropriate degrees Perceived performance .52 .471
at school
of freedom.
Worse than average 7.9 7.4
All outcome analyses were intent-to-treat. Odds ratios (ORs) As average or above 92.1 92.6
and their corresponding Condence Intervals (95% CI) were esti- Family living situation .56 .453
mated as measure of association between experimental condi- Living with both 83.9 84.6
tions and behavioral outcomes. A 3-level mixed regression parents
Other living situation 16.1 15.4
model [27] was tted to account for the hierarchical structure of
 M.P. Caria et al. / Journal of Adolescent Health 48 (2011) 182188 185

Table 2
Odds ratio (OR) and 95% condence interval (95% CI) of weekly alcohol use and of alcohol-related problem behaviours for students in the intervention group
compared to the controls, the EU-Dap Study, 18-month follow-up

Weekly drinking Alcohol-related problems in the previous 12 months

Program Control OR 95% CI Program Control OR 95% CI
Yes/No Yes/No Yes/No Yes/No

Whole sample 562/2,224 625/2,085 .93 .791.09 176/2,615 224/2,494 .78 .63.98
Female 216/1,122 242/1,125 .95 .751.20 82/1,255 106/1,264 .80 .581.11
Male 346/1,099 383/960 .91 .751.11 94/1,357 118/1,230 .75 .551.01
Baseline drinkers 242/182 262/161 .95 .721.27 60/363 73/347 .77 .541.10
Baseline non drinkers 317/2,017 361/1,895 .88 .731.07 149/2,118 112/2,227 .73 .56.95
School performance average or above 486/2,031 534/1,918 .94 .801.11 150/2,373 191/2,270 .79 .621.00
School performance below average 66/151 77/118 .71 .461.10 21/195 28/166 .62 .341.11
Parents would not at all allow alcohol drinking 231/1,413 256/1,376 .97 .801.19 85/1,562 92/1,547 .94 .701.26
Parents would allow alcohol drinking 325/760 355/669 .90 .731.11 90/999 126/900 .68 .50.93

lems as a result of drinking during the past year were reported by
6% of the students in grade 7 and 8, and by 9% in grade 9.
The overall prevalence of current alcohol drinking increased
from 15.5% (n 850) at baseline to 35.0% (n 1,918) at follow-
up. The proportion of students that reported consumption of
alcoholic beverages at least weekly increased two-fold, from
9.5% (n 518) to 21.6 % (n 1,187), as did the proportion of
students who reported at least one alcohol-related problem dur-
ing the previous 12 months, from 3.4% (n 185) to 7.3% (n
400).
In regression models, adjustment for the considered potential
confounders did not yield estimates that were different from the
crude ones, which are therefore presented in Table 2.
Participation in the program did not modify the overall risk of
being a current drinker or a frequent (weekly) current drinker,
while it was associated with a signicantly lower prevalence of
alcohol-related behavioral problems reported at follow-up. For
this latter outcome, the estimated relative reduction compared
with the controls was about 22% and the absolute risk reduction
was 1.9% (95% CI .56 3.31). This reduction was statistically
signicant only among students who were not current drinkers
at baseline and among students who perceived parents toler-
ance concerning alcohol drinking. For both outcomes, there was
an indication of stronger programs effects among students who
rated their school performance below average (Table 2), al-
though the estimates did not attain the statistical signicance.
As a whole, the program effect on alcohol-related problem
behaviors was stronger among boys than among girls. However,
in a separate analysis by gender and age (data not shown), the
program was associated to a signicant risk reduction among
girls aged 12 years (OR .31, 95% CI .13.74).
Table 3 shows the analysis of transitions between stages of
alcohol use, from baseline to follow-up. Among nondrinkers at
baseline, students from the intervention arm were more likely to
remain nondrinkers (p 0.12) and less likely to progress toward
frequent drinking (p 0.05) as compared with the controls.
Among occasional drinkers at baseline, students from the inter-
vention arm showed a lower progression toward frequent drink-
ing (p 0.08) compared with the controls.
Table 4 shows an analysis of the transitions in the reports of
alcohol-related behavioral problems from baseline to follow-up.
Among adolescents who did not report alcohol-related problems
at baseline, a higher proportion of students from the intervention
arm remained in the same stage (p .05) and a lower proportion
reported frequent alcohol-related behavioral problems at
follow-up (p .05) as compared with the controls.
Attrition
Of the 7,079 students, 78.3% answered their corresponding
18-month follow-up questionnaires (79.3% in the intervention
group and 77.3% in the control group, a statistically signicant

Table 3
Stages of behaviorBaseline to follow-up transitions in the frequency of current alcohol drinking, by intervention arm, the EU-Dap Study 2004 2006

Intensity of drinking 18-month follow-up survey

None Occasionala Frequentb Total (n)
% 95% CI % 95% CI % 95% CI

Intervention arm
Baseline
None 73.9 72.175.6 12.5 11.213.9 13.6 12.215.0 2,334
Occasionala 25.6 19.132.0 30.1 23.336.9 44.3 36.951.7 176
Frequentb 17.7 13.022.5 16.1 11.520.7 66.1 60.272.0 248
Total (n) 1,813 386 559 2,758
Control arm
Baseline
None 71.9 70.073.7 12.1 10.813.5 16.0 14.517.5 2,256
Occasionala 27.6 20.534.6 18.6 12.524.7 53.9 46.061.7 156
Frequentb 20.2 15.425.1 13.1 9.117.2 66.7 61.072.3 267
Total (n) 1,718 338 623 2,679
a
Occasional: monthly but not weekly drinking.
b
Frequent: at least weekly drinking.
186 M.P. Caria et al. / Journal of Adolescent Health 48 (2011) 182188
Table 4
Stages of behaviorBaseline to follow-up transitions in the intensity of alcohol-related problems in the previous 12 months, by intervention arm, the EU-Dap Study
2004 2006
Alcohol-related problems 18-month follow-up survey
None
% 95% CI
Intervention arm
Baseline
None 94.5 93.695.4
Yes, 1 or 2 68.3 56.580.2
Yes, 3 70.0 49.490.6
Total (n) 2,593
Control arm
Baseline
None 92.8 91.893.8
Yes, 1 or 2 68.4 58.078.7
Yes, 3 53.9 34.373.4
Total (n) 2,469
different retained proportion). As expected, the students who
dropped out were signicantly more likely to have higher base-
line prevalence of past 30-day alcohol use and of problems re-
lated to drinking, compared with students who were retained in
the study. In an analysis of drop-out risk, the interaction terms
between intervention condition and baseline behaviors were not
statistically signicant for any variable (data not shown), indicat-
ing that patterns of drop-out were similar across experimental
conditions.
The sensitivity analysis performed using the last observation
carried forward method and the best-case scenario produced
results in line with the available case analysis. In the worst-case
scenario most of the point estimates were still below unity, albeit
considerably attenuated and no longer statistically signicant.
Discussion
In this trial, European students who attended a new sub-
stance abuse prevention program in school were less likely to
experience alcohol-related behavioral problems than students
attending usual school education.
The overall frequency of alcohol consumption, however, was
not affected by participation in the curriculum. A previous report
from this study showed that the program was associated with a
reduced frequency of recent episodes of drunkenness [21]. Taken
together, these data suggest that the preventive effects of this
curriculum concerned problematic drinking rather than the fre-
quency of consumption.
This lack of effectiveness on consumption of alcoholic bever-
ages was not unexpected, as school-based prevention of alcohol
drinking among adolescents only achieved limited success even
in previous studies [29]. Ellickson suggested a possible explana-
tion to justify the moderate and short-lived effect on alcohol
consumption in the Project ALERT, a drug prevention curriculum
for middle school students recognized as a model program by the
Center for Substance Abuse Prevention [30]. According to this
interpretation, the social acceptance of alcohol use may under-
mine curriculum messages to avoid any or moderate alcohol use,
by far the most frequently stated purpose of universal prevention
[31]. In fact, most adolescents may choose to drink alcohol be-
cause this is part of the daily life in their communities and, for
many youths, in their homes [32]. Consequently, individual-level
variables such as skills, beliefs, and intentions may only account
Yes, 1 or 2 Yes, 3 Total (n)
% 95% CI % 95% CI
4.0 3.24.7 1.6 1.12.0 2,686
18.3 8.528.2 13.3 4.722.0 60
25.0 5.544.5 5.0 4.814.8 20
122 51 2,766
4.8 4.05.6 2.4 1.83.0 2,587
20.3 11.329.2 11.4 4.318.4 79
26.9 9.544.3 19.2 3.834.7 26
147 76 2,692
for a small proportion of the variance in alcohol use among
adolescents [33]. Therefore, in the European countries where
alcohol consumption is deeply rooted in culture and society,
school-based programs may need to be combined with extracur-
ricular, family, and community strategies to produce sustained
decreases in alcohol consumption among youth. In fact, pro-
grams with positive effects on alcohol consumption, such as the
Project Northland [34] and the Midwestern Prevention Project
[35], provided an extensive school- and community-based inter-
vention, much of which was outside the classroom. Such multi-
component programs are more demanding and difcult to im-
plement than curricula-only interventions.
Although Unplugged was not associated with an overall
decrease in the frequency of alcohol consumption, baseline non-
drinkers and occasional drinkers in the intervention group pro-
gressed toward frequent consumption less often than controls.
Similar results were obtained in Project Northland, which was
particularly effective among baseline nondrinkers [34].
The preventive effects of the EU-Dap curriculum on problem
behaviors related to alcohol drinking are in line with previous
reports on advanced substance use, such as drunkenness experi-
ence and marijuana use [21]. A possible explanation of why this
program positively affected problem behaviors rather than fre-
quency of alcohol consumption could be that in this age-group
the variability in frequency of alcohol use is very low, because the
majority of adolescents drink alcohol only on particular occa-
sions (such as parties). In contrast, larger inter-individual varia-
tion may be found concerning heavy occasional alcohol use and
related behavioral consequences. Ellickson et al. [19] reached
similar conclusions when they noted that school-based preven-
tion has a greater chance of making inroads on problem drinking,
a less socially acceptable behavior than any or moderate alcohol
use. In fact, the evaluation of the revised Project ALERTs, where
the emphasis was put on deterring alcohol misuse, yielded re-
sults very similar to ours [19]. Few other studies have extended
the evaluation of middle school drug prevention programs to
include behavioral consequences of adolescents alcohol use,
among which were the Alcohol Misuse Prevention Study and the
School Alcohol Harm Reduction Programme. The rst study re-
ported signicant reduction of harmful drinking but not of alco-
hol consumption [36]. In the second study [15], the students who
participated in the program consumed 20% less alcohol and ex-
perienced 33% less harm associated with their own use of alco-
 M.P. Caria et al. / Journal of Adolescent Health 48 (2011) 182188
hol, than did the comparison group. Moreover, the program was
particularly effective among early drinkers. This stronger effect
among high-risk groups also applies to the revised Project ALERT.
In the EU-Dap study, the estimate of effect size is fairly similar for
baseline nondrinkers and baseline drinkers, but with larger im-
precision for the latter group, because of its small size. However,
the emphasis on components of indicated prevention was stron-
ger in all these previously evaluated programs compared with
Unplugged. We also found that Unplugged was somewhat
more effective in reducing alcohol-related problem behaviors
among boys than among girls, consistently with previous nd-
ings from the same study [37]. Theoretical models suggest that
boys are more inuenced by school or community environments,
whereas girls are more inuenced by family protective factors
[38], which were not strongly emphasized in the EU-Dap curric-
ulum. Because we found indications of effectiveness in the
youngest among females, a possible conclusion is that universal
preventive curricula delivered in early adolescence are needed to
achieve sizeable effects among girls.
The EU-Dap trial was the rst school-based prevention trial in
Europe that used a standardized curriculum and a standardized
evaluation protocol on a large sample size. The wide variety of
school environments from seven different European socio-
cultural contexts adds weight to our results.
Two limitations of this study should also be noted. First attri-
tion, a common problem in longitudinal studies, was not negli-
gible. However, attrition is unlikely to have undermined the
validity of our nding. In fact, the absence of signicant interac-
tion between intervention condition and baseline behaviors re-
veals that patterns of drop-out were similar across experimental
conditions. Furthermore, a sensitivity analysis did not support
the possibility of important bias. Self-reported outcome informa-
tion should be a minor concern, because youths answers on their
own drinking behavior in anonymous questionnaires generally
appear to be highly reliable [39]. In addition, we ensured ano-
nymity by using a self-generated unique identication code.
In conclusion, school-based comprehensive social inuence
programs may have a favorable effect on patterns of alcohol
drinking linked to negative consequences, such as relational and
learning problems, ghting, injuries and hospitalization, which
in turn lead to signicant harm both at the individual and at the
community level. Therefore, even moderate effects such as the
ones found in this study may have important long-term popula-
tion health effects [40].
Acknowledgments
We acknowledge teachers and students who volunteered in
this study and all colleagues who participated in the eld work.
The following authors contributed signicantly to the work:
F.F. and M.R.G. designed the study. M.P.C. and M.R.G. drafted the
paper. F.F. and R.B. contributed to revising the paper. M.P.C. and
R.B. analyzed the data. The members of the EU-Dap Study Group
carried out the intervention and collected the data. M.P.C. had
overall responsibility for the paper. All authors contributed to
and have approved the nal manuscript.
EU-Dap is a project funded by the European Commission
(European Public Health program 2002 grant # SPC 2002376).
Additional national funding was provided by Compagnia di San
Paolo (grant # 2002-0703) and Lega Italiana per la Lotta contro i
Tumori (grant # 2003 43/4) for the Novara centre, Swedish Coun-
cil for Working Life and Social Research (grant # 2002-0979),
187
Stockholm County Council (Public Health grant # LS 0401-0117),
and Alcohol Research Council of the Swedish Alcohol Retailing
Monopoly (grant # 07-8:1) for the Swedish centre. The funding
sources had no further role in study design; in the collection,
analysis, and interpretation of data; in the writing of the report;
or in the decision to submit the paper for publication.
EU-Dap Study Group: Roberta Siliquini, Barbara Zunino, Luca
Cuomo, Federica Vigna-Taglianti, Serena Vadrucci, Laura Vitale
(Piedmont Centre for Drug Addiction Epidemiology, Turin, Italy);
Karl Bohrn (Institut fur Sozial und Gesundheitspsychologie,
Wien, Austria); Peer van der Kreeft (De Sleutel, Gent, Belgium);
Juan Carlos Melero, Laura Varona (EDEX, Bilbao, Spain); Gudrum
Wiborg (IFT-Nord, Kiel, Germany); Clive Richardson (University
Mental Health Research Institute, Athens, Greece); Maro Vassara
(Pyxida, Thessaloniki, Greece); Maria Rosaria Galanti, Sara
Sanchez (Stockholm Centre of Public Health and Department of
Public Health Sciences, Karolinska Institutet, Stockholm, Swe-
den); Gregor Burkhart (EMCDDA, Lisbon, Portugal); Fabrizio Fag-
giano, Massimiliano Panella (Department of Clinical and Experi-
mental Medicine, Avogadro University, Novara, Italy); Leila
Fabiani, Maria Scatigna (Department of Internal Medicine and
Public Health, University of LAquila, LAquila, Italy).
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