This research was part of the international HBSC study [9–11]. Therefore, the presented analysis is the first attempt to compare data on the consumption of alcohol between adolescents from Estonia, Latvia, and Lithuania with respect to other European countries and in historical perspective of eight years of the study. This was partially achieved due to significant attention paid to the issues of validity in this survey. The response rates were rather high in the three Baltic countries, therefore there is less probability of the prevalence rates underestimation.
The data on trends of alcohol use among adolescents in the Baltic countries have not been presented extensively before although some smaller scale publications were available in these countries [12, 28–31]. This health issue, however, was on the agenda of the developed industrial countries for a few decades. Researchers from the United States and European countries have found high prevalence in the consumption of alcohol without significant increase during the last few decades in different groups of young people [7, 32]. However, the rise in alcohol consumption during the last decades was reported in Finland  and some other European countries .
The results of our study indicated the increase of alcohol consumption among young people in the Baltic countries over the period between 1993 and 2002. We compared how the prevalence of drunkenness was changing in 15-year-old students of the Baltic countries during the study period in European context. In 1993/94 Denmark, Wales, Scotland, and Finland were among the countries, which exceeded the limit of 50 percent according to our criteria of drunkenness ("two and more times") for boys and girls. Out of 25 countries or regions participating in the survey Latvia took the 12th place, Lithuania took the 18th place, and Estonia took the 20th place in ranking order by descending frequency rate of drunkenness estimated as a mean for boys and girls . The HBSC survey conducted in 2001/02 reaffirmed that Denmark, Wales, Scotland, and Finland exceeded the drunkenness frequency limit of 50%. Greenland and England were included into this group of countries too. Lithuania and Estonia went down to number 8 and 9, respectively out of 35 countries that had conducted the HBSC survey. Latvia retained the middle position and was rated as number 20 . The corresponding figures for the 15-year-olds were also obtained for other indicators of alcohol consumption. These findings suggested that young people from the Baltic countries had a tendency to integrate among their peers from those West European and Nordic countries (Denmark, Wales, Scotland, Finland, Greenland, England), where alcohol consumption among the students is high.
We have compared the methods used and our results with other cross-national health behavior surveys. ESPAD (European School Survey on Alcohol and other Drugs) conducted in 1995, 1999, 2003 with the aim to investigate the consumption of alcohol, drugs, and tobacco among 15–16-year-old students is similar but at the same time much more specialized . The Baltic countries were also involved in this survey among 35 other European countries. The set of ESPAD questions is rather different from HBSC questionnaire: this research instrument included more items on each separate behavioral problem (alcohol, drugs, and smoking). Despite some methodological differences, the comparison of results from both studies allowed having a deeper scientific insight into the problem when comparing the trends.
Alcohol use 20 times or more during the last 12 months is a measure from the ESPAD study that could be considered as the most comparable to regular alcohol drinking measure in our study. According to the ESPAD report , an increase of the proportion of students who drank alcohol in this regularity was observed in a large number of countries, mainly in the Eastern Europe. Over the years from 1995 to 2003, Estonia and Lithuania (data for Latvia in 1995 are missing) were among those countries where a continuously increasing proportion of students reported drinking 20 times or more within the last 12 months.
The ESPAD survey of 2003 reports that the majority of the 15–16-year-olds have been drunk at least once in their lifetime in 30 countries out of 35 studied . Moreover considering the changes between the surveys of 1995 and 2003, the proportion of students who have been drunk 20 times or more in a lifetime in 12 out of 28 countries increased considerably, while the decrease was observed only in one of the participating countries . Two of the three Baltic countries, Estonia and Lithuania, were included into the group of countries, where unidirectional increase in the proportion of students, who reported this behavior, was observed over the years. This finding of the ESPAD study significantly correlates with the results of our study showing a particular increase in the prevalence of drunkenness among Estonian and Lithuanian students. It is also important to note that both the HBSC and the ESPAD studies identify Denmark as the country where the proportion of students who reported having been drunk remained in the highest rank over the studied period.
In general the comparisons between the HBSC and the ESPAD surveys demonstrate very similar results in trends of alcohol consumption among students in the Baltic States during the last decade. Therefore it is more difficult to draw inferences on the other countries of Central and Eastern Europe because of less evident similarities between the HBSC and the ESPAD surveys conducted in these countries.
The Baltic countries are considered an example of regional homogeneity, especially when taking into consideration historical parallels of the last century, economical indicators, and similar growth of the national economies. The Baltic economies grew by almost half from their initial level during 1996–2003: cumulative growth was 51% for Estonia, 59% for Latvia, and 52% for Lithuania . However, the official statistics and research surveys have already proved that there is non-homogeneity in the area of health and behaviors in the Baltic countries [2, 18–20]. It allowed developing the hypothesis regarding possible difference of health behavior, which is the outcome of economical, social, and cultural differences. The market also plays an important role in establishing health behaviors, such as the use of alcohol. Although on the aggregate level of the country it is impossible to assess the impact of particular factors on the patterns recorded, taking into account the changes of lifestyle and the policies related to alcohol might facilitate the interpretation of these data.
Obviously, eight years is a relatively short period for the assessment of the changes in national lifestyles. However, these years in the Baltic countries were of particular interest due to political and economic situation. The period of transition has opened up borders, has changed the values and opportunities and has begun the process accompanied by stress and turmoil. Following the privatization and economic liberalization alcohol and tobacco industry in the region started marketing campaigns aiming to increase the production and sales. The recorded annual consumption of pure alcohol according to the official statistics varied from 8 to 12 liters per capita over 1994–2000 [35, 36]. The extent of unrecorded consumption of alcohol was also significant .
One of the unfortunate consequences of transition period is the increased willingness of many young people to experiment with legal and illegal drugs, while these drugs become more easily available. Branding and advertising associate alcohol consumption and smoking with an affluent and advantaged western lifestyle or with other images, which are directly appealing to young people. Over the last decade the advertising of alcohol (except beer in Latvia) was restricted by law across all the Baltic countries, particularly for broadcast media. Age limit for purchasing alcoholic beverages in a bar or in a shop is 18 years. Although all the Baltic countries have reported partial restriction on alcohol (mostly spirits) consumption in public places, beer marketing is on the increase in sport events and pop music concerts, targeting young people .
It is evident that globalization of culture sometimes has different behavioral effects in young people. Also more liberal and open marketing of alcohol, tobacco products could have the negative consequences [7, 39]. In our research alcohol consumption behavior was assessed in the broader international context in order to evaluate the process of integration of the Baltic countries to the European economical and cultural space. The data of three HBSC surveys in sequence demonstrated that young people from the Baltic countries were consuming the quantities of alcohol which were drawing them closer to some of the western countries (Denmark, UK, Finland, etc.), characterized by relatively high consumption of alcohol in young generation. Assimilation of lifestyles between the adolescents from Eastern, Central and Western Europe has been detected regarding smoking, drug use, and other habits as well .
The evidence is growing that the lifestyle is also influenced by behavioral patterns common to a person's social group and by more general socio-economic conditions . In the majority of the developed European countries material welfare has increased in a rather limited, socially and economically privileged, population group, which was better placed to adopt health promoting changes in behavior . Such assumption raised an important objective for our research – to test the relationship between alcohol consumption and family economic status in young people from the Baltic countries.
Evidence about the relationship between socio-economic status and health risk behaviors in adolescence, however, is often inconsistent or even contradictory. The picture gets even more complex with the introduction of differences between male and female adolescents . Our study has demonstrated that students from the wealthy families were more likely to drink alcoholic beverages weekly than students from the poorer families (significant associations were found among the boys from all the Baltic countries and among the girls from Estonia). Similar results for Lithuania and Estonia (data for Latvia were missing) as well as for some other countries were presented in the ESPAD report 2003 .
These findings could be explained by the recently popular term – "the diseases of affluence" – which relates to higher levels of noncommunicable disease risks due to improved access of population for consumption of unhealthy food (alcohol, diet rich in fat and carbohydrates) and use of industrialized services . This phenomenon is apparently common in the developed societies, but could be also related to some specific socio-economic periods of transition such as in the Baltic countries influencing health behavior of adolescents.
Given the increasing prevalence of alcohol use among youth in the Baltic countries considerable efforts should be directed towards identifying effective preventive measures. The main implication of our findings is that the rise of economy in the region does not mean the improvement in risky health behavior of adolescents. The most recent and promising prevention approaches are based on the psychosocial influences that promote alcohol use initiation by increasing an awareness of the social influences, restriction in laws and norms unfavorable towards alcohol use, and building drug resistance skills [43, 44]. These approaches are on the agenda of the national health policy but have not been put into practice yet in any of the Baltic countries [1, 14].
Data from many recent studies imply that social determinants should be taken into account when conducting intervention programmes, which are aiming to prevent alcohol consumption in youth. The paradigm on "diseases of affluence" also implies that risk factors of non-communicable disease could also have an impact on middle and higher income population groups . Due to this reason such interventions should be appropriately designed for adolescents from higher socio-economic backgrounds and attempt to diminish their positive attitudes towards excessive alcohol consumption. Literature review shows that the most promising preventive strategies to achieve this objective might include the development of parental skills and functional family therapy, social competence skills, use of young leaders as models, youth involvement in alternative leisure activities, etc. .
In conclusion, the results of this study indicate that there was an increase of alcohol consumption among young people in the Baltic countries over the period between 1993 and 2002. This has caused young people from the Baltic countries to integrate among their peers from those West European and Nordic countries, where alcohol consumption among students is relatively high. It is also alarming that the risk of alcohol consumption among young people in the Baltic region was linked to the higher wealth of the family. These results of the study raise important policy implications for the development of alcohol abuse prevention programs for youth. A combination of measures should be employed in efforts to deal with this problem, including strategies relevant for the period of transition. National health programs for the Baltic countries aim to reduce alcohol consumption by 25% by the year 2010 [37, 45].