Introduction: Training in addiction medicine and addiction psychology is essential to ensure the quality of treatment for patients with substance use disorders. Some earlier research has shown varying training between countries, but no comprehensive study of addiction training across Europe has been performed. The present study by the European Federation for Addiction Societies (EUFAS) aimed to fill this gap. Methods: A Delphi process was used to develop a questionnaire on specialist training in addiction treatment in 24 European countries. The final questionnaire consisted of 14 questions on either addiction medicine or addiction psychology, covering the nature and content of the training and institutional approval, the number of academic professorial positions, and the estimated number of specialists in each country. Results: Information was not received from all countries, but six (Belgium, Denmark, Ireland, Italy, Poland, and Romania) reported no specialized addiction medicine training, while 17 countries did. Seven countries (Belgium, France, Ireland, Italy, Russia, Switzerland, and the Netherlands) reported no specialized addiction psychology training, while 14 countries did. Training content and evaluation methods varied. Approval was given either by governments, universities, or professional societies. Eighteen countries reported having professorships in addiction medicine and 12 in addiction psychology. The number of specialists in addiction medicine or psychology varied considerably across the countries. Discussion: The survey revealed a large heterogeneity in training in addiction medicine and addiction psychology across Europe. Several countries lacked formal training, and where formal training was present, there was a large variation in the length of the training. Harmonization of training, as is currently the case for other medical and psychology specializations, is warranted to ensure optimal treatment for this under-served patient group.

Substance use disorders and alcohol use disorders are important yet often overlooked [1], and patients with these disorders are often not recognized [2, 3]. Specific training and research in addiction medicine and psychology have long been lagging behind other fields in public health [4]. Fortunately, we see a slow increase in funding for addiction research and a growth in the number of professionals involved in addiction medicine and psychology, reflected in an increase in professional societies and scientific journals in the addiction field [5].

In 2010, 23 addiction societies from 16 European countries founded the European Federation of Addiction Societies (EUFAS) [6]. Since then, EUFAS has grown to include 36 national societies from 24 countries. The member societies represent both addiction medicine, addiction psychology, and, in some cases, addiction practice related to social care. EUFAS aims to improve addiction treatment and prevention measures at a European level and to support countries with less comprehensive systems. In addition, EUFAS attempts to increase funding for addiction research as well as enhance and harmonize knowledge and training in addiction medicine and psychology across Europe. However, there are still large differences in training among European countries, and some countries struggle with declining professional recruitment [7].

Throughout Europe and beyond, the larger domains in health care have developed comparable treatment approaches and similar curricula in the training of medical doctors, psychologists, and other specialists. We do not know if this holds true also for addiction medicine and psychology as they are relatively new disciplines in a field that has been fronted by social workers and public health nurses for decades [8]. An earlier study described 34 addiction education programs across 25 universities in eight European countries [9]. Of these programs, five were medically based and four psychologically based. The programs varied greatly in format and content. In addition, some countries have published more detailed description of the trainings. For instance, a study in the Czech Republic showed a broad range of graduate and postgraduate education programs [10], and a US-based study found quite comprehensive educational programs [11]. Finally, a Canadian study investigated the feasibility of training in addiction medicine and research simultaneously, documenting possibilities for this approach [12]. To the best of our knowledge, no broad European overview has been presented so far.

Training at specialist level should be comprehensive, evidence-based, and aimed at continuous quality improvement [13]. Recommendations state that training should follow a stringent curriculum, be integrated into university programs, be provided by skilled teachers trained in university hospitals with dedicated internships, be multidisciplinary, and include educational activities in psychiatry and general medicine [14‒16].

Overall, increased traveling and academic exchange in Europe have been fueled by exchange programs like Erasmus. Also, the recent development of European training curricula and board exams in a growing number of medical specialties reflects this necessity. To make such exchange possible, also for the addiction field, there is a need for harmonizing the quality of addiction specialties. The basis for such harmonizations is a thorough knowledge of the current situation of addiction medicine and addiction psychology training. Thus, the aim of the present study was to investigate the organization and extend specialized training in addiction medicine and/or psychology across the 24 European countries conforming to the EUFAS to provide an updated overview of the training and research infrastructure that form the basis for education of addiction specialists. The survey covered formal training in addiction medicine or psychology among other educational aspects.

The current study on training in Addiction Medicine and Psychology in Europe (EUFASamp) was initiated by a working group in the EUFAS in collaboration with all authors.

Development of the Questionnaire

The authors J.G.B. and M.L. used a modified Delphi technique [17] for consensus building among experts, which resulted in the final online survey EUFASamp (online suppl. Fig. S1; for all online suppl. material, see https://doi.org/10.1159/000531502). For the Delphi process, an international committee of experts was composed from the list of EUFAS member societies. When identifying experts, special attention was given to obtaining a wide geographical coverage while keeping the committee small enough to allow efficient exchanges. Other selection criteria were scientific and clinical experience in the field of addiction medicine and/or psychology, extensive knowledge of addiction medicine or psychology visible in scientific papers, and having a central role in the addiction training in their respective countries. Following these criteria, we were able to incorporate a wide range of expertise and different perspectives. At the end of the selection process, 13 addiction clinicians and researchers alike, across ten European countries (Belgium, France, Italy, the Netherlands, Poland, Portugal, Spain, Sweden, the UK, and three from Germany), comprised the expert committee and were involved in the Delphi process.

In the first round, the experts received via e-mail a draft of the survey on “Status of Addiction Medicine and Psychology Specialist Training in European Countries” (EUFASamp) in English and were asked to comment on completeness, structure, and comprehensibility of the survey. After the first round, authors J.G.B. and M.L. discussed the comments of the experts and programmed a synthesis of the results within “Nettskjema” [18], an online solution for data collection for research. In a second round, the experts were invited to comment on the feasibility of the online survey and the answer options of all items. This resulted in a two-armed survey – one arm for addiction medicine training and another arm for addiction psychology training – taking country-specific circumstances into account. After a third expert round, a consensus was reached. The final online EUFASamp comprised 14 questions concerning different aspects of addiction medicine and psychology training, respectively. Each item consisted of a multiple-choice question followed by a comment section, enabling the report of country-specific aspects. To verify the technical feasibility of the online survey (e.g., use of different browsers, filter functions, view on PC, smartphones, tablets, etc.), a pre-test among eight colleagues was conducted. The final EUFASamp survey can be found in online supplementary material.

Data Collection

A snowball sampling [19] was used by sending the survey to all 34 member societies of the EUFAS by e-mail in April 2021. The survey included the option to provide an e-mail to another person who might answer the survey. This person then automatically received the survey by e-mail. Gentle reminders and personal e-mails were sent to further representatives of the different countries where EUFAS has member societies between May and June 2021. By June 30, 2021, we had received 36 responses from all 24 countries. The number of responses per country ranged from one to five with an average of 1.5 responses and a median of one response per country. We received 11 responses concerning addiction medicine training and five responses concerning addiction psychology training only; the remaining 18 responses were for both arms of the survey. For some countries, we did not receive responses on the psychology arm (Czech Republic, Denmark, Finland, Poland, Spain, the UK).

There were some duplicate answers, i.e., countries with more than one response both in the medical and psychology arms. These were studied in detail and noted in tables. In case of conflicting results, a summary of the responses was sent to the societies for verification.

Analysis

All data were compiled in a spreadsheet; numerical data were entered into tables and figures; and from the text in the commentary answer options, a short country summary was prepared. Following this step, 24 country reports were produced. For those countries that provided information on the training, the responses were e-mailed back to the member society of the respective country for feedback on the authors’ interpretation of the results. The responses were integrated into the final results presented.

Addiction Medicine

Having an officially recognized specialization in addiction medicine was reported from 17 out of 24 countries (Table 1), with training durations ranging from 0.5 months (Germany) to 72 months (Norway). Most countries (16 of 17) included theoretical learning, education about basic procedures, pharmacological treatments, and non-pharmacological treatments, and most of them reported clinical supervision (14 of 17), tutorials or interactive learning (12 of 17), practical courses (14 of 17), medical emergencies (12 of 17), medical complications (15 of 17), and dual diagnosis (15 of 17). Of the 17 countries that reported having addiction training, an official authorization, diploma, or approval was given by the government in seven countries, by a professional society in six countries, and by universities in four countries (see Table 1 for details). The approval/authorization was given after an examination in 15 of the countries. Eight countries included a written task on their final approval, and nine countries included an evaluation of the course work.

Table 1.

Training for addiction medicine in Europe

CountryLength of training, monthsTrainingWho certifies?Certificate/diploma/degreeComment
typecontent
theoretical learningclinical supervisiontut./intera. learningpractical coursesnon-pharmacologicalpharmaco-therapybasic proceduresmedical emergenciesmed. complicationsdual diagnosis
Austria 6–48 Professional society Oral theoretical examination, written master thesis, and course work evaluation  
Belgium No specific training              
Croatia 24 Government Oral theoretical examination, written thesis, and course work evaluation  
Czech Republic 12–24      University Oral theoretical examination and master thesis Recertification every 3 years 
Denmark No specific training              
Finland 24–36 Professional society Theoretical examination  
France 12–24  University Oral theoretical examination, written thesis, and course work evaluation  
Germany 0,5   Professional society Oral examination 5-6 weekend courses in addition to other medical specialty 
Greece 12–24 University Oral theoretical examination and written thesis Part of psychiatric training 
Hungary 24         University Theoretical examination and course work evaluation Some part of psychiatric training 
Ireland No specific training              
Italy No specific training             Some training in psychiatry or gastroenterology 
Lithuania Some ad hoc training       Some training in psychiatry or toxicology 
Luxembourg No information          Government Theoretical examination  
Norway 60 Government Theoretical examination, written thesis, and course work evaluation  
Poland No specific training             Part of psychiatric training 
Portugal Professional society Theoretical examination  
Romania No specific training              
Russia 24  Government Oral theoretical examination, written thesis, and course work evaluation Part of “narcology” 
Spain 12 Government Course work evaluation Can be chosen as part of psychiatric training 
Sweden 30   Government Theoretical examination  
Switzerland 12–24  Professional society Oral theoretical examination and master thesis Recertification every 3 years 
The Netherlands 24 Government Theoretical examination and course work evaluation Master class 
UK 12  Professional society Course work evaluation Recertification every 5 years 
CountryLength of training, monthsTrainingWho certifies?Certificate/diploma/degreeComment
typecontent
theoretical learningclinical supervisiontut./intera. learningpractical coursesnon-pharmacologicalpharmaco-therapybasic proceduresmedical emergenciesmed. complicationsdual diagnosis
Austria 6–48 Professional society Oral theoretical examination, written master thesis, and course work evaluation  
Belgium No specific training              
Croatia 24 Government Oral theoretical examination, written thesis, and course work evaluation  
Czech Republic 12–24      University Oral theoretical examination and master thesis Recertification every 3 years 
Denmark No specific training              
Finland 24–36 Professional society Theoretical examination  
France 12–24  University Oral theoretical examination, written thesis, and course work evaluation  
Germany 0,5   Professional society Oral examination 5-6 weekend courses in addition to other medical specialty 
Greece 12–24 University Oral theoretical examination and written thesis Part of psychiatric training 
Hungary 24         University Theoretical examination and course work evaluation Some part of psychiatric training 
Ireland No specific training              
Italy No specific training             Some training in psychiatry or gastroenterology 
Lithuania Some ad hoc training       Some training in psychiatry or toxicology 
Luxembourg No information          Government Theoretical examination  
Norway 60 Government Theoretical examination, written thesis, and course work evaluation  
Poland No specific training             Part of psychiatric training 
Portugal Professional society Theoretical examination  
Romania No specific training              
Russia 24  Government Oral theoretical examination, written thesis, and course work evaluation Part of “narcology” 
Spain 12 Government Course work evaluation Can be chosen as part of psychiatric training 
Sweden 30   Government Theoretical examination  
Switzerland 12–24  Professional society Oral theoretical examination and master thesis Recertification every 3 years 
The Netherlands 24 Government Theoretical examination and course work evaluation Master class 
UK 12  Professional society Course work evaluation Recertification every 5 years 

Table 2 shows the number of professorships dedicated to addiction medicine in the different countries responding to the survey. Also, the estimated number of medical specialists dedicated to addiction medicine is provided, together with the number of new specialists each year. Of the 24 countries, 18 reported having dedicated professorships for addiction medicine. For four of these, we did not receive an indication of number. Of the remaining 14, the numbers varied from 1 full-time professorship in Denmark and Norway to 23 in France. The number of dedicated addiction units for addiction medicine was highest in France with 10 units. Germany tops the list for number of specialists in addiction medicine per capita, followed by Denmark, Finland, France, and Norway.

Table 2.

Professional body of addiction medicine (academic and clinical) in Europe

CountryProfessorshipsAddiction specialists
full-timepart-timein totalper 1 million inhabitantsnew per year
Austria 3a 3a    
Belgium  3a    
Croatia  3/20 25 3–5 
Czech Republic  30 1–2 
Denmark  144 25 10–15 
Finland 146 26 10 
France 23  1,000–2,000 15–31 100 
Germany 1/2 7,000 84 200 
Greece     
Hungary 160 17 1–2 
Ireland    
Italy    
Lithuania      
Luxembourg      
Norway  150 28 20 
Poland 0a   
Portugal  70  
Romania  
Russia    
Spain 0a 
Sweden  60  
Switzerland    
The Netherlands 100–200 6–12 30 
UK  81 20–25 
CountryProfessorshipsAddiction specialists
full-timepart-timein totalper 1 million inhabitantsnew per year
Austria 3a 3a    
Belgium  3a    
Croatia  3/20 25 3–5 
Czech Republic  30 1–2 
Denmark  144 25 10–15 
Finland 146 26 10 
France 23  1,000–2,000 15–31 100 
Germany 1/2 7,000 84 200 
Greece     
Hungary 160 17 1–2 
Ireland    
Italy    
Lithuania      
Luxembourg      
Norway  150 28 20 
Poland 0a   
Portugal  70  
Romania  
Russia    
Spain 0a 
Sweden  60  
Switzerland    
The Netherlands 100–200 6–12 30 
UK  81 20–25 

The letter “n” indicates that there are some, but number is unknown. Blank cells indicate no information. Zero (“0”) indicates known non-existent. Slash (“/”) indicates more and conflicting responses.

aAddiction medicine is taught by other professorships, like psychiatry.

Addiction Psychology

Nineteen countries reported on addiction psychology specialist training. Fourteen of these countries indicated having some specialist training, and 12 reported on length of training ranging from 2–4 months (Spain) to 5 years (Croatia, Norway, Sweden) (Table 3). The amount of content of training varied between the countries: in 10 of 14 countries, theoretical learning is an element within the specialist addiction training, while clinical supervision (6 of 14), tutorials or interactive learning (7 of 14), and practical courses (6 of 14) are further elements of specialist training. Of the 14 countries that reported having a specialist training, an authorization or approval was given by the government in two countries (Luxembourg, Spain), by a professional society in four countries (Austria, Norway, Portugal, Sweden), and by universities in four countries (Czech Republic, Greece, Hungary, Lithuania). The approval/authorization was given after an examination in six of the countries and oral examinations in three cases. Five countries included a written task on their final approval, and four countries included an evaluation of the course work.

Table 3.

Training for addiction psychology in Europe

CountryLength of training, monthsTraining typeWho certifies?Certificate/diploma/degreeComment
theoretical learningclinical supervisiontut./intera. learningpractical courses
Austria 6–48 Professional society Oral theoretical examination, written master thesis, and course work evaluation  
Belgium No specific training        
Croatia 60   Oral theoretical examination, written master thesis, and course work evaluation  
Czech Republic 12–24     University  Several ways into specialization 
France No specific training        
Germany       The 3- and 5-year psychotherapy courses following a master’s degree, end with a certificate that allows for publicly funded treatment of all mental disorders, including addiction  
Greece 24 University Oral theoretical examination, written master thesis, and course work evaluation  
Hungary 24   University Theoretical examination and written thesis  
Ireland No specific training        
Italy No specific training        
Lithuania 24  University  Master’s program, no certification 
Luxembourg No information    Government Theoretical examination  
Norway 60  Professional society Written thesis  
Portugal No information Professional society   
Russia No specific training        
Spain 2–4 Government Course work evaluation  
Sweden 60    Professional society Theoretical examination and written thesis  
Switzerland No specific training        
The Netherlands No specific training        
CountryLength of training, monthsTraining typeWho certifies?Certificate/diploma/degreeComment
theoretical learningclinical supervisiontut./intera. learningpractical courses
Austria 6–48 Professional society Oral theoretical examination, written master thesis, and course work evaluation  
Belgium No specific training        
Croatia 60   Oral theoretical examination, written master thesis, and course work evaluation  
Czech Republic 12–24     University  Several ways into specialization 
France No specific training        
Germany       The 3- and 5-year psychotherapy courses following a master’s degree, end with a certificate that allows for publicly funded treatment of all mental disorders, including addiction  
Greece 24 University Oral theoretical examination, written master thesis, and course work evaluation  
Hungary 24   University Theoretical examination and written thesis  
Ireland No specific training        
Italy No specific training        
Lithuania 24  University  Master’s program, no certification 
Luxembourg No information    Government Theoretical examination  
Norway 60  Professional society Written thesis  
Portugal No information Professional society   
Russia No specific training        
Spain 2–4 Government Course work evaluation  
Sweden 60    Professional society Theoretical examination and written thesis  
Switzerland No specific training        
The Netherlands No specific training        

Table 4 shows the number of professorships dedicated to addiction psychology in the 16 different countries that responded to this part of the survey. Additionally, the number of specialists dedicated to addiction psychology is shown, together with the number of new specialists qualifying each year. Of the 16 countries, 12 reported to have dedicated professorships for addiction psychology. For two of these, we have not received an indication of a number, but among the remaining 10, numbers varied from one part-time professorship (in Italy) to ten full-time professorships and one part-time professorship dedicated to addiction psychology in the Czech Republic, followed by six part-time professorships in Austria. These figures are in some ways reflected in the number of dedicated units for addiction psychology and the number of specialists, with Germany topping the list. Norway and Portugal top the list for number of specialists in addiction psychology.

Table 4.

Professional body of addiction psychology (academic and clinical) in Europe

CountryProfessorshipsAddiction specialists
full-timepart-timein totalper 1 million inhabitantsnew per year
Austria     
Belgium 1a     
Croatia 10 20  
Czech Republic  20 1–2 
Germany 2/3    
Greece     
Hungary  10 0–1 
Ireland    
Italy     
Lithuania      
Luxembourg      
Norway  100 19  
Portugal  100 10  
Spain 0a 
Sweden  30  
Switzerland    
CountryProfessorshipsAddiction specialists
full-timepart-timein totalper 1 million inhabitantsnew per year
Austria     
Belgium 1a     
Croatia 10 20  
Czech Republic  20 1–2 
Germany 2/3    
Greece     
Hungary  10 0–1 
Ireland    
Italy     
Lithuania      
Luxembourg      
Norway  100 19  
Portugal  100 10  
Spain 0a 
Sweden  30  
Switzerland    

The letter “n” indicates that there are some, but number is unknown. Blank cells indicate no information. Zero (“0”) indicates known non-existent. Slash (“/”) indicates more and conflicting responses.

aAddiction psychology is taught by other professorships.

Training in addiction medicine and psychology showed a large heterogeneity across 24 European countries, both in training procedures and the magnitude of academic staff. For addiction medicine, 17 of 24 countries reported a specialized training, with a length varying from a short addition to psychiatric training, to a fully independent specialty of up to 5 years. Belgium, Denmark, Ireland, Italy, Poland, and Romania did not report specialized training in addiction medicine. Most training programs required some form of examination before authorization. The large variation in the number of academic positions dedicated to addiction medicine ranged from the high number of 23 in France to none in five countries. Lastly, the number of medical doctors authorized as specialists in addiction medicine varied greatly, with higher numbers reported in Germany, having a shorter training duration, but with quite high numbers even in Finland, France, and Norway that all had longer specialized training.

Similarly, for addiction psychology, 14 of 19 countries reported having specialized training. Belgium, France, Ireland, Italy, Russia, Switzerland, and the Netherlands did not report specialized addiction psychology training. The length of the training varied from one to 5 years, most with some form of examination before authorization. Professorships were less common compared to addiction medicine and were mostly found in the Czech Republic, Germany, and Austria. Also, the number of addiction psychology specialists was low compared to addiction medicine, with Portugal and Norway topping the list.

The large heterogeneity observed in our study is discordant with the growing need for harmonization in health care within Europe [20]. The great variability in the training offered and the number of positions dedicated to addiction training may lead to inequalities in the provided treatments across Europe and probably indicate that not all patients are receiving treatment that fulfills the criteria of qualified specialist practice [13‒15]. Most worrisome is that quite a few countries lack any formal training in the addiction medicine and psychology fields.

Further research should analyze how differences in training correlate with differences in treatment provision and treatment facilities for the same addiction problems across Europe. In addition, varying structures and funding systems of addiction services may promote a different composition of the workforce of addiction professionals an affected individual may encounter at various stages of disease and recovery. Therefore, training of other professional groups, including social workers and nursing practitioners, should be investigated. The known wide treatment gap between need and provision for people suffering from addictions receiving specialized treatment also calls for the analysis of addiction education that is included in the training of other health care professionals [21].

The European Union of Medical Specialists (UEMS) aims to promote the highest standard of training at European level and to define standards for each medical specialty [22] but does not have addiction medicine as one of the specialties. Addiction is only mentioned as a subspecialty of psychiatry.

There is a huge variation in addiction medicine and psychology specialist provision per capita ranging from zero to around 100 per million inhabitants. It is not easy to determine what would be an optimal level as this depends on many factors inherent in the health care provisions in each country. But decreasing this cross-country heterogeneity, mostly by introducing specialization in countries where such specialization is not provided, could ensure better health care for these patients, also through reduction of stigma. Furthermore, the harmonization of the quality of addiction specialties across Europe would also contribute to an improved cross-country exchange regarding student mobility and knowledge. Thus, there is a need to ensure good quality education of both general health care and addiction professionals across Europe to decrease the burden of disease caused by addictions [16].

Limitations

The survey did not reach all the countries and country representatives. The information presented only includes those responding. Also, responses were not supported by official documents or regulations. The information was based on personal declarations by the respondents, which might be subject to error. However, respondents were identified as key stakeholders of the field, including leaders of national associations or scientific societies of addiction medicine or psychology, reducing the risk of information bias. The survey could have gone for stricter and more systematized definitions of education and training, but that would have come with the risk of not counting initiatives and arrangements falling just outside more narrow and specified definitions. The multidisciplinary nature of the addiction field, only including training and professorships in medicine and psychology, may also have introduced “blind spots” in the survey. Taking these limitations into account, the survey may still be viewed as a preliminary overview and a baseline measurement that needs to be expanded and repeated. It can be a starting point for discussions on the future development of addiction training throughout Europe.

Some European countries have local trainings for addiction medicine and psychology, and some incorporate this training in other specializations, while others still lack formal training. The heterogeneity in training and, especially, the lack of training in some countries are of great concern. Like other health care disciplines, a harmonized (minimum) curriculum for addiction medicine and psychology training in Europe should be set up.

Ethical approval and consent were not required as this study was based on publicly available data.

Jørgen G. Bramness, Marja Leonhardt, Geert Dom, Albert Batalla, Gerardo Florenz Menendez, Karl Mann, Frieder Wurst, Colin Drummond, Emanuele Scafato, Toni Gual, Cristina Maria Ribeiro, and Ulrich Frischknecht declare no conflicts of interest. Marcin Wojnar has done consulting and been on advisory boards for Polpharma, Janssen, and Gedeon Richter, and has given lectures and workshops for Polpharma, Janssen, Gedeon Richter, Egis, Krka, and Lilly. Olivier Cottencin has been a chair or speaker for Recordati, Indivior, Almirall, and Janssen. Benjamin Rolland received lecture or consultancy fees from Lundbeck, Indivior, Camurus, Ethypharm, Recordati, Zentiva, Accord Healthcare, Grünenthal, H.A.C. Pharma, Otsuka, Polpharma, and Janssen.

The study was performed and the manuscript was written with only internal funding.

Jørgen G. Bramness, Colin Drummond, Karl Mann, and Benjamin Rolland had the idea for the paper. Jørgen G. Bramness and Marja Leonhardt headed the Delphi process, including all the co-authors. Karl Mann, Ulrich Frischknecht, Albert Batalla, and Jørgen G. Bramness wrote the first draft of the paper, with M.L. writing the methods section and Emanuele Scafato and Toni Gual writing the first critical revision. Jørgen G. Bramness, Marja Leonhard, Geert Dom Albert Batalla, Gerardo Florenz Menendez, Karl Mann, Frieder Wurst, Marcin Wojnar, Colin Drummond, Emanuele Scafato, Toni Gua, Cristina Maria Ribeiro, Olivier Cottencin, Ulrich Frischknecht, and Benjamin Rolland revised the information from their own country and contributed to the final wording of the document. Jørgen G. Bramness, Marja Leonhard, Geert Dom Albert Batalla, Gerardo Florenz Menendez, Karl Mann, Frieder Wurst, Marcin Wojnar, Colin Drummond, Emanuele Scafato, Toni Gua, Cristina Maria Ribeiro, Olivier Cottencin, Ulrich Frischknecht, and Benjamin Rolland read, commented on, and approved the final draft of the manuscript before submission.

All data generated or analyzed during this study are included in this article and its online supplementary material files. Further inquiries can be directed to the corresponding author.

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