INTRODUCTION:Using Diffusion of Innovations Theory, we investigated whether countries with higher innovation capacity showed earlier tipping points (shift from increasing to decreasing drunkenness) and steeper declines in adolescent drunkenness (2002-2022). Innovation capacity likely facilitates these shifts through knowledge generation, policy implementation, and norm diffusion. METHODS:Trends in adolescent drunkenness were examined across 46 countries using six cross-sectional school-based survey waves from the international HBSC study (N = 319,843 15-year-olds). Data were complemented by country-level innovation capacity, per capita GDP, and Gini-coefficients. Two-level random effects models tested cross-level interactions between innovation capacity and linear and quadratic time trends in adolescent drunkenness frequency. RESULTS:Significant small-to-moderate cross-level interactions were found. Countries with high innovation capacity showed immediate linear declines (B = -.217, SE = .083), that flattened or showed an upward shift by 2022 (B = .031, SE = .007). Countries with low innovation capacity displayed an inverted U-shape trend in the early 2000s with a later tipping point (B = -.006, SE = .002). A steeper linear decline was observed for countries with higher (vs. lower) innovation capacity from their respective tipping point onward (B = -.273, SE = .083). DISCUSSION:Innovation capacity may accelerate adoption and diffusion of healthier behaviors through more rapid translation of health evidence into effective policy, parenting, and norms. While countries with high innovation capacity showed earlier declines, their initially higher levels of drunkenness may have created greater urgency for action. Earlier peaks and subsequent faster reductions in future alcohol-related health care needs are expected in these countries, though the possible recent trend reversal warrants close monitoring.

Purpose: Building on research suggesting that the COVID-19 pandemic may have led to an exacerbation of deteriorating trends in mental health among adolescents, this paper examined trends in adolescents' psychological and somatic complaints across 35 countries from 2010 to 2022, and tested trends in sociodemographic inequalities in these outcomes between 2018 and 2022. Methods: Using data from 792,606 adolescents from 35 countries (51% girls; mean age 1/4 13.5; standard deviation 1.6) across four Health Behaviour in School-aged Children surveys (2010, 2014, 2018, 2022), hierarchical multilevel models estimated cross-national trends in adolescent psychological and somatic complaints. We tested whether observed values in 2022 were in line with predicted values based on 2010-2018 linear trends. Finally, moderation effects of age, family affluence, and family structures on the outcomes were tested (2018-2022). Results: Both girls and boys showed substantially higher levels of psychological complaints in 2022 compared with the predicted values. For somatic complaints, higher levels than predicted in 2022 were observed only in girls. Moderation analyses revealed an increase from 2018 to 2022 in age gaps and a narrowing in the socioeconomic gap for both outcomes. Also, there was a widening gap between adolescents living with 2 parents and those living in a single parent household in 2022 compared to 2018. Discussion: Cross-national increases in adolescent psychological and somatic complaints were higher than expected in 2022, based on previous trends. Magnitudes of change varied across different sociodemographics groups, with implications for pre-existing mental health inequalities. (c) 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

ObjectivesWe examined how the proportion of adolescents who engaged in early sexual intercourse (before the age of 14) changed between 2002 and 2022 across 37 countries.MethodsData of 15-year-old adolescents participating in the 2002, 2006, 2010, 2014, 2018, and 2022 survey rounds of the Health Behaviour in School-aged Children study were analysed (N = 312,702). We used uni- and multivariate multilevel binary logistic regression models to test whether rates of early sexual initiation changed over time. Country, gender, family affluence, parental support and the clustering effect of school were incorporated in the statistical models; linearity was tested by cubic and quadratic terms in the multivariate models.ResultsA significant but very small decline over time was found in early sexual initiation across survey years. Girls and less affluent adolescents had lower odds of early initiation. Parental support (and its interaction with time) also had a significant but small protective role.ConclusionDespite a small decrease over time, still 4% of participants reported early sexual initiation in 2022. Concerted and sustained efforts are needed to support adolescent sexual health.

Non-alcoholic and low-alcohol (NoLo) beverages are increasingly popular among adolescents, raising concerns about their potential gateway effect on alcohol use. This study combines a mapping review of the literature and an analysis of the Dutch Health Behavior in School-Aged Children (HBSC) study (N = 4746, mean age 13.74). The review identified three studies on NoLo prevalence (18.35-31.8%, all in Eastern populations) and two on parental attitudes. National data revealed that 46% of Dutch adolescents aged 12-16 had tried NoLo beverages, with 8% reporting weekly use. NoLo drinkers are overall more similar to non-drinkers, but exhibit characteristics like fewer peer problems and more hyperactivity similar to alcohol drinkers. NoLo use is most common among younger adolescents and those in pre-university tracks. Our findings highlight the need for nationally representative research on NoLo consumption in Western societies. Adolescents may use NoLo beverages to experiment with risk behaviors as an alternative to alcohol, driven by social conformity or a desire for new experiences.

Research shows that both-sex attracted adults have poorer mental health than other- and same-sex attracted adults, but evidence regarding whether similar disparities exist among adolescents remains limited. To investigate this, the current study examines differences in life satisfaction and emotional problems between both-, other- and same-sex attracted adolescents. It also studies whether bullying victimization can explain these differences and whether the associations vary by gender and age. Cross-sectional data from the nationally-representative Dutch Health Behavior in School-aged Children (HBSC) study conducted in 2017 and 2021 were analyzed, including 11,683 adolescents (Mage = 14.7, SD = 1.60; 49.7

BACKGROUND:Internalising problems have increased considerably among adolescents in the last decades, particularly among girls, resulting in widening gender gaps. This study examined whether the gender gap in psychological symptoms increased more in more gender-equal countries in the period 2002-2022, and if so, to what extent this could be explained by changes over time in the experience of stressors (i.e. schoolwork pressure, body dissatisfaction, low classmate support) among boys and girls in these countries. METHODS:National data on gender inequality (UNDP Gender Inequality Index) were combined with aggregated individual-level data from the Health Behaviour in School-aged Children (HBSC) study (2002-2022) across 43 countries (N = 1,268,220). Absolute and relative gender gaps in psychological symptoms were regressed on survey cycle, GII and their interaction. Next, interactions of survey cycle and either schoolwork pressure, body dissatisfaction or classmate support were added to the model. RESULTS:Increases in the absolute and relative gender gap in psychological symptoms between 2002 and 2022 were stronger in more gender-equal countries, mainly due to larger increases in psychological symptoms among girls in these countries. Also, less favourable time trends for schoolwork pressure and classmate support were found in more gender-equal countries for boys and especially girls. The larger increase in schoolwork pressure among girls in more gender-equal countries partly explained the increased absolute gender gap in psychological symptoms in these countries. CONCLUSIONS:While national-level gender equality was positively associated with boys' and girls' mental health in the early 2000s, this association has become negative for girls in more recent years. The benefits of gender equality for girls' mental health may have become overshadowed by the increased experience of stressors, especially schoolwork pressure. Far from advocating that gender equality is a negative situation, these findings suggest that much work remains to achieve full gender equality, where men and women really share the burdens and stressors in everyday life.

Early sexual intercourse initiation has been associated with immediate and long-term risks, which makes the study of trends in sexual initiation an important topic for policy makers. This study investigated trends over time in reported sexual initiation among 15-year-olds across 33 countries between 2010-2018. In addition, we examined if there were cross-country differences in the gender gap in reported sexual initiation in 2018, and whether these could be attributed to gender inequality and gender role attitudes. To answer these questions, we combined individual-level data from the international Health Behaviour in School-aged Children study collected in 2010 (N = 57,656), 2014 (N = 56,745) and 2018 (N = 55,127) with country-level data on gender inequality and gender role attitudes. We found a decrease over time in early sexual initiation in most countries, but also cross-country differences in these trends. More boys than girls reported sexual initiation in 2018. This gender gap also varied across countries and slightly decreased over time. In countries with less progressive gender role attitudes and more gender inequality, fewer girls reported early sexual initiation, resulting in a larger gender gap in these countries. To conclude, policy makers, healthcare providers and educators should focus on changing stereotypical gender norms.

This study aimed to assess differences between other-sex attracted and same- and both-sex attracted adolescents in profiles of peer and family social support, online contacts, and preferences for online communication. Data stem from the 2017 Dutch "Health and Behavior in School-Aged Children" (HBSC) survey (N = 6,823; 4.0% same- and both-sex attracted; M age=14.73, SD = 1.59, range = 12-18). We conducted latent profile analyses to estimate profiles in peer and family social support, online contacts, and preferences for online communication. Then we assessed the association between sexual attraction and profile membership. A five-profile solution fitted the data best. Profiles were characterized as high support, online contact, and average online communication preference (35.6%); high support, low online contact, and weak online communication preference (42.9%); average support, high online contact, and strong online communication preference (9.9%); low support, low online contact, and average online communication preference (6.9%); and low support, average online contact, and average online communication preference (5.0%). Same- and both-sex attracted adolescents had higher odds than other-sex attracted adolescents of being in the latter three profiles than in the first profile. Thus, same- and both-sex attracted adolescents were more likely to report average to low rates of peer and family social support, high to low frequency of online contact, and an average to strong preference for online communication than other-sex attracted adolescents. The average to low levels of support especially influenced these sexual orientation-based differences in profile membership.

In the absence of suitable indicators of adolescent socioeconomic status, the Family Affluence Scale (FAS) was first developed in Scotland 25 years ago. Since then, it has been adapted for use in the Health Behaviour in School-Aged Children (HBSC) Study to research inequalities in adolescent health in Europe and North America. FAS has also been used as an indicator of adolescent socioeconomic status in research studies outside of HBSC, worldwide. There has been a need for FAS to evolve and change its component items over time in order to take into account social and technological changes influencing the families of adolescents. This paper uniquely charts the development of FAS describing the methodological work carried out to validate the measure internationally and over time. It also presents an overview of the body of evidence on adolescent health inequalities produced over years from the HBSC Study and other research studies. Interviews conducted with policy stakeholders reveal that the evidence from FAS-related HBSC work has influenced their strategic work to raise awareness of inequalities and make the case for action to address these. Finally, the future of FAS is discussed with respect to its continual evolution in the context of technological, environmental and social change.

Adolescent mental health and life satisfaction are grounded in social and economic factors. However, studies investigating these relations across European and Asian contexts, using identical questionnaires, are scarce. The 2017/18 Health Behaviour of School-aged Children (HBSC) study conducted with 4,168 Dutch adolescents (Mage 13.0 years) and 1,948 Hong Kong adolescents (Mage 13.1 years) aged 11, 13, and 15 reported on family status and affluence, school experiences, relations with parents and friends, psychological symptoms (irritability/bad temper, feeling low or nervous, difficulty sleeping), and life satisfaction. Dutch boys had the lowest number of psychological symptoms. Dutch girls and Hong Kong girls and boys reported significantly more symptoms. Dutch boys had the highest level of life satisfaction, followed by Dutch girls and, subsequently, Hong Kong girls and boys. In the Netherlands and Hong Kong, communicative and supportive relationships with parents, low school pressure, school liking, and helpful fellow students related to less psychological symptoms and higher life satisfaction. In addition, family affluence further enhanced life satisfaction. It is concluded that cultural and gender differences may permeate the structuring of adolescent relations with parents, teachers, and peers but that an identical set of social and economic determinants affect adolescent girls' and boys' symptoms and satisfaction in a highly similar fashion in the Netherlands and Hong Kong.

Aims: This study investigated gender and educational differences in trends in schoolwork pressure between 2001 and 2017 in nationally representative samples of Dutch adolescents in secondary education. Methods: Data from five surveys of the Dutch Health Behaviour in School-aged Children study were used. Results: Across the surveys, an increase in perceived schoolwork pressure was observed. Girls and adolescents enrolled in the higher educational levels reported higher levels of perceived schoolwork pressure and the strongest increase in schoolwork pressure over time. Especially for girls, there was a stronger increase in schoolwork pressure for those enrolled in higher educational tracks. Conclusions: Increases in schoolwork pressure over time were stronger among Dutch girls and students in the higher educational levels. Over time, schoolwork pressure increased most among girls in the highest educational levels. Explanations and implications for these results are discussed.

-Societal gender inequality relates to gender differences in adolescent substance use.-The gender gap in adolescent substance use is larger in countries with higher levels of gender inequality.-Girls in these countries were less likely to get drunk, use alcohol or smoke cigarettes than boys.

BACKGROUND This article presents the scope and development of the Health Behaviour in School-aged Children (HBSC) study, reviews trend papers published on international HBSC data up to 2012 and discusses the efforts made to produce reliable trend analyses. METHODS The major goal of this article is to present the statistical procedures and analytical strategies for upholding high data quality, as well as reflections from the authors of this article on how to produce reliable trends based on an international study of the magnitude of the HBSC study. HBSC is an international cross-sectional study collecting data from adolescents aged 11-15 years, on a broad variety of health determinants and health behaviours. RESULTS A number of methodological challenges have stemmed from the growth of the HBSC-study, in particular given that the study has a focus on monitoring trends. Some of those challenges are considered. When analysing trends, researchers must be able to assess whether a change in prevalence is an expression of an actual change in the observed outcome, whether it is a result of methodological artefacts, or whether it is due to changes in the conceptualization of the outcome by the respondents. CONCLUSION The article present recommendations to take a number of the considerations into account. The considerations imply methodological challenges, which are core issues in undertaking trend analyses.

BACKGROUND:Tobacco-related heath inequalities are a major public health concern, with smoking being more prevalent among lower socioeconomic groups. The aim of this study is to investigate the mechanisms leading to socioeconomic inequalities in smoking among 15-year-old adolescents by examining the mediating role of psychosocial factors in the peer group, family and school environment.METHODS:Data were derived from the international WHO-collaborative 'Health Behaviour in School-aged Children (HBSC)' study 2005/2006, including 52 907 15-year-old students from 35 European and North American countries. Socioeconomic position was measured by the Family Affluence Scale. Multilevel logistic regression models were conducted to examine the contribution of family, school and peer factors in explaining the association between family affluence and weekly smoking.RESULTS:Across countries, adolescents from low affluent families had an increased risk of weekly smoking (OR(boys) 1.14, confidence interval (CI) 1.05-1.23; OR(girls) 1.36, CI 1.26-1.46) compared with adolescents from high affluent families. Family and school factors mediated the association between family affluence and smoking to a high extent up to 100% (boys) and 81% (girls) in joint analyses. The most important single factors were family structure, relationships with parents, academic achievement and school satisfaction. Peer factors did not mediate the association between family affluence and adolescent smoking.CONCLUSION:The association between socioeconomic status and adolescent weekly smoking can largely be explained by an unequal distribution of family- and school-related factors. Focusing on the parent-adolescent relationship and adolescent school achievement can help to better understand inequalities in adolescent smoking behaviour.

Background: Cannabis and tobacco use frequently co-occur. Adolescents who consume both substances experience more respiratory distress and psychosocial problems and are less likely to stop compared with those who use either tobacco or cannabis alone. This study examined time trends in tobacco and cannabis use among 15-year-olds in Europe and North America between 2002 and 2010. Methods: Twenty-eight countries were included and merged into six regions based on their welfare systems. Adolescents (n = 142 796) were divided in four 'user groups': 'no-users', 'tobacco and cannabis users', 'tobacco-only users' and 'cannabis-only users'. Prevalence rates are reported by study-wave and region. Logistic regressions with study wave as independent variable were used to study trends in the user groups and regions. Interaction effects between time and gender were considered. Results: Overall, tobacco use, and concurrent tobacco and cannabis use decreased by 3 and 3.7%, respectively, but prevalence rates varied by region. Only in North America, an interaction effect between time and gender was found in tobacco and cannabis users. Conclusions: Although this study demonstrates a decrease in tobacco and cannabis use in most regions, it also shows that the use of both substances is related. Therefore, studying the co-occurring use of tobacco and cannabis is necessary.

AIMS To analyse how adolescent drunkenness and frequency of drinking were associated with adult drinking patterns and alcohol control policies. DESIGN, SETTING AND PARTICIPANTS Cross-sectional survey data on 13- and 15-year-olds in 37 countries who participated in the Health Behaviour in School-Aged Children (HBSC) Study in 2010 (n = 144 788) were linked to national-level indicators on alcohol control policies and adult drinking patterns. MEASUREMENTS Outcome measures were self-reported weekly drinking and life-time drunkenness (drunk once or more). Data were analysed using multi-level logistic regression models. FINDINGS In the mutually adjusted models, adolescent drunkenness was associated significantly with high adult alcohol consumption [odds ratio (OR) = 3.15 among boys, 95% confidence interval (CI) = 2.13-4.64, OR girls = 2.44, CI = 1.57-3.80] and risky drinking patterns in the adult population (OR boys = 2.02, CI = 1.33-3.05, OR girls = 1.61, CI = 1.18-2.18). The level of abstainers in the adult population was also associated significantly with girls' drunkenness; a 10% increase in the number of abstainers in a country reduced the odds of drunkenness with 21% (OR = 0.79, CI = 0.68-0.90). Weekly drinking was associated significantly with weak restrictions on availability (OR boys = 2.82, CI = 1.74-4.54, OR girls = 2.00, CI = 1.15-3.46) and advertising (OR boys = 1.56, CI = 1.02-2.40, OR girls = 1.79, CI = 1.10-2.94). CONCLUSIONS Comparing data cross-nationally, high levels of adult alcohol consumption and limited alcohol control policies are associated with high levels of alcohol use among adolescents.

AIMS To examine cross-national changes in frequent adolescent cannabis use (40+ times consumed over life-time at age 15) over time and relate these trends to societal wealth, family affluence and gender. DESIGN Data from three cycles (2002, 2006, 2010) of the Health Behaviour in School-aged Children (HBSC) Study were used for cross-sectional and trend analyses of adolescent cannabis use. SETTING Representative surveys in 30 European and North American countries. PARTICIPANTS A total of 160 606 15-year-old students. MEASUREMENTS Respondents' life-time cannabis use, demographics, family affluence (FAS) and frequency of peer contacts were measured individually. Indicators of wealth (gross domestic product per capita, GDP) and perceived availability of cannabis were obtained from national public data bases. FINDINGS The frequency of life-time cannabis use decreased over time among adolescents in Europe and North America, particularly in western European countries and the United States (relative risk (RR) = 0.86: confidence interval (CI) 0.79-0.93). This trend was not observed consistently in rapidly developing countries in eastern, central and southern Europe. Over time (2002-10), cannabis use became: (i) less characteristic of high GDP countries in contrast to lower GDP countries (RR = 0.74: CI 0.57-0.95); (ii) less characteristic of youth from high FAS families in contrast to youth from low FAS families (RR = 0.83: CI 0.72-0.96); and (iii) characterized by an increasing gender gap, i.e. consumption was higher among males (RR 1.26: CI 1.04-1.53). Perceived availability of cannabis and peer contacts remained strong predictors of frequent cannabis use. CONCLUSIONS Among 30 European and North American countries, cannabis use appears to have 'trickled down' over time, with developing countries taking on the former (heavier) use pattern of richer countries, and less affluent youth taking on the former (heavier) use pattern of more affluent youth. Cannabis use continues to be more common among adolescent males than females.