The Health Behaviour in School-aged Children (HBSC) study is a large school-based survey carried out every four years in collaboration with the WHO Regional Office for Europe. HBSC data are used at national/regional and international levels to gain new insights into adolescent health and well-being, understand the social determinants of health and inform policy and practice to improve young people’s lives. The 2021/2022 HBSC survey data are accompanied by a series of volumes that summarize the key findings around specific health topics. This report, Volume 3 in the series, focuses on adolescent substance use, using the unique HBSC evidence on adolescents aged 11, 13 and 15 years across 44 countries and regions in Europe, central Asia and Canada. It describes the status of adolescent substance use (cigarette smoking, electronic cigarette use, alcohol consumption, drunkenness and cannabis use), the role of gender, age and social inequality, and how adolescent substance use has changed over time. Findings from the 2021/2022 HBSC survey provide an important evidence benchmark for current research, intervention and policy-planning.

Key findings

• Adolescents’ current use of all substances (except cannabis, questions on which were presented only to 15-year-olds) increased sharply with age in almost all countries and regions.
• Substance use was generally higher in boys than girls at age 11, while the gender gap tended to narrow or disappear from age 13.
• A quarter of 15-year-olds had smoked in their lifetime, and 15% had smoked at least once in the past 30 days. 
• More than 30% of 15-year-olds had used electronic cigarettes (e-cigarettes) during their lifetime and 20% had used them in the past 30 days.
• Lifetime alcohol use was reported by 57% of 15-year-olds and past-30-day use by just under 40%, with higher prevalence in girls.
• One in five 15-year-olds had been drunk at least twice in their lifetime, with no significant gender differences in most countries and regions.
• The prevalence of both lifetime and current cannabis use was higher among boys than girls at age 15 (13% versus 11% for lifetime use and 8% versus 5% for current use).
• Between 2018 and 2022, there was an overall increase in current alcohol use and drunkenness among older girls. In contrast, a decrease in alcohol use was observed among 15-year-old boys.
• A decrease in current smoking since 2018 was also observed among 15-year-old boys.
• Socioeconomic differences in substance use varied by substance type. Cigarette smoking showed higher prevalence among adolescents from low-affluence families, while e-cigarette use, alcohol consumption and drunkenness were more prevalent among high-affluence adolescents.
• Data from the 2022 survey confirm wide variability in substance use among countries and regions.

Implications

• Substance use remains a crucial public health problem among adolescents, especially in light of the steady or once again growing trend seen in many countries and regions.
• Data from recent literature suggest that the coronavirus disease 2019 (COVID-19) pandemic may have had an impact on adolescent substance use. In this perspective, the results of the Health Behaviour in School-aged Children (HBSC) 2021/2022 survey provide an important benchmark for interventions and policy-planning.
• All interventions should be evidence-based in line with international standards, tailored, gender sensitive, developmentally appropriate and ethical.
• Comprehensive actions are required at multiple levels, including families, communities, youth centres and hospitals, alongside strong referral pathways that provide the necessary services for young people.
• The gender convergence registered in many countries and regions from the age of 13, with higher prevalence among females even for substances traditionally consumed more by males (such as alcohol), suggests the need for the adoption of interventions that take this phenomenon into account.Greater efforts to reduce the attractiveness of substance use among adolescents are needed, and ongoing monitoring of adolescent behaviour in relation to substance use can help countries and regions assess the effectiveness of their interventions.
• Attention should be given to banning or strongly regulating new products like e-cigarettes, as they are marketed predominantly to young people. E-cigarettes are highly addictive and efforts should be made to decrease their availability to young people by banning advertisements, promotions and flavours and regulating other elements and components that increase toxicity, attractiveness and addictiveness of e-cigarettes for young people.