New WHO study reveals that while smoking by school-aged children has declined significantly, young people’s health and well-being is being undermined by gender and social inequalities

A new pan-European WHO survey of schoolchildren reveals that the proportion of 15-year-olds who first smoked at the age of 13 has fallen significantly since 2010. The report goes on, however, to warn that while 80% of respondents report generally high rates of life satisfaction, differences between genders and socioeconomic status are adversely affecting many young people’s health, well-being and lifestyle choices at a critical stage in their development.

The Health Behaviour in School-aged Children (HBSC) study, which is updated every four years, reveals that the proportion of 15-year-old Europeans who reported having a first cigarette at the age of 13 or younger fell from 24% to 17% between 2009/2010 when the last survey was conducted and 2013/2014. The reduction reported among girls (22% to 13%) was larger than that among boys (26% to 22%), and the data show no consistent association with family affluence, suggesting that smoking behaviour is only partially determined by socioeconomic factors.

This positive news on smoking is tempered by other aspects of the report, however, which reveal that overall life satisfaction decreases slightly as children grow older and that those from lower-income families generally report lower levels of satisfaction.

Successive studies carried out since 2002 have shown that differences in reported life satisfaction between adolescents in western and eastern Europe have narrowed, with countries such as Croatia, Estonia, Latvia, Lithuania, the Russian Federation and Ukraine reporting significant increases in life satisfaction over the period, although figures have stabilized since the last study in 2010. 

Data inform policy development for adolescents

Data collected for the study are based on surveys completed by thousands of adolescents, thereby ensuring that their voices and concerns can be taken fully into account when WHO frames its European strategies, policies and actions for improving child and adolescent health and well-being. The study feeds into a growing body of evidence calling for more effective and targeted interventions by governments and policy-makers to tackle the effects of social, health and gender inequalities among young people in Europe.

“Health behaviours and social habits and attitudes acquired in the critical second decade of a young person’s life can carry on into adulthood and affect the entire life-course,” said Dr Zsuzsanna Jakab, WHO Regional Director for Europe. “A good start can last a lifetime.”

“Despite considerable advances in adolescent health, such as the welcome reduction in adolescent smoking behaviours, many still face huge inequities; girls and children from lower-income families consistently report poorer physical and mental health and lower rates of physical activity than boys and children from more affluent families, for example. The data in the HBSC study point us to interventions that can narrow this gap and support the development of positive, lifelong health behaviours.”

The WHO report Growing up unequal: gender and socioeconomic differences in young people’s health and well-being covers 42 countries in Europe and North America. Results are analysed by 340 in-country researchers supported and coordinated by the International Coordinating Centre at the University of St Andrews in Scotland and the Data Management Centre at the University of Bergen in Norway.

The cross-national surveycovers diverse aspects of adolescent health and social behaviour, including self-assessment of mental health; obesity and body image; dietary habits; engagement in physical activity; support from families and peers; tobacco, alcohol and cannabis use; and bullying.

The latest HBSC report, which presents data from the 2013/2014 surveys, has a special focus on the effects of gender and socioeconomic differences on the way that young people grow and develop.

Dr Jo Inchley, HBSC International Coordinator and lead editor of the report, said: “The findings highlight large gender disparities in health, which emerge or worsen during the adolescent years. While girls are more likely to eat fruit and vegetables and brush their teeth than boys, they report more negative self-perceptions and poorer mental well-being. Boys are generally more physically active but also more likely to engage in risky behaviours. Differences across countries show the importance of understanding the role of gender norms and cultural expectations in influencing behaviour.

“Many aspects of health are socially patterned. Young people from more disadvantaged backgrounds not only report lower levels of health-promoting behaviours and poorer health outcomes but also have fewer social assets such as support from family and friends.”

Much of WHO’s European strategy for improving child and adolescent health is based on data drawn from successive HBSC studies. The strategy sets out a vision, guiding principles and priorities for countries working across sectors – from governments to nongovernmental and civil society organizations – to protect and promote the health and well-being of children and adolescents throughout the WHO European Region.

The HBSC study has influenced policy and legislation in numerous European countries in the 33 years since its first report was published. After its 2003 report identified a dramatic spike in alcohol consumption among young Germans, for example, the Government of Germany increased tax on “alcopops” and improved labelling; this has led to a significant decline in such consumption. Data gathered in successive HBSC reports were used to inform the development of the Scottish Government’s Pregnancy and Parenthood in Young People Strategyof 2013, and alarming downward trends in the mental health of young Swedes identified by HBSC prompted a major initiative by the Public Health Agency of Sweden to identify the causes of this decline and address them.

“We must no longer treat young people as a homogeneous group for whom a uniform set of interventions is an appropriate response for tackling their needs,” said Dr Zsuzsanna Jakab. “Young people are as rich and diverse as their adult counterparts; they require a range of interventions that reflect their diversity and take fully into account their age and gender, and their social and cultural environments. In the report, young people tell it like it is and highlight what is important to them – we must act on this trust.”

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WHO Regional Office for Europe

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Key findings from the 2013/2014 cross-national HBSC study


On health and health behaviours

·         Girls report poorer mental health than boys, and the difference between genders increases with age. By the age of 15, one in five girls (20%) report their health as being fair or poor, while one in two (50%) experience multiple health complaints more than once every week.

·         Overweight and obesity is higher among boys than girls, yet girls are more likely to think that they are fat; this increases with age from 26% at 11 years to 43% by 15 years. One quarter (25%) of 15-year-old girls are on a diet or taking some form of action to lose weight.

·         Eating habits worsen with age: the frequency of breakfast consumption, eating fruit and taking meals with family all decrease between the ages of 11 and 15; by the age of 15 only 29% of boys eat fruit daily (compared to 37% of 15-year-old girls) and 22% of boys drink soft drinks every day.

·         Levels of physical activity remain very low, with only 25% of 11-year-olds and just 16% of 15-year-olds meeting current guidelines. Girls are persistently less likely than boys to meet currently recommended levels of physical activity.

·         On average, half of boys (50%) and 40% of girls report at least one medically attended injury in the last 12 months. Prevalence is higher among boys of all ages and is associated with higher affluence, possibly due to greater involvement in sports among these groups.

On risk-taking behaviour

·         The study reports a major decline in smoking behaviour since the previous report (2009/2010) – the proportion of 15-year-olds who first smoked at the age of 13 or under fell from 24% to 17% (HBSC average) over the period between studies. The reduction was greater among girls (22% to 13%) than boys (26% to 22%).

·          The study shows considerable declines in alcohol use since 2009/2010: the proportion of 15-year-olds reporting weekly drinking has fallen from 21% to 13% (HBSC average), while the proportion of 15-year-olds who report having been drunk at least twice has fallen from 32% to 22% (HBSC average). Boys are more likely to drink regularly than girls, but the gender gap has reduced in recent years.

·         Lifetime cannabis use (15-year-olds only) varies dramatically by country, from 29% of boys in Estonia, France and Switzerland to 0% of girls in Armenia. The impact of affluence on lifetime cannabis use also varies; it has strong associations with high affluence in some countries (such as Denmark and Estonia) and with low affluence in others (including Scotland).

·         Reports of experiencing sexual intercourse have declined for boys and girls since the previous study: the rate is down from 29% to 24% for boys and from 23% to 17% for girls. Boys are more likely to report having had sex than girls, though girls report it more commonly than boys in England and Wales.

On social interaction with family and peers

·         A majority of young people report good relationships with their parents, but communication and support declines with age, particularly for girls.

·         Most countries show that family support and communication is higher in more affluent families.

·         Peers can be an important source of social support; unlike parental support, levels of peer support remain stable at all ages and are not subject to decline as young people grow older. 

·         The overall prevalence of being bullied was around 12% for boys and 10% for girls, with boys more likely to be bullied and to bully others.