Structural gender inequality and gender differences in adolescent substance use: A multilevel study from 45 countries

Abstract

Purpose Although adolescent substance use has declined, young people’s tobacco and alcohol use levels are still among the highest in Europe and North America. Historically, boys reported higher levels of substance use than girls; however, in recent decades gender convergence in adolescent substance use was observed in some, mostly Western, countries. Previous research has shown associations between societal gender inequality and gender differences in some externalizing behaviors in adolescents. Therefore, there is a need to go beyond individual-level associations and apply a socio-ecological perspective when examining gender differences in adolescent substance use. This study examines whether gender differences in adolescent substance use relate to societal gender inequality. Methods Current and lifetime substance use (i.e., alcohol drinking, drunkenness, cigarette smoking) were measured in 11-, 13 and 15-year-olds in the 2017/18 Health Behaviour in School-aged Children study (n=224,876). Individual data were linked to national gender inequality (Gender Inequality Index, 2018) in 45 countries and regions, and their association was tested using mixed effects (multilevel) logistic regression models Results Large cross-national variations were observed in gender differences in substance use. Greater gender inequality at country level was associated with heightened gender differences in substance use, however with different effects depending on the substance type. For most substances, few gender differences emerge in countries characterized by low levels gender inequality. The largest gender differences were observed in countries characterized by high gender inequality Conclusions Societal gender inequality reflects social and cultural norms that relate to adolescents’ engagement with substance use. Public health policy should target societal factors that impact on young people’s behavior.