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 (ORboys 1.14, confidence interval (CI) 1.05–1.23; ORgirls 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.

The Health Behaviour in School-aged Children (HBSC) study is an international research project in collaboration with the World Health Organization (WHO) for over 35 years. HBSC is the largest study on child and adolescent health and one of the most important sources of data for the WHO's international comparative health monitoring. Every four years, data on the health and health behaviour of students aged 11, 13 and 15, as well as the social contexts and conditions for growing up healthy, are collected. A total of 50 countries belong to the HBSC network, with 45 countries taking part in the 2017/18 survey. Germany has contributed to the HBSC surveys since 1993/94. For the most recent 2017/18 cycle, students at 146 schools in Germany were interviewed (response rate of schools: 15.6%). A net sample of n = 4,347 girls and boys was achieved for Germany (response rate: 52.7%). Participation was voluntary and the survey was conducted in German school years five, seven and nine (corresponding to ages 11, 13 and 15). A weighting procedure was applied to allow for representative findings on the health of children and adolescents in Germany. HBSC offers a valuable contribution to health monitoring and provides numerous starting points to identify needs, risk groups and fields of action to initiate targeted and actual needs-based measures of prevention and health promotion in the school setting.

Background: Studies have shown constant or increasing health inequalities in adulthood in the last decades, but less is known about trends in health inequalities among adolescents. The aim is to analyse changes in socioeconomic differences in subjective health complaints from 1994 to 2010 among 11- to 15-year-olds in Europe, North America and Israel. Methods: Data were obtained from the international ‘Health Behaviour in School-aged Children’ (HBSC) survey. Analyses were based on the HBSC surveys conducted in 1994 (19 countries), 1998 (25 countries), 2002 (32 countries), 2006 (37 countries) and 2010 (36 countries) covering a time period of up to 16 years. Log binomial regression models were used to assess inequalities in multiple health complaints. Socioeconomic position was measured using perceived family wealth. Results: Inequalities in multiple health complaints emerged in almost all countries, in particular since 2002 (RR 1.1–1.7). Trend analyses showed stable (29 countries), increased (5 countries), decreased (one country) and no social inequalities (2 countries) in adolescent health complaints. Conclusion: In almost all countries, social inequalities in health complaints remained constant over a period of up to 16 years. Our findings suggest a need to intensify efforts in social and health policy to tackle existing inequalities.

In Western countries, smoking accounts for a large share of socio-economic inequalities in health. As smoking initiation occurs around the age of 13, it is likely that school context and social networks at school play a role in the origin of such inequalities. So far, there has been little generic explanation of how social ties at school contribute to socio-economic inequalities in smoking. The SILNE (Smoking Inequalities – Learning from Natural Experiments) survey was designed to test the hypothesis that a combination of peer effect, homophilous social ties, and school context may explain how smoking inequalities are magnified at school – a theory known as network-induced inequality. In this paper, the survey theory and design are presented. The social network survey was carried out in 2013 in six medium-sized European cities with average incomes similar to the national average: Namur (Belgium), Tampere (Finland), Hannover (Germany), Latina (Italy), Amersfoort (The Netherlands), and Coimbra (Portugal). In each city, 6 to 8 schools were selected in a stratified sampling procedure. In each school, two grades in secondary education, corresponding to 14-16-year-olds, were selected. All adolescents in these two grades were invited to participate in the survey. Social ties were reported using the roster approach, in which each adolescent had to nominate up to 5 friends from a directory. The survey collected information from 11,015 adolescents in 50 schools, out of a total of 13,870 registered adolescents, yielding a participation rate of 79%. The SILNE survey yielded 57,094 social ties, 86.7% of which referred to friends who also participated in the survey. The SILNE survey was designed to measure the association between adolescents’ social ties at school, their socio-economic background, and their smoking behaviour. Two difficulties were encountered, however: legal privacy constraints made it impossible to apply the same parental consent procedure in all countries, leading to somewhat lower participation rates in two cities: Hannover and Latina. It was also difficult to match the 6 cities in terms of both age and type of education. The SILNE survey provided a comparable database for the study of smoking inequalities across European cities from a social network perspective.

Background Although there is evidence for socioeconomic inequalities in health and health behaviour in adolescents, different indicators of socioeconomic status (SES) have rarely been compared within one data sample. We examined associations of five SES indicators with self-rated health (SRH) and smoking (ie, a leading cause of health inequalities) in Europe. Methods Data of adolescents aged 14–17 years old were obtained from the 2013 SILNE survey (smoking inequalities: learning from natural experiments), carried out in 50 schools in 6 European cities (N=10 900). Capturing subjective perceptions of relative SES and objective measures of education and wealth, we measured adolescents’ own SES (academic performance, pocket money), parental SES (parental educational level) and family SES (Family Affluence Scale, subjective social status (SSS)). Logistic regression models with SRH and smoking as dependent variables included all SES indicators, age and gender. Results Correlations between SES indicators were weak to moderate. Low academic performance (OR=1.96, 95% CI 1.53 to 2.51) and low SSS (OR=2.75, 95% CI 2.12 to 3.55) were the strongest indicators of poor SRH after adjusting for other SES-indicators. Results for SSS were consistent across countries, while associations with academic performance varied. Low academic performance (OR=5.71, 95% CI 4.63 to 7.06) and more pocket money (OR=0.21, 95% CI 0.18 to 0.26) were most strongly associated with smoking in all countries. Conclusions Socioeconomic inequalities in adolescent health were largest according to SES indicators more closely related to the adolescent’s education as well as the adolescent’s perception of relative family SES, rather than objective indicators of parental education and material family affluence. For future studies on adolescent health inequalities, consideration of adolescent-related SES indicators was recommended.

Introduction As trend studies have shown, health inequalities by income and occupation have widened or remained stable. However, research on time trends in educational inequalities in health in Germany is scarce. The aim of this study is to analyse how educational inequalities in health evolved over a period of 21 years in the middle-aged population in Germany, and whether the trends differ by gender. Methods Data were obtained from the German Socio-Economic Panel covering the period from 1994 to 2014. In total, n=16 339 participants (106 221 person years) aged 30–49 years were included in the study sample. Educational level was measured based on the ‘Comparative Analysis of Social Mobility in Industrial Nations’ (CASMIN) classification. Health outcomes were self-rated health (SRH) as well as (mental and physical) health-related quality of life (HRQOL, SF-12v2). Absolute Index of Inequality (Slope Index of Inequality (SII)) and Relative Index of Inequality (RII) were calculated using linear and logarithmic regression analyses with robust SEs. Results Significant educational inequalities in SRH and physical HRQOL were found for almost every survey year from 1994 to 2014. Relative inequalities in SRH ranged from 1.50 to 2.10 in men and 1.25 to 1.87 in women (RII). Regarding physical HRQOL, the lowest educational group yielded 4.5 to 6.6 points (men) and 3.3 to 6.1 points (women) lower scores (SII). Although educational level increased over time, absolute and relative health inequalities remained largely stable over the last 21 years. For mental HRQOL, only few educational inequalities were found. Discussion This study found persistent educational inequalities in SRH and physical HRQOL among adults in Germany from 1994 to 2014. Our findings highlight the need to intensify efforts in social and health policies to tackle these persistent inequalities.