Immigrant Status, Family Support, and Psychoactive Substance Use Among Adolescents: A Multilevel Analysis of the Cross-National HBSC Study Data

Background: Immigrant adolescents experience distinct risk and protective factors related to substance use; however, cross-national differences between immigrant and native-born youth remain insufficiently understood. This study examines differences in the prevalence of psychoactive substance use between immigrant and non-immigrant 15-year-old adolescents and assesses the protective role of family support across Europe, Central Asia, and North America. Materials and Methods: Data were drawn from nationally representative samples of the 2021/2022 WHO Health Behaviour in School-aged Children (HBSC) survey, including 15-year-olds from 32 countries, representing Belgium by two separate regions ( n = 66,400). Outcomes included cigarette smoking, electronic cigarette use, alcohol consumption, drunkenness, and cannabis use in the past 30 days. Key predictors were immigrant status and family support. Multilevel analyses incorporated country-level indicators, including the proportion of immigrant youth and the Inclusiveness Index, and were adjusted for sex and family affluence. Results: Substantial cross-national variation in substance use prevalence was observed. Immigrant adolescents were more likely to smoke cigarettes, use electronic cigarettes, and use cannabis, whereas alcohol consumption was more common among non-immigrant adolescents. However, in countries with a low proportion of immigrant youth (<5%), immigrant adolescents showed an elevated likelihood of engaging in all forms of psychoactive substance use, including alcohol consumption. Low family support emerged as the strongest and most consistent predictor of substance use across all outcomes. Conclusions: Immigrant adolescents living in countries with low immigration rates constitute a particularly vulnerable group facing increased risk of substance use. Family support is protective against adolescent substance use for both immigrant and non-immigrant youth, with the strongest effect for alcohol use in low-immigration contexts.