Adolescence is a critical developmental stage marked by significant physical, emotional, and psychological changes [1]. During this period, many young people engage in health risk behaviours such as alcohol use, smoking, and cannabis consumption. These behaviours can have long-term negative effects on their health and well-being. However, the presence of family support can play a crucial role in mitigating these risks. Research has consistently shown that adolescents who feel supported by their families—whether emotionally, socially, or through open communication—are less likely to engage in harmful behaviours [2].

Family support can take many forms, including emotional encouragement, advice, and practical assistance [3]. Studies indicate that adolescents who feel emotionally supported by their families are less likely to engage in behaviours like drinking [4], cigarette smoking [5,6], and drug use [7]. For instance, a supportive family provides a sense of security and self-worth that discourages adolescents from seeking validation through risky behaviours. Additionally, families that are actively involved in their children’s lives, offering guidance and setting clear boundaries, are more likely to foster an environment where harmful behaviours are less appealing.

A key factor in the association between family support and risk behaviour is communication [8]. Adolescents who can openly discuss their problems with their parents tend to make healthier decisions. Effective communication creates an atmosphere of trust, where teens feel safe enough to share their experiences, challenges, and concerns. In contrast, adolescents who feel that they cannot talk to their parents often turn to peer groups or external sources for support, which can sometimes encourage negative behaviour [9,10].

Parents, who show an interest in their children’s lives, such as discussing daily experiences, talking about emotions, or even making joint decisions, create a supportive atmosphere that reduces the temptation to engage in risky behaviours [11]. When parents are approachable and willing to listen without judgement, adolescents are more likely to seek their guidance when faced with challenges like peer pressure or stress. This can help prevent behaviours such as alcohol consumption, smoking, or drug use, which are often influenced by peer pressure or the desire to fit in.

Moreover, when families work together to set clear expectations and provide consistent reinforcement, adolescents are less likely to engage in risk behaviour. For example, a teenager who knows their parents are concerned about their well-being and are willing to discuss decisions openly may feel more confident in resisting peer pressure [12]. In such environments, teens are encouraged to make decisions that align with their values, even when faced with the temptation to follow the crowd.

The ease of talking with parents about problems, desires, and pressures is another vital aspect of reducing health risk behaviour. If adolescents feel comfortable discussing their challenges with their parents without fear of criticism or punishment, they are more likely to approach their family for advice and support when they encounter situations involving alcohol, smoking, or drugs [13]. In contrast, when adolescents feel that their parents are too strict, dismissive, or uninterested, they may struggle to communicate their concerns and may be more susceptible to risky behaviours in search of acceptance from peers. Families that build open, non-judgemental relationships foster an environment, where adolescents can make more informed, responsible choices. In these cases, adolescents are less likely to rely on unhealthy coping mechanisms such as substance use or smoking to deal with stress or emotional challenges.

Adolescence is a turning point in gender differences related to health behaviours. During this developmental stage, psychosomatic complaints increase in girls together with worsened emotional well-being, while health risk behaviours (e.g., injuries and accidents) become more prevalent among boys [14]. In terms of substance use, the recent trends outline a ‘catch-up’ pattern among girls engaged in substance use. Despite the diminishing gender differences in health risk behaviours, qualitative differences remain in terms of frequency and quantity in the use of harmful substances [14,15]. Gender plays also an important role in how adolescents respond to family support and how the ease of communication with parents affects young people’s behavioural health [13,16].

Most of the studies reviewed above focused on individual components of adolescent problem behaviour rather than examining multiple components simultaneously [17]. However, adolescents often engage in several risk behaviours at once, indicating that interventions should target multiple behaviours concurrently rather than in isolation. Several studies have explored patterns of multiple risk behaviours (MRBs) among adolescents—such as alcohol use, cigarette smoking, and drug use—in a more comprehensive manner. For instance, the Avon Longitudinal Study of Parents and Children [18] investigated how MRBs cluster in adolescents. The study found that MRBs tend to cluster by the number of behaviours rather than by forming distinct behavioural profiles. Similarly, the Korean Youth Risk Behaviour Survey [19], which analysed data from over 100,000 Korean adolescents, reported that 6.4% of males and 3.8% of females engaged in MRBs, including alcohol use, smoking, and illicit substance use. Increased age, low socioeconomic status, and mental health issues were associated with a higher likelihood of engaging in MRBs. These findings suggest that interventions should focus on the cumulative number of risk behaviours rather than targeting specific behaviour patterns. Studies such as those cited above and others [20] employed various Structural Equation Modelling (SEM) techniques to analyse the data. We considered SEM an appropriate method for examining the association between adolescent multiple health risk behaviour and familial factors. To our knowledge, no such study has yet been conducted to date.

Health Behaviour in School-aged Children (HBSC) is a cross-national study focused on adolescent health and well-being conducted in collaboration with the World Health Organisation (WHO) Regional Office for Europe [21,22]. At present, the HBSC study was implemented in more than 40 countries in Europe, Central Asia, and North America. The sample of each participating country includes adolescents aged 11, 13, and 15 years. The main topics covered by HBSC concern adolescents’ attitudes and experiences about mental health and well-being, physical activity, health risk behaviours, eating and dieting, electronic media communication, family culture, peer culture, leisure time, school experience, chronic conditions, etc. [21]. Communication with parents and family support are considered important factors of a social environment in the HBSC study [23].

Given the above provided background, the current study aimed to explore the association between multiple health risk behaviours (excessive use of alcohol, (e)cigarette smoking, cannabis use) taken comprehensively, that is, altogether, and several familial factors (ease of communication with parents and family support) in the total HBSC sample, as well as by comparing Bulgarian and Lithuanian adolescents aged 15 years, with a focus on gender differences. These two countries were chosen for the case study because they have not only many similarities, but also differences.

Bulgaria and Lithuania are Central and Eastern European countries that share many similarities in their past and recent societal development. In terms of trends in young people’s health behaviour, both countries show some differences related to lower prevalence of cigarette smoking, alcohol use, drunkenness, and cannabis use among Lithuanian adolescents compared to their Bulgarian counterparts [22]. In Lithuania, since the restoration of their independence in 1990, the concept of family has evolved alongside societal modernisation, legal reforms, and cultural shifts. Today, laws promote the active involvement of both parents in childcare (such as encouraging paternity leave), prohibit all forms of violence against children, and empower children to have a greater voice within the family. However, families continue to face challenges, including the growing difficulty of shielding children from the increasing availability of narcotic substances [24]. Similar changes in the concept of family were observed in Bulgaria related to the active promotion of positive parenting, a child-centred approach in policy making, as well as the adoption of the principle of the child’s best interest in legal documents and policies with the aim to promote child and family well-being [25].