A novel questionnaire for evaluating digital tool use (DTUQ-D) among individuals with type 2 diabetes: exploring the digital landscape.

Introduction: Effective healthcare currently incorporates a patient-centric system and accessible technology for patient self-management. This study aimed to develop and validate a novel questionnaire titled the Digital Tool Use Questionnaire for Diabetes (DTUQ-D) - a screening tool identifying the type, number, and frequency of digital tools used by Type 2 Diabetes Mellitus (T2DM) patients with within HMOs, online, and via applications. Methods: The questionnaire was administered to two ethnic groups and both genders. A mixed-methods approach was used. In the qualitative phase, the questionnaire was developed through phone surveys of 29 T2DM patients, two endocrinologists and two technology experts. In the quantitative phase, involving 367 participants, convergent validity, construct validity, and reliability were examined. Results: Findings indicated that the DTUQ-D is valid and reliable, successfully identifying digital tools utilized by T2DM patients, notwithstanding variations in factor structures between ethnic groups. This questionnaire provides a foundation for future research, offering a standardized approach to evaluating digital tool usage. Discussion: The study enhances understanding of the role of digital tools in healthcare, especially for T2DM self-management. It also can be easily adapted to assess digital tool use for other illnesses by adjusting instructions and the wording of certain items.

Exploring the personality and relationship factors that mediate the connection between differentiation of self and phubbing.

One of the family patterns crucial for mental and physical well-being is differentiation of self. In this study, our aim was to investigate its impact on the phenomenon of phubbing-where individuals prioritize smartphones over in-person interactions. The prevalence of phubbing behavior has risen substantially in tandem with the increased adoption of smartphones. The study investigated familial, interpersonal, and personal factors that could potentially contribute to the escalation of phubbing behaviors. It was hypothesized that differentiation of self would be associated with phubbing through the mediation of fear of missing out, romantic relationship satisfaction, and loneliness in intimate relationships. We also expected gender differences in the study variables. A sample of 431 young adults, with an average age of 29 (M = 29.05, SD = 9.14), completed the DSI-R, Phubbing, FoMO, ENRICH, and LIRS questionnaires online. Results indicated that fear of missing out mediated the relationship between three dimensions of differentiation of self-emotional reactivity, emotional cutoff, and fusion with others-and phubbing behavior. However, the expected mediation by romantic relationship satisfaction and loneliness in intimate relationships did not reach significance, although these variables were found to be associated with differentiation of self. Women reported higher levels of phubbing behavior, emotional reactivity, and fusion with others, whereas men reported higher levels of I-position. We conclude that fear of missing out may serve as a catalyst, triggering anxiety in individuals, which in turn drives them to adopt phubbing as a coping mechanism. Moreover, individuals with lower levels of differentiation of self appear to be at increased risk of engaging in phubbing behaviors through the mediation of fear of missing out.

What Counteracts Problematic Social Media Use in Adolescence? A Cross-National Observational Study.

PURPOSE: Social media use has increased rapidly during the past decade, raising concerns about adolescents who display problematic social media use (PSMU), as indicated by addiction-like symptoms (e.g., preoccupation, tolerance). We aimed to assess the extent to which an individual resource (health literacy), and social resources (friend support and family support), moderated the association between a range of individual characteristics (gender, age, family affluence, and depressive feelings) and PSMU; also the association between PSMU and health outcomes (self-rated health, life satisfaction, and sleep difficulties), both cross-nationally and nationally. METHODS: Our sample included 22,226 adolescents from six European countries. We used data from the Health Behaviour in School-aged Children cross-sectional survey (2017/2018). Random-effects models and moderator analyses were applied. RESULTS: Six moderations were found, with the resources moderating the association between individual characteristics and PSMU. One moderation emerged cross-nationally, namely that a higher level of family support was associated with a lower likelihood of PSMU, especially among adolescents who did not have frequent depressive feelings. In addition, five national moderations were identified. For example, a higher level of health literacy was associated with a lower likelihood of PSMU among Finnish girls. The resources were also found to moderate the association between PSMU and health outcomes, with two moderations emerging cross-nationally. For instance, a higher level of family support was related to higher self-rated health, especially among problematic users. In addition, nine national moderations were identified; these included a higher level of health literacy being associated with having less sleep difficulties, especially among problematic users in Germany. DISCUSSION: In adolescence, health literacy, family support, and friend support have the potential to moderate the association between individual characteristics and PSMU, and between PSMU and health outcomes, cross-nationally and nationally. We recommend the use of universal and targeted interventions to promote individual and social resources to counteract PSMU.

A cross-national comparison of problematic gaming behavior and well-being in adolescents.

BACKGROUND AND AIMS: The popularity of playing games among adolescents has increased during the last decades, possibly affecting the prevalence of problematic gaming behavior. The current study aimed to compare country-level prevalence rates of adolescents' problematic gaming behavior in five countries and identify cross-cultural similarities and differences in the relationship between problematic gaming and well-being (life satisfaction, psychological complaints, and peer support). METHODS: Cross-national data from the Health Behavior in School-aged Children (HBSC) study were used. The sample comprised 14,398 gamers (61% boys) aged 11 to 16 (average age between 13.31 and 13.85) from Azerbaijan, England, Serbia, Slovenia, and the Netherlands. RESULTS: The findings showed that the prevalence of problematic gaming differs between countries. The highest prevalence of problematic gaming was seen in Azerbaijan (16.1%) and the lowest in the Netherlands (4.3%). In contrast, Azerbaijan reported the lowest gaming intensity, whereas the Netherlands and England showed the highest gaming intensity. Additional analyses revealed that problematic gaming was associated with lower life satisfaction, more psychological complaints, and lower peer support in all countries, although the strength of these associations varied between countries. DISCUSSION AND CONCLUSIONS: The current study's results are consistent with the assumption that problematic gaming negatively affects adolescents' social and mental well-being. These findings are further discussed in light of the normalization theory which suggests that cultural gaming norms (i.e., the percentage of gamers per country) would influence the strength of the relationship between problematic gaming and adolescents' well-being. The present findings highlight the need for adequate prevention strategies aiming at problematic gaming among youngsters.

Adolescent use of social media and associations with sleep patterns across 18 European and North American countries.

OBJECTIVE: Over the past decade, concurrent with increasing social media use (SMU), there has been a shift toward poorer sleep among adolescents in many countries. The purpose of this study was to examine the cross-national associations between adolescent SMU and sleep patterns, by comparing 4 different categories of SMU (nonactive, active, intense, and problematic use). DESIGN, SETTING, AND PARTICIPANTS: Data were from 86,542 adolescents in 18 European and North American countries that participated in the 2017/18 Health Behaviour in School-aged study. MEASUREMENTS: Mixed-effects linear regression models were used to examine cross-national associations between 4 SMU categories and adolescent sleep duration, bedtime and social jetlag derived from self-reported data. RESULTS: For all countries combined, nonactive SMU was associated with longer sleep, earlier bedtimes, and less social jetlag, compared to active SMU, although the differences were minor. By comparison, intense and problematic SMU were associated with less sleep and later bedtimes on both school and nonschool days, and greater social jetlag, compared to active SMU. While findings were relatively consistent between countries, some differences were observed, suggesting that the national and cultural context may be important in interpreting results. CONCLUSIONS: These findings suggest that both intense and problematic SMU are associated with poorer sleep patterns in adolescents across most countries. Further research is needed to identify effective policies, programs, and messaging to promote the healthy use of social media and prevent potential negative impacts on adolescent sleep.

Precursors of Openness to Provide Online Counseling: The Role of Future Thinking, Creativity, and Innovative Behavior of Future Online Therapists.

The outbreak of the COVID-19 pandemic has accelerated the need for online counseling to preserve therapeutic processes that have begun face to face and to provide service to others in need during lockdowns. Previous studies underscored the importance of providing updated training as counselors frequently hesitate to use technological advances in therapeutic sessions. This study aims at reducing such barriers by revealing personal characteristics of future professionals that might inhibit or encourage their openness toward providing online counseling. To this end, this study is focused on several precursors of openness to provide online counseling: preference to communicate emotions online, identification of emotional expressiveness advantages in providing online counseling, innovative behavior, creativity, and future problem-solving thinking skills. The question at focus is which constructs would be found contributive to students' openness to provide online counseling. The sample included 277 undergraduate students (future counselors) who filled out questionnaires. Data were analyzed using Partial Least Squares Structural Equation Modeling. Our findings pointed to the centrality of students' preference to communicate their emotions online in explaining their openness to conducting online counseling. This study might help pinpointing the adjustments curriculum designers should address to better reflect the intensive changes within the counseling field that necessitate transferring face-to-face skills to online settings.

Cross-national validation of the social media disorder scale: findings from adolescents from 44 countries.

BACKGROUND AND AIMS: There is currently no cross-national validation of a scale that measures problematic social media use (SMU). The present study investigated and compared the psychometric properties of the social media disorder (SMD) scale among young adolescents from different countries. DESIGN: Validation study. SETTING AND PARTICIPANTS: Data came from 222 532 adolescents from 44 countries participating in the health behaviour in school-aged children (HBSC) survey (2017/2018). The HBSC survey was conducted in the European region and Canada. Participants were on average aged 13.54 years (standard deviation = 1.63) and 51.24% were girls. MEASUREMENT: Problematic SMU was measured using the nine-item SMD scale with dichotomous response options. FINDINGS: Confirmatory factor analyses (CFA) showed good model fit for a one-factor model across all countries (minimum comparative fit index (CFI) and Tucker-Lewis index (TLI) = 0.963 and 0.951, maximum root mean square error of approximation (RMSEA) and standardized root mean square residual (SRMR) = 0.057 and 0.060), confirming structural validity. The internal consistency of the items was adequate in all countries (minimum alpha = 0.840), indicating that the scale provides reliable scores. Multi-group CFA showed that the factor structure was measurement invariant across countries (ΔCFI = -0.010, ΔRMSEA = 0.003), suggesting that adolescents' level of problematic SMU can be reliably compared cross-nationally. In all countries, gender and socio-economic invariance was established, and age invariance was found in 43 of 44 countries. In line with prior research, in almost all countries, problematic SMU related to poorer mental wellbeing (range ßSTDY = 0.193-0.924, P < 0.05) and higher intensity of online communication (range ßSTDY = 0.163-0.635, P < 0.05), confirming appropriate criterion validity. CONCLUSIONS: The social media disorder scale appears to be suitable for measuring and comparing problematic social media use among young adolescents across many national contexts.

Adolescents at risk of eating disorders: The mediating role of emotional distress in the relationship between differentiation of self and eating disorders.

Introduction: Adolescents may feel dissatisfied with their bodies, which may lead to a risk of eating disorders (EDs) due to several factors, with emotional distress being one of the most important. Evidence suggests that family might be one of the most significant factors that may increase or decrease emotional distress. An important family pattern found to contribute to mental and physical health is the differentiation of self (DoS). The primary purpose of the current study was to map the complex relationships between DoS, emotional distress, and EDs among adolescents. We hypothesized that emotional distress would mediate the relationship between DoS and the risk of EDs among adolescents. Moreover, based on findings indicating a higher risk of EDs among females, we expected sex differences in the research indices and the mediation model. Methods: The sample included 194 non-clinical adolescents (mean age 15.15; mean BMI 21.66). Preliminary analyses examined differences between males and females using t-tests. In addition, Pearson correlations were run to assess the association between background variables and the study metrics among males and females. To examine the mediation effect, we ran SEM. Results: Due to a sex moderation effect, two mediation models were run (SEM), one for females and one for males. Results indicated that emotional distress partially mediated the relationships between DoS and the risk of EDs. In addition, sex differences were found in the mediated indices, showing that among female adolescents, perfectionism is the only dimension of EDs that was associated with DoS through the mediation of emotional distress. While the relationship between emotional distress and the risk of EDs is well documented. Conclusions: It is concluded that high DoS may reduce emotional distress, which may, in turn, decrease the risk of EDs. In addition, the results enable an in-depth understanding of specific risk factors of EDs that characterize each sex.

Czech adolescents' remote school and health experiences during the spring 2020 COVID-19 lockdown.

Schools around the world were closed during the spring 2020 lockdown to reduce the spread of COVID-19. As such, these rapid changes to adolescent daily routines may have had immediate as well as long-term effects on their physical, social, and mental health. Therefore, the aim of this study was to examine the experiences, health behaviors and perceived change in health behaviors among adolescents in Czechia during the spring 2020 lockdown. Adolescents (n = 3,440, 54% girls; Mage = 13.5 years, SD = 1.6) from all regions of Czechia were recruited to complete a self-report survey based on the Health Behaviour in School-aged Children study, with additional items on household disruptions and socialization during lockdown, as well as items on perceived changes in health behaviors during lockdown. First, we described the self-reported impacts of the spring lockdown by gender and grade. Second, log-linear analyses were used to examine the perceived behavioral changes based on standardized cut-off values reporting for health behaviors and gender. Less than a third, 19% and 32% of the respondents reported economic and psychosocial disruptions to their family life, 79% indicated they had positive opportunities for family interactions or learning new things. Girls and older adolescents reported the worst levels of social and mental well-being. Changes in respondents' perceived health behaviors varied by reported behavior frequencies and gender. These results may be useful to compare with future secular trends, and may serve as input in developing strategies to counter the impact of the spring 2020 or future similar lockdowns on the adolescents' well-being..

Parents' Psychopathology Promotes the Adoption of Ineffective Pornography-Related Parenting Mediation Strategies.

Approximately half of all adolescents aged 9-16 are exposed to pornography. Research has indicated that parents often try to employ various mediating strategies (negative active, restriction and co-use) in order to regulate their children's exposure to undesired content, and that most of these strategies are ineffective or have the opposite effect. In the present study, we investigated whether parental psychopathology (depression, anxiety, stress) promotes the adoption of less optimal parenting styles and an ineffective mediating strategy to regulate their child pornography exposure. The sample comprised 1,070 Jewish-Israeli parents to 10-14-year-old adolescents. Results indicated that for parents who characterized with mild anxiety and/or stress tend to adopte more authoritarian and less authoritative parenting style, which were linked with more ineffective mediating strategies with their child regarding pornography exposure - restrictive and negative active. These findings provide an opportunity for therapists as well as parents to gain a better insight into the link between psychopathology, parenting styles and the ability to regulate pornography exposure among children.

Social Media Use and Cyber-Bullying: A Cross-National Analysis of Young People in 42 Countries.

PURPOSE: Social media use (SMU) has become an intrinsic part of adolescent life. Negative consequences of SMU for adolescent health could include exposures to online forms of aggression. We explored age, gender, and cross-national differences in adolescents' engagement in SMU, then relationships between SMU and victimization and the perpetration of cyber-bullying. METHODS: We used data on young people aged 11-15 years (weighted n = 180,919 in 42 countries) who participated in the 2017-2018 Health Behaviour in School-aged Childrenstudy to describe engagement in the three types of SMU (intense, problematic, and talking with strangers online) by age and gender and then in the perpetration and victimization of cyber-bullying. Relationships between SMU and cyber-bullying outcomes were estimated using Poisson regression (weighted n = 166,647 from 42 countries). RESULTS: Variations in SMU and cyber-bullying follow developmental and gender-based patterns across countries. In pooled analyses, engagement in SMU related to cyber-bullying victimization (adjusted relative risks = 1.14 [95% confidence interval (CI): 1.10-1.19] to 1.48 [95% CI: 1.42-1.55]) and perpetration (adjusted relative risk = 1.31 [95% CI: 1.26-1.36] to 1.84 [95% CI: 1.74-1.95]). These associations were stronger for cyber-perpetration versus cyber-victimization and for girls versus boys. Problematic SMU was most strongly and consistently associated with cyber-bullying, both for victimization and perpetration. Stratified analyses showed that SMU related to cyber-victimization in 19%-45% of countries and to cyber-perpetration in 38%-86% of countries. CONCLUSIONS: Accessibility to social media and its pervasive use has led to new opportunities for online aggression. The time adolescents spend on social media, engage in problematic use, and talk to strangers online each relate to cyber-bullying and merit public health intervention. Problematic use of social media poses the strongest and most consistent risk.

Clusters of Contemporary Risk and Their Relationship to Mental Well-Being Among 15-Year-Old Adolescents Across 37 Countries.

PURPOSE: Adolescents' mental well-being has become a growing public health concern. Adolescents' daily lives and their engagement in risks have changed dramatically in the course of the 21st century, leading to a need to update traditional models of risk to include new exposures and behaviors. To date, studies have examined the relationship between (mainly traditional) risk behaviors and adolescent mental well-being or looked at risk factors that jeopardize mental well-being such as lack of social support but have not combined them together to highlight the most significant risks for adolescent mental well-being today. The present study included new and traditional risk behaviors and risk factors, robustly derived an empirically based model of clusters of risk, and examined the relative association of these clusters to adolescent mental well-being. METHODS: Data from the 2017-2018 Health Behaviours in School-aged Children study were used. The sample included 32,884 adolescents (51.7% girls) aged 15 years from 37 countries and regions. The principal component analysis was used to determine the existence of clusters of risk, using 21 items related to adolescent mental well-being that included both risk behaviors (e.g., substance use) and risk factors (e.g., peer support). Analysis was conducted in both a randomly split training and test set and in gender separate models. Mixed-effects logistic regressions examined the association between clusters of risk and mental well-being indices (low life satisfaction and psychosomatic complaints). RESULTS: Seven clusters of risk were identified: substance use and early sex, low social support, insufficient nutrition, bullying, sugary foods and drinks, physical health risk, and problematic social media use (SMU). Low social support and SMU were the strongest predictors of low life satisfaction (odds ratios = 2.167 and 1.330, respectively) and psychosomatic complaints (odds ratio = 1.687 and 1.386, respectively). Few gender differences in predictors were found. Exposure to bullying was somewhat more associated with psychosomatic complaints for girls, whereas physical health risk was associated with reduced relative odds of low life satisfaction among boys. Split-sample validation and out-of-sample prediction confirmed the robustness of the results. CONCLUSIONS: The results highlight the importance of contemporary clusters of risk, such as low social support and SMU in the mental well-being of young people and the need to focus on these as targets for prevention. We propose that future studies should use composite risk measures that take into account both risk behaviors and risk factors to explain adolescents' mental well-being.

Adolescents' Intense and Problematic Social Media Use and Their Well-Being in 29 Countries.

PURPOSE: This study examined (1) whether intense and problematic social media use (SMU) were independently associated with adolescent well-being; (2) whether these associations varied by the country-level prevalence of intense and problematic SMU; and (3) whether differences in the country-level prevalence of intense and problematic SMU were related to differences in mobile Internet access. METHODS: Individual-level data came from 154,981 adolescents (meanage = 13.5) from 29 countries that participated in the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey. Intense SMU was measured by the time spent on social media, whereas problematic SMU was defined by symptoms of addiction to social media. Mental (life satisfaction and psychological complaints), school (school satisfaction and perceived school pressure), and social (family support and friend support) well-being were assessed. Country-level data came from aggregated individual-level data and data from the Organisation for Economic Co-operation and Development (OECD) on Internet access. RESULTS: Two-level regression analyses indicated that in countries with a lower prevalence of intense SMU, intense users reported lower levels of life satisfaction and family support and more psychological complaints than nonintense users. In contrast, in countries with a higher prevalence of intense SMU, intense users reported higher levels of family support and life satisfaction than nonintense users, and similar levels of psychological complaints. In all countries, intense users reported more friend support than nonintense users. The findings regarding problematic SMU were more consistent: In all countries, problematic users reported lower well-being on all domains than nonproblematic users. Observed differences in country-level prevalence rates of intense and problematic SMU could not be explained by mobile Internet access. CONCLUSIONS: Adolescents reporting problematic SMU are particularly at risk of lower well-being. In many countries, intense SMU may be a normative adolescent behavior that contributes positively to specific domains of their well-being.

Parental Mediation Regarding Children's Pornography Exposure: The Role of Parenting Style, Protection Motivation and Gender.

Communication between parent and child regarding pornography can be awkward. In the following study, we examined if parenting style (authoritarian, authoritative, or permissive) and gender was associated with parental mediation strategies (restrictive, active, and co-use) in relation to pornography exposure, mediated by threat appraisal and coping appraisal (protection motivation theory). A sample of 1,070 Israeli parents of 10- to 14-year-old youth completed a set of online questionnaires. Findings suggested that authoritarian and permissive parents, who had lower scores in authoritative parenthood, were more likely to have dysfunctional (i.e., low-quality) communication about pornography and subsequently be less active in their mediation regarding pornography. Conversely, parents who were more authoritative were more likely to perceive 1 the severity of pornography consumption and were more restrictive and active in mediating pornography. Finally, fathers tended to have more dysfunctional communication about pornography than mothers and were consequently less active in their mediation strategies concerning pornography.

Links between Adolescents' Deep and Surface Learning Approaches, Problematic Internet Use, and Fear of Missing Out (FoMO).

This study was aimed at exploring links between adolescents' deep and surface approaches to learning, Fear of Missing Out (FoMO), and Problematic Internet Use (PIU) by using Partial Least Squares Structural Equation Modeling (PLS-SEM). The analysis corroborated the postulated positive links between surface learning, FoMO, and PIU. Moreover, the FoMO construct represented a complimentary mediation between the surface learning approach and PIU constructs. This study may lead to a plausible inference according to which both FoMO and surface learning share a common core characteristic of decreased levels of self-regulation that might lead to PIU. Having students acquire and practice skills of self-regulation might help them control their levels of FoMO, and consequently their PIU at schools or out-of-school learning environments.

The role of identity and psychosomatic symptoms as mediating the relationship between discrimination and risk behaviors among first and second generation immigrant adolescents.

The study examines psychosomatic symptoms, and host and heritage identities as mediators of the relationship between discrimination and aggressive behavior and substance use. Israeli data from the 2013-14 Health Behaviors of School-aged Children study included a representative sample of 1503 first- and second-generation immigrant adolescents aged 11-17 years (45.2% male) from the Former Soviet Union and Ethiopia in Israel. Structural equation modeling, controlling for age, gender, family affluence and immigrant generation, showed different pathways for the two groups. For FSU-heritage adolescents, the relationship between discrimination and aggressive behavior and substance use was partially mediated by psychosomatic symptoms. Lower host and heritage identities also predicted psychosomatic symptoms. For Ethiopian-heritage adolescents, the relationship between discrimination and outcomes was fully mediated by psychosomatic symptoms and a weaker host identity. Results support an externalizing model, whereby discrimination leads to a weaker host identity and increased psychosomatic symptoms, associated with substance use and aggressive behavior.

International trends in electronic media communication among 11- to 15-year-olds in 30 countries from 2002 to 2010: association with ease of communication with friends of the opposite sex.

BACKGROUND: Electronic media has become a central part of the lives of adolescents. Therefore, this study examines trends in adolescent electronic media communication (EMC) and its relationship with ease of communication with friends of the opposite sex, from 2002 to 10 in 30 European and North American regions. METHODS: Data from the HBSC study were collected using self-report questionnaires from 11-, 13- and 15-year-old participants (N = 404 523). RESULTS: EMC use has grown over the years in most of these regions and increases with age. Even though Internet usage is often blamed for its negative effects on teenagers' social interactions in the physical world, in this study EMC was found to predict ease of communication with friends. Especially, the more they use EMC, the easier they find it to talk with friends of the opposite sex. Although these findings suggest that EMC reinforces communication, the interaction between year (2002-2006-2010) and EMC usage was not significant. CONCLUSION: This finding contradicts research that suggests that EMC contributes to loneliness and isolation, and supports other studies that present electronic media as a powerful tool for helping to connect people.

Supportive communication with parents moderates the negative effects of electronic media use on life satisfaction during adolescence.

OBJECTIVES: To examine the impact of electronic media (EM) use on teenagers' life satisfaction (LS) and to assess the potential moderating effect of supportive communication with parents (SCP). METHODS: Data were drawn from the cross-national Health Behaviour in School-aged Children (HBSC) study (2009/2010) in Canada, England, Germany, Hungary, Italy, Israel, The Netherlands, Poland and Scotland. Sample size: 53,973 students aged 11-15 years. RESULTS: More hours per day spent on the computer were associated with lower LS; more EM communication with friends with higher LS. This relationship became negative if EM use reached and exceeded a certain threshold. SCP moderated the effect of EM communication with friends, but not computer use for the total sample. SCP seems to be more important than computer use or EM communication with friends for LS and it seems to buffer negative effects of EM use. CONCLUSIONS: Communication with parents seems to buffer the negative effects of EM use on LS during adolescence. Higher computer use was related to lower LS, but "optimal" frequency of EM communication with friends was country specific.

Frequent electronic media communication with friends is associated with higher adolescent substance use.

OBJECTIVES: This study investigated the unique associations between electronic media communication (EMC) with friends and adolescent substance use (tobacco, alcohol, and cannabis), over and beyond the associations of face-to-face (FTF) interactions with friends and the average level of classroom substance use. METHODS: Drawn from the cross-national 2009/2010 Health Behaviour in School-aged Children (HBSC) study in The Netherlands, 5,642 Dutch adolescents (Mage = 14.29) reported on their substance use, EMC, and FTF interactions. Two-level multilevel analyses (participants nested within classrooms) were run. RESULTS: Electronic media communication was positively associated with adolescent substance use, though significantly more strongly with alcohol (ß = 0.15, SEß = 0.02) than with tobacco (ß = 0.05, SEß = 0.02, t (5,180) = 3.33, p < 0.001) or cannabis use (ß = 0.06, SEß = 0.02, t (5,160) = 2.79, p < 0.01). Further, EMC strengthened several positive associations of FTF interactions and average classroom substance use with adolescent substance use. CONCLUSIONS: Electronic media communication was uniquely associated with substance use, predominantly with alcohol use. Thus, adolescents' EMC and other online behaviors should not be left unnoticed in substance use research and prevention programs.