Associations Between Health-promoting and Health-risk Behaviors Among Montana High School Students: A 10-Year Analysis Using YRBSS Data

Background: Adolescence is a critical period for establishing lifelong health behaviors. Risk behaviors such as substance use and physical inactivity often co-occur, particularly in rural areas like Montana where geographic and structural barriers may limit access to health-promoting resources. This study examined clustering among health-risk and health-promoting behaviors using 2023 Montana Youth Risk Behavior Surveillance System (YRBSS) data and explored 10-year trends from 2013–2023. Methods: We conducted a cross-sectional analysis of the 2023 Montana YRBSS dataset (n ≈ 1,600), assessing associations between selected health-risk (e.g., vaping, alcohol, marijuana, methamphetamine use) and health-promoting behaviors (e.g., physical activity, sleep, breakfast consumption). Chi-square tests (p < 0.05) determined statistical significance. Behavioral clustering was defined as four or more significant pairwise associations between risk and protective behaviors. Results were stratified by sex. Publicly available YRBSS data from 2013–2023 were also analyzed to assess long-term trends. Results: Significant behavioral clustering was found among both male and female students. Frequent vaping, marijuana use, and self-perceived weight concerns were associated with reduced sleep, physical activity, and breakfast consumption. Shared associations included marijuana use and breakfast skipping, and vaping with physical inactivity. Sex-specific differences emerged: alcohol use was more strongly associated with poor sleep and diet in females, while frequent smoking and injection drug use were associated with inactivity in males. Ten-year trend analyses revealed declines in cigarette and alcohol use, but persistent rates of e-vapor use and inadequate sleep, nutrition, and physical activity. Conclusions: Findings underscore persistent clustering of health-risk behaviors and declining engagement in protective routines among Montana adolescents. Sex-specific patterns suggest a need for tailored prevention efforts. Longitudinal trends reveal limited progress in improving adolescent health in rural contexts, emphasizing the importance of integrated, multi-behavioral school and community interventions that are both gender-responsive and place-based.