Triantafyllou C, Ntikoudi A, Papachristou A
… +3 more, Psiakis V, Fonseca VR, Breda J
Eur J Public Health
· 2026 Apr · PMID 41575280
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Public health indicators serve as vital monitoring tools of population's health while assisting policy makers in their leadership role while guiding policy decisions. Standardized indicator development continues to face...Public health indicators serve as vital monitoring tools of population's health while assisting policy makers in their leadership role while guiding policy decisions. Standardized indicator development continues to face substantial obstacles regarding their conceptual definition, methodological precision, and national compatibility. The aim of this review was to combine academic and institutional literature to assess the application of quality indicators in public health settings. A scoping review of the existing literature on public health quality indicators was conducted. The search was performed in PubMed, EMBASE, and CINAHL databases. Eleven publications were included, and the extracted data were organized in a structured table. Research findings showed that indicators must retain a balance between usefulness, national context adaptability and standardized frameworks. The ECHI, EUHPID, and PAHO's frameworks established systematic methods to organize indicators and create measurement systems. Subnational programs highlighted that data quality and coverage remained insufficient. Public health indicators serve as essential tools for tracking population health status while assisting in policy decisions. The practical application of indicators depends on their methodological soundness, ethical approach and their practical implementation possibilities. Research demonstrates that public health indicators require continuous investment regarding their technical infrastructure and conceptual frameworks. Future research should include indicator policy impact assessment, framework improvement and real-time public health system assessment.
Zarro M, Ferranti A, Garagozzo G
… +2 more, Fico G, Pecchia L
Eur J Public Health
· 2026 Mar · PMID 41570090
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Regulatory frameworks that integrate environmental sustainability into the lifecycle of medical devices (MDs) are essential to ensure quality, safety, and effectiveness for patients while minimizing environmental impact....Regulatory frameworks that integrate environmental sustainability into the lifecycle of medical devices (MDs) are essential to ensure quality, safety, and effectiveness for patients while minimizing environmental impact. The Medical Device Regulation 2017/745/EC (MDR) establishes the core framework for MDs, but additional EU legislation addresses Ecodesign, sustainable packaging, financial incentives, and waste management. Although sustainability is not explicitly included in the MDR, understanding how complementary EU regulations contribute to the European Green Deal agenda is crucial to inform decisionmakers and guide future integration of sustainability principles into medical device governance. We employed a validated policy mapping methodology, derived from the scoping review approach and adapted to systematically identify and analyse regulatory documents from policy repositories rather than academic databases. This method has been previously applied in diverse policy domains, including health, education, and digital innovation. Findings were reported according to the PRISMA-ScR. Eight binding regulations that are either directly applicable or transferable to MDs in the European Union were identified. Together, they introduce requirements on Ecodesign, packaging, financial incentives, and waste management. These complement the MDR framework by embedding sustainability principles into various stages of the MD lifecycle, even though they are not explicitly mandated within the MDR itself. While environmental sustainability provisions remain absent from the MDR, complementary EU regulations create an emerging framework that supports systemic economic transformation in line with the European Green Deal. Future research should examine enforcement and practical implementation of this framework across Member States to assess its impact on medical device regulation and environmental performance.
Baz-Lomba JA, Perälä J, Pitkänen T
… +1 more, Leino T
Eur J Public Health
· 2026 Mar · PMID 41535241
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Wastewater-based surveillance (WBS) is increasingly recognized as a valuable tool for monitoring public health at the population level. However, its integration into national public health frameworks across Europe remain...Wastewater-based surveillance (WBS) is increasingly recognized as a valuable tool for monitoring public health at the population level. However, its integration into national public health frameworks across Europe remains uneven. In mid-2024, the EU-WISH Joint Action conducted a system mapping survey across 27 European countries to assess the governance, development, and integration of WBS systems. The survey combined quantitative and qualitative data to evaluate national strategies, legal and financial frameworks, and system capacities. By May 2024, most participating countries had operational WBS systems, primarily targeting SARS-CoV-2. Other monitored targets included influenza and other respiratory viruses, poliovirus, antimicrobial resistance (AMR), emerging pathogens, illicit drugs, and health-related biomarkers. Prioritization in system design was largely based on operational feasibility and perceived public health value. Challenges identified included fragmented governance, lack of sustainable financing, and limited workforce capacity. Integration into public health decision-making varied, and dissemination practices differed significantly across countries and surveillance targets. The EU-WISH survey provides a baseline assessment of WBS implementation across Europe and highlights key enablers and barriers to its institutionalization. The findings support ongoing efforts at national and EU levels to enhance coordination, sustainability, and integration of WBS into routine public health frameworks.
Ekezie W, Gogoi M, Papadopoulou N
… +4 more, Badakshi F, Bowman KJ, Igein B, Pareek M
Eur J Public Health
· 2026 Mar · PMID 41533742
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Antimicrobial resistance (AMR) is a growing global health problem. Several public interventions have been designed to increase AMR knowledge and awareness. This review assesses the availability and effectiveness of commu...Antimicrobial resistance (AMR) is a growing global health problem. Several public interventions have been designed to increase AMR knowledge and awareness. This review assesses the availability and effectiveness of community-based AMR interventions in Europe. Four databases-Medline (OVID), Pubmed, Scopus, Web of Science- and grey literature were searched for AMR interventions in community settings in Europe between 2000 and 2024. Studies reporting empirical findings in English were considered. A narrative synthesis was performed, and findings were presented in text and tables. Forty-nine studies were eligible for inclusion from 14 European countries. Interventions were primarily educational to raise awareness, targeting individuals, small groups, or the general public through mass campaigns, school-based programmes, online games, and pledges. Some interventions also monitored adherence, consumption, and doctor consultation. The majority of interventions reported increased knowledge and awareness of antibiotics and AMR; reduced antibiotic prescription, purchase, use, and non-compliance; reduced respiratory incidence and doctor consultations, and increased overall adherence. Fluctuations in knowledge over time were observed, but evidence was insufficient to analyse the long-term sustainability of outcomes of the interventions. Our findings show that community-based interventions can enhance knowledge and awareness of appropriate antibiotic use and AMR risks among different population groups. These can also positively improve adherence, expectation, and prescribing. However, long-term engagement and interventions are needed to attain sustainability and bring behavioural changes.
Incardona F, Bellerba F, Gandini S
… +1 more, Cozzi-Lepri A
Eur J Public Health
· 2026 Mar · PMID 41533737
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Armed conflicts often expose groups protected under international humanitarian law, such as healthcare workers (HW) and journalists (JN), to disproportionate risks and in the Israel Gaza war it was particularly evident....Armed conflicts often expose groups protected under international humanitarian law, such as healthcare workers (HW) and journalists (JN), to disproportionate risks and in the Israel Gaza war it was particularly evident. However, quantitative assessments of their mortality relative to the general population remain limited. Using official data sources, cross-referenced lists from professional associations, and rigorous statistical methods, we estimated higher mortality among HW and JN during the 2023-24 Israel Gaza war. Mortality risks were consistently higher among these protected groups, ranging from 36% to more than sixfold higher for journalists compared with Gaza residents of the same age and sex. Our findings highlight the urgent global need to protect HW and JN in all conflict settings and to ensure accountability for violations of international humanitarian law.
Eur J Public Health
· 2026 Mar · PMID 41533731
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Public stigma toward individuals with mental illness and addiction remains a major barrier to treatment, recovery, and social integration. While previous studies have documented widespread negative attitudes, less is kno...Public stigma toward individuals with mental illness and addiction remains a major barrier to treatment, recovery, and social integration. While previous studies have documented widespread negative attitudes, less is known about the role of recovery narratives in shaping stigma. This study draws on the 2025 Icelandic Stigma Study to examine whether descriptions of recovery reduce preferred social distance from individuals experiencing schizophrenia, alcohol addiction, or heroin addiction. Data were collected using a nationally representative online panel (N = 1755). Respondents were randomly assigned to vignettes describing a character with one of the three conditions, with or without an added description of recovery. Preferred social distance was measured using a scale of eight items, and responses were analyzed with OLS regression models controlling for vignette characteristics and respondent demographics. Results show that descriptions of recovery significantly reduced preferred social distance across all conditions. The effect was strongest for alcohol addiction (33% reduction), followed by heroin addiction (23%) and schizophrenia (8%). Recovery narratives also reversed the relative ordering of conditions: while alcohol addiction was initially more stigmatized than schizophrenia, individuals in recovery from alcohol addiction were viewed more positively than those in recovery from schizophrenia. Female vignette characters elicited less social distance, while respondent characteristics had limited and inconsistent effects. The findings highlight the importance of recovery-oriented narratives in reducing stigma, particularly for addiction. Public campaigns that emphasize successful treatment and recovery may be especially effective in contexts such as Iceland, though condition-specific tailoring remains crucial.
Kendzia B, Behrens T, Brüning T
… +3 more, Stang A, Jöckel KH, Ahrens W
Eur J Public Health
· 2026 Mar · PMID 41525298
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The incidence of germ-cell testicular cancer (TC) has increased in recent decades. Current evidence does not indicate a unanimous association between occupational exposure to welding fumes and TC risk. However, most publ...The incidence of germ-cell testicular cancer (TC) has increased in recent decades. Current evidence does not indicate a unanimous association between occupational exposure to welding fumes and TC risk. However, most publications do not provide information on exposure levels to welding fumes. We investigated the association between occupational exposure to welding fumes and the risk of TC in a German case-control study (268 cases and 797 control subjects). A measurement-based welding-exposure matrix was used to estimate year-specific exposure values which were linked to job-task descriptions. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated via logistic regression, conditional on study area and 5-year age groups. ORs were adjusted for a history of cryptorchidism, a family history of TC, and ever exposure to metal-working fluids (MWF). Regular welding was associated with an elevated TC risk (OR: 2.26, CI: 0.92-5.53) compared to occasional welding (OR: 1.14, CI: 0.78-1.69). For non-seminoma, there was an indication of a strong association among regular welders (OR: 3.71, CI: 1.08-12.80) and for non-welders using MWFs (OR: 3.39, CI: 1.21-9.53). However, these estimates were based on few exposed cases. We did not observe dose-effect relationships with increasing lifetime exposure to welding fumes, duration, or average intensity. We found an association between regular welding and TC risk based on standardized job-task descriptions, but not when using the year-specific exposure values.
Zarour A, Bachmann C, Dandolo L
… +4 more, Holstiege J, Hoffmann F, Scholman C, Golub Y
Eur J Public Health
· 2026 Mar · PMID 41520292
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Cannabis use can have detrimental effects on adolescents' mental health, often co-occurring with child and adolescent psychiatric disorders (CAPD). This study assessed diagnostic prevalence trends in cannabis-related dis...Cannabis use can have detrimental effects on adolescents' mental health, often co-occurring with child and adolescent psychiatric disorders (CAPD). This study assessed diagnostic prevalence trends in cannabis-related disorders and co-occurring diagnosed CAPD in adolescents receiving outpatient treatment in Germany. Outpatient claims data from the national public health insurance system, covering almost 4 million children and adolescents, were assessed for diagnostic prevalence of cannabis-related disorders (ICD-10 diagnoses F12.X) in insurees aged 12 to 17 years for the years 2013-22, stratified by age group and sex. In addition, the diagnostic prevalence of co-occurring CAPD during the year 2022 was evaluated. From 2013 to 2022, the diagnostic prevalence of cannabis-related disorders among German adolescents utilizing outpatient services increased from 0.08% to 0.10% (+22.4%), with a decline during the COVID-19 pandemic and a higher diagnostic prevalence in older adolescents. Up to 14 years of age, the diagnostic prevalence of cannabis-related disorders was distributed evenly among males and females, while from age 15 onwards, the diagnostic prevalence was higher in males. Overall, 78.3% of adolescents diagnosed with cannabis-related disorders had at least one co-occurring CAPD diagnosis in 2022. Most common co-occurring conditions were depressive disorders, conduct disorders, adjustment disorders, attention-deficit/hyperactivity disorders, and anxiety disorders. Co-occurring depression was particularly often diagnosed, underscoring the urgent need for integrated treatment approaches addressing both disorders simultaneously in this age group.
Rovira P, Lai T, Reile R
… +2 more, Hassan AS, Rehm J
Eur J Public Health
· 2026 Mar · PMID 41511414
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Estonia is planning an update of its national alcohol policies where an economic return on investment (ROI) analysis is needed to guide decisions against their monetary returns. Using mostly national data sources, the RO...Estonia is planning an update of its national alcohol policies where an economic return on investment (ROI) analysis is needed to guide decisions against their monetary returns. Using mostly national data sources, the ROI analysis was based on direct healthcare costs and productivity losses due to premature mortality. The interventions compared comprised availability restrictions and taxation increases. For taxation increases, associated revenue increases to government were included. All analyses used a one-year time horizon and different sensitivity analyses. In 2023, all alcohol-attributable harms in Estonia totalled €510.00 million (1.3% of the Gross Domestic Product of Estonia) with €263.91 million direct costs and €246.08 million indirect costs. The proposed availability reductions are expected to yield a net benefit of €6.33 million, whereas a 15% increase in alcohol excise taxation could lower healthcare costs and productivity losses by €1.77 million in addition to increasing tax revenue by €32.27 million. Moreover, the interventions were estimated to lead to substantial reductions in mortality and hospitalizations. In terms of ROI, the availability interventions would result in €15 gained for each euro invested, and the taxation increase in €477 per euro invested, and without revenue in €25 per euro invested. Positive ROI was also shown in all sensitivity analyses. The proposed alcohol control policies for Estonia would not only reduce mortality and morbidity but also bring sizeable gains for each euro invested. Higher ROI for taxation increase compared to availability restrictions was mainly due to the added tax revenue.
Meurisse M, Estupiñán-Romero F, Perola M
… +4 more, Paajanen T, González-Galindo J, Van Goethem N, Bernal-Delgado E
Eur J Public Health
· 2026 Mar · PMID 41511171
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To assess the impact of large-scale severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination campaigns in real-world settings across regions, we performed a reproducible cross-border comparison of the rea...To assess the impact of large-scale severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination campaigns in real-world settings across regions, we performed a reproducible cross-border comparison of the real-world effectiveness of primary vaccination in preventing SARS-CoV-2 infections across three sites: Aragon (Spain), Brussels and Wallonia (Belgium), and Finland. This observational study emulated a target trial by daily matching primary vaccinated individuals 1:1 to un- or partially vaccinated individuals using propensity scores estimated on a set of relevant confounders from January to September 2021. Matched individuals were followed up until a SARS-CoV-2 infection was contracted or a censoring event occurred. Vaccine effectiveness in preventing infections was estimated by the difference in restricted mean survival time (RMST). Primary vaccination extended the average free-of-infection time by 35.9 [95% confidence interval (CI) (34.9-37.0)], 59.6 [95% CI (59.3-60.0)], and 1.6 [95% CI (1.1-2.0)] days over 365 days in the population cohort of Aragon (Spain), Brussels and Wallonia (Belgium), and Finland, respectively. This federated population-based observational study showed the effectiveness of the SARS-CoV-2 primary vaccination campaign in prolonging the mean time to infection in the Aragon (Spain) and Brussels and Wallonia (Belgium) population cohorts. Only a minor difference over this time frame was found in Finland's population cohort.
Gentili S, Locatelli G, Bellocco R
… +7 more, Calderón-Larrañaga A, Rizzuto D, Doheny M, Lennartsson C, Hedberg-Rundgren Å, Fratiglioni L, Vetrano DL
Eur J Public Health
· 2026 Feb · PMID 41499142
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We examined sociodemographic, clinical, and functional characteristics influencing avoidable and unavoidable hospital admissions in older adults over 15 years. The study included 3166 participants aged 60+ years from the...We examined sociodemographic, clinical, and functional characteristics influencing avoidable and unavoidable hospital admissions in older adults over 15 years. The study included 3166 participants aged 60+ years from the Swedish National Study on Aging and Care in Kungsholmen. Hospital admissions were identified through national registers and classified as avoidable using official Swedish criteria. Multistate models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for both admission types. During the 15-year follow-up, the incidence rates of avoidable and unavoidable hospital admissions were, respectively, 5.74 and 35.17 per 100 person-years. Avoidable admissions due to chronic conditions were more common than those due to acute conditions (3.94 vs. 1.80 per 100 person-years over 15 years). Women had lower risk of both avoidable and unavoidable admissions compared to men (HRs range 0.46-0.76), while being unpartnered increased the risk for both hospitalization types (HRs range 1.13-1.33). Receiving formal care lowered the risk of unavoidable admissions (HR 0.78, 95% CI 0.73-0.84), whereas informal care increased the likelihood of avoidable admissions due to chronic condition (HRs range 1.17-1.34). Multimorbidity, slow gait speed, and polypharmacy associated strongly with avoidable admissions (HRs range 1.41-2.50). Conversely, cognitive impairment and disability lowered risk of avoidable admissions for chronic conditions (HRs range 0.62-0.83). Multimorbidity, slow gait speed, and polypharmacy predicted higher risks for avoidable admissions from chronic conditions, while disability and cognitive impairment showed lower risks. These findings underscore the need for timely and comprehensive evaluation strategies to reduce the burden of avoidable hospital care.
Eur J Public Health
· 2026 Feb · PMID 41493398
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BACKGROUND: Previous studies indicate initial health improvements following resettlement for refugees, but the long-term trajectories remain unclear. This study explores health outcomes and healthcare use among Syrian re...BACKGROUND: Previous studies indicate initial health improvements following resettlement for refugees, but the long-term trajectories remain unclear. This study explores health outcomes and healthcare use among Syrian refugees in Norway, focusing on the impact of early health and quality of life (QOL) on future outcomes. METHODS: This prospective cohort study used data from the Changing Health and health care needs Along the Syrian Refugees' Trajectories to Norway and Integration for Health projects. Baseline factors, self-rated health (SRH) and QOL, were collected 1 year after arrival. Health outcomes and healthcare use were assessed at 1 and 4 years (2019-2023) post-resettlement. Changes over time were analysed with generalized estimating equations, and associations with baseline factors were assessed using generalized linear models, presenting relative risks (RR) with 95% confidence intervals. RESULTS: A total of 132 individuals participated in both follow-ups. Chronic pain prevalence increased from 28% to 51% (RR 1.80, 1.46-2.23), with similar increases in non-communicable diseases, symptoms of poor mental health and chronic impairments. Use of emergency (RR 2.06, 1.50-2.82) and specialist care (RR 3.47, 2.62-4.60) also increased, while general practitioner visits and hospitalizations remained stable. Good SRH and higher QOL at baseline were associated with better health outcomes and reduced healthcare use over time. CONCLUSION: Refugees reporting good SRH and higher QOL during the early postmigration period experienced more favorable health outcomes and decreased healthcare use later on. Our findings raise the subject of the possibility of capitalizing on early interventions to support refugee health and ease the burden on healthcare systems over time.
Alonso-Colon M, Moreno-García S, Guerras JM
… +3 more, Donat M, Gonzalez-Recio P, Belza MJ
Eur J Public Health
· 2026 Mar · PMID 41493375
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Trans and non-binary individuals are particularly vulnerable to discrimination in public spaces, workplaces, housing, and healthcare. The exclusion they experience also affects their participation in physical activity (P...Trans and non-binary individuals are particularly vulnerable to discrimination in public spaces, workplaces, housing, and healthcare. The exclusion they experience also affects their participation in physical activity (PA). This study aimed to estimate the proportion of trans and non-binary individuals living in Spain that engage in PA several times per week and to explore potential associated factors. A cross-sectional study was conducted using data from 1473 participants aged 15 or older, recruited between October 2023 and March 2024 through an online national survey on trans and non-binary health. PA engagement was estimated with 95% confidence intervals (95% CIs). A Poisson regression model with robust variance was used to identify associated factors, obtaining adjusted prevalence ratios (aPRs) with 95% CI. Overall, 23.2% (95% CI: 21.1%-25.5%) reported engaging in PA several times per week. In the adjusted analysis, PA was less common among trans women (aPR = 0.46, 95% CI 0.35-0.62) and non-binary individuals (aPR = 0.67, 95% CI 0.52-0.85) compared to transmasculine individuals. Lower PA levels were also observed in those unable to legally change their name due to barriers (aPR = 0.71, 95% CI 0.52-0.97), and those with mental health issues in the past year (aPR = 0.76, 95% CI 0.62-0.93). Higher PA participation was associated with being ≥29 years old (aPR = 1.41, 95% CI 1.08-1.84) and better self-perceived health (aPR = 1.33, 95% CI 1.07-1.65). Trans women and non-binary individuals engage in PA less frequently. Sociodemographic factors, health, and legal barriers significantly impact PA participation. Policies should encourage PA, especially among young trans individuals, and ensure equitable and discrimination-free access.
Eur J Public Health
· 2026 Feb · PMID 41493373
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Socioeconomic inequalities in healthcare costs are large, but the underlying behavioral mechanisms remain unclear. We examined how neighborhood socioeconomic status (NSES) and lifestyle behaviors-physical activity (PA),...Socioeconomic inequalities in healthcare costs are large, but the underlying behavioral mechanisms remain unclear. We examined how neighborhood socioeconomic status (NSES) and lifestyle behaviors-physical activity (PA), sport participation, smoking, and alcohol use-jointly relate to healthcare costs in the Netherlands. Using a population-wide ecological dataset of 6213 neighborhoods, we linked relative (i.e. age- and sex-standardized) healthcare costs with survey-based estimates of lifestyle behaviors. Linear regression models estimated the associations between lifestyle factors and relative healthcare costs, adjusting for demographic and urbanization characteristics. Additional models stratified by NSES decile assessed socioeconomic modification of lifestyle-cost associations. A strong socioeconomic gradient in relative healthcare costs was observed; the most deprived NSES decile having €1096 higher average costs than the most affluent decile. NSES alone explained over €300 of this inter-decile cost gap. Across all neighborhoods, each 1-percentage-point higher sport participation, PA adherence, and smoking prevalence were associated with cost changes of -€14.27 (95% CI -16.96 to -11.59), -€6.96 (95% CI -9.59 to -4.32), and +€22.06 (95% CI 17.96 to 26.16), respectively; alcohol use showed no association. Within-decile analyses revealed strong protective effects of sport in the most deprived neighborhoods (-€37.26, 95% CI -47.54 to -26.97) and consistent cost increases associated with smoking across all deciles. Lifestyle-cost associations differ markedly by socioeconomic context. Structured sport participation shows the greatest cost-saving potential in disadvantaged neighborhoods, while smoking remains the dominant cost driver nationwide. Addressing behavioral inequalities is key to narrowing socioeconomic disparities in healthcare expenditures.
Radó MK, Kisfalusi D, Laverty AA
… +3 more, van Lenthe FJ, Been JV, Takács K
Eur J Public Health
· 2026 Feb · PMID 41493161
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Despite decreasing overall smoking rates, ethnic inequalities in smoking persist. Although smoking is largely a social behavior, the underlying social network mechanisms for this are still unclear. We disentangled and te...Despite decreasing overall smoking rates, ethnic inequalities in smoking persist. Although smoking is largely a social behavior, the underlying social network mechanisms for this are still unclear. We disentangled and tested potential social network mechanisms responsible for persistent ethnic inequalities in smoking. We applied Stochastic Actor-Oriented Models for 1644 friendships of 299 Roma and Non-Roma Hungarian adolescents in nine classes and 1605 antipathies of 294 adolescents in eight school classes over two panel waves. Adolescents were more likely to nominate same-ethnic peers as friends [odds ratio (OR) of Non-Roma nominating a Non-Roma = 1.15; 95% confidence interval (CI) = 1.03-1.28] and less likely to nominate them as antipathies (OR of Roma nominating a Roma = 0.77; 95% CI = 0.68-0.87). Smokers were more likely than non-smokers to receive friendship nominations (OR = 1.18; 95% CI = 1.01-1.38) but did not statistically significantly differ in antipathy nominations (OR = 1.16; 95% CI = 0.97-1.39). Non-Roma smokers tended to nominate as friends other Non-Roma smokers (OR = 1.37; 95% CI = 1.12-1.68) and avoided nominating Roma non-smokers (OR = 0.55; 95% CI = 0.35-0.87). Neither friends (OR = 1.28; 95% CI = 0.88-1.86) nor antipathies (OR = 1.15; 95% CI = 0.69-1.91) influenced peers' smoking behaviors significantly. We identified three processes that could potentially contribute to ethnic smoking inequalities: (i) adolescents tend to nominate same-ethnic peers as friends, (ii) smokers are attractive for friendship selection, and (iii) Roma received higher encouragement to smoke than Non-Roma since Non-Roma received more while Roma received less friendship nomination from Non-Roma peers if they do not smoke. We found no impact of antipathy on smoking.