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This study explored patterns of health-risk behaviors among Japanese high school students and examined if a cluster and an accumulation of health-risk behaviors existed. Self-administered questionnaires were employed in 1999 using a sample of 1,466 students (male 50.5%, female 49.5%) in grades 10 through 12 at seven public senior high schools in Okinawa, Japan. Health-risk behaviors studied included cigarette smoking, alcohol use, thinner use, nonuse of seat belts, suicide ideation, sexual intercourse, weight loss practices, and physical inactivity. Among male and female students, cigarette smoking, alcohol use, and sexual intercourse clustered. Accumulation of these risk behaviors also occurred because the observed proportion was greater than the expected proportion assuming independent occurrence. Vocational high school students and upper graders were strongly associated with accumulation of health risk behaviors. These findings identify a high-risk target group among Japanese adolescents and suggest that preventive intervention strategies should take into consideration the cluster and accumulation of health-risk behaviors. (J Sch Health. 2001;71(1):23-29), Two-thirds of deaths among the Japanese population result from lifestyle-related diseases such as cancer, heart disease, and cerebrovascular disease.[1] Among both youth and young adults in Japan, the leading causes [...]