Playing video games is a common leisure activity for adolescents, but a minority can develop maladaptive gaming patterns and experience impairments in various health domains. Most research has been conducted within the dichotomy of “non-problematic gaming” and “problematic gaming” with convenience and unrepresentative samples, necessitating further investigation to provide more robust and generalizable evidence. In this study, we examined the impact of gaming on different groups of gamers with distinct degrees of gaming involvement in relation to various psychological and physical health outcomes and behaviours. Data included a nationally representative sample of 89321 adolescents (11–17 years) from the 2022 Italian Health Behaviour in School-aged Children study. We compared groups of gamers (low risk, high risk, and problematic) with non-gamers concerning their (mental) health, nutrition, physical activity, sleep, and social well-being. Logistic regressions were used to estimate the odds ratios (adjusted for gender, age, material deprivation, and family structure). Compared with non-gamers (33.7 % of the sample), low-risk gamers (51.6 %) reported better health-related outcomes (i.e., lower risk of depression, lower stress, fewer psychological and somatic symptoms). High-risk (11.6 %) and problematic gamers (3.1 %) showed significantly higher impairments in all health-related outcomes than non-gamers did, the associations being especially pronounced in the problematic gaming group. Video games are not inherently harmful, and adolescents who reported a low risk of gaming problems showed slightly better health-related outcomes than non-gamers did. However, a minority of vulnerable users engaged in problematic use associated with negative consequences, functional impairment (e.g., sleep interference), and various unhealthy behaviours.