Understanding the Association between In-School Bullying and Likelihood of Smoking

Amongst Adolescents: A Quantitative Analysis

Sargam Choudhury, Lia Musumecia, Alexandra Tsangarakis, Michael Hagen

Boston University
SPH PH 717: Quantitative Methods for Public Health
11 December 2023
Abstract

Purpose: Youth smoking is a major public health problem that can lead to more chronic

behaviors and substance use disorders, including addiction (Torabi, et al., 1993). Grades 9

through 12 specifically make up a critical window in which young adolescents may be more

susceptible to peer pressure through bullying. Although there have been studies to determine

how behaviors undertaken during this critical period may affect the health of adolescents, there

has not been enough research done concerning the effects of peer pressure on the development of

these behaviors. Our study aims to understand the association of in-school bullying and smoking

behaviors.

Methods: A cross-sectional study nested within the Youth Risk Behavior Surveillance Study was

performed. We included a subset of 1,000 randomly selected respondents out of a total sample of

15,425 included in the parent Youth Risk Behavior Surveillance Study, sampled through a

multi-staged sampling plan. We investigated the association between students grades 9 through

12 experiencing in-school bullying (n = 177) and students who smoked within the past 30 days

(n = 179), categorized by variables bully.sch and smoke30days, respectively, and then stratified

by sex.

Results: The prevalence of smoking in the past 30 days was approximately 1.47 [95% CI: (1.09,

1.99)] times greater in students who were bullied on school property as compared to students

who were not bullied on school property. This association was statistically significant (p-value =

0.01). After adjusting for having consumed alcohol within the past 30 days, suicidal ideation, and

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exhibiting signs of obesity, the adjusted odds ratio for smoking in the previous 30 days was 1.390

(95% CI = 0.885, 2.165) and the association was not statistically significant (p-value = 0.15).

Conclusions: These findings indicate that being bullied in school is a marginally statistically

significant risk factor against smoking, even after adjusting for many other risk factors such as

participants’ weight, alcohol consumption habits, and suicidal intentions.

Introduction

Youth smoking is a major public health problem that can lead to more chronic behaviors

and substance use disorders, including addiction (Torabi, et al., 1993). Grades 9 through 12

specifically encompass a critical window in which young adolescents may be more susceptible to

peer pressure; while there have been many studies to determine how behaviors undertaken

during this critical period may affect the health of adolescents, a lack of existing literature fails to

describe the effects of peer pressure on the development of these behaviors. Our research study

aims to understand the association between in-school bullying - a notable factor associated with

peer pressure - and smoking behaviors amongst adolescents between grades 9 through 12. We

hypothesized that adolescents who experience in-school bullying were more likely to develop

smoking behavior, particularly if they were males who are more exposed to in-school bullying.

To address this hypothesis, we conducted a study based on the Youth Risk Behavior Surveillance

Study. The Youth Risk Behavior Surveillance Study was an epidemiological study undertaken

by the CDC to monitor different behaviors of public and private school students in grades 9

through 12 that affect health. In a nationally representative sample of 15,425, 1,000 students

were randomly selected to be interviewed. Data on demographic characteristics, bullying,

suicidal thoughts, and substance use behavior was collected from each of these respondents.

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Using the data from this study, the CDC aimed to estimate the prevalence of bullying among

students, what factors were associated with being bullied, and the association between being

bullied and suicidal ideation. In a cross-sectional sample of the Youth Risk Behavior

Surveillance Study, we assessed our primary exposure of interest as experience of in-school

bullying in association with our primary outcome of interest as the likelihood of smoking

amongst young adolescents, stratified by sex.

Methods

The study design was a cross-sectional study nested within the Youth Risk Behavior

Surveillance Study. A cross-sectional study design entails the collection of population data at a

single point in time, where information is gathered regarding characteristics, behaviors, and

experience of the target group. We included a subset of 1,000 randomly selected respondents out

of a total sample of 15,425 included in the parent Youth Risk Behavior Surveillance Study,

sampled through a multi-staged sampling plan. The study collected information from these

respondents about their demographics, characteristics, experiences of being bullied over the past

12 months, suicidal thoughts over the past 12 months, and substance use behavior at a single

point in time. This approach allowed us to estimate the prevalence of bullying, identify

demographic factors associated with being bullied, and explore the association between being

bullied and smoking use behavior. The study targeted public and private school students in

grades 9 through 12; therefore, the eligibility criteria for the participants were students grades 9

through 12 and these students were drawn from both public and private schools.

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Statistical Analysis

First, we compared characteristics of the 1,000 students between those who reported to

have smoked and not smoked within the prior 30 days. We investigated the association between

students grades 9 through 12 experiencing in-school bullying (n = 177) and students who

smoked within the past 30 days (n = 179), categorized by variables bully.sch and smoke30days,

respectively, and then stratified by sex. We calculated the prevalence ratio and a 95% confidence

interval. Statistical significance of associations were assessed through a chi-square test of

independence. We also used a multivariable logistic regression analysis to compute a crude and

an adjusted odds ratio of prevalent cases of in-school bullying and 95% confidence intervals.

Further, we estimated the prevalence difference and a 95% confidence interval.

Results

Population Description

A comparison of adolescent characteristics and factors associated with social pressures

were compared with those who did and did not experience bullying. Alcohol use, indiciation of

suicide, and obesity were reported less prevalent amongst those who experienced bullying

compared to those who did not experience bullying. We also compared male and female students

to better understand differences that could affect the association between bullying and smoking.

Within this survey responses, females had reported slightly more alcohol use than males and

reported a greater rate of being bullied and indication of suicide than males. The only variable

that males reported a higher rate than females was obesity.

Association of In-School Bullying with Smoking in the Prior 30 Days

Our calculations showed that the prevalence of smoking in the past 30 days was

approximately 1.47 [95% CI: (1.09, 1.99)] times greater in students who were bullied on school

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property as compared to students who were not bullied on school property (Table 3), and this

association was statistically significant (p-value = 0.01). Among those who were bullied, there

were 8 [95% CI: (1, 15)] excess cases of smoking in the last 30 days per 100, compared to those

who were not bullied.

Figure 1 and table 4 indicates a large difference in both male and female reports of

smoking in the last 30 days versus not smoking in the last 30 days. Of the smaller group of

respondents that reported smoking in the last 30 days, males at a proportion of 19.5% were

slightly more likely than females (16.4%) to report having smoked in the last 30 days.

The crude odds of smoking in the previous 30 days among students who underwent

in-school bullying was 1.16 times larger than among students who did not undergo in-school

bullying (95% CI = 1.089-2.374, 0.885-2.165; Table 5). After adjusting for having consumed

alcohol within the past 30 days, having considered suicide, and exhibiting signs of obesity, the

adjusted odds ratio for smoking in the previous 30 days was 1.390 (95% CI = 0.885, 2.165) and

the association was not statistically significant (p-value = 0.15). The adjusted and crude odds

ratios differed by more than higher than the crude odds ratio suggesting that confounding was

present. In the multivariable models, suicide and signs of obesity were also not significant

predictors of reporting smoking within the past 30 days (p>0.05), but consuming alcohol within

the past 30 days remained a significant predictor.

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 Table 1: Comparison of Characteristics between Adolescents who did and did not
experience bullying.
Bullied (n=243) Not Bullied (n=757)

Male 90(37.0%) 381(50.3%)

Female 153(63.0%) 376(50.0%

Any Alcohol Use 103(42.4%) 266(35.1%)

Indication of Suicide Risk 78(33.0%) 108(14.2%)

Obese 24(9.88%) 113(14.9%)

Table 2: Potential Confounding Variables Associated with Smoking Stratified by Sex

Male (n=471) Female (n=529)

Any Alcohol Use 167(35.5%) 202(38.2%)

Any Bullying 90(19.1%) 153(28.9%)

Indication of Suicide Risk 68(14.4%) 118(22.3%)

Obese 83(17.6%) 54(10.2%)

Table 3: Contingency Table of Experiencing In-School Bullying (primary exposure of

interest) and Smoking Within the Past 30 Days (primary outcome of interest)
Smoke 30 days No smoke 30 days Total

Bullied in School 43(24.1%) 134(16.3%) 177(17.7%)

Not bullied in school 136(75.9%) 687(83.7%) 823(82.3%)

Total 179(17.9%) 821(82.1%) 1,000

Prevalence Ratio (95% CI): 1.47 (1.09, 1.99)
Prevalence Difference (95% CI): 0.08 (0.01, 0.15) = 8 per 100

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 Figure 1: Prevalence of Smoking within the Past 30 Days Stratified by Sex

Table 4: Contingency Table of Smoking versus Not Smoking Within the Past 30 Days
Stratified by Sex
Males Females Total

Smoke30days 92(19.5%) 87(16.4%) 179(17.9%)

No Smoke30days 379(80.5%) 442(83.6%) 821(82.1%)

Total 471(47.1%) 529(52.9%) 1,000

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Table 5: Adjusted Odds Ratios for Potential Confounding Variables on Reporting Smoking
within the past 30 Days.
Variable Coefficient Crude Odds Adjusted 95% P-Value
Ratio & Odds Ratio Confidence
95% Interval
Confidence
Interval

Bullied in 0.330 1.621 (1.089, 1.390 0.885, 2.165 0.148

School 2.378)

Consumed 2.564 12.991 8.616, 20.180 <0.001

Alcohol
within the
past 30 Days

Considered 0.321 1.378 0.874, 2.155 0.163

Suicide

Weightcat -0.021 0.979 0.756, 1.257 0.870

Discussion

These findings indicate that being bullied in school is a marginally statistically significant

risk factor of smoking, even after adjusting for many other risk factors such as participants’

weight, alcohol consumption habits, and suicidal considerations. However, this study has some

limitations. First, it relied on students in accurately self-reporting their behaviors. Students may

have distrusted the interviewers and felt uncomfortable disclosing their smoking habits. This

potential non-differential misclassification of smoking behaviors may have caused some students

who do smoke to be classified as non-smokers, therefore biasing our results through the null.

Secondly, this study focused on school bullying, but other forms of accounted bullying, such as

online bullying, may have also impacted smoking behavior.

Residual confounding might be present in this study due to the broad age range of youths;

there is a lot of variability between students in 9th grade and students in 12th grade. For

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example, students of age 18 years or older are able to legally purchase cigarettes while students

who are younger are not. This study used a multi-stage sampling plan to make sure the sample of

youth was nationally representative. This increased the generalizability of the study results.

However, the cross-sectional design limited our study since data was collected at a single

point in time. Additionally, the small sample size of this study may have caused precision issues.

Due to these limitations, the generalizability of this study may be compromised. The results of

this study may not be adequately generalizable to larger populations of all high school students

across the United States and around the world, and these findings fail to apply to school-age

children outside of the 9th to 12th grade boundary with potentially different characteristics and

social pressures.

The surveillance system of the Youth Risk Behavior Surveillance Study study may have

response bias. There are likely some groups of students who had chosen not to participate in this

study despite being invited to the sample. For example, students who had constant absenteeism

were most likely excluded from the study because they were more difficult to keep in contact

with. Hence, this may have caused an underestimate of the association between smoking and

bullying stratified by sex. This bias likely affected our results since those who declined to

participate in the study or were hard to reach may have been more likely to be exposed to

smoking behaviors, therefore under-representing our study sample.

The CDC published results from a study stating that 9 out of 10 adults who currently

smoke started smoking before the age of 18 (CDC, 2023). This displays the vulnerability of high

school-age students to tobacco addiction. Tobacco use has a large implication on an individual's

physical and mental health, therefore it is necessary to highlight potential risk factors and social

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pressures that encourage smoking to facilitate an intervention that prevents lifelong addiction to

tobacco use.

Conclusion

In-school bullying exacerbates the prevalence of smoking amongst adolescents between

grades 9-12, however, this cross-sectional study design presents the likelihood of biased data and

alternative social risk factors associated with smoking. While stratifying our primary outcome of

interest by sex suggested a slight statistical difference between male and female adolescents, our

research emphasized the underlying presence of social factors that are associated with smoking,

which should be considered for future studies examining these associations through the lens of

bullying. Future studies should utilize a cross-sectional study design to account for alternative

confounding variables with a more carefully crafted survey questionnaire that encourages honest

feedback and transparently defines each topic of concern.

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R Code Appendix

A. R Code for Table 1

> alcohol <-ifelse(alcohol30days+alcohol5plus>0, 1, 0)
> bullying <-ifelse(bully.online+bully.sch>0, 1, 0)
> suiciderisk <-ifelse(suicide.attempt+suicide.consider+suicide.plan>0, 1, 0)
> obese=ifelse(weightcat>2, 1, 0)
>table(sex1f2m,bullying)
>table(alcohol,bullying)
>table(suiciderisk,bullying)
>table(obese,bullying)

B. R Code for Table 2

> alcohol <-ifelse(alcohol30days+alcohol5plus>0, 1, 0)
> bullying <-ifelse(bully.online+bully.sch>0, 1, 0)
> suiciderisk <-ifelse(suicide.attempt+suicide.consider+suicide.plan>0, 1, 0)
> obese=ifelse(weightcat>2, 1, 0)
> table(alcohol, sex1f2m)
> table(bullying,sex1f2m)
> table(suiciderisk, sex1f2m)
> table(obese, sex1f2m)

C. R Code for Figure 1

>barplot(table(smoke30days,sex1fm2),beside=TRUE,names=c(“Females”,”Males”),col=c(“re
d”,”yellow”),main=”Smoking Status by Sex”,ylab=”Number of individuals”)
>legend(x=2.5,y=400,legend=c(“Smoke30days,”NoSmoke30days),fill=c(“red”,”yellow”),title=
”Smoking Status”)

D. R Code for Table 3

>table(sex1f2m, smoke30days)
>prop.table(table(sex1f2m, smoke30days)

E. R Code for Table 4

> table(bully.sch, smoke30days)
smoke30days
bully.sch 0 1
0 687 136
1 134 43
> prop.table(table(bully.sch, smoke30days), 1)
smoke30days
bully.sch 0 1
0 0.8347509 0.1652491
1 0.7570621 0.2429379

Chi-Square Test for Independence

> chisq.test(table(bully.sch, smoke30days), correct = FALSE)

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 Pearson's Chi-squared test

data: table(bully.sch, smoke30days)

X-squared = 5.9826, df = 1, p-value = 0.01445

F. R Code for Table 5

> crude_model <-glm(smoke30days~bully.sch, family=binomial(link="logit"))
> summary(crude_model)

Call:
glm(formula = smoke30days ~ bully.sch, family = binomial(link = "logit"))

Deviance Residuals:
Min 1Q Median 3Q Max
-0.7461 -0.6010 -0.6010 -0.6010 1.8975

Coefficients:
Estimate Std. Error z value Pr(>|z|)
(Intercept) -1.61968 0.09385 -17.26 <2e-16 ***
bully.sch 0.48304 0.19881 2.43 0.0151 *
---
Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1

(Dispersion parameter for binomial family taken to be 1)

Null deviance: 939.75 on 999 degrees of freedom

Residual deviance: 934.13 on 998 degrees of freedom
AIC: 938.13

Number of Fisher Scoring iterations: 4

exp(crude_model$coeff)
(Intercept) bully.sch
0.1979622 1.6209943

exp(confint(crude_model))
Waiting for profiling to be done...
2.5 % 97.5 %
(Intercept) 0.1640534 0.2370785
bully.sch 1.0892457 2.3784856

> exp(crude_model$coeff)
(Intercept) bully.sch
0.1979622 1.6209943
> exp(confint(crude_model))
Waiting for profiling to be done...
2.5 % 97.5 %

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(Intercept) 0.1640534 0.2370785
bully.sch 1.0892457 2.3784856

> adjusted_model<-
glm(smoke30days~bully.sch+alcohol30days+suicide.consider+weightcat,family=binomial(link="lo
git"))
> summary(adjusted_model)

Call:
glm(formula = smoke30days ~ bully.sch + alcohol30days + suicide.consider +
weightcat, family = binomial(link = "logit"))

Deviance Residuals:
Min 1Q Median 3Q Max
-1.2309 -0.3503 -0.2984 -0.2953 2.5199

Coefficients:
Estimate Std. Error z value Pr(>|z|)
(Intercept) -3.0686 0.2660 -11.538 <2e-16 ***
bully.sch 0.3296 0.2279 1.447 0.148
alcohol30days 2.5643 0.2164 11.848 <2e-16 ***
suicide.consider 0.3208 0.2299 1.395 0.163
weightcat -0.0212 0.1295 -0.164 0.870
---
Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1

(Dispersion parameter for binomial family taken to be 1)

Null deviance: 939.75 on 999 degrees of freedom

Residual deviance: 734.49 on 995 degrees of freedom
AIC: 744.49

Number of Fisher Scoring iterations: 5

>exp(adjustedmodel$coeff)
(Intercept) bully.sch alcohol30days suicide.consider weightcat
0.0464882 1.3904415 12.9910594 1.3782730 0.9790185
> exp(confint(adjustedmodel))
Waiting for profiling to be done...
2.5 % 97.5 %
(Intercept) 0.02715482 0.07719914
bully.sch 0.88475196 2.16513004
alcohol30days 8.61595227 20.17961585
suicide.consider 0.87380679 2.15506669
weightcat 0.75612275 1.25745915

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 References

CDC (2023). Youth and Tobacco Use. Centers for Disease Control and Prevention.
https://shorturl.at/gpvMU

Torabi, M. R., Bailey, W. J., & Majd-Jabbari, M. (1993). Cigarette Smoking as a Predictor of
Alcohol and Other Drug Use by Children and Adolescents: Evidence of the “Gateway
Drug Effect.” Journal of School Health, 63(7).
https://onlinelibrary.wiley.com/doi/10.1111/j.1746-1561.1993.tb06150.x

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