International Journal of Mental Health and Addiction

https://doi.org/10.1007/s11469-023-01200-0

ORIGINAL ARTICLE

Peer‑Related Correlates of e‑Cigarette Use in Australian

Adolescents: a Cross‑sectional Examination

Emily Hunter1 · Lauren A. Gardner1 · Siobhan O’Dean1 · Nicola C. Newton1 ·

Louise Thornton1,2 · Amy‑Leigh Rowe1 · Tim Slade1 · Nyanda McBride3 ·
Emma K. Devine1 · Lyra Egan1 · Maree Teesson1 · Katrina E. Champion1

Accepted: 8 November 2023

© The Author(s) 2023

Abstract
Background This study examined cross-sectional associations between e-cigarette use and
(i) perceived peer use of e-cigarettes and (ii) bullying (perpetration and/or victimisation) in
Australian adolescents.
Methods Data were collected in 2022 as part of a cluster randomised controlled trial.
Logistic regressions examined associations between e-cigarette use (ever use) and the
perceived proportion of friends who use e-cigarettes, bullying victimisation, bullying
perpetration and “bully-victim” status (i.e. having perpetrated and been bullied).
Results The sample comprised 4204 participants (­Mage = 15.70, SD = 0.60). Perceived
peer e-cigarette use (OR = 2.59, 95% CI = 2.42, 2.77 p < .001), bullying victimisation
(OR = 1.26, 95% CI = 1.08, 1.46, p = .004), bullying perpetration (OR = 3.00, 95% CI
= 2.45, 3.66, p < .001) and being a “bully-victim” (OR = 2.58, 95% CI = 2.06, 3.24, p <
.001) were associated with increased odds of ever having used an e-cigarette.
Conclusions While further longitudinal research is required, results suggest that future
prevention efforts for adolescent e-cigarette use could target peer-related factors, such as
perceived peer use and bullying.

Keywords E-cigarette use · Adolescent · Peer relationships · Peer e-cigarette use · Bullying
involvement

In recent years, the use of e-cigarettes, also known as “vapes”, has emerged as a global
public health priority. The significant growth in e-cigarette use is particularly troubling in
adolescent populations, especially among youth who have never used tobacco cigarettes
(Aljandaleh et al., 2020; Gallus et al., 2021; Health, 2016; Kennedy et al., 2017; Yoong

* Emily Hunter
e.hunter@sydney.edu.au
1
The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney,
Level 6, Jane Foss Russell Building, Sydney 2006, Australia
2
School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia
3
National Drug Research Institute, Enable Institute, Faculty of Health Science, Curtin University,
Perth, Western Australia

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 International Journal of Mental Health and Addiction

et al., 2021). In Australia, the most recent (2019) nationally representative survey reported
that 10% of 14–17-year olds had ever used an e-cigarette (Welfare, 2020). Most recently,
data from a survey of 4204 adolescents aged 14–17 years old showed this number has
increased to 26% (Gardner et al., 2023). This is a significant concern due to the unknown
long-term health effects of e-cigarettes (Banks et al., 2023). Given the potential for harm
and the rapidly growing trajectories of use in youth, there is an urgent need to establish
a robust body of evidence to inform prevention efforts within Australia’s unique legal
(Alcohol & Drug Foundation, 2023) and social context (Jongenelis, 2023).
Peers play a significant role in shaping adolescent risk behaviour (Forman-Alberti,
2015). Social influence theory explains this relationship as occurring due to the function
of social comparison, whereby individuals determine whether their own behaviour is
appropriate through continuous comparison with others’ (Maxwell, 2002). Additionally,
peer selection, whereby an individual selects a peer group based on their behaviour (e.g.
using e-cigarettes), is another key process contributing to e-cigarette use behaviour among
social networks (Valente et al., 2023). Adolescents in particular look to their peers to shape
normative beliefs, and interpret information related to risky behaviour (Maxwell, 2002).
Much adolescent e-cigarette research currently focuses on demographic correlates (e.g. age,
gender, ethnicity) of use (Bold et al., 2017; Camenga et al., 2014; Carroll Chapman & Wu,
2014; Donaldson et al., 2021; Gardner et al., 2023; Hrywna et al., 2020; Krishnan-Sarin
et al., 2015; McCabe et al., 2020); however, less is known about modifiable peer factors,
such as perceived peer vaping behaviour and bullying victimisation and/or perpetration,
which could inform future prevention efforts.
Peer substance use, both actual and perceived, has been shown to be associated with
increased adolescent substance use both internationally (Dishion & Loeber, 1985; Er
et al., 2019; Simons-Morton & Farhat, 2010; Watts et al., 2023) and in Australia (Gazis
et al., 2009; White et al., 2013). Emerging international research, predominantly from the
USA, indicates this association holds true for adolescent e-cigarette use (Cavazos-Rehg
et al., 2021; Durkin et al., 2021; Patanavanich et al., 2021; Valente et al., 2023; Wang
et al., 2022). It is however important to note that all but one study (Valente et al., 2023),
measured perceived, rather than actual peer e-cigarette use. For example, in a survey of 562
adolescents in the USA, the perceived proportion of friends who use e-cigarettes directly
correlated with a higher likelihood of having ever used an e-cigarette (Durkin et al., 2021).
In Australia, a cross-sectional study of 15–30-year olds found a positive association
between number of friends who use e-cigarettes and increased e-cigarette use (Pettigrew
et al., 2023); however, younger adolescents (aged 15–18) only made up a minority of the
sample. Alarmingly, e-cigarette use now commonly occurs in many contexts, including
in schools (Jongenelis & Robinson, 2023; Pettigrew et al., 2023). Further research among
Australian adolescents is needed to specifically examine the association between perceived
peer use and rates of e-cigarette use, as well as other important peer- and school-related
factors, such as bullying.
The association between bullying perpetration and substance use (including alcohol,
marijuana and cigarette use) is well established (Carlyle & Steinman, 2007; Gaete et al.,
2017; Kelly et al., 2015; Lambe & Craig, 2017; Picoito et al., 2019; Stone & Carlisle,
2017; Thomas et al., 2017). To our knowledge, only one US study has examined the
association between bullying perpetration and adolescent e-cigarette use, finding nicotine
e-cigarette use to be associated with both in-person and online bullying perpetration
(Boccio & Leal, 2022). Despite a less expansive literature base, research has identified
an association between bullying victimisation and increased substance use (Kelly et al.,
2015; Lee et al., 2022; Moore et al., 2017; Tharp-Taylor et al., 2009). Emerging research

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International Journal of Mental Health and Addiction

suggests this relationship holds firm when applied to e-cigarette use, although none has
been conducted in Australia (Azagba et al., 2020; Boccio & Leal, 2022; Doxbeck, 2020;
Ihongbe et al., 2021; Liu et al., 2023; Mereish et al., 2023; Tabaac et al., 2021). Only one
study has examined the relationship between bully-victim status (i.e. an individual who
has been both a victim and perpetrator of bullying) and e-cigarette use, finding they were
strongly associated (Boccio & Leal, 2022). To our knowledge, this study will be the first
to examine the relationship between bullying (victimisation and/or perpetration) and
e-cigarette use in a large Australian sample.
Emerging research suggests that a better understanding of the relationship between
peer factors and e-cigarette use in adolescents is needed, as peer-related behaviours have
the potential to be modified through preventative intervention. Using cross-sectional
data collected as part of the Health4Life Study (Teesson et al., 2020), a school-based
cluster randomised controlled trial (RCT), this study aims to fill that gap by examining
the associations between peer-related risk factors and e-cigarette use in a large sample of
Australian adolescents. Specifically, this paper will address the following research questions:

1. Is perceived peer e-cigarette use associated with adolescent e-cigarette use?

2. Is bullying (victimisation and/or perpetration) associated with adolescent e-cigarette
use?

Methods

Participants

This study used cross-sectional data collected from participants who completed the
36-month post-baseline assessment of the Health4Life study, a cluster RCT conducted in
71 secondary schools in Australia from 2019-2022.
Despite the longitudinal nature of the cohort, data on e-cigarette use were only collected
during the final follow-up period between July-December 2022 (n = 4204; 63% of baseline
sample; see Table 1). Further details, including recruitment and consent procedures, can be
found elsewhere (Champion et al., 2023; Teesson et al., 2020).

Table 1  Participant characteristics stratified by “ever used e-cigarette”

Never used e-cigarette Ever used e-cigarette

N (%) 3110 (73.9) 1094 (26.1)

Age, mean (SD) 15.70 (0.67) 15.75 (0.56)
Bullying perpetration, n (%) 329 (10.9) 265 (25.3)
Bullying victimisation, n (%) 1244 (40.4) 482 (45.5)
Bully-victim, n (%) 250 (8.1) 185 (17.4)
Perceived proportion of friends who have used e-cigarettes, n (%)
None 1363 (43.9) 51 (4.7)
Less than half 994 (32.0) 212 (19.4)
About half 356 (11.5) 176 (16.1)
More than half 242 (7.8) 301 (27.5)
All or almost all 153 (4.9) 353 (32.3)

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Measures

E‑Cigarette Use

Participants were provided with a definition of e-cigarettes, as well as a list of additional

names they are called (e.g. vapes, Juul, pods). Ever use of e-cigarettes was measured using
a single item, “Have you ever used an e-cigarette, even one or two puffs?”, with response
options “yes” or “no”.

Bullying

Bullying perpetration, victimisation and bully-victim status were determined by using

two questions from the Olweus Bully/Victim Questionnaire (Olewus, 1993), which has
demonstrated good psychometric properties (Kelly et al., 2015; Kyriakides et al., 2006).
Participants responded “yes” or “no” to the items “have you ever been bullied?” and “have
you ever bullied others?” A bully-victim variable was created to represent those who
reported both bullying and being bullied by others.

Perceived Proportion of Friends Who Use e‑Cigarettes

Perceived peer e-cigarette use was measured using a single item, “About what proportion
of your friends and acquaintances have used e-cigarettes (even one or two puffs)?” This
was measured via a 6-point Likert scale, with responses coded 0- “none”, 1- “less than
half”, 2- “about half”, 3- “more than half”, 4- “all or almost all”.

Sociodemographic Covariates

Gender identity was measured using an item extracted from surveys administered by
ACON (a LGBTQIA+ affirmative organisation). Responses included “male”, “female”,
“non-binary/gender fluid”, “other identity” and “prefer not to say”.
School socio-educational advantage was measured using the Index of Socio-Educational
Advantage (ICSEA). Each school in Australia is allocated a relative position (scaled to a
normal distribution), which captures features of the school student population.
School geographical remoteness (major city or regional) was used as a substitute for
participant geographic remoteness, as many students were unaware of their current postcode.

Statistical Analysis

Separate multilevel logistic regression models investigated the associations between

ever using an e-cigarette and each peer-related factor: bullying perpetration, bullying
victimisation, bully-victim status and perceived peer use. To account for the clustered
nature of the data, we included a random effect for school. To account for any potential
effect of the Health4Life intervention on student outcomes, we controlled for interven-
tion status in all models. To test the robustness of the associations between our out-
comes, we ran the same models controlling for sociodemographic characteristics that
may have been related to using e-cigarettes: age, gender, state (New South Wales,

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International Journal of Mental Health and Addiction

Queensland, Western Australia), school type (catholic, independent, public), school

geographic remoteness (major city vs regional) and relative socio-economic status. We
report both the adjusted and unadjusted odds ratios for the associations between each
peer risk factor and lifetime e-cigarette use. All models were conducted in R (version
4.3.1) (RStudio Team, 2021) using the lme4 (Bates et al., 2015) package.

Results

Sample Characteristics

Sample characteristics are reported in Table 1. A total of 4204 participants were

included in these analyses (­Mage = 15.70, SD = 0.60; female = 47.1%). Twenty-six
percent of the sample reported having ever used an e-cigarette. In comparison to those
who reported never using an e-cigarette, those who had used an e-cigarette demonstrated
higher rates of bullying perpetration, bullying victimisation, being a bully-victim and
perceived that a higher proportion of their friends had used e-cigarettes. E-cigarette
use by socio-demographic characteristics (gender, state, school type, remoteness and
relative socio-economic status) for this sample have been reported elsewhere (Gardner
et al., 2023).

Peer Correlates of e‑Cigarette Use

Results of the multilevel logistic regressions are reported in Table 2. Higher perceived
peer e-cigarette use was associated with greater odds of ever having used an e-cigarette
(OR = 2.59, 95% CI = 2.42, 2.77, p < .001). Bullying victimisation (OR = 1.26, 95%
CI = 1.08, 1.46, p = .004), bullying perpetration (OR = 3.00, 95% CI = 2.45, 3.66, p <
.001) and being a bully-victim (OR = 2.58, 95% CI = 2.06, 3.24, p < .001) were associ-
ated with increased odds of ever having used an e-cigarette.

Table 2  Summary of separate mixed effects logistic regression models investigating the association
between ever having used an e-cigarette and perceived peer e-cigarette use, bullying victimisation, bullying
perpetration and bully-victim status

Unadjusted model estimates Adjusted model ­estimates1

Odds ratio (95% CI) P-value Odds ratio (95% CI) P-value

Perceived peer e-cigarette use 2.58 (2.42, 2.76) < .001 2.59 (2.42, 2.77) < .001
Bullying victimisation 1.26 (1.09, 1.46) .002 1.26 (1.08, 1.46) .004
Bullying perpetration 3.09 (2.55, 3.74) < .001 3.00 (2.45, 3.66) < .001
Bully-victim 2.72 (2.19, 2.37) < .001 2.58 (2.06, 3.24) < .001

Note1: Model adjusted for age, gender, state, school type, school geographic remoteness and relative socio-
economic status

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 International Journal of Mental Health and Addiction

Discussion

This is the first paper to examine the relationships between peer factors and e-cigarette use
in a large sample of Australian adolescents. These findings build on international research
that has demonstrated associations between adolescent e-cigarette use and both perceived
peer use (Barrington-Trimis et al., 2015; Cavazos-Rehg et al., 2021; Durkin et al., 2021;
Patanavanich et al., 2021; Valente et al., 2023; Wang et al., 2022) and bullying involve-
ment (Azagba et al., 2020; Boccio & Leal, 2022; Doxbeck, 2020; Ihongbe et al., 2021; Liu
et al., 2023; Mereish et al., 2023; Tabaac et al., 2021). Our findings indicate that there is a
robust cross-sectional association between ever using an e-cigarette and bullying perpetra-
tion, bullying victimisation, bully-victim status and perceived peer use, even after adjusting
for key sociodemographic characteristics.
The finding that those who have ever used an e-cigarette, in comparison to non-users,
were 2.59 times more likely to perceive their peers as using e-cigarettes, suggests that peer
influence, peer selection and social context potentially play a role in adolescent e-cigarette
use. These results are consistent with international literature that emphasises the role of
social networks in e-cigarette uptake and continuation in adolescents (Pichel et al., 2022).
E-cigarette use behaviour may be more normalised or socially accepted in some peer
groups, and adolescents may select or be influenced by peers who share similar beliefs
(Valente et al., 2023). An association between perceived peer use and e-cigarette use pre-
sents an opportunity to challenge misconceptions through normative education (e.g. 76%
of the sample perceived at least half of their peers to have used an e-cigarette, yet only 26%
reported ever trying an e-cigarette), and aligns with research that has found adolescents
tend to overestimate their peers’ substance use (Henneberger et al., 2019).
An implication of these results is the possibility of leveraging the influence of peers
within prevention programs. There is good evidence for the use of peer-led and social influ-
ence principles to prevent and reduce substance use, including e-cigarette use (Veenstra &
Laninga-Wijnen, 2022; Wyman et al., 2021). These projects incorporate established behav-
iour modification techniques (challenging social norms, increasing knowledge and refusal
skills, improving health literacy) alongside a peer-to-peer education structure, capitalising
on the strong theoretical basis of social diffusion theory (Wyman et al., 2021). Peer-led
and social influence programs provide the opportunity to challenge normative beliefs about
vaping (Sanchez et al., 2019). It may also be important within these interventions to iden-
tify particular clusters of peer groups that are at-risk and offer additional supports along-
side the peer-led intervention.
Interestingly, perpetrators of bullying were three times more likely than non-perpe-
trators to have used an e-cigarette, while bullying victims were more likely than non-
victims to have used an e-cigarette. While these associations individually are consist-
ent with existing literature (Azagba et al., 2020; Boccio & Leal, 2022; Doxbeck, 2020;
Ihongbe et al., 2021; Liu et al., 2023; Mereish et al., 2023; Tabaac et al., 2021), it is
noteworthy to examine the possible explanations for the difference in odds for per-
petrators and victims. Bullying perpetrators often experience difficulties in emotional
regulation, externalising behaviour and impulsivity, and are more likely to associate
with delinquent peers and seek social dominance. These are all factors associated with
both bullying perpetration and substance use (Arcadepani et al., 2021; Cho, 2018; Luk
et al., 2016; Reijntjes et al., 2013; Zucker et al., 2011). This interrelationship does not
appear as strong in bullying victims, despite research positing that victims may turn
to substance use as a form of maladaptive coping (Doherty et al., 2012; Lee et al.,

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International Journal of Mental Health and Addiction

2022), and experience anxiety and depression at higher rates (Balluerka et al., 2023),
our results suggest that the individual and peer-community contexts of perpetrators are
more closely interrelated with e-cigarette use than victims. Importantly, bully-victims
were also more likely than those who reported no bullying involvement to have ever
used an e-cigarette. Bully-victims are a particularly vulnerable group and experience
greater rejection by peers, as well as significant adjustment issues (Boccio & Leal,
2022). Future research could investigate the motivations of bullying perpetrators, bul-
lying victims and bully-victims in relation to using e-cigarettes in order to develop and
implement targeted preventive strategies.
The association between all three subtypes of bullying involvement highlights the
importance of strengthening anti-bullying measures at an individual level through edu-
cation about respect, individualised support for both victims and perpetrators, and at a
school/community level through review of school anti-bullying policy, group programs
and education. Additionally, the present findings suggest that prevention programs that
target shared underlying risk factors, such as externalising problems (e.g. the Good
Behaviour Game) (Kellam et al., 2011) or personality traits (Kelly et al., 2020), may
be worth further exploration as strategies to prevent both bullying and substance use,
including e-cigarette use.
This study has several limitations. Although data for this study were derived from
students attending secondary schools across three Australian states, it is not nationally
representative (Showalter & Mullet, 2017). It does however use the largest, most recent
sample of Australian adolescents to examine peer correlates of e-cigarette use and aligns
with nationally representative data in another research (Kelly et al., 2016). Secondly,
the data are cross-sectional, as e-cigarette data was only collected at the 36-month fol-
low-up timepoint, precluding longitudinal examinations. Further research is required to
examine the directionality of associations between peer correlates and adolescent e-cig-
arette use, and to establish causality longitudinally. Additionally, the bullying question-
naire items were not specifically concerned with e-cigarette use or related peer pres-
sure, so future research may wish to examine effects of more specific questions. Our
measure of peer e-cigarette use was limited to one item that assessed perceived peer use
and we did not collect data to enable analysis of larger friendship group and/or whole
school networks to better understand the peer processes occurring and how these relate
to e-cigarette use.
Importantly, future research should also seek to examine the associations between
actual peer use and adolescent e-cigarette use. One potential mechanism for this is
through social network analysis, whereby an index individual nominates peers closest
to them, allowing for peer networks to be identified (Valente et al., 2023). Thus, self-
reported actual use can be compared with perceived use to identify inconsistencies.
These analyses may also disentangle peer selection and peer influence to evaluate their
individual impacts, as research suggests they exert different effects at each developmen-
tal stage (Mundt et al., 2012). Additional investigation into bullying and underlying fac-
tors that may increase vulnerability towards e-cigarette use is also an important area
for future research. While this paper focuses on two important peer correlates, future
studies should also longitudinally consider other important factors which may be related
to e-cigarette use, such as peer pressure, resistance skills, personality traits, school poli-
cies, home environment and parenting practices, in order to advance understanding and
inform development of preventive interventions. Notwithstanding these limitations, this
study significantly adds to the urgent need for research in the space of e-cigarette use
among young people.

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 International Journal of Mental Health and Addiction

Conclusions

This cross-sectional analysis revealed important findings regarding the associations

between peer factors and adolescent e-cigarette use. Our results suggest that perceived peer
use and bullying may be important targets for intervention efforts to prevent e-cigarette
use, such as peer-led programs and normative education about peer vaping use. However,
further longitudinal research is required to determine causality and to investigate other
mechanisms of peer influence.

Funding Open Access funding enabled and organized by CAUL and its Member Institutions The Health-
4Life study was funded by the Paul Ramsay Foundation, the Centre of Research Excellence in the Pre-
vention and Early Intervention in Mental Illness and Substance Use (PREMISE; APP11349009) and the
Australian National Health and Medical Research Council via Fellowships (K.C., APP1120641; M.T.,
APP1078407 and N.N., APP1166377). The funders had no input in the design of the study, collection of
data and statistical analysis, decision to publish or manuscript preparation.

Declarations
Ethics Approval Ethics approval was provided by the Human Research Ethics Committees of the University
of Sydney (2018/882), the University of Queensland (2019000037), Curtin University (HRE2019-0083), the
NSW Department of Education (SERAP no. 2019006) and the relevant ethics committees of each participat-
ing school. All procedures performed in this study involving human participants were in accordance with the
ethical standards of University’s Research Ethics Board and with the 1975 Helsinki Declaration, as revised
in 2000.

Informed Consent Informed consent was obtained from all participants. Opt-out parent/guardian consent
was also obtained.

Conflict of Interest The authors declare no competing interests.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Com-
mons licence, and indicate if changes were made. The images or other third party material in this article
are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the
material. If material is not included in the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly
from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

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