Impact of Family Functioning and Peer Pressure on Nicotine Dependence: A Cross-sectional Study Among Medical Students in South Punjab, Pakistan
Conditions: Nicotine Dependence, Tobacco Use Disorder, Family Functioning, Peer Influence
Sponsor: Nishtar Medical University

Title: 
Impact of Family Functioning and Peer Pressure on Nicotine Dependence: A Cross-
Sectional Study Among Medical Students in South Punjab, Pakistan  
Authors’ list:   
Fakiha Sultana Malik1 ; Areej Imtiaz1 ; Tayyaba Abdullah1 ; Zaynab Salman1 ; 
Muhammad Salman Nadeem1 ; Mahnoor Fatima2 ; Muhammad Farhan Jamil3 
1 Nishtar Medical College, Nishtar Medical University Multan, Pakistan  
2 Shaheed Ziaur Rahman Medical College, Rajshahi Medical University, Bogura, 
Bangladesh  
3 Department of Community Medicine, Nishtar Medical University Multan, Pakistan  
Date: 07/30/2025 
Background 
The issue of nicotine dependence is escalating, especially among young adults, including 
medical students, which poses a significant threat to public health.1 Despite the awareness 
of nicotine’s adverse health effects, a significant number of medical students remain 
engaged in smoking and other nicotine products. 2 Family factors like parental smoking, 
family disputes, and supervision levels greatly influence nicotine addiction.3 Moreover, 
nicotine dependence in medical students is often fueled by peer pressure, encouraging 
them to smoke for social acceptance 4    
 
A comprehensive analysis involving 107,527 student health professionals across 70 
countries with response rate ranging from 40% to 100% found that nicotine intake among 
medical students was highest in European countries (20%) and the Americas (13%).5 
Similarly, another study identified peer pressure as the most common determinant 
(57.69%) for developing  smoking habits among medical students.6  
 
The role of family and social environment in shaping adolescent e-cigarette use is crucial, 
with studies demonstrating a proportionate rise in nicotine use and domestic conflicts .7
According to study, peer pressure, hostel life, social acceptance emerged as major 
contributors to nicotine initiation among medical students.8      
 
The motivation behind this research is the increasing prevalence of nicotine addiction 
among medical students, particularly due to limited research on the interplay between 
peer pressure and family environment. 9 Research on nicotine addiction among the 
general population is well documented, but there is limited attention given to the medical 
students. Exploring how family and peer relationships influence nicotine dependence will 

provide preventive strategies, policies to counter this rising trend and consequently lead 
to better public health outcome 
  
Rationale 
This research is necessary to assess the impact of familial and peer related factors on 
nicotine addiction among medical students in South Punjab. This will help design 
targeted interventions and preventive strategies to mitigate the increasing trend.    
Objectives 
To determine the influence of the family environment and familial relationships on 
nicotine dependence among medical students.     
To assess the impact of peer pressure on nicotine use and dependence.  
To determine whether a positive or negative family and peer environment affects the 
likelihood of developing nicotine addiction.  
 Study Design 
Cross-sectional study 
Participants 
Inclusion Criteria: Student enrolled in medical colleges in South Punjab, willing to 
participate.  
Exclusion Criteria:  
Students who didn’t give consent    
Those who were absent   
Uncooperative students  
Methods 
Data Collection Procedure 
Data will be collected through a structured, self-administered questionnaire in 
English. The initial section of the questionnaire will collect basic demographic 
information, including age, gender, medical college, and year of study. 
 

Assessment Tools 
Nicotine Dependence 
To assess nicotine dependence, the Fagerström Test for Nicotine Dependence 
(FTND)—a globally validated tool—will be used.<sup>14</sup> This test includes six 
questions focusing on behaviors such as the use of cigarettes, e-cigarettes, and other 
tobacco-containing products immediately after waking, smoking in prohibited 
areas, and difficulty in giving up the first session of the day. It also inquires about 
daily frequency and whether the participant smokes despite illness (Table 1). 
The FTND provides a continuous score ranging from 0 to 10, based on six items: 
 
Three yes/no items will be scored as 0 (No) and 1 (Yes), 
 
Three multiple-choice items will be scored from 0 to 3. 
The total score will be used to classify nicotine dependence as follows: 
 
0–2: Very Low 
 
3–4: Low 
 
5: Moderate 
 
6–7: High 
 
8–10: Very High 
Each question will offer specific response options that aid in categorizing dependence 
levels. Reliability analysis is expected to yield a Cronbach’s alpha of approximately 
0.702, indicating acceptable internal consistency, as reported in prior studies. 
Family Functioning 
Participants will also be provided with the Family Assessment Device – General 
Functioning subscale (FAD-GF), which includes 12 questions to evaluate overall 
family functioning (Table 2).<sup>15</sup> Each item will be rated on a 4-point Likert 
scale, ranging from 1 (Strongly Agree) to 4 (Strongly Disagree), with negatively 
worded items reverse-coded to maintain scoring consistency. Higher scores will reflect 
poorer family functioning. 
A cutoff mean score of 2.00 will be applied: 
 
Mean score ≥ 2.00 will indicate unhealthy or dysfunctional family functioning, 
 
Mean score < 2.00 will reflect relatively healthy family functioning. 
The FAD-GF scale is expected to demonstrate a Cronbach’s alpha of approximately 
0.736, indicating acceptable internal consistency. 
Peer Pressure 

Peer pressure will be assessed using items adapted from Subramaniam et al. This scale 
includes six yes/no questions divided into direct and indirect peer pressure: 
 
Three questions will assess direct peer pressure, 
 
Three questions will assess indirect peer pressure. 
Students answering ‘yes’ to any question will be considered to have experienced peer 
pressure, while those who respond ‘no’ to all questions will be categorized as not 
experiencing peer pressure. 
Statistical Analysis Plan 
Statistical analysis will be carried out using SPSS version 26. Descriptive statistics 
will be used to summarize demographic data, smoking status, peer pressure, and family 
functioning. A two-way analysis of variance (ANOVA) will be conducted to assess the 
interaction effects of family functioning and peer pressure on nicotine dependence. For 
group comparisons, an independent t-test will be performed between students with 
functional and dysfunctional families experiencing peer pressure. A Chi-square test will 
be used to examine associations between gender, year of study, peer pressure, and 
smoking status. Assumptions for normality and equal variances will be verified prior to 
applying parametric tests, and the level of statistical significance will be set at p < 0.05. 
Ethical Approval 
Ethical approval will be obtained from the Institutional Ethical Review Board 
(IERB), Nishtar Medical University, Multan, Pakistan, prior to data collection. The 
study will ensure that subjects participate on a voluntary and anonymous basis. Prior to 
participation, informed consent will be obtained from each participant. 
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