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The results for combined bullying-victimization were more mixed, with generally weaker effects. Effects were based on a large variability in operationalizations and measures of bullying and substance use, impeding the interpretation of the pooled effect sizes. Although bullying appears to be a risk factor for substance use, no inferences can be made about so-called causal risk factors that can provide the basis for preventive interventions. There is evidence that adolescents and particularly children who bully their peers have a higher
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