570917
research-article2015
WHSXXX10.1177/2165079915570917Workplace Health & SafetyWorkplace Health & Safety
Workplace Health & Safety
February 2015
ARTICLE
Alcohol, Cigarette, and Illegal Substance Consumption Among Medical Students A Cross-Sectional Survey M. Gignon, MD, PhD1,2,3, E. Havet, MD, PhD2, C. Ammirati, MD, PhD1,2, S. Traullé, MD2, C. Manaouil, MD, PhD2, T. Balcaen, MJ2,3, G. Loas, MD, PhD2, G. Dubois, MD, PhD2,3, and O. Ganry, MD, PhD2,3
Abstract: This study investigated addictive substance use by French medical students. A cross-sectional survey was distributed to 255 participants randomly selected from 1,021 second- to sixth-year medical students. Questionnaires were self-administered and included questions on sociodemographic characteristics, mental health, and alcohol (The Alcohol Use Disorders Identification Test [AUDIT test]), tobacco (Fagerstrom test), and illegal substance consumption (Cannabis Abuse Screening Test [CAST test]). The AUDIT scores indicated that 11% of the study participants were at risk for addiction and 21% were high-risk users. Tobacco dependence was strong or very strong for 12% of the participants. The CAST score showed that 5% of cannabis users needed health care services. Cannabis users were also more likely than non-users to fail their medical school examinations (89% vs. 39%, p < .01). One quarter of medical student participants (n = 41) had used other illegal drugs, and 10% of study participants had considered committing suicide during the previous 12 months. Psychoactive substance consumption by French medical students requires preventive measures, screening, and health care services.
Keywords: medical students, France, alcohol consumption, tobacco, cannabis
E
xcessive alcohol consumption and binge drinking among adolescents and young adults have been recognized as significant risk behaviors, increasing the likelihood of health problems, drunk driving, aggression, unsafe sexual activity, and accidents (Maddock, Laforge, Rossi, & O’Hare, 2001; Wechsler et al., 2002). Heavy drinking during adolescence and young adulthood is predictive of future alcohol-related problems and academic failure in certain groups (Jennison, 2004).
Heavy drinking is highly prevalent among college and university students (Hingson, Heeren, Winter, & Wechsler, 2005), including medical (Granville-Chapman, Yu, & White, 2001) and nursing students (Oliveira & Furegato, 2008). For many health professions students, alcohol consumption may be a way of coping with the stress of challenging curricula and clinical education (Henriquéz & Carvalho, 2008; Kjøbli et al., 2004). The known interaction between binge drinking and other drugrelated behaviors such as cannabis and cigarette smoking is also prevalent among medical students (Newbury-Birch, Walshaw, & Kamali, 2001). Cannabis use has been associated with a range of adverse effects (e.g., impaired attention, memory and psychomotor performance, traffic accidents, and depression) and social problems (e.g., low educational attainment; Hall & Solowij, 1998). Cannabis can also reduce symptoms of depression, psychopathology, and psychosocial distress (Delile, 2005; Ries, 1993). The harmful effects of substance use by health professions students are well described (Baldwin, Bartek, Scott, Davis-Hall, & DeSimone, 2009; Baldwin et al., 2008; Baldwin et al., 2006; Baldwin, Scott, DeSimone, Forrester, & Fankhauser, 2011). Consumption may be the cause or consequence of individual student challenges and academic success. In addition, physicians, particularly young physicians, are susceptible to psychological distress and addictions (Brooks, Chalder, & Gerada, 2011). Health professions students experience higher rates of depression, burnout, and mental illness than the general population, with deteriorating mental health during the course of their educational programs (Deasy, Coughlan, Pironom, Jourdan, & Mcnamara, 2014; Dyrbye et al., 2010; Dyrbye, Thomas, & Shanafelt, 2006; Givens & Tjia, 2002; Goebert et al., 2009). Medical students report higher rates of burnout (Dyrbye et al., 2008) and depressive symptoms associated with suicidal ideation (Dahlin, Joneborg, & Runeson, 2005; Tyssen, Vaglum, Grønvold, & Ekeberg, 2001), suicide (Hays, Cheever, & Patel, 1996), and
DOI: 10.1177/2165079915570917. From 1University Paris 13, 2Jules Verne University of Picardy, and 3Amiens University Hospital. Address correspondence to: M. Gignon, MD, PhD, Public Health Department, Amiens University Hospital, Amiens, France; email: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
54 Downloaded from whs.sagepub.com at Yale University Library on July 21, 2015
Workplace Health & Safety
vol. 63 ■ no. 2
impaired quality of life than age-matched populations. However, it is well documented that physicians are as healthy, or even healthier, than other comparable population groups (Frank & Segura, 2009). A medical career is more frequently associated with good health than with poor health (Aasland, Hem, Haldorsen, & Ekeberg, 2011). It could be assumed that medical students have ready access to health care in view of their studies and role in the health care system. Unfortunately, the literature does not confirm this assumption (Chew-Graham, Rogers, & Yassin, 2003; Rosenthal & Okie, 2005; Tjia, Givens, & Shea, 2005). Medical students engage in potentially harmful methods of coping, such as excessive alcohol consumption (Kjøbli et al., 2004). Strategies should therefore not only be repressive (i.e., zero tolerance for substance use or suspending and expelling students who transgress), but also provide a global preventive approach including harm minimization (e.g., school-based health promotion taking into account the assessment of the psychological, educational, economic, and social life of the students; Evans-Whipp et al., 2004). Although secondary schools commonly implement alcohol prevention policies to reduce alcohol misuse, the efficacy of these policies has only been rarely evaluated (Evans-Whipp, Plenty, Catalano, Herrenkohl, & Toumbourou, 2013). Alcohol consumption in the World Health Organization (WHO) European regions is high (Rehm, Taylor, & Patra, 2006). Mortality due to diseases related to excessive alcohol consumption in the study university is significantly higher than that in other parts of France (Beck, Legleye, Le Nézet, & Spilka, 2005). A reduction in alcohol consumption, especially among young people, is one of the five regional health priorities. In France, the sale of alcohol and tobacco is prohibited to individuals less than 18 years of age. French law prohibits smoking in all public places and the possession of drugs, including cannabis, is prohibited and illegal. Consumption of alcohol and other addictive substances by students is a major concern at the study university. To define the most appropriate prevention and health care strategies, the researchers asked medical students about their alcohol, smoking, and drug-related behaviors. The use of psychoactive substances raised questions about the ability of these students to succeed in medical school and meet their future professional responsibilities. This study investigated addictive substance consumption by French medical students and possible associations between this consumption and personal and school-based characteristics in an attempt to identify patterns that could guide prevention policies and strategies.
Method A cross-sectional survey was conducted from March 2011 to May 2011 by randomly selecting (using an interval of 4) 255 medical students from the 1,021 students enrolled in their second to sixth year in a French medical school. Second- and
Applying Research to Practice Psychoactive substance consumption by medical students is worrisome. Preventive and educational programs at the university may be required to prevent and eliminate substance abuse among medical students. Students and practicing physicians could benefit from consultation and screening for psychoactive substance consumption at an occupational health service. Students’ wellbeing and stress must be considered by medical schools. Teaching students how to manage stress could be included in the curriculum. Medical schools should also ensure that their organization is not a source of unnecessary stress. A strong consistent correlation between physicians’ personal health practices, including their alcohol intake, and their counselling practices has been found. Healthier caregivers are better caregivers for their patients. third-year medical students are enrolled in the preclinical phase of their education; fourth-, fifth-, and sixth-year students are enrolled in the clinical phase and are preparing for a highly competitive national examination. This research was conducted in the context of a public health course. Eighteen students, supervised by a public health faculty member, designed and implemented this study. The study was approved by the University Medical School Board. Participants did not receive any financial compensation. Students were told the questionnaires were anonymous and their participation was entirely voluntary. Students were invited to participate primarily via an email invitation sent to all randomly selected students. Students were sent up to four email reminders that ceased with completion of the survey or their refusal to participate. Because the survey responses were anonymous, specific monitoring or referral to mental health resources for students who reported depression or suicidal ideation was impossible. However, participants were provided with systematic information, inviting them to seek care at the university health service in the case of alcohol, tobacco, drug, or mental health problems.
Survey Instrument Questionnaires were self-administered and included questions on student sociodemographic characteristics, their well-being and mental health, as well as standardized instruments on alcohol, tobacco, and illegal substance consumption. Well-being and mental health were assessed with simple closed-ended questions. To validate the results, multiple questions on the same topic were included for participants to answer. Alcohol consumption was assessed via the Alcohol Use Disorders Identification Test (AUDIT), a 10-item questionnaire 55
Downloaded from whs.sagepub.com at Yale University Library on July 21, 2015
Workplace Health & Safety
February 2015
Table 1. Reasons for Consumption Positive valence
Negative valence
Internal to the person
Reinforcement reasons
“Coping” reasons
I drink alcohol
I drink alcohol
because I like to drink alcohol
because it helps me when I am depressed or nervous
to forget my worries
to feel good
External to the person
Social reasons
Conformity reasons
I drink alcohol
I drink alcohol
because it allows me to enjoy an evening
to be part of a group
because it is an opportunity to celebrate
to be more sociable
Source. Windlin, Delgrande Jordan, and Kuntsche (2011).
that covers the domains of alcohol consumption (Questions 1-3), drinking behavior and dependence (Questions 4-6), and alcohol-related problems (Questions 7-10; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993). Each question was scored from 0 to 4; the range of possible scores was 0 to 40. The AUDIT test distinguishes between normal drinking, hazardous drinking, and harmful drinking. The French version of the AUDIT tool recommends a score of 13 to identify alcoholdependent individuals. The accepted score to identify hazardous drinkers is 7 for males and 6 for females (Gache et al., 2005). The WHO recommends a score of 11 or more in the original version to identify a potential alcohol problem, but currently the generally accepted score for adults with potential alcohol problems is 8 (Reinert & Allen, 2002). The AUDIT tool is widely used and has been validated in student populations. The study by Kokotailo et al. suggested that AUDIT is a valid instrument for alcohol screening in a college-age population (Kokotailo et al., 2004). Students at risk were identified in accordance with the internationally accepted score of 8. The conventional score of 8 has a sensitivity of 0.82 and a specificity of 0.78 to detect high-risk drinkers. Participants were also asked about their reasons for drinking. The reasons for alcohol consumption were classified as internal or external to the individual according to their “positive” or “negative” valence (Table 1; Windlin, Delgrande Jordan, & Kuntsche, 2011). “Positive” valence included the following reasons for alcohol consumption: “because I like it” or “because it allows me to celebrate or enjoy a party.” “Negative” valence included the following reasons for alcohol consumption: “because I am nervous or depressed,” or “because it’s a way to be a part of a group.” Smoking was assessed by the Fagerstrom test for nicotine dependence, a widely used and validated six-item questionnaire
(Heatherton, Kozlowski, Frecker, & Fagerström, 1991). The accepted score for identifying nicotine dependence is 4 or more and 6 or more for severe nicotine dependence. Cannabis consumption was assessed by the Cannabis Abuse Screening Test (CAST), a six-item scale (Legleye, Karila, Beck, & Reynaud, 2007) that identifies patterns of cannabis use leading to negative social or health consequences for the user or others. The researchers used the binary version of CAST. The binary and the full version of CAST are equally useful for cannabisrelated disorders screening (Legleye, Piontek, & Kraus, 2011). The accepted score for cannabis-related screening is 4. The questionnaire also included questions on other illegal substance use and the frequency of consumption during the previous 12 months.
Data Analysis Descriptive statistical analysis was used on responses to closed-ended questions and qualitative analysis was used on responses to open-ended questions. Quantitative variables were expressed as the mean and standard deviation or as percentages. A Pearson’s Chi-square test or a two-tailed Fisher’s exact test was used to compare percentages after assessing the conditions of test use. Student’s t test or Mann–Whitney twotailed test was used to compare means. Statistical significance was set at p < .05. All analyses used the Statistical Package for the Social Sciences (version 11.0, SPSS, Inc). Variables were dichotomized and included stage of medical education, gender, study years repeated, scholarships, stress, and substance use. Substance use was defined as abuse of at least one of the three substances, namely, alcohol, tobacco, and cannabis. Simple linear regression was used to assess the links
56 Downloaded from whs.sagepub.com at Yale University Library on July 21, 2015
Workplace Health & Safety
vol. 63 ■ no. 2
Table 2. Distribution and Response Rates by Year of Study Years of study
Number of students drawn
Number of students enrolled in the study
Participation rate %
Preclinical medical students
2nd year
62
53
85
3rd year
56
49
87
Clinical medical students
4th year
54
39
72
5th year
46
13
28
6th year
37
17
46
between substance use, stress, socioeconomic status, gender, and examination success. Multiple logistic regression was also used with significance set at p < .05.
Results In this group of 255 randomly selected medical students, 171 complete questionnaires were returned (67%). The distribution and response rates by medical school classification are summarized in Table 2. The sex ratio was 0.79 (75 males/95 females) and the average age was 22.1 years ± 1.7 (range = 17-28). Fifty-three percent of students had never repeated a year during medical school; 35% had repeated once, and 12% had repeated at least twice. One quarter of students had a scholarship, 30% of students lived with their parents, 32% came from families in which at least 1 parent was a health care professional, and 10% came from families in which both parents were health care professionals.
Alcohol Consumption The majority (97%) of students consumed alcohol. The results of the AUDIT score indicated that 11% of students were hazardous drinkers, 21% were harmful drinkers, and 68% were not at risk. Seventy-eight percent of students had been drunk on at least one occasion during the previous 12 months. The average number of drunk episodes during the previous year was 11.8 (±12.6). Over the past 12 months, 17% of students with a driver’s license had driven while drunk. Preclinical medical students more frequently engaged in risky or hazardous alcohol consumption (47%) than clinical medical students (16%; p < .05). No significant difference in alcohol consumption by economic status or parental occupation was observed. Analysis of responses to the various questions on the AUDIT tool showed a difference between male and female students in terms of the frequency of alcohol consumption, the number of drinks on each occasion, the ability to stop drinking, a history
of being injured or having injured someone else in an alcoholrelated context, and type of consumption (Table 3). The reasons for alcohol consumption are summarized in Figure 1. Students at at greater risk of hazardous or harmful alcohol consumption more frequently reported the following reasons for drinking compared with students reporting normal drinking •• •• •• •• •• •• ••
to forget their worries (26% vs. 12%, p < .05), pressure from friends (24% vs. 6%, p < .01), to enjoy a party (99% vs. 69%, p < .01), to be more sociable (71% vs. 35%, p < .01), because they like to drink alcohol (95% vs. 61%, p < .01), to fit into a group (70% vs. 27%, p < .01), to feel good (61% vs. 32%, p < .01).
Cigarette Smoking In this study population, 21% of students were regular tobacco smokers and another 16% were occasional smokers. Dependence scores were strong or very strong for 12% of students, and nearly two thirds of students (65%) reported very low dependence scores. The majority (74%) of smokers wanted to quit smoking. No significant difference was observed by gender, economic status, or parental occupation.
Illegal Substances The majority of students (77%) had used cannabis during the previous 12 months: 7% at least once a day, 14% several times a week, 12% several times a month, and about two thirds of students (65%) had used cannabis once a month or less. The responses to the CAST tool showed that 5% of cannabis users required health care and 10% should seriously consider the consequences of their consumption. No significant difference was observed by gender, economic status, or parental occupation. Cannabis users were found to more frequently fail their medical school examinations (89% vs. 39%, p < .01). One quarter of students (n = 41) had also used other illegal drugs during the previous 12 months, most commonly “poppers” (93%; alkyl, cyclic or aliphatic nitrites), followed by magic mushrooms (14%), LSD (lysergic acid diethylamide-25) and 57
Downloaded from whs.sagepub.com at Yale University Library on July 21, 2015
Workplace Health & Safety
February 2015
Table 3. Sample Characteristics of AUDIT Scores by Gender
Question
Replies
Women
Men
n (%)
n (%)
p values
research-article2015
WHSXXX10.1177/2165079915570917Workplace Health & SafetyWorkplace Health & Safety
Workplace Health & Safety
February 2015
ARTICLE
Alcohol, Cigarette, and Illegal Substance Consumption Among Medical Students A Cross-Sectional Survey M. Gignon, MD, PhD1,2,3, E. Havet, MD, PhD2, C. Ammirati, MD, PhD1,2, S. Traullé, MD2, C. Manaouil, MD, PhD2, T. Balcaen, MJ2,3, G. Loas, MD, PhD2, G. Dubois, MD, PhD2,3, and O. Ganry, MD, PhD2,3
Abstract: This study investigated addictive substance use by French medical students. A cross-sectional survey was distributed to 255 participants randomly selected from 1,021 second- to sixth-year medical students. Questionnaires were self-administered and included questions on sociodemographic characteristics, mental health, and alcohol (The Alcohol Use Disorders Identification Test [AUDIT test]), tobacco (Fagerstrom test), and illegal substance consumption (Cannabis Abuse Screening Test [CAST test]). The AUDIT scores indicated that 11% of the study participants were at risk for addiction and 21% were high-risk users. Tobacco dependence was strong or very strong for 12% of the participants. The CAST score showed that 5% of cannabis users needed health care services. Cannabis users were also more likely than non-users to fail their medical school examinations (89% vs. 39%, p < .01). One quarter of medical student participants (n = 41) had used other illegal drugs, and 10% of study participants had considered committing suicide during the previous 12 months. Psychoactive substance consumption by French medical students requires preventive measures, screening, and health care services.
Keywords: medical students, France, alcohol consumption, tobacco, cannabis
E
xcessive alcohol consumption and binge drinking among adolescents and young adults have been recognized as significant risk behaviors, increasing the likelihood of health problems, drunk driving, aggression, unsafe sexual activity, and accidents (Maddock, Laforge, Rossi, & O’Hare, 2001; Wechsler et al., 2002). Heavy drinking during adolescence and young adulthood is predictive of future alcohol-related problems and academic failure in certain groups (Jennison, 2004).
Heavy drinking is highly prevalent among college and university students (Hingson, Heeren, Winter, & Wechsler, 2005), including medical (Granville-Chapman, Yu, & White, 2001) and nursing students (Oliveira & Furegato, 2008). For many health professions students, alcohol consumption may be a way of coping with the stress of challenging curricula and clinical education (Henriquéz & Carvalho, 2008; Kjøbli et al., 2004). The known interaction between binge drinking and other drugrelated behaviors such as cannabis and cigarette smoking is also prevalent among medical students (Newbury-Birch, Walshaw, & Kamali, 2001). Cannabis use has been associated with a range of adverse effects (e.g., impaired attention, memory and psychomotor performance, traffic accidents, and depression) and social problems (e.g., low educational attainment; Hall & Solowij, 1998). Cannabis can also reduce symptoms of depression, psychopathology, and psychosocial distress (Delile, 2005; Ries, 1993). The harmful effects of substance use by health professions students are well described (Baldwin, Bartek, Scott, Davis-Hall, & DeSimone, 2009; Baldwin et al., 2008; Baldwin et al., 2006; Baldwin, Scott, DeSimone, Forrester, & Fankhauser, 2011). Consumption may be the cause or consequence of individual student challenges and academic success. In addition, physicians, particularly young physicians, are susceptible to psychological distress and addictions (Brooks, Chalder, & Gerada, 2011). Health professions students experience higher rates of depression, burnout, and mental illness than the general population, with deteriorating mental health during the course of their educational programs (Deasy, Coughlan, Pironom, Jourdan, & Mcnamara, 2014; Dyrbye et al., 2010; Dyrbye, Thomas, & Shanafelt, 2006; Givens & Tjia, 2002; Goebert et al., 2009). Medical students report higher rates of burnout (Dyrbye et al., 2008) and depressive symptoms associated with suicidal ideation (Dahlin, Joneborg, & Runeson, 2005; Tyssen, Vaglum, Grønvold, & Ekeberg, 2001), suicide (Hays, Cheever, & Patel, 1996), and
DOI: 10.1177/2165079915570917. From 1University Paris 13, 2Jules Verne University of Picardy, and 3Amiens University Hospital. Address correspondence to: M. Gignon, MD, PhD, Public Health Department, Amiens University Hospital, Amiens, France; email: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
54 Downloaded from whs.sagepub.com at Yale University Library on July 21, 2015
Workplace Health & Safety
vol. 63 ■ no. 2
impaired quality of life than age-matched populations. However, it is well documented that physicians are as healthy, or even healthier, than other comparable population groups (Frank & Segura, 2009). A medical career is more frequently associated with good health than with poor health (Aasland, Hem, Haldorsen, & Ekeberg, 2011). It could be assumed that medical students have ready access to health care in view of their studies and role in the health care system. Unfortunately, the literature does not confirm this assumption (Chew-Graham, Rogers, & Yassin, 2003; Rosenthal & Okie, 2005; Tjia, Givens, & Shea, 2005). Medical students engage in potentially harmful methods of coping, such as excessive alcohol consumption (Kjøbli et al., 2004). Strategies should therefore not only be repressive (i.e., zero tolerance for substance use or suspending and expelling students who transgress), but also provide a global preventive approach including harm minimization (e.g., school-based health promotion taking into account the assessment of the psychological, educational, economic, and social life of the students; Evans-Whipp et al., 2004). Although secondary schools commonly implement alcohol prevention policies to reduce alcohol misuse, the efficacy of these policies has only been rarely evaluated (Evans-Whipp, Plenty, Catalano, Herrenkohl, & Toumbourou, 2013). Alcohol consumption in the World Health Organization (WHO) European regions is high (Rehm, Taylor, & Patra, 2006). Mortality due to diseases related to excessive alcohol consumption in the study university is significantly higher than that in other parts of France (Beck, Legleye, Le Nézet, & Spilka, 2005). A reduction in alcohol consumption, especially among young people, is one of the five regional health priorities. In France, the sale of alcohol and tobacco is prohibited to individuals less than 18 years of age. French law prohibits smoking in all public places and the possession of drugs, including cannabis, is prohibited and illegal. Consumption of alcohol and other addictive substances by students is a major concern at the study university. To define the most appropriate prevention and health care strategies, the researchers asked medical students about their alcohol, smoking, and drug-related behaviors. The use of psychoactive substances raised questions about the ability of these students to succeed in medical school and meet their future professional responsibilities. This study investigated addictive substance consumption by French medical students and possible associations between this consumption and personal and school-based characteristics in an attempt to identify patterns that could guide prevention policies and strategies.
Method A cross-sectional survey was conducted from March 2011 to May 2011 by randomly selecting (using an interval of 4) 255 medical students from the 1,021 students enrolled in their second to sixth year in a French medical school. Second- and
Applying Research to Practice Psychoactive substance consumption by medical students is worrisome. Preventive and educational programs at the university may be required to prevent and eliminate substance abuse among medical students. Students and practicing physicians could benefit from consultation and screening for psychoactive substance consumption at an occupational health service. Students’ wellbeing and stress must be considered by medical schools. Teaching students how to manage stress could be included in the curriculum. Medical schools should also ensure that their organization is not a source of unnecessary stress. A strong consistent correlation between physicians’ personal health practices, including their alcohol intake, and their counselling practices has been found. Healthier caregivers are better caregivers for their patients. third-year medical students are enrolled in the preclinical phase of their education; fourth-, fifth-, and sixth-year students are enrolled in the clinical phase and are preparing for a highly competitive national examination. This research was conducted in the context of a public health course. Eighteen students, supervised by a public health faculty member, designed and implemented this study. The study was approved by the University Medical School Board. Participants did not receive any financial compensation. Students were told the questionnaires were anonymous and their participation was entirely voluntary. Students were invited to participate primarily via an email invitation sent to all randomly selected students. Students were sent up to four email reminders that ceased with completion of the survey or their refusal to participate. Because the survey responses were anonymous, specific monitoring or referral to mental health resources for students who reported depression or suicidal ideation was impossible. However, participants were provided with systematic information, inviting them to seek care at the university health service in the case of alcohol, tobacco, drug, or mental health problems.
Survey Instrument Questionnaires were self-administered and included questions on student sociodemographic characteristics, their well-being and mental health, as well as standardized instruments on alcohol, tobacco, and illegal substance consumption. Well-being and mental health were assessed with simple closed-ended questions. To validate the results, multiple questions on the same topic were included for participants to answer. Alcohol consumption was assessed via the Alcohol Use Disorders Identification Test (AUDIT), a 10-item questionnaire 55
Downloaded from whs.sagepub.com at Yale University Library on July 21, 2015
Workplace Health & Safety
February 2015
Table 1. Reasons for Consumption Positive valence
Negative valence
Internal to the person
Reinforcement reasons
“Coping” reasons
I drink alcohol
I drink alcohol
because I like to drink alcohol
because it helps me when I am depressed or nervous
to forget my worries
to feel good
External to the person
Social reasons
Conformity reasons
I drink alcohol
I drink alcohol
because it allows me to enjoy an evening
to be part of a group
because it is an opportunity to celebrate
to be more sociable
Source. Windlin, Delgrande Jordan, and Kuntsche (2011).
that covers the domains of alcohol consumption (Questions 1-3), drinking behavior and dependence (Questions 4-6), and alcohol-related problems (Questions 7-10; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993). Each question was scored from 0 to 4; the range of possible scores was 0 to 40. The AUDIT test distinguishes between normal drinking, hazardous drinking, and harmful drinking. The French version of the AUDIT tool recommends a score of 13 to identify alcoholdependent individuals. The accepted score to identify hazardous drinkers is 7 for males and 6 for females (Gache et al., 2005). The WHO recommends a score of 11 or more in the original version to identify a potential alcohol problem, but currently the generally accepted score for adults with potential alcohol problems is 8 (Reinert & Allen, 2002). The AUDIT tool is widely used and has been validated in student populations. The study by Kokotailo et al. suggested that AUDIT is a valid instrument for alcohol screening in a college-age population (Kokotailo et al., 2004). Students at risk were identified in accordance with the internationally accepted score of 8. The conventional score of 8 has a sensitivity of 0.82 and a specificity of 0.78 to detect high-risk drinkers. Participants were also asked about their reasons for drinking. The reasons for alcohol consumption were classified as internal or external to the individual according to their “positive” or “negative” valence (Table 1; Windlin, Delgrande Jordan, & Kuntsche, 2011). “Positive” valence included the following reasons for alcohol consumption: “because I like it” or “because it allows me to celebrate or enjoy a party.” “Negative” valence included the following reasons for alcohol consumption: “because I am nervous or depressed,” or “because it’s a way to be a part of a group.” Smoking was assessed by the Fagerstrom test for nicotine dependence, a widely used and validated six-item questionnaire
(Heatherton, Kozlowski, Frecker, & Fagerström, 1991). The accepted score for identifying nicotine dependence is 4 or more and 6 or more for severe nicotine dependence. Cannabis consumption was assessed by the Cannabis Abuse Screening Test (CAST), a six-item scale (Legleye, Karila, Beck, & Reynaud, 2007) that identifies patterns of cannabis use leading to negative social or health consequences for the user or others. The researchers used the binary version of CAST. The binary and the full version of CAST are equally useful for cannabisrelated disorders screening (Legleye, Piontek, & Kraus, 2011). The accepted score for cannabis-related screening is 4. The questionnaire also included questions on other illegal substance use and the frequency of consumption during the previous 12 months.
Data Analysis Descriptive statistical analysis was used on responses to closed-ended questions and qualitative analysis was used on responses to open-ended questions. Quantitative variables were expressed as the mean and standard deviation or as percentages. A Pearson’s Chi-square test or a two-tailed Fisher’s exact test was used to compare percentages after assessing the conditions of test use. Student’s t test or Mann–Whitney twotailed test was used to compare means. Statistical significance was set at p < .05. All analyses used the Statistical Package for the Social Sciences (version 11.0, SPSS, Inc). Variables were dichotomized and included stage of medical education, gender, study years repeated, scholarships, stress, and substance use. Substance use was defined as abuse of at least one of the three substances, namely, alcohol, tobacco, and cannabis. Simple linear regression was used to assess the links
56 Downloaded from whs.sagepub.com at Yale University Library on July 21, 2015
Workplace Health & Safety
vol. 63 ■ no. 2
Table 2. Distribution and Response Rates by Year of Study Years of study
Number of students drawn
Number of students enrolled in the study
Participation rate %
Preclinical medical students
2nd year
62
53
85
3rd year
56
49
87
Clinical medical students
4th year
54
39
72
5th year
46
13
28
6th year
37
17
46
between substance use, stress, socioeconomic status, gender, and examination success. Multiple logistic regression was also used with significance set at p < .05.
Results In this group of 255 randomly selected medical students, 171 complete questionnaires were returned (67%). The distribution and response rates by medical school classification are summarized in Table 2. The sex ratio was 0.79 (75 males/95 females) and the average age was 22.1 years ± 1.7 (range = 17-28). Fifty-three percent of students had never repeated a year during medical school; 35% had repeated once, and 12% had repeated at least twice. One quarter of students had a scholarship, 30% of students lived with their parents, 32% came from families in which at least 1 parent was a health care professional, and 10% came from families in which both parents were health care professionals.
Alcohol Consumption The majority (97%) of students consumed alcohol. The results of the AUDIT score indicated that 11% of students were hazardous drinkers, 21% were harmful drinkers, and 68% were not at risk. Seventy-eight percent of students had been drunk on at least one occasion during the previous 12 months. The average number of drunk episodes during the previous year was 11.8 (±12.6). Over the past 12 months, 17% of students with a driver’s license had driven while drunk. Preclinical medical students more frequently engaged in risky or hazardous alcohol consumption (47%) than clinical medical students (16%; p < .05). No significant difference in alcohol consumption by economic status or parental occupation was observed. Analysis of responses to the various questions on the AUDIT tool showed a difference between male and female students in terms of the frequency of alcohol consumption, the number of drinks on each occasion, the ability to stop drinking, a history
of being injured or having injured someone else in an alcoholrelated context, and type of consumption (Table 3). The reasons for alcohol consumption are summarized in Figure 1. Students at at greater risk of hazardous or harmful alcohol consumption more frequently reported the following reasons for drinking compared with students reporting normal drinking •• •• •• •• •• •• ••
to forget their worries (26% vs. 12%, p < .05), pressure from friends (24% vs. 6%, p < .01), to enjoy a party (99% vs. 69%, p < .01), to be more sociable (71% vs. 35%, p < .01), because they like to drink alcohol (95% vs. 61%, p < .01), to fit into a group (70% vs. 27%, p < .01), to feel good (61% vs. 32%, p < .01).
Cigarette Smoking In this study population, 21% of students were regular tobacco smokers and another 16% were occasional smokers. Dependence scores were strong or very strong for 12% of students, and nearly two thirds of students (65%) reported very low dependence scores. The majority (74%) of smokers wanted to quit smoking. No significant difference was observed by gender, economic status, or parental occupation.
Illegal Substances The majority of students (77%) had used cannabis during the previous 12 months: 7% at least once a day, 14% several times a week, 12% several times a month, and about two thirds of students (65%) had used cannabis once a month or less. The responses to the CAST tool showed that 5% of cannabis users required health care and 10% should seriously consider the consequences of their consumption. No significant difference was observed by gender, economic status, or parental occupation. Cannabis users were found to more frequently fail their medical school examinations (89% vs. 39%, p < .01). One quarter of students (n = 41) had also used other illegal drugs during the previous 12 months, most commonly “poppers” (93%; alkyl, cyclic or aliphatic nitrites), followed by magic mushrooms (14%), LSD (lysergic acid diethylamide-25) and 57
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Workplace Health & Safety
February 2015
Table 3. Sample Characteristics of AUDIT Scores by Gender
Question
Replies
Women
Men
n (%)
n (%)
p values
