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Work-related stress and cognitive enhancement among university teachers ab

Constantin Wiegel , Sebastian Sattler Diewald

bcd

e

, Anja S. Göritz & Martin

b

a

International Institute for Empirical Social Economics, Stadtbergen, Germany b

Faculty of Sociology, Bielefeld University, Bielefeld, Germany

c

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Institute for Sociology and Social Psychology, University of Cologne, Cologne, Germany d

Cologne Graduate School in Management, Economics and Social Sciences, University of Cologne, Cologne, Germany e

Department of Psychology, University of Freiburg, Freiburg, Germany Accepted author version posted online: 09 Mar 2015.Published online: 10 Apr 2015.

To cite this article: Constantin Wiegel, Sebastian Sattler, Anja S. Göritz & Martin Diewald (2015): Work-related stress and cognitive enhancement among university teachers, Anxiety, Stress, & Coping: An International Journal, DOI: 10.1080/10615806.2015.1025764 To link to this article: http://dx.doi.org/10.1080/10615806.2015.1025764

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Anxiety, Stress, & Coping, 2015 http://dx.doi.org/10.1080/10615806.2015.1025764

Work-related stress and cognitive enhancement among university teachers Constantin Wiegela,b, Sebastian Sattlerb,c,d*, Anja S. Göritze and Martin Diewaldb

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a International Institute for Empirical Social Economics, Stadtbergen, Germany; bFaculty of Sociology, Bielefeld University, Bielefeld, Germany; cInstitute for Sociology and Social Psychology, University of Cologne, Cologne, Germany; dCologne Graduate School in Management, Economics and Social Sciences, University of Cologne, Cologne, Germany; eDepartment of Psychology, University of Freiburg, Freiburg, Germany

(Received 2 February 2013; accepted 1 March 2015) Background: Working conditions of academic staff have become increasingly complex and occupational exposure has risen. This study investigates whether work-related stress is associated with the use of prescription drugs for cognitive enhancement (CE). Methods: The study was designed around three web-based surveys (n1 = 1131; n2 = 936; n3 = 906) to which university teachers at four German universities were asked to respond. It assessed past CE-drug use and the willingness to use CE-drugs as factors influencing future use. Overlap among participants across the surveys allowed for analyses of stability of the results across time. Results: Our study suggests a currently very low prevalence of CE-drug use as well as a low willingness to use such drugs. The results showed a strong association between perceptions of work-related stress and all measures of CE-drug use (when controlling for potential confounding factors). They also showed that past use of CE-drugs increased participants’ willingness to use them again in the future, as did lower levels of social support. Two different measures showed that participants’ moral qualms against the use of CE-drugs decreased their probability of using them. Conclusions: The results increase our knowledge about the prevalence of CE-drug use and our understanding of what motivates and inhibits the use of CE-drug. Keywords: work-related stress; cognitive enhancement; non-medical use of prescription drugs; moral perceptions; social support; drug instrumentalization

Introduction Working conditions in academia have become increasingly complicated, and academics perceive their work as increasingly stressful (Barkhuizen, Rothmann, & van de Vijver, 2014; Kataoka, Ozawa, Tomotake, Tanioka, & King, 2014; Mark & Smith, 2012). In Germany, half of full-time professors and about a third of non-professorial staff describe their job as “very stressful” (Jakob & Teichler, 2011). Similar findings exist for other countries (e.g., Winefield & Jarrett, 2001). But despite this, research on work-related stress and coping strategies in academia is scarce (Abouserie, 1996; Brown et al., 1986; Hogan, Carlson, & Dua, 2002). Our study aims therefore to examine the use of cognitive enhancement (CE) drugs as a response to work-related stress. *Corresponding author. Email: [email protected] Constantin Wiegel and Sebastian Sattler contributed equally to the manuscript. © 2015 Taylor & Francis

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CE can be defined as the augmentation of cognitive performance without medical indication (Bostrom & Sandberg, 2009; Glannon, 2008; Normann & Berger, 2008). One frequently discussed means of CE is pharmaceuticals, especially prescription drugs, which are investigated here. Other pharmaceuticals that are used for CE include over-thecounter and illegal drugs (e.g., Eickenhorst, Klapp, & Groneberg, 2012; Middendorff, Poskowsky, & Isserstedt, 2012). These are not investigated here. Prescription drugs potentially used to enhance cognitive capacities such as memory or attention include methylphenidate, amphetamine–dextroamphetamine, donepezil, and modafinil (e.g., Greely et al., 2008). With the exception of a few anecdotal reports of professors using modafinil to enhance productivity or reduce jetlag, little is known about the use of CE-drugs among academic staff (Sahakian & Morein-Zamir, 2007). The use of CE-drugs is not without risks, including side effects and long-term health consequences, such as headaches, high blood pressure, cardiac dysrhythmia, depression, and addiction (e.g., Greely et al., 2008; Winder-Rhodes et al., 2010). Self-medication with such drugs can pose increased risks due to the unknown dosage for healthy individuals, the dangers of counterfeit drugs, and the potentially dangerous combining of different substances (e.g., Maher, 2008; Sussman, Pentz, Spruijt-Metz, & Miller, 2006). The present research seeks to understand self-medication with CE-drugs to enhance cognitive performance by applying a decision-making approach (Gibbons, Gerrard, Blanton, & Russell, 1998; Gibbons, Houlihan, & Gerrard, 2009; Sattler, Sauer, Mehlkop, & Graeff, 2013; Sattler & Wiegel, 2013). In seeking to achieve their goals, individuals face personal and social constraints that facilitate or impede goal attainment. Similar assumptions can also be found in the Self-Medication Hypothesis (West, 2005), which posits that individuals intentionally choose (addictive) drugs in order to reduce cognitive interference or to deal with certain deficits or psychological problems while nonetheless bearing in mind the negative aspects of such self-medication (Khantzian, 1997). This hypothesis has been also discussed in the context of CE, since individuals intentionally enhance their cognitive performance through self-medication while taking into account the potential health risks (Sattler et al., 2013; Sattler & Wiegel, 2013). The discussion of instrumentalized psychoactive drug use – in which drug use is seen as a “functional adaption to modern environments” (Müller & Schumann, 2011) and as a means of coping with demands (cf. Crutchfield & Gove, 1984) – has been applied to CEdrug use as well (Sattler et al., 2013; Sattler & Wiegel, 2013). For university teachers, stress is often a function of the pressure to balance teaching load, research, and administrative duties within a limited amount of time (Brown et al., 1986). Recently, decreasing job security, university reorganization, higher self-expectations, and more pressure to secure funding have also contributed to stress (Hogan et al., 2002; Mark & Smith, 2012; Thorsen, 1996). Current university jobs are comparable to jobs in the business world in their constant demand for a high level of cognitive and physical performance, whereby employees often lack time to recover from these pressures (Müller & Schumann, 2011; Weber & JaekelReinhard, 2000). Consequently, the use of CE-drugs with the aim of reducing fatigue or increasing mental alertness for work purposes, for example, might be seen as a potentially beneficial “self-medicating answer to difficulties” (Crutchfield & Gove, 1984, p. 503). Drug users might use medication to prolong or re-establish desired mental states, such as feeling alert or being able to focus even after long periods of work (Müller & Schumann, 2011). As work performance suffers due to stress, and individuals attempt to minimize or

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avoid this undesirable effect, we expect CE-drug use to increase accordingly in response. This expectation is supported by studies of other populations in which stressful working conditions have been associated with the use of substances such as alcohol and illicit and prescription drugs (Martin, Blum, & Roman, 1992; Zhang & Snizek, 2003). Accordingly, we propose the following hypothesis (H): H1work-related stress: The higher the self-perceived work-related stress, the higher the likelihood of using CE-drugs.

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In addition to the relationship between work-related stress and CE-drug use, we also investigated other factors that might be related to CE-drug use or used for coping with stress. Based on previous research and theoretical reasoning, we tested several hypotheses related to the following factors: Prior CE-drug use: While some people may experiment with drugs only once, others continue using them for a variety of reasons, such as having had a positive experience (cf. Müller & Schumann, 2011). Previous research has shown that prior CE-drug use makes subsequent use more likely (cf. Sattler & Wiegel, 2013) and that prior CE-drug use is associated with a higher willingness to use CE-drugs again (Sattler, Mehlkop, Graeff, & Sauer, 2014). The latter finding is consistent with the Theory of Planned Behavior (Beck & Ajzen, 1991; Ouellette & Wood, 1998), which postulates that past behavior predicts intentions and future behavior. It can be assumed that CE-drug users have already reached a decision that corresponds to their preferences, and that decisions are also influenced by other factors, such as lack of self-control (Beck & Ajzen, 1991; Nagin & Pogarsky, 2001). If these factors are stable over time, they should continue to affect subsequent choices similarly. The influence of prior use may be due to the role of experience and habituation and/or to unobserved characteristics related to a willingness to use drugs. Moreover, if a CE-drug user’s expectations of a drug’s effects are confirmed, this behavior might be engaged in repeatedly without additional deliberation (Ouellette & Wood, 1998). There is also evidence that CE-drug users perceive the side effects of such substances to be less severe than non-users do (Sattler & Wiegel, 2013). We propose the following hypothesis: H2prior

CE-drug use:

Prior CE-drug use increases the likelihood of repeated CE-drug use.

Moral perceptions: Scholars have discussed whether the use of performance-enhancing medication is an unfair means of achieving success (Bostrom & Sandberg, 2009; Farah et al., 2004; Greely et al., 2008). Studies have found that many people perceive CE-drug use as morally problematic, as a form of cheating that not only disadvantages others, but also puts pressure on them to use such drugs as well (Bell, Partridge, Lucke, & Hall, 2013; Forlini & Racine, 2009). Several studies (Ajzen, 1991; Bachman, Paternoster, & Ward, 1992; Beck & Ajzen, 1991; Bishop, 1984) have shown that moral perceptions have a strong impact on decision-making and subsequent behavior. Such moral perceptions can be seen as “internal controls” (Cochran, Chamlin, Wood, & Sellers, 1999). They can threaten individuals with feelings of guilt or shame if they behave immorally (Grasmick & Bursik, 1990). These threats can be perceived by individuals as costly (e.g., in terms of reduced self-esteem or psychological discomfort) and deter them from choosing morally problematic behavior by reducing its expected utility. Previous research

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has found that moral qualms reduced respondents’ willingness to take CE-drugs (Riis, Simmons, & Goodwin, 2008; Sattler et al., 2013, 2014). We propose the following hypothesis:

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H3moral perceptions: The more the use of CE-drugs is perceived as immoral, the less likely CE-drugs will be used.

Social support: Social support is an important resource that helps people achieve life goals and deal with the problems of everyday life (House & Kahn, 1985), such as workrelated stress. Several studies report that social support and high quality interactions with friends and family members help to protect against illicit drug use, alcohol use, and drug dependency (e.g., Bergen, Gardner, Aggen, & Kendler, 2008; Steptoe, Wardle, Pollard, Canaan, & Davies, 1996). There are two main types of social support: instrumental support refers to concrete, tangible assistance in case of material or physical need, and emotional support provides empathy, concern, and encouragement (House, 1981). University teachers who perceive themselves as possessing a good deal of social support might be more successful and satisfied with their lives in general (Cohen & Syme, 1985; Thoits, 1982) and thus have less incentive to enhance their functioning through CE-drugs. Social support is also a resource for coping with the demands of everyday life and the burdens of stressful situations or phases of life. Thus, we assume that CE is a resource or strategy used to deal with these demands and burdens and thus to compensate for a deficiency of social support. Accordingly, we hypothesize that university teachers with low social support are more likely to use CE-drugs than those with high social support: H4social

support:

Social support decreases the likelihood of CE-drug use.

In summary, in three surveys among German university teachers we test whether higher work-related stress, prior CE-drug use, lower moral qualms against CE-drug use, and smaller amount of social support are associated with higher CE-drug use. Methods Design For study 1 of our three web-based surveys, we randomly selected four German universities and 55 academic disciplines from a list provided by the Federal Statistical Office of all universities and existing academic disciplines. All teachers listed in the respective university calendars for the current semester were contacted (Table 1). All teachers (still) listed in the two subsequent semester calendars of the same universities and academic disciplines were contacted (again) for study 2 (6 months later) and study 3 (12 months later). The use of the same sampling procedure for the three studies resulted in overlapping respondents (see below), but due to retirement, job changes, sabbaticals, etc., several university teachers contacted in study 1 were not contacted for studies 2 and 3, and instead replaced by new respondents, such as newly hired colleagues. University teachers received notification letters explaining the purpose of the study followed by e-mail invitations sent approximately a week later. Up to two e-mail reminders were sent. The letters explained that participants could choose one of four rewards (each worth 5 Euro) at the end of the questionnaire (i.e., a payment via PayPal, a voucher for an online store, a donation to a local charity, or a donation to a

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Table 1. Study characteristics and descriptive information. Study

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Period of data collection Sample statistics Number of contacts Number of respondents Response rate (%) Number of analyzed cases Dependent variables CE Willingness-Scale (M; SD) CE Willingness-Dummy (Yes, %) Prior CE-drug use (Yes, %) Independent variables Work-related stress (M; SD) Moral perceptions (version 1; M; SD) Moral perceptions (version 2; M; SD) Social support (M; SD) Demographic variables Female (%) Age (median)b High status (%) Medical/health-related disciplines (%)

1

2

3

26 August 2010– 5 October 2010

8 March 2011– 15 April 2011

30 August 2011– 16 October 2011

3618 1460 40.36 1131

3655 1402 38.36 936

3916 1399 35.72 906

.37 (.90) –a .88%

–a 11.86 –a

–a 13.58 –a

2.40 (0.83) –a –a –a

2.53 (.85) 3.65 (2.03) –a –a

2.49 (.82) –a 4.42 (1.33) 2.54 (.50)

34.57 36–40 16.62 11.76

35.58 36–40 21.41 12.07

33.33 36–40 17.00 10.82

a Not assessed in this study; branging from 0 = “below 20”; 1 = “20–25”; 2 = “26–30”; 3 = “31–35”; 4 = “36– 40”; 5 = “41–45”; 6 = “46–50”; 7 = “51–55”; 8 = “56–60”; 9 = “61–65”; 10 = “66–70” to 11 = “71 and above.”

global charity). The letter, the e-mail invitations, and the first page of the questionnaire emphasized that participation in the studies was voluntary and anonymous and that data security was a priority. A data protection officer allocated a token consisting of six random letters to every teacher. This token was part of a personal survey link, which was automatically transmitted to our survey software during participation. It allowed an anonymous linkage of the responses across the three studies. All procedures were approved by the legal services of Bielefeld University. Since the respondents were informed about this procedure, participation can be understood as implied consent. Similar response rates (comparable to Blix, Cruise, Mitchell, & Blix, 1994; Daniels & Guppy, 1992) were achieved in all studies (Table 1). In study 1, we have valid responses for all variables of 1131 respondents, 936 in study 2 and 906 in study 3. Linking the data from responding university teachers in more than one study (n1∩2 = 429; n1∩3 = 364; n2∩3 = 372; n1∩2∩3 = 219) allowed us to perform tests on the stability of repeated measures and on the robustness of results across different measures.

Dependent variables The prevalence of CE-drug use has been reported to be below 5% among German students (Franke et al., 2011; Sattler & Wiegel, 2013), but the prevalence among university teachers

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is unknown. It has been postulated, however, that CE-drug use is increasing (e.g., Castaldi et al., 2012; Farah et al., 2004). One method of determining whether such a trend exists is measuring respondents’ willingness to use CE-drugs. In research on the use of (licit and illicit) substances, willingness-measures can be seen as proximal antecedents of future behavior (Gerrard et al., 2006; Gibbons, Gerrard, Blanton, et al., 1998; Gibbons, Gerrard, Ouellette, & Burzette, 1998). Imperfect correlations between willingness and behavior may be explained by changes in behavioral restrictions over time (cf. Grasmick & Bursik, 1990). Willingness-measures have the additional advantage of eliciting fewer refusals to answers to questions about the willingness to conduct a certain behavior as they are less sensitive than measures of behavior (e.g., Gibbons, Gerrard, Blanton, et al., 1998).

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Willingness to use CE In study 1, CE-drug use willingness was measured on a scale ranging from 0 = “very unlikely” to 5 = “very likely” in response to the following question: “Some university teachers boost their cognitive abilities with the help of prescription drugs, though there is no medical need (e.g., for mental concentration, memory, or vigilance). Regardless of whether or not you have done so in the past, can you imagine doing something like that?” (cf. Sattler & Wiegel, 2013). In studies 2 and 3, we used the same question but with dichotomous response categories; 0 = “No, I would not do that under any circumstances”; 1 = “Yes, I would do that under certain circumstances.” Prior CE-drug use Prior CE-drug use was measured in study 1 using the same introduction as for the willingness-measure and asking: “Have you ever done that?” Five response categories were provided: 0 = “no, never”; 1 = “yes, within the last 30 days”; 2 = “yes, between the last 30 days and 6 months”; 3 = “yes, between the last 6 months and 1 year”; 4 = “yes, more than 1 year ago.” Due to the low prevalence, we computed a dichotomous variable indicating no use (0) and use (1). Independent variables Work-related stress All three studies employed the work-related stress-scale developed by Enzmann and Kleiber (1989) consisting of six items, such as “I often feel overburdened.” Responses ranged from 1 = “not applicable at all” to 5 = “completely applicable.” Due to the onedimensional factorial structure and the good internal consistency of this measure (Cronbach’s αs in study 1: 0.83; study 2: 0.84; and study 3: 0.83), mean values across all items were computed (Table 1). Moral perceptions (two versions) In study 2, moral perceptions (version 1) regarding CE-drug use were measured using the question: “How do you personally evaluate the use of prescription drugs to enhance work performance without any medical necessity?” on a 7-point scale ranging from 0 = “not correct at all” to 6 = “fully correct” (sample item: “It gives me a bad conscience” (Sattler et al., 2013). Internal consistency of the scale was good (α = 0.89) and factorial

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structure one-dimensional. To test the robustness of results for moral perceptions, study 3 used another instrument, which referred to the concept of the “oughtness” of social norms (version 2): “One should take prescription drugs to enhance cognitive performance only if a physician prescribed them.” Participants responded to three items: “Do you think this norm is important or not important?” ranging from 0 = “very unimportant” to 6 = “very important; “How do you evaluate people transgressing the norm?” ranging from 0 = “very negative” to 6 = “very positive,” reverse coded; and “Do you agree with the norm?” ranging from 0 = “never” to 6 = “always.” The scale had a satisfactory consistency (α = 0.76) and a one-dimensional structure, so the mean value was computed. This instrument refers to the theoretical concept by Lindenberg, Joly, and Stapel (2011, retracted). It is important to point out that although the third author of this retracted paper manipulated the data-set without the knowledge of his coauthors, the results of our study are not affected by this manipulation. However, our operationalization of the norm variables was guided by this paper. We believe that this operationalization captures the notion of norms provided by Hechter and Opp (2005).

Social support In study 3, perceived social support was assessed by using the Berlin Social Support Scales (Schulz & Schwarzer, 2003). Four items each covered emotional (sample item: “There is always someone there for me when I need comforting”) and instrumental support (“There are people who offer me help when I need it”). We used a scale with anchors 1 = “not at all true,” 2 = “barely true,” 3 = “moderately true,” 4 = “exactly true.” Factor analysis revealed a one-dimensional structure. The internal consistency was 0.92. To save space for reporting, we used the combined scale, because similar results were found when using emotional and instrumental support separately (see supplementary Table S5).

Prior CE-drug use In addition to analyzing prior CE-drug use as a dependent variable, which is common in research on CE-drug use (Franke et al., 2011; Wolff & Brand, 2013), it was also used as an independent variable to examine whether it is a precondition for the willingness to use CE-drugs (cf. Sattler et al., 2014; see the list of dependent variables above and H2prior CEdrug use in the introduction).

Demographic variables Women were coded “1” and men “0.” Age was assessed with 11 categories (see Table 1, also for the other demographics). We grouped disciplines into either medical and healthrelated disciplines (coded “1) or other (“0”). High-status individuals (full and assistant professors) were coded “1” and all others were coded “0” indicating a lower status. A correlation matrix of all key study variables can be found in supplementary tables (see Tables S6a–S6c).

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Statistical analysis

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Negative binomial regression models were applied in study 1 to analyze the effects of the predictors on the CE willingness scale, because of highly skewed responses (skewness = 2.98) and overdispersion (p < .001). In such a case, these models are less likely to produce biased estimates than ordinary least squares regressions (Long & Freese, 2001). For these models incidence-rate ratios (IRR) are reported. An IRR greater than 1 indicates a positive effect of the independent variable on the outcome variable. An IRR smaller than 1 points to a negative effect, while an IRR equal to 1 indicates no effect. To analyze the effects of the predictors on the dichotomous measures of willingness to take CE-drugs (studies 2 and 3), logit regression models (e.g., Long & Freese, 2001) were applied. For both types of logit analyses, odds ratios (OR) are reported. An OR greater than 1 indicates a positive effect of the independent variable on the outcome variable. An OR smaller than 1 points to a negative effect, while an OR equaling 1 indicates no effect.

Results Willingness to use CE-drugs In study 1, 79.6% of the respondents deemed any personal future use of CE-drugs as very unlikely (Table 1). The rates of refusal to use CE-drugs were similar across studies 2 (88.1%) and 3 (86.4%). The results indicate that willingness was similar across times of measurement and different measures. Furthermore, the overlap of respondents in our series of three studies allowed for more informative stability tests among respondents. We used the willingness-measures from earlier studies to test their associations with the willingness-measures in subsequent studies using logit regression models. If the willingness observed in study 1 increased by one unit on the 6-point scale, the odds of reporting willingness to use CE-drugs would have increased by 128% (OR = 2.28, p < .001, N = 429) in study 2 and by 163% (OR = 2.63; p < .001, N = 364) in study 3. Willingness also increased in study 3 (OR = 25.49, p < .001, N = 372), if university teachers reported being willing to use CEdrugs in study 2. These results demonstrate the high stability of willingness to use CE-drugs. In the next step, we investigated factors that potentially influenced this willingness by applying negative binomial regression models in study 1. We found that an increase of work-related stress by one unit significantly (p < .001) increased this willingness, by 68% (IRR = 1.68) (see Model 1 in Table 2 for study 1, Model 3 in Table 2 for study 2, and Model 1 in Table 3 for study 3). In all models, the effects of work-related stress were robust against potentially confounding factors. Therefore, H1work-related stress was supported. We also found that prior CE-drug use increased the willingness by a factor of 6.75 (p < .010, see Model 2 in Table 2), which supports H2prior CE-drug use. Furthermore, the inclusion of prior use was also a test for the robustness of the stress effect because this variable may measure unobserved influences. We found that the effect of work-related stress remained significant after controlling for “prior CE use.” Moreover, both measures of moral perceptions were negatively associated with willingness (for version 1, see Model 4 in Table 2, and for version 2 see Model 2 in Table 3), thereby supporting H3moral perceptions. Furthermore, we found the hypothesized protective effect of social support, which supports H4social support (see Model 3 in Table 3). We also considered a stress-buffering effect of social support (e.g., Viswesvaran, Sanchez, & Fisher, 1999) on willingness to use CE-drugs, which means that high social support decreases the effect of work-related stress on willingness. We found

Study 1 (n = 1131) Model 1 IRR Work-related stress Female (=yes) Age Medical/health (=yes) High status (=yes) Prior CE-drug use (=yes) Moral perceptions (version 1) AIC χ2

1.68*** 0.98 0.93 0.93 1.08

Model 2

[95% CI] [1.41, [0.73, [0.87, [0.58, [0.69,

–a 1694.93 38.70

Study 2 (n = 936)

2.00] 1.34] 1.00] 1.49] 1.67]

IRR 1.65*** 0.98 0.94 0.98 1.11 6.75** –a

Model 3

[95% CI] [1.39, [0.72, [0.88, [0.62, [0.72, [2.15, 1681.34 54.28

1.96] 1.33] 1.02] 1.55] 1.70] 2.12]

OR 1.65*** 0.59* 0.94 0.87 0.71 –a

Model 4

[95% CI] [1.29, [0.37, [0.85, [0.45, [0.39,

669.99 23.61

2.10] 0.94] 1.05] 1.67] 1.27]

OR 1.78*** 0.57* 0.95 0.96 0.59 –a 0.67***

[95% CI] [1.38, [0.35, [0.85, [0.49, [0.32,

2.30] 0.92] 1.06] 1.89] 1.08]

[0.61, 0.75] 612.76 82.84

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Table 2. Multiple negative binomial regression models (Models 1 and 2) and multiple logistic regression models (Models 3 and 4) to assess associations of work-related stress, gender, age, discipline (medical/health vs. others), professional status, prior CE-drug use, and moral perception (version 1) with willingness to use CE-drugs.

Note: Model 1 shows that increasing work-related stress increases the willingness to use CE-drugs in study 1. Model 2 shows that prior CE-drug use also increases this willingness. Model 3 replicates the effect of work-related stress in study 2 and shows a lower CE-drug use willingness among females. Model 4 shows that stronger moral qualms about CE-drug use (version 1) decrease the CE-drug use willingness. n, number of observations; IRR, incidence rate ratio; OR, odds ratio; CI, confidence interval; AIC, Akaike information criterion. a Not assessed in this study. *p < .05, **p < .01, ***p < .001.

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Table 3. Multiple logistic regression models to assess associations of work-related stress, gender, age, discipline (medical/health vs. others), status, moral perceptions (version 2), and social support with willingness to use CE-drugs. Study 3 (n = 906) Model 1

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OR Work-related stress Female (=yes) Age Medical/health (=yes) High status (=yes) Moral perceptions (version 2) Social support AIC χ2

Model 2

[95% CI]

1.67*** 0.76 0.84** 1.37 1.22

[1.31, [0.49, [0.75, [0.72, [0.67,

2.13] 1.16] 0.94] 2.58] 2.22]

Model 3

OR

[95% CI]

OR

[95% CI]

1.66*** 0.79 0.84** 1.37 1.25 0.61***

[1.305, 2.14] [0.50, 1.22] [0.75, 0.95] [0.71, 2.65] [0.68, 2.32] [0.53, 0.70]

1.58*** 0.88 0.82** 1.40 1.29 0.61***

[1.22, 2.04] [0.56, 1.38] [0.73, 0.93] [0.72, 2.69] [0.700, 2.39] [0.53, 0.70]

0.62* 698.89 32.82

652.14 81.58

[0.42, 0.93] 648.77 86.94

Note: Model 1 shows that increasing work-related stress increases the CE-drug use willingness in study 3, while increasing age is associated with a lower willingness. Model 2 shows that stronger moral qualms about CE-drug use (version 2) also decrease respective willingness. Model 3 shows that increasing social support impedes a high willingness. n, number of observations; OR, odds ratio; CI, confidence interval; AIC, Akaike information criterion. *p < .05, **p < .01, ***p < .001.

no such interaction effect. Due to space limitations, we do not depict and discuss this finding in detail. Regarding our demographic variables, women demonstrated lower willingness scores than men in study 2 (p = .020 in Model 4 in Table 2), while no such effect was found in study 1 (p = .874 in Model 2 in Table 2) and study 3 (p = .574 in Model 3 in Table 3). Increasing age reduced willingness to use CE-drugs in study 3 (p = .003 in Model 1) but not in studies 1 and 2 (p = .271). In all studies, status and academic discipline had no effect. Prior CE-drug use Fewer than 1% of respondents reported prior CE-drug use (Table 1). Rare events logit regression analysis shows that prior CE-drug use was more likely when work-related stress was higher (OR = 2.04; p = .033), thereby supporting H1work-related stress. No gender difference was found. Older respondents were more likely to report prior CE-drug use (OR = 0.66; p = .046). No statistical analysis could be conducted for discipline and status, since none of the cases of CE-drug use were reported by medical and health-related university teachers or the high-status group.

Discussion Our three interconnected, large studies of German university teachers show that the prevalence of CE-drug use is very low. The declared willingness to use such drugs in the future was higher than the current use; this discrepancy was stable over time and robust across two measures. There may be several reasons for the difference between intake

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willingness and behavior. For example, university teachers might like to use such medications but do not have access, or they may not have previously had any reason to use CE-drugs but would be willing to do so if a reason arose. Some teachers might wait until more powerful and/or safer medication is available. This assumption is supported by Franke, Bonertz, Christmann, Engeser, and Lieb (2012), who found that 80% of the German students investigated would consider using CE-drugs if the drugs did not cause long-term damage or addiction. Maher (2008) found a prevalence of about 20% in a population that consisted primarily of scientists from 60 different countries. Thus, the low prevalence found in our study could be due to the fact that the projected upcoming trend (Franke et al., 2012) has not yet reached Germany. Work-related stress has recently increased in universities (Mark & Smith, 2012; Winefield & Jarrett, 2001). We anticipated that some healthy individuals would consider meeting these heightened job demands by CE. Using multiple measures of CE in three studies, we found that higher work-related stress was consistently and robustly associated with a higher willingness to use enhancers as well as with the prior use of such drugs, thus supporting H1work-related stress. As in other studies (Sattler et al., 2014; Sattler & Wiegel, 2013), here, too, prior CEdrug use was shown to promote willingness to use CE-drugs in the future, thus supporting H2prior CE-drug use. This finding may indicate that time-invariant factors (such as preferences or lack of self-control) that influenced prior decisions also influence subsequent decisions (cf. Beck & Ajzen, 1991; Nagin & Pogarsky, 2001). Habituation and/or prior experience might also account for this effect. Further analysis should investigate the mechanism behind this effect, how much deliberation is involved, and whether this effect indicates addictive tendencies. In our analyses, we cannot distinguish between these two possibilities, but the inclusion of prior CE-experience allowed us to consider potentially unobserved heterogeneity among drug users and non-users. Furthermore, we found that stronger moral qualms against CE-drugs decreased CEdrug use willingness, thereby supporting H3moral perceptions (Sattler et al., 2014). This finding might be explained by the effect of internal control and the associated fact that feelings of shame might arise from violating such moral perceptions (cf. Cochran et al., 1999; Grasmick & Bursik, 1990). This effect was demonstrated by two different measures for assessing moral considerations, which indicates the robustness of our results. We also corroborated H4social support: University teachers reporting having less social support – which is an important resource for achieving life goals, dealing with problems, and creating well-being – reported greater willingness to use CE-drugs. Therefore, CEdrug use could be interpreted as a strategy to compensate for this deficiency. No stressbuffering effect of perceived social support was found, however. Similar to studies in other samples, results for gender were mixed. While no associations were found in studies 1 and 3 (cf. Rabiner, Anastopoulos, Costello, Hoyle, & Swartwelder, 2010; Weyandt et al., 2009), women were less willing to use CE-drugs in study 2 (cf. McCabe, Knight, Teter, & Wechsler, 2005; Rabiner et al., 2009). One explanation for the latter finding might be that men tend to engage in risky behavior more often (e.g., Dohmen et al., 2011) and therefore might be more willing to accept risks associated with CE-drug use. Furthermore, due to the model of the male breadwinner in Germany, men might feel greater pressure to succeed at work, which would indicate that men have stronger incentives to use CE-drugs. But there are also opposing mechanisms. Due to structural discrimination, women in high-status jobs need to work harder to rise in

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the hierarchy compared to men. Additionally, women are more likely to have double and triple the amount of chores (work, children, household). Due to inconsistent findings, gender effects need further empirical investigation. Younger university teachers more often reported a prior use of CE-drugs in study 1 and were more willing to use CE-drugs in study 3. One can argue that CE is a recent phenomenon and is therefore more widespread among younger university teachers, who might be more open to experimentation. Furthermore, younger university teachers might have stronger incentives than older colleagues to invest in achievement strategies. CEdrug use is also risky because of potential side effects and long-term health consequences, and risk-taking generally declines with age (Turner & McClure, 2003). But these assumptions need to be demonstrated in further studies because age was not related to the CE-drug use willingness in studies 1 or 2. The lower professional status group reported more prior drug use, but no difference in willingness was found between status groups. Because of potentially greater competition for prospective jobs in the lower professional status group, this group might expect to gain more from CE compared to the higher status group, who have already reached prestigious and secure positions. But, even in the German high-status group, there is a considerable degree of competition for recognition and resources within organizations and among peers in different organizations, which might account for the equally high willingness to use CE-drugs reported by low- and high-status groups. No clear differences were found among academic disciplines. University teachers in medical and health-related disciplines may have both better access to CE-drugs and more knowledge about the application of CE-drugs (cf. Franke et al., 2011; Teter, McCabe, LaGrange, Cranford, & Boyd, 2006), but they may also be better informed about the side effects and limited enhancement effects in healthy individuals (Husain & Mehta, 2011). Thus, positive and negative effects may offset each other.

Limitations and future research With the exception of the measure inquiring about past CE-drug behavior, only willingness-measures were employed. Previous research has shown that willingness reliably predicts behavior associated with health risks (Gibbons et al., 2009), and we find it unlikely that work-related stress would influence reported willingness to use CE-drugs but not behavior. The prevalence of prior CE-drug use was very low, and the willingness to use CE-drugs was only moderate. In addition to the above-mentioned explanations, another methodological explanation may be a response bias due to the topic’s sensitivity. The willingness question might be perceived as less sensitive because no moral perception is violated until the drug is actually consumed. This might lead to reporting higher willingness compared to prior use (cf. Gibbons, Gerrard, Blanton, et al., 1998). An important risk factor for biased answers is lack of anonymity (Ong & Weiss, 2000). We employed several measures to minimize socially desirable responding and provided full anonymity (see Methods). Moreover, web surveys increase reporting of sensitive information and achieve higher accuracy (Crutzen & Göritz, 2010; Kreuter, Presser, & Tourangeau, 2008). We recalculated all results after applying multiple imputation techniques (Royston, 2005) to analyze the impact of dropout and item-non-response for the investigated variables. Results with imputed data are similar to those with nonimputed data (see supplementary Tables S1–S3).

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To statistically address the low number of past CE-drug users, rare events logistic regression models were used. Due to the low prevalence of CE-drug use, huge and costly data-sets are needed for future investigations on behavior. Therefore, our willingnessmeasures are valuable for elucidating trends in CE-drug use. Response rates indicate that a noticeable share of university teachers chose not to participate in the study. But our response rates were satisfactory because university teachers have high opportunity costs for participation. Comparisons of willingnessmeasures for all participants in each single study and those who participated in one or more studies reveal similar results (see supplementary Table S4a); hence, those who did not participate in more than one study did not alter the measured prevalence. Moreover, the level of work-related stress is very similar among those who participated once, twice, or three times (cf. supplementary Tables S4a–S4b). These findings are indicative of random dropout. Furthermore, we verified that our study outcomes were not biased due to selective study participation by recalculating all models with sampling weights (Winship & Radbill, 1994) (cf. supplementary Tables S7–S10), since gender proportion and discipline affiliation were available for the contacted sample. But future studies should investigate potential biases regarding other variables than gender and academic discipline. Similarities in the results across studies may have resulted, in part, from stabilities among persons who participated more than once. In total, 219 teachers participated in all studies. The data from the repeated participants allowed for several stability tests and were therefore important to this under-investigated topic. We reanalyzed all models using only the one-time participants to test whether the results were affected by repeated participation. These analyses (see supplementary Tables S11–13) produced similar results in terms of all effect sizes. Due to the resulting smaller sample and consequently decreased statistical power, however, the effects of perceived social support on willingness in study 3, and work-related stress and age on prior CE-drug use in study 1 no longer achieved a conventional level of significance (see supplementary Tables S11 and S13).

Implications Our results illustrate that CE-drug use is less common than sensationalized in the media. But prevalence may increase under the conditions discussed above. In the framework of drug instrumentalization (Müller & Schumann, 2011), the effect of work-related stress on CE-drug use can be understood as a non-addictive, functional adaption to complex, competitive, fast-changing modern microenvironments by increasing, sustaining, or restoring work performance. Individuals can perceive CE-drug use as a means of achieving income, status, mental health, etc. But instrumental drug use can also lead to addiction and unwanted side effects as well as have long-term health consequences (Müller & Schumann, 2011). In societies or (sub-)groups in which CE-drug use is prevalent and harmful, drug regulation and prevention might be advised, and our results can support such endeavors. Since several university teachers consider CE-drug use a strategy for coping with stress, it may be advisable to encourage other psychological treatments and non-pharmacological means such as sleep, meditation, or physical exercise (Dresler et al., 2013; Sahakian & Morein-Zamir, 2007; Thoits, 1982) to improved cognitive performance, work–life balances, and relaxation. The CE willingness-inhibiting effect of social support could

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also be utilized for prevention. Universities could provide teachers with increased support to reduce work-related stress and the consequent instrumentalization of CE-drugs. By fostering discussions about the moral problems of CE-drug use (e.g., fairness) and strengthening regulations, the belief that CE-drug use is immoral could be used to impede willingness to engage in CE (Sattler et al., 2013). Furthermore, prior users and potential users could be informed about the limited enhancements in healthy individuals through CE-drugs (Husain & Mehta, 2011) and about the risk of severe side effects (e.g., Greely et al., 2008; Winder-Rhodes et al., 2010). The inscription of such information into the semantic drug memory may reduce expectations about the benefits of instrumentalizing CE-drugs (Müller & Schumann, 2011). Moreover, the supervised and informed use of safe drugs as well as alternative strategies for maintaining and increasing mental performance and treating stress could replace risky self-medication (Dubljevic, 2013; Sahakian & Morein-Zamir, 2007). Acknowledgments We would like to thank all the people who helped to conduct this study, especially Dominik Koch, Ines Meyer, Andrea Schulze, Floris van Veen, and Sebastian Willen. We thank Olaf von dem Knesebeck for critical comments as well as Siegwart Lindenberg for his discussion of our application of his moral perception measure. Furthermore, we also thank the two anonymous reviewers for their insightful comments. The FMER did not influence any interpretations or force the research team to produce biased results. The views expressed do not necessarily reflect the policies of the funder. The authors did not receive any research support from public or private actors in the pharmaceutical sector.

Disclosure statement No potential conflict of interest was reported by the authors.

Funding This research was funded by the Federal Ministry of Education and Research [FMER; 01PH08024], headed by Sebastian Sattler and Martin Diewald). Sebastian Sattler’s research was supported by the Rectorate Fellowship of the Bielefeld University and by a PostDoc Fellowship [Az. 20.13.0.161] of the Fritz-Thyssen-Foundation and the Cologne Graduate School in Management, Economics, and Social Sciences.

Supplemental data Supplemental data for this article can be accessed here.

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