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Trends in medical student use of tobacco, alcohol and drugs in an Irish university, 1973–2002
Drug and Alcohol Dependence 85 (2006) 123–128
Trends in medical student use of tobacco, alcohol and drugs in an Irish university, 1973–2002 M. Boland a , P. Fitzpatrick a,∗ , E. Scallan a , L. Daly a , B. Herity b , J. Horgan b, , G. Bourke b b
a UCD School of Public Health and Population Science, University College Dublin, Ireland Department of Public Health Medicine and Epidemiology, University College Dublin, Ireland
Received 12 July 2005; received in revised form 23 March 2006; accepted 28 March 2006
Abstract Questionnaire surveys of medical students in an Irish university were carried out in 1973 (n = 765), 1990 (n = 522) and 2002 (n = 537), with differentiation of western students (e.g., from the Republic of Ireland, the UK, or Australia) and non-western students (e.g., Malaysia). We report on changes in tobacco smoking, drinking and drug-taking over three decades, and we note that, among western students, estimated prevalence of being a current smoker has declined overall from 28.8% in 1973 to 15.3% in 1990 to 9.2% in 2002 (p < 0.001), falling in both males (p < 0.001) and females (p < 0.01). Ex-smokers rose from 5.9% to 15.1% between 1990 and 2002, corresponding with the decline in current smokers. The prevalence of current drinkers has risen over the period, to 82.5% among western students in 2002 (p < 0.05); female drinking has increased steadily since 1973 (p < 0.001), and the overall proportion of CAGE-positive drinkers has risen since 1990 (p < 0.001). The mean weekly alcohol consumption has risen in both sexes since 1990 (males 14.3 units to 19.4, p < 0.01; females 6.0 to 9.5, p < 0.001). There was an increase in the proportion of students ever offered drugs between 1973 and 2002 (p < 0.001). Although smoking rates have fallen, our findings show a marked increase in alcohol and drug consumption between 1973 and 2002. Personal misuse of addictive substances by doctors may mean that doctors will fail to take misuse by patients seriously. A need for preventative and ameliorative action during the medical school years is clear. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Medical students; Trends in smoking; Drinking; Drug use
1. Background Medical students are exposed to both active and subliminal personal health education during their undergraduate years. Several studies have examined the prevalence of smoking, alcohol intake or drug misuse in medical students (Brynner, 1967; Collier and Beales, 1989; Croftons et al., 1994; McAuliffe et al., 1984a,b) at a given point in time. The changing trends over time in attitude and behaviour that have developed in the population of medical students towards alcohol, tobacco or drugs have been less researched, but signal a growing problem with alcohol intake (Baldwin et al., 1991; Newbury-Birch et al., 2001; O’Brien et al., 2002; Webb et al., 1998).
∗
Corresponding author. Tel.: +353 1 7167345; fax: +353 1 7167407. E-mail address: [email protected] (P. Fitzpatrick). Deceased.
0376-8716/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.drugalcdep.2006.03.016
The behaviour of young adults in Ireland towards the addictive substances of tobacco, alcohol, and non-prescription drugs has been changing over the past few decades. Measured over one recent 4-year period (Centre for Health Promotion Studies, 2002), the trends in young adults specifically are towards decreasing rates of cigarette smoking, rising non-prescription drug use and continued high alcohol consumption. Changes in behaviour may be preceded by attitudinal change. Exploration of attitudes and health behaviours can provide valuable information for understanding behaviour and for targeting health education to drive change towards positive healthy behaviour. The aim of this study was to report on secular trends in attitudes to and behaviour around alcohol, smoking and drugs among medical students over a 29-year period, as documented by surveys in a single medical school in 1973, 1990 and 2002. We sought to examine changes in the patterns of addictive substance use in students, and to explore whether increases in general knowledge of the deleterious effect of substances were
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reflected in changes in attitudes and behaviour among medical students. 2. Methods Using similar methodologies and survey instruments, three surveys of medical school students in University College Dublin were carried out over a 29-year period. A census of all students present in the relevant classes was taken. No prior sample size calculations were made but the anticipated recruitment of approximately 500 students per survey gave a confidence interval width in the region of ±2.5% to ±4.5% on point estimates of prevalence ranging from 10% to 50%. Apart from the initial survey – see below – all registered medical students in the university in the survey year were eligible for participation. One particular lecture was chosen for each class to be surveyed and permission was sought from the relevant lecturer for some class time to administer the questionnaire. The purpose of the survey was explained by one of the research team and the questionnaire was distributed for completion there and then. Anonymity was guaranteed. A second member of the research team counted those present at any time during the period the questionnaire was being completed – thus including those who arrived late or departed early – and this formed the basis of the within-class response rate. The first survey (Herity et al., 1977), referred to as the 1973 survey, was carried out among first, third, fourth and sixth year medical students in the academic session 1972 and first, third and sixth year students in 1973. Of 1013 students registered, 776 were present and 765 (98.6%) responded (75.5% of total registered). The second survey was carried out in 1990. Of 660 students registered in all six undergraduate classes, 546 were present for the survey and 522 (95.6%) of these responded (79.1% of total registered). The final survey was carried out in 2002. Of 905 students registered, 570 were present for the survey and 537 (94.2%) responded (63.0% of total registered). The questionnaires used in each survey were broadly similar and changes from survey to survey related mostly to extra questions included. Each questionnaire addressed respondents’ smoking and drinking habits, and exposure to and use of psychoactive drugs. Respondents were also asked to document their age, sex, place of residence during term, and parental occupation. The 2002 survey included a question on country of origin, as there are increasing proportions of students from middle-eastern and other countries where cultural beliefs and practices are pertinent to lifestyle habits. A western country of origin was defined as Ireland, UK, other European country, USA, Australia, New Zealand or Canada. Non-western included students from Malaysia and Botswana predominantly. The smoking questions ascertained if subjects had ever smoked and the quantity they smoked now if they were current smokers. Those who had ever smoked were asked the age they started, and ex-smokers were asked when they had quit. For this analysis current smoking was defined as smoking more than one cigarette a day or equivalent in cigar or pipe at the time of the survey. Similar questions were asked concerning alcohol consumption but quantities (separately determined for stout/beer/lager, spirits and wine/sherry) were based on consumption in the previous month. Many surveys reporting on alcohol consumption use ‘consuming alcohol in the previous month’ to determine drinking prevalence (Centre for Health Promotion Studies, 2002) as the definition ensures that a person regularly consuming alcohol, but who may not have done so in a shorter time period prior to the survey, is identified as a drinker. For our study it also allowed comparability between the different periods since it was the definition used in the 1973 study (Herity et al., 1977), For this analysis quantities of alcohol were converted to ‘units’ of alcohol based on the Irish standard used in the early 2000s. One unit was defined as a half pint of stout/beer/lager, a standard measure of spirits, or a glass of wine/sherry. The CAGE screening test for problem drinking (Mayfield et al., 1974) was included in the 1990 and 2002 surveys. A set of similarly worded questions were asked in relation to smoking, prior to the actual CAGE questions, to dilute the significance of the alcohol questions from a respondent perspective The question on smoking first thing in the morning however omitted any stated reason for this (unlike the question on alcohol re-eye-opener). The χ2 -tests for trend across the 3 study years, χ2 -tests and t-tests were used at a 5% two-sided level of significance. Adjustment for age was conducted using Mantel Haenzel techniques for prevalence of alcohol use in students in the 1990
survey and western students in the 2002 survey. Statistical analysis of trends was not always possible due to unavailability of raw data from the 1973 survey. Since the lifestyle choices of non-western students may be cultural in origin for some aspects of analysis only the subgroup of students of western origin from the 2002 survey was included, and compared to all students in 1973 and 1990, when the proportion of non-western students was very small.
3. Results The socio-demographic characteristics of students surveyed are shown in Table 1. The proportion of female students nearly doubled between 1973 and 2002. In 2002 western country of origin was reported by 81.4% of respondents. Trends in smoking practices are shown in Table 2. A reduction in smoking prevalence has occurred between 1973 and 2002 (western) overall (p < 0.001) and in both males (p < 0.001) and females (p < 0.01), to an overall prevalence of 9.2% in 2002 (among western students only). Between 1990 and 2002 there was a change in the distribution of smoking behaviour, with the percentage of ex-smokers rising from 5.9% in 1990 to 15.1% in 2002 (western students only) with a corresponding decline in current smokers from 15.3% to 9.2%. The mean age of starting smoking remains unchanged for males and has fallen slightly for females (p > 0.05). The pattern of cigarette consumption has changed over the three studies, with a reduction in those smoking greater than 10 cigarettes per day (p < 0.01) (Table 2). In 2002 the lifetime prevalence of smoking was higher in western (96/423) respondents than non-western (9/91; p < 0.01). Between 1990 and 2002 (western students only) there was no significant change in the percentage of current smokers who felt often/very often that they should cut down on smoking (74.3% in 1990, 65.8% in 2002; p > 0.05). Trends in alcohol drinking are shown in Table 3. The percentage of students reporting themselves as a current drinker has risen between 1973 and 2002 (western students) (p < 0.05). This rise is seen predominantly among females. Among males
Table 1 Socio-demographic characteristics of respondents to the three surveys (1973, 1990, 2002) of Irish medical students Year of survey
p-value
1973 (%) (n = 753)
1990 (%) (n = 522)
2002 (%) (n = 537)
1973–2002
Age group <19 years 19–22 years >22 years
28.7 41.3 30.0
19.2 61.4 19.4
7.0 67.6 25.3
<0.001
Sex Male Female
66.7 33.3
48.1 51.9
41 59
Residence Home residence Flat/shared house Lodgings/digs Other
62.1 18.4 8.6 10.6
43.1 42.0 9.0 5.9
36.0 53.2 3.6 7.2
a
Comparing proportions living at home vs. elsewhere.
<0.001 <0.001a
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Table 2 Trends in smoking among medical students over three surveys, with detail on western and non-western students in 2002 Year of survey 1973
Prevalence of current smokers Overall 28.8% (215/746a ) Male 33.8% (168/497) Female 18.9% (47/249)
p-value 1990
15.3% (80/522a ) 15.5% (39/251) 15.1% (41/271)
Mean age (years) at starting smoking in ever-smokers Overall Unavailable 16.4 Male 16.6 15.6 Female 18.0 17.3
2002 western
9.2% (39/423a ) 8.9% (15/168) 9.1% (23/254) 16.3 16.0 16.5
Number of cigarettes per day in current smokers (% of smokers) <6 21.4% 41.3% 33.3% 6–10 27.2% 24.0% 41.0% 11–20 37.0% 32.0% 23.1% >20 14.4% 2.7% 2.6% a b
2002 non-western
2002 all
Comparing years 1973, 1990, 2002 (western only)
Comparing 2002 western vs. non-western
7.7% (7/91a ) 14.0% (6/43) 2.1% (1/48)
9.5% (50/529a ) 10.0% (21/211) 7.9% (24/302)
<0.001 <0.001 <0.01
0.64 0.33 0.10
17.7 17.9 16.0
16.4 16.4 16.5
28.6% 28.6% 42.9% 0.0%
36.0% 36.0% 26.0% 2.0%
0.77b 0.39b 0.11b <0.01
0.11 0.06 Not calculable 0.72
Missing data. 1990 vs. 2002 western only, as 1973 raw data unavailable.
there is no overall rise over the three decades, but there is a rise between 1990 and 2002 (western students) (p < 0.05) that persists overall and also among males and females separately after adjustment for age. The mean weekly consumption has risen between 1990 and 2002 (western students) (p < 0.05); this rise has been seen in both males (p < 0.01) and females (p < 0.001). Among current drinkers the mean number of units consumed in the past month rose from 41.5 in 1990 to 56.5 in 2002 (western students; p < 0.01); among males the number of units rose from 58.3 to 81.5 (p < 0.01) and in females from 24.0 to 39.8 (p < 0.001). In both 1990 and 2002 consumption was higher in males than females (p < 0.05). The overall proportion of CAGE-positive current drinkers has risen since 1990 (p < 0.01); the proportions in males and females have similarly risen (Table 4). The male score was higher than
the female score in both 1990 and 2002 surveys (p < 0.05). In 1990 CAGE-positive individuals had higher mean alcohol consumption per month (58.1 units versus 32.9 in CAGE-negative; p < 0.05). The mean alcohol unit intake in past month was higher in CAGE-positive respondents in 2002 (85.1 units) compared to CAGE-positive in 1990 (p < 0.05). The marked rise in levels of alcohol consumption is demonstrated by the fact that CAGE-negative individuals in 2002 consumed a higher mean alcohol (67.2 units) than CAGE-positive individuals in 1990 (58.1 units), although this did not reach statistical significance. The proportions drinking over the limit have risen between 1990 and 2002 in females (p < 0.01) and to a lesser extent in males (p > 0.05). There was increase in the proportion of students ever offered non-prescribed illicit drugs between 1973 and 2002 (p < 0.001)
Table 3 Trends in drinking among medical students over three surveys, with detail on western and non-western students in 2002 Year of survey 1973
Prevalence of current drinkers Overall 74.6% (561/752a ) Males 81.2% (407/501) Females 61.4% (154/251) Mean age (years) when started Overall Unavailable Males 17.3 Females 18.1
p-value 1990
2002 western
2002 non-western
2002 all
Comparing years 1973, 1990, 2002 (western only)
Comparing 2002 western vs. non-western
68.7% (346/504a ) 70.5% (177/243) 62.4% (169/261)
82.5% (348/422a ) 83.3% (140/168) 81.8% (207/253)
20.0% (18/90a ) 35.7% (15/42) 6.3% (3/48)
71.2% (375/527a ) 73.4% (160/218) 69.5% (214/308)
<0.05±b 0.78±b <0.001±b
<0.001 <0.001 <0.001
17.1 16.8 17.4
16.4 16.2 16.4
18.5 18.7 17.6
16.5 16.6 16.5
<0.001c <0.001 <0.001
0.07 0.12 0.16
13.3 18.7 9.3
<0.001 <0.01 <0.001
0.62 0.62 0.92
Mean weekly alcohol consumption in past month for current drinkers (units per week) Overall – 10.2 13.5 14.5 Males – 14.3 19.4 15.7 Females – 6.0 9.5 9.1 a b c
±unadjusted p-value. Unadjusted p-value. 1990 vs. 2002 western only, as 1973 raw data unavailable.
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Table 4 Comparisons of CAGE score and percentage of drinkers drinking over recommended limits, by sex, in 1990 and 2002 surveys of medical students Year of survey 1990 (%)
p-value
2002 (western only) (%)
CAGE score positive of current drinkers Overall 34.4 52.5 Males 40.7 61.2 Females 27.8 46.6
<0.001 <0.001 <0.001
Drinking over recommended limits in past month (% of drinkers) Male 23.2 32.6 0.06 Female 10.3 21.9 <0.01
(Table 5). This was not a consistent rise however, with the 1990 sample reporting the lowest prevalence. Among all 2002 survey respondents 67.7% had been offered drugs at some time previously, and 40.7% had ever taken drugs for other than medical reasons; the proportions were higher among western than non-western students (Table 5). During the past year the 144 students who had used illicit drugs did so on average 8.7 times in the year. When cannabis and ecstasy were excluded the 16 students who had used other drugs did so on average 4.4 times in the past year. Those students of western origin had a higher lifetime prevalence of being offered drugs (p < 0.001) and also of taking drugs compared with non-western students (p < 0.001). 4. Discussion This study gives a unique overview of the changing trends in the lifestyle choices of medical students over three decades. We see a fall in smoking prevalence, a major increase in numbers of drinkers and amounts of alcohol consumed and a rise in the proportions offered and using illicit drugs. While we noted a trend towards younger age at starting smoking in female students, one encouraging feature of this research was the significant trend towards reduction in smoking prevalence and reduction in number of cigarettes smoked per day. The fall in overall cigarette consumption is welcomed. In Ireland national prevalence studies of smoking show a fall in the
number of young males smoking (Centre for Health Promotion Studies, 2002) but a rise in smoking among young females. The university medical student group appears to differ in some respects. In population statistics a marked social class gradient is seen in smoking prevalence in young people (Centre for Health Promotion Studies, 2002) and a greater number of university medical students come from higher socio-economic groups than is represented by population peers, which may account for some of the difference. The rise in quantity of alcohol consumed by student drinkers reflects the national rise in alcohol consumption in young people; this is a point of serious concern. The recent ESPAD study of 15- to 16-year olds from European countries showed Irish students to have among the highest prevalence of binge drinking and episodes of drunkenness (Hibell et al., 2004). Similarly high prevalence is seen among our adult population (Department of Health and Children, 2002; Ramstedt and Hope, 2004). The national lifestyle survey (Centre for Health Promotion Studies, 2002) reported an increase from 1998 to 2002 in the number of people binge drinking. Ireland has had the highest increase in alcohol consumption among EU countries (Department of Health and Children, 2002) over the last decade, with a 41% increase in alcohol consumption per capita between 1989 and 1999. Alcohol consumption appears to be an integral part of the student experience, it is socially acceptable and there may be peer pressure to drink. Among young people there are clear links between the use of alcohol, tobacco and illegal drugs (Patton et al., 2002; World Health Organisation, 2001). A study in another Irish university (O’Brien et al., 2002) examining the trends between 1992 and 1999 found a fall in alcohol use in male students however, which is contrary to our study and to our national figures. The rise in percentage of CAGE-positive students is of major concern as this reflects likely addiction. The proportion is higher than comparable population figures (13%) for 20- to 24-year olds in another Irish study (Jackson, 1997), and does not closely reflect international studies where the pattern and prevalence of alcohol dependence in medical students and young doctors is consistent with age peers in the general population (Flaherty and Richman, 1993). Interestingly, other studies found a pattern of increased alcohol problems with increased age in physicians, rather than the diminution seen in
Table 5 Trends in drug behaviour among medical students over three surveys, with detail on western and non-western students in 2002 Year of survey 1973 (%)
p-value 1990 (%)
2002 western (%)
2002 non-western (%)
2002 all (%)
Comparing years 1973, 1990, 2002 (western only)
Comparing 2002 western vs. non-western
Lifetime prevalence of being offered drugs Overall 55.9 46.3 Males 63.1 55.0 Females 41.4 38.3
76.7 82.7 72.7
24.4 35.7 14.6
67.7 73.4 63.6
<0.001 <0.001 <0.001
<0.001 <0.001 <0.001
Lifetime prevalence of accepting drugs Overall 32.0 20.7 Males 39.2 25.3 Females 17.5 16.4
46.2 51.8 42.5
13.3 21.4 6.3
40.7 46.3 36.6
<0.001 0.16 <0.001
<0.001 <0.01 <0.001
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the general population (Donovan et al., 1983; McAuliffe et al., 1984a). In the last decade there has been a marked rise in the number of students of non-western origin attending our medical school. As expected, we found fewer drinkers among those students from non-western countries where drinking is less prevalent. Those non-western students who did drink had an older mean age at starting drinking (although non-significant due to small numbers); but unexpectedly they matched their western counterparts in terms of mean consumption, suggesting that these students take on the habits of their Irish/western classmates. Students are entering university at an older age in Ireland and 2002 students in this study were older; however we found that the increase in current drinkers in 2002 compared to 1973 and 1990 persisted after adjustment for age distribution. Furthermore, lack of gender difference has been identified, where women’s drinking prevalence equalled that of men’s by the end of medical school (Flaherty and Richman, 1993; McAuliffe et al., 1984b). We concur with these findings, as, in our study, among western students in 2002, the prevalence of current drinkers was similar in men and women. There is a well-documented national rise in the prevalence of drug abuse (European Monitoring Centre for Drugs and Drug Addiction, 2004). Medical students see the social and physical effects of alcohol and drug abuse graphically through patient exposure, but they may detach themselves from these clinical pictures and view themselves as different to their patients. Although medical students may have more knowledge about substance abuse this does not translate into differences in attitudes or behaviour (Knopf and Wakefield, 1974). The most recent (2002) study shows that more students are being offered illicit drugs at some time in their life, and a greater number are accepting these drugs. More males than females are being offered and taking drugs. The figures in 1990 show a reduction in drug exposure in males from 1973, followed by a surge in 2002 above the 1973 figures. The figures in females show a less marked change from 1973 to 1990 and then a doubling in reported drug usage from 1990 to 2002. There appears to be a decline in obvious parental presence, as demonstrated by the proportions of students living outside the family home, with increasingly larger numbers residing in flats or shared houses. The high (and rising) levels of alcohol and drug use found in our study indicate a worrying problem and confirm national concerns. This study may in fact underestimate problem drinkers or users of drugs, as those absent from lectures may include those affected by the after effects of consumption. The implications of our findings are serious. During college life, significant positive associations have been found between alcohol consumption and experiences such as missing study, becoming more sexually involved and getting into a physical fight or argument (NewburyBirch et al., 2000). Patterns of substance misuse established in university may persist into professional life and doctors are at special risk of developing addiction problems (Strang et al., 1998). Substance misuse may impair an individual’s capacity to perform professional responsibilities, and the problematic use of drugs and alcohol is a common reason for reporting of doctors
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to the Irish Medical Council (Hillery, 2004). The stigma associated with addiction may result in concealment until an adverse event occurs, rather than early seeking of assistance. Stress and high anxiety may be present in doctors, and the use of alcohol to cope with tension has been described in medical students (male and female equally) as an independent risk factor for hazardous drinking (Tyssen et al., 1998). Another study (Kjobli et al., 2004) suggested that, in addition to stress, personality traits were implicated in hazardous drinking. The personality characteristic of psychoticism has been associated with alcohol and illicit drug consumption (Newbury-Birch et al., 2000). Drinking has been linked to depression in women doctors (Firth-Cozens, 1998). Personal misuse of addictive substances means a doctor may fail to take misuse by patients seriously. Since the promotion of healthy lifestyles is an important part of a doctor’s job it may augment health promotion messages if the doctor can “practise what he/she preaches”. Addictions may originate in medical school (Moore et al., 1990; Murray, 1976) and so an understanding of the patterns of behaviour in medical students may indicate opportunities for prevention. It is recommended that personally relevant health education should be provided as early as possible (Brynner, 1967; Knopf and Wakefield, 1974; Room et al., 2005) and that uniform national guidelines are needed to sensitise medical students to the dangers of substance abuse (Hughes et al., 1992). Medical students should be encouraged to increase their own awareness about their own drinking habits and acknowledge the difficulty they have in changing them (Ritson, 1990). The phenomenon of ‘drinking to cope’ should be targeted for preventive measures against hazardous drinking. Integrated teaching about alcohol and other forms of substance abuse should be provided and its impact monitored; World Health Organisation guidelines are available on integration into the core medical curriculum (Ariff and Westermeyer, 1988). Early identification of substance misuse is vital in the university setting, with access to appropriate diagnostic, treatment and rehabilitation services, and greater awareness among students of the existence of services and supports. Furthermore, doctors require increased professional awareness of the issue of addiction, and support and intervention in the workplace is also needed to identify and assist those with alcohol and/or drug problems, for the benefit of individual doctors and the general public. References Ariff, A., Westermeyer, J., 1988. Manual of Drug and Alcohol Abuse. Guidelines for Teaching in Medical and Health Institutions. Plenum Press, New York. Baldwin Jr., D.C., Hughes, P.H., Conard, S.E., Storr, C.L., Sheehan, D.V., 1991. Substance abuse among senior medical students. A survey of 23 medical schools. JAMA 265, 2074–2078. Brynner, J., 1967. Medical Students’ Attitudes Towards Smoking. HMSO, London. Centre for Health Promotion Studies, 2002. The National Health and Lifestyle Surveys. SLAN (Survey of Lifestyle, Attitudes and Nutrition). National University of Ireland, Galway. Collier, D.J., Beales, I.L., 1989. Drinking among medical students: a questionnaire survey. BMJ 299, 19–22.
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Trends in medical student use of tobacco, alcohol and drugs in an Irish university, 1973–2002 M. Boland a , P. Fitzpatrick a,∗ , E. Scallan a , L. Daly a , B. Herity b , J. Horgan b, , G. Bourke b b
a UCD School of Public Health and Population Science, University College Dublin, Ireland Department of Public Health Medicine and Epidemiology, University College Dublin, Ireland
Received 12 July 2005; received in revised form 23 March 2006; accepted 28 March 2006
Abstract Questionnaire surveys of medical students in an Irish university were carried out in 1973 (n = 765), 1990 (n = 522) and 2002 (n = 537), with differentiation of western students (e.g., from the Republic of Ireland, the UK, or Australia) and non-western students (e.g., Malaysia). We report on changes in tobacco smoking, drinking and drug-taking over three decades, and we note that, among western students, estimated prevalence of being a current smoker has declined overall from 28.8% in 1973 to 15.3% in 1990 to 9.2% in 2002 (p < 0.001), falling in both males (p < 0.001) and females (p < 0.01). Ex-smokers rose from 5.9% to 15.1% between 1990 and 2002, corresponding with the decline in current smokers. The prevalence of current drinkers has risen over the period, to 82.5% among western students in 2002 (p < 0.05); female drinking has increased steadily since 1973 (p < 0.001), and the overall proportion of CAGE-positive drinkers has risen since 1990 (p < 0.001). The mean weekly alcohol consumption has risen in both sexes since 1990 (males 14.3 units to 19.4, p < 0.01; females 6.0 to 9.5, p < 0.001). There was an increase in the proportion of students ever offered drugs between 1973 and 2002 (p < 0.001). Although smoking rates have fallen, our findings show a marked increase in alcohol and drug consumption between 1973 and 2002. Personal misuse of addictive substances by doctors may mean that doctors will fail to take misuse by patients seriously. A need for preventative and ameliorative action during the medical school years is clear. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Medical students; Trends in smoking; Drinking; Drug use
1. Background Medical students are exposed to both active and subliminal personal health education during their undergraduate years. Several studies have examined the prevalence of smoking, alcohol intake or drug misuse in medical students (Brynner, 1967; Collier and Beales, 1989; Croftons et al., 1994; McAuliffe et al., 1984a,b) at a given point in time. The changing trends over time in attitude and behaviour that have developed in the population of medical students towards alcohol, tobacco or drugs have been less researched, but signal a growing problem with alcohol intake (Baldwin et al., 1991; Newbury-Birch et al., 2001; O’Brien et al., 2002; Webb et al., 1998).
∗
Corresponding author. Tel.: +353 1 7167345; fax: +353 1 7167407. E-mail address: [email protected] (P. Fitzpatrick). Deceased.
0376-8716/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.drugalcdep.2006.03.016
The behaviour of young adults in Ireland towards the addictive substances of tobacco, alcohol, and non-prescription drugs has been changing over the past few decades. Measured over one recent 4-year period (Centre for Health Promotion Studies, 2002), the trends in young adults specifically are towards decreasing rates of cigarette smoking, rising non-prescription drug use and continued high alcohol consumption. Changes in behaviour may be preceded by attitudinal change. Exploration of attitudes and health behaviours can provide valuable information for understanding behaviour and for targeting health education to drive change towards positive healthy behaviour. The aim of this study was to report on secular trends in attitudes to and behaviour around alcohol, smoking and drugs among medical students over a 29-year period, as documented by surveys in a single medical school in 1973, 1990 and 2002. We sought to examine changes in the patterns of addictive substance use in students, and to explore whether increases in general knowledge of the deleterious effect of substances were
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reflected in changes in attitudes and behaviour among medical students. 2. Methods Using similar methodologies and survey instruments, three surveys of medical school students in University College Dublin were carried out over a 29-year period. A census of all students present in the relevant classes was taken. No prior sample size calculations were made but the anticipated recruitment of approximately 500 students per survey gave a confidence interval width in the region of ±2.5% to ±4.5% on point estimates of prevalence ranging from 10% to 50%. Apart from the initial survey – see below – all registered medical students in the university in the survey year were eligible for participation. One particular lecture was chosen for each class to be surveyed and permission was sought from the relevant lecturer for some class time to administer the questionnaire. The purpose of the survey was explained by one of the research team and the questionnaire was distributed for completion there and then. Anonymity was guaranteed. A second member of the research team counted those present at any time during the period the questionnaire was being completed – thus including those who arrived late or departed early – and this formed the basis of the within-class response rate. The first survey (Herity et al., 1977), referred to as the 1973 survey, was carried out among first, third, fourth and sixth year medical students in the academic session 1972 and first, third and sixth year students in 1973. Of 1013 students registered, 776 were present and 765 (98.6%) responded (75.5% of total registered). The second survey was carried out in 1990. Of 660 students registered in all six undergraduate classes, 546 were present for the survey and 522 (95.6%) of these responded (79.1% of total registered). The final survey was carried out in 2002. Of 905 students registered, 570 were present for the survey and 537 (94.2%) responded (63.0% of total registered). The questionnaires used in each survey were broadly similar and changes from survey to survey related mostly to extra questions included. Each questionnaire addressed respondents’ smoking and drinking habits, and exposure to and use of psychoactive drugs. Respondents were also asked to document their age, sex, place of residence during term, and parental occupation. The 2002 survey included a question on country of origin, as there are increasing proportions of students from middle-eastern and other countries where cultural beliefs and practices are pertinent to lifestyle habits. A western country of origin was defined as Ireland, UK, other European country, USA, Australia, New Zealand or Canada. Non-western included students from Malaysia and Botswana predominantly. The smoking questions ascertained if subjects had ever smoked and the quantity they smoked now if they were current smokers. Those who had ever smoked were asked the age they started, and ex-smokers were asked when they had quit. For this analysis current smoking was defined as smoking more than one cigarette a day or equivalent in cigar or pipe at the time of the survey. Similar questions were asked concerning alcohol consumption but quantities (separately determined for stout/beer/lager, spirits and wine/sherry) were based on consumption in the previous month. Many surveys reporting on alcohol consumption use ‘consuming alcohol in the previous month’ to determine drinking prevalence (Centre for Health Promotion Studies, 2002) as the definition ensures that a person regularly consuming alcohol, but who may not have done so in a shorter time period prior to the survey, is identified as a drinker. For our study it also allowed comparability between the different periods since it was the definition used in the 1973 study (Herity et al., 1977), For this analysis quantities of alcohol were converted to ‘units’ of alcohol based on the Irish standard used in the early 2000s. One unit was defined as a half pint of stout/beer/lager, a standard measure of spirits, or a glass of wine/sherry. The CAGE screening test for problem drinking (Mayfield et al., 1974) was included in the 1990 and 2002 surveys. A set of similarly worded questions were asked in relation to smoking, prior to the actual CAGE questions, to dilute the significance of the alcohol questions from a respondent perspective The question on smoking first thing in the morning however omitted any stated reason for this (unlike the question on alcohol re-eye-opener). The χ2 -tests for trend across the 3 study years, χ2 -tests and t-tests were used at a 5% two-sided level of significance. Adjustment for age was conducted using Mantel Haenzel techniques for prevalence of alcohol use in students in the 1990
survey and western students in the 2002 survey. Statistical analysis of trends was not always possible due to unavailability of raw data from the 1973 survey. Since the lifestyle choices of non-western students may be cultural in origin for some aspects of analysis only the subgroup of students of western origin from the 2002 survey was included, and compared to all students in 1973 and 1990, when the proportion of non-western students was very small.
3. Results The socio-demographic characteristics of students surveyed are shown in Table 1. The proportion of female students nearly doubled between 1973 and 2002. In 2002 western country of origin was reported by 81.4% of respondents. Trends in smoking practices are shown in Table 2. A reduction in smoking prevalence has occurred between 1973 and 2002 (western) overall (p < 0.001) and in both males (p < 0.001) and females (p < 0.01), to an overall prevalence of 9.2% in 2002 (among western students only). Between 1990 and 2002 there was a change in the distribution of smoking behaviour, with the percentage of ex-smokers rising from 5.9% in 1990 to 15.1% in 2002 (western students only) with a corresponding decline in current smokers from 15.3% to 9.2%. The mean age of starting smoking remains unchanged for males and has fallen slightly for females (p > 0.05). The pattern of cigarette consumption has changed over the three studies, with a reduction in those smoking greater than 10 cigarettes per day (p < 0.01) (Table 2). In 2002 the lifetime prevalence of smoking was higher in western (96/423) respondents than non-western (9/91; p < 0.01). Between 1990 and 2002 (western students only) there was no significant change in the percentage of current smokers who felt often/very often that they should cut down on smoking (74.3% in 1990, 65.8% in 2002; p > 0.05). Trends in alcohol drinking are shown in Table 3. The percentage of students reporting themselves as a current drinker has risen between 1973 and 2002 (western students) (p < 0.05). This rise is seen predominantly among females. Among males
Table 1 Socio-demographic characteristics of respondents to the three surveys (1973, 1990, 2002) of Irish medical students Year of survey
p-value
1973 (%) (n = 753)
1990 (%) (n = 522)
2002 (%) (n = 537)
1973–2002
Age group <19 years 19–22 years >22 years
28.7 41.3 30.0
19.2 61.4 19.4
7.0 67.6 25.3
<0.001
Sex Male Female
66.7 33.3
48.1 51.9
41 59
Residence Home residence Flat/shared house Lodgings/digs Other
62.1 18.4 8.6 10.6
43.1 42.0 9.0 5.9
36.0 53.2 3.6 7.2
a
Comparing proportions living at home vs. elsewhere.
<0.001 <0.001a
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Table 2 Trends in smoking among medical students over three surveys, with detail on western and non-western students in 2002 Year of survey 1973
Prevalence of current smokers Overall 28.8% (215/746a ) Male 33.8% (168/497) Female 18.9% (47/249)
p-value 1990
15.3% (80/522a ) 15.5% (39/251) 15.1% (41/271)
Mean age (years) at starting smoking in ever-smokers Overall Unavailable 16.4 Male 16.6 15.6 Female 18.0 17.3
2002 western
9.2% (39/423a ) 8.9% (15/168) 9.1% (23/254) 16.3 16.0 16.5
Number of cigarettes per day in current smokers (% of smokers) <6 21.4% 41.3% 33.3% 6–10 27.2% 24.0% 41.0% 11–20 37.0% 32.0% 23.1% >20 14.4% 2.7% 2.6% a b
2002 non-western
2002 all
Comparing years 1973, 1990, 2002 (western only)
Comparing 2002 western vs. non-western
7.7% (7/91a ) 14.0% (6/43) 2.1% (1/48)
9.5% (50/529a ) 10.0% (21/211) 7.9% (24/302)
<0.001 <0.001 <0.01
0.64 0.33 0.10
17.7 17.9 16.0
16.4 16.4 16.5
28.6% 28.6% 42.9% 0.0%
36.0% 36.0% 26.0% 2.0%
0.77b 0.39b 0.11b <0.01
0.11 0.06 Not calculable 0.72
Missing data. 1990 vs. 2002 western only, as 1973 raw data unavailable.
there is no overall rise over the three decades, but there is a rise between 1990 and 2002 (western students) (p < 0.05) that persists overall and also among males and females separately after adjustment for age. The mean weekly consumption has risen between 1990 and 2002 (western students) (p < 0.05); this rise has been seen in both males (p < 0.01) and females (p < 0.001). Among current drinkers the mean number of units consumed in the past month rose from 41.5 in 1990 to 56.5 in 2002 (western students; p < 0.01); among males the number of units rose from 58.3 to 81.5 (p < 0.01) and in females from 24.0 to 39.8 (p < 0.001). In both 1990 and 2002 consumption was higher in males than females (p < 0.05). The overall proportion of CAGE-positive current drinkers has risen since 1990 (p < 0.01); the proportions in males and females have similarly risen (Table 4). The male score was higher than
the female score in both 1990 and 2002 surveys (p < 0.05). In 1990 CAGE-positive individuals had higher mean alcohol consumption per month (58.1 units versus 32.9 in CAGE-negative; p < 0.05). The mean alcohol unit intake in past month was higher in CAGE-positive respondents in 2002 (85.1 units) compared to CAGE-positive in 1990 (p < 0.05). The marked rise in levels of alcohol consumption is demonstrated by the fact that CAGE-negative individuals in 2002 consumed a higher mean alcohol (67.2 units) than CAGE-positive individuals in 1990 (58.1 units), although this did not reach statistical significance. The proportions drinking over the limit have risen between 1990 and 2002 in females (p < 0.01) and to a lesser extent in males (p > 0.05). There was increase in the proportion of students ever offered non-prescribed illicit drugs between 1973 and 2002 (p < 0.001)
Table 3 Trends in drinking among medical students over three surveys, with detail on western and non-western students in 2002 Year of survey 1973
Prevalence of current drinkers Overall 74.6% (561/752a ) Males 81.2% (407/501) Females 61.4% (154/251) Mean age (years) when started Overall Unavailable Males 17.3 Females 18.1
p-value 1990
2002 western
2002 non-western
2002 all
Comparing years 1973, 1990, 2002 (western only)
Comparing 2002 western vs. non-western
68.7% (346/504a ) 70.5% (177/243) 62.4% (169/261)
82.5% (348/422a ) 83.3% (140/168) 81.8% (207/253)
20.0% (18/90a ) 35.7% (15/42) 6.3% (3/48)
71.2% (375/527a ) 73.4% (160/218) 69.5% (214/308)
<0.05±b 0.78±b <0.001±b
<0.001 <0.001 <0.001
17.1 16.8 17.4
16.4 16.2 16.4
18.5 18.7 17.6
16.5 16.6 16.5
<0.001c <0.001 <0.001
0.07 0.12 0.16
13.3 18.7 9.3
<0.001 <0.01 <0.001
0.62 0.62 0.92
Mean weekly alcohol consumption in past month for current drinkers (units per week) Overall – 10.2 13.5 14.5 Males – 14.3 19.4 15.7 Females – 6.0 9.5 9.1 a b c
±unadjusted p-value. Unadjusted p-value. 1990 vs. 2002 western only, as 1973 raw data unavailable.
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Table 4 Comparisons of CAGE score and percentage of drinkers drinking over recommended limits, by sex, in 1990 and 2002 surveys of medical students Year of survey 1990 (%)
p-value
2002 (western only) (%)
CAGE score positive of current drinkers Overall 34.4 52.5 Males 40.7 61.2 Females 27.8 46.6
<0.001 <0.001 <0.001
Drinking over recommended limits in past month (% of drinkers) Male 23.2 32.6 0.06 Female 10.3 21.9 <0.01
(Table 5). This was not a consistent rise however, with the 1990 sample reporting the lowest prevalence. Among all 2002 survey respondents 67.7% had been offered drugs at some time previously, and 40.7% had ever taken drugs for other than medical reasons; the proportions were higher among western than non-western students (Table 5). During the past year the 144 students who had used illicit drugs did so on average 8.7 times in the year. When cannabis and ecstasy were excluded the 16 students who had used other drugs did so on average 4.4 times in the past year. Those students of western origin had a higher lifetime prevalence of being offered drugs (p < 0.001) and also of taking drugs compared with non-western students (p < 0.001). 4. Discussion This study gives a unique overview of the changing trends in the lifestyle choices of medical students over three decades. We see a fall in smoking prevalence, a major increase in numbers of drinkers and amounts of alcohol consumed and a rise in the proportions offered and using illicit drugs. While we noted a trend towards younger age at starting smoking in female students, one encouraging feature of this research was the significant trend towards reduction in smoking prevalence and reduction in number of cigarettes smoked per day. The fall in overall cigarette consumption is welcomed. In Ireland national prevalence studies of smoking show a fall in the
number of young males smoking (Centre for Health Promotion Studies, 2002) but a rise in smoking among young females. The university medical student group appears to differ in some respects. In population statistics a marked social class gradient is seen in smoking prevalence in young people (Centre for Health Promotion Studies, 2002) and a greater number of university medical students come from higher socio-economic groups than is represented by population peers, which may account for some of the difference. The rise in quantity of alcohol consumed by student drinkers reflects the national rise in alcohol consumption in young people; this is a point of serious concern. The recent ESPAD study of 15- to 16-year olds from European countries showed Irish students to have among the highest prevalence of binge drinking and episodes of drunkenness (Hibell et al., 2004). Similarly high prevalence is seen among our adult population (Department of Health and Children, 2002; Ramstedt and Hope, 2004). The national lifestyle survey (Centre for Health Promotion Studies, 2002) reported an increase from 1998 to 2002 in the number of people binge drinking. Ireland has had the highest increase in alcohol consumption among EU countries (Department of Health and Children, 2002) over the last decade, with a 41% increase in alcohol consumption per capita between 1989 and 1999. Alcohol consumption appears to be an integral part of the student experience, it is socially acceptable and there may be peer pressure to drink. Among young people there are clear links between the use of alcohol, tobacco and illegal drugs (Patton et al., 2002; World Health Organisation, 2001). A study in another Irish university (O’Brien et al., 2002) examining the trends between 1992 and 1999 found a fall in alcohol use in male students however, which is contrary to our study and to our national figures. The rise in percentage of CAGE-positive students is of major concern as this reflects likely addiction. The proportion is higher than comparable population figures (13%) for 20- to 24-year olds in another Irish study (Jackson, 1997), and does not closely reflect international studies where the pattern and prevalence of alcohol dependence in medical students and young doctors is consistent with age peers in the general population (Flaherty and Richman, 1993). Interestingly, other studies found a pattern of increased alcohol problems with increased age in physicians, rather than the diminution seen in
Table 5 Trends in drug behaviour among medical students over three surveys, with detail on western and non-western students in 2002 Year of survey 1973 (%)
p-value 1990 (%)
2002 western (%)
2002 non-western (%)
2002 all (%)
Comparing years 1973, 1990, 2002 (western only)
Comparing 2002 western vs. non-western
Lifetime prevalence of being offered drugs Overall 55.9 46.3 Males 63.1 55.0 Females 41.4 38.3
76.7 82.7 72.7
24.4 35.7 14.6
67.7 73.4 63.6
<0.001 <0.001 <0.001
<0.001 <0.001 <0.001
Lifetime prevalence of accepting drugs Overall 32.0 20.7 Males 39.2 25.3 Females 17.5 16.4
46.2 51.8 42.5
13.3 21.4 6.3
40.7 46.3 36.6
<0.001 0.16 <0.001
<0.001 <0.01 <0.001
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the general population (Donovan et al., 1983; McAuliffe et al., 1984a). In the last decade there has been a marked rise in the number of students of non-western origin attending our medical school. As expected, we found fewer drinkers among those students from non-western countries where drinking is less prevalent. Those non-western students who did drink had an older mean age at starting drinking (although non-significant due to small numbers); but unexpectedly they matched their western counterparts in terms of mean consumption, suggesting that these students take on the habits of their Irish/western classmates. Students are entering university at an older age in Ireland and 2002 students in this study were older; however we found that the increase in current drinkers in 2002 compared to 1973 and 1990 persisted after adjustment for age distribution. Furthermore, lack of gender difference has been identified, where women’s drinking prevalence equalled that of men’s by the end of medical school (Flaherty and Richman, 1993; McAuliffe et al., 1984b). We concur with these findings, as, in our study, among western students in 2002, the prevalence of current drinkers was similar in men and women. There is a well-documented national rise in the prevalence of drug abuse (European Monitoring Centre for Drugs and Drug Addiction, 2004). Medical students see the social and physical effects of alcohol and drug abuse graphically through patient exposure, but they may detach themselves from these clinical pictures and view themselves as different to their patients. Although medical students may have more knowledge about substance abuse this does not translate into differences in attitudes or behaviour (Knopf and Wakefield, 1974). The most recent (2002) study shows that more students are being offered illicit drugs at some time in their life, and a greater number are accepting these drugs. More males than females are being offered and taking drugs. The figures in 1990 show a reduction in drug exposure in males from 1973, followed by a surge in 2002 above the 1973 figures. The figures in females show a less marked change from 1973 to 1990 and then a doubling in reported drug usage from 1990 to 2002. There appears to be a decline in obvious parental presence, as demonstrated by the proportions of students living outside the family home, with increasingly larger numbers residing in flats or shared houses. The high (and rising) levels of alcohol and drug use found in our study indicate a worrying problem and confirm national concerns. This study may in fact underestimate problem drinkers or users of drugs, as those absent from lectures may include those affected by the after effects of consumption. The implications of our findings are serious. During college life, significant positive associations have been found between alcohol consumption and experiences such as missing study, becoming more sexually involved and getting into a physical fight or argument (NewburyBirch et al., 2000). Patterns of substance misuse established in university may persist into professional life and doctors are at special risk of developing addiction problems (Strang et al., 1998). Substance misuse may impair an individual’s capacity to perform professional responsibilities, and the problematic use of drugs and alcohol is a common reason for reporting of doctors
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to the Irish Medical Council (Hillery, 2004). The stigma associated with addiction may result in concealment until an adverse event occurs, rather than early seeking of assistance. Stress and high anxiety may be present in doctors, and the use of alcohol to cope with tension has been described in medical students (male and female equally) as an independent risk factor for hazardous drinking (Tyssen et al., 1998). Another study (Kjobli et al., 2004) suggested that, in addition to stress, personality traits were implicated in hazardous drinking. The personality characteristic of psychoticism has been associated with alcohol and illicit drug consumption (Newbury-Birch et al., 2000). Drinking has been linked to depression in women doctors (Firth-Cozens, 1998). Personal misuse of addictive substances means a doctor may fail to take misuse by patients seriously. Since the promotion of healthy lifestyles is an important part of a doctor’s job it may augment health promotion messages if the doctor can “practise what he/she preaches”. Addictions may originate in medical school (Moore et al., 1990; Murray, 1976) and so an understanding of the patterns of behaviour in medical students may indicate opportunities for prevention. It is recommended that personally relevant health education should be provided as early as possible (Brynner, 1967; Knopf and Wakefield, 1974; Room et al., 2005) and that uniform national guidelines are needed to sensitise medical students to the dangers of substance abuse (Hughes et al., 1992). Medical students should be encouraged to increase their own awareness about their own drinking habits and acknowledge the difficulty they have in changing them (Ritson, 1990). The phenomenon of ‘drinking to cope’ should be targeted for preventive measures against hazardous drinking. Integrated teaching about alcohol and other forms of substance abuse should be provided and its impact monitored; World Health Organisation guidelines are available on integration into the core medical curriculum (Ariff and Westermeyer, 1988). Early identification of substance misuse is vital in the university setting, with access to appropriate diagnostic, treatment and rehabilitation services, and greater awareness among students of the existence of services and supports. Furthermore, doctors require increased professional awareness of the issue of addiction, and support and intervention in the workplace is also needed to identify and assist those with alcohol and/or drug problems, for the benefit of individual doctors and the general public. References Ariff, A., Westermeyer, J., 1988. Manual of Drug and Alcohol Abuse. Guidelines for Teaching in Medical and Health Institutions. Plenum Press, New York. Baldwin Jr., D.C., Hughes, P.H., Conard, S.E., Storr, C.L., Sheehan, D.V., 1991. Substance abuse among senior medical students. A survey of 23 medical schools. JAMA 265, 2074–2078. Brynner, J., 1967. Medical Students’ Attitudes Towards Smoking. HMSO, London. Centre for Health Promotion Studies, 2002. The National Health and Lifestyle Surveys. SLAN (Survey of Lifestyle, Attitudes and Nutrition). National University of Ireland, Galway. Collier, D.J., Beales, I.L., 1989. Drinking among medical students: a questionnaire survey. BMJ 299, 19–22.
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