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Use of Drugs, Tobacco, Alcohol and Illicit Substances in a French Student Population
Thérapie 2012 Septembre-Octobre; 67 (5): 429–435 DOI: 10.2515/therapie/2012056
ADDICTOVIGILANCE
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Use of Drugs, Tobacco, Alcohol and Illicit Substances in a French Student Population Agnès Sommet1,2, Nicolas Ferrières1, Vidiane Jaoul3, Laurence Cadieux3, Jean-Marc Soulat3,4, Maryse Lapeyre-Mestre1,2 and Jean-Louis Montastruc1,2 1 Laboratory of Medical and Clinical Pharmacology, Pharmacoepidemiology, Inserm U1027, Toulouse University, Faculty of Medicine, Toulouse, France 2 Service of Clinical Pharmacology, Midi-Pyrénées Pharmacovigilance Pharmacoepidemiology and Drug Information Centre, University Hospital of Toulouse, Toulouse, France 3 Interuniversity Service for Prevention and Health Promotion (SIMPPS), Paul Sabatier University, Toulouse, France 4 Department of Environmental and Occupational Diseases, University Hospital of Toulouse, Toulouse, France Text received January 3rd, 2012; accepted July 16th, 2012
Keywords: students; drug use; health survey; pharmacoepidemiology
Abstract – Objective. To investigate perceived health status and prevalence of drug use, tobacco smoking, consumption of alcohol and illicit substances in a student population. Methods. Data were obtained from an anonymous questionnaire distributed to first-year students of the Toulouse University. Collected data concerned socio-demographic characteristics, perceived health status, and consumption of tobacco, alcohol, illicit substances and drugs. Results. Fifty seven percent of the 3 561 responders declared to have taken at least one drug during the week preceding the questionnaire. Most commonly Anatomical, Therapeutic and Chemical (ATC) classes used were genito-urinary system and sex hormones (29.6%), nervous system (16.4%) and alimentary tract and metabolism (14.1%). Twenty three percent of students were smokers. Differences according to health perception were found for tobacco and cannabis consumption. Anxiety was significantly more prevalent among students reporting that they did not consume alcohol (p<0.05). Conclusion. More than half of students use drugs. Other consumptions (tobacco, alcohol and illicit substances) are related with perceived health status.
Mots clés : étudiant ; consommation de médicament ; enquête de santé ; pharmacoépidémiologie
Résumé – Consommation de médicaments, tabac, alcool et substances illicites dans une population d’étudiants français. Objectif. Évaluer la santé perçue et les prévalences de consommation de médicaments, tabac, alcool et substances illicites dans une population d’étudiants. Méthodes. Des étudiants inscrits en première année à l’université de Toulouse ont répondu à un questionnaire anonyme comportant des informations sociodémographiques, de santé, et de consommation de tabac, alcool et substances illicites. Résultats. Parmi les 3 561 participants, 57 % déclarent avoir pris au moins un médicament la semaine précédent l’enquête. Les classes anatomique, thérapeutique et chimique (ATC) les plus utilisées sont les médicaments du système génito-urinaire (29,6 %), du système nerveux (16,4 %), et du système métabolique (14,1 %). Vingt-trois pour cent des étudiants sont fumeurs. Il existe des différences concernant la santé perçue selon la consommation de tabac et de cannabis. L’anxiété est significativement plus fréquemment rapportée parmi les étudiants ne rapportant aucune consommation alcoolique (p < 0,05). Conclusion. Plus de la moitié des étudiants consomment des médicaments. Les autres consommations (tabac, alcool et substances illicites) sont liées à la santé perçue.
1. Purpose There is a global concern about health of adolescents and young people.[1-3] A survey done in 2007[4] showed that 93.5% of the students considered themselves healthy. Nevertheless, 31.3% declared to have felt depressed (in particular women) for at least 15 days in one year. Among this population, 8.8% expressed suicidal thoughts.
This ill-being could be explained by a period of transition (loss of marks, competition, orientation), often precarious living conditions, dysfunctions of the education system (working rhythm, uncertainty of future professional life) and family pressure (particularly for students of modest origin).[5] This ill-being can be related to a more important consumption of alcohol, tobacco and/or illicit substances among young people than in the whole population.
* For the list of participants, see end of article.
Article publié par EDP Sciences
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The french population is an important drugs’ consumer, in particular for antibiotics and psychotropic drugs. A recent report indicated that France is the first country for drug consumption, before four other European countries (Germany, United Kingdom, Spain, and Italy). In 2003, the total expense of pharmaceutical products was 2.11% of the Gross Domestic Product in France against 1.86% in Italy, 1.62% in Germany, and 1.22% in United Kingdom.[6] Since several studies have shown relations between drugs’ use and consumption of alcohol, tobacco or illicit substances,[7] we could suspect that drug use is also important in a university population. However, it is not known if the french overconsumption of drugs begins early or late in the lifetime. Since studies on substances consumption of students were principally carried on psychoactive substances (alcohol, tobacco, narcotics, psychotropic drugs), but did not include all drugs,[8] it is difficult to extrapolate results of other studies to our interest population. Moreover, health systems and access to drugs are different between studies, and could induce differences in term of prevalence of drug use. The objective of this study was to investigate the perceived health status and the prevalence of drug use, tobacco smoking, consumption of alcohol and illicit substances in a French student population.
2. Methods 2.1. Survey This survey was conducted in Toulouse (South Western, France) from September 2006 to June 2007 in collaboration with the University Service of Medicine and Promotion of Health (SIMPPS). Majority of first year students registered at the University of Toulouse are subjected to a mandatory medical examination performed in order to monitor vaccination status. In addition, health problems that could hinder the academic progress of the students are identified. During the academic year 2006-2007, it was offered to the students to fill an anonymous questionnaire on their health status, their drugs and other substances consumptions just before the medical examination. About 5 000 students were invited to this medical convocation, and 3 561 accepted to answer to this survey (response rate: 71.2%). 2.2. Variables Self-administered questionnaires included questions on sociodemographic factors (age, gender), extra scholar activities (job, culture, and physical activity), consumptions of tobacco, alcohol, illicit substances and drugs. Consumption of tobacco and alcohol was specified with the usual frequency of use. Information on illicit
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substance consumption was collected from a checklist including different types of substance (cannabis, cocaine, amphetamines, ecstasy, opiates, plants and others). For drugs, only medications during the last week were asked, with information on motive, frequency of use (every day or occasionally) and the mode of getting (prescription, advice in a pharmacy, parents, self-medication). Drugs were listed according to the anatomic, therapeutic and chemical classification (ATC) recommended by Worldwide Organization of Health (WHO). Information on health was collected by questions requiring about perceived health (a four scale of their self-rated health, problems of sleep [yes/no], anxiety [yes/no], tiredness [yes/no], concentration and memorization [yes/no]), about medical consultation during the last year [yes/no], hospitalization during the last year [yes/ no], use of contraception [yes/no] and kind of contraception. For more synthetic information, the four-point scale of selfrated health of the students was dichotomized into “poor” and “good”, with “poor” equal to not at all or not much satisfactory, and “good” equal to rather or very satisfactory. 2.3. Statistical analysis Quantitative variables are presented by mean, minimum, maximum and standard error, and qualitative data by percentage. Statistical analyses were based on Chi-square tests or Fisher tests, according to application condition, with SAS version 9.1. After a descriptive analysis of the population and their substances’ and drugs’ use, we compared these consumptions according to the health status. People having declared to take a drug without specifying which one and those not having answered this question were excluded from the comparative analysis.
3. Results 3.1. Characteristics of the population The 3 561 responders were mainly women (59.6%), with a mean age of 19.4 years (15.9-36.4; s.e: 1.6) [table I]. They played a sport and had cultural activity (reading, music, TV, Internet) more than once a week respectively in 56.1% and 87.3% of cases. They lived predominantly in their own flat or with their parents (64.4%). About one third of students received financial helps (36.4%). The majority of students (95.7%) were covered by the French national health Insurance, and 88.9% had a complementary mutual insurance. 3.2. Health-related variables During the last 12 months, 91.1% went to a doctor and 10.2% reported an hospitalization (table II). Ninety-five for one hundred
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Table I. Socio-demographic characteristics of the 3 561 students.
Table II. Health characteristics of the 3 561 students.
Socio-demographic variables (number of respondents) Age (n=3470) [years; min-max] Gender, (n=3 491) Women Men
Health characteristics (number of respondents) Health insurance National health insurance (n=3 250) Complementary health insurance (n=3 056)
3 110 (95.7%) 2 717 (88.9%)
2 081 (59.6%) 1 410 (40.4%)
Practice of sport, (n=3 382) More than once a week More than once a month Less than once a month
Medical care access during the last year Medical consultation (n=3 500) Hospitalization (n=3 363)
3 188 (91.1%) 343 (10.2%)
1 897 (56.1%) 767 (22.7%) 718 (21.2%)
Cultural activity (reading, music, internet, television), (n=3 476) More than once a week More than once a month Less than once a month
Self-rated health status (n=3 524) Not at all satisfactory Not much satisfactory Rather satisfactory Very satisfactory
16 (0.4%) 161 (4.6%) 1 858 (52.9%) 1 479 (42.1%)
3 036 (87.3%) 340 (9.8%) 100 (2.9%)
Outings, (n=3 459) More than once a week More than once a month Less than once a month
1 114 (32.2%) 1 646 (47.6%) 699 (20.2%)
Other perceived health status* Sleep disorders (n=3 497) Anxiety (n=3 478) Tiredness (n=3 492) Memorization disorders (n=3 483)
697 (19.9%) 936 (26.9%) 1 423 (40.8%) 630 (18.1%)
Housing, (n=3 509) Individual flat Parents Colocation University room Dormitory
Contraception Women (n=2 035) Men (n=1 135)
1 164 (57.2%) 320 (28.2%)
1 178 (33.6%) 1 081 (30.8%) 690 (19.6%) 492 (14.0%) 68 (2.0%)
Scholarship, (n=3 380)
1 230 (36.4%)
19.4 (15.9-36.4)
judged their health status “rather” or “very satisfactory”. Some of them felt however a feeling of anxiety (26.9%) and tiredness (40.8%). Almost the fifth of the population declared problems of memorization (18.1%) or sleep (19.9%). Almost half of the students used a contraceptive means (47.0%), mainly condom (18.0%). 3.3. Tobacco, alcohol, illicit substances Among these substances, alcohol was the more used (80.6%) followed by tobacco (23.3%) and cannabis (16.8%). Majority of the students were non smokers (76.7%) at the moment of the survey. Among smokers, 44.0% smoked less than 9 cigarettes a day. Even if the fifth of the students reported that they never drank alcohol, the great majority used it occasionally (80.0%). More than a fifth (21.4%) declared have already drunk more than 5 glasses of alcohol in the same opportunity, which represents a “binge drinking” behavior. Cannabis was the illicit substance taken with the highest prevalence (16.8% of consumers), in most cases occasionally (14.3%) [table III]. Cocaine, amphetamines, ecstasy, opiates, plants and hallucinatory mushrooms represented a marginal use. Other substances
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n (%)
* Students could choose more than one option. CMU : couverture maladie universelle (universal health coverage).
that students spontaneously declared to use for psychoactive need (open question) were beedies, ether, poppers, datura, LSD, Chinese tea, vitamins, homeopathy, and antidepressants (1 or 2 cases only for each product). 3.4. Drugs More than half of the students (57.0%) declared to have taken at least one drug during the week preceding the questionnaire (including contraception pills, plants, homeopathy, and vitamins). Among the consumers, the mean number of drugs consumed was 1.7 (min: 1, max: 8, s.e: 1.0). The majority took a drug every day (63.1%). Doctor's instruction, self-medication, parents and advice in a pharmacy represented respectively 66.5%, 13.8%, 10.3% and 9.4% of modes of getting. The ATC classes most often used (number of times that a particular ATC class was taken at least once during the preceding week) were genito-urinary system and sex hormones (G – 29.6%), nervous system (N – 16.4 %), alimentary tract and metabolism (A – 14.1 %), respiratory system (R – 11.0%) and musculo-skeletal system (M – 4.7%) [figure 1]. Drugs not included in the ATC classification (15.4%) were those still not having an ATC code (Z), those for which an ATC code was not possible to determine from students’ answer (syrups, eyewashes, produces to inhale, homeopathy, herbal medicine, others) and those unclassified (cosmetic products).
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Table III. Number and proportions of illicit substances users.
Frequency of use (number of respondents) Cannabis (n=3 464)
Never n (%)
Occasionally n (%)
Weekly n (%)
Daily n (%)
2 882 (83.2%)
494 (14.3%)
59 (1.7%)
29 (0.8%)
Cocaïne (n=3 448)
3 428 (99.4%)
20 (0.6%)
-
-
Amphetamines (n=3 444)
3 431 (99.6%)
11 (0.3%)
2 (0.1%)
-
Ecstasy (n=3 443)
3 430 (99.6%)
13 (0.4%)
-
-
Opiates (n=3 434)
3 427 (99.8%)
6 (0.2%)
1 (0.03%)
-
Plants, mushrooms (n=3 431)
3 380 (98.5%)
49 (1.4%)
1 (0.03%)
1 (0.03%)
Other substances (n=3 437)
3 420 (99.5%)
16 (0.5%)
1 (0.03%)
-
Fig. 1. Use frequency of the 3 376 drugs reported to be consumed during the last week according to the ATC classification.
Among genito-urinary system and sex hormones, the more used were sex hormones and modulators of the genital system (G03 – 29.4% of class G use) and more particularly contraceptive hormones for systematic use (G03A – 24.7% of class G use). Excluding subjects taking only one drug from the G03A class, the prevalence of drug use became 44.3% (versus 57.0% with G03A class). Eighty-three percent of the nervous system’s drugs were analgesic drugs (N02 – 13.7%), mainly paracetamol (N02BE01 – 10.9%). Mainly obtained without prescription (80.8%), paracetamol was used punctually (94.0%) for various pain but also against acne, sore throats, bronchitis, flu-like syndromes, tiredness, fever, cold, sinusitis, or viral infections. Other central nervous system’s drugs used were antiepileptic (N03 – 0.4%), psycholeptic (N05 – 1.9%, mainly benzodiazepines and related) and psychoanaleptic (N06 – 0.4%,
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mainly antidepressants) drugs. Antiepileptic and psychoanaleptic drugs were practically all consumed every day following a medical prescription. In contrast, psycholeptic drugs were used either occasionally or every day. Their medical prescription varied according to under classes: always after medical prescription for antipsychotic, predominantly for anxiolytic and half for hypnotic and sedative drugs. Among products not listed in the ATC classification, homeopathy (4.8%) and phytotherapy (2.5%) took a large place. Vitamins (A11) were about 67% of the alimentary tract and metabolism class, and 9.5% of the total use of drugs. Generally not prescribed (80.3%) and taken every day (59.4%), they were used for several reasons: tiredness, followed by hypothyroïdism and cystic fibrosis. The H1 antihistamine for systemic use (R06 – 4.2%) were around 38 % of the respiratory system drugs (R – 11.0%).
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Ibuprofen (M01AE01 – 3.4%) was the mainly used anti-inflammatory and anti-rheumatic drugs (M01 – 4.6%). This drug, prescribed in 40.0% of cases, was predominantly used punctually (91.2%) for various pains but also for sore throats, flu-like syndromes, fever, inflammations, and nasopharyngitis. 3.5. Relation between health status and drug use Some relations were found between the health status of students and their drug use (table IV). In most cases, use of drug was associated with a poor health status. Opiates’ consumption (N02A) was about 10 times more important when students declared to present a poor health status (p<0.0001). This consumption was also more important in case of sleep disorders, anxiety, tiredness and memorization disorders (p<0.05). Sleep disorders and tiredness were also related to the use of anti migraine drugs (N02C) [p<0.05]. Both health disorders and anxiety were related with other antalgic and antipyretic drugs’use (p<0.05). Antiepileptic drugs use (N03) was statistically significantly associated with a poor health status, sleeping and memorization disorders (p<0.05). Among psycholeptic drugs (N05), the use of anxiolytics (N05B) and hypnotic and sedative (N05C) drugs was statistically significantly associated with all perceived healthrelated variables (p<0.05). Use of antidepressant drugs was statistically significantly linked to every health disorders, except tiredness and sleep disorders, with more consumption in case of a poor perceived health status. Use of vitamins was statistically significantly associated with a poor perceived health status (except sleep disorders). 3.6. Relation between health status and tobacco, alcohol and illicit substances use A poor health status, sleeping disorders, anxiety, tiredness and problems of concentration were statistically significantly associated to the use of tobacco (p<0.05). Except for anxiety, same relations were found between health perception and cannabis use. In contrast, alcohol consumption was significantly associated only with anxiety (p<0.05), with more consumers among not anxious students. A statistical significant association was found between use of amphetamines and plants and tiredness and memorization disorders (p<0.05). No statistically significant association was found between use of cocaine and ecstasy and self-rated health (ns).
4. Discussion The main result of this work is the relatively important prevalence of drugs users among a young population of students (44% excluding oral contraception), irrespective of whether a prescription had been issues. Most of previously published studies were only
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descriptive. As far as we know, there were relatively few studies to also investigate relation with perceived health status. These results are in concordance with others studies. A Portuguese study on drug use from students of the university of Lisbon in 2000 showed that 57% of the students had taken at least one drug during the 15 days preceding the survey.[9] The drug users felt more often in poor health or subjected to an intense daily stress (p<0.001). The main pharmacological classes were antalgic (22.2%), antiinflammatory (14.5%), sex hormones (9.8%) and psycholeptic (7.8%) drugs. Paracetamol was the most frequently drug used (9.1%). Pain, infections and psychological disorders represented the main health’s problems. Concerning psychoactive drugs, 7.2% of the students used tranquillizers (anxiolytic, hypnotic and sedative drugs), 1.9% psychostimulants and 1.7% antidepressant drugs. A more recent spanish study found similar results with a prevalence of 57.8% drug users in a university population, including both prescribed and non-prescribed drugs.[10] Drugs more often used were medication for colds (33.9% of students), medications for pain or fever (23.6%), followed by contraceptives (15.6%). Drug consumption was significantly higher among cannabis, tobacco or alcohol users. Unfortunately, none information was given on perceived health status in this study. The present study allows extending these observations to a very large population (more than 3 500 students): Toulouse university is one of the biggest in France. Thus, our results are generalizable and representative of the general sudents’ population. Thirty one European countries participated to the European School survey Project on Alcohol and other Drugs (ESPAD) study in 2007.[11] The French students (15-16 year-old) appeared in first position (14%) to have at least once used tranquillisers or sedatives with doctor’s prescription, and in third position (15%) without prescription. The relatively high drug consumption in our population could also be explained (at least partly) by an important consumption in the whole French population. Prevalence of overall drug use in a French workers sample in 2006 was similar (40.7%) than in the present study.[12] In another cross-sectional study on consumption of medicines performed in 1 020 children and adolescents (10 to 21 years; mean age 15.3 years), 60.2% used at least one drug during the week before the study.[13] Further epidemiological longitudinal studies could investigate the hypothesis of the relationship between early drug use and later drug use at different stages of life. We chose to perform a study in a general student population in order to collect information on prescribed and non-prescribed drugs, as well as other substance use, information on health status, lifestyle and socio-demographic factors. Even if the universitary medical service has to perform a mandatory medical examination, some students do not come at this convocation. Those accepting may differ from non-accepting for different reasons, in particular for healthrelated reasons. Since the response rate was relatively important (71.2%) in this study, we can consider that non-response bias should be of minor importance.
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N02A
6 (0.2)
24 (0.7)
23 (0.7)
7 (0.2)
12 (0.4)
26 (14.9) 283 (8.7)
5 (2.9)
5 (2.9)
7 (4.0)
5 (2.9)
2 (1.2)
24 (13.8) 388 (12.0)
Good n=3 242 n (%) 13 (0.4)
*: p-value <0.05 **: p-value <0.01 ***: p-value <0.001 ns: no statistically sgnificant
vitamins
A11
antidepressants
N06A
hypnotics
N05C
anxiolytics
N05B
antiepileptics
N03
antimigraine
N02C
other analgesics
N02B
opiates
Poor n=174 n (%) 8 (4.6)
Self-rated health
**
***
*
***
***
ns
ns
***
p
6 (0.2)
9 (0.3)
7 (0.3)
6 (0.2)
305 (11.2) 8 (0.3)
ns
***
***
**
*
**
p No n=2 720 n (%) 11 (0.4) **
70 (10.3) 234 (8.6) ns
5 (0.7)
20 (2.9)
23 (3.4)
7 (1.0)
6 (0.9)
107 (15.7)
Yes n=682 n (%) 11 (1.6)
Sleep disorders Yes n=911 n (%) 12 (1.3)
No n=2742 n (%) 10 (0.4)
Anxiety
**
p
3 (0.1)
5 (0.2)
8 (0.3)
7 (0.3)
9 (0.4)
**
***
***
ns
ns
121 (13.3) 181 (6.6) ***
8 (0.9)
24 (2.6)
22 (2.4)
6 (0.7)
5 (0.5)
137 (15.0) 274 (10.0) **
Table IV. Some drugs use according to perceived health status among the students.
No n=2017 n (%) 8 (0.4) *
p
4 (0.2)
6 (0.3)
5 (0.3)
5 (0.3)
4 (0.2)
ns
***
***
ns
*
191 (13.8) 115 (5.7) ***
7 (0.5)
23 (1.7)
24 (1.7)
7 (0.5)
10 (0.7)
213 (15.4) 200 (9.9) ***
Yes n=1382 n (%) 14 (1.0)
Tiredness
*
ns
ns
6 (0.2)
*
15 (0.5) ***
16 (0.6) ***
6 (0.2)
328 (11.8) 10 (0.4)
77 (12.7) 225 (8.1) ***
5 (0.8)
13 (2.1)
13 (2.1)
6 (1.0)
4 (0.7)
85 (14.0)
Concentration and memorization disorders p No Yes n=608 n=2 782 n (%) n (%) 11 (1.8) 11 (0.4) **
434 Sommet et al.
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Another bias could be the nature of the survey (auto questionnaire). Students with major social and medical problems could be less likely to participate and/or to answer to questions concerning their health status. On the same way, more important drug and other substance consumers may underestimate their declared consumption. However, even under this hypothesis, we found a statistical significant association between consumption of nervous system drugs, vitamins, tobacco, illicit substances and reported health disorders. These associations between consumptions and poor perceivedhealth status could indicate that students who use these substances are experiencing situation with complex health problems. Only alcohol use differed, since the percentage of students indicating drinking was more important when they judged their health rather and very satisfactory or when they were not anxious. At our knowledge, none study found similar results. However, we were not able to determine in this cross-sectional study if consumptions were cause or consequence of health disorders. However, health practitioners and adults working with students should be aware of these associations, in order to detect a health problem or a potential illicit substance use. In conclusion, this study shows that more than half of students use drugs. This frequent drug use is largely explained by an important use of ATC drugs like paracetamol. The use of other substances (tobacco, alcohol, and illicit substances) is consistent, and associated with health reported disorders. These results underline the importance of the interface between health practitioners at university and students. These results also suggest the need to develop pharmacological education on drug risks for all students, whatever their university course of study.
Conflict of interest. None.
Abbreviations. ATC: anatomic, therapeutic and chemical classification; CMU: couverture maladie universelle (universal health coverage); ESPAD: European School survey Project on Alcohol and other Drugs; SIMPPS: University Service of Medicine and Promotion of Health; WHO: Worldwide Organization of Health.
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ADDICTOVIGILANCE
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Use of Drugs, Tobacco, Alcohol and Illicit Substances in a French Student Population Agnès Sommet1,2, Nicolas Ferrières1, Vidiane Jaoul3, Laurence Cadieux3, Jean-Marc Soulat3,4, Maryse Lapeyre-Mestre1,2 and Jean-Louis Montastruc1,2 1 Laboratory of Medical and Clinical Pharmacology, Pharmacoepidemiology, Inserm U1027, Toulouse University, Faculty of Medicine, Toulouse, France 2 Service of Clinical Pharmacology, Midi-Pyrénées Pharmacovigilance Pharmacoepidemiology and Drug Information Centre, University Hospital of Toulouse, Toulouse, France 3 Interuniversity Service for Prevention and Health Promotion (SIMPPS), Paul Sabatier University, Toulouse, France 4 Department of Environmental and Occupational Diseases, University Hospital of Toulouse, Toulouse, France Text received January 3rd, 2012; accepted July 16th, 2012
Keywords: students; drug use; health survey; pharmacoepidemiology
Abstract – Objective. To investigate perceived health status and prevalence of drug use, tobacco smoking, consumption of alcohol and illicit substances in a student population. Methods. Data were obtained from an anonymous questionnaire distributed to first-year students of the Toulouse University. Collected data concerned socio-demographic characteristics, perceived health status, and consumption of tobacco, alcohol, illicit substances and drugs. Results. Fifty seven percent of the 3 561 responders declared to have taken at least one drug during the week preceding the questionnaire. Most commonly Anatomical, Therapeutic and Chemical (ATC) classes used were genito-urinary system and sex hormones (29.6%), nervous system (16.4%) and alimentary tract and metabolism (14.1%). Twenty three percent of students were smokers. Differences according to health perception were found for tobacco and cannabis consumption. Anxiety was significantly more prevalent among students reporting that they did not consume alcohol (p<0.05). Conclusion. More than half of students use drugs. Other consumptions (tobacco, alcohol and illicit substances) are related with perceived health status.
Mots clés : étudiant ; consommation de médicament ; enquête de santé ; pharmacoépidémiologie
Résumé – Consommation de médicaments, tabac, alcool et substances illicites dans une population d’étudiants français. Objectif. Évaluer la santé perçue et les prévalences de consommation de médicaments, tabac, alcool et substances illicites dans une population d’étudiants. Méthodes. Des étudiants inscrits en première année à l’université de Toulouse ont répondu à un questionnaire anonyme comportant des informations sociodémographiques, de santé, et de consommation de tabac, alcool et substances illicites. Résultats. Parmi les 3 561 participants, 57 % déclarent avoir pris au moins un médicament la semaine précédent l’enquête. Les classes anatomique, thérapeutique et chimique (ATC) les plus utilisées sont les médicaments du système génito-urinaire (29,6 %), du système nerveux (16,4 %), et du système métabolique (14,1 %). Vingt-trois pour cent des étudiants sont fumeurs. Il existe des différences concernant la santé perçue selon la consommation de tabac et de cannabis. L’anxiété est significativement plus fréquemment rapportée parmi les étudiants ne rapportant aucune consommation alcoolique (p < 0,05). Conclusion. Plus de la moitié des étudiants consomment des médicaments. Les autres consommations (tabac, alcool et substances illicites) sont liées à la santé perçue.
1. Purpose There is a global concern about health of adolescents and young people.[1-3] A survey done in 2007[4] showed that 93.5% of the students considered themselves healthy. Nevertheless, 31.3% declared to have felt depressed (in particular women) for at least 15 days in one year. Among this population, 8.8% expressed suicidal thoughts.
This ill-being could be explained by a period of transition (loss of marks, competition, orientation), often precarious living conditions, dysfunctions of the education system (working rhythm, uncertainty of future professional life) and family pressure (particularly for students of modest origin).[5] This ill-being can be related to a more important consumption of alcohol, tobacco and/or illicit substances among young people than in the whole population.
* For the list of participants, see end of article.
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The french population is an important drugs’ consumer, in particular for antibiotics and psychotropic drugs. A recent report indicated that France is the first country for drug consumption, before four other European countries (Germany, United Kingdom, Spain, and Italy). In 2003, the total expense of pharmaceutical products was 2.11% of the Gross Domestic Product in France against 1.86% in Italy, 1.62% in Germany, and 1.22% in United Kingdom.[6] Since several studies have shown relations between drugs’ use and consumption of alcohol, tobacco or illicit substances,[7] we could suspect that drug use is also important in a university population. However, it is not known if the french overconsumption of drugs begins early or late in the lifetime. Since studies on substances consumption of students were principally carried on psychoactive substances (alcohol, tobacco, narcotics, psychotropic drugs), but did not include all drugs,[8] it is difficult to extrapolate results of other studies to our interest population. Moreover, health systems and access to drugs are different between studies, and could induce differences in term of prevalence of drug use. The objective of this study was to investigate the perceived health status and the prevalence of drug use, tobacco smoking, consumption of alcohol and illicit substances in a French student population.
2. Methods 2.1. Survey This survey was conducted in Toulouse (South Western, France) from September 2006 to June 2007 in collaboration with the University Service of Medicine and Promotion of Health (SIMPPS). Majority of first year students registered at the University of Toulouse are subjected to a mandatory medical examination performed in order to monitor vaccination status. In addition, health problems that could hinder the academic progress of the students are identified. During the academic year 2006-2007, it was offered to the students to fill an anonymous questionnaire on their health status, their drugs and other substances consumptions just before the medical examination. About 5 000 students were invited to this medical convocation, and 3 561 accepted to answer to this survey (response rate: 71.2%). 2.2. Variables Self-administered questionnaires included questions on sociodemographic factors (age, gender), extra scholar activities (job, culture, and physical activity), consumptions of tobacco, alcohol, illicit substances and drugs. Consumption of tobacco and alcohol was specified with the usual frequency of use. Information on illicit
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substance consumption was collected from a checklist including different types of substance (cannabis, cocaine, amphetamines, ecstasy, opiates, plants and others). For drugs, only medications during the last week were asked, with information on motive, frequency of use (every day or occasionally) and the mode of getting (prescription, advice in a pharmacy, parents, self-medication). Drugs were listed according to the anatomic, therapeutic and chemical classification (ATC) recommended by Worldwide Organization of Health (WHO). Information on health was collected by questions requiring about perceived health (a four scale of their self-rated health, problems of sleep [yes/no], anxiety [yes/no], tiredness [yes/no], concentration and memorization [yes/no]), about medical consultation during the last year [yes/no], hospitalization during the last year [yes/ no], use of contraception [yes/no] and kind of contraception. For more synthetic information, the four-point scale of selfrated health of the students was dichotomized into “poor” and “good”, with “poor” equal to not at all or not much satisfactory, and “good” equal to rather or very satisfactory. 2.3. Statistical analysis Quantitative variables are presented by mean, minimum, maximum and standard error, and qualitative data by percentage. Statistical analyses were based on Chi-square tests or Fisher tests, according to application condition, with SAS version 9.1. After a descriptive analysis of the population and their substances’ and drugs’ use, we compared these consumptions according to the health status. People having declared to take a drug without specifying which one and those not having answered this question were excluded from the comparative analysis.
3. Results 3.1. Characteristics of the population The 3 561 responders were mainly women (59.6%), with a mean age of 19.4 years (15.9-36.4; s.e: 1.6) [table I]. They played a sport and had cultural activity (reading, music, TV, Internet) more than once a week respectively in 56.1% and 87.3% of cases. They lived predominantly in their own flat or with their parents (64.4%). About one third of students received financial helps (36.4%). The majority of students (95.7%) were covered by the French national health Insurance, and 88.9% had a complementary mutual insurance. 3.2. Health-related variables During the last 12 months, 91.1% went to a doctor and 10.2% reported an hospitalization (table II). Ninety-five for one hundred
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Table I. Socio-demographic characteristics of the 3 561 students.
Table II. Health characteristics of the 3 561 students.
Socio-demographic variables (number of respondents) Age (n=3470) [years; min-max] Gender, (n=3 491) Women Men
Health characteristics (number of respondents) Health insurance National health insurance (n=3 250) Complementary health insurance (n=3 056)
3 110 (95.7%) 2 717 (88.9%)
2 081 (59.6%) 1 410 (40.4%)
Practice of sport, (n=3 382) More than once a week More than once a month Less than once a month
Medical care access during the last year Medical consultation (n=3 500) Hospitalization (n=3 363)
3 188 (91.1%) 343 (10.2%)
1 897 (56.1%) 767 (22.7%) 718 (21.2%)
Cultural activity (reading, music, internet, television), (n=3 476) More than once a week More than once a month Less than once a month
Self-rated health status (n=3 524) Not at all satisfactory Not much satisfactory Rather satisfactory Very satisfactory
16 (0.4%) 161 (4.6%) 1 858 (52.9%) 1 479 (42.1%)
3 036 (87.3%) 340 (9.8%) 100 (2.9%)
Outings, (n=3 459) More than once a week More than once a month Less than once a month
1 114 (32.2%) 1 646 (47.6%) 699 (20.2%)
Other perceived health status* Sleep disorders (n=3 497) Anxiety (n=3 478) Tiredness (n=3 492) Memorization disorders (n=3 483)
697 (19.9%) 936 (26.9%) 1 423 (40.8%) 630 (18.1%)
Housing, (n=3 509) Individual flat Parents Colocation University room Dormitory
Contraception Women (n=2 035) Men (n=1 135)
1 164 (57.2%) 320 (28.2%)
1 178 (33.6%) 1 081 (30.8%) 690 (19.6%) 492 (14.0%) 68 (2.0%)
Scholarship, (n=3 380)
1 230 (36.4%)
19.4 (15.9-36.4)
judged their health status “rather” or “very satisfactory”. Some of them felt however a feeling of anxiety (26.9%) and tiredness (40.8%). Almost the fifth of the population declared problems of memorization (18.1%) or sleep (19.9%). Almost half of the students used a contraceptive means (47.0%), mainly condom (18.0%). 3.3. Tobacco, alcohol, illicit substances Among these substances, alcohol was the more used (80.6%) followed by tobacco (23.3%) and cannabis (16.8%). Majority of the students were non smokers (76.7%) at the moment of the survey. Among smokers, 44.0% smoked less than 9 cigarettes a day. Even if the fifth of the students reported that they never drank alcohol, the great majority used it occasionally (80.0%). More than a fifth (21.4%) declared have already drunk more than 5 glasses of alcohol in the same opportunity, which represents a “binge drinking” behavior. Cannabis was the illicit substance taken with the highest prevalence (16.8% of consumers), in most cases occasionally (14.3%) [table III]. Cocaine, amphetamines, ecstasy, opiates, plants and hallucinatory mushrooms represented a marginal use. Other substances
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n (%)
* Students could choose more than one option. CMU : couverture maladie universelle (universal health coverage).
that students spontaneously declared to use for psychoactive need (open question) were beedies, ether, poppers, datura, LSD, Chinese tea, vitamins, homeopathy, and antidepressants (1 or 2 cases only for each product). 3.4. Drugs More than half of the students (57.0%) declared to have taken at least one drug during the week preceding the questionnaire (including contraception pills, plants, homeopathy, and vitamins). Among the consumers, the mean number of drugs consumed was 1.7 (min: 1, max: 8, s.e: 1.0). The majority took a drug every day (63.1%). Doctor's instruction, self-medication, parents and advice in a pharmacy represented respectively 66.5%, 13.8%, 10.3% and 9.4% of modes of getting. The ATC classes most often used (number of times that a particular ATC class was taken at least once during the preceding week) were genito-urinary system and sex hormones (G – 29.6%), nervous system (N – 16.4 %), alimentary tract and metabolism (A – 14.1 %), respiratory system (R – 11.0%) and musculo-skeletal system (M – 4.7%) [figure 1]. Drugs not included in the ATC classification (15.4%) were those still not having an ATC code (Z), those for which an ATC code was not possible to determine from students’ answer (syrups, eyewashes, produces to inhale, homeopathy, herbal medicine, others) and those unclassified (cosmetic products).
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Table III. Number and proportions of illicit substances users.
Frequency of use (number of respondents) Cannabis (n=3 464)
Never n (%)
Occasionally n (%)
Weekly n (%)
Daily n (%)
2 882 (83.2%)
494 (14.3%)
59 (1.7%)
29 (0.8%)
Cocaïne (n=3 448)
3 428 (99.4%)
20 (0.6%)
-
-
Amphetamines (n=3 444)
3 431 (99.6%)
11 (0.3%)
2 (0.1%)
-
Ecstasy (n=3 443)
3 430 (99.6%)
13 (0.4%)
-
-
Opiates (n=3 434)
3 427 (99.8%)
6 (0.2%)
1 (0.03%)
-
Plants, mushrooms (n=3 431)
3 380 (98.5%)
49 (1.4%)
1 (0.03%)
1 (0.03%)
Other substances (n=3 437)
3 420 (99.5%)
16 (0.5%)
1 (0.03%)
-
Fig. 1. Use frequency of the 3 376 drugs reported to be consumed during the last week according to the ATC classification.
Among genito-urinary system and sex hormones, the more used were sex hormones and modulators of the genital system (G03 – 29.4% of class G use) and more particularly contraceptive hormones for systematic use (G03A – 24.7% of class G use). Excluding subjects taking only one drug from the G03A class, the prevalence of drug use became 44.3% (versus 57.0% with G03A class). Eighty-three percent of the nervous system’s drugs were analgesic drugs (N02 – 13.7%), mainly paracetamol (N02BE01 – 10.9%). Mainly obtained without prescription (80.8%), paracetamol was used punctually (94.0%) for various pain but also against acne, sore throats, bronchitis, flu-like syndromes, tiredness, fever, cold, sinusitis, or viral infections. Other central nervous system’s drugs used were antiepileptic (N03 – 0.4%), psycholeptic (N05 – 1.9%, mainly benzodiazepines and related) and psychoanaleptic (N06 – 0.4%,
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mainly antidepressants) drugs. Antiepileptic and psychoanaleptic drugs were practically all consumed every day following a medical prescription. In contrast, psycholeptic drugs were used either occasionally or every day. Their medical prescription varied according to under classes: always after medical prescription for antipsychotic, predominantly for anxiolytic and half for hypnotic and sedative drugs. Among products not listed in the ATC classification, homeopathy (4.8%) and phytotherapy (2.5%) took a large place. Vitamins (A11) were about 67% of the alimentary tract and metabolism class, and 9.5% of the total use of drugs. Generally not prescribed (80.3%) and taken every day (59.4%), they were used for several reasons: tiredness, followed by hypothyroïdism and cystic fibrosis. The H1 antihistamine for systemic use (R06 – 4.2%) were around 38 % of the respiratory system drugs (R – 11.0%).
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Use of Drugs in a Student Population
Ibuprofen (M01AE01 – 3.4%) was the mainly used anti-inflammatory and anti-rheumatic drugs (M01 – 4.6%). This drug, prescribed in 40.0% of cases, was predominantly used punctually (91.2%) for various pains but also for sore throats, flu-like syndromes, fever, inflammations, and nasopharyngitis. 3.5. Relation between health status and drug use Some relations were found between the health status of students and their drug use (table IV). In most cases, use of drug was associated with a poor health status. Opiates’ consumption (N02A) was about 10 times more important when students declared to present a poor health status (p<0.0001). This consumption was also more important in case of sleep disorders, anxiety, tiredness and memorization disorders (p<0.05). Sleep disorders and tiredness were also related to the use of anti migraine drugs (N02C) [p<0.05]. Both health disorders and anxiety were related with other antalgic and antipyretic drugs’use (p<0.05). Antiepileptic drugs use (N03) was statistically significantly associated with a poor health status, sleeping and memorization disorders (p<0.05). Among psycholeptic drugs (N05), the use of anxiolytics (N05B) and hypnotic and sedative (N05C) drugs was statistically significantly associated with all perceived healthrelated variables (p<0.05). Use of antidepressant drugs was statistically significantly linked to every health disorders, except tiredness and sleep disorders, with more consumption in case of a poor perceived health status. Use of vitamins was statistically significantly associated with a poor perceived health status (except sleep disorders). 3.6. Relation between health status and tobacco, alcohol and illicit substances use A poor health status, sleeping disorders, anxiety, tiredness and problems of concentration were statistically significantly associated to the use of tobacco (p<0.05). Except for anxiety, same relations were found between health perception and cannabis use. In contrast, alcohol consumption was significantly associated only with anxiety (p<0.05), with more consumers among not anxious students. A statistical significant association was found between use of amphetamines and plants and tiredness and memorization disorders (p<0.05). No statistically significant association was found between use of cocaine and ecstasy and self-rated health (ns).
4. Discussion The main result of this work is the relatively important prevalence of drugs users among a young population of students (44% excluding oral contraception), irrespective of whether a prescription had been issues. Most of previously published studies were only
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descriptive. As far as we know, there were relatively few studies to also investigate relation with perceived health status. These results are in concordance with others studies. A Portuguese study on drug use from students of the university of Lisbon in 2000 showed that 57% of the students had taken at least one drug during the 15 days preceding the survey.[9] The drug users felt more often in poor health or subjected to an intense daily stress (p<0.001). The main pharmacological classes were antalgic (22.2%), antiinflammatory (14.5%), sex hormones (9.8%) and psycholeptic (7.8%) drugs. Paracetamol was the most frequently drug used (9.1%). Pain, infections and psychological disorders represented the main health’s problems. Concerning psychoactive drugs, 7.2% of the students used tranquillizers (anxiolytic, hypnotic and sedative drugs), 1.9% psychostimulants and 1.7% antidepressant drugs. A more recent spanish study found similar results with a prevalence of 57.8% drug users in a university population, including both prescribed and non-prescribed drugs.[10] Drugs more often used were medication for colds (33.9% of students), medications for pain or fever (23.6%), followed by contraceptives (15.6%). Drug consumption was significantly higher among cannabis, tobacco or alcohol users. Unfortunately, none information was given on perceived health status in this study. The present study allows extending these observations to a very large population (more than 3 500 students): Toulouse university is one of the biggest in France. Thus, our results are generalizable and representative of the general sudents’ population. Thirty one European countries participated to the European School survey Project on Alcohol and other Drugs (ESPAD) study in 2007.[11] The French students (15-16 year-old) appeared in first position (14%) to have at least once used tranquillisers or sedatives with doctor’s prescription, and in third position (15%) without prescription. The relatively high drug consumption in our population could also be explained (at least partly) by an important consumption in the whole French population. Prevalence of overall drug use in a French workers sample in 2006 was similar (40.7%) than in the present study.[12] In another cross-sectional study on consumption of medicines performed in 1 020 children and adolescents (10 to 21 years; mean age 15.3 years), 60.2% used at least one drug during the week before the study.[13] Further epidemiological longitudinal studies could investigate the hypothesis of the relationship between early drug use and later drug use at different stages of life. We chose to perform a study in a general student population in order to collect information on prescribed and non-prescribed drugs, as well as other substance use, information on health status, lifestyle and socio-demographic factors. Even if the universitary medical service has to perform a mandatory medical examination, some students do not come at this convocation. Those accepting may differ from non-accepting for different reasons, in particular for healthrelated reasons. Since the response rate was relatively important (71.2%) in this study, we can consider that non-response bias should be of minor importance.
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N02A
6 (0.2)
24 (0.7)
23 (0.7)
7 (0.2)
12 (0.4)
26 (14.9) 283 (8.7)
5 (2.9)
5 (2.9)
7 (4.0)
5 (2.9)
2 (1.2)
24 (13.8) 388 (12.0)
Good n=3 242 n (%) 13 (0.4)
*: p-value <0.05 **: p-value <0.01 ***: p-value <0.001 ns: no statistically sgnificant
vitamins
A11
antidepressants
N06A
hypnotics
N05C
anxiolytics
N05B
antiepileptics
N03
antimigraine
N02C
other analgesics
N02B
opiates
Poor n=174 n (%) 8 (4.6)
Self-rated health
**
***
*
***
***
ns
ns
***
p
6 (0.2)
9 (0.3)
7 (0.3)
6 (0.2)
305 (11.2) 8 (0.3)
ns
***
***
**
*
**
p No n=2 720 n (%) 11 (0.4) **
70 (10.3) 234 (8.6) ns
5 (0.7)
20 (2.9)
23 (3.4)
7 (1.0)
6 (0.9)
107 (15.7)
Yes n=682 n (%) 11 (1.6)
Sleep disorders Yes n=911 n (%) 12 (1.3)
No n=2742 n (%) 10 (0.4)
Anxiety
**
p
3 (0.1)
5 (0.2)
8 (0.3)
7 (0.3)
9 (0.4)
**
***
***
ns
ns
121 (13.3) 181 (6.6) ***
8 (0.9)
24 (2.6)
22 (2.4)
6 (0.7)
5 (0.5)
137 (15.0) 274 (10.0) **
Table IV. Some drugs use according to perceived health status among the students.
No n=2017 n (%) 8 (0.4) *
p
4 (0.2)
6 (0.3)
5 (0.3)
5 (0.3)
4 (0.2)
ns
***
***
ns
*
191 (13.8) 115 (5.7) ***
7 (0.5)
23 (1.7)
24 (1.7)
7 (0.5)
10 (0.7)
213 (15.4) 200 (9.9) ***
Yes n=1382 n (%) 14 (1.0)
Tiredness
*
ns
ns
6 (0.2)
*
15 (0.5) ***
16 (0.6) ***
6 (0.2)
328 (11.8) 10 (0.4)
77 (12.7) 225 (8.1) ***
5 (0.8)
13 (2.1)
13 (2.1)
6 (1.0)
4 (0.7)
85 (14.0)
Concentration and memorization disorders p No Yes n=608 n=2 782 n (%) n (%) 11 (1.8) 11 (0.4) **
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Another bias could be the nature of the survey (auto questionnaire). Students with major social and medical problems could be less likely to participate and/or to answer to questions concerning their health status. On the same way, more important drug and other substance consumers may underestimate their declared consumption. However, even under this hypothesis, we found a statistical significant association between consumption of nervous system drugs, vitamins, tobacco, illicit substances and reported health disorders. These associations between consumptions and poor perceivedhealth status could indicate that students who use these substances are experiencing situation with complex health problems. Only alcohol use differed, since the percentage of students indicating drinking was more important when they judged their health rather and very satisfactory or when they were not anxious. At our knowledge, none study found similar results. However, we were not able to determine in this cross-sectional study if consumptions were cause or consequence of health disorders. However, health practitioners and adults working with students should be aware of these associations, in order to detect a health problem or a potential illicit substance use. In conclusion, this study shows that more than half of students use drugs. This frequent drug use is largely explained by an important use of ATC drugs like paracetamol. The use of other substances (tobacco, alcohol, and illicit substances) is consistent, and associated with health reported disorders. These results underline the importance of the interface between health practitioners at university and students. These results also suggest the need to develop pharmacological education on drug risks for all students, whatever their university course of study.
Conflict of interest. None.
Abbreviations. ATC: anatomic, therapeutic and chemical classification; CMU: couverture maladie universelle (universal health coverage); ESPAD: European School survey Project on Alcohol and other Drugs; SIMPPS: University Service of Medicine and Promotion of Health; WHO: Worldwide Organization of Health.
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