Personal and perceived peer use and attitudes towards the use of nonmedical prescription stimulants to improve academic performance among university students in seven European countries

Highlights

• Students’ nonmedical use of prescription stimulants (NMUPS) varied across Europe.

• Personal approval of NMUPS was high among European university students.

• Students perceived the peer NMUPS to be higher than their personal use.

• Perceived peer use was associated with higher personal use of NMUPS.

Abstract

Background

Overestimations of non-prescribed stimulant use of peers are well documented in the USA and have also been identified as predictive of personal stimulant consumption. This study aimed to examine whether overestimations of peer use and approval of the use are associated with personal use and attitude towards the use of non-prescribed stimulants among European university students.

Method

The EU funded ‘Social Norms Intervention for the prevention of Polydrug usE (SNIPE)’ study was conducted in seven European countries. In a web-based questionnaire, 4482 students were asked about their personal use and their attitude towards non-prescribed stimulant use, as well as the perceived peer use and peer attitude.

Results

59% of students thought that the majority of their peers used non-prescribed stimulants more frequently than themselves, and only 4% thought that the use of the majority was lower than their personal use. The perception that the majority of peers had used non-prescribed stimulants at least once was significantly associated with higher odds for personal use of non-prescribed stimulants (OR: 3.30, 95% CI: 2.32–4.71). In addition, the perception that the majority of peers approved of the non-prescribed use of stimulants was associated with a 4.03 (95% CI: 3.35–4.84) times higher likelihood for personal approval.

Discussion

European university students generally perceived the non-prescribed use of stimulants of peers to be higher than their personal use. This perception, as well as a perception of higher approval in the peer group, was associated with a higher likelihood of personal non-prescribed stimulant medication use and approval.

Introduction

The nonmedical use of prescription medicines (NMUPM) is a debated topic in science, society and media (Arria and DuPont, 2010). For instance, interest in this topic was stirred in 2008 when one informal online poll revealed that 20% of a sample of 1400 scientists from 60 countries reported that they had used medicines not prescribed by a physician to stimulate their focus, concentration, or memory (Maher, 2008). Currently, there are several prescription medicines available that are known for their potential to enhance cognitive functioning. One well-known substance is the stimulant ‘methylphenidate’ which is used for attention deficit hyperactivity disorder (ADHD) treatment. Methylphenidate formulations like Ritalin^® and Concerta^® are approved in Europe for the treatment of ADHD in children and adolescents, as well as for persons continuing treatment into adulthood. Regarding the approval of ADHD treatment for persons diagnosed in adulthood, there are differences across European countries. In Germany, methylphenidate is approved for treatment of adult ADHD (BfArM, 2011) and in the U.K., adult ADHD is recognized as a condition (NICE, 2016) whereas other countries, such as Belgium and Denmark, only approved methylphenidate for treatment of ADHD in children and adolescents aged 6–17 years. Methylphenidate was also the substance most commonly used by those scientists who reported cognitive enhancement in the above-mentioned study (Maher, 2008).

Previous research has demonstrated that the prevalence of NMUPM can be particularly high among university and college student populations compared to their same-age counterparts in the general population (Herman-Stahl et al., 2007). Most lifetime nonmedical users of prescription stimulants started consuming during high school (Austic, 2015) or during their early college years (Teter et al., 2006). Within the range of prescription medicines, stimulants were more often used by students compared to other medications, such as pain relief or anti-anxiety medications (Brandt et al., 2014). Reasons for nonmedical use of prescription stimulants (NMUPS) among university students are to improve concentration and to perform better in university (Teter et al., 2006). Considering the existing evidence base of NMUPS, in our study, NMUPS was defined as the nonmedical use of medication which was not prescribed and which was used with the intention to improve academic performance.

The nonmedical use of prescription stimulants to improve cognitive achievement has raised some public health concerns because of possible adverse side effects in healthy young adults (Lakhan and Kirchgessner, 2012). Furthermore, an approved medication intended for a different indication may give consumers a false impression of such medication’s safety combined with a low awareness of possible side effects if used non-prescribed (Compton and Volkow, 2006). Indeed, research has shown that NMUPS is associated with a higher likelihood to use other substances, including alcohol, tobacco and cocaine (Sepulveda et al., 2011). This is a major concern, because previous research suggested that students who used non-prescribed stimulants and alcohol simultaneously experienced considerably more negative consequences of use compared to students that did not use both substances at a time (Egan et al., 2013).

One highly influential factor in predicting substance use behavior in young people is the perception of the behavior among peers. Research in this field showed that inaccurate perceptions regarding others’ substance use behavior exist (Perkins, 1997, Perkins, 2007). Young adults may falsely assume that the peer group behaves differently from the actual existing norm (misperception) or from their individual self-reported behavior (self-other discrepancies; Borsari and Carey, 2003). Perceptions of substance use in the peer group can be related to the quantity and frequency of peer substance use (descriptive norm) or to perceptions of peer approval of substance use (injunctive norm). Most evidence on incorrect perceptions regarding substance use in student populations is related to descriptive norms regarding alcohol use (Berkowitz, 2004, Page et al., 2008, Perkins et al., 2005, Perkins et al., 1999). It is known that perceived descriptive norms of peer alcohol use have an impact on individual drinking behavior. Studies showed that the perception of alcohol use among peers is associated with a higher likelihood of personally consuming alcohol more heavily (Lintonen and Konu, 2004, Perkins, 2007, Perkins and Wechsler, 1996). However, the role of descriptive norms in relation to NMUPS is not well understood. Furthermore, only few studies have investigated the role of perceived injunctive norms in predicting personal substance use behavior. There is some indication that perceived peer approval of alcohol (McAlaney et al., 2015), tobacco (Pischke et al., 2015) and illicit substance use (Dempsey et al., 2016, Helmer et al., 2014) is associated with personal approval toward such substances. Neighbors et al. also suggested that an association between injunctive drinking norms of proximal reference groups and personal drinking exists (Neighbors et al., 2008). However, we are unaware of any studies focussing on associations between perceived NMUPS approval and personal NMUPS in student populations.

The objectives of this study were to describe NMUPS among students from seven European countries, to assess discrepancies between estimated peer and personal NMUPS behavior/approval and to determine whether perceptions of peer norms are associated with personal NMUPS behavior/approval.