Prevalence of Substance Abuse among Medical Students and Outcomes of Smoking Cessation Treatments in Saudi Arabia

Naif Abdullah Alsughier; Abdulmajeed Alkhamees

doi:10.36468/pharmaceutical-sciences.spl.1031

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Research Paper

Prevalence of Substance Abuse among Medical Students and Outcomes of Smoking Cessation Treatments in Saudi Arabia

Naif Abdullah Alsughier^* and Abdulmajeed Alkhamees

Department of Psychiatry, College of Medicine, Qassim University, Buraydah 52571, Saudi Arabia

*Corresponding Author:: Naif Abdullah Alsughier
Department of Psychiatry, College of Medicine, Qassim University, Buraydah 52571, Saudi Arabia
E-mail: n.alsughier@qu.edu.sa

This article was originally published in a special issue, “Integrative Approaches in Biomedical Sciences for Drug Discovery and Development”

Indian J Pharm Sci 2024:86(6) Spl Issue “19-34”

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

DOI: 10.36468/pharmaceutical-sciences.spl.1031

Abstract

In Saudi Arabia, the intake of alcohol or other addictive substances is deemed illegal, according to Islamic Sharia norms. Despite that, alcohol abuse is the most common substance misuse form in Saudi Arabia’s addiction facilities and specialized psychiatric centres, according to reports. To estimate the prevalence of alcohol and drug use as well as to determine perception and the self-reported consequences of them among medical students in Saudi Arabia. A sectional study was conducted, including a non-probability snowball sample of medical students in the Kingdom of Saudi Arabia. An anonymous online self-administered Arabic questionnaire through social media platforms was utilized, including sociodemographic characteristics, four questions from the core, alcohol and drug survey, and the alcohol, smoking, and substance involvement screening test (Arabic version 3.0). A total of 632 students were included in the study. The majority of students were females (65.2 %) and aged between 21 y and 25 y (75 %). The most used substances were tobacco products (27.2 %), followed by sedatives/sleeping pills (8.4 %) and alcoholic beverages (4 %). The universities did not differ significantly in any of the substance use aspects, namely lifetime substance use, substance use urge, substance use problems, and substance use failures. A significant association has been observed between universities as regards campus policies on alcohol and drugs χ2 (3)=15.13, p=0.002; the presence of a campus prevention program for alcohol and drugs χ2 (3)=10.28, p=0.016; campus concerns about drugs and alcohol prevention χ2 (3)=14.29, p=0.003. Substance abuse among medical students was low except for tobacco products. Substance abuse problems and substance abuse-related failures were significantly associated with the lifetime substance use, frequency, and urge to consume.

Keywords

Substance abuse, cancer, tobacco, smoking cessation

Substance Use Disorder (SUD) is a serious illness that develops as a result of long-term drug use[1]. Psychoactive substances impact mental processes such as perception, consciousness, cognition, mood, and emotions[2]. This condition is characterized by continued usage of the substance despite considerable unfavourable outcomes. SUD imposes significant physical, psychological, and financial costs on users themselves, their families, and society[1]. Abuse of alcohol and other substances is now a significant health and social problem[1]. Tobacco use has long been a leading cause of chronic diseases like cancer, chronic lung disease, diabetes, and cardiovascular disease. However, it is now a significant concern among college students worldwide[3]. According to a recent World Health Organization (WHO) estimate, there are around 2 billion alcoholics, 1.3 billion smokers, and 185 million drug users globally[4]. This problem is particularly prevalent among college students, with over 23 % of them being found to use substances that fulfil the criteria for substance abuse and dependence[3]. College is a period of transition when students live independently with less direct parental supervision, rely on making their own decisions, face intense academic pressures, possibly share living quarters with strangers, and form new social groups with values that are less restrictive than parental values. That may encourage young kids to engage in dangerous behaviours such as smoking, drinking, and using drugs[5].

According to research performed among students in Italy, 28.0 % smoked cigarettes, while 23.2 % admitted to drinking alcohol. Nearly half of the students had experienced an illicit substance, with cannabis (46.7 %) the most commonly used, followed by cocaine (13.3 %)[5]. It is similar in the Arab world, even though these substances are not as available. A survey of substance abuse among students in Lebanon found that 20.9 % of students had ever drunk alcohol, 12.3 % had used cannabis, and 11 % had used tranquilizers. However, just 3.3 % had used cocaine, and only 3.6 % had used hallucinogenic drugs. Substance abuse among undergraduate students in Kuwait is 29.9 %; this has been shown to be high, requiring early detection and preventive measures[5]. Excessive alcohol use is frequent among medical students and professionals all over the world, according to studies[3]. Students have overused substances like tobacco, alcohol, cannabis, and numerous allopathic medicines for a variety of reasons despite their well-known negative consequences[6].

In Saudi Arabia, the intake of alcohol or other addictive substances is deemed illegal, as the law is founded on Islamic Sharia norms that prohibit the consumption of any amount of alcohol or other substances[3]. There is a scarcity of information about the scope of the problem in Saudi Arabia. However, according to Saudi Arabia's Ministry of Health, outpatient visits and inpatient admissions to specialized mental facilities increased significantly in 2007 compared to 2003[3]. Alcohol abuse is the most common substance misuse form in Saudi Arabia's addiction facilities and specialized psychiatric centres, according to reports. Furthermore, it has been observed that the use of amphetamines and cannabis is increasing[3]. Everyday life pressures, particularly those linked with the study of medicine, should be managed with caution because they may have an impact on medical students' general well-being and learning outcomes and also give rise to alcohol or substance abuse[3]. The primary elements that may lead to alcohol and other substance misuse were revealed to friends, peer pressure, life difficulties, tobacco smoking, and curiosity[3].

Tobacco use is the most serious global health problem, causing more than 8 million deaths per year. It is a major risk factor for cardiovascular and respiratory diseases, over 20 different types or subtypes of cancer, and many other debilitating medical problems[6]. Nicotine induces feelings of pleasure by activation of reward pathways in the brain, which is mediated by dopamine. Chronic nicotine use increases the number of nicotine receptors in the brain. Eventually, more nicotine is needed to achieve the desired effect and result in tolerance and dependence[7]. Abrupt cessation of smoking can cause withdrawal symptoms, including craving, irritability, anxiety, concentration problems, and sleep disturbance[8]. Smoking cessation substantially reduces mortality and morbidity, improves life expectancy, and decreases healthcare costs associated with smoking-related issues[9]. Pharmacotherapies for smoking can increase cessation rates by about two to three-fold[10]. Several pharmacological agents can be used in smoking cessation. The Food and Drug Administration has approved many medications for this purpose; Nicotine Replacement Therapy (NRT), bupropion, and varenicline[11].

This study aims to estimate the prevalence of alcohol and drug use as well as to determine the perception and the self-reported consequences of them among medical students in Saudi Arabia and to evaluate the efficacy of smoking cessation pharmacological treatments.

Materials and Methods

A cross-sectional study for all medical students in the Kingdom of Saudi Arabia was conducted. Students got the Arabic anonymous online self-administered questionnaire through social media platforms (Twitter and WhatsApp). The contents of the questionnaire were sociodemographic characteristics such as age in years, sex, academic year, living status, marital status, family income, part-time job, four questions from the Core and Alcohol and Drug survey, which is validated WHO questionnaire that assess student’s perceptions of their medical school's alcohol and drug policy[12] and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST; Arabic version 3.0)[13], which is a self-administered model core questionnaire, was adapted from a validated WHO questionnaire. The adapted ASSIST questionnaire was divided into four sections; demographic information; lifetime prevalence of substance use (tobacco, alcohol, stimulants, cocaine, heroin, tranquilizers, and hallucinogens); frequency of substance use in the previous 3 mo (from never to daily use): and the impact of substance use on the student's academic performance, health, and life in terms of social, financial, psychological factors, and legal problems. A question on the questionnaire asked if the students thought substance misuse was a frequent problem that needed to be addressed and handled. The questionnaire's average test-retest reliability coefficient (kappa) ranged from 0.90 to 0.58. No personal information was required, such as name, phone number, study year, or address. This was done to maintain privacy and encourage participation and full admission of drug and alcohol usage.

The total number of medical students enrolled in Saudi Arabian medical schools throughout the academic year 2023-2024 accounts for 26 216 students. The sample size was calculated using the Epi Info program, based on a 95 % confidence interval, a 5 % margin of error, and a prevalence of SUD of 7 %-8 % from a recent Saudi study[14]. The estimated sample size was 379.

Because of limitations in time, cost, and accessibility, a non-probability snowball sampling technique was utilized to recruit the medical students to participate in the online questionnaire.

Criteria:

Saudi medical students of both sexes who live in Saudi Arabia and have social media accounts.

Ethical approval:

Ethical approval of the study was obtained from the Research Ethics Committee at Qassim University. The informed consent was clear, indicating the objective of the study. Participants were assured that this was an online questionnaire and that the names of participants, schools, or any personal information were not required before filling out the questionnaire.

Statistical analysis:

A frequency analysis was conducted to assess the prevalence of substance use, including lifetime substance use, substance use frequency, substance use urge, substance use problems and failures, and substance use concerns. A Pearson’s correlation analysis was performed to investigate the relationship of substance use with substance use problems and failures. Finally, a series of one-way Analysis of Variances (ANOVAs) between subjects was employed to explore differences in substance use among universities, whereas a series of Chi-square (χ²) tests of association was conducted to evaluate differences in substance use policies among universities. All data were analysed using Statistical Package for Social Sciences (SPSS), version 28.0. Statistical significance was determined at a p<0.05.

Results and Discussion

A descriptive analysis was conducted to evaluate the sociodemographic characteristics of the sample (n=632). The majority of students were women (65.2 %), aged between 21 y to 25 y (75 %). Almost a 1/3^rd of them were in their 5^th y of studies (35.1 %), with a Grade Point Average (GPA) of 4.5 to 5.0 (39.1 %). Most of them were single (94.9 %) and lived with their family (90.7 %) in a household of 5 to 7 family members (45.1 %) and a family income of >20 000 SAR (Table 1).

	n	(%)
Gender
Male	220	34.8
Female	412	65.2
Age (y)
18-20	108	17.1
21-25	474	75
26-30	41	6.5
31-35	5	0.8
>35	4	0.6
Marital status
Single	600	94.9
Married	26	4.1
Divorced	5	0.8
Widowed	1	0.2
Number of family members
2-4	67	10.6
5-7	285	45.1
8-10	232	36.7
45609	33	5.2
>14	15	2.4
Monthly family income (SAR)
1000-4999	85	13.4
5000-9999	78	12.3
10 000-14 999	129	20.4
15 000-20 000	131	20.7
>20 000	209	33.1
Residence place
Alone	36	5.7
With roommate(s)	13	2.1
With fraternity/sorority	10	1.6
With family	573	90.7
Academic year
Pre-med-1^st y	36	5.7
MD (1^st and 2^nd) y	47	7.4
MD (2^nd and 3^rd) y	115	18.2
MD (3^rd and 4^th) y	111	17.6
MD (4^th and 5^th) y	225	35.6
Internship	98	15.5
GPA
<2.5	3	0.5
2.9-2.5	18	2.8
3.4-3.0	53	8.4
3.9-3.5	112	17.7
4.0-4.4	199	31.5
4.5-5.0	247	39.1

Table 1: Descriptive analysis on the Sociodemographic Characteristics of the Sample (n=632)

A frequency analysis was performed to explore the prevalence of non-medically prescribed substance use (n=632). The most used substances were tobacco products (27.2 %), followed by sedatives/sleeping pills (8.4 %) and alcoholic beverages (4 %). The least used substance was cocaine (0.5 %). Regarding substance use in the past 3 mo, tobacco products were the most frequently used substances, with 13 % of the respondents using them daily or almost daily (13 %). None of the students used alcoholic beverages, inhalants, hallucinogens, and opioids almost daily, while only one individual reported taking cocaine once or twice in the last 3 mo (Table 2 for lifetime substance use and Table 3 for substance use frequency).

	n	(%)
Tobacco products
No	460	72.8
Yes	172	27.2
Alcoholic beverages
No	607	96.0
Yes	25	4.0
Cannabis
No	609	96.4
Yes	23	3.6
Cocaine
No	629	99.5
Yes	3	0.5
Amphetamine-type stimulants
No	617	97.6
Yes	15	2.4
Inhalants
No	625	98.9
Yes	7	1.1
Sedatives or sleeping pills
No	579	91.6
Yes	53	8.4
Hallucinogens
No	626	99.1
Yes	6	0.9
Opioids
No	624	98.7
Yes	8	1.3

Table 2: Descriptive Analysis on Lifetime Substance Use (n=632)

	n	(%)
Tobacco products
Never	498	78.8
Once or twice	30	4.7
Monthly	9	1.4
Weekly	13	2.1
Almost daily	82	13.0
Alcoholic beverages
Never	617	97.6
Once or twice	13	2.1
Weekly	2	0.3
Cannabis
Never	620	98.1
Once or twice	8	1.3
Monthly	3	0.5
Almost daily	1	0.2
Cocaine
Never	629	99.5
Once or twice	1	0.2
Weekly	1	0.2
Almost daily	1	0.2
Amphetamine-type stimulants
Never	623	98.6
Once or twice	4	0.6
Monthly	1	0.2
Weekly	1	0.2
Almost daily	3	0.5
Inhalants
Never	628	99.4
Once or twice	4	0.6
Sedatives or sleeping pills
Never	591	93.5
Once or twice	19	3.0
Monthly	7	1.1
Weekly	8	1.3
Almost daily	7	1.1
Hallucinogens
Never	629	99.5
Once or twice	3	0.5
Opioids
Never	626	99.1
Once or twice	4	0.6
Monthly	2	0.3

Table 3: Descriptive Analysis On Substance Use Frequency in the Past 3 MO (n=632)

Similar to the above observations, most individuals reported craving for tobacco products in the past 3 mo almost daily (11.1 %), whereas the least daily or nearly daily urges were identified in alcoholic beverages (0.2 %), amphetamine-type stimulants (0.2 %), inhalants (0.2 %), and opioids (0.2 %). Accordingly, the use of tobacco products was most commonly reported as being related to problems in several areas of one's life in the past 3 mo; once or twice (4.1 %), monthly (0.6 %), weekly (0.8 %), and almost daily (1.7 %). In contrast, the almost daily problems were expressed for alcoholic beverages (0.2 %), amphetamine-type stimulants (0.2 %), sedatives/sleeping pills (0.2 %), and hallucinogens (0.2 %). Finally, regarding the failures to complete one's normal obligations in the past 3 mo due to the use of specific substances, tobacco products were the most frequently related to such failures; once or twice (1.3 %), monthly (0.6 %), weekly (0.8 %), and almost daily (1.3 %). The least daily or nearly daily failures were observed for alcoholic beverages (0.2 %), hallucinogens (0.2 %), and opioids (0.2 %) (Table 4 for substance use urges; Table 5 and Table 6 for substance use problems and failures).

	n	(%)
Tobacco products
Never	483	76.4
Once or twice	44	7.0
Monthly	16	2.5
Weekly	19	3.0
Almost daily	70	11.1
Alcoholic beverages
Never	611	96.7
Once or twice	13	2.1
Monthly	3	0.5
Weekly	4	0.6
Almost daily	1	0.2
Cannabis
Never	615	97.3
Once or twice	11	1.7
Monthly	2	0.3
Weekly	4	0.6
Cocaine
Never	631	99.8
Monthly	1	0.2
Amphetamine-type stimulants
Never	621	98.3
Once or twice	8	1.3
Monthly	1	0.2
Weekly	1	0.2
Almost daily	1	0.2
Inhalants
Never	625	98.9
Once or twice	6	0.9
Almost daily	1	0.2
Sedatives or sleeping pills
Never	591	93.5
Once or twice	24	3.8
Monthly	3	0.5
Weekly	7	1.1
Almost daily	7	1.1
Hallucinogens
Never	629	99.5
Once or twice	2	0.3
Weekly	1	0.2
Opioids
Never	626	99.1
Once or twice	3	0.5
Monthly	1	0.2
Weekly	1	0.2
Almost daily	1	0.2

Table 4: Descriptive Analysis on Substance use Desire or Urge in the Past 3 MO (n=632)

	n	(%)
Tobacco products
Never	586	92.7
Once or twice	26	4.1
Monthly	4	0.6
Weekly	5	0.8
Almost daily	11	1.7
Alcoholic beverages
Never	626	99.1
Once or twice	3	0.5
Monthly	1	0.2
Weekly	1	0.2
Almost daily	1	0.2
Cannabis
Never	628	99.4
Once or twice	1	0.2
Monthly	2	0.3
Weekly	1	0.2
Cocaine
Never	629	99.5
Once or twice	1	0.2
Weekly	2	0.3
Amphetamine-type stimulants
Never	627	99.2
Once or twice	3	0.5
Weekly	1	0.2
Almost daily	1	0.2
Inhalants
Never	628	99.4
Once or twice	2	0.3
Weekly	2	0.3
Sedatives or sleeping pills
Never	618	97.8
Once or twice	10	1.6
Weekly	3	0.5
Almost daily	1	0.2
Hallucinogens
Never	629	99.5
Once or twice	1	0.2
Monthly	1	0.2
Almost daily	1	0.2
Opioids
Never	624	98.7
Once or twice	2	0.3
Monthly	2	0.3
Weekly	4	0.6

Table 5: Descriptive Analysis on Problems Related to Substance use in the Past 3 Mo (n=632)

	n	(%)
Tobacco products
Never	607	96.0
Once or twice	8	1.3
Monthly	4	0.6
Weekly	5	0.8
Almost daily	8	1.3
Alcoholic beverages
Never	626	99.1
Once or twice	3	0.5
Monthly	2	0.3
Almost daily	1	0.2
Cannabis
Never	629	99.5
Once or twice	1	0.2
Weekly	2	0.3
Cocaine
Never	629	99.5
Once or twice	2	0.3
Weekly	1	0.2
Amphetamine-type stimulants
Never	627	99.2
Once or twice	2	0.3
Monthly	2	0.3
Weekly	1	0.2
Inhalants
Never	629	99.5
Once or twice	3	0.5
Sedatives or sleeping pills
Never	623	98.6
Once or twice	4	0.6
Monthly	2	0.3
Weekly	3	0.5
Hallucinogens
Never	628	99.4
Once or twice	2	0.3
Monthly	1	0.2
Almost daily	1	0.2
Opioids
Never	628	99.4
Once or twice	1	0.2
Weekly	2	0.3
Almost daily	1	0.2

Table 6: Descriptive Analysis on Failures Related to Substance use in the Past 3 Mo (n=632)

Regarding substance use concerns expressed by friends and relatives, most of them were related to tobacco product users, both as to use in the last 3 mo (7.8 %) and beyond the last 3 mo (4.7 %). The least concerns in the last 3 mo were expressed for amphetamine-type stimulants (0.2 %), inhalants (0.2 %), and hallucinogens (0.2 %) users. For the period beyond the last 3 mo, the lowest numbers of concerns were seen for alcoholic beverages (0.2 %), cocaine (0.2 %), and inhalants (0.2 %) users. Similarly, tobacco products users reported the most attempts to reduce use in the last 3 mo (7.6 %) and beyond the last 3 mo (4.4 %). The least attempts within the last 3 mo were observed for alcoholic beverages (0.2 %), cocaine (0.2 %), inhalants (0.2 %), and hallucinogens (0.2 %). Beyond the last 3 mo, the lowest numbers were reported for cocaine (0.2 %) and inhalants (0.2 %) (Table 7 and Table 8).

	n	(%)
Tobacco products
Never	553	87.5
Yes (in the last 3 mo)	49	7.8
Yes (not in the past 3 mo)	30	4.7
Alcoholic beverages
Never	628	99.4
Yes (in the last 3 mo)	3	0.5
Yes (not in the past 3 mo)	1	0.2
Cannabis
Never	623	98.6
Yes (in the last 3 mo)	5	0.8
Yes (not in the past 3 mo)	4	0.6
Cocaine
Never	628	99.4
Yes (in the last 3 mo)	3	0.5
Yes (not in the past 3 mo)	1	0.2
Amphetamine-type stimulants
Never	628	99.4
Yes (in the last 3 mo)	1	0.2
Yes (not in the past 3 mo)	3	0.5
Inhalants
Never	630	99.7
Yes (in the last 3 mo)	1	0.2
Yes (not in the past 3 mo)	1	0.2
Sedatives or sleeping pills
Never	611	96.7
Yes (in the last 3 mo)	11	1.7
Yes (not in the past 3 mo)	10	1.6
Hallucinogens
Never	629	99.5
Yes (in the last 3 mo)	1	0.2
Yes (not in the past 3 mo)	2	0.3
Opioids
Never	627	99.2
Yes (in the last 3 mo)	5	0.8

Table 7: Descriptive Analysis on the Concerns Expressed about Substance use (n=632)

	n	(%)
Tobacco products
Never	556	88.0
Yes (in the last 3 mo)	48	7.6
Yes (not in the past 3 mo)	28	4.4
Alcoholic beverages
Never	626	99.1
Yes (in the last 3 mo)	1	0.2
Yes (not in the past 3 mo)	5	0.8
Cannabis
Never	626	99.1
Yes (in the last 3 mo)	3	0.5
Yes (not in the past 3 mo)	3	0.5
Cocaine
Never	630	99.7
Yes (in the last 3 mo)	1	0.2
Yes (not in the past 3 mo)	1	0.2
Amphetamine-type stimulants
Never	628	99.4
Yes (in the last 3 mo)	2	0.3
Yes (not in the past 3 mo)	2	0.3
Inhalants
Never	630	99.7
Yes (in the last 3 mo)	1	0.2
Yes (not in the past 3 mo)	1	0.2
Sedatives or sleeping pills
Never	621	98.3
Yes (in the last 3 mo)	7	1.1
Yes (not in the past 3 mo)	4	0.6
Hallucinogens
Never	631	99.8
Yes (in the last 3 mo)	1	0.2
Opioids
Never	629	99.5
Yes (in the last 3 mo)	3	0.5

Table 8: Descriptive Analysis on Substance use Reduction Attempts (n=632)

A Pearson's correlation analysis was employed to investigate whether substance use-related health, social, legal, or financial problems were associated with lifetime substance use, substance use frequency, and substance use urge. The results indicated that substance use problems were significantly and positively correlated with lifetime substance use (r=0.37, p<0.001), substance use frequency (r =0.39, p<0.001), and substance use urge (r =0.33, p<0.001).

Furthermore, it was assessed if substance use-related failures to fulfil normal obligations were related to lifetime substance use, substance use frequency, and substance use urge. Substance use-related failures were significantly and positively related to lifetime substance use (r=0.29, p<0.001), substance use frequency (r=0.33, p<0.001), and substance use urge (r=0.31, p<0.001) (Table 9).

	1	2	3	4	5
Substance use problems	1
Substance use failures	0.84**	1
Lifetime substance use	0.37**	0.29**	1
Substance use frequency	0.39**	0.33**	0.79**	1
Substance use urge	0.33**	0.31**	0.63**	0.76**	1

Note: **p<0.001

Table 9: Pearson’s Correlation Coefficients for the Relationship of Substance use Failures and Problems with Lifetime Substance use, Substance use Frequency, and Substance use Urge, (n=632)

The universities did not differ significantly in any of the substance use aspects, namely lifetime substance use (F3351=1.16, p=0.33, η2=0.010), substance use frequency (F3351=0.73, p=0.54, η²=0.006), substance use urge (F3351=1.31, p=0.27, η²=0.011), substance use problems (F3351=0.65, p=0.58, η²=0.006), and substance use failures (F3351=0.30, p=0.82, η²=0.003) (Table 10).

		n	Mean	Standard deviation
Lifetime substance use	Taibah University	150	0.33	0.69
	Qassim University-College of Medicine	80	0.34	0.78
	Unaizah College of Medicine	72	0.54	1.20
	Alrayan Colleges	53	0.38	0.56
Substance use frequency	Taibah University	150	1.07	0.17
	Qassim University-College of Medicine	80	1.07	0.18
	Unaizah College of Medicine	72	1.10	0.23
	Alrayan colleges	53	1.10	0.20
Substance use urge	Taibah University	150	1.08	0.19
	Qassim University-College of Medicine	80	1.07	0.17
	Unaizah College of Medicine	72	1.13	0.28
	Alrayan Colleges	53	1.09	0.20
Substance use problems	Taibah University	150	1.02	0.14
	Qassim University-College of Medicine	80	1.02	0.06
	Unaizah College of Medicine	72	1.04	0.24
	Alrayan Colleges	53	1.05	0.15
Substance use failures	Taibah University	150	1.02	0.15
	Qassim University-College of Medicine	80	1.01	0.052
	Unaizah College of Medicine	72	1.02	0.11
	Alrayan Colleges	53	1.03	0.13

Table 10: Descriptive Statistics on Substance use Aspects among Universities (n=355)

A Pearson's χ² test was conducted to assess if there is a significant relationship between campus policies on alcohol and drugs and different universities (n=355). The following universities were included in the analysis; Taibah University (n=150), Qassim University-College of Medicine (n=80), Unaizah College of Medicine (n=72), and Alrayan Colleges (n=53). The results showed a significant association between campus policies on alcohol and drugs and universities, χ² (3)=15.13, p=0.002, and Cramer's V=0.34 (Table 11).

Campus policies on alcohol and drugs	No	Yes
Taibah University	0.031	0.969
Qassim University-College of Medicine	0.267	0.733
Unaizah College of Medicine	0.04	0.96
Alrayan Colleges	0.25	0.75
Campus prevention program
Taibah University	0.186	0.814
Qassim University-College of Medicine	0.308	0.692
Unaizah College of Medicine	0.143	0.857
Alrayan Colleges	0.52	0.48
Campus concern about prevention
Taibah University	0.182	0.818
Qassim University-College of Medicine	0.393	0.607
Unaizah College of Medicine	0.083	0.917
Alrayan Colleges	0.4	0.6
Efforts in alcohol and drug prevention on campus
Taibah University	0.88	0.12
Qassim University-College of Medicine	0.913	0.088
Unaizah College of Medicine	0.861	0.139
Alrayan Colleges	0.811	0.189

Table 11: Differences Between Universities Regarding Campus Policies on Alcohol and Drugs (n=355)

A significant association between the presence of a campus prevention program for alcohol and drugs, and the type of university has been shown, χ² (3)=10.28, p=0.016, and Cramer's V=0.33 (Table 11). A significant association, χ² (3)=14.29, p=0.003, and Cramer's V=0.29, has been observed between campus concerns about drugs and alcohol prevention and the type of university (Table 11).

A non-significant association was observed between the active efforts to prevent drug and alcohol use on campus and the type of university, χ² (3)=3.11, p=0.37, and Cramer's V=0.09 (Table 11).

The overall smoking cessation rate for 1 y was 38 %. The smoking cessation rates for nicotine replacement therapy, varenicline, and bupropion were 46.7 %, 33.8 %, and 30 %, respectively, and were statistically significant (p>0.001) (Table 12).

Medications	n	(%)	1 y cessation	1 y cessation (%)
Nicotine replacement therapy	77	44.7	36	46.7
Varenicline	65	37.7	22	33.8
Bupropion	30	17.4	9	30

Table 12: Descriptive Analysis on Smoking Cessation Rates using Pharmacological Agents (n=172)

Saudi Arabia is a higher-income country positioned in Southwest Asia[15]. It is located near areas that suffer from poverty, conflicts, and wars. Such difficulties in those neighbourhoods increase the chance for illegal drugs to be abused and produced without control[16,17]. Therefore, Saudi Arabia has a main problem, and many seizures of different substances have been recorded over the years[18,19]. Widespread ignorance of the possible ill impacts of certain drugs and legal prohibitions against the illegal use of those drugs constitute an obstacle to any epidemiological study of drug abuse in Saudi Arabia. The resulting unwillingness on the part of abusers to collaborate in such studies for worry of prosecution or stigmatization seems comprehensible, though misguided. However, it is essential to understand the nature and size of the problem if meaningful and effective preventive procedures are considered[20]. In the current study, we aimed to determine the prevalence of alcohol and drug use among medical students in Saudi Arabia, as well as determine the self-reported consequences of medical student substance use and identify perceptions of medical school substance use policies.

Smoking is considered one of the most common health problems around the world, and it has a significant devastating impact on health, increasing morbidity and mortality rates. Smoking is one of the most commonly abused substances in Saudi Arabia[21]. In the current study, tobacco products were the most used substance among medical students (27.2 %). This is higher than reported in a previous study conducted among King Saud University medical students, which reported that the prevalence of smoking was 11.65 %[22] as well as a study by Albuhairan et al. which was conducted among adolescents in 13 regions of Saudi Arabia reported a prevalence of 16.2 %[23]. Moreover, another study conducted among university students in Jazan region showed that 20.7 % of the students were smokers[24]. Furthermore, our incidence of smoking was lower than reported in some other studies conducted internationally, including a study of Chege et al. among undergraduate medical students at the University of Nairobi, which showed that 17.2 % of the students reported consuming tobacco products[25], as well as study of Arora et al., which showed that the use of tobacco product was reported in 25.27 % of the medical students in north India (where 23.1 % as smoking and 2.17 % as chewing)[26] and was 22.5 % among university students in Egypt[27]. Some other studies reported a significantly lower incidence of tobacco product use in university students, including the study among Canadian medical students, which reported that only 6.8 % of the students reported smoking[28].

The high prevalence of use of tobacco products in the current study can be explained by some reasons. First, smoking was not the main outcome in studies conducted in Saudi Arabia; therefore, underestimating the prevalence of smoking could be possible in those studies. Second, in comparison with international studies, smoking was low because of the availability of other products, including alcoholic beverages, which was reported in 40.2 % of undergraduate students in a study by Nairobi University[25], 19.13 % in a study of Arora et al.[26], and 46.4 % among Canadian medical students[28]. In comparison, the consumption of alcoholic beverages was reported in only 4 % of medical students in the current study. In a study by Karm et al., among medical students, the authors showed that alcohol was the most commonly used substance with an overall lifetime prevalence of 58 %, followed by cigarette smoking and illegal drug abuse at 21.9 % and 13.7 %, respectively[29].

Other used substances included sedatives/sleeping pills, which were reported in 8.4 % of the students, cannabis (3.6 %), and amphetamine-type stimulants (2.4 %). Another study conducted among medical students at King Saud University in order to assess the prevalence of using sedative pills reported a higher prevalence than our study, indicating that 17.0 % of them reported using sedative pills[22]. Moreover, another Turkish study reported that sedative drugs were used in 22.5 % of junior students, 20 % of senior students, and 9 % of residents[30]. Furthermore, another study conducted in the Republic of Macedonia reported that over 50 % of students had used alcohol, while 12 % of them used hypnotics[31]. In a previous study conducted to investigate the prevalence of illicit use of stimulants among medical students in Riyadh, the authors showed that 5.8 % of the participants reported using stimulant drugs; however, 57.4 % of those students reported using them medically as being Attention Deficit and Hyperactivity Disorder (ADHD) patients, and 42.6 % had not diagnosed with ADHD which indicated similar prevalence of illicit use of stimulants as our study (2.46 %)[32]. However, the prevalence of illicit use of stimulants in our study is lower than reported in different studies, ranging between 7.5 % and 10.4 %[33-35]. Legal prohibition of many illicit drugs and religious prohibition of them were the reasons for the lower incidence of consuming many of these drugs in the current study, except for tobacco products, which are legally distributed in Saudi Arabia.

In addition, the current study showed that substance use problems and substance use-related failures were significantly associated with lifetime substance use, frequency, and urge to consume. Problems in several areas of one's life and failures to complete one's normal obligations were reported most commonly among users of tobacco products. One report in Canada showed that there is an association between offending and substance use, where the study showed that around 42 % of crimes might not occur if the offender was not under the impact of substances or seeking them[36]. Furthermore, different studies reported a positive relationship between the use of illegal substances and the prevalence of mental illness[37,38]. This is helpful in raising our understanding of the association between illicit substance use and psychological problems and provides a clue to the possibility of benefit from any preventive or treatment strategies that focus on this relation[39].

The current study showed the differences between different universities considering the presence of campus policies on alcohol and drugs, campus prevention programs, campus concerns about prevention, and efforts in alcohol and drug prevention on campus. Increasing the focus on increasing the awareness of students toward the problems associated with dependence on illicit drugs could be important in reducing the prevalence of these medications. Moreover, helping the students cope with different stressors faced because of social life or college would significantly improve the psychological status of the students.

The current study showed that the overall success rate of smoking cessation for one year using pharmacological agents was 38 %; the highest overall success rate was found in the nicotine replacement therapy group at 46 %, but there was only a modest difference with other medications. Recently, a meta-analysis study demonstrated that varenicline, bupropion and nicotine replacement therapy were all more effective than placebo smoking cessation at 1 y[40]. Pharmacological treatments have been shown to be effective, with successful cessation rates ranging from 22 % to 45 %[41], which is similar to cessation rates in this study 38 %.

This study had some limitations, including depending on a self-reported questionnaire, which may lead to some personal bias where some students may not report their dependence on illicit drugs, making them choose smoking instead, and leading to overestimating the prevalence of smoking over other illegal drugs. Moreover, the study depended on some information from the past, which may lead to some recall bias.

The current study showed low substance use among medical students except for tobacco products, which was reported by more than a quarter of the sample. Substance use, particularly tobacco products, was associated with problems in one's life. In addition, the current study showed that substance use problems and substance use-related failures were significantly associated with lifetime substance use, frequency, and urge to consume. Pharmacological therapy for smoking cessation is safe and efficacious and, therefore, recommended to be offered to every smoker willing to cease smoking. More investigations to understand the reasons for high tobacco product use among medical students should be conducted, as well as to understand the prevalence of substance use in non-medical students in Saudi Arabia.

Conflict of interests:

The authors declared no conflict of interests.