Perceptions of Pakistani medical students about drugs and alcohol: A questionnaire-based survey

Abstract

Drug abuse is hazardous and known to be prevalent among young adults, warranting efforts to increase awareness about harmful effects and to change attitudes. This study was conducted to assess the perceptions of a group of medical students from Pakistan, a predominantly Muslim country, regarding four drugs namely heroin, charas, benzodiazepines and alcohol.
In total, 174 self-reported questionnaires were received (87% response rate). The most commonly cited reasons for why some students take these drugs were peer pressure (96%), academic stress (90%) and curiosity (88%). The most commonly cited justifiable reason was to go to sleep (34%). According to 77%, living in the college male hostel predisposed one to using these drugs. Sixty percent of students said that the drugs did not improve exam performance, while 54% said they alleviated stress. Seventy-eight percent said they did not intend to ever take drugs in the future. Females and day-scholars were more willing to discourage a friend who took drugs. Morality (78%), religion (76%) and harmful effects of drugs (57%) were the most common deterrents against drug intake. Five suggestions to decrease drug abuse included better counseling facilities (78%) and more recreational facilities (60%).
Efforts need to be made to increase student awareness regarding effects and side effects of drugs. Our findings suggest that educating students about the adverse effects as well as the moral and religious implications of drug abuse is more likely to have a positive impact than increased policing. Proper student-counseling facilities and healthier avenues for recreation are also required.

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BioMed Central
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Substance Abuse Treatment,
Prevention, and Policy
Open Access
Research
Perceptions of Pakistani medical students about drugs and alcohol:
a questionnaire-based survey
Majid Shafiq*
1
, Zaman Shah
1
, Ayesha Saleem
1
, Maham T Siddiqi
1
,
Kashif S Shaikh
1
, Farah F Salahuddin
1
, Rizwan Siwani
1
and Haider Naqvi
2
Address:
1
MBBS Class of 2006; Medical College, Aga Khan University, Stadium Road Karachi 74800, Pakistan and
2
Department of Psychiatry, Aga
Khan University, Stadium Road Karachi 74800, Pakistan
Email: Majid Shafiq* - theyoungdoc@yahoo.co.uk; Zaman Shah - zamanaku@gmail.com; Ayesha Saleem - ayesha_saleem@yahoo.com;
Maham T Siddiqi - maham_s@hotmail.com; Kashif S Shaikh - kashif.shakoor@gmail.com; Farah F Salahuddin - farahsalahuddin@gmail.com;
Rizwan Siwani - rizwansiwani@gmail.com; Haider Naqvi - haider.naqvi@aku.edu
* Corresponding author
Abstract
Background: Drug abuse is hazardous and known to be prevalent among young adults, warranting
efforts to increase awareness about harmful effects and to change attitudes. This study was
conducted to assess the perceptions of a group of medical students from Pakistan, a predominantly
Muslim country, regarding four drugs namely heroin, charas, benzodiazepines and alcohol.
Results: In total, 174 self-reported questionnaires were received (87% response rate). The most
commonly cited reasons for why some students take these drugs were peer pressure (96%),
academic stress (90%) and curiosity (88%). The most commonly cited justifiable reason was to go
to sleep (34%). According to 77%, living in the college male hostel predisposed one to using these
drugs. Sixty percent of students said that the drugs did not improve exam performance, while 54%
said they alleviated stress. Seventy-eight percent said they did not intend to ever take drugs in the
future. Females and day-scholars were more willing to discourage a friend who took drugs. Morality
(78%), religion (76%) and harmful effects of drugs (57%) were the most common deterrents against
drug intake. Five suggestions to decrease drug abuse included better counseling facilities (78%) and
more recreational facilities (60%).
Conclusion: Efforts need to be made to increase student awareness regarding effects and side
effects of drugs. Our findings suggest that educating students about the adverse effects as well as
the moral and religious implications of drug abuse is more likely to have a positive impact than
increased policing. Proper student-counseling facilities and healthier avenues for recreation are also
required.
Background
Substance abuse is defined as a maladaptive pattern of
substance use leading to clinically significant impairment
or distress, wherein the person may also suffer from toler-
ance and withdrawal [1].
Published: 25 October 2006
Substance Abuse Treatment, Prevention, and Policy 2006, 1:31 doi:10.1186/1747-597X-1-
31
Received: 06 June 2006
Accepted: 25 October 2006
This article is available from: http://www.substanceabusepolicy.com/content/1/1/31
© 2006 Shafiq et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Substance abuse is a common problem worldwide. Paki-
stan, a South Asian developing country with a population
of 150 million, is no exception. Ninety seven percent of
Pakistan's population is Muslim, with highly conservative
customs and traditions governing the lives of many. All
substances of abuse are publicly despised, but none more
than alcohol, which finds a direct reference in the Koran.
This absolute taboo is in stark contrast to the acceptability
that alcohol finds in the Western society. Nonetheless,
alcohol is widely consumed by various sections of the
society, most notably by the very affluent and the impov-
erished.
Cultivation of poppy has been carried out in the northern
part of Pakistan for a long time. During the British rule,
opium was sold in licensed shops throughout the Indo-
Pak subcontinent. At the time of independence in 1947,
there were approximately 100,000 regular and registered
opium users in Pakistan [2].
In 1979, the Islamic Revolution in Iran, the Soviet inva-
sion of Afghanistan and the enforcement of Hadd Ordi-
nance in Pakistan directly or indirectly affected the
geopolitical situation in the country. [3] The ordinance
outlawed cultivation, production, distribution and sale of
all substances of abuse including opium, charas and alco-
hol. If anything, however, the same period marked a sub-
stantial increase in the consumption of such substances in
Pakistan.
The events in Iran and Afghanistan drove nearly 5 million
refugees into Pakistan. A number of them were involved
in cultivation, production and smuggling of drugs, includ-
ing heroin. Heroin was virtually not known in Pakistan
prior to 1979. On the other hand, the Hadd Ordinance
drove the drug trade underground and led to the emer-
gence of drug mafia. Existence of long established routes
in Pakistan for trade to and from Afghanistan provided
convenient and organized channels for drug smuggling.
According to the 5th and last national survey (National
Survey on Drug Abuse – N.S.D.A) conducted in 1993 by
the Pakistan Narcotic Control Board, there were nearly 3
million drug dependents in Pakistan with 51 % of them
being heroin dependents. [2]. This represents nearly a
three fold increase in the total number of dependents and
30 fold increase in the number of heroin dependents
when compared to the findings in the 1st N.S.D.A report
of 1982.
Survey data was based on community based samples
using robust case ascertainment methods. Although the
government of Pakistan had envisaged conducting these
national surveys every five years, no further survey have
been conducted since 1993. The Pakistan Narcotic Con-
trol Board (PNCB) was disbanded in the mid 90s. Pres-
ently an Anti Narcotic Force (A.N.F) operates in order to
serve as narcotic control and enforcement agency with no
mandate to carry out steps toward drug abuse prevention
or long term rehabilitation.
Among the drugs of abuse, heroin is the most commonly
abused drug followed by hashish, charas, (the latter two
derived from resinous exudates of the flowering tops of
female Cannabis sativa plant) bhang, opium, alcohol and
psychotropic drugs [2].
The medical personnel are vulnerable to substance abuse
and dependence due to ready access to substances of
abuse. Many studies have estimated this prevalence
among students of the medical sciences. According to one
study, there is a higher occurrence of misuse of alcohol,
tranquillizers and psychedelics among medical students,
and dependence rates are 5% for medical students and 3%
for doctors [4]. A study conducted among undergraduate
medical students in two medical colleges of Calcutta indi-
cated that during 1993, the point prevalence values of
total and current drug abusers were 48.9% and 27.9%
respectively among the respondent student population
[5]. Turkey, a predominantly Muslim country (as is Paki-
stan), has reported point prevalence figures of only 4% for
the use of illicit drugs (cannabis, ecstasy, cocaine) among
medical students. However, 46.1% of the students con-
sumed alcohol, among which 7.4% had risky alcohol use
[6].
It is plausible that the medical personnel's knowledge and
understanding of drugs of abuse is overestimated. Clearly,
knowledge about the desirable and undesirable effects of
a drug may significantly alter the drug's usage. We there-
fore aim to assess the knowledge and attitude of under-
graduate students of a private medical college regarding
drugs, including alcohol. To our knowledge no such study
has previously been published from Pakistan.
Methods
This was a cross-sectional study conducted among the
undergraduate students of a private medical university in
Karachi. Most of the university's students hail from afflu-
ent families. Like all institutions in Pakistan, it offers a
five-year course in "bachelor of medicine and bachelor of
surgery" (M.B., B.S.). Students typically get enrolled into
this course immediately after completing high school, i.e.
at around 18 years of age. In order to become a registered
medical practitioner, the M.B., B.S. graduate has to do one
year of internship, which comprises of six months' train-
ing in medicine and another six in surgery.
The study was conducted in compliance with 'Ethical
principles for medical research involving human subjects'

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of Helsinki Declaration. Study protocol was discussed
among the students and facilitating faculty for possible
ethical concerns. All possible measures were taken to
ensure the confidentiality of all participants. Verbal
informed consent was obtained from the subjects.
Two hundred subjects were selected through convenience
sampling and a standard, pre-tested questionnaire was
administered in English language. Participants were
allowed to return the filled questionnaire forms to any
one of the persons designated by investigators within 15
days.
The questionnaire was formulated on the basis of thor-
ough review of literature, after detailed discussions and
peer-review among investigators and facilitating faculty.
The preliminary questionnaire was pre-tested on 25 stu-
dents and modified to address the identified deficiencies.
The first part of the questionnaire sought information
related to demographics of the participants. Perceptions
of students regarding four common drugs of abuse
namely alcohol, charas, heroin and benzodiazepines
(BDZs) were assessed in the second part of the question-
naire. This included their beliefs regarding possible bene-
ficial (e.g. stress alleviation) or harmful effects of these
drugs, factors predisposing to initiation and continuation
of drugs, factors deemed justifiable to use drugs, and their
possible reaction to a colleague taking drugs. They were
also asked whether they intended to ever take drugs in the
future.
In order to exclude interviewer bias, the terms "misuse"
and "abuse" were avoided in the questionnaire and the
term "use" or "take" was employed instead.
Respondents were not asked about their own drug and
alcohol practices. This was done in order to avoid discour-
aging students from participating, since drugs and alcohol
are a taboo subject in our society as mentioned earlier.
Data was entered and analyzed in Statistical Package for
Social Sciences 13.0 (SPSS 13.0). Descriptive statistics of
socio-demographic information and perceptions were
determined. Chi square test was used to examine putative
associations between perceptions and demographic varia-
bles. For all purposes, a p-value of <0.05 was considered
as the criteria of significance.
Results
Out of the 200 questionnaires distributed, 174 filled ques-
tionnaires were received (87% response rate). There were
96 males and 78 females. The ages ranged from 18 to 25
years, with a mean of 21.3 years. Table 1 illustrates the
other demographic characteristics.
Figure 1 illustrates the frequency of each of the substances
under study perceived by the students to be serious/non
trivial. For alcohol, even once-in-a-lifetime use was con-
sidered serious by 34%, while another 22% said that daily
use (or more) was non-trivial. Forty-seven percent said
that once-in-a-lifetime use of charas was non-trivial, while
14% cited intake at only social gatherings to be the mini-
mum serious frequency. Once-in-a-lifetime use of heroin
was considered serious by 58%, and use at only social
gatherings by another 11%. For BDZs, 26% said that a
daily use would be the minimum serious frequency, while
another 20% cited once-a-week as that rate.
Table 2 illustrates the most common factors perceived as
predisposing students to taking drugs. Consumption of
drugs by friends and consumption by family members
were among the most common predisposing factors iden-
tified (90% and 74%, respectively), as was tobacco smok-
ing (76%).
When asked to identify the reasons for students taking up
drugs, respondents cited peer pressure (96%), academic
stress (90%), curiosity/for experimentation and "to get
high" (88% each) as the leading ones. To sleep (34%),
academic stress (20%) and curiosity/for experimentation
(20%) were the leading reasons deemed justifiable by the
respondents.
Top reasons why certain students do not take drugs
included moral unacceptability (78%) and religion
(76%). "Harmful effects of drugs" was cited as a reason by
57% of respondents, while 38% cited "fear of being
caught" as one reason.
Ten percent of the respondents said that drugs improved
performance in exams, 60% said drugs did not, while 30%
said they did not know. According to 54%, drugs helped
alleviate stress, 18% said drugs did not, while 28% said
they did not know. For each of these questions, a higher
proportion of respondents belonging to the senior or
'clinical' years (4
th
and 5
th
) replied in the negative (chi-
square = 12.3, df = 2, p = 0.01 and chi-square = 10.2, df =
2, p = 0.01 respectively).
Seventy-seven percent said that living in the college male
hostel predisposed one to using drugs, the top reasons
being greater peer pressure (65%), easier access to drugs
(59%), lack of parental influence (58%) and greater expo-
sure to stresses (44%). According to 22%, living in the
female hostel predisposed one to using drugs.
Seventy-eight percent of the respondents said they did not
intend to ever take drugs in the future, 10% said they did
and nine percent said they did not know. Seventy-one per-
cent of males and 89% of females said they would dis-

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courage a colleague using drugs; gender was associated
with reaction to a colleague's use of drugs (chi-square =
42.3, df = 1, p = 0.01). Day-scholars were more willing
than hostellers to discourage their colleagues (chi-square
= 24.8, df = 1, p = 0.01).
Table 1: Demographic characteristics of the study subjects
VARIABLE SUBJECTS (%)
SEX MALE 96 (52)
FEMALE 78 (48)
YEAR OF UNDERGRADUATE MEDICAL
COURSE
1
ST
37 (20)
2
ND
30 (16)
3
RD
38 (21)
4
TH
54 (29)
5
TH
25 (14)
RESIDENCE HOSTELLITE 130 (71)
DAY-SCHOLAR 54 (29)
Minimum frequency of intake considered by the respondents as "serious/non-trivial"Figure 1
Minimum frequency of intake considered by the respondents as "serious/non-trivial".
Minimum frequency of intake
considered as "serious/ non-trivial"
0
10
20
30
40
50
60
70
H
ERO
I
N
CHARAS
A
LC
O
HO
L
B
D
Z
s
Substance
Percentage (%)
Once in lifetime
Certain social
gatherings
Once a month
Once a week
Daily
None of the above

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Respondents were asked to identify adverse outcomes
associated with intake of the afore-mentioned drugs.
Addiction (92%), threat to own or others' lives (80%),
socially inappropriate behavior (72%) and diminished
academic performance (67%) were the leading problems
recognized. When asked to identify adverse outcomes spe-
cifically associated with alcoholism, 95% cited chronic
liver disease. This was followed by depression (65%),
neurological illness (60%) and reduced life expectancy
(58%). Those who identified at least three adverse out-
comes were more likely to consider a less than daily use of
alcohol as serious/not-trivial (chi-square = 3.9, df = 1, p =
0.05).
Lastly, respondents were asked to make suggestions on
how to reduce the problem of drug use on campuses. The
most common responses were availability of student
counseling facilities (78%), more recreational facilities on
campus (60%), more frequent hostel checking by the
security staff (51%) and drug rehabilitation programs
(48%).
Discussion
In our study, different levels of acceptability were
observed for different substances (figure 1). Respondents
were more likely to be comfortable with an occasional
intake of alcohol as compared to charas or heroin. BDZs
had an even higher acceptance among the participants.
We feel that the low threshold for use of BDZs reflects its
widespread acceptability as a relatively benign sleeping
pill, which is supported by the observation that "to get to
sleep" was the most commonly cited justifiable reason to
take drugs. The relative acceptability of alcohol over
charas or heroin is evidently due to a lack of knowledge
about its harmful effects, since respondents who identi-
fied at least three adverse outcomes were more likely to
consider a less than daily use of alcohol as serious. In the
same vein, "harmful effects of drugs" was a commonly
cited reason for certain students not taking up drugs.
Many of the common factors predisposing to drug misuse
perceived by our subjects have already been established
through Western studies on college students. These
include peer involvement, living away from home, poor
self-esteem and male gender [1,2,5,7]. According to a
study conducted among Thai adolescents, male gender
was a risk factor for every untoward drug-related behavior.
Poor self-esteem was also a risk factor, while socio-envi-
ronmental factors included being in a gang and loneliness
[8].
The most common reasons for students misusing drugs
identified by our subjects were peer pressure (96%), aca-
demic stress (90%), curiosity/for experimentation (89%)
and "to get high" (88%). According to a study carried out
on a Norwegian population, curiosity and peer pressure
were the main reasons for starting drugs. Family conflicts,
school and mental problems were each reported by about
40% of the subjects [7]. Of note, not only was academic
stress the second most commonly cited reason among our
respondents, it was also the second most common reason
deemed to justify drug intake.
Tobacco smoking was identified as a predisposing factor
by 76% of our respondents. According to a study carried
out in the United States, those who had smoked cigarettes
were more likely to consume cocaine (OR = 7.5), heroin
(OR = 16.0), crack (OR = 13.9) and marijuana (OR = 7.3).
These associations were consistent across age-strata and
remained after adjusting for race and gender [9]. This and
other studies suggest that cigarette smoking may be a gate-
way drug to illegal drugs as well as to alcohol, although
that is not conclusively proven yet [10,11].
According to seventy-seven percent of our respondents,
living in the campus' male hostel predisposed one to mis-
using drugs. According to a study carried out in neighbor-
ing India, too, more hostellers were found to be drug
consumers than non-hostellers [4]. When our respond-
ents were asked to state the reasons, they cited greater peer
Table 2: Factors perceived by respondents as predisposing to drug usage among students
PREDISPOSING FACTOR FREQUENCY (%)
FRIENDS USING DRUGS 166 (90)
TOBACCO SMOKING 139 (76)
FAMILY USING DRUGS 136 (74)
CERTAIN SOCIAL GATHERINGS 128 (70)
LIVING AWAY FROM HOME 114 (62)
MALE GENDER 98 (53)
LOW SELF-ESTEEM 93 (51)
INADEQUATE RECREATIONAL FACILITIES 91 (50)

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pressure (65%), easier access to drugs (59%), lack of
parental influence (58%) and greater exposure to stresses
(44%), among others. Notably, half of all respondents
cited "inadequate recreational facilities" as a predisposing
factor to drug misuse (Table 2); it is possible that this fac-
tor may have played an important role in the hostellers'
inclination toward drugs. Students need to be shown that
there are better, safer ways to enjoyment than resorting to
drugs.
In conformity with our subjects' views, religiosity has
been seen to be associated with lower frequencies and
quantities of alcohol intake [4]. It is also conceivable that
a greater knowledge of harmful effects of drugs would lead
to decreased consumption of the same, since our subjects
were clearly deficient in such knowledge. Moreover, over
half of all respondents cited "harmful effects of drugs" as
a reason why certain students do not take up drugs.
As already mentioned, a commonly identified predispos-
ing factor was living in the campus male hostel. Steps
undertaken by Western institutions to curb drug con-
sumption in hostels include cutting access to drugs,
greater checking and swifter punishments [12]. However,
our study suggests that students possess a mature sense of
censorship that is responsive to moral and medical rea-
soning: 78% cited "moral unacceptability" as a reason for
students not taking up drugs and 76% cited "religion".
Fifty-seven percent cited "harmful effects of drugs" as a
deterrent while only 38% cited "fear of being caught" as a
reason for abstinence. This suggests that our students are
more willing to pay attention to moral, religious and med-
ical reasoning than to increased policing. Besides, cutting
students' access to drugs would be much easier said than
done.
Academic stress was identified as a very important factor
in drug misuse. This illustrates the pressure felt by the stu-
dents to excel in their studies, which could result from
overly competitive environments or from very high expec-
tations placed by teachers, family and/or friends. A con-
scious effort needs to be made in alleviating this pressure
as much as possible without unduly decreasing the need
felt by the students to study.
A major limitation of our study was that it was carried out
on students from a single medical college. Moreover, we
chose a private medical college, which has a higher tuition
fee as compared to public medical colleges across the
country. Therefore, students of this college are likely to
belong to more affluent and more educated families on
average than students of a typical public medical college
in Pakistan, thereby introducing a selection bias.
Conclusion
We conclude that undergraduate medical students are
inadequately aware of the effects and side effects of com-
mon drugs of abuse. The relative acceptance of BDZs is a
point of particular concern. Much needs to be done in
order to increase awareness and change attitudes towards
this hazard.
Our findings suggest that educating students about the
dangers of drug intake as well as its moral and religious
implications is likely to be more beneficial than increased
policing. Integration of addiction medicine into the
undergraduate medical curriculum might be of value for
the professional development of the aspiring doctors. In
this regard, guidance can be sought from Western recom-
mendations such as the one made by 2004's Leadership
Conference on Medical Education in Substance Abuse
[13]. Efforts need to be made to make students under-
stand that experimental use of drugs may lead to abuse
and dependence later on. Importantly, efforts need to be
begun at around high-school level, since that is a common
age for developing such habits [14].
Students also need to be shown healthier coping alterna-
tives and avenues for recreation.
For those who have trouble quitting drugs, a counseling
and support system needs to be made readily available.
Such a system should be independent in the sense that the
counselors should not be academic evaluators of these
students. Students need to be assured that they will be
helped rather than victimized for admitting their prob-
lems. An assurance such as that along with easy accessibil-
ity and absolute confidentiality are required in order to
win the trust of needy students.
Declaration of competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
MS participated in designing the study, data gathering and
literature search. He also carried out statistical analysis
and drafted the manuscript. ZS and AS each participated
in study designing, data gathering, literature search and
manuscript writing. MTS conceived of the study and par-
ticipated in its designing as well as in data gathering. KSS
participated in study designing and data gathering and
helped draft the manuscript. FFS participated in study
designing, data gathering and literature search. RS was
involved in study designing and data gathering. HN par-
ticipated in study designing and coordination and helped
draft the manuscript. All authors read and approved the
final manuscript.

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Acknowledgements
We wish to thank the Department of Psychiatry, Aga Khan University Hos-
pital for examining and approving the protocol of this study.
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