Associations between physical and cognitive doping--a cross-sectional study in 2.997 triathletes

Use of Sport Supplements and Doping Substances by Athletes: Prevalence and Relationships

Background: The use of sport supplements may represent a risk factor for the use of doping in sports. To explore this putative risk, the current study examined the frequency of sport supplement use and associations between the use of sport supplements and the use of doping substances and methods in athletes. Methods: The participants (n = 345; 56% male, 22 ± 5 years, 18-43 years) completed measures of sport supplement use, sport supplement beliefs, doping likelihood, and doping use. Based on the Australian Institute of Sport's "Sports Supplement Framework", the participants were asked whether they used 23 sport supplements from four categories (sport foods, medical supplements, performance supplements, other). They were also asked whether they used six classes of doping substances and methods (alphabodies, stimulants, steroids, erythropoietin, growth hormone, blood doping). Results: Sport supplements were used by 96% of the athletes, whereas doping substances were used by 4% of the athletes. Moreover, athletes who used more sport supplements also used more doping substances. The use of sport supplements was related to the use of doping substances both directly and indirectly via sport supplement beliefs and doping likelihood. Conclusions: Consumption of sport supplements is common, whereas doping is rare, and, moreover, the belief that sport supplements help optimize performance in competitive sport confers an increased risk for doping.

Performance-Enhancing Drugs in Healthy Athletes: An Umbrella Review of Systematic Reviews and Meta-analyses

CONTEXT

Many clinicians, trainers, and athletes do not have a true understanding of the effects of commonly used performance-enhancing drugs (PEDs) on performance and health.

OBJECTIVE

To provide an evidence-based review of 7 commonly used pharmacological interventions for performance enhancement in athletes.

DATA SOURCES

PubMed and Scopus databases were searched on April 8, 2022.

STUDY SELECTION

Systematic reviews (SRs) and meta-analyses (MAs) assessing the performance-enhancing effects of the following interventions were included: androgenic anabolic steroids (AAS), growth hormone (GH), selective androgen receptor modulators (SARMs), creatine, angiotensin-converting enzyme (ACE)-inhibitors, recombinant human erythropoietin (rHuEPO), and cannabis.

STUDY DESIGN

Umbrella review of SRs and MAs.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Primary outcomes collected were (1) body mass, (2) muscle strength, (3) performance, and (4) recovery. Adverse effects were also noted.

RESULTS

A total of 27 papers evaluating 5 pharmacological interventions met inclusion criteria. No studies evaluating SARMs or ACE-inhibitors were included. AAS lead to a 5% to 52% increase in strength and a 0.62 standard mean difference in lean body mass with subsequent lipid derangements. GH alters body composition, without providing a strength or performance benefit, but potential risks include soft tissue edema, fatigue, arthralgias, and carpel tunnel syndrome. Creatine use during resistance training can safely increase total and lean body mass, strength, and performance in high-intensity, short-duration, repetitive tasks. Limited evidence supports rHuEPO benefit on performance despite increases in both VO2max and maximal power output, and severe cardiovascular risks are documented. Cannabis provides no performance benefit and may even impair athletic performance.

CONCLUSION

In young healthy persons and athletes, creatine can safely provide a performance-enhancing benefit when taken in controlled doses. AAS, GH, and rHuEPO are associated with severe adverse events and do not support a performance benefit, despite showing the ability to change bodily composition, strength, and/or physiologic measures. Cannabis may have an ergolytic, instead of ergogenic, effect.

Cigarette Smoking, Risky Alcohol Consumption, and Marijuana Smoking among University Students in Germany: Identification of Potential Sociodemographic and Study-Related Risk Groups and Predictors of Consumption

(1) Background: Cigarette smoking, risky alcohol consumption, and marijuana smoking are the most common behaviors related to legal and illicit drug use worldwide, including among university students. To plan effective evidence-based programs to prevent the risky consumption of these substances among university students, the present study aimed to identify potential sociodemographic and study-related risk groups and predictors of consumption. (2) Methods: A cross-sectional online health survey with approximately 270 health-related items was conducted among students at the University of Mainz, Germany. Cigarette smoking, risky alcohol consumption (AUDIT-C score: female ≥ 4, male ≥ 5), and marijuana smoking were chosen as dependent variables. Of the 270 health-related items, 56 were chosen as independent variables and collated into five groups (sociodemographic, psychological, study-related psychosocial, general psychosocial and health behavior). The prevalence of cigarette smoking, risky alcohol consumption, and marijuana smoking was assessed using established and validated instruments. Pearson's chi-square test was used to analyze the differences in prevalence between the sociodemographic and study-related groups, and binary logistic regression was used for analyses with stepwise inclusion of the five variable groups. (3) Results: Of the 3991 university students who entered the analyses, 14.9% reported smoking cigarettes, 38.6% reported risky alcohol consumption, and 10.9% reported smoking marijuana. The prevalence of these differed between genders, fields of study, and aspired degree level, among other factors. Binary logistic regression analyses revealed nine significant predictors (p ≤ 0.05) of cigarette smoking (Nagelkerke R2 = 0.314), 18 significant predictors of risky alcohol consumption (Nagelkerke R2 = 0.270), and 16 significant predictors of marijuana smoking (Nagelkerke R2 = 0.239). (4) Conclusions: This study showed cigarette smoking, risky alcohol consumption, and marijuana smoking among university students in Germany to be associated with multiple factors, especially health behaviors. Furthermore, each of the substances was highly associated with each of the two other substances we examined. Other variable groups, such as psychological or psychosocial variables, seemed to play a rather minor role. Therefore, our recommendation for future prevention programs is that substance use among university students should be addressed as a whole, not just in terms of specific substances.

Are dietary supplement users more likely to dope than non-users?: A systematic review and meta-analysis

In the past decade, a body of evidence has reported that dietary supplement use is related to prohibited performance enhancing substance use (i.e., doping). To help international and national sport organisations understand the degree to which dietary supplement use is related to doping, the objectives of this systematic review and meta-analysis were to 1) compare the prevalence of doping between dietary supplement users and non-users and 2) identify whether supplement use is related to doping social cognitive factors. We searched for studies sampling athletes and that measured both dietary supplement use and doping in EMBASE, MEDLINE, PsychINFO, CINAHL and SPORTDiscus from database creation to May 2022. Risk of bias was assessed using JBI Critical Appraisal Checklist for cross-sectional studies and the STROBE checklist. Twenty-six cross-sectional studies, involving 13,296 athletes were included. Random-effect models revealed that doping was 2.74 (95% CI=2.10 to 3.57) times more prevalent in dietary supplement users (pooled prevalence = 14.7%) than non-users (6.7%), and that users reported stronger doping intentions (r=0.26, 0.18 to 0.34) and attitudes (r=0.21, 0.13 to 0.28) compared to non-users. Preliminary evidence also suggests that dietary supplement users were less likely to dope if they were more task oriented and had a stronger sense of morality. Results of the review are limited by the cross-sectional design used in all studies and lack of consistency in measurement of dietary supplement use and doping. Data indicate that athletes using dietary supplements are more likely to self-report doping Anti-doping policy should, therefore, target dietary supplement use in anti-doping education programmes by providing alternative strategies for performance enhancement or highlighting the safest ways they can be consumed. Similarly, as a large proportion of athletes use dietary supplements without doping, further research is needed to understand the factors that protect a dietary supplement user from doping. No funding was received for the review. A study protocol can be found here: https://osf.io/xvcaq.

Recreational Athletes' Use of Performance-Enhancing Substances: Results from the First European Randomized Response Technique Survey

BACKGROUND AND AIM

Measuring the prevalence of doping in recreational sport is difficult. However, to fit their initiatives, National Anti-Doping Organizations are interested in knowing the numbers, so their scarce resources are not wasted. The present study aimed to estimate the prevalence of doping and over-the-counter medicine use for performance enhancement among recreational athletes in eight European countries.

DESIGN

A survey covering + 200 sports aimed at recreational athletes 15 years and older was distributed via social media to sports clubs and individuals in eight European countries. To overcome social desirability bias, we applied indirect questioning by using the Randomized Response Technique and asked for the use of over-the-counter medicine and doping for the year 2019.

RESULTS

The prevalence of the use of over-the-counter medications for performance enhancement was estimated at 10.4%. We differentiated between the concept of "doping" as the behavior to enhance performance in a certain sport and the concept of "a doper" as a property of a person. The prevalence of dopers in recreational sport was found to be 0.4%, with 3.1% male and 0% female dopers. Responses were separated into four categories: "Artistic sports," "Combat sports," "Games," and "CGS sports" (i.e., sports measured in centimeters, grams, and seconds). The overall prevalence of doping in recreational sports was found to be 1.6%, and the results from Artistic and CGS sports did not differ significantly from this. However, in Games we found an estimated doping prevalence of 6.9%.

DISCUSSION

The estimates for the prevalence of dopers and doping in this study do not equal Anti-Doping Rule Violations as stipulated by the World Anti-Doping Agency. Still, while doping is not absent in recreational sport in Europe, it appears to be a low frequent phenomenon. Also, the differences in doping prevalence between the sports categories might reflect structural and competition-related differences, rather than differences in the logic of the sporting competition or discipline-related subcultures.

CONCLUSION

While few recreational athletes appear to use illegal drugs to enhance performance, those who do use them are more often men than women. Yet, 1 in 10 recreational athletes uses over-the-counter medication for performance enhancement and more than 4 out of 10 use medication for other reasons than performance enhancement when doing sports. The highest doping prevalence was found in the sub-category of Games, which can likely be attributed to competition-related differences between the categories. Therefore, research on doping in recreational sports needs tailored approaches to come to a better understanding of the phenomenon.

Are Dietary Supplements a Gateway to Doping? A Retrospective Survey of Athletes' Substance Use

Background: It is proposed that the use of dietary supplements might lead to the use of doping substances. This has been termed the gateway hypothesis. However, within an athletic sample, no research has examined the order in which these substances are consumed and what may explain the progression from dietary supplement use to doping. Objective: To identify whether dietary supplement use precedes doping and examine what moderates the dietary supplement-doping relationship. Methods: Competitive athletes (N=1,081, 42.0% female; Age=29.3±10.8 years) completed an online survey measuring dietary supplement use, doping use, doping subjective norms and age of using a supplement and/or doping substance. Results: Dietary supplement users were 11 times more likely to dope than non-users (OR=11.28, 95% CI = 2.72 to 46.77). Age for first use of a dietary supplement was younger than use of a doping substance (mean difference=-4.5±5.1 years old, p<0.001, d=0.90). Over three-quarters of doping users reported using a dietary supplement first (77.1%), whereas a small proportion of athletes started using dietary supplements and doping at the same time (12.5%) and some used doping substances before using dietary supplements (10.4%). Moderation analysis revealed that dietary supplement users may be more likely to dope because of a more favourable social acceptance of using prohibited substances than non-users. Conclusions: Data suggest that dietary supplement use is more likely to precede doping. However, not all doping users begin with using dietary supplements, which highlights the importance of measuring the temporal order of dietary supplement and doping use in future research.

Hidden figures: Revisiting doping prevalence estimates previously reported for two major international sport events in the context of further empirical evidence and the extant literature

Background

High levels of admitted doping use (43.6% and 57.1%) were reported for two international sport events in 2011. Because these are frequently referenced in evaluating aspects of anti-doping, having high level of confidence in these estimates is paramount.

Objectives

In this study, we present new prevalence estimates from a concurrently administered method, the Single Sample Count (SSC), and critically review the two sets of estimates in the context of other doping prevalence estimates.

Methods

The survey featuring the SSC model was completed by 1,203 athletes at the 2011 World Championships in Athletics (WCA) (65.3% of all participating athletes) and 954 athletes at the 2011 Pan-Arab Games (PAG) (28.2% of all participating athletes). At WCA, athletes completed both UQM and SSC surveys in randomised order. At PAG, athletes were randomly allocated to one of the two surveys. Doping was defined as "having knowingly violated anti-doping regulations by using a prohibited substance or method."

Results

Estimates with the SSC model for 12-month doping prevalence were 21.2% (95% CI: 9.69-32.7) at WCA and 10.6% (95% CI: 1.76-19.4) at PAG. Estimated herbal, mineral, and/or vitamin supplements use was 8.57% (95% CI: 1.3-16.11) at PAG. Reliability of the estimates were confirmed with re-sampling method (n = 1,000, 80% of the sample). Survey non-compliance (31.90%, 95%CI: 26.28-37.52; p < 0.0001) was detected in the WCA data but occurred to a lesser degree at PAG (9.85%, 95% CI: 4.01-15.69, p = 0.0144 and 11.43%, 95% CI: 5.31-11.55, p = 0.0196, for doping and nutritional supplement use, respectively). A large discrepancy between those previously reported from the UQM and the prevalence rate estimated by the SSC model for the same population is evident.

Conclusion

Caution in interpreting these estimates as bona fide prevalence rates is warranted. Critical appraisal of the obtained prevalence rates and triangulation with other sources are recommended over "the higher rate must be closer to the truth" heuristics. Non-compliance appears to be the Achilles heel of the indirect estimation models thus it should be routinely tested for and minimised. Further research into cognitive and behaviour aspects, including motivation for honesty, is needed to improve the ecological validity of the estimated prevalence rates.

Assessment of knowledge, perception, attitude, and use of performance-enhancing substances among students of Faculty of Medicine, Alexandria University, Egypt: a pilot study

Background

The market for performance enhancement substances (PESs) is currently one of the fastest expanding sectors. Most studies have always concentrated on athletes in terms of PESs’ misuse, ignoring a critical segment of the community: the future health-care workers. Thus, the aim of the study was to probe the knowledge, perception, and attitude of medical students regarding the misuse of PESs in sports and medical academic study. A cross-sectional study was conducted among students of Alexandria Faculty of Medicine, Egypt. Data were collected via self-administered electronic survey from 208 students of both sexes (aged from 18 to 26 years old). Analysis of factors affecting the consumption of PESs like gender differences, and their prior knowledge and perception was performed using logistic regression models.

Results

More than half of the participants have no idea about law concerning the use of doping substances. There were no significant disparities in knowledge and perception between males and females. Female students, on the other hand, consistently reported having a better understanding of the negative impacts of PESs’ misuse. Surprisingly, females are more prone to consume PESs for cognitive enhancement rather than the physical performance.

Conclusions

The study is the first to explore the awareness of the medical students, their attitude, and perception towards different ethical scenarios confronted in the daily practice. This finding pinpoints that the common trend of striving for fitness and an ideal body shape and weight has produced a shift in the prevalence of the PESs use according to gender in Egypt. Moreover, females in medicine academics are more prone to use PESs to improve the cognitive functions albeit it is nonsignificant statistically. Therefore, efforts should be directed to raise the awareness of medical practitioners of diverse categories of these substances, health hazards, laws, and penalties. More importantly, policy measures for their production, marketing, and misuse among university students should be reconsidered by the government.

[Ophthalmic drug therapy in professional athletes-what is allowed, what is doping?]

At first sight, ophthalmic drugs are not necessarily suspected of being used as performance-enhancing agents in competitive sports. However, there are some restrictions that must be noted, especially when certain drugs are taken orally. A structured analysis of the doping relevance of ophthalmic drugs was performed on the basis of a literature review, taking into account the current guidelines of the National Anti-Doping Agency of Germany and the World Anti-Doping Agency. Use of the most common ophthalmological drug groups is possible without restrictions, especially in the case of topical application. An exception is the oral use of diuretics, which is prohibited at all times. For glucocorticoids, topical application to the eye is allowed, but oral application is prohibited in competition. A similar restriction applies to the use of epinephrin, for which all forms of systemic application are prohibited in competition. When taking beta-blockers, the sport being played is the determining factor: use is prohibited in billiards, archery, darts, golf, motor sports, shooting sports, skiing/snowboarding, ski jumping, freestyle aerials/half pipe, snowboard half pipe/big air, and underwater sports. For shooting and archery, beta-blockers are also prohibited outside of competitions. Athletes with pre-existing ophthalmological conditions should seek comprehensive advice from an ophthalmologist before using any medication, and together they should choose a permissible active ingredient, consider the appropriate route of application, and, if necessary, apply for a Therapeutic Use Exemption. It is currently not known how many of the national and international athletes have to be treated with eye drops.

The Prevalence of Pharmacological Neuroenhancement Among University Students Before and During the COVID-19-Pandemic: Results of Three Consecutive Cross-Sectional Survey Studies in Germany

Background

According to the literature, the conditions of studying and living as well as the psychological, social and health behavior-related variables, which were strongly related to pharmacological neuroenhancement (PN) before the pandemic, significantly changed during the pandemic. For this reason, it is expected that the prevalence of PN among university students is higher during the pandemic compared to before the pandemic. Therefore, the present study aimed to investigate and compare the prevalence of PN among university students before and during the COVID-19-pandemic.

Methods

Three online surveys assessing the 12-month prevalence of PN were conducted among university students at the University of Mainz, Germany. The first survey took place in summer term 2019 (before the pandemic), the second in summer term 2020 (during the first German lockdown), and the third in summer term 2021 (after the second German lockdown). Pearson's chi-square test was used to test whether the 12-month prevalence of PN differed significantly between the three surveys.

Results

The 12-month prevalence of PN was 10.4% in 2019, 11.3% in 2020, and 8.0% in 2021. Chi-square tests revealed no statistical difference in the prevalence of PN between 2019 and 2020. Overall, the use of PN was lower in 2021 compared to 2019 (p < 0.0001) as well as in comparison to 2020 (p = 0.001). Only the use of cannabis slightly increased from 2019 to 2020 (7.1 vs. 8.3%) and decreased in 2021 (5.4%). At all three time points, cannabis was the most commonly used substance for the purpose of PN. Consequently, the results suggest that the prevalence of PN was highly intertwined with the prevalence of cannabis use for PN.

Discussion

The decrease in the prevalence of PN of around three percentage points in 2021 compared to the previous years was a surprising finding. It may be mainly due to the decrease in the prevalence of cannabis for the purpose of PN. However, the fairly high prevalence of PN of around 8% in 2021 is still an important finding that demonstrates that there is still an urgent need for prevention initiatives among university students to combat the use of PN.

Potential risk groups and psychological, psychosocial, and health behavioral predictors of pharmacological neuroenhancement among university students in Germany

Aiming to develop and implement intervention strategies targeting pharmacological neuroenhancement (PN) among university students more specifically, we (1) assessed the prevalence of PN among German university students, (2) identified potential sociodemographic and study-related risk groups, and (3) investigated sociodemographic, psychological, study-related psychosocial, general psychosocial and health behavior related factors predicting the 12-month prevalence of PN. Therefore, a cross-sectional online survey was administered to students of the University of Mainz, Germany. A binary logistic regression with stepwise inclusion of the five variable groups was performed to predict PN. A total number of 4351 students out of 31,213 registered students (13.9%) participated in the survey, of which N = 3984 answered the question concerning PN. Of these, 10.4% had used one substance for PN at least once in the past 12 months. The regression analysis revealed 13 variables that were significantly related to the 12-month prevalence of PN. Specifically, the group of health behavior related variables showed the strongest relationship with PN. Therefore, an approach to the prevention of PN should be multifactorial so that it addresses social conditions, as well as education on substance use and healthy behaviors in terms of non-pharmacological strategies as alternatives of PN.

Efficient Ways to Combat Doping in a Sports Education Context!? A Systematic Review on Doping Prevention Measures Focusing on Young Age Groups

Youth is characterized by testing and crossing natural boundaries, sometimes with the help of performance-enhancing substances. In this context, doping prevention measures play a crucial role to protect individuals both within and outside the context of elite sport. Based on the PRISMA guidelines, a systematic literature search was conducted in the databases ProQuest (ERIC), Scopus, PSYNDEX/PsychInfo, PubMed, and Web of Science Core Collection to provide an overview of the impact of doping prevention measures, with particular attention to the underlying understanding of learning. As a result of the screening process, 30 of the initial 5,591 articles met the previously defined and recorded eligibility criteria. The analysis led to heterogeneous results regarding content, implementation, target group, or outcome variables considered relevant. Two-thirds of the studies related to the competitive sports context. Nevertheless, there has been a growing interest in studying doping prevention and its effects on non-elite athlete target groups in recent years. In terms of effectiveness, many measures did not achieve long-term changes or did not collect any follow-up data. This contrasts with understanding learning as sustained change and reduces the intended long-term protection of prevention measures, especially for adolescent target groups. Even young age groups from 10 years upwards benefited from doping prevention measures, and almost all doping prevention measures enabled their participants to increase their physical and health literacy. No conclusion can be drawn as to whether doping prevention measures based on constructivist ideas are superior to cognitivist approaches or a combination of both. Nevertheless, programs that actively engage their participants appear superior to lecture-based knowledge transfer. Most of the prevention measures offered a benefit-orientation so that participants can achieve added value, besides trying to initiate health-promoting change through rejection. Because of the lack of sustained changes, a further modification in doping prevention seems necessary. The review results support the value of primary prevention. Doping prevention measures should enable tailored learning and development options in the sense of more meaningful differentiation to individual needs. The implementation in a school context or an online setting is promising and sees doping as a problem for society. The review highlights the importance of accompanying evaluation measures to identify efficient prevention components that promote health and protect young people.

Ego orientation is related to doping likelihood via sport supplement use and sport supplement beliefs

ABSTRACTA growing body of evidence suggests sport supplement use is positively related to doping likelihood, both directly and indirectly via beliefs that sport supplements are effective for improving performance. However, it is unclear what leads an athlete to use sport supplements and whether such factors play a role in the supplement-beliefs-doping relationship. To address this issue, we examined whether motivational goal orientations were related to doping likelihood directly and indirectly via sport supplement use and sport supplement beliefs. Competitive athletes (N = 362, 39% female, mean ± SD; age = 23.6 ± 10.3 years, hours per week training = 5.8 ± 2.1, years competing = 5.8 ± 5.4) from a range of sports (e.g. athletics, soccer, weightlifting) completed an online survey measuring task and ego goal orientation, sport supplement use, sport supplement beliefs, and doping likelihood. Results indicated that ego orientation, but not task orientation, was indirectly related to doping likelihood via sport supplement use and sport supplement beliefs. This suggests that athletes who are ego oriented are more likely to use supplements, believe supplements are effective, and dope. These data suggest that researchers should consider ego goal orientations when interpreting relationships between sport supplement use and doping likelihood.

Doping Prevalence in Competitive Sport: Evidence Synthesis with "Best Practice" Recommendations and Reporting Guidelines from the WADA Working Group on Doping Prevalence

BACKGROUND

The prevalence of doping in competitive sport, and the methods for assessing prevalence, remain poorly understood. This reduces the ability of researchers, governments, and sporting organizations to determine the extent of doping behavior and the impacts of anti-doping strategies.

OBJECTIVES

The primary aim of this subject-wide systematic review was to collate and synthesize evidence on doping prevalence from published scientific papers. Secondary aims involved reviewing the reporting accuracy and data quality as evidence for doping behavior to (1) develop quality and bias assessment criteria to facilitate future systematic reviews; and (2) establish recommendations for reporting future research on doping behavior in competitive sports to facilitate better meta-analyses of doping behavior.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to identify relevant studies. Articles were included if they contained information on doping prevalence of any kind in competitive sport, regardless of the methodology and without time limit. Through an iterative process, we simultaneously developed a set of assessment criteria; and used these to assess the studies for data quality on doping prevalence, potential bias and reporting.

RESULTS

One-hundred and five studies, published between 1975 and 2019,were included. Doping prevalence rates in competitive sport ranged from 0 to 73% for doping behavior with most falling under 5%. To determine prevalence, 89 studies used self-reported survey data (SRP) and 17 used sample analysis data (SAP) to produce evidence for doping prevalence (one study used both SRP and SAP). In total, studies reporting athletes totaled 102,515 participants, (72.8% men and 27.2% women). Studies surveyed athletes in 35 countries with 26 involving athletes in the United States, while 12 studies examined an international population. Studies also surveyed athletes from most international sport federations and major professional sports and examined international, national, and sub-elite level athletes, including youth, masters, amateur, club, and university level athletes. However, inconsistencies in data reporting prevented meta-analysis for sport, gender, region, or competition level. Qualitative syntheses were possible and provided for study type, gender, and geographical region. The quality assessment of prevalence evidence in the studies identified 20 as "High", 60 as "Moderate", and 25 as "Low." Of the 89 studies using SRP, 17 rated as "High", 52 rated as "Moderate", and 20 rated as "Low." Of the 17 studies using SAP, 3 rated as "High", 9 rated as "Moderate", and 5 rated as "Low." Examining ratings by year suggests that both the quality and quantity of the evidence for doping prevalence in published studies are increasing.

CONCLUSIONS

Current knowledge about doping prevalence in competitive sport relies upon weak and disparate evidence. To address this, we offer a comprehensive set of assessment criteria for studies examining doping behavior data as evidence for doping prevalence. To facilitate future evidence syntheses and meta-analyses, we also put forward "best practice" recommendations and reporting guidelines that will improve evidence quality.

The Use and Impact of Cognitive Enhancers among University Students: A Systematic Review

INTRODUCTION

Cognitive enhancers (CEs), also known as "smart drugs", "study aids" or "nootropics" are a cause of concern. Recent research studies investigated the use of CEs being taken as study aids by university students. This manuscript provides an overview of popular CEs, focusing on a range of drugs/substances (e.g., prescription CEs including amphetamine salt mixtures, methylphenidate, modafinil and piracetam; and non-prescription CEs including caffeine, cobalamin (vitamin B12), guarana, pyridoxine (vitamin B6) and vinpocetine) that have emerged as being misused. The diverted non-prescription use of these molecules and the related potential for dependence and/or addiction is being reported. It has been demonstrated that healthy students (i.e., those without any diagnosed mental disorders) are increasingly using drugs such as methylphenidate, a mixture of dextroamphetamine/amphetamine, and modafinil, for the purpose of increasing their alertness, concentration or memory.

AIM

To investigate the level of knowledge, perception and impact of the use of a range of CEs within Higher Education Institutions.

METHODOLOGY

A systematic review was conducted in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Whilst 1400 studies were identified within this study through a variety of electronic databases (e.g., 520 through PubMed, 490 through Science Direct and 390 through Scopus), 48 papers were deemed relevant and were included in this review.

RESULTS

The most popular molecules identified here included the stimulant CEs, e.g., methylphenidate, modafinil, amphetamine salt mixtures and caffeine-related compounds; stimulant CEs' intake was more prevalent among males than females; drugs were largely obtained from friends and family, as well as via the Internet. It is therefore suggested that CEs are increasingly being used among healthy individuals, mainly students without any diagnosed cognitive disorders, to increase their alertness, concentration, or memory, in the belief that these CEs will improve their performance during examinations or when studying. The impact of stimulant CEs may include tolerance, dependence and/or somatic (e.g., cardiovascular; neurological) complications.

DISCUSSION

The availability of CEs for non-medical indications in different countries is influenced by a range of factors including legal, social and ethical factors. Considering the risk factors and motivations that encourage university students to use CE drugs, it is essential to raise awareness about CE-related harms, counteract myths regarding "safe" CE use and address cognitive enhancement in an early stage during education as a preventative public health measure.

Refined Analysis of a Cross-Sectional Doping Survey Among Recreational Triathletes: Support for the Nutritional Supplement Gateway Hypothesis

Introduction: The current literature provides no consensus that nutritional supplements (NS) may provide a gateway to doping. In particular, studies in recreational athletes are lacking. Within a previous cross-sectional empirical study, our group provided first evidence that the use of NS may provide a gateway for the use of doping substances in recreational triathletes. For the present paper, we refine the analysis of the triathletes’ survey in order to provide evidence for a NS gateway hypothesis in recreational athletes.

Methods: A self-report, paper-and-pencil questionnaire was distributed to a sample of 2,997 competitive ironman and half-ironman (n = 1,076; 36.1%) triathletes. The randomized response technique (RRT) was used to assess the 12-month prevalence estimate for the use of doping substances. The prevalence for the use of NS was assessed by using direct questioning. Two-tailed (α = 0.05) large-sample z-tests were performed to assess whether the estimated prevalence for the use of doping substances differs significantly between users and nonusers of NS.

Results: The 12-month prevalence estimate for the use of doping substances is significantly higher in athletes who report using NS (20.6%) compared to those who do not (11.4%; z = 2.595, p = 0.0097).

Conclusion: The present results are consistent with the hypothesis that the use of NS provides a gateway to the use of doping substances. Therefore, doping prevention concepts should not primarily focus on preventing the use of doping substances per se, but should start one step earlier, namely by the use of NS.

Cognitive Enhancing Drugs in Sport: Current and Future Concerns

Sporting authorities and policy makers have warned of a radical increase in the availability and use of so-called 'smart' drugs, which putatively deliver cognitive enhancements in the form of improved focus, concentration, alertness, and rapid decision-making. Although the potential for health risks is well documented when it comes to performance enhancing drugs in sport, the health implications of cognitive enhancing drugs (CEDs) remain unclear. Objectives: This article aims to provide a foundational understanding about CEDs and their application in sport. It considers what little is known about the types, nature, impact, and implications of their use for athletes and sport policy. Method: A narrative literature review was undertaken to ascertain the emerging role of CEDs beyond their clinical use to treat prescribed disorders, including the limited studies in the sporting domain. This review also considered literature pertinent to the impact of CEDs in sport and the challenges for sport policy. Results: Given the prospects of negative health impacts, policy-makers interested in preventing and controlling the use of CEDs, as well as reducing harm to athletes at all levels of performance, need guidance. This article highlights multi-faceted concerns and shines a spotlight on key issues for sporting bodies to consider regarding the critical impact that widespread use and adoption of these substances might entail. Conclusion: While the World Anti-Doping Agency (WADA) is seemingly awake to the threat posed, actions to circumvent the spread of CEDs throughout sport are nascent and require greater understanding and attention.

Pharmakologisches Neuroenhancement in Deutschland

Hintergrund Die Angaben zur Verbreitung des pharmakologischen Neuroenhancements (pNE) in Deutschland variieren stark. Der Beitrag diskutiert, inwieweit dieser Umstand methodischen Aspekten der Prävalenzstudien geschuldet sein könnte.

Methode Der Beitrag gibt einen Überblick zum aktuellen Forschungsstand und beleuchtet methodische Probleme der Prävalenzforschung in Deutschland.

Ergebnisse Die Prävalenzangaben variieren je nach Erhebungsmethode, abgefragtem Zeitpunkt der Einnahme und untersuchten Zielgruppen und Stoffen bei verschreibungspflichtigen und illegalen Substanzen zwischen einem und 39%. Für frei erhältliche Mittel werden z. T. höhere Prävalenzen berichtet. Es lassen sich 4 große methodische Probleme der Forschung identifizieren: 1.) Die Heterogenität der Definitionen, 2.) die Heterogenität der Befragungsmethoden und die Qualität der Stichproben(ziehungen), 3.) Defizite bei der Frageformulierung, 4.) das Fehlen wichtiger Angaben in den zugehörigen Veröffentlichungen.

Schlussfolgerung Verlässliche Aussagen zur Verbreitung von pNE in Deutschland sind schwierig. Zwischen den Untersuchungen bestehen inhaltlich und methodisch große Unterschiede, die Ergebnisse lassen sich nur bedingt vergleichen. Notwendig sind regelmäßige bevölkerungsrepräsentative Erhebungen auf Basis einheitlicher Definitionen.

The Prevalence of Legal Performance-Enhancing Substance Use and Potential Cognitive and or Physical Doping in German Recreational Triathletes, Assessed via the Randomised Response Technique

This study investigated the use of performance-enhancing substances in recreational triathletes who were competing in German races at distances ranging from super-sprint to long-distance, as per the International Triathlon Union. The use of legal drugs and over-the-counter supplements over the previous year, painkillers over the previous 3 months, and the potential three-month prevalence of physical doping and or cognitive doping in this group were assessed via an anonymous questionnaire. The Randomised Response Technique (RRT) was implemented for sensitive questions regarding "prescription drugs […] for the purpose of performance enhancement […] only available at a pharmacy or on the black market". The survey did not directly state the word "doping," but included examples of substances that could later be classed as physical and or cognitive doping. The subjects were not required to detail what they were taking. Overall, 1953 completed questionnaires were received from 3134 registered starters at six regional events-themselves involving 17 separate races-in 2017. Of the respondents, 31.8% and 11.3% admitted to the use of dietary supplements, and of painkillers during the previous three months, respectively. Potential physical doping and cognitive doping over the preceding year were reported by 7.0% (Confidence Interval CI: 4.2-9.8) and 9.4% (CI: 6.6-12.3) of triathletes. Gender, age, experience in endurance sports, and number of weekly triathlon training hours were linked to potential physical or cognitive doping. Given the potentially relevant side effects of painkiller use and physical and or cognitive doping, we recommend that educational and preventative measures for them be implemented within amateur triathlons.

Use and Propensity to Use Substances as Cognitive Enhancers in Italian Medical Students

International media has paid attention to the use of substances by healthy subjects to enhance cognitive performance. Medical students are liable to use cognitive enhancers (CE) with the aim of improving academic performance. The study explored use and attitudes toward the use of CE in Italian medical students. The authors anonymously surveyed 433 medical students of the University of Modena and Reggio Emilia with an ad hoc 36-items questionnaire. CE were broadly defined as any substance taken with the purpose of improving cognitive functions, from readily available beverages and substances, such as coffee, tea, energy drinks, and supplements to prescription only medication, such as psychostimulants and modafinil. Response rate was 83.8% (n = 363). While the majority of the students (74.7%; n = 271) said that they had used substances to improve cognitive functions, only 2 students (0.6%) reported the use of prescription-only medications in the last 30 days. Main reasons for not taking prescription-only drugs were concerns about safety and side effects, reported by 83.3% of students (n = 295). A positive attitude toward use was held by 60.3% (n = 219) subjects. The surveyed Italian medical students used many substances as CE, but this did not seem to apply significantly to psychostimulants. A multivariable analysis showed that the following variables were related to the propensity to use substances as CE: male gender, self-reported memory impairment, concerns about worsening of cognitive performance, lifetime use of at least one illegal substance, use of any substance (both legal or illegal) in the last 30 days.

Prevalence Estimates for Pharmacological Neuroenhancement in Austrian University Students: Its Relation to Health-Related Risk Attitude and the Framing Effect of Caffeine Tablets

Background: Pharmacological neuroenhancement (PN) is defined as the use of illicit or prescription drugs by healthy individuals for cognitive-enhancing purposes. The present study aimed (i) to investigate whether including caffeine tablets in the definition of PN within a questionnaire increases the PN prevalence estimate (framing effect), (ii) to investigate whether the health-related risk attitude is increased in students who use PN. Materials and methods: Two versions of a paper-and-pencil questionnaire (first version included caffeine tablets in the definition of PN, the second excluded caffeine tablets) were distributed among university students at the University of Graz, Austria. The unrelated question model (UQM) was used to estimate the 12-month PN prevalence and the German version of the 30-item Domain-Specific Risk-Taking (DOSPERT) scale to assess the health-related risk attitude. Moreover, large-sample z-tests (α = 0.05) were performed for comparing the PN prevalence estimates of two groups. Results: Two thousand four hundred and eighty-nine questionnaires were distributed and 2,284 (91.8%) questionnaires were included in analysis. The overall PN prevalence estimate for all students was 11.9%. One-tailed large-sample z-tests revealed that the PN estimate for students with higher health-related risk attitude was significantly higher compared to students with lower health-related risk attitude (15.6 vs. 8.5%; z = 2.65, p = 0.004). Furthermore, when caffeine tablets were included into the example of PN, the prevalence estimate of PN was significantly higher compared to the version without caffeine tablets (14.9 vs. 9.0%; z = 2.20, p = 0.014). Discussion: This study revealed that the PN prevalence estimate increases when caffeine tablets are included in the definition of PN. Therefore, future studies investigating the prevalence of, and predictors for, PN should be performed and interpreted with respect to potential framing effects. This study further revealed that the PN prevalence estimate is increased in students with a higher health-related risk attitude compared to students with a lower one. Therefore, future education and prevention programs addressing PN in the collective of students should not only inform about potential side effects of its use but also address the limited effects on cognition and potential alternatives of PN.

Physical and cognitive doping in university students using the unrelated question model (UQM): Assessing the influence of the probability of receiving the sensitive question on prevalence estimation

STUDY OBJECTIVES

In order to increase the value of randomized response techniques (RRTs) as tools for studying sensitive issues, the present study investigated whether the prevalence estimate for a sensitive item [Formula: see text] assessed with the unrelated questionnaire method (UQM) is influenced by changing the probability of receiving the sensitive question p.

MATERIAL AND METHODS

A short paper-and-pencil questionnaire was distributed to 1.243 university students assessing the 12-month prevalence of physical and cognitive doping using two versions of the UQM with different probabilities for receiving the sensitive question (p ≈ 1/3 and p ≈ 2/3). Likelihood ratio tests were used to assess whether the prevalence estimates for physical and cognitive doping differed significantly between p ≈ 1/3 and p ≈ 2/3. The order of questions (physical doping and cognitive doping) as well as the probability of receiving the sensitive question (p ≈ 1/3 or p ≈ 2/3) were counterbalanced across participants. Statistical power analyses were performed to determine sample size.

RESULTS

The prevalence estimate for physical doping with p ≈ 1/3 was 22.5% (95% CI: 10.8-34.1), and 12.8% (95% CI: 7.6-18.0) with p ≈ 2/3. For cognitive doping with p ≈ 1/3, the estimated prevalence was 22.5% (95% CI: 11.0-34.1), whereas it was 18.0% (95% CI: 12.5-23.5) with p ≈ 2/3. Likelihood-ratio tests revealed that prevalence estimates for both physical and cognitive doping, respectively, did not differ significantly under p ≈ 1/3 and p ≈ 2/3 (physical doping: χ2 = 2.25, df = 1, p = 0.13; cognitive doping: χ2 = 0.49, df = 1, p = 0.48). Bayes factors computed with the Savage-Dickey method favored the null ("the prevalence estimates are identical under p ≈ 1/3 and p ≈ 2/3") over the alternative ("the prevalence estimates differ under p ≈ 1/3 and p ≈ 2/3") hypothesis for both physical doping (BF = 2.3) and cognitive doping (BF = 5.3).

CONCLUSION

The present results suggest that prevalence estimates for physical and cognitive doping assessed by the UQM are largely unaffected by the probability for receiving the sensitive question p.

Body Image and Eating Disorders are Common among Professional and Amateur Athletes Using Performance and Image Enhancing Drugs: A Cross-Sectional Study

The use of performance and image enhancing drugs (PIEDs) is not uncommon in athletes and appears to be associated with several psychopathological disorders of unclear prevalence. In this multicenter, cross-sectional study, we aimed to evaluate the prevalence of body image disorders (BIDs) and eating disorders (EDs) in PIED-using athletes vs. PIED nonusers. We enrolled 84 consecutive professional and amateur athletes training in sport centers in Italy, who underwent semi-structured interviews (SCID-I, SCID-II) and completed the Body Image Concern Inventory (BICI) and the Sick, Control, One, Fat, Food Eating Disorder Screening Test (SCOFF). PIEDs were searched for in participants' blood, urine, and hair. Of these, 18 (21.4%) used PIEDs, the most common being anabolic androgenic steroids, amphetamine-like substances, coffee and caffeine derivatives, synthetic cathinones, and ephedrine. PIED users and nonusers did not differ in socio-demographic characteristics, but differed in clinical and psychopathological features, with PIED users being characterized by higher physical activity levels, higher daily coffee and psychotropic medication use (e.g., benzodiazepines), more SCID diagnoses of psychiatric disorders, especially substance use disorder, body dysmorphic disorder (BDD), EDs, and general anxiety disorder, higher BICI scores (indicating higher risk of BDD), and higher SCOFF scores (suggesting higher risks for BIDs and EDs).

Sport-Induced Substance Use-An Empirical Study to the Extent within a German Sports Association

In cooperation with the Sports Association of the Palatinate (SBP), a survey was conducted on substance use by recreational and amateur athletes. Distribution of the online questionnaire took place by means of chain-referral sampling, and questions on substance use were presented using the randomized response technique (RRT) to protect the anonymity of respondents and prevent socially desirable answers. The estimated lowest limit for the population share for use of prohibited substances during the last season (4%) and for lifetime use (3.6%) did not differ significantly. Approximately 21% of respondents had used substances for training or competitions that were taken for a purpose other than performance enhancement (e.g., to improve their mood or to help with recuperation from a minor injury or illness) in the last year. 49% had done so at some point in their life.

A Comparison of the Cheater Detection and the Unrelated Question Models: A Randomized Response Survey on Physical and Cognitive Doping in Recreational Triathletes

Purpose

This study assessed the prevalence of physical and cognitive doping in recreational triathletes with two different randomized response models, that is, the Cheater Detection Model (CDM) and the Unrelated Question Model (UQM). Since both models have been employed in assessing doping, the major objective of this study was to investigate whether the estimates of these two models converge.

Material and Methods

An anonymous questionnaire was distributed to 2,967 athletes at two triathlon events (Frankfurt and Wiesbaden, Germany). Doping behavior was assessed either with the CDM (Frankfurt sample, one Wiesbaden subsample) or the UQM (one Wiesbaden subsample). A generalized likelihood-ratio test was employed to check whether the prevalence estimates differed significantly between models. In addition, we compared the prevalence rates of the present survey with those of a previous study on a comparable sample.

Results

After exclusion of incomplete questionnaires and outliers, the data of 2,017 athletes entered the final data analysis. Twelve-month prevalence for physical doping ranged from 4% (Wiesbaden, CDM and UQM) to 12% (Frankfurt CDM), and for cognitive doping from 1% (Wiesbaden, CDM) to 9% (Frankfurt CDM). The generalized likelihood-ratio test indicated no differences in prevalence rates between the two methods. Furthermore, there were no significant differences in prevalences between the present (undertaken in 2014) and the previous survey (undertaken in 2011), although the estimates tended to be smaller in the present survey.

Discussion

The results suggest that the two models can provide converging prevalence estimates. The high rate of cheaters estimated by the CDM, however, suggests that the present results must be seen as a lower bound and that the true prevalence of doping might be considerably higher.

Pharmacological Neuroenhancement in the Field of Economics-Poll Results from an Online Survey

Introduction: The use of over-the-counter, prescription, and illicit drugs to increase attention, concentration, or memory—often called (pharmacological) neuroenhancement—shows a broad range of prevalence rates among students. However, very little data is available on neuroenhancement among employed persons. The aim of this study was to provide first data on substance use for neuroenhancement among readers of the German “Handelsblatt” coming from the field of economics.

Methods: Readers of the online edition of the Handelsblatt, a leading print and online medium for the field of economics, were invited to participate in a survey via a link on the journal homepage to complete a web-based questionnaire. Within the questionnaire, participants were asked for their gender, current age, current professional status, hours of work per week, prevalence rates of substance use for the purpose of neuroenhancement as well as for reasons of its use. Binary regression analyses with stepwise forward selection were used to predict the dependent variables “use of illicit and prescription drugs for neuroenhancement” (yes/no), “use of over-the-counter drugs for neuroenhancement” (yes/no), and “use of any drug for neuroenhancement” (yes/no).

Results: A total of 1021 participants completed the anonymous survey. Lifetime prevalence for the use of any drug for neuroenhancement was 88.0% and for the use of illicit and prescription drugs for neuroenhancement 19.0%. Reasons and situations that predicted neuroenhancement with illicit and prescription drugs were “curiosity,” “to enhance mood,” ”for a confident appearance,” “stress/pressure to perform,” and “deadline pressure.”

Discussion: The study shows that neuroenhancement with drugs is a widespread and frequent phenomenon among people belonging to the professional field of economics. Given in the literature that the use of drugs, especially prescription, and illicit drugs, may be associated with side effects, the high epidemic of drug use for neuroenhancement also shown in the present paper underlines the new public health concern of neuroenhancement.

Analgesics use in competitive triathletes: its relationship to doping and on predicting its usage

The two major objectives of this study were (i) to assess variables that predict the use of analgesics in competitive athletes and (ii) to test whether the use of analgesics is associated with the use of doping. A questionnaire primarily addressing the use of analgesics and doping was distributed among 2,997 triathletes. Binary logistic regression analysis was performed to predict the use of analgesics. Moreover, the randomised response technique (RRT) was used to estimate the prevalence of doping in order to assess whether users of analgesics have a higher potential risk for doping than non-users. Statistical power analyses were performed to determine sample size. The bootstrap method was used to assess the statistical significance of the prevalence difference for doping between users and non-users of analgesics. Four variables from a pool of 16 variables were identified that predict the use of analgesics. These were: "version of questionnaire (English)", "gender (female)", "behaviour in case of pain (continue training)", and "hours of training per week (>12 h/week)". The 12-month prevalence estimate for the use of doping substances (overall estimate 13.0%) was significantly higher in athletes that used analgesics (20.4%) than in those athletes who did not use analgesics (12.4%). The results of this study revealed that athletes who use analgesics prior to competition may be especially prone to using doping substances. The predictors of analgesic use found in the study may be of importance to prepare education material and prevention models against the misuse of drugs in athletes.

Using the simple sample count to estimate the frequency of prescription drug neuroenhancement in a sample of Jordan employees

BACKGROUND

Epidemiological research indicates that the use of prescription drugs to enhance cognitive functioning is prevalent in Western countries, however, research on this phenomenon in Arab countries is lacking. Our study aimed to investigate the frequency of neuroenhancement (NE) using prescription drugs in a sample of employees in Jordan.

METHODS

A sample of 1186 employees (37.11±8.37 years old, 495 female), of whom 723 (35.65±7.53 years old, 396 female) served as teachers, completed a paper-pencil questionnaire. The single sample count technique (SSC) was used in order to secure confidential, self-reporting of prescription drug NE.

RESULTS

The 12-month prevalence of NE, estimated with the SSC was 15.43%. At 26.16%, the prevalence estimate was markedly higher in the subsample of teachers compared to non-teachers, 0.29%. Surprisingly, 336 participants did not use the SSC and directly affirmed or denied prescription drug NE. These direct responses yielded a prevalence of 11.57% for the full sample, 9.73% for the teachers and 15.60% for the non-teachers.

CONCLUSION

This is the first study of the frequency of NE in an Arab sample. Results indicate that the use of prescription drug NE is not limited to Western countries and that teachers in Jordan might constitute a high-risk population. Further, participants seem to differ in their use of indirect estimation methods for reporting prescription drug NE. For future research, it might be useful to triangulate standard self-reports and indirect estimation methods to assess NE. Possible cultural differences and specific high-risk populations for NE should be investigated further.

Cerebral Correlates of Automatic Associations Towards Performance Enhancing Substances

The direct assessment of explicit attitudes toward performance enhancing substances, for example Neuroenhancement or doping in sports, can be affected by social desirability biases and cheating attempts. According to Dual Process Theories of cognition, indirect measures like the Implicit Association Test (IAT) measure automatic associations toward a topic (as opposed to explicit attitudes measured by self-report measures). Such automatic associations are thought to occur rapidly and to evade voluntary control. However, whether or not such indirect tests actually reflect automatic associations is difficult to validate. Electroencephalography (EEG) has a superior time resolution which can differentiate between highly automatic compared to more elaborate processing stages. We therefore used EEG to examine on which processing stages cortical differences between negative or positive attitudes to doping occur, and whether or not these differences can be related to BIAT scores. We tested 42 university students (31 females, 24.43 ± 3.17 years old), who were requested to complete a brief doping IAT (BIAT) on attitudes toward doping. Cerebral activity during doping BIAT completion was assessed using high-density EEG. Behaviorally, participants D-scores exhibited negative attitudes toward doping, represented by faster reaction times in the doping + dislike pairing task. Event-related potentials (ERPs) revealed earliest effects between 200 and 300 ms. Here, a relatively larger occipital positivity was found for the doping + dislike pairing task. Further, in the LPP time range between 400 and 600 ms a larger late positive potential was found for the doping + dislike pairing task over central regions. These LPP amplitude differences were successfully predicting participants' BIAT D-scores. Results indicate that event-related potentials differentiate between positive and negative doping attitudes at stages of mid-latency. However, it seems that IAT scores can be predicted only by the later occurring LPP. Our study is the first to investigate the cerebral correlates that contribute to test scores obtained in the indirect testing of automatic associations toward doping. The implications of our results for the broader NE concept are discussed in light of the conceptual similarity of doping and NE.