In 2014 the Moroccan National Observatory for Drugs and Addictions (Observatoire national marocain des drogues et des addictions) reported that the prevalence of tobacco smoking and alcohol consumption among Moroccan male population in general aged 20 and over were 34.5% and 14% respectively (18). In our study, the prevalence of these harmful habits was 36.6% for tobacco smoking, 7.3% for hookah, 5.8% for tobacco snuff, 18.4% for cannabis smoking, 10.5% for alcohol consumption, and 2.7% for other psychotropic substances consumption. In a study about alertness amongst professional drivers in Morocco, the prevalence amongst taxi drivers was 45.7% for tobacco smoking, 11.8% for alcohol consumption, 9.9% for cannabis smoking and 4.4% for consumption of other psychotropic substances (22). In a survey about stress amongst taxi drivers in Fez, almost 50% of surveyed subjects were smoking tobacco (2). In another work about vigilance amongst professional heavy truck drivers in Casablanca, the prevalence of tobacco smoking was 49.6%, of alcohol consumption 11.8%, cannabis smoking 12% and consumption of other psychotropic substances 3.9% (21).

In the Moroccan general population, a study conducted by the Ministry of Health reported that the prevalence of tobacco smokers was 32% among men: 35.2% among those aged under 45s and 23% among those over 45s (30). However, in our study, the prevalence for these age groups was higher: 40.2% and 33.4% respectively. The most frequent associations were tobacco-alcohol (6.8%), tobacco-cannabis (4.1%) and tobacco-cannabis-alcohol (2%). Our results were similar to those of the health barometer 2014 of the National Institute of Prevention and Education for Health in France (INPES) where the prevalence of tobacco smoking among adults was 34.1%. According to this Institute, the association of tobacco-cannabis- alcohol concerned 1.8% and tobacco-alcohol 6.2% (15, 34). Several studies had reported that professional drivers smoked more than the general population: 66.3% in Israel (37), 54% in the USA (19) and 49% in China (20). The high consumption of psychoactive substances by our private taxi drivers can be explained by hard conditions at work (difficult traffic, stress and constraints during the wait for the customers, long daily working hours and atypical working rhythm, etc.), and social vulnerability (daily gain, low and irregular income, absence of social and medical insurance, etc.). Self-employed taxi drivers in China had a higher rate of neurotic problems, psychiatric diagnosis and a higher frequency of substance use than the city government-employed bus drivers (24). Even within the same country, however, it is possible to observe differences in the use of alcohol, as shown by the study on the use of alcohol in Italy (43).

The prevalence of consumption of psychoactive substances is inversely proportional to socio-economic status (10, 39). Professional driving is considered as a “high job strain” (16, 42). According to MC Cartt, 70.5% of drivers reported that their work schedules were irregular, and their day of rest was random (29). In the Sabbagh-Ehrlich study, 53.2% had an irregular working rhythm, 42% said that their employer forced them to work beyond the legal 12 hour daily limit and felt work stress (37). In our study, the irregular rhythm at work was associated with high prevalence of all toxic habits except for tobacco smoking. Forty-six percent of taxi drivers in Fez were stressed by difficult working conditions, 59% felt insecure at work and 68% suffered from job instability. Stress increased tobacco smoking among one-third of them (2). Daily work of more than ten hours among our drivers was associated with high prevalence of psychoactive substance use except for tobacco smoking. In our study, among users the prevalence of misuse was 36.6% for tobacco smoking, 37.2% for cannabis smoking and 56.5% for alcohol consumption, compared with a university-based study in Marrakesh, the rates of misuse for tobacco, cannabis and alcohol were 86.4%, 76.6% and 16.4% respectively (18). The prevalence of toxic habits among our taxi drivers living alone was more important than that of married drivers except for tobacco snuff and consumption of other psychotropic substances, the same result was found among Moroccan fishermen (23). In our survey, the prevalence of alcohol consumption of 10.5% was probably underestimated due to religious beliefs, cultural habits, regulations and laws because alcohol consumption is not allowed by Islam, that makes alcohol issues taboo. In the general Moroccan population, a study conducted by the Ministry of Health reported that 20% of men had rarely consumed alcohol (30).

Cannabis is the illicit drug most used in the world (15). It is cultivated in Morocco and costs less than manufactured tobacco. In our study, the prevalence of cannabis smoking among taxi drivers was 18.4%, more than double that of professional heavy truck drivers in Morocco: 7.5% (21) but it is lower than that of fishermen, which was 36.2% (5). Water pipe is known under different names in parts of the world: hookah, narghile, shisha or goza. It is now the object of a renewed interest because its use has been spreading very fast among young people in Western countries and in Morocco. The number of bars and establishments where the water pipe can be smoked is increasing and almost are attended by mostly young people. The arguments they use for justifying water pipe smoking are the “natural”, healthy and safety aspect of the product, its fruity flavors (apple, strawberry, etc.), the sharing of the dose enhancing a sense of community belonging, the novelty of the product, and a distinction from the smoking habits of adults. The conviction is that water acts as a filter and that this way of smoking tobacco is less dangerous than cigarette smoking. In our study, the hookah prevalence was 4.5% among the over 40s versus 10.2% among the under 40s, that confirmed the recent craze for this habit imported from the Middle East and considered nowadays as a world epidemic (5). The consumption of other psychotropic substances in our study was lower than that of Moroccan professional drivers: 2.7% versus 4.4% (22). A substantial number of studies have reported an increased traffic accident risk associated with the use of benzodiazepines (32, 35, 45).

The consumption of psychoactive substances is an alarming problem of public health and occupational safety. It has an impact on professional and social life and in case of accident the taxi driver is held responsible. It can threaten the safety of drivers and road users. Several legal texts about the fight against the consumption of addictive substances exist in Morocco. The physical and mental fitness of the professional driver has a twofold appreciation in Law 65-99 of the Labor Code, in Law 52-05 of the Traffic Code and in their application texts (26, 27). Like all workers, professional drivers are subject to occupational health Laws (Articles 304-341 of the Labor Code) and must undergo a medical examination for fitness for work by an occupational health physician. In addition, every two years, they must consult a doctor approved by the Ministry of Health (Article 14 of the Traffic Code) to obtain a medical certificate of driving fitness for the renewal of the driving license. The prevention of addictive behavior and its penalties are detailed in the Law related to the Traffic Code, the Penal Code and the Law related to the Commerce, Detention and Use of Poisonous Substances (25). The latter Law combines the medical care of the consumers and the judicial repression of the dealers. Articles 39-42 of the Traffic Code compel professional drivers to receive ongoing formation from approved establishments. Article 177 deals with screening and criminal sanctions for driving under the influence of alcohol, narcotics or some medications that are forbidden while driving. However, professional drivers’ knowledge of on the risks of the use of psychotropic substances while driving was very limited: 27% revealed to have information about the Traffic Code and 80.6% did not know the Moroccan legislation related to the use alcohol and narcotics while driving (28).

Our study presents two main limitations. Our survey was cross sectional, the healthy worker effect could create a selection bias. The weak points of self-reporting must be underlined especially for the consumption of psychoactive substances, mainly for alcohol. The prevalence of alcohol use was probably underestimated because the Muslim religion of our subjects prohibits its consumption, and the related issues remain taboo. There was no solution to avoid or limit individual variation in self-reporting. The target was a global quantification and approach. However, this study can be considered a faithful representation of the situation in Morocco, since it concerned all taxi drivers who went through official, obligatory control areas on a daily basis during the second quarter of 2014, and the cities have been randomly selected according to the residence of the investigating physicians.