Doping has been defined as the use of prohibited drugs, methods, or other substances for performance enhancement. It occurs in all age groups, genders and at all levels of sport competition (Fernandez and Hosey, 2009). The use of PESs among athlete populations is to gain a competitive advantage. The World Anti-Doping Agency (WADA) definition of doping applies to competitive athletes and is defined as the occurrence of one or more of the 13 anti-doping rule violations (ADRV) of the World Anti-Doping Code (WADC). These ADRV's includes the “Use or Attempted Use by an Athlete of a Prohibited Substance or a Prohibited Method” (World Anti-Doping Agency, 2021).

The WADA publishes an annual list of prohibited substances and methods (World Anti-Doping Agency, 2021), recognized by all WADC signatories. The prohibited substances, and rules, that elite or competitive athletes are subjected to with respect to anti-doping rule violations and sanctions are also governed by WADA. However, doping in sports or the use of PESs is not only observed in professional athletes (Striegel et al., 2010), but also in recreational athletes (Striegel et al., 2006) who may have different motives for using PESs compared to elite athletes (Barkoukis et al., 2013; Chirico et al., 2021). Although the Anti-Doping Rules may apply to recreational level athletes (South African Institute for Drug-Free Sport, 2021), they may face similar or less severe sanctions, if at all, for using PESs (South African Institute for Drug-Free Sport, 2021).

In addition of the use to enhance sports performance, there is a growing trend to use substances that enhance cognitive function for academic performance, attention, memory, or mood. Students use these with the intention to optimize study duration, concentration, improve attention span, and also decrease anxiety (De Santis et al., 2008; Rabiner et al., 2009). Cognitive doping or “neuro-enhancement” (the use of drugs to improve cognitive performance) in the absence of any medical need is gaining attention (Franke et al., 2013), and is of concern (Maher, 2008; Striegel et al., 2010; Dietz et al., 2013). Cognitive doping may include using illicit substances (e.g. cocaine) and prescription drugs such as stimulants (e.g. amphetamines and methylphenidate) (Franke et al., 2011b), which are commonly used for conditions such as Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder (ADHD/ADD) and narcolepsy. Beyond the cognitive doping effects, they have the potential for physical performance enhancement and in most countries are available to patients only with a physician's prescription. University students diagnosed with ADHD/ADD may legitimately use such stimulants with the therapeutic intention of normalizing a diagnosed medical condition. However, using such stimulants for non-medical purposes poses significant public health risks and it has been recommended that tertiary institutions include non-medical use of stimulants in their policies of academic integrity (Faraone et al., 2020). There may be those that abuse these substances to promote academic advantage (Cakic, 2009), such as improved memory and less sleep with the intention of increasing study time (Teter et al., 2006; Cakic, 2009). Studies of amphetamines use in high school and/or university students report that prescription drug use for cognitive enhancement was common among American and German students (Teter et al., 2006; Wilens et al., 2008; Franke et al., 2011a). A Swiss-based study showed a lifetime prevalence rate of 6.2% by students for non-medical use of prescription stimulants (methylphenidate, amphetamine, and/or modafinil) (Ott and Biller-Andorno, 2014).

University students all have the common objective of academic success, and some may also be student athletes where peak sporting performance is also a goal. This may place them at increased risk for substance abuse (Wechsler et al., 1997). This poses a number of scenarios: (a) student athletes that use PESs for sporting performance; (b) non-athlete students that use neuroactive drugs (stimulants and/or cannabinoids) for cognitive performance; (c) student athletes that use PESs, including neuroactive drugs for academic benefit; and (d) student athletes that use neuroactive drugs for cognitive and academic benefit (and not intentionally for sporting performance). The latter, if are also elite athletes, and fall within a WADA or national anti-doping agency registered testing pool (South African Institute for Drug-Free Sport, 2021), have the potential of unintentionally falling foul of anti-doping regulations in sport. Students that are neither elite or recreational athletes but use PESs for cognitive enhancement would not face anti-doping rule violation sanctions, however, depending on the substances used, may be subjected to institutional disciplinary or even criminal charges.

Few studies on PESs use have been conducted in young athletes at school level and even fewer in university students. A Swedish study on school students reported that a single trial of performance-enhancing substance use occasionally reached 15% (Kindlundh et al., 1998), and high school boys in Johannesburg, South Africa reached as much as 30% (Gradidge et al., 2011). Motives for the use include pressure from peers, teammates, coaches, and sometimes families; and a desire to win at all costs (Gradidge et al., 2011; Pappa and Kennedy, 2013; Yager and O'Dea, 2014).

Prevalence data in United States of America university students of cognitive enhancing substance use estimates stimulant use between 5 and 35% (Smith and Farah, 2011), and among United Kingdom students, <10% lifetime prevalence use has been reported (Singh et al., 2014). Among Swiss university students 4% reported using methylphenidate, and entertained the idea that cognitive performance enhancement was acceptable (Maier et al., 2013). Although a low prevalence rate of use was observed among German students, 80% of the study participants stated that they would consider using stimulants (Franke et al., 2011a). In an Australian survey, 2.4% of university students reported using academic enhancing substances despite most expressing concern about their efficacy and potential adverse effects (Mazanov et al., 2013).

Avois et al. as far back as 2006 reported that doping with central nervous system stimulants poses significant public health risks and preventive measures should be proactively pursued (Avois et al., 2006). They reported that since 1988 International Olympic Committee accredited laboratories have reported on positive tests for stimulants which is now the second most commonly used PESs after anabolic androgenic steroids (World Anti-Doping Agency, 2020). Of all stimulants, methylphenidate is the most commonly used (World Anti-Doping Agency, 2020). To date the use of PESs and CNS stimulants by university students in South Africa is yet to be documented, which together with student attitudes and perceptions, is salient to address.

The knowledge and research gap was identified as being the use of PESs by university students, either for sport or cognitive doping. The use of substances prohibited in sport according to the WADA Prohibited List was the ADRV point of reference explored in this study.

This is the first such study that we are aware of conducted in university students in South Africa, and aimed to explore the use, behavioral attitude and perceptions of the use of sport and neuroactive performance enhancing substances.