Our study evaluates the drug abuse risk related to alcohol and marijuana/hashish in university students who will become future healthcare providers (nurses), which represents an issue with great social and health implications [26]. Most of the surveyed students reported regular alcohol intake, with one-third being classified as having “risky alcohol use”, while one-fifth met the criterion for hazardous drinking based on the AUDIT score. The reasons underlying the widespread consumption of alcohol and cannabis derivatives in university students have been found to be multifaceted [27] and are attributable to important changes in lifestyle (e.g., leaving the family home to live alone or sharing an apartment with other people, moving to other cities, working and seeking independence in making life decisions, wishing to earn their own money, etc.) [9,10]. In addition, such students endure stress due to the academic workload, pressure to succeed, and competition among peers [11].

A qualitative study using ethnographic open-ended interviews performed among Mexican university students suggested different factors associated with changes in role and status, friendship, and increased autonomy as reasons for their alcohol use after entering university [28]. According to the risk categories proposed by the WHO, more than 30% of the students were classified as having “risky alcohol use” (AUDIT score ≥8), and approximately 20% could be considered hazardous drinkers (AUDIT score ≥16). According to the guidelines for AUDIT screening in primary healthcare, those students with scores between 8–15 are the most appropriate targets for simple advice focused on reducing risk consumption, while in the case of individuals with scores between 16–19, brief therapy and continuous monitoring is advised in addition to simple advice [20]. In turn, AUDIT scores equal to or greater than 20 would require referral to a specialist for a broader diagnostic evaluation of alcohol dependence, though we found no such cases in our study sample. There is some evidence that hazardous drinking in medical school is predictive of later hazardous drinking, thus underscoring the importance of interventions to minimize alcohol intake [29]. Alcohol consumption has traditionally been related to the male gender [26], but no gender differences were found in our sample related to alcohol exposure. This can be attributed to the increase in consumption among women over the last few decades [26]. A study conducted in the United States has reported similar results and suggests that this is due to the social, economic, and role changes that women have achieved in recent years, which, in turn, may increase risk behaviors [29,30]. These results were seen to be reproduced in each of the academic courses, reinforcing the findings of a recent study showing that this trend begins in pre-university stages and continues later on in university academic life [31].

Exposure to cannabis derivatives (marijuana and hashish) was recorded in over 30% of our study sample, representing the second most common drug of abuse consumed by university students [30,32]. In contrast to alcohol exposure, the consumption of marijuana and hashish in our sample showed gender differences, being significantly greater in males compared to females. These results are consistent with those of two surveys among university students that confirm the gender difference in cannabis use [33,34]. A possible explanation for this finding is the greater social rejection of illegal drug use among women [35,36], and the fact that young males are more likely to enter treatment for cannabis misuse [37,38]. The increased prevalence of cannabis use in male students, and the fact that schizophrenia in males develops during adolescence or early adulthood and earlier than in women [39], might suggest a potential role of cannabis during university studies as a potential trigger for schizophrenia, especially in males. Nevertheless, the observed trend is towards similar consumption rates for all substances in both genders [30]. Despite the increasing prevalence of recreational cannabis use among the young population [40] and medical students [41], mainly for its rewarding effects [42,43], the use of cannabinoids among students might also be explained by their anxiolytic, antidepressant, and sleep-promoting effects [44] as a means to mitigate the effects of exposure to different stressors and burnout [11,45,46]. The use of both alcohol and cannabis may affect the current academic performance of students [47], and they may also contribute to misjudgments and misperceptions as future nurses towards patients with substance use disorders [48]. It has been reported that student attitudes towards substance use behaviors influence their future preventive counseling practices [49]. Consequently, the study of lifetime and especially current cannabis use among medical and nursing students is of great importance. This issue is of particular concern for the long-term mental health of the future nursing staff who work under pressure and endure possible employment-related stress that may lead to ongoing use during their professional life, with possible adverse consequences for them and their patients.

Young people who start their university studies have the highest alcohol consumption rates, even compared to those of the same age who choose other non-university options [50,51,52]. In our sample, the older students (>25 years of age) showed lower rates of alcohol and marijuana/hashish exposure and suffered fewer consequences (remorse or forgetting what happened while consuming, need to drink on fasting to recover, or injuries derived from such consumption), regardless of the academic year. There may be a number of explanations for these observations. In effect, working during university studies could increase responsibility in living independently without the economic coverage of the parents, and it could reduce risky behaviors such as the consumption of these substances [53,54]. On the other hand, the knowledge acquired during academic training might synergize with the effect provided by imminent incorporation to the labor market, thereby also diminishing the pattern of consumption of these substances. Academic training, even at pre-university levels, is positively associated with lower rates of substances use such as alcohol or cannabis [55]. However, unhealthy habits and behaviors do not always improve during the degree, suggesting that nursing studies do not always help to encourage healthy habits [56].

A systematic review concluded that nurses are sufficiently prepared to detect and act on problems related to the consumption of substances such as alcohol [57], and that acquired health knowledge, therefore, also influences risk behaviors. However, the percentage of higher education students who consume alcohol and marijuana/hashish remains much higher than what would be expected from an academic health education such as nursing. A qualitative study carried out in nursing students based on participatory action research methodology concluded that stress, social acceptance, environmental influences, and the availability of alcohol are the most influential factors in the consumption of these substances among nursing students [15].

Educational intervention campaigns could be an option for dealing with these problems, employing a set of strategies that have been shown to be effective in changing alcohol-related behaviors to more healthier ones [58]. A study was carried out in the United Kingdom involving a health self-care behavior intervention among new university students, consisting of self-affirmation manipulation, health messages based on the theory of planned behavior, and the implementation of intention tasks. The results showed a significantly lesser use of alcohol among participants in the intervention group than in the control group [59]. Consequently, it is necessary to assess the impact of such health behavior-promoting programs among university students in order to help create a safe and healthy learning environment and promote the development of an integrative health culture.

Another strategy to minimize drug misuse for stress relief purposes is to learn how to cope with stress. A study by Jensen et al. [60] demonstrated that students who choose coping responses that do not moderate stress where possible, may cause themselves additional distress and prevent the learning of more effective coping responses. Helping students to understand stress and coping, and to develop realistic stress appraisal techniques, may assist students in general to maintain manageable distress levels and functioning [61]. Coping strategies for predicting general health in nursing students have shown promising results for interventions in nurses [62,63]. Students may also need increased curricular knowledge regarding drug misuse from the medical, psychological and social perspectives. In order to respond to all these potential concerns and tailor such interventions, a health promotion office should be available with staff to answer questions and provide needed resources. If such a service already exists on university campuses, increased support should be offered to the staff to allow for the best possible resource availability and the maintenance of anonymity. Creating and supporting such health promotion services may also assist in more efficient collection of data regarding university substance abuse issues and needs.