“They’re doing it anyway, let’s have a conversation about it”: exploring student and stakeholder attitudes towards drug education programmes for university students

Abstract

Purpose

Drug (including alcohol) use among UK university students is estimated to be widespread and associated with adverse social, physical, and mental health consequences. Drug Education Programmes (DEPs) may reduce drug-related harm although there is a sparsity of literature exploring their use in higher education settings; a gap our research aimed to fill.

Materials and Methods

We conducted semi-structured qualitative interviews with 20 university students and four individuals involved in the development and/or implementation of university drug education services. Interviews explored students’ experiences of drug use and the perceived barriers and facilitators for implementing university DEPs.

Results

Using reflexive thematic analysis, we developed the following five themes: (1) A culture of drug use; (2) Balancing risk and reward; (3) Drug use as a coping mechanism; (4) The current approach is failing students; and (5) A new approach.

Conclusions

While DEPs are a promising way of reducing harm, students’ fears of judgment, punishment, and criminalization may prevent them from fully engaging with them. Successful implementation of DEPs would therefore require structural changes to encourage students to access any future interventions.

Keywords:

• Drugs education
• harm reduction
• university
• qualitative
• student

Introduction

Drug use peaks during young adulthood, declining to moderate levels thereafter (Bachman et al., 2001). The prevalence of illicit drug use among university students is estimated to be higher than their same-age, non-student peers (Bennett, 2014). A recent survey of university students found that 58% reported using an illicit recreational drug within the first term of the 2020 academic year with 86%, 50%, and 24% of these reporting using cannabis, ketamine, and cocaine respectively (NeuroSight, 2021). Student alcohol consumption is also high, with 40% of students across seven universities displaying hazardous levels of alcohol consumption and a further 11% showing evidence of an alcohol use disorder (Heather et al., 2011). More recently, a survey of students at one university found that around half of the participants demonstrated high-risk alcohol-consumption behaviors (Tarrant et al., 2019).

High levels of drug use among university students may increase their risk of experiencing harms. Drug use among young people is associated with increased sexually transmitted infections (Vivancos et al., 2008), dependence (NeuroSight, 2021) which may extend into adulthood (McCarty et al., 2004), poor sleep quality (Fadhel, 2020; Kushkestani et al., 2020), unbalanced diet (Aceijas et al., 2017), poor academic performance (Bajwa et al., 2013) and negative effects on mental health (Release & National Union of Students, 2018). Given this, universities may view preventing drug-related harm as a priority in safeguarding their students. However, while the UK’s most recent drugs strategy sets out guidance for secondary schools to educate pupils about drugs and to safeguard vulnerable children (HM Government, 2021), no such guidance exists for Higher Education Institutions.

A survey of 151 UK universities found that the majority employ a ‘zero tolerance’ approach to drug use, including punitive, criminal justice, and surveillance practices, meaning that 40% of students would fear punishment if they approached their institution for support (Release & National Union of Students, 2018). These practices may be creating more harmful environments for students by inadvertently encouraging riskier drug use (Dunn & Degenhardt, 2009; Grigg et al., 2018) and preventing access to support, as well as failing to reduce the prevalence of use. Importantly, it has been shown that these punitive policies may increase inequalities for certain students: individuals from minority ethnicity backgrounds and lower social classes are disproportionately affected by criminal justice approaches to drug use (Sentencing Council, 2020), limiting their education and career prospects (Release & National Union of Students, 2018). Additionally, it has been argued that evidence-based information around safe drug use is not routinely offered to students, which may encourage students to seek information from unreliable sources which are susceptible to misinformation (Ozcubukcu & Towl, 2022).

In response to growing concerns that zero-tolerance policies may not be having the intended effects, the University of Bristol (UoB) and the University of the West of England (UWE), both in Bristol, UK, have been working as part of a multi-agency partnership with local drug treatment providers, police and public health, to create a novel approach to student drug use (Torrance et al., 2020). Since 2019 (UWE) and 2020 (UoB), the universities have committed to a harm reduction stance, meaning that students will be provided with support and advice as an alternative to punishment if they ‘admit’ to illicit drug use at university.

As part of their approach, UoB has commissioned Bristol Drugs Project (BDP) to provide harm reduction services for students, including one-to-one harm reduction advice sessions and the provision of reagent testing kits where appropriate. Additionally, the university began offering a Drugs Education Programme (DEP) for students, designed by the local police in partnership with local mental health services, and facilitated by an NHS professional which includes information on the risks of different drugs (including alcohol) and the legal implications of drug use. DEPs aim to educate individuals about drugs and reduce drug-related harms, and students appear interested in receiving this type of educational intervention (NeuroSight, 2021). Research in this area is limited; there have previously been extensive efforts to examine the use of drug education in schools (for a review, see McBride, 2003), however, there have been fewer contributions in recent years. Research exploring how DEPs may be used in universities, as well as examining UK university students’ experiences of drug use, is extremely sparse.

To our knowledge, the Bristol universities were the first in the UK to formally implement a harm reduction policy, although others have since followed suit. In February 2022, Universities UK and other Higher Education stakeholders launched a new task force to tackle student drug use, with a particular emphasis on harm reduction (Blake, 2022), with implications for the entire Higher Education sector. Despite considerable media attention and support both within and outside of the university, student uptake of the services at the UoB has thus far been poor. If other institutions are to adopt a similar approach, more work is needed to further establish the evidence base around student drug use and students’ needs for drugs education.

We aimed to address the following questions: (1) What are students’ experiences of drug use while at university? (2) What do students need from an educational drug use intervention? What are their specific concerns? (3) What would make an educational drug use intervention attractive and relevant for students? and (4) What are the perspectives of stakeholders involved in implementing university drugs education on what could be feasible and acceptable to implement in a university setting?

Methods

Study Design

Between April and June 2021, we conducted semi-structured qualitative interviews with University of Bristol students (n = 20) and stakeholders (n = 4) involved in the development and/or implementation of drug education and harm reduction services for students in Bristol. The student interviewees were asked to attend the university-run DEP prior to their interview. Ethical approval was obtained from the UoB’s School of Psychological Science Ethics Committee (approval code: 140421117134).

Participant recruitment

Participants were required to be over the age of 18 and be fluent in English. In addition, students were required to be currently studying at the UoB and have ever consumed alcohol and/or any illicit drug. Stakeholders were required to be involved at any stage in the development and/or delivery of drug education services for UoB students.

Participants were recruited through university mailing lists and through the School of Psychological Sciences Experimental Hours Scheme, in which Psychology students participate in research studies in exchange for course credits. We identified potential stakeholders using our existing networks.

We used the concept of ‘information power’ to identify an appropriate sample size (Malterud et al., 2016). While this study had narrow aims and high sample specificity, there was a limited theoretical background and, with the interviewer Lilli Waples being a novice qualitative researcher, we anticipated that the study may require more participants to achieve good quality dialogue. We, therefore, planned to recruit a sample of 20 students and 10 stakeholders. Throughout data collection, we continuously reviewed the data to assess whether the planned sample sizes were still suitable and concluded that 20 students was an appropriate sample size to achieve rich, nuanced data with a variety of experiences and perspectives. Given the stakeholders’ high level of knowledge and experience specific to the research questions, we deemed that we had sufficiently detailed data for the research questions and ceased data collection after four stakeholder interviews.

Interview Design

We collected data using semi-structured one-to-one interviews rather than focus groups as we felt that students may be reluctant to honestly discuss their drug use in a group (Adlaf et al., 2009). We designed separate topic guides for the students and the stakeholders (see Supplementary Materials). The student interviews focused on their thoughts on the DEP they had attended, their thoughts on university drug policies and practices, and their experiences of drug use at university. The stakeholder interviews focused on the barriers and facilitators for implementing a harm reduction approach and drugs education services for university students. These topic guides were used flexibly to allow us to explore emergent topics in greater detail where appropriate.

Procedure

While the interview procedures were identical for students and stakeholders, the student participants were required to attend the University’s DEP prior to their one-to-one interview. Both the DEP and the interviews were carried out online due to ongoing COVID-19 restrictions. After completing the consent form, the student participants were provided with joining instructions for the DEP and booked a slot for their interview to take place within two weeks of the DEP.

The DEP took place online on two occasions, with three participants attending on the first occasion and the remaining 17 attending the second. The DEP acted as an important stimulus to facilitate meaningful discussions with participants around what they would want or expect from a university-based DEP. It lasted two hours and included a discussion of (1) local context: drug use prevalence and associated issues in Bristol; (2) drug identification and categorization; (3) risks and harm reduction; (4) motivations for drug use and (5) support available for people who use drugs. The session included content discussing alcohol as well as illicit drugs.

The follow-up interviews were conducted by the first author and lasted 30–60 minutes. Participants were given the opportunity to ask questions and provided consent to proceed with the interview. Participants were reminded that they only needed to share information they were comfortable with and that they were welcome to ask for a break or stop the interview at any point without giving a reason. On interview completion, participants were debriefed, provided final consent, and reimbursed for their time (either £25 via bank transfer, or 2.5 Experimental Hours credits). As stakeholders were interviewed during their usual working hours, they were not reimbursed for their time.

Data analysis

The analysis and theme development was led by the first author in consultation with the others. We used reflexive Thematic Analysis (Braun & Clarke, 2006, 2019, 2021) to identify patterns across the datasets due to its theoretical flexibility (Braun & Clarke, 2013) and compatibility with the epistemological underpinning of the study, which was critical realism (Bhaskar, 2010, 2013; Maxwell, 2012). Drawing on this, we sought to understand the experiential reality of student and stakeholder perspectives on student drug use, as well as to locate these experiences within their wider context.

After reviewing the content of both sets of interviews, we concluded that analyzing the student and stakeholder interviews together would provide the most meaningful data. The process of Thematic Analysis moves through data familiarisation and systematic coding into theme development and review. The first author led the coding process, which involved systematically generating a mixture of sematic and latent codes (Braun & Clarke, 2012). Initial themes were then developed by clustering similar codes to identify broader patterns, each with a central organizing concept.

The first author used a research diary to regularly reflect on the ‘progress and process’ of the research, including her feelings on how the interview went and her experiences of analyzing the data. Regular meetings with the co-authors provided further opportunities to reflect on the assumptions she brought to the analysis and how these might be shaping data interpretation. The first author advocates for evidence-based drug policy reform and during this work was the Chapter leader of the grassroots drug policy campaign group Students for Sensible Drug Policy (SSDP). It is the view of all the authors that drug policy should promote social justice and compassion for people who use drugs. These views have undoubtedly influenced the focus of this research project and our decisions to explore the perspectives of students who use drugs.

Results and discussion

Participant characteristics

Students’ characteristics are displayed in Table 1 alongside their pseudonyms. We did not collect information on ethnicity or socio-economic background due to time constraints in obtaining ethical approval and recruiting participants for the study, but UoB students are predominantly of White ethnicity and are from advantaged backgrounds (50% in the most advantaged quintile; UCAS, 2021). While we did not collect information on participants’ drug use behaviors, the UoB is in the South West of England, the region with the highest rate of illicit drug use across England and Wales (Home Office, 2019) and Bristol has been dubbed ‘the cocaine capital of the world’ (Barnes, 2019).

Table 1. Student participant characteristics

Pseudonym	Age	Gender	Year of study	Level of study*	Programme of study
Sophia	18	Female	1	UG	Psychology
Kayleigh	19	Female	1	UG	Psychology
Caroline	20	Female	1	UG	Psychology
Gina	20	Female	1	UG	Psychology
Ella	20	Female	1	UG	Psychology
Megan	20	Female	2	UG	Psychology
Beth	22	Female	3	UG	Psychology
Natasha	22	Female	Masters	PG	Biology
Ryan	18	Male	1	UG	Psychology
Joe	18	Male	1	UG	Psychology
Diego	19	Male	1	UG	Psychology
James	20	Male	1	UG	Psychology
Milo	19	Male	2	UG	Anthropology
Luca	20	Male	2	UG	Psychology
Matt	21	Male	2	UG	Psychology
Patrick	25	Male	Masters	PG	Psychology
David	22	Male	Masters	PG	Law
Adam	22	Male	Masters	PG	Law
Charlie	20	Non-binary	2	UG	Psychology
Alex	21	Non-binary	2	UG	Psychology

*Abbreviations: UG: Undergraduate; PG: Postgraduate

We interviewed four stakeholders: individuals identified as being involved in the development and/or delivery of drug education services for university students in Bristol, within Bristol’s multi-agency partnership approach to student drug use. The sample consisted of stakeholders working for/in conjunction with the University (1), the Students Union (1), and local drug and alcohol treatment services (2). We did not collect further demographic information from the stakeholders due to the high likelihood that they could be identified from this information.

Overview of themes

We identified five themes: (1) A culture of drug use; (2) Balancing risk and reward; (3) Drug use as a coping mechanism; (4) The current approach is failing students and (5) A new approach. These themes are presented below along with illustrative quotes. Students’ quotes are presented along with their age and gender (Male = M; Female = F; Non-binary = NB). Stakeholders have an identifying number presented alongside their quotes (SH01, SH02, etc).

Note that the views presented here are of those who have been interviewed and the authors, and not necessarily the views of the University of Bristol.

A culture of drug use

Students perceived UK universities to have a culture of drinking and drug use, with drug use seen as highly prevalent and an ingrained part of university life. While alcohol was described as the most used drug, numerous participants stated that they, and most of their peers, had also tried a drug other than alcohol during university. For instance, Matt (21, M) explained: ‘I don’t know a single person who hasn’t seen someone do drugs or anything like that at Uni, if not participated themselves. It’s everywhere.’

Alcohol was seen by students as being particularly ingrained into university culture, often through university societies and sports clubs where everything ‘revolves around drinking.’ – Megan (20, F). It is possible that some students may be inclined to engage in heavy drinking as this is normative among their peers (Livingstone et al., 2011). Indeed, social pressure around drinking and other drug use was a salient topic. With many of their peers regularly using drugs, several students described feeling a need to ‘fit in’. As Sophia (18, F) explains: ‘It’s so easy to just get influenced by others and be like, ‘Okay, everyone does that, so let me try it.’ This perceived need to conform with others is particularly prominent among first-year students, who are in a new environment among new people, and who may feel a great sense of pressure to make new friends:

In first year, it’s a mad scramble to find groups and find friends. You might not necessarily be the type of person to go out of your way to take drugs, but because everyone’s doing it, and you don’t want to be ostracised, you indulge in them.

–Diego (19, M)

Rather than ‘peer pressure’ in the sense of being actively encouraged by friends to join in, the need to conform is defined more as an internalised desire not to feel like an outsider:

That’s how you bond with friends: you see people, you take drugs together, you drink together, that’s the way it is. It’s university culture. It is peer pressure, but it’s not like how you think peer pressure would be – you know, like ‘Go on! Take some! Don’t be a whimp!’ It’s not like that. Everyone’s really nice about it. It’s just an internal thing.

–Ella (20, F)

Some students expressed concerns that the culture at universities may influence some students to use drugs when they otherwise may not have done. This concern was particularly common among the international students interviewed, who indicated that attitudes towards drug use at UK universities can be surprising for students coming from different cultural backgrounds:

I am from a different country where you can go out and not drink. In parties, people from my culture, they are like, ‘Okay, let’s go party!’ Whereas here my flatmates might say, ‘Okay, let’s go drinking!’ which for me, it’s different.

–Sophia (18, F)

There have been well-documented concerns that some international students may feel marginalized and excluded by the UK university culture of binge drinking (Forestier, 2013; Thurnell-Read et al., 2018). There is, however, a sparsity of literature exploring international students’ use of drugs other than alcohol, or how the prevalence of these drugs in UK universities may impact their sense of social integration.

The above findings indicate that many students may benefit from the provision of activities which are not centered on drinking, such as ‘sober societies’ (Megan, 20, F), as a means of promoting the inclusion of students who choose not to drink or use other drugs. As well as international students, this may be beneficial for students who are having difficulty managing their own drug use.

Balancing risk and reward

This theme relates to students’ experiences of trying to balance the perceived risks and rewards of drug use. Drug use is often functional: driven by certain motives, to elicit some form of reward (Boys et al., 2001). Students reported a range of motivations for drug use, the most common being a desire to have fun and experiment:

Students just want to have fun, and there’s less responsibilities - nobody’s sort of giving them a bedtime, or really commenting on their behaviours, like they would when you’re at home with parents. So a lot of it is just fun, and more freedom.

–Charlie (20, NB)

Student drug use is also driven by social motives – to improve social interactions or to bond with others (Biolcati & Passini, 2019). In particular, alcohol was seen as a good way to lower social inhibitions and promote feelings of closeness, particularly during the early stages of university life when students are surrounded by new people. According to Ella (20, F), ‘Some students feel better meeting people and interacting with people when they’re not sober – be it through social anxiety, or it’s just more fun if they’re not sober… it can make things easier.’ Similarly, Beth (22, F) described MDMA as ‘the love drug’¹ as it promotes ‘deep-rooted bonds’ with other people.

Students also discussed a variety of drug-related harms they had experienced (or seen others experience) whilst at university. For example, James discussed how his relationships with his housemates was strained due to a change in their behavior, which James attributed to their drug use: ‘All they seemed to care about was just doing drugs. It played a really big impact on my mental health.’ (James, 20, M). Students described their experiences of more acute drug-related harms, such as accidents and injuries; ‘blacking out’ and forgetting parts of the night; risky sexual behavior; vomiting; and, on rare occasions, overdosing. Rather than actively seeking out risk, a certain level of risk was seen as part and parcel of drug use.

This level of risk may be compounded by the finding that students may underestimate the risks posed by the use of certain drugs. In particular, students seem to perceive alcohol as being fairly harmless. Beth (22, F) suggested: ‘Alcohol is by far the biggest harm that students face… but it all gets disguised as lad culture or university culture.’ Previous research conducted among Australian university students finds that students have poor knowledge about alcohol risks and see themselves as invulnerable to alcohol-related harm (Hasking et al., 2005). Furthermore, Milo raised concerns that students do not spend time considering the risks associated with their behavior – particularly when multiple drugs are involved:

I think if they’re new to a substance, they’ll say, ‘Yeah, screw it, let’s try it.’ Especially considering a lot of those instances will happen after being drunk or being high on something else. And nobody will ever consider the implications of taking it.

- Milo (19, M)

However, our data suggests that some students do attempt to educate themselves on the potential risks of a drug before deciding to use it, and decide whether to use it by balancing risks and perceived rewards:

If you’re doing drugs for the fun, for the experience – like let’s say you’re doing a pill at a rave. You’ve planned ahead. I think you’re likely to look at the harm reduction strategies and be like, ‘Okay, so how can I experience this in a fun, safe way and not cause harm to myself or to others?’

– Natasha (22, F)

These findings suggest that at least for some students, drug use is based on a rational appraisal of the perceived risks and rewards, as opposed to being ‘a passive reaction to the context in which a substance is available’ (Boys et al., 2001, p. 458). Drug education may therefore be more effective for some students than for others, particularly for those who are already motivated to make informed decisions around drug use. Ella suggested that there is a distinction between students who want to ‘push the limits’ and would perhaps be less receptive to harm reduction education, compared to students who may be more concerned about safe drug use:

People who take drugs fairly often – they’re comfortable with it, but they know their limits. They don’t overstep. They don’t want to get so far gone that they’re an embarrassment, or they hurt themselves or other people. But then you have the minority of people who just want to push the limits and see what happens. I think [drugs education] is not incompatible, it’s just going to be less effective for the people who are pushing boundaries.

– Ella (20, F)

Gendered safety concerns

It is important, when talking about the balance of risk and reward involved in student drug use, to consider that for female, non-binary, and trans students, this balance may be more difficult to achieve. These students can be seen as being disproportionally vulnerable while under the influence of drugs, due to the risk of drink spiking (Weale, 2022), sexual assault (Office for National Statistics, 2021), sexually transmitted infections, or unwanted pregnancy (Kaly et al., 2002; MacNeela & Bredin, 2011).

As a woman your main risks are the people around you… you’re running the risk of STIs, of accidental pregnancies, of ‘was I even consenting?’ … I’ve never heard of any boys trying to get home and waking up in an alley.

- Beth (22, F)

In the present study, sexual assault was seen as a common occurrence for female and non-binary students, either whilst under the influence of alcohol or as a result of being drugged. Alex (21, NB) shared that they have ‘several friends who have experienced sexual assault because they have been drugged.’

While the DEP attended by the study participants included content exploring spiking and drug-facilitated sexual assault, there is no evidence to suggest that educating young women will prevent them from being victimized while intoxicated. The role of DEPs is to inform students about the risks of drug use and equip them with strategies to mitigate these risks. Young women are frequently encouraged to look out for themselves and for other women, to guard their drinks from being spiked, and to avoid contact with strangers on nights out (Bancroft, 2012). However, these so-called ‘prevention’ strategies pose the danger of perpetuating a ‘victim-blaming’ narrative where the responsibility of preventing gender-based violence is placed upon women (Lawson, 2003). As such, interventions may instead place the onus on male students to change their behavior, and it has been recommended that HEIs ensure they have robust institutional policies in place to safeguard students and tackle any instances of gender-based violence in a robust manner (Jennings et al., 2007; National Union of Students, 2019).

Drug use as a coping mechanism

Another common theme was students’ discussions of drug use as a strategy to cope with various stressors. Cannabis and alcohol were commonly referred to as methods of ‘loosening up’ (Kayleigh, 19, F) and a means of relieving some of the stresses of everyday university life. Students spoke positively about being able to drink and/or smoke with friends as a way of unwinding at the end of a busy week: ‘It can be a stressful time. And [people] can feel like drinking or using drugs can help them get through that.’ (Caroline, 20, F)

There is a wealth of literature exploring how a desire to cope with negative emotions acts as a motivational pathway for drug use (for a review, see Cooper, 2015) and how these coping motives are predictive of the development of later drug-related problems (e.g. Merrill et al., 2014). While not explored in depth here, the interviews provided insight into how some students appear to use drugs to self-medicate and mask the symptoms of more serious mental health issues. For example, Adam (22, M) said: ‘I know of a friend who uses alcohol to kind of manage his symptoms of depression and anxiety.’ Some students also observed that an unintended consequence of this is that drug use can worsen the very symptoms they are trying to cope with. James (20, M) described seeing a friend’s mental health being detrimentally impacted by their cocaine use: ‘it definitely highlighted some residual mental health problems, that really came to light in a big way when they were on it.’

Another prominent topic in the interviews was the impact of the COVID-19 pandemic on students’ drug use. Drugs were seen as a ‘fast fix’ (Joe, 18, M) to help cope with stress, depression, and anxiety as well as an intense sense of boredom and monotony during this time.

Interestingly, one student suggested that drug use is not always necessarily a maladaptive coping mechanism. Patrick described his use of psychedelics as a harmless way of improving his mental state during a difficult time – a way of escaping mentally while being physically confined:

I want to get out of this house without actually getting out this house. So what do I do? Maybe take something, like a psychedelic or something like that, you know, go somewhere a little different for a bit. And I think actually, that probably has quite a lot of restorative, positive health benefits to that, you know?

– Patrick (25, M)

Students’ experiences of using drugs as a coping mechanism are therefore varied - for some, drug use can worsen mental health-related symptoms. However, for others like Patrick, drug use can serve as a potentially effective coping strategy without necessarily causing complications.

While the findings of the present study are specific to the time in which the study took place – a period of uncertainty, anxiety, and ongoing lockdown restrictions – they still hold important implications for our understanding of student wellbeing and drug use in ‘normal’ times. Feelings of loneliness, isolation, depression, and anxiety among students are not restricted to the pandemic (McIntyre et al., 2018). Understanding the relationship between student drug use and mental health is therefore key for developing good quality drugs education and minimizing the harms of drug use on students’ mental well-being. Some students argued that drugs education should incorporate information on the effects of drugs on mental health:

I think everyone knows the risks of certain things – you know that drinking is bad for your liver and smoking is bad for your lungs. But people know less about the mental effects of these things… Things like that, I think need better education surrounding them.

– Natasha (22, F)

It was also suggested that another useful element of drugs education would be to incorporate some practical advice for coping with stress and poor mental health which do not involve drugs:

I think maybe stress of students in general and giving them other healthier ways to deal with stress and anxiety [rather] than needing to take drugs. Maybe promoting stuff like mindfulness or yoga, or something other than that. Just kind of being like, there are other options to just drowning your sorrows or getting really high.

– Megan (20, F)

The current approach is failing students

This theme concerns problems with current policies and practices which students and stakeholders identified as being unhelpful or even causing undue amounts of harm. Overwhelmingly, both groups of interviewees expressed concerns with (perceived) punitive drug policies.

Perceived punitive policies discourage Help-Seeking

When asked what might prevent them from seeking advice or support about drug use, including attending a DEP or asking for help with problematic drug use, students described systemic issues relating to punitive, ‘zero-tolerance’ drug policies and academic and professional consequences, both within the University and beyond. Students were largely unaware of the UoB’s harm reduction approach or were uncertain about what it means in practice.

I wouldn’t be too open about whether or not I’d done drugs, because I’d be concerned that it might impact whether or not you get kicked off your degree, that sort of thing, like getting kicked out of university. I know that they say it’s a harm reduction policy, but you can never be certain until you’re in that situation when they know [about your drug use]. Then what happens?

– Diego (19, M)

This lack of trust was echoed among several students, who suggested that university staff may be more interested in ‘catching’ students who use illicit drugs, rather than supporting them:

People might think that the University has an ulterior motive. And I feel like, even though you could tell someone a million times, ‘No, we are just trying to help you’ I think it’s really hard to get over that [lack of trust], especially with students and especially in such a prestigious university.

– Beth (22, F)

The perception that the UoB takes a zero-tolerance approach towards illicit drug use may stem from the fact that many other universities do: many students have faced severe disciplinary proceedings from their university relating to their drug use. These instances often generate media attention (Fagan, 2019; McGowan, 2021; Polianskaya, 2018) and are therefore likely to be noticed and remembered by students. As one stakeholder argued, ‘A lot of students have the assumption that all universities have a zero-tolerance approach. It’s a fair assumption to make in the sense that most of them do.’ (SH02).

Regardless of the University’s drug policy, it is possible that, for some students, accessing support for drug use results in concerns about the impact this could have on their professional lives:

If you’re studying a course which is governed by an external body, and you’re seen to be attending a drugs awareness session, you might be seen to be incompetent. It would filter back to Fitness to Practise, I think. So that is a massive deterrent for me to do that. But if I didn’t study that course, then I probably wouldn’t have any hesitation.

– Adam (22, M)

Fitness to Practise procedures, as referenced by Adam, are generally set by external regulatory bodies which govern the professional behavior of individuals (including students) working in specific professions such as medicine, nursing, and social work. Undoubtedly, these procedures exist to ensure the safety of members of the public whom these students will interact with whilst on placement or upon entering the workforce. However, it is concerning if these measures deter students from accessing support, or even simply attending an education session. In order to prevent drug-related harm among these student groups, it may perhaps be beneficial for universities to consult with regulatory bodies to discuss policies which may encourage students to access support. Furthermore, universities might consider weaving DEPs into the training of students on these professional courses in order to maximize impact and engagement.

Another concerning finding was that students reported feeling afraid to access help even in an emergency, due to fear of punishment. Three students described separate incidents where they felt they should have called an ambulance or sent for help, but uncertainty around the potential repercussions prevented them from doing so. These students were under the impression that paramedics could report them to the police for having taken illicit drugs, or even search students or their homes to confiscate any illegal substances. Fear of criminalization is clearly a barrier to seeking help, potentially undermining the impact of policy changes at a university level. While possession of illicit drugs continues to be criminalized, the ability of universities to effectively implement a harm reduction approach is undermined:

I feel like the University can say it’s a harm reduction approach and then the police can just be like, ‘Yeah, no. It’s still illegal, you can’t do that.’ I suppose that’s why I’d probably be sceptical [about seeking help], the fact that the University’s not in complete control.

– Matt (21, M)

This is consistent with previous findings that among UK students who reported using illicit drugs, 16% stated that they had at some point had a ‘scary experience’ but had not gone to the hospital or asked for help (NeuroSight, 2021). The consequences of not accessing support in an emergency could be fatal. An assurance of confidential support without repercussions was identified as a potential means of overcoming students’ lack of trust in university staff:

Make students more aware that the policy isn’t to punish students, it’s to help them, and that whatever they say is strictly confidential. I think that’s the message they need to get across - that they just want to help, not punish anyone.

– Caroline (20, F)

Drug taboos lead to stigmatising views

Punitive drug policies may perpetuate a taboo around illicit drug use through the establishment of norms of what is ‘right’ versus ‘wrong’ behavior:

I know we’re all adults, but there’s always going to be that barrier between students and, like, a higher power, discussing these sorts of things, because drugs are illegal. You wouldn’t want to tell people that you’re doing these kinds of things. There’s always a judgement aspect to it.

– Luca (20, M)

Previous research has shown that discussions of illicit drug between young people and people in perceived positions of authority is a taboo (da Silva et al., 2021), although our stakeholders were keen to break down these taboos ‘they’re doing it anyway, let’s have a conversation about it’ (SH01). These taboos may act as an additional barrier preventing students from engaging with support and education services due to the perceived stigma associated with admitting to drug use:

When [the DEP facilitator] was asking questions, I knew the answers, but I didn’t want to tell him. I didn’t want him to think I’m a drug user, or that I’ve used every drug under the sun. I didn’t want to come across in a certain way.

– Beth (22, F)

Additionally, it was argued that the taboo around drugs does little to reduce drug use. In fact, some participants argued that it may have the opposite effect:

Sometimes, in fact, just outright telling them not to take drugs has the adverse effect. ‘Don’t press this big, red shiny button.’ What are they gonna do? They’re gonna want to press it now, out of curiosity, or defiance.

Patrick (25, M)

Furthermore, it was argued by members of both the student and stakeholder samples that DEPs with an over-emphasis on ‘scare stories’ (Adam, 22, M) can reinforce stigmatizing views around drugs and the people who use them and do little to reduce harms: ‘I think it will not prevent people from taking drugs, it will just make them feel like, ‘I’m going to end up in prison, or dead.’ (Alex, 21, NB).

A new approach

Both students and stakeholders agreed that a new approach at universities is necessary to reduce drug-related harm among students and we present practical recommendations from students for future university-based DEPs in the Supplementary Materials.

While both students and stakeholders felt that the responsibility to reduce drug-related harm fell under the university’s duty of care, some students felt that it was their responsibility to make their own decisions. Mandating attendance at a drugs education intervention may undermine its effectiveness; a better approach would be to make students aware of the support that is available, and perhaps to provide incentives for attendance.

The importance of collaboration

For the stakeholders, the most important facilitator in implementing the harm reduction approach was the collaboration of both internal and external stakeholders. In particular, the involvement of the Students’ Union (SU), a democratic representative for university students, was seen as key:

There is real need to have student representation in this because otherwise, we don’t capture what students need. And [the SU’s] ear will always be much more to the ground than the University’s is. They are usually students, or have just been students, they know what it’s like.

– SH02

Another important opportunity for collaboration is with mainstream drug services. Stakeholders discussed two notable benefits to this: firstly, mainstream services have access to a wealth of specialist knowledge and experience, reducing the university’s need to provide specialist training for their staff. Universities can set up a referrals process where students requiring specialist drug use support can be referred to mainstream services.

Secondly, the involvement of external drug services was seen to improve students’ engagement with brief interventions and education services due to their lack of trust in university staff and services as outlined in the previous theme:

In people’s heads, if someone works for the University, what they put in their database they think is automatically going to also be accessible by their personal tutor, and the person who’s marking their essays, and the person that decides if they can progress on to the Masters course. So [working with external services] has been really helpful.

– SH03

It is important to acknowledge, however, that resources for mainstream treatment services are limited due to extensive government funding cuts. It therefore may not be realistic to expect these services to be able to offer time and resources for university students without additional funding. Indeed, one stakeholder (SH03) argued that ensuring that service providers are adequately compensated for their work helps to maintain their capacity to continue providing their services and expertise over a longer period, thus fostering an approach to student drug use that is consistent and sustainable.

Furthermore, BDP (who are commissioned by UoB to provide harm reduction services to students) are relatively unique as a mainstream drug treatment service in that they have particular expertise in ‘party drugs’ and harm reduction, meaning that they are well-equipped to support students. Other treatment providers who do not have this specific focus on harm reduction and ‘party drugs’ may not have the capacity to support students in this way, and they may also be less attractive to students who might be less inclined to engage with mainstream services if they do not see them to be relevant to their needs. Thus, it may be important for universities in other areas of the country to work collaboratively with their local treatment providers to ensure that they are able to provide relevant support for students in the local community.

Consistency is key

Both students and stakeholders recommended promoting transparency and clarity of the University’s approach to drug use. Knowing which procedures staff will follow if a student makes a drug-related disclosure, and having assurance the student will not be subject to disciplinary action, may promote trust and improve engagement:

I didn’t know that they are committed to a harm reduction strategy. So that would be really great if that were in an email or something to students, not only for the sake of information, but also for the sake of students being able to hold the university accountable. I think they don’t want to be too transparent because they don’t really want to be held accountable too much.

– Alex (21, NB)

Staff training was suggested as a method of achieving consistency in the application of university drug policies and practices, although participants varied in their views on what this training should entail. Some suggested that staff should simply have an awareness of how to signpost students to relevant support services, while others suggested that some staff (particularly those with a pastoral role) should be able to identify the signs that a student is experiencing problematic drug use and deliver brief interventions where necessary.

Conclusions

Our findings demonstrate that drug use is a prominent feature of student life and is driven by various motivations to elicit social and emotional rewards. Despite this, drug use is seen to be a taboo topic between students and authority figures. Considering the drug-related harms reported by several of the students in this study, universities should be considering how to reduce drug-related harm among their students.

Our evidence indicates that students would benefit from drug education. Firstly, drugs education could help address gaps in students’ knowledge and enhance their ability to make informed decisions around drug use; secondly, DEPs could be an opportunity to equip students with healthy coping strategies to manage their mental well-being. While the findings of the present study are specific to the time in which the study took place – a period of uncertainty, anxiety, and ongoing lockdown restrictions – they still hold important implications for our understanding of student wellbeing and drug use in ‘normal’ times. Feelings of loneliness, isolation, depression, and anxiety among students are not restricted to the pandemic (McIntyre et al., 2018). Understanding the relationship between student drug use and mental health is therefore key for developing good quality drugs education and minimizing the harms of drug use on students’ mental well-being.

The present findings support a need for changes on a structural level to improve engagement with drug education services. When students perceive that their university takes a zero-tolerance stance against drug use, they are deterred from accessing support or having honest conversations. Underpinning this is a fear of criminalisation due to the legal status of many of these drugs. Students also have overwhelmingly negative perceptions of the support that is available at university, which serves as a further barrier for asking for help. In a recent debate paper, it was argued that a student not disclosing their illicit drug use due to fear of negative repercussions from their university could be ‘the difference between life and death in an emergency’ (Ozcubukcu & Towl, 2022, p35). It is in the best interests of universities to safeguard their students, and it is imperative that their policies and practices relating to student drug use reflect this.

To our knowledge, our research is the first to provide evidence-based guidance in response to calls for universities to implement harm reduction approaches to student drug use (Garius, 2021; Release & National Union of Students, 2018). It, therefore, provides the foundational, contextual knowledge to inform the development of future interventions. However, our research is potentially limited by the period in which it was conducted, which was characterised by stress and uncertainty owing to the continuation (and gradual removal) of COVID-19 lockdown restrictions. Future research and intervention developers should consider how these findings are transferrable to other contexts.

A further limitation is that we did not collect data on the ethnicity, sexuality, or disability status of students. The issue of race and ethnicity did not emerge during the interviews, and as this research did not aim specifically to explore the influence of race on experiences of student drug use or attitudes towards DEPs, this was not included in the interview topic guides. However, given the importance of race in drug policy discussions, future research should aim to specifically explore this in relation to student DEPs. Furthermore, given previous research findings that female, LGBT+, and disabled students are more likely to use the drug in order to self-medicate for their mental health (Release & National Union of Students, 2018), future research should focus on the experiences of students from these groups and how this might influence their experiences of drug use interventions in universities.

We also did not interview any postgraduate research students, or mature students over the age of 25, who are likely to have very different experiences of student drug use owing to their age, education level, and other demographic factors. While qualitative research does not necessarily aim to be ‘generalisable’, it is important to consider how such demographic factors may have influenced participants’ responses.

To conclude, our findings suggest that consistent messaging around universities’ drug policies would encourage more students to access these services. Collaboration with students, Student Unions, and external drug services also appears essential when developing a drug strategy. Clear, robust harm reduction policies have the potential to foster a healthier university environment and reduce levels of drug-related harm among students.

Ethical approval

Ethical approval was obtained from the xxx Research Ethics Committee (approval code: 140421117134).

Author contributions

LW: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft and Writing – review and editing. VRC: Conceptualization, Supervision, Writing – review and editing. OMM: Conceptualization, Funding acquisition, Methodology, Supervision, Writing – review and editing.

Consent form

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). Informed consent was obtained from all patients for being included in the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Anonymised transcripts for student interviews only (given their content, stakeholder interviews cannot be meaningfully anonymised) are available from the University of Bristol’s Research Data Repository (DOI available upon acceptance).

Additional information

Funding

This research received no external funding and was supported by a personal budget awarded to Olivia M. Maynard by the School of Psychological Science at the University of Bristol.

Notes

1 MDMA is sometimes termed ‘the love drug’ due to its association with feelings of love, warmth and social connectivity (Lyubomirsky, 2022).