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First Steps in Integrating Teaching about Alcohol into the Medical Curriculum

M. Varga and L. Buris

Department of Forensic Medicine, University Medical School of Debrecen, H-4012, Debrecen, P.O.Box 25, Hungary


A study was conducted with medical students to observe their drinking habits and alcohol misuse. The students completed questionnaires composed of AUDIT and SMAST questions. A significant proportion (33%) of students drank more than the recommended safe limit and screened positive at the AUDIT cut-off score of 11. The high score of DSM-III criterion questions indicate that problem drinking on college campuses continues to be a significant public health concern. Our opinion is that the prevention of alcohol misuse should be started at medical universities. The medical school curriculum must integrate education about alcohol. First the attitude of medical professionals should be changed so that we can achieve results in alcohol misuse prevention in society as a whole.


Increasing consumption of alcoholic beverages is a worldwide health issue. Inaccurate beliefs about normative drinking could promote excessive drinking. Collegiate norms coupled with an alcohol-permissive society could encourage alcohol misuse and impose sanctions on those who do not drink. Medical students should be the first target population for medical education and interventions against alcohol misuse because they have not yet definitively formed their lifestyles and their attitude towards alcohol at the beginning of their studies. Medical students are sensitive to medico-social problems, and because they will later become physicians they should be the leaders in the fight against alcoholism. Excessive alcohol consumption among medical students has been a concern of the medical profession for many years. The students should be encouraged to increase their awareness about their own drinking habits and to acknowledge the difficulty they have in changing them (Ritson, 1990).

Alcohol use is integrated into cultural norms of Hungarian society. The per capita alcohol consumption, the rate of alcoholism and alcohol-related mortality in Hungary are 9.0- 10.7 l; 2.5-5.0% and 13.0-23.1/100,000, respectively. The distribution is: heavy drinkers 7%, moderate drinkers 33%, infrequent drinkers 40% and abstainers 20% (Agarwal and Goedde, 1992). Despite the high values and rates, no widespread systemic substance misuse training exists at medical universities in this country. Epidemiological studies on alcohol consumption in the population are helping in the design of primary and secondary preventive measures. The present study was undertaken to assess drinking habits and problem drinking among medical students, using AUDIT (Babor et al., 1987; Babor and Grant, 1989) and SMAST (Pogorny at el., 1972) questionnaires that may be useful in the student health care setting and in the recognition of inadequacies in drug and alcohol medical education.


A study was conducted using a sample of 250 fifth-year students at the University Medical School of Debrecen, Hungary. The students completed a research questionnaire including the ten-item-scale section of AUDIT and six questions of the shortened form of the MAST, plus a question about their gender. Some of the original questions were sligthly modified so that they could meet local circumstances. The ten AUDIT questions included two questions on quantity and frequency, a question on binge drinking, two CAGE questions, and five DSM- III criterion questions which were focused on cutting down on drinking, annoyance by criticism by others about drinking, guilty feelings about drinking and the use of an eye opener (see Table 1). The physical and laboratory sections of the AUDIT was not tested in this study. The mean of items based on a scoring scheme of questions: 0-5 for item 2; 0-4 for the other nine items. The six SMAST questions covered many aspects of drinking behaviour, lifestyle and personality (see Table 2). Students were classified as abstainers, light drinkers, frequent drinkers or heavy drinkers based on how often and how much alcohol they consumed on each drinking occasion. These data were calculated from the two questions on quantity and frequency. The categories were as follows. Light drinker: one who drinks once or twice a month in small or medium amounts, or drink three or four times a month in small amounts, or drink one to six times a year in small, medium or large amounts, or once or twice a week in small amounts. Frequent drinker: one who drinks once or twice a month in large amounts, or three or four times a month in medium amounts, or once or twice a week in medium amounts. Heavy drinker: one who drinks once or twice a week in large amounts, or every day in medium to large amounts, or three to four times a month in large amounts. Small amount: 1 bottle of beer, or 1 glass of wine, or one shot of whisky (or equivalent high spirit), or less. Medium amount: 2-4 beers, or 2-3 glasses of wine, or 2-3 shots of whisky. Large amount: 5-6 beers, or 1 bottle of wine, or 6-7 shots of whisky, or more. Since in comparative studies 8 g alcohol equals 1 unit, the small amount represents approximately 2, the medium amount approx. 5, the high amount approx. 14 units.

Having finished the study we made a survey of the students' interest in an optional course on alcohol and alcoholism. We had to limit the number of participants to 22. These students attended a 16-hour course and were asked about only the frequency-quantity of their alcohol consumption.


The breakdown of each of the drinking categories was: 13.8% heavy drinkers; 34.9% frequent drinkers; 47.5% light drinkers; and 3.8% abstainers. The frequent and heavy drinkers were classified as potential problem drinkers.The bingers (1.7%) who drink seldom but for intoxication were taken together with heavy drinkers. The abstainers/light drinkers were found to be 51.3%, and the potential problem drinkers 48.7% of the students.

The results of the AUDIT item analysis are summarized in Table 1.

Table 1
AUDIT Item Analysis Results

No. AUDIT items mean SD
1 How often do you have a drink containing alcohol? 2.36 1.12
2 How many drinks containing alcohol do you have on a typical day when you are drinking? 3.07 1.44
3 How often do you have six or more drinks on one occasion? 0.95 0.87
4 How often during the last year have you found that you were unable to stop drinking once you started? 0.32 0.66
5 How often during the last year have you failed to do what was normally expected from you because of drinking 0.35 0.61
6 How often during the last year have you needed a first drink in the morning to get you going after a heavy drinking session? 0.17 0.38
7 How often during the last year have you felt guilt or remorse after drinking? 0.55 0.76
8 How often during the last year have you been unable to remember what happened the night before because of drinking? 0.26 0.35
9 Have you or someone else got into trouble as the result of your drinking? 0.26 0.51
10 Has a friend, relative, doctor, or other health worker been concerned about your drinking or suggested you cut down? 0.39 0.71

The mean score for students in our sample was 8.20 (range = 0-22: SD = 5.03) out of the possible 41 AUDIT points. At the cut-off score of 11, which was recommended by WHO, 33% (n = 79) of the students screened positive. At the cut-off score of 13, which is proposed to be more adequate for screening purpose (Fleming et al., 1991), 19% (n = 46), and at 15 11% (n = 27) of the subjects were positive. Only 3.76% (n = 9) of the students reported abstinence during the previous year. Four per cent (n = 10) of the participants reached more than 19 AUDIT scores indicating a harmful drinking pattern (Claussen and Aasland, 1993). Twenty-eight per cent (n = 68) drank more than six drinks (12 units) on one occasion one or more times per week. Four male students (1.7%) admitted drinking a high amount (at least 14 units) but less frequently than once a month. Twenty-three per cent (n = 55) reported being unable to stop drinking once they started. Thirty-four per cent (n = 83) had neglected obligations, family, or work at least once during the past year due to drinking. Fifteen per cent (n = 36) of the respondents reported that they had ever needed an eye-opener. Eight per cent (n = 18) had a feeling of guilt at least once a month after drinking. Twenty-five per cent (n = 61) of the students had experienced a blackout after drinking. Twenty-six per cent (n = 62) had got into trouble because of drinking. It had been suggested to thirty-six per cent (n = 79) to cut down on drinking.

The pattern of results from SMAST part of the questionnaire is shown in Table 2. Only 8.8% (n = 21) of the students regarded themselves abnormal drinkers and 12% (n = 29) were thought to be abnormal drinkers by their friends or relatives. One male student out of the respondents had been treated in a detoxication unit after heavy drinking and another male one had undergone treatment for alcoholism. This is the only student in the study to seek medical help about his drinking. One male and one female student reported that they had lost friends because of drinking.

Table 2
SMAST Item Analysis Results

No. SMAST items n %
1 Do you feel you are an abnormal drinker? 21 8.78
2 Do your friends, family members, doctors think you are an abnormal drinker? 29 12.1
3 Have you ever had treatment for alcoholism? 1 0.41
4 Have you ever lost a friend because of your drinking? 2 0.83
5 Have you ever been treated in a detoxication unit of a hospital because of your drinking? 1 0.41
6 Have you ever gone for help about your drinking? 1 0.41

The survey of 167 students showed that 62 % (n = 63) would like to attend a course or read material on alcohol and alcoholism. Thirty-six students wanted to register and the first 22 were admitted. Nine out of them reported to be abstainers and 13 were light/moderate drinkers.


We have chosen some of the questions of the AUDIT and SMAST questionnaires to screen alcohol misuse and drinking problems among fifth-year medical students. The results indicate a slightly higher occurrence of frequent or heavy drinking among the fifth-year medical school population than certain recent studies in other college or university groups (Baer et al., 1991: Engs et al., 1991). However, they were lower than the results of Rio et al. (1989) and were similar to those of McAuliffe et al. (1991). In contradiction to McAuliffe, who reported that physicians and medical students did not drink especially heavily and were no more vulnerable to alcoholism than were other professionals (McAuliffe et al., 1991), we found that the percentage of problem drinkers among medical students was higher than that established in the general population (Agarwal and Goedde, 1992). There was a significant proportion of students who drank more than the recommended safe limit. At the recommended AUDIT cut-off score of 11, 33% of the students screened positive, but only 4% reached the score of 19 indicating a harmful drinking pattern. The high scores of DSM-III criterion questions indicate that problem drinking on college campuses continues to be a significant public health concern.

It is interesting that none of the participants of the course were from among potential problem drinkers. This fact emphasizes the need to increase students' awareness about their drinking habits and to involve them in similar courses.

Our opinion is that alcohol misuse prevention and intervention programmes should be started at medical universities and the medical curriculum should assimilate the results of the survey on problem drinking of medical students and provide assistance for those who may have potential problems with alcohol. The curriculum should be focused not only on the biomedical manifestation of end-stage alcoholism and treatment of late medical complications but also on identifying patients at risk and intervening at an early stage. The primary target of education about alcohol must be the medical students themselves, the future educators in their communities. It is not possible to change the attitude of society towards alcohol while the attitude of medical professionals remains unchanged.


Agarwal, D. P. and Goedde, H. W. (1992) Medicobiological and genetic studies on alcoholism. Clinical Investigation 70, 465-477.

Babor, T.F. and Grant, M. (1989) From clinical research to secondary prevention. International collaboration in the development of the Alcohol Use Disorders Identification Test (AUDIT). Alcoholism and Health Research World 13, 371-374.

Babor, T. F., Stephens, R. S. and Marlatt, G.A. (1987) Verbal report methods in clinical research on alcoholism: response bias and its minimization. Journal of Studies on Alcohol 48, 410-424.

Baer, J. S., Stacy, A. and Larimer, M. (1991) Biases in the perception of drinking norms among college students. Journal of Studies on Alcohol 52, 580-586.

Claussen, B. and Aasland, O. G. (1993) The Alcohol Use Disorders Identification Test (AUDIT) in a routin health examination of long-term unemployed. Addiction 88, 363-368.

Engs, R. C., Slawinska, J. B. and Hanson, D. J. (1991) The drinking pattern of American and Polish University students: a cross-national study. Drug and Alcohol Dependence. 27, 167- 175.

Fleming, M. F., Barry, K. L. and Macdonald R. (1991) Tha Alcohol Use Disorders Identification Test (AUDIT) in a college sample. International Journal of the Addictions 26, 1173-1185.

McAuliffe, W. E., Rohman, M., Breer, P., Wyshak, G., Santangelo, S. and Magnuson E. (1991) Alcohol use and abuse in random samples of physicians and medical students. American Journal of Public Health 81, 177-182.

Pogorny, A., Miller, B. A. and Kaplan H. B. (1972) The brief MAST: a shortened version of the Michigan Alcoholism Screening Test. American Journal os Psychiatry 129, 342-345.

Rio, C. D., Alvarez, F. J. and Queipo, D. (1989) Pattern of alcohol use among university students in Spain. Alcohol and Alcoholism 24, 465-471.

Ritson, E. B. (1990) Teaching medical students about alcohol. British Medical Journal 301, 134.


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