Iraqi J Pharm Sci, Vol.32( 1 ) 2023 University students and life style medications DOI: https://doi.org/10.31351/vol32iss1pp185-193 185 Awareness and Frequency of using Lifestyle Medications among University Students in Kurdistan Region-Iraq ,*Othman Kawa Zhinya ,** Saeed Hama Ghafour Ahmed ,1,* Marouf Hassan Bushra ***Ahmed Jaza Mohammed Roya and *Gharib M Othman Sava ,*Karim Arkan Sima Iraq Sulaimani ,Sulaimani of University Pharmacy, of College ,Toxicology and Pharmacology of Department * Iraq Sulaimani ,Sulaimani of University Pharmacy, of College , Pharmacy Clinical of Department ** Iraq , Sulaimani, Sulaimani of University ,Medicine of College *** Abstract Life style medications (LSMs) are used for the improvement of lifestyle of an individual. These drugs are being taken to modify a non-medical or non-health-related purpose. This study aimed to investigate the extent of using LSMs among university students, reasons for using them, and identify the types, adverse effects to provide helpful information for justification and prevention of this phenomenon. A descriptive observational cross-sectional study was conducted. A questionnaire was designed to target undergraduate medical and pharmacy students at three universities of Sulaimani (UOS), Hawler Medical University (HMU), and University of Duhok (UOD) in Sulaimani, Hawler, and Duhok Cities-Kurdistan Region-Iraq respectively. Student knowledge, awareness of the use of LSMs, the motivations for using these medications were assessed by addressing these aspects in different sections of the questionnaires. The Number of respondents was 209 from which, the number of students who were using LSMs was 149 (71.3%). The source of information on LSMs among those who had aware of using LSMs was advertisement 25(12%), family 28(13.4%), friends 51(24.4%), medical needs 51(24.4%), internet 115(55%) and the pharmacies 4(1.9%). The most frequent agent that has been used by the highest number of the students was caffeine 71(47.7%), followed by dietary supplement 63(42.3%) then cosmetics 48(32.2%). 135 (64.6%) students did not agree on the prevention of the use of LSMs, while the rest 74 (35.4%) encouraged the prevention of LSMs intake by providing many strategies to prevent this phenomenon. In conclusion, prevalence of using LSMs among university students is high and tendency for medicalization of healthy individuals in the aim of better academic performance and improve quality of life is increasing. The prevention of LSMs intake by providing many strategies to prevent this phenomenon was raised by 74 (35.4%) of the participants. Key words: Life style medications, LSMs, Motives, Prevention strategies, University students العراق-الكردستان االقليم في الجامعات الطلبة بين الحياة النمط األدوية تناول و تكرارالوعي ،*غريب محمد عثمانه ساڤ ،*كريم اركان سيما عثمان، كاوة ژينيا ،**سعيد حمة غفور احمد ، 1* معروف حسن بشرى *** احمد جزا محمد رۆيا العراق ، سليمانيةال السليمانية، جامعة الصيدلة، كلية والسموم، االدوية فرع* العراق ، سليمانيةال السليمانية، جامعة الصيدلة، كلية السريرية، الصيدلة عفر ** العراق ، سليمانيةال السليمانية، جامعة الطب، كلية *** الخالصة بحالة متعلق وغير طبي غير غرض لتحسين األدوية هذه تناول يتم الفرد. حياة نمط لتعزيز تستخدم التي األدوية من الحياة نمط ادوية تعتبر أنواعها على والتعرف استخدامها ودوافع الجامعات طلبة بين الحياة نمط األدوية استخدام مدى معرفة هو الدراسة هذه إجراء من الهدف إن المرضية. الجامعات. طلبة بين تناولها من والوقاية الضوابط لوضع قيمة بمعلومات الجامعات تزويد أجل من الموضوع هذا على المفيدة البيانات لجمع السلبية وتأثيراتها في والصيدلة الطب الكليات وطالبات طالب منها الطبية المجموعة طلبة استهدف الذي استبيان تصميم خالل من مستعرضة مقطعية وصفية دراسة أجريت لألدوية الطالب معرفة مدى تقييم تم التوالي. على دهوك و أربيل السليمانية، التالية، المحافظات في دهوك جامعة و هوليرالطبية جامعة و السليمانية جامعة يستخدمون كانوا الذين الطالب عدد طالبا. 209 لالستبيان استجاب االستبيان. في المختلفة األقسام في الموجودة األسئلة خالل من االدوية هذه الستخدام ووعيهم ينالذ أولئك بين االدوية لهذه المعلومات مصدر بان تبين االطالق. على االدوية هذه يستخدموا لم ٪(28.7) 60 بينما ٪(71.3) 149 هو الحياة نمط أدوية ٪( 24.4) 51 الطبية األحتياجات من ، ٪(24.4) 51 األصدقاء ، ٪(13.4) 28 األسرة ٪(،12) 25 اإلعالنات خالل هومن االدوية لهذه علم لديهم كانوا 63 الغذائي المكمل يليه ، ٪(47.7) 71 الكافيين هو الطالب قبل من استخدامه شيوعا األكثر المادة ٪(.1.9) 4 والصيدليات ، ٪( 55) 115 االنترنيت من ، 74 الباقون أيد بينما الحياة نمط أدوية استخدام منع على المشاركين طالب من ٪(64.6) 135 يتفق لم ٪(.32.2) 48 التجميل المستحضرات ثم ٪(42.3) نمط أدوية استخدام نسبة بان الدراسة هذه من نستنتج . الظاهرة هذه لمنع االستراتيجيات من عديد وضع خالل من االدوية هذه تناول منع على ٪(35.4) االزدياد. في الحياة نوعية وتحسين األكاديمي أدائهم تحسين لغرض االصحاء األشخاص قبل من االدوية تناول الى والميل جدا عالية الجامعات طلبة بين الحياة . الظاهرة هذه لمنع ٪( 35.4) 74 المشاركين من نسبة قبل من االستراتيجيات من عديد االقتراح تم لقد الجامعات. طلبة الوقاية، طرق االستخدام، دوافع الحياة، نمط أدوية المفتاحية: الكلمات 1Corresponding author E-mail: bushra.marouf@univsul.edu.iq Received: 18/ 3/2022 Accepted: 31/ 5/2022 Iraqi Journal of Pharmaceutical Science https://doi.org/10.31351/vol32iss1pp185-193 Iraqi J Pharm Sci, Vol.32( 1 ) 2023 University students and life style medications 186 Introduction The term lifestyle medication (LSM) has multifaceted definition and various descriptions are frequently used interchangeably for this term as there is incomplete consensus on its definition, types, indications and its access. (1,2) However, general consensus has agreed on the medications that are intended for improvement of lifestyle of an individual. These drugs are being taken to modify a non-medical or non-health-related purposes. It can be used to alter the appearance as well as the physical and mental capabilities of the individual such as improving academic performances, changing and/or improving physical appearance. These drugs as named as non-essential drugs that used to manage non-serious medical issue which is non-life threatening and non-painful status such as indicated for baldness, erectile dysfunction or impotence, postpone menstruation, muscle building, physical, mood alteration, acne, and wrinkle. (1,3) There are many medications and pharmaceutical products that are considered as LSMs, these include drugs that are utilized for hair loss prevention such as: minoxidil, finasteride or hair tonics; orlistat for losing weight; bupropion for smoking cessation, sildenafil for erectile dysfunction, onabotulinumtoxin A for wrinkle and aging marks; melatonin as a sleep aid; cyproheptadine as appetite enhancer and dietary supplements that may improve physical appearance. (4) These medications are taken in an attempt to improve personal life quality rather than to manage a medically identifiable and well-defined disease (5) Today, the use of lifestyle medications is increasing due to easy accessibility and persuasive advertisement of pharmaceutical products such as cosmetics, dietary supplements, and weight-loss products which increases the concerns of misuse of these medications. (6) Additionally, disease mongering which is defined as maximizing minor illness into severe medical issue, treating mid illness as serious one, all these have increased the medicalization of these conditions. (7) On the other hand, university student’s living environment, socio-economic factors, modernized life and peer pressures are considered as the factors that make students to be at high-risk for using LSMs. (8) The issue of LSMs usage have been investigated in many studies and there have been some reports about the prevalence of LSMs usage among students and healthy people. (4,9) Rahman et al, 2010 stated that lifestyle has itself become an object of medical attention and the impact of these medications on the society need to be more elaborated (1). Moreover, the majority of the students who were LSMs users confessed that most of LSMs were unnecessarily used. (4) Unfortunately, these LSMs are not without adverse effects thus the development of preventive strategy and educational awareness for reducing the use of LSMs requires information on the most commonly used medications among students. Furthermore, factors for using these drugs and prevalence of the usage of these medications in the university environment should be addressed. (9) Therefore, the aims of this study were to investigate the extent of using lifestyle medications among university students, motives for using them, and identify the types, adverse effects and other measurable outcomes to provide helpful information for justification and prevention of this phenomenon. Methods Study design and development of the questionnaire This was an anonymous descriptive cross- sectional on-line survey where a multiple-choice with single word answer questionnaire was designed to target undergraduate medical and pharmacy students at the University of Sulaimani, Hawler Medical University, and University of Duhok in Sulaimani, Hawler, and Duhok Cities-Kurdistan Region-Iraq respectively from June 2020 to January 2021. A self-administered questionnaire was used in this study, which was designed after extensive literature review. (4,10) The questionnaire was divided into four sections and it was utilized for collection of socio- demographic characteristics, knowledge on LSMs, the most commonly used LSMs and preventive measure for LSMs practice. A pilot study was conducted among ten medical and pharmacy students to assess the understandability, reliability, and clarity of the questionnaire. Validation of the questionnaire was performed by face validity based on an expert panel from pharmacists and biostatisticians. The purpose of the research has been clarified for the students and the researchers assured them of their information confidentiality. The students also have been informed on how to fill this questionnaire. Demographic information included age, gender, university and colleges and the current academic year of the student. The questionnaire was sent out via email to the students at the targeted colleges through the college representative member. Student knowledge, awareness of the use of LSMs, motives for using these medications were assessed by addressing these issues in different sections of the questionnaires. Objectives of the study was explicitly described at the beginning of the questionnaire form to each participant. Iraqi J Pharm Sci, Vol.32( 1 ) 2023 University students and life style medications 187 Inclusion and exclusion criteria The sampling scheme included undergraduate university students of both gender, age of 18 and above years, residing at the university campuses in the three cities; Sulaimani, Hawler, and Duhok Cities-Kurdistan Region-Iraq. The questionnaire has sent to the levels from 2nd year to the last year of the academic study. The survey included students who were using prescription and non- prescription medications without a medical diagnosis. Postgraduate students and students who were identified as users of these medications to treat serious and chronic diseases have been excluded. Ethical consideration The project of the study was registered and approved by the Ethics and Research Registration Committee of the College of Pharmacy–University of Sulaimani with Registration number (PH-17-20 in 15.11.2020). Consenting students was also assured for confidentiality of the volunteered information; thus, the study designed as anonymous on-line survey without name and personal details of the students. Statistical Analysis Analysis and graph of the data were performed in GraphPad Prism version 9.3.1. Descriptive statistics; frequency, percentage, confidence intervals, minimum and maximum range, graphs, were conducted for data presentation. Results Basic characteristics of the participants The recommended sample size for the current study was calculated based on a formula that was described in a previous research with modification. (11) The Number of responses was 215 which is 66.5% of the recommended sample size, six responses have been excluded as they were postgraduate students and were using prescribed medications. The included students from the three universities were 209. Basic characteristics of the participants is illustrated in Table 1. Half of the responses 104(49.8%) were obtained from University of Sulaimani while 79(37.8%) were from University of Duhok and 26 (12.4%) students were from Hawler Medical University. The majority of the respondents were female (70.3%). Most of the respondents were from third and fourth grade (56%, 66%) respectively. Nearly three quarters of the students 152 (72.7%) were with the age range between (18-21), 50(24%) students were with (22- 24) and 7(3.3%) were 25 years and above. About two-third of the students 161 (77%) were living inside the cities while the rest 48 (23%) were from rural areas. Table 1. Demographic characteristics of the participants n=209 Frequency % Universities of the participants University of Sulaimani 104 49.8 Hawler Medical University 26 12.4 University of Duhok 79 37.8 Gender Female 147 70.3 Male 62 29.7 Age (Year) 18-21 152 72.7 22-24 50 24.0 25 and above 7 3.3 Year of the study 2nd 47 22.5 3rd 56 26.8 4th 66 31.6 5th 40 19.1 Place of living Urban area 161 77.0 Rural area 48 23.0 Knowledge, source of information and student’s attitude on LSMs Majority of the students 144(68.9%) were aware of LSMs intake, while around one third 65(31.1%) had never heard about LSMs. The source of information on LSMs among those who had aware of using LSMs was advertisement, family, friends, medical needs and rarely from the pharmacies 4(1.9%) while highest number of the students 115(55%) were obtained information on LSMs from internet. Table 2 shows the number of students who were using LSMs. The frequency of using LSMs and number of the drugs per students was also calculated as shown in Table 2. The majority of the participants 112(53.5%) were using one LSMs, and 39(18.6%) were not using any LSMs. The current study also elaborated on the purpose and benefit of using LSMs among students by providing multiple options in the questionnaire. The perception of the students on the purpose of LSMs usage varies and the majority of the students were using LSMs as a tonic for improving their health (26.3%) and to alleviate stress (21.5%). Furthermore, some of them use LSMs as cosmetics (13.4%), to increase immunity (9.6%) , treat minor condition (8.1%), for improvement of physical appearance and as body builder (1.4%)(Figure.1). Iraqi J Pharm Sci, Vol.32( 1 ) 2023 University students and life style medications 188 Table 2. Awareness and information on LSMs among university students n=209 Knowledge on LSMs Frequency % Students have information on LSMs 144 68.9 Students have never heard about LSMs 65 31.1 Sources of information on LSMs Advertisement 25 12.0 Family 28 13.4 Friends 51 24.4 Medical needs 51 24.4 Internet 115 55.0 Pharmacy 4 1.9 Students use LSMs Number of students using LSMs 149 71.3 Number of students not using LSMs 60 28.7 Number of LSMs used by the students 0 39 18.6 1 112 53.5 2 42 20.0 3 10 4.8 more than 3 6 2.9 Figure 1. Purpose and benefit of using LSMs. The most frequently used LSMs, adverse effects associated with the use of LSMs This study has recorded the frequency of the drugs that have been taken by all the students during their lifetime. Table 3 has summarized the most frequently used LSMs used by the students in the studied colleges. Table 3. The most frequently used LSMs by the university students Life Style Medications (LSMs) Number % 95% CI Alcohol 5 3.4 (0.46, 6.25) Dietary Supplement 63 42.3 (34.35, 50.21) Antioxidants 23 15.4 (9.63, 21.24) Benzodiazepines 7 4.7 (1.3, 8.1) Caffeine (Caffeinated products) 71 47.7 (39.63, 55.67) Beta-Blockers for alleviate anxiety and social phobia (Propranolol, Atenolol) 18 12.1 (6.85, 17.31) Bupropion “stop smoking” 3 2.0 (0, 4.27) Nicotine replacement therapy 5 3.4 (0.46, 6.25) Cosmetics (skin depigmenting agents) 48 32.2 (24.71, 39.72) Cyproheptadine (Appetite stimulant) 11 7.4 (3.18, 11.58) Hair loss prevention (Alopecia) agents 25 16.8 (10.78, 22.78) Melatonin 20 13.4 (7.95, 18.9) Norethisterone or contraceptive pill as a “period delay pill” like for Ramadan or any other private occasion 6 4.0 (0.87, 7.18) Orlistat “any other weight reduction pills” 15 10.1 (5.24, 14.9) Stimulants (Amphetamines, Modafinil, Methylphenidate) 10 6.7 (2.69, 10.73) Vitamin C 3 2.0 (0, 4.27) Anabolic Steroid 3 2.0 (0, 4.27) Fluoxetine 1 0.7 (0, 1.98) Iraqi J Pharm Sci, Vol.32( 1 ) 2023 University students and life style medications 189 The most frequent agent that has been used by the highest number of the students was caffeine 71(47.7%), followed by dietary supplement 63(42.3%) then cosmetics (skin depigmenting agents) 48(32.2%). Only one (0.7%) student was using a prescription drug without medical diagnosis as LSMs for alleviating stress. The other common LSMs are summarized in table 3. Furthermore, the adverse effects associated with LSMs intake is summarized in Table 4. Headache and/or mood changes, dryness of mouth, drowsiness or insomnia as well as nausea and vomiting are the most repetitive adverse effects that have been experienced and recorded by the students. In another part of the study, opinion of the student on the effect of LSMs on drug-drug interaction and possibility of side effect potentiation have been recorded as shown in Table 5. Half of the students 106(50.7%) believed that LSMs lead to Drug-Drug interaction and the possibility of side effects are increased. Table 4. The most common adverse effects associated with the use of LSMs experienced by the university students Adverse effects Number % 95%Cl Constipation and/or stomach upset 15 10.1 (5.24, 14.9 ( Diarrhea 24 16.1 )10.2, 22.01 ( Dizziness or agitation 20 13.4 )7.95, 18.9 ( Drowsiness or insomnia 34 22.8 )16.08, 29.56 ( Dryness of mouth 38 25.5 )18.5, 32.5 ( Facial hair growth and/or hormonal disturbance 24 16.1 )10.2, 22.01 ( Fatigue and/or sedation 18 12.1 )6.85, 17.31 ( Headache and/or mood changes 43 28.9 )21.58, 36.13 ( Loss of appetite 30 20.1 )13.7, 26.57 ( Nausea and vomiting 32 21.5 (14.88, 28.07) Steatorrhea 15 10.1 (5.24, 14.9) Stinging and/or dermatitis 5 3.4 (0.46, 6.25) Weight gain 20 13.4 (7.95, 18.9) Table 5. Perception of the students for the impact of LSMs- drug interaction and potential side effects Type of Response Number % 95% Cl Students believed that LSMs May lead to Drug-Drug interaction 84 40.2 (48.41, 64.34) Students believed that LSMs do not lead to Drug-Drug interaction 19 9.1 (7.4, 18.11) Student believed that LSMs definitely lead to Drug-Drug interaction 106 50.7 (63.87, 78.42) Motives or factors enhancing the use of LSMs among students The highest response on the motives that are enhancing the use of LSMs was associated with the treatment of non-serious minor condition 82 (39.2%) then social media or TV advertisement 49 (23.4%). The other factors that boost the use of these medications have illustrated in Figure 2. Figure 2. Motives enhance the use of LSMs among students Students perception on the effects of LSMs on quality of life Table 6 depicts the students’ perception about the effects of using LSMs on the individual’s quality of life. The majority of the students 107 (51.2%) were disinterested upon the impact of LSMs on quality of life, while 67 (32.1%) and 13(6.2%) agreed and strongly agreed on the intake of LSM respectively, because they believed that LSMs can improve the quality of life of the individuals. The rest either strongly disagreed or disagreed on the use of LSMs for the purpose of quality of life improvement. Iraqi J Pharm Sci, Vol.32( 1 ) 2023 University students and life style medications 190 Table 6. Perception of students toward using LSMs to improve quality of life Type of Response Number % 95% CI Agree 67 32.1 (36.98, 52.95) Disagree 14 6.7 (4.71, 14.08) Neutral 107 51.2 (64.59, 79.04) Strongly Agree 13 6.2 (4.19, 13.26) Strongly disagree 8 3.8 (1.75, 8.99) In the last part of the survey, the preventive measure for LSMs intake was elaborated therefore, students’ opinion on prevention of LSMs has been collected. 135 (64.6%) students did not agree on the prevention of the use of LSMs, while the rest 74 (35.4%) encouraged the prevention of LSMs intake by providing many strategies to prevent this phenomenon. Among those methods self-education about their side effects 83(39.7%), providing college counsellors 33(15.8%), establishing university on- campus counseling centers 32(15.3%), social media and TV advertising regulation 31(14.8%) and mass media campaigns 15(7.2%) have been mentioned by the students as shown in Figure 3. Figure 3. Prevention strategies for the use of LSMs among university students Discussion The change in lifestyle gave rise the emergence of various medications that address the aspects of quality of life and lifestyle of individuals, therefore the use of these medications without medical diagnosis or as off-labeled drugs raises a public, ethical and safety concerns. (12) They also have a significant unfavorable socioeconomic and safety impact on public health and society especially in developing countries. (10) University students are a diverse group of relatively healthy individuals who are subjected to lifestyle and physical change. Within the first year of university, students report an increase in body weight and body fat due, in part, to the changes in their diet and the stress of the new university environment (13) thus, they might be more prone to use LSMs. The present study demonstrated the prevalence of using LSMs among university students in three universities. It has revealed that three quarter of the participants were using those medications during their lifetime with the intention to either improve their immunity and wellbeing or to decrease stress for better academic performance. These purposes were also stated by a study conducted in Tokyo on the Japanese students who were registrants of Macromill Inc and their age was between 18-24 years old. The students experienced high prevalence of consumption of these medications. (14) Clear differences in the prevalence of LSMs between and within the countries have been reported for example a study in an Australian university revealed that 75.5% of the students used stimulants to enhance academic performance while US data from a systematic review displayed a range between 5% and 35% of non-medical use of the stimulants by university students (15) . In the present study, the most common life style substances used among the participants was caffeine (47.7%) followed by dietary supplement (42.3%) and cosmetics (32.2%). The finding of the present study in the context of caffeine consumption is consistent with other studies which conducted in some universities such as Egypt, Lebanon and United State. (16,17,18) Caffeine is the most consumed psychoactive drug in the world, as a psychostimulant. It shows all the pharmacological properties of classical psychostimulants, such as cocaine and amphetamine. An epidemiological study on caffeine withdrawal and dependence indicated that regular caffeine intake creates dependence, which in part depends on withdrawal symptoms. (19) Perceptions for consuming caffeine among university students in the previous studies were feeling of alertness, improved performance, attention in task performance, concentration, improved long-term memory and faster locomotors speed (20,21) feeling of energy and capability to do work for long periods of time after taking caffeine. The perceptions for not taking caffeine were irritability, increasing heart rate, bad feelings, and insomnia. (22) The popularity of consumption of the caffeinated products associated with the food related social behaviors, individual habits and hereditary traits. (18) Literature suggests that the consumption of caffeine among young people is significantly high all over the world and different caffeinated products are easily accessible. (23) Approximately 90% of the college students in United States are using caffeine (18) and in another study conducted among students of Dutch university a daily consumption of caffeine Iraqi J Pharm Sci, Vol.32( 1 ) 2023 University students and life style medications 191 was 87.8%. (24) In addition, the consumption of caffeine products among Canadian young people was found to be 73.6% and approximately one in six consumers had exceeded the usual guidance for maximum daily consumption thus potentially increasing their risk of experiencing adverse effects. (25) Moreover, the intake of caffeine was reported to be 97% in India (26) and 98.5% in United Arab Emirates. (27) Additionally, the prevalence of the use of dietary supplements has globally increased and dietary supplements are extensively consumed worldwide despite unproven efficacy. In the present study, the consumption of dietary supplement among the college student; which are intended to provide the diet with additional nutrients, were also high. Approximately less than half of the participants were using dietary supplement during their lifetime which is consistent with the studies conducted in different countries including Japan, the United States and European countries (14,28,29,30,31) The main issues of using dietary supplements as a LSMs are associated with lack of enough knowledge on its properties, active ingredients, beneficial effects as well as its adverse effects such as nephrotoxicity, hepatotoxicity, immunotoxicity. (32,33) The present study reported that some students had experienced adverse events with the use of these LSMs which is impart might related to the use of dietary supplements such as constipation and/or stomach upset, dizziness or agitation, loss of appetite, weight gain, facial hair growth and/or hormonal disturbance, headache and/or mood changes. Cosmetics and dermatological products consumption were also demonstrated in the responses of the participants. It has been found that one-third of the students were using cosmetics including skin depigmenting agents and products for female hirsutism which were quite close to the data recorded by other researchers in different countries such as Nigeria where the prevalence of use of skin lightening products among female of undergraduate medical students was quite high. (34) Moreover, skin toning practices have been reported among young women in Ghana and considerable number of university students in Saudi Arabia who use topical steroids on the face without knowing its nature. (35,36) Stressful environment and workload on the medical university students also led to administration of B- blockers such as propranolol or atenolol especially during examination. This practice is addressed in many other studies shown among medical and dental students at King Saud University in Riyadh where inappropriate use of beta-blockers has been used for relieving their anxiety and stress during examinations, and most of them were self- prescribed. (37) In another section of the study the motives and the factors influencing the use of LSMs among the students have been investigated. The treatment of non-serious minor condition then social media or TV advertisement and peer pressure or friend influence were considering as the main motives for usage of LSMs among university students while reasons and motives for using these medications in another study was mostly peer pressure and to alleviate stress and anxiety (4) . Advertisement of pharmaceutical companies and their impact in medicalizing healthy life (7) have a crucial role in influencing the students to use these medications. In the present study, the prevention of LSMs usage among university students has been suggested only by one-third of the students. They provided useful strategies for awareness of LSMs usage among students to decrease this phenomenon. Their suggestions were parallel with the previous reports which stated that providing appropriate education on dietary supplement among university students particularly pharmacy and medical students is crucial for their health and for their future profession as a pharmacist and physician. (38) The present study has certain limitations, despite the good response rate that was received, the sample size was relatively smaller for cross sectional studies on awareness, attitudes, and use. As this is a cross-sectional study design, thus factors affecting student’s responses cannot be studied over time. Another limitation was the number of universities, i.e., UOS, HMU and UOD which cannot be generalized to other universities of Iraq. Therefore, more studies are required from different universities which might have different opinions. In conclusion, prevalence of using life style medications among university students is high and tendency for medicalization of healthy individuals in the aim of better academic performance and improve quality of life is increasing. Advertisement of pharmaceutical companies on a particular product has an important role in influencing the university students to use these medications for non-serious medical states. The prevention of LSMs intake by providing many strategies to prevent this phenomenon was raised by approximately half of the participants. Acknowledgements The authors would like to thank the respondents in the University of Sulaimani University (UOS), Hawler Medical University (HMU), and University of Duhok (UOD) for their participations in this project. References 1. Rahman S, Gupta V, Sukhlecha A, Khunte Y. Lifestyle drugs: Concept and impact on society. Indian J Pharm Sci. 2010; 72(4):409. 2. Gilbert D, Walley T, New B. Lifestyle medicines. BMJ. 2000;321(7272):1341–4. Iraqi J Pharm Sci, Vol.32( 1 ) 2023 University students and life style medications 192 3. Møldrup C. The use of the terms ‘lifestyle medicines’ or ‘lifestyle drugs.’ Pharm World Sci. 2004;26(4):193–6. 4. D. Mwambete K, Shemsika T. Prevalence of Life Style Drugs Usage and Perceived Effects among University Students in Dar es Salaam. Am J Biomed Res. 2014; 2(2):29–35. 5. Harth W, Seikowski K, Hermes B. Lifestyle Drugs in Old Age – A Mini-Review. Gerontology. 2009; 55(1):13–20. 6. Jernigan D, Noel J, Landon J, Thornton N, Lobstein T. Alcohol marketing and youth alcohol consumption: a systematic review of longitudinal studies published since 2008: Alcohol marketing and youth drinking. Addiction. 2017; 112:7–20. 7. Moynihan R. Selling sickness: the pharmaceutical industry and disease mongering * Commentary: Medicalisation of risk factors. BMJ. 2002; 324(7342):886–91. 8. Oliveira LG de, Alberghini DG, Santos B dos, Andrade AG de. Polydrug use among college students in Brazil: a nationwide survey. Rev Bras Psiquiatr. 2013; 35(3):221–30. 9. d’Angelo L-SC, Savulich G, Sahakian BJ. Lifestyle use of drugs by healthy people for enhancing cognition, creativity, motivation and pleasure: Lifestyle use of drugs by healthy people. Br J Pharmacol. 2017; 174(19):3257–67. 10. Ramu B, Mounika I. Lifestyle drugs: concept and impact on society. J Hum Virol Retrovirology. 2018; 6(2):46–9. 11. Khan A, Ahmed ME, Aldarmahi A, Zaidi SF, Subahi AM, Al Shaikh A, et al. Awareness, Self- Use, Perceptions, Beliefs, and Attitudes toward Complementary and Alternative Medicines (CAM) among Health Professional Students in King Saud bin Abdulaziz University for Health Sciences Jeddah, Saudi Arabia. Evid Based Complement Alternat Med. 2020; 2020:1–11. 12. Schelle KJ, Olthof BMJ, Reintjes W, Bundt C, Gusman-Vermeer J, van Mil ACCM. A survey of substance use for cognitive enhancement by university students in the Netherlands. Front Syst Neurosci. 2015; 9. 13. Beaudry KM, Ludwa IA, Thomas AM, Ward WE, Falk B, Josse AR. First-year university is associated with greater body weight, body composition and adverse dietary changes in males than females. Meyre D, editor. PLOS ONE. 2019;14(7):e0218554. 14. Kobayashi E, Sato Y, Umegaki K, Chiba T. The Prevalence of Dietary Supplement Use among College Students: A Nationwide Survey in Japan. Nutrients. 2017; 9(11):1250. 15. Mazanov J, Dunn M, Connor J, Fielding M-L. Substance use to enhance academic performance among Australian university students. Perform Enhanc Health. 2013; 2(3):110–8. 16. El-Nimr N, Bassiouny S, Tayel D. Pattern of Caffeine Consumption Among University Students. J High Inst Public Health. 2019; 49(3):154–61. 17. Ghozayel M, Ghaddar A, Farhat G, Nasreddine L, Kara J, Jomaa L. Energy drinks consumption and perceptions among University Students in Beirut, Lebanon: A mixed methods approach. Haighton C, editor. PLOS ONE. 2020;15(4):e0232199. 18. Mahoney CR, Giles GE, Marriott BP, Judelson DA, Glickman EL, Geiselman PJ, et al. Intake of caffeine from all sources and reasons for use by college students. Clin Nutr. 2019; 38(2):668–75. 19. Budney AJ, Brown PC, Griffiths RR, Hughes JR, Juliano LM. Caffeine Withdrawal and Dependence: A Convenience Survey Among Addiction Professionals. J Caffeine Res. 2013; 3(2):67–71. 20. Christopher G, Sutherland D, Smith A. Effects of caffeine in non-withdrawn volunteers. Hum Psychopharmacol Clin Exp. 2005; 20(1):47–53. 21. Ferré S. Mechanisms of the psychostimulant effects of caffeine: implications for substance use disorders. Psychopharmacology (Berl). 2016; 233(10):1963–79. 22. Maqsood U, Zahra R, Latif MZ, Athar H, Shaikh GM, Hassan SB. Caffeine Consumption & Perception of Its Effects Amongst University Students. Proc Shaikh Zayed Med Complex Lahore. 2020; 34(4):46–51. 23. Bucher J, Fitzpatrick D, Swanson AG, Abraham SP. Caffeine Intake Habits and the Perception of Its Effects on Health Among College Students. Health Care Manag. 2019; 38(1):44–9. 24. Mackus M, van de Loo AJAE, Benson S, Scholey A, Verster JC. Consumption of caffeinated beverages and the awareness of their caffeine content among Dutch students. Appetite. 2016; 103:353–7. 25. Reid JL, McCrory C, White CM, Martineau C, Vanderkooy P, Fenton N, et al. Consumption of Caffeinated Energy Drinks Among Youth and Young Adults in Canada. Prev Med Rep. 2017; 5:65–70. 26. Gera M, Kalra S, Gupta P. Caffeine intake among adolescents in Delhi. Indian J Community Med. 2016; 41(2):151. 27. Alaa Hammami MB, Al Shaikh YG, Hashem AM, Mukhles Adi OM, Ahmed Aal Yaseen I, El Menawy ZM, et al. Caffeine Consumption Levels and Knowledge Among Adults in the United Arab Emirates: Insights from a Nationwide Survey. J Caffeine Adenosine Res. 2018; 8(2):71–9. 28. Kantor ED, Rehm CD, Du M, White E, Giovannucci EL. Trends in Dietary Supplement Use Among US Adults From 1999-2012. JAMA. 2016; 316(14):1464. Iraqi J Pharm Sci, Vol.32( 1 ) 2023 University students and life style medications 193 29. Lieberman HR, Marriott BP, Williams C, Judelson DA, Glickman EL, Geiselman PJ, et al. Patterns of dietary supplement use among college students. Clin Nutr. 2015; 34(5):976–85. 30. Garcia-Alvarez A, Egan B, de Klein S, Dima L, Maggi FM, Isoniemi M, et al. Usage of Plant Food Supplements across Six European Countries: Findings from the PlantLIBRA Consumer Survey. Müller M, editor. PLoS ONE. 2014; 9(3):e92265. 31. Wiltgren A, Booth A, Kaur G, Cicerale S, Lacy K, Thorpe M, et al. Micronutrient Supplement Use and Diet Quality in University Students. Nutrients. 2015; 7(2):1094–107. 32. García-Cortés M, Robles-Díaz M, Ortega- Alonso A, Medina-Caliz I, Andrade R. Hepatotoxicity by Dietary Supplements: A Tabular Listing and Clinical Characteristics. Int J Mol Sci. 2016; 17(4):537. 33. Grubbs V, Plantinga LC, Tuot DS, Hedgeman E, Saran R, Saydah S, et al. Americans’ Use of Dietary Supplements That Are Potentially Harmful in CKD. Am J Kidney Dis. 2013; 61(5):739–47. 34. Egbi OG, Kasia B. Prevalence, determinants and perception of use of skin lightening products among female medical undergraduates in Nigeria. Skin Health Dis. 2021; 1(3). 35. Agyemang-Duah W, Mensah CM, Anokye R, Dadzie E, Gyimah AA, Arthur - Holmes F, et al. Prevalence and patterns of skin toning practices among female students in Ghana: a cross- sectional university-based survey. BMC Res Notes. 2019;12(1):299. 36. Majed D, Alnujaidi M, Almohammadi N, Kokandi AA. Use of topical steroids on the face among university students in Saudi Arabia. Biomed Res. 2018; 29(13). 37. Abukhalaf A, Alomar A, Alsalame N, Sumaya O, Alessa O, Alasbali M, et al. Inappropriate use of beta-blockers among medical and dental students at King Saud University, Riyadh. J Fam Med Prim Care. 2020; 9(8):4391. 38. Chiba T, Kobayashi E, Okura T, Sekimoto M, Mizuno H, Saito M, et al. An educational intervention improved knowledge of dietary supplements in college students. BMC Public Health. 2020; 20(1):633. This work is licensed under a Creative Commons Attribution 4.0 International License. http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/