Drug and Alcohol Dependence 106 (2010) 230–232

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Drug and Alcohol Dependence

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Randomized response estimates for doping and illicit drug use in elite athletes
Heiko Striegel a,∗ , Rolf Ulrich b , Perikles Simon c
a
Medical Clinic, Department of Sports Medicine, University of Tübingen, Silcherstraße 5, 72076 Tübingen, Germany
b
Department of Cognitive and Biological Psychology, University of Tübingen, Friedrichstrasse 21, 72072 Tübingen, Germany
c
Department of Sports Medicine, Disease Prevention and Rehabilitation, Johannes Gutenberg University, Albert-Schweitzer-Str. 22, 55128 Mainz, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Background: To date, there are estimates for the percentage of unknown cases of doping and illicit drug
Received 2 December 2008 use in fitness sports, but not for elite sports. This can be attributed to the problem of implementing
Received in revised form 28 July 2009 questionnaires and surveys to get reliable epidemiological estimates of deviant or illicit behaviour.
Accepted 28 July 2009
Methods: All athletes questioned were subject to doping controls as members or junior members of
Available online 8 September 2009
the national teams. In order to estimate the prevalence of doping and illicit drug abuse, the athletes
were either issued an anonymous standardized questionnaire (SQ; n = 1394) or were interviewed using
Keywords:
randomized response technique (RRT; n = 480). We used a two-sided z-test to compare the SQ and RRT
Illicit drugs
Doping
results with the respective official German NADA data on the prevalence of doping.
Randomized response technique Results: Official doping tests only reveal 0.81% (n = 25,437; 95% CI: 0.70–0.92%) of positive test results,
Prevalence while according to RRT 6.8% (n = 480; 95% CI: 2.7–10.9%) of our athletes confessed to having practiced
doping (z = 2.91, p = 0.004). SQ and RRT both revealed a prevalence of about 7% for illicit drug use, but SQ
failed to indicate a realistic prevalence of doping (0.20%; 95% CI: 0.02–0.74%).
Conclusions: We demonstrate for the first time that data from official doping tests underestimate the true
prevalence of doping in elite sports by more than a factor of eight. Our results indicate that implementing
RRT before and after anti-doping measures could be a promising method for evaluating the effectiveness
of anti-doping programs.
© 2009 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
To date, there are estimates for the percentage of unknown cases
of doping and illicit drug use in fitness sports (Kanayama et al.,
2001, 2008; Simon et al., 2006; Striegel et al., 2006). In elite sports,
however, this percentage is widely unknown. There are only three
studies using different methods for estimating the doping preva-
lence (Pitsch et al., 2007; Scarpino et al., 1990; Thevis et al., 2008).
Data from official doping tests by the World and National Anti-
Doping Agencies (WADA/NADAs) reveal that about 1% of all tests
are positive. This figure has been stable across nations for the last 5
years. Here we argue that this figure underestimates the true preva-
lence of doping. To support this view, we compared the German
NADA figure with data from the randomized response technique
(RRT) – an anonymous indirect interview technique – and also
with data from a standard questionnaire (SQ) technique. Based
on the findings of our previous research on fitness sports, where
the problem of illegal drug use also suffers from under reporting,
we conjecture that athletes would admit doping when interviewed
∗ Corresponding author. Tel.: +49 7071 29 85163; fax: +49 7071 29 5162.
E-mail address: heiko.striegel@med.uni-tuebingen.de (H. Striegel).
with RRT rather than in an SQ, because the perceived anonymity is
higher with RRT (Nordlund et al., 1994; Simon et al., 2006; Warner,
1965).
2. Methods
2.1. Sample
All athletes in the study were subject to doping controls as members or junior
members of the national teams. The median age was 16 years (SQ and RRT). In
Germany, elite athletes are included in the doping control system starting at the
age of 14 years. 67.4% (SQ) vs. 67.7% (RRT) practiced individual sports. Altogether,
athletes from 43 different sports were questioned, although track and field (20.2% vs.
19.2%), soccer (13.0% vs. 9.4%), handball (9.0% vs. 11.0%), and cycling (8.1% vs. 8.8%)
were the most prevalent sports. Between 2003 and 2005, all members that consulted
the Olympic Training Base in Stuttgart or the Department of Sports Medicine in
Tübingen, Germany, for physical examination were either issued an SQ (n = 1394)
or were interviewed using RRT (n = 480). After an athlete filled in the questionnaire,
he or she deposited the questionnaire into a box that was locked. The questionnaire
did not contain any names, locations, or any other information that would enable
conclusions to be drawn about specific persons. The RRT offers a certain degree
of perceived protection vis-à-vis the interviewer when replying to the sensitive
question, because all responses, whether to a neutral or a sensitive question, are
given according to a randomized procedure.
Athletes were informed in writing and in person about the study and its vol-
untary nature, as well as about possible consequences resulting from the outcome
of the study. After being thus informed for the RRT, athletes willing to participate
in the study gave oral consent. For the SQ, there was a passage at the beginning

0376-8716/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.drugalcdep.2009.07.026
 H. Striegel et al. / Drug and Alcohol Dependence 106 (2010) 230–232
Table 1
Comparison of SQ and RRT.
Study technique
Elite athletes
Response rate [%]
Median age [years] (interquartile range)
Sex [male or female]
Sports [team or individual]
Doping use [%] (95% CI)
Illicit drug use [%] (95% CI)
of the questionnaire which declared that by completing the questionnaire, sub-
jects had received information and consented to participation in the study. This was
important for this study, as it ensured complete anonymity of the subjects. Both
procedures, SQ and RRT, were approved by the internal review board and according
to the declaration of Helsinki. None of the participants received financial compen-
sation. The SQ included an explicit question that enabled us to exclude data from
repeated participation (n = 244). RRT was only performed once per person. RRT and
SQ were administered according to our previous research on fitness sports (Striegel
et al., 2006; Simon et al., 2006).
2.2. Randomized response technique
Athletes in the RRT-sample were asked to draw a hidden card of their choice
from a deck of 20 cards. Seventy-five percent of the cards contained the sensitive
question “Have you ever used doping substances” and 25% contained the neutral
question “Is your mother’s birthday in the first 10 days of her birth month”. Since
the interviewer cannot know which card the respondent has drawn, the latter can
reply honestly without compromising themselves.
Although the actual question remained unknown to the interviewer, the pro-
portion (i.e. dark figure) of “yes” responses with respect to the sensitive question
can be inferred from the answers of all respondents using the following formula:
a − (1 − p) · I
S = , SQ survey are lower, which coincides with RRT surveys in other
p
where a denotes the number of respondents in the sample who answered “yes” to the
drawn card, irrespective of the question, p is the probability of drawing the sensitive
card from the deck (i.e. in our case p = 3/4), and I corresponds to the probability of
answering the neutral question with “yes”. The variance of the sampling distribution
for S can be estimated from:
a · (1 − a)
Var(S ) = , government anti-drug laws, or that athletes see the danger of being
n · p2
where n denotes the number of respondents in the sample. This variance was used
to compute a 95% confidence interval for S (Nordlund et al., 1994). In addition, we
calculated a sample size of about n = 500 by employing the expression from above
for Var(S ) such that the resulting standard error for the estimate S would not
be larger than 0.03. The identical procedure with a different sensitive question was
employed to estimate the prevalence of illicit drug abuse. We used a two-sided z-test
to compare the SQ and RRT results with the respective official German NADA data.
These computations and the estimation of confidence intervals were performed
using the statistical tool box of MatLab 2006a.
3. Results
By NADA and German sports associations were performed
25,437 tests between 2003 and 2005, and 205 athletes tested pos-
itively for doping substances (0.81%; 95% CI: 0.70–0.92%). In the
present RRT study, 6.8% of the athletes confessed to having used
doping substances (Table 1). This figure is about eight times higher
than the percentage of positively tested athletes in the NADA data
(z = 2.91, p = 0.004). In contrast, SQ only revealed a figure of 0.20%,
which is about four times lower (z = 3.88, p < 0.001). Nevertheless,
RRT and SQ revealed similar estimates for the percentage of illicit
drug abuse.
4. Discussion
Several conclusions emerge from this study. First, despite being
subjected to strict doping rules and controls in Germany, about 7%
231
SQ (n = 1126) RRT (n = 480)
86.9 (n = 978) 100 (n = 480)
16 (14–18) 16 (15–18)
62.6% male (n = 611) 62.7% male (n = 301)
37.4% female (n = 364) 37.3% female (n = 179)
31.5% team (n = 302) 32.3% team (n = 155)
68.5% individual (n = 658) 67.7% individual (n = 325)
0.20 (0.02–0.74) 6.8 (2.7–10.9)
6.29 (4.85–7.99) 8.8 (4.5–13.1)
of the athletes confessed to having practiced doping. In this connec-
tion, it is important to take into account that in the present survey,
athletes were asked whether they had ever used doping substances,
whereas the official doping statistics reflect only a certain period
of time. This period of time strongly depends on the half-life of the
substance in question; the half-life again determines whether it is
at all possible for doping tests to lead to a positive result. In this
respect, the quality of the doping analysis techniques and addi-
tional factors also play an important role. However, it is important
to remember that athletes are repeatedly tested for doping sub-
stances throughout their careers. On the other hand, the young
mean age of the questioned athletes would suggest that lifetime
self-report of doping drug use would more accurately reflect recent
doping control tests. Due to the great discrepancy between the offi-
cial doping statistics and the prevalence found in the RRT survey,
we can assume that despite the aforementioned controls the official
statistics underestimate the real prevalence of doping consider-
ably. Moreover, it is important to consider that the estimates of our
research fields (Nordlund et al., 1994). Thus, RRT may still under-
estimate the true prevalence of doping, if athletes are reluctant to
answer the sensitive question truthfully.
Secondly, SQ seems appropriate to study illicit drug abuse but
not doping in elite athletes. One reason for this could be that
anti-doping regulations for elite athletes are more restrictive than
detected through standard questionnaires with regard to doping.
However, this danger does not seem to be feared by athletes to
the same degree with regard to illegal drugs. Quite in contrast to
this, fitness athletes appear to respond more guardedly to questions
about the use of illegal drugs than to those about doping substances
(Simon et al., 2006). In the latter study, the results from SQ and
RRT show the same prevalence for the use of doping substances,
whereas the prevalence of illegal drugs was three times higher in
RRT than in SQ (Striegel et al., 2006; Simon et al., 2006). Irrespec-
tive of this, it is important to consider that the use of illicit drugs
represents a stigmatised behaviour which can lead to the actual
prevalence being underestimated.
Finally, due to the more than eight-fold higher figures revealed
by RRT, our results indicate that implementing RRT before and
after anti-doping measures not only in elite athletes but also in
recreational sports could be a promising method for evaluating the
effectiveness of anti-doping programs (Simon et al., 2006).
Role of Funding Source
There are no sources of funding.
Contributors
Heiko Striegel: Study concept, Questionnaire design, Statistics,
Manuscript preparation.
232 H. Striegel et al. / Drug and Alcohol Dependence 106 (2010) 230–232
Rolf Ulrich: Statistics, Supervision, Manuscript preparation.
Perikles Simon: Study concept, Questionnaire Design, Statistics,
Manuscript preparation.
Conflict of Interest
There are no conflicts of interest.
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