Printer Friendly

Beliefs and social norms about codeine and promethazine hydrochloride cough syrup (CPHCS) use and addiction among multi-ethnic college students.

Abstract--In this study a qualitative approach is used to investigate relevant beliefs and norms concerning the consumption, initiation, and perceived addiction of codeine and promethazine hydrochloride cough syrup (CPHCS) among 61 college-age students who identified themselves as current CPHCS users. In general, a majority of students stated that doctors and pharmacists were the greatest facilitators of CPHCS acquisition. A majority of students believed that their friends felt codeine promethazine use was "normal" and "cool" among college students their age, and that reinforcing factors, such as peer pressure and curiosity, contributed to initial CPHCS use.

Keywords--beliefs, codeine initiation, cough syrup, social norms, students


Cough syrup containing codeine and promethazine hydrochloride, known as "lean" and "drank" on the streets, has become a drug of choice for African-American teenagers in many Texas communities (Elwood 2001). The use of codeine and promethazine hydrochloride cough syrup (CPHCS) was encouraged by an innovative form of hip-hop rap music in the Houston area known as "screw music" (Demby 2001). The Texas Commission on Alcohol and Drug Abuse has expressed a growing concern about the availability of cough syrups containing codeine (Elwood 1999). A recent study by Peters and colleagues (2003a) revealed that 25% of Houstonian at-risk youth reported lifetime CPHCS use, while 10% reported use within the last 30 days.

Codeine, a naturally occurring narcotic, is generally used for pain control and as an antitussive agent in prescribed cough syrups. Promethazine hydrochloride is a phenothiazine derivative used in cough syrups for its antihistaminic, antiemetic, and sedative effects (Hickson, Altemeier & Clayton 1990). A popular trend in CPHCS use calls for mixing it with soda (Sprite or Big Red) and/or fruit candy, such as Skittles or Jolly Ranchers brand candies (Peters et al. 2003a). Consuming large quantities of these two drugs prolongs and intensifies each drug's sedative effects and is responsible for an increase in life-threatening events (Matto et al. 1997; Gerostamoulos, Burke & Drummer 1996).

Although CPHCS is addictive, the relationship between the onset of use and addiction is unknown (Gerostamoulos, Burke & Drummer 1996). In a Houston-based study conducted by Peters and colleagues (2003a), 50% of high school CPHCS users interviewed stated that they were addicted after their initial consumption. In addition, 69% of users studied stated that their second CPHCS use event occurred during the same day or the day following their initial use. Another study by Matto and colleagues (1999) defined codeine cough syrup addiction as unsuccessful attempts to quit.

To address the gaps in the literature, the present authors undertook a qualitative study to explore CPHCS use and addiction in a multi-ethnic sample of current CPHCS-using college students. When coupled with the theory of planned behavior, beliefs and subjective norms are important constructs in understanding behavior (Ajzen 1991). According to the theory, the most significant determinant of a person's behavior is behavior intent. The individual's intention to perform a behavior is a combination of attitude toward performing the behavior and subjective norm. The individual's attitude toward the behavior includes their behavioral belief, evaluations of behavioral outcome, subjective norms, normative beliefs, and the motivation to fulfill their behavior. Accordingly, we selected a qualitative approach to allow the language, perceptions, beliefs, and subjective norms of the young adults studied to manifest themselves in our research results.



Members of the project team met with administrative personnel from a large historically Black university in the southwestern region of the United States to secure approval to conduct the study on campus. Project personnel used face-to-face recruitment methodology to identify study participants. After receiving approval, five trained graduate research assistants were asked to identify undergraduate students who would be interested in participating in focus groups about attitudes and behaviors related to CPHCS use. Focus groups and one-on-one interviews were the data-gathering methods used in this study. The five research assistants (four females and one male) explained the participation requirements and procedures to interested students. CPHCS use status was determined using criteria based on the Youth Risk Behavior Survey's (YRBS) definition of a current drug user as one who has used the drug at least one day during the past 30 days(CDC 2004). A two-step process was used to identify current CPHCS users. First, students were asked, "Have you used syrup in the last 30 days?" Students who reported 30-day use were asked, "What brand of cough syrup do you use?"

Krueger's (1994) methodology for focus group conduct was used to guide this investigation. The interviews were tape-recorded and documented. The graduate research assistants conducted all of the focus groups. The qualitative research session began with a short introduction of this investigation and an overview of the confidentiality of the focus group. This preceded questions on age, race, sex, and an "icebreaker" question: "What is your favorite spring break activity?" In closing the focus groups, we extended our appreciation for the student's participation.

Nine open-ended questions were used to obtain participants' views and beliefs regarding their early experiences with CPHCS and how they view their stage of addiction. They were: (1) What influenced you to use syrup? (2) Why do people use it? (3) Where do people get it from? (4) What do people drink it with? (5) What do your friends feel about people who use codeine promethazine? (6) What other drugs might you use with codeine promethazine? (7) What are some consequences of codeine promethazine use? (8) What is a barrier to people quitting codeine promethazine use? (9) When do you know someone is addicted to codeine promethazine? All questions represent the theoretical constructs of social norms and personal beliefs.

Each interview was transcribed verbatim, with interviewers being called on to neutrally draw complete responses to certain questions. Upon completion of the interviews, the transcripts were coded in order to categorize participants' beliefs regarding their use of and addiction to CPHCS.


Sample Characteristics

A total of 307 college students were invited to participate in this study. Of these, 61 participants reported being current CPHCS users. Of these 61 participants, 34 (56%) were male. Most of these participants (70%) were Black.


Table 1 illustrates quotations portraying beliefs related to themes associated with codeine use and perceived addiction. These broad themes are presented as directly reported by participants. Table 2 illustrates comparisons of themes by gender.

What Influenced You to Use Syrup?

This question was used to ascertain reasons of onset. Both genders named "peer pressure" (71% males vs. 72% females) as the primary impetus to their use of syrup. Respondents noted "curiosity" (14% males vs. 16% females) as the second most prevalent influence for use, while a total of 20% from both groups had no idea what initially influenced them to use CPHCS.

Why Do People Use It?

This question was designed to gather information concerning the current factors that contribute to CPHCS use. Some gender variability appeared in the reasons people used CPHCS (Table 2). A high percentage of male and females (58% males vs. 72% females) indicated they used CPHCS for its "euphoric effect." However, five times as many males indicated that they used CPHCS because of "self-medication/ coping" (25% males vs. 5% females)

Where Do People Get It?

Both groups indicated "doctors" as the primary mode of CPHCS procurement (36% males vs. 29% females). Females appear to rely more on pharmacist (26%) as the second source for securing CPHCS, while males use friends (26%) as their second source for obtaining CPHCS. Both groups indicated that they use "streets" (13% males vs. 11% females) and "drug dealers" (10% males vs. 15% females) as additional sources for CPHCS procurement.

What Do People Drink It With?

The majority of students stated that they drank CPHCS with Sprite (33% males vs. 66% females) and other soda or fruit juice (57% males). A relatively small percentage of respondents reported that they used alcohol (8% males) with CPHCS. It is interesting to note that the same number of females (12%) reported using alcohol with CPHCS as reported taking CPHCS straight. No males reported taking CPHCS straight.

What Do Your Friends Feel About People Who Use Codeine Promethazine?

The most influential statements among females were found to be those such as "cool image" (61%), while male respondents stated that the majority of their friends (63%) felt it was "normal" to use CPHCS.

What Other Drugs Might You Use with Codeine Promethazine?

Both genders' chief response was "weed" (marijuana) (70% males vs. 75% females). Other themes related to other drugs used with CPHCS included Xanax (19% males vs. 15% females) and Ecstasy (8% males vs. 10% females).

What Are Some Consequences of Codeine Promethazine Use?

"Drowsiness," (55% males vs. 54% females) followed by "damage to organs," (27% males vs. 31% females) ranked highest among consequences of CPHCS use (Table 2). Both genders indicated that "death" (10% males vs. 4% females) and "addiction" (7% males vs. 9% females) were additional consequences of CPHCS use.

What Is a Barrier to People Quitting Codeine Promethazine Use?

"Withdrawal" (45%) followed by "addiction" (32%) and "peer pressure" (22%) emerged as the most frequent barriers to quitting CPHCS use among males. For females, "addiction" (69%) was by far the most frequent barrier to CPHCS cessation.

When Do You Know Someone Is Addicted to Codeine Promethazine?

"Craving/fiend" (54% males vs. 65% females) emerged as the most frequent response for all respondents. For males, "slurred speech" (6%) and "weight gain" (6%) were found to be strong indicators of addictive behavior.


Using a qualitative approach, the current study explored the beliefs and norms associated with CPHCS initiation and perceived addiction among current CPHCS users. The college students who participated in these focus groups believed that their friends considered codeine promethazine use "normal" and "cool" among students their age, and that several factors, including peer pressure and curiosity, contributed to the onset of abuse. Most of the participants believed that people use CPHCS for the euphoric effect, because of peer pressure, and for self-medication, and that the major consequences of CPHCS use are drowsiness and "damage to organs." Participants reported that most users take CPHCS with soda, and that other drugs often used with CPHCS include "weed" and Xanax (alprazolam). In addition, study participants believe that people have a serious fiend or craving when addicted to CPHCS. These findings build on earlier work by Peters and colleagues (2003b) suggest that some CPHCS users believe that if someone wanted to stop it would be difficult because of the addictiveness and peer pressure involved with its use. In addition, the current study suggests that CPHCS ingestion can be viewed among college students as a normal social event.

A majority of students reported that doctors and pharmacists were the most frequent facilitators of CPHCS acquisition. In addition, withdrawal and addiction were the major barriers to CPHCS cessation. Some physicians and pharmacists have sold and prescribed CPHCS illegally for financial gain. However, for legitimate doctors, it is difficult to determine if a patient is visiting the clinic because of a real health problem or for secondary gain. The diagnosis of a medical problem is based on the information received from the patient and how it corresponds with results from physical exams given by doctors. However, coughing is a symptom that could easily be fabricated by a patient and demonstrated while visiting the doctor's office. It would be wise for doctors to prescribe antitussives that do not contain codeine, promethazine hydrochloride or other substances that have high abuse potential, such as benzonate (Tessalon Perles) and dextromethorphan (Robitussin DM).

Since the inception of slavery, Blacks have created and diffused various forms of music to communicate community problems and concerns. MC Herc in the Bronx, New York, created hip-hop music for inner-city youths to communicate their thoughts and experiences. In Houston, DJ Screw invented a slow beat version of this music that heavily endorsed CPHCS use. This art form has diffused through radio and music videos and the record industry has profited from multi-platinum sales across the United States. While "screw music" may be considered an ingenious and inventive art form by many, its messages, which advocate reckless use of CPHCS, may have unmeasured and unwanted repercussions for the individual user and for society.

Qualitative research provides an opportunity to explore subjective aspects of human behavior and to identify salient personal beliefs. The present findings are limited by the number and types of questions asked of participating students. Because participants were recruited from a single historically Black university in the southwestern United States, the generalizability of findings to different college populations is unknown. However, the data uncovered in this research offer interesting possibilities for future quantitative research.

While the sample size was limited and did not have balanced gender representation, a wealth of information was received from each of the 61 student participants. Future studies, both qualitative and quantitative, can address gender as well as ethnic comparisons in college student beliefs related to codeine promethazine use and addiction. A particular gender-oriented question that was stimulated by this research and requires clarification is the potential physical and behavioral effects that may occur as a result of the strength of CPHCS used. For example, in this study only females reported using CPHCS straight. To what extent is this pattern reflective of the general historical Black college students or the Black population in general? What, if any physical (e.g., dizziness and blackouts) and/or behavioral (e.g., fighting and sexual indiscretions) effects may occur for females who have ingested CPHCS at full strength?

With respect to alcohol, men who consume five or more drinks in a row over a short period of time are considered binge drinkers (Wechsler 2000) Women only require four or more drinks to be designated binge drinkers. Research has indicated that a host of alcohol problems may occur as a result of binge drinking, such as fighting (Wechsler 2000). Is there a comparable gender definition for CPHCS use as there is for binge drinking? Such interesting questions are stimulated by the current investigation and require clarification in further research. These limitations aside, the current qualitative investigation helps to elucidate college students' social norms and beliefs regarding CPHCS dependence and may assist in the prevention of initial consumption.


Ajzen, I. 1991. The theory of planned behavior. Organizational Behavior and Human Decision Processes 50: 1-33.

Centers for Disease Control and Prevention (CDC). 2004. Youth Risk Behavior Survey United States 2003. Atlanta, GA: Centers for Disease Control and Prevention.

Demby, E. 2001. Codeine overdose killed DJ Screw. Available at www.

Elwood, W. 2001. Sticky business: Patterns of procurement and misuse of prescription cough syrup in Houston. Journal of Psychoactive Drugs 33: 121-33.

Elwood, W. 1999. Leaning on Syrup: The Misuse of Opioid Cough Syrup in Houston, Texas. Austin, TX: Commission on Alcohol and Drug Abuse.

Gerostamoulos, J.; Burke, M. & Drummer, M. 1996. Involvement of codeine in drug-related deaths. American Journal of Forensic Medicine and Pathology 17: 327-35.

Hickson, G.; Altemeier, W. & Clayton, E. 1990. Should promethazine in liquid form be available without prescription? Pediatrics 86: 221-25.

Krueger, R. 1994. Focus Groups: A Practical Guide for Applied Research. Second Edition. Thousand Oaks, CA: Sage Publications.

Matto, S.; Basu, D.; Sharma, A.; Balaji, M. & Malotra, A. 1999. Subtypes of codeine cough syrup abuser. Indian Journal of Medical Science 53: 97-102.

Matto, S.; Basu, D.; Sharma, A.; Balaji, M. & Malotra, A. 1997. Abuse of codeine containing cough syrups: A report from India. Addiction 92: 1783-87.

Peters, R.; Kelder, S.; Markham, C.; Yacoubian, G.; Peters, L. & Ellis, A. 2003a. Beliefs and social norms about codeine and promethazine hydrochloride cough syrup (CPHCS) onset and perceived addiction among urban Houstonian adolescents: An addiction trend in the City of Lean. Journal of Drug Education 33 (4): 415-25.

Peters, R.; Tortolero, S.; Addy, R.; Markham, C.; Yacoubian, G. & Escobar-Chaves, E. 2003b. Drug use among alternative school students: Findings from Houston's Safer Choices II Program. Journal of Psychoactive Drugs 35 (3): 383-87.

Wechsler, H. 2000. Binge drinking: Should we attack the name or the problem? Chronicle of Higher Education 47: B12-13.

Ronald Peters, Jr., Dr.P.H., M.S. *; George S. Yacoubian, Jr., Ph.D. **; Warren Rhodes, Ph.D. ***; Karry J. Forsythe, B.A. ****; Kameko S. Bowers, B.S. ****; Valencia M. Eulian, B.S. ****; Clemmie A. Mangum, B.S. ****; Jamie D. O'Neal, B.S. ****; Queen Martin, Dr.P.H. ***** ; ; & E. James Essien, M.D., Dr.P.H. ******

* Assistant Professor, University of Texas School of Public Health, 7000 Fannin Suite 2618, Houston, TX.

** Research Scientist, Pacific Institute for Research Evaluation, Calverton, MD.

*** Professor, Department of Psychology, Morgan State University, Baltimore, MD.

**** Graduate Student, Department of Health and Human Performance. Prairie View A & M University, Prairie View, TX.

***** Assistant Professor, Department of Health and Human Performance. Prairie View A & M University, Prairie View, TX.

****** Associate Professor, College of Pharmacy, University of Houston, Houston, TX.

Please address correspondence and reprint requests to Ronald Peters, Jr., Dr.P.H., M.S., 7000 Fannin, 26th Floor, Houston, Texas 77030. Tel.: 713-500-9642; Fax.: 713-500-9602; Email.:
Examples of Salient Beliefs Related to Codeine Promethazine Use and
Perceived Addiction

Bad/Poor Image "Don't care to hang out with people who
 do that"

Boredom "I was bored and was trying to pass time and
 had nothing else to do"

Cool/Image "Cause they think it's the bomb baby,"
 It's cool

Curiosity "To experience the feeling-same feeling as if
 you were drinking alcohol"

Doctors "People that get Medicaid would get it from a
 doctor and sell it,". "People get it from the
 doctor when they get well, they sell
 the rest"

Drowsiness "It makes me drowsy, may wreck if I am
 driving," "It makes me fall out,",
 Reaction is slow

Drug Dealers/ "A friend who has a friend, who knows
Prescription someone, that knows someone that is a
Acquisition pharmacist," "Shit, from the syrup man,"
 "I had a friend who worked at the pharmacist
 and she used to hook it up like that," "Get
 it from your local syrup man or your local
 drug dealer"

Euphoric Effect "It makes you feel good and taste good,"
 That high level or other level, "Relieve
 stress in your life,"
 "I like the high I get," "The feeling they
 get, you ain't gonna taste nothing like it
 and the feeling you get is straight too"

Lack of Knowledge "Don't see the harm," "There's a lot of drugs
 out there that help people with the flu and
 something, and somebody get a hold
 of it and be abusing it"

Media Modeling "Rappers are using that purple stuff," "The
 music I listen to, it was all they talked
 about in the music I listen to and that is
 what interests me"

Peer Pressure "To be a part of the crowd,"
 It's socially acceptable

Recurrence "Want it all the time," "Want it constantly
 24-7," "Can't go 30 days wthout it"

Self-Medication/Coping "Something to relieve the stress and relax"

Soda "Depends on what kind of soda you drank,
 I sip mine with Sprite."

Taste "I like taking medicine," "Cause they
 like the taste"

Withdrawal "They want it all the time no matter how much
 it cost or what it takes to get it," "Need it
 to function on a daily basis," "When you
 drink it so much, and didn't have it anymore,
 your stomach starts to hurt and
 you will fiend for it"

Gender Comparisons of Salient Beliefs Related to Codeine Promethazine
Use and Perceived Addiction


What influenced you to use syrup? Peer pressure 71% (24)
 Curiosity 14% (5)
 Don't know 14% (5)

Why do people use it? Euphoric effect 58% (18)
 Self-med/ coping 25% (8)
 Peer pressure 16% (5)

Where do people get it? Doctors 36% (11)
 Friends 26% (8)
 Pharmacist 13% (4)
 Streets 13% (4)
 Drug dealers 10% (3)

What do people drink it with? Sprite 33% (16)
 Soda 27% (13)
 Fruit Juice 18% (9)
 Big Red soda 8% (4)
 Alcohol 8% (4)
 Coke 4% (2)

What do your friends feel about people Normal image 63% (12)
who use codeine promethazine? Bad/poor image 21% (4)
 Condone It 15% (3)

What other drugs might you use with Weed 70% (26)
codeine promethazine? Xanax 19% (7)
 Ecstasy 8% (3)
 Vicodin 3% (1)

What are some consequences of codeine Drowsiness 55% (16)
promethazine use? Damage to organs 27% (8)
 Death 10% (3)
 Addiction 7% (2)

What is a barrier to people Withdrawal 45% (10)
quitting codeine promethazine use? Addiction 32% (7)
 Peer pressure 22% (5)

When do you know someone is addicted Crave it /fiend 54% (18)
to codeine promethazine? Don't know 33% (11)
 Slurred speech 6% (2)
 Weight gain 6% (2)


What influenced you to use syrup? Peer pressure 72% (13)
 Curiosity 16% (3)
 Don't know 6% (1)
 Boredom 6% (1)

Why do people use it? Euphoric effect 72% (13)
 Peer pressure 22% (4)
 Self-med/ coping 5% (1)

Where do people get it? Doctors 29% (8)
 Pharmacist 26% (7)
 Family/friends 18% (5)
 Drug dealers 15% (4)
 Streets 11% (3)

What do people drink it with? Sprite 66% (16)
 Straight 12% (3)
 Alcohol 12% (3)
 Jolly Ranchers 4% (1)
 Water 4% (1)

What do your friends feel about people Cool image 61% (11)
who use codeine promethazine? Not important 27% (5)
 Bad/poor image 5% (1)
 Stupidity 5% (1)

What other drugs might you use with Weed 75% (15)
codeine promethazine? Xanax 15% (3)
 Ecstasy 10% (2)

What are some consequences of codeine Drowsiness 54% (12)
promethazine use? Damage to organs 31% (7)
 Addiction 9% (2)
 Death 4% (1)

What is a barrier to people Addiction 69% (9)
quitting codeine promethazine use? Peer pressure 15% (2)
 Environment 15% (2)

When do you know someone is addicted Crave it/fiend 65% (15)
to codeine promethazine? Don't know 34% (8)

Note: Frequencies are shown in parentheses.
COPYRIGHT 2007 Haight-Ashbury Publications
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2007 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Peters, Ronald, Jr.; Yacoubian, George S., Jr.; Rhodes, Warren; Forsythe, Karry J.; Bowers, Kameko S
Publication:Journal of Psychoactive Drugs
Geographic Code:1USA
Date:Sep 1, 2007
Previous Article:An exploratory study of OxyContin use among individuals with substance use disorders.
Next Article:Understanding the working alliance between persons with substance abuse problems and strengths-based case managers ([dagger]).

Related Articles
The abuse of dextromethorphan-based cough syrup: a pilot study of the community of Waynesboro, Pennsylvania.
Coughs get choc therapy.
Pain pills addiction warning.

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters