The drive to succeed, to perform at the highest attainable level, is a natural component of competitive athletics. Among certain athletes, this drive may culminate in the use of performance enhancing substances or devices (Catlin et al., 2008; Lippi et al., 2008a). Sports governing bodies, such as the World Anti-Doping Agency (WADA), are primarily concerned with athletic performances achieved with unfair of dangerous means - whether these be specific techniques, equipment, substances, or medications. Drug ‘doping,’ the chemical alteration of athletic performances by a substance or procedure, can be associated with deleterious effects on health (Davis and Summers, 2008; Dodge and Jaccard, 2008; Lage et al., 2002, Spedding and Spedding, 2008). The WADA characterizes a drug as “illegal” in competition if it satisfies two of the following three criteria: 1) enhances performance, 2) represents a risk to health, and 3) violates the “Spirit of the Sport” (Savulescu et al., 2004). Non-pharmacological means of gaining unfair advantage, such as unsanctioned equipment modifications, typically fall under the jurisdiction of sports’ individual governing bodies.

Despite potential health risks and penal repercussions (e.g., forfeiture of winnings, sport banishment) associated with doping and the use of other unsanctioned products/equipment, the use of banned performance enhancing products (PEPs) remains an issue in virtually all adult competitive sports (Lippi et al., 2008b; Noakes, 2004). In the empirical literature, the use of any substance (sanctioned or unsanctioned) to enhance performance in the face of perceived obstacles is generally defined as “doping behavior” (Johnson, 2000; Laure, 2000). Although ample evidence illustrates the dangers of doping and prevalence rates among athletes in different sports (Alaranta et al., 2006), research exploring the attitudes and beliefs that may contribute to use of unsanctioned substances/products are inconsistent. While some findings suggests that doping users and non-users may perceive health risks differently, the contributions of proposed demographic and psychological variables (e.g., self esteem, anxiety) are equivocal (Kirby et al., 2011; Laure and Binsinger, 2007; Laure et al., 2004; Mazanov et al., 2008). Despite uncertainty in the literature, it is generally understood that athletes’ rationales for using PEPs likely include a desire to maximize performance/succeed (Anshel, 1991; Laure and Binsinger, 2005) and perceptions of risks to health (Lentillon-Kaestner et al., 2012).

A challenge in developing theoretically sound and applicable PEP use models is the complexity and heterogeneity in which these behaviors occur. It is well known in the social sciences literature that beliefs, motivations, attitudes and environmental factors play an important role in understanding and predicting behavior (Ajzen, 2001). Within the context of doping behaviors, this is perhaps best summarized in Backhouse’s WADA manuscript on drug use attitudes and behaviors in sports (Backhouse et al., 2011). In this comprehensive literature review, the authors systematically highlight how doping appraisals and actions are largely dependent on contextual factors, including the type of sport (e.g., body building vs. cycling), level of competition (e.g., high school, college, professional competition), and the characteristics of the individual (e.g., athlete, coach, general population).

Existing models of doping behaviors attempt to account for the complexity of this phenomenon, and often incorporate key psychological and societal/environmental factors. For example, the Drugs in Sports Deterrence model (DSDM) highlights the role of decisional processes involved in performance enhancer use, as well as the contributions of other factors (e.g. affect, cognition) that may influence this cost-benefit analysis (Strelan and Boeckmann, 2003). Another conceptual framework, the Drug Compliance in Sports Model, presents eight factors believed to influence intentions towards drug use: threat appraisal; benefit appraisal; personal morality; legitimacy; personal self-esteem; reference group opinion; drug affordability; and drug availability (Donovan et al., 2002). While these and other promising theories exist (Petróczi and Aidman, 2008 ; Strelan and Boeckmann, 2003), further empirical derived models are need, as existing perspectives often fail to account for considerable amounts of variance in predicting doping behaviors and attitudes (Petróczi, 2007).

A challenge encountered by sports governing bodies is the reality that it is virtually impossible for laws/regulations/rules to keep up with the technological advances of doping, particularly as newer drugs mimic natural human processes (Savulescu et al., 2004). This challenge also falls on athletes; in pursuit of an advantage, a competitor may find a category of PEPs that is not explicitly listed as banned or non-banned. Legal/non-banned PEPs is a broad and subjective category, as an athlete may (correctly or incorrectly) perceive virtually anything as contributing to improved performance (e.g., equipment, dietary modifications, clothing, etc). Even among established guidelines, the ethics of PEPs use can be unclear, confusing, and contradictory. For example, while the use of technologically-constructed hypoxic environments are approved by many sports governing bodies, the mechanisms underlying their efficacy are similar to those of erythropoietin (EPO), a banned substance (Loland and Caplan, 2008). Another example is the well-publicized use of AOD-9604, an analogue of growth hormone releasing factor, by the Australian Essendon Football Club in 2012. This relatively new compound fell under the WADA’s “S.O.” category, and thus, should have been prohibited (Paton, 2013). Predictably, the ethics of “legal” and “illegal” performance enhancement have become increasingly blurred as recent studies illustrate that society has become more tolerant of doping over time (Vangrunderbeek and Tolleneer, 2011). Another potential concern lies in dietary supplements - frequently used by athletes as non-banned PEPs - which are not required to undergo testing to confirm efficacy or safety (Dodge and Jaccard, 2007). Unfortunately, our knowledge of effective anti-doping programs is still in its infancy; this outcome literature is narrowly focused in the realm of anabolic steroid use (Sjöqvist et al., 2008), and results suggest that education alone is likely insufficient to change behaviors (Backhouse et al., 2011).

To fully understand the complexity of doping/cheating drives among athletes, it is important to also understand the motivations and attitudes driving legal/non-banned PEP use. As most efforts to eradicate doping/cheating among elite cyclists have been ineffective (Lippi et al., 2008b), a greater understanding of the interplay between athletes attitudes and beliefs about PEPs and doping behaviors is essential. Thus, the aim of the present pilot study is to examine legal, ethical, and practical considerations in choosing to use legal/non-banned PEPs among a sample of competitive cyclists, and how these attitudes may influence sanctioned/banned PEP use behaviors. Additionally, we sought to examine the differential importance of World Anti-Doping Agency (WADA) and Union Cycliste Internationale (UCI) doping criteria among non-banned PEP users.

Participants comprised 68 adult non-professional competitive cyclists (61 males and 7 females; M age = 36.38, SD = 10.35). Participants had to be 18 years or older. The sample’s household income (M = $128.84 thousand, SD = $151.93) and educational attainment (77.9% had either a college or graduate degree; only one participant had no college or graduate education) suggests overall moderate to high socioeconomic status. The racial breakdown of our sample was as follows: Caucasian (n = 59); Hispanic/Latino (n = 6); Asian or Pacific Islander (n = 1); and “other” (n = 2).

The present study was approved by the University of Florida Institutional Review Board. The study was advertised through flyers posted throughout the University of Florida campus as well as bike shops and cycling races in the surrounding community. Interested cyclists were provided a URL to access the web-based survey. The survey took less than five minutes to complete and consisted of twenty-two items assessing demographic characteristics and attitudes towards performance enhancing products (PEPs). Only select items were used for the present study. Informed consent was obtained from each cyclist and all responses were anonymous.

Visual analogue scale (VAS) measurements were used by participants to evaluate the importance of choosing PEPs for several distinct categories. These included “UCI Items” - four doping rationale categories presented in a UCI anti-doping certification program, and “Incentive Items” - additional factors that related to doping incentives (Table 1). Three of the four UCI items are also consistent with WADA criteria for doping. VAS anchors were “Not at all important” and “Extremely important.”

Cyclists were first asked to rate the importance of four criteria (i.e., the UCI Items) believed to be of significance in choosing to use PEPs: 1) getting caught by the Antidoping Agency (ADA); 2) amount of performance improvement; 3) risk to health; and 4) violation of the spirit of the sport. Participants rated the importance of each of these factors by the “legality” of the PEPs - either banned or non-banned PEPs - comprising a total of eight VAS ratings.

For the “Incentive Items,” cyclists rated the importance of choosing any PEP (i.e. PEP legality was not specified) for three additional factors: 1) winning, 2) obtaining/retaining sponsorship, 3) and maintaining competitiveness with other cyclists using PEPs.

Cyclist responded either “yes” or “no” as to whether they used non-banned PEPs.

Means and standard deviations were calculated for all continuous VAS survey outcomes (Table 1). Frequencies were calculated for all categorical variables.

UCI Items/Factors: A 4 x 2 x 2 mixed-model ANOVA examined the relationship between the four UCI Items and related PEP factors. The importance of PEP legality (i.e. choosing banned or non-banned PEPs) served as a dichotomous within-subjects factor. Non-banned PEP users vs. non-users served as a dichotomous between-subjects factor. All significant main effects and interactions were further decomposed with Bonferroni adjusted post hoc comparisons.

Incentive Items/Factors: A 3 x 2 mixed-model ANOVA examined the relationship between the three Incentive Items and non-banned PEP use. Similar to the first ANOVA, non-banned users vs. non-users served as the dichotomous between-subjects factor. All significant effects were further decomposed with Bonferroni adjusted post hoc comparisons.

On average, the sample had over nine years experience as competitive cyclists (M = 9.16, SD = 8.08). Only five cyclists reported that they had ever used a banned PEP, while the vast majority (n = 63) denied using said products. Each of the five cyclists reported using one banned PEP each: marijuana, EPO, amphetamines, Viagra, and “B complexes, vitamin C and D.” Over half the cyclists (n = 41) reported using non-banned PEP, while 27 denied use of these products. There was wide range of perceived non-banned PEPs endorsed, including over the counter supplements, energy drinks, electrolyte replacement products, EP-No, equipment modifications (e.g., power meter, aero efficient equipment, HR monitor, altitude tent, etc.) and Viagra. The fact that a non-banned PEP was perceived as banned (i.e. “b complexes, Vitamin C and D”) and vice versa (i.e. Viagra) illustrates the confusion regarding PEPs likely experienced by many athletes. Means and standard deviations for survey VAS outcomes are presented in Table 1.

UCI Items were overall rated from most to least important in the following order: risk to health; performance improvement; violating the spirit of the sport; and being caught by the ADA. There were significant overall differences between the four factors (p < 0.001); only the difference between performance improvement and violating the spirit of the sport was not statistically significant (p > 0.05). Ratings of PEP legality (i.e., banned vs. non-banned) and non-banned users vs. non- users were not significant (p > 0.05).

An interaction between UCI Items and PEP legality was observed (p < 0.001). While the importance of choosing non-banned PEPs had an identical UCI Item rank order as described above, for banned PEPs, the rank order (from most to least important) was as follows: health; spirit of the sport; performance improvement; and being caught by the ADA. Additionally, only the difference between risk to heath and violating the spirit of the sport was not significant. Comparing individual UCI Items, violating the spirit of the sport and being caught by the ADA were more important when choosing banned PEPs; performance improvement was more important when choosing non-banned PEPs.

There was a significant 3-way interaction spanning all domains - UCI Items, PEP users vs. non-users, and PEP Legality (p < 0.001). For example, the importance of spirit of the sport over performance improvement was only consistent within the context of choosing banned PEPs; within the context of non-banned PEP use, performance improvement was more important for non-banned PEP users while these items were equally important for non-users. Additional post hoc comparisons for the interaction are detailed in Table 2.

Overall, both winning (p < 0.001) and maintaining competitiveness with other riders using PEPs (p < 0.001) were significantly more important than maintaining sponsorship (Table 3). There was no significant difference between winning and maintaining competition with other cyclists using PEP (p > 0.05). There were no overall significant differences between PEP users and non-users (p > 0.05), although the interaction of this factors with UCI Items trended towards significance (p = 0.058).

The aim of the present investigation was to identify the importance of several factors, including WADA/UCI doping criteria, in choosing to use PEPs among competitive cyclists, and to determine the extent to which these factors interact across different contexts. A unique aspect of this pilot study was the examination of attitudes towards non-banned PEP use - an areas that has received scant attention in the literature (Dodge and Jaccard, 2007). Although use of banned PEPs was low in our sample (less than 8 %), over 60% of the cyclists endorsed using non-banned PEPs. Overall, risk to health was the most important factor and being caught by the ADA was least important in selecting PEPs. Not surprising for our sample of non-professional athletes, winning and maintaining competiveness were viewed as more important than preserving sponsorship. Although not a priori hypothesized, several interactions between factors were observed, highlighting the complexity of attitudes towards PEP use across different contexts and sample sub-populations.

Although rated as the overall most important criteria in choosing to use PEPs, risk to health was deemed as important as other UCI Items under certain conditions. For example, violating the spirit of the sport was as important as risk to health when considering banned PEPs. Within the context of non-banned PEP use, performance improvement was as important as risk to health, though only for cyclists acknowledging non-banned PEP use. The value of health (compared to other UCI items) was consistently high for cyclists identifying themselves as PEP non-users.

Getting caught by the ADA was the least important UCI factor when choosing a PEP under most circumstances. Within the context of banned PEP use, performance improvement was equally unimportant. Not surprisingly, being caught by the ADA was generally less important when choosing to use a non-banned PEP.

Performance improvement (along with spirit of the sport), was one of the UCI Items that was most influenced by contextual factors. Although typically falling somewhere between the important of health and being caught by the ADA, under certain contexts (described above) it was as meaningful as the most important factors or as insignificant as the least important factor. Within the context of non-banned PEP use, performance improvement was more important than spirit of the sports for non-banned users and equally important as spirit of the sports for non-users.

The WADA code of ethics (2009) defines “Spirit of The Sport” as “the celebration of the human spirit, body and mind” characterized by several values, including “ethics, fair play, and honestly,” “respect for rules and laws,” “health,” and “excellence in performance.” Some research suggests that, among the general population, “heath” is often considered when conceptualizing this concept (Mazanov et al., 2008). This UCI Item was highly context dependent. For example, within the context of choosing banned PEPs, non-banned PEP users rated it as equally important as health while non-users rated health as more important. Furthermore, within the context of choosing non-banned PEPs, spirit of the sport was much less important than performance improvement for non-banned PEP users, while these factors were equally important for non-users.

Our sample viewed maintaining competitiveness and winning as more important than retaining sponsorship across all settings. This was an expected finding considering the sample of non-professional athletes. A trend towards significance (p = 0.058) suggests that non-banned PEP users may value winning and competition more than their non-user counterparts. Additional studies are needed with larger sample sizes to explore this relationship.

There were several limitations to this study. Firstly, this population represents a convenience sample of cyclists who responded to study advertisements at races and through online message boards, making our research susceptible to potential selection bias issues common in survey research. Also, although the use of self-report measures is prevalent in doping research, these measures have some limitations, including the tendency for self-presentation bias (Backhouse et al., 2011). More work also is needed to establish the psychometric properties of our survey measure. While our examination of non-banned PEPs was a strength, no specific definition of non-banned PEPs was given. The findings could have been enriched if we examined banned PEP users and non-users in our model. Although these data were collected, a limited sample of PEP users (n = 5) would have drastically limited the interpretations of those findings. We hope to present findings from a more robust data set in the future. Although the factors examined in this study were composed of WADA and UCI doping criteria, survey construction was not driven by a specific theoretical model. Similarly, the authors understand that there are several possible contributors to doping behavior (e.g., affect, self-esteem, reference group opinion) that were not incorporated into the pilot study; we aim to broaden the scope of our investigation in future iterations of our survey methodology. Finally, although the sample size was too small for model testing, the investigators hope is that these findings will contribute to existing or new hypothesis-driven theoretical models.

These results show that PEP use is widespread, even in a sample of amateur, well-educated, relatively wealthy cyclists. The distinction between “banned” and “non-banned” products is often unclear, and the use of these products by the cyclist sample is not decided on simple factors. Non-banned PEPs that purport to manipulate the same parameters as banned substances (red blood cell count, for instance) might still be used, despite potentially similar risks to health. This highlights that the decision to use banned or non-banned PEPs is likely complex and multifactorial, and may support a “slippery slope” conceptualization of PEP use. Forming firm distinctions between types of PEPs and the criteria for their legality is difficult, and perhaps not always well understood by the typical athlete. This may contribute to lessening the distinction between banned and non-banned approaches, and subsequent use. Findings from the current investigation are important contributions to the literature as there is relatively sparse evidence, empirical or theoretical, on factors that may impact PEP use among athletes (Petróczi and Aidman, 2008). Although some theory-driven models have been developed (Perko et al., 2000, Dodge et al., 2003), this literature is still in it’s infancy. Understanding the differences in attitudes among adult athletes who use and don’t use PEPs may help to formulate theories on how other factors (e.g., societal, psychological) drive doping behaviors, and ultimately, may inform effective anti-doping measures and prevention programs.