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What is the primary mechanism by which generic Provigil promotes wakefulness and alertness?
Are there any long-term side effects associated with the regular use of Provigil online?
How does cheap Provigil compare to other cognitive enhancers, such as Ritalin or Adderall, in terms of effectiveness?
Is Provigil no prescription approved for use in treating conditions beyond narcolepsy, like ADHD or chronic fatigue syndrome?
Can Provigil be safely used by individuals without sleep disorders for occasional cognitive enhancement?
How do ethical considerations differ between using Provigil over the counter for medical purposes versus performance enhancement?
What role does modafinil play in industries or professions that require extended periods of focus, such as aviation or healthcare?

Provigil, a prescription-only drug, is primarily used to treat narcolepsy and other sleep disorders.
However, it is also used without a prescription as a cognitive enhancer by approximately 10% of UK university students. Previous studies have primarily examined the prevalence of and motivations for these behaviors. This research specifically focused on whether students perceive this behavior as cheating. Using a scenario-based approach, we quantified and qualitatively analyzed student perspectives on the issue. The majority of students did not consider this behavior to be cheating, partly due to comparisons with freely available stimulants such as caffeine and the belief that cognitive enhancement does not provide new knowledge or understanding.

A minority of students did view it as cheating, citing concerns related to fairness and access. Only a small number of students expressed no strong opinion on the matter. These perspectives remained largely unchanged even when students were presented with additional considerations about the ethics of cognitive enhancement using Provigil.

Introduction
Neuroenhancement refers to the use of drugs or other interventions to “modify brain processes with the aim of enhancing memory, mood, and attention in individuals not impaired by illness or disorder” (1). Cognitive enhancement, a subset of neuroenhancement, describes the use of stimulant drugs, often without a prescription, to improve performance on cognitive tasks such as university assessments. Commonly used cognitive enhancers include Provigil® (modafinil), Ritalin® (methylphenidate), and Adderall® (d-amphetamine) (2,3).

Provigil is a first-line treatment for narcolepsy and is available in the UK only by prescription (4). It is generally well-tolerated with a low risk of harm or abuse, leading to less stringent regulation compared to other prescription stimulants. For instance, in the United Kingdom, Provigil is classified as Schedule IV(II), meaning it is not illegal to possess without a prescription, though supplying it is prohibited (5).

While Provigil is officially approved for narcolepsy, it is widely prescribed “off-label” for conditions like excessive sleepiness linked to multiple sclerosis and depression. A 2004 report from its manufacturer estimated that 90% of Provigil prescriptions were for such off-label uses (6).

There is growing concern about the non-prescription use of prescription stimulants, such as Provigil, as cognitive enhancers (CEs) by university students. Media reports often portray this behavior as widespread (7). However, estimates of its prevalence vary. A recent review of cognitive enhancer use among UK university students found that 6.9% had used such drugs, with Provigil being the most common (9.9%) compared to methylphenidate (3.3%) and dexamphetamine (1.9%) (8).

The exact mechanism of action of Provigil is not fully understood, but it appears to involve catecholamine transport and activation of orexin neurons, leading to increased hypothalamic histamine release, which promotes wakefulness and alertness (9). In vitro studies have shown that Provigil inhibits dopamine reuptake (10). It has a long half-life of 12–15 hours (11). Common side effects of Provigil include anxiety, irregular heartbeat, headache, insomnia, nausea, and dizziness (10), though some of these effects may be influenced by placebo or expectancy (12). Provigil is inexpensive and widely available, with a single dose costing approximately £1.00 GBP ($1.21 USD, €1.15 EUR) and readily accessible via online black markets (13).

Although Provigil has attracted significant attention as a cognitive enhancer, its effects are relatively modest. A 2019 meta-analysis of studies up to July 2016 found a small but significant effect size (g = 0.1) across various standardized tests of attention, executive function, processing speed, and memory. Among these, the largest effect was observed for processing speed (g = 0.2), while effects on attention and memory were not statistically significant. The cognitive effects of Provigil overlap considerably with those of caffeine and have been likened to the impact of “a strong cup of coffee” (5). Similarly, its enhancement effects are comparable in magnitude to those of acute exercise (g = 0.1), though exercise may influence different cognitive processes and be accompanied by some negative effects on specific tasks (14).

The use of cognitive enhancers, such as Provigil, by university students raises ethical questions—chiefly, whether it constitutes cheating. While some researchers argue that it is, the most commonly raised concerns among academics and the general public center on issues of justice, safety, and coercion (15), rather than cheating per se. For example, healthy individuals who use Provigil to improve cognitive performance may gain an unfair advantage, allowing them to study longer and process information more quickly. Public attitudes toward cognitive enhancement tend to be more accepting when its use is “restorative” (addressing a problem) rather than “enhancing” (improving normal performance) (16).

This ethical dilemma mirrors debates in competitive sports, where cognitive enhancers like Provigil are considered “doping” agents. The World Anti-Doping Agency (WADA) includes Provigil on its list of banned substances, and some competitive activities, such as esports and chess, test participants for cognitive enhancer use (17).

It remains uncertain whether the use of cognitive enhancers, such as Provigil, by university students constitutes academic misconduct. This issue raises multiple concerns for universities, including health risks, legality, and academic integrity. In the United States, a policy analysis revealed that most universities classify unauthorized use of cognitive enhancers as drug misuse, yet very few include it under their academic integrity policies (18). Similarly, a UK study found that cognitive enhancers were largely absent from university policies on both academic integrity and drug misuse, even though their unauthorized use could logically fall under both categories (19). A qualitative study of policymakers in Australia echoed these findings, framing the use of cognitive enhancers as primarily a health issue rather than one of academic integrity (20).

Conversely, the authorized use of stimulants, including Provigil, has long been prevalent in military settings, although there is limited academic research on its use in this context (21). In military applications, Provigil is primarily used to counter the cognitive impairments caused by sleep deprivation rather than to treat narcolepsy. Furthermore, there is growing commercial interest in the cognitive enhancement potential of Provigil and similar substances. For instance, in 2018, the energy drink company Red Bull filed a patent for a Provigil analogue called “CE-123,” intended to improve motivation, cognitive function, and memory (22).

The aim of this study was to determine whether university students perceive cognitive enhancement with Provigil as a form of cheating. To achieve this, we conducted a scenario-based survey. The study initially captured students’ views on this issue and then examined their opinions on factors previously reported to influence perceptions of whether using Provigil constitutes cheating. These factors included whether performance enhanced by Provigil is an authentic reflection of true ability, the potential for coercion to use Provigil, equality of access, and comparisons to other enhancers such as caffeine (15). After considering these factors, students were asked again whether they believed Provigil use should be classified as cheating.

Methods
Ethical approval for this study was obtained from Swansea University’s Medical School Research Ethics Sub-Committee (SUMS RESC) (ethics approval number: 2022-0125).

Participants and Inclusion Criteria
Participants were recruited through the online platform Prolific (www.prolific.co). Eligible participants were required to (1) be university students in the UK, (2) be in at least their second year of study to ensure prior experience with higher education assessments, and (3) not be enrolled in professional programs (e.g., Medicine, Dentistry, Nursing, Law). Students in professional programs were excluded due to the potential influence of “Fitness to Practice” principles, which require adherence to ethical standards and could affect their attitudes toward cognitive enhancers and their responsibility to act if admitting to such use.

Recruitment
The Prolific advertisement invited participants to complete an anonymous survey about their views on the use of Provigil as a cognitive enhancer among UK university students. Participants were informed about attention checks and compensated at the Prolific-recommended “good” rate of £9/hour. A pilot study with 10 participants was conducted on February 10, 2023, to test the functionality of the Qualtrics/Prolific interface and confirm the survey duration for payment purposes. Since no adjustments were necessary after the pilot, additional participants were recruited and completed the study on February 13, 2023.

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