PONE-D-23-05413Exploring Perceptions of Self-Stigma of Substance Use and Current Substance Use Patterns among College StudentsPLOS ONE

Dear Dr. Bravo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

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Boshra Ismael Ahmed Arnout

Academic Editor

PLOS ONE

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Additional Editor Comments:

Dear Author

The paper PONE-D-23-05413 has been reviewed by experts in the field who consider that the paper can publish after major revision.

We wish you a meaningful day.

Yours Sincerely

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This study examined the relationship between perceived self-stigma related to substance use disorders and engagement in substance use among non-clinical populations. The results showed that individuals with lifetime use but no substance use in the last 30-day reported higher levels of self-stigma. Perceived impact of SUD on sense of self-efficacy and self-esteem related negatively to nearly all observed factors of alcohol and marijuana use. The study suggests that increased awareness of the consequences of SUD on the sense of self has an impact on alcohol and marijuana use among young adults.

Overall, the background is well-written and provide a clear overview of the current state of knowledge regarding substance use stigma and the specific research questions addressed in the present study. The background also effectively highlights the gap in the literature regarding the role of self-stigma in the development of SUDs and the need for more research in this area. The background also provides a good introduction to the study's hypotheses and research questions, outlining the specific aims of the study and how they relate to the broader literature on substance use stigma. The use of the theory of planned behavior as a framework for understanding the relationship between self-stigma and substance use outcomes is a useful approach and shows that the study is grounded in a strong theoretical foundation. The background provides appropriate citations to support the claims made, and the use of direct quotes from previous literature adds credibility to the discussion.

The authors did good job in outlining their methods, result, and discussion. However, based on the information provided, here are some recommendations for the authors:

- The authors discuss their findings within the scope of SUD; however, they only measured alcohol and marijuana. It is not scientifically sound to pinpoint two substances only and generalize it to SUD. My recommendation is to revise your title and hypothesis to indicate in within alcohol and marijuana instead of SUD.

- Clarify the study design and sampling method: The authors should provide more information on how participants were recruited, the inclusion/exclusion criteria, and any potential biases in the sample.

- Provide more detail on the measures used: While the authors briefly described the measures used, it still misses important information such as the operational definitions and elements of NSE, NSEF, B-MACQ; CUDIT-R, etc.

- Discuss implications and future directions: While the authors briefly discussed the implications of their findings, they could provide a more in-depth discussion of how their results could inform future research or interventions for substance use disorders. Additionally, they could discuss any potential limitations of their study and areas for future research.

Thank you for doing such important work.

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

**********

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PONE-D-23-05413R1Exploring perceptions of self-stigma of substance use and current alcohol and marijuana use patterns among college studentsPLOS ONE

Dear Dr. Bravo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Dec 28 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Lakshit Jain, MD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Thank you for revising your article and making edits as recommended.

Unfortunately, there are still some minor concerns that need to be addressed. Please specifically address concerns raised by reviewer 3 and 7.

Thanks 

Lakshit  

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

Reviewer #5: All comments have been addressed

Reviewer #6: All comments have been addressed

Reviewer #7: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: I Don't Know

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: I Don't Know

Reviewer #7: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: This is a well-written manuscript. I liked reading this manuscript and believe that it is very promising. At the same time, I identified couple of issues that require the authors’ attention. It is interesting to see the correlation between pre-clinical substance use, stigma and its impact on individuals' future. Professional use of English language is at par. The manuscript is based on impressive empirical evidence and makes an original contribution but there should be some comment on possible bias like reporting bias of the study participants and also their understanding of the difference between pre-clinical substance uses and SUD itself. It will be very interesting to see the follow up study on these subject individuals regarding how many of these develops SUD.

Reviewer #3: The authors have addressed most of the review comments except as stated below. Once the pending comment is addressed the article may be accepted for publication.

1) The authors discuss their findings within the scope of SUD; however, they only

measured alcohol and marijuana. It is not scientifically sound to pinpoint two

substances only and generalize it to SUD. My recommendation is to revise your title

and hypothesis to indicate in within alcohol and marijuana instead of SUD.

The title is more clear and the hypothesis is now more sound

** 2) Clarify the study design and sampling method: The authors should provide more

information on how participants were recruited, the inclusion/exclusion criteria, and any

potential biases in the sample.

The authors have clarified this comment

3) Provide more detail on the measures used: While the authors briefly described the

measures used, it still misses important information such as the operational definitions

and elements of NSE, NSEF, B-MACQ; CUDIT-R, etc.

The authors have clarified this comment

4) Discuss implications and future directions: While the authors briefly discussed the

implications of their findings, they could provide a more in-depth discussion of how

their results could inform future research or interventions for substance use disorders.

Additionally, they could discuss any potential limitations of their study and areas for

future research.

The authors have clarified this comment. However, the current manuscript brings an important question. The authors themselves report how in pre problematic use population self stigma may prevent problematic use but in patients with Use Disorders they may serve as a deterrent to seek treatment. The authors may identify this as a study area where populations can be compared, or stratify their data and present the results of stigma in groups stratified on the basis of amount/frequency of use or substance of use (alcohol or cannabis).

This would make this paper more methodologically rigorous and increase the scientific impact of this paper.

I look forward to reading the revised manuscript.

Reviewer #4: Thank you for the opportunity to review this brief report that examines the relationship between self stigma related to alcohol and MJ use and engagement in use in college students.

The manuscript is well written, and succinct and the background section explains the rationale for the study well.

The findings are clearly communicated.

The authors seem to have addressed the concerns of the previous reviewer well making significant changes especially to the discussion section which was well written, especially the limitations.

The main finding of the study that shows that self stigma could potentially play a protective role against use is valuable and an important contribution to the literature.

I don’t have any other major edits/suggestions.

Great work.

Reviewer #5: The research paper details the relationship between the self-stigma of marijuana and alcohol use and engagement in these substances among college students. It Indicates that individuals with lifetime use of marijuana and alcohol, but no recent use reported higher self-stigma. Negative self-esteem and self-efficacy were found to relate negatively to nearly all observed factors of alcohol and marijuana use.

Feedback:

The assertion positing a link between self-stigma and involvement in substance use is substantiated by robust research findings, which reveal that individuals who have a history of substance use but no recent use exhibits elevated levels of self-stigma. This solid empirical basis lends credence to the argument, rendering it valid. Likewise, the claim proposing a negative relationship between negative self-esteem and self-efficacy with alcohol and marijuana use is bolstered by the study's outcomes. The argument finds strong empirical support in the research data, further establishing its validity. Moreover, the argument asserting that an enhanced awareness of the impact of substance use disorders on an individual's sense of self can influence alcohol and marijuana use is well-founded in the study's results. This logical reasoning harmonizes effectively with the study's objectives, thus underscoring its validity.

The authors have diligently responded to the concerns raised in the previous review and have effectively rectified the identified issues. Their commitment to addressing these concerns is evident in the revised manuscript. They have demonstrated a high level of responsiveness and professionalism in dealing with the feedback, which reflects positively on the overall quality of the research. The corrections made by the authors have notably improved the clarity and coherence of the manuscript. The revised version now presents a more refined and accurate portrayal of their research findings, strengthening the overall credibility and impact of their work. The authors' attention to detail and their willingness to make the necessary revisions exemplify their commitment to producing a high-quality academic contribution. This constructive engagement with feedback not only benefits the authors by enhancing the quality of their work but also contributes to the scholarly community by ensuring that accurate and reliable research is disseminated. It is evident that the authors' dedication to addressing the concerns raised in the previous review will enhance the value and relevance of their research within the academic field.

Reviewer #6: (No Response)

Reviewer #7: Thanks for giving me the opportunity to review this article. The article is interesting as it explores the protective effect of self stigma on alcohol and marijuana use. This is a rare concept that has not been explored much so far. The article is very unique in that aspect. The sample size is excellent. Also the author has been very candid in acknowledging the limitation of the study that majority of participants were females. It would be interesting to see the results of the study if all genders were included( Including LGBT etc)

2. One limitation of the study is the study included college students. There are a lot of students that drop out of high school due to substance use problems and it would be great to know how their self stigma compares to someone who has made it to college.

SOLUTION: Please include in the limitation that perhaps including the college going students have skewed the results of the study and the results may not be extrapolated to the entire population.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

Reviewer #5: Yes: Aditi Sharma

Reviewer #6: No

Reviewer #7: Yes: Jasleen Kaur MD

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PONE-D-23-05413R2Exploring perceptions of self-stigma of substance use and current alcohol and marijuana use patterns among college studentsPLOS ONE

Dear Dr. Bravo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Feb 25 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Lakshit Jain, MD

Academic Editor

PLOS ONE

Additional Editor Comments:

Three reviewers have recommend to accept this article, but reviewer 8 is seeking this article for the first time, they have raised multiple concerns that should be resolved prior to accepting this article

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #5: All comments have been addressed

Reviewer #8: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

Reviewer #8: Partly

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

Reviewer #8: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

Reviewer #8: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

Reviewer #8: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

Reviewer #3: The authors have sufficiently and succinctly made appropriate changes to the manuscript to make it more reader friendly. The paper presents an interesting approach to alcohol and cannabis use disorder propagation and at this stage would benefit from acceptance in the journal. Thank you for the opportunity to review this paper.

Reviewer #5: The paper has improved after the revisions. The authors' meticulous efforts have substantially strengthened the manuscript, aligning it more closely with the standards of PLOS ONE

Reviewer #8: This manuscript presents information on college students’ perception of self- stigma associated with developing a substance use disorder (SUD) in the context of alcohol and marijuana use. It is well written and below are my suggestions on how the manuscript can be improved.

Abstract

Generally, the abstract would benefit from a structure; introduction of different sections will improve focus and clarity

Line 32

There is no mention of the instruments used to collect the data.

Line 34 – 40

The results in this section require the support of the numbers that tell the story. Presentation could benefit by stating the actual figures obtained in the statistical analysis, including the p values while mentioning the significance levels.

For instance, were the higher levels of self- stigma mentioned in Line 37- 38 statistically significant? What were the actual figures?

Line 44- 46

“Rather, we interpret these findings to indicate that increased awareness of the consequences of substance use disorder on the sense of self has an impact on alcohol and marijuana use among young adults”. When one has the objectives of the study in mind, it appears the different patterns of alcohol and marijuana use are actually the independent variables with self- stigma, and not awareness, as the dependent variable. This may require clarification.

The conclusion of “increased awareness” cannot emanate from the findings of this particular study; there was no measure of awareness of the consequences of SUD. What was measured here was the self- stigma. Additionally, the increased awareness in this context sounds more like insight into the consequences of SUD.

Introduction

The use of alcohol use disorder (AUD), marijuana use, and SUD interchangeably in this section may be problematic. For instance, Line 70- 71; “problematic marijuana use may culminate in a SUD”; why not a cannabis use disorder (CUD)?

Measures

Line 122-126

The statement …we replaced the term “mental illness” with “substance use disorder” throughout the measure…is worrying. Were the psychometric properties of the new instrument, created by replacing terminology, ascertained or was it an assumption that they were acceptable? Was there a definition of the term SUD that was provided to all the participants, or were they expected to respond using their own individual definitions and interpretation of what SUD meant- not a standardized one? Was it actually meant to be AUD, CUD or the actual DSM-5 TR SUD? Is there a possibility that the participants understood it to mean opioids, cocaine, nicotine, inhalants, hallucinogen and other substance use disorders? Was this how it was intended to be understood? Did SUD mean severity? Was a pilot on the instrument ever done after changing the terminology, to establish reliability and validity? So, do we actually know what was measured by this novel measure/ instrument and what the content of the results we are discussing here are?

If this was the thrust of the study, why not use ‘perception of self- stigma associated with developing a SUD in the context of substance use’, instead of alcohol or cannabis use? Alternatively, use ‘perception of self- stigma associated with developing an AUD/ CUD in the context of their use’. This would enable us to confidently compare “apples” with “apples” and not “oranges”.

Results

From the presentation of the results, it is clear that the participants’ socio-demographic characteristics were not considered, even with the obvious gender imbalance. Despite the fact that this was not part of the objectives, it would have been nice to know their residence, living arrangements, finances, marital status, educational level of study, age, and other characteristics that could be factors associated with the outcome.

Line 208- 209

Table 1- I suggest that the “significant differences” column is given a figure/ value/ number, to denote and support the significance level. The explanation given in the table is a repetition (see text in Line 203- 207) and should be removed.

Line 222- 223

Table 2- Were there scatter plots done to establish linearity? Does 1,2, 3…. columns represent the corresponding 1,2, 3…. rows in the bi-variate correlations? If so, it does not reflect the expected quality that a variable is always perfectly correlated with itself (r=1). May require clarification.

Discussion

This is largely determined by the findings; I have highlighted the concern in the findings. However, it was easy to notice that the limitations and future research section (Line 260- 309) was twice as long as the discussion (238- 258). Separating the limitations from the future research, so that they are two distinct sections could improve clarity. Future research begins from Line 270; although there is a small section, Line 277- 281 which is mainly focused on limitations.

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Reviewer #2: No

Reviewer #3: No

Reviewer #5: No

Reviewer #8: No

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PONE-D-23-05413R3Exploring perceptions of self-stigma of substance use and current alcohol and marijuana use patterns among college studentsPLOS ONE

Dear Dr. Bravo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================\\While 2 reviewers recommed accepting this Manuscript, Reviewer 8 has raised severela concerns. The reviewer also feels that many of the concerns they raised in their previous review have not been addressed. please see the review and address these concerns. This manuscript presents information on college students’ perception of self- stigma associated with developing a substance use disorder (SUD) in the context of alcohol and marijuana use. It is well written and below are my suggestions on how the manuscript can be improved.

Abstract

Generally, the abstract would benefit from a structure; introduction of different sections will improve focus and clarity

Line 32

There is no mention of the instruments used to collect the data.

Line 34 – 40

The results in this section require the support of the numbers that tell the story. Presentation could benefit by stating the actual figures obtained in the statistical analysis, including the p values while mentioning the significance levels.

For instance, were the higher levels of self- stigma mentioned in Line 37- 38 statistically significant? What were the actual figures?

Line 44- 46

“Rather, we interpret these findings to indicate that increased awareness of the consequences of substance use disorder on the sense of self has an impact on alcohol and marijuana use among young adults”. When one has the objectives of the study in mind, it appears the different patterns of alcohol and marijuana use are actually the independent variables with self- stigma, and not awareness, as the dependent variable. This may require clarification.

The conclusion of “increased awareness” cannot emanate from the findings of this particular study; there was no measure of awareness of the consequences of SUD. What was measured here was the self- stigma. Additionally, the increased awareness in this context sounds more like insight into the consequences of SUD.

Introduction

The use of alcohol use disorder (AUD), marijuana use, and SUD interchangeably in this section may be problematic. For instance, Line 70- 71; “problematic marijuana use may culminate in a SUD”; why not a cannabis use disorder (CUD)?

Measures

Line 122-126

The statement …we replaced the term “mental illness” with “substance use disorder” throughout the measure…is worrying. Were the psychometric properties of the new instrument, created by replacing terminology, ascertained or was it an assumption that they were acceptable? Was there a definition of the term SUD that was provided to all the participants, or were they expected to respond using their own individual definitions and interpretation of what SUD meant- not a standardized one? Was it actually meant to be AUD, CUD or the actual DSM-5 TR SUD? Is there a possibility that the participants understood it to mean opioids, cocaine, nicotine, inhalants, hallucinogen and other substance use disorders? Was this how it was intended to be understood? Did SUD mean severity? Was a pilot on the instrument ever done after changing the terminology, to establish reliability and validity? So, do we actually know what was measured by this novel measure/ instrument and what the content of the results we are discussing here are?

If this was the thrust of the study, why not use ‘perception of self- stigma associated with developing a SUD in the context of substance use’, instead of alcohol or cannabis use? Alternatively, use ‘perception of self- stigma associated with developing an AUD/ CUD in the context of their use’. This would enable us to confidently compare “apples” with “apples” and not “oranges”.

Results

From the presentation of the results, it is clear that the participants’ socio-demographic characteristics were not considered, even with the obvious gender imbalance. Despite the fact that this was not part of the objectives, it would have been nice to know their residence, living arrangements, finances, marital status, educational level of study, age, and other characteristics that could be factors associated with the outcome.

Line 208- 209

Table 1- I suggest that the “significant differences” column is given a figure/ value/ number, to denote and support the significance level. The explanation given in the table is a repetition (see text in Line 203- 207) and should be removed.

Line 222- 223

Table 2- Were there scatter plots done to establish linearity? Does 1,2, 3…. columns represent the corresponding 1,2, 3…. rows in the bi-variate correlations? If so, it does not reflect the expected quality that a variable is always perfectly correlated with itself (r=1). May require clarification.

Discussion

This is largely determined by the findings; I have highlighted the concern in the findings. However, it was easy to notice that the limitations and future research section (Line 260- 309) was twice as long as the discussion (238- 258). Separating the limitations from the future research, so that they are two distinct sections could improve clarity. Future research begins from Line 270; although there is a small section, Line 277- 281 which is mainly focused on limitations.==============================

Please submit your revised manuscript by Apr 22 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Lakshit Jain, MD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

Reviewer #5: All comments have been addressed

Reviewer #8: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

Reviewer #5: Yes

Reviewer #8: Partly

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

Reviewer #5: Yes

Reviewer #8: I Don't Know

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

Reviewer #5: Yes

Reviewer #8: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

Reviewer #5: Yes

Reviewer #8: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: The authors have sufficiently addressed and improved the manuscript in order for it to meet publication requirements and with the current revision I recommend that the paper be accepted for publications

Reviewer #5: The authors diligently addressed all comments provided by reviewers, ensuring clarity, coherence, and accuracy throughout the manuscript. Each comment was carefully considered, and revisions were made accordingly to enhance the overall quality of the work. This meticulous approach reflects the authors' commitment to producing a comprehensive and thoroughly vetted piece of scholarly literature.

Reviewer #8: The manuscript has really improved after the revisions. It is aligned closer to the standards of PLOS ONE.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

Reviewer #5: Yes: Vinod Sharma

Reviewer #8: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Exploring perceptions of self-stigma of substance use and current alcohol and marijuana use patterns among college students

PONE-D-23-05413R4

Dear Dr. Bravo,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at http://www.editorialmanager.com/pone/ and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Lakshit Jain, MD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: