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Learn more: PMC Disclaimer | PMC Copyright Notice Discov Ment Health . 2026 Mar 7;6(1):60. doi: 10.1007/s44192-026-00412-9 Search in PMC Search in PubMed View in NLM Catalog Add to search Association between academic stress and caffeine expectancy among medical students in Jeddah Saudi Arabia Ayat El-Zayat Ayat El-Zayat 1 Ayat El-Zayat -Clinical Science department-MBBS program, Fakeeh College for Medical Sciences, Jeddah, 21461, Fakeeh Care Group Saudi Arabia Find articles by Ayat El-Zayat 1 , Sadia Sultan Sadia Sultan 1 Ayat El-Zayat -Clinical Science department-MBBS program, Fakeeh College for Medical Sciences, Jeddah, 21461, Fakeeh Care Group Saudi Arabia Find articles by Sadia Sultan 1, ✉ , Renad Sarhan Renad Sarhan 1 Ayat El-Zayat -Clinical Science department-MBBS program, Fakeeh College for Medical Sciences, Jeddah, 21461, Fakeeh Care Group Saudi Arabia Find articles by Renad Sarhan 1 , Rouz Banjar Rouz Banjar 1 Ayat El-Zayat -Clinical Science department-MBBS program, Fakeeh College for Medical Sciences, Jeddah, 21461, Fakeeh Care Group Saudi Arabia Find articles by Rouz Banjar 1 , Ruba Qadi Ruba Qadi 1 Ayat El-Zayat -Clinical Science department-MBBS program, Fakeeh College for Medical Sciences, Jeddah, 21461, Fakeeh Care Group Saudi Arabia Find articles by Ruba Qadi 1 , Layan Kutub Layan Kutub 1 Ayat El-Zayat -Clinical Science department-MBBS program, Fakeeh College for Medical Sciences, Jeddah, 21461, Fakeeh Care Group Saudi Arabia Find articles by Layan Kutub 1 , Rahaf Al-Tuwairqi Rahaf Al-Tuwairqi 1 Ayat El-Zayat -Clinical Science department-MBBS program, Fakeeh College for Medical Sciences, Jeddah, 21461, Fakeeh Care Group Saudi Arabia Find articles by Rahaf Al-Tuwairqi 1 , Web Site Web Site 1 Ayat El-Zayat -Clinical Science department-MBBS program, Fakeeh College for Medical Sciences, Jeddah, 21461, Fakeeh Care Group Saudi Arabia Find articles by Web Site 1 Author information Article notes Copyright and License information 1 Ayat El-Zayat -Clinical Science department-MBBS program, Fakeeh College for Medical Sciences, Jeddah, 21461, Fakeeh Care Group Saudi Arabia ✉ Corresponding author. Received 2025 Sep 30; Accepted 2026 Feb 20; Collection date 2026 Dec. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13079242 PMID: 41793613 Abstract Background Medical students experience high stress, often leading to increased caffeine consumption as a coping mechanism. The relationship between specific stressors and caffeine expectancy—beliefs about caffeine’s effects—is poorly understood in the Saudi context. Aim This study aimed to examine the association between perceived stress levels and caffeine expectancy among medical students ( n = 500), exploring how stress may affect different domains of caffeine-related beliefs and behaviors. Methods A cross-sectional study was conducted among 500 medical students in Jeddah, Saudi Arabia, using an online questionnaire. It included demographic data, the Brief-Caffeine Expectancy Questionnaire (B-CaffEQ), and the Medical Student Stressor Questionnaire (MSSQ). Data were analyzed using correlation and multivariate regression. Results: Participants (mean age 22 ± 2 years; 64.2% female) reported high stress, particularly in academic domains. Total stress was strongly correlated with total caffeine expectancy ( r = 0.597, p < 0.0001), and academic stress was strongly correlated with energy/work enhancement expectancy ( r = 0.59, p < 0.0001). Regression analysis identified stress as the strongest positive predictor of caffeine expectancy (β = 0.583, p < 0.0001), while attending a private college was a negative predictor (β = −0.100, p = 0.007 indicating that students in private colleges reported lower caffeine expectancy scores compared with those in public institutions. Conclusion Perceived stress emerged as the strongest statistical independent variable affecting caffeine expectancy in the regression model. Students under high academic pressure develop strong expectations that caffeine will enhance performance. Addressing the root causes of academic stress and promoting healthier coping strategies is crucial for student wellbeing. Supplementary Information The online version contains supplementary material available at 10.1007/s44192-026-00412-9. Keywords: Medical students, Perceived stress, caffeine expectancy, Academic stress, Saudi Arabia Introduction Medical education is widely recognized as a profoundly demanding period, characterized by an intense academic workload, high-stakes examinations, and significant psychological pressure. This unique environment frequently places students at an elevated risk for chronic stress, burnout, and mental health challenges [ 1 ]. In response to these relentless demands, many medical students adopt various coping mechanisms, among which caffeine consumption is one of the most prevalent and socially accepted [ 2 ]. Caffeine, a central nervous system stimulant, is commonly used to promote alertness, counteract fatigue, enhance cognitive performance and improve mood [ 3 , 4 , 5 ]. Individuals’ consumption patterns are not solely driven by the pharmacological effects of caffeine but are also significantly influenced by their “caffeine expectancy”—the set of beliefs and expectations regarding its positive effects (e.g., enhanced energy and focus) and negative consequences (e.g., anxiety and sleep disturbance). These expectancies can powerfully shape usage behaviors, potentially leading to a cycle of consumption aimed at managing stress despite awareness of adverse effects [ 5 ]. However, caffeine directly affects the physiological stress systems, particularly the Hypothalamic–Pituitary–Adrenal (HPA) axis, raising cortisol and adrenocorticotropin secretion. This, in turn, increases cardiovascular and neuroendocrine stress reactivity, which raises stress levels overall [ 6 , 7 ]. Additionally, caffeine use is positively correlated with perceived stress levels, and excessive caffeine consumption can cause anxiety and panic episodes in susceptible people [ 8 , 9 ]. As a result, using caffeine to boost motivation to increase academic performance may have negative effects linked to high levels of stress, such as causing or exacerbating anxiety disorders [ 10 ]. In Saudi Arabia, the path to becoming a physician is marked by intense academic rigor within a competitive environment. Medical students nationwide face significant pressures, with studies indicating a high prevalence of stress-related symptoms among this population [ 11 , 12 ]. A common coping strategy observed is the high consumption of caffeinated beverages, among medical students [ 13 , 14 ]. While the high prevalence of stress and caffeine use among medical students has been individually documented, the intricate relationship between the specific sources of stress and the dimensions of caffeine expectancy remains inadequately explored, particularly within the Saudi Arabian context. Understanding this relationship is crucial, as it moves beyond mere consumption metrics to uncover the psychological drivers that lead students to view caffeine as a strategic tool for academic survival and coping. Therefore, this study aims to investigate the association between perceived stressors and caffeine expectancy among medical students in Jeddah, Saudi Arabia. It seeks to determine whether stress levels, particularly from academic pressures, affect stronger expectations of caffeine’s benefits, thereby offering valuable insights for targeted interventions to promote healthier coping strategies and improve student wellbeing. Methods Study design, setting, and participants This cross-sectional study was conducted among medical students from multiple medical schools (public and private) in Jeddah, Saudi Arabia, between January 1 and June 30, 2025. The study was approved by the Institutional Review Board of Fakeeh College of Medical Sciences, Jeddah (No. 418/2023). Inclusion criteria were age ≥ 18 years, both sexes, and current enrollment in any academic year (1st–6th) in a Saudi Arabian medical college. Exclusion criteria included medical interns, graduates, students from non-medical colleges, or participants with self-reported psychiatric disorders that could interfere with assessment of stress or caffeine use. The questionnaires were administered in English. Cronbach’s alpha values in this study were 0.961 (B-CaffEQ) and 0.974 (MSSQ), indicating high reliability. Data management and analysis. Data were coded and managed using Microsoft Excel 2019 and analyzed with IBM SPSS version 25. Descriptive statistics included frequencies and percentages for categorical variables and mean ± SD or median for numerical variables. Normality was assessed using the Kolmogorov-Smirnov test. Spearman correlation assessed associations between continuous variables, and the Kruskal-Wallis test compared groups. Multivariate regression analysis was conducted to assess factors affecting caffeine expectancy. P < 0.05 was considered statistically significant. Recruitment and sampling Participants were recruited using a snowball sampling technique. Initial respondents were asked to invite eligible colleagues. Recruitment was initiated through multiple independent professional and social networks (Facebook, Twitter, WhatsApp) to reduce clustering and overrepresentation from any single subgroup. Initial contacts were selected using independent student accounts to reach different subgroups within the target population. Questionnaire and procedures Data were collected via a Google Form. The first section included mandatory screening questions to assess eligibility; only eligible participants could proceed. The introductory section explained the study purpose, voluntary participation, confidentiality, anonymity, and electronic informed consent. Participants could not submit multiple responses. The questionnaire was tested for technical functionality and usability prior to distribution. The questionnaire included three sections: Demographics: age, gender, residence (urban/rural), chronic diseases, college type, academic year, and GPA. Actual caffeine consumption was not assessed. Brief-Caffeine Expectancy Questionnaire (B-CaffEQ): a 21-item validated tool with 7 subscales (Withdrawal/Dependence, Energy/Work Enhancement, Appetite Suppression, Social/Mood Enhancement, Physical Performance Enhancement, Anxiety/Negative Physical Effects, Sleep Disturbance) scored on a 6-point Likert scale [ 15 ]. Higher scores indicate greater expectancies. Medical Student Stressor Questionnaire (MSSQ): a 40-item validated tool assessing 6 stress domains (Academic, Intrapersonal/Interpersonal, Teaching/Learning, Social, Drive/Desire, Group Activities), scored on a 5-point Likert scale [ 16 ]. Domain scores are means of items; total stress is the mean of all 40 items. Scores are categorized as mild (0–1), moderate (1.01–2), high (2.01–3), or severe (3.01–4). Results The study included 500 medical students with a mean age of 22 years (SD = 2). The majority were female (64.2%), resided in urban areas (86.4%), and were enrolled in public colleges (61.0%). Hypertension was the most reported chronic condition (11.8%). Students were distributed across all academic years, with the highest proportion in the fifth year (23.0%). Most students reported a high GPA, with 44.2% having a GPA between 4 and 5 (Table 1 ). Table 1. General characteristics of the studied participants ( n = 500) General characteristics Frequency Percentage Gender Male 179 35.8 Female 321 64.2 Residence Urban 432 86.4 Rural 68 13.6 Having chronic diseases Hypertension 59 11.8 Diabetes mellitus 40 8 Autoimmune 31 6.2 Cardiac 28 5.6 Renal 18 3.6 College Public 305 61.0 Private 195 39.0 Academic year First 35 7.0 Second 71 14.2 Third 90 18.0 Fourth 96 19.2 Fifth 115 23.0 Sixth 93 18.6 Last GPA < 1 5 1.0 1- <2 18 3.6 2- <3 67 13.4 3- <4 189 37.8 4–5 221 44.2 Open in a new tab Stress levels were high among participants. Academic-related stressors were the most severe, with 11% of students reporting highest stressor in this domain. Overall, only 26% of students experienced mild stress, while 35% reported moderate stress, 33% reported high stress, and 6% reported severe stress (Fig. 1 ). Fig. 1. Open in a new tab Medical student stressors. Bars represent percentages of students reporting each stress level by domain. Mild (dark blue), Moderate (orange), High (gray), Severe (yellow). Data labels show % values A strong, positive association was observed between stress levels and caffeine expectancy. As stress levels increased from mild to severe, mean scores for all caffeine expectancy dimensions increased significantly ( p < 0.0001) (Table 2 ). Table 2. The association between medical student stress and caffeine expectancy ( n = 500) Medical student stress Caffeine expectancy Withdrawal/ dependence Energy/work enhancement Appetite suppression Social/mood enhancement Physical performance enhancement Anxiety/ negative physical effects Sleep disturbance Total Cause mild stress ( n = 128) Mean 6.3 6.4 6.6 6.1 6.4 6.2 4.7 42.8 SD 4 4 4 3 4 3 3 20 Median 6 5 6 6 6 6 4 40 Cause moderate stress ( n = 177) Mean 9.1 9.8 9.4 9.2 9.2 8.5 6.3 61.4 SD 4 4 4 3 4 4 3 19 Median 9 10 9 9 9 8 6 62 Cause high stress 9n = 165) Mean 10 11.8 10.9 10.4 10.8 10.5 7.3 71.9 SD 4 4 4 4 4 4 3 22 Median 11 12 11 11 11 11 8 75 Cause severe stress ( n = 30) Mean 12.7 13.7 13.4 13.1 12 13.6 9 87.6 SD 5 4 4 4 5 5 3 22 Median 14 15 14 14.5 12 14.5 10 92.5 P -value 0.0001* 0.0001* 0.0001* 0.0001* 0.0001* 0.0001* 0.0001* 0.0001* Open in a new tab *P <0.05 value is statistically significant, Kruskal-Wallis test Bivariate correlation analysis revealed that most medical student stressor domains showed positive and statistically significant correlations with multiple caffeine expectancy domains ( p < 0.0001) (Table 3 ). Total stressors showed the strongest correlation with total caffeine expectancy ( r = 0.597). Among specific domains, academic-related stress showed a particularly strong correlation with energy/work enhancement expectancy ( r = 0.59). The weakest, though still significant, correlations were observed with the sleep disturbance expectancy domain. Table 3. The correlations between medical student stressors and caffeine expectancy domains ( n = 500) Caffeine expectancy Medical student stressors Withdrawal/ dependence Energy/work enhancement Appetite suppression Social/mood enhancement Physical performance enhancement Anxiety/ negative physical effects Sleep disturbance Total Academic R 0.409 0.59 0.483 0.502 0.468 0.497 0.462 0.574 P -value 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** Intrapersonal and Interpersonal R 0.378 0.475 0.435 0.469 0.391 0.518 0.414 0.518 P -value 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** Teaching and learning R 0.427 0.512 0.464 0.511 0.46 0.474 0.415 0.55 P -value 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** Social R 0.436 0.496 0.479 0.503 0.474 0.536 0.428 0.565 P -value 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** Drive and desire R 0.397 0.452 0.44 0.471 0.422 0.461 0.353 0.506 Sig. (2-tailed) 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** Group activities R 0.416 0.479 0.468 0.495 0.438 0.530 0.43 0.548 P -value 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** Total stressors R 0.445 0.565 0.506 0.537 0.485 0.546 0.466 0.597 P -value 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** 0.0001 ** Open in a new tab *P < 0.05 value is statistically significant, Spearman correlation test Intrapersonal and interpersonal stressors show significant correlations with both positive expectancy dimensions (e.g., energy/work enhancement, social/mood enhancement) and negative expectancy dimensions, particularly anxiety/negative physical effects ( r = 0.518, p=0.05) (Table-3). This pattern implies that caffeine may be used as a self-regulatory response to emotional and relational stress, despite recognition of its potential adverse effects. Social stressors show some of the strongest overall associations, notably with anxiety/negative physical effects ( r = 0.536) and total caffeine expectancy ( r = 0.565)(Table-3). This indicates that caffeine consumption may be used to cope with social demands and expectations, even when accompanied by heightened awareness of physiological or psychological side effects. Finally, a multivariate regression model was used to assess the effect of independent variables on the caffeine expectancy. The model included the following demographic and academic variables: gender, age, academic year, GPA, college, and residence. In addition, selected health-related variables (hypertension, diabetes mellitus, autoimmune diseases, cardiac diseases, renal diseases, and other chronic conditions) and overall medical student stressors. All independent variables were entered simultaneously into the multiple linear regression model without hierarchical or stepwise procedures, as all these variables were included based on evidence from the literature. The analysis confirmed that medical student stress was a significant positive independent variable affecting caffeine expectancy (β = 0.583, p < 0.0001), after controlling for demographic and academic variables. Attending a private college was a significant negative independent variable (β = -0.100, p = 0.007). No other variables, including gender, age, GPA, or chronic health conditions, were significant in the model (Table 4 ). Table 4. The multivariate regression analysis of caffeine expectancy ( n = 500) Unstandardized coefficients Standardized coefficients t P -value 95.0% confidence interval for B Collinearity Statistics B Std. Error Beta Lower bound Upper Bound Tolerance VIF Gender 0.171 1.855 0.003 0.092 0.927 −3.475 3.816 0.949 1.054 Age − 0.040 0.236 − 0.007 − 0.168 0.866 − 0.503 0.423 0.485 2.062 Academic year − 0.200 0.647 − 0.013 − 0.309 0.757 −1.472 1.071 0.478 2.092 GPA 0.905 1.077 0.033 0.841 0.401 −1.211 3.021 0.816 1.226 College −4.947 1.817 − 0.100 −2.722 0.007* −8.518 -1.377 0.954 1.048 Residence −2.079 2.597 − 0.029 − 0.800 0.424 −7.182 3.024 0.948 1.055 Hypertension −1.974 2.903 − 0.026 − 0.680 0.497 −7.678 3.730 0.852 1.174 Diabetes 0.077 3.591 0.001 0.021 0.983 −6.979 7.133 0.787 1.270 Autoimmune diseases 3.235 3.911 0.032 0.827 0.409 −4.449 10.918 0.843 1.186 Cardiac diseases −3.439 4.428 − 0.033 − 0.777 0.438 −12.140 5.262 0.718 1.393 Renal diseases −4.652 5.426 − 0.036 − 0.857 0.392 −15.314 6.011 0.734 1.363 Other diseases 4.387 3.013 0.056 1.456 0.146 −1.534 10.308 0.869 1.151 Medical student stressors 0.404 0.025 0.583 15.981 0.0001* 0.354 0.453 0.966 1.035 Open in a new tab * P -<0.05 value is statistically significant Key regression assumptions were assessed prior to analysis. Linearity and homoscedasticity were evaluated through inspection of residual plots, normality of residuals was assessed visually, and multicollinearity was examined using tolerance and variance inflation factor (VIF) values. Tolerance values ranged from 0.478 to 0.966 and variance inflation factor (VIF) values ranged from 1.035 to 2.092, all are below the commonly accepted thresholds for concern (tolerance < 0.10 or VIF > 5–10). These findings indicate that no significant multicollinearity was present among the independent variables, including the stress-related variables (Table 4 ). The regression model demonstrated a moderate explanatory power with an R 2 of 0.375 and an adjusted R² of 0.358, indicating that approximately 37.5% of the variance in the outcome variable was explained by the included independent variables. The overall model was statistically significant (F(13, 486) = 22.44, p < 0.001), indicating that the independent variables collectively contributed significantly to the model (Table 5 ). Table 5. The model summary of multiple linear regression analysis of the caffeine expectancy ( n = 500) Model R R Square Adjusted R Square Std. error of the estimate Change statistics R square change F change df1 df2 Sig. F change 1 .612 a 0.375 0.358 19.36616 0.375 22.440 13 486 0.000 Open in a new tab Discussion This study examined the relationship between perceived stress and caffeine expectancy among medical students, revealing a robust positive association between the two constructs. Higher stress levels across various domains were associated with stronger expectations that caffeine enhances energy, focus, and work performance. The most prevalent source of stress identified was academic in nature consistent with extensive literature describing intense workload, high stake examinations and sustained cognitive demands characteristic of medical education [ 17 ]. Our finding that this specific academic stress domain demonstrated the strongest correlation with expectations of energy and work enhancement ( r = 0.59) is particularly insightful and moves beyond a simple observation of stress. Expectancy domains such as energy/work enhancement, mood/social enhancement, and physical performance enhancement were strongly associated with higher stress. These findings align with previous work indicating academically stressed students tend to hold stronger belief about caffeine’s ability to improve attention concentration and performance even when actual consumption is not measured [ 18 , 19 , 20 ]. Expectancy patterns may reflect perceptions of caffeine as a potential resource for managing academic and psychosocial demands [ 21 ]. Our findings extend this body of work by demonstrating that such expectancy patterns are not limited to academic performance alone but also encompass mood and physical performance domains. The sharp rise in withdrawal/dependence expectancy from mild to severe stress in our study is particularly concerning. This may highlight a potential vulnerability of medical students to dependence-related cognitions and should be a focus for further research on risk of problematic use. Beyond academics, positive correlations between all stressor domains (interpersonal, intrapersonal, teaching-related, social) and positive caffeine expectancies suggest a generalized pattern of stress-related expectancies, consistent with studies showing psychosocial stressors are associated with stronger caffeine expectancies among students. These findings mirror previous studies reporting various psychosocial stressors contribute to increased caffeine expectancy, where caffeine is anticipated to support perceptions of control and efficacy [ 22 , 23 ]. These findings align with expectancy theory, which posits that beliefs about caffeine’s effects shape subjective experiences and may influence consumption patterns among students, as demonstrated in prior caffeine research [ 24 ]. A notable finding was the significant positive correlation between stress levels and the expectation of caffeine’s negative effects, particularly anxiety, jitteriness, and gastrointestinal distress [ 25 ]. Given their medical background, many students are likely aware of potential negative effects and the observed associations suggest that increased stress amplifies both positive and negative expectancy scores. Consistent with previous work, stressed students may still report stronger positive expectancies despite concurrent awareness of risks, indicating a tendency to prioritize anticipated short-term benefits (e.g., enhanced alertness and performance) over concerns about adverse outcomes [ 25 , 26 ]. Consistent with behavioral reinforcement models, stronger positive expectancies for energy, mood, and performance observed here alongside stress may be relevant to future caffeine use patterns through anticipated reinforcement, even with awareness of negative effects [ 27 ]. Regression analysis identified perceived stress as the strongest independent predictor of caffeine expectancy while GPA, age, and the presence of chronic health conditions were non-significant independent variable. This indicates the association reflects the subjective experience of being overwhelmed rather than demographic or performance-related factors. Caffeine shows a dose dependent increase in energetic arousal, improved hedonic tone, increased concentration, mainly by eliminating distractors [ 28 , 29 ] which may contribute to students’ beliefs that caffeine enhances academic performance. These results highlight caffeine expectancy as a potential perceptual marker of stress among medical students, extending prior work linking stress to caffeine-related beliefs independent of actual consumption. Another intriguing finding from the regression analysis was that students enrolled in private medical colleges reported significantly lower caffeine expectancy scores than their counterparts in public universities. This difference may reflect systemic and environmental factors such as variation in institutional culture, academic workload, competitiveness and assessment systems. Furthermore, students in private institutions often come from different socioeconomic backgrounds, which could influence both their baseline stress levels (e.g., less financial stress) and their attitudes towards using substances for performance enhancement [ 30 ]. Exploring this disparity could reveal important modifiable factors that institutions could address to improve student wellbeing. The findings of this study carry important implications for medical educators, administrators, and student support services. The strong link between academic stress and caffeine expectancy should serve as a red flag indicating that students experiencing high academic stress report stronger expectancies regarding caffeine’s benefits. These findings have direct implications for screening and prevention in academic mental health programs. Elevated caffeine expectancy patterns observed here could inform brief screening tools as potential indicators of high stress among medical students. Integrating psychoeducation about caffeine and its risks into existing stress-management and wellbeing programs may help shift students toward healthier coping strategies and reduce reliance on caffeine as a primary means of managing academic pressure. There is also a need for targeted education on substance use and cognitive enhancement. Medical students may underestimate the risk of high caffeine consumption such as its potential to exacerbate anxiety, disrupt sleep architecture, and risk of dependency [ 31 ]. Workshops or informational campaigns that provide evidence-based information on safe caffeine consumption, its effects, and healthy alternative stress-management techniques (e.g., mindfulness, time management, exercise) could be highly beneficial. Several limitations of this study must be considered when interpreting its results. First, the cross-sectional design establishes a clear association but cannot determine causality. While the logical pathway suggests that increasing stress influences the development of heightened caffeine expectancies, a bidirectional relationship is plausible. It is possible that students who consume more caffeine and experience its anxiety-inducing side effects may subsequently report higher stress levels, or that a shared underlying factor influences both. The reliance on self-reported measures for both stress and expectancy introduces potential recall and social desirability biases, and the snowball sampling approach could have introduced selection bias limiting the representativeness and generalizability of the sample. Also, with online data collection, a precise response rate couldn’t be calculated. Finally, and perhaps most importantly, this study measured expectations of caffeine’s effects, not actual consumption behaviors, patterns, or the presence of Caffeine Use Disorder. Expectancy is a powerful predictor of use, but it is not a perfect proxy. Future research must build upon these findings using longitudinal designs. Tracking a cohort of students over time would allow researchers to observe how changes in stress levels affect subsequent changes in actual caffeine intake and vice versa, helping to untangle the causal relationships. Additionally, employing mixed-methods approaches—combining quantitative surveys with qualitative interviews—could provide richer, more nuanced data on the decision-making processes, the cultural norms within medical schools, and the personal experiences of students using caffeine to cope. Research could also explore the efficacy of institutional interventions aimed at reducing stress and promoting healthier coping mechanisms, and their subsequent impact on caffeine use patterns. Conclusion This study demonstrates robust associations between perceived stress and caffeine expectancy among medical students, with stress emerging as the strongest independent variable affecting it across multiple domains and expectancy types. Academic stress showed the strongest correlations with performance-related expectancies, while all stressor domains were linked to broader positive expectancies independent of actual consumption patterns. These findings extend prior research on stress and caffeine beliefs among students and highlight caffeine expectancy as a perceptual correlate of student stress that warrants attention in medical education wellbeing programs. Supplementary Information Below is the link to the electronic supplementary material. Supplementary Material 1 (18.1KB, docx) Acknowledgements None. Author contributions The manuscript has been read and approved by all authorsConceptualization, AE and SS.; methodology, AE and SS.; software, AE.,SS., RB, RS, LK, RQ, RA; validation, AE., SS, RB, RS, LK, RQ, RA; formal analysis, investigation, resources; data curation, AE.,SS, RB, RS, LK, RQ, RA.; writing—original draft preparation AE., SS; writing—review and editing, RB, RS, LK, RQ, RA.; visualization, AE, SS.; supervision, AE.; project administration, AE; All authors have read and agreed to the published version of the manuscript. Funding No funds were granted for this research. Data availability The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Declarations Dual publication The results of this study have not been published elsewere. Authorship All authors agreed for the publication. Permission to use third-party material Authors created the images and figures not published elsewere. Competing interests The authors declare no competing interests. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. Voltmer E, Köslich-Strumann S, Voltmer JB, Kötter T. Stress and behavior patterns throughout medical education–a six-year longitudinal study. BMC Med Educ. 2021;21(1):454. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 2. Kosecka O, Charzyńska E, Czerwiński SK, Rudnik A, Atroszko PA. Caffeine intake mediates the relationship between problematic overstudying and psychological distress. Nutrients. 2025;17(17):2845. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 3. McLellan TM, Caldwell JA, Lieberman HR. A review of caffeine’s effects on cognitive, physical and occupational performance. Neurosci Biobehavioral Reviews. 2016;71:294–312. [ DOI ] [ PubMed ] [ Google Scholar ] 4. Smit HJ, Cotton JR, Hughes SC, Rogers PJ. Mood and cognitive performance effects of energy drink constituents: caffeine, glucose and carbonation. Nutr Neurosci. 2004;7(3):127–39. [ DOI ] [ PubMed ] [ Google Scholar ] 5. Bradley JR, Petree A. Caffeine consumption, expectancies of caffeine-enhanced performance, and caffeinism symptoms among university students. J Drug Educ. 1990;20(4):319–28. [ DOI ] [ PubMed ] [ Google Scholar ] 6. Lane JD, Adcock RA, Williams RB, Kuhn CM. Caffeine effects on cardiovascular and neuroendocrine responses to acute psychosocial stress and their relationship to level of habitual caffeine consumption. Biopsychosoc Sci Med. 1990;52(3):320–36. [ DOI ] [ PubMed ] [ Google Scholar ] 7. Lovallo WR, Al’Absi M, Blick K, Whitsett TL, Wilson MF. Stress-like adrenocorticotropin responses to caffeine in young healthy men. Pharmacol Biochem Behav. 1996;55(3):365–9. [ DOI ] [ PubMed ] [ Google Scholar ] 8. Klevebrant L, Frick A. Effects of caffeine on anxiety and panic attacks in patients with panic disorder: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2022;74:22–31. [ DOI ] [ PubMed ] [ Google Scholar ] 9. Talwar V, Bhambri SD. Caffeine use and its association with perceived stress among young adults. Int J Interdisciplinary Approaches Psychol. 2025;3(5):1202–13. [ Google Scholar ] 10. World Health Organization. International statistical classification of diseases and related health problems. 11th ed. WHO; Geneva. 2019. Accessed on 9 June 2025. 11. Abdulghani HM, AlKanhal AA, Mahmoud ES, Ponnamperuma GG, Alfaris EA. Stress and its effects on medical students: a cross-sectional study at a college of medicine in Saudi Arabia. J Health Popul Nutr. 2011;29(5):516. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 12. Rahman AA, Al Hashim BN, Al Hiji NK, Al-Abbad Z. Stress among medical Saudi students at college of medicine, King Faisal University. J Prev Med Hyg. 2013;54(4):195. [ PMC free article ] [ PubMed ] [ Google Scholar ] 13. Alfaifi MH, Gosadi IM, Alfaifi SM, Alfaifi AJ, Shajeri MA, Alsam HA, Tawhari FY, Abuageelah BM. Assessment of caffeine consumption behavior among Jazan University students in the south of Saudi Arabia: a cross-sectional study. Medicine. 2022;101(51):e31651. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 14. AlAteeq DA, Alotaibi R, Al Saqer R, Alharbi N, Alotaibi M, Musllet R, Alraqibah R. Caffeine consumption, intoxication, and stress among female university students: a cross-sectional study. Middle East Curr psychiatry. 2021;28(1):30. [ Google Scholar ] 15. Kearns NT, Blumenthal H, Natesan P, Zamboanga BL, Ham LS, Cloutier RM. Development and initial psychometric validation of the Brief-Caffeine Expectancy Questionnaire (B-CaffEQ). Psychol Assess. 2018;30(12):1597. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 16. Yusoff MS, Rahim AF, Yaacob MJ. The development and validity of the Medical Student Stressor Questionnaire (MSSQ). ASEAN J psychiatry. 2010;11(1):231–5. [ Google Scholar ] 17. Al-Shahrani MM, Alasmri BS, Al-Shahrani RM, Al-Moalwi NM, Al Qahtani AA, Siddiqui AF. The prevalence and associated factors of academic stress among medical students of King Khalid University: An analytical cross-sectional study. InHealthcare 2023 11(14), 2029. [ DOI ] [ PMC free article ] [ PubMed ] 18. Dahlawi M, Hennawi YB, Baharith M, Almurakshi M, Bawashkhah A, Dahlawi S, Alosaimi SB, Alnahdi FS, Alessa TT, Althobity O, Obaid M. The association between caffeine consumption and academic success in Makkah Region, Saudi Arabia. Cureus. 2024;10(16):4. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 19. Hardy R, Kliemann N, Dahlberg P, Bode A, Monroe E, Brand J. The relationship between energy drink consumption, caffeine content, and nutritional knowledge among college students. J Prim Prev. 2021;42(3):297–308. [ DOI ] [ PubMed ] [ Google Scholar ] 20. Cappelletti S, Daria P, Sani G, Aromatario M. Caffeine: cognitive and physical performance enhancer or psychoactive drug? Curr Neuropharmacol. 2015;13(1):71–88. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 21. Lazarus RS. Coping theory and research: past, present, and future. Biopsychosoc Sci Med. 1993;55(3):234–47. [ DOI ] [ PubMed ] [ Google Scholar ] 22. Samaha A, Al Tassi A, Yahfoufi N, Gebbawi M, Rached M, Fawaz MA. Data on the relationship between caffeine addiction and stress among Lebanese medical students in Lebanon. Data brief. 2020;28:104845. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 23. Haddad RA. The caffeine usage among medical students and their knowledge of its benefits and side effects. Al-Iraqia Med Coll J. 2024;1(1):45–55. [ Google Scholar ] 24. Juliano LM, Kardel PG, Harrell PT, Muench C, Edwards KC. Investigating the role of expectancy in caffeine withdrawal using the balanced placebo design. Hum Psychopharmacology: Clin Experimental. 2019;34(2):e2692. [ DOI ] [ PubMed ] [ Google Scholar ] 25. Richards G, Smith A. Caffeine consumption and self-assessed stress, anxiety, and depression in secondary school children. J Psychopharmacol. 2015;29(12):1236–47. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 26. Liu C, Wang L, Zhang C, Hu Z, Tang J, Xue J, Lu W. Caffeine intake and anxiety: a meta-analysis. Front Psychol. 2024;15:1270246. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 27. Lee YZ, Chua KN, Voon FL, Tham CL, Ho YC, Lee MT. Neurobiology of chronic caffeine use and withdrawal: mechanisms, effects and implications. Food Chem Toxicol. 2025;115817. 28. Ferré S. Role of the central ascending neurotransmitter systems in the psychostimulant effects of caffeine. J Alzheimer’s Disease. 2010;20(s1):S35–49. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 29. Nehlig A. Effects of coffee/caffeine on brain health and disease: What should I tell my patients? Pract Neurol. 2016;16(2):89–95. [ DOI ] [ PubMed ] [ Google Scholar ] 30. Al-Khlaiwi T, Habib SS, Akram A, Al-Khliwi H, Habib SM. Comparison of depression, anxiety, and stress between public and private university medical students. J family Med Prim care. 2023;12(6):1092–8. 10.4103/jfmpc.jfmpc_1719_22. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 31. Meredith SE, Juliano LM, Hughes JR, Griffiths RR. Caffeine use disorder: a comprehensive review and research agenda. J caffeine Res. 2013;3(3):114–30. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials Supplementary Material 1 (18.1KB, docx) Data Availability Statement The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. 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