Our cross-sectional study discussed undergraduate medical students’ consumption of CE. Our survey revealed that 88.3% of medical students in three countries (Egypt, Jordan, and Sudan) had consumed at least one substance considered a CE during their studies. A similar prevalence of CE use (87.6%) was observed in Pakistan (24). Interestingly, our study showed that females consumed CE more often than men (60.8% vs. 39.2%) which aligns with another study conducted in Poland (10). However, It was the opposite, in Iran, males were more likely to use CE than females (25). A possible cause of this variation may be due to psychological, and psychosocial factors as academic pressure, lack of sleep, the increasing availability and accessibility of CE, and mental health issues like depression or anxiety (26).
In our study, the higher consumption of CE was in the second year 260 (21%) as well as the fourth year 262 (21.2%). While third year and fifth-year students consume less CE 194 (15.7%) vs. 212 (17%), respectively. Moreover, the least usage of CE was among the senior’s years. However, Kudlow and his peers observed the highest percentage of CE use among senior students (27). These results can be attributed to the variation in the sample size between studying years and the timing of questionnaire distribution.
According to a study conducted in U.S, about half of the population (48.5%) received CE from a peer or a relative (28). In our study the leading source of acquisition of CE cited by the students were themselves. Additionally, the proportion of male and female students who prescribed the CE for themselves was nearly equal (64% for men and 60% for women). The ease of obtaining these substances may significantly impact the acquisition source. Most participants heard about these substances from a family member. In UK, the Internet was the main information source for learning about CE, followed by the experiences of peers, personal experiences, and scientific research (11). In fact, peer pressure and perceived stress play an important role in motivating students to consume these substances (28).
The coffee drinks were the first choice for medical students as a CE (above 90% in males and females). Our findings were consistent with the results of surveys done in Lithuania (21). A study conducted at Zayed University in Dubai revealed that almost 99% of students used caffeine, with over 30% admitting to being addicted to it (29). Although the reasons for these results are not clear, it could be because of the caffeine-induced psycho-stimulation effect by reducing the inhibitory effects that endogenous adenosine has on the dopamine and arousal system (30). The second-ranked CE consumed by students was energy drinks in both males (40%) and females (38%). In eastern Croatia, about 52% of university students consumed energy drinks during their years at university. It was found that males were more likely to drink energy drinks than females (31). Furthermore, in Pakistan, males (48.8%) were more consumers of energy drinks than females (37.1%) (32).
The two reasons leading students to start taking CE were to concentrate on both males and females (72% and 75 respectively) and to enhance alertness (61% male, and 63% female). These results walk in the same line with the study done among UAE students (9) and Portugal (33), which showed that students take CE without being diagnosed with any cognitive disorders to boost their academic performance during studying or exams. Indeed, a recent systematic review of studies conducted on university students found that academic pressure was a common reason for using CE (2).
A very high percentage of participants showed that they take CE daily (69% female, and 61% male), and the consumption increased during exam periods to reach around 40%. The same results were obtained in the study of UAE students (9). Those results are consistent with the high percentage of students who believe that CE increases concentration and alertness, as they consume more CE during exam periods to focus more. In addition, it was important to study the impact of CE on students’ grades, and it is recommended to be added to a future survey.
Furthermore, there was no significant difference between genders in their knowledge of maximum dose (male 54%, female 51%). In addition, approximately half of participants from both genders knew the side effects (49% in females, 53% in males). They suffered from many side effects, however, they continued to consume CE. Most students suffered from headaches, anxiety, and sleeplessness. Perceived stress and long wakefulness due to academic pressure may play a role in developing these symptoms (34). However, males were more unlikely to develop an adverse effect.
As a preventative public health approach, this study emphasizes the importance of increasing awareness of the hazards of CE use, dispelling beliefs about its safety, and addressing these issues from an early stage of higher education. Indeed, colleges should focus on rectifying the incorrect perception of the advantages of long-term usage of smart pharmaceuticals.
limitations
This is the first multi-national study discussing medical students' knowledge and levels of CE consumption in the MENA region. Further, the large sample size, as the data were collected from three Arab countries, provided a broader estimate of the current situation. However, we recognize some limitations to our study, such as the convenience sampling method, leading to a possible selection bias and failure to establish a causative relation between examined independent and dependent variables of the cross-sectional study design. the results may be influenced by recall bias. The questionnaire was distributed in English in Arab countries. This may be a reason for misunderstanding some questions, which subsequently may affect the response accuracy. However, the medical curriculum in the three countries is in English. The study did not estimate the relationship between CE use and sleep pattern and academic performance. So, future studies are still needed to confirm our findings and assess the association between CE use and sleep pattern and academic performance using suitable tools. Thus, we hope that future research designs a longitudinal study to better establish this relation.