Abstract
Background
Medical students often face significant psychological and lifestyle challenges during examination periods, including sleep disruption, increased caffeine intake, altered dietary habits, low physical activity, and higher tobacco use. These behaviors may influence academic performance, yet evidence remains inconsistent.
Methods
A cross-sectional study was conducted from April to October 2025 among 403 medical students from five universities in Palestine. Data were collected via an Arabic-language, self-administered online questionnaire covering sociodemographic, dietary and beverage habits, smoking, sleep, and physical activity. Academic performance was self-reported for the last two semesters. Statistical analysis included correlation, Mann–Whitney U, and regression models to assess relationships between lifestyle behaviors and academic performance.
Results
Participants reported low sleep duration (< 7 h/day: 89.3%) and low physical activity (19.1%). Caffeine intake was moderate, with most students consuming ≤ 1 cup/day of traditional or instant coffee. Waterpipe smoking was more prevalent than cigarette or e-cigarette use and increased during exams. Regression analysis revealed small but significant negative associations between traditional coffee and tea consumption and average grades. Other dietary habits, energy drinks, sleep, and exercise were not significantly associated with average grades. Waterpipe use was unexpectedly positively associated with average grades, likely due to confounding factors.
Conclusion
Examination periods are associated with unhealthy behaviors among medical students, particularly increased caffeine and tobacco use, short sleep, and low physical activity. Among these, only coffee and tea consumption showed a small negative impact on academic performance.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12909-026-09591-z.
Keywords: Medical students, Lifestyle behaviors, Academic performance, Caffeine, Sleep, Smoking
Background
Medical education is widely recognized as highly demanding and a major source of psychological stress, particularly during high-stakes examination periods. During these times, students often experience marked changes in their lifestyle, including heightened stress levels, disrupted study patterns, and increased reliance on last-minute cramming to sustain performance. Such pressures can negatively affect overall well-being, impair essential cognitive functions such as memory consolidation, and increase the risk of both academic fatigue and physical burnout [1].
Sleep, in particular, is a critical determinant of cognitive functioning, memory consolidation, and learning. Recent evidence from a 2025 cross-sectional study among medical and health sciences students showed that poor sleep quality is highly prevalent, affecting more than 70% of students, and is significantly associated with lower academic performance and reduced well-being [2]. Similarly, other studies have demonstrated that academic stress is strongly linked to sleep disturbances and decreased life satisfaction among medical students, highlighting the complex interaction between stress, sleep, and academic outcomes [3].
Caffeine consumption is another key behavior that tends to increase during exams, as students often rely on caffeinated beverages to enhance alertness and sustain study efforts. Recent research indicates that varying levels of caffeine intake are associated with differences in stress levels among University students, suggesting that caffeine use may both reflect and contribute to academic stress [4]. While moderate caffeine intake may temporarily improve alertness, excessive or poorly timed consumption can negatively affect sleep quality, which may in turn impair academic performance. Earlier experimental and observational studies have also shown that exam stress is associated with increased caffeine use and reduced sleep duration, reinforcing the cyclical relationship between stress, stimulant use, and sleep disruption [5].
In addition to caffeine, other lifestyle behaviors such as smoking, dietary habits, and physical activity may also change during stressful academic periods. Medical students have been shown to experience high levels of stress globally, often exceeding 50% prevalence in some populations, which is associated with unhealthy coping strategies, including substance use and sedentary behavior [6]. These behaviors may further influence cognitive performance and academic achievement, although the strength and direction of these relationships remain inconsistent across studies.
Despite the growing body of literature, the relationship between lifestyle factors and academic performance is still not fully understood. In the Palestinian context, medical students may face additional stressors that can further exacerbate unhealthy lifestyle behaviors during examination periods. These include ongoing political instability, mobility restrictions, financial challenges, uncertainty related to the educational environment, and limited access to mental health and wellness resources. Previous studies among Palestinian medical students have reported high levels of stress-related symptoms and sleep disturbances, with altered sleep patterns and academic burden identified as important contributing factors [7]. Such contextual pressures may intensify reliance on maladaptive coping behaviors, including excessive caffeine intake, smoking, irregular eating patterns, and reduced physical activity. Despite these unique challenges, there remains limited evidence examining how these behaviors collectively relate to academic performance among Palestinian medical students during high-stress examination periods. Therefore, investigating these associations within this context is particularly important to better inform culturally and institutionally relevant interventions aimed at improving both student well-being and academic outcomes.
Accordingly, this study aims to assess lifestyle behaviors among medical students during examination periods, including caffeine consumption, sleep patterns, dietary habits, physical activity, and smoking, and to examine their association with academic performance.
Methodology
Study design and population
This study employed a cross-sectional analytical design to assess how lifestyle behaviors, such as caffeine use, sleep, diet, physical activity, and smoking, during exam periods relate to medical students’ academic performance. The study was conducted from 1 April 2025 to 1 October 2025 among medical students enrolled at An-Najah National University, Hebron University, Palestine Polytechnic University, Al-Quds University, and Arab American University. Ethical approval was obtained from the Institutional Review Board (IRB) of Hebron University. Participation was voluntary, and electronic informed consent was obtained prior to initiating the questionnaire. No personal identifiers were collected. Data were stored in password-protected files accessible only to the research team and were used solely for research purposes.
Samples and the inclusion criteria
The required sample size was calculated using Cochran’s formula for cross-sectional studies, assuming a 95% confidence level, 5% margin of error, and an expected prevalence of 50% due to the absence of prior local estimates, yielding a minimum of 384 participants; a total of 403 participants were ultimately included.
Participants were eligible for inclusion if they were enrolled medical students aged 18 years or above and providing electronic informed consent to participate; non-medical students were excluded. As all questionnaire items were mandatory, no missing data were recorded. Data were collected via a self-administered online questionnaire distributed through Google Forms and disseminated via social media platforms. Participation was voluntary, anonymity was ensured, and no personal identifiers were collected.
Data collection tool
The questionnaire was designed in Arabic to align with Palestinian cultural norms and common lifestyle practices. It accounted for locally prevalent habits, including the consumption of traditional beverages such as mate and the frequent use of waterpipe smoking. The instrument was primarily adapted from existing literature on student lifestyle behaviors and reviewed for content validity to ensure relevance and clarity in the local context [8]. It consisted of three main sections: (1) sociodemographic and academic characteristics (e.g., gender, age, year of study, living arrangement, and self-reported academic average); (2) eating and drinking behaviors during the exam period (e.g., frequency of breakfast consumption, fast food intake, number of cups of tea, coffee, mate, and energy drinks per day/week); and (3) smoking behaviors before and during the exam period (e.g., type of smoking, number of cigarettes per day, and frequency of water pipe use). Academic performance was measured by self-reported average grades from the two most recent semesters.
Statistical analysis
Data were analyzed using IBM SPSS Statistics. Categorical variables were summarized using frequencies and percentages (n, %), while continuous variables were presented as mean ± standard deviation (Mean\ SD). The normality of the data distribution was assessed, and since the main outcome-related variables (GPA) violated the assumption of normal distribution, non-parametric methods were employed. Bivariate associations between students’ habits and their self-reported GPA were evaluated using Spearman’s rank correlation for ordinal and continuous variables, and the Mann-Whitney U test for categorical variables with two groups. To identify factors independently associated with GPA, a multiple linear regression model with robust estimators was fitted. This approach was chosen to provide reliable estimates despite the non-normality of the data. The final regression model included sex, traditional smoking, waterpipe consumption, and daily intake of traditional coffee and tea during exams. For all tests, a two-sided p-value < 0.05 was considered statistically significant.
Results
Descriptive statistics revealed that the sample consisted of 403 students, with 60.3% female and 39.7% male. The mean age was 20.59 ± 2.92 years, and the mean average grades was 82.78 ± 6.05%. Almost one third (31.5%) were second-year students, while sixth-year students made up 13.6%. Most participants (67.5%) lived in their own homes, and most participants (71.7%) lived with family members; 23.6% lived in dorms, and just over 10% lived alone (Table 1).
Table 1.
Characteristics of the study population
| Student Characteristics | n (%) or mean ± SD |
|---|---|
| Sex | |
| Female | 243 (60.3%) |
| Male | 160 (39.7%) |
| Age (years) | 20.59 ± 2.92 |
| Average Grades (%) | 82.78 ± 6.05 |
| Year of study | |
| 1st year | 72 (17.9%) |
| 2nd year | 127 (31.5%) |
| 3rd year | 71 (17.6%) |
| 4th year | 28 (6.9%) |
| 5th year | 50 (12.4%) |
| 6th year | 55 (13.6%) |
| Residency type | |
| Owned house | 272 (67.5%) |
| Rented house | 36 (8.9%) |
| Dormitory | 95 (23.6%) |
| Living partners | |
| Alone | 42 (10.4%) |
| Family | 289 (71.7%) |
| Friends/Roommates | 72 (17.9%) |
Caffeine intake during exam time was relatively low. A little over half either did not or only consume a limited amount of traditional coffee (0–1 cup/day: 51.6%), and only a small percentage (12.7%) reported consuming ≥ 4 cups/day. Tea followed the same pattern: 61.7% were at 0–1 cup/day, and less than 1 in 10 reported drinking ≥ 4 cups/day. For instant coffee, the vast majority consumed between 0 and 1 cup/day (59.8%), while ≥ 4 cups/day was uncommon (7.5%).
The consumption of other beverages was also limited. The majority of students reported consuming energy drinks (59.1%); 27.3% consumed them 1–3 times per week, and only 4.5% reported consuming ≥ 7 per week. Nearly half (45.70%) consumed natural juice 1–3 times per week, 41.9% did not consume any, and few reported higher intakes. Fruit consumption was relatively moderate, with 33% reporting 1–2 times/week and 21.1% reporting daily consumption.
Regarding eating patterns, only 39.2% of students maintained a regular eating schedule during exam time. Breakfast patterns were polarized: 35.0% ate breakfast daily, while 14.4% skipped breakfast entirely. Most students consumed fast food rarely or ≤ 1–2 times/week (69%). Snacking was more frequent (62.5% 1–4 times/week; 22.8% daily). Vitamin C supplementation was generally low (68.7% never used it; 3.2% ≥7 times/week).
Sleeping and physical activity showed evidence of high academic pressure, as 89.3% of students slept less than 7 h/day during midterm and finals periods, and only 19.1% reported exercising. Barriers to attending university were evenly distributed (~ 50% yes/no).
Descriptive comparisons and bivariate patterns showed that heavier tea and traditional coffee consumption were associated with slightly lower average grades, while instant coffee showed an inverted-U pattern, with moderate intake associated with better grades and higher intake associated with lower grades. Moderate fast-food intake (1–2 times/week) was associated with slightly higher grades than daily consumption. Other dietary variables, including energy drinks, vitamin C, and natural juice, showed no consistent pattern. Sleep duration (< 7 vs. ≥ 7 h) was not significantly different in relation to grades, while exercise showed a slight positive trend (Table 2).
Table 2.
Students’ habits and average grades for each group
| variable | Frequency (percent) | Mean average grades ± SD | |
|---|---|---|---|
| Traditional Coffee (cups/day during exams) | 0 | 122 (30.3) | 83.8 (6.5) |
| 1 | 86 (21.3) | 83.1 (6.1) | |
| 2 | 84 (20.8) | 81.8 (5.1) | |
| 3 | 60 (14.9) | 82.1 (7.2) | |
| 4 | 33 (8.2) | 82.8 (3.2) | |
| 5 or more | 18 (4.5) | 81.8 (6) | |
| Tea (cups/day during exams) | 0 | 111 (27.5) | 83.6 (6.3) |
| 1 | 138 (34.2) | 82.9 (5.8) | |
| 2 | 68 (16.9) | 82.1 (6.8) | |
| 3 | 47 (11.7) | 82 (5.9) | |
| 4 | 24 (6) | 82 (4.2) | |
| 5 or more | 15 (3.7) | 81.6 (5.6) | |
| Instant Coffee (cups/day during exams) | 0 | 113 (28) | 82.8 (6.7) |
| 1 | 128 (31.8) | 83.6 (6.3) | |
| 2 | 95 (23.6) | 82.1 (5.2) | |
| 3 | 37 (9.2) | 82.1 (5.5) | |
| 4 | 14 (3.5) | 83.2 (5.7) | |
| 5 or more | 16 (4) | 81 (4.6) | |
| Energy Drinks (250 ml/week during exams) | 0 | 238 (59.1) | 83 (6) |
| 1–3 | 110 (27.3) | 82.2 (6.3) | |
| 4–6 | 37 (9.2) | 82.4 (5.7) | |
| 7 or more | 18 (4.5) | 84.6 (6) | |
| Natural Juice (cups/week during exams) | 0 | 169 (41.9) | 83.3 (6.4) |
| 1–3 | 184 (45.7) | 82.1 (5.9) | |
| 4–6 | 36 (8.9) | 84.4 (5.2) | |
| 7 or more | 14 (3.5) | 81.2 (4.8) | |
| Fruit Intake (times/week during exams) | Rarely | 103 (25.6) | 82.8 (6.1) |
| 1–2 | 133 (33) | 82.4 (6.4) | |
| 3–4 | 82 (20.3) | 82.6 (5.3) | |
| Daily | 85 (21.1) | 82.5 (5.8) | |
| Vitamin C Tablets (times/week during exams) | Never | 277 (68.7) | 82.6 (6.5) |
| 1–3 | 73 (18.1) | 83.8 (4.9) | |
| 4–6 | 40 (9.9) | 81.5 (4.7) | |
| 7–10 | 10 (2.5) | 84.7 (5.2) | |
| 11 or more | 3 (0.7) | 84.7 (0.6) | |
| Regular Diet (during exams) | No | 245 (60.8) | 82.8 (6) |
| Yes | 158 (39.2) | 82.8 (6.2) | |
| Breakfast Days (days/week during exams) | 0 | 58 (14.4) | 83.4 (7) |
| 1 | 36 (8.9) | 84 (4.9) | |
| 2 | 55 (13.6) | 82.3 (6.4) | |
| 3 | 38 (9.4) | 80.8 (7.1) | |
| 4 | 35 (8.7) | 82.9 (6) | |
| 5 | 28 (6.9) | 83.5 (7.5) | |
| 6 | 12 (3) | 82.5 (5.5) | |
| 7 | 141 (35) | 82.7 (5.2) | |
| Fast Food (times/week during exams) | Rarely | 153 (38) | 82.7 (5.7) |
| 1–2 | 125 (31) | 83.7 (5.7) | |
| 3–4 | 64 (15.9) | 82 (7.3) | |
| Daily | 61 (15.1) | 81.9 (6) | |
| Snacks (times/week during exams) | Rarely | 59 (14.6) | 82.3 (6.1) |
| 1–2 | 131 (32.5) | 83 (6.3) | |
| 3–4 | 121 (30) | 82.2 (6) | |
| Daily | 92 (22.8) | 83.5 (5.7) | |
| Sleep (hours/day during exams) | Less than 7 | 360 (89.3) | 82.8 (5.9) |
| More than 7 | 43 (10.7) | 82.7 (7) | |
| Exercise (during exams) | No | 326 (80.9) | 82.7 (6.2) |
| Yes | 77 (19.1) | 83.2 (5.2) | |
| Barriers to University (during exams) | No | 201 (49.9) | 82.7 (5.9) |
| Yes | 202 (50.1) | 82.8 (6.2) | |
Among the participants, hookah smoking was the most common form of tobacco use. In the sample only a few people were cigarette-only smokers (≈ 3.0%) or were exclusive e-cigarette users (≈ 4.0%), with hookah being very much more prevalent: about 7.8% smoked hookah only, and about 9.2% smoked hookah in addition to cigarettes. Ex-smokers made up about 4.5% of the sample (Fig. 1).
Fig. 1.
Smoking habits among participants
Cigarette consumption tended to spike during exam periods. Outside of the exam, most cigarette smokers used low amounts, with approximately nine participants smoking one to five cigarettes per day and one participant smoking greater than 20 cigarettes. During the exam period, the number of light smokers, as previously mentioned, decreased from nine to seven participants. The number of six- to ten-cigarette smokers increased from two to three participants, twice the number of 21- to 30-cigarette smokers increased from one to two participants, and a small group emerged who smoked greater than 31 cigarettes during the exam. Waterpipe use followed a similar pattern: outside of the exam, the dominant use category was occasional (two people once a week, one person twice a week), and no one used it on a daily basis. During the exam period, there was more frequent use reported: three people smoked once a week, two people smoked twice or more a week, and one person smoked daily. Electronic cigarette usage was fairly rare, but like the rest of the sample, electronic cigarette use had shifted towards increased use during the exam period—monthly or quarterly use dropped off, while the number of people vaping at least twice a week or daily increased (Fig. 1).
Results of correlation analysis showed that during the exam period, average grades had a minor negative correlation with traditional coffee consumption (ρ = -0.137, p = 0.006). Tea was borderline significant (ρ = -0.097, p = 0.051), while instant coffee was not significant (ρ = -0.086, p = 0.085). All other variables—including energy drinks, fruit intake, fast food, snacks, sleep duration, and time alone—showed no significant correlations with average grades (all p > 0.05). Results of Mann–Whitney U tests showed that there were no significant differences in average grades based on regular diet patterns (p = 0.874), exercise during exams (p = 0.756), or reported barriers to university attendance (p = 0.605) (Table 3).
Table 3.
Relationship between different types of habits during exam period and self-reported students’ average grades using Spearman’s rank correlation and Mann-Whitney U test
| Variable | Spearman’s ρ | p-value |
|---|---|---|
| Traditional Coffee (cups/day during exams) | -0.137 | 0.006 |
| Tea (cups/day during exams) | -0.097 | 0.051 |
| Instant Coffee (cups/day during exams) | -0.086 | 0.085 |
| Energy Drinks (250 ml/week during exams) | -0.031 | 0.532 |
| Natural Juice (cups/week during exams) | -0.068 | 0.173 |
| Fruit Intake (times/week during exams) | -0.086 | 0.085 |
| Vitamin C Tablets (times/week during exams) | -0.013 | 0.795 |
| Breakfast Days (days/week during exams) | -0.028 | 0.577 |
| Fast Food (times/week during exams) | -0.031 | 0.530 |
| Snacks (times/week during exams) | -0.006 | 0.908 |
| Sleep (hours/day during exams) | -0.01 | 0.834 |
| Alone (hours/day during exams) | 0.054 | 0.281 |
| Variable | p-value | |
| Regular Diet (during exams) (yes/no) | 0.874 | |
| Exercise (during exams) (yes/no) | 0.756 | |
| Barriers to University (during exams) (yes/no) | 0.605 | |
ρ = Spearman’s rank correlation coefficient; p-value < 0.05 was considered statistically significant. Significant values are shown in bold
Results of multiple linear regression analysis showed that waterpipe use was positively associated with higher average grades and was statistically significant (Model 1: B = 2.13, 95% CI 0.61–3.65, p = 0.006; Model 2: B = 2.67, 95% CI 1.10–4.24, p < 0.001). In contrast, each additional cup of traditional coffee and tea per day was associated with slightly lower average grades (traditional coffee: B = -0.46 in Model 1 and − 0.40 in Model 2; tea: B = -0.54 in Model 1 and − 0.52 in Model 2; all 95% CIs excluded 0). Sex was not significant in Model 1 (B = 1.12, p = 0.079) but became significant in Model 2 (B = 1.48, p = 0.031), suggesting possible confounding effects. Traditional smoking showed a negative but non-significant association with grades (B = -1.60, p = 0.080). (Table 4).
Table 4.
Multiple linear regression with robust estimators for students’ average grades
| variable | model 1 | model 2 | ||||
|---|---|---|---|---|---|---|
| B | 95% CI (lower - upper) | Sig. | B | 95% CI (lower - upper) | Sig. | |
| sex (ref: female) | 1.12 | -0.13-2.37 | 0.079 | 1.482 | 0.138–2.825 | 0.031 |
| traditional smoking (ref: no) | -1.598 | -3.386-0.19 | 0.08 | |||
| waterpipe (ref: no) | 2.128 | 0.606–3.649 | 0.006 | 2.672 | 1.101–4.242 | < 0.001 |
| Traditional Coffee (cups/day during exams) | -0.457 | -0.849–0.065 | 0.022 | -0.402 | -0.793–0.01 | 0.044 |
| Tea (cups/day during exams) | -0.537 | -0.958–0.115 | 0.013 | -0.521 | -0.946–0.097 | 0.016 |
B = unstandardized regression coefficient, CI confidence interval, Sig. = p-value, Ref. = reference category. Significant values are shown in bold
Discussion
Exam periods were associated with unhealthy habits among medical students, including short sleep, low physical activity, and increased use of caffeine and tobacco. Among all factors, only traditional coffee and tea showed a small but significant negative association with average grades, while other dietary habits were not significantly related. Although waterpipe use appeared positively linked to average grades, this is likely due to confounding rather than a real effect. Overall, lifestyle changes during exams have limited and multifactorial effects on academic performance.
The observed association between coffee and tea consumption and lower average grades is particularly relevant, as caffeinated beverages are widely used by students during examination periods to enhance alertness and sustain prolonged study sessions [9, 10]. This pattern is consistent with previous research demonstrating increased caffeine consumption among medical students during periods of academic stress [9]. Caffeine intake has also been shown to negatively affect sleep quality, particularly when consumed later in the day, which may indirectly impair learning processes and academic performance [10, 11]. However, the literature remains inconsistent, as several studies have failed to demonstrate a direct relationship between caffeine intake and academic achievement, suggesting that the effect may be modest and influenced by dose, timing, and behavioral context of use [12]. The present findings are broadly consistent with a Syrian study reporting weak but negative associations between certain dietary behaviors during examination periods and academic performance [8].
In contrast, energy drinks were not significantly related to average grades in our study [13, 14]. This finding may be explained by the relatively low prevalence of energy drink use in the study population, resulting in limited statistical power to detect meaningful associations. Previous studies, however, have shown that energy drinks are commonly consumed by University students during periods of intensive academic workload, including studying and examinations [13]. Other evidence has linked energy drink use to poorer sleep quality, reduced sleep duration, increased fatigue, and lower academic performance in some student populations [14–18]. The discrepancy between these findings and the present study may reflect differences in consumption patterns, measurement approaches, and contextual factors across populations and educational systems [13, 14, 16, 17].
Smoking behavior emerged as another notable finding in this study. Waterpipe smoking was the most prevalent form of tobacco use and was reported to increase during examination periods [8]. This observation aligns with regional data indicating high prevalence of waterpipe smoking among University students in Palestine, where it is often perceived as socially acceptable compared to cigarette smoking [19]. Although cigarette smoking demonstrated a negative but non-significant association with academic performance in regression analyses, existing literature consistently links tobacco use and nicotine dependence with poorer academic outcomes, including lower grades, increased absenteeism, and reduced academic engagement [20]. The observed positive association between waterpipe smoking and average grades should therefore be interpreted with caution. This observation is unlikely to indicate a genuine protective effect and may instead be attributable to residual confounding, limited subgroup size, or unmeasured socioeconomic and behavioral influences. Importantly, substantial evidence indicates that waterpipe smoking is associated with impaired cognitive functions, including attention, working memory, and executive functioning [21–23].
Dietary behaviors demonstrated a largely neutral association with academic performance in this study. Variables such as breakfast consumption, overall diet quality, fruit intake, natural juice consumption, fast food intake, snack consumption, and vitamin C supplementation were not significantly associated with average grades. This does not necessarily imply that these behaviors lack importance, as previous systematic reviews have suggested that healthier dietary patterns, including regular breakfast consumption, may be associated with improved attention, cognitive function, and academic outcomes [24, 25]. However, these associations are usually small, and the results are not always the same across studies [25]. However, these associations are generally modest and inconsistent across studies. Differences in dietary evaluation techniques and the dependence on self-reported academic outcomes may partly account for the inconsistent results reported across the literature. Therefore, the present results may indicate that dietary behaviors exert only subtle effects on academic performance during examination periods, or that such effects are difficult to detect in cross-sectional study designs [18, 25].
Sleep duration and physical activity levels were also suboptimal in the study population, with most students reporting less than seven hours of sleep per night and very low levels of exercise during examination periods [18, 26]. Although these variables were not significantly associated with average grades in the current analysis, the lack of significance may be attributable to the limited variability in exposure, given the high prevalence of poor sleep within the study population. Previous research has consistently demonstrated that adequate sleep quality is associated with improved cognitive performance, memory consolidation, and academic achievement among medical students [26]. Similarly, physical activity has been associated with better academic performance in several studies, although findings remain heterogeneous across populations [27]. Consequently, the absence of statistically significant associations in this study should not be interpreted as evidence of lack of effect [18, 26, 27].
Overall, the findings of this study suggest that examination periods are associated with shifts toward less healthy behavioral patterns among medical students, particularly increased caffeine consumption, reduced sleep duration, low physical activity, and increased tobacco use. However, the overall associations between these behaviors and academic performance were weak, indicating that academic achievement is likely influenced by a complex interplay of multiple behavioral, psychological, and environmental factors rather than any single lifestyle component [8, 18]. These findings highlight the need for targeted institutional strategies aimed at supporting student health during high-stress academic periods, including guidance on appropriate caffeine use, smoking cessation interventions, sleep hygiene education, and promotion of physical activity and stress management strategies [11, 18, 20, 26, 27].
This research provides insight into the lifestyle behaviors of medical students in Palestine during high-pressure examination periods, a critical yet underexplored context. By identifying behaviors linked to academic performance, the study informs targeted strategies to promote healthier habits, optimize cognitive performance, and reduce stress-related health risks. The findings also contribute region-specific evidence to the global literature on student well-being and performance.
Based on these findings, universities should implement targeted interventions to promote healthier habits during exam periods. Educational campaigns can guide students on appropriate caffeine use, particularly regarding timing and quantity, to minimize its negative effects on sleep and performance. Institutions should also strengthen anti-smoking initiatives, with specific attention to the widespread use of waterpipe smoking. Furthermore, interventions aimed at improving sleep hygiene, supporting consistent physical activity, and expanding access to mental health and stress-management resources may contribute to preserving student well-being during academically demanding periods. Future research should adopt longitudinal designs and include more detailed measures of lifestyle behaviors, such as caffeine timing, sleep quality, and nicotine dependence, to better understand their relationship with academic performance.
Limitations
This study has a number of limitations, the first being its cross-sectional design, which does not allow for causal conclusions regarding the relationship between lifestyle behaviors and academic performance. Second, data were self-reported, including academic performance in the last two semesters, which may introduce recall bias as well as social desirability bias into the data. Third, high-intake subgroups for certain behaviors (e.g., energy drinks, waterpipe use) were small, limiting statistical power. Finally, detailed measures of sleep quality, caffeine timing, and nicotine dependence were not assessed, which may underestimate the true effect of these behaviors on academic performance.
Conclusion
Medical students experienced significant lifestyle disruptions during examination periods, including poor sleep, low physical activity, and increased caffeine and tobacco use. Traditional coffee and tea consumption were associated with a slight but statistically significant reduction in academic achievement, while other behaviors showed no clear relationship. Interventions targeting healthier lifestyle habits, particularly regarding caffeine use, sleep, and tobacco, may help support students’ well-being and academic outcomes.
Supplementary Information
Authors’ contributions
Author ContributionsWasef Alhroub and Maaweya Jabareen conceptualized and designed the study, supervised the project, and critically revised the manuscript for important intellectual content. Ahmad Fasfoos and Omair Bseiso contributed to study design, data analysis, and interpretation of results. Joana Deeik and Ahmad Hasan Ahmoud contributed to data interpretation and manuscript drafting. Amro K. Al-Manasrah, Ibraheem Mohammed Thalji, Ahmad Basil Abu Arish, Iyyad Moayad Adawi, and Mustafa Murad Alqawasmeh were responsible for data collection and initial data curation. Monther M. Hroub and Jamal Ahmad contributed to statistical analysis and methodological support. Musbah Hroub provided senior supervision and critically revised the manuscript. All authors contributed to drafting or revising the manuscript, approved the final version, and agree to be accountable for all aspects of the work in accordance with authorship criteria.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Data availability
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Ethical approval was obtained from the Institutional Review Board (IRB) of Hebron University (IRB Registration No. ER.CM.05.2026). All participants provided informed consent prior to participation. The study was conducted in accordance with the Declaration of Helsinki.
Consent for publication
All participants provided consent for the anonymous use of their responses in publications arising from this study.
Competing interests
The authors declare no competing interests.
Clinical trial number
Not applicable.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Maaweya Jabareen and Wasef Alhroub contributed equally to this work.
References
- 1.Roehe MA, et al. Study Smarter, Sleep Better: Learning Approaches as Predictors of Sleep Quality Among Medical Students. Academic Medicine. 2026;101(6):664-72. [DOI] [PubMed]
- 2.Hassan S, et al. Association Between Sleep Quality and Academic Performance Among Undergraduate Medical Health Sciences Students: A Cross-Sectional Study. Cureus. 2025;17(9):e91548. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Ozdemir E, Yazarkan Y, Pehlivanoglu B. Medical Students’ Stress Levels Are Correlated with Their Sleep Quality and Life Satisfaction. Int J Med Students. 2024;12(1):53–9. [Google Scholar]
- 4.Al-Garni AM, et al. Influence of different doses of caffeine consumption on stress levels among students enrolled in King Khalid University, Saudi Arabia. J Family Med Prim Care. 2025;14(11):4635–41. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Zunhammer M, Eichhammer P, Busch V. Sleep quality during exam stress: the role of alcohol, caffeine and nicotine. PLoS ONE. 2014;9(10):e109490. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Almojali AI, et al. The prevalence and association of stress with sleep quality among medical students. J Epidemiol Glob Health. 2017;7(3):169–74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Anaya F, et al. Epidemiological and clinical characteristics of headache among medical students in Palestine: a cross sectional study. BMC Neurol. 2022;22(1):4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Bitar A, et al. Dietary and smoking habits during the exam period and their effect on the academic achievement among Syrian medical students. BMC Med Educ. 2024;24(1):60. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Pulla A, Syed A, Bolisetti V. Patterns of caffeine consumption among medical undergraduates in Secunderabad, Telangana, India. J Educ Health Promot. 2024;13:280. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Sawah MA, et al. Perceived Stress and Coffee and Energy Drink Consumption Predict Poor Sleep Quality in Podiatric Medical Students A Cross-sectional Study. J Am Podiatr Med Assoc. 2015;105(5):429–34. [DOI] [PubMed] [Google Scholar]
- 11.O’Callaghan F, Muurlink O, Reid N. Effects of caffeine on sleep quality and daytime functioning. Risk Manag Healthc Policy. 2018;11:263–71. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Dahlawi M, et al. The Association Between Caffeine Consumption and Academic Success in Makkah Region, Saudi Arabia. Cureus. 2024;16(4):e57975. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Protano C, et al. Consumption patterns of energy drinks in university students: A systematic review and meta-analysis. Nutrition. 2023;107:111904. [DOI] [PubMed] [Google Scholar]
- 14.Alshumrani R, et al. Consumption of energy drinks and their effects on sleep quality among medical students. J Family Med Prim Care. 2023;12(8):1609–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Kaldenbach S, et al. Energy drink consumption and sleep parameters in college and university students: a national cross-sectional study. BMJ Open. 2024;14(2):e072951. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Champlin SE, Pasch KE, Perry CL. Is the Consumption of Energy Drinks Associated With Academic Achievement Among College Students? J Prim Prev. 2016;37(4):345–59. [DOI] [PubMed] [Google Scholar]
- 17.Pettit ML, DeBarr KA. Perceived stress, energy drink consumption, and academic performance among college students. J Am Coll Health. 2011;59(5):335–41. [DOI] [PubMed] [Google Scholar]
- 18.Reuter PR, Forster BL. Student health behavior and academic performance. PeerJ. 2021;9:e11107. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Hawash M, et al. The Prevalence of Water Pipe Smoking and Perceptions on its Addiction among University Students in Palestine, Jordan, and Turkey. Asian Pac J Cancer Prev. 2022;23(4):1247–56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Alqahtani JS, et al. Impact of Smoking Status and Nicotine Dependence on Academic Performance of Health Sciences Students. Subst Abuse Rehabil. 2023;14:13–24. [DOI] [PMC free article] [PubMed]
- 21.Toukan Y, et al. The Effect of a 30-Min Water-Pipe Smoking Session on Cognitive Measures and Cardio-Pulmonary Parameters. Nicotine Tob Res. 2020;22(8):1347–53. [DOI] [PubMed] [Google Scholar]
- 22.Nadar MS, Hasan AM, Alsaleh M. The negative impact of chronic tobacco smoking on adult neuropsychological function: a cross-sectional study. BMC Public Health. 2021;21(1):1278. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Valentine G, Sofuoglu M. Cognitive Effects of Nicotine: Recent Progress. Curr Neuropharmacol. 2018;16(4):403–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Adolphus K, Lawton CL, Dye L. The effects of breakfast on behavior and academic performance in children and adolescents. Front Hum Neurosci. 2013;7:425. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Burrows TL et al. Associations between Dietary Intake and Academic Achievement in College Students: A Systematic Review. Healthc (Basel). 2017;5(4):60. [DOI] [PMC free article] [PubMed]
- 26.Falloon K, et al. Sleep well to perform well: the association between sleep quality and medical student performance in a high-stakes clinical assessment. Sleep Adv. 2022;3(1):zpac019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Trott M, et al. Associations between total physical activity levels and academic performance in adults: A systematic review and meta-analysis. J Educ Health Promot. 2024;13:273. [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
Data Availability Statement
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.