Introduction

Energy drinks (EDs), which typically contain stimulants such as caffeine, taurine, and guarana, are especially popular among college students seeking to stay awake and focused during studies or night shifts [1-3]. While EDs may enhance alertness, energy, and mood, excessive intake can lead to health issues such as anxiety, insomnia, headaches, and gastrointestinal problems due to their high stimulant content [4,5].

These risks have led the American Academy of Pediatrics to advise against ED use in children and adolescents [3]. For healthy adults, daily caffeine intake up to 400 mg is generally considered safe [6]. However, EDs can contain 80–300 mg of caffeine per serving—often approaching or exceeding this limit when combined with other sources such as coffee, tea, or colas [7,8]. Among adolescents and young adults, the prevalence of regular (i.e., consumption within the past 7 days or daily use) ED consumption varies widely, from 0.31% to 75% [9]. A meta-analysis found that 76.4% consumed EDs less than once per week, 20.5% consumed one or more per week, and 1.2% reported daily intake [4]. These findings underscore growing concerns regarding excessive stimulant intake in young populations.

The risk of adverse events increases when individuals consume alcohol mixed with energy drinks (AmED), with an estimated 37% of undergraduates engaging in this behavior [10]. AmED has been shown to increase the desire to consume more alcohol compared to drinking alcohol alone [11]. Caffeine does not offset alcohol’s depressant effects; instead, it masks intoxication, increasing alcohol intake and harm risk. AmED use has been associated with greater risks than alcohol use alone, including binge drinking, impaired driving, risky sexual behavior, and a higher likelihood of alcohol dependence [11,12]. In response to these concerns, the U.S. Food and Drug Administration banned premixed caffeinated alcoholic beverages in 2010 [13]. Nevertheless, AmED remains popular in the form of consumer- or bartender-mixed drinks.

ED use is associated with gender, with male students typically consuming more EDs than female students [2,13]. It is also linked to various health behaviors, including physical activity, alcohol, drug, and tobacco use, with these associations often differing by gender. Previous studies have reported that male students are more likely to consume energy drinks for athletic performance [14], and that ED use among young men has been associated with adherence to traditional masculinity ideology [15]. In contrast, female students are more likely to consume EDs as a substitute for coffee or for weight control [14]. In a study of first-year university students, ED use in female students was significantly associated with alcohol use, nonprescription drug use, and tobacco use, whereas in male students such associations were observed only with certain drug use and smoking [2].

Gender-specific physiological factors may also contribute to these patterns. Males, with a higher basal metabolic rate, metabolize stimulants more rapidly, which may lead to greater consumption and higher risk of dependence. In contrast, females may metabolize caffeine more slowly during menstrual cycle phases with elevated estrogen, potentially resulting in lower ED intake [2,16,17]. Moreover, adverse effects of caffeine—such as anxiety, restlessness, insomnia, and palpitations—are more frequently reported by females [2]. These behavioral and physiological differences may interact with mental health factors, potentially amplifying gender-specific patterns of ED use. Indeed, ED use has been consistently linked to mental health concerns, with higher perceived stress and increased anxiety symptoms both correlating with greater ED use [18-20]. Such interactions between gender-specific responses and psychological distress highlight the importance of considering both biological and psychosocial determinants when examining high-risk ED use. Despite the rapid growth of the ED market in the Asia-Pacific region [21], research on gender-based ED use, AmED behavior, and mental health among college students remains limited. This underscores the need for a theoretical framework that captures the interplay of personal, behavioral, and environmental factors in explaining and addressing high-risk ED use.

This study is grounded in Social Cognitive Theory (SCT), which explains human behavior as the product of reciprocal interactions among personal, behavioral, and environmental factors [22,23]. Among the key concepts of SCT are outcome expectations—beliefs about the likelihood and value of the consequences of behavioral choices—and observational learning, defined as learning new behaviors through exposure to interpersonal or media demonstrations, particularly via peer modeling [23]. In the context of ED or AmED use, outcome expectations may correspond to reasons reported in previous studies [5,24,25], such as enhancing alertness, boosting energy, or alleviating stress during academic demands. Observational learning may occur when individuals are influenced by peers who engage in ED or AmED use [13], thereby reinforcing and normalizing these behaviors.

Therefore, this study aimed to compare ED use, health behaviors, and mental health between male and female college students, and to identify factors associated with high-risk ED use.

Methods

Study design and participants

We employed a cross-sectional descriptive study design and recruited a convenience sample of college students from two universities in South Korea. Inclusion criteria were: age ≥18 years, enrollment in an undergraduate program at the time of data collection, ability to complete a questionnaire in Korean, and voluntary participation. The sample size was calculated using the G*Power 3.1.9.7 program. An alpha level (α) of .05, a power of 0.90, and an odds ratio (OR) of 1.7 resulted in a required sample size of 243 participants. Initially, 259 students responded to the survey; however, three students who were on a leave of absence at the time of data collection were excluded, resulting in an attrition rate of 1.2%. Accordingly, 256 students (125 males and 131 females) who met the inclusion criteria were included in the final analysis. As the number of responses slightly exceeded the required sample size due to concurrent participation, the survey link was subsequently closed to end data collection.

Measurements

1. Socio-demographics and health behaviors characteristics

Socio-demographic characteristics included gender, age, major, and academic year. Health behaviors were assessed using five items: (1) alcohol drinking (yes/no), (2) current smoking (yes/no), (3) engagement in recommended levels of physical activity (150–300 minutes of moderate or 75–150 minutes of vigorous activity per week; yes/no), (4) average daily sleep duration (<7 hours or ≥7 hours), and (5) subjective sleep quality. Sleep quality was assessed on a five-point scale (very good, good, fair, poor, very poor) and subsequently dichotomized: "very good" and "good" were categorized as good, and "fair," "poor," and "very poor" as poor.

2. ED and AmED use

Survey questions were derived from two previously published studies on energy drink (ED) and alcohol mixed with energy drink (AmED) use among college students [24,25], as well as from the Energy Drink Safety Survey administered in Korea to adolescents and college students [26], with items selected based on their relevance to the study’s purpose. ED use was assessed through 10 items, including lifetime use (yes/no), age of initial use, frequency of use, reasons for use, increased consumption during specific periods (e.g., examinations), and experience of adverse effects. AmED use was assessed by items on lifetime use (yes/no), frequency, primary locations of consumption, and reasons for use. Notably, questions regarding reasons for ED use, adverse effects experienced, primary locations of AmED use, and reasons for AmED use allowed for multiple responses.

3. Mental health

Mental health was assessed using the Korean version of the Depression Anxiety Stress Scale (DASS-21) [27,28]. The DASS-21 is a public domain tool that can be used without specific approval. It consists of 21 items, divided into three subscales: depression (7 items), anxiety (7 items), and stress (7 items). Responses were rated on a 4-point scale (0=did not apply to me at all, 3=applied to me very much or most of the time). Each subscale score ranges from 0 to 21, with higher scores indicating more severe symptoms. In the present study, Cronbach's alpha was 0.83 for depression, 0.72 for anxiety, and 0.84 for stress.

Data collection and ethical considerations

Data collection was performed from October 6, 2023 to January 17, 2024. This study was approved by the research ethics committee of the first author’s institution (IRB No. 1040198-230829-HR-118-02). After obtaining approval, the study was promoted at two universities with faculty cooperation, using student representatives and social media to distribute recruitment notices containing the survey link. Participation was voluntary, and informed consent was obtained online after participants reviewed the study information sheet. The self-administered questionnaire took approximately 10 minutes to complete. The survey was closed once the target sample size was reached, and 40 respondents were randomly selected to receive a USD 4 mobile gift card.

Statistical analysis

All statistical analyses were performed with IBM SPSS Statistics Version 26.0 for Windows. Independent t-tests and chi-square tests were conducted to examine gender differences in ED use, health behaviors, and mental health among college students. Binary logistic regression analyses were used to identify predictors of high-risk ED use. In this study, high-risk ED use was defined as consuming EDs at least once per week or mixing them with alcohol at any frequency, based on previous literature [2,29].

Results

Sociodemographic characteristics, health behaviors, and mental health

The participants’ mean age was 22.4 years (SD=2.08), and 51.2% were female. The most common major was nursing (59.4%), followed by engineering (20.3%), social sciences (15.3%), and natural sciences (4.7%). The majority of participants were non-smokers (81.2%) and reported alcohol consumption (63.7%), while only 35.2% engaged in regular exercise. Additionally, 62.9% slept fewer than 7 hours per night, and 60.2% reported poor sleep quality. The mean scores for depression, anxiety, and stress were 2.53 (SD=2.82), 2.48 (SD=2.60), and 3.95 (SD=3.50), respectively (Table 1).

ED and AmED use

The majority of participants (85.5%) had used EDs at some point, with a mean initiation age of 16.8 years (SD=2.46). The most common frequency of use was once every 2–3 months (54.8%), followed by at least once a month (28.3%). During high-stress periods, such as examinations, 52.5% reported consuming an additional can per day compared to their usual intake. The main reasons for using EDs were to stay awake (53.3%), boost energy (21.2%), and enjoy the taste or flavor (11.9%). After ED use, 77.6% of users experienced adverse effects, most commonly sleep problems (26.4%), heart palpitations (21.3%), and fatigue (11.9%). Among ED users, 21.5% reported consuming AmED. Of these, the majority (87.2%) used it fewer than three times per year. The most common setting for AmED use was at home (42.1%). Reasons for AmED use included enhanced taste of alcohol when mixed with EDs (63.2%) and peer influence (22.7%) (Table 1, Supplementary Table 1).

Gender differences in ed use, health behaviors, and mental health

Male students were significantly more likely than females to consume EDs (χ²=10.39, p<.001), consume them frequently (χ²=37.30, p<.001), and use AmED (χ²=10.54, p=.001). However, no gender difference was observed in reasons for ED use, such as staying awake, boosting energy, or taste preference. Although adverse effects were slightly more reported by female students (68.0%) than males (58.9%), common symptoms—sleep disturbances, palpitations, and fatigue—were similar between groups. Male students most frequently consumed AmED at home (50.0%), whereas female students primarily did so in pubs or bars (52.9%). Both cited enhancing alcohol taste as the main reason. Peer influence was reported more by females (31.3%) than males (19.5%).

Male students also reported more regular physical activity (χ²=11.69, p=.001) and smoking (χ²=18.88, p<.001). Other health behaviors showed no gender difference. Depression scores were significantly higher in female students (t=-1.89, p=.039), but anxiety and stress levels were similar (Table 2, Table 3).

Predictors of high-risk ED use

Participants who reported ED use at least once per week or any AmED use were classified as the high-risk group. Binary logistic regression analysis was conducted to identify predictors of high-risk ED use. The results indicated that male gender (OR 3.87, 95% confidence interval [CI] 1.91–7.84), younger age at first ED use (OR 0.87, 95% CI 0.76–0.99), current smoking (OR 4.48, 95% CI 2.11–9.54), and sleeping less than 7 hours per day (OR 2.17, 95% CI 1.05–4.50) were significantly associated with increased odds of high-risk ED use. The Hosmer–Lemeshow goodness-of-fit test indicated acceptable model fit (χ²=10.27, p=.246), and the overall classification accuracy was 73.1% (Table 4).

Discussion

This study found that male gender, early ED initiation, smoking, and insufficient sleep significantly increase the likelihood of high-risk ED use. Males reported higher weekly ED use than females and AmED use was over twice as prevalent in males, consistent with previous research [18,30]. Most students in our sample used EDs to stay awake or enhance energy, reflecting positive outcome expectancies. Nevertheless, a substantial proportion experienced adverse effects such as sleep disturbances and palpitations. In line with previous findings [2], female students were more likely than male students to report these adverse effects, potentially reflecting both behavioral and physiological differences in caffeine metabolism.

In addition, 21.5% of participants reported mixing EDs with alcohol, with males more than twice as likely as females. This gender disparity is noteworthy, given prior evidence linking AmED use to impulsive and risky behaviors, including accidents and violence [31]. Furthermore, the combination of alcohol and caffeine increases hepatic strain and may elevate the risk of liver and pancreaticobiliary diseases with prolonged use [32]. Sensation seeking —a known driver of AmED use and other risky behaviors such as smoking and alcohol misuse—has been found to be more common among males [29,33,34]. Although sensation seeking was not directly assessed in this study, its potential role in AmED use warrants further investigation.

Peer influence was a minor factor for ED use (3.5%) but notable for AmED use (22.7%). Females were more likely to be influenced by peers and consumed AmED in social setting, while males did so at home. This pattern suggests gender-based vulnerability related to social environments and aligns with prior findings that males score higher in sensation seeking and females in peer influence [35]. From a SCT perspective [23], the stronger peer influence on female AmED use exemplifies observational learning, whereas the higher prevalence among males may be explained by reinforcement from prior experiences and engagement in risk-prone social contexts.

Together, these results underscore the need for gender-sensitive interventions that address distinct patterns of ED and AmED use and their related health outcomes. Awareness campaigns on student-frequented platforms (e.g., TikTok, Instagram) can effectively convey AmED risk. Policy measures are needed to address ED sales in campus vending machines—through restrictions or mandatory warning labels about excessive consumption—and to limit the availability of AmED during university festivals, where heavy drinking is common.

Participants reported a mean ED initiation age of 16.8 years, with nearly half starting in middle or high school (14–17 years) and 9.1% as early as 10–13 years. This aligns with data from the Korean Youth Health Behavior Online Survey, which indicate that ED initiation typically occurs between ages 12 and 14 [36]. Early ED use is concerning, as excessive stimulant and sugar intake during this critical developmental period may impair brain development, emotional regulation, and increase the risk of metabolic disorders [4,16,37].

Given that initiation often occurs during the academically demanding middle and high school years, school-based health education should address ED ingredients (e.g., caffeine, sugar, and other additives), potential short- and long-term health risks, and the possibility of habitual use and dependence. Education should also cover social and behavioral factors such as peer influence, marketing exposure, and the dangers of AmED, as well as healthy alternatives for enhancing alertness without caffeine dependence. Public policies that regulate ED marketing to adolescents, along with improved access to mental health resources, could further mitigate early initiation and high-risk use [38,39]. However, while some European countries have implemented age restrictions on ED sales [40], South Korea still lack comprehensive regulations, highlighting the need for stronger, context-specific policies.

A significant association was found between current smoking status and high-risk ED use. Consistent with previous studies, smokers—especially adolescents and college students—were more likely to use EDs than nonsmokers [19,36,38]. Nicotine and caffeine are both stimulants, and their combined use may amplify physiological effects [41,42]. College students under academic and social stress may use both substances as coping strategies. Male smokers, in particular, are prone to additional risky behaviors, including alcohol use [33,43]. These findings support integrated health promotion program targeting smoking, ED, and alcohol use. Collaboration with local smoking cessation centers could enhance campus-based programs by simultaneously addressing ED and alcohol use alongside smoking cessation efforts, providing a more comprehensive approach to student health promotion.

ED use has been associated with poor sleep quality and shorter sleep duration [4,44], with sleep disturbance reported as the most frequent adverse effect. Caffeine, a key component of EDs, increases alertness but disrupts sleep by reducing total and deep sleep duration, especially when consumed in the evening due to its half-life of about five hours [44,45]. Periods of high academic stress, such as examinations, may lead to increased ED consumption, further impairing sleep quality. While EDs are often used to enhance study performance, prior research has found a negative association between ED use and academic achievement [1]. AmED use worsens sleep and may create a cycle of fatigue and repeated intake [29,46]. Therefore, education on sleep hygiene and stress management is essential to mitigate excessive ED use and its adverse consequences.

In this study, depression scores were significantly higher in female students compared with males, whereas anxiety and stress did not differ by gender. However, in the final regression analysis, mental health variables did not emerge as significant predictors of high-risk ED use. Depression, anxiety, and stress were measured using the DASS-21. Mean scores for all three subscales—depression, anxiety, and stress—were lower than those reported in a validation study of the Korean DASS-21 among university students [47]. Compared with a psychometric evaluation study of Korean adults [27], anxiety scores were similar, whereas depression and stress scores were lower. Moreover, the standard deviations for all three subscales were smaller than those reported in both studies [27,47], suggesting that participants in this study constituted a relatively homogeneous group with generally low levels of depression, anxiety, and stress. Such restricted variability may have reduced the statistical power to detect associations with high-risk ED use, potentially contributing to the absence of significant findings. Future research should include more diverse samples to better capture variability in mental health status and clarify its relationship with high-risk ED use.

This study has several limitations. First, all data were self-reported, which may be subject to recall or social desirability bias. Second, only ED frequency—not total caffeine intake—was assessed, and other dietary caffeine sources were not included. These constraints may have led to underestimation of overall stimulant exposure. Future studies should incorporate objective measures, such as 24-hour dietary recall or biomarkers (e.g., paraxanthine, salivary caffeine concentration), to more accurately assess caffeine consumption and related health effects.

Conclusions

This study, grounded in SCT, examined gender differences and predictors of high-risk ED use among South Korean college students. Male gender, early ED initiation, smoking, and insufficient sleep were significant predictors. Males reported higher weekly ED and AmED use, whereas peer influence—a key SCT construct of observational learning—was more prominent in female AmED consumption. ED use often increased during high-stress periods, such as examinations. These findings highlight distinct risk profiles and call for gender-sensitive interventions integrating education on ED and AmED risks, links with smoking and alcohol use, peer influence, sleep hygiene, and stress management, delivered via student-preferred platforms. Sustainable impact may require institutional commitment and public health policies, such as restricting ED sales in campus vending machines or mandating warning labels, along with regulation of youth-targeted marketing.

Supplementary Materials

References

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