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High-Risk Alcohol Use Associated with Past 30-DAY Energy Drink Use.

INTRODUCTION

Studies have indicated that 30%-50% of college students report regular consumption of energy drinks (Arria et al., 2011; Gallucci, Martin, & Morgan, 2016) with rates of up to 80% among specific college populations (Buxon & Hagan, 2012; Hoyte, Albert, & Heard, 2013). While the reasons for this high consumption rate are varied, research has suggested that increased use may be linked to strategic marketing through which energy drinks have been portrayed as having positive effects on health, endurance, and alertness (Reissig, Strain, & Griffiths, 2009). Students have reported multiple motivations for energy drink consumption including increasing energy, insufficient sleep, and drinking with alcohol to enhance effects (Malinauskas, Aeby, Overton, et al. 2007). Recent studies also indicated that consumption increases if students perceive energy drinks to be safe (Kumar, Park, & Onufrak, 2015; Treloar et al., 2017). Health concerns related to energy drinks have led medical and regulatory organizations to propose marketing and access restrictions in an effort to reduce overall consumption among children and adolescents (Thorlton, Colby, & Devine, 2014). Public health professionals urged the U.S. Food and Drug Administration to provide increased regulations on energy drinks due to the potential health consequences; however, energy drinks remain relatively unrestricted (Thorlton et al., 2014).

Energy drink consumption has been linked to various health risks including poor dietary behaviors, increased body mass index, increased use of licit and illicit drugs, high-risk driving, and increased risk for alcohol dependence (Arria et al., 2011; Gallucci et al., 2016; Housman, Williams, & Woolsey, 2016; Housman, Williams, & Woolsey, 2017; Scalese et al., 2017; Velazquez, Poulos, Latimer, & Pasch, 2012; Williams, Housman, Odum, & Rivera, 2017; Williams, Odum, & Housman, 2017; Williams, Housman, Woolsey, & Sather, 2018; Woolsey et al., 2015a; Woolsey et al., 2015b; Woolsey, Williams, Housman, & Sather, 2017). Of particular concern is the relationship of energy drinks and alcohol. While much research has explored the use of alcohol mixed with energy drinks among adolescents and young adults, relatively few studies have examined whether being a regular energy drink consumer (without alcohol) increases high-risk alcohol use or abuse. In a study of students at a private, minority-serving institution, researchers did find a relationship between energy drink consumption and drinking alcohol to inebriation (Spierer, Blanding, & Santella, 2014). College freshmen who consumed energy drinks have shown an increase in weekly and monthly alcohol use compared to those who did not consume energy drinks (Velazquez et al., 2012). In Australia, adult energy drink users were more likely to be heavier alcohol consumers (Trapp et al., 2014). A study of high school students in the U.S. showed that energy drink consumption was strongly correlated to 30-day alcohol use (Terry-McElrath, O'Malley, and Johnston, 2014). More recently, Gallucci and colleagues (2016) indicated that energy drink consumption was associated with heavy episodic alcohol drinking in a study examining college athletes and non-athletes. The extensive literature on alcohol mixed with energy drinks suggests a complex relationship between these two beverages which has been shown to increase overall health risks among consumers.

However, there is some literature suggesting that behavioral patterns of energy drink users may not align with behavioral intentions. A study of Taiwanese college students revealed that while alcohol and energy drink use were positively correlated, participants held more negative attitudes towards alcohol consumption (Change, Peng, and Lan, 2017). Other researchers have suggested that the relationship between energy drink and alcohol use may be overstated or misunderstood. In a critical review and meta-analysis funded by a major energy drink manufacturer, Verster and colleagues (2018) suggested that energy drink users (specifically those who consumed alcohol mixed with energy drinks compared to those who consumed alcohol only) showed lower odds of various risk-taking behaviors including negative alcohol-related consequences. The limited and conflicting research exploring how energy drink use (without alcohol) may be linked to overall alcohol consumption suggests a need to further study this relationship. The purpose of this study was to assess the relationship of energy drink use with specific 30-day measures of high-risk alcohol consumption among U.S. college students.

METHODS

Data Collection

IRB approval was granted by the participating university prior to sample recruitment. An estimated 3,000 college students were recruited to participate through an email sent via the campuswide announcement system at a midwestern U.S. university. All students who received the recruitment email were provided the opportunity to complete the survey; therefore, those who did chose to participate were self-selected. In total, 605 students completed the survey which included measures of energy drink and alcohol consumption, health behaviors, and demographics. Due to incomplete surveys and missing data, the sample used in this study included 557 participants.

Alcohol and energy drink consumption were measured using a modified version of the National Institute on Drug Abuse's Quick Drinking Screen tool. The Quick Drinking Screen was developed as a guided interview tool that provides a retrospective estimate of a person's average alcohol consumption using is a quantity-frequency and daily estimation measures. It has been adapted to be used as a self-administered survey tool and has been modified to also include measures energy drink consumption in addition to alcohol. The modified tool has been used in several published alcohol and energy drink studies (de Haan, de Haan, van der Palen, Olivier, & Verster, 2012; Johnson, Alford, Verster, & Stewart, 2016; Woolsey, 2010; Woolsey et al., 2015 a; Woolsey et al., 2015b). Wilcoxon test yielded a test-retest coefficient of r = .92 for reliability (p < .001).

Participant energy drink use was dichotomized into two groups: a) past 30-day use and b) no past 30-day use. Similar to other energy drink research (Woolsey et al., 2015b), participants were asked to report frequency of various alcohol-use behaviors including high-risk consumption. For measurement of heavy episodic drinking, the standard frequencies of 5+ drinks in a row on one occasion for males and 4+ in a row on one occasion for females was used (Gallucci et al., 2016). Binary logistic regression analysis was used to examine demographic differences related to energy consumption while Mann Whitney U, Cohen's D and effect sizes were calculated to determine if past 30-day energy drink use was related to high-risk consumption of alcohol.

RESULTS

This study yielded a sample of 557 participants with 51.1% (n = 295) reporting energy drink use during the past 30 days. Mean age was 21.97 [+ or -] 4.268 (Mean [+ or -] SD) while the sample was primarily female (67.6%) and white (88.1%). A binary logistic analysis (Nagelkerke R2 = .071) indicated gender (Wald = 22.581; P < 0.01; OR = 0.409) and age (Wald = 5.596; P < 0.01; OR = 1.056) had statistically significant relationships with past 30-day energy drink use. Males were more likely than females to have consumed energy drinks during the past 30-days (65.4% vs. 58.6% of females). Past 30-day energy drink users reported slightly lower mean ages in comparison to non-users (21.51 [+ or -] 3.771 vs. 22.45 [+ or -] 4.692). No significant difference in past 30-day use was associated with participants' ethnicity (Wald = 0.811; P = 0.368; OR = 1.277).

A statistically significant relationship was found between energy drink use and each of the alcohol use measures (Table 1). Compared to nonusers (3.35 [+ or -] 2.803), participants who used energy drinks during the past 30 days (5.14 [+ or -] 3.424) reported a higher average number of alcoholic drinks consumed per occasion (P < .001; Cohen's D = 0.57; r = 0.28). Past 30-day energy drink users reported significantly higher scores on the number of days drinking alcohol (P < .001; Cohen's D = 0.55; r = 0.26), number of days 'getting drunk' (P < .001; Cohen's D = 0.61; r = 0.29), and number of days participating in 'binge' or heavy episodic drinking (P < .001; Cohen's D = 0.64; r = 0.30). Energy drink users also reported significantly higher averages when asked to report the greatest number of alcoholic drinks consumed on one occasion during the past 30 days (P < .001; Cohen's D = 0.74; r = 0.35) and when asked to report the number of hours of alcohol consumption during that single occasion (P < .001; Cohen's D = 0.53; r = 0.26). In addition to the 30-day alcohol measures, participants were also asked about the greatest number of alcoholic drinks consumed during one occasion over the past year. Similar to the 30-day measures, energy drink users reported significantly higher averages scores on the greatest number of drinks consumed on one occasion over the past 12 months (P < .001; Cohen's D = 0.73; r = 0.34).

DISCUSSION

Males were more likely than females to consume energy drinks in the past 30 days, while younger students were more likely to consume energy drinks than older students in this sample. Thirty-day energy drink use did not differ when examined by race/ethnicity. While effect sizes were small, past 30-day energy drink use was related to increased alcohol consumption among college students. Past 30-day energy drink users reported consuming alcohol nearly twice as many days as non-energy drink users. Of specific concern is that past 30-day energy drink users reported patterns of unsafe alcohol consumption (i.e., significant increases in heavy episodic drinking, number of days drunk, and greatest number of drinks on one occasion). For example, energy drink users reported a regular average consumption amount of 5.14 standard alcohol drinks per occasion which is higher than the intake criteria for heavy episodic drinking (Gallucci et al., 2016). Additionally, energy drink users reported both getting drunk and heavy episodic drinking on over twice as many days during the past month when compared to non-energy drink users. Furthermore, past 30-day energy drink users reported drinking for longer periods of time (1.5 hours longer) per alcohol drinking sessions compared to non-energy drink users.

In addition to these 30-day measures, energy drink users also reported consuming greater amounts of alcohol during heavy episodic drinking sessions over the past year. This is an important measure because it suggests that high-risk consumption among college student energy drink users may be occurring over a longer period of time thus increasing alcohol-related risks.

This study provides support for recent research which suggests energy drink use increases consumption of other substances including alcohol (Gallucci et al., 2016; Housman et al., 2016; Housman et al., 2017; Terry-McElrath et al., 2014; Woolsey et al., 2015a) While much of the research on energy drinks and alcohol focuses on the combined use of these two substances, this study provides additional evidence suggesting that young adults who regularly consume energy drinks may also be more likely to regularly use, misuse, or abuse alcohol. In addition to recognizing this behavioral correlation while designing interventions, substance use prevention and public health professionals may need to take on a more active role in the continued advocacy to reduce or restrict adolescent access to energy drinks.

Limitations of this study include the cross-sectional design, as well as the convenience sample and self-reported nature of the survey. Generalizability may be limited; however, the results are similar to other published studies (Gallucci et al., 2016; Spierer et al., 2014; Velazquez et al., 2012) suggesting some outcome reliability. A strength of this study is that it explores the energy drink-alcohol relationship beyond the more often-examined combined use of the two beverages together. Most research on this topic explores the combined use of alcohol mixed with energy drinks, so a strength of this study is that it explores the relationship between the independent consumption of these two substances. It provides evidence of the increased alcohol-related risks that are frequently experienced among energy drink users. Prevention and intervention initiatives should address the misuse and abuse of alcohol, but also seek to reduce the growing consumption of energy drinks.

References

Arria, A.M., Caldeira, K.M., Kasperski, S.J., Vincent, K.B., Griffiths, R.R., & O'Grady, K.E. (2011). Energy drink consumption and increased risk for alcohol dependence. Alcoholism: Clinical and Experimental Research, 35, 365-375.

Buxton, C. & Hagan, J.E. (2012). A survey of energy drink consumption practices among student-athletes in Ghana: Lessons for developing health education intervention programmes. Journal of the International Society of Sports Nutrition, 9, 9. doi: 10.1186/1550-2783-9-9.

Chang, Y.J., Peng, C.Y., & Lan Y.C. (2017). Consumption of energy drinks among undergraduate students in Taiwan: Related factors and associations with substance use. International Journal of Research in Public Health, 14, E954.

de Haan, L., de Haan, H., van der Palen, J., Olivier, B., & Verster, J.C. (2012). Effects of consuming alcohol mixed with energy drinks versus consuming alcohol only on overall alcohol consumption and negative alcohol-related consequences. International Journal of General Medicine, 5, 953-960.

Gallucci, A.R., Martin, R.J., & Morgan, G.B. (2016). The consumption of energy drinks among a sample of college students and college student athletes. Journal of Community Health, 41, 109-118.

Housman, J.M., Williams, R.D., & Woolsey, C.L. (2016). Impact of alcohol and alcohol mixed with energy drinks on non-medical prescription stimulant use among a national sample of 12th grade students. American Journal on Addictions, 25, 378-384.

Housman, J.M., Williams, R.D., & Woolsey, C.L. (2017). Energy drinks, energy shots, and nonmedical prescription opioid use among adolescents. American Journal of Health Studies, 32, 186-194.

Hoyte, C., Albert, D., & Heard, K. (2013). The use of energy drink, dietary supplements, and prescription medication by United States college students to enhance athletic performance. Journal of Community Health, 38, 575-580.

Johnson, S.J., Alford, C., Verster, J.C., & Stewart, K. (2016). Motives for mixing alcohol with energy drinks and other non-alcoholic beverages and its effects on overall alcohol consumption among UK students. Appetite, 96(1), 588-597.

Kumar, G., Park, S., & Onufrak, S. (2015). Perceptions about energy drinks are associated with energy drink intake among U. S. youth. American Journal of Health Promotion, 29(4), 238-244.

Malinauskas, B.M., Aeby, V.G., Overton, R.F., Carpenter-Aeby, T., & Barber-Heidal, K. (2007). A survey of energy drink consumption patterns among college students. Nutrition Journal, 6, 35. doi: 10.1186/1475-2891-6-35.

Reissig, C.J., Strain, E.C., & Griffiths, R.R. (2009). Caffeinated energy drinks--a growing problem. Drug and Alcohol Dependence, 99, 1-10.

Scalese, M., Denoth, F., Siciliano, V., Bastiani, L., Cotichini, R., Cutilli, A., & Molinaro, S. (2017). Energy drink and alcohol mixed energy drink use among high school adolescents: Association with risk taking behavior, social characteristics. Addictive Behaviors, 72, 93-99.

Spierer, D.K., Blanding, N., & Santella, A. (2014). Energy drink consumption and associated health behaviors among university students in an urban setting. Journal of Community Health, 39, 132-138.

Terry-McElrath, Y.M., O'Malley, P.M., & Johnston, L. D. (2014). Energy drinks, soft drinks, and substance use among United States secondary school students. Journal of Addiction Medicine, 8(1), 6-13.

Thorlton, J., Colby, D.A., & Devine, P. (2014). Proposed actions for the U.S. Food and Drug Administration to implement to minimize adverse effects association with energy drink consumption. American Journal of Public Health, 104, 1175-1180.

Trapp, G.S.A., Allen, K.L., O'Sullivan, T., Robinson, M., Jacoby, P, & Oddy, W.H. (2014). Energy drink consumption among young Australian adults: Associations with alcohol and energy illicit drug use. Drug and Alcohol Dependence, 134, 30-37.

Treloar, J.A., Tidwell, D.K., Williams, R.D., Buys, D.R., Oliver, B.D., & Yates, J. (2017). Applying Theory of Planned Behavior to energy drink consumption in community college students. American Journal of Health Studies, 32(1), 222-234.

Velazquez, C.E., Poulos, N.S., Latimer, L.A., & Pasch, K.E. (2012). Associations between energy drink consumption and alcohol use behaviors among college students. Drug and Alcohol Dependence, 123, 167-172.

Verster, J.C., Benson, S., Johnson, S.J., Alford, C., Godefroy, S.B., & Scholey, A. (2018). Alcohol mixed with energy drink (AMED): A critical review and meta-analysis. Human Psychopharmacology, 33(2), e2650.

Williams, R.D., Odum, M., & Housman, J.M. (2017). Adolescent energy drink use related to intake of fried and high-sugar foods. American Journal of Health Behavior, 41(4), 454-460.

Williams, R.D., Housman, J.M., Odum, M., & Rivera, A. (2017). Energy drink use linked to high-sugar beverage intake and BMI among teens. American Journal of Health Behavior, 41(3), 259-265.

Williams, R.D., Housman, J.M., Woolsey, C.L., & Sather, T.E. (2018). High-risk driving behaviors among 12th grade students: Differences between alcohol-only and alcohol mixed with energy drink users. Substance Use and Misuse, 53, 137-142.

Woolsey, C.L. (2010). Energy drink cocktails: A dangerous combination for athletes and beyond. Journal of Alcohol and Drug Education, 54(3), 41-68.

Woolsey, C.L., Williams, R.D., Jacobson, B.H., Housman, J.M., McDonald, J.D., Swartz, J.H., ... Davidson, R.T. (2015). Increased energy drink use as a predictor for illicit prescription stimulant use. Substance Abuse, 36, 413-419.

Woolsey, C.L., Williams, R.D., Housman, J.M., Barry, A.E., Jacobson, B.H., & Evans, M.W. (2015). Combined use of alcohol and energy drinks increases participation in high-risk drinking and driving behaviors among college students. Journal of Studies on Alcohol and Drugs, 76, 615-619.

Woolsey, C.L., Williams, R.D., Housman, J.M., & Sather, T.E. (2017). Age at first use of energy drinks associated with risky alcohol-related motor vehicle behaviors among college students. Journal of Child and Adolescent Substance Abuse, 26, 376-386

Ronald D. Williams, Jr., PhD, CHES

Conrad L. Woolsey, PhD, CMPC, CHES

Jeff M. Housman, PhD, MCHES

Corresponding author: Ronald D. Williams, Jr., PhD, CHES, Associate Professor, Department of Health and Human Performance, Texas State University, 601 University Drive, Jowers Center A145, San Marcos, TX 78666, Phone: 512-245-2947, Fax: 512-245-8678, ronwilliams@txstate.edu
Table 1
Demographic Characteristics of Respondents

Alcohol Use Measure             Energy      N    Mean     SD       P
                              Drink Past
                              30-Day Use

When you use alcohol, how      Non-User    273   3.35    2.803   <.001
many standard drinks do you      User      293   5.14    3.424
usually have? *

In the past 30 days, how       Non-User    281   4.42    4.849   <.001
many days did you drink          User      294   7.27    5.556
alcohol?

In the past 30 days, how       Non-User    281   1.89    3.220   <.001
many days did you get            User      295   4.15    4.170
drunk?

In the past 30 days, how       Non-User    231   2.13    3.639   <.001
many times have you had 5        User      261   4.85    4.841
or more drinks on one
occasion (if you are a
male) or 4 or more drinks
on one occasion (if you are
a female)?

In the past 30 days, what      Non-User    231   2.13    3.639   <.001
was the greatest number of       User      261   4.85    4.841
alcoholic drinks you had on
one occasion?

On that occasion, over how     Non-User    280   3.27    2.612   <.001
many hours did you consume       User      294   4.65    2.568
alcohol?

In the past 12 months, what    Non-User    281   7.17    5.672   <.001
was the greatest number of       User      294   12.05   7.509
alcoholic drinks you
consumed on one occasion?

Alcohol Use Measure             Energy      Mean    Cohen's   Effect
                              Drink Past    Rank       D      Size r
                              30-Day Use

When you use alcohol, how      Non-User    233.22    0.57      0.28
many standard drinks do you      User      330.35
usually have? *

In the past 30 days, how       Non-User    237.19    0.55      0.26
many days did you drink          User      336.56
alcohol?

In the past 30 days, how       Non-User    232.32    0.61      0.29
many days did you get            User      342.01
drunk?

In the past 30 days, how       Non-User    193.95    0.64      0.30
many times have you had 5        User      293.01
or more drinks on one
occasion (if you are a
male) or 4 or more drinks
on one occasion (if you are
a female)?

In the past 30 days, what      Non-User    193.95    0.64      0.30
was the greatest number of       User      293.01
alcoholic drinks you had on
one occasion?

On that occasion, over how     Non-User    241.12    0.53      0.26
many hours did you consume       User      331.67
alcohol?

In the past 12 months, what    Non-User    228.13    0.73      0.34
was the greatest number of       User      346.00
alcoholic drinks you
consumed on one occasion?

* Standard amounts for one drink of beer, wine, and liquor were
provided to participants on the survey instrument
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Author:Williams, Ronald D., Jr.; Woolsey, Conrad L.; Housman, Jeff M.
Publication:American Journal of Health Studies
Article Type:Report
Date:Jun 22, 2018
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