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Energy drink use and high-risk behaviors: Research evidence and knowledge gaps

Amelia m arria , ph.d., brittany a bugbee , b.a./b.s., kimberly m caldeira , m.s., kathryn b vincent , m.a..

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Corresponding Author: Amelia M. Arria, Ph.D., Associate Professor; Director, Center on Young Adult Health and Development, Department of Behavioral and Community Health, University of Maryland School of Public Health, 2387 School of Public Health Building, College Park, MD 20742, USA. Phone: 1-301-405-9795; Fax: 1-301-314-9167; [email protected]

Sales of caffeine-containing energy drinks (CCEDs) have increased rapidly since their introduction to the marketplace. Despite the health concerns raised about highly caffeinated CCEDs, surprisingly little data are available to estimate the prevalence of use. This paper presents the results of secondary data analyses of a nationally representative dataset of US schoolchildren. Approximately one-third of students are recent CCED users with substantial variation by age, sex, and race/ethnicity. Among the health and safety concerns related to CCED use is the possibility of potentiation of risk-taking behaviors. A review of the research reveals that although there appears to be a strong and consistent positive association between CCED use and risk-taking behavior, all but one study have used cross-sectional designs, limiting their ability to make inferences about the temporal nature of the association. More research is needed to understand the nature of this association and how CCEDs might impact adolescent health and safety, especially given the high prevalence of use among youth.

Keywords: caffeine, energy drinks, energy shots

INTRODUCTION

Although no formal definition has been proposed, beverages labeled and marketed as energy drinks comprise a heterogeneous beverage category, most of which contain caffeine and a variety of other ingredients, including guarana, taurine, and B vitamins. 1 , 2 Several types of caffeine-containing energy drinks (CCEDs) are carbonated and contain sugar, 3 , 4 although sugar-free variations are available. 5 Public health concerns have been raised primarily because of the high levels of caffeine in these beverages, both in amount and in concentration. The amount of caffeine varies considerably among CCEDs, ranging from 50 to 500 milligrams per container, 6 with some containers containing more than a single serving. 7 Energy shots come in smaller-sized containers, typically less than three ounces. The caffeine concentration in energy shots differs by product, with some products containing in excess of 100 milligrams per fluid ounce. 6 Currently no maximal limit on caffeine is imposed by the US Food and Drug Administration for either CCEDs or energy shots. In contrast, the maximal limit on caffeine in a cola-type beverage is 71 milligrams per 12 ounce serving. 8

CCEDs were first introduced to the US marketplace in the late 1990s, and since then there has been rapid growth in both the number of different types of products available and the varieties within a particular brand. 6 Industry data indicate that CCEDs and energy shots constitute one of the fastest growing segments of the beverage market, with sales in the US expected to increase from $12.5 billion in 2012 to $21.5 billion in 2017. 9

Along with the rise in popularity of CCEDs has been an increase in reports of emergency department visits related to CCED use. Namely, from 2007 to 2011, there was an estimated two-fold increase in the number of individuals presenting to emergency departments after consuming a CCED, from 10,068 in 2007 to 20,783 in 2011. 10 A majority of these individuals were between 18 and 39 years old, with 42% using a substance in addition to a CCED. In 2011, 1,499 adolescents ages 12 to 17 were admitted to the emergency department following consumption of a CCED. Multiple cases in which consumption of CCEDs resulted in hospitalization have been reported voluntarily to the US Food and Drug Administration’s Center for Food Safety and Applied Nutrition Adverse Event Reporting System. 11 , 12 Data on hospitalizations resulting from CCED use are not systematically collected. Recent concerns about possible cardiovascular effects from high levels of caffeine in CCEDs have been raised in the scientific literature. 7 , 13 – 16 More generally, the American Academy of Pediatrics has raised safety concerns about the inclusion of CCEDs in the diets of children, 17 and the American Medical Association issued a resolution to ban the marketing of CCEDs to individuals under the age of 18. 18

Data to describe consumption patterns among the US population are scarce. Federally-funded US national epidemiologic surveys that track annual trends in health behaviors and nutritional habits among adults and children have included very few questions about CCED consumption. In 2010, the National Health Interview Survey included a supplement containing one question on CCEDs: “During the past month, how often did you drink sports and energy drinks, such as Gatorade ® , Red Bull ® , and Vitamin Water ® ?” 19 To our knowledge, there have been no published reports of these data. The National Health and Nutrition Examination Survey accepts entries of CCEDs as part of a 24-hour dietary recall on beverages, and provides example cards of energy beverages, but does not specifically inquire about their consumption. 20

One of the most widely used surveys to measure the health-risk behaviors of American school children is the NIH-funded Monitoring the Future (MTF) Survey, which began asking about CCEDs in 2010. Estimates of consuming alcohol containing caffeine are available in the MTF reports since 2011 and indicated that 10.9%, 19.7%, and 26.4% of eighth, tenth, and twelfth graders consumed caffeinated alcoholic beverages during the past year, respectively. 21 For college students and young adults ages 19 to 28, these estimates are even higher (33.8% and 36.7%, respectively). Although the data are publicly available, the annual MTF reports have not included estimates of consuming CCEDs and energy shots without alcohol. An analysis of MTF data on CCEDs and energy shots by Terry-McElrath, O’Malley, and Johnston 22 found an association between CCED and energy shot frequency and substance use; however, that study analyzed CCED and energy shot use as one variable, rather than analyzing use of the products separately. Additionally, that study did not describe subgroup variation of CCED or energy shot use by race or grade level, and did not report data on quantity of CCEDs consumed.

It is important to understand the extent to which CCEDs are becoming a part of the adolescent and young adult diet. The nutritional requirements of adolescence, defined as the period between the ages of 13 and 18, is marked by complex hormonal changes that result in pubertal development and growth. The rapid physical growth that occurs during this period requires the increased intake of calories, protein, vitamins, and minerals. 23 Future eating patterns are often established during adolescence, making this a critical period with lifelong nutritional implications. 24

To our knowledge, no research has specifically focused on the potential effects of caffeine consumption on physical growth and development during childhood and adolescence. However, the effects of caffeine use on disrupted sleep patterns are well recognized. 25 Interestingly, daytime sleepiness related to caffeine and other substance use has been shown to be related to poor academic performance among a large sample of adolescents. 26 A laboratory study of caffeine use during a critical developmental period has shown a relationship between caffeine administration and decreases in sleep quality and brain maturation. 27

In addition to the attention raised about possible cardiovascular effects of consuming high levels of caffeine in CCEDs, 7 , 13 – 16 other research studies have pointed to an association between CCED consumption and different types of risk-taking behavior among adolescents and young adults. Adolescence is a peak developmental period for risk-taking, which many believe is normative and biologically-driven. 28 New research in the field of developmental neuroscience has shed light on the complex structural and functional changes that take place in the brain from adolescence through the early 20s. 29 – 35 These changes might explain why adolescents are more likely than older individuals to take risks without regard for possible consequences and why there might be an inherent reliance on peers when making decisions.

Because of the pharmacologic stimulating properties of caffeine, it is possible that CCEDs might potentiate the risk-taking behavior that is normative to adolescent development. At least two non-mutually exclusive mechanisms have been suggested to explain the relationship between energy drinks and substance use. First, from a biological perspective, through its interaction with dopamine, early caffeine use could potentially prime neural reward circuitry such that the individual experiences a more positive response to other drugs. 36 , 37 Supporting this hypothesis is evidence suggesting cross-sensitization between caffeine and nicotine. 38 Second, consumers of energy drinks might be more likely to use other drugs because of an underlying general propensity for risk-taking.

In this paper, we report prevalence estimates of CCED and energy shot use by grade, gender, and race/ethnicity from secondary data analyses of the MTF dataset. We complement these findings with a summary of results from studies utilizing college student and adult samples. The second purpose of this paper is to summarize research on the link between CCED use and various forms of risk-taking behavior.

CCED USE DURING ADOLESCENCE: FINDINGS FROM THE MONITORING THE FUTURE (MTF) SURVEY

Data from MTF are available for public use via the National Addiction and HIV Data Archive Program. 39 To estimate the prevalence of CCED consumption, we analyzed data from the 2010 and 2011 surveys, the most recent data available. These secondary data analyses were approved by the University of Maryland Institutional Review Board. MTF is a cross-sectional paper-and-pencil survey administered annually to eighth, tenth, and twelfth graders attending more than 100 public and private schools across the 48 contiguous states. 40 Multistage random sampling occurs first at the level of geographic areas, or “primary sampling units”; next at the school level within each selected geographic area; and finally at the class level within each selected school. Surveys are then self-administered to all students in selected classrooms (or the entire school, for smaller schools). Due to the large number of topics assessed, several alternative forms of the MTF questionnaire are developed each year (i.e., six for twelfth graders; four for eighth and tenth graders), with each form containing only a subset of all possible questionnaire items. Forms are distributed randomly, and the resulting subsamples show no significant differences.

Response rates for the 2011 survey ranged from 83% for twelfth graders to 91% for eighth graders. 40 Data were downloaded from the National Addiction and HIV Data Archive Program and analyzed in SPSS 41 to estimate the prevalence of CCED use and examine variation in prevalence estimates by grade, gender, and race/ethnicity. Standard weighting procedures were used to adjust for differences in selection probabilities at each level of the sampling design (i.e., students, schools, and geographic areas) by assigning a sampling weight, provided in the dataset, for each respondent. 42 Valid data from 2011 on CCEDs and/or energy shots were available for 5,207 eighth graders, 4,965 tenth graders, and 2,209 twelfth graders (weighted sample sizes). Analyses were replicated using data collected in 2010 from separate samples of comparable size (5,036 eighth graders, 5,089 tenth graders, and 2,142 twelfth graders); however, for ease of presentation, comparisons across demographic subgroups are presented herein for 2011 data only.

The questionnaire provided participants with the following background information: “‘Energy drinks’ are non-alcoholic beverages that usually contain high amounts of caffeine, including such drinks as Red Bull ® , Full Throttle ® , Monster ® , and Rockstar ® . They are usually sold in 8- or 16-ounce cans or bottles” and “Energy drinks are also sold as small ‘shots’ that usually contain just 2 or 3 ounces.” The questionnaire did not differentiate between sugar-containing and sugar-free CCEDs. Ordinal responses to the original survey question, “About how many (if any) energy drinks do you drink per day on average?” were recoded into a three-level categorical variable representing daily use (“One”, “Two”, “Three”, “Four”, “Five or six”, and “Seven or more” per day), less than daily use (“Less than one” per day), and non-use (“None”). No time frame was specified in the original question; therefore, we operationalized current use as encompassing both daily use and less than daily use. Similar procedures were used for energy shots.

Figure 1a displays the 2011 prevalence estimates of CCED use by gender and race/ethnicity for eighth, tenth, and twelfth graders. Overall, 35% of eighth graders and 29% of both tenth and twelfth graders indicated that they used CCEDs. One striking observation is that eighth graders were more likely to consume CCEDs compared with tenth and twelfth graders. For every grade, males were more likely than females to use CCEDs. Black individuals had the lowest prevalence of CCED use regardless of grade. The highest prevalence was observed among Hispanic eighth graders (43%), and the lowest among Black twelfth graders (19%).

Figure 1a Prevalence of recent CCED use, by gender, race/ethnicity, and grade.

Figure 1b Prevalence of recent energy shot use, by gender, race/ethnicity, and grade.

Figure 1b presents similar data related to energy shot consumption. Overall, the consumption of energy shots was less prevalent than for CCEDs, with 12%, 9%, and 10% of eighth, tenth, and twelfth graders using energy shots, respectively. While gender differences were similar to what was observed for CCEDs, racial/ethnic variations were less apparent. However, Hispanic eighth graders stood out as having a particularly high prevalence (20%) relative to all other subgroups.

Because questions on CCEDs and energy shots were asked separately, it was possible to examine what proportion of students consumed both types of products. As shown in the lowest layer of bars in Figure 2 , between 8% and 12% of students consumed both CCEDs and energy shots. Interestingly, almost all energy shot users also consumed CCEDs. Between 20% and 24% consumed CCEDs, but not energy shots, as shown in the highest layer of bars. It is also noteworthy that there is considerable consistency in the results from 2010 to 2011.

Prevalence of recent use of CCEDs and/or shots, by grade and year.

Table 1 shows data on the daily use of CCEDs and energy shots. Eighth graders showed the highest prevalence of daily use for both CCEDs (18%) and energy shots (7%). Consistent with results from Figures 1a and 1b , Hispanic eighth graders stood out again as the subgroup with the highest prevalence of daily use of CCEDs (22%) and energy shots (11%).

Prevalence of daily use of CCEDs a and energy shots by grade.

Caffeine-containing energy drink

Among individuals who consumed these products, most drank only one or less than one per day (see Table 2 ). Although individuals who drank two or more per day were in the minority, their proportion decreased with age, similar to the trends observed in prevalence of use and daily use. For instance, 24% of CCED consumers in the eighth grade were drinking two or more per day, compared with 16% and 13% of their counterparts in tenth and twelfth grade, respectively. This trend was evident in all six of the subgroups we examined, but was perhaps most pronounced among Hispanics, with nearly a three-fold difference in two-a-day use between eighth and twelfth graders (30% vs. 11% drinking two or more CCEDs per day). On the other hand, two-a-day use was most prevalent among Black eighth graders (33%). The age-related decrease in quantity consumed was less consistent for energy shot users. In at least two subgroups—namely, females and Blacks—the proportion of energy shot users drinking two or more shots per day changed very little with age.

Number of CCEDs a and energy shots consumed per day, among users, by sex, race, and grade.

PREVALENCE AMONG COLLEGE STUDENTS

The prevalence of CCED use among college students is presented in Table 3 . As can be seen, CCED use varies substantially among the samples studied, primarily because of the different time frames used to assess consumption. Both Arria et al. 43 and Miller 44 reported that 10% of college students in their samples were “weekly” consumers. Others reported higher estimates for weekly consumption. 45 In a study about CCED consumption patterns Malinauskas et al. 5 found that 51% of college students consumed more than one CCED each month in an average month during the past semester. Across the various studies, even with the differences in methodology, CCED use appears to be even more common among college students than younger adolescents.

Summary of studies on the relationship between CCED a use and risk behaviors.

controlled for other types of caffeine use

RELATIONSHIP BETWEEN CCED USE AND RISK-TAKING BEHAVIORS AMONG COLLEGE STUDENTS

Several observational studies and one experimental study have examined the association between CCED use and various types of risk-taking behaviors (see Table 3 ). All of the studies were conducted among college students and young adults, except for one study of 18- to 45-year-old musicians. All but one of the studies have gathered data using cross-sectional survey designs, where questions about CCED consumption were asked along with questions about risk-taking behaviors. The results of these studies are consistent and clearly show that CCED users are more likely to engage in risk-taking behavior.

Many forms of risk-taking behavior have been investigated, including marijuana, tobacco, other forms of drug use, sexual risk-taking, and seat belt omission. CCED consumption, regardless of mixing with alcohol at the time of consumption, has been associated with alcohol-related outcomes. In a study of 298 college students, Skewes et al. 45 found a positive association between the typical number of CCEDs consumed per week and measures of alcohol dependence, current symptoms of alcohol dependence, and alcohol-related problems when controlling for age, gender, and frequency of binge drinking. Specifically, CCED consumption was positively associated with scores on the Alcohol Use Disorders Identification Test (a screening tool used to identify hazardous drinking), the Young Adult Alcohol Consequences Questionnaire (a measure of alcohol-related problems), and the Short Alcohol Dependence Data questionnaire (a measure of current alcohol dependence symptoms). Typical CCED frequency was also associated with two types of alcohol use motives: enhancement motives (i.e., drinking for enjoyment or for fun) and coping motives (i.e., drinking to forget one’s problems).

Arria et al. 43 found a positive relationship between the frequency of CCED use and risk for alcohol dependence among college students, even after statistical adjustment for the level of alcohol consumption (i.e., typical quantity) and a wide range of background variables and other known risk factors for alcohol dependence, including sensation-seeking, conduct problems before the age of 18, the age of first alcohol intoxication, depressive symptoms, and parental history of alcohol problems. Demographic variables also included in the model were sex, race/ethnicity, socioeconomic status, and involvement in a fraternity or sorority. Also unique to this study was that use of other caffeinated products was measured and used as a covariate in the analyses. The breadth of variables included in this model was important because it points to the possibility that CCED use and alcohol dependence might be interrelated in a meaningful way, rather than merely co-occurring due to shared risk factors such as a general propensity to drink more alcohol.

Another study of college students reported that approximately one third of past-month CCED users had mixed CCEDs and alcohol during the past month. 46 CCED use frequency was also associated with alcohol quantity consumed during a single event. A study of Australian young adults 47 also found that alcohol quantity was associated with consuming CCEDs at least monthly. In another study, Miller 44 found that CCED frequency and alcohol problems were positively associated for White but not Black undergraduates.

A study of musicians ages 18 to 45 found that the frequency of CCED consumption was positively associated with binge drinking and alcohol-related social problems, even when controlling for demographic variables, sensation-seeking, impulsivity, and other types of caffeine use. 48

Other substance use has also been associated with the consumption of CCEDs, including marijuana, tobacco, and nonmedical use of prescription drugs. 44 , 48 – 50 Woolsey et al. 50 found that past-month frequency of CCED use was associated with nonmedical use of prescription stimulants, with 22.2% of CCED consumers using prescription stimulants nonmedically. Miller 44 found that CCED consumption was associated with nonmedical use of prescription drugs among White, but not Black undergraduates. In another study, Miller and Quigley 48 also found that CCED consumption was associated with nonmedical prescription drug use even when controlling for other types of caffeine use. Trapp et al. 47 reported that consuming CCEDs at least monthly was associated with using ecstasy and marijuana, as well as the number of illicit drugs used.

Several other risk behaviors have been linked to CCED consumption. Miller 44 found that sexual risk-taking (e.g., unprotected intercourse, having intercourse under the influence of alcohol or other drugs), participating in extreme sports, seatbelt omission, and taking risks on a dare were more common among high-frequency (at least once a week) CCED consumers than low-frequency consumers. Another study of college students found that past-week consumption of CCEDs accounted for 29% and 21% of the variance in anxiety and sleep disturbances, respectively, when controlling for other types of caffeine use. 51 A study of students at a predominantly minority university reported that CCED consumption was associated with drunk driving and riding in a car with an inebriated driver. 52

One experimental study has been conducted on risk-taking behaviors related to CCED consumption. 53 Participants attended four sessions. They were randomly assigned to consume one of four beverages at each session in a counterbalanced order: a CCED, alcohol, a CCED mixed with alcohol, or a placebo beverage. Doses of alcohol and caffeine were based on body weight. After consuming the beverages, participants completed the Balloon Analogue Risk Task, a laboratory measure of risk-taking. A small but significant increase in risk-taking was seen only among participants who had consumed the non-alcoholic CCED.

The only prospective study conducted to date on the relationship between CCED use and risk-taking behavior was guided by prior research suggesting that use of caffeine might exacerbate the underlying vulnerability to the use of other substances. Arria et al. 49 examined the prospective relationship between CCED use during the second year of college and the risk for other forms of drug use during the subsequent year, after adjusting for prior use of each drug, demographic characteristics, and the use of other types of caffeine. The results showed that after adjustment for these variables, CCED users were more likely to initiate nonmedical use of prescription stimulants and analgesics and they increased the frequency with which they smoked tobacco. The adjusted odds ratio associated with CCED use for incident stimulant and analgesic use were 2.05 and 1.46, respectively.

The consumption of alcohol mixed with CCEDs has been linked to acute health risks and serious alcohol-related consequences. 54 – 60 For further discussion of the consumption of alcohol mixed with CCEDs, see Marczinski et al. in this issue.

Among adolescents, Terry-McElrath et al. 22 found that the consumption of CCEDs and energy shots is associated with past-month frequency of alcohol, cigarettes, marijuana, and amphetamine use among eighth, tenth, and twelfth graders, even after adjusting for demographic variables.

CONCLUSION AND KNOWLEDGE GAPS

Our analyses of MTF data show that almost one in three secondary school students in the US recently consumed a CCED. Data on CCED consumption from Canadian adolescents shows wide variation by province with estimates ranging from 57.2% to 64.6% on adolescents consuming CCEDs during the past year. 61

The high prevalence of consumption of CCEDs observed in the current study underscores the need to demonstrate the safety of consuming these beverages, especially for individuals between the ages of 13 and 18. As mentioned earlier, the amount of caffeine per serving and the concentrations of caffeine among this beverage class varies widely. 6 , 7 The acute and long term health consequences of such consumption are not known.

Research is needed to develop more comprehensive assessment methods for CCED and energy shot consumption. Despite the methodological strengths of the MTF survey, including its large sample size and its national representativeness, only a few questions were asked about CCEDs and energy shots. Because of this, the results cannot provide sufficient information about patterns of use, specific products consumed, contexts, or consequences. It would be useful to know the proportion of youth that have used various types of CCEDs in a defined time period, such as the past year or the past month, to more accurately estimate how much caffeine is being consumed by adolescents. Among users, assessments are needed that can reliably measure how much is consumed (e.g., typical, maximum, minimum) and how regularly consumption occurs. Given the concerns regarding ingesting high doses of caffeine on acute cardiovascular functioning, and during physical activity, future measures should attempt to characterize CCED use patterns (e.g., acute, chronic) and the contexts during which they are used (e.g., during exercise or sporting activities). CCED marketing messages often involve associations with physical activity and sporting events. 18 , 62

Moreover, it is important to understand how these beverages are being incorporated into the usual dietary intake of adolescents. It is possible that they are replacing other beverages (e.g., water, soda, sports drinks) or alternatively, they might be consumed in addition to other types of beverages. Concerns have been raised about the dietary choices that adolescents and young adults make, including the types of nutritional supplements and beverages they consume. 63 , 64 Recent data suggest that caffeine intake among children and adolescents in the US has remained steady during the last decade, but the proportion of caffeine intake that comes from energy drinks and coffee is increasing. 65 The extent to which CCED consumption might be contributing to weight gain is not as well understood as for other sugar-sweetened beverages. 66 Our data show that few youth report consuming energy shots only, but rather consume them in addition to larger-volume CCEDs. Although data from MTF does not differentiate between sugar-containing and sugar-free CCEDs, some CCEDs contain substantial amounts of sugar in addition to caffeine. It will be important for future research to understand the extent to which CCED consumption is a source of “empty calories” in the adolescent diet, and therefore could be a target for obesity prevention strategies. Malinauskas et al. 5 reported that 74% of college students who consumed CCEDs drank sugar-containing versions, with females being over-represented among individuals who consumed sugar-free versions.

In contrast to the health concerns about cardiovascular effects of CCEDs that have been raised for several years, a newer concern relates to the possible effects of high levels of caffeine on the developing brain of adolescents. 27 , 67 , 68 A limit of 2.5 milligrams per kilogram of caffeine per day has been suggested for children. 67

Specific subgroups appear to be at increased risk for consuming excessive caffeine. Namely, eighth graders were both more likely to have consumed a CCED and to have consumed greater quantities of CCEDs and energy shots than their older counterparts. Similarly, Hispanic youth were more likely to consume CCEDs and energy shots than other racial/ethnic groups. No data are available to shed light on possible contributory factors underlying this observed subgroup variation. Adolescents begin to make more autonomous dietary choices during this time, and personal preference begins to play a larger role. 24 Although parents’ influence on food choices decreases throughout this period, parental modeling still plays a role in determining adolescents’ food choices. 24 , 69 For example, in one study of adolescent consumption of soft drinks, adolescents were approximately three times more likely to consume soft drinks regularly if they reported that their parents also consumed them regularly. 69 Taste preference, peer habits, habit strength, and mass media have also been identified as important influences on adolescence food and beverage choices. 69 – 72 While it is tempting to speculate that differences in family modeling of dietary practices or targeted marketing practices might underlie these differences, future research is needed to fully explain different patterns of consumption.

Little research has been conducted to understand CCED patterns among high-risk populations, such as young individuals with cardiovascular abnormalities. No data are available to evaluate the safety of consuming highly-caffeinated CCEDs concurrently or simultaneously with stimulant medications and/or illicit substances used by adolescents and young adults.

With respect to the association between CCED consumption and risk-taking behavior, the studies reviewed herein consistently demonstrate the existence of an association. However, more research is needed to clarify the nature of the observed relationship. For example, it is not entirely clear whether the association stems from a general increased propensity for risk-taking behavior among CCED users or whether CCEDs potentiate risk-taking among users. A few studies adjusted statistically for measures of general risk-taking propensity and still found strong associations between CCED use and alcohol-related problems. 43 , 48 Further research is needed to understand the extent to which caffeine use during adolescence potentiates the reinforcing properties of other substances, especially because it is a period of rapid brain development. 31 , 73 Additionally, more longitudinal research is needed to understand the temporal relationship between CCED use and risk-taking behaviors. The one prospective study conducted to date observed a relationship between CCEDs and the incident or “new” use of nonmedical prescription stimulants and analgesics, even after statistical adjustment for other indicators of risk-taking behavior. 49

Given other research suggesting that adolescents are more likely to experience the rewarding properties of substances, 74 it is important to understand if high levels of caffeine early in adolescence might be related to increased risk for use of other psychoactive substances later in life. 36 , 37 It is clear that neurobiological changes during adolescence partially explain why adolescents are more likely than older individuals to engage in risk-taking behavior 75 – 77 and perhaps less likely to fully recognize the consequences of such behavior. How caffeine and CCED use fit into the sequence of underage alcohol use and the use of other drugs among adolescents requires further inquiry.

It is possible that CCED consumption during the developmental periods of adolescence and young adulthood potentiates natural risk-taking behaviors of young people due to the stimulating pharmacological effects of caffeine. This possibility raises questions about the appropriateness of marketing and selling highly caffeinated CCEDs to adolescents because they might be especially susceptible to the potentiating effects of CCED use on risk-taking behavior. More research is warranted to fully understand the relationship between CCED use and risk-taking behavior, and how dose and pattern of caffeine consumption might mediate the relationship. Resolving these issues based on scientific evidence is needed to promote and protect adolescent health and safety.

Acknowledgments

Special thanks are given to Kaitlin Hippen, the interviewing team, and the participants.

The investigators acknowledge funding from the National Institute on Drug Abuse (R01DA014845, Dr. Arria, PI). The National Institute on Drug Abuse played no role in the study design, data collection and analysis, manuscript preparation and revision, or publication of this manuscript. Data collection for the Monitoring the Future survey was also funded by the National Institute on Drug Abuse (R01DA001411, Dr. Johnston, PI).

DECLARATION OF CONFLICT OF INTEREST

The authors have no relevant conflicts of interest to declare.

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Risk of Energy Drink Consumption to Adolescent Health

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1 Department of Nutrition and Center for Nutrition in Schools, University of California, Davis, California.
PMID: 30627071
PMCID: PMC6311602
DOI: 10.1177/1559827618803069

Energy drinks are beverages marketed to quickly increase alertness and performance of the consumer that typically contain relatively high quantities of caffeine, simple carbohydrates, and a mixture of additional ingredients. The carbohydrate sources, usually glucose and sucrose, found in the beverages supply the substrates needed for physiological energy, while the high caffeine content supplies the perceived energy through enhancing feelings of alertness during fatigued states. Although mean youth caffeine consumption as a whole has decreased over the past 2 decades, adolescent energy drink consumption has significantly increased in the past 10 years. High energy drink consumption of youth is concerning due to the range of reported adverse reactions attributed to excessive caffeine consumption, ranging from mild sleep disturbances to death. Reactions are severe enough to require reporting to the National Poison Data System and may even require emergency medical treatment. Studies have also shown that adolescents who consume energy drinks are likely to also use tobacco, alcohol, and illicit drugs. There is substantial evidence to suggest that the risk energy drinks pose to health are incredibly hazardous and should not be consumed by children and adolescents.

Keywords: adolescent; adverse reactions; caffeine; energy drinks.

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Coffee and energy drink use patterns in college freshmen: associations with adverse health behaviors and risk factors

Dace s svikis, pamela m dillon, steven e meredith, leroy r thacker, kathryn polak, alexis c edwards, danielle dick, kenneth kendler.

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Received 2020 Dec 31; Accepted 2022 Mar 11; Collection date 2022.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, 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 changes were made. 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/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Public health concern over college students mixing caffeine-containing energy drinks (EDs) and alcohol has contributed to an array of ED-focused research studies. One review found consistent associations between ED use and heavy/problem drinking as well as other drug use and risky behaviors (Nutr Rev 72:87–97, 2014). The extent to which similar patterns exist for other sources of caffeine is not known. The present study examined associations between coffee and ED consumption and alcohol, tobacco and other drug use; alcohol use problems; and parental substance abuse and mental health problems in a sample of college freshmen.

Subjects were N = 1986 freshmen at an urban university who completed an on-line survey about demographics; caffeine; alcohol, tobacco and other drug use; and family history. The sample was 61% female and 53% White. Chi-square analyses and multivariable binary or ordinal logistic regression were used to compare substance use, problem alcohol behavior, and familial risk measures across 3 caffeine use groups: ED (with or without Coffee) (ED + Co; N = 350); Coffee but no ED (Co; N = 761); and neither coffee nor ED (NoCE; N = 875) use.

After adjusting for gender and race, the 3 caffeine use groups differed on 8 of 9 symptoms for alcohol dependence. In all cases, the ED + Co group was most likely to endorse the symptom, followed by the Co group and finally the NoCE group (all p < .002). A similar pattern was found for: use 6+ times of 5 other classes of drugs (all p < .05); extent of personal and peer smoking (all p < .001); and paternal problems with alcohol, drugs and anxiety/depression as well as maternal alcohol problems and depression/anxiety ( p < .04).

Conclusions

The response pattern was ubiquitous, with ED + Co most likely, Co intermediate, and NoCE least likely to endorse a broad range of substance use, problem alcohol behaviors, and familial risk factors. The finding that the Co group differed from both the ED + Co and NoCE groups on 8 measures and from the NoCE group on one additional measure underscores the importance of looking at coffee in addition to EDs when considering associations between caffeine and other risky behaviors.

Keywords: Caffeine, Energy drinks, Coffee, Alcohol, College students, Smoking, Family history

While caffeinated energy drink (ED) use has been linked to numerous physical and mental health problems, the popularity of ED use worldwide continues to rise [ 1 ]. In the US, since 2011, ED sales have shown steady growth, with sales in 2016 exceeding $2.8 billion [ 2 ]. ED use is most prevalent in adolescents and young adults, with one-third to one-half of adolescents and college students reporting recent (past month) ED use [ 3 – 6 ]. These are the age groups often targeted by aggressive ED marketing efforts [ 7 ].

In the US, early ED research was kindled by the landmark study of O’Brien and colleagues (2008) who examined the consumption of EDs mixed with alcohol, which was gaining popularity on college campuses across the country [ 8 ]. The investigators found that college drinkers who mixed alcohol with EDs (AMED) were at greater risk for alcohol-related consequences than non-AMED drinkers, even after adjusting for amount of alcohol consumed. It should be noted, however, that the investigators did not assess or adjust for group differences in other sources of caffeine intake [ 8 ].

Subsequent cross-sectional studies focused almost exclusively on EDs as a source of caffeine and showed that ED use alone was associated with alcohol, tobacco, and drug use and other risky behaviors [ 1 ]. In a review of the literature, Arria et al. (2014) [ 9 ] summarized studies showing correlations between ED consumption and: alcohol use [ 4 , 10 – 17 ], symptoms of Alcohol Use Disorder [ 11 , 15 ], tobacco use [ 4 , 10 , 12 , 14 , 16 ], illicit drug use [ 4 , 10 , 12 , 14 , 16 , 18 , 19 ], nonmedical use of prescription drugs [ 10 , 12 , 14 , 20 ], other risky behavior (sexual risk taking, fighting, not wearing a seatbelt, etc.) [ 14 , 21 ], and poor nutrition habits [ 18 ].

Given the cross-sectional nature of this research, the mechanisms governing the associations between ED use and other risky behaviors are unknown. Some researchers have suggested that ED consumption is one of many activities associated with a broader pattern of risk-taking behavior [ 14 ]. Advertising campaigns that tout the stimulant effects of EDs and, in some cases, glorify drug use may help promote the use of EDs among risk takers or sensation seekers who are more likely to use drugs [ 22 ].

The key to the relationship between ED use and other risky behavior, however, might not be ED consumption, per se. Rather, it might lie in the main psychoactive ingredient in EDs—caffeine. Some research has shown that heavy caffeine use (i.e., coffee, tea, and/or soft drinks) and caffeine dependence are associated with dependence on alcohol and illicit drugs [ 23 ]. This is significant because in a recent survey of college students, it was coffee, in fact, that was reported as the most widely consumed caffeinated product with almost three-fourths of students (72%) reporting past-year use [ 24 ]. Kelpin et al. (2018), using survey data collected prior to ED popularity in the USA, found college females who were daily coffee drinkers were more likely than non-daily coffee users to report heavy alcohol use and a variety of alcohol-related problems [ 25 ].

The present study, then, examined associations between coffee and ED consumption and other substance use and related problems in a sample of college freshmen to better understand the significance of caffeine source on observed associations between caffeine intake and adverse health behaviors. Study variables included alcohol and other drug use and related problems, self and peer cigarette smoking, and parental drug and alcohol abuse and mental health concerns. We hypothesized that students reporting ED consumption with or without Coffee (ED + Co) would be most likely to use and report problem behaviors, followed by those consuming only coffee (Co) and finally those reporting no use of either substance (NoCE).

Participants

Participants were college students attending an urban university and participating in the Spit for Science study (see Dick et al., 2014) [ 26 ]. They were drawn from an initial pool of N = 2056 college freshmen who completed an on-line survey and provided a saliva DNA sample in the fall of 2011. Seventy subjects were subsequently dropped from analyses because of missing data for gender ( N = 12); caffeine use ( N = 55) or both ( N = 3), yielding a final sample of N = 1986.

Students were initially informed via campus email about the Spit for Science study. They were told the 15–30-min survey focused on personality and behavior, as well as family, friends, and experiences growing up. For students interested in the study, the email message also contained a link to an on-line survey, where they were given additional information about the study. Informed consent was obtained from students who chose to participate, using Institutional Review Board approved procedures. Compensation ($10 and a “Spit for Science” T-shirt) was dispensed at a central location on-campus, at which time students were invited to provide a saliva DNA sample for an additional $10 (for a more detailed description of Spit for Science study procedures, see Dick et al., 2014) [ 26 ].

The on-line survey was designed to collect broad-based data on substance use (including caffeine) and problems as well as mental health symptoms, personality traits and various risk and protective factors. Study data were collected and managed using REDCap electronic data capture tools hosted at Virginia Commonwealth University [ 27 ]. When possible, standardized measures were used for data collection. The present study analyzed survey responses from the following domains:

Demographics

Variables included age, gender and race/ethnicity (dichotomized into White vs Non-White).

Caffeine use

Participants were asked about recent consumption of caffeine (“In the last month, in a typical week, on how many days did you drink …” ). The present study focused specifically on coffee, EDs (e.g., Red Bull, Monster, AMP), and energy shots (e.g., 5-Hour Energy). Coffee drinkers were defined as those reporting coffee consumption 1 or more days per week, and caffeinated ED users were defined as those reporting ED use (EDs and/or shots) 1 or more days per week.

Alcohol use

Participants were asked to classify their current alcohol use into one of seven categories, which, for purposes of analyses, were collapsed into four groups: Non-users (abstainers); Minimal Users (infrequent and light drinkers); Moderate Users (moderate drinkers) or Heavy/Problem Users (heavy drinkers + problem drinkers + former problem drinkers).

Alcohol problems

Symptoms of alcohol dependence were assessed with nine questions adapted from the Semi-Structured Assessment of the Genetics of Alcoholism [ 28 ]. Two items had yes/no response options: a) Strong desire to drink or drank too much in situations where alcohol was not permitted; and b) Tolerance (need to drink more alcohol to get the same effect). The other 7 items had three response options (never; 1–2 times; > 3 times) and focused on: wanting to stop drinking; drinking despite self-promise not to drink or drinking more than intended ; getting drunk when did not want to; stopping or cutting back on important activities to drink; spending several days drinking or recovering from the effects; continuing to drink despite knowing it was causing physical or mental problems; and having withdrawal symptoms (feeling sick for several days after stopping regular drinking). Responses for these 7 items were subsequently dichotomized into No (the symptom never happened) or Yes (it happened 1 or more times).

Other drug use

Participants were asked whether they had used each of the following drugs or classes of drugs (illicit or non-medical) 6 or more times in their lives: cannabis, sedatives, stimulants, cocaine, and opioids. Non-medical use was defined as “use without a doctor’s prescription, in greater amounts than prescribed, or for other reasons than those recommended by a doctor.”

Tobacco use

Respondents were asked how many cigarettes they had smoked in their lifetime. Responses were classified into 3 groups: 0 cigarettes (never smoked); 1–99 cigarettes; or > 100 cigarettes. Peer smoking was assessed using items from the Monitoring the Future survey [ 29 ]. Specifically, participants were asked to think about friends they saw regularly and spent time with (in or outside of school) during the past year and describe the extent to which such friends smoked. Initial response items were combined to create 3 categories: None of them; A Few or Some of them; and Most or All of them.

Parental history

Participants were asked whether they thought their biological mother and father had ever experienced problems (yes/no) separately for alcohol, other drugs, and depression/anxiety [ 26 ].

Coffee/ED use groups

For the present study, self-reported coffee and ED consumption were used to classify N = 1986 participants into one of three groups: a) No coffee or ED use (NoCE; N = 827); b) Coffee but no ED use (Co; N = 761); and c) Use of ED with or without coffee (ED ± Co; N = 350). The latter group (ED ± Co) was similar to published literature looking specifically at ED use and included N = 266 individuals with ED and coffee use and N = 84 individuals with ED use only.

Data analysis

Categorical data are presented as percentages while continuous data are presented as mean + SD. Group comparisons for categorical data were performed using the χ 2 test with the corresponding degrees of freedom, while group comparisons for continuous variables were performed with either a one-way analysis of variance or a non-parametric Kruskal-Wallis test. For all analyses, a p -value < 0.05 was considered to be statistically significant. Percentages adjusted for gender and race as well as adjusted odds ratios (OR’s) and 95% confidence intervals for the adjusted OR’s were calculated using either a multivariable binary logistic regression model or an ordinal logistic regression model for variables with more than two levels.

The sample of N = 1986 freshmen had a mean age of 18.5 (SD = 0.6) years; approximately one-third was male (38.8%) and half were white (52.7%). Demographic characteristics for the total sample and across the 3 coffee/ED use groups are summarized in Table 1 . While the 3 groups were similar in age, they differed on gender (χ 2 = 87.91, d.f. = 2, p < 0.0001) and race (χ 2 = 19.25, d.f. = 2, p < 0.0001). Specifically, there were more females in the Co group (74.5%) as compared to both the NoCE (52.2%) and ED ± Co (54.6%) groups. The 3 groups also differed in racial representation, with a higher percentage of White participants in the ED ± Co (63.0%) as compared to the Co (54.9%) and NoCE (46.6%) groups. Subsequent group comparisons were adjusted to take into account differences in gender and race composition.

Demographic Data by Coffee/ED Use Group

Alcohol use and problems by coffee/ED use group

The data for gender and race-adjusted group effect test comparisons of the 3 coffee/ED use groups on measures of alcohol, tobacco and other drug use as well as parental history variables are summarized in Table 2 . In addition, adjusted odds ratios are shown for all possible 2-group comparisons (Co to NoCE, ED ± Co to NoCE and ED ± Co to Co).

Personal, Peer and Family Substance Use and Problems by Coffee/ED Use Group

(Percentages adjusted for gender and race as well as Adjusted Odds Ratios (OR) and 95% Confidence Intervals (CI))

For alcohol, group effects were found for pattern of alcohol use (None, Minimal users, Moderate users and Heavy/Problem users), with greater moderate and heavy use among the ED ± Co group and higher rates of abstinence in the NoCE group. Group effects were also found for 8 of the 9 symptoms of alcohol use disorder (AUD) and in all but one case, the ED ± Co group was most likely to endorse the item, followed by the Co and finally the NoCE group. For 3 of the symptoms, (tolerance; wanting to stop; consuming more than intended), the Co group was 1.46–1.78 times more likely to endorse the symptom than the NoCE group. The ED ± Co group differed from the NoCE group on all 8 symptoms, with Adjusted Odds Ratios (AORs) ranging from 2.04 (95% CI: 1.42–2.93) for desire to cut down/stop drinking to 3.13 (95% CI: 2.02–4.84) for drinking more than they intended. Finally, the ED ± Co group differed from the Co group on 7 of the 8 symptoms, with AORs ranging from 1.70 (95% CI: 1.23–2.33) for drinking more than they intended to 2.19 (95% CI: 1.36–3.52) for reduced other activities due to drinking.

Tobacco use by coffee/ED use group

For tobacco, significant group effects were found for all three cigarette smoking variables: smoking at least one cigarette (lifetime), number of cigarettes smoked (lifetime) and proportion of friends who smoke. Specifically, ED ± Co group members were 1.53 times more likely to have ever smoked a cigarette than Co group members (CI: 1.18, 2.0) and Co group members were 1.91 times more likely to have ever smoked than NoCE group members (CI: 1.53, 2.39). The largest difference was found between the ED ± Co and NoCE groups, with ED ± Cos nearly 3 times more likely to report ever smoking than NoCEs (AOR: 2.94; CI: 2.25, 3.84). Similar patterns were seen for smoking quantity (lifetime), with AOR’s ranging from 1.73 (ED ± Co vs CO) to 3.21 (ED ± Co vs NoCE), as well as peer smoking (ED ± Cos most likely and NoCEs least likely to report most/all of their friends smoked).

Parental problems by coffee/ED use group

The 3 coffee/ED use groups differed in prevalence of maternal alcohol problems and depression/anxiety (.005 < p < .01) and paternal alcohol and drug problems and mental health (.004 < p < .04). For maternal alcohol problems and depression/anxiety, only the ED + Co group differed from the NoCE group with OR’s ranging from 1.57 for mental health to 1.97 for alcohol problems. For fathers, group effects were found for alcohol problems, with ED + Co group members differing from both the Co (AOR: 1.55; CI: 1.15, 2.11) and NoCE (AOR: 1.17; CI: 1.17, 2.12) groups. Similarly for paternal drug problems, the ED ± Co group differed from both the Co (AOR: 1.61; CI: 1.14, 2.29) and NoCE (AOR: 1.50; CI: 1.07, 2.10) groups. For paternal depression/anxiety, only the ED ± Co group differed from the NoCE group (AOR: 1.47; CI: 1.0 2.12). symptoms.

Principal findings

Spurred by the steady rise in ED use and the targeted marketing of these drinks to young adults, much of the existing research regarding caffeine use by college students has focused exclusively on EDs and their associations with a variety of risky health behaviors [ 9 ]. Studies have shown, however, that other sources of caffeine such as coffee and soft drinks are more frequently used by college students than EDs, and these sources of caffeine should be considered when evaluating associations between caffeine and other substance use and problem behaviors [ 25 ]. The present study is among the first to look concurrently at coffee and ED use in college students and to evaluate associations between their use and alcohol, tobacco and other drug use; alcohol use problems; and parental substance abuse and mental health problems. Analyses found students who consumed EDs (with or without concurrent coffee use) were most likely to report other substance use, alcohol-related problem behaviors, and peer/family risk factors for substance use followed by students who consumed coffee only, and finally, students who reported using neither EDs nor coffee. The data are particularly noteworthy for the consistent response pattern observed across almost all domains assessed.

In most previous research, the relationship between other sources of caffeine and adverse health behaviors was either not considered ,14,17,30 or used as a covariate in the data analysis [ 11 ]. The focus on EDs as the singular source of caffeine in these studies started with the compelling data from O’Brien and colleagues (2008) who reported an association between the use of EDs mixed with alcohol and both risky drinking and alcohol-associated adverse health behaviors [ 8 ]. Subsequent researchers continued to focus on EDs and risky health behaviors, in part because of the intense marketing efforts ED makers directed at college-age students and the relatively higher amounts of caffeine in EDs compared to traditional sources of caffeine (e.g., 40 mg caffeine in a 12-oz can of Coca-Cola vs 80 mg in a 12-oz can of Red Bull). More recently, however, many specialty coffee drinks (150 mg in a 12-oz cappuccino) and even soft drinks (110 mg caffeine in a 12-oz can of Coke Energy) contain caffeine in amounts like those found in EDs. Another reason researchers focused singularly on EDs was because these beverages often are consumed more rapidly than hot caffeinated beverages like coffee. Many thought the relatively rapid rate of consumption of EDs may lead to higher caffeine levels and thus, greater association with risky health behaviors, compared to caffeinated drinks that are typically consumed more slowly, like hot coffee drinks. White et al. (2016) however, recently showed there was no clinically significant difference in caffeine exposure (i.e., T max , MRT, MAT or AUC 0–∞ ) regardless of the rapidity with which caffeine was consumed [ 30 ].

Much of the early research in college students who mixed EDs with alcohol showed that these students consumed alcohol more frequently, in higher amounts, and with more episodes of binge and problem drinking than students consuming alcohol without ED mixers [ 8 , 30 , 31 ]. Not surprisingly, AmED users also were more likely than non-AmED users to engage in other risky health behaviors including risky sexual behavior, dangerous driving behavior, and physical altercations [ 8 , 32 , 33 ]. Both clinical and laboratory research suggest students who consume AmED have altered perceptions of their levels of intoxication, with these students not recognizing their levels of impairment [ 8 , 34 ]. Early research also consistently found college students who used ED, independent of concomitant alcohol use, were more likely to report alcohol use; meet criteria for alcohol dependence; use tobacco, marijuana, and nonmedical prescription drugs; and engage in risky sexual and physical behaviors [ 10 , 14 , 21 ].

A few significant exceptions to the early ED-only and AmED-only focused research in college students showed that other sources of caffeine also were associated with risky health behaviors. Thombs and colleagues (2011) compared the effects of AmEDs to alcohol mixed with cola and alcohol alone on alcohol use in college students [ 35 ]. The researchers found a dose-dependent relationship between the estimated amount of caffeine consumed from both EDs and soft drinks and risky alcohol use. Using data from a group of Icelandic college students, Kristjansson et al. (2015) showed that daily consumption of coffee, soft drinks, and EDs, but not tea, was positively associated with drinking AmEDs [ 36 ]. In addition, Anderson and Juliano (2012) showed that estimated mean weekly caffeine consumption, regardless of the source, was positively correlated with the amount of alcohol consumed by college students [ 37 ]. These cross-sectional studies suggest the amount of caffeine consumed is more important than the source of caffeine with regard to the likelihood that college students will engage in adverse health behaviors. More recently, Dillon and colleagues (2019) investigated the relationship between all sources of caffeine and adverse health behaviors in college freshmen [ 38 ]. They found that students who consumed caffeine daily from any source were more likely to report alcohol, cigarette, and nonmedical drug use and problem drinking than those who did not consume caffeine.

In the present study, we elected to focus on coffee and ED consumption in college students for three reasons. First, these beverages typically have the highest caffeine content and, over time, they have come to represent a greater proportion of caffeine intake in US children and adolescents [ 39 ]. Second, coffee is used frequently by college students [ 24 , 40 ], with one recent convenience sample survey of college students finding coffee to be their primary source of caffeine intake (72%), followed by soft drinks (69%), tea (61%), and EDs (36%) [ 24 ]. Third, research done by our group prior to the surge in popularity of EDs underscored the importance of considering coffee when evaluating the effects of caffeine on substance use. Our research showed that college women who drank coffee daily were more likely to report heavier drinking and alcohol-related problems than non-daily coffee drinkers [ 25 ].

Like previous work, this research found an association between caffeine and risky health behaviors. This relationship was more robust for students in the ED + Co group compared with those who drank coffee only and those consuming neither beverage. While the cross-sectional nature of the work limits our ability to establish a causal relationship between caffeine, other substance use, and alcohol use problems, the associations are likely a result of a combination of genetic, psychobiological, and environmental factors.

Our study is among the first to look at familial factors associated with caffeine use. We found participants reporting ED ± Co use were more likely to report maternal alcohol problems and depression/anxiety symptoms as well as paternal alcohol and drug problems and depression/anxiety. Such familial clustering may occur because of both a shared environment and genetic factors. In fact, Kendler, Myers, and Gardner (2006) [ 23 ], in a study in adult twins, found that a link between caffeine use and the development of substance use and psychiatric disorders was due primarily to familial factors, including genetic factors. With the compelling and consistent association between EDs and risk-taking behaviors, most frequently other substance use, researchers have linked sensation-seeking personality traits and ED use. College students who scored higher on measures of sensation-seeking were more likely to consume ED and AmED [ 10 , 14 , 41 ]. This may be due to caffeine’s potentiation of the psychostimulant effect of other drugs of abuse through its effects on the adenosine and dopamine pathways. In addition, when combined with alcohol, caffeine blunts the depressant effects and enhances the stimulant effects of alcohol, which alone is associated with risk-taking, by affecting the same pathways [ 42 ]. The increased stimulant effect, decreased depressant effects, and propensity for risk-taking may lead to increased sensation-seeking behavior, including ED use.

Environmental factors likely impact the association between caffeine use and risky health behaviors as well. Almost all college students use caffeine regularly [ 43 ]. At the same time, most college students are in the age range, late teens and early 20s, at highest risk for the onset of many substance use disorders [ 26 ]. The temporal intersection between high frequency caffeine use and increased prevalence of substance use may explain the association between caffeine and risky health behaviors. Patterns between ED use and other drug use have also been found in younger age groups (8th, 10th, and 12th graders) [ 3 ]. In addition, alcohol and other substances like marijuana and tobacco are often part of the college milieu, and students may use caffeine to affect the pharmacodynamic effects of these other substances. For instance, students may concurrently consume caffeine to offset the depressant effects of alcohol or marijuana while socializing or use caffeine to increase their energy when they have school obligations after a night of heavy drinking. Finally, there is evidence that peer influence increases adolescents’ substance use, and this may contribute to the risky behaviors reported by our sample [ 44 ]. Indeed, we found that students who used EDs and/or coffee (ED ± Co and Co groups) were more likely to report smoking and having friends who smoked than the NoCE group.

Limitations

There are several limitations to the present study. First, we relied on retrospective self-report data to address our research question. Second, participants were surveyed about recent (past 30 days) caffeine consumption, which did not allow us to examine use patterns over longer periods. Nonetheless, a 30-day timeframe focused on recent caffeine use appeared to be an appropriate starting point for examining substance use/problems associated with cross-beverage caffeine consumption. Third, the low number of ED only (no coffee) users ( N = 84) prevented statistical power for a 4-group comparison. Instead, present study analyses included an ED + Co group in which three-fourths of the sample reported use of both ED and coffee (76%) and one-fourth reported ED use but no coffee. One advantage of the ED + Co group is that it is similar to much of the published research in which ED use was defined without attention to concurrent coffee use, and this allows our data to be compared to the extant literature. Fourth, only frequency of caffeine use was assessed, with no quantity of use data. The survey used for this research was originally designed to assess alcohol use in college students, with limited caffeine use questions, and future research should collect more detailed quantitative data about quantity and frequency of caffeine use. Fifth, caffeine use was restricted to only coffee and ED use; other sources of caffeine intake (e.g., tea, sodas) were not included.

The current study presents benchmark data on the elevated risks associated with ED + Co and Co use compared to use of neither substance (NoCE). Specifically, we found a consistent response pattern in which NoCE users were least likely to report substance use and related problem behaviors and ED ± Co users were most likely to endorse such behaviors, with Co users falling in the middle. Whereas the relationship between caffeine use and risky behavior has been previously established [ 14 ], the mechanisms underlying these associations are unknown and are likely a confluence of factors. Additional research is needed to disentangle the effects of amount and type of caffeine use from genetic factors, personality traits, and environmental influences that may mediate these adverse health behaviors.

Present study findings have significant public health implications. Caffeine use is ubiquitous on college campuses, and it is associated with a host of substance-related and other risky adverse health behaviors. The present study found relationships between coffee and ED use and other substance use, alcohol-related problems, and several risk factors for alcohol and drug use. These relationships were strongest for the ED group, but coffee consumption was also associated with risky health behaviors. While evaluating regular caffeine use from a variety of sources including coffee and EDs is important for research purposes, the findings from this research unequivocally show that ED use is most significant for identifying students at risk for other substance use and associated adverse health behaviors. With the social acceptability of EDs, screening for regular ED use in college students may provide a non-stigmatizing way to identify students at higher risk for alcohol/drug misuse, and to prioritize them to receive substance use education and intervention.

Acknowledgements

We would like to thank the Spit for Science participants for making this study a success, as well as the many University faculty, students, and staff who contributed to the design and implementation of the project.

The Spit for Science Working Group j :

Spit for Science Director: Danielle M. Dick h,j .

Registry management: Kimberly Pedersen, Zoe Neale, Nathaniel Thomas.

Data cleaning and management: Amy E. Adkins, Nathaniel Thomas, Zoe Neale, Kimberly Pedersen, Thomas Bannard & Seung B. Cho.

Data collection: Amy E. Adkins, Peter Barr, Holly Byers, Erin C. Berenz, Erin Caraway, Seung B. Cho, James S. Clifford, Megan Cooke, Elizabeth Do, Alexis C. Edwards, Neeru Goyal, Laura M. Hack, Lisa J. Halberstadt, Sage Hawn, Sally Kuo, Emily Lasko, Jennifer Lend, Mackenzie Lind, Elizabeth Long, Alexandra Martelli, Jacquelyn L. Meyers, Kerry Mitchell, Ashlee Moore, Arden Moscati, Aashir Nasim, Zoe Neale, Jill Opalesky, Cassie Overstreet, A. Christian Pais, Kimberly Pedersen, Tarah Raldiris, Jessica Salvatore, Jeanne Savage, Rebecca Smith, David Sosnowski, Jinni Su, Nathaniel Thomas, Chloe Walker, Marcie Walsh, Teresa Willoughby, Madison Woodroof & Jia Yan.

Genotypic data processing and cleaning: Cuie Sun, Brandon Wormley, Brien Riley, Fazil Aliev, Roseann Peterson & Bradley T. Webb.

Abbreviations

Energy Drink

Coffee and Energy Drink Use

Coffee but no Energy Drink Use

Neither Coffee nor Energy Drink Use

Alcohol Mixed with Energy Drinks

Alcohol Use Disorder

Adjusted Odds Ratio

Confidence Interval

Authors’ contributions

DS designed the study; played key role in data analyses and was primary author of the manuscript. PD co-designed the study and contributed to interpretation of findings and manuscript writing. SM provided expert guidance on subject matter and guided interpretation of findings and manuscript writing. LT contributed to data analytic plan and conducted the analyses. KP was involved in drafting of the manuscript; DP contributed to literature review; AE contributed to interpretation of findings; and DD and KK played integral roles in primary study data collection and made important contributions to intellectual content of the manuscript. All authors reviewed manuscript drafts and contributed important intellectual content that helped shape the final version of the manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. The author(s) read and approved the final manuscript.

Spit for Science has been supported by Virginia Commonwealth University, P20 AA017828, R37AA011408, K02AA018755, P50 AA022537, and K01AA024152 from the National Institute on Alcohol Abuse and Alcoholism, and UL1RR031990 from the National Center for Research Resources and National Institutes of Health Roadmap for Medical Research. This research was also supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number U54DA036105 and the Center for Tobacco Products of the U.S. Food and Drug Administration. The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH or the FDA.

Availability of data and materials

Data from this study are available to qualified researchers via dbGaP (phs001754.v2.p1).

Declarations

Ethics approval and consent to participate.

The study was approved by the Virginia Commonwealth University Institutional Review Board. All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from students who chose to participate, using Institutional Review Board approved procedures.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Dace S. Svikis, Email: [email protected]

Pamela M. Dillon, Email: [email protected]

Steven E. Meredith, Email: [email protected]

Leroy R. Thacker, Email: [email protected]

Kathryn Polak, Email: [email protected].

Alexis C. Edwards, Email: [email protected]

David Pomm, Email: [email protected].

Danielle Dick, Email: [email protected].

Kenneth Kendler, Email: [email protected].

Spit for Science Working Group, Email: [email protected]

Spit for Science Working Group:

Danielle M. Dick , Kimberly Pedersen , Zoe Neale , Nathaniel Thomas , Amy E. Adkins , Nathaniel Thomas , Zoe Neale , Kimberly Pedersen , Thomas Bannard , Seung B. Cho , Amy E. Adkins , Peter Barr , Holly Byers , Erin C. Berenz , Erin Caraway , Seung B. Cho , James S. Clifford , Megan Cooke , Elizabeth Do , Alexis C. Edwards , Neeru Goyal , Laura M. Hack , Lisa J. Halberstadt , Sage Hawn , Sally Kuo , Emily Lasko , Jennifer Lend , Mackenzie Lind , Elizabeth Long , Alexandra Martelli , Jacquelyn L. Meyers , Kerry Mitchell , Ashlee Moore , Arden Moscati , Aashir Nasim , Zoe Neale , Jill Opalesky , Cassie Overstreet , A. Christian Pais , Kimberly Pedersen , Tarah Raldiris , Jessica Salvatore , Jeanne Savage , Rebecca Smith , David Sosnowski , Jinni Su , Nathaniel Thomas , Chloe Walker , Marcie Walsh , Teresa Willoughby , Madison Woodroof , Jia Yan , Cuie Sun , Brandon Wormley , Brien Riley , Fazil Aliev , Roseann Peterson , and Bradley T. Webb

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SOLVED: Create a research and null hypothesis for the following two
Energy Drink Experiment by Ragan Ware on Prezi
Energy drink health consequences revealed in horrifying new scientific
Experiment on Effect of Energy Drinks on Athletic Performance
Which Energy Drink Keeps You Up The Most? by Ryan

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What Do Energy Drinks Do To Your Body?
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Energy Drinks: Why Are They Sending So Many People to the ER?
The Speedy Rise of the Energy Drink
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Energy Drinks and the Neurophysiological Impact of Caffeine
Aside from occurring organically in tea and coffee, caffeine is now an additive in soft drinks, energy drinks, chocolates, bottled water, chewing gum, and medication (Mednick et al., 2008). The aim of this paper is to elicit an awareness of the neurophysiological effects of caffeine.
Impact of High Volume Energy Drink Consumption on ...
Energy drinks have been linked to an increase in emergency room visits and deaths. We aim to determine the impact of energy drinks on electrocardiographic and hemodynamic parameters in young healthy volunteers. Methods and Results. A randomized, double‐masked, placebo‐controlled, crossover study was conducted in healthy volunteers.
Energy Drinks and Their Adverse Health Effects: A Systematic ...
Alcohol mixed with energy drinks significantly reduced the likelihood of sedation effects but increased the likelihood of stimulatory effects. Energy drink consumption significantly increased the odds of insomnia (OR, 5.02; 95% CI, 1.72-14.63) and jitteriness/activeness (OR, 3.52; 95% CI, 1.28-9.67) compared with the control group.
Energy Drinks and Their Impact on the Cardiovascular System ...
This article reviews the potentially adverse hemodynamic effects of energy drinks, particularly on blood pressure and heart rate, and discusses the mechanisms by which their active ingredients may interact to adversely affect the cardiovascular system.
Energy drink use and high-risk behaviors: Research evidence ...
A review of the research reveals that although there appears to be a strong and consistent positive association between CCED use and risk-taking behavior, all but one study have used cross-sectional designs, limiting their ability to make inferences about the temporal nature of the association.
Energy Drinks and Sports Performance, Cardiovascular Risk ...
The consumption of energy drinks (e.g., containing caffeine and taurine) has increased over the last decade among adolescents and athletes to enhance their cognitive level and improve intellectual and athletic performance.
Risk of Energy Drink Consumption to Adolescent Health
High energy drink consumption of youth is concerning due to the range of reported adverse reactions attributed to excessive caffeine consumption, ranging from mild sleep disturbances to death. Reactions are severe enough to require reporting to the National Poison Data System and may even require emergency medical treatment.
Energy Drinks and Sports Performance, Cardiovascular Risk ...
The consumption of energy drinks (e.g., containing caffeine and taurine) has increased over the last decade among adolescents and athletes to enhance their cognitive level and improve intellectual and athletic performance.
Perceptions of Sports and Energy Drinks: Factors Associated ...
To understand what factors are associated with adolescents’ perceived healthfulness of sports drinks (SD) and of energy drinks (ED), with a focus on health risk, athletics, and media-related variables.
Coffee and energy drink use patterns in college freshmen ...
Public health concern over college students mixing caffeine-containing energy drinks (EDs) and alcohol has contributed to an array of ED-focused research studies. One review found consistent associations between ED use and heavy/problem drinking as well as other drug use and risky behaviors (Nutr Rev 72:87–97, 2014).

Energy drink use and high-risk behaviors: Research evidence and knowledge gaps

INTRODUCTION

CCED USE DURING ADOLESCENCE: FINDINGS FROM THE MONITORING THE FUTURE (MTF) SURVEY

PREVALENCE AMONG COLLEGE STUDENTS

RELATIONSHIP BETWEEN CCED USE AND RISK-TAKING BEHAVIORS AMONG COLLEGE STUDENTS

CONCLUSION AND KNOWLEDGE GAPS

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Risk of Energy Drink Consumption to Adolescent Health

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Coffee and energy drink use patterns in college freshmen: associations with adverse health behaviors and risk factors

Conclusions

Participants

Demographics

Caffeine use

Alcohol use

Alcohol problems

Other drug use

Tobacco use

Parental history

Coffee/ED use groups

Data analysis

Alcohol use and problems by coffee/ED use group

Other drug use and problems by coffee/ED use group

Tobacco use by coffee/ED use group

Parental problems by coffee/ED use group

Principal findings

Limitations

Acknowledgements

Abbreviations

Authors’ contributions

Availability of data and materials

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Consent for publication

Competing interests

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