Risks of Alcoholic Energy Drinks for Youth

• Risk
• Alcohol Drinking
• Energy Drinks
• Drug Abuse
• Adolescence
• Behavioral Science
• Research Letter

The concept of getting someone sober by loading him or her with coffee is a time-honored tradition. The newer activity of ingesting energy drinks that contain alcohol to maintain the feeling of alertness potentially increases the risk of physical and social harm.^1,2 It gives the perception of decreased intoxication without altering impairment.^1,3,4 Previously a do-it-yourself activity by college students,⁵ entrepreneurs made it easier for underage individuals by producing premixed drinks, such as Rock Star 21, Joose,⁶ and Steel Reserve,^6–9 usually by adding vodka, with an alcohol content of 6% to 9.9%, and caffeine (80 to 400 mg) to the energy drink.^6–9

When asked to speak on this topic to a parents’ group, I was uneducated. To determine if this was an individual failing, an informal poll of a family medicine department and residency revealed that only just more than one third of the faculty and residents were aware of the use of alcohol in energy drinks.

Carbonated energy drinks such as Red Bull, Monster, and Blast, for example, contain ingredients intended to induce alertness, concentration, and focus.^10,11 The main stimulant is caffeine in doses of 80 to 400 mg, compared with 80 to 175 mg in a cup of coffee. Energy drinks also contain taurine, carbohydrates, glucuronolactone, inositol, niacin, pantanol, and B vitamins as well as proprietary substances^1,11–17 and even ethanol.¹⁸ Caffeine alone is associated with sensation seeking and impulsivity among college students,¹⁹ including sexual activity, marijuana use, seatbelt omission, taking a dare, smoking, alcohol problems, illicit prescription drug use, and “identity and masculinity behaviors” associated with sports.^20,21

The above behaviors may be enhanced by consuming alcohol with energy drinks.^1,9 An association between the heavy use of caffeine and heavy alcohol use was noted as early as 1984.^22,23 A survey by Malinauskas² of 496 university students revealed that 65% to 67% used one energy drink to stay awake because of insufficient sleep and to increase energy, and 54% commonly used 3 or more energy drinks with alcohol while partying.

Physicians should be familiar with the well-established effects of alcohol, including an artificially increased sense of well-being and competence, prolonged reaction time, and decreased coordination, social inhibition, and judgment.²⁴ At higher doses there can be sedation, amnesia, and loss of consciousness, but adding energy drinks to alcohol does several things.

• Carbonation tends to increase the rate of absorption of alcohol.²⁵

• Diluted concentrations of alcohol are emptied from the stomach into the faster absorbing small intestine more rapidly than high concentrations.²⁵

• Caffeine keeps one awake and blunts the sedative effects of the alcohol.^14,26

• Lengthened time awake theoretically allows greater alcohol intake before loss of consciousness.^14,26

• At low blood alcohol levels, caffeine appears to decrease some of the physical and mental impairment from the alcohol. At higher blood alcohol levels caffeine does not appear to have a modifying effect on either the physical or mental impairment induced by the alcohol.²⁶

• Energy drink ingredients give the consumer a greater false sense of physical and mental competence and decrease the awareness of impairment.^26,27

The physiologic and psychological response to alcohol depends on well-known factors, including body weight, sex, sleep status, general health, hepatic health, nutrition, and medication.²⁸ Therefore, the quantities of caffeine, alcohol, and other ingredients in alcoholic energy drinks, as well as the ratios needed to produce alertness despite impairment from intoxication, are dependent on the individual and their previous exposure to and tolerance of alcohol and caffeine.^11,29,30

The final result of the combination of caffeine, carbonation, and alcohol may be a more rapid absorption of alcohol, a greater total volume of alcohol absorbed, greater physical impairment, and a significantly reduced perception of intoxication in oneself as well as others.^14,25–27 This prevents one from recognizing impairment or risky behavior in others, such as not recognizing that one's driver is drunk,^1,3,4,27and may enhance risk-taking behavior^1,31 by young individuals who are known to have a baseline of less mature judgment concerning sexual activity and motor vehicle use, an increased sense of immortality, and disregard for the risks of pregnancy, sexually transmitted diseases, accidents, and injury. A recent survey of patrons leaving bars showed that those who consumed alcohol with energy drinks had a 3-fold increased risk of intoxication and a 4-fold increased intent to drive compared with those ingesting only alcohol.³¹ There is also concern for precipitating sudden cardiac arrhythmia in individuals with an arrhythmogenic predisposition.³²

Alcohol ingestion and subsequent risk-taking behavior may be further enabled by marketing strategies that make it easier for youth to obtain alcohol and hide alcohol use.^9,33 The packaging of the combination drinks is nearly identical to energy drinks without alcohol, resulting in the sale of these products to minors or unsuspecting parents.^9,33–35 Because the Food and Drug Administration previously determined that these products were adequately labeled as alcoholic beverages, they could be placed next to plain energy drinks in areas of a store that are not necessarily associated with alcohol.^36,37 The Food and Drug Administration controls and requires drinks with less than 7% alcohol content to have all ingredients listed on the label (reference 38 and FDA Public Affairs Specialist 9, personal communication). Previously, drinks with an alcohol content of 7% or greater were controlled by the Bureau of Alcohol, Tobacco, and Firearms, which did not require labeling other than the alcohol content, which was often in fine print.³⁹ These drinks with higher alcohol content are now regulated by the Division of Alcohol Tobacco Tax and Trade Bureau. Some alcohol-laced beverages have been priced lower than similarly packaged, nonalcoholic energy drinks,^9,33 and they are certainly less expensive than purchasing energy drinks and alcohol separately. Although most studies to date have been on college-age adults, the association of energy drink use with increased alcohol problems²⁰ raises concern for younger individuals who consume energy drinks as early as 12 years old.⁹ The Simmons Teen Survey revealed that 28% of 12- to 14-year-olds, 31% of 12- to 17-year-olds, and 34% of 18- to 24-year-olds consumed energy drinks regularly.^9,20 Sparks (Steel Brewing Co., Milwaukee, WI) and Spykes (Anheuser-Busch, St. Louis, MO) have been withdrawn from the market, and caffeine and other stimulants have been removed from Tilt and Bud Extra (Anheuser-Busch) after several states’ Attorneys General alleged inaccurate labeling of alcohol content and marketing to minors.^6,40–42

The awareness among the medical community of the use of alcohol with energy drinks is unknown. This should be studied further, and efforts should be made to identify at-risk children and youth. A screening question about energy drink use as well as alcohol and caffeine use added to a patient's social history may be an indicator of other substance use and/or risky behavior.²⁰ Efforts to educate students, parents, families, schools, communities, medical students, residents, and practicing physicians should be established. Further research is needed about how education is best done and if presentations by physicians (especially team physicians) or ancillary personnel to parent organizations, educators, and school personnel improves awareness and detection of signs children are using alcohol and energy drinks together.

• Received for publication November 20, 2009.
• Revision received March 18, 2010.
• Accepted for publication March 25, 2010.