1. Caffeinated Cocktails: Energy Drink Consumption, High-Risk Drinking and Alcohol-Related Consequences Among College Students. Mary Claire O’Brien, MD NIDA/ODS Caffeine Symposium July 8, 2009

2. Acknowledgements Supported by Grants Number RO1 AA14007-2 and 2R01AA014007-06A1 from the National Institute on Alcohol Abuse and Alcoholism, and North Carolina DHHS/ OJJDP EUDL Award Number 2004-AH-FX-0014.

3. Co-authors  Thomas P. McCoy  Scott D. Rhodes  Ashley Wagoner  Mark Wolfson

4. Presenter Disclosure The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Mary Claire O’Brien, M.D. “No relationships to disclose”

5. Yes! It really is like the TV show.

6. Youth and alcohol  Risk taking  Independence seeking  Experimentation  Underage drinkers consume almost 20% of all alcohol in the U.S.  6 th, 7 th, and 8 th graders: 31.5% reported drinking all types of alcohol  4 out of 5 college students drink; ½ binge  18-25 yr olds: highest rate of binge drinking among all U.S. adults

7. Study to Prevent Alcohol-Related Consequences Among College Students (“SPARC”)  Randomized group trial  Community organizing approach  Environmental strategies  Availability (e.g. keg restrictions, compliance checks, responsible beverage service policies…)  Price/ marketing (e.g. regulation of “happy hours,” limits on alcohol industry presence on campus…)  Social norms (e.g. substance free housing, parental notification…)  Harm minimization (e.g. Safe Ride programs)  PrincipaI investigator: Mark Wolfson, Ph.D.

8. SPARC: The Evaluation  College Drinking Survey (CDS)  Resident Advisor Survey  Alcohol Incident and Injury Reports  Campus Police, Student Affairs, Campus Health, Campus EMS  Coalition Member Survey  Environmental Strategies and Implementation Survey (ESIS)  Coalition Activity Tracking

9. Annual Consequences of College Drinking  1,700 deaths  599,000 injuries  696,000 assaults  97,000 sexual assaults  2.8 MILLION DWI Hingson, 2005

11. Effects of Energy Drink Ingestion on Alcohol Intoxication. Ferreira SE, Tulio de Mello M, Pompeia S, Oliviera de Souza- Formigoni ML. Alcoholism: Clinical and Experimental Research. Vol 30, No 4, 2006: pp 598-605.

12. Breath alcohol concentration Motor coordination Visual reaction time Feelings of intoxication 26 Energy drink 26 Alcohol + Energy drink 26 Alcohol

13. Results  Alcohol alone:  Dizzy, weak, tired, headache, trouble walking  Alcohol + Energy drink:  Same BAC  Felt much less “intoxicated”  NOTE!  Performance on motor coordination and visual reaction time were the same for both groups!

14. “Buzz Beer” ≠

16. Caffeinated liquor

17. “Mix-your-own”  Jager Bomb  Liquid Viagra  Crunk Juice  Bullvodka  Irish Trash Can  Bull Blaster  Up All Night  Liquid Cocaine #6  Tucker Death Mix  Butt Plug  Dirty Gecko  Panty Dropper Punch  Cherry Bomb Shot  Bazooka #2  Jacobo’s Melon Bomb  Touchdown  Canadian Bull  Flaming Liquid Cocaine Blaster  Flip Passion  Raging Bull #2  Heart Attack

18. 2006 SPARC CDS  Ten NC Universities  Stratified random sample  Email invitation to participate  Web-based (secure URL)  Anonymous  Reminder emails to non-respondents  307 items, with skip patterns (~20 min)  Paypal ® incentive

19. SPARC College Drinking Survey: Content  Demographic variables  Alcohol consumption behaviors  Alcohol availability  How obtained (e.g. where, from whom)  Where consumed  Attitudes about drinking (one’s own, perception of other students’)  Perceived campus drinking norms  Knowledge of university policies  Perception of enforcement (on campus, in the community)  Consequences of one’s own drinking  Consequences of other students’ drinking  Sexual behaviors  Other substance use behaviors

20. 2006 Additional Goals  Estimate the prevalence of mixing alcohol with energy drinks (AmED) among past 30-day drinkers  Examine the association of AmED and high-risk drinking  Examine the association of AmED with alcohol- related consequences, after adjusting for drinking behaviors

21. 2006 Sample characteristics  N = 4,271  Average age 20.4 ± 2.8 yrs  61% Female  78% Non-Hispanic White  26% Fr; 25% So; 25% Jr; 20% Sr  12% Greek society member or pledge  22% intramural athlete; 5% varsity  57% on-campus resident

22. 2006 SPARC CDS 4,271 students 2,886 past 30-day drinkers (68%) 1,385 non past 30-day drinkers (32%) 697 past 30-day AmED (24%) 4,237 answered drinking questions (99.2%) AmED = Alcohol mixed with energy drinks

23. Reasons given for consuming AmED  To hide the flavor of the alcohol  To drink more and not feel as drunk  To drink more and not look as drunk  To not get a hangover  “Because it was being served at a party”  “Because it was the only mixer available”  “Because that’s how you make Jagerbombs”

24. AmED more likely…  Male (p < 0.001)  White (p < 0.001)  Intramural athletes (p < 0.001)  Greek society members or pledges (p < 0.01)  Younger (p<0.01)  Average age of first drink: 15.1 yrs  (vs. 16.0 yrs for non-AmED; p <0.001)  More drinking during last year of high school (p < 0.001)  More non-medical use of prescription stimulants (p < 0.001)

25. Drinking Behavior Non-AmED N=2,189 (76%) AmED N=697 (24%) b 95% CI z statisticp-value Typical # drinks in single episode 4.5  0.155.8  0.17 1.4 (1.1, 1.6) 11.69<0.001 # days with 5/4 heavy episodic drinking past 30 days 3.4  0.176.4  0.23 2.9 (2.5, 3.3) 14.21<0.001 # days drunk in a typical week 0.73  0.041.4  0.05 0.70 (0.61, 0.79) 15.44<0.001 Most # drinks single episode past 30 days 6.1  0.158.3  0.19 2.2 (1.9, 2.5) 14.28<0.001 High-Risk Drinking

26. Consequence Non-AmED N=2,189 (76%) AmED N=697 (24%) AOR 95% CI z statistic p-value Was taken advantage of sexually 3.7% (2.9, 4.8) 6.4% (4.7, 8.7) 1.77 (1.23, 2.55) 3.050.002 Took advantage of another sexually 1.7% (1.2, 2.4) 3.7% (2.5, 5.4) 2.18 (1.34, 3.55) 3.130.002 Rode with a driver who was under the influence of alcohol 22.5% (18.6, 26.9) 38.9% (32.7, 45.6) 2.20 (1.81, 2.68) 7.83<0.001 Was hurt or injured 5.9% (4.8, 7.2) 12.3% (9.9, 15.3) 2.25 (1.70, 2.96) 5.74<0.001 Required medical treatment 1.2% (0.8, 1.8) 2.6% (1.7, 4.1) 2.17 (1.24, 3.80) 2.700.007 Alcohol-Related Consequences

32. “Buzz Beer” ≠

33. 2007 SPARC CDS 3,813 students 2,669 past 30-day drinkers (70%) 1,114 non-drinkers (30%) 704 past 30-day AmED (26%) 3, 783 answered drinking questions (99.2%) 249 Pre-mix + MYO (35.4%) 59 Pre-mix only (8.4%) 393 MYO only (55.8%) AmED = Alcohol mixed with energy drinks Pre-mix = Pre-mixed alcoholic energy drinks (e.g. Sparks ®, Tilt ® ) MYO = Mix-your-own alcoholic energy drinks (e.g. Jagerbomb, Red Bull ® and vodka)

34. AME: Availability  BOUGHT IT THEMSELVES: 65.5%  Of these, 48.3% were under age 21 (223 of 462)  GIVEN THE ED FOR FREE: 13.4%  Of these, 79.8% were under age 21 (75 of 94)  SOMEONE ELSE BOUGHT FOR THEM: 13.9%  Of these, 71.4% were under age 21 (80 of 112)

35. Questions?