Energy drinks and alcohol: research supported by industry may be downplaying harmsBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5345 (Published 12 September 2013) Cite this as: BMJ 2013;347:f5345
All rapid responses
Red Bull meets the Australian Dietary Guidelines
Peter Miller is right to be concerned about the role of manufacturers in the production of scientific knowledge around ‘energy drinks’ particularly when they are mixed with alcohol.(1) In many respects, this issue is no different to the difficult line that researchers tread with pharmaceutical companies or medical appliance manufacturers and it needs to be treated as seriously. At the very least is there is certainly the issue of propriety. Then there is the very real potential of distorting the scientific evidence, even if it is simply by not posing the hard questions and instead swamping the literature with experimental evidence of no harm from one can of energy drink mixed with modest amounts of alcohol. This does not reflect real world levels of use (especially among young people) of these highly caffeinated beverages with and without alcohol and why there is so much concern about them.(2)(3)
What happened next with the scientific evidence is even more concerning. When the draft Australian Dietary Guidelines came out in December 2011 for public consultation it read, as below. However, when the final guidelines were published in 2013, the section Interaction of alcohol with caffeine and other stimulants was rather reduced – the main parts excised have been italicised:
‘A new category of alcoholic drinks is now being marketed in Australia with added caffeine and sometimes other stimulants. The effects of alcohol and other components in these energy drinks appear to be synergistic, resulting in increased intoxication. In comparison to alcohol alone, the combination of alcohol and energy drink significantly reduces the intensity of subjective perceptions of headache, dry mouth, weakness and impairments of motor coordination.(4) The concern is that consuming caffeine, a central nervous system stimulant, and alcohol, a depressant, at the same time will reduce subjective perceptions of alcohol-induced impairment in comparison to alcohol alone.(5)(6) Reduced ability in recognising alcohol impairment may enhance risk-taking behaviour and possibly lead to greater alcohol intake.(7)
'In the absence of any research to quantify safe levels of concurrent consumption of energy drinks and alcohol, this combination should be avoided.(8)’
So, by 2013 what was previously to be avoided was now to be ‘used with caution’(9) and of the four studies quoted in the final guidelines, two were as in the draft guidelines(4)(5) along with one new one sponsored by Red Bull(10) and one new review.(11) Of the three authors of the review, two had received funding from Red Bull within the last three years, and one of these funded researchers was a co-author on the other new (sponsored) paper.
It seems unlikely that it can be good for public health policy discussion and debate for so much industry funded research, researchers(12)(13)(10)(14) (15)(16) and comment(17) on one issue to have gained so much traction.
Author email: firstname.lastname@example.org
1. Miller P. Energy drinks and alcohol: research supported by industry may be downplaying harms. Bmj 2013;347:f5345.
2. Gunja N, Brown JA. Energy drinks: health risks and toxicity. The Medical journal of Australia 2012;196(1):46-9.
3. Pennay A, Lubman DI. Alcohol and energy drinks: a pilot study exploring patterns of consumption, social contexts, benefits and harms. BMC research notes 2012;5:369.
4. Ferreira SE, de Mello MT, Pompeia S, de Souza-Formigoni ML. Effects of energy drink ingestion on alcohol intoxication. Alcohol Clin Exp Res 2006;30(4):598-605.
5. Price SR, Hilchey CA, Darredeau C, Fulton HG, Barrett SP. Energy drink co-administration is associated with increased reported alcohol ingestion. Drug and alcohol review 2010;29(3):331-3.
6. Thombs DL, O'Mara RJ, Tsukamoto M, Rossheim ME, Weiler RM, Merves ML, et al. Event-level analyses of energy drink consumption and alcohol intoxication in bar patrons. Addictive behaviors 2010;35(4):325-30.
7. Weldy DL. Risks of alcoholic energy drinks for youth. Journal of the American Board of Family Medicine : JABFM 2010;23(4):555-8.
8. National Health and Medical Research Council. Australian dietary guidelines, incorporating the Australian guide to healthy eating: providing the scientific evidence for healthier Australiand diets. In: National Health and Medical Research Council, editor: Australian Government, 2011.
9. National Health and Medical Research Council. Eat for health: Australian dietary guidelines. In: Department of Health and Ageing Commonwealth of Australia, editor. Canberra: National Health and Medical Research Council, 2013.
10. de Haan L, de Haan HA, van der Palen J, Olivier B, Verster JC. Effects of consuming alcohol mixed with energy drinks versus consuming alcohol only on overall alcohol consumption and negative alcohol-related consequences. International journal of general medicine 2012;5:953-60.
11. Verster JC, Aufricht C, Alford C. Energy drinks mixed with alcohol: misconceptions, myths, and facts. International journal of general medicine 2012;5:187-98.
12. de Haan L, de Haan HA, Olivier B, Verster JC. Alcohol mixed with energy drinks: methodology and design of the Utrecht Student Survey. International journal of general medicine 2012;5:889-98.
13. Benson S, de Haan HA, de Haan L, van der Palen J, al. e. Cognitive and mood effects of alcohol and ernergy drinks alone and in combination. Drug and alcohol review 2012;31:47.
14. de Haan L, de Haan HA, van der Palen J, al. e. Mixing alcohol with energy drinks decreases alcohol consumption. Drug and alcohol review 2012;31:46.
15. Alford C, Hamilton-Morris J, Verster J. Do energy drinks mask subjective awareness of alcohol intoxication. Drug and alcohol review 2012;31:46.
16. Alford C, Hamilton-Morris J, Verster JC. The effects of energy drink in combination with alcohol on performance and subjective awareness. Psychopharmacology 2012;222(3):519-32.
17. Verster JC, Alford C. Unjustified Concerns about Energy Drinks. Current drug abuse reviews 2011;4(1):1-3.
Competing interests: No competing interests
The author of "Energy drinks and alcohol: Research supported by industry may be downplaying the harms" (1) is to be commended for their recognition of the primary gap in the literature regarding the consumption trend of mixing alcohol with energy drinks (AmED). The lack of research administering higher doses or adopting more complex dosing procotols to assess the dose-dependent interactive effects of alcohol and energy drinks (EDs) restricts inferences regarding the intoxication experience of consumers in the night-time economy (2). We cannot conclusively make any statements regarding the pharmacological interactive effects of these two constituents until this situation is rectified.
However, we would further argue that such research should not be restricted to only assessing the pharmacological effects of co-ingestion. Psychological factors, such as consumer expectancies of AmED effects, could contribute to the intoxication experience. Research has demonstrated that AmED consumers report specific expectations for their intoxication experience. A study of US college athletes showed that consumers reported anticipating increased alertness and aggression and expected to sober up faster after AmED compared to when they consume alcohol without EDs (3). However, to date there has been no research assessing the contribution of AmED versus alcohol expectancies to potential differences in perceived intoxication. There is preliminary research in this area looking at the interactive effect of alcohol with caffeine, the primary psychoactive ED ingredient, on subjective intoxication. A recently published study (4) has shown that co-administration of caffeine (mean dose=220mg) with alcohol reduced subjective ratings of intoxication relative to when alcohol was ingested without caffeine. This effect occurred independent of whether participants were expecting to receive caffeine. However, the authors note that this study may have limited generalizability to AmED consumption. The study assessed a caffeine dose equivalent to a higher ED volume (approximately 2.75 standard 250mL EDs) than that administered in past AmED research (typically 1 standard 250mL ED). However, research involving administration of the whole beverage is required in order to account for the role of: (i) other ED ingredients which may contribute to performance outcomes (e.g., 5), and (ii) ED-specific expectancies (versus general caffeine expectancies).
The need for this research is heightened when we examine the typical characteristics of AmED consumers relative to alcohol consumers, with the former generally displaying higher risk-taking propensity (6). This predisposition towards risky behaviour coupled with specific expectancies regarding the AmED intoxication experience could create a situation of heightened risk for both the consumer and others in the drinking environment. Determining the relative role of pharmacological and psychological factors in the AmED intoxication experience is important from a harm minimisation perspective: at present we do not have a solid evidence-base upon which to base our response to this consumption practice. Undertaking such research could inform policy response regarding ED marketing and sales with alcohol, and indicate the potential efficacy of public health campaigns targeted at ensuring consumers are accurately informed regarding the AmED intoxication experience.
Author email: Amy.Peacock@utas.edu.au
1. Miller, P. (2013). Energy drinks and alcohol: Research supported by industry may be downplaying harms. British Medical Journal, 2013, 347, f5345
2. Peacock, A., Bruno, R., Martin, F. H., & Carr, A. (2013). The impact of alcohol and energy drink consumption on intoxication and risk-taking behavior. Alcoholism: Clinical and Experimental Research, 37, 1234-1242.
3. Woolsey, C., Waigandt, A., & Beck, N. C. (2010). Athletes and energy drinks: Reporting risk-taking and consequences from the combined use of alcohol and energy drinks. Journal of Applied Sport Psychology, 22, 65-71.
4. Heinz, A. J., de Wit, H., Lilje, T. C., & Kassel, J. D. (2013). The combined effects of alcohol, caffeine, and expectancies on subjective experience, impulsivity, and risk-taking. Experimental and Clinical Psychopharmacology, 21, 22-234.
5. Peacock, A., Martin, F. H., & Carr, A. (2013). Energy drink ingredients. Contribution of caffeine and taurine to performance outcomes. Appetite, 64, 1-4.
6. Brache, K., & Stockwell, T. (2011). Drinking patterns and risk behaviors associated with combined alcohol and energy drink consumption in college drinkers. Addictive Behaviors, 36, 1133-1140.
Competing interests: Peacock and Bruno have received placebo samples from Red Bull GmbH for an experimental study in 2011-2012. This organisation had no role in study design, data analysis, or manuscript preparation, or in subsequent experimental research.
It has long puzzled me why there is a strong demand among some populations for combinations of sedative and stimulant drugs. When researching substance use among both young offenders and adults in prison, I observed ‘The combination of excitable aggression (with cocaine) along with disinhibition and remorselessness (with alcohol) seems to cause an escalation of offending, in the context of committing antisocial acts’ (p160). The aggressive behaviour of some Australians who combine high dose alcohol with stimulant ‘energy drinks’ seems similar  (and cannot be attributed to the alcohol-specific metabolism of cocaine into cocaethylene).
In the UK the Youth Taskforce coined the term ‘the Friday/Saturday Night problem’ for the alcohol-related injuries that stream into emergency departments and police cells and turn already hectic departments into weekly horror shows. Reducing pressures on emergency services (especially clinicians on the A&E frontline) is a national priority. One of the known phenomena in addictive behaviour is that one, habitual behaviour (like binge drinking) readily entrains other behaviours (think of a casino with drinks and gambling on offer together). In the UK in 2013 we need to know whether energy drinks or similar (soi-disant) "harmless" stimulants used in combination with alcohol are escalating the pressure on A&E, for example by changing minor arguments into major incidents.
1. Caan W. Adolescent drug use and health: problems other than dependence. In: Drink, Drugs and Dependence. London: Routledge, 2002.
2. Miller P. Energy drinks and alcohol: research supported by industry may be downplaying harms. BMJ 2013;347:f5345.
Competing interests: Advisor to the All Party Parliamentary Group on alcohol misuse