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Alcohol Mixed with Energy Drinks

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Abstract
This study examined the effects consumption of alcohol mixed with energy drinks (AMED), and gender had on overall alcohol consumption and negative alcohol related consequences. One hundred and seventy two Psychology students from Swinburne Online, (male n =92), completed a two part survey relating to AMED and alcohol consumption, and negative alcohol related consequences. Based on previous research, it was hypothesised that overall alcohol consumption and negative alcohol related consequences would not be increased by the consumption of AMED. It was also predicted that males were more likely than females to consume excess amounts of alcohol and experience more negative alcohol related consequences independent of drink type. Statistical tests supported the hypotheses that related to AMED, and partially supported the hypothesis that these variables were also influenced by gender. Based on survey results and a review of the literature it is advised that, independent of drink type or gender, consumption of alcohol should be limited to a maximum of four standard drinks per session, as advised by The Australian National Health and Medical Research Council safety guidelines.

An Investigation into the Effects of Mixing Alcohol with Energy Drinks
Over the last decade, there has been an increasing trend in the use of alcohol mixed with energy drinks (AmED), and previous research has raised concern regarding this practice and the possible negative outcomes on health and behaviour (Peacock, Bruno, & Martin, 2012a). Caffeine is the main active ingredient in energy drinks and its stimulant effect is thought to counteract the sedative effects of alcohol, which may lead to an increase in alcohol consumption and negative alcohol related consequences (de Haan, de Haan, van der Palen, Olivier, & Verster 2012). In a web based survey, O’Brien, McCoy, Rhodes, Wagoner and Woflson (2008) examined the relationship between energy drink use, high-risk drinking behaviour and alcohol related consequences among college students, and concluded that students who consumed AMED were at an increased risk for alcohol related consequences compared to students who consumed only alcohol. A limitation of this study as suggested by Verster, Aufricht and Alford (2012), is that the authors failed to provide scientific evidence that supported a cause and effect relationship between AMED and high risk behaviours. It was also recommended that to properly define the effects of energy drinks, clinical studies should use a within-subject design that included occasions where participants consumed AMED and occasions where participants consumed alcohol alone (Verster et al., 2012).
One such study was conducted among Dutch university students by de Haan et al. (2012). In this study, data was analysed and compared between occasions where participants had consumed AMED and alcohol only. Contrary to the previous between-subject study conducted by O’Brien et al. (2008), results from this study concluded that the consumption of AMED decreased the overall consumption of alcohol and the likelihood of negative alcohol-related consequences. One factor that may have biased this study is that the survey was supported by a grant from Red Bull. Peacock, Bruno and Martin (2012b) explored independent and combined energy drink and alcohol patterns, and behavioural risk-taking consequences among Australian adults, and concluded that the odds of engaging in risk behaviours were significantly lower during AMED sessions compared to alcohol only sessions. Contrary to the previous research, participants in this study were recruited from beyond a university population and had a mean age of 23.1 years (sd=3.8), which may have contributed to the differences seen in results when compared to previous studies. Furthermore, this sample was made up primarily of females (61%).
Significant differences between genders have been reported in other studies related to excessive alcohol consumption and negative alcohol related consequences. Velazques, Poulos, Latimer and Pasch (2011), explored associations between energy drink consumption and alcohol use among American college students, and concluded that the consumption of AMED and episodes of heavy drinking were significantly higher among males than females, a pattern that had been previously reported by O’Brien et al. (2008). A small response rate of 20.3%, did limit the gerneralizability of this study against the larger college population. Berger, Fendrich and Fuhrmann (2013) also supported differences between genders in relation to alcohol consumption and negative alcohol related consequences in a study that examined the associations between AMED use, hazardous drinking and alcohol related consequences among college students. In this study of undergraduate students, results showed that when consuming excessive amounts of alcohol, males were significantly more likely to have been hurt or injured, and to have driven a car while under the influence, whereas females were significantly more likely to have had unwanted sexual contact. As well as exploring negative alcohol related consequences when consuming AMED, and gender differences, previous studies have examined the effects AMED has on overall alcohol consumption. The Australian National Health and Medical Research Council safety guidelines, as cited in Peacock, Bruno and Martin (2012a), recommend maximum consumption of four standard drinks in a single session. Thombs, Rossheim, Barnett, Weiler, Moorehouse and Coleman (2011) conducted a field study in a US college bar district and results showed that there was no difference in intoxication levels between participants who drank cola-caffeinated alcoholic beverages and those who consumed AMED. This study did not reveal how many cola-caffeinated beverages were consumed compared to AMED, although BAC results were similar for both groups and showed alcohol content to be in excess of recommended guidelines. Peacock et al. (2012a) also discussed the correlation between AMED and alcohol consumption and found that although participants consumed more alcohol and energy drinks than the recommended intake, AMED sessions occurred relatively infrequently compared to alcohol only sessions.
Results from existing studies into the use of energy drinks and overall alcohol consumption, effects of drink type on involvement in negative alcohol related consequences and the influence that gender differences have on these variables, have differed among researchers. The aim of this study was to further investigate these relationships using a within-subject design. It was hypothesised that: * The consumption of AMED does not increase the risk of negative alcohol related consequences when compared to the consumption of alcohol only * Males are more likely than females to consume excess amounts of alcohol and experience more negative alcohol related consequences regardless of drink type * Overall alcohol consumption is not increased by the consumption of AMED
Method
Participants
Participants for this study included 172 psychology students enrolled with Swinburne Online, male (n =92), female (n =80), with a mean age of 20.83 years (sd =3.89), who were randomly selected from a larger group that had participated in a nationally run survey in the previous teaching period. Although more females than males are enrolled in psychology at Swinburne Online, marginally more males (53.5%), than females (46.5%), participated in the study. Involvement in the study was voluntary and no reward was offered to students as an enticement to participate.
Design
Participant results were split into groups dependent on risk-taking personality scores and gender. Males and females who scored between 4 and 10 when answering the risk-taking questionnaire were placed into the low risk-taking personality group, and those who scored between 11 and 17 were placed in the high risk-taking personality group. Groups were then split according to gender. A within-subject analysis was conducted to measure the consumption of alcohol and AMED for males and females in both the low risk-taking personality group and high risk-taking personality group. Negative alcohol related consequences were measured using the Brief Young Alcohol Consequences Scale (BYAACQ), and scores for both males and females in the low risk-taking personality group and high-risk taking personality group were also analysed using a within-subject study.
Materials
The survey that was used consisted of two parts. In part 1, demographic data were collected. Consumption questions were asked for alcohol alone, energy drinks alone, alcohol mixed with energy drinks, and alcohol mixed with another preferred mixer. In addition, using a modified version of the BYAACQ, negative drinking behaviours were scored for when drinking alcohol alone, when mixing alcohol with energy drink and when mixing alcohol with another preferred beverage. Finally, level of risk taking behaviours was determined with the RT-18. In part 2, personality aspects were assessed. Several self-report instruments including the Depression Anxiety Stress Scale (DASS-21), the Toronto Alexithymia Scale (TAS-20) and the Person’s Relating to Others Questionaire (PROQ-2a) were given. The purpose of part 2 was to investigate the psychological health of the population and relate this to total alcohol consumption. Brief Young Alcohol Consequences Scale (BYAACQ; Kahler, Stong & Reid, 2005). This scale examines alcohol-related negative consequences, and consists of 24 possible consequences of alcohol that can be answered with ‘yes’ or ‘no’ depending on whether the statement was applicable to the participants during the previous year. The BYAACQ has been found to have high reliability and validity (Cronbach’s Alpha of .86 and scores correlated significantly with other similar surveys; Verster, Van Herwjinen, & Oliver, 2009). The authors of the current study added an additional two items. Each item answered with a ‘yes’ scores one point giving a score range of 0 to 26, with higher scores representing involvement in a greater number of negative consequences.
Risk-Taking Questionnaire 18 Items (RT-18; Verster, Kulpers, & Kuerten, 2009). The RT-18 was developed from items of subscales on Impulsiveness and Venturesomeness and the IVE questionnaire (Eysenck, Pearson, & Easting, 1985; Lijfijt, Caci, & Kenemans, 1993). Novelty Seeking from the Temperment and Character Inventory (TCI; Cloniger, Scracik, & Przybeck, 1993; Duijsens, Spinhoven, & Goekoop, 2000), and Impulsive Sensation Seeking (ImpSS) from the Zuckerman Kuhlman Personality Questionnaire (Zuckerman, Kuhlman, & Hornquist, 1991). Questions of the RT-18 can be answered with either ‘yes’ and ‘no’ or ‘correct’ and ‘incorrect’. Scores have a possible range from 0 to 18 with greater scores representing a higher risk-taking propensity.
Procedure
Participants completed the survey in their own time. Consent information was provided at the beginning of the survey and consent was implied by submission of the survey. All participants were free to exit the survey at any time. The survey used a within subjects design (participants completed the questions for occasions when mixing alcohol with energy drink and occasions when alcohol was mixed with another beverage).
The data was screened for any participants who did not meet the criteria, i.e., surveys completed within seven minutes, surveys completed between 2 am and 7 am, and surveys submitted from the same computer (although conservative and risks losing valid responses from people sharing a computer, it is the best way to ensure valid data). Finally, if any participant answered ‘no’ to the final question, whether they have honestly and correctly answered all of the questions, they were excluded.
Results
To establish whether mixing energy drinks and alcohol has an impact on negative alcohol related consequences and total alcohol consumption, and whether these behaviours are more prevalent among specific genders, within-subject comparisons were performed for both males and females in the low and high risk-taking personality groups. The number of drinks consumed and negative alcohol related consequences were dependent on gender and the types of drinks consumed (AMED or alcohol only). Negative alcohol related consequences were measured using the BYAACQ scale. The results of these comparisons are summarised in Table 1 below.
Table 1

Between-group comparisons for low and high risk-taking personality groups who consumed alcohol mixed with energy drinks (AMED) and those who drank alcohol only Gender | Consumption | BYAACQ Score | | AMED | Alcohol | AMED | Alcohol | Low Risk-Taking
Personality Group |
M |
SD |
M |
SD |
M |
SD |
M |
SD | Femalea | 4.21 | (2.77) | 5.88 | (4.30) | 4.46 | (4.24) | 7.63 | (4.31) | Maleb | 4.71 | (4.33) | 6.71 | (4.20) | 6.50 | (6.36) | 7.63 | (4.55) | High Risk-Taking Personality Group |
M |
SD |
M |
SD |
M |
SD |
M |
SD | Femalec | 4.74 | (3.73) | 5.95 | (2.72) | 6.74 | (4.81) | 11.05 | (4.81) | Maled | 6.58 | (3.88) | 7.33 | (4.07) | 6.83 | (5.51) | 10.42 | (3.52) |
Note. Consumption – Number of standard drinks per session.
BYAACQ = Brief Young Alcohol Consequences Scale
Low Risk-Taking Personality (RT score 4-10), High Risk-Taking Personality (RT score 11-17) an =32. bn =54. cn =48. dn =38.
The within-subject analyses revealed that in the low and high risk-taking personality groups, the BYAACQ scores for both males and females were lower when consuming AMED compared to alcohol only. Males and females in both risk-taking personality groups also consumed less alcohol when drinking AMED than when consuming alcohol alone. Males in the low and high risk-taking personality groups consumed more alcohol than females when consuming both AMED and alcohol only. In the low risk-taking personality group, BYAACQ scores were lower for females,  4.46 (sd =4.24) than males, 6.50 (sd =6.36) when consuming AMED. Scores were the same for both females,  7.63 (sd =4.31) and males,  7.63 (sd =4.55) when consuming alcohol only. In the high risk-taking personality group BYAACQ scores were lower for females,  6.74 (sd =4.81) than males,  6.83 (sd =5.51) when consuming AMED. Scores were higher for females,  11.05 (sd =4.81) than males,  10.42 (sd =3.52) when consuming alcohol only.
Discussion
The aim of this study was to determine what effect the consumption of AMED had on overall alcohol consumption, whether drink type increased the risk of negative alcohol related consequences and to examine what impact the difference in genders had on these variables. The consumption of AMED did not increase the risk of negative alcohol related consequences compared to drinking alcohol only, which supported the first hypothesis and was consistent with previous studies by de Haan et al. (2012), and Peacock et al. (2012b). The second hypothesis that males were more likely to consume excessive amounts of alcohol and experience more negative alcohol related consequences than females was partially supported, with males in both risk-taking personality groups having consumed more alcohol when consuming both AMED and alcohol only. In both the high and low risk-taking personality groups, males reported experiencing more negative alcohol related consequences than females when consuming AMED.
Contrary to what was predicted, females in the high risk-taking personality group reported experiencing more negative alcohol related consequences than males, when consuming alcohol only. Both males and females in the low risk-taking personality group reported experiencing similar negative alcohol related consequences when consuming alcohol only. A breakdown on negative alcohol related consequences was not examined in this study, so results may have been consistent with Berger et al. (2013), who reported males experiencing more of certain negative types of alcohol related consequences than females and vice versa. The third hypothesis stated that overall alcohol consumption would not be increased by the consumption of AMED. This hypothesis was also supported, with males and females in both risk-taking personality groups consuming less alcohol when drinking AMED than when consuming alcohol only, and agreed with results reported by both Thombs et al. (2011), and Peacock et al. (2012a).
Using a within-subject design approach to this study as suggested by Verster et al. (2012), showed a clearer picture of the effects energy drinks have on negative alcohol related consequences and overall alcohol consumption when compared to a between-subject design, as used in some previous studies such as the one conducted by O’Brien et al. (2008). Contrary to findings published by O’Brien et al. (2008), the consumption of AMED resulted in significantly less alcohol related consequences for both males and females, particularly in the high risk-taking personality group, and less overall alcohol consumption.
The results of this study do not suggest that university students do not consume alcohol in excess of the recommended limit of four standard drinks in a single session when consuming AMED. Nor does it suggest that AMED users don’t experience negative alcohol related consequences, although the consumption of alcohol appears to be the main contributing factor. It is recommended that future studies explore more comprehensively the overall alcohol consumption of university students, independent of mixers, and provide a clearer picture of the negative alcohol related consequences reported by both males and females. There were some limitations to this study. The data was from a subset of a larger study and may not have been representative of the broader Swinburne Online Psychology student population. Although more females than males are enrolled in Psychology at Swinburne Online, more males than females participated in the survey, however the difference was only marginal, male (n =92), female (n=80). Another limitation of this study was that the data was self-reported and thus subject to potential bias.
Co-ingestion of energy drinks with alcohol appears to reduce overall alcohol consumption and negative alcohol related consequences. Males are more likely than females to consume excessive amounts of alcohol independent of drink type. Both males and females experience negative alcohol related consequences when consuming AMED and alcohol only, although it is unclear from this study what types of negative consequences each gender experience.

References
Berger, L., Fendrich, M. & Fuhrmann, D. (2013). Alcohol mixed with energy drinks: Are there associated negative consequences beyond hazardous drinking in college students? Addictive Behaviours, 38, 2428-2432. Retrieved from http://dx/doi.otg/10.1016/j.addbeh2013.04.003. de Haan, L., de Haan, H.A., van der Palen, J., Olivier, B. & Verster, J.C. (2012). Effects of consuming alcohol mixed with energy drinks versus consuming alcohol only on overall alcohol consumption and negative alcohol-related consequences. International Journal of General Medicine, 5, 953-960. Retrieved from http://dx.doi.org/10.2147/ijGM.S38020.
O’Brien, M.C., McCoy, T.P., Rhodes, S.D., Wagoner, A. & Wolfson, M. (2008). Caffeinated Cocktails: Energy Drink Consumption, High-risk Drinking, and Alcohol-related Consequences among College Students. Academic Emergency Medicine, 15(5), 453-460. doi:10.1111/j.1553-2712.2008.00085.x
Peacock, A., Bruno, R. & Martin, F.H. (2012a). Patterns of Use and Motivation for Consuming Alcohol Mixed With Energy Drinks. Psychology of Addictive Behaviours, 27(1),
202-206. doi:10.1037/a0029985
Peacock, A. Bruno, R. & Martin, F.H. (2012b). The Subjective Physiological, Psychological, and Behavioural Risk-Taking Consequences of Alcohol and Energy Drink Co-Ingestion. Alcoholism: Clinical and Experimental Research, 36(11), 2008-2015. doi: 10.111/j.1530-0277.2012.01820.x
Thombs, D., Rossheim, M., Barnett, T.E., Weiler, R.M., Moorhouse, M.D. & Coleman, B.N. (2011). Is there a misplaced focus on AMED? Associations between caffeine mixers and bar patron intoxication. Drug and Alcohol Dependence, 116, 31-36. doi:10.1016/j.drugalcdep.2010.11.014
Velazques, C.E., Poulos, N.S., Latimer, L.A. & Pasch, K.E. (2012). Associations between energy drink consumption and alcohol use behaviours among college students. Drug and Alcohol Dependence, 123, 167-172. doi:10.1016/j.drugalcdep.2011.11.006
Verster, J.C., Aufricht, C. & Alford,C. (2012). Energy drinks mixed with alcohol: Misconceptions, myths, and facts. International Journal of Medicine, 5, 187-198. Retrieved from http://www.dovepress.com.

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