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EDITORIAL
doi:10.1111/add.12594
Caffeine addiction? Caffeine for youth? Time to act! While data accumulate and discussion evolves on the clinical importance of caffeine addiction and its classification, the growing practices of (i) adding increasing amounts of caffeine to drinks and other consumables, (ii) promoting these as performance enhancers and (iii) targeting youth as the consumer raise concerns that require immediate action. To the average Joe, questioning the existence of caffeine addiction probably seems absurd. The web abounds with quotes and exposés about the addictive nature of caffeine using catchy slogans about coffee that borrow from other substance addiction phraseology: ‘My blood type is coffee’; ‘Coffee, if you’re not shaking you need another cup’; ‘Espresso—just our little way of free-basing coffee’. Academics and clinicians, however, have not yet reached consensus about the potential clinical importance of caffeine addiction (or ‘use disorder’*) [1]. The DSM-5 designated caffeine withdrawal as a formal disorder, an important step towards recognizing the potential to develop clinically significant problems related to caffeine use [2]. Moreover, caffeine use disorder was included in Section III (conditions for further study), acknowledging the merit of the condition while conveying the need for further research before an official designation. Of note, the World Health Organization (WHO) has long included caffeine on its list of psychostimulants that produce withdrawal or dependence disorders in the ICD-10. These DSM-5 decisions triggered considerable reaction, with the media poking fun at coffee addiction being a ‘mental disorder’ and some professionals voicing worry about trivializing other addictive and psychiatric disorders. We refer the reader elsewhere for a careful consideration of the evidence supporting the classification of a caffeine use disorder [3]. In this editorial, we argue that the robust psychostimulant properties of caffeine, its potential for addiction and excessive use and the increased presence and marketing of caffeinated products call for greater attention to the impact that regular caffeine use may have on the physical and mental health of children and adolescents. In the United States, nearly 75% of children under the age of 18 consume caffeine on any given day [4,5]. Data on the prevalence of caffeine use among children internationally are not readily available, but global concerns appear ubiquitous as regulatory actions and controversy abound world-wide [6,7]. Soft drinks have traditionally been the largest source of caffeine among youth, yet the contribution from coffee and tea has more than doubled
since 1999, due perhaps to the current craze of heavily sugared coffees and teas available at speciality coffee shops and fast-food restaurants. These drinks appeal to young palates by turning coffee, a bitter acquired taste, into a sweet treat with chocolate, caramel and whipped cream. Energy drinks are also becoming increasingly popular among adolescents [5,8–10]. These highly caffeinated beverages (50–357 mg) contain additional ingredients (e.g. guarana, ginseng, B-vitamins and frequently sugar), and are promoted to improve mood (e.g. ‘gives you wings’) and cognitive and motor performance (e.g. ‘unleash the beast’). Energy ‘shots’ (50 ml), and ‘drops’ (concentrated liquid additive) are also marketed as a method to more efficiently administer caffeine. While energy drinks currently constitute a small portion of the total caffeine intake among youth, use has been linked to nausea, anxiety, racing heart, seizures, heart failure and increased emergency room visits [6,11]. The marketing practices of energy drink manufacturers have come under fire; including using young athletes and superstars in advertisements, edgy and attention-grabbing packaging, sponsorship of events popular with adolescents and advertising in youth venues (e.g. social media, MTV2) [5,12]. Caffeine use among youth raises multiple concerns. First, regular use can result in symptoms of ‘dependence’; daily users as young as 13 experience withdrawal symptoms [13,14]. Secondly, children who consume moderate amounts of caffeine for an adult (100–400 mg/day) can experience anxiety/nervousness, hyperactive behavior and disrupted sleep [13,14], which could adversely impact learning and developmental processes. Thirdly, small to moderate amounts of caffeine have positive, immediate effects on mood, mental alertness and motor performance [14], effects that have a more potent impact on repeated use than negative, delayed consequences of chronic use (the behavioral recipe for development of addictive behavior). Fourthly, the effects of caffeine may act synergistically with other substances, reinforcing the development of unhealthy behaviors [14,15]. For example, caffeine in sugary drinks can reinforce poor dietary habits and contribute to obesity, caffeine’s neurobiological effects may prime the rewarding effects of nicotine and caffeine combined with alcohol can lessen the subjective effects of impairment and increase risk for binge drinking. Indeed, energy drink use has been associated with alcohol and other substance misuse [16,17]. Finally, as children learn to use caffeine to modify their mood or performance [18], it is unknown how such intentional behavior at a young age generalizes to use of other substances.
*In the DSM-5, the diagnosis, ‘use disorder’, has replaced DSM-IV diagnoses of ‘abuse’ and ‘dependence’ in the Substance Use Disorders section of the manual. © 2014 Society for the Study of Addiction
Addiction, 109, 1771–1772
1772
Editorial
As we wait for more data relevant to the classification of caffeine use disorder, it seems clear that increased attention should be directed at the potential consequences of caffeine use at increasingly younger ages. With the growing popularity of sweet beverages containing more caffeine than soda, and the marketing of caffeinated beverages and additives as performance enhancers, caffeine intake from non-traditional sources will probably continue to escalate. The US market for energy drinks is predicted to reach more than $21 billion by 2017 [12], yet calls to limit the availability of energy drinks to children have been critized as scaremongering [19]. The data and associated concerns about caffeine use among youth clearly indicates urgency for action in the research and regulatory communities. The line blurs between the addictive potential of caffeine, its capacity for harm and the social acceptance of caffeine as a harmless and perhaps beneficial substance. Here, we did not even broach the growing practice of adding caffeine to an assortment of other consumables under the pretext of increased energy and performance, e.g. oatmeal, sunflower seeds, peanuts, sport jellybeans, gum, mints or ‘active metabolism’ vitamins. Marketing tactics for caffeinated products targeting youth appear as egregious as previously admonished practices of the tobacco and alcohol industries. As researchers we should move more quickly to understand more clearly the impact of caffeine products on youth health and behavior. In the meantime, initiation of actions (e.g. mandatory labeling, retail and marketing restrictions, educational campaigns) [5] to curtail and counter marketing promotions that promise our youth a better life through caffeine would appear the responsible thing to do. We should not worry—no one is going to take away our Joe. Declaration of interests None. Keywords Addiction, caffeine, children, energy drinks, marketing, policy. ALAN J. BUDNEY & JENNIFER A. EMOND
Geisel School of Medicine at Dartmouth, Lebanon, NH, USA. E-mail: [email protected] References 1. Budney A. J., Brown P. C., Griffiths R. R., Hughes J. R., Juliano L. M. Caffeine withdrawal and dependence: a convenience survey among addiction professionals. J Caffeine Res 2013; 3: 67–71. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edn. Arlington VA: American Psychiatric Association; 2013.
© 2014 Society for the Study of Addiction
3. Meredith S. E., Juliano L. M., Hughes J. R., Griffiths R. R. Caffeine use disorder: a comprehensive review and research agenda. J Caffeine Res 2013; 3: 114–30. 4. Branum A. M., Rossen L. M., Schoendorf K. C. Trends in caffeine intake among US children and adolescents. Pediatrics 2014; 133: 386–93. 5. Pomeranz J. L., Munsell C. R., Harris J. L. Energy drinks: an emerging public health hazard for youth. J Public Health Policy 2013; 34: 254–71. 6. Seifert S. M., Schaechter J. L., Hershorin E. R., Lipshultz S. E. Health effects of energy drinks on children, adolescents, and young adults. Pediatrics 2011; 127: 511–28. 7. Lachenmeier D. W., Wegert W., Kuballa T., Schneider R., Ruge W., Reush H. et al. Caffeine intake from beverages in German children, adolescents, and adults. J Caffeine Res 2013; 3: 47–55. 8. Blankson K. L., Thompson A. M., Ahrendt D. M., Patrick V. Energy drinks: what teenagers (and their doctors) should know. Pediatr Rev 2013; 34: 55–62. 9. Terry-McElrath Y. M., O’Malley P. M., Johnston L. D. Energy drinks, soft drinks, and substance use among United States secondary school students. J Addict Med 2014; 8: 6–13. 10. Reissig C. J., Strain E. C., Griffiths R. R. Caffeinated energy drinks—a growing problem. Drug Alcohol Depend 2009; 99: 1–10. 11. Substance Abuse and Mental Health Services Administration. The DAWN report: emergency department visits involving energy drinks annual medical examiner and emergency data. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality; 2011. 12. US Senate Committee on Commerce Science and Transportation. Energy drinks: exploring concerns about marketing to youth. What’s all the buzz about? A survey of popular energy drinks finds inconsistent labeling, questionable ingredients and targeted marketing to adolescents. 2013. Press Release. Available at: http://www.commerce.senate .gov/public/index.cfm?p=Hearings&ContentRecord_id =8d4fc1e4-18a4-40e0-8ae5-aab438ecba22 (Archived at http://www.webcitation.org/6PZCghGtQ on 14 May 2014). 13. Bernstein G. A., Carroll M. E., Thuras P. D., Cosgrove K. P., Roth M. E. Caffeine dependence in teenagers. Drug Alcohol Depend 2002; 66: 1–6. 14. Temple J. L. Caffeine use in children: what we know, what we have left to learn, and why we should worry. Neurosci Biobehav Rev 2009; 33: 793–806. 15. Malik V. S., Pan A., Willett W. C., Hu F. B. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr 2013; 98: 1084–102. 16. Arria A. M., Caldeira K. M., Kasperski S. J., O’Grady K. E., Vincent K. B., Griffiths R. R. et al. Increased alcohol consumption, nonmedical prescription drug use, and illicit drug use are associated with energy drink consumption among college students. J Addict Med 2010; 4: 74–80. 17. Patrick M. E., Maggs J. L. Energy drinks and alcohol: links to alcohol behaviors and consequences across 56 days. J Adolesc Health 2014; 54: 454–9. 18. Hughes J. R., Hale K. L. Behavioral effects of caffeine and other methylxanthines on children. Exp Clin Psychopharmacol 1998; 6: 87–95. 19. Roehr B. Energy drinks: cause for concern or scaremongering? BMJ 2013; 347: f6343.
Addiction, 109, 1771–1772
EDITORIAL
doi:10.1111/add.12594
Caffeine addiction? Caffeine for youth? Time to act! While data accumulate and discussion evolves on the clinical importance of caffeine addiction and its classification, the growing practices of (i) adding increasing amounts of caffeine to drinks and other consumables, (ii) promoting these as performance enhancers and (iii) targeting youth as the consumer raise concerns that require immediate action. To the average Joe, questioning the existence of caffeine addiction probably seems absurd. The web abounds with quotes and exposés about the addictive nature of caffeine using catchy slogans about coffee that borrow from other substance addiction phraseology: ‘My blood type is coffee’; ‘Coffee, if you’re not shaking you need another cup’; ‘Espresso—just our little way of free-basing coffee’. Academics and clinicians, however, have not yet reached consensus about the potential clinical importance of caffeine addiction (or ‘use disorder’*) [1]. The DSM-5 designated caffeine withdrawal as a formal disorder, an important step towards recognizing the potential to develop clinically significant problems related to caffeine use [2]. Moreover, caffeine use disorder was included in Section III (conditions for further study), acknowledging the merit of the condition while conveying the need for further research before an official designation. Of note, the World Health Organization (WHO) has long included caffeine on its list of psychostimulants that produce withdrawal or dependence disorders in the ICD-10. These DSM-5 decisions triggered considerable reaction, with the media poking fun at coffee addiction being a ‘mental disorder’ and some professionals voicing worry about trivializing other addictive and psychiatric disorders. We refer the reader elsewhere for a careful consideration of the evidence supporting the classification of a caffeine use disorder [3]. In this editorial, we argue that the robust psychostimulant properties of caffeine, its potential for addiction and excessive use and the increased presence and marketing of caffeinated products call for greater attention to the impact that regular caffeine use may have on the physical and mental health of children and adolescents. In the United States, nearly 75% of children under the age of 18 consume caffeine on any given day [4,5]. Data on the prevalence of caffeine use among children internationally are not readily available, but global concerns appear ubiquitous as regulatory actions and controversy abound world-wide [6,7]. Soft drinks have traditionally been the largest source of caffeine among youth, yet the contribution from coffee and tea has more than doubled
since 1999, due perhaps to the current craze of heavily sugared coffees and teas available at speciality coffee shops and fast-food restaurants. These drinks appeal to young palates by turning coffee, a bitter acquired taste, into a sweet treat with chocolate, caramel and whipped cream. Energy drinks are also becoming increasingly popular among adolescents [5,8–10]. These highly caffeinated beverages (50–357 mg) contain additional ingredients (e.g. guarana, ginseng, B-vitamins and frequently sugar), and are promoted to improve mood (e.g. ‘gives you wings’) and cognitive and motor performance (e.g. ‘unleash the beast’). Energy ‘shots’ (50 ml), and ‘drops’ (concentrated liquid additive) are also marketed as a method to more efficiently administer caffeine. While energy drinks currently constitute a small portion of the total caffeine intake among youth, use has been linked to nausea, anxiety, racing heart, seizures, heart failure and increased emergency room visits [6,11]. The marketing practices of energy drink manufacturers have come under fire; including using young athletes and superstars in advertisements, edgy and attention-grabbing packaging, sponsorship of events popular with adolescents and advertising in youth venues (e.g. social media, MTV2) [5,12]. Caffeine use among youth raises multiple concerns. First, regular use can result in symptoms of ‘dependence’; daily users as young as 13 experience withdrawal symptoms [13,14]. Secondly, children who consume moderate amounts of caffeine for an adult (100–400 mg/day) can experience anxiety/nervousness, hyperactive behavior and disrupted sleep [13,14], which could adversely impact learning and developmental processes. Thirdly, small to moderate amounts of caffeine have positive, immediate effects on mood, mental alertness and motor performance [14], effects that have a more potent impact on repeated use than negative, delayed consequences of chronic use (the behavioral recipe for development of addictive behavior). Fourthly, the effects of caffeine may act synergistically with other substances, reinforcing the development of unhealthy behaviors [14,15]. For example, caffeine in sugary drinks can reinforce poor dietary habits and contribute to obesity, caffeine’s neurobiological effects may prime the rewarding effects of nicotine and caffeine combined with alcohol can lessen the subjective effects of impairment and increase risk for binge drinking. Indeed, energy drink use has been associated with alcohol and other substance misuse [16,17]. Finally, as children learn to use caffeine to modify their mood or performance [18], it is unknown how such intentional behavior at a young age generalizes to use of other substances.
*In the DSM-5, the diagnosis, ‘use disorder’, has replaced DSM-IV diagnoses of ‘abuse’ and ‘dependence’ in the Substance Use Disorders section of the manual. © 2014 Society for the Study of Addiction
Addiction, 109, 1771–1772
1772
Editorial
As we wait for more data relevant to the classification of caffeine use disorder, it seems clear that increased attention should be directed at the potential consequences of caffeine use at increasingly younger ages. With the growing popularity of sweet beverages containing more caffeine than soda, and the marketing of caffeinated beverages and additives as performance enhancers, caffeine intake from non-traditional sources will probably continue to escalate. The US market for energy drinks is predicted to reach more than $21 billion by 2017 [12], yet calls to limit the availability of energy drinks to children have been critized as scaremongering [19]. The data and associated concerns about caffeine use among youth clearly indicates urgency for action in the research and regulatory communities. The line blurs between the addictive potential of caffeine, its capacity for harm and the social acceptance of caffeine as a harmless and perhaps beneficial substance. Here, we did not even broach the growing practice of adding caffeine to an assortment of other consumables under the pretext of increased energy and performance, e.g. oatmeal, sunflower seeds, peanuts, sport jellybeans, gum, mints or ‘active metabolism’ vitamins. Marketing tactics for caffeinated products targeting youth appear as egregious as previously admonished practices of the tobacco and alcohol industries. As researchers we should move more quickly to understand more clearly the impact of caffeine products on youth health and behavior. In the meantime, initiation of actions (e.g. mandatory labeling, retail and marketing restrictions, educational campaigns) [5] to curtail and counter marketing promotions that promise our youth a better life through caffeine would appear the responsible thing to do. We should not worry—no one is going to take away our Joe. Declaration of interests None. Keywords Addiction, caffeine, children, energy drinks, marketing, policy. ALAN J. BUDNEY & JENNIFER A. EMOND
Geisel School of Medicine at Dartmouth, Lebanon, NH, USA. E-mail: [email protected] References 1. Budney A. J., Brown P. C., Griffiths R. R., Hughes J. R., Juliano L. M. Caffeine withdrawal and dependence: a convenience survey among addiction professionals. J Caffeine Res 2013; 3: 67–71. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edn. Arlington VA: American Psychiatric Association; 2013.
© 2014 Society for the Study of Addiction
3. Meredith S. E., Juliano L. M., Hughes J. R., Griffiths R. R. Caffeine use disorder: a comprehensive review and research agenda. J Caffeine Res 2013; 3: 114–30. 4. Branum A. M., Rossen L. M., Schoendorf K. C. Trends in caffeine intake among US children and adolescents. Pediatrics 2014; 133: 386–93. 5. Pomeranz J. L., Munsell C. R., Harris J. L. Energy drinks: an emerging public health hazard for youth. J Public Health Policy 2013; 34: 254–71. 6. Seifert S. M., Schaechter J. L., Hershorin E. R., Lipshultz S. E. Health effects of energy drinks on children, adolescents, and young adults. Pediatrics 2011; 127: 511–28. 7. Lachenmeier D. W., Wegert W., Kuballa T., Schneider R., Ruge W., Reush H. et al. Caffeine intake from beverages in German children, adolescents, and adults. J Caffeine Res 2013; 3: 47–55. 8. Blankson K. L., Thompson A. M., Ahrendt D. M., Patrick V. Energy drinks: what teenagers (and their doctors) should know. Pediatr Rev 2013; 34: 55–62. 9. Terry-McElrath Y. M., O’Malley P. M., Johnston L. D. Energy drinks, soft drinks, and substance use among United States secondary school students. J Addict Med 2014; 8: 6–13. 10. Reissig C. J., Strain E. C., Griffiths R. R. Caffeinated energy drinks—a growing problem. Drug Alcohol Depend 2009; 99: 1–10. 11. Substance Abuse and Mental Health Services Administration. The DAWN report: emergency department visits involving energy drinks annual medical examiner and emergency data. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality; 2011. 12. US Senate Committee on Commerce Science and Transportation. Energy drinks: exploring concerns about marketing to youth. What’s all the buzz about? A survey of popular energy drinks finds inconsistent labeling, questionable ingredients and targeted marketing to adolescents. 2013. Press Release. Available at: http://www.commerce.senate .gov/public/index.cfm?p=Hearings&ContentRecord_id =8d4fc1e4-18a4-40e0-8ae5-aab438ecba22 (Archived at http://www.webcitation.org/6PZCghGtQ on 14 May 2014). 13. Bernstein G. A., Carroll M. E., Thuras P. D., Cosgrove K. P., Roth M. E. Caffeine dependence in teenagers. Drug Alcohol Depend 2002; 66: 1–6. 14. Temple J. L. Caffeine use in children: what we know, what we have left to learn, and why we should worry. Neurosci Biobehav Rev 2009; 33: 793–806. 15. Malik V. S., Pan A., Willett W. C., Hu F. B. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr 2013; 98: 1084–102. 16. Arria A. M., Caldeira K. M., Kasperski S. J., O’Grady K. E., Vincent K. B., Griffiths R. R. et al. Increased alcohol consumption, nonmedical prescription drug use, and illicit drug use are associated with energy drink consumption among college students. J Addict Med 2010; 4: 74–80. 17. Patrick M. E., Maggs J. L. Energy drinks and alcohol: links to alcohol behaviors and consequences across 56 days. J Adolesc Health 2014; 54: 454–9. 18. Hughes J. R., Hale K. L. Behavioral effects of caffeine and other methylxanthines on children. Exp Clin Psychopharmacol 1998; 6: 87–95. 19. Roehr B. Energy drinks: cause for concern or scaremongering? BMJ 2013; 347: f6343.
Addiction, 109, 1771–1772
