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J Community Health. Author manuscript; available in PMC 2017 February 06. Published in final edited form as: J Community Health. 2016 October ; 41(5): 897–902. doi:10.1007/s10900-016-0167-9.

Energy Drink Use Among Ohio Appalachian Smokers Genevieve Davison1,3, Abigail Shoben1, Keryn E. Pasch2, and Elizabeth G. Klein1 1Ohio

State University College of Public Health, 1841 Neil Ave., Columbus, OH 43210, USA

2University 3400

of Texas at Austin, 2109 San Jacinto Blvd, Austin, TX 78712, USA

King Ave., Columbus, OH 43201, USA

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Abstract

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Caffeine-containing energy drinks have emerged as a public health concern due to their association with caffeine toxicity and alcohol use. Despite the fact that previous research has linked caffeine use in the form of coffee drinking to smoking, there is little research examining the association between energy drinks and smoking. The present study examines demographic and behavioral factors associated with energy drink use among a sample of rural Ohio Appalachian smokers. It was hypothesized that male gender, young age (21–30 years.) and alcohol use would be associated with energy drink use. A sample of adult smokers (n = 298) from Ohio Appalachian counties were interviewed regarding demographic and behavioral factors. Logistic regression analysis was used to assess the association between these factors and energy drink use. Seventy percent of Ohio Appalachian smokers studied had ever used an energy drink and 40 % had used an energy drink in the past month. Young age, male gender, and single marital status were associated with higher odds of ever having used an energy drink. Young age, and binge drinking were associated with higher odds of past 30-day use while abstinence from drinking was associated with lower odds of past 30-day use. Ohio Appalachian adult smokers had higher rates of energy drink use compared to previous estimates of ever or past month use found in other studies. The combined use of caffeine, nicotine, and alcohol warrants attention due to potential for health risk.

Keywords Energy drinks; Smokers; Rural; Ohio Appalachia; Caffeine; Nicotine; Alcohol

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Introduction As energy drinks continue to be popular in the United States (US), these beverages have emerged as a growing area of public health concern. In 2013, sales of the top 5 US energy drinks totaled almost $8 billion [1] and energy drink use is likely increasing. Between 1999–

Correspondence to: Genevieve Davison. Contributors Author Davison conducted literatures searches, data analysis and manuscript preparation. Author Klein assisted with study design and manuscript review. Author Shoben assisted with statistical analysis and manuscript review. Author Pasch assisted with manuscript review. Compliance with Ethical Standards Conflict of interest None of the co-authors have any conflicts of interest to declare.

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2000 and 2007–2008 the prevalence of sports/energy drink use in the U.S. increased for adolescents, young adults and adults (127–167, 119–229, and 116–147 kcal/day respectively) [2]. In 2012, caffeine-containing energy drinks outsold bottled water in the US for the first time ($6.9 billion vs. $6.7 billion) [3]. According to the National Institute of Health (NIH), energy drinks are beverages that contain moderate to high amounts of added caffeine ranging from 50 to 505 mg of caffeine per serving [4]. Energy drinks often contain additives such as taurine, guarana, B-vitamins, and ginseng [5, 6] some of which (e.g. guarana and ginseng) also contain caffeine.

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In general, consumers use energy drinks in order to increase energy, promote wakefulness and alertness, enhance mood and improve cognitive performance [7]. Increased energy drink use is a source of concern because high caffeine intake is associated with caffeine toxicity, a condition characterized by tachycardia, heart palpitations, anxiety, headache, and in extreme cases stroke, heart attack, seizure, or death [6, 8]. Energy drinks have been identified as an emerging trend in poisonings, and were added to tracking systems at national poison centers in 2010 [9].

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While there is an emerging body of literature examining the negative effects of combining energy drinks with alcohol [10–15] less research has examined the effects of combing energy drinks with nicotine or characterizing patterns of energy drink use among nicotine users. Descriptive research on caffeine and smoking shows that, in general, smokers ingest more caffeine in the form of coffee than the general public (86.4 % of smokers consume coffee compared to 77.2 % non-smokers) [16]. There is also evidence that caffeine and nicotine interact pharmacologically. For example, nicotine accelerates caffeine metabolism meaning regular nicotine users must ingest more caffeine than non-users to achieve the same effect [6, 16]. This interaction may be problematic as discontinuing nicotine use may lead to caffeine toxicity if individuals do not also reduce their caffeine intake [16, 17]. In addition, there is evidence of a relationship between coffee drinking, smoking and alcohol use. Carmody et al. [18] found that in a sample of healthy, middle class men and women, smokers and ex-smokers were more likely to drink larger amounts of coffee and alcohol compared to non-smokers. Similarly, a recent study of Danish young adults found that energy drink use was associated with both alcohol and cigarette use [19].

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In the United States, energy drink use has primarily been studied among college students [10, 11, 13–15, 20] and has consistently been found to be associated with male gender as well as alcohol, tobacco, and other drug use in these populations. One community-based survey of adults found that almost one-third of survey respondents had consumed an energy drink in their lifetime, with roughly 25 % reporting past year energy drink consumption, where the past year users were more likely to be male, young adults and non-black minorities [21]. In contrast, Arria et al. [15] found that 65 % of college students had consumed an energy drink in the past year. Given the possible negative health effects of energy drink use and the association between energy drink use and other drug use, it is important to investigate patterns of energy drink use outside of colleges, especially among populations that may be at risk for tobacco, alcohol, or other drug use.

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The present study investigated energy drink use in a non-student population and in particular, investigated factors associated with energy drink use in a population of smokers who may be at greater risk for increased caffeine and alcohol consumption. The present study is particularly relevant to Ohio Appalachia because research has found disparities in cancer incidence throughout Appalachia and has identified several behaviors associated with cancer, including tobacco use, that are particularly prevalent in the region [22]. Theories of health behavior change [23] hold that interventions aimed at promoting behavior change in a given population must take into account the individual, social, and environmental barriers to smoking cessation faced by the population. Given that discontinuing nicotine use may lead to caffeine toxicity, energy drink use may present a barrier to smoking cessation for residents of Ohio Appalachia.

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The purpose of this study was to determine: (1) the prevalence of energy drink use among adult Ohio Appalachian smokers, and (2) the factors that predict energy drink use. We hypothesized that energy drink use will be most prevalent among men age 30 and younger, and risk factors would include a selection of problem alcohol use behaviors.

Methods The data used in this study were originally collected as part of the Ohio Health Warning Label study [24]. A brief summary of methods follows. Study Sample

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A total of 298 adult participants were included in the study. Participants were eligible for inclusion criteria if they were (1) a resident of one of 32 Ohio Appalachian counties, (2) smoked at least 100 cigarettes in their life, (3) were a current smoker, (4) were age 21 or older and (5) provided informed, written consent. Participants were given a $50 gift card as an incentive. Procedures Recruitment occurred face-to-face, through participant referral to friends or family, advertisements in local newspapers, flyers and brochures. Trained field interviewers operating out of private office space in two Ohio Appalachian counties screened potential participants for eligibility by telephone. Following the experimental protocol displaying consumer product advertisements onscreen, participants completed a survey regarding demographic variables, smoking behaviors, and alcohol use. The study protocol was approved by the Ohio State University Institutional Review Board.

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Measures In this analysis, there are two primary outcome variables: ever use of an energy drink and past 30-day energy drink use. Participants were asked if they had ever consumed an energy drink and how many, if any, energy drinks they had consumed in the past 30 days. Past 30day energy drink use was coded as binary for purposes of analysis.

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Primary covariates of interest were related to alcohol use and binge drinking. Current alcohol use was assessed by the question, “What type of alcohol do you drink most frequently?” Responses to the latter question included: Beer, wine, malt beverage, liquor, other, and “I do not drink.” Participants who responded, “I do not drink” to this question were coded as not a current alcohol user; all other responses were coded as a current alcohol user. Binge drinking in males was assessed by the question “Considering all types of alcoholic beverages, have you had 5 or more drinks in one sitting in the past 2 weeks?” this question was modified to 4 drinks instead of 5 drinks for females. This categorization of binge drinking is based on a standard defined by the National Institute on Alcohol Abuse and Alcoholism [25]. Alcohol dependence was assessed using CAGE scores with scores ≥2 considered clinically significant [26]. Participants were also asked the age at which they had had their first drink.

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To characterize smoking behaviors, nicotine dependence was assessed using an abbreviated Fagerström Test of Nicotine Dependence [27]; scores ranged from 0 to 6 (0–2 = low, 3–4 = medium, 5–6 = high). Participants were also asked about history of any serious attempt to quit smoking (yes/no). Other covariates included several demographic and behavioral variables, including age, gender, whether or not participants considered themselves Appalachian, education, household income, marital status, number of people in household, opinion of own health, health literacy, and health insurance; race/ethnicity were not assessed due to lack of variability within the sample. Data Analysis

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Logistic regression was used to assess the association of predictor variables with outcome variables following the methods described by Hosmer et al. [28]. Briefly, each candidate predictor was first evaluated in univariate models. Predictors that were significant in univariate models at the alpha = 0.05 level were then all included in a multiple logistic regression model. The final multiple logistic regression models reported reflect predictor variables that were significant at the 0.05 level and associated adjusted odds ratios. Age and gender were included in all models to prevent any residual confounding. Data analysis was performed using the statistical package Stata12™ [29].

Results

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Of the 298 participants included in the study, 66.8 % were female and 96.3 % were Caucasian. The mean participant age was 41 years (SD 12) with an age range from 21 to 68 years. Almost three quarters (72.2 %) of participants had ever consumed an energy drink and 39.3 % had consumed an energy drink in the past month. Additionally, about three quarters of participants had low nicotine dependence scores, and about 80 % reported ever making a serious attempt to quit smoking. About 30 % of participants indicated that they did not consume alcohol while almost 60 % binge drank in the past 2 weeks. The percentage of participants with a clinically significant CAGE score for alcohol dependence was 20.1 %.

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Ever Used an Energy Drink

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Younger age, male gender, and single marital status were associated with increased odds of ever having consumed an energy drink (see Table 1). Specifically, compared to those between 21 and 30, the odds of having ever consumed an energy drink were significantly lower among those 41–54 years old (OR 0.37; 95 % CI 0.16–0.86) and those older than 55 (OR 0.05; 95 % CI 0.02–0.16). The odds of males having ever consumed an energy drink were twice as high as the odds for females (OR 2.00; 95 % CI 1.02–3.92). Finally, the odds of ever having used an energy drink among those who were married or living with a partner were lower compared to the odds for single participants (OR 0.29; 95 % CI 0.13–0.62). Notably, alcohol use, severity of nicotine dependence, and quit attempt history were not found to be significantly associated with ever having used an energy drink. Past 30-Day Energy Drink Use

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Younger age, drinking any alcohol, and binge drinking were associated with past 30-day energy drink use (see Table 2). Compared to those between 21 and 30, participants ages 41– 54 had significantly lower odds of having consumed an energy drink in the past 30 days (OR 0.50; 95 % CI 0.27–0.94), and those older than 55 also had significantly lower odds having consumed an energy drink in the past 30 days (OR 0.09; 95 % CI 0.02–0.33). Not drinking alcohol was associated with lower odds of past 30-day energy drink use (OR 0.28, 95 % CI 0.14–0.55) compared to current alcohol users. Further, binge drinking was associated with higher odds of past 30-day energy drink use (OR 2.31; 95 % CI 1.28–4.18). The association between gender and past 30-day energy drink use was not found to be statistically significant in the multivariate model. Notable covariates that were not found to be significantly associated with past 30-day energy drink use include other measures of alcohol use, (CAGE score and age of first drink) as well as nicotine dependence and quit attempt history.

Discussion

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In contrast to previous community studies of energy drink use [21], which report that roughly a third of adults had ever used an energy drink, we found that over 70 % of Ohio Appalachian smokers reported ever consuming an energy drink, including 87 % of those between 21 and 40 and 67 % of those between 41 and 54. While past 30-day energy drink use was similar to what has previously been reported [13, 30], those studies have generally been conducted with a much younger, college-aged sample. Given that young age has consistently been found to be a predictor of energy drink use, it would be expected that an older sample would show lower rates of energy drink use. Indeed, 51 % of 21–30 year olds in the present sample reported past 30 day energy drink use and participants age 31–40 were not found to have significantly different patterns of energy drink use compared to those 21– 30 years of age. Despite the fact that energy drink use was similar among 21–30 year olds and 31–40 year olds, the present study found that age was strongly associated with both measures of energy drink use. This is consistent with previous research [21, 31] and would be expected given that energy drinks are heavily marketed towards young adults. Contrary to previous research, male gender was only significantly associated with ever having used an energy drink but not

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with past 30 day use (although males were more likely to have used within the past 30 days). Miller [30] suggests that energy use among college students is part of a larger pattern of behavior that emphasizes risk taking and masculine norms. It may be that energy drink use among Ohio Appalachian smokers is not motivated by the same gendered factors. Future research should investigate risk-taking behavior among Ohio Appalachian smokers.

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Consistent with previous research [11, 13, 15], the odds of past 30 day energy drink use were higher among those who binge drank compared to those who didn’t. Notably, the reported binge-drinking rate among this study population was higher than national estimates (59.4 % compared to 17.1 %) [32]. Our results support Skewes et al.’s [11] hypothesis that energy drink use, alcohol use, and tobacco use may be part of a general, sensation seeking behavior pattern. It is also possible that alcohol use mediates the relationship between energy drink use and smoking in that energy drink use and smoking are not-correlated independent of alcohol use. While caffeine, nicotine, and alcohol use tend to co-occur, more research is needed to fully understand the relationships between these commonly used drugs. The present study has several limitations. By design, the study can only reflect a convenience sample of smokers, and does not include non-smokers. While the resulting sample reflected characteristics of the Ohio Appalachian region, participants were disproportionately white and non-Hispanic, and may not reflect the racial/ethnic make-up in other rural areas.

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At present few, if any, other studies have looked specifically at energy drink use among smokers. Given the biological and behavioral associations between nicotine and caffeine, and the high prevalence of smoking in Ohio Appalachia, we believe our findings suggest this combination of risk-taking behaviors are worthy of greater attention. For the future, qualitative research to explore the contexts in which smokers consume energy drinks and their motivations for use may give insight into usage patterns. In order to establish a reliable estimate of national and regional energy drink use, there would be a substantial benefit for large, national health questionnaires such as the BRFSS and the NHANES to assess energy drink use separately from sports drinks. Additionally, since alcohol use is associated with smoking relapse [33] and smoking cessation can lead to caffeine toxicity in caffeine users [16, 17], broader patterns of drug use are important to consider in the context of smoking cessation programs.

Acknowledgments This study was funded by the National Cancer Institute/Center for Tobacco Products (R01CA129771).

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for working-class, multiethnic populations. Preventive Medicine. 2003; 37(3):188–197. [PubMed: 12914824] 24. Klein EG, Shoben AB, Krygowski S, Ferketich A, Berman M, Peters R, et al. Mediation of the size, attention and recall of graphic warning labels on cigarette advertising: An eye-tracking study. Nicotine & Tobacco Research. Under review. 25. National Institute on Alcohol Abuse and Alcoholism. NIAAA council approves definition of binge drinking, NIAAA Newsletter, No. 3. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism; 2004. 26. Ewing JA. Detecting alcoholism: The CAGE questionnaire. The Journal of the American Medical Association. 1984; 252(14):1905–1907. [PubMed: 6471323] 27. Heatherton T, Kozlowski L, Frecker R, Fagerström K. The Fagerström test for nicotine dependence: A revision of the Fagerström tolerance questionnaire. British Journal of Addiction. 1991; 86(9):1119–1127. [PubMed: 1932883] 28. Hosmer, DW., Lemeshow, S., Sturdivant, RX. Applied logistic regression. 3rd. Hoboken, NJ: Wiley; 2013. 29. StataCorp. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP; 2013. 30. Miller K. Wired: Energy drinks, jock identity, masculine norms, and risk taking. Journal of American College Health. 2008; 56(5):481–489. [PubMed: 18400659] 31. Park S, Onufrak S, Blanck H, Sherry B. Characteristics associated with consumption of sports and energy drinks among US adults: National Health Interview Survey, 2010. Journal of the Academy of Nutrition and Dietetics. 2013; 113(1):112–119. [PubMed: 23260728] 32. Centers for Disease Control and Prevention. Vital signs: Binge drinking prevalence, frequency, and intensity among adults—United States, 2010. Morbidity and Mortality Weekly Report. 2012; 61(1):14–19. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a4.htm? s_cid=mm6101a4_w. [PubMed: 22237031] 33. Lisha N, Carmody T, Humfleet G, Delucchi K. Reciprocal effects of alcohol and nicotine in smoking cessation treatment studies. Addictive Behaviors. 2014; 39(3):637–643. [PubMed: 24333039]

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Table 1

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Estimated odds for ever having consumed an energy drink versus not ever having consumed an energy drink among Ohio Appalachian smokers N = 298 (%)

% Ever using energy drink

Adjusted odds ratio (95 % CI)

21–30

25.3

86.7

1.00 (reference)

31–40

24.2

87.5

1.30 (0.47, 3.56)

41–54

38.4

66.7

0.37 (0.16, 0.86)

55+

12.1

27.8

0.05 (0.02, 0.16)

Female

66.8

69.4

1.00 (reference)

Male

33.2

77.8

2.00 (1.02, 3.92)

Single

35.9

86.9

1.00 (reference)

Married or living together

34.6

64.1

0.29 (0.13, 0.62)

Divorced or separated

21.8

66.2

0.53 (0.22, 1.30)

7.7

56.5

0.84 (0.25, 2.86)

Age

Gender

Marital status

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Widowed

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Table 2

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Estimated odds ratios and 95 % confidence intervals for energy drink consumption in the past 30 days versus no energy drink consumption in the past 30 days among Ohio Appalachian smokers N = 298 (%)

Past 30 day energy drink use (%)

Adjusted odds ratio (95 % CI)

21–30

25.3

50.7

1.00 (reference)

31–40

24.2

50.0

0.92 (0.47, 1.81)

41–54

38.4

34.2

0.50 (0.27, 0.94)

55+

12.1

8.3

0.09 (0.02, 0.33)

Female

66.8

36.2

1.00 (reference)

Male

33.2

45.5

1.48 (0.86, 2.52)

No

70.2

45.7

1.00 (reference)

Yes

29.8

23.9

0.28 (0.14, 0.55)

No

51.7

38.0

1.00 (reference)

Yes

48.3

40.1

2.31 (1.28, 4.18)

Age

Gender

I don’t drink

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Binge drink

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Energy Drink Use Among Ohio Appalachian Smokers.

Caffeine-containing energy drinks have emerged as a public health concern due to their association with caffeine toxicity and alcohol use. Despite the...
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