Matthew E. Rossheim

Event-level analyses of energy drink consumption and alcohol intoxication in bar patrons

AIM To assess event-level associations between energy drink consumption, alcohol intoxication, and intention to drive a motor vehicle in patrons exiting bars at night. METHOD Alcohol field study. Data collected in a U.S. college bar district from 802 randomly selected and self-selected patrons. Anonymous interview and survey data were obtained as well as breath alcohol concentration (BrAC) readings. RESULTS Results from logistic regression models revealed that patrons who had consumed alcohol mixed with energy drinks were at a 3-fold increased risk of leaving a bar highly intoxicated (BrAC> or =0.08g/210L), as well as a 4-fold increased risk of intending to drive upon leaving the bar district, compared to other drinking patrons who did not consume alcoholic beverages mixed with energy drinks. DISCUSSION These event-level associations provide additional evidence that energy drink consumption by young adults at bars is a marker for elevated involvement in nighttime risk-taking behavior. Further field research is needed to develop sound regulatory policy on alcohol/energy drink sales practices of on-premise establishments.

Is there a misplaced focus on AmED? Associations between caffeine mixers and bar patron intoxication

BACKGROUND Previous research on alcohol mixed with energy drinks (AmED) suffers from measurement problems. Missing from the research literature are studies that assess caffeine-alcohol co-ingestion in natural drinking environments. METHODS This field study collected data in a U.S. college bar district from 328 randomly selected patrons. Anonymous data were obtained from face-to-face interviews and self-administered surveys, and from breath tests. RESULTS Cola-caffeinated alcoholic beverage consumers left bars in a more highly intoxicated state than those who consumed alcohol only. There was no significant difference between the intoxication level of the AmED group and the cola-caffeinated alcoholic beverage group. Results from a multivariate regression model indicated that quantity of caffeinated alcoholic beverage consumption had a significant, positive association with bar patron intoxication after adjusting for potential confounders. CONCLUSIONS Findings indicate that caffeine may have a dose-dependent relationship with alcohol intoxication in the bar/nightclub setting. In addition, results revealed that cola-caffeinated alcoholic drinks may pose similar levels of risk to bar patrons as those associated with AmED beverage consumption. Product labeling requirements about alcohol risks may need to be extended not only to energy drinks, but to caffeinated soft drinks as well.

MAPIT: Development of a web-based intervention targeting substance abuse treatment in the criminal justice system

Although drug and alcohol treatment are common requirements in the U.S. criminal justice system, only a minority of clients actually initiate treatment. This paper describes a two-session, web-based intervention to increase motivation for substance abuse treatment among clients using illicit substances. MAPIT (Motivational Assessment Program to Initiate Treatment) integrates the extended parallel process model, motivational interviewing, and social cognitive theory. The first session (completed near the start of probation) targets motivation to complete probation, to make changes in substance use (including treatment initiation), and to obtain HIV testing and care. The second session (completed approximately 30days after session 1) focuses on goal setting, coping strategies, and social support. Both sessions can generate emails or mobile texts to remind clients of their goals. MAPIT uses theory-based algorithms and a text-to-speech engine to deliver custom feedback and suggestions. In an initial test, participants indicated that the program was respectful, easy to use, and would be helpful in making changes in substance use. MAPIT is being tested in a randomized trial in two large U.S. probation agencies. MAPIT addresses the difficulties of many probation agencies to maximize client involvement in treatment, in a way that is cost effective and compatible with the existing service delivery system.

Artificial Sweeteners, Caffeine, and Alcohol Intoxication in Bar Patrons

BACKGROUND Previous laboratory research on alcohol absorption has found that substitution of artificially sweetened alcohol mixers for sucrose-based mixers has a marked effect on the rate of gastric emptying, resulting in elevated blood alcohol concentrations. Studies conducted in natural drinking settings, such as bars, have indicated that caffeine ingestion while drinking is associated with higher levels of intoxication. To our knowledge, research has not examined the effects of alcohol mixers that contain both an artificial sweetener and caffeine, that is, diet cola. Therefore, we assessed the event-specific association between diet cola consumption and alcohol intoxication in bar patrons. We sought to determine whether putative increases in blood alcohol, produced by accelerated gastric emptying following diet cola consumption, as identified in the laboratory, also appear in a natural setting associated with impaired driving. METHODS We conducted a secondary analysis of data from 2 nighttime field studies that collected anonymous information from 413 randomly selected bar patrons in 2008 and 2010. Data sets were merged and recoded to distinguish between energy drink, regular cola, diet cola, and noncaffeinated alcohol mixers. RESULTS Caffeinated alcohol mixers were consumed by 33.9% of the patrons. Cola-caffeinated mixed drinks were much more popular than those mixed with energy drinks. A large majority of regular cola-caffeinated mixed drink consumers were men (75%), whereas diet cola-caffeinated mixed drink consumers were more likely to be women (57%). After adjusting for the number of drinks consumed and other potential confounders, number of diet cola mixed drinks had a significant association with patron intoxication (β = 0.233, p < 0.0001). Number of drinks mixed with regular (sucrose-sweetened) cola and energy drinks did not have significant associations with intoxication (p > 0.05). CONCLUSIONS Caffeines effect on intoxication may be most pronounced when mixers are artificially sweetened, that is, lack sucrose which slows the rate of gastric emptying of alcohol. Risks associated with on-premise drinking may be reduced by greater attention given to types of mixers, particularly diet colas.

Alcohol mixed with energy drink: use may be a consequence of heavy drinking

AIMS In recent years, studies have indicated that consumers of alcohol mixed with energy drink (AmED) are more likely to drink heavily and experience more negative consequences than consumers who avoid these beverages. Although researchers have identified a number of plausible hypotheses that explain how alcohol-energy drink co-ingestion could cause greater alcohol consumption, there has been no postulation about reverse causal relations. This paper identifies several plausible hypotheses for the observed associations between AmED consumption and greater alcohol consumption, and provides initial evidence for one such hypothesis suggesting that heavy drinking may be a determinant of AmED use. METHOD Data collected from 511bar patrons were used to examine the plausibility of one of the proposed hypotheses, i.e., AmED is an artifact of heavy drinking. Associations between the consumption of an assortment of alcoholic beverage types and total alcohol consumption were examined at the event-level, to assess whether AmED is uniquely related with greater alcohol consumption. RESULTS Increased alcohol consumption was associated with greater odds of consuming most alcoholic beverage types; this association was not unique to AmED. CONCLUSIONS Results support the overlooked hypothesis that AmED use is an artifact of heavy drinking. Thus, AmED consumption may be a consequence or marker of heavier drinking. Much of the existing research on alcoholic beverage types is limited in its ability to implicate any specific type of drink, including AmED, as a cause of increased alcohol consumption and related harm. More rigorous study designs are needed to examine causal relationships.

Letter to the editor in regard to Peacock, Bruno, and Martin (2012): "the subjective physiological, psychological, and behavioral risk-taking consequences of alcohol and energy drink co-ingestion": misleading results and unjustified conclusions.

THE CONCLUSIONS PUBLISHED in Alcoholism: Clinical and Experimental Research (2012;36:2008– 2015) by Peacock and colleagues are not justified, at least as explained in their paper. The authors conclude that alcohol mixed with energy drink, or AmED-drinking sessions, are associated with less involvement in risk behavior because individuals were observed to be less likely to engage in these behaviors during AmED sessions compared with alcoholonly drinking sessions in the past 6 months. However, AmED sessions were far less frequent than alcohol-only drinking sessions. Therefore, the relationship between type of drinking session and engagement in risk behaviors is distorted by the large difference in the total number of AmED and alcohol-only drinking sessions, resulting in spurious effect estimates. Not accounting for this difference in the analysis produced misleading results, which in turn, led to conclusions that cannot be supported by the data. A growing body of literature has observed that consumers of AmED engage in more risk-taking behavior while drinking and experience more negative alcohol-related consequences than individuals who do not consume AmED (Brache and Stockwell, 2011; O’Brien et al., 2008; Thombs et al., 2010). The recent study by Peacock and colleagues (2012) sought to discern whether (i) AmED use, or caffeinated alcohol consumption, prompts increased involvement in risk behavior during drinking sessions or (ii) AmED users represent a subpopulation of young adults who have a heightened propensity or proneness for engaging in multiple risk behaviors. These alternative hypotheses are at the center of the current debate about the need to regulate caffeinated alcohol use. Unfortunately, weaknesses of the Peakcock and colleagues study further muddle our understanding of these important issues. Others have already begun citing Peacock and colleagues (2012) as a within-participant study providing evidence of no relationship (Howland and Rohsenow, 2013) or a protective relationship (Pennay and Lubman, 2012) between AmED consumption and engagement in risk behavior. Unfortunately, due to the limitations of the study design and analysis plan, this paper, as written, cannot provide a definitive answer to that question. Any interpretation of the reported findings needs to be conditioned on severe, fundamental limitations. The study design raises several serious concerns. First, the online survey instrument has 303 items, which was reported to be completed by the participants in 10 to 30 minutes. This indicates that on average, respondents took between 2 and 6 seconds to read, comprehend, and respond to each survey item. Given such quick response times to a relatively long survey, questions need to be raised about whether participants responded indiscriminately to survey items merely for a chance to win an Apple iPad2 . Second, during these relatively rapid responses to survey items, respondents were asked to form judgments about whether their engagement in each risk behavior was due to their consumption of AmED. Serious questions can be raised about the validity of survey items that rely on the ability of respondents to correctly attribute their involvement in risk behavior to their AmED consumption (Wood et al., 1997). Such an approach may result in an overestimate of the association if respondents incorrectly attribute their risk behavior to AmED consumption. Conversely, respondent assessment of their attributions could also lead to an underestimate if they incorrectly failed to attribute their risk behavior to AmED consumption. Use of these attribution measures elicited subjective responses that contribute little to the science on caffeinated alcohol consumption. From the Department of Behavioral and Community Health (MER, DLT), University of North Texas Health Science Center, Fort Worth, Texas. Department of Biostatistics (SS), University of North Texas Health Science Center, Fort Worth, Texas. Received for publicationMarch 12, 2013; accepted April 12, 2013. Reprint requests: Matthew E. Rossheim, MPH, Department of Behavioral and Community Health, School of Public Health, 3500 Camp Bowie Blvd., UNT Health Science Center, Fort Worth, TX 76107-2699; Tel.: 941-323-0778; Fax: 817-735-2619; E-mail: matthew.rossheim@live. unthsc.edu Copyright© 2013 by the Research Society on Alcoholism.

Self-efficacy to drive while intoxicated: insights into the persistence of alcohol-impaired driving

BACKGROUND Scant research has examined event-level risk factors for impaired driving in natural drinking settings. This study assessed driving self-efficacy among intoxicated individuals to better understand decision-making about alcohol-impaired driving at night after exiting on-premise drinking establishments. METHODS Interview and breath test data were collected from bar patrons (n = 512) exiting 2 college bar districts in Florida and Texas. RESULTS Results from a multivariable linear regression model indicated that self-efficacy to drive while intoxicated was more strongly associated with situational variables, that is, perceived drunkenness and self-estimated blood alcohol concentration than patron traits, that is, past-year history of drinking, risk proneness, and sex. A large proportion of bar patrons, particularly men, expressed confidence in their ability to drive, despite being highly intoxicated. Moreover, the majority of legally intoxicated patrons who were confident in their ability to drive were aware of their high level of intoxication. CONCLUSIONS Emphasis should be placed on the enactment and enforcement of policies and laws to prevent alcohol-impaired driving.

Associations Between Drug Use and Motorcycle Helmet Use in Fatal Crashes

Objective: Helmet use reduces mortality risk for motorcyclists, regardless of drug and alcohol use. However, the association between drug use and motorcycle helmet utilization is not well known. This study examines the relationship between drug use and motorcycle helmet use among fatally injured motorcycle riders. Methods: Using data from the 2005–2009 Fatality Analysis Reporting System (FARS), we examined the association between drug use and motorcycle helmet use in a multivariable logistic regression analysis of 9861 fatally injured motorcycle riders in the United States. Results: For fatally injured motorcycle riders, use of alcohol, marijuana, or other drugs was associated with increased odds of not wearing a motorcycle helmet, controlling for the effects of state motorcycle helmet laws and other confounding variables. Predicted probabilities indicate that helmet use substantially decreases among fatally injured riders mixing alcohol with marijuana and other drugs. Furthermore, the likelihood of helmet use between marijuana-only users and other drug users is virtually the same across all blood alcohol content (BAC) levels. Conclusions: This study provides evidence that alcohol, marijuana, and other drug use is associated with not wearing a motorcycle helmet in fatal motorcycle crashes. There is a clear need for additional prevention and intervention efforts that seek to change helmet and drug use norms among motorcycle riders.

Associations between bar patron alcohol intoxication and tobacco smoking.

OBJECTIVE To examine the event-specific relationship between alcohol intoxication and nighttime tobacco smoking among college bar patrons. METHODS In this secondary analysis of existing data, we examined event-specific associations between self-report measures of tobacco smoking and breath alcohol concentration (BrAC) readings obtained from 424 patrons exiting on-premise drinking establishments. RESULTS In a multivariable logistic regression analysis, acute alcohol intoxication was positively associated with same-night incidents of smoking tobacco, adjusting for the effects of established smoking practices and other potential confounders. CONCLUSIONS This investigation is the first known study using data collected in an on-premise drinking setting to link alcohol intoxication to specific incidents of tobacco smoking.

Multiple fruit-flavored alcoholic drinks in a can (MFAC): an overlooked class of potentially harmful alcohol products.

Abstract This article examines an overlooked class of alcohol products, described herein as multiple fruit-flavored alcoholic drinks in a can (MFAC). The article describes how characteristics of these products likely contribute to hazardous alcohol consumption among youth. Government regulation of these products may be needed to protect adolescent and young adult populations. National substance abuse surveillance systems should consider immediate adoption of MFAC use indicators to determine use and harm associated with these products, and to assess the effectiveness of future regulatory actions.