Energy Drink and Alcohol mixed Energy Drink use among high school adolescents: Association with risk taking behavior, social characteristics. Sabrina Molinaro, PhD Institute of Clinical Physiology ,National Research Council of Italy (CNR) Lisbon Addiction Conference Lisbon 24-26 Octoberr 2017

INTRODUCTION: STATE OF THE ART ENERGY DRINKS (ED) Energy drinks (EDs) are a group of beverages used to provide an extra burst of energy, promote wakefulness, increase attention , maintain alertness, and improve athletic performance. The main active ingredients of EDs includes varying amounts of caffeine, glucose, B- vitamins, herbs and stimulants such as ephedrine, taurine, ginseng, guarana, green tea, carnitine and yerba mate. Caffeine content ranges from a modest 50mg to an alarming one of 505mg per can or bottle [1,2] Since the introduction of the first ED brand in Austria in 1987, the energy drink market has grown exponentially and their consumption has become increasingly popular among teenagers and young adults, especially students and athletes over the past few years [3] [1] Higgins, J. P., (2010); [2] Reissig, C. J., (2009).

INTRODUCTION: STATE OF THE ART ED CONSUMERS The majority of users consumed them to reduce sleep (67%), to increase energy (65%), and to drink with alcohol while partying (54%) [4] An European study including 16 countries, found that 68% of adolescents had consumed energy drinks in the previous year (30% of adults, 18% of children) Consumption of ED and alcohol was observed in 53% of adolescent ED consumers and 56% of adult ED consumers (71% in “young adults”) [5] [4] Malinauskas, B. (2007) [5] Nomisma-Areté Consortium. Gathering (2013);

INTRODUCTION: STATE OF THE ART ED ADVERSE EFFECTS The most common adverse events affect the cardiovascular and neurological systems, due to excessive consumption of EDs, and in particular of caffeine, the most common ingredient in EDs [7] Excessive caffeine consumption among youth can lead to both minor side effects such as irritability, nervousness, anxiety, dizziness, dehydration, gastrointestinal disturbances, insomnia and sleep disorders, as well as more serious side effects, such as, arrhythmia, tachycardia, [8] [7] Ali, F., Rehman, (2015); [8] O'Brien, M., McCoy, T., (2008)

INTRODUCTION: STATE OF THE ART ENERGY DRINK MIXED WITH ALCOHOL (AmEDs) Public health alarm is increasing concerning the way young people consume alcohol mixed with energy drinks (AmEDs) especially during socializing events such as “partying” longer [9,10] Energy drinks can mask the effects of alcohol so the drink number tends to be greater when combined with energy drinks [11] Mixing energy drinks with alcohol could be riskier than drinking alcohol alone, because the altered perception of drunkenness can favor longer drinking sessions [11,12] Consumption of AmEDs has been associated with binge drinking (five or more drinks on one occasion) and a range of risk behaviors, like driving while intoxicated, being in a verbal and physical fight, requiring medical treatment, being hurt or injured, being taken advantage of sexually and using stimulant drugs [13] [9] O'Brien, M. (2010). [11] McKetin, (2014). [12] Peacock, A.,. (2012). [13] Brache, K., (2011).

INTRODUCTION: STATE OF THE ART WHAT’S MISSED To date, some studies among college students have been conducted about use of EDs/AmEDs and their association with other risk-taking behaviors, but there is a lack of information with respect to younger adolescents' use and habits.

AIM THE KEY OBJECTIVES OF THIS STUDY ARE TO: EXAMINE THE PREVALENCE OF ENERGY DRINK (ED) AND ALCOHOL MIXED WITH ENERGY DRINK (AMED) CONSUMPTION INVESTIGATE THE RELATIONSHIPS BETWEEN ED AND AMED WITH ALCOHOL, BINGE DRINKING AND DRUGS ACCOUNTING FOR OTHER AT RISK BEHAVIORS, INDIVIDUAL AND FAMILY CHARACTERISTICS.

DESIGN AND METHODS The study is based on data drawn from the ESPAD®Italia2015 survey, conduced on sample of 30.588 Italian high school students, aged 15–19 years https://www.epid.ifc.cnr.it/

DESIGN AND METHODS DIPENDENT VARIABLE INDIPENDENT VARIABLE Use of EDs MEASURES DIPENDENT VARIABLE ENERGY DRINK USE IN LAST 12 MONTHS Use of EDs Use of AmEDs INDIPENDENT VARIABLE Family, friend and school environment/relationship wellness/health behaviors Substance use

Statistical Analysis Prevalence of ED and AmED, students' social background, attitudes and drug use were summarized by using percentages. Binary logistic regression analysis, adjusted for gender and age, was conducted separately on each variable to assess relationships between ED and AmED drinking and the other adolescents' characteristics. Multivariate logistic regression analyses, included gender, age and all variables with a significance of 0.1, were also performed to determine the independent association of the potential predictor characteristics with the outcomes; the final model was selected by stepwise backward analysis.

LY PREVALENCE OF ED and AmED FINDINGS: LY PREVALENCE OF ED and AmED

FINDINGS Multivariate logistic regression analysis between main behaviors adopted by students and use of energy drink in the last 12 months

FINDINGS Multivariate logistic regression analysis between main behaviors adopted by students and use of alcohol mixed energy drink in the last 12 months

DISCUSSION ASSOCIATION WITH PSICOACTIVE SUBSTANCES USE: EDs consumer also crave for other stimulants such as cocaine and nicotine while AmEDs substances promoting relaxation such as heroin. Both EDs and AmED are positively associated with cannabis consumption and binge drinking. Among legal psychoactive substances, ED and AmED consumers use tranquillizers and sedatives without medical prescription. These findings drive the attention on an inclination well recognized to be an arming behaviour. FOCUS ON SPORT: Adolescents performing sports in a regular manner are more prone to consume EDs and AmEDs probably in the attempt to enhance their performance and encouraged by trainers.

DISCUSSION ASSOCIATION WHIT RELATIONSHIP WITH FAMYLY AND FRIENDS: Good relationships with parents and friends loose significance at the multivariate suggesting that motivation to drink ED or AmED resides in factors having a stronger influence on adolescent behaviour. ASSOCIATION WHIT LIFE HABITS AND RISKY BEHAVIOR: in both EDs and AmEDs consumers going out with friends for leisure, experiencing accident or injury, engaging in sexual intercourse without a condom and being involved in an accident while driving yourself are positively associated. Only EDs consumers report to have experienced physical fights. The association with risky behaviours must encourage the development other studies in order to clarify the cause-effect relationship.

CONCLUSION These results support the importance of comprehensive educational programs among the young population focusing on potential health concerns of EDs, alcohol, and the combination of the two, designed to empower the ability to manage these drinking habits These findings should lead one to reflect upon how to improve policy and legislation including marketing of already mixed ED with alcohol and the amount of caffeine, and other stimulant compounds, allowed in the pre-mixed alcoholic drinks Political and marketing intervention should implement strategies to protect teenagers from unexpected dangerous health consequences

Thank you for your attention! Acknowledgment Acknowledgement Marco Scalese Francesca Denoth Valeria Siciliano Luca Bastiani Rodolfo Cotechini Arianna Cutilli WWW.epid.ifc.cnr.it molinaro@ifc.cnr.it Thank you for your attention! Sabrina Molinaro, Ph.D Responsabile della Sez. Epidemiologia Istituto di Fisiologia Clinica Consiglio Nazionale delle Ricerche www epid.cnr.it