Alcohol Mixed with Caffeinated Energy Drinks: Consumption Patterns and Trends Among Canadian Youth & Young Adults by Cassondra McCrory A thesis presented to the University of Waterloo in fulfillment of the thesis requirement for the degree of Master of Science in Health Studies and Gerontology Waterloo, Ontario, Canada, 2015 © Cassondra McCrory 2015 Author’s Declaration I hereby declare that I am the sole author of this thesis. This is a true copy of the thesis, including any required final revisions, as accepted by my examiners. I understand that my thesis may be made electronically available to the public. ii Abstract Use of caffeinated energy drinks (CEDs) and alcohol mixed with energy drinks (AmEDs) is a growing trend worldwide, and in Canada, youth and young adults are the biggest consumers. Health Canada has recently changed regulations for CEDs, mildly affecting AmEDs. There are growing concerns around AmED use, including adverse health effects, excessive caffeine and alcohol consumption, and risk behaviours. There is currently insufficient evidence around AmED use in Canada to adequately inform policy and support stricter regulations. The current study sought to examine AmED use among youth and young adults in Canada, including associations with socio-demographics and behavioural characteristics. Responses were collected from an online-survey for 1989 respondents in Canada between the ages of 12-24. AmED outcomes, including awareness, use, type of AmED, location of use, reasons for use and risk behaviour were examined with multivariate logistic regression models including covariates sex, age, ethnicity, BMI, province, sleep patterns, school grades, maternal education, spending money, sensation seeking and binge drinking. Approximately 25% of the total sample reported AmED use in their lifetimes, and 74% of users reporting use in the past 12 months. Ever having AmED was greater (at p<0.05) among older youth and young adults, those living in BC or AB, SK, MB, and who binge drink. Current AmED use was greater among non-‘Whites’, those who did not report sleep time, and who reported greater binge drinking. Binge drinking was associated with the majority of AmED outcomes examined, including ever use, current use, pre- mixed AmEDs, AmED served by a bartender, used for intoxication or energy, and AmED awareness. Consumption of AmEDs is common among youth and young adults, and strongly associated with age, binge drinking and location of residence. iii Acknowledgements I would like to acknowledge and express my gratitude to many individuals who have contributed to the success of my studies at the University of Waterloo. First and foremost, Dr. David Hammond, thank you for being such an incredible supervisor. Over the past two years you have shared your expertise, taught me, guided me, and provided me with all the opportunities I needed to develop skills and competencies beyond my thesis alone. I could not have accomplished all that I have without your support. I would also like to thank my committee members, Dr. Joel Dubin and Dr. Steve Manske, for your time, expertise and advice throughout the writing of this thesis. Thank you to the many professors at the UW who have contributed to my success. To Dr. Kelly Anthony, you are an inspiring person, thank you for being such an uplifting and caring individual. To the Hammond Lab, I could not have done this without you. Seema, Lana, Christine C., Heather, Kathy, Sam, Cesar, Amanda, Christine W. and Jess, thank you for making this experience so enjoyable: for the academic assistance, moral support, sweet treats and making me smile everyday. On a more personal note, thank you to my mama, Carlyne McCrory, for always reminding me that I can accomplish anything I set my mind to, and encouraging me always. Some of the sweetest women I know: Tiffany Dhaliwal, Ashley Adams and Hiliary Monteith, milles mercis for being the best friends I could ever hope for. Thank you to all the Lang’s, my family, who have listened to my academic rants and followed my progress attentively with encouragement and love. Thank you to the McCrory’s, my peeps, who always fill me with love, and fill the room with laughter and fun. To uncle Wayne and auntie Cheller, thank you for offering me a home away from home, and helping me onto this path. To Maryam Shahidi, Keero Birla and the little men, words cannot describe what you mean to me, and who you have become in my life. Thank you for all of your support, and making the road to success a little easier. Spencer Gooderham, my scholar and gentleman, you save me in more ways than one. You’ve made all of my joys greater, and all of my challenges a little smaller. Thank you for all you do to make my life sweeter, for your support, and for challenging me to be my best each and every day. Cassondra Michelle McCrory University of Waterloo January 2015 Do not go where the path may lead, go instead where there is no path and leave a trail. ~ Ralph Waldo Emerson iv Table of Contents Author’s Declaration ....................................................................................................................... ii Abstract .......................................................................................................................................... iii Acknowledgements ........................................................................................................................ iv List of Figures .............................................................................................................................. viii List of Tables ................................................................................................................................. ix 1.0 INTRODUCTION .................................................................................................................... 1 1.1 Caffeinated Energy Drinks .................................................................................................... 1 1.1.1 Product Composition ...................................................................................................... 1 1.1.2 Caffeinated Energy Drink History .................................................................................. 3 1.1.3 Marketing of Caffeinated Energy Drinks ....................................................................... 4 1.1.4 Caffeinated Energy Drink Market Share and Sales ........................................................ 6 1.1.5 Caffeinated Energy Drink Regulations ........................................................................... 7 1.1.6 Prevalence of Caffeinated Energy Drinks .................................................................... 13 1.1.7 Determinants of Caffeinated Energy Drink Consumption ........................................... 19 1.1.8 Side Effects of Caffeinated Energy Drink Consumption ............................................. 22 1.2 Alcohol Mixed with Energy Drinks .................................................................................... 27 1.2.1 History of Alcohol Mixed with Energy Drinks ............................................................ 27 1.2.2 Alcohol Mixed with Energy Drinks Regulations ......................................................... 27 1.2.3 Prevalence of Alcohol Mixed with Energy Drinks ...................................................... 28 1.2.4 Determinants of Consumption of Alcohol Mixed with Energy Drink ......................... 34 1.2.5 Physiological Effects of Alcohol Mixed with Energy Drinks ...................................... 36 1.2.6 Behaviours Associated with Alcohol Mixed with Energy Drink Consumption .......... 38 1.3 Caffeinated Alcoholic Beverages in Canada ....................................................................... 39 2.0 RATIONALE .......................................................................................................................... 42 2.1 Research Questions ............................................................................................................. 43 3.0 METHODS ............................................................................................................................. 44 3.1 Study Protocol ..................................................................................................................... 44 v 3.2 Study Participants ................................................................................................................ 45 3.3 Measures.............................................................................................................................. 45 3.3.1 Demographic Information ............................................................................................ 47 3.3.2 Energy Drink Consumption .......................................................................................... 51 3.3.3 Alcohol Mixed with Energy Drink Consumption ........................................................ 52 3.3.4 Risk Behaviour ............................................................................................................. 57 3.3.5 Ethical Clearance .......................................................................................................... 58 4.0 ANALYSIS ............................................................................................................................. 59 4.1 Hypotheses .......................................................................................................................... 60 5.0