Blackout in a Can and Epidemiology

Courtesy of http://www.ivygateblog.com/2010/11/columbia-mourns-departure-of-four-loko/

As you have probably picked up from my previous posts, epidemiology is a critical part of public health. One important area that epidemiology plays a role in is public policy. Epidemiological studies are important in public policy formulation because they serve as a scientific basis for making the decision, rather than just relying on arbitrary or unproven information. Obesity and its effects have been the focus of several recent epidemiological studies and public policy efforts (for example, requiring certain restaurants to display nutritional information). Cigarette smoking has also been studied extensively, and the results of these studies have led to such public policies as banning smoking in restaurants or even whole campuses.

Alcohol studies have resulted in many changes in public policies through the years. For example, after several studies in the 1970’s showed that lowered drinking age was associated with higher car crash rates, many states raised their minimum legal drinking age to 21. Here is a quick history of the legal drinking age in the United States, for those that are interested. Different policies have been enacted as more studies have been done. A recent example that some people may know about is the FDA ban of alcoholic drinks that also feature caffeine. Specifically, it was aimed at energy drink/alcohol combos such as Four Loko and Joose. The main argument in the ban was that caffeine component of the alcoholic drink masks the effects of the alcohol, causing people (specifically college students) to drink more than they usually do. Several high profile hospitalizations led to the increased attention on these drinks in particular, including one party in which 9 different people had to be rushed to the emergency room for alcohol related reasons. Here is a short video discussing the ban. I would have embedded that video, but CBS News forbids it and what they say goes.

So does the ban come with the backing of epidemiological studies? One of the most commonly cited studies was published by Wake Forest in 2008. The study examines the relationship between alcoholic energy drink use, high-risk drinking behavior, and alcohol-related consequences. The cross-sectional study found students who consumed alcoholic energy drinks had dramatically higher rates of serious alcohol-related consequences. They concluded, “Almost one-quarter of college student current drinkers reported mixing alcohol with energy drinks. These students are at increased risk for alcohol-related consequences, even after adjusting for the amount of alcohol consumed. Further research is necessary to understand this association and to develop targeted interventions to reduce risk.” It is important to note that the study found only associations and no causal relationships. They also admitted that the generalizability of the study was limited by several limitations.

Courtesy of http://www.ivygateblog.com/2010/11/columbia-mourns-departure-of-four-loko/

 Another study by the University of Florida, published in 2010, studied associations between energy drink consumption, alcohol intoxication, and intention to drive a motor vehicle in patrons exiting bars at night. They found patrons who had consumed alcohol mixed with energy drinks were at a 3-fold increased risk of leaving a bar highly intoxicated as well as a 4-fold increased risk of intending to drive upon leaving the bar district. They concluded, “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.” Again you will notice that associations were found, not causation, and further study was needed before action should be taken in the regard to alcohol/caffeine related drinks.

Other than these two largely cited studies, there has been a lack of scientific focus on the subject. I don’t think anyone would argue that binge drinking has many negative effects on people, physically or otherwise, but does adding caffeine make these adverse effects worse? The studies done so far have done found associations, but they are far from conclusive. Even the authors of the studies admit that further studies need to be undertaken. Many questions remain unanswered. Does consuming these drinks cause the undesired consequence? Are the people who consume these drinks inherently more likely to involve in risky behavior? Just think of all the confounders that could be addressed: age, sex, race, education level, other drinks consumed, period over which drinks were consumed, other drugs consumed, actual alcohol/caffeine drink consumed, different drinking environments, etc, etc, etc.

Regardless, Four Loko and related drinks were banned in their caffeine-included form. Was there a need for further investigation before this move was made? Or was the available epidemiological evidence and the hospitalizations nationwide attributed to the drinks enough?

How about a vote?